Hello everybody. Thank you for this opportunity. Welcome to this ASPS Global Partners webinar series. Today from Argentina, at the end of the world, we have a wonderful webinar about breast surgery and we have the opportunity to have Mitch Brown from Toronto. So thank you Mitch for being here. Dr. Martin Colombo, who is our president for our national society and Dr. Claudio Angrigiani, who is a very well-known breast surgeon and has several contributions to plastic surgery. So Mitch, the screen is yours to begin with the webinar. Thank you very much, Alberto. What an honor and pleasure to be here. I'm just sorry we can't be doing it in person, but I know that we'll get a lot out of this presentation today. I'm going to talk a bit about some of the things that I've learned about trying to avoid complications in implant-based reconstruction. I have no disclosures. I always put up a slide of Scott Spear just because he's somebody that has taught me so much about breast reconstruction and implant-based breast reconstruction. The three things I want to really focus on today are tips to avoid or manage complications using capsules or managing capsules with a cellular dermal matrix, managing implant malposition using a technique called popcorn capsuloraphy and where large volume fat and pre-expansion might have a role in managing complications in implant-based reconstruction. I think we learn a lot from what we know in augmentation and aesthetic surgery in what we do in reconstructive surgery. If you look at these two patients, the patient who's had reconstruction has some contracture. She has a bit of a malposition and some scar tissue issues. The augmentation patient has a malposition and a synmastia. Just because one's an augmentation and one's a reconstruction doesn't really make them different. They share very similar principles in trying to manage these types of problems. I think we can learn a lot and share a lot between our augmentation and our reconstruction practices. In augmentation surgery, the most common reasons for reoperation in breast implant surgery for me are malposition, size change, and rupture, and contracture not so much of a problem anymore. In reconstruction, I think it's different. Contracture is a common problem, maybe the most common problem. Asymmetry, largely because we're frequently doing unilateral surgeries, and then malposition and rupture and rippling sort of less commonly. When you have a revision case, and here's a perfect example of someone with a suboptimal result, I always think of three basic approaches. You can always tell somebody, unless they have a significant problem, that option one is to do nothing, because we always know we can make patients worse. Doing nothing sometimes is an acceptable option. The second option is to remove the implant with or without some degree of soft tissue modification or conversion to autologous reconstruction. I tell patients the only way I can guarantee that they won't have further surgery later in life related to implants is not to have an implant at all. Then finally, we can try to revise it with the use of implants and either do that in one stage or two stages. I think this is a nice way of thinking about presenting options to patients. You have to be prepared. In revision surgery, it's remarkable how often you get in there and someone has operated three or four times previously, and you find things that you don't expect to find. In revision cases, be prepared. Have the tools available to you that you may need in an unexpected way to manage difficult and complex problems. Let's talk first about capsular contracture. I think still a very leading cause of reoperation in implant-based reconstruction, largely because the environment in reconstruction is different than in augmentation. It's longer surgical procedures. You have more people involved in the room operating in a reconstructive setting. It's not as atraumatic a dissection as it is in an augmentation. The tissues are sometimes compromised. They have been operated on previously. Sometimes they're radiated. Capsular contracture occurs, and so the key is prevention. For me, one of the most critical things is to try to maximize soft tissue coverage. Good soft tissue coverage, I think, leads to lower incidence of capsular contracture. This is an example of someone having a skin reduction, mastectomy, and immediate reconstruction. We can see that there's an autoderm or a dermal flap inferiorly. There's the pectoral muscle superiorly. There's some acellular dermal matrix laterally, all with a nice vascular overlying skin flap, and that tends to give us a nice outcome where this patient's had a skin reduction, mastectomy, immediate direct-to-implant reconstruction, and good symmetry and softness we have a lot of healthy tissue covering the implant. I'm conflicted a little bit about pre-pectoral reconstruction. I like doing pre-pectoral reconstruction, but we're now decreasing the amount of soft tissue coverage, and for that reason, people are using acellular dermal matrix quite a great deal. I think the book is still out on how valuable that will be and whether ADM materials are necessary or add value as opposed to just meshes, but when we use ADM materials in revision surgery, we're using them to try to manage one of three types of problems. We either want to get some soft tissue coverage. We either want to try to manage malposition and use it to help hold an implant in position, or we may be using ADM to try to manage difficult contracture patients. We know that when you place ADM into a pocket, you do not get a capsule in that area, which is very unique, and so people have felt, you know what, maybe you could deal with problematic capsule problems with the use of ADM materials. This is an interesting patient. She's 46 years of age. She's had a saline breast augmentation 10 years earlier, and she's doing fine, but then she develops cancer of the right breast. She's had a lumpectomy, radiation, and because of the radiation, she's developed a very significant contracture under the pectoral muscle. Now, we would all know that trying to manage a subpectoral Baker 4 contracture in the presence of radiation is a very difficult problem and difficult to do a capsulectomy, even difficult to do a site change, so what I did in this lady was to do an implant removal, remove as much of the inferior capsule as we could, safely remove, leave the superior capsule or the portion that was attached to the ribcage, place a new implant, and then use ADM material in the lower pole of the breast to try to maintain softness and decrease the recurrence of contracture, and you can see that the patient at six months and two years, although she's a bit asymmetric because of her lumpectomy and her radiation, she's maintained a nice degree of softness and a correction of the contracture even two years after surgery. This is a lady who's had a previous bilateral subcutaneous mastectomy for mastodonia. She had pre-pectoral breast reconstruction years ago and has bilateral Baker 4 contracture, so another difficult problem, and if we want to try to maximize soft tissue coverage, because this lady has no soft tissue coverage, we can do a total capsulectomy, do a site change to place her under the pectoral muscle, use some ADM material to support the implant in place, and then perform a mastopexy, and there she is at six months after surgery with a nice improvement, a better shape, maximizing soft tissue coverage over the implant. Let's switch now to implant malposition. What do we need to think about with malposition? First, we have to recognize, especially in North America, as we are switching so much from textured to smooth, that it's really a different operation. Smooth implants move in a pocket in a way completely different from textured devices, so you need precise pocket control. You have to dissect a pocket very precisely. You cannot over-dissect a pocket. Otherwise, in breast reconstruction, you place a smooth implant, the implant will move wherever it wishes, and we have a high degree or high likelihood of implant malposition. So we can classify malposition based on direction, from superior, inferior, medial malposition, or one of the more common types of malposition in breast reconstruction, I feel, is lateral malposition. Malposition, if it occurs, is really a problem of the implant pocket. I like to think of it that you can have many reasons why a malposition occurs, but once the implant's in the wrong place, you have a pocket problem. The pocket's either too big, it's too small, or it's in the wrong position. So we can think of correcting implant malpositions by doing one of two things. We either leave the implant in the same pocket and adjust that pocket through a variety of different techniques, or we can say, listen, we don't like the pocket at all. Let's take the implant out of the pocket and do a site change and place the implant in a brand new, fresh pocket. And there's a variety of ways that we can do that. So this is an example of that lady I showed before. She has an implant malposition when she lies down. So she's going to have a mastectomy of the right side. She's had reconstruction on the left side. She lies down, and you can see her right breast is natural and falls to the side, and the left reconstructed breast is falling too far laterally. So she has a big vacancy or emptiness medially near the sternum. So one of the best techniques that I know of is this technique called popcorn capsulography. And I'm leaving the audio on because I want you to hear the noise. And that is why it's called the popcorn technique. It basically makes a popping sound, and it's thermal shrinkage, essentially, of the capsule. So we're looking at this patient from the top. This is the lateral gutter, and we're shrinking the capsule through thermal coagulation of the tissue. And if we take a look at the patient, we can look at her before, and without any sutures, without any closure of the skin, you can see how much more dramatically the implant slides over simply through thermal shrinkage of the lateral gutter. It's a very, very powerful technique. If we look at this patient on your left, you can see that it's an implant malposition with both implants falling quite laterally to the side. And our plan was to do a pocket revision with a capsulography, and then to do a mastopexy. Well, if we look at her picture intraoperatively, you can see that on the one side, we've actually done the capsulography and the mastopexy. And on her left breast, we've done the capsulography only, just a popcorn capsulography, haven't done anything, haven't done the mastopexy yet. And look how dramatically that implant moves over without doing anything at all with sutures or to the skin, a very powerful technique. This lady falling laterally, 650 cc round implants bilaterally, popcorn technique, cauterized thermally laterally, and look without any sutures, how dramatically that implant comes over. So it works very nicely. If you want to reinforce it with sutures, you can go ahead and do so. And there she is in a sitting position, nothing more than a few sutures and a lateral capsulography with cautery. Sometimes you can add to that, use a little lateral capsular flap where you hinge a flap that's based laterally off of the posterior wall. I use that sometimes in my implant augmentation patients. This is a lady who has bilateral malposition. Implants are too far out to the side. She doesn't like that. She has a right inferior malposition. So we're going to go ahead, take out her implants, do a correction, do a lateral capsulography using popcorn technique only, change her implants, and look at six months how much those implants have been pushed in more towards the sternum with a much better shape simply by closing off the lateral gutter and the lateral pocket of the breast. Sometimes you get extremely complex patients like this lady, multi-directional malposition. She's had multiple previous surgeries. She's had a nipple sparing mastectomy on the right with implant reconstruction, and she's had an augmentation to balance on the left side. She's got contracture. She has malposition. The only good thing for us is that she has saline implants. So we can do a preoperative deflation with her saline implants, leave it for a couple weeks, get a better idea of what the normal anatomy looks like, and then we can just go back in and try to rebuild the breast using whatever muscle tissue we can find, adding a cellular dermal matrix where it's necessary. We can use an intraoperative sizer, build the ADM around the intraoperative sizer, pull the pectoral muscle down as much as possible, and we don't get a perfect result. She's had so many different operations, but we can get a much better overall stable position of the implant using a variety of appropriate techniques. I want to finish by just quickly talking about fat. Everybody on this call I'm sure is very comfortable and familiar with large-volume fat grafting, but it can be a lifesaver in breast reconstruction. This is a simple procedure. Someone who's had implant reconstruction has hollowness at the top, and we know that we can take a very small amount of fat and add it and get a really nice improvement to the contour. What about larger volumes, however? If you want to put much larger volumes, I'm a believer in external expansion techniques and that we need to externally expand in order to be able to put large volume and get enough fat so that we do not get fat necrosis and oil cysts. This is a lady who's had mastectomy, chemo, radiation, implant reconstruction. She's flat. It's irregular. It needs volume. What we can do is change the implant, but if we can put a lot of fat over top, we get a much more attractive-looking outcome. Here we are. We're going to do some external expansion. There she is after the external expansion. Then we can see in the bottom, once we've changed the implant and we've placed a significant amount of fat over both breasts, there's still some rippling. We need to take her back and do some more, but we have a really improved overall shape. Here's a lady, large lady, difficult reconstruction. Someone's done a skin-sparing mastectomy. She's had contractures. She's had exchanges, and she has an unsatisfactory result. On one hand, you could take this all out and convert her to autogenous reconstruction, or we could use this as a nice foundation, leave the implants, and then build breast over top of it with fat, almost creating a composite reconstruction. That's what we're going to do. We're going to try to create a composite result. We will externally expand, change the implant. We've put 240 cc's of fat over each breast, and we can see a much nicer overall aesthetic shape of the breast by leaving the implant and building fat over top. This lady had a nipple-sparing mastectomy, pre-pectoral bilateral reconstruction. Unsatisfactory on the left side with significant rippling, so large volume fat grafting makes a beautiful difference. Use fat to create essentially a composite reconstruction. The final case, this is a lady in the top left that had sub-pectoral, young woman, sub-pectoral reconstruction, had tremendous animation, was very unsatisfied. We converted her to pre-pectoral reconstruction in the bottom left, totally got rid of her animation, but left her with irregularity around the edges, brought her back and fat grafted over top of the pre-pectoral reconstruction, and we now have a very satisfactory looking outcome. So in summary, I think the primary goal in any implant-based reconstructions prevent complications and reoperations. So using ADM where appropriate, very cautious surgical technique, maximizing soft tissue coverage, all critical. And I would say, especially as it relates to pre-pec reconstruction, I think we should all use a bit of caution in adopting new techniques and make sure we have long-term follow-up before we all jump into doing one particular type of procedure. I thank you very much. My apologies for having to go to a university meeting that I could not reschedule, but it was a pleasure to be a part of this panel. Thank you. Thank you, Mitch. Thank you for your effort. Wonderful concepts. Just while Martín is preparing his next presentation, just a question. And to everybody, if you have any questions for Mitch, you can send it by chat and we will redirect the questions to Mitch and he will kindly answer them. Mitch, when you talk about ADM and meshes, what is your experience about capsular contracture and ADMs? So do you really believe that putting ADM reduces capsular contracture, right? Yeah. You know, I don't know that it's necessary in routine cases. And I have to say, to be honest with you, in pre-pectoral reconstruction, I think the idea of completely wrapping an implant with ADM is exceptionally expensive and there's no evidence-based medicine to support that. I will say that in recurrent capsular contracture patients, ones that have had three or four surgeries and they continue to get a contracture, that I have found that ADM helps tremendously. So I don't think that you need it routinely. I'm not even sure you need it preventatively, but I think ADM in the complex recurrent contracture patient or the patient that's high risk, like trying to do implant-based reconstruction in a radiated field, I think those patients, ADM can make a big difference. But not synthetic. Do you speak about ADM or synthetic is also an option? I think synthetic has great benefit for stability of an implant in place and minimizing implant malposition. But I don't think synthetic devices or meshes have a significant impact or any impact at all on prevention of capsular contracture. Would you recommend synthetic for malposition? Absolutely. So I want to make it clear, if I'm treating a malposition, I would rarely use ADM. I think for holding an implant in position or for even most pre-pectoral reconstructions, I think you can do that with synthetic mesh. I use Vicromesh, Galaflex, materials like that, I think are excellent. But I think ADM is specific when I'm trying to modify the response of the capsule, not for malposition. This is very important because that's not to compare as if it is the same to use one. They have their indications and price. It's always an issue when you need a large amount of these materials. Yes, I would agree. Okay, Mitch, we know we are in the middle of meetings and surgery, so thank you for being here and hope to have you again. Thank you for accepting our invitation. Thank you, Alberto. Have a wonderful day. Thank you, bye-bye. Thank you. And now Martin Colombo who is going to talk about breast reconstruction in risk-reducing mastectomy. So Martin, please, the screen is yours. Thank you, Alberto. Thank you everyone, especially as president of the Argentinian Plastic Surgery Society, SACPR, I would like to thank the American Society of Plastic Surgeons for sharing this online platform that has a worldwide reach and allow us to share our knowledge and experience and probably different point of views. So I'm going to talk about what's my main interest in in plastic surgery, that's breast reconstruction, and to talk about a procedure that is getting more and more popular, at least in my practice, and I think it's definitely worldwide. That's the risk-reducing mastectomy and the evolution in reconstruction to pre-pectoral implants. I'm a speaker for Polytech Aesthetics and to start quickly with a little bit of history, this very important American surgeon William Halsted in 1907 introduces the radical mastectomy and as a note of color, he wrote there, beware of the man with the plastic operation, probably being concerned about initial reconstructions done on oncologic procedures, but the man with the plastic operation did a huge evolution from there and with improvements in mastectomy and reconstruction techniques and starting in the 70s with this kind of results with the radical mastectomies improving to Italian Umberto Beronesi with conservation surgery, a huge step with preserving skin, mentioned by and published by Stephen Kroll in the 90s and arriving to what is probably our absolute envelope conservation in nipple-sphering mastectomies. Evolution with reconstruction techniques, with device improvement, shapes, surfaces, expanders, valves, two or three compartments, and in evolution in autologous reconstruction to what I think is the Rolls-Royce of reconstructions, that's the deep flaps. But we now not only treat breast cancer, but we're also trying to prevent breast cancer and reconstruct the prevention of breast cancer. That's how we arrived now to this reducing mastectomies in two senses, in the contralateral or prophylactic mastectomy in oncologic patients or in bilateral reconstruction in high-risk patients, especially with gene markers. So these kind of procedures, as from the statistics of the American Society in 2017, is rising. In 15%, it has an annual increase. That's why, to put a little bit of science and light on this, the American Society of Breast Surgeons, with its consensus in 2016, trying to clarify this, they arrived to a conclusion saying that in average risk women, the probability or risk of having a contralateral breast cancer is low, 1 to 5% every 10 years, but it's different and it's high in patients with gene markers, BRCA1 and 2, with an age of 70, a life cumulative risk of 60 and 50%, the same as with strong family histories, rising to 30 to 40% in 10 years. So who will benefit of this kind of procedures? Actually, the conclusions are definitely patients with BRCA1 and 2 gene carriers and patients with significant family history without genetic tests and who may benefit of a contralateral prophylactic mastectomy are BRCA negative markers, but with a strong family history. Strong family history is a very important factor in this and especially patients who decide in their reconstruction symmetry and patients who are extremely anxious about having a second tumor or a recurrence tumor in the contralateral breasts. In terms of what surgical options for this kind of procedures, there is no objectively defined single technique for RRM and reconstruction. There are no randomized trial evidence and all data we have now is just from cohort studies. Surgical approaches will depend on breast size and shapes, definitely. Previous histories of patients, new scientific evidence, surgeon's personal experience, and institutional possibilities. But the three items that we need to consider when we're going to do a risk reduction mastectomy and its reconstructions are what kind of mastectomy we will be doing, the type of incisions we will be using, and what kind of reconstructive procedures. If we go to deciding the mastectomy type, definitely the complete skin preservation and the envelope preservation that the nipple sparing mastectomy will give us combines the removal of all at-risk tissue with the best, definitely the best, aesthetic outcomes. In terms of being oncologically safe, this multistudy institutional study shows that the prophylactic nipple sparing mastectomy has a significant reduction in breast cancer events in patients with BRCA mutations and actually 40% of nipple sparing mastectomies, this kind of mastectomy, is performed in therapeutic reasons, but 60% is performed in prophylactic reasons. And the local regional recurrence is, the rate is low and obviously significantly higher in therapeutic nipple sparing mastectomies. Concerning this type of mastectomy and the breast cue improving cosmetic results, the psychological well-being and satisfaction with breast in nipple sparing mastectomy has a higher median post-reconstructive score compared to any other technique. So we decided that nipple sparing is our kind of mastectomy. What kind of incisions we will be using? Lots of papers. This is a meta-analysis published in 2019 reviewing 49 studies and the most popular or the most used incisions are definitely the inframammary and the radial incisions, less used the periareolar mastopexy of previous scars or even endoscopic. And if we go to which ones have more complications, nipple or periareolar mastopexy incisions have definitely higher complications than inframammary and radial in nipple areola necrosis or even in total necrosis. Something to take in account if you use of mammary incisions, this paper very recent February this year paper shows that the size of the breast is important and ischemic complications using inframammary incisions definitely. If the distance from mid-clavicular to inframammary fold is greater than 30 centimeters, the risk of having ischemic complications is four times greater than if that measurement is lower. So size is a very important decision maker in type of incisions. If we have to decide what kind of in reconstruction, most of papers now show that statistically direct to implant reconstruction is evolving and is taking more incidence compared to the two stage. The autologous kind of reconstruction depends definitely about institution, but direct to implant it's coming to be even more popular. So with all this, I want to share our experience in more than 10 years with this procedure. We started like in this 61 year old patients with a right breast carcinoma using the initially lateral incisions that we thought that will allow us to reach to the axilla in the case of sentinel lymph node biopsies and that was the case. Reconstructing the prophylactic mastectomy in the contralateral side in a mirror way using the same kind of incision, same type of mastectomy and reconstruction. This incision gave us a very comfortable approach to for the mastectomy and we get into the axillary pit to the sentinel lymph node with any problem. We started reconstructing with retro-pactoral implants using anatomical textured implants. Next step, same kind of patient with a left breast cancer in a 61 year old. We kept using the same kind of lateral incision, doing the same on the contralateral side, but our first change was in the surface kind of implant and from textured implants we we changed, we switched to polyurethane implants. Considering that the surface of polyurethane implant allows much safer result in the terms of the polyurethane. It's a kind of surface that when you put the implant it sticks into the place where you put it, defines exactly and properly the inframarrow fold, has less less incidences of seroma, rippling. So we switch into a kind of surface that we started getting much more comfortable and constant good results. From there trying to use and innovate in different type of incisions in this 53 year old BRCA negative patient, but with a strong family history, more to narrow breast, dense breast and especially extremely anxious patient. We decided with a patient to perform a bilateral risk reduction mastectomy and to try to improve a little bit the position of the nipple so we used a superior periareolar incision and as published the increased rate of complication exactly happens. This was the case. We had a problem in healing with that with both nipple area. It was worse on the right side. We are not using that kind of incision anymore even if in this patient everything finished without any problems. Again using anatomical polyurethane implants, but we are not using that kind of incision anymore. We learned with experience. Our next step was still using the lateral incision on the right breast on the oncologic side. We started using for cosmetic reason trying to improve the posthumous of the incision result the inframammary fold. This was some years ago. We started with this and at the same time we started switching from pre-pectoral to from retro-pectoral to pre-pectoral implants. Still using and we're still using this kind of anatomical polyurethane implants that even in the pre-pectoral surface we know that has less capsular contraction rates. We know that the polyurethane implant is a kind of implant that is used worldwide. It's not used in in the States, but I think that this kind of presentation showing our experience that using this type of implants will probably open eyes and and let you know that we are using a kind of implant that we feel definitely a superior implant in the sense of surface and results. From there on we our next evolution was to switch in the incision position. We stopped using the lateral incision having very good results with submammary fold incisions. We start doing the oncological reconstruction and oncological breast mastectomy and risk reducing both of them with bilateral inframammary incisions. We do our own mastectomies that gives us a relief with experience. You know exactly the thickness of the of the flap skin flap that you're leaving. We start separating the gland from the from the muscle that will that will allow us in the subdermal resection to have a less bloodless field. We do the subcutaneous resection with scissors trying to avoid the heating and complications that can arrive in the in the skin flap with the heating of the bovie. So all our separation from dermal implant from dermal to gland is with scissors and using inframammary incision we use a separate lateral incision when whenever we need to do sentinel lymph node biopsy. That was the marking before and this is results from the submammary using pre-pectoral polyurethane implants. We always use drug suction drain Jackson Pratt and this is an immediate result in both oncological and prophylactic mastectomy contralateral. We don't use ADM or meshes in both senses stitching it to the to the to the pectoral muscle and the inframammary fold. We don't use that ravioli technique of involving a smooth implant. We think that using the kind of implants that we're using there's no need. We will replace absolutely the need of an ADM. We know the pros of the ADM what is published less mechanical shift, less capsular contracture, less rippling but it's expensive. Definitely, there are no long-term data on its outcomes at yet. There are many publications on probably increasing complications, especially in seroma. And we think that using polyurethane implants replaces all ADM benefits in a cheaper reconstruction. We have less mechanical shift. The polyurethane implant sticks to the position and it doesn't move, rotates. You don't have to be so careful with the pocket. It has definitely less capsular contractures even in the perpetual plane, less rippling, less seroma. In conclusion risk reduction mastectomy requires a fully informed discussion of benefits and risks. Each case requires its own technique selection. Nipple sparing mastectomy is an oncological safe procedure and has proved to have the best aesthetic results. And regarding reconstruction, submammary and radial incisions have the lower complication rates. We just test their use and deciding also depending on the size and shapes of the breast. The incision selection depends on the breast size and ptosis. There is a steady increase in direct to implant reconstruction. There is a steady increase in pre-pectoral reconstruction. Definitely, it gives you no animation distortion. That's a complication in the retro-pectoral. And polyurethane implants have all ADM benefits and definitely with a cheaper reconstruction. Thank you very much for that. Thank you, Martin. Thank you for showing your experience and let's go to Claudio's presentation and then we will have time to make some questions and answers. So Claudio, please, can you share your screen? No, I can't. I don't know why. Okay, in the meanwhile, while Claudio tries to... Why do you think... Ah, here it is. Okay. Let's go to Claudio's presentation over... Give me a second. Give me a second. Yes. Laterally designed anterior intercostal artery perforator flap for breast volume restoration or reconstruction after implant explantation. Well, it's a long title. Thank you for the invitation. I think I've been doing this kind of sub-mammary flap or thoracodorsal, the name you wish, to reconstruct the nipple areola after skin sprain mastectomy. Kind of like this and then you can replace the resurfaced area that you resected with the surgery. You have then the envelope and you put up an implant and you have the immediate reconstruction. During all this years, after more than 20 years, we have always observed that at the base of the flap there is a vascular pedicle always present, which is the anterior branch of the fifth intercostal, anterior intercostal vessels. That artery has been originally described by Karl Manshutt in his fantastic paper, book about arteries of the body and it recently has been extensively studied in cadavers by Occhi and presented by Perisketi this year. And you have here the cadaver dissections that we have done in more than 20, 25 specimens. The fifth anterior intercostal, the sixth anterior always present, consistent finding. The fifth anterior can be accompanied by two small, it's side, they are connected one to each other. And here again, and then you can raise a flap based on this pedicle. Mustafa Hamdi was the first ones to raise an anterior intercostal flap. And recently, Shavarian presented this type of flap for volume reconstruction. We were unaware of this presentation when we started with our experience. Breast implant explantation is frequently, or each day more frequently, indicated and requested due to the problems that we really have seen with the previous presentators about the complications that they have. In this case of explantation, volume preservation is decimal, no doubt. And local tissue is the best option. Usually, another implant is rejected, and local tissue reaccommodation may give you some kind of volume. We have treated, from 2012 until now, 27 patients with this method. The idea is to use this fifth anterior intercostal perforator which is in the middle of the breast in the submammary sulcus, and to raise the epithelialized flap from the lateral side of the thoracic cage. The red arrow will show you approximately where the anterior perforator is placed. The yellow arrow where the lateral perforator, one space below and the sixth space. Then if you use flaps with the lateral, with the licap, you are losing this 10 centimeters of valuable tissue. And when you harvest the flap, you have to go invade the back. And the blue arrow is placed approximately where the thoracodorsal perforator is placed, quite far from the breast, so the final scar will be much larger. So to make it simpler, the licap will be in the lateral side, and here it would be in the fifth intercostal space, our perforator. Mainly, what do we do? Well, we just, in these cases, we do, we mark for mastopexy, we remove the implants, we remove the capsule. And usually with a 20 by eight centimeter flap that you can always do, with a two centimeters thick, you are having a 320 cc average volume in a quite mute donor area. This is one side without the implants, and with the epithelialized flap volume, and the other side still with the implants, and for comparison of volume. This is a patient, 57 year old, with recidivine capsular contracture, three times pre-pectoral, sub-pectoral, blah, blah, blah. And she now has 255 cc implants, she requests removal of the implant and volume preservation. Quite difficult with the only local tissue, so we propose that this flap, we remove the implant here, the pecs is already almost done. The flap is the epithelialized, it will be nourished by the vessel, which is here, and then flipped over to the breast, pre-op, three months post-op, four years post-op, no lipotransference, no lipofilling, only the flap, the donor area, four years post-op, pre-op, four years post-op. This is another case of a patient who has several implant changes, and now she has a 215 cc implants. She requires, because of mastodonia, problems, pain, to remove the implants. Here is the flap design, just the tip of the flap on the posterior axillary line, we know that this tissue in this area will survive without any problem. We don't use ICG, usually, but you can use it, but clinically you can prove it. The flap, the epithelialized, two months post-op, two months post-op. Now, this is a patient with the recurrent seroma, and she declares to have a 350 cc implants, and this comes and goes, has a lot of pain. She wants to solve this problem, not to have any more implants, obviously, we suggested the same thing, and to remain with an approximate volume as she has, and she refuses any vertical scar. She doesn't want any mastopexy. She loves her breast like it is, but this breast has a 350 cc implant. So we remove the implant, and this is the flap that we designed. If it is six by 25, this would be 180, and two and a half centimeters thick, that will give you a 360 cc flap, and pre-op, post-op, two months post-op, no implant in any of the breast, no lipofilling, and that's what you see from the back. The scar does not invade the back. It just reaches there. We presented this initial series in the American Association meeting in 2019 with 15 cases. Now we have 30 cases. It's a very reliable flap and very satisfactory result. Patients are very happy. Thank you very much. I think questions or whatever. Thank you, Claudio. Yes, I have some questions. Just for case where you have an inframammary fold incision for the implant placement, do you think that the sixth perforator is enough to tailor this kind of flap? Because if you have an inframammary fold, perhaps you have destroyed the fifth eye cap. In both possibilities, in both cases, it's a better situation. If they've done a sub-mammary and they destroy the fifth, the sixth will have a kind of physiological delay, and it will be a very good pedicle. And if they didn't destroy the fifth perforator, it will be enlarged by the capsule because the capsule requires a lot of blood. So it's a much better situation if you have the capsule and an implant previously than if you do, let's say, the flap or version case. So in both cases, now you can check it preoperatively with a Doppler, or even if you want, with now, as well, you know, because you do it with me, with a selected angio, microangiotop. But it's not necessary with a good Doppler. Why I say it's not necessary? Because obviously, they must be there anatomically. It's consistent finding. If the fifth is destroyed, the sixth would be enlarged by the delay procedure of nature. Okay, and do you arrive just to the anterior axillary line? Which is your limit to tailor this flap? Well, in our experience is that the tissue survives perfectly well up to the anterior axillary line. Obviously, there are cases that you can go further, but if you want to be sure, you have to do a pinch test to measure the volume that you're going to be able to harvest and stop at the anterior axillary line. In that situation, all the cases survive perfectly well. When we went beyond that, with skin or with deep patellar lives, in some cases, we had suffering. So that the safe method would be stop at the anterior axillary line. Anterior or posterior? Anterior. Anterior. That's for an aesthetic detail also, not to be saying- If you go posterior, you might finish posterior with a scar, but the valuable tissue has to be calculated up to the anterior axillary line. So when you close, that chip, you must, or discard or whatever, and you end up at the posterior axillary line with your scar, with your final scar. And that's why you don't, you hardly see the scar from the back. And that's, I think, is the main advantage of this flap compared with LICAP. If you do LICAP, which is a very reliable flap, you always end up with a huge scar on the back and patients, they don't accept. And have you tried with fat grafting over this flap? Well, we are presenting this flap without lipofilling. With lipofilling, you get whatever you want because you have this trauma, this kind of, well, living tissue that you can lipofill without any problem immediately intraoperatively or later on. And then you have a fantastic thing to lipofill. But I wanted to present only the flap alone to see what you can get with the flaps. But just to illustrate this possibility, do you preserve the capsule over the pocket just to hold the fat grafting? Or do you always make a capsulelectomy when you make the explantation? No, it's a good question. I only do capsulelectomy when they had problems like this seroma patient, or when the capsule is really hard and yes, it's calcified and all that stuff. If the capsule is something, let's say normal, I leave it and you can lipofill between the capsule and the skin without any problem. If not, if you remove capsule or you make a lipofilling more carefully in the flap and the wall, the remaining wall, or you wait and you do it in a secondary procedure. Have you used it? I don't have such a large experience in that. A few cases, I don't have so many cases just to say a statistical analysis of what happened in each case with the fat graft. Claudio, have you used that as a primary option for reconstruction? And what I showed about nipple spermatoctomies with submammary incisions, will you consider that as an option instead of using implants? Sounds like a good option. No, wait, the first series of cases I showed to show the flap and the pedicle on the base, they were done like 20 years ago for replacement of the nipple areola complex. But when you do it as a direct flap, like a direct submammary flap, you end up with two scars. And then was criticized, blah, blah, blah. But nowadays, you can do this island flap, the epithelial lies in the base, and you can replace the nipple areola complex. And we had presented that, and maybe this kid is publishing it. But the nipple is very mastectomy, but- The nipple is very mastectomy. It means for volume reposition. Only. Only if you have, no doubt, is the best. For me, it's fantastic. Because if you have the volume in the lateral side, for me, for example, if I do it myself, I will have a fantastic boobs. But usually, moderate BMI patients, they're not extremely elevated, but normal, a little over normal. They do have, I show you the second case, the third case was a normal, average 60-year-old patient with fat there. But you do a pinch test. You hold it like this, and you calculate, you say, how much I have here? Very easy to calculate. And then you say, I can move here 350 cc's. So, there you balance, how much I'm gonna reset. And if you have it there, I think it's a fantastic autologous reconstruction because you can lipotransfer later, and you avoid the implant. I don't want to be against the industry, please, but without implant, always is better. Thank you. Even polyurethane, which is good. Martin, regarding your presentation in risk-reducing mastectomy, and I like your message that we must be aware of these cases because more and more, we are having more risk-reducing younger patients, bilateral, and as you told, there are patients that request a really an aesthetic result. So, when you are in front of one of these patients, and you calculate the volume of the implant you are replacing, do you suggest, do you treat these patients like a patient that wants to have a nice outcome in the result, and you hear the needs of augmentation? Do you respect the volume that you reset to replace it with the implant? How do you manage this balance? Well, that's definitely a conversation with a patient, but my suggestion also always is try to replace equal volume for equal volume. Mentioning that, if you start increasing size of volume and you put more tension on skin, you probably can end with a higher complication rates. So, what I mentioned to them is, we are probably be thankful that we are gonna conserve your skin, your nipple, we are gonna hide your incision, and we are gonna preserve your volume as it is, or slightly bigger, not more than that, but don't consider that this is gonna be an augmentation. And usually, the way I calculate the size is, I, with experience, you approximately know what's gonna be the volume. I have different size of volumes in operating room. We do the mastectomy, we weight it, and with the weight of the mastectomy, we try to do a similar weight and volume with the implant. But what I recommend is same volume, or at least slightly bigger, not more than that. I am your patient, and I say, no, Martin, this is my opportunity. I will not go again to the operating room, and I want a bigger volume. Do you go to two stages? Do you place an expander? If the patient wants a two-stage operation, because that's something that she would like, I would consider it, yes. But usually, my experience is that patients, they want to end this with a one-stage operation. And definitely, I tell you, I have no patient that I have done a two-stage operation having the possibility of having a one-stage operation. If you preserve skin and everything, it will preserve the whole envelope. Do you always have an expander as a backup in this kind of surgery, just in case something goes wrong with technique, or you have an ischemia or something? Always, always, because definitely, I think we do our own mastectomies procedures. But, and we don't use all the, we don't have all the spy technology and everything to see the ischemic condition of the skin. And we mainly work with our experience in the thickness of, but if there is, if you go very, very shallow, if you go into a very thin skin flap, we have an expander and we put a deflated expander trying to see what's the evolution of the skin. And that has been the case in, especially at the beginning, several cases. Do you make your infiltration with clean solution prior to use your scissors, or you go just as you showed, making the mastectomy first, cutting the perforators over the pectoralis muscle? We do infiltration, yes. We do infiltration only of the subdermal plane. We don't go deep into the plane in between muscle and gland. Yeah, we do infiltration for that. And the use of meshes, not ADMs, but synthetic meshes, do you combine something? Never, I have never used them. Okay, what do you think that just, if you don't make the mastectomy and you have a large pocket and it has run above the limits, how do you think? We tailor the pocket. I think that you have to tailor the pocket. But the mastologist makes the mastectomy and asks you, please make the reconstruction. And you have a violation of the inframammary fold, the lateral dissection of the latissimus. We tend to reconstruct the pocket. Without any mesh. Without any mesh, stitches, close it, tailor it and try it. And I think that that's important, especially if you're using implants that has the possibility of moving or rotating. Obviously with smooth implants, definitely you have to have a very tight and tailored pocket. With polyurethane implants, that gives you a little more possibilities of not having such a perfect pocket. But the pocket position is very important. Okay, thank you very much. Well, I think we are running out of time. So I would like to thank you both of you for this good information we have today. And I thank the ASPS for this opportunity to be present here in this webinar series. And Laura, please, you can take care of the screen.

implant-based breast reconstruction

popcorn capsuloraphy

acellular dermal matrix

capsular contracture

nipple-sparing mastectomy

direct-to-implant reconstruction

polyurethane implants

intercostal artery perforator flap

autologous tissue reconstruction

breast reconstruction techniques