I want to welcome everyone to the next ASPS Global Partners webinar series, entitled A Plastic Surgery Residents Association with an International Appetite for Collaborations Corporation Conversation, PLASTA UK. My name is Lisa Gfreda, I am the current resident representative to the board of ASPS and the PSF. And we are extremely proud to be able to partner with PLASTA UK, which is a plastic surgery trainees association in the United States, and also with BAPRAS, the British Association of Plastic Reconstructive and Aesthetic Surgeons. Please go to the next slide. For this webinar, we have the same format as for prior webinars, where you can submit questions through the Q&A feature at the bottom of your screen, and we will address your questions at the end of every talk. Please also note that today's webinar is recorded and will be posted to the ASPS EdNet for ASPS members. So if you remember, you have access to this webinar at any time. Next slide, please. We have three excellent speakers today, who I'm very impressed with. Our first speaker will be Dimitris Risis, and he told me how to pronounce it right before this webinar, and I hope I said it correctly. He is the current president of PLASTA UK, and also a plastic surgery registrar in London, working at the Royal Free Hospital. He has a special interest in pediatric surgery and microsurgical reconstruction, and has been very heavily involved with medical education. And he would like to promote the collaboration between PLASTA UK and the ASPS. We also have Dr. Matthew Murphy, who is the PLASTA research representative. He is an academic clinical fellow in the University of Manchester, and a specialist trainee in his fifth year. He spent a lot of time in the United States doing research in Dr. Longacres in Charles Chan's lab, and he will be presenting his work today. And then Vic Sharma, who is the current PLASTA UK vice president, who is a surgery resident in the Pan Thames program in London, and is the current vice president of PLASTA UK, and also an ASPS member. He has a lot of interests, including craniofacial trauma and general plastic surgery, and he will also be presenting his very interesting work to us today. So with that, I will ask Dr. Reeses to give his talk and speak about PLASTA UK. Thank you very much, Lisa, for the kind introduction and for inviting us to be part of this Global Partners webinar series with ASPS. It is our great honour to join you on behalf of PLASTA and BATPREZ from the UK as well. So as Lisa said, my name is Dimitris, and I'm the current PLASTA president. I'm also a plastic surgery registrar in London and also an international ASPS member as well. And I want to talk to you a little bit about PLASTA today and what we are and what we do, and how we can support trainees both in the UK and internationally, and hopefully build a bit of collaboration going forwards between PLASTA and trainees in the UK and ASPS and residents in the US as well. So as PLASTA, essentially, we are proud to be the voice of plastic trainees in the UK and Ireland. And we take this responsibility very seriously and also bring as many trainees as possible together to build the collaboration within our network in the UK and Ireland. We currently have roughly 2,000 members and an additional 1,000 members who are international members as well from all countries in the world. And we're looking to build this collaborative network as far as possible in order to bring as much benefit to trainees and collaborative research and projects around the world. Our main focus for trainees in the UK and Ireland is to ensure that all trainees have equal and high standard access to training and clinical education. And we survey our membership regularly to make sure that all of the projects and scope that we put on offer for trainees is representative of what is current for them and the most important for them at this time. We represent all trainees regardless of age, gender, race, disability, or sexual orientation. And we've done a lot of work recently in gender diversity and stamping out bullying and harassment and promoting diversity and equality throughout our workforce. We represent trainees throughout the country and throughout the UK and Ireland. And we make sure that we represent them all equally. So wherever a trainee is working, they have equal representation from PLASTA and equal support from us at any level. And this is all supported in our constitution, which is updated every year in order to be especially current for our trainee members. And I'd just like to show you a brief glimpse of our committee. We have an expanding committee year on year. And I want to show you how you can contact any member of our committee essentially if there's anything that you'd like to discuss or any possible projects or ideas that you have. So we have the team that you see today, me as president and Vic as vice president. And the rest of our committee covers all areas that could be useful to you, including Matt, who's our research rep on today. And as I've touched on equality and diversity and also innovation leads and represents more the main specialty associations in the UK and Ireland. If you ever want to contact us, you can simply click on here and all of our contact emails will be available, easy to access for anyone who wants to do so. We also have regional representatives. So the UK and Ireland being a slightly smaller country than the USA, we're able to have a representative in every single region of the UK and Ireland. They've been a little bit more shy with uploading their photos on the website, but you can see that every single region is represented with an easily accessible email. So we're able to keep our finger on the pulse essentially for what's going on in each department and each unit. So if there's ever an issue that a trainee is facing, we're aware of it very quickly and we can help to address it to support trainees to benefit their training as much as possible. As Plaster as well, we're an independent association specifically organized for supporting trainees in the UK and Ireland and also more recently internationally. But we're very collaborative and we have conversations and projects with a lot of associations and societies. And this is just a quick snapshot of those that we work with most closely at the moment. We have BAPRAS, of course, which is the British Association of Plastic and Reconstructive and Aesthetic Surgeons, which I guess is the equivalent of ASPS in the UK and Ireland. BARPS is our Aesthetic Society, the JCST is our training committee, and we work very closely with our specialty advisory committee for plastic surgery to build our curriculum and indicative logbook numbers to make sure that these are representative for what trainees need to enhance their training. We also work very closely with ICOPLAST, who I'm sure a lot of you know is the International Confederation of Plastic Surgery Societies, and they are very keen to develop collaboration internationally and it's perhaps a route through which Plaster and ASPS can develop even more collaboration on a global scale. Thereafter, we work a lot with the Royal College of Surgeons in the UK and Ireland, at Edinburgh and Scotland as well, and a lot of other associations for the different specialties within plastic surgery and the other training associations. And this builds a lot of the framework around which we are able to support trainees as much as possible, but also we'd like very much to bring ASPS within to this community and bring ASPS members the benefits of working with all these other associations and also expand the reach of the great work that ASPS are doing on a number of different levels to the members of all these associations as well. Just coming on to some of the resources that we offer for our membership, both in the UK and Ireland and internationally. We've been running a webinar series since 2019, even before the pandemic, and I'll just show you a glimpse of some of the webinars that are available. These are those designed specifically for training for the FRCS, which is the exit exam, essentially the equivalent of the board exam in the UK and Ireland. And we have all the webinars easily available for our members free of charge. And they're all then available on demand afterwards. You can see a lot of great speakers, including Professor Nelligan and others from the US, as well as a lot from the UK and Ireland and internationally. And topics including breast reconstruction, aesthetics, head and neck, congenital, craniofacial, hand, the list goes on. We've got quite a big library with some esteemed speakers and great resources for all trainees and residents to access on demand. And simply by being a member of Plaster, which is free, you can access all of these. More recently, we've also built a webinar library and program for more junior residents and medical students and junior trainees. And again, we're building a very nice catalogue of these that are available on demand for all trainees and perhaps only residents who want to learn about how to manage the common plastic surgery emergencies, prepare for their interviews, and then stepping up to be a more senior resident or registrar in plastic surgery as well. Recently, in the UK, we're very proud to have collaborated with BATPRAS and the SAC, which is our Specialty Advisory Committee, to develop a national teaching program. So through this, every two weeks, all members of Plaster and all trainees in the UK and Ireland have access to a standardised teaching, but of the highest quality, delivered by experts in their field across the UK and Ireland. And each session has been mapped closely to each topic within the new plastic surgery curriculum to make it as relevant as possible for the exams for the coming years. And it's available to all trainees wherever they're working in the UK and Ireland, of course, at the same time. So they all log in at the same time. We're able to have a discussion about each topic and access the resource together. And if we're not able to access the teaching live, we're also able to access the schedule here and say we missed this skin session, we're able to access it and pick up on it as part of our revision, or just if we weren't able to attend the session live as well. We also, similar to the PRS Journal Club and the PRS Go Journal Club, we host two journal clubs through Plaster and through collaboration with JPRAS initially, which is the Journal of Plastic Reconstructive and Aesthetic Surgery based out of the UK. And we run a monthly journal club in which the editor of JPRAS, Andrew Hart, is present, as well as authors of one of their papers from the issue each month. And we have a nice collaborative discussion where a trainee presents a critical appraisal of the paper, and we discuss this. And I'll just show you how easy it is to link to this on Spotify or Apple Podcasts or any other media. If you search JPRAS Journal Club, you can see the range of different editions that we have for the JPRAS Journal Club. And equally, we run a very similar program with the EJPS, which is the European Journal of Plastic Surgery. This is in a close collaboration with ICOPLAST. And again, this is on a bimonthly basis. And you'll see a new episode of the EJPS Journal Club coming available for you to access. And this is available to everyone on demand if you access it through your social media platform. Just quickly, we run a lot of events throughout the year, and these range from different training events, microsurgical skills and flap courses, to more large-scale national and international events. Recently, we held a National Congress on Mentorship, and this was actually very well attended and sparked a new interest amongst the trainees in mentorship. And we're now preparing for our next big event, which is on the 2nd of December at the Royal College of Surgeons in London. And hopefully, it will be available for international residents to dial in remotely as well. And it'll be focusing on innovations and the future of plastic surgery and innovations to support plastic surgery training. So this is a really exciting space and something that we hope you'll be able to join us for. And we also have a lot of information with regards to fellowships as well, both fellowships that you're able to come and do in the UK, and also fellowships that trainees from the UK can come and do elsewhere and abroad. So I'll quickly show you a glimpse of this. You're able to input any information you have about fellowships into a spreadsheet. And then we load these onto an interactive map. And if you click here, you'll find there's fellowships available in each region and also abroad. We have fellowships available in all different areas in different parts of the world. And we'd love to build a bit of an extra aspect of this fellowship database with regards to fellowships available in the US for our trainees to be able to come out to the US to complete fellowships. To complete fellowships, but also for residents and ASPS members to be able to come and find what fellowships are most available in the UK. I know there's a bit of a resource already on ASPS website, but the only fellowship I can see is one at Great Ormond Street, which is amazing. But there are plenty available that residents may not know about. So we could easily collaborate there to make them available for all. I've touched on our membership and off the back of our mentorship conference recently, we've launched a mentorship program where we've teamed up junior trainees with senior trainees and allow them to meet at least once or twice a month in an online setting in order to establish a more informal mentorship relationship to support each other through their training and help the junior trainees to provide them with the knowledge and know-how that we wish we had when we were a year or so before. And this is something that's really taking off now. And we're looking to provide this for every trainee going forwards after our pilot scheme this year. We offer a lot of support for trainees undergoing research and both in terms of supporting their academic practice and research grants and also awards and prizes for trainees in the form of essay prizes and prizes at our different conferences to support them to be able to attend and add to their repertoire of achievements as well. And so I'd encourage you all to visit us at plaster.org and click here. If you're not already a member, you can click on join Plaster. And if you do so, you'll come to this page. And there's a few points, but for international members, you can simply click here and it'll take you to a very quick form to fill out just your email address, name and country and then submit that just at the bottom. And you'll be added immediately to our mailing list and be able to take advantage of all of the different resources that we've talked about today. So just before I finish, I just wanted to touch on a few ideas that hopefully can spur a bit of discussion between Plaster and ASPS in terms of further collaboration in order to bring the benefits for both of our memberships across the pond, hopefully. And a few ideas I had while putting this together is that we can host webinars like this together and look to build our collaboration in this way, perhaps journal clubs linking in the great journal club that PRS run with a journal club with JPRAS and perhaps see if there's a bit of synergy there, maybe best articles of the year or something like that we can look to link together. We can look perhaps to develop an online conference and different competitions, perhaps even fun quizzes between the UK and the USA to look to build a bit of collaboration between our residencies. In the future, perhaps I'd have a vision of reciprocal membership between Plaster and ASPS to enable both of our cohorts to kind of come together and gain access to shared educational content. And just finally, on the fellowship side of things, I think this is an area that's really important for us to make as much information available to all of our members as possible and building on the databases that we both have. And also, perhaps in the future, facilitating an exchange whereby a resident may come over to the UK and a trainee from the UK may come over to the US. And that's just a couple of ideas just to have a bit of discussion. Thank you very much. I look forward to seeing you. I'll be online, but I'll see you in Atlanta. And if you have any questions or thoughts, please get in touch with me at president.plaster at gmail.com. Thank you very much. Wow. You know, I think it's very impressive what you have organized and the resources that you've built are just amazing. So congratulations to all of you. That's really fantastic. I feel like I'll just speak for a minute from the ASPS side. You know, we're kind of working on the same things, but it seems like we're working in a bubble. So I absolutely agree. I absolutely agree. We should work together and have meetings together. The ASPS Resident Council, and maybe that's a good first start. I think that'll be amazing. Yeah. Yeah. No, we'll definitely do that. You know, I think a lot of the people listening are interested in collaborating with both Plaster UK and the ASPS Resident Council. So I basically said, well, the best first step is to sign up for both societies. But what, in your opinion, is a good way to really get involved with Plaster UK? So it depends if you wanted to get involved organizing a webinar, that'd be a great start because it shows your enthusiasm. If you wanted to get involved with different research and collaborate with a center in the UK, we have a whole range of sites that are available to link in. And Matt is actually our research rep. And you can get in touch to build a collaborative research project, perhaps. We're also looking for a lot of collaboration with regards to our work on EDI, so Equality and Diversity and Inclusion. So if anyone's particularly interested in that, we'd love to learn. I know that America's even steps ahead of what we're doing in the UK. So it'd be great to hear some of the work that you may have done in your departments and how we can translate that over here to improve things here as well. But really, there's no limit. Any idea you have is a great idea. And just send it our way and we can start a collaboration. We do the same with ICOPLAST quite a lot. And we have a very organic relationship there where ideas just flow. And simply just by getting in the same room or the same meeting like this, you can have a quite nice, open discussion. And get things flowing. I think, like you said, Lisa, there's a lot of similarities between what we're doing on each side of the pond. And it's almost a shame for them to just happen side by side without linking them together where they can benefit everyone. So yeah, that's where we come from. So any ideas you have, as big or as small as they are, we'd be glad to support them. All right, great. So I hope everyone in the audience was listening and is going to send their ideas to your email address. The other question I have for you is, if residents have concerns, maybe it's burnout, maybe it's COVID, how can they bring their concerns up to PLASTA UK to make their voice heard? Yeah, so we have our regional representative network. So the regional rep for the area in which that trainee is working is the first point of contact. And then I hold a meeting with all the regional reps, with Vic as well, who's on this call, once a month. And so we touch base and make sure that any issues are raised at that time. If anything urgent is raised, then, of course, it's brought up at an ad hoc manner. But we have a great network of regional representatives around the UK and Ireland that enables us to really just, as I said, keep our finger on the pulse of what's going on. And almost all trainees, I would say, in the UK and our members are PLASTA. There's only 340-odd plastic surgery trainees, registrars who are equivalent of residents in the UK. And so we represent them all as closely as we can. We can keep in touch with a lot of them quite often. And they all know where we are, and we're open to hearing from them at any time. OK, wonderful. I hope that addresses all the questions that the audience may have. I encourage everyone to sign up for PLASTA UK and the ASPS Resident Council. And on our end, we will have a meeting and hopefully collaborate more in the future to work towards, you know, a global plastic surgery education for residents essentially. Yeah, that would be amazing. Yeah, thank you so much, Dimitris. So our next speaker will be Dr. Matthew Murphy, who will talk about his research that he did, both in the US and UK entitled a transatlantic bridging of bench bedside research in the management of burst CMC, J osteoarthritis. Thank you so much for the introduction. It's my pleasure to be here tonight. Well tonight in Portugal, today in America. And really, although my title is quite a long one, it's just really simply to describe my journey, coming initially from Ireland, then to America, and back in the UK, all for the cause of trying to discover trying to work out how we can better manage first CMC J osteoarthritis, also known as base of thumb arthritis. So by 2040, it's estimated that nearly 80 million adults in the US will have doctor diagnosed arthritis. Osteoarthritis is the most common form of arthritis. Osteoarthritis commonly affects the joints of the knee, hip and the base of thumb. The base of thumb for me is of particular interest as it's an area that I started looking at while in medical school. Osteoarthritis leads to progressive degeneration of particular joints leading to irreversible destruction of hyaline cartilage. As a medical student, I was fortunate to be involved in research while at a university called Dublin. And we looked at ways of managing osteoarthritis of the first CMC J. And what we did was we used BMAC, which is bone marrow aspirate concentrate, whereby we take out some bone marrow aspirate, we spin it down, and we take out what we believe to be the stem cell rich layer within the aspirate that has been spun down in centrifuge. Then what we do is we go into the affected joint, we make small micro fractures into the articular surface, and then apply the stem cell rich paste onto the affected joint. Now micro fracturing is a technique that's been used since the 1960s. It's commonly used by orthopedic surgeons for people with osteoarthritis of the knee. And what has been believed is that by making these small micro fractures into the joint surface, you're going to somehow stimulate a stem cell population. So they thought that in the 60s, 70s, 80s, but really nobody had any idea about what actual effect it had on the resident stem cell population. So my initial study was a small pilot study, very pioneering, but we had no way of really determining how it was affecting resident stem cells. It was one of many stem cell trials throughout the world. And as you can see, most of these studies take place within the United States of America. And they typically involve adult sources of stem cells. And this could be anything from adipose stem cells, muscle-derived stem cells, or bone marrow-derived stem cells. Most of these trials are pilot studies, a bit like the one that I've performed, just to make sure that these are effective and safe. But there's no real understanding as of yet as to how these trials are affecting tissue samples, because we can't really determine that on patients. We can only assess functional outcome. There are many groups that have been trying to define what is the skeletal stem cell. And many of them have their own ideas as to certain specific markers on resident cells that might be some sort of osteoprogenitor cell that has the ability to heal bony tissue. But really, the point that interested me the most, or the finding that interested me the most, was in a group in Stanford University led by Dr. Longacre and Charles Chan, who in 2015 have identified a mouse skeletal stem cell. This stem cell has the ability to differentiate into bone, cartilage, and stromal tissue, and has the ability to self-renew. These are two key characteristics of what defines a stem cell. And they determine the characteristics of the cell type in vivo, which is essential. I was then very fortunate in 2018 to be part of the team that identified the human skeletal stem cell. Again, this had the ability to form bone, cartilage, and stromal tissue. How we did it was we prospectively isolated these cells using FACS, which is fluorescent-assisted cell sorting. And what that enables us to do is to characterize these cells. And we then were able to transplant these cells that we had isolated, either the bone, cartilage, or stromal populations, and work out and see in vivo that these cells did behave the way we expected them to. We were also able to use a new therapy, or a new way of being able to identify clonality within tissues. And clonality is a key marker for stem cells. So, they're able to regenerate themselves. And so, by using this model whereby cells within an animal model are stochastically labeled different colors, we can see that if there are clonal populations, they will all have a similar color. Being able to identify a specific cell population allows us to understand what's happening to those stem cell populations and their needs. So, I was very fortunate to be involved in a group led by a colleague of mine, Chase Ransom, who was able to uncouple and work out that with distraction osteogenesis of the jaw, these stem cells somehow reverted to a more primitive type of stem cell following mechanical stimulation. So, that was a really interesting key finding for tissue engineering. Equally, only last month, a colleague of mine, Thomas Ambrosie, published in Nature showing that aged skeletal stem cells generate an inflammatory degenerative niche. So, it's a two-way street in the way we can affect the stem cells using mechanical stimulation and also stem cells themselves can influence the niche or the environment that they're in. My research was really looking, again, going back, what could we do or how could we try and regenerate cartilage? So, if you think back to my initial study, whereby we were micro-fracturing these joints of patients with osteoarthritis at the base of the thumb, I was then able to use the technology and work out, hang on, does micro-fracturing actually affect the joints? Does it actually activate a stem cell population? And what we found was that, yes, after micro-fracturing, there is a transient increase in skeletal stem cell populations. However, left unaided, they would form fiber cartilage. However, by the addition of two key components, BMP2 and inhibiting VEGF signaling, we were able to form robust hyaline-like cartilage. And this was a key finding. So, our findings were both in mouse and in human tissues, whereby we were able to acutely activate these stem cell populations using micro-fracture surgery and then allow the regeneration of cartilage through the application of BMP2 and VEGF receptor 1 in local topical application onto the joint surface. So, we were excited with our findings and the new spread about what we were doing, and we were fortunate to be featured in forums in the New York Times. And as a result, then, we had many different groups coming from all around the world interested in the research and interested in sharing their findings. And I suppose the next phase of our research will be looking into ways and translating our findings into larger animal studies before we're then able to bring it back into clinical practice. So, at the moment, I'm at the University of Manchester, and I'm working with a fantastic group of scientists there, led by Jason Wong and Adam Reed. And we are sharing all of our findings. My particular area of interest is in osteoarthritis and bone, really. And their group as well is involved in multiple different tissue types, including nerve and skin and soft tissues. So, it's a fantastic opportunity to collaborate with many different groups. I'd like to thank specifically my transatlantic mentors throughout my career, Professor Sean Carroll, Professor Michael Longacre, Professor Charles Chan, Professor Adam Reed, and Professor Jason Wong. Without all of their help and mentorship, I wouldn't be where I am today. And these are just some of the institutions that have helped me along my career. So, thank you very much, and invite any questions. Well, first of all, Matthew, that's a very extensive body of work, and I don't think a lot of people at your stage in their career have these kinds of achievements. So, it's really special what you've done. And I'm sure that everyone in the audience is thinking, how can I achieve this? And how can I set up a transatlantic collaboration like you did? So, I mean, I think I was really more fortunate, and I think it's about being the right time at the right place. And for me, I know that a lot of the support I got at an early stage and really helped, and being encouraged in the right direction, and being given advice as to thinking about the bigger picture, about what you want to achieve. And it's impossible to be able to achieve everything. And I think it's important, a bit of advice, sometimes as plastic surgeons, it's all about, you know, how many papers you can publish every year. But really, the most important thing is what you can actually do to try and make a difference, not really about silly, small things. So, it's important to think about where am I going? What's my area of interest early on? And then think about how can I make a big impact? And I think being able to think outside the box as well, and collaborating with other groups, so not just plastic surgeons, but engineers, basic scientists, they can teach you so much more and give you perspective that you never really thought that you had. And equally, you can give them insights into what is achievable clinically, and what might be a little bit, sort of, too advanced, potentially. So, it's a great, I found, particularly at Stanford University and at the University of Manchester, there is such a great crosstalk between specialties, that it really allows, it really, it changed my life, and it changed how I approached my day-to-day clinical plastic surgery practice. Yeah, I couldn't agree more with everything you've said. Are there things within PLASTA or initiatives in PLASTA UK that you think would be helpful for researchers or plastic surgeons who are interested in collaborating with the University of Manchester or US institutions? So, we have a list of academic institutions within the UK, really more for the PLASTA UK members, and we have, sort of, essay prizes and things like that. With regards to collaboration, I do think it needs to be from, sort of, top up, although I do believe that junior scientists and residents can initiate collaboration, and certainly I know that the researchers that I met at Stanford had already been collaborating with the UK over many years, and I think what the UK allows for many American institutions is the fact that it has the National Health Service. So, once it's approved any scientific advancement, you suddenly have open doors to the entire nation, whereas in the US, it's a little bit trickier with every different health group with its own insurance companies, and it's a little bit more red tape. So, I think, particularly for clinical trials, the United Kingdom is a fantastic place to start that. Yeah, I mean, I think I can add a little bit from the US perspective. I think a lot of research labs are very open to collaborating with international students and researchers. Oftentimes, you know, emailing someone or trying to have a coffee at a conference is enough to start a whole research collaboration, so I think I would encourage everyone who's interested in research to just approach the person who you want to work with, and I think you'll be very surprised at how open a lot of them are in working with you. ASPS is working on a site called Roadmap for Plastic Surgery, and we have a list of all the labs in the United States that have plastic surgery research labs, so that might also be a good resource for any of you who are interested in finding out which labs exist and just seeing what their focus is, essentially. All right, well, thank you so much, Matthew. Last but not least, Dr. Sharma will be speaking about autologous fat grafting for intractable coccydynia measurably improves outcomes in lower back pain. Thank you, Lisa, and thank you, everyone, for the opportunity to speak today. It's great seeing you all on both sides of the Atlantic, so good morning, good afternoon, and good evening. So I'm going to present some work that was previously presented at the 2020 virtual meeting, but if you missed it, here's another chance. So it's using autologous fat grafting to improve outcomes in lower back pain, a specific type called coccydynia. I've got nothing to declare. So coccydynia, coccygodynia, coined by Simpson in 1859, is essentially pain in the region of the coccyx. It's a prolonged sitting, leaning back while seated, or rising from the seated position that makes it worse, and the coccyx gets its name from the Greek for the cuckoo's beak, and it's down here at the base of the spine. Essentially, it's a triangular bone with some up to five few segments with multiple ligamentous insertions. It forms a tripod to stabilize the spine and provide weight-bearing support when someone is seated. Affects five times as many females as males. The incidence is unknown, and broadly, it's got traumatic and non-traumatic causes, so sort of external forces, but someone falls backwards, can often bruise or dislocate or fracture the coccyx. Internal causes include childbirth, especially if there's instrumented delivery. Non-traumatic causes we know is obesity, disc degeneration, abnormal mobility of the joint, infection, tumour, and differences in morphology. The mainstay of treatment is actually non-operative and quite straightforward with worry-shaped cushions, posture training, so sitting properly when you're doing long procedures or replants, it's very important, and can be treated with non-steroidal and anti-inflammatory drugs or transcutaneous electrical nerve stimulation. When that doesn't work, there are invasive options which include image-guided local anaesthetic or steroid injection using ultrasound or fluoroscopic modalities, where you target the ganglion impar down here to induce a sympathetic blockade. There is then a coccygeoplasty, where you essentially inject polymethylmethacrylate cement or insert tension sutures to basically stabilise the coccyx, but there's limited evidence behind its effect. And then more aggressively, there's the coccygectomy, which is the central surgical amputation of the entire coccyx, which you can see here. These images are below. But this does have a fairly high complication rate, which ranges from the minor ones, including wound infection and haematomas, to more serious bowel injury and rectal prolapse. The British Association of Spinal Surgery also document the downtime associated with spinal surgery, as a patient is unable to drive for four weeks, they can't resume a seated job for six weeks, and swimming and running for up to three months. So there is a lot of morbidity associated with this more aggressive surgery. So clearly, a new surgical modality was required for this specific cause of low back pain. So there is evidence of fat grafting in neuralgia. So severe chronic pain affects almost 20% of people globally. Typically, you get the paresthesia shooting pain with electric shocks, burning and hyperalgesia. Often, there's medical treatment, the antiepileptics, opioid, Botox and topical patches. But these often fail because you're not addressing the underlying cause of the problem. So there is evidence from Klinger, who describes fat grafting in post-surgical occipital neuralgia, which has been resistant to medical treatments, which shows improved pain scores up a year. And in other cases, with Venturi, Collette and Vickers showing improvements in pudendal and trigeminal neuralgia, where fat grafting has been used. It is hypothesized that the fat grafting actually remodels the scar architecture, by inserting the cannula that I'll show shortly in the video, you actually release the scar tissue. And this also secretes analgesic factors to give the pain relief that we see. As Matt has described the stem cells in very good detail, there's also the adipose derived stem cells, the ASCs, which are known to secrete cytokines and growth factors, which increase angiogenesis, reduce the inflammation and also have this analgesic effect by repairing damaged nerves. So we felt that could fat grafting improve outcomes in coccydynia, where it's resistant to the non-surgical minimally invasive treatments. So we reviewed 20 consecutive patients referred from our senior spinal surgeon to our senior plastic surgeon that satisfied these criteria. We use an internationally validated gold standard questionnaire called the Oswestry low back pain disability questionnaire. And we quantify the patient's degree of pain and disability preoperatively, and then review the outpatient clinic at three, six, and 12 months. And the questionnaire, which we'll show in a second, has 10 domains, including pain intensity, personal care, lifting, walking, sitting, standing, sleeping, and the patient's sex and social life. So this is just a snapshot. So in pain intensity, so if you have no pain at movement, that's called zero. One is mild, two is moderate, three is fairly severe, four is very severe, and five is the worst imaginable pain. And there's these 10 domains, and then you index it in terms of minimal, moderate, severe disability, or if they're actually crippled and unable to function due to their pain. So we'll show the operative technique now. So following a WHO check, a patient is position prone, IV antibiotics are administered, standard betadine is prepped, and a stab incision is made in the flank. A cannula is then inserted. The FAT is then processed as per a modified Coleman technique and then centrifuged at 3000 RPM for 40 to 60 seconds. The inferior end of the coccyx is palpated and a stab incision is made just inferior to the natal cleft. We then use a reinjection cannula and multiple passes, as you can see here. Multiple passes are used to disrupt the scar tissue and you keep a finger, the left index finger in this case, distally to prevent the cannula tip going too far. And as you can see, as the cannula is inserted, it's initially quite difficult as the fibrotic adhesions are released. The fat is then injected in the plane and it's changed in different directions to disrupt more scar tissue and basically to ensure an even distribution of the fat. You must take care to inject only the lateral and posterior surface of the cortex and also subperiosteally, if possible. Again, you can inject further fats as required, again, keeping close to the coccyx surface and you must ensure the injection planes are changed regularly. I just want to say this is a day case local anesthetic procedure with minimal downtime associated with it. Okay the wound is then closed with a simple absorbable suture such as a fiber repeat and then simple dressing. We then see the patient sort of six three months time and then at every clinical review we see them and reassess them. So in terms of results the majority of our patients were female and small proportion were male average age of 51.1 and on average just under 20 mils was injected each time. The starting disability score was almost 40% indicating a moderate or severe disability as per the lower back pain questionnaire. What this graph shows here is in the majority of cases where treatment has been completed 65% of patient report their pain is better 30% report it's worse and a small proportion report no improvement. Although the series was quite small 11 patients report a reduction in their pain scores of 16.5% which was highly statistically significant. Those where the score was worse by an average of 6% it was not statistically significant those where there was no change in score was a minimal. So what we can conclude from our small study is that we can measurably show that autologous fat grafting reduces the degree of disability by approximately 65% of patients with coccydynia. As mentioned it's day case surgery there are no complications reported so far and it's very well tolerated with minimal downtime and we propose a mechanism of action is that it releases fibrotic scar tissue and utilizes the anti-inflammatory properties of fat stem cells rather than just providing some padding. We are continuing to expand our case series in terms of numbers and in the interest of our kind of talks today with collaboration we would like to look into further in vitro and in vivo studies looking at animal models to see if we can tie up what we see in humans supported by in vivo and in vitro data. Just a couple of references. Thank you very much for your attention and for everyone who's dialed in today. If you have any questions regarding the talk please email me or Mr Park on the emails given there or any further collaborations I'm very happy to hear from you. Many thanks. Thank you Vikram. I think the topic of fat grafting and pain is very interesting. It's somewhat of a newer concept and you know I think we don't quite understand it yet. I'm curious because you know oftentimes the animal models are difficult for these types of problems. When I think about this specific problem I wonder you know what is really the cause and how can you mimic that in a model? Is it the bone you know? Is it the soft tissue surrounding the bone? Is it the nerves? How will you model that? It's a good question. I mean in humans the kind of proposed sequence is there is a trauma of some sort and then that you get the downstream inflammation and then the adhesions of the fibrotic tissue that forms around the coccyx and then that sort of deforms and displaces its resting position and then you get the sort of intractable pain that people report. So what we've shown is that just by disrupting that scar tissue and then injecting the fat it's kind of a two-fold effect of the surgery. So anytime you're releasing scar tissue wherever it is in the body you're sort of restoring normal anatomy or normal function even temporarily. And then the adjunct of the fat is hopefully secreting these factors that are repairing the nerve endings and having an anti-inflammatory effect a lot longer than say non-steroidals or systemic therapy could. In terms of modeling that's a good question. So if anyone does have any ready-made animal models out there or has something that may work we're very happy to kind of hear from you and collaborate as we've sort of demonstrated an effect in humans an association but what's more important is essentially the causation. That's where the lab studies will really help. Yeah well if I have an idea I'll let you know. If anyone else here has an idea then definitely let Rick know because I know from my own research it's sometimes really difficult with pain animal models. So there is a question from Alessandra Canal. She is interested in knowing what post-op regimen you have after fat grafting. Yeah it's relatively straightforward. So as we said it's a day case general anaesthetic procedure. So the patient is sort of mobilized gently pretty soon after the operation. There's no specific restrictions that we place. I mean there's sort of standard wound healing for the stab incision of six weeks but you know as long as the patient mobilizes, ambulates sensibly, there's no real restrictions that we place compared to say if you have a big spinal surgery then there is associated downtime of between 4 and 12 weeks and the associated complications. So it's a good sort of intermediate option where the patient doesn't want the full spinal surgery but they do want relief and as we get kind of more patients back through the door as you know the pandemic is easing we're allowed to resume a lot of these elective procedures and we are seeing this improvement is sustained over time. That's wonderful. I'm also curious whether you think, I mean obviously there's an anti-inflammatory effect or whatever you will research in the future but do you think that adding a little bit of volume is still beneficial? Like do you think you know if you added I don't know 50 cc's instead of 10 would that help kind of prevent further trauma if patients you know keep doing what they're doing repetitively? I think you'd think you know the more padding the better but as you know with fat grafting anywhere in the body in a kind of a normal anatomical field up to 50% can get reabsorbed certainly when you fat graft in the breast and all the rest of you have to counsel the patient a lot of the fat you're injecting will get reabsorbed so it has to be more than just the padding effect. That's why we're seeing this sort of analgesic anti-inflammatory effect that is sustained over time. You know patients they do require I think probably two episodes of fat grafting. These are relatively quick general aesthetic procedures and we are seeing this sustained over time a lot longer than you'd expect for just simply placing some fat in that area. It's the actual physical mechanical effect of disrupting the scar tissue and then the effects on the stem cells improving the inflammatory environment reducing pain and inflammation that's found there. Great. There is one more question from Hartono Cartavia and I'm very sorry I did mispronounce that name. Do you use dry or wet technique in liposuction and do you use microfractional fat? Yeah so yeah I mentioned it briefly so it's a dry technique to to aspirate the fat from the flanks and then I think because the the area we're injecting is it's not it's quite it's quite large so anatomically you just need to be in the correct plane so we don't need to kind of fraction it further using microfractional fat. Again it's it's the the disruption with the injection cannula of the the scar tissue that's kind of more important that we find is crucial to this technique. All right wonderful. I think these were all the questions from the audience. We also answered some in the chat. I really think this was a wonderful webinar. I am so glad that we learned about what you're doing in PLASTA UK, all the resources you have and all the interesting research that all of you are working on. I think this will be a great working relationship and we'll certainly work on being more collaborative with all of you in the future and I just want to point out one more time for all the people listening in please sign up on the PLASTA homepage that was posted in the chat and I also posted the ASPS resident site in the chat and feel free to email any of us if you have questions or want to get involved. Do any of the panelists have closing remarks? I'd just like to say thank you very much Lisa and the ASPS team for for inviting us to be part of this global partners series. It's a great series and if it opens the collaboration that we're hoping we'll have follow-up meetings and everyone is invited to them as well. We're very much looking forward to what the future holds so thank you so much for this. Thank you. Well thank you Dimitris, thank you ASPS for organizing this and we'll see you all soon at our next webinar series. Have a great night. Have a great day everyone.

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