minutes to let everybody get in the webinar and we will begin soon. Just a minute and we will be beginning. I'll see you after. Okay, good afternoon everybody. I am Dr. Gladys Chow-Li, Vice President of the Venezuela Society of Plastic Reconstructive Aesthetic and Maxillofacial Surgery, and I will be moderating today's session. We are very pleased to present as global partner of the American Society of Plastic Surgeons this first webinar about breast surgery refinement, different approach and fields. I want to remind everybody that we will have all the questions at the end of the session. Please write them in the chat box of the Q&A and we'll make them all at the end of both presentations. Today we will have two speakers with solid experience both in reconstructive and aesthetic surgery of the breast. First we will have Dr. Rafael Casanova Duarte, who will talk about obtaining aesthetic result in reconstructive breast surgery, and then we will have Dr. Linda Rincon, past president of our society, who will present things to highlight combining mastopexy with implants. Now I will let you with Dr. Edgar Martinez, our current president, for the introduction. Thank you. Dear American Society of Plastic Surgeons, President Mrs. Lynn Jeffers, the Venezuelan Society of Aesthetic, Reconstructive, Maxillofacial and Plastic Surgery, as member of ASPS global partner since September of 2019, committed to maintain a high level of principles in surgical practice, professional ethics, transparency and autonomy of the parties. Today has taken from the hand of the ASPS a very important step in the history of our society, after 63 years of its foundation. However, always pray to the ASPS. This association is a product of the contact of both societies for more than three years, achieving the beginning of the relationship that will be beneficial for both medical societies, not only academically, but in the human and the cultural aspect, which will allow us to get to know each other widely. We are beginning our participation in the webinar series sponsored by the ASPS, with prominent professionals from our nation in a subject of daily management in our specialty, such as breast surgery, where particular views of both aesthetic and reconstructive aspects will be exposed, with personal variables that will be very useful in our practice. Without further ado, Dr. Rafael Casanova is going to take the word. Thank you very much for your attention. Thank you very much to the American Society of Plastic Surgeons for this opportunity to share our experience of breast reconstructive surgery in Venezuela. Every day, we observe in our clinic that our patients undergoing breast reconstructive plastic surgery expect good results in terms of aesthetic or cognitive parameters. Although this topic is a very wide field, we will present some cases and we will touch some aspects in breast asymmetry, and then into the oncological area, including oncoplastic breast, constipation, including oncoplastic breast, conserving surgery, and nipple and skin-sparing mastectomies, and finally, reconstruction after radical modified mastectomy using musculopectaneous flaps. It's very important, carefully, communications between the plastic surgeon, surgical oncologist, and radiation oncologist with regards to the surgical plan is crucial to optimize patient outcomes. We will start the presentation with the hypoplastic breast anomalies that still remain a reconstructive challenge. In this first patient, is a 16-year-old patient with breast asymmetry, and we practice lipofilling on her right breast using a FAP obtained of the abdominal region, and previously centrifugated for 3 minutes, 3,000 RPM, and immediately injected using a 1.2-millimeter cannula. According to the technique of Professor Sidney Coleman, total FAP injected were 224 cc in the quadrants described by the same column. In addition, a multiple rigoromys were done in the lower quadrant by insertion of the 18-gauge needle in order to increase the distance between the areola border and the summary crease. In the same surgical time, we practiced a left breast reduction of 150 grams using a inferioretical technique. In this photograph, we can observe the immediate postoperative use two weeks, and in the next photo, it's possible to see the result five years after the surgery. We can observe an acceptable symmetry and shape and need some improvement in her left areola. Note the small multiple point scar due to the rigoromy in the lower part of the breast. The next patient is an 18-year-old woman with a tuberous right breast deformity presenting a unilateral hyperplasia and left breast ptosis as well. In this patient, 250 cc of FAP, previously centrifugated, was injected, and using the same 1.2-point cannula in all quadrants, and in the lower quadrant was done a rigotomy. An additional vertical mastopexy was practiced in the left breast. In this photograph, the improvement in size, shape, and symmetry and appearance of the breast after five years of the surgery, but she needs actually reduced the diameter of her left areola, and concerning the rigotomy, she had a good healing of the lower quadrant. Into the oncological field, we have the oncoplastic breast conserving surgery, and in this patient is a 41-year-old woman with stage 1 ductal carcinoma located in the upper inner quadrant of the right breast with small hypertrophy and a preoperative localization of tumor 1cc using a wire ultrasound guide was practiced. A partial mastectomy, including the upper inner quadrant, was resected on her right breast using an areolar approach. After the quadrantectomy, immediate mammography confirmation of the tumor receptor was done. After the surgery, the gap between the borders of the residual quadrant was sutured in order to close the gap and give a new cone shape of the breast, and finally, the areola was sutured without tension, and leaving a drain and a simple dressing with a micropore. Symmetry was not necessary, and this photograph we can observe a good result in size and symmetry and appearance six months after surgery. She needs radiotherapy in her post-op. In this next patient is a 48-year-old with stage 2 ductal carcinoma of the lower outer quadrant on her left breast. In addition, she had a bilateral hypertrophy and ptosis. By the way, a periodic approach was practiced, including a small amount of skin. We proceed to perform a lower external quadrantectomy after the sentinel node story was negative. After the recession, we closed the gap between the residual quadrant borders, leaving a metal mark into the tumor beds. In order to close the areola was placed a continuous non-absorbent suture using the Professor Hammond technique, and overhand, finally, symmetrization using the same technique was completed. A blank drain was placed and leaving a compressive simple dressing using a micropore. She received a radiotherapy and chemotherapy in her post-op. In this photograph, the patient three weeks after the surgery. The next photograph is the patient five years after surgery, and we can observe good results in terms of size, symmetry, and appearance. The next patient is a 33-year-old woman with stage 3A ductal carcinoma located in the upper quadrant on her left breast. We practiced a partial mastectomy, including the upper or quadrant and its overlying skin, and axillary dissection as well. The symmetrization was completed using a periareolar approach in combination with a mirror quadrantectomy. In this photograph, four weeks after surgery, and in this photograph, the patient 10 years after surgery. The next patient was a 22-year-old woman with stage 1 ductal carcinoma in the lower pole of her right breast, hour 6, 3 centimeters over the areola border. In this case, we practiced a radical modified mastectomy using a breast reduction-wise pattern and the T-inverted scar. A contralateral breast was reduced using the upper pedicle technique, and also she received a radiotherapy and chemotherapy post-op, and the nipple areola complex was reconstructed six months after surgery using, for the nipple, the modified double-opposite tap technique described by Dr. Kroll in 1997, and a simple tattoo for the areola one month later. The next patient is a 40-year-old woman with a incisor carcinoma in the upper or a quadrant of her left breast, and a small focus of atypic ductal hyperplasia in the upper or a quadrant of her right breast. For this pathological findings, a bilateral nipple spurring total mastectomy was practiced through a summary approach, and immediately reconstruction were performed of both breasts by using a sub-memory tensile flap described by Professor Heinz Bummert in Germany, attached to the pectoralis major muscle, previously elevated. Finally, it's placed on an anatomical implant of 260 cc. This is the photograph of the second day of the surgery, after surgery, one week after surgery, and one year after surgery. The next patient is a 40-year-old that was submitted a lower quadrantectomy for stage one and breast implant. She received radiotherapy, and after that presented obstruction by infection. For this reason, we decided to do a reconstruction of the defect using a latissimodorsi musculocutaneous flap in combination with an anatomical implant, 240 cc. Six months after the procedure, she presented some retraction of the upper and lower pole, and was in this area, and was necessary to perform lipophilin and rigotomies, and small skin resection in this area in the back. And this photograph is the patient with the area of the rigotomies, and in this photograph is the patient five years after the last surgery procedure. The next patient is a 46-year-old woman with stage two ductal carcinoma located in the retroarterial region on her right breast. And a steward incision was used in the radical modified mastectomy, a latissimodorsi musculocutaneous flap in combination with a 260 cc anatomic implant for the immediate reconstruction was used. Note the shape and the place of the steward incision, and the place of skin island in the subscapular region, in order that the final scar will be placed inconspicuous into the bra. The nipple areola complex was done three months later of the surgery, and the patient only received antistrogenic treatment. Note the scar into the bra. The next photograph is a patient 32 years old with stage two retroareolar ductal carcinoma and was practicing skin spurting radical mastectomy on her right breast. And simultaneously were elevated latissimodorsi musculocutaneous flap and placed a 430 baker, 35 spander in order to do a complete reconstruction of the breast. A nipple areola complex was reconstructed three months after surgery, and she received also chemotherapy post-op. In this photo we can see the nipple reconstructed using the crawl technique and the tattoo areola. And this is the patient before the surgery, and this is the final result here three years after the procedure. Next patient was a 39 years old woman with bilateral breast ductal carcinoma, T1NOMO. Localization of both tumors were retroareolar region, and by the way, simultaneously were performing a bilateral skin spurting total mastectomies and bilateral latissimodorsi musculocutaneous flap for reconstruction in combination with a 250 cc anatomic implant in both breasts. The sentinel nodes were negative. After this is the patient two months after the surgery, and three months after surgery were reconstructed both nipples using the crawl technique and simple tattoo for both areolas. I would like to do myself the tattoo. And this is the patient 10 years after the procedure. The next patient was a 49 years old woman with a stage 2 ductal carcinoma in retroareolar position on her left breast and was practicing a radical modified skin spurting mastectomy and simultaneously was done the breast reconstruction using a pedicle trans flap. She received radiotherapy and also chemotherapy post-op, and the nipple areolar reconstruction was practiced three months later after mastectomy. We can see the patient 10 years after the surgery was not necessary to do this symmetrization. And finally the last patient that I will present was a 51 years old woman that I received in my clinic with a radical left mastectomy and immediately reconstruction with a pedicle trans flap operated by another team. And she desired an improvement of her breast and the abdominal region as well. And we do a reconstruction of the nipple in the first time. And we place a breast implant of 430 cc in both breasts. Six months later, she returned to our office with the skin retraction just over the areola area and a displacement of the the implant in the upper pole of the breast. And for that reason, we decided to do a a rigotomy and lipoinjection of this area and then replace or change the the implant for a 330 cc with a new pocket on her left breast. This is the the patient the first time after the first procedure, after the second procedure. And now this is the patient five years after the last procedure. Well, a multidisciplinary approach to the management of breast patients definitely improves care and outcomes from oncological diseases to all aspects of reconstruction, cosmetic breast surgery, and breast reduction. And a plastic surgeon needs to be involved in their local breast cancer team as members of those teams they need to bring into focus the cosmetic purpose team as part of the decision making. Thank you very much. Can you share? No, I need it. It says that I cannot share the screen. Okay, we will see what happens. Maybe I go out and then come again? Yeah, I think you can go out and then we share the screen. Okay. Have you seen my screen? Yeah, we can see the screen now. Okay, let me see if it goes, because it's taking a few minutes. I don't know why. Okay, I think here it comes. Do you have it in full screen? Yes, it's perfect, Linda. Okay, things to highlight combining implants and mastopexy. These are the different societies which I belong. This is an intellectual property. The concepts emitted in the next presentation are part of a personal technique that is in the process of publication. It is appreciated not to take photographs or make use of concepts without prior authorization of the author. Thanks in advance to the American Society of Plastic Surgeons. As the international member, I'd be very, very happy to share with you this knowledge. And thank you because you have been doing a good job with the global international societies associations. Breast is a very complex issue. Breast is a three-dimensional geometric even structure in the chest that we need to make a proportion symmetric when we are going to surgery. So we need to handle all the problems we have to face in each surgery. When we have a breast in our consult, we need to determine the tissue. If it has little tissue, we can go with the breast augmentation and a lot of techniques we also everybody know. If we go into the breast that has a lot of tissue, a breast reconstruction will be work well. But in the middle, if we have a moderate tissue breast, we need to decide which is the quality and consistency of that tissue. If this has a good quality, we go with a pure mastopexy. But if it is a bad quality or a poor consistency tissue, certainly we need to add implants and mastopexy. So this is where we're going to talk this next minutes. So we are doing a little bit difficult because we decide to use mastopexy with implants but in one stage. Why? Because one stage is one recovery. One stage means less budget and less cost. Malushi and Branford made a good study where they determined the population in UK and they decide in that study that most of the women in that UK population want the 45-55 proportion between the upper poor and the inferior poor. But here in Venezuela and most in South America, people, women wants to have 50-50 relation between the upper poor and the inferior poor. So we want to achieve doing the mastopexy with implants, upper poor projection, but it is important to make a right proportions and form. And the most important thing, trying to stay with the long-term results and stability. One stage has trouble. That is the main thing, but we have to deal with the trouble. And we need to think some thoughts that we have to make in practice and put in practice to avoid double bubble, septotosis, bottom-out and asymmetry. The main problem will be the double bubble or the waterfall deformity. Here we have the first pool. We're going to ask you how many of you do the mastopexy with implants in one stage or if you prefer to do two-stage mastopexy. You have 12 seconds to answer. What do you prefer? One-stage mastopexy with implants or two-stage mastopexy? One stage. Okay. Keep going. Keep going. So here we want you to invite you to reset some things or thoughts because mastopexy with implants is not as easy as we think. So here we want to think in some of our principles or thoughts that we want to reset. The first of one will be the new position of the nipple area complex. The way we learned, we think that it was a subjective, unprecise maneuvers. We prefer to make this to find the new nipple area position. We have to find a vertical axis and a recentral axis where we are going to put the nipple area complex. And how we do that? We mark a medial sternal line. We mark an anterior axillary line. And the distance between both, we're going to go with the vertical axis, which will be our meridian. And the recentral axis is into the inferior border of the patient's fourth rib. There will be our new position of nipple area complex. We use a level if we have some asymmetry or skeletal anatomical asymmetry. We have the second pool here. How do you find your nipple area position? Measuring 18-22 centimeters from sternal notch, projecting the inframammary fold, or taking into account the inferior margin of the fourth rib. measurement from the center notch projecting inframammary fold or inferior margin of force read. Measurement 18 and 22. We think this maneuver is imprecise and very dependent operator and we prefer to stabilize our measurements doing the proportional anthropometric skeletal points. Okay, next. Another thing, another thought we have to reset is how we make the marking. We have to consider these three factors, the grade of doses, the inferior pull, laxity, and the vascular pattern. The grade of doses is the distance between the actual nipple areola position and the ideal new nipple areola position will be in the inferior border of our, of the patient for a brief. The grade of doses with the comparing in each patient is a different, they have different inferior pull laxity. It's not the same when we have few tissue in the inferior pull or a lot of tissue in the inferior pull and that depends the size of the pattern that we're going to put on. And the last factor and very important is the use of the 3D mammogram to determine the vascular pattern, especially in those patients who have multiple surgeries. So if we have a breast and we're going to make the marking and we are just decide which is the pedicle we're going to use. If we already know if you're going to go with the superior pedicle or a bipedicle or an inferior pedicle, that depends the way that we are going to mark. But if we have just laxity in the central part of the breast, we are going to with the syncorareolar scar. If we have a very few tissue in the inferior pull, we go with a circumverticle. If we have a little more tissue in the inferior pull, we have to compensate a little scar in the recentral. And if we have facing a lower pull laxity, a big lower pull laxity, certainly we need to make a big wide T inverted pattern. Here you have a video where I can show you that we have a lot of ways to make the marking, but we have to be very, very precise in doing the less scar we could. Because it is important to the woman not have any scar, especially at the recent segment. These concepts that I am talking today are already published in the Hebrew-Latin American journal, and it is coming soon, our systematizing mastopexy with implants. Another thought we have to reset is how to choose the implant. Implant has to be into the chest has to be into the chest in a specific position between the second rib and the sixth rib, internally to the medial external line and anteriorly, now in inner, the anterior axillary line. We need to find the good implant who make the base and proportion ideal for each patient. So we need to work with a lot of implants to achieve our best results. Implant size is not related with amount of pre-existent breast tissue. That is a way we don't take into account the pinch test, because we decide that the tissue that the patient has is not well quality and is not necessary to keep it. So we're going to take it out. Implant size must be the same and the symmetry will be obtained from the flap symmetry. That is the important thing we are trying to let you know from this speech. Don't leave unnecessary weight. Tailor the flaps. Don't leave unnecessary weight. Choose right implant volume. Combine these thoughts and you will get better results. None of the mastopexy techniques prevent secondary ptosis. So it is useful to make a mastopexy with the tissue and then add some implants. It's better to tailor the flap and take it out of the tissue. Remove the tissue and tailor the flaps two or three centimeters, not taking into account the pinch test. Another thought we have to reset is the implant position. We prefer the submuscular plane, but we make some changes in the submuscular plane. The first of it will be that we achieve the muscle toward the fourth rib and we kept the window muscle open to avoid the restoration of the mechanical function of the muscle. And the second important thing is to find the fascicles, the costal fascicles of the muscle of the pectoralis muscle, because they are independent and they are shorter and they probably are the responsible that the implant goes downwards and laterally. And those are very, very independent fascicles. We have to try in the submuscular space to avoid the animation deformity. Here we have a small video where we are cutting the costal fascicles who attach into the fourth rib. Another thing, another thought we have to reset is about the inframammary fold fixation. Every time we transgrease the fold, we need to readapt, we need to reattach. And that is the way that we fix it with non-absorbable free hormone-aligned suture to the sixth rib. If we have some loose skin between the inferior pole and upper part of the abdomen, we need to take it out and tailor that zone, okay, to make a good shape in that place. Here we have another pool. How do you make your inframammary fold fixation? Do you make it always, sometimes, or never? How often do you use inframammary fold fixation? Always, sometimes, or never? It is important to tell you that it is the way that we are doing our surgery, okay, sometimes. All right, let's go. Okay, inframammary fraud recreation is a part of our skill surgery. If we have a flaminid fold, we need to reshape it. And if we need to put some fat into it, we need to do it and we have to do it. Some of the patients who have a short vertical also has this problem here with a flaminid medial part of the fold, and we need to put some fat. In other cases, we need to go with the liposuction to take out some tissue and to reshape that part of the breast. Another important thought to reset is the closure, how you make the closure. We have to keep in mind that we have a vertical mass that will be our mass like a ship. With the structure, if we could put the vertical in the right position, we have the breast in the right position. So we begin to close our breast from downwards to upwards, not from the top to the bottom. That is why we decide to do that because we stabilize our vertical axis. The scar must not sacrifice shape, neither the insufficient nor so big that will be useless. We can't do T-inverted with that shape or period roller with that shape. We have to do the right scar to make a good shape. So taking into account that the goal will be keeping together the maximum projection point of the breast and the maximum projection point of the implant together. That will be our main goal. Look here, a mammogram where the surgeon kept some additional tissue and appeared a double bubble or the water fall deformity. And this is a mammogram where the patient was treated in all the concepts we are talking today and they are aligned, the maximum projection points are aligned. Those are my accomplices in crime, my equipment team and plastic surgeons and my anesthesiologist. Here we have some video that we're going to edit for you, not to take a lot of time. And the way we do the marking, finding the axis, the horizontal axis and the vertical axis where we're going to go with the new position of the knee perviola complex. Establishing the distance, transposing to the upper pole and putting in place the new position of the areola complex. Then we make the pre-marking of the quantity of tissue we think we are going to take out, but just a pre-marking, but we're going to be sure during the surgery what kind of resection we're going to make. We're going to go into the surgery, infiltration is still and still and mark the areola with a cookie cut. And then we go to inside the breast through a vertical incision, avoiding and respecting two centimeters from the dermal of the superior zone. We dissect all the glandular space and then we go to the subpectral space and make the pocket will be a submuscular modify. We reach the fascicles and cut them. They are cutted already. And when we cut them, we can go easily to the superior inter quadrant. Then we make a running suture with the observable suture. We call that the marsupialization to avoid damage to the muscle when we are introducing the implant. Here, we already put the implant inside and let the window muscle open. Then we are going to stabilize our mast will be the vertical axis, take the tissue and tailor the flaps and let the flaps two or three centimeters depth. After that, we are going to readapt the demoglandular flaps to the muscle with observable suture, just to keep one structure together. I mean, the demoglandular flap with the implant inside the pocket. Here, we are doing four different stitches in all the four quadrants, inner and outer, inferior and superior. And here we are putting our first stitch that will be our stabilization of the mast. Then we mark the quantity of tissue we're going to take out of the skin. We're going to take out from the peripheral or zone. And we do three different round block sutures, one with the bicryl, 3O bicryl, then proline, 3O proline, and the last one will be the Goretex, 3O Goretex. And then when we have done the three different round block, we keep going closer in the vertical segment. And if we need to compensate a little tissue, a little skin in the recental place, we go with a mini T or depends on each case. Okay, here we have some cases. 430 cc superior pedicle, periareolar incision, another periareolar with 380 cc. Another one in the secondary surgery. This is another patient who have a displacement of the implant, and he has been lost any of the missions of the anatomical position of the implant. We rebuild all of that, fixate the inframammary fold, and keep those missions in place. Here we have a circumvertical pattern with a superior pedicle in a patient after massive weight loss. A circumvertical pattern in other patients with a primary surgery. Another with a circumvertical in a primary surgery. Depends on the laxity of the infratal pole, some of the patients will need the vertical scar, and we have to talk with them. Another one with a secondary surgery. We achieve good shape and symmetry. Some cases with very bad asymmetry, and at the follow-up, we have some difference between one and another, but we prefer to use same implants and tailor the flaps. Maybe we needed more tissue resection in this patient. Another, this is a snoopy breast, circumvertical, superior pedicle, circumvertical in a primary surgery. And this is the patient from the video. It was the patient who we tried to avoid the scar in the recent place, and we couldn't do it. And we have this circumvertical post-op result. 40-30, 430 cc. Another patient with asymmetry and good results, good form and symmetry. Another one with a secondary surgery. And this is a superior medical pedicle. We began with a plan with a superior pedicle, but we decided to convert in the superior medical pedicle to get a better rotation of the knee pergola complex. This is after weight-load patients. This is a difficult case because it has a very complicated shape, and we solved that problem with that pedicle, modified pedicle. And he's post-op, four months post-op. There's another patient here who probably we think from the beginning that we are going to have a big inverted T, and we go with the mini inverted T, with that modified superior pedicle. Here is a video where we can show you the pedicle. We go to the medial pedicle and the vascular pattern of the intercostal and from the mammary. This patient has the vascular pattern confirmed that they are good vessels in that place. There's another case with an inverted T but not so big. We take out those amount of tissue. And a bipedicule pedicle, we need to take in mind that we have to tailor the flaps of the vertical pedicle as also to the flaps, because all of them have to match in the same depth. This is a bipedicle patient with good symmetry. We made in this patient the upper superior contral superior contral surgery, after brachial lobes patient. And here we have the last video for you that will be how we do the infertile pedicle surgery. We need to be very, very careful not to put the vertical segment of the pedicle too wide because we're going to use an implant and we have to avoid tight closure. Here we are going to mark the pedicle, not to be so wide there. And with a wide base because we're going to preserve the intercostal preference of the third six ribs. Then we go to the surgery, tailor the pedicle, and we're going to make a pedicle with the two centimeters depth and the wide enough to keep the vessels intact. Then we go to the subglandular space, take the tissue, tailor the flaps. Here we have the pedicle and then keep going, tailor the flaps. We have to be sure that all the flaps are the same depth. Go toward the muscle the same way as always, look in the fascicles, cutting them, keeping the muscle window open, putting the implant. We have to be very careful and not going so far in the lateral dissection. Here we have the implant inside and we are going to re-adapt the infertile pedicle to the muscle. Then we want to make the closure beginning from a stabilization of the pedicle, we want to make the closure beginning from a stabilization of the vertical axis and then going periodic and then finally to this horizontal segment. Okay, this is a modified infertile pedicle post-op. So despite our efforts to avoid weight in the infertile pole, we could see some bottoming out in these patients. So when we have to do an when we have to do an infertile pedicle, we need to do it and we can deal with that, but certainly it has this problem. This is another patient with a free graft. This is some of our next final tools. Implant size average. Which is your implant size average? 280, 380, 430, 535. Let's vote. Implants size average, 280, 380, 430, 535. And I'll see the results, the average is 380, okay. Implant surface, what is the most implant surface you use? Smooth, microtextured, microtextured or nanotextured. Implant surface, smooth, microtextured, microtextured or nanotextured. Let's see. Smooth, okay, could be a lot of Latin American people here in this webinar. Implants position, there's an arrow here, it's a sub-glandular space, sub-facial, dual plane or sub-masculine. Okay, let's vote. We're almost ending this speech. Let's see, okay, sub-muscular, all right. This changed with time. Our pool is 380 cc average, smooth implants and modified sub-muscular, okay. So just about to end, some tools that we have to keep in mind. We use non-absorbable sutures anytime to the closure. We have no, we don't use drains and we use percutaneous ultrasound in some cases where we're gonna need some help to relax some edema in the patient. And we did in two weeks after surgery. Another part of tools would be the shapers who are make of foam and water. And we use that here in the area of the periureolar area zone. And we use that here to keep the implant in place for three months after operation. And the elastic band, we use it in some cases when we need to maintain the distance in the vertical part. We use shock waves if necessary when the patients have a muscle contracture pass up and we send it to our physician, the physiotherapy and they will go with that shock waves. So complications, we have a lot of complication. Certainly we are avoiding most of the capsular contracture we have from the beginning or a zinatury or a skin or a nipple areola accomplice necrosis doing this change or resetting our thoughts that we wanna share to you. We keep having seromas, hematomas, infection, dehiscence and fat liquefaction. But we, that are not our main disturbance in the surgeries. We must not sacrifice shape for minimal scar. We have to consider none of the glandular and mastopexy techniques prevent secondary ptosis, even the less the skin texture. The use of inadequate site splicing could dissociate maximum projection point alignment. We must be self-critical with our results. Each surgeons defend his own way to do things, but a sees whether we are achieving the goal. If we have the maximum projection point aligned or if we have right proportion and shapes, if we have long-term stability of the result, we are doing very well. Breast is a three-dimensional geometrical puzzle. And certainly we need to have some specific thoughts and tools to win. If you like our results, we invite you to reset some concepts. Change of paradigms from these, from volumes, big volumes and non-proportional and non-symmetric breasts, to more symmetric aesthetic proportionate breasts. And definitely this is our best reward, our patient's feedback, our patient's photos at the social network and they send it to us. This is our best reward. And this is our last slide. I am not a politician, but I am a citizen with rights and need to you to thank US government for all the support to Venezuelan people. Thank you very much. Thank you, Dr. Rico and Dr. Casanova, very great presentation for both of you. We will try to make the Q&A in 10 minutes. We have around 10 minutes to do the question. I will begin with Dr. Casanova. Dr. Casanova, you close it with something that I think is very important, that is the teamwork. For you, that is the key point to work to get the better result in case of reconstructive surgery, the multidisciplinary teamwork? Well, you know, Dr. Sho, in Latin America, there are many groups that they're using a short program, call it the mastology. For mastology, usually it's one or two year training. And when using that training, those physician, they can do, you know, aesthetic or cosmetic surgery of the breast, like breast reduction or breast augmentation, mastopexy. And they can do, for example, lumpectomy or quadrantectomies, or even the total or radical modified mastectomies, and all of kind of reconstructions. And, you know, I prefer, you know, in my instance, to do primarily a general surgery program, and then a full program of plastic surgery. And then if it's possible to work with a multidisciplinary team, with an oncologic surgeon, plastic surgeon, the radiotherapist, oncologist, pathologist, radiologist, in order to obtain a very good result. And that, for me, is our goal, in order to obtain a good result in the breast. This, you know, this is my position. Yeah, I think it's important in order to get our specialty a good projection, and get all the patient the best medical results. We have 10 minutes, so I will go now with Dr. Rincon. Dr. Rincon, how long is the follow-up of your patient, so you can evaluate that operable that is in country like Venezuela, maybe Colombia? Is something that patient look for, the operable? Yeah, I think there is no magic surgery to keep the operable stable all the time. But we have been following up our patients for more over four or five years. And they are, I mean, they come down a little bit, but they keep maintaining the operable fullness. So, that is the reason why we have to share all the thoughts that we presented, because it's not the volume of the implants. If we are not fixing the inframammary fold, if we are not taking out the tissue, and enough tissue that the patient needs, if we're not considering all the main factors that we discussed, we put a very big volume, but it will come down. So, while we're follow-up is almost four or five years, and we have been seeing a little migration of one or two centimeter from the operable, but kept stable all that time. Do you have a limitation in age for this kind of technique? I mean, do you use this in younger patient even? Yeah. Those who have not go for pregnancy and that? I mean, you said the technique or the volume or what? Because you take tissue, you just kind of take tissue and put the implants, so you don't have both factor. Yeah. Yeah. In the rest. So, you use them in younger patient even? Yeah, because, I mean, we all know that if we have one centimeter of glandular tissue, it will go well with lactation and breast feed. So, if the patient is young, but it has a very, very loose skin, a very bad quality breast, it's better to tailor the flaps and be able to take out the tissue and put an implant. That is my way to see the things right now, because when I get graduate, I made a lot of reconstructive breast surgeries with the own tissue. And I think nowadays, I think the only breast that I kept the tissue, it will be the ones who have a very good quality or glandular tissue. Is that, okay. Okay, perfect. I will go with the question of the chat. Here we have one question for Dr. Casanova. Dr. Casanova, how are patient educated regarding breast implants associated anaplastic large cellular lymphoma and the use of texture and atomic implants? Yes, it's possible, you know, to open my video that is closed and I can't open. Oh, you want to open a video? Yeah, I need to open my video, my imagine, because- But we have a little, not a lot of time. Dr. Harris was the one asking. Okay, okay, okay. Well, you know, I recently, I assisted to INCAS international meeting that was held in Paris at the end of the January and the first day of February. And I was part of the panel concerning the actual stories about the anaplastic lymphoma and the breast implant. And now for, at that time in the world, were no more than 600 cases. And we need more data support. And even though that many department around the world, they are not using anymore the texture implant and they also recommend they only use the smooth implant for those patients. But we can see the same lymphoma with patient with the smooth implant as well. And we are still using the texture implant because they are very good devices. But, you know, the final recommendation is we need to do more research. We need to obtain or recovering more data about that particular pathology. That is concerning to the anaplastic lymphoma. Okay. And there is another pathology that is the concerning all about the immunological systems. And it's the same. There are a few papers around the world studying the relation between the implant and this immunological problem with patient that has, for example, arthritis or any thematose, lupus or sclerodermia or whatever. And we need to do more studies about those diseases. Okay. I will, because we don't have a lot of time, I will ask a question for Dr. Linda Rincón now, several questions so you can answer them in the best way possible. In your experience, what is the percent of revision mastopexy in those patients with severe doses? What kind of suture do you use? Non-absorbent suture, but what do you use specifically? And what is the average of the implant you use? You use, the poll say 380 cc, but what is the one you use? And there is a very interesting question for Dr. Laugani. He asks, how do you address a patient who has had a mutation mastopexy in the past with an unknown pedicle and impossibility to get operative report? What pedicle do you choose for her secondary surgery? I know the answer, but it's gonna be good so they know what we do in those case. Okay. Okay, the percentage of our revisions is very, very low. We are going to publish our technique soon and you can take a review of all our cases, 481 cases in 10 years. And I remember two cases with the after weight loss patients where we have to go to surgery two years after to take some skin out in the inferior pole, but it's not a really a double bubble because those patients have a lot of problem in the dermal tissue. But our percentage of revision is very, very low. I'd consider less than 1%. My team can tell about it too. The other one is the average. The average is close to 430. They are fighting, I mean, 380 and 430. And that depends on the patient which came to our office because if we have tall patients and white thorax and white chest, we are going to use an average between 430 or 480. It depends on the patient that comes to the office because we don't have a special implant size that depends on each patient, okay? And the last one is about the pedicle than a patient who has prior surgeries. That is the reason why we have going to evaluate what will be the best way to planning our surgery when we don't know the prior surgery. And that is why we use vascular pattern with the three mammogram tomosynthesis and because it will tell us which is the best way to get into the breast, avoiding and not to damage the pedicle that are preserved. So 3D mammogram, and that is an article published in the very Latin American journal and we invite you to read. If we don't have the possibility to go to the 3D mammogram prior to surgery, it's better to go with a bipedical pedicle. But that depends on the amount of tissue or the scar we're going to go through. Thank you, Dr. Rincón. We have to wrap up, but I want to close with two questions for Dr. Casanova. Dr. Casanova, how is your experience with the lipophilia and the percentage of the fat grafting and who you will not use the fat grafting? Well, you know, the fat grafting is a gold standard for doing the lipophilia through a reconstructive procedure, not only in congenital anomalies, but also in cancer area. I feel that we must understand clearly the technique of the lipo injection and if we do with a very good technique, the lipo injection, it has a very good result that I show you, you know, five years or six years after the surgery, it is possible to see very good result. But if you don't do that, maybe in a couple of months, you are going to see maybe 100% of the absorption of the fat in terms of the technique. But the relation between the fat and the cancer is there is exist a task force created by American Society of Plastic Surgery in the year 2007. And they started, you know, the relation between the possibilities to change the biology of the tissue after the fat tissue injected. But there is no data actually with those kind of changes. For that reason, we need to still use, you know, that particular technique in our patient. It's really a safe procedure. And, but we need to go further more into the technique to obtain very good results. Thank you very much, Dr. Casanova and Dr. Arincón. This has been a really, really, really great presentation for the both of you. And we want to thank the ISPS for this big opportunity to share our experience. We would like to stay here and keep going with the question. We don't have any more time. We invite you to make them through our website or through our email so we can answer them. And we just want to thank everybody who's been with us this morning and this afternoon already in Venezuela. So very thank you.

breast surgery

aesthetic surgery

reconstructive techniques

lipofilling

oncoplastic surgery

musculocutaneous flaps

mastopexy

implants

multidisciplinary approaches

surgical collaboration

patient outcomes