Oh, hi, everybody. Welcome to the ASPS Global Partners webinar with our esteemed Korean plastic surgery colleagues. Today we are so fortunate to have three excellent experts in their respective fields and really honored to have them talk to us today. So let's go to the next slide. And so just a little bit of the logistics for today, we'll have three speakers, I'll introduce each of them, and then we'll hear their talks, it will be a videotaped version, but the speakers are here, and then we will do a question and answer at the end. So in order for us to get your questions, please submit your questions throughout the presentation and the speakers, they may actually choose to answer by typing in the answers or they may actually talk and present to us at the end. And just a plug in for today's webinar is something that's offered by ASPS, the American Society of Plastic Surgeons, and the webinar will be recorded and then also be available for our ASPS members on our website. And if you're interested in joining and learning more about membership of ASPS, please feel free to reach out to our membership staff, Romy, who is actually on the call today. So without further ado, let's introduce our first speaker is Dr. Ji Yong Jae. He has an impressive resume, and he's the director of the Plastic Surgery Clinic. He's the president of Korean Academic Association of Rhinoplasty Surgeons. He's also the president of Seoul Rhinoplasty Forum, and he has lectured extensively internationally in many, many countries and taught rhinoplasty forum and educational courses throughout the world. And he has co-authored multiple articles and he also has co-authored several books, including one on the latest technique of rhinoplasty, an aesthetic surgery book, and then also another rhinoplasty book called Rebuilding the Nose, and that has been translated into multiple languages. And his topic for today is five tips to do open rhinoplasty better in Asian nose. Hello everyone. It's my great pleasure to give a lecture in this ASPS webinar. Today I will share my experience about Asian rhinoplasty. Topic is 5 tips to do open rhinoplasty better in Asian nose. These are my books for Asian rhinoplasty. You can find my today's presentation in English version. So why open approach? As you know, the open approach has revolutionized Asian rhinoplasty field because the open approach enables accurate identification of internal structures and underlying frameworks. An open approach allows surgeons to release nasal ambula from osteocartilageous frameworks and to do various procedures including foreign body and scar removal, suture techniques and graft techniques. In secondary nose, we can confirm the internal deformity and correct more precisely. On the other hand, recently we can meet many complex problems that looks difficult to solve. These kinds of difficult obstacles make surgeon very frustrated. So I want to talk about doing Asian rhinoplasty better. No.1 Understanding the difference. We have to understand many difference between Asian and Caucasian rhinoplasty. Asian nose is smaller compared to Caucasian and nasal bone is usually short, tiny or thick. And at the keystone, the length of overlapping between nasal bones and operator cartilage is shorter in Asian, which requires more delicate manipulations. Cartilage framework is weaker and smaller in Asian nose because supporting structures and ligament are more fibrotic and densely attached to the cartilages. So these ligaments need to be released for Asian rhinoplasty. This is interdermal ligament, intercoral ligament, longitudinal scroll ligament. Here we can see the vertical scroll ligament, pitiform ligament and pitiform aperture ligament. These fibrotic attachments should be released for adequate tip projection and lengthening in Asian nose. I always explain about tip releasing technique as LRVOI advancement. Using blade or scissor, longitudinal scroll ligament can be released for dividing. After releasing LR cartridge, it is freely released from the operator cartridge. So tip projection or caudal rotation can be obtained without tension. And then various grafting and sutures can be applied for better tip shape. Generally, Asian nose have thicker and more sebaceous skin than Caucasian, and it seems to have wide spectrum range from thin to very thick. As you know, skin characteristic is one of major factors affecting to surgical outcomes. In most Asian nose, tip and supratip area have very thick skin and sebaceous glands are well developed. So according to characteristics, management will be different when doing burbosity correction. This diversity due to SMAS characteristics reflected onto the skin. In my previous article, I divide the SMAS classes into three groups depending on the thickness and features. So according to the group, operation procedure will be different and result also different. Many problematic nose have envelope deformity showing non-elastic and hard texture due to previous scars. So underlying scars should be released very carefully using scoring and trimming. These are result, before and after. We can get the better result than we expected. And we have to understand the difference in surgical techniques and operative goals. Asian rhinoplasty is mainly based on augmentation, while Caucasian rhinoplasty is based on reduction. Recently, preservation rhinoplasty was introduced in Caucasian rhinoplasty. However, it is difficult to apply in Asian nose due to the below reasons. Second, management control. We need to learn about handling the entire management from pre-operative to post-operative process. During consultation, it is important to record every single details. It includes patient wish list, objective finding, and surgical plans. You should check and list up every problems and make a plan before the operation. Endoscopy and CT scans are very useful to evaluate patient condition, especially internal structures. Also, in secondary nose, CT scan gives a lot of information that we cannot detect. And we can evaluate the difference by comparing before and after operation. So, we should make detailed plan and build the entire operation sequence before the operation. Entire operation process is just like making a good movie. You can be a good director for successful outcome if you prepare well. And time management. Most problems come from long time operation. You should always be conscious on proper time distribution during each steps. One stage definite surgery is not always possible in difficult case. So, staged operation should be concerned. We have to decide the proper timing and decide whether perform the operation in single stage or multiple stage. During consultation, we have to consider both psychological and physical perspectives before deciding the timing. And we have to check the patient mental state and demand. And medically, patient nose condition should be evaluated carefully. Also, post-operative management and follow-up are very important. This is my routine. Also, post-operative management and follow-up are very important. This is my routine check-up. If you keep this routine checking, you can get more long-term result. And you can realize the change of patient result. Our rhinoplasty is the operation of clean contaminated wound. Because nasal cavity is always exposed to outside. No matter what kind of materials, inflammation can cause deformity, contracture and even more severe problems. If inflammation and infection is suspicious, you should open it up without hesitation. Because only medication is useless. Especially, inflammation around columella makes difficult to manage and require multiple operation. And complaint management is also important. It includes consideration about revision. We can try minor revision earlier to enhance our result and reduce complaint. For example, simple change of implant to higher one. Irregularity correction using fat graft or filler. Simple adding graft using cross-door approach. We can do simple and minor revision after 3 months. For pinch-tip correction. For correction of implant deviation. Or correction for over-reduced nasal bones. We can carefully try revision earlier. And number 3. Technique as a craftsman. Dr. Lowry said rhinoplasty is the operation of millimeters. But I think rhinoplasty is the operation of micrometers. Every single change during local anesthesia, bisection, implant, cartilage grafting, even small ones affect to the final result. Your skill makes your nose better and fine. The more surgeon dedicates, the better result comes. For example, I use about 10 or more blades for precise handling during one operation. All these surgical procedures depend on your precise handling. And we have to check the final refinement with our finger. I think local injection is the first and most important step in entire operation process. Proper injection gives a lot of advantages. I use dental syringe and cartridge of 2% Ritocaine with epinephrine. And I prefer to use withdrawal injection technique. Because this technique has many advantages such as minimizing direct vascular infiltration and maximizing hydro-dissection. As you can see, swelling induced by local injection will disappear within 30 minutes after injection. And proper instrument provide more convenient and good surgical environment. Because nose is very small one, so we use fine and small instrument as much as possible. I'm going to show the big difference between fine and blunt instrument on my cadaver study. Right side bone was done with percutaneous lateral osteotomy with 2mm osteotome. And left side was done with internal continuous lateral osteotomy using guarded osteotome. After completing osteotomy, we check the stability of fractured bone and both sides compared. You can see the difference. So fracture pattern and stability. And then skin envelope was elevated and we check the internal bony fracture state. We found that right side was very stable even after fracture. But left side fractured bone was very unstable and there was a huge bony gap. So as you can see, using the sharp osteotome causes less damage to the bone. During open approach in such a case with a problem, careful flap elevation and precise handling are necessary. This patient had previous rhinoplasty 8 times, so her columnar flap was deficient and thin with multiple scars. And meticulous wound management should be considered postoperatively. Similar patient. And precise incision and closure makes scar less visible. And need more care about choosing incision in secondary cases. If not, you may have serious problem. Moreover, these problems will more difficult and takes a long time. So please remember that we are not scientist, but a craftsman, at least in the operation room. There is no operation which uses various materials like Asian rhinoplasty. We have to consider choosing proper materials. And you can use various atrocious tissue, ear cartilage, septal cartilage, rib cartilage, and deep temporal fascia or thoracic graft. From the western papers, complication rate related with implant is known to be high. However, application of silicone implant is still popular among Asian rhinoplasty because complication rate is relatively lower than the westerns. In my 18 years experience, I think silicone implant is one of best material for Asian rhinoplasty. However, we always keep in mind and try to minimize potential complication related with implant. Such as implant deviation, demarcation, skin redness, classification, contract deformity, and extrusion. Potential complication should be concerned and should be solved properly. And finally, look back. Look back your previous works, review your research, and record your operation. And every single record, video, or photo should be stored. A backup is also important. This is my backup storage since I started my practices. And we need to keep doing practices and looking back like this because no one was born as rhinoplasty surgeons. If you do, you can obtain better result than before. Thank you for your attention. Thank you so much, Dr. Jeong. And I will reserve some questions at the end. Thank you so much. Let's introduce our next speaker, Dr. Hong Lim Choi. Dr. Choi did his training at Yosan University Medical Center. He also got his PhD there. And currently, he is the director of JW Plastic Surgery Clinic. He's a director-at-large of Korean Society of Aesthetic Plastic Surgery. He's the academic board member of Oculo Research Institute, Korean Society of Plastic Surgeons. And he has co-authored several textbooks as well, one for the Korean Society of Aesthetic Plastic Surgery and also with Dr. Lilligan. And his topic for today is factors for making favorable fold during upper blepharoplasty. I'm so sure we'll have lots to learn from Dr. Choi. Hi, everyone. I'm Dr. Hong Lim Choi from Korea. Today's topic is factors for making favorable fold. Double eyelid plastic is the most common surgery in Asia. But making ideal and natural fold is very difficult. So secondary blepharoplasty is one of the most common surgeries in Asia. What is a favorable fold? I think favorable fold is that have optimal height, proper volume, enough power, minimal adhesion, and adequate depth. There are five major factors to make a natural fold. These are height, depth, adhesion, power, and volume. Most of the secondary blepharoplasty cases are related to inadequacy of these factors. Today, we talk about each factor using secondary cases. First, let's see the height. At primary case, the distance between double fold line and the margin of the lid is the fold height. If the height of the fold is high, it stands up easily. It goes well with the person who has long palpebular tissue and thin skin. But it may cause prolonged swelling after the surgery. Besides, it makes precaution for this when it is performed to inappropriate patient. Thus, most of patients are recommended to make moderate to low fold, especially for male patients. Fold height is very subjective. Fold height is very subjective to patient. So, final decision is up to patient. In the past, Asians wanted westernized high fold. But it is not fit to Asians. So, now they want to reduce the fold. Although there is no room of skin, it can reduce the length. Some patients want very low fold. So, we change out fold to in fold. Presently, most of our patients want natural and not too high fold. Second, let's see the volume of the eyelid. The volume problems are roughly divided into two categories, furless and sunken. Most of the sunken eyelid is related with levator function and it can easily cause pseudoptosis. Most of the sunken cases are corrected only with levator surgery and preoperative neurotic bed repositioning without bed injection. This is the case of levator advancement and preoperative neurotic bed repositioning. In this case, sunken is noted but main problem is ptosis. It is not necessary to perform bed injection in most cases. Pre-touch-up fold is proportional to fold height. So we must make low to moderate fold in thick eyelid and reduce the volume by removing fat and soft tissue in upper flap. When we perform the reduction of the volume, it should be avoided to remove too much OOM of the low flap. It is not effective for volume reduction and can make unnatural double fold. If patient's eyelid is thick, it is easy to make unnatural fold. So we should make low to medium sized fold. To reduce the pre-touch-up fold, height control is essential. Third, let's see the levator function. Good levator function is the basic factor for double eyelid surgery. If levator function is weak, fold is easily loosened or looked unnatural. Most of the secondary cases are caused by dead levator function. If levator function is not good, although fold is not loosened, it does not look bright. If levator function is weak, fold will be easily loosened. Restoration of levator function is essential for making natural fold. In doing the ptosis surgery, we must think about the levator injury, especially in medial side. Aponeurosis is thin and highly positioned in medial side. Dissection must be started from lateral side after confirming the aponeurosis. Dissection proceeded to medial side at the same plane, taking care of the levator injury. Levator was transected in previous surgery, so we used the conjoined fascia for ptosis correction. Fourth, let's see the adhesion. In incisional method, an appropriate adhesion is important to make natural double fold. If the adhesion is deficient, it is prone to be loosening. If the adhesion is excessive, the fold line is easy to become unnatural. Depressed scar is also made. For making favorable fold, adhesion must be made linear. If adhesion is made planar, it may cause depression. The patient's fold shows obvious depression in closing state, so we release the adhesion and make a new fold to make even. More natural look after correction. Obvious depression is improved. Also, she looked more natural. The ideal fold has no depression in closing state, and fold is appealed by levator action lately. It is the most ideal fold. For prevention of depression, we must use OOM for fixation instead of pure dermis. More exact structure is OOM fascia. Too much depression is reduced as possible. Medial epicondroplasty also restored and planning a second stage. Too much scarring is noted, and defolding and dermal break graft was done in left side. We're planning the second stage. Fifth, let's see the depth of eyelid. Depth is one of the most important factor in making double fold. The depth is the distance of the movement of the lower flap. Different depths may result in different fold, even with the same height. For the depth control, fold fixation point and method are very important. If a fixation point is high, the fold tends to be deep. For changing the default to shallow fold, release old pre-aponeurotical and pre-causal adhesion, and then low flap is fixed at neutral position. I used three-point fixation using OOM, aponeurosis, and tarsal plate. Default tends to be high fold, and gaping is formed at folding side. Shallow folds look more natural. Now, I introduce my personal approach for controlled intensity of fold. General fold is made following these procedures. Pre-causal preparation was done with only deep tissue, and three-point fixation is done at neutral position using 7-0 PBS, and final intensity is estimated with mild rash aversion. Let's see the video. Incision is made at pre-causal OOM, and different to pre-causal area. It is not good for secure fixation and fast recovery to expose bare tarsus. After marking the fixation site, dissection is proceeded to low flap for the pre-causal preparation, and pre-causal fat is removed for secure fixation. Not too much fat is removed. If the fat is too much removed, the depression is occurred. Especially, medial and lateral pre-causal fat is more trimmed for prevention of loosening. Soft tissues that inhibit the proper adhesion is trimmed. Septum and aponeurosis is trimmed to control the tension. It also not too much septum is removed. Three-point fixation was done using aponeurosis, tarsal plate, and OOM using 7-0 PBS. Intensity is estimated with rash aversion. In its general case, if patient have entropion, thick eyelid, or severe ptosis, fold has more prone to be loosening. So, in these cases, we must prepare more pre-tarsal tissue and fix the low flap at more high position. In entropion and ptosis case, we must make more deep fold. Especially, in elderly patient, their main purpose is correction of hooding. So, although we design a little bit high, but fixation must be low for natural fold. In this case, design high, but fix the low, so make natural fold. In fixation, the medial and lateral fixation is the key site. So, this portion must not be shallow, and a little bit more depth is needed. But, the most lateral and medial must be shallow, and just continue to fold. Center portion depth is general. Typical Asian case. In conclusion, we must think about these factors during the double eyelid surgery for making natural and favorable fold. Today's contents will be published next coming Nelligan textbook. Please refer to them. Thank you for listening. Thank you, Dr. Choi. That was beautiful. Those were beautiful results. Really, appreciate your talk. And then, again, we'll save the questions for the end of the presentations. So, let's introduce our third speaker. This would be Dr. Jaejin Ok, and he did his medical training at University of Ulsan, and also did his residency and fellowship training in plastic surgery at Asan Medical Center. He's currently the director of the Plastic Surgery Clinic. He's adjunct professor of Asan Medical Center. He's director of Academic Relations Committee of the Korean Society of Aesthetic Plastic Surgery. He's an academician for three professional societies, namely the Korean Society of Aesthetic Plastic Surgery, Korean Society of Plastic and Reconstructive Surgeons, and also Korean Association of Aesthetic and Reconstructive Breast Surgery. And he's also the expert commissioner of High Court of Justice in Korea. And his topic today would be Aesthetic Interest and Realization in Breast Augmentation in Asia. Good morning, everyone. I'm Jaejin Ok from the Plastic Surgery Clinic, Seoul, Korea. It's my honor to participate in the ASPS webinar series. After 20 years of breast augmentation surgery, my main concerns have continued to change. After going through volume, shape, and complication, I'm now interested in aesthetics of breast. Today, I'd like to talk about breast aesthetics, bringing application, and some specific concerns, such as inter-mammary space, implant migration, and animation deformity. What is a beautiful breast? It depends on the time, cultural background, and personal preference, but perhaps in the world, it's a breast that goes well with the whole body. Moreover, the aesthetic standards of Asians are different from those of Westerners. I researched and published a paper to find the criteria. I value the breast footprint and lateral profile. Many Asians prefer the narrow inter-mammary span. I recommend the inter-mammary distance Many Asians prefer the narrow inter-mammary span. I recommend the inter-mammary distance between 1.5 to 2 centimeters. The lateral view of the breast should be above from the upper body so that the curve from the shoulder breast, waist, to hip becomes more attractive. On the lateral view, the upper breast border is located in the middle way from sternal latch to nipple, and the lower border should be lowered by a third distance from sternal latch to nipple. The vertical distance from the nipple to IMF corresponds to attractive breast projection in the lateral view. Slight concave lateral line and straight line was preferred on the ground that is natural for a long time. Now the breast upper breast is concave but the lower side is preferred on convex curve. Patients have come to find it's more attractive as natural and express sufficient border with the ground. When planning a surgery, the size of the breast is determined by implant projection rather than diameter. The shape can be adjusted with a counter of implant pocket. I consider breast position within the upper body to determine the implant position. When considering the location between sternal latch and umbilicus, identical location is 45%, IMF 60%. Left patient has a lower breast, right patient higher breast. I am afraid of deficient upper pore in the left patient and upper pore protrusion in the right patient. Should we place the implant in the same position for these two patients? Dr. Malucci recommended round implant location as 45 to 55. This argument started based on the aesthetics perspective of the Caucasian. Most of my patients think anesthetic. I usually locate round implant in the ratio of 55 to 45 in the basis of post-operative nipple location. But I set higher implant location when the breast is located lower and vice versa. We need to counter the implant pocket to change the breast shape. I regulate low porous patient and change the point of maximal projection. I say PMP in my presentation. When implant is inserted, the soft tissue covering implant is expanded. At this point, the expansion happens more likely where the seno and the lesser portion of intervening structure is, so to speak. The portion which is not covered by muscle is more expanded. This is a picture of Dr. Tabet and Dr. Sammon explaining the dual implant. As you can see, various designs can be applied by determining the portion that needs to be more expanded. We also control the level of dual implant in transaxillary breast augmentation depending on the range of subpressure and submuscular dissection. But usually, the lateral portion of the pacmajor is located more upward. This is type 1, type 2, type 3. This is a video clip of dual implant dissection in transaxillary approach. At first, start subpressure dissection. After dissection of supramuscular area, change the pocket to submuscular. This is submuscular plane. Now I'm cutting the original pectoralis major muscle. I meet the pre-made subfascial pocket when cut the original pec major. We can see the muscular end on the bottom in supra-muscular pocket. We also find muscular end at the top of visceral pit in submuscular scope. I use a different level of diaphragm in transaxillary approach and elevate NAC position more about on the left side. As you can see, P and P vary according to the location of the pancreas muscle pressed in front. In other words, the muscle pressed upper side, P and P is lower and vice versa. So the P and P can be adjusted by the level of diaphragm. The amount of expansion will be more in the area of P and P. And this way, we can further expand the required area through the control of P and P and expansion. The P and P should be higher when the upper pore volume is insufficient and vice versa. Paradigm of the breast implant has been changed from stable implant to adaptable implant. Smooth, more viscoelastic, movable implant are preferred. But actually, all the implants have both properties of stability and adaptability. I prefer more stable implant especially in the following cases. First, in the case of short nipple to IMF distance, constricted breast, tubular breast or augmentation in partial mastectomy patient. Next, my specific aesthetic consideration. My aesthetic goals for intramammary space are as follows. Intramammary span with 1.5-2 cm gap, more clear round circle in the lower border, find more bigger round circle in the upper border. Some additional space in the middle portion of breast border so that implant can move more medially. But we can meet the wide sternum in some cases, we should make more expansion of breast envelope. Sometimes, I cut the sternal orifin of hemature to make a narrow cavity. Sheath mass here can be avoided if the sternum is provided. Patient want various privacy in width and cleavity. I check the patient needs before the operation and decide the necessity of flat ground. The patient's left breast side has deep throat. Left breast implant is more likely to move left breast side. The patient's left breast side has deep throat. Left breast implant is more likely to move lateral side, lying position. The low chest on the right side is sunken. Right breast implant will move more than once due to gravity. So we have to consider chest case for proper pocket. We can see the asthmatic implant position on two months after the operation, which is corrected spontaneously. All the smooth implants have some mobility, so implant migration can occur. That is important to balance the tension around the implant for maintenance of post-op result. We often operate lateral entrance in transaxillary approach. So, it is helpful to cut the pec major origin in inferomedial portion to balance the tension. We also balance medial to lateral erection and superior to inferior erection. I cut the pinnate origin and attenuated the sterile origin of pec major in the case of pectus caviator. It makes a bit of surplus in the medial area. But the chest rat has a power to push the implant more lateral side, so balance tension is made. If the patient has sunken chest inferiorly, I make more sphere move the pocket and cut the pec major instead of leaving more muscular gravity. In Asians, cutting pec major is not enough to adjust level of IMF. I have to lower IMF level by surgery or induce more expansion. It is more difficult to induce IMF lowering by going along the fascia of pec major muscle while keeping fascia continually. Personally, I prefer to cut the stump of pec major muscle again since muscle already keep the implant from being lowered excessively. The low forward expansion is not enough to match the IMF in the sitting position. I cut the stump of pec major again to induce more expansion. This is jaw cutting. We can see more expansion on the left breast. The next is about animation deformity. That is inevitable when we use a muscular pocket. How to control it? Animation deformity is caused by contraction of pec major. We also adjust the higher level of cutting as sternal origin is, the more the vector of pec major becomes parallel from being oblique. If the vector of pec major is oblique, the animation is more prominent. We are also able to weak muscle power by partial cutting the sternal origin. There is more animation deformity when the starting point of contraction is lower than PNP of implant. After starting point of contraction is higher than PNP, therefore animation deformity is less prominent. We can make different animation deformity. You can see the marked animation deformity. So it's a type of animation with an acceptable range in right patient. The beautiful breast should be harmonious to the body. Aesthetical spans of the proportion and balance and the selection and pocket control should also be planned under this principle. Thank you so much. Thank you so much for the excellent talks. And definitely, I learned a lot and a lot of things for me to consider and keep contemplating. So now, we're open for questions. So please feel free to type your questions into the chat so that we can answer. And I'm happy to answer any questions that you have. I'll have the speakers give us their expert opinion. And while I wait for some questions, let me start with Dr. Zhang. You mentioned that, I mean, thanks for excellent talk. I know you're an expert in rhinoplasty and revision rhinoplasty. I definitely have the privilege to observe your surgery and learn from you and hear your talks at international meetings. So you mentioned about the importance of having a long-term follow-up and getting patients to come back to visit so that you can review your results. Like, how do you actually get patients to follow up long-term? Like, such as a year or more? And also, during the pandemic, do you find that easier or harder to get them to come back to follow up with you? Actually, my... Thank you for the question. Actually, my routine checkup for immediate result after the operation, two weeks and one month and three months and six months is my immediate follow-up for immediate result. And then, actually, there is no routine follow-up, but sometimes patients, during their life, they worry about some problem after these minor trauma or after catching a cold or some discomfort. So they always come back. And so that's why I had some long-term follow-up. Great, great. And then you also mentioned that if there's inflammation, then you need to intervene pretty urgently. How do you make that distinction based on experience between something that's pretty mild versus something that's more severe, especially for people who are beginners or actually have to take care of patients who are not necessarily anesthetic surgeon? What are the things that we need to watch out for? Actually, if we already know about the definite sign of the inflammation, as we learned, some erythema or some swelling pain or redness, sometimes after the linoplasty, especially when the patient used implants such as silicone, that we need to more care about the inflammation control. So I carefully checked during one or two weeks. If there is no improvement, there is a very, very high possibility for removing the implant. But there is no implant, just only ultrasound tissue, ear cartridges or dermal factor replacement. After the waiting of one or two weeks with the antibiotics, if there is no improvement, I check the operation site and opening up and some cleansing is very helpful to control the inflammation. So a little bit different implant overlap. Great, great, great. That's very helpful. Thank you. Thank you. Yeah, so for Dr. Oak, I am very curious because I know you mentioned implant placement in partial mastectomy. So can you clarify if that means someone who had a partial mastectomy, like a lumpectomy, like part of the breast was removed, then you put an implant in. How do you decide ahead of time what type of implant you put in? Usually, I recommend the time of operation is about six months over one year after the mastectomy. And the deformity is minimal. I recommend implant insertion with FACLAPT or FACLAPT with SVF. But the deformity is marked. I recommend otolaryngology reconstruction. But usually, many patients who receive the lumpectomy or partial mastectomy prefer the implant reconstruction. So in that situation, actually, minimal deformity and some difference between the breast shape will be made. I see. So are these, the partial mastectomy patient, they are not necessarily cancer patient, meaning that they may not need to go for radiation. Is that correct? Or would you still put implant in at six months or maybe a couple? If they were radiated, would you still put implants in afterwards? Actually, absolute timing, time interval between operation and radiation is not important. Most important thing is tissue elasticity. Every time I check the tissue elasticity, some patients have good elasticity. Some patients have moderate elasticity. Some patients have very tight and inelastic tissue. In that situation, I will not recommend the implant reconstruction. In that situation, I recommend otolaryngology reconstruction. Sometimes, some patients have middle state and elasticity and inelasticity. In that situation, I recommend tissue expander. During the expansion, I can judge the state of the successful expansion or there is a limitation of tissue expansion. In that situation, I recommend otolaryngology tissue reconstruction. Yeah, but if the tissue expansion is failed, but we can acquire some additional breast envelope, in that situation, I can minimize the otolaryngology tissue skin island. It is also helpful for the patient. That sounds great. That sounds great. That's a good algorithm. I appreciate it because I have patients asking about that. But hearing your talk, then maybe that's something we can consider for the patient instead of subjecting them always to, I don't know, reconstruction, live with the defect or subjecting them to otolaryngology reconstruction. So that's really helpful. Thank you. And then for Dr. Choi, thanks for the great presentation also. Can you give us some ideas as to how you discuss with your patient about what type of, like the fold height? Like how do you make patient understand what fold height they are looking for? I mean, are there some tests or do you have to demonstrate to them ahead of time? Thank you for the question. In consultations, I use like some pin device and then make a fold directly with the patients. And then several height is made. And then I ask the patient, choose what is better for you. And then discuss with the patient. Discuss with the patient and then make the height. Great, great. And what is your post-op management after blood flow plasticity? Just immediately after the operation, I put some tapes, some tapes in just the operated side to prevent the triple fold. And then six days later, we just stitch out and then just see the fold. And then if the, especially in prostate surgery, if the level is changing, the early revision is needed within the two weeks. And then the common follow-up is done in three months later. Because three months is, I think, the standard period. If the fold is not loosened until the three months, the fold never loosened. But if the fold is loosened, within the three months, everything has happened. So I think the three months follow-up is important for the patient. Great, great. There's a question from the audience. It's a question about possible ischemia of the skin flap in the multiple re-operation in the nose. How do you predict that the flap will have a good outcome versus potential ischemia? I think this would be a question for Dr. John. OK. Actually, skin flap problems usually occur around the columnar. Because recently, open approach is very used widely. So two times, three times, or five times or more operated the nose, we always should be careful. So before the operation, first thing is we have to check the previous columnar incision scar. Some people, even the multiple operated history, there has a one or two scar. But the other patient have a lot of incision scar there. So before the operation, we have to decide which one we have to choose. So I always, when the patient had a multiple open approach, I always choose the highest one, not the lowest one. Because upper portion of the columnar flap is more vulnerable to the ischemia than the lower flap. So important thing is choosing selection of the columnar incision site. And second one is, as you know, the dissection or handling or traction that makes, actually, operation is just like a habit. So precise handling and management of the flap during the operation, you can save your columnar flap. If not, we'll have a big problem. Thank you. Thank you. One last question, because we are running out of time, is for Dr. Choi. Does dissecting the pre-tarsal soft tissue incur more edema than? I'm sorry, hold on. Does dissecting the pre-tarsal soft tissue incur more pre-tarsal edema? Here, the pre-tarsal dissection may cause the edema. So in the primary case, we dissect the pre-tarsal area very minimally, and just remove the pre-tarsal pit just a little bit. But in secondary case, especially in the too much adhesions, at that time, it is unavoidable for the dissection of the pre-tarsal area. And then you just think about the edema will lasting more than primary surgery. But for the more favorable result, we must dissect the pre-tarsal area. But it is the best way to just preserve the pre-tarsal area if we can do that. All right. Thank you, everybody. It's a wonderful presentation, and with beautiful results from everyone. So we are so privileged to hear from all of you. And I think our time is up. So again, thank you, all the speakers. And for anyone who is interested in membership for ASPS, please feel free to reach out to us. Thank you very much, everybody. Thank you. Bye-bye.

rhinoplasty

blepharoplasty

breast augmentation

Asian patients

surgical techniques

anatomical differences

post-operative complications

implant positioning

aesthetic preferences

plastic surgery

open rhinoplasty

Asian noses

upper blepharoplasty

breast aesthetics

implant migration

post-operative care

cultural preferences

secondary complications

ASPS membership