Good morning, good afternoon, and good evening, everyone. My name is Romina Valadez, and I am the International Relations Manager at ASPS. Before we get started, I would like to talk to you about ASPS. On behalf of the entire ASPS leadership, we thank you for your participation today. ASPS is the largest plastic surgery organization in the world, with over 12,000 members and subscribers, including plastic surgeons, residents, medical students, and other member categories. ASPS provides lots of opportunities for members to become and remain engaged with the society. We currently have 50 global partners at ASPS. The International Visiting Professor Programs conduct virtual visits to international plastic surgery institutions. The International Residence Forum offers opportunities to contribute to ongoing projects and develop new projects specific to residency training and beyond. In addition to research grants, the Plastic Surgery Foundation also includes innovative global health initiatives through our Volunteers in Plastic Surgery and SHARE programs. GAPS is a new PSF pilot program to build international union and foster exchange between US and global partner training programs. The Plastic Surgery Education Network, ASPS EdNet, is the online learning center developed by the American Society of Plastic Surgeons with the cooperation of several plastic surgery specializations. EdNet offers fresh content in all areas of plastic surgery every month. The ASPS Education Network offers more than 90 self-assessment models for practicing surgeons and residents. Each model provides journals, article readings, presentations, videos, and testimonials to help students learn more about plastic surgery and how to be a better surgeon. The ASPS Education Network provides a wide range of training programs, including clinical trials, evidence videos, and tests that cover all aspects of the specialty. Program directors are welcome to enroll their residents in the ASPS Education Network, REC, and review transcripts to track progress. On the screen are some of the benefits of international membership at ASPS. We had a very successful annual meeting in October in Austin, and we hope you can all attend Plastic Surgery, the meeting in late September this year. And the 2024 ASPS Spring Meeting will be held virtually in March for more outstanding education. It is free for all resident subscribers to ASPS until February 16, so I strongly recommend that if you are interested, you register before February 16. There are so many benefits to membership in ASPS for our international colleagues, including subscription to PRS and a member discount to Plastic Surgery, the meeting. To learn more about the society or to join today, we have QR codes with discounts for residents and practicing plastic surgeons on the screen. I will also share my contact information on the chat in case you have any questions. And now I would like to introduce you to our first moderator today, Dr. Samuel Lean. Dr. Samuel Lean is a highly regarded plastic surgeon and educator based in Boston, Massachusetts. As an associate professor of surgery at Harvard Medical School, he holds dual board certifications in plastic surgery and otolaryngology, head and neck surgery, underscoring his expertise and dedication to continuous learning. Dr. Samuel Lean is, excuse me, a distinguished figure in plastic surgery, education, research, and philanthropy, making significant contributions to the medical community. I thank you for your time and welcome, Dr. Lean. Hi, everyone. Thank you so much, Romy. I'm really pleased to introduce the first panel of this webinar series on rhinoplasty A through Z. All the speakers really need no introduction and are well-known across the world and world experts in rhinoplasty. They've taught many, many generations of Chinese and contributed much to our society in plastic surgery over many decades. And I'm pleased to announce the speakers and their topics in order. Dr. Rod Roerich will be talking in finesse, regarding finesse and tip shaping with septal extension grafts, key to excellent results in rhinoplasty. Dr. Arturo Regalado-Briz will be speaking on his long experience on aloe preservation, 28-year experience with his technique. Dr. Alan Matarazzo will be combining two talks in demystifying closed primary rhinoplasty, 10 essential steps. There is a Q&A box at the bottom of your screen that you can enter questions for and we'll have a 15 minute Q&A session at the end of all three talks. Thank you, Sam. Hi, good morning, everybody. Welcome to this exciting educational symposium. I'm gonna talk a little bit about rhinoplasty and some of the advances in rhinoplasty and primarily about tip shaping and tip support, which I think has changed completely. And these are my disclosures. I have book royalties, instrument royalties, and I do educational seminars. And of course, we welcome all of you to Dallas Rhino, which is coming up in March, which many of you have probably been at already, but it's kind of in depth on the new advances in rhinoplasty preservation, minimally invasive, and a lot of the things I'm gonna talk about today. But let's talk about tip shaping and the finesse that you require to get it consistent and reproducible. So the way to do that in the past has been traditionally thought of as support. What is the support of the tip? Usually it's been thought to be the length and strength of the lower lateral and all of the ligaments that are associated with that. That is still true. But in modern rhinoplasty, we rely less on this length and strength, but more on how we can support it in a rigid but mobile fashion. And tensioning is the key to tip shaping. Remember that phrase, tensioning is the key to tip shaping. As we have gone through the evolution of using sutures and Kaji Miller struts, I'm gonna show you why this fixed mobile septal extension graft really is superior to all of those methods. And in the past, we've talked about the role of the Kaji Miller strut, and all of these are in PRS, obviously, which Romina said it's the number one journal in the world for plastic surgery. And the rationale for the use of the Kaji Miller strut is if you have good projection and rotation, and you wanna maintain it, a Kaji Miller strut is excellent for that. You place it between the feet of the mitochora and you suture it into place. That is all very good to do. But in a patient like this that has excellent tip projection and rotation, but has a deviated nose and a caudally deviated septum and good lower laterals, you can straighten it and support it with a Kaji Miller strut. And that's exactly what was done in this case. You can see that the nose is straight, the tip is shaped, and the Ailer-Kaji Miller angle, nasolibial angle is not changed. So we didn't change the rotation or the tip projection, and it works great for that. But if you wanna rotate or decrease or increase tip projection, it really is not that reliable long-term. And we've done a study, and again, that's been published in PRS, that shows that you really can't get consistency in the Kaji Miller strut use. So what is the current thoughts on consistency and reproducibility? This is a modification of a septal extension graft, which in the past required a lot of cartilage and was much more rigid. And so we talked about this and this was also published in PRS. And I'm gonna explain to you how I've changed it and what things we've done. The big thing is, these are four concepts that I think are important. It's fixed at the septum, but it's mobile. And it requires that you tension the lower lateral cartilages and use five different sutures to do that. And we showed that the septal extension graft was superior over Kaji Miller strut recently in the white journal as well. And basically, you can alter the rotation and advancement by altering the angulation based upon your new anterior septal angle as seen here. And the Kaji Miller strut in this article showed that it was really worse statistically for both rotation and projection when compared to other modalities, specifically the fixed mobile extension graft, especially in males and in ethnic patients. It was far more likely to lose tip projection. So that's very important as you keep this in mind. So the hallmark is fixed at the septal angle, mobile at the tip, predictable projection, and rotation. That's very important. And what I'm gonna talk about here is really how you, and I'm gonna move this, how you shape the septal extension graft. And you're harvesting it, and you don't really need a lot of cartilage. And in this patient, what we're gonna do is we're gonna be decreasing tip projection. So you're placing it on one side of the septum, usually the contralateral side, and then you're fixing it into place with four sutures. And so when you're putting it into place, you're putting half of it below the septal angle and half above. And usually it's at 90 degrees. And then you place four sutures, two stabilization and two fixation sutures. And it can, the distance from that to the tip is usually between eight and 12 millimeters. And I usually start at 12 millimeters because you can always reduce it. And that's really important. So you can maintain rotation. You could increase rotation based upon the angulation. And obviously that's beyond the scope of this brief webinar, but we'll talk about that a lot at Dallas Rhino. And actually we'll show you how to do it in the cadaver lab as well, and you can do it. So two stabilization sutures in the body, and then two fixation sutures as you come superiorly and inferiorly to prevent that rotation and the angulation. And this is done with 5-O PDS suture. So these are the two fixation sutures. You're placing them superiorly and inferiorly and into the septum. So it's fixed yet mobile, which is just like your nose. And what you see is what you get in contrast to calumetastratum. Where you see it in the operating room is where it's going to stay. So it's fixed, it's mobile, it's reliable. And that's very important. So how do you then put in the sutures? There's five different sutures that I use. And this is the sequence that I do it in. It's transdomal, gruber times two, septal extension graft sutures, interdomal, and high intercurl. And I'll show you each of these. So basically, you come from the top and you make your new septum. It's really a dial-a-tip. And this is a transdomal suture going from caudal to superior. And then this suture here is the gruber suture, which is in the cephalic portion of the lower lateral cartilage. And you're placing it so that you get superior angulation and tensioning. And so you do that, and then you place your interdomal sutures to the septal extension graft. And you can do these individually, which I like to do, so that you can get the right angulation, which should be, the resting angle should be about 100 degrees, which is from the upper lateral to the lower lateral. And I'll show you all of those things in the end here. And in the end, you're putting a high intracranial suture inferiorly. So your end goal should be a diamond-tip end point. You can see this here. That should be your end point. So you're taking the angulation from the left of a malformation of the lower laterals to really shaping finesse of the tip. And all of this is reliant on tensioning the tip. This is an important concept that I think has been overlooked so much in rhinoplasty. You have to tension the lower laterals, just like you have to tension the upper laterals. And in the end, these are the four cardinal points that you must do. And you must have superior caudal edge, you must be straight lateral cura, you have to evert it, and you have to have a diamond-shaped tip. This is the ideal tip shape. Straight, eversion, caudal higher than the cephalic, and diamond-shaped tip. And I'll just go through a few examples of that. Bulbous tip, primary rhinoplasty, caudally deviated tip. So you're taking it, you're doing an open approach, you're doing all of these things I talked about. And here she is, beautiful dorsal aesthetic lines, tip shaping, refinement of the dorsum, thick skin, no debulking, but the use of a powerful septal extension graft to shape it and provide contour in this area. And it works for all kinds of noses, because you truly can control the tip precisely. Remember I talked about consistency of reproducibility? Over-projecting nose, very over-rejecting nose. You can do these same concepts, but you can overlap and transect the medial cura. No longer should you abide by the tripod theory of transecting the lateral cura, which I think is a no-no in most cases. So in this case, we transect the medial cura, do the septal extension graft, close dead space. Obviously, that's beyond the scope of the webinar, but certainly you'll see it when you come to Dallas Rhino. You're closing the dead space, you're closing the Petangue's ligament, which is a very hot topic now and you're restoring it when you're doing the tip shaping. And this is a patient, again, all of these are over a year up, beautiful dorsal aesthetic lines, tip shaping, nice subtle super tip break in this patient. And all of these are obviously done with an open approach as well. So you're doing it, over-rejecting. Here's a thin skin patient, same type of concept, but in thin skin patients, you have to be very careful not to debulk the tip, use these same concepts. But the most important thing in the thin skin patient is that you do, not only are you reshaping it, but you're also gonna do a butterfly graft to restore the facets of the soft tissue triangle. And that's the cardinal rule so that in a patient with thin skin, you can refine the soft tissue triangle in this case. And you can see that this nice, beautiful tip shaping and the facets are restored and actually enhanced from pre-op. And then the last patient is a thick skin patient. These are always the challenges, significant dorsal hump, excess tip rejection, drooping nasal tip, using all these concepts. You're doing closure of the dead space, preserving and restoring the tip ligaments. But the cardinal is tensioning in the lower lateral to a fixed mobile septal extension graft using these five sutures, reshaping it and restoring it. And you can get a beautiful result. This lady is now almost a year and a half post-op. And again, this is the kind of consistency you want in rhinoplasty. It's giving you beautiful mobility, but consistent shape and contour. So the key is fixed at the septal angle with a mobile septal extension graft gives you a predictable projection and rotation. And alert tensioning is key. So hopefully that will have helped you. And I'm happy to answer any questions you have about this. Thanks so much, Sam. Thanks so much, Rod, as usual. A tour de force of so many pearls, much appreciated. Next time, and please again, enter all your questions in the Q&A box below. Next talk, we have Dr. Regalado-Briz. Thank you for the opportunity to be here this morning. It's a real pleasure to be here. And we can start right now. One of the 10 commencements in rhinoplasty through the history is resectocephalic portion of the lateral crura to the ailers to improve or rotate the nasal lobule. But we should be aware of every incision has consequences. Every dissection has consequences. Every resection has consequences. Sadly, we are not like this nice amphibian axolotl capable to regenerate 100% an amputated limb. We as humans just make scars. And a few words, my concept is primum non nocere, the first commandment in medicine. My slogan is reshape rather than resect and respect the anatomy and physiology. For me, the main commandment is preserve and make the best framework possible. And when the cephalic portion of the ailers is resected, is there an emptiness, nothing? The answer for me is, of course, no. Why to preserve the two ailer cartilage? The cartilage is a purpose-driven structure in anatomy and physiology are preserved. Preserve the junction, ULC, LLC, in our words, internal valve preservation. The scar tissue will substitute the gap left by cartilage resection to often the scar contracts, thickens and create secondary deformities and unpredictable factor is added to the rhinoplasty equation. Usually, fibrous tissue is more than an enemy rather than a friend. In case of secondary surgery, the dissection is easier and this approach reduces the need of grafts described by Tevez or Gunter. And nowadays, the surgical techniques are more conservative, are greener in every medicine field. So it's more natural, a magic word, nowadays. And the possible vectors of contractors in these slides are in red and there are some, at least six possible negative consequences of resecting the cephalic portion, internal and external valve collapse, loss of tip projection and definition, increase in inner margin curvature and hanging columella. The philosophy of my technique is reshape these areas underlined in red, just basically with sutures. And this approach is a marriage between preservation rhinoplasty plus structural rhinoplasty too. And regarding the tip, the maneuvers in tip are in position, size, shape and strength. This is the general guidelines of the primary approach in my hands. Create a level of discrepancy torsion tip four to 12 millimeters, create a stable interdomal distance of five to 14 millimeters, create a lateral curve of flat or slightly concave as needed create a tip with adequate rotation and projection. The framework must be symmetrical, be free to use any shaping suture or conservative resection only of the redundant supradomal cartilage in the midline. This is really important. Use cartilage grafts as needed, set midline support of aileron framework by columnar strut, tongue and groove or septal extension graft, whatever is needed in any given case. No, I never perform parallel steel. I never perform middle curve overlapping. I don't perform deliberate approach both only infracart incision and when indicated hemi or complete transfixion incision and respect or repair ligaments and close that spaces. These both papers are from my own, are the basics of this lecture in PRS and Aesthetic Journal. And this drawing shows the main concept of my approach. In the red and violet lines are the possible potential places to be resected if needed to improve the shape and position and rotation of the, sorry, of the ailers. And in this frontal view is basically the same. Look, the wedges is what the way I call it can be asymmetrical. Why? Because too often the framework is actually asymmetrical. So the solutions should be asymmetrical too. That's why. And basically this is based in sutures and very conservative resection if needed. Sometimes I don't resect nothing at all. And this drawing shows the intercephalic sutures with or without grasping the dorsal ledge near of the anterior septal angle of the septum. Well, in this view, we can see the placement of the sutures. There is no specific cook recipe to use it. It's in every given case, what I have in my mind is to change the shape. What I need to do to get that goal, it doesn't matter for me. Just make what you need to do. And I designed the sutures published in 2005, cephalocoron suture just to flatten or if I want to create some supple concavity in the supradomal area. And some pictures of this, this is the anatomy preserved always in the midline. The anatomy is preserved. If this happens, the resection is really conservative. And some example of this, placement of pulmonary strut, domal sutures. If needed, some groover sutures or now I can use even other kind of sutures to change the contour. I'm not specifically related to any specific technique, just change the contour with sutures as you need. Change the contour with sutures as you need. We're short of time. That's why I need to show somewhat faster. This, for example, is a domal spur graft made with a cartilaginous hump. And if I want to shorten, to create a subtle rotation in the supradomal area, I can make a very conservative medially based wedges just to shorten and create some rotation or even a slight definition in the supra-tip area. And these are the sutures, just to stabilize, to obtain symmetry, to obtain a good contour with sutures. And this is another example. This suture can also used to help to improve the overall contour in the supradomal area or in other words, the supra-tip area. And this is what I do in most of the cases. I design the suture, I told you before, cephalocular suture. This change was done without any resection at all. And some videos, this is what I do, three reference sutures at scroll, pitangue and the other side scroll, following the Hansel and Gretel, you know, tail. And after the, I give, I use the, I do the tip work just at the end. And after the placement, for example, columnar strut before domal sutures, look the change in the contour, the lateral cura after the domal sutures. After both sides, there is evident change in the contour of the lateral cura. And if I consider need, if I need it, I place lateral cura spanning sutures described by Tevitz in 1994. And it's a really powerful suture usable nowadays in my hands. Of course, it's really, really powerful suture. Of course, if I try to match the suture, I can induce some internal and external bowel collapse. This is really powerful suture. And sometimes I reset the cephalic base wedges. And this is the framework after the modifications. Sometimes I don't use the PEG because I'm satisfied with this diamond-like shape. Or sometimes I use the PEG just to obtain stable interdomal distance and stable interdomal distance to be able to defend against the contractors. Interdomal contractors is what I'm saying. That's why sometimes I use the PEG not for projection purposes, just for stability. This suture, I designed this intercrural suture, crural or domal in 1999. And I place the septal extension graft, I set the projection. And if I see the contour is still with some convexity, I can place the groovers or navis sutures in more present times also. I use boats. I do whatever I need to do to obtain my goals. And this is the change. Sometimes I use a very small encephalic lateral crural spandex sutures, the mini version of lateral crural spandex sutures also. And this is what I do. This is the shape what I have. Look, this suture, and this suture, what I designed it, the steps to place it, cephalocrural suture. Now I use, in the vast majority of my cases, I use PDS 5.0, and this is what I do. As the cephalocrural suture is tightened, there is a change in the supradomal and infradomal contour also. And it's a very powerful, usable suture. Of course, should be used judicially. Frequently I use a gyrus suture to supra-tib dermis. And sometimes if I consider it necessary, I reset some of the supra, the skin in the columnar. Some examples of this with thin skin, a long, somewhat long, natural results. This is what I do in my cases. I don't like to rotate the tips too much. I prefer, strongly prefer natural results in my cases. This is what I do. Five years follow-up. And with medium thickness skin is the majority of my cases. This is the kind of results what I can obtain with this approach. At the test of time, five years follow-up. I use and still use some shins or pecs, wraps. I don't care, it's not a problem for me in medium or thick skin. 19 years follow-up. We can see the results is maintain and even 24 years follow-up. And in this case, she had in the post-op one year of follow-up, a slight deviation to the tip to the left. 23 years after, 24 years, this still is a little bit to the left. What it means? Stability. What for me is really important. She's satisfied. She's okay with it. And finally, with thick skin, definition is what desperately she needed. And it's what I've done with her. And in this case, I also perform a slight ingenioplasty. And this is the last patient in my, at least in my hands, it's for me impossible to obtain definition without increasing, augmenting the nose. That's why I was directly to augmentation because there was no other choice. And finally, the conclusions. Currently I reset a little bit more. At the beginning, the cephalic base wedges was an average five by two millimeters. Now what is this? Six, seven by three, four millimeters. And medial base wedge was two by one millimeter. Now it's three by two on average. It's more anatomic and physiologic. The interplay between sutures can be more complex to understand, especially if you see this for first time is, wow, what is this? There is some tendency to under-correction because this technique pushes you to be conservative, reducing it of cartilage grafting to nasal lobe, respect and repair the nasal ligaments and avoid that spaces and the complications are under-projection, over-projection, asymmetry and graft displacements. The same, so of course I have it. For me, nowadays is a marriage of preservation and structural rhinoplasty. For your attention, thank you very much. This is a picture of my place. Thank you. Thank you. Beautiful. Thank you so much and wonderful results over a long period of time for follow-up. And thirdly, we have Dr. Matarazzo speaking on two topics. Hello, I'm Alan Matarazzo from New York and I'm gonna be discussing today demystifying the closed primary rhinoplasty, 10 essential steps. I have no financial disclosures. So the order of today's discussion will be an introduction, 10 essential steps, some videos, my most often used operative steps and some examples of closed primary rhinoplasty. Then for purposes of showing you what I do all the time, I'll show you nine consecutive cases of closed tippy version rhinoplasty. Then I'll show you some data from the American Board of Plastic Surgery, Continuous Surgery, and the American Institute of Plastic Surgery. The Plastic Surgery Continuous Certification, tracer data, and it'll give you some idea of what your colleagues are doing and then a summary. So rhinoplasty is often considered a difficult operation. It's hard to teach, learn and perform for many reasons. There are many anatomic variations with multiple solutions. It's often considered too complex. There's no agreement on basic principles. And when we try to learn it, it's extraordinarily analyzed and there are strong differences of opinions about how to do things. So there's really no standard rhinoplasty, but my goal today is to take you through a very typical, if you will, primary rhinoplasty. This was an article written by Mark Constantian from New Hampshire asking why good surgeons can't seem to learn rhinoplasty. As Mel Spiro, the former chief of Baylor said, it's the one operation you can never do enough of during your residency. And Ronald Daniel gave a well-known address about why plastic surgeons often stop doing rhinoplasties a few years after they get into practice. So as Rod has said, and the Einstein quote, the definition of genius is taking the complex and making it simple. And that hopefully will be the purpose of this lecture. So the 10 key operative steps that I use is skeletonizing the nose through a bilateral intercartilaginous incision down to a full transfixion incision. This just takes a minute or two, allows you to completely skeletonize the nose for a closed rhinoplasty and not encounter a lot of swelling after you do it. And by the way, although I will be talking about closed rhinoplasty, everything we do you can do in an open rhinoplasty should you decide that you prefer to do it open. The concepts are the same, we're just not making a collumella incision. The periosteum is then elevated off the nasal bones and then we sweep the depressor septi off the maxilla, which improves the plunging that you see with a nose when smiling. The next step is we detach. We don't do a submucosal dissection, but we detach the upper lateral cartilage from the septum with an 11 blade and protect the skin with an Alfred retractor. The tip is then addressed through algorithmic tip surgery via a tip aversion technique, a conservative cephalic trim, leaving four, five, six or so millimeters of cartilage. Then most of the time we use a collumellar strut, which can go up to the domes with a strut or even slightly beyond. I don't feel it's necessary to bring it down all the time to the anterior nasal spine. I think one of the most significant things is use of cartilage reshaping sutures, which will show you intracorral, intradomal or lateral spanning sutures, which really bring in the lateral curve very significantly. I use a cap or shield graft frequently. Often I will use the lower lateral cartilage to make the cap graft, I'll often use it in layers. And I use Durabond glue to glue it together and then I actually glue it onto the dome area. These are some other things that we can do to the lateral cora, although they're done less frequently. Medial coral surgery is done by trimming a hanging collumella. And when you trim the hanging collumella, the lower two thirds of it will shorten the nose. If you angle the upper third, that'll angle the nose more cephalically. A wedge removal of the medial cora is done to decrease the projection when that's necessary. And then at the end of the operation, if the foot plates are flaring out, we'll often bind them together to prevent flaring. Dorsal component surgery is done usually as a reduction of the upper lateral and the septum with, and I have no financial interest, with a super cut, stilly foam and scissors, which I find is an essential part of my tray. And then I rasp the nasal bone. If it's a very significant nasal bone, I'll reduce it with a double guarded 10 osteotome. Cartilage grafts are used towards the end of the procedure. As indicated, I very often use dome grafts or lateral sidewall grafts. I very rarely, if ever, use spreader grafts on primary rhinoplasties. And sometimes instead of a strut, I will use an extension graft. Caudal septal modification, as I mentioned, is done on the lower two thirds or the upper third to angle it up. Then I will do an osteotomy low to low laterally, a medial oblique osteotomy with a guarded osteotome. And I don't hesitate to do a percutaneous osteotomy when indicated with a two millimeter osteotome if I feel my osteotomy is incomplete. At the end of the case, I assess them for an alor base reduction. And occasionally when I'm doing an alor base reduction with the ala in the air, I thin inside the ala to thin a thickened ala. And you can see the reference to that was in October, 2001 in the journal. This is a typical tray that we use for a rhinoplasty. The only thing that's not on this tray, which is essential, is a tip scissors. And you can see the black handle large scissors there is the Stille Fomen super cut scissors, which I find very important for using to take down the dorsum and the upper lateral cartilages. And let me show you quickly in a video a little bit about what we've just talked about. This is the inter cartilaginous incision being made bilaterally and skeletonizing the nose with a 15 blade. The knife is turned around, brought down to the dome. And then a button knife is introduced to complete the transfixion incision by retracting the collumella downward with two single hooks. And when I get to the base of the collumella, and notice how straight the collumella is there. I'll mention that at the end. When I get to the base, I finish that off with scissors. I'm detaching the upper lateral cartilage now with the Alfred protecting the skin using an 11 blade. We're detaching that from the septum. So now the nose is completely skeletonized and using a rimming incision, I'm delivering the lower lateral cartilage. And trimming the cephalic and doing a cephalic trim of the lower lateral, leaving about five millimeters of cartilage. And this is both sides that have been removed. I'm shortening the caudal septum and I'm about to rotate it by angling the upper third of the caudal septum and trimming the mucosa with the scissors. And now I will deliver my lower lateral cartilage. And when indicated, place a strut between the medial cora. In this case, there's no strut. These are 5-OPDS sutures and these are just intracoral cartilage reshaping sutures with 25 gauge needles, equilibrating the cartilage. And intradomal sutures, and those will either be simple or mattress sutures in the dome. And at the end, we'll show a diagram of these sutures. So the cartilage is reintroduced and that's that portion of the operation. So let's take the first example of a patient who dislikes the appearance of her nose. This is her pre-op and on the bottom post-op. And the operative techniques that we used in her were skeletonization, algorithmic tip surgery that we showed, segmental dorsal reduction of the bony hump, the septum and the upper lateral. At the end, she appeared a little bit crooked despite working on the septum. So we used a lateral nasal sidewall graft made of lower lateral cartilage that was crushed. And then we did osteotomies on her. This is her picture in the worm's eye view. And this is delivering her tip with a strut graft held in place with 25 gauge needles. This is her pre and post and her data sheet. And you can see on the data sheet that she has a strut graft, a cap graft that's glued together and then glued on the dome and in green, the lateral nasal sidewall graft and pre and post-op. So what are the most often used operative techniques? Most of these are done under general or LMA anesthesia. I use cocaine packing, the cocaine is diluted and then 1% local anesthesia with epi for injection and TXA pre-op intravenously. I use a bilateral inter cartilaginous incision and then I skeletonize the nose with a knife down to a full transfixion incision using a button knife. A Joseph periosteal elevator is then used to sweep the periosteum off the nasal bones and the depressor septinasal muscle off the maxilla. Alfric retractor is used to detach the upper laterals with an 11 blade from the septum. Then I do a rimming incision, I deliver the tip, cephalic trim, collumel or strut grafts, cartilage reshaping sutures and then a cap or shield graft that's glued on with Dermabond. And then I go to the caudal septum, I shorten or rotate the caudal septum as indicated. Then I do my middle third of the nose, trimming the upper lateral and trimming the septum, rasp the dorsum and then I do a low to low osteotomy using a number three osteotomy in females and a number four osteotomy in males. I use a guarded osteotome for oblique osteotomies and then I will perform a percutaneous osteotomy using a number two osteotome if indicated. Grafts are used at the end of the procedure and then we assess the patient at the completion of the endonasal portion of the operation for the need for alar base resections or alar rim incisions to thin the alar rim. And as I go through this process, I'm constantly reassessing the dynamics of the nose and going back to what I may need to alter. So let's look at some examples of closed rhinoplasties. These are two sisters that came in before on the left and postoperative on the right. This is a 15 year old before and after a rhinoplasty using the techniques that we discussed. On the top is pre, the bottom is post-op. And this is her sister. Similar technique, we rasped the dorsum, took down the upper laterals and the dorsal septum, did a tippy version technique with a cephalic trim and used cartilage reshaping sutures with an intracoral strut and we shortened and rotated her septum. Before on the left and on the right postoperatively. And you can see on the top pre and the bottom post-op. There were no spreader grafts used here or upper lateral flap retention spanning sutures for the upper laterals. That was just reduced. In the operating room, as I mentioned, we use a gram of TXA, actually a half hour pre-op, packed with cocaine and an inject with lidocaine and epinephrine solution. Postoperatively, I almost never pack the nose unless we're doing combined breathing surgery and the ear, nose and throat surgeon wants to use it. We just squirt some bacitracin endonasally. Most often use an aquaplast splint and then a mustache dressing. Occasionally, you'll see a patient that has had a nasal fracture and will want some cosmetic changes. In these cases, we reduce the fracture first and then while stabilizing the pyramid, we do whatever cosmetic grasping is necessary on the dorsum or the middle third and then complete the cosmetic rhinoplasty. Often, these patients will require an osteotomy on the non-fractured side. The point being that you can do the cosmetic work with a nasal fracture reduction. And this is an example of a patient with a nasal fracture repair and a rhinoplasty at the same time, pre one week and six weeks on top and her post-op's on the bottom. And same pre on top, post on the bottom following a reduction of a fracture and some minor cosmetic changes that you requested. So, you know, the best results that we get are the results that the patients are happy with. So it's very important, I feel, with rhinoplasty not to over-operate. As Yogi Berra said, operate only as much as you need to operate. Don't over-operate on these patients. This is another example of a randomly selected 16-year-old. On the left is pre-op and on the right is post-op. You can see using these maneuvers that we just discussed, a standard rhinoplasty in a 16-year-old endonasally, same patient, post-op. And this is her data sheet. She had a strut placed and intracoral sutures and then intradermal sutures using a mattress suture and some spanning sutures from the lateral cora. Her foot plates were flaring out. So at the end of the operation, we bind the foot plates using a chromic suture. And you can see on her sagittal view, we've shortened her septum and rotated the septum to prevent some of the plunging. Another example, this is done along with an ENT person, in conjunction with an ENT person. This is one week post-op. And note, she has a very flat forehead and a soft chin. This is her result from her rhinoplasty immediately post-op. Unfortunately, we haven't seen her much since. This is a 17-year-old girl following a rhinoplasty and intranasal functional surgery. This is her data sheet using really the same procedures that we discussed, medial and lateral osteotomy, reduction of the upper lateral and septum, and then cartilage reshaping sutures with a strut, no cap graft, and lateral spanning sutures of the lateral cora, which really bring the lateral cora in on these wide noses. So, you know, we often talk about how, what the patients see, and the results of our rhinoplasty are often judged by what the patient sees in their profile view. This is an example of that. Again, a randomly selected example, pre, one week post-op, and then six weeks following an endonasal closed rhinoplasty. Another example, secondary facelift, secondary brow, secondary laser, and a rhinoplasty in an older woman. And she had her dorsum rasped, osteotomy, upper laterals reduced, a tippy version with a cephalic trim, and cartilage reshaping sutures on her tip. And this is her example at two weeks, and then at three weeks, she went to an event at the White House at 19 Days and sent us this picture. So for the next section of this, I thought I would show you some consecutive cases of rhinoplasty so you can see what we're doing on a regular basis for rhinoplasties. So these are nine consecutive rhinoplasty cases. Obviously, they each have some different indications. This is the first young lady. She's a 15, almost 16-year-old patient that wanted a little bit of a scoop of her nose. She was pretty adamant about that and wanted her buccal fat pads reduced. This is before her rhinoplasty, before liposuction of the neck and buccal fat pad removal, one month and then two months following rhinoplasty, liposuction of the neck, and buccal fat pad removal. And the opposite side, lateral view, the left is pre-op and the far right is two months post-op. This is her data sheet. Using the methods that we talked about, the tip was averted. She had a strut placed in there, intracoral, intradermal, and lateral spanning sutures. We rotated the septum, as you can see in the sagittal view, did a medial and lateral osteotomy and an ALER base resection. And with the ALER base up in the air, we thinned the ALER by reducing the ALER rim. This is her before on the left and post-op on the right with her data sheet in the middle. And as I wrote on the data sheet in the upper left there, the patient wanted a more done, if you will, scooped-out appearance of her nose. Now the second case is a woman that had a prior rhinoplasty, and philosophically, when we operate on secondary rhinoplasties that are not our own, I like to see if possible their old records and photographs and identify very specific concerns that the patient wants addressed because you can't always achieve what you might in a primary rhinoplasty. So I try to emphasize any limitations of the secondary procedure. When the patient is confident and I'm confident in the primary rhinoplasty surgeon, I'll often suggest they go back to that person. This is a woman that was very specific about these three things. This is her before picture on the left, post-op day 12, and then five weeks later, and then she went back to Texas where she lives. She has a hanging collumella. She wanted her nose straightened a bit, and she wanted more of a scooped appearance to her nose. She had some difficulty breathing. We did her surgery with an ENT colleague who worked on the functional rhinoplasty part. He prefers to do them open, so she had hers done open, and we addressed those three aspects of the cosmetic appearance of her nose, and you can see her open scar. This is her pre at day 12, and then five weeks post-op. Secondary rhinoplasty with grafting and ear, nose, and throat work. Case three is a primary rhinoplasty in a very thick-skinned patient. On the left is the pre-op, and the right is the post-op. This is her pre and post with a data sheet. She had a lot of bleeding, and we did the same things that we talked about, a medial and lateral osteotomy. We did not rotate her septum or shorten her septum at all. She had a strut graft with intracoral, intradermal, and lateral coral spanning sutures, and then we defatted the dome a little bit above the dome area in the skin to reduce some of the fullness and thickness of her skin. This is the Dermabond that we use when we glue grafts together. I find that when you're making a cap or a shield graft in layers, that sometimes it's a little difficult to sew it together, so if you place just a drop of Dermabond glue, and it doesn't exceed the boundaries of the cartilage, you won't get a foreign body reaction, and you can glue the cartilage together, and then, in fact, glue it right onto the dome if you choose to, as long as the Dermabond doesn't get outside of the width of the graft. And this is that same patient before and after a month, and she went back to school with thick, oily skin, and in these people with thick, oily skin, which case number three and number four are, we sometimes will use Preoperatin A. It's very important to provide a good intraoperative framework for these people. I will be a little aggressive in excising fibrofatty tissue in the tip area. If necessary, we can use low-dose Accutane postoperatively, and I find this elastic taping and nose cone very helpful in reducing the edema and the swelling in the tip, particularly in these people with thick skin. This is another example. This is the fourth case. She's a secondary rhinoplasty, and she has thick, oily skin with a short, tethered collumella, which we're going to talk about that a little bit, and this is her pre- and post-op. On the top, pre- and nine-days post-op, in a secondary rhinoplasty, she had thick, oily skin with a short collumella, which we'll discuss in a minute. She had a multilayered tip graft that was glued together and glued onto the dome, and the medial footplate and medial cora were bound together to prevent the flaring. This is her data sheet. She had a cephalic trim, intracoral, intradomal, and lateral canthal sutures. You can see the footplate is bound together at the end of the case, and we didn't shorten her nose, but we rotated her by the upper third of the septum trim of the caudal septum, and this is her before on the left and post-op on the right. Case five happened to be a nasal fracture that wanted some cosmetic work. You can see pre- in the middle, seven days, and eight weeks post-op, and the pre is top and post is on the bottom, and you can see her nose is straightened, and she had some minor cosmetic changes to her nose. You can see pre and post, we reduced her fracture and just really rasped her dorsum a little bit and actually did an osteotomy on the opposite side. So the next case is really going from rhinoplasty 101 to rhinoplasty 401, if you will. This is a lady that had a tertiary rhinoplasty in our consecutive series of cases, and we really had to deconstruct the nose basically and start all over. This was the patient many years ago on the left. She came in for a secondary rhinoplasty. Years later, in the second picture, she's pre-op, a tertiary rhinoplasty, then post-op one week and post-op six weeks. It's very hard to see, but in the second picture, her skin is very wrinkled over her cartilage grafts that had been placed by the earlier surgery, and you can see the outline of her grafts in the second picture here, and in the third picture, post-op, her third rhinoplasty, the skin is smoothed out, a new graft is placed in that's no longer palpable, and in the final picture on the far right, she has a smooth dorsum, both with the skin and the graft. So when she came in for a secondary rhinoplasty, the second picture is before her tertiary rhinoplasty, then one week after and six weeks after her tertiary rhinoplasty. She had surgery along with the ENT person for breathing, so we used an open approach, which is his preference. The old dorsal grafts that had been there after the secondary rhinoplasty were removed, and these were used for lateral coral onlay grafts, and then we used MTF cartilage for spreader grafts, and on the left side of the spreader graft, we pushed that caudally to make it a septal extension graft. We then used Alloderm, wrapped it around crushed MTF cartilage for a dorsal onlay graft, and then we made a shield graft out of the MTF cartilage graft. So pre-op, this is her post-op, and prior to her tertiary rhinoplasty, one week and six weeks post-op. This is her surgery. She had some—she had dorsal onlays of the lateral cora to give more support to the lateral cora, medial and lateral osteotomies. The dorsal graft was taken off, crushed, and used for lateral coral extension grafts, and then you can see she has a large shield graft and an extension graft was placed on the left side, and this was done through an open rhinoplasty approach. On her left is her pre-op and post-op. On the right at six weeks. Case number seven is a young man who also had breathing surgery, all done through a closed approach, pre-op, one week post-op, and seven weeks post-op in this 18-year-old man. He had intracoral, intradomal mattress and simple sutures, and lateral corals spanning sutures, which are above the dome and brings the lateral cora together. I often don't tie this down as a knot, but tie it as an air knot so that the lateral cora aren't brought too close together. This is an example of lower lateral cartilage reshaping sutures from the article by Sam Lennon and Rod Warwick that was in the February 23 White Journal. This article is an outstanding review article for cosmetic rhinoplasty and also shows you the common sutures that we use, sutures numbers two, three, four, and five, and then occasionally sutures on the lateral coral sutures six and one. This is him pre, post, and then seven weeks post-op. And this is his data sheet with the intracoral and intradomal sutures, and the foot plates are binded together with a septal strut graft in between taken from the dorsum, and the nose is also shortened and rotated on him as well by modifying the caudal septum. He had nasal packing and nasal splints because of the ENT work that was done intranasally. Pre, post, and seven weeks post-op, and you can see the change in the profile particularly on him. Now, I want to just make mention of this. This is what we call a waistline sign. When you put two hooks in the bottom of the collumella and a double prong in the dome area and you pull apart the collumella, you'll see some ischemia in the middle of the collumella because in the shortened tethered collumellas that you need a graft in, the skin is also shortened. And then when you get the cartilage out, as you can see with the green arrow, the green arrow at the top shows kinking in the cartilage. And so in these people, you can determine preoperatively as you distract the collumella, there'll be some ischemia in the skin. And then when you dissect out the lower lateral cartilage, because of the shortened skin, the lower lateral cartilage will be kinked. So you've got to dissect the mucosa off both sides of the cartilage, place a strut and sutures in that to straighten out the kinking in the lower lateral cartilage, and also to increase their projection. This is what we call a waistline sign in a shortened tethered collumella with a kinked lower lateral medial coral footplate cartilage. Another example in a video showing this technique, intercartilaginous incisions, and the nose is skeletonized through the intercartilaginous incision with a 15 blade, the knife is reversed, taken down to the dome, a button knife is placed and a full transfixion incision is made. You can see the cartilage is distracted with the single hooks, and the depressor septi is taken off with a Joseph periosteal elevator, which is then used to free the periosteum off the nasal bones. The nose is now skeletonized and that's completed by detaching the upper laterals from the septum where they join with an 11 blade. And now we're going to evert the lower lateral cartilages through a rimming incision. And the rimming incision is completed on her right side, the tip is delivered, a cephalic trim is performed, saving the lateral aspect of the lower lateral cartilage to prevent an external nasal valve collapse. The same thing is done on the opposite side, we're delivering the lower lateral cartilage on the left side, trimming some of the fiber fatty tissue, doing a cephalic trim, preserving that lateral outer third of the lower lateral cartilage to prevent a valvular collapse. This is taking down the dorsal septum, and we'll use that for a graft, taking down the upper lateral now with a stilly foam and scissors. And trimming the upper lateral further, rasping the dorsum with a five, number five rasp. And then we'll deliver the lower lateral cartilage, stabilize them, and make sure the domes are equal, place our strut between the lower lateral cartilages, secure everything with 25-gauge needles, and using a 5-0 PDS, place intracoral sutures incorporating the strut graft into that. And as I mentioned, the strut graft goes up to the dome, occasionally beyond the dome, and I don't find that I necessarily have to go down to the nasal spine. These are intradomal sutures, and this is going to be a lateral spanning suture where I'm bringing the lateral core together, replacing it, and then constantly reassessing the appearance of the nose. A converse retractor used, and I just shortened the nose, and I'm performing my medial osteotomy after I did my lateral osteotomy. This is with a guarded osteotome, and now a 2-millimeter percutaneous osteotomy, marking for alar bases. Alar base is done, and sewn lateral to medial. And this is case number eight, three, and on your right, post-op. We've been unable to see her beyond a week. She's a banker, hasn't been able to come in. And this is her data sheet using the techniques that we discussed. She has a strut, and then cartilage reshaping sutures. No shortening of the caudal septum. No shortening of the caudal septum at all. And the final case is a primary rhinoplasty, six weeks post-op, pre and post-op, pre and post-op, controlling the tip projection and the tip points. And this is her on her data sheet. We've shortened her septum, rotated her septum, taken down the middle third of the nose, used a strut graph with intracoral and intradermal sutures, and bind her footplate. And this is her appearance pre and post-op. And you can see in the lower picture how much that's changed her projection before and after. So let's move to the final section. This is section nine. What are your colleagues doing? What we did is we looked at the tracer data from the American Board of Plastic Surgery, and we looked at a cohort of patients looking at how rhinoplasty had changed among practicing plastic surgeons. This is published in Aesthetic Plastic Surgery Journal, looking at this data. And just to summarize, this is all of the cosmetic tracer data that was appeared to the American Board of Plastic Surgery. Unfortunately, rhinoplasty was the lowest percentage. It was 1.4%. Breast augmentation was the most commonly selected tracer data. It was 62.5%. And then facelift, blepharoplasty, liposuction, abdominoplasty were also reported. Rhinoplasty was 1.4% of the total of 50,000 cases that were reported. And cosmetic tracer was 62% of all tracer data. This is just a summary of what plastic surgeons were doing. 96% of the plastic surgeons were using general anesthesia. The age range was 13 up to age 84 that were having rhinoplasties. The mean age was 32. 80% of the patients were female. 81% of the cases were open. As I mentioned, with this closed tippy version rhinoplasty that we just presented, the steps and the maneuvers is the same. There's just no collumellar incision. 54% of the patients had septal surgery. 50% had septal struts, 45%. And it doesn't distinguish between primary, secondary rhinoplasty, had spreadographs. Most of the patients had osteotomies. About 10% had alert-based resections and concomitant procedures. Other than the nose was performed in about 15% of the patients and about 5% had breathing surgery done in conjunction with your nose and throat surgeon. So that gives you sort of an overview of what your colleagues are doing in the rhinoplasty practices. So to summarize this closed tippy version endonasal primary rhinoplasty, these are the 10 key standard steps that we work off of. And then the primary workhorse maneuvers in a primary rhinoplasty is appropriate skeletonization, dorsal surgery, the upper lateral septum, algorithmic tip surgery with a conservative cephalic trim, cartilage reshaping sutures, collumellar strut and cap graft, medial and lateral osteotomies, percutaneous as necessary, miscellaneous grafts if needed, and then also if needed, an alert-based resection. These are the workhorse maneuvers on primary non-traumatic endonasal rhinoplasty. Thank you for your attention. Good day. Wonderful. Thanks so much, Alan, and lots of details and video that I think everyone learned a lot. I want to be respectful of the next panel and time, and so we have just about 15 minutes right to the questions for Dr. Rorick. First question, can I know where you usually harvest your septal extension graft and how do you address cartilage warping? Great question, Sam. I think the most important thing is you want to harvest it in the mid to lower septum. It's usually the straightest part, especially anterior, so harvesting straight septum is important. If it's not straight, then you can shave it on one side or the other, you can score it, but I think the most important thing about rhinoplasty, and all of the speakers mentioned it, is that you have to do things that are consistent and reproducible, and rhinoplasty is very complicated, so if you can break it down into small, simple steps, that gives you the best results, so I can't overemphasize that, and that's why I think one of the most cardinal things that I talked about and that a lot of the others talked about is that do things that work and that are consistent and reproducible, and I also like to do things that don't have visible grafts. That's very important to me. I rarely use visible grafts except for in secondary rhinoplasty and also in ethnic patients or thick-skinned patients, so simple is better, and preservation and structural, I think they're just modifications of the same thing. The key is, you know, less is more. Don't be destructive, and preservation rhinoplasty is kind of amplifying what we've always done in structural rhinoplasty. Wonderful. I want to expand on that. Can the other panelists also comment on their thoughts on preservation rhinoplasty, which as we all know was described in the late 1800s, early 1900s, and now is sort of a third resurgence and renaissance, but I would be interested to hear what others also have to say. I mean, I've done about 30 cases of preservation rhinoplasty. It's a great technique in a very highly selected patient. Straight dorsal static lines, not so deviated. I think people are in the zealot phase. They're using it for everything. You know, remember, don't reinvent the wheel. And rhinoplasty is hard enough. You have to master, in my opinion, you have to master structural rhinoplasty concept. Be interesting what Alan and Arturo think. You have to master structural rhinoplasty first before you do preservation, because preservation is a misnomer. And I love it, it is not preservation, because you have to really understand the septum. And Sam, since you're dual boarded, I think you'll agree. I was recently on a webinar with Sam Most, who's a facial plastic surgeon, and he said he's very, very reticent to do the low septal procedure, and he's actually backed off a lot. So be selective in doing it. It's a good technique, but not for everybody. Dr. Ragonado, please. Okay. I agree with Rod, basically. And in general terms, almost all of the cases should be called hybrid or mixed rhinoplasty. For example, in Europe, all of the stuff about preservation, but with the single use of columnar strut or variations of septal extension graft, by adding a piece to make the framework stronger or more stable, by definition, it's a kind of structure. In other words, it's mixed or hybrid. For me, regarding specifically about the ailers, after 20 years doing this, I'm strongly convinced why to resect something, purpose-driven structure. That's why last time I did, for example, a cephalic resection was 28 years ago. 100% of the time we have any resection, excision, or whatever, we will get scar with the well-known consequences. That's why I strongly avoid. My slogan is clear. We shape rather than resect. That's it. In ailers, it's different in comparison with the dorsum. It's not the same. I'm talking about ailers. The first description of the technique was written by me in PRS in 1999. I'm following this original idea. I've taken enough of your time. I don't really have anything to add. Ellen, have you done a preservation? I've just played with it, but not on my own, Rod. I would defer to what Rod said, who's always taught me more than I've taught him. I agree with what you said. Sam Most has been excellent with that, but no, I don't have enough experience to really comment yet. I think the people on this webinar should understand is that there are no absolutes in medicine and certainly not in rhinoplasty. Everything's an evolution. Do things that work and well in your hands. That's why I rarely ever say never or always, because there are always exceptions. The type of practice that I have is very diverse because it's North America. Sometimes in some parts of the world, people like to have over-rotated and really defined tips and slope. That's okay, but it varies in the part of the world you live in. As Arturo mentioned and Ellen showed as well, never do anything that's outside your aesthetic norm because then you don't know when to stop. Well said by all. Thank you. I definitely have some thoughts on that. We have some interesting data. We talk about aesthetic outcomes for the Northeastern rhinoplasty on that component, dorsal component versus preservation and interlacing function. Thank you. Next question, anyone's thoughts on TXA? Dr. Matarazzo, of course, presented his concoction with using local and TXA coming from North Macedonia. I love TXA, just like Ellen said. I use it IV and I use it topically. I give a gram pre-op and in secondaries and males and revisions, I use two grams. It's very safe to do. You can do it per kilo, but usually two grams is max. The other thing I've actually pulled back, Ellen, on using it with my local because in my facelift patients, I've had some instances of atypical skin issues. I stopped using it after about three or six months of facelift. I stopped using it in rhinoplasty, but it's very powerful to use for topical. I mix it with equal amounts of lidocaine. It's both a hemostatic agent and an antifibrinolytic. IV, it's magical, but it's not a substitute for hemostasis. It's like anything else. I concur. I got that also from Rod. I started using it during the end of COVID. I've been using it really in everything, but I backed off on the face a little bit. I don't want to spend too much time on that, but I had some issues with it. I definitely use it exactly as Rod has written and described on a nose. It's not going to prevent a hematoma. It's going to give you less ecchymosis. I've had my experience with it in rhinoplasty. Can't say no, not in rhinoplasty. Thank you. Next question comes about MTF grafts. Everyone's thoughts on longevity. Well, I published it recently in the White Journal. I've used it now almost 13 years, well over now probably 1,500 patients. What people have to understand is that it's not a radiated fresh frozen rib. It's not a radiated tissue. It acts just like your own, and we've shown that both in histologic and in longitudinal studies. I use it two, three times a week. If you like harvesting rib, I did rib harvest for 15 years. The last 15 years I've used fresh frozen rib. It's not available in all countries. I think it's phenomenal. I use it in primary rhinoplasty sometimes in patients that have weak cartilages. I use it a lot in my Hispanic patients when you get in there and they have no septum, and you can't support a tip unless you have significant septal support using a septal extension graft. I absolutely concur with that. In those nine consecutive cases, it was essential in two of them. I think it's great. It's been a real game changer. Okay. I know Rod's paper about it, and I fully agree with it, but in my country, basically we don't have available yet in that kind of cartilage. That's why I use autologous in vivo rib harvesting. Great. I think if you don't have a fresh frozen rib from MTF, and I have no interest in the company. In fact, it's New Jersey, New York. I would not use a radiated rib. I would use a fresh frozen rib. I do that sometimes when a patient requests it, but patients also, they like it because there's no additional scar. There's no pain. I recently did one, and all the post-op, my post-op FaceTimes and stuff were all not about the rhinoplasty. It was about the donor site. It doesn't matter how small the incision either. It hurts. You know, the other thing that we put on all of, and I learned this really from Tom Reese, we put on all of our consents, possible cartilage graft, possible ABR. Because there are many times that I've gotten in and I just say, you know, let's warm up the cartilage and I need it. So it's on the consent for all patients. Yeah. Same here. And it's easy to do that, but it's not easy to say, oh, by the way, you may wake up with a rib harvest. Exactly. That's not a surprise that most people don't like. They should know in advance, of course. Agreed. Wonderful. And then last question right now for Dr. Matarazzo, our next one, talking about rhinoplasty following nasal fractures. Can you please elaborate on the optimal timing for performing the procedure after the acute fracture? So, you know, the point was that, you know, we have a golden period, obviously, with a fracture. And some people have said that you shouldn't reduce the fracture and do the cosmetic rhinoplasty. I don't know how my colleagues feel, and I would like to hear how they feel. But the point there was that I was doing it within the golden period, within that two weeks or so before you get a callous formation in the bone. So I think in most cases, I'm okay doing cosmetic work at the time of an acute reduction. Rod, Arturo, how do you feel? I mean, I think you can depend, honestly, depends on if it's a simple fracture, and it's nothing else going on. But if it's a, you know, a real yeah, yeah. Community factory, of course, I'm not going to do that. I've infrequently done that. But I'm not opposed to it. Like you said, if you know, if it's a simple fracture, like this week, I saw an NBA player that got slammed on the on the floor. And, you know, that one, I wouldn't I mean, I've done a cosmetic procedure on but I would say it's okay. In general, though, like, especially if you're taking your oral exam, I probably would say don't do it, right? No, I think I would emphasize what Rod said. I mean, if it's if it's, you know, the dog jumping up and you have a simple fracture on one side, and then they want to reduce the hop or, or take down the thickness of the tip fine. But if it's a difficult, then you're just better off doing it in a in a later day at a later date. Generally speaking, I'm reluctant to perform it because being the rhinoplasty equation, really, really complicated in my hands for me in my mind. Doing something in a patient especially cosmetic before in a patient who I didn't meet before standing, discussing, discussing pros and cons in the of the procedure, the goals, my own my opinion, my goals, and my opinion in comparison with the patient's goals and opinions is really for at least for me really complicated. That's why I prefer to say unless it's a simple, linear, small fracture, nasal fracture, I could say, okay, without tip trauma because it's really complicated in the normal standing patient in your office in a selective consultation in the OR or somewhere else in the hospital for me is really difficult. I prefer to postpone the surgery after several, two, three, perhaps months, at least, to be sure about what we want, and if we can match the patient's goals with my abilities, my goals to obtain it. That's, that's why I prefer to wait, generally speaking. Right. Wonderful. Well, we're out of time now. I want to really thank our panelists for spending their weekend day Saturday with us and globally, and we'll move on to the next panel. I want to introduce my friend and colleague. Thanks so much, everyone. I want to thank my panelists and also welcome Dr. Amy Caldwell, our friend and colleague, who will moderate the next session on breast pearls. Amy. Thanks so much, Sam. It's really a pleasure to be with you here today to moderate the breast session. We are excited to have Dr. Hector Duran and Dr. Patricia McGuire with us today to give their talks on breast surgery. Neither needs an introduction, but Dr. Duran is based in Merida, Mexico. He's a sought after speaker worldwide and really has special interests in evidence-based medicine as well as fat transfer. Today, he's going to talk to us about pearls and breast augmentation and mastopexy. Dr. Patricia McGuire is a native of St. Louis, Missouri, where she did her training and where she is in private practice. Dr. McGuire is a world expert on breast implant safety and breast implant illness. Today, she's going to talk to us about how and why plastic surgeons should incorporate high-resolution ultrasound into their breast practice. Dr. Duran is going to start with us today and then we'll definitely submit your questions. We'll have a Q&A session afterwards. Dr. Duran. Thank you so much for allowing me to present this. Let me check. I'm doing it right. Okay, so I'm going to share my screen. And here we go. Okay, thank you so much for allowing me to share with you all this. So, thank you so much. My name is Hector Duran. I'm a plastic surgeon in Merida, Yucatan. This is in Mexico. These are some of my disclosures. And also, I want to share with you some pearls related with breast augmentation and breast mastopexy. So, the first pearl that I want to share with you is that I usually evaluate my patients with their arms up. This is very important for me because we usually are known to evaluate the patients with the arms down, but I believe that using the arms in both areas, I can have a better, it can provide us with additional information that this can be crucial for decision making in the related with the breast. So, this is why I usually use this kind of procedure. So, it gives me more information. Very, very important for me, as I think so more and more. So, what usual, what information? Well, elevating the arms can help me to improve the breast tissue appearance and the observations related with this breast asymmetries and also the inframammary fold. This perspective, this is very important related to breast shape, volume, asymmetries, and it's valuable for both medical professionals and individuals since they can help me to see clearly, very clearly some asymmetries. But the more important issue is that it allowed me to know how bad breast stosis is. I use also, this is another pearl, I use 3D simulator. I think that 3D simulators played nowadays a significant role in decision making. It benefits both the healthcare providers, but also the patients. It is important, however, to emphasize that patients, to the patients that a simulation is not a guarantee against potential complications or issues. Also, I'm not guaranteed to give that outcome to the patients. This is very important and also legally bind it. So, it's important for me so the patient knows that it is not a guarantee. But why do I use 3D simulation? Because it provides me with also additional typical objective information. For me, the most valuable data includes breast volume measurements and disparities. Furthermore, once I've selected the implant, it enables me to visually present the patient's expected outcomes and goals of the procedure. This is an example. The first image is the original one. The second is the simulation and the third one is the real outcome. As you can see, they are very similar to the simulation. I think I have a very good range of outcomes that I can share with the patient. Another very important pearl in breast augmentation is that I measure the desired implant base, not the breast footprint. Don't take me wrong. I measure both, but what truly matters is the implant's base position into the breast area. So, these both are different and very distinct. When contemplating the long-term evolution of the breast implant, I want to avoid the lateral displacement. That's why I decided to focus on the breast implant area rather than the breast footprint. If I use the breast footprint for deciding the base implant, I usually end with more dissection laterally and with a long-term lateral displacement of the implant. So, my recommendation is not to dissect more laterally than the areola. So, this dissection technique is applicable to both subglandular and double-placed pockets. I avoid, as I mentioned, dissecting laterally to the areola to prevent this lateral displacement. Also, with this approach, it helps me to preserve the muscle lateral fibers, so it gives more additional support. As you can see in this breast immediate postoperative photo, the dissection area is roughly confined to the two middle thirds of the breast footprint. This technique not only achieves a pleasing cleavage because the implant is pushing immediately, but also contributes to the overall aesthetic outcome. These are some postoperative examples of this. So, with this technique, I find that it is very useful for the cleavage also. And don't worry about synmestia. As you have dissected below the muscle, the muscle will avoid this synmestia. Here is some three months after the surgery image. Another parallel related is deciding the incision location. This is always the question, the question where to locate the height of the incision and also how long and where in the inframammary fold. Regarding this incision site, my recommendation is to adhere to the C-point distance recommended by the your breast implant company. This measurement assist us in determining where we should adjust the inframammary fold or even consider even a different implant position. Projection, sorry, sorry. So what's this C-point incision? It's the C-point distance. It's the distance between the more projected in the middle of the implant and then the area more lower. So this distance tells us the distance where the 50% of the implant is located. So it will help me to locate also the incision. And closing, well, I first close the, the first closing is with a 2-O-PDS, taking bites of a scarpa, then aponeurosis, and then a scarpa. This will allow me to force the inframammary fold to be seen. And the second line with a 3-O monocryl in very simple sutures. And I always start with the streams to avoid dog ears. And then I finish midline. And the third line, it's an intradermal 4-O monocryl suture. So I don't have to take out any suture after all. I usually leave no drain. Some other of the examples. And some other of the examples of this technique. And this is a patient with a six month postoperative outcome. And this is, of course, a photo the patient has sent to me, looking how the breast cleavage looks like. So also one of the problems is I invite you to know something called minimal access breast augmentation. This is done through a two centimeter incision or even less. For it, it requires a very pliable or distendable implant. In my case, I use Motiva Ergonomics or Ergonomics II implant. And it requires, of course, a funnel. And usually it's done through a submuscular double plane. So this breast augmentation minimal access is something we can have with a very beautiful outcome. And don't forget about periareolar mastopexy. I think it's nowadays very important. It can be particularly beneficial in two specific options or situations. It's effective for just a small nipple areola complex, elevations of less than two centimeters, of course, some tuberous breasts. But it is also, and I have find it very useful for medializing the areola complex in case of diverging position, as for example, in this patient. And this is another example of medializing the divergent periareolar with a periareolar incision. So related with some pearls in augmentation mastopexy, I think the markings are very important. Usually try to locate the areola complex and the nipple. So it is in the center of the breast footprint. So for time's sake, I won't be able to show completely the markings. Maybe I have done this video, but I will maybe in the next meeting, I will gladly show with you. Well, for time's sake, I will concentrate on some specific pearls. Here are some valuable insights. In the past two years, one of the most challenging aspects has been accurately determining the placement for the inframammary incision. For this, I recommend never cut the lateral skin arms of the breast before presenting the breast reduction. Concentrate always in the midline. And once the midline, and I mean the flap and the elevation of the areola, and then the long distance, the vertical incision, the long distance, the vertical incisions, once they have been set, then after concentrate in the lateral aspects, because you have to follow the curve line of the inframammary incision, in the inframammary fold. So once it's done, then you can rearrange your markings. Try not to go also at the extremes beyond the IMF, the visually IMF to avoid that the horizontal incision can be seen. Another pearls, well, remember that the super remedial flap is indeed a fantastic option. However, you can enhance it, assuring you are incorporating a very good flap irrigation. So this can be carried out perioperatively or intraoperatively using tools like ultrasound. Nowadays, there are very portable and very good ultrasounds that you can use with an iPad or a cell phone. So they even have Doppler. So of course, once you have located the irrigation, this gives the surgeon a greater flexibility and safety during the dissection of the flaps. So this is very good, and you can use it in every of your surgeries. For me, symmetry and roundness are the key of the beautiful breast implant in this kind of surgery. I mean, a central areola with a round symmetric breast volume and also symmetric incisions in both breasts are usually a beautiful outcome. So that's why I try to do it in every surgery to measure each one of the components of the breast augmentation, and to be sure that the areola relative position is also at the same distance with the inframammary fold, trying to assure that the inframammary fold is also rounded. It's important to know this, the inframammary fold is not a straight line, but rather a curved one. So you can enhance sometimes if it's not working using an internal bra to enhance the placement of this incision with respect to these factors. Some other examples and some other views of the breast and what I'm trying to tell you about having the same exact positions and also the symmetry of both breasts. And some examples of the way we can lift the breast in three months after a surgery outcome. And here's another example. So in secondary mastopexy, same principles apply. This is an example of a secondary mastopexy in which we could provide a very more beautiful outcome, but we all know the secondary mastopexy could have another webinar dedicated to it. So it's a very difficult challenge each and every time. So these are some of the pearls that I wanted to share with you. Thank you so much. Thank you. That was a really excellent talk. A lot of great pearls. I'm sure the audience has some questions. I know I do, but before we get to that, we're gonna have Dr. McGuire give her talk on ultrasound. So Dr. McGuire. Morning, I was asked to give my best tip for cosmetic breast surgery. The first thing that came to mind to me was a piece of equipment that I use every day in my practice. So this morning, I'm gonna talk about why and how we should be incorporating high-resolution ultrasound in our breast surgery practice. Here are my disclosures. So I was at the FDA device hearing in March of 2019. There, the FDA expressed concerns that their recommendation for a routine MRI three years after implants are placed and every other year after that was not being followed. And patients expressed concerns that they want a reliable, affordable, convenient way to have breast implant surveillance. The FDA did change their guidance in 2021 from an MRI at three years to either an MRI or a high-resolution ultrasound at five years and every two to three years after that to screen for silent rupture. Why ultrasound versus MRI? Well, it's less expensive. You're not exposing the breast to radiation. It's quick and easy to do. It's painless. No worries about claustrophobia, no restrictions for pacemakers, clips or ports. It's a high sensitivity and specificity with a short learning curve. Why do we need to do this? Well, to show the FDA we're serious about following our patients. And this encourages patients to follow up. And they come in instead of just telling them, oh, your implants are fine. We can show them that the implants are fine with an ultrasound. There's benefits to your practice. It differentiates you from those practice who are not offering this follow-up device for their patients, better patient communication and it improves conversion rates. It's a great device to be found for augmentation and revision patients. And with better follow-up, the patients are more likely to be in your office. So they're more likely to utilize services and purchase products. Also for evaluation, patients for revision surgery. It allows me to better plan my surgical planning of our surgical procedure or evaluate for seromas and no operative surprises. So lots of different options for ultrasound machines. You can get them anywhere from $1,000 to $30,000. So you can choose the device that suits your needs, the price, the portability, the wavelength you're gonna need depending on what you're using it for. What about training? We first need to understand the basics of how ultrasound works. Then when you buy a system, get training on your system so you know how to use it. The most important thing I can tell you is ultrasound, every breast implant patient that comes in, that you know their implants are intact. You can learn what an implant, intact implant looks like. And patients are happy to let you do this. They've had children. So it's something that's easy to do. So they're happy to do it. You may wanna get radiologist confirmation with an ultrasound or an MRI before you have surgery. If the patient says, you know, I'm only gonna do it if this implant's ruptured. Then correlate your ultrasound findings with your operative findings and it'll speed your learning curve. There's still a lot of hesitation. What I hear from plastic surgeons is, what about easy, reliable equipment to use? That's much better now than when I first started doing this. What about training? How long is it gonna take? And the single most common fear in the U.S. is fearful of litigation. So just like everything else, informed consent's very important. You have to make sure these patients understand that in-office ultrasound is not breast implants imaging, it's implant surveillance. They need to continue their standard breast imaging per the radiology guidelines for routine breast imaging. And you'd be very explicit that this is a tool to look at the implant and the capsule, not the breast tissue. This is informed consent that Dr. Caroline Glixman, who has a master's degree in medical device law, wrote and specifically says, what are the alternatives, what are the options, and the limitations to what we're doing and suggests considering correlation with an MRI. Now, we're not radiologists. Can we accurately read ultrasounds and how long does it take to become accurate? It's a paper we published last year in Aesthetic Surgery Journal. We did an evaluation of 350 of our readings on ultrasound with operative correlation to our findings. What we found was there was a linear improvement. We reached over 93% after evaluating 30 patients or 60 breasts. And this is higher than the radiology standard, which is defined as 79%. Our specificity was even better, starting at 95%, which is much higher than the literature standard of 63%. So we can read these. What about the time committed? I actually think it can reduce the time it takes for a consult. A follow-up scan with an intact implant takes less than five minutes. If you have patients with issues or concerns, it can help focus the appointment and determine quickly if there's something going on, especially for patients with textured implants. For revision patients, this helps with preoperative planning so we have no surprises in the operating room. So this is doing a scan on a patient in the office, takes less than five minutes to do. And remember, the patient is actually looking at this with us. They're seeing what we're seeing on the screen. And so it's very good communication tools. You can explain to them what you're seeing as you're seeing it. What about training? Both the ASPS and Aesthetic Society offer courses at their meeting. Ultrasound is at every patient who comes in that you know has an intact implant. You know there's something different. And then ultrasound patients in the OR prior to surgery, you should get immediate feedback on your reading. I think that shortens the learning curve. So what are we looking at? Well, the top is the patient's skin. The inside, the bottom is the inside of the implant. This is breast tissue. This is the pectoralis muscle. This brighter line is the implant capsule. These two lines are the implant shell. We want this to be a continuous line. We want the inside of the implant to look relatively clear. These are all intact implants. Once you know what this looks like, it's easier to read, to do other readings. This is an ultrasound video. You can see the continuous line of the shell clear on the inside of the implant. I always hear worries about you're gonna miss something if it's posterior. You're not, because if there is a disruption, the gel is gonna be hydrated and you'll see a different signal. So this obviously looks very different from this. This is the shell has collapsed on the inside of the implant. Here's the implant capsule. This, what's referred to as a snowstorm. This is hydrated gel. So you can see now you have gel on the outside of this implant shell on the inside of the capsule. So this is a intracapsular rupture. Just run through some clinical cases. The patient's 11 years post-op. She did augmentation. She's concerned about ALCL because she had a biocell implant. Here's the ultrasound. So both of her implants intact. There's no fluid. If there were fluid in the shell, here's the capsule, here's the shell. This space would be different. And I'll show you some seromas later. My reading was confirmed in the operating room. This patient's concerned. She has systemic symptoms. She's associated with her implant. She had an augmentation mastopexy. Her right breast has changed. So she's concerned she has a rupture. So there's a left side implant. You can see intact shell. Wait a minute, what's going on here? The shell doesn't have a continuous line. Here's the ultrasound video. What this represents is a flipped implant. This is the implant patch. You can tell this is a continuous line on the inside. This is just a different how the patch shows. So patient's 15-year-old implant. You can see this implant looks very different from this implant. Remember the patient's looking at this with me. Here's the video. Collapsed shell into the gel. This is the implant capsule. Hydrated gel with a different signal here. Knowing that, I removed the implant and the capsules together. Here's her ruptured implant. This patient's 12 years post-op gel implant. She's worried about having textured implants. Right side's intact. Left side's very different. You can see here's a capsule. Here's a collapsed shell. Ruptured implant. I show a lot of those because patients say, oh, I'm afraid I'm gonna miss it. What about a swollen breast? This patient comes in 12, this is a recent case of mine, 12 years post-op augmentation. Her right breast is getting bigger. Ultrasound show the left implant is ruptured. The right, there is a little disruption of the shell at the superior portion. You can see hydration of the gel, but there's also a fluid collection here. But why not just say, well, I'm gonna remove her implants and capsules anyway. Why not just take her to the operating room? Because you have to have a diagnosis before you go to the operating room. An on-block capsulectomy for malignancy is a very different operation than an implant removal capsulectomy. And that diagnosis needs to be made before surgery. If this does end up being an ALCL, the patient's best chance for cure is with surgery. So you wanna make sure you have all the information before you go in. So we use ultrasound guided aspiration of a fluid for these patients. This is what I aspirated on her, bloody looking fluid, negative for CD30 positive or C56 for squamous cell. This is what we found in the operating room. You can see here, it says little disruption, the upper pole, double capsule on that side, other implant was ruptured. This is a really good image of a double capsule. Here's the shell of the implant. Here's the capsule. This is the area of the double capsule. I think it shows because there was a little bit of fluid around that implant. This patient was sent to me by another plastic surgeon. She had a breast augmentation performed outside of the United States. No idea what implant she has. Right breast has been swollen for two weeks. Now here's her ultrasound. Shell of the implant, it's floating around, it's a fluid. This is a textured implant. The signal's not as bright as a smooth implant and it's a little bit irregular. This is what a smooth device looks like. Much smoother, much brighter signal. So I aspirated the fluid under ultrasound guidance. It was negative for ALCL. She refused surgery. Here's her ultrasound four weeks later and the seroma's gone. Four years later, she came back with another fluid collection on the same side. Again, aspirated that fluid. It was negative. Genuine removal of implants and capsules. This patient came in 15 years post-op, augmentation mastectomy, not any problems. She just had a normal mammogram. Both of her implants were ruptured. She didn't schedule surgery right away because she had other things going on. But two weeks later, she called and her right breast was swollen. Repeated her ultrasound. Now she has a fluid collection around that implant. So aspirated 80 cc's, not 800 cc's of clear fluid. Negative cytology, removed her implants and capsules. This patient, six years post-op, augmentation, textured implant. Calls the office because her breast has been swollen for about five days. She just wants her implants removed without replacement. Here's her ultrasound. Again, textured surface implant, irregular shell, not a bright signal, floating around a lot of fluid. 80 cc's of fluid aspirated. This is breast implant associated ALCL. PET scan showed only uptake in the fluid. She had an on-block resection. Seroma only, ALCL stage 1A. This is what we owe our patients. From the time this patient had her first symptom till she had her surgery was less than three weeks. How about some normal findings that may look, I have no, this is a saline implant. This is the valve of a saline implant, which can throw you off. Saline implants also tend to have a lot of this reverberation artifact inside of the implant, which can be tricky as well. And that's where seeing this valve can be helpful. You can see this is a reverberation. This is a locator dot in a style 410 implant. Again, it can look like a disruption, but you see how this goes in and also will reflect into the breast tissue. Now, unfortunately, I'm gonna show you that I got wrong. I really didn't understand what was going on. This patient wants her implants removed. No idea. Implants have been in for a long time. Thin shells on these implants, old implants. There's some hydrate, looks like hydrated gel on the inside. Repeat them in the operating room. I'm reading this as ruptures. Well, what it was was a double lumen implant with one of the lumens ruptured. This is style 153 implant. This could easily be read as a rupture if you didn't understand the implant type. Here's a shell of the implant. This is a shell of the inner gel lumen, but this is all clear. This is intact. This is an intact double lumen implant. This patient, 15-year-old gel implant. She's had a previous exchange for a rupture. She has capsular contracture. I read this as a rupture because I couldn't see well in this area. It looked like there was a disruption in the shell. Repeated her ultrasound in the morning of surgery, and I'm like second-guessing myself because this shell looks like it's intact. But there was still this irregular area. What this ended up being was extra capsuloid silicone, a siliconoma from a previous rupture. Here she is six weeks post-op. This patient has smooth gel implants, recent new capsular contracture on the right side. Here's her ultrasound. The shell looks discontinuous to me. Not a lot of hydration in the gel, but I read this as a rupture. What this ended up being was a fracture of the gel, and she was gonna undergo surgery anyway because of her capsular contracture, but this wasn't a normal implant, but it was not a rupture. So the bottom line with this is practice, practice, practice. The more you do with the ultrasound, the better you will get. Correlate your readings with operative findings. This can make your office hours more productive. It's helpful for planning and revision procedures. I think the most important thing is it's a great communication tool with your patients, and it encourages follow-up. Thank you. Thank you, Dr. McGuire. Now we will have our question and answer session. We have about 15 minutes, and I just wanted to start with Dr. Duran. I think that for your breast augmentation curls, I think probably one of the most important ones I find is limiting that lateral dissection. I think you can make a mistake and dissect too far initially and then, like you said, end up with your implant way too lateral. And if you just make that small pocket, and I think this is really particularly important for any of the residents or young plastic surgeons on the call, you make that tight pocket, and then you can just gently stretch it in order to accommodate the implant. Is that mostly what you found? Yes, but also there's some characteristics of the lateral tissue of the breast that it's more prone to dissection. So there's a fine line between going exactly and then going too much. It's very difficult to understand. This comes only with experience. But once you do this limited dissection and you put the implant and you find out there's a little bit more of dissection needed, what I usually recommend is with the finger, do a little bit of not cutting dissection, because you usually need just a little bit of dissection. If you do a lateral big cut, it will absolutely after some years go lateral, sorry. Is that, Dr. McGuire, you're obviously an expert as well. Is that sort of how you do a breast augmentation in terms of the lateral dissection? Yeah, I completely agree with that. When I used a lot of textured implants, you could dissect the pocket and the implants pretty much stayed where you put them. When I changed from textured to smooth implants, the capsules are much thinner. You guys, Steve Teitelbaum always says the ideal capsule would be a Baker 1.4, where the capsules are a little bit thicker. And I think that was part of the stability when I used textured implants. The new implants, the capsules are very thin. And I actually tell the patients, your implant's gonna look a little bit too high and a little bit flat on the side the first few weeks after surgery, because I do under dissect the pocket. It's much easier if it stays too medial, which usually like Hector said, they like the cleavage better anyway. It's better to be a little bit too medial than too lateral. So once it falls into the axilla, it keeps falling into the axilla. So I completely agree with that point. And also there are some small thorax patients when if you didn't choose the right implant and it goes beyond, it usually goes in the lateral border of the thorax and then it falls. It's just gravity also. But I also agree. I usually have used it all my life, all my practice smooth implants. That's a very big difference also. Over switching over to ultrasound, we have a question from the audience, which I think you answered, but would you do ultrasound for breast implants placed by other surgeons? And you showed us some examples of that, but I think it ties into the question of sort of charging. So this question comes up. So you've got the ultrasound and maybe you have a patient from somebody else's practice. Are you gonna do their surveillance ultrasound and not charge them? Or how do you manage that? If a patient makes an appointment for an evaluation, revision, or we've had a couple of surgeons who've retired in the area and the patients have come to us. I don't charge patients for ultrasound. My own patients, I don't. Other surgeons, patients who come in for a consult or a revision consult, I don't charge for the ultrasound. I think everybody has a different approach to that. I know some surgeons will charge patients for ultrasound and it's a reasonable, it's less expensive than they'd be paying for an MRI, but I've found it keeps patients in the office. If you have a patient come in, I have a revision patient come in or a follow-up patient come in, and I find an ultrasound, I find a rupture, those patients are gonna schedule surgery. So a little bit of time, the five minutes that it takes me, and these patients then go out and tell their friends, hey, I saw Dr. McGuire, not only did she see me, I got something, I got this ultrasound, they're more likely to consider coming. And our primary augmentation patient, or patient comes in for an augmentation consult, you tell them we do these follow-ups, we don't charge for it. It does change, it has changed our conversion rate. Great, great, yep. Do you, Dr. Duran, do you use high resolution ultrasound in your practice? Yes, I do. I usually do it. I have it in my office and another one in my OR. And I can tell you that it's been a game changer, really. For example, I do a lot of body contouring, and it is so much important, but for breast, also too much. Great, great. Talking about augmentation mastopexy now, we all know that that's a little bit more challenging than just our direct breast augmentation. So first, with the periareolar mastopexy, you mentioned that, you mentioned it as being important for nipple position and changes. What sutures are you using to sort of maintain that position and diameter? Oh my God, this is a topic I really, I have been thinking about publishing this, but I think for maybe five years, and I don't think I will be, but this is important for me to share with you because I think is the key of having a good outcome in periareolar mastopexy. The troubles related with this procedure is that some surgeons usually abuse of the capacity of these procedure. It is a very beautiful one, but it has some limitation. But for the, what I do is I do the procedure periareolar resection, then go with the implant, then I close the pocket. Then for the periareolar, I do a round block, but this round block is usually done with a very big PDS. I think it's more like a zero PDS. And then after I put something called, it's been published by a Mexican author. It's called Margarita, I don't know the translation for this but it is a little bit of like this work of the, I forgot his name, but it is, let me describe it. I forgot his name. There's also a breast augmentation surgeon in United States. I forgot his name, sorry. But it is, it goes to all the quadrants like- Dr. Hammond. Yeah, right, exactly, Dr. Hammond, I'm sorry. Yeah, like Dr. Hammond, but it is, this is done with a very small suture. It's like a nylon or proline three or four zero. So what it does, this is the first one keeps the tension for a long time, almost four or six months. And I mean the PDS. But if you do this with a non-resorbable suture, it will be seen after a while. So that's why I use PDS because the PDS will resorb after it. But the other suture, the proline, the non-resorbable will allow the borders of be very concise, very well-positioned. So this combination of these two sutures can give a long-term outcome, very beautiful. And lastly, a subdermal suture with a monocle four O can be done. Thank you. I have a question from the audience too for Dr. McGuire. Number one, where can young plastic surgeons go and learn about implant ultrasound? That's a good question. That's always a concern is training. Both ASPS and the Ascetic Society have ultrasound courses at the national meetings. I was the chair of the breast and body meeting in Scottsdale, Arizona. We have a certificate course offered at that meeting. The other thing I have, surgeons will come spend a day with me. Holly and Simeon Wall came, spent a day with me. If you have a surgeon in your area or a colleague or a friend that does it, doing it hands-on and seeing patients. And my patients are very happy. You say, hey, do you mind, I have this doctor here with me. The patients are happy to get an ultrasound with it. But it's not as difficult as you think, but seeing it and having someone with you to do it. And the courses both ASPS and the Ascetic Society offer are very good for that. Then the second follow-up question is, do you mind sharing what kind of portable device you have? Yeah, I have one. I have a more expensive device that I got five years ago. It was from a company called Plastic Surgery Imaging. It's a little bit bigger. I also have a butterfly. That one, the cost runs about $2,500. It's a very good, usual one. It has a cord on it. The other one that I have used that I think is very good is Clarius. They have different wavelengths. They have a 15 megahertz. If you're doing facial things, you need very high resolution. That works. They also have a seven, which is good for body and breast. The advantage of that one is it's cordless. So if you're using it in the operating room for gluteal fat grafting, it's a lot easier than having to have a cord. But there's a lot of really good ones out there. I was at a meeting in Portugal in October and a surgeon there had one they'd gotten off of Amazon for like $1,000 that worked, as well as some of them that we were using. So it depends on what you're using it for, your budget, whether you're using it in the operating room, out of the operating room. We're very lucky now because there's a lot of good options that you can use. Thanks for that, Dr. McGuire. Back to Dr. Duran, question from the audience. Can you clarify how you're measuring for the base width for your implant choice in relation to your under-dissected pocket the time of surgery? You know, you mentioned you're really, you're not choosing your implant based on the footprint of the breast. You're going more narrow. So how is it that you're choosing that diameter? Yes, this is, thank you for the question. This is very important. When I was a game changer for my practice, I learned that I have to choose my implant base according to the breast footprint. But I started measuring the footprint, the breast footprint with the arms down. So I usually ended choosing a bigger implant. And also, this is related with lateral displacement. So after a while, I discovered when the patient got out their breast, the breast tissue was tensioned and I couldn't see more the relation of the breast with the thorax. And I find out that what I really wanted was not this lateral displacement, but also to know where my implant was gonna be into her thorax related. So I started measuring this area, which is more or less a little bit, just a little bit more lateral than the areola complex. But also I measure with this rule. This is very important. I always measure without seeing the distance. I put the rule, this moving rule. I don't know what's the name. The L one? Yeah, Galloper. Yeah, the Galloper. But with the numbers, looking at the patient. So I don't see the numbers because when I seen the numbers, sometimes I get myself misleading. So I measure and I say, okay, this is it. And then I look at myself and say, oh, this is the exact position. Yeah, so I don't fool myself because sometimes you measure and when you're seeing the numbers, you're saying, oh, this is too big. Oh, no, no, no. So I measure what the patient really needs. But as I mentioned it, I don't no more focus on their breast footprint, but where I want the implant to be in and what's the base that I want for this patient. Okay, excellent, perfect. I think we have time for one more question. I think this can be answered maybe by both of the panelists. In augmentation mass defects, this is from the audience, how do you prevent excess tissue in the inferior pole post-op when a patient has grade one or two or three ptosis? So basically, how are you dealing with the inferior pole? Dr. McGuire, you wanna answer first and then Dr. Duran? Yeah, I think that's what patients don't like is the tissue hanging over the inframammary fold. When I do a mass defects augmentation, I kind of follow the Holly Wall's total muscle coverage for mass defects augmentation where the muscle, although I dissect through the muscle a little bit, but I leave that pectoralis fascia intact. That's kind of like my internal bra, like instead of using mesh or something in the breast, you use the muscle for that. And then I'll put the implant in, have it completely covered by the muscle. Then I think you can really deal with that lower pole tissue, resect a lot of it, you know, the plus minus, resect a lot of that tissue because you're not worrying about exposure of your implant. And I take as much of that lower tissue as I can get because patients really don't like that tissue hanging down. And the bad thing about mass defects augmentation patients is they need a mass defects augmentation because they have bad tissues. And so their tissues are gonna likely get more ptosis, that lower pole is gonna expand over time. So take out a lot of that tissue that's less forces on that, I think using either some sort of soft tissue support or I'd say, I like Holly Wall's method where you use the muscle as your lower pole support because it's gonna stretch with time. Yeah, I mean, I think that's an important point. So if you're going to take out the inferior pole tissue, you really wanna have something controlling the implant. So that could be the muscle, if you keep the muscle intact, or that could be a mesh if you decide to use mesh. But if you use neither, then you're relying on the soft tissues of the breast, which are usually poor, as you mentioned, augmentation mass affects you. So that can get really tricky. Dr. Duran, any other thoughts, additions to that? Yes, I like some of, if you can check on Marcelo Ono's work, this is a Brazilian plastic surgeon, which have a lateral support, a sling. But the hanging tissue in the breast is not always, but most of the time lateral, not medially. So if you have this central part, you can take, of course, the tissue for reduction, but you have to lower triangles. The middle one, I try to epitalize, but also to keep a little bit of the tissue because usually the trouble with this area is that you don't have enough volume. But if you take this triangle, you end up being a little bit flatter then. But at the lateral triangle, I usually take it as a block and then I close it very, very good. I think that the bigger troubles I have experienced with is not taking enough tissue of the lateral triangle. So if I take enough tissue, then I will avoid having hanging breast there. I think also Hector showed in his talk, superior medial pedicle, I think is also a key in debulking that lower pole. And you can take that tissue out because it's not contributing to the blood supply. And then substitute with a very good closure of the pillars, bringing up to the middle. Excellent. Well, thank you both for sharing your time with us today. I know the audience really appreciates it. And I think that with that, we'll conclude the webinar. Thank you. It's been a pleasure to be here. And Patricia, you look amazing. Thank you. Good to see you again. You too.

American Society of Plastic Surgeons

ASPS

March 2021 webinar

plastic surgery

rhinoplasty

breast surgery

Dr. Samuel Lean

tip shaping

septal extension grafts

ailar cartilage

closed rhinoplasties

breast augmentation

mastopexy

high-resolution ultrasound

patient outcomes

plastic surgeons

international collaborations

educational programs

septal extension graft

reshaping anatomy

closed primary rhinoplasty

implant surveillance

Q&A session