Hi, good morning to everybody. I'm Dr. Lázaro Cárdenas Camarena, president of the Mexican Society of Aesthetic Plastic and Reconstructive Surgery, and I welcome everybody to this seminar. And I thank the American Society of Plastic Surgery for allowing us to present this webinar about facial surgery. We are four members of the Mexican Association of Plastic, Aesthetic, and Reconstructive Surgery, and I'm going to present them. The first one is going to be Dr. Martín Morales, and he's going to talk about face and neck surgery in prebiotic patients, and then I will talk about facial feminization, and our third speaker will be our past president of the Mexican Association of Plastic, Reconstructive, and Aesthetic Surgery, Alfonso Vallarta. And finally, our last speaker will be Hector González Miramontes. So we're going to begin. Thank you very much. Remember that if you want to ask some questions, you have to use the chat that is in there. And finally, at the end of the presentation, we will share all your questions and we'll answer all your questions. So Dr. Martín Morales, thank you very much for being here, so you can share your presentation with all of us. Thank you very much. Thank you very much. Hello, everyone, everybody. First of all, thank you to the ASPS for the invitation, and I have to say that it's a real honor to be here with these three great plastic surgeons from Mexico and from the world. Thank you so much. Well, I have to say that my professional practice in a public hospital, it's in a reference center of massive weight loss patients. So I can say that 1% of the patients that I see and I treat in that hospital are post bariatric patients. I don't have conflict of interest. And I have to start this lecture talking about what is the importance of the post bariatric surgery nowadays. Well, the answer is the obesity. What is important because now the obesity is a pandemic, is a world pandemic, and it seems that it's going to be here so many years because the numbers from 2016 say and have referred that almost 2 billion adults with overweight, more than 600 million with adults with obesity, and 41 million children with obesity. That's real alarming numbers because we are in a real pandemic that is going to be here a lot, a lot of time. The report by the World Organization of Health is every five years. So we don't know what is going to happen the next 2021, but we have some projections in this continent and we can see all the countries that has the highest rates of obesity, USA, Mexico, Chile, Uruguay, Argentina, Venezuela, according to the numbers of the Organization for Economic Development and Growth, America's in overweight and obesity is going to be, is going to be with a real increasing from now to 2030 or 40. But the question is, can we stop the obesity? Well, this is the figure that I like you can see. What is important and what is the meaning of this, of this projections? The meaning of the probability of operating an ex-obese patient is every day higher. Higher? I don't know. I have a lot of friends, have colleagues that say, no, I don't treat a postpartum patient, but I'm sure that they're going to do it in the next years. Talking about the general numbers in massive weight loss surgery, well, the first surgery, the first surgery performed, it's the lower body lift. The second surgery is the upper body lift. And the third is the face and neck lift, just with 7.9%. This data is from Mexico, but in the rest of the world is similar. But why is the less requested, the neck and face surgery? We have three factors. The first is the economic factors because the most of patients prefer to be operated to a lower body lift, abdominal or breast region. And in the third stage of reconstruction of the face and neck, that's a real trouble because we have a great increase of non-surgical treatment. In my personal opinion, non-surgical treatment is not recommended for this kind of patient, but now we have a boom. So the patient is tired of the surgeries, of being in an operating room, that when the patient want to finish all the reconstruction, sometimes they prefer a non-surgical treatment. What is the face and neck characteristics and what are the difference with a conventional patient? Well, here we have two patients, a patient that was ex-obese and a non-ex-obese patient. We can see that they have almost 20 years of difference, but the patient of 44 years old, she had a bypass, a gastric bypass, and the other patient is without any procedure. So we can see that almost 20 years of difference make that the post-bladder patient look older. So what I want to say with this, that this patient has changes similar to a premature aging face. The specific fascial changes are in all the strings in this order, dermatocallosis, sinking of the periorbital area, deepening of nasojugal, malar, nasogenal circles, excessive expression lines in the perioral and preauricular area, of course, decrease of the fat, of course, puppet lines, and the most important and the thing that makes more evident the changes are the sequels in the neck. They have lost all the definition of the mandibular arc and cervical fascial circles. In the most of cases, the submandibular gland is atrophic, is lax, and sometimes it is ascending. Sometimes we can see it. Here we have this profile picture where we can see these severe changes in the neck. We have loss of definition. We have that gray skin laxity in the midline of the neck, and this laxity is extended laterally until the supraclavicular area. Of course, we have an unstable muscular plane. We have vertical and horizontal skin force, and the most important is an obtuse mentocervical angle. You can see an obtuse angle is between 120 and 140 degrees, and the normal is in a patient is between 85 or 95 degrees, but this patient has an obtuse mentocervical angle that is the more evident stigma that they have lost weight. Something important to tell is that these patients, when they lost weight, they have some areas in the body with more concentration of collagen quantity, and the supraclavicular area is one of that areas. Well, what is the real challenge in the post-biotic patient? The answer is the neck. Here we have three patients, and we can see the obtuse mentocervical angle is the same in the three patients, but they have difference about 10 or 15 years, 53 years old, 42 years old, 36 years old, and they have the same sequela. The problem, so, is that we have a young patient, a heavy neck, and obtuse mentocervical angle. We have here a clinical case where we can see that, oh, sorry, the mentocervical angle after the surgery is almost the same. We can see a little bit of improvement, a little improvement in the definition of the neck, but the angle continues being obtuse. Well, why is a suboptimal result? The answer is that we have special characteristics in the post-biotic patients and a limited approach. Here we have this patient, the laxity is real, and the approach, the conventional approach described, sometimes doesn't work to the subversive core in the hanging neck. We have some pictures of an extended incision, midline plicature application, so we can see that with the pass of the time, the hanging skin, every side to the midline is going to be, again, with the sequela. Don't forget that we're talking about a heavy neck. All these characteristics, of course, the loss of definition in the changes in the skin are the principal thing that we have to think before to operate these patients. Here we have the heavy neck, the hanging skin, the midline with skin, and here we have the area, supraclavicular, when we have more concentrated quantity of collagen. So what is the clinical or practical meaning? We have this triangle, the hanging skin, where the skin is lax. We have to track to operate this skin, and here we have this triangle in red, high concentration of collagen. So this is going to be, we're going to have two opposing traction forces. It's not enough. It's not enough in the surgery because we're going to have suboptimal results. So what is the suggested technique? Please perform a modified Y-dissection with a lateral platysmal application without touching the midline incision. The proposed is make a retrovicular incision more than 10 centimeters, make a subcutaneous dissection to the supraclavicular area, make a lateral application, and make a big dissection with an overtraction. The advantage we're going to have is that we're going to get a great neck definition and we're going to avoid the midline incision. We have this patient. We can see this patient is young, 39 years old. And in the video, we can see all the sequelae. Everybody could think that this patient is older, but no, it's 39 years old. So of course, we have to complete the preoperative goals, talking about the body mass index. We have to complete the mass between the first reconstruction and the second or third. The marking is really important because we're going to make a maneuver touching the skin, the lax skin, in a diagonal vector to the earlobe. And we're going to mark the pre- and the post-auricular incision that, as you can see, it's going to be longer, longer than a conventional. With the conventional, maybe sometimes it's six to eight centimeters. In this case, I prefer to make sometimes 12 or more centimeters. And this area in red is the area that we're going to dissect to release the skin and make a better traction. Other important point is to mark from the chin an horizontal line to the posterior cervical triangle, and one centimeter from the earlobe, a vertical line. And we're going to have the point where we're going to do the platysmal application in an ascending way. This point, the intersection between two vertical and horizontal, is a point where we're going to make the platysmal application. The important thing is that we have to be conscious that the patient has the changes in the skin. Here we have in the other side, and in the marking, it's all important. Talking about the surgery, well, the important thing is that when we are in the surgery, we have to make an infiltration with a Tomasin solution. Well I use 500 milliliters of Harman solution with one ampoule of adrenaline. We make 10 minutes of latency period. So we make a liposuction just to release the skin, make the incision, and continue with the hand. Sometimes people think that if we don't make a good Tomasin, we're going to have more bleeding. That's real. I'm going to show you this dissection. All this area is the area marked to the supraclavicular edge. This is a non-cutting dissection, we can see, and we're going to release all the skin. If we have a good Tomasin area, we don't have bleeding. We continue the dissection, and finally we make the application with non-absorbable. We can see it, and the important thing is that we have to mark again the intersection in the platysmal. This is the area. We can see that the heavy neck in the post-bariatric patients is not just the skin, it's about all the structures, and of course the platysmal has a greater function in this hanging neck. So we have to make, in this point, to move the muscle to the earlobe, and we're going to have about five centimeters in each side. In each side, we have to make three or four points, and continue to the mid-face, to the central face, with an absorbable. We have to complete and put the flaps in the area. We can see that the patient has a great quantity of skin. The rest of the management of the central face is over. I don't use a high-smart, something different, because I try to make more the difference in the neck. Well, remembering, for me, this is the more important step, release the skin. We have this kind of results. This is the more important thing to the patient, because she's scared. She has three days. We have to talk. We have to talk a lot with the patient that it's going to have a long recovery time, but we can see that we don't have a nerve injury. Here we have the patient one year after, and as you can see, the principle, the main goal that was the neck. Here we have the result. We are looking the neck definition. The main disadvantage has high risk complications, a long scar, or the slow recovery time. The complications, the principle is not a complication, but there's a bruising in the aseptic area, but it's just for four or five days, and nervous injury. The scar is long, sometimes, as I said at the first, we have five centimeters between each side, but it's almost not perceptible, not visible. The slow recovery is slow. We see that one month after, the patient is still recovering his face. Two months is the time that I suggest. We have the same case. The scar, you can see six weeks after, but the patient, when they see a good result in the neck definition, sometimes they forget sometimes the scar. The satisfaction scale is high, and sometimes the patient cannot see the result when they have a picture, a frontal picture, but they can see the result in a profile picture. The same case, three weeks, big, big, big edema, great edema, but in two months, they have the result that we're looking for. Finally, the patient can be three years later with the results that, well, in my case, the first disadvantage is that we were trying to look at techniques with more time, and I prefer doing more aggressive. Well, it's not aggressive. It's extended, this section, or way. Anyway, in conclusion, I can say that the neck management in a post-operatic patient has to be not aggressive, but I have to say that it has to be extended to all the affected areas. If we wanted to get optimal results, we have to touch all the affected areas until the supraclavicular area. A post-operatic patient never, never should be treated as a conventional aesthetic patient. Thank you. Thank you very much, Dr. Martín Morales, for your wonderful presentation about biotic patients. Now it's my turn. I'm going to talk about facial surgery, facial feminization, and remember, remember that you have to send all your questions to our chat so we can answer them when we finish this webinar. Well, let me share my screen. Well, thank you very much. Thank you very much for all of you being here and for the American Society of Plastic Surgeons to allow us to present this work. I don't have any conflict of interest, and I'm going to talk about different surgical procedures for facial feminization. When I began to do this surgery, why I began to do this surgery, well, because I began to see a lot of patients that had a lot of problems on her faces, trying to change their faces with injections. And I began to see patients like this with a lot of changes on her chin, cheeks, deformation on the forehead, on the cheeks. And so they were trying to have a more female look. So my goal was to analyze the anthropometric difference between the male and female faces, and then to know if there were any alternative for facial feminization. And finally, to perform surgical procedures according to the needs of these patients. So we know that there are significant anthropometric difference between male and female faces, but when I began to do this surgery, there were not a lot of procedures, so not a lot of doctors or plastic surgeons who did this type of work. And the first one, and the one who is the father of facial feminization was Osterhout, that wrote a lot of things about this surgery. When we talk about the surgical procedures of this technique, all of these are basically on the middle part of the face, talking about the central area, and doing reshaping about moving or remodeling the bones of the facial structure, especially the orbital area, and the chin, and the jaw. So what we do for this type of patient, well, we do the surgery, we do the anesthesia, and the first thing that we do is we approach the forehead to a hairline incision, and to that incision that we do on the hairline, we lift all the flap until we go to reach the suborbital area, and we do a burring of this area. We do an internal burring of this area, and we can change the shape of forehead like this, and we can see here, and we can achieve this type of results. And if we see the patient from the profile, only with the burring, we can go all the way through here, and we can change this prominence, or we can eliminate this prominence and make the forehead totally flat. Also, on the forehead, we can make an orbital enlargement. So when we have very big or very prominent bones in here, and the patient needs some enlargement of the orbit, what we do is we burr this area, as you can see, until we have this elimination. We eliminate the bone on this side, making a more open orbital area. So this is the area where the orbit was closed, and we opened, we removed the bone. We have the bones on both sides opened, and you can see the bone that can be removed with this technique in this area. And also, we have to work on the muscles, and we have to work on the eyebrows. So we cut the muscles and the periosteum to allow to leave the eyebrows. We have to be very careful with the suborbital nerves right here, but with the cut of the periosteum, or the cutting of the periosteum, we can leave more of the eyebrows. And finally, on this type of the forehead surgery, we cut the extra skin so we can make the forehead smaller, and sometimes we can reach a lot of extra skin that can be removed. But we can see this patient, this patient with the surgery only the forehead and the nose, and you can see on the profile how we eliminate the suborbital areas of prominence, and we make a smooth curve between the nose and the forehead. Unfortunately, we have patients that have a very, very big sinus, and we have to cut the sinus to set it back. So this patient that have a big sinus like this one, we have to set it back. And during surgery, you have to make a transillumination. We are going to see a video of how to do the surgery. It's a type three surgery, also how it's called type three surgery, where you have to cut the bone and set it back. So in this patient, has a very prominence of a very big sinus. So what we do in this case, we used to do this. We don't do it anymore, lift a periosteum flap, because now we lift the periosteum on the upper part of the flap, and we don't need to lift the periosteum like we are doing in this way. So what we do in this case, or on the video, we're trying to show you that you need to lift the periosteum, and you're careful with the periosteum, because the periosteum is the one that we're going to give blood supply to the bone that we're going to work. During surgery, we turn off all the lights of the surgical room, and then we mark the area where the sinus is, and so we can know where we have to cut. In this case, first of all, we have to board the area, so we're going to have some bone chips that we're going to use on the final process of this surgery, and then we cut the bone. We cut the outer part of the sinus, and that, when we cut the outer part of the sinus, then we cut a little bit more, the sinus and the bone, and give it a more rounded curvature to that bone. So we leave the external part of the cortical, the external cortical area of the sinus, of the bone, and then we remove all the tissue from the sinus, because we used to obliterate the osteum, so we close the sinus. Sometimes we don't do it, but usually we do this, because we like to not to have any more sinus, and to prevent any infection after surgery. We have to remoulade also. We are making remoulade in this case of the internal part of the sinus and the bone, so we can set a little bit more back, and finally, we are going to use dermis, a dermis wrap with platelet-rich plasma to put it into the sinus, so we are going to, like I said, we are going to obliterate the sinus with the platelet-rich plasma, we are going to put it right here, and the dermal wrap. And then with stitches, we make a bone wrap, and then we put the bone that we were recollecting during surgery, like an organic glue, that is going to cover all the area where was the fracture. And at the end, we put the graft, the flap in this case, like I told you in the beginning, we are not using this flap anymore, what we are using is the flap with the periosteum at the same time. This is the patient, you can see the results in this patient. We're going to show all the patients later with this type of surgery. Well, also, we do rhinoplasty, we're not going to talk about rhinoplasty, but we do rhinoplasty to make a female looking. We also do cheek augmentation, we can do it with implants, or we can do it with fat, depending on each patient, and we're talking with the patient, and the patient has to decide which is the best option. And then we go to the lips. On the lips, what we're trying to do is to achieve this type of lips, so what we do is to remove a strip of skin on the lower part of the nose, and on the upper part of the lip to make a lip lifting, and with the lip lifting, we can shorten the distance between the lip and the nose, and also, we do fat grafting. The fat grafting is going to allow us to give you shape, shape to the lip, and also to give volume to the lip, like in this case, that we're trying to achieve this type of lip. In this patient, you can see the six days after surgery, how the lip was improved, and then we go to the lower eye of the face. The lower eye of the face, the jaw, the chin, and the trachea. On the jaw, what we do is we can make it smaller only with reduction with burring, or also, we can cut a segment of the bone on the posterior area of the bone, as you can see, and on the chin, we can do a lot of things. On the chin, we can remove some portion of the chin. We can, or only we can do a lateral osteotomy and remove that part of the bone, so we can make it more rounded, we can make it more rounded and diminish the length of the chin and put a chin implant, or also, we can remove a strip, like osteotomy of the chin, and we can diminish the length of the chin. So, we can do a lot of things, and usually, we do a jaw and chin remodeling at the same time. And, well, we finish with the surgery in some patients when they needed an adequate reduction. I'm going to show you some clinical cases. Here, one case two years after the surgery, where we did all the surgeries on the forehead, rhinoplasty, lip lifting, and you can see how the forehead looks much better, the face looks smaller, but the main change in this patient was the forehead. You can see how the forehead was improving, and also the chin, also the tracheal shape. This is another patient, two years after surgery, we did a lot of surgeries also. She had injected some silicone on the chin area because she tried to change that area with injections. So, we make all the changes with sliding osteotomy, and we changed also the forehead. All the forehead was changed with the surgery, and you can see how the improvement was done with the surgery. This is two years after surgery. This patient came back for a tracheal shape, so we take the photograph at that time, and you can see how was the improvement of this patient doing practically almost all the surgery that we're talking about. Another patient, and this patient, the most important thing that was that we did also a hair rafting when she came back again, and we did an osteotomy in this area to make the jaw and the chin a little bit smaller. Three years after surgery, with all this type of surgery that we're talking about, and the patient that we show you at the beginning of this one, as you can see, it's a very big, important, a very important improvement only with the forehead and the nose. You can see, only has three weeks after surgery, you can see how the improvement was in this case, and how the nose was in the proportion, and this is a very early patient after surgery. I presented this patient because you can see how much you can advance the hairline at the surgery and remove the prominence of the frontal sinus and have these results. And this is another patient where we did the surgery, all the surgery on her face, but we inject fat in this area also, so we can have, we eliminate this area where some patients doesn't like it, but in this patient, we also cut the jaw, we also cut the chin, we inject some fat on the face, we did the forehead, we did the nose, it's a big change about the masculine features. And in this patient, sometimes they don't have hair, but the scar is not very noticeable, as you can see here. This is another patient, we did almost the same surgery as the last patient, and also she had baldness. And anyway, we can see that the improvement is a very good improvement with the nose, and the chin, and the jaw, and changing the lips, all the surgeries done on these patients, and you can see the results. How is it that when the patient has hair in it, well, it's totally different. Well, I'm going to present in the four more minutes that I have here for my presentation, what we are trying to achieve with this type of patient is to change their lifestyle. They want to be like a woman, they want to have an behavior like a woman, so they send me pictures after several months, or after several years, or what we have, how are they, and these pictures, I know that these are not clinical pictures, but I can see that we are achieving the goals that we are looking with this type of surgery. For example, this patient, she sent me the marriage after the surgery, and she is from England, and she was very happy because she can have the marriage after the facial feminization. This is another patient, from this to this, but the most important change was, this was the patient before the surgery, and now we have this change after surgery. This is a patient from Germany also, so we have a lot of patients that send out their photographs after the surgery, and how the lifestyle and the surgery changed their lives dramatically. We can see this patient, the one that I showed you that we make a great advancement of the hairline, and this is a patient from Poland, and you can see we have a lot of hormonal, because this patient take hormones, a hormonal change in surgery until we reach from here, because when we began to see this patient was, in this case, from here to here, but the most important is when we saw the patient, when we did the first surgery to have these changes, but the most important thing is, if you can see how he began, before he began with hormones, and after two surgeries with us and hormones, we can achieve this type of results. I already showed this patient, she's a performer in Las Vegas, and this one I already showed you, also can change the lifestyle, and this is our last patient. Our last patient is a patient who was a model, a male model. A lot of areas was doing modeling, and he wanted to change to be a woman model, and so we did a facial feminization, and we achieved these results with this patient on the face and then on the body. So, our conclusion is that there are significant anthropometrical difference between the male and female faces, and this difference, as we said, are on the middle part of the face, especially on the bones area, and we have multiple surgical procedures that we can do in this patient to improve their faces, but we need a special training because it's not easy to do them if we are not allowed or even have practice in doing them. We have to combine these procedures, and we can feminize a male face to a female face. This is possible, but we need an integral evaluation of each patient to produce the best results, and remember, these are one of our patients, and with this type of surgery, there is no gender. We can go from one gender to another one, talking about physical features, and finally, I can present some of our results of some of a lot of patients that we have done this type of surgery and facial feminization. Well, thank you very much. With this, I finish my presentation, and I'm going to ask Dr. Alfonso Vallarta to present his work about security on facial surgery, and remember, I remember you to send all your questions through the chat that we have open for that. Dr. Vallarta, thank you very much for being here. Dr. Vallarta is a past president of the Mexican Association of Plastic, Esthetic, and Reconstructive Surgery, and also is a very big, a good friend of us. Alfonso, poncho for me. It's your turn. Thank you very much, Lazaro, for your presentation. I'm really thankful with ASPS for this opportunity and also for Hector and Martin to share their experience with us. I'm Alfonso Vallarta from Mexico City, and what should we worry about? Facelift is not between the top five cosmetic plastic procedures as stated on the ASPS statistics of 2018. On the same way, we are looking at the decrease of the total face and neck procedures of 17.2 on this ASPS 2018 statistics. Maybe it could be because we are not considering well our procedures. When we see a patient that wants a facelift or a facial rejuvenation surgery, we need to consider age, the genetics of our patient, how are the hormones charged, if they smoke or not, if they have some damages, and also increases or decreases of the weight and the quality of the skin. At the same way, we have to know if they have had primary surgeries, multiple surgeries, and the history of nerve palsy or injuries. And also, we have to consider the experience of the surgeon that is doing the procedure and also that we have an informed consent to allow us to do this surgery. Because the patient is looking for some goals as rejuvenation, the long term of the procedure, and also to get the complete satisfaction of it. The surgeon has to establish the goals doing a quality and safety procedure in order to have good results. For that, the evaluation of our patient has to be easy, has to be in extents, we have to know their lack of symmetry, even whatever history of another pathology is very important. We have to do general clinical examinations and also to consider right now because of the pandemic, COVID also, and establishing our pictures and videos of each patient. The subjective evaluation is also very important. We have to limit to realistic results our procedure and knowing the expectations that is looking at our patient if they have or not have any psychological disturbances. In this video that is social media, we can see the process of facial aging. Here we can see the way a kid goes into a mature patient and later on an elderly patient. What is occurring, we have a process of elongation, deflation, and reabsorption. Remembering that we have a lack of elasticity of collagen and elastin fevers on the soft tissues and also a deflation of the fat tissue that is accompanied by the reabsorption of the bony structure, just as you see here on the bony orbits, the midface, and also on the mandibular symphysis. All that reabsorption causes the ptosis of the soft tissue and as Ventura, Omar Ventura from Buenos Aires states on a paper of the Philips Journal, the retaining ligaments are having a displacement vector. We have to correct them using the reestablishment of these vectors. For all this, we have to do safe dissection for the young surgeons, I highly recommend to go to DecaDaver to make subcutaneous dissection, sub-mass dissection, and also the subperiosteal approach in order to have all the security in this procedure and to avoid injuries, for example, of facial nerve in all the branches that you know very clearly. And to establish some safety measures, we have to know how we do our procedure. So we began establishing a volumetric reposition as Dr. Guerrero-Santos published on a late 90s paper at PRA Journal. He recommended highly to see on a seagull and a worm's view, our patient, defining what are the lacking zones and that need the fat transfer. We prepare the fat transfer with decantation. We pass through several sizes of syringes until we get to the one centimeter syringe that is used with a cannula of one millimeter or two millimeters in order to put about 30 centimeters of fat transfer in each size of the face. Here we are using it to the mylar zone, to the lip-cheek junction, to the nasolabial fold, and also for the lip. We are doing this in a multi-planar way. Also for the eyebrow, we put about two centimeters here, and this will give us a good shape for the zone. When I finished my training in the early 90s, our professor showed us how to plan our scars, where we have to put them, and knowing if they have emigration or not, but also to establish the requirements of each patient. We know how to make a flap dissection, the procedures for deflating the zone of the region, the placations of this mass and also knowing the thickness of the flap. What we do when we approach with the subcutaneous dissection is an incision one centimeter below the submental crease in order to make a direct lipectomy that helps us to remove all the fat part. After that, we made a placation of the platysma just as Joel Feldman established with the corset plastic technique in the early 90s. This way, we made just one unit of our platysma sling. After that, when we finish the corset plastic, we mark our incision pre and retro auricular with the limits of our subcutaneous dissection, including the cheek and the neck. We do it on the local anesthesia, and after that, we see the movement of the tissues in order to make the placation of the platysma and also of this mass, so we can remodel all the cheek and the neck. We adjust the skin and divide this big flap into flaps. We put our stitch at the radix of the earlobe. After that, we made the resection of the skin with undermining a little bit the fat in order to make thinner our flap. We adjust finally, and we put some drainage, one for the neck and another to the cheek, and close with a subdermal suture as you can see here. In this case, we also put a little bit more of a transfer for the nasolabial folds. So, we learned how to make our posterior and superior vectors without tension using a dermal support when it is necessary, subdermic suture, and the use of drainage. Here are some cases with this technique, but what happens when you have an unsanitized patient that is asking for more? We can think that a monoplanar technique just lifts loyers one and two of Neligan's, but a compound technique with two loyers lifting that can reshape the face. In our case, we use a two-loyers approach using a superior vertical vector for the midface and a mass platysmal oblique vector for the neck and also to remodel or reshape the cheek. Our midfacial approach is with a temporal incision. We dissect between the intermediate, the superficial and deep temporal fascia in order to get to the midface dissection in a subperiosteal approach. We also continue with an intraoral incision that can rip the periosteum and can let us to lift it with a complete movement. We put a needle that we will see inside the flap, the compound flap. There we put a stitch of PDS 3O, and with that we can pull all the compound flap passing the stitch to the temporal incision. Look at the movement of all the surf. This made a complete restitution of the deep plane pulling up the compound flap. We anchor the stitch at the deep temporal fascia as you can see in this video. All this is on the Philips journal. And after that, we add the removing of a strip of skin just to elevate the tail of the eyebrow. Eyebrow. Here we add also some stitches for the S-mass in order to have a reshaping, complete reshaping of the sun. So it lift out the bulging. With this technique, we have several advantages. First of all, the palpable fissure is just equidistant from the eyebrow and the surf. This is a sign of youth. We have minimal incisions without the use of endoscope. We are not going. And also here you are having the movement of the psychomatic muscles. Just as you see with the video, we are lifting our lip commissures and we are taking some procedure of the smiling dynamics. These are safe dissections. We are thinking on volume and also on the skin adjustment. Here are some cases of the post-operative at 30 days. Another case at six months. Six months also. Another case with six months. One and a half year. At two years, look the changes. Three years. Another four years post-operative. And finally, at three and at seven years on the right. The post-operative care, the dressing and bandages, no pressure, using drainages and all the recommendation for general care that you know very well. This post-op garment that is very useful. And we have to continue looking at the wounds to establish a good control. We can have complications of hematoma and infections, like in this case that we have the pictures at four days and at seven days with a complete swollenness. This is after antibiotic and drainage at 45 days and our post-op with the control of three years. The nerve injury, the most injured nerve is the great auricular with 15%. And also we can have, as in the picture, injuries for the temporal branch of the facial nerve or as in the video, injuries for the zygomatic and marginal mandibular. We can have prolonged edema and echemosis. These cases were used with the laser at the same time. I do not recommend it anymore. And also we can have pathologic scarring as in this case that we solve it, removing the scars, making a secondary lifting and using radiotherapy for the zone. So to make a facial rejuvenation surgery is very important to have a pre-op evaluation, a perfect surgical plan with a good surgical technique and considering our post-operative care. So in this way we can change the intention of this 27 million that are looking for the word facial rejuvenation on Google or this 12.5 million that are searching for some facial rejuvenation surgery in real surgeries that can change the numbers of faith lifting and raising the levels of this procedure that is emblematic for our specialty. Thank you very much for this opportunity. Thanks, Lázaro. Thank you very much, Dr. Vallarta. And well, we're going to present our last speaker. Our last speaker is Dr. Héctor González Miramontes. And Dr. Héctor González Miramontes is going to present one technique that is the author of this technique. So, Héctor, thank you very much for being here. And well, let's share your screen and let's see your presentation. Okay. Thank you very much, Dr. Lázaro Cárdenas. Thanks for inviting me and the American Society for considering me in this important meeting. And I want to congratulate you on your presentation because it was really wonderful. Okay. I want to talk about the super high smiles like I described, like personal innovation in retinoplasty. Okay. In facial cosmetic surgery, there are a variety of procedures to achieve rejuvenation. Personally, I seek to obtain the best possible result and maximum naturalness. You have to share your screen. My screen? In the lower part, you have to share your screen on the green arrow that you have there. I'm sorry. Let's see. Let's see. Okay. Got it. It's okay. Not now. Let's see. Let's see. Okay. That's it. We have it. Okay. I'm really sorry because I'm not a specialist for this thing. But did you hear me? What I'm talking about before? Okay. Perfect. Thank you. Okay. And today, I'm going to focus on personal modification in super smiles like this. My philosophy is to perform a surgical technique that gives us an immediate and long term result of true facial rejuvenation that respect the natural aging of the face without causing anatomical distortion of the soft tissue. Okay. My goal in retinoplasty is to get the natural lasting result, evident facial rejuvenation, harmonic balance of anatomical structures, anatomical control, and firmness in the position of soft tissues. Maintain the natural and rejuvenate facial expression and patient satisfaction. Okay. The natural result is achieved by the anatomical reposition of the tissues, respecting and giving the face a natural volume as if the person was young. And we can observe evident facial rejuvenation. In many occasions, with the traditional SMAS technique, it is impossible to achieve the true periorbital rejuvenation. And this I achieve with the super high SMAS with my personal technique. On many occasions, it is not necessary to perform a blepharoplasty. With my technique, I get very good results. The other goal is to have a harmonic balance of anatomical structures. And we can see different type of cases. In every case, we get the really, really natural. But in retinoplasty, fundamentally, it must be based on three important principles, my principles. Okay. I call the volumes, vector, and support. All of these together, balance these together, we can get really natural results. Okay. The volume. When the volume is giving volume to the face through fillers or fat transfers, could be missing the opportunity to achieve the natural result. One of the main formulas to achieve natural results in the face after surgery is to give back volume to the face through its own tissues. We have an example here, an actress here in Mexico, she went to California to have a yellow runny axis, and the doctors introduced, I don't know how much volume introduced, but to feel, you know, the the fillers in the flaccid face. And we can get probably nice and good results because all creases can disappear. But the real truth, we like to have this type of results. Okay. But when we put a fat transfer, this is an important patient because my professor, Bruce Cornell, a long time ago, I worked with him in this case, but with the surgery. But this patient, the years after we performed the surgery, he would like to have more. I told my professor, say, he looks wonderful, he doesn't need anything else. But other college or other plastic surgeons, he said, no Bruce, probably with the fat transfer, with fat injection, we can produce a really nice result. Okay. But I say, fat transfer to the face from another part of the body has different genetic memory. The fat has different genetic memory. And nobody knows how much this fat will be grow on the face. Because if we gain weight, like 20 pounds on body, okay, we get more fat on body. But in the face, in the normal part of the face, it doesn't increase a lot. Okay. But if patient gains weight, in this case, when they have a fat transfer, we also increase the face and creating like a morphological alteration like we've seen in this case. In vectors, I describe different type of vector like many other college in the world, but superficial vectors are only on the skin and deep vectors came from this mass platysma. Deep vectors are the basis for the anatomical soft tissue displacement. This is, I describe these three main vectors. This not means these only vectors. Okay. I describe these three main my vectors about my technique. The red, there is the wrong vectors. And for me, the black one is the ideal vectors. The first vectors I described there is impossible to do without doing the super highest mass. Following the ideal vectors would result in the harmonic balance of the face. Make a deep pain facelift without making the ideal vectors, we obtain a face without a natural volumetric dimension. This is my first vectors on the top of the vector. This is, I call this the first one. Okay. If you see that, that vectors is over the psychometric arch. Okay. But the first vector I say it is not possible to find this first vector without performing super highest mass dissection. Okay. I would, I would make, you know, concentrate about this point super highest mass dissection. Okay. Yeah. But super mass dissection support is achieved through highest mass, like many really wonderful college around the world, like Timothy Martin, Garth Fisher, my professor, Bruce Cornell, like for a long time, they're excellent and really expert to doing highest mass. But what's, why I doing a super highest mass. Okay. Because, okay. In these pictures, this is, you have to know the anatomical point. Okay. In the past, I did that like a transaction at the over psychometric arch bone. Okay. This is the transaction, the highest mass. This is another picture to see how I did that a long time ago, like my professor, like many good college. Okay. But what's the different super highest mass. Super highest mass. I call it that because I do higher dissection. Okay. No higher transaction. I don't do any, any more, any transaction of this mass. This is higher dissection of the upper edge of the psychometric arch, approximately like four centimeters higher. Okay. Super highest mass. We get that integrity of this mass flap. No smash transaction is mass with greater resistance because if we don't transaction this mass, we can have a greater resistance. Uniformity of the reposition structure, best elevation of this mass in the correct vector, improve the highest part of the initial level fall, improve initial growth without putting any fillers. With the highest mass, like Timothy Martin performed, sometimes you can complete the treatment with nanofat transfer. I don't know that this thing, because with super highest mass, it's possible to correct the nasolabial group without any fillers or any fat injection. The anatomical displacement of the orbicularis oculi muscle of the lower lids, this permit us to have a really nice rejuvenation of periorbital area. And natural and better projection of the malar fat path. Okay, this is the scan, this is the picture of my patient of the super highest mass. If you can see this picture, okay, you can see the blue line, you know, in the upper part of the triangles, that the line is the marking of where's the psychomaric arch. The psychomaric arch are, and you can observe, I do like four centimeters above the psychomaric arch. And there is anatomical confuse in many of my colleagues, in many books, textbooks, about the upper part of this mass is continuous with what? Okay, this mass upper of the psychomaric arch is not continuous with any other layer. It's going over the gallia or the temporal parietal fascia. You can see the scissor behind of that fascia is completely different anatomical, you know, the section. Okay, here you can see at the left side of the image, the video, the small video, and you see the black line or the blue line of what the psychomaric arch are, and you can observe the dissection after that. And you can see the different layers, the gallia or this temporal parietal fascia is completely different. And you can see the skin flap, SMAS flap, psychomaric arch mark, the deep temporal fascia and temporal parietal fascia. It's very important to have really good precision of the dissection. If you don't do that, you can miss the plane. Let's see. Okay, I want to be talking about, to be clear the difference, because super high SMAS about Dr. B.G., he described about the incision place at the line connecting the supratragus area to the lateral canthus. Okay, he's performed a transduction he calls super high SMAS. This is incorrect? No, this is correct because this is above, this is super high SMAS. The difference is this point of my technique, personal concept, super high SMAS is, I do dissection. He do, he performed a transsection about this SMAS. You know, the super high SMAS of Dr. B.G. is that he make a transsection with a release in the ligaments and this make this tissue support more vertical. And therefore, there could be less definition of the final contour of the face. This is the difference of this concept. And here, here. The incision is designed extending from the tragus to almost the lateral canthus area. Okay, this is described of Dr. B.G. He's performed a transsection. I don't do any transsection and we cause the same super high SMAS. But to be the difference, I can say super high SMAS dissection. Okay, this is, you know, the picture just to be clear a little bit more about the difference. Super high SMAS AGM, this is my initial vector, has an effect on the orbicularis muscle. If we don't do a super high SMAS dissection, it's impossible reposition or, you know, define the contour of the lower legs. To the, to the orbicularis oblique. In the green line is where's the bone of psychomarriage arch bone are. The yellow arrow is when you do a transsection of the highest mass, and then you have to pull more vertical, you know, for transposition of the SMAS flap. But if you see the light, the light blue lines, okay, you can see the transsection of Dr. Bigini, he calls super high SMAS, but his direction is gonna be like the blue light arrow and there it's more vertical. If you see that that blue, my vector, my own vector, with that vector, it's possible 100% for to correct, you know, the sagging of the, of the orbicularis muscle, because the orbicularis muscle on the lower legs is when, when this is with the edges coming like sagging, this looks like a edge in phase two. It's very important to, to correct that, that anatomic area to have a complete aesthetic final result. This is a close up view, but this is the same, the green one, it's the psychomic arch, the blue line is the transsection of the highest mass of Dr. Bigini, and the other areas I described before. Okay, but we can see, we can compare different technique. Okay, whatever technique you perform in the world about the facial rejuvenation, you can improve. Okay, but my goal is to try to do the best and the more natural with my technique. If you see at the right side, this is the before and after. If we don't release complete the ligaments of the supras mass dissection, we can have like wrong vectors, like you can see the corner of the mouth, it's a little bit more horizontal, and it's for me in my impression, okay, this is, I don't want to fastidious anybody, but this is because I want to talk about the different. The projection of the molar area, this is not, has not nice control. You see of the right side, okay, this is my patient before and after, you can see the, you know, the balance, the harmonious control of the face with their own tissue. I don't do, I don't use any fine injection because if I release complete the ligaments of the attachment to, you know, provokes like reposition the tissues, if I free, I release that ligament, it's possible to have same volume, like people's looks like they were young, okay. I want to show you some results. I almost finished. Okay, this is before and eight days after surgery. I don't do, I don't use any bandage. This is right here back just to remove sutures. And this is my patient before and one year after. If you've served clearly like in the lower lids without any skin removed in that area, I did just only like transconjunctival lipoplasty. I removed just the part, but I don't do any skin cut and I performed all 100% of the surgery by my super high smart dissection. And in that dissection, I include the orbicularis oculi in the same flap. This is before, one year after. Okay, this is before, one year after, and a few year after. You can see this result stayed for really, really long time and looks really natural. One year before, sad look. After one year, look really nice rejuvenation of that area. This is before and after. Okay, she had surgery before with other plastic surgeon. I did this surgery with my technique. That's before six months after. I complete my result with a whole balance of the face, you know, neck, face, brow, whatever. I do whatever the patient need, but my goal is to have the best natural result as possible. Okay, this is before three months after, before two months after, and before one year after, 54 years old. This is before five months after. And when she looks down there, which you see in the area, the preorbital area, you know, still keeping the nice shape of there. This is before and after. And this is before and after. Sometimes like this patient doesn't need to change, complete the face, but after have to look like really soft, like soft, natural, and nice look. Okay, in conclusion, the dissection of the super highest mass and vector I have described, help to displacement and support the umbilical muscle of the lower lids, giving natural preorbital rejuvenation, which is not achieved with the highest mass. Okay, but this is very important. The aesthetic sense and the visual artistic dimension is individual in each surgeon. Everybody will have different vision, artistic vision. And for me, the black is really nice. For other colleagues, black is horrible. Okay, this is, we have different sense of artistic. Okay, thanks for permitting me to be over time, but thank you very much. Thank you, Hector. Thank you, Hector, for your presentation. We're going to ask some questions to our panelists. One question for each one, so we can finish. We're going to begin with Dr. Martín Morales. Dr. Martín Morales, do you think that the facelift in patients that have had bariatric surgery will be, or needs to be, or what are the advantages of having a first procedure of this patient after the waist loss? Or you think that has to be, first of all, other procedures, or what do you think about that? Hi, Dr. Lázaro. That is a great question, because the most of patients, when they are real post-bariatric patients, because it's not the same patient that lost with diet and exercise, and maybe they can get improvement with exercise, but when it's a real post-bariatric patient, they have sequelae in all the body, upper body lift, lower body lift, and in the face and in the neck. So the first procedure, it has to be always the biggest sequelae. So I suggest that the first procedure should be the abdominal area or the breast area, but sometimes when the patient is very, very, or too young, I had some patients from 28 to 38 years old, so that patients cannot continue living with that stigma at the level of the neck and the face. So just in that cases, I can accept to do in the first stage, the face and neck lift, because if they are maybe 45 years old and they have big sequelae in all the areas, so I suggest that the face should be treated as a second or third stage. So my recommendation is that. Okay, thank you very much, Dr. Martín. Now, Dr. Vallarta, can you tell us the three principle recommendations of safety in this type of surgery or facial surgery? Well, thank you, Lazaro. The thing is that we should plan very well our procedure, but first of all, we have to know very well our patient. Knowing the patient will avoid you a lot of failures and the lack of safety in the procedure. If you see a patient that is having trouble getting in the route for the lift surgery, lifting surgery, you will have problems. So you have to know the patient well, you have to do a perfect procedure, and finally, you have to control your surgery very well, having the expectations you have for this procedure. Okay, thank you very much. Hector, well, there is a question. If you can explain a little bit more about the difference in a short way, the difference between the highest mass and the super highest mass, the one that you perform. Okay, the main thing, the main difference is the super highest mass of Dr. Bigi, he talking about a super highest mass transection, okay? But I'm talking about super highest mass dissection. If we don't release all those ligaments, okay, I include the orbicularis oculi in my super highest mass flap. If I don't release the attachment of the orbicularis oculi, all the molar area, and over the cycle of the major muscle, it's impossible to have this correction in the correct vector. If we don't do release these ligaments, we have to finish our vector more vertical. If we do more vertical, we cannot have a really nice definition of the projection of the malar fat path. And this is, you cannot see where's the ending or beginning the orbicularis oculi muscle or the malar fat path. This is like one volume, like one plane. This is, it's a little bit difficult to have a different. I don't know if I understand, but super highest mass that I carried out is based on the complete dissection of the ligament of the malar zygomatic area and not based on the super highest mass transection. In fact, in the personal super highest mass that I described, the transection is not performant, but the integrate of this mass is maintained. When I perform super highest mass dissection, I include the orbicularis oculi. This is the difference. This is the main difference. I don't know if it was a clear, my answer, but I'll be here. Okay, yes, yes. Thank you, Hector. Now, this is a question for me about how do I make the sutures on the bone when I cut the bone. I don't use splats. I only use sutures. I use triology bone to do the sutures. I make holes on the bone and then five holes on the bone and the structure around the bone. And I make five sutures. So with that, I can stabilize the bone because it's a bone that's not going to be moving. So we don't need to do any more. But we use the glue, the organic glue that we perform during surgery. The organic glue that we perform during surgery is the platelet-rich plasma that we remove for the patient when we begin the surgery. And then we mix it with the cheaper bones that we have obtained when we are burying the bone. So we mix it. First of all, we make the suture between the bone and the structure with holes. And then we put this glue on the top of the bone, on the areas where is the fracture. And then we cover with a periosteum flap. So that's the way that we make the vacation of this area. Well, this is the last question because we're finishing for Hector. Here's another question. Let me see. How do you avoid to make injury to the nerve that is deep in the temporal parietal fascia when you are doing the dissection? Okay. This is a very important question because when we start at the resident or study this type of work, everybody are afraid about that, okay? But when you are doing more and more cases, but with special training, with specializing this area, it's easier to find the planes, okay? But you have, this is with the spirits, but it's possible to go at the correct plane without have that type of damage. For me, it's more risk, higher risk to do endoscopic because when you raise up and you are really close with the periosteum of the psychomeric arch, if you have some injury of the periosteum, you can have an injury of the nerve. But with this technique, I don't have that type of problem because I have experienced to do that, but we have to know and to go at the correct plane. No, there is no problem to have some injury. And I say nerve injury, more than 90% is from to use the cautery, not from to have injury with direct injury. This is my impression. Okay, thank you, Hector. Well, with this, we're going to finish this webinar. We would like to thank you, all the attendants that were connected to this webinar. And we want to thank the Mexican Association of Static Plastic and Reconstructive Surgery. We want to thanks to American Society of Plastic Surgeons to allow us to present this webinar. Thank you very much for all the speakers. Thanks very much, Dr. Vallarta, Dr. Martin, Dr. Hector. Well, we'll see you next time. Bye-bye. Thank you.

facial surgery

post-bariatric patients

obesity epidemic

excess skin

facial feminization

brow reshaping

rhinoplasty

cheek augmentation

jaw contouring

facelift safety

super high SMAS

individualized treatment

gender affirmation

facelift operations

super high SMAS technique

plastic surgery

obesity trends

customized surgical plans

patient satisfaction

surgical demand

innovative techniques