get started now. Hello everyone and welcome to this edition of the ASPS Global Webinar Series. My name is Dr. Giulio Tarantino and I'm a plastic surgery resident from Rome, Italy and today I'm honored to be here with all the other members and like to present today's webinar. I'm also here as a co-moderator and member of the International Residents Forum of ASPS and I'd just like to start off by saying what a success this webinar is for everyone as there are around 350 people who have signed up from around 75 different countries from around the world so it's thrilling to have so many participants joining us today. However, before we get started I just have a few quick housekeeping functions, housekeeping notes. The first of all is the Q&A function so please feel free to submit your questions throughout the session using the Q&A function and we'll do our best to address them during the Q&A at the end of both presentations. Additionally, please note that this webinar is being recorded and will be available on ASPS EdNet however exclusively for ASPS members and if you're not yet a member and would like to join please reach out to Romina Valadez for more information and here's the email you can contact her. I'd also like to take this opportunity to invite all of you to the upcoming plastic surgery meeting PSTM which will take place in New Orleans from October 9th to the 12th. If you would like to register there's a QR code in the bottom right of the slide free to scan. It's a great chance to grow colleagues from around the world so please feel free to join us and last but not least I'd like to now on it's my honor to introduce today's moderator Dr. Alan Matarazzo. Dr. Alan Matarazzo is a clinical professor of surgery and systems chief of cosmetic surgery at the Zucker School of Medicine at Hofstra Northwell. Recognized later in the field he currently serves as president of the PSF the Plastic Surgery Foundation for 2025 and is the assistant national secretary for ISAPS the International Society of Aesthetic Plastics Plastic Surgery. Dr. Matarazzo is also a past president of several prestigious organizations including ASPS as of 2019, the Rhinoplasty Society in 2010 and the New York Regional Society of Plastic Surgeons in 2007. His contributions to education and plastic surgery are reflected in his role as a traveling professor for both ASPS and PSF in 2003, the Rhinoplasty Society in 2017 and the American Society for Aesthetic Plastic Surgery the ASAPS in 2001. He is widely respected for his expertise and leadership and Dr. Matarazzo continues to shape the future of aesthetic and reconstructive surgeries through clinical innovation teaching and organizational service. So the word on to you Dr. Matarazzo. Thank you Giulio. I appreciate you being here. It's very late for you in Italy and I thank everybody for joining us for an exciting program on female finesse high definition abdominal contouring. We have two outstanding speakers. I will introduce both of them so that we don't have to interrupt in between. Our first speaker is Dr. Stephen Williams. Stephen went to medical school at Yale and trained in plastic surgery at Yale. Uh he now practices in Dublin, California and he's our immediate past president of the American Society of Plastic Surgeons and an esteemed colleague and friend. The second speaker is Dr. Arthur Yu who practices also in California in Las Pinadas and his main interest is in non-surgical and minimally invasive surgical approaches for patients. Arthur is going to give us a completely different look at how he does abdominal contouring. We'll take questions. Please please save your questions until the end. We'll take them after both speakers speak and we'll begin with Dr. Stephen Williams. Stephen thank you. Thanks Alan. That's a very nice introduction and uh you know I actually love being parts of uh parts of these types of seminars. I think they're really uh they're very engaging. It's wonderful to connect with colleagues and friends around the world and uh share ideas and so uh with that I'm going to share my screen here and we're going to get started. All right sorry let me back up here. Okay can everyone see that? Great okay so um I just wanted to talk about abdominal contouring and this is a maybe a little bit of a different lecture than um some people have have kind of went through. I really wanted to take one case and just show kind of differences in my technique and approach and um again this these are such great events because it's really about sharing ideas and I really encourage people to leave questions. There's no question that uh that I'll take offense to. I want to hear what everyone has to say um because that's how we get better is really you know sharing these ideas, techniques, and patient stories. I have no disclosures. As Dr. Matarazzo pointed out, I'm the immediate past president of the American Society of Plastic Surgeons. I've had past relationships with Johnson & Johnson, AbbVie, RealSelf, ACAPS, and the Aesthetic Society, but nothing of relevance here. So I wanted to start this talk with this slide and the concept here is that the idea of what the ideal abdomen is is it's different and it changes over time and these 1950s and 60s ads, sorry they're a little cringy and they're definitely not uh kind of appropriate, but the concept here is that different contours, different approaches, and and different looks um change and what's aesthetically valuable changes over time and um and that's one of the things that I would highly recommend those just starting out their career kind of keep in the back of your mind. You want to do things that are potentially long lasting, but you also need to recognize that your techniques and your approach to patients and how you interact with them and what you um the tools that you use to understand what they want and how to get them there are going to evolve over the the course of your career. So we're definitely a little bit more in this kind of protein world ad here where it declares are you beach body ready and the things that we can kind of um glean from looking at this ad are people are really looking for this much leaner waistline. They want to see definition of the abdominal wall musculature and they um don't they really don't tolerate loose skin um or a inferior abdominal bulge and so it's all about what techniques are available to achieve this safely for the patient reproducibly and effectively uh to um manage potential complications and meet patient expectations. Okay so this is um this is one of my patients and this is going to be kind of her journey and so she approached me several years ago and said I really haven't had any plastic surgery but I want a flatter abdomen and I want better curves and I also want a breast augmentation and I want big breasts and so for those international colleagues that are on the call I think you'll recognize these are really big breasts and um there's a little tiny bit of bottoming out but they're kind of exactly where they're supposed to be. You can see the inframammary fold incisions there, but the approach to the abdomen was a very typical one that I used to do and so this is a tumescent liposuction. I used power-assisted liposuction. We use a reciprocating handpiece, multiple cannulas, generally three to four millimeters and there's particular attention to the external oblique area and you know the goal is to really kind of trace this course over the inguinal ligament to really get some hip bone definition, a little bit of that central rectus definition centrally on the abdomen, but not do anything that really creates loose skin, not do anything that potentially is going to leave contour or deformities and definitely towards the beginning of my career I was much more conservative even with a patient that in this case might be ideal for abdominal etching and this was someone who really said I really want to see a noticeable change and you can see this picture is approximately, I think approximately six months post-operative. You can see my incision sites right above that pink underwear line there. I use a total of three port sites, one in the umbilicus, but I think reasonably good improvement. You can see that the inframammarial area is definitely, the contour is enhanced. There's definitely a definition over the pelvic rim and along the inguinal ligament that differentiates her abdominal profile, her lateral abdomen from her rectus and that's what a lot of patients are looking for when they say I want, you know, a more defined abdomen. So success, patient was happy overall and again, she kind of came back to me later in life and said, no, no, no, let me show you what I really want. I want to be beach body ready, which is why I keep showing this ad and so she came back to me. What was interesting now is this is her, she's had one child. You can see she now has a C-section scar that she didn't have before. Her breasts look much more reasonable for her overall. That's probably some of the involutionary changes after breastfeeding, but the liposuction, the abdominal wall contouring is held up relatively well. The general principles that I had as a younger plastic surgeon were still intact. You can see that lateral portion of the abdomen, that area where that inguinal ligament sits in, you know, over the external obliques, there's still a nice carved out triangle there. You can still see the pelvic rim. You can still see the differentiation point between the lateral edge of the rectus muscles and the rest of the abdominal wall. A little bit of contour deformity if I'm being super critical, but nothing that we couldn't balance out with a little bit more liposuction. And so my secondary approach now, the tools I'm using, I've changed my cannulas a little bit. All my redo liposuctions, I'm definitely using VASER. And I'm really working to do specific additional etching. And the main thing that I've changed in the operating room is being much more aggressive. And so when I'm looking at these patients, especially someone who's coming back to me who has the following criteria, she's been liposuctioned before. I know there's going to be scar tissue. I know I need to do something to break up those firmer areas of subcutaneous scar that I've left in that plane and find those areas of native subcutaneous fat that haven't been touched by previous liposuction. I know that she has additional loose skin and skin laxity because she's status post of previous pregnancy. And even the best youngest skin is a little bit more stretchy after someone's had a baby. And so, you know, knowing those two things in mind, I want to be able to access those areas that have the native fat around that scar. I want to be able to break through the scar. And I want to have some ability to affect some skin tightening. And so in my practice, the concept is tumescent liposuction. I do an initial pass of vasoliposuction. And I try to stay relatively deep, breaking up the initial scar to allow me to get access. On her abdomen, the total ultrasonic energy time was approximately four minutes for my first pass. I generally use a two-ring cannula, and I'm usually at 80% efficiency. Now, obviously, I'll change those clinical parameters based on the overall scar pattern or what I'm sensing in the operating room. And then secondarily, I'll do a pass generally with a basket cannula. And basket cannulas get a bad reputation because there's a lot of talk about them stretching out the ligamentous attachments or the fibrous attachments between the skin and the deeper layers, disrupting some of those architectural elements that you really want. But especially in a redo, you need to be able to make some space. And so I generally do a pass with a four, three-millimeter basket cannula. And then I have more aggressive multiport cannulas that I use to get out additional volume. After that, I'm doing some contouring along those areas, the lateral abdomen over the inguinal ligament area. I'm doing that central liposuction there to really kind of create, in some ways, a scar pattern, to create this reduction in overall volume, but also to create an area that's going to stick down and become scarred. And that's in my more recent iterations of liposuction, that has become a really useful tool. And then I'll pay a lot of attention in those spaces to liposuctioning with directional cannulas. And so I'm actually liposuctioning the underside of the dermis and the deeper side preferentially. And then I'll do a second pass with VASER. And then I'll do an additional liposuction pass to remove the VASER debris. The second pass of VASER, I'm actually doing just below the dermis. And I think that when you're first starting out, you have to be a little bit careful with the technique. I've actually never burned anybody, but it definitely can be done. I've definitely heard of it in the community. I've definitely seen it in the lectures. And so you want to be conscientious of it, but you're actually using that thermal energy that's generated by the ultrasonic cannula to tighten some of those collagen fibers. Now, there are different ways I think that you can successfully do it. There are different devices. There are plasma devices. There are radio frequency devices. The general, and I think they all have different levels of success, and it's largely dependent on what people are comfortable using. But the overall concept is you want to be able to be aggressive with your liposuction and get some skin retraction. It's not going to be with any device in anyone's hands. It's not going to be centimeters and centimeters of skin retraction, but a centimeter or half a centimeter skin retraction over the length of the abdomen in the appropriate candidate can make a really, really big difference, especially in these very localized areas. And so in my hands, I'm using ultrasonic energy to create that collagen fiber tightening to the underside of the dermis. But as you're developing this in your practices, just be very careful about whatever device you use, because that's probably one of the biggest liabilities. Larger chances of seromas, larger chance of thermal injury to the dermis. So the postoperative course is incredibly critical. And I think I'd say that this is probably the largest difference that has come in my evolution of abdominal contouring. I used to kind of, you know, we would perform the procedure. We would put patients in post-operative garments that are designed to keep compression over the area to help for skin tightening and minimize seroma formation. And then we would kind of say, we'll see you in a week. And then, you know, they would come back and we would kind of make sure everything looked good. And we would put them back in the garment. So we'll see you in three weeks. And then they come back in three weeks and we put them in a second stage garment. Like, okay, we'll see you in three months. And what we've really changed now is we're aggressively using body contouring foam, especially in these areas. And this picture to the right really shows kind of this patient called me, she's like, I've got this weird line. And I'm like, that's exactly what I wanna see. It's kind of this contour of this foam where we've done this central liposuction both in multiple vectors, again, directional liposuction on the dermis, directional liposuction on the deep side of the subcutaneous space with energy. But we really want that scar to tighten down. We really don't want fluid collections forming in those types of areas. And so that's exactly what we want. And then this device to the left is what we use in our office. It's a pneumatic compression device that's designed and in the United States is FDA approved for lymphatic massage. And the reason we like this, instead of actually having people do it, it's a very consistent lymphatic drainage procedure. And so we know exactly and we have protocols exactly for the different areas for the amount of volume we've taken out and for specific intervals. And so in the old days where we would kind of do this and then turn the patients loose and see them at longer intervals, we're seeing our patients much more diligently and much more aggressively. We're being very specific about where we want compression. We're being very specific about tailoring and cutting foam and we're being very specific about our lymphatic drainage procedures. And so this is all the same patient. So this is her before I touched her. This is her at her intermediary operation after her pregnancy. And this is her at about, I think she's about four months out here. And so you can see this is kind of more of what most of these patients are asking for when they're looking for abdominal contour. There's really a much more aggressive definition of these anatomical areas. You can really see the border of the rectus muscle. There's this really clear central division between the rectus muscles. And again, being a little bit critical, I'd say in that superior third of that, there's still a little tiny bit of fullness that I would probably recommend some aggressive massage to see if I can get that to settle down a little bit. But at our practice, we're looking for a very kind of natural look that kind of very much fits my beach body ready. And so she sent me that picture again. She's like, you nailed it. And again, I nailed it in a harder patient. This is someone who again has had liposuction by me and I'm relatively aggressive in my liposuction even in my earlier years. And it's someone who's had pregnancy. So she had a greater chance of skin laxity. And so I think this is an excellent example of the right techniques, very basic principles, not super expensive equipment or fancy techniques that only a handful of people in the world can do. This is very, very reproducible and something that you can integrate into your practice even at any stage. I'm an old man, it's hard to teach me new tricks. And so I think the important things whenever you're at a lecture like this is there's always limitations. And it's important that we all recognize as plastic surgeons that one of the peaks or spikes that people have in complications are after lectures like this or after going to national meetings because everyone's like, that looks really easy, I'm gonna try it. And so pieces of advice that I'd recommend as you're integrating some of this higher definition types of techniques is, the first thing is you need to know the limits of liposuction. And at least in my hands, in my practice, neither of these patients are candidates for high definition liposuction alone. And so the patient on the left has a very significant rectus diastasis. She had an abdominoplasty with a rectus placation and then also had liposuction and some fat transfer, obviously. This is a patient that liposuction alone, I wouldn't be able to, I think, give her a satisfactory result. The patient to the right, similar issues. There's a degree of skin laxity and poor skin quality that I'm not gonna be able to get appropriate skin tightening, again, at least in my hands with my tools and the techniques that I'm comfortable using. She has frequent stria in that lower portion of the abdomen. And in my hands, liposuction alone for that patient makes that skin worse. And so again, tummy tuck with some liposuction. I also think it's important as you're kind of focusing or as anybody's focusing on a new technique to realize how patients evaluate themselves. And this lecture is largely directed at the abdominal contour and ways to get additional high def contour, but it's important to recognize that patients evaluate themselves in multiple dimensions. So this is a patient, this is a liposuction patient. I think she had a little bit of fat transfer too. And she has a high def result on the front, but we were really, really conscientious to make sure that we were discussing 360 degree liposuction with the patient and then also discussing her hip contour because all of those things give that patient that higher satisfaction. And sometimes if you nail a high def result and you're like, wow, this patient's gonna be really happy, they come to your office and they're still upset. And the reason why is because you've ignored the fact that they're going to, when they're at home by themselves, look at themselves from all different directions in the mirror. And they may give you the benefit of the doubt saying, well, I only asked for my abdomen, but nine times out of 10, they're gonna say, I don't like the way I look. And it's because you haven't addressed the rest of it. And so just make sure that you're thinking about that as you're moving forward. And then lastly, we get these cool techniques. And when I started learning some of this and implementing it I wanted to use it on everybody, but it's important to realize that not everybody wants that. And so make sure your surgical approach mirrors the conversations that you have with your patients. The first and most important time is those initial conversations with that patient to understand what they want. So this is a patient of mine who I'm like, oh, with a tummy tuck, I could definitely give you a high definition picture and we could inscribe that rectus border and the central linea. She's like, I don't want any of that. I wanna look like, she's like, I'm a mom. I wanna look like I have a mom. I just wanna look like I'm a mom. Like I've got a great abdomen and a bathing suit. And so just be conscientious of, again, listening to your patients. Not every patient wants that technique. The other piece of suggestion I would use is multiple operations tend to give the patient bigger impact. And so again, this is tummy tuck mastopexy. I think there's an implant exchange, fat transfer, and then a little bit of high definition liposuction, not as aggressive. This is kind of one of my older techniques, not as aggressive as I would do today. And so then the things are always what's on the horizon. And a lot of times this is an international call, which is a lot of fun for me because a lot of times I'm looking to our international colleagues because they tend to be able to do things and think about things that in the United States we're a little bit slower. Obviously, Dr. Hoyos is a friend of mine and that's his Rib Revolution book. Once you've kind of mastered this abdominal high def liposuction, there are other techniques that you can employ to kind of give people even more contour, again, in the right patient with the right considerations. And one of them is a little bit of rib sculpting, the inferior ribs to give patients a little bit more of a waistline. I'm probably not gonna implement that myself yet. I think it's amazing technology. I need to go spend some time with Dr. Hoyos and get some training in it. But my patient population isn't in super high demand for that. But one of the things I am gonna start implementing, I have a couple of patients lined up, is what you're seeing on that slide on the right, and that's raft procedures. I think that I wanted to spend a couple of minutes on this because I think as we're getting more and more advanced with high definition liposuction, it's important to recognize that at some point, you've taken the fat out, you've done what you can for skin tightening, and then you're out of techniques unless you're gonna do an abdominoplasty. So if you're looking for another minimally invasive procedure, putting fat into the rectus muscles to give you that volume segmentally into the rectus is a very, very powerful technique. And I've tried it. I have a couple of early patients who I think look great. I just don't have long-term follow-up on them yet. But the concept is, you're using an ultrasound to make sure you're in the right space, and that's kind of me with a probe there. And you're using very relatively small, at least in my hands, relatively small aliquots of fat in each rectus segment bilaterally that you wanna achieve. And that's usually about 20 to 30 cc's. And it's, again, the next level of thinking about how am I gonna manage this overall abdominal contour because the abdomen isn't just fat. It's not just skin. There's rectus muscles underneath it. And the right patient, this is an incredibly powerful technique. And for my colleagues in the United States, we have to kind of get through that barrier of what we've told people for safety about autologous fat grafting to the buttocks, which is like never put fat in the muscle, never put fat in the muscle. It's important to understand the anatomic differences between the gluteus maximus and the rectus muscles and understand the blood supply and why it's safer to do it in the rectus muscles compared to fat grafting to the buttocks. And so just things to think about on the future. I'm hoping that Jeremiah and Romy invite me back in a couple of years and I can talk about some of my results there. So that's kind of just my journey. I wanted to be very specific, and hopefully it's generated some questions that I'm happy to answer. Thank you, Steve, for a very interesting and thorough presentation. Our next speaker is Arthur Yu, who's gonna give us a very different approach with his technique using PDO threads in the abdomen. Arthur, thank you. Yeah. Arthur, we'll give you a two to three minute warning so you know where we are time-wise. Absolutely. Okay. Some of mine, it's blocked. Okay, so my, welcome everybody. My topic is PDO optimization for suction and reduce the need for tummy tucks. I practice in Arcadia, California. The learning objectives. First, use high-definition liposuction technique and the PDO threads to improve the umbilicus position and shape permanently. Tighten the lower abdomen permanently and cut the need for tummy tucks in select patients. The reason why I want to cut the need for tummy tucks, and we actually were talking about it, the reason is I'd love to do tummy tucks, but every time I see my tummy tuck patients post-op, I always just look at the upper part and never ever try to lay my eyes on the scar region because the scars, most of the time, they're just terrible. So, and my patients are very conservative, so I just can't bear that. And that's the reason why I was looking for methods, and here we go. Okay, this is a typical patient of mine before the invention of this technique. And as you can see, she had a modest high-depth liposuction, but the umbilicus is very flat. I did not use any energy device. I think doctors using energy device properly could actually help this, but I was using smart lipo a lot. According to the company, I was probably one of the most productive plastic surgeon in the world. I did more than 1,000 smart lipo, laser lipos, but I had some disasters, and that's why I actually stopped it. You can tell that the lower abdomen still has a pooch. The ideal umbilicus position was depicted as, you know, the xiphoid to umbilicus, and umbilicus to pubis distance should be about equal. And umbilicus to iliac crest should be, the distance should be as close to zero as possible. So, and this patient came to me, said, you know what, you know, I went to doctors, you know, they just want me to have a tummy tuck, and she is actually a good tummy tuck candidate, but I don't want it. So, and I tested on her, and I pulled her upper tummy up, and I was like, okay, the umbilicus is elevated, and also the lower abdomen is also elevated. But, you know, how could I do this, and besides smart lipo laser, because, you know, I had some disasters. So, then I thought about it, because I do most of my non-surgical procedures myself, threads, fillers, and everything else. So, I start to use a power assist liposuction with a three millimeter Mercedes cannula alone, you know, aligning with Dr. Williams' warning, the, you know, you do not want to destroy the structural fibers. So, I always use a small one. I do not find this small cannula being less efficient. This is a long bidirectional PDO thread, 43 centimeter long. And in order to place it, I would have to use a double blunt cannula to make it happen. Okay. And this is after the high def liposuction, placement of the thread. I use a 16G cannula. Okay, that edit was made with a needle. It's not playing. I'm sorry. So, essentially, the cannula was introduced through the side foot region, reaching the edit in the umbilicus, and the thread is passed into the cannula. And this cannula is placed, this thread is placed about 0.5 centimeter away from the linear oval. The video is very slow. Sorry for that. Okay, I think this is when I'm placing a second thread, about one centimeter away from the linear oval. Then I cinch and tie. The amount of skin elevation on the OR table is anywhere from 4 cm to 8 cm. Okay, this patient, she's actually a perfect candidate. She's very tall, yet she has a very low-lying umbilicus with a pooch and her waistline is mediocre, not really too high. So I did high definition liposuction on her. I made her waistline about one inch higher. Okay, of course, with the help of the thread, I'm also able to elevate the umbilicus. Three weeks result, 12 months result. Look at the umbilicus and her umbilicus elevation, I believe, was quite high, but I cannot see it here. Look at the waistline. As long as you raise the waistline, you are able to see results that is so much better than whatever you can with other methods when you do not do the waistline elevation. You can tell that the waistline is placed about one inch higher. That makes the patient looking like below the breast, it's all legs. That's really important for people with very short limbs. This is another example with the PDL thread placement after liposuction. This is what happened. Before the liposuction, you have all the fat, you have the two layers, deep and superficial. After that, you preserve the scabous fascia and then you honeycomb, take the fat out. Essentially, you have a honeycomb effect. The fibers are kept and then you place the PDL thread. This is how it's placed subcutaneously. And you tie and cinch. At 12 months, the threads are long gone, but the result is remaining. Look at the umbilicus position and also look at the lower tummy pooch. When stretched, the pooch is no more. The bunching after the thread is tied will disappear after two to eight weeks. This is the immediate result right off the OR table. The first time when I saw this, I was like, oh my god, I'm going to get a lawsuit. But then I felt comfort in myself. I said, maybe it's just tomorrow, I'll just take it out. Anyway, this is second day, POD1. All the skin is gone. So what happens? It's very simple, it took me four years to realize. I actually bumped into one of the most basic plastic surgery principles, that is primary contracture. Every time you elevate a skin flap or actually a skin graft, the skin will shrink by about 40%, sometimes even more if there is enough dermis. The primary contracture typically takes place in the first week. Most of it actually happens on the first day. And then, of course, whatever is left will be taken care of by secondary contracture, which starts from about day 10 until three months. And I use an egg crate foam pad and the tight garment from post-op day two. I do not do it on day one because I think the patient's skin actually needs more blood flow. So I use it from day two. And then after three weeks, I change it to a lipo foam. This is easily commercially available, half an inch thick. So yet another patient showing the results, you know, belly button elevation and low abdomen tightening and flattening and elongation. This patient had two-time liposuction failed with a lot of divots. And she was advised that she would really need to have an abdominal plasticity. And she saw me and I told her, actually, don't worry about it. I'll just do a liposuction and I don't think you need a tummy tuck. And here you go, three weeks and 12 months. She looks beautiful. Three-quarter view. Oh, this is the belly button shape change, you know. The divots almost all gone. Three-quarter view. Okay. You can also tell that, you know, I did a breast contouring by liposuctioning the breast tail. This is actually, I always do this. Every time I do abdominal liposuction, I always contour the breasts on the sides, on the side, because, you know, only young people, young girls will have this kind of breast. Old mama, they never have this. This guy, very big guy, 6'6", he was told that he needs to have a tummy tuck. He said, what? Hell no, I'm not going to go for abdominal plasticity. So he happened to hear that, you know, I do this kind of fancy thread lifting, you know, and then of course, and then I did the liposuction for him with the PDO threads. And you can tell that the umbilicus is now sitting in a much more reasonable position. The whole abdomen, I did not really do a very sharp muscle etching because I think, you know, with this kind of body, he gains weight easily. If I do a lot of muscle etching, he's going to have a lot of trouble down the way. Look at the umbilicus position. Okay. This patient, he sought help from five plus surgeons. Every single one of them told her that she would need to have abdominal plasticity. And she said, you know what? I never even had a baby. Why should I have abdominal plasticity? I saw her and I was scratching my head. I was like, you know, maybe, maybe not, you know, let me just do it. And I told her actually, you probably will need to have a little skin removal at the end. I cannot guarantee, okay, the result would be beautiful enough that actually the skin will shrink completely. And this is the result, six months. She looks wonderful. She never had the abdominal plasticity. She never had a baby. So there's no, no issue with the, with, with the muscles. And also I tested her. Most of the fat is actually outside on the abdominal wall. This is how I do it. I put a anchoring suture first on the prepack fascia. Then I place a thread the same way, but this way it's from a different direction. Please note that the central thread is placed already. and then cinch and tie. And also tie the anchoring suture so that the thread is fixed in a good place. And it will also, by using this anchoring stitch, I'm also able to prevent being pulled down. The anchoring stitch is a PDO thread. Okay, and three quarter view of this patient. Look at how beautiful the result is. She's big, but I think I love this kind of big body feature because as long as you give them curves, they always look very nice. Okay, this guy, again, he was a street warrior, got a lot of scars. He was also told, you know, the best way is probably to just get a mini tummy tuck. He said, you know, I'm not gonna do it. So this is my work with the PDO thread placement. Again, the umbilicus sits in a much more reasonable position instead of being lying low because lying low, the umbilicus actually does make people look old. The groin is also liposuctioned. And it was also helped by the PDO threads that I placed on sideways. Three quarter view. This patient, she has C-sectioned two times. She was told that she would need to have a mini tuck. And actually, she would need to have a full tummy tuck. But if it were done like this, you know, she does not have enough skin and the result will be like this. I did not do this, okay? This is a very beautiful patient of mine. And unfortunately, she's very young and then she's completely destroyed with this kind of scar. Okay, this is what I did. I did the high def liposuction with the PDO thread placed in three different vectors. And the C-section scar is elevated. The whole lower abdomen is flat. So flat, you know, when I first saw this picture, I was like, you know, did I use a board on the patient? No, I did not. I used the foam. Three quarter view. It looks very nice. Okay, there's no more need to worry about the lower abdominal push. Though with this patient, I think I liked the result initially. Then I realized I did not repair her rectus abdominis muscle or pressure. But when I use ultrasound to do studies on these patients, then I realized actually the rectus abdominis, the rectus diastasis does not happen to everybody. How often does it happen? I did 20 patients ultrasound studies and I've only found two rectus diastasis. So what happens? Very simple. I think it's really the whole fascia system, especially the external oblique, that's actually stretched. Okay, so the so-called rectus diastasis, you know, we really have to look into it, do a series of study and demonstrate how many people does have it. So that the placation or fascia placation can be changed in different ways. This is patient I did the evaluation on her. Very loose, three babies. Lost about 40 pounds. I was able to stretch it up by about five centimeters and I drew the line. And this is for the external oblique placation. I demonstrated that she did not have a rectus diastasis. And this is the final markings. Okay, and she does have a C-section scar that's inverted, so she wanted me to do a scar revision. That's what I did. I took out about eight millimeters of skin around the scar. Okay. Yeah, this is a cervical dilator. You don't really need to do a fancy dissection, actually. Cervical dilator can seriously, it takes you only three minutes to make space for your external oblique placation. I just use one suture and then do it over and over. And then this is placement of the threads. And on the side. Okay. And the result is amazing. And then everybody look at this will say, you know what, she has rectus diastasis, but she does not. Okay. Three quarter view. And now I'm actually developing a technique with only three centimeter incision that I can also do the external oblique with my, without a endoscopy system, actually. So, same thing. As long as you can put in the cervical dilator, you should be able to accomplish the external oblique placation. So this is the patient. This is the scar, or is the incision. The result is wonderful. The scar is barely visible. And the, I was able to eliminate the lower abdominal brooch. Three quarter view. So, the BMI of my patients from 20 to 31.6, the umbilicus almost all turned vertical, or more vertical. Elevation of the umbilicus was 3.89 centimeter at three weeks, 2.44 at 12 months. It is actually the first number that's more important, but that's how you judge your patient's skin compliance when you pull the skin up. And as long as the patient can be shown that whenever you elevate the bed button, if there's no more abdominal row, lower abdominal brooch, you should be able to do this procedure. Complications, there's almost really none. I have no skin irregularity after two to six months. Conclusion. This method utilizes basic plastic surgery principles, primary and secondary contractors. A resource improves the umbilicus position and shape, creates flatter lower abdomen, functions as a reverse tummy tuck, and natural, satisfying, and permanent. I'm able to do this, apply this to gynecomastia patients. You know, everybody, you know, he told me, you know, he always hates his nipples, you know, hanging. And I was able to do liposuction, getting the breast tissue out, and I was able to use a different threading technique to pull the nipples up by about one inch. On the face, liposuction, in combination with PDO threads, I'm able to get this result. This is to a, this young man came to me and said, you know, he got engaged, because before that, he never had a girlfriend. But I did this in combination with fat grafting to the chin and also a little bit to the nasal jugal groove and he looks so much better. Thank you. Thank you, Arthur. Very nice and clear presentation. Why don't we begin? There's some questions in the audience. Yes. We have a few questions. Shall we start with, should we start with the first question for Dr. Williams or for Dr. Yu? Okay. Okay. The first one actually is a question for Dr. Williams, was a person was, somebody was specifying about a nice belly button and they'd like to know what Dr. Williams' technique is. So again, my journey is all about evolution. And I remember as a resident, and I was kind of a little bit under the foot of Dr. Matarazzo, but I trained at Yale with John Persing. And I remember I kind of did the belly button the way I wanted to. And I just did a vertical incision, not taking any skin out. And if you were to ask me that now, that is 100% wrong. I'm really like a full like transverse incision. But the biggest, I think the biggest difference is, I definitely core out fat, but the umbilicus has to match the size of the skin incision or excision in the abdominoplasty flap. And I know it seems like a super basic concept, but the minute you start doing that, and then I also parachute my umbilicus down to the abdominal wall, but the biggest change I think was matching that size as close as I could to make sure I got good approximation. That was a huge, huge difference. But I really do like the transverse incision. It gives you a little bit more safety margin as you're pulling your flap too, because it decompresses the tension on the flap. Steve, you're not excising any abdominal skin. You're just making that transverse incision. That's right, that's right. I think excising abdominal skin is a mistake because you have so much tension that you don't need to take skin out. The whole, you'll make the whole. And about how long is the transverse incision approximately? Yeah, it's usually about two centimeters, but it's a little bit variable. It depends on the size of the patient a little bit. And again, the most critical part is actually matching that incisional size so the umbilicus fits really well in there and then kind of parachuting it down. Yeah, I personally concur with that. I make a two and a half centimeter and I make just a little bit of a V. I just come down on the sides a little bit, but thank you very much. It was a very, very nice result. You wanna keep going with the questions from the audience? Whatever you'd prefer, Dr. Matarazzo. No, no, go right ahead. They've been waiting. We have just one more question from the audience so far. Another colleague wrote up a little bit about their experience and says, in my own practice, I've been combining suspension, this is for Dr. Yu, first of all, sorry. Sorry, I didn't mention. Dr. Yu, someone asked, in my own practice, I've been combining some suspension techniques with retraction plasma and collective muscle grafting for moderate cases, achieving very promising outcomes so far. Wouldn't a cautious combination of technologies respecting anatomical limits be a path to enhance outcomes in selected patients with greater laxity? I think it's a great idea, but I actually tried to use my old smart lipo laser to further improve some people's loose skin. However, here's the issue. I did notice that the patients who seriously need to have a little more kick for further skin tightening, their skin react somewhat differently to energy device. In my case, smart lipo laser, there's gonna be a lot of very severe shrinkage of the skin, bunching so much that, you know, because there's a lot of stretch marks, it's essentially scar tissue. So when the scars bunch together, they look horrible. And that's why after a few cases, I just decided, you know, it's not my dish. I never tried VASER. Maybe VASER is a good idea. Dr. Williams probably can provide some insights. Yeah, thank you, Dr. Yu. I think that all energy-based skin tightening uses the same principle, right? It's about tightening that underlying collagen. And so I actually don't think there's as much specificity on the importance of the device. I think it's really how you use it, making sure you understand it well and picking the appropriate patient. It's all the same concept, right? It's thermal energy to the underside of the dermis or to the residual connections to the deeper tissues, shortening or tightening those. That's the principle of skin retraction or the tightening of the overall contour. And it's just energy. And I think energy is actually relatively replaceable. It's the device that you're comfortable with and you know the limits too. Steve, do you routinely, you gave a very nice menu in the secondary patient that you showed of initially VASER, the three to four millimeter basket cannula, then a multi-port PAL, and then I believe back to the VASER. Yep. Do you find that on primary cases that you do that or is that particularly just on secondary? I think the more, so if I'm trying to get better skin retraction or if I'm really trying to get more etching, you wanna use more thermal energy. It's double purpose. Part of it is tightening that regional area of dermis. But part of it too is you're setting up a denser scar base, right? The people who originally were doing VASER, when they went back and had to redo their liposuction patients, it's a disaster because it's all really socked down and scarred down. You want a little bit of that. And that's why the postoperative management is incredibly important in these patients because you've created a potential scar bed. You wanna use that to really get that shape and contour. And so I think that, again, an energy-based device there when you're really trying to be more aggressive is useful because I want a more robust scar bed as they're healing up to have a lasting contour there. Great, thank you. Arthur, you mentioned that you use a 43 centimeter quill, what number quill are you using? The brand name? No, no, the the 2.0 You know how strong? I think it's I think it's 1.0. No, actually, I think it's 1.1. Okay, so a number one Yeah mint It's from mint. It was designed to do the facial face Elevation actually face lifting and it's supposed to be anchored to the temple Okay, and on the face. Are you using that quill in the neck or just above the mandible? I use a different thread. I use tying method. I put two threads in two different Parallel to each other. Okay, and then I tie them around the mastoid Region and also up there. I tie it just above the zygomatic arch so yeah, that is a Completely different talk. Actually, I gave that talk three times already on the face The principle is I think in by by using the thread you're able to elevate the tummy skin elevate the skin Elevate the skin here. So that this once you honeycomb the fat The tissue is now being forced backward or upward and they heal in a new position So that's why you know, I think threats in this case is very important without the thread You're not going to be able to force that much elevation What are the limits of your method either in the face or the abdomen on the face? I choose people who has skin elasticity still so in other words younger than 55 on the tummy I basically, I judged the amount of umbilicus elevation so that I can decide in the if it's Less than three four centimeter excess skin on the lower abdominal wall Or the pooch then I I'm sure I can do it, but if it's beyond five centimeter now tell the patient Okay, I can't do it, but I will I will do it I will elevate your belly button, but you better be be prepared for a secondary surgery That is skin removal so far only have one patient that require that procedure. I had to remove about two centimeters of skin Do you find that the threads cause any more discomfort or delay their return to activity Great question. The answer is no, but I have done that on on the back for the brow row The result is great, but the patient complained almost every week Pain so the back actually the that motion actually causes more pain, but the tummy absolutely no because they know how to avoid it If I could ask both presenters a little bit they they alluded to the use of foam They both use foam and and dr. Williams Showed the compression device Can you? Explain get into a little more detail about the use of the foam I know that Arthur you switch to a thinner foam down the road I personally like the concept of the foam as I mentioned to you before we started But Steve in particular you use the foam and then you go to that lymphatic type machine Can you get into a little more detail there, please? Yeah And so again, the overall concept is originally the evolution was we would put everyone in compression garments because it makes sense, right? We put them in compression garments In the recovery area they go home with them We tell them don't take them off for the first seven days and then afterwards you can take them off to shower But we want you in it for four to six weeks And so that was the original concept the challenge is compression garments don't fit people very well And we actually want specific pressure in in very specific areas because when we're trying to get that definition We want that scar tissue to actually take hold there And if that compression garment isn't putting the appropriate pressure there, then it's not it's not effective And so when we're dressing it, you know We I close my liposuction incisions on everybody does I use a 40 chromic to close them? I think the scars are better. We put a tag 2x2 and a tegaderm over it So it's an inclusive dressing We then will put an ABD over it because our patients 100% of the time will call us seven hours after surgery It's a I'm bleeding. Well, you're not bleeding. It's probably the tumescent fluid show me a picture And so that's a very common conversation We have the ABDs tend to lessen that a little bit absorb some of the fluid and then over that we have Foam and again, it's commercially available on on Amazon or any retailer It's just these big foam pads and we have the nurses now that we've they've kind of know the protocol We have them cut the shapes We usually draw the shapes on the patient as we're finishing and they they'll tape it To that with some surgical tape and then they put the compression garment on and so when the patients come back We take the compression garment off. We take the foam off we look and then we'll cut new pieces of foam And again, it's a whole process now We cut new pieces of foam and we align it to exactly where we want it We instruct the patients don't take off the foam keep the garment on And you know the most annoying patient things the patients have is they hate the compression garments, especially in the summer It's hard hygiene is difficult for the first week or two But we really want them to keep that on for the first two weeks and then even using the restroom can be somewhat challenging for the patient because those garments aren't all always the easiest thing to get On and off but that's just a very important evolution. We've had in terms of results Steve when do you allow them to shower? Yeah, so I don't and this is true of all my surgeries and I don't know if it's controversial but you know I don't let my my patients shower at all for the first four or five days and the main reason is I don't think that there's there's a There's nothing good that comes from them taking their dressing off in the first three or four days It's most of the time. It's not harmful. It's fine But it usually people are concerned or have questions And then when they come in we tell it we take everything off we look and the reason I have kind of that For it's for faceless. Sometimes it's a little bit earlier But the reason we have that four to five day period is that's what I'm looking for Infections or you know skin breakdown there's not a lot that I'm gonna see for most of the operations we do in the first day or two that we're going to salvage with with something interventional Whereas at that post-op day three post-op day four if there's a seroma if there's a little hematoma if there's you know Some other issue it's a more reasonable time to manage it And Arthur, do you alter your post-operative care? Between a straight abdominal. I'm sorry straight liposuction patient versus the liposuction patient that has the threads Does that cause you to change any of your post-operative care? No my practice basically when I do liposuction now, I always use threads So so it's it's like, you know five years ago versus five years later And and I did find the benefit of the foam being super super important Contrary to yeah Arthur if I can interrupt you there So you'll do put the threads in in a 26 year old abdomen that you're sucking out 600 cc's. You'll still use the threads. I Would the reason is very simple, you know, all these people who comes in through the door Then they do have umbilicus deformity Okay, and that simply improves the shape if it's not for the position and you don't find that the foam Displaces the thread at all or the quill By never. Yeah, it was one of the questions that was raised, but it never did. Okay Well, there was a question from the audience for dr. Williams, but I believe he's answered it about his post-operative compression dressing Arthur what percentage of your patients Do you think benefit from this method, you know, how often do you not do this versus some excisional procedure? I Well, I used to do about 20 abdominal plasties a year now, I only do one or two a year so There's a huge shift My patient population is still the same. They're relatively smaller and they're not really as big as when I was Doing my residency in Brooklyn So, yeah, so we're actually talking about select patients We're at the eight o'clock hour I would just like to ask Julio and thank him because it's quite late in Italy ask Julio if you have any other questions or you see anything else from the audience Please Just one. Actually, we have somebody from the audience who has asked Specifically the the name or the brand of thread that dr. You you use Mentioned mint, right? It's called mint 43 Go ahead Sorry, I'm as I'm a resident and I kind of take this into my own Experience and I speak on behalf of other residents do and this is an open question for both of you, of course Thank you very much for your presentations. They were amazing and I was very happy to be here and listen to you both My question is do you have any piece of advice or tips and tricks for residents or young Plastic surgeons starting out like the first couple years on their own who are starting out in their own practice and dealing with high-definition Domino sculpting especially with use of threads because speak on behalf of myself and other residents who maybe don't have experience with threads with threads Most surgeons plastic surgeons do not have any experience with the threats Some don't even have experience with fillers. I think that need to be changed. I have done hundreds of Face threads and that's reason why actually it was kind of easy for me to transition from the face to the abdomen And I think for all residents, I think you guys should open up your heart Don't just think you're you're just a plastic surgeon. You go to those cosmetic conferences Go learn from other specialties and then you come back You know you you combine it with your own plastic surgery training You'll find out that you become a much better surgeon than you could I mean The the I always talk about this the ENT guys You know, why are they taking over a lot of things that we're doing very simple. They learn from us and They've become dominant in certain areas and then this should not really happen You know, we all see this coming in both in the local markets and also in the international arena a lot of ENT doctors that they are able to do a lot of things that we think oh Why did not why didn't I think about it? We should actually go out and then say you know what? I'm gonna watch these guys. I'm gonna go talk in their podium and then you know what you will take over Yeah, I agree with doctor you I think there's always a lot to be learned and and I think the nice thing is Plastic surgeons are the most innovative and so the things that we see we usually do better or find better ways to use kind of What's out there? You know, I think as you're starting out my one caution would be You know a lot of the things you're seeing the great thing about the Internet the great thing about these types of conferences is there's These a world of ideas a world of learning to be had But a lot of times like starting out slowly and making sure that you're comfortable with the techniques You understand the risk benefits and alternatives different techniques. You understand the way to manage those, you know potential complications If you see a serum, are you supposed to drain it doesn't make sense to put that 18 gauge needle in it And it doesn't necessarily mean that you have to experience those complications yourself You can talk to your mentors. You can talk to your training programs You can talk to colleagues around you but just be very careful because you know One of the things I said in my talk is very true The spike in conflict there's a spike in complications after you know, these types of meetings these types of conferences Because what dr. Yu is doing certainly, you know, if I were to you know in a great PDO through I've been doing this for 20 Years, I'm very comfortable with body contouring But I you know, I would have a learning curve using PDO threads and the results he's getting are amazing But I'm sure I would have a lot more skin bunching or some chronic pain or you know It did this one one side held the other side didn't now what am I gonna do? And so when you look at people who have mastered those techniques I think it's always important to remember that it takes some time and take some Complications and it takes some experience to master them and so go at your own pace Don't over promise patients things and and you know Make sure that you're the surgeon you're directing the care and don't let people talk you into things You don't have enough experience with yet. It always ends up badly Thank you very much Those are two wonderful final comments If there's no other comments Julio or any of the speakers The speakers have any final comments, please feel free to share them If not, I want to thank everybody from the ASPS office Madison and and Romy and Jeremiah for putting this together and our international colleagues And we look forward to seeing you for the next one And thank you again for the speakers and thank you Julio for being and helping us so late in the evening Good night, everybody. Thanks everyone. Thank you

high-definition abdominal contouring

plastic surgery

VASER technology

post-operative management

PDO threads

non-invasive techniques

surgical techniques

patient-specific approaches

aesthetic outcomes

Plastic Surgery Meeting