First of all, I would like to thank ASPS for the opportunity to moderate this session. We are going to talk about now on implant-based breast reconstruction, and the topic today is Hot Pockets, Tips and Tricks in Plain Conversion. The first speaker is Dr. Aparna Bijay Asarkaran, who is a plastic surgeon at a major clinic in Rochester, Minnesota. So welcome, Aparna. We would love to hear your presentation. Good morning, good evening, depending on where you are right now. My name is Aparna, and I'm one of the plastic surgeons at a major clinic in Rochester, Minnesota in the United States. And today I'm here to talk about pocket change, particularly pertaining to pre-vexal breast reconstruction. I have no disclosures, and before I start, I would like to thank ASPS, as well as all the panelists for being here today. So pre-vexal breast reconstruction has seen a massive resurgence, I would say, in the last 10 years. I would say even going back as far as 2014 or 2015, when I was a resident here at Mayo, I would say we were still doing a fair share of sub-vexal breast reconstruction because that was just the standard of care. Pre-vexal reconstruction has, I would say, evolved, and it's pretty much here to stay, I would think, at least for now. And I think this has been made possible by advancements in flash and already available to the ADM and other tools that have made this possible. That being said, even though I don't do a lot of pre-vexal breast reconstruction, I do see a lot of these patients in my clinic for revisional procedures. Some of the reasons that we see patients back for revision of out-of-change are what number one being the most common is animation deformity. Sometimes we see the back for tightness or capsular contracture, aesthetic concerns, mainly lateral displacement of the implant, I would say, is the most common. So these are some of my patients that I have seen in clinic over the last few years. So this patient, particularly, as you can see, she has a sub-vexal reconstruction on the left. And she presents to my clinic mainly because she's concerned with animation deformity. And even this visible ledge here, I think, is a telltale sign of sub-vexal recon. And this is from the attachment of the muscle in the area where they're kind of meshed in the process with the ADM if they have any in the interior. And basically, it's the tethering of the skin to the muscle, to the underlying capsule. This is a slightly better video, but as you can see, this patient has clearly animation deformity on the side and showing exactly where the muscle is tethering the implant and the skin. This is another patient of mine who I saw in clinic with a primary complaint of capsular contracture and tightness. And if I remember correctly, she actually expressed to me that she feels that she was wearing an internal bra that she just couldn't take off. She had lots of issues with tightness and a lot of pain. Another patient. So as you can see, these are patients, paid-off patients from 2004 when she underwent transplanting mastectomies. And this is her in my clinic 10 years, 10 to 11 years out here to talk about the visible deformity and animation deformity, which drove her to this appointment. Another patient with very high-riding, tight laterally-displaced implants. This patient here has another what I think is a plastic tell-tale sign of self-controlled recon. As you can see, if the patient were to wear a blouse or a slightly low-cut shirt, you could see that she has pretty good fullness, but it's on the lower pole of the breast. You can see there's a lot of skin excess. And this is, I think, pretty classic because the implants are so contracted and displaced by the pecs so purely that she has all this laxity inferiorly. So the solution. I mean, I would say for most of these problems, the gold standard that has been well-described in textbooks is pocket change. Now pocket change, there have been many papers, especially over the, I would say, most of the literature has been relatively new between the past five to eight years, I would say. We've had papers with Dr. Maxwell, Dr. Hammond, and some of the surgeons who do a lot of these cases. And all of them have a common theme. They just talk about their technique with slight different nuances as to how they do a pocket change. So case one, this is a patient who presented to me in 2018. She was status post a subfetral reconstruction in 2009. She may be presented with concerns for animation deformity as well as little bedding concerns. As you can clearly see the animation deformity, especially in the picture to the top right. So she underwent a single stage plane change from subfetral to prefetral with a full ADM wrap. And she also had a back wrapping at the time. Now one of the things I always counsel patients when I do a pocket change is I say that they probably might lose a little bit of the upper forefoot because part of the fullness that they have, like she does in the bottom right, is likely due to the pec muscle. So when you drop the pec and place an implant up top, they do notice a slightly deficient superior pole. Now sometimes I correct it by back wrapping right away, but you know the skin flaps can take the lack of feeling at the same time when the skin flaps are good, but a lot of times I do stage it. This is another patient who came to me with subfetral smooth silicone high profile 690 CC implant, and she presented with concerns of lateral displacement and animation deformity. And as you can see here, this lateral displacement bothered her, especially in clothes, and she said it was very visible, and this is her with almost a five-year follow-up in 2023. Now I think she could probably benefit from some back wrapping, but this doesn't bother her right now, and she's not interested in any kind of artificial procedure. Moving on to case number three, this is a 59-year-old patient who presented to my clinic as a mom of a patient, as a mom of something, a daughter, who had been recently diagnosed with breast cancer. So basically the daughter was seeing me in the context of undergoing a two-stage expanded implant-based replant. Actually, she ended up getting a two-stage expanded T, but mom was with her, so as we were talking about the expander, mom goes, oh yeah, I have an expander, and I was like, I know all about it, and she was like the most pleasantly sweet lady, and I was like, what do you mean you have an expander, like you couldn't get it out? I thought maybe she had surgery recently, but no, she had a left mastectomy with expander since 2007, and since then she had been lost to follow-up, and this was, I think she saw me in 2019, and as you can see, this was her, so basically she made a separate appointment to see me as a patient, and during the visit when I performed the exam, this was what I noted. She basically had a highly contracted, rock-hard, she expanded her sub-pack, sitting way up high. So I did look forward to staging this, but then I thought, you know, this was a patient who was lost to follow-up, so I was concerned that she would never come for any follow-up, so I thought for her, the best I could do in a single-stage procedure, so we did a left capselectomy, a plain change with a smooth, round, high-profile 550cc implant. I also did a right reduction for symmetry. On the left, I did do a full ADM wrap. She was very happy with the results. She actually kind of told me that she missed the fullness a little bit. She liked having it, so I actually placed her implant slightly higher than I normally would. Case number four, slightly different, so this is a patient who finally came in with an atypical complaint. She came in with a quiet dimestia, almost. She had had two revisional procedures, following a sub-pectoral recon, and she had residual capsular contracture. She also had aesthetic concerns about how her implants were. She also had sub-pectoral recon. So when I saw her, so you can see that this was a little different, as you can see when I looked at her, I thought maybe she didn't have that much fullness there, she had a little ledge here, so maybe I thought she was not a sub-pectoral recon, but she was. But the pack had pulled away so far and was reflected really high. So in my hand, she underwent a pocket change, she underwent a full ADM wrap, and smooth silicone implants, and I downsized her a little bit. And I tried to place some sutures, I used some mesh slightly to correct her dimestia as much as possible. Now, this was a patient that I had counseled prior, that she would again lose some fullness up top, especially because, you know, she has kind of a low-lying breast footprint, and I felt that even with a cohesive implant, she would probably lack some volume up top, especially since she wanted to downsize. So this patient, unfortunately, had one of the most, I would say, not common things, but we do see it infrequently in our practice, a flipped implant, a visibly flipped implant. So this is where we flipped her back in clinic, and this is actually a video of my PA, who did a great job flipping it back in clinic. I mean, I feel she can flip any implant in clinic. So going back to management of a flipped implant, so yes, you can flip it back in clinic, then the question becomes, who do we surgically treat? I feel it bothers some patients more than the other, and some patients are symptomatic from it, and so I think it really depends on having a real conversation with the patient as to how much it bothers them. I think the solution is always going to be better optic control, and maybe changing out the implant, you know, going down in profile, and I'll mention the nuances in a little bit. Finishing up, I would say this was my, for the last of the KCOAs that I was presenting. So this is a patient who's slightly different, again, came to me from an outside hospital. She had had a mastectomy with a subrectal DTI at an outside hospital. She came to Mayo because she wanted the nipple excised due to a positive margin from the outside hospital, and she came in with concerns of animation, cosmesis, and she also wanted to upsize. My main concern with this patient was extremely thin skin, as you can see here, you can see visible rippling, kind of, almost you can feel every crease of the implant down there. The other red flag in this patient chart that I did not put down was she said that when she had the mastectomy, she had two weeks of hypothyroid because the flaps were thin and they were concerned about the skinny flaps. So you would say they were thin flaps, half HVO, not wanting a pocket change. So to me, that was a, I was concerned about that. So what I did in her was I did a fat level building, meaning I did fat grafting to improve the skin quality up front. So this was just purely after fat grafting, and this is three months after. And as you can see, it has improved the skin quality to a certain extent. As you can see, less rippling, there's some substance, more substance to it, I would say circumferentially on both sides. That being said, while I think the fat grafting improved the skin quality, I don't think it fixed the problem. So we did proceed with our second stage, which was conversion to a prefabricated plane. I used small silicone implants and did final reconstruction with a high-profile 525cc implant with an ADL wrap. Now this was her 2020, and this is her with a three-year follow-up. And as you can see, she also wanted it, and so I performed a lipectomy. I would add that I would usually talk to them handily before doing a tummy tuck or a lipectomy in this situation, just because for a recon patient, if at all they thought of bleeding a teeth, I think it's important for them to make an informed choice, knowing the implications of burning that donor site. So this is her, and she was very, she's one of my happiest patients. Now that being said, she always said that she wishes that she could be bigger, and she probably might be someone who might pay me for up-sizing, we'll see. Tips and tricks, I would say, so I just want to stress upon three things. You know, there are three major tools that we have that are very powerful tools in helping, you know, that we have in hand when we go into these cases. I would say one is lipofilling, meaning fat grafting, two would be implant choice, and the mesh. I think these are three tools that we can control, and two that we can use interchangeably in varying combinations to optimize patient results and tailor it kind of to their own personal situation. So lipofilling, now I truly feel that is the gold. So I do a lot of fat grafting for my implant-based recon patients, especially that now that we have kind of lost some access to the textured implant, and I really think it improves the aesthetics of the breast footprint in setting up reconstruction with a smooth, round implant. So timing of it, so I would say you could do this, you know, any number of times. You can do it either as a prep filling, meaning you can, like the last patient that I showed, you can do a pre-op to optimize the skin quality before proceeding with a pocket change. You could do it all at the same time if they have good quality skin flaps, although sometimes I feel it is limiting as to how much fat you can put in if you're doing it acutely at the time of a capsuleectomy and a pocket change. Sometimes I bring them back if needed, if I feel like it's not worth it to fat graft at the same time, I do do it as a stage procedure. So if a single stage is feasible, I think some factors that kind of point in the direction I would say are higher BMI patients, thick skin flaps, if they have prior fat grafting or just need some, to a big degree, better skin flap quality. And also if they're not too picky about like, you know, how much fullness they want, I feel like they are, that's something they're focused on, then maybe I do try to stage them so I can give them a much better volume and a much better contour, more aggressive contouring, I would say. And last, I would say it is okay to stage. When it comes to the implant, which is the next tool that we have, I think, you know, we, when you think of an implant, we think about profile, we think about volume, and we think cohesiveness. And I would say the flipped implant is the most common thing that we like to avoid, and I would say a highly cohesive, higher profile, and larger implant are just more prone to flipping. So in these patients, I would focus on pocket control, and the setting of pre-fat, like I said, I think that's the single most thing, setting the breast footprint, setting a snug pocket to minimize the risk of flipping, also maybe avoiding, say, like a super extra high profile, unless the patient really wants it, I think it makes a big difference in how they behave post-op and how well the pocket is controlled post-op. Last but not the least, mesh. I would say in my hands, I always use mesh in these cases. That being said, I'm kind of like trialing out, maybe doing pre-fat for a week on without mesh in some patients who have good pockets, say, from robotic mastectomies, or say, if they are thin patients who want to upsize, but majority of the time, I still do use mesh. I use a combination of a similar double matrix, if available, or sometimes I do use P4HV. I do think mesh helps in the setting in multiple ways. I think it helps with pocket control, it minimizes incline flipping, and also provides an additional plane for lipopilling. I do believe mesh also might minimize risk of capsular contracture, although the data on that is lacking a bit. I would say we do have some unpublished or in-the-works research from our institute where we looked at our own experience. We looked at almost 160 plane change patients, and we followed them for three years, and I think our capsular contractual rates are close to 9%, which I think is pretty good. But again, we want probably more long-term follow-up, but it's exciting to see. We are trying to delve and try to figure out, study better, and understand the effects of mesh, and whether it truly has a role in preventing CAPCOM. So summary and key takeaways, I would say, it is safe to switch to a prefabricated plane and stay on stage in the setting of good skin flaps. I would consider a prop lipopilling or a fat grafting session for patients with extremely thin skin or prior radiation when you're nervous about skin flap perfusion. I always use mesh, at least in my hands, I think it's critical. Pocket control is key to avoid a flipped implant. I would say for implant choice, higher the profile, greater the chance of flipping, so I would usually stay away from the extra high, unless, you know, for some personal reason, the patient really desires it, and then we have a true conversation about the risk before going forward with it. And the last but not the least, I always tell to the patient that they may need additional procedures for fat grafting or minor adjuncts. Thank you very much, and thanks again for TASPS for this opportunity, and I'm thankful to all the panelists. Thank you. Thank you, Aparna, for this very nice presentation. We are going to leave all the questions for the end of all presentation. Our next speaker is Dr. Mitchell Rofton. Dr. Mitchell Rofton is in private practice in Raleigh, North Carolina, at Amelia Aesthetics. Her practice is, during the last five years, is exclusively dedicated to breast surgery and body contouring. So welcome, Mitchell. We are all ears. Great. Hopefully, you can hear me and you can see my screen? Yeah, we can see it. Perfect. All right. Good evening, everybody. Thank you for having me. I don't have any disclosures. As you previously mentioned, I've been five years in private practice now. I'm 100% aesthetics, but I had a job very similar to Aparna's before academic practice with a lot of implant-based reconstruction. In my life now, there are many reasons why the patients may seek out implant exchange, but for the most part, time, pregnancy, nursing, changes in their body weight, BMI, they want a new size. But when they're specifically complaining of something with their implants. It's either rippling, implant show where they see imperfections because they're quite thin, capsular contracture, or animation of their implants. And so the first part of my talk is how do I go from under the muscle, so submuscular to subglandular, and I thought I would break it up into kind of the things that I talk to the patients about and then the things that as a surgeon you might be thinking about. So for patients, if they've never had an under the muscle implant, they've not been through the drop and fluff. They haven't been through the pressure, the strange Frankenstein look to the upper breast, and it's going to take them a minute and weeks for that to look more normal, so it's important that you get in front of that. Also the breast will move independently from the implant, meaning that when they bend forward, for example, the muscle is going to hold the implant back and the breast will tend to fall off of that. If they've not had that before, they're not expecting it, and then finally when they do move their chest muscles, when they're shirtless, etc., they're going to see their implants move, and while they may have noticed it before, it is a little bit more noticeable when there's an implant under the muscle. And then for surgeons, obviously, the capsule could be calcified. You know, those implants have been in a long time. If their capsular contracture, don't be surprised. The implant is going to go to the path of least resistance, which I've learned the hard way, and what that means is that if you don't get your submuscular pocket closed off well, one single flexion, you're going to, it's going to flip, I'm sorry, if you don't get your subglandular pocket closed off well, one simple muscle flexion is going to flip that implant right back into the subglandular plane. And so I love to run suture. I like to be efficient in the operating room, but from experience, I would recommend that you run it and put in a couple of interrupteds as your belts and suspenders. Have a lift in the back of your mind. These women may not have needed a lift 20 years ago when they had their implants put in, but they may have had a few babies since then. They've gained weight. They've lost weight. Their skin elasticity is not what it used to be. And also, their implant is going to sit a little bit higher in the breast than it did when it was subglandular. And so therefore, their breast is going to sit relatively lower to the implant than it did before. And so whether you do the lift at the same time you change the plane is one thing, but mentioning that they might need it in my hands is really important, like letting them know that it's possible that they're going to have a bit of a waterfall deformity. Super helpful. It means the world if you've told them up front. And so then I have a couple of videos, and hopefully they'll play, of what you might find in your subglandular pocket. So on the left side, we have a completely benign, normal. The pec is down. The capsule's super thin. And then on the right-hand side of the screen, you can find kind of what I dread finding, which is a calcified capsule. You've got that eggshell look, a ton of inflammation. I don't recommend leaving this in place. I think the patient can feel that afterwards, and they're not going to like it. And so my recommendation when you find a capsule like the one on the right is that you want to consider total or subtotal capsulectomy for those people. And then I'm trying to illustrate here what we've done, which is to, you now need to make your submuscular pocket. So you need to cut down deep through your subglandular pocket. You need to elevate this up. You need to, I like to go ahead and cauterize while it's under tension in that subglandular pocket, because you want it to seal down to itself. And then let's see if this will play. And then what we're seeing here is just elevating. We went all the way straight down through the muscle to get to the chest wall, and we're going to be able to elevate that. Here is what you can see when you have to do that total capsulectomy, right? Like you want to get all of that out. And then now, instead of having a nice subglandular pocket that you can quilt down, you've actually just got two raw surfaces. You still need to quilt this down. But it's important to realize, at least in my hands, when you're quilting down those two raw surfaces, you may actually create some contour irregularities that are temporary, but also something to mention to the patient that they may notice that. They may notice some contour irregularities from where you quilted the breast down to itself. And then you sew the muscle edge. Now you can see this is the subglandular. Hopefully you can see. The subglandular pocket is quilted together and sewn down so that when you now put the implant under the muscle, there's a solid breast on top of it. Let's see. I don't know if that's shown itself or not yet. Let's see. All right. So there are other times when you might want to go from under the muscle to over the muscle. And then, wait, you might want to go, I think I just had that reversed. I'm sorry about that. This is a patient with capsular contracture. And she, this is a capsular contracture on the right side. And what we've done is taken from over the muscle to under the muscle and done a lift at the same time. And she also did want to upsize a bit as I find more than I would choose my patients want. Similar example, except this patient wants smaller. She's gone from over the muscle to now under the muscle with a breast lift. And you can see how much higher those implants sit on her chest wall if you look relative to her shoulder where that upper implant border is. This patient also wants to be smaller and softer because she actually has capsular contracture, which is worse on the right. This patient I performed on block capsulectomies for and also a lift. This patient would like to be the same size but have the capsular contracture resolved. I also switched her to under the muscle and did a breast lift. Right-sided capsular contracture again under the muscle and this patient did not require a breast lift. Sometimes we go from under the muscle or submuscular to subglandular and typically that's related to animation. So for patients, the pearls is that this is going to resolve your animation mostly. There's still some scar, etc. It's never perfect but it will be much better. However, when the implant, as you guys all know, when it goes from under the muscle to over the muscle, there's less tissue, soft tissue around the breast implant. So you're going to have more breast implants show it's closer to the surface and they are more likely to have capsular contracture than they were with their under the muscle breast implants. Now as a surgeon, the muscle's no longer holding the implant up and so especially with the bigger implants that are heavier, that lower pole from the nipple down can stretch in the same way I told you when you went from over to under it would sit higher was going to sit a little bit lower. Sometimes these implants were saline implants. You might need to consider making the inframammary incision a little bit longer because ideally you want to put that muscle back down on the chest wall and you need to be able to see. So don't be afraid to increase your incision a bit. And then I found the long alices work pretty well for me. So you can see here what I've done is attach my alices to the muscle edge and then I've just dissected it free and then I've secured it to the chest wall. These are patients so this is one patient who I've had quite a series of encounters with. So she came to see me. She was a patient of one of my partners who retired and she said, gosh, I had these under the muscle implants. I really don't like the double bubble that I see mostly on my left side and I have a bit of a waterfall deformity. And I said, no problem. You know what will fix this is a breast lift. And she also wanted to increase her volume. I've managed to make it worse. The double bubble on her left side and she's also now complaining of an animation deformity which is worse with the bigger implants that are sitting higher. No problem. I switched her implants out to now over the muscle and you can see these heavier implants. They're 620 cc. Now they've stretched out her lower pole and her nipples too high on the device. She is to be determined. She is not fully managed yet because she doesn't like any of my options which probably will include mesh. What do we do about flipped implants? And so it's a little difficult to see in two dimensions. It's for some reason more obvious in person but this patient's right breast implant is flipped on the images to the left of your screen and I flipped it back on the images to the right of your screen. But there's this very strange flat surface and as Aparna mentioned, you know, I see this with the bigger the implant and the more cohesivity but I don't actually know if it's happening more often or if it's just more visible because when I take out saline implants they're upside down probably a third of the time and then I'm just showing you sometimes it's a little bit more obvious to see in the video that it's upside down when you mash on it and you can kind of see that it's the flat side is on the top and so then what I did here was just video taking it out to confirm that it was in fact upside down or the disc portion of the device is on the top which it is and then I just had to show you my pain that it was now both sides in this particular patient. So what are the odds? And so what I did for her was I just changed her out to saline breast implants because again I see a lot of these being upside down. I don't notice it as much in aesthetics but I do think it has to do with the fact that there are tighter pockets right because there's a breast and there's no breast surgeon that has obliterated all of my landmarks. There's less ADM so I think that the good news about the ADM in my hands was I think it did decrease my capsular contraction rates but by the same token my pocket didn't contract around my implant. In my hands pocket tightening alone without either managing the breast or managing the implant has not been super successful and so I tend to not do that in isolation. I'm happy to manage to tighten the pocket with capsuloraphy but I will also liberally use a breast lift so that my breast itself isn't the thing that's moving around so much. I find that flatter devices so obviously the lower projecting devices just like a Parnaset are better and then also learning how to flip it back and just like she did I have a do-it-yourself video. I find that either having them bend over and let gravity help me let that implant fall away from the chest or having them lay down is another way that I've been able to flip the implant back and forth and it sometimes takes more than than one try and they have to be kind of patient with it. Let's see and then this is an example of managing the patient with the bilateral flipped implants who had just about lost her mind with me. I switched her out to saline implants and she's round and she's quite happy because it doesn't really matter what shape her or what orientation her implant is in because it's always round and so thank you very much to ASPS for allowing me to participate in tonight's webinar and I look forward to taking your questions when it is the time for questions. Thank you Michelle for this enlightening presentation. We are moving to our last talk. The last presenter is Professor Scott Hollenbeck. We all know Scott. Scott is chair of University of Virginia Department of Plastic Surgery and is the current president of ASPS. So we are going to hear his presentation. Hello my name is Scott Hollenbeck and I am the chair of the Department of Plastic Surgery, Maxillofacial and Oral Health at the University of Virginia in Charlottesville, Virginia. I'm also the president of the American Society of Plastic Surgeons and I'm really honored to be here to give you a presentation, share some of my ideas, some of my experience related to breast reconstruction and a lot of this comes from experience and using different techniques over time but the main focus is going to be on transitioning pockets or the idea of switching the location of your reconstruction from below the muscle, the pectoralis muscle, to above the pectoralis muscle. So I hope you enjoy it and I'm going to bring up my slides now at this point and at this stage it should be possible to see my slides and I'm going to switch this to this view here and I hope you'll be able to see this. So anyway the title of my talk is called Hot Pockets, Switching the Plane from Subpectral to Prepectral and I'm going to start with talking about implants first because this is going to be the most common scenario where the pocket transition is going to come into play. For many years historically breast implants replaced were placed in the submuscular position. This is in part due to the advent of tissue expanders which allowed for stretching of the muscles which was in part due to the need to place implants under the muscle because of a high rate of capture contracture associated with the original breast implants which were placed in the subcutaneous position. So just to rephrase that again, the original breast implants which existed were placed in the subcutaneous plane following mastectomy, high rate of capsular contracture that led to the advent of the creation of a tissue expander which allowed for placement of devices under the pectoralis and serratus muscle, total submuscular coverage, with then expansion of that muscle pocket and then placement of the implant which actually performed well over time with less capsular contracture but had associated issues with it related to pain and discomfort and then the advent of other techniques involving partial submuscular and then where we are now in many cases pre-pectoral. So I'm going to kind of put that out there as a baseline and I'm going to start with this image here and you know this is the downside of submuscular reconstruction done sort of in the modern way with a partial sling of ADM or mesh or something is you can get tremendous degree of animation and you can see in this patient when she flexes her pectoralis muscle, the muscle now not only moves but it moves almost twice as far as it could in the past because now it has a longer excursion related to the ADM which is acting like a tendon in this case. So you know the solution for that problem as well as other problems was the pre-pectoral reconstruction technique described in 2015 out of Austria. In this particular image we see what appears to be a direct implant approach where the ADM has been fastened to around the implant and then the implant ADM construct has been placed simply in the pre-pectoral position or the subcutaneous position. You know I typically do this in a two-stage approach. I do like tissue expanders. I generally think that you know if I'm creating a pocket or a new pocket, I always think tissue expander. Believe strongly that tissue expanders are unmatched in their ability to create a new pocket or a pocket out of scratch. So if you enter into a case it's mastectomy has been performed, there is no remnant of a pocket. It is a clavicular down to below the IMF resection all the way to the sternum out to the latissimus border. As a traditional mastectomy borders are often defined there is no pocket there and you will be creating a pocket and in my experience using a tissue expander is the best way to create a pocket. So again in revision surgery other things if I think I'm making a new pocket here I often think tissue expander. And this is a typical case as a patient pre-op and then six weeks post-op following her tissue expander removal and implant placement. And you can see here that this patient has incredibly natural looking result. Well that's in part due to the fact that she has anatomic gel implants. But of course as many of you know for a variety of reasons we typically are not using textured anatomic gel implants at this point in time. As a result of that there's kind of a new problem that's developed with this pre-pectoral approach and that is shown here and these two comparative patients who are kind of similar both with nipple sparing mastectomies done through the IMF. One with a submuscular ADM sling. She has nice upper pole fullness. This patient here with a pre-pectoral and total ADM coverage done again in two stage. You can see here in the upper pole we have this new problem of rippling. And this is a problem that occurs very frequently in part due to the fact it's not just the implant that's rippling. It is the fact that the implant has now accommodated to the pocket. Has now even perhaps stretched the pocket. Swelling has gone down and as such you get rippling within the skin as well as within the implant. But this is due to a pocket that is not completely tight for a patient. Well you know there's a new kind of solution for that with every problem become there's an opportunity for solution. So for many patients with rippling a lot of us have found that fat grafting can be very helpful. Here's an example of a patient with a partially inflated tissue expander and you can see we've got some tremendous rippling and I'm going to fat graft that here to try to improve that rippling. I typically do not do this anymore during my implant placement. Believe it or not, I actually most commonly do fat grafting as a third separate stage, in part because the loss of the fat graft through the capsule, if you are injecting the fat between the capsule and the skin, and you've done the implant placement, you often have disrupted the capsule in order to reposition the implant to an ideal position, and when you disrupt that capsule, as soon as you inject the fat, much of it will leak out into the capsule, and then you'll have a suboptimal take of your fat grafting, and that will be the reason why. So here's an example, really, of kind of what I typically do. Here's a patient who's had a bilateral mastectomy. We've done kind of a nipple lifting procedure as part of that to reduce the skin. You can see here, she's now got her implants in, we've got quite a bit of rippling, and so the treatment of that is fat grafting. This is, in fact, the same patient. It's just hard to believe that you can get that much improvement with fat grafting and improve the quality of the fat there, but you can. So I mentioned this, changing the pockets, going from submuscular to prepeck. So, you know, what I've shown so far is patients that just started out and either had, you know, a submuscular or had a prepeck. What if we want to change a patient from this situation, who is in this kind of uncomfortable, highly animated, partial submuscular to a prepeck? How do we do that? And do we do that? Should we do that? And I believe that's very reasonable, and for these kind of patients, this is often what we're dealing with. This is a patient that's had a partial submuscular implant-based reconstruction, and just, you know, really kind of surprising to see this kind of result and to have this patient sort of, you know, be told this is the way it is, and that's the end of the story, but she did wish to try to have an improvement and try to have this look more natural. We can determine on physical exam that this is a partial submuscular reconstruction. She's very unhappy with it. She feels like she looks, quote-unquote, looks like a man. Her chest does in that way, and also feels like she's uncomfortable, and for this patient, we will offer her, because of her concerns, because of her general well-being and her request, we will offer a pocket conversion to go from a submuscular, in this case a partial submuscular, to a prepectoral reconstruction. So, on exam, I'm going to excise the scar. I've got her sort of measured out, and you can see she has real high-quality skin flaps, and that is helpful if you're going to convert the pocket. Obviously, now you're going to be in the subcutaneous space, and having high-quality skin flaps, as this patient does, is in fact very, very helpful. So, steps in the plane conversion, rather straightforward. The first step is simply to enter into the implant region and remove the implant and the capsule. This often involves some form of mesh or ADM that has been placed in there. Just take it all out. Then, I will often suture down the pectoralis muscle to the chest wall. You can use PDS sutures or Vicryl. It will scar down there and stick, but I do want to put that muscle back into its anatomic position. Then, you have to recreate the mastectomy defect. So, remember, the skin is going to be stuck to the pectoralis muscle, so the skin needs to be freed up from the pectoralis muscle, and then I want to make it look like somebody was just there. The best breast surgeon in the world was just there and just created a new, new mastectomy defect, because that's what I want to work with. So, recreate the mastectomy defect. Then, create a new pocket. Again, remember, when I think about creating a new pocket, tissue expander. ADM is my choice to support that, and then also drain that. Usually, I use one drain. Then, re-drape the skin over top, around. And then, we proceed on, and here she is with some final pictures, just to give you an idea how it's turned out. I can show you a couple angles here. So, here's another patient that shows this as well. But, just to show you a couple other, sort of, final, kind of, outcomes from this pre-pectoral approach. This was a two-stage tissue expander implant at pre-pectoral. High-quality skin flaps. We did not need fat grafting here. So, here's another patient. This is probably my most, kind of, typical situation or typical approach on doing implant-based reconstruction. Again, a three-stage pre-pectoral reconstruction. Nipple-sparing mastectomy, pre-PEC, tissue expander, and ADM. That's surgery number one. Surgery number two, as I said, is a tissue expander to an implant. And then, I wait about three to six months, assess for rippling, and assess for hollowing, or certain areas that have contoured deformities, and then address those precisely with fat grafting. I don't do that at the same time as I manipulate the capsule, because fat will leak out into the capsule. So, I do that in isolation. My preferred donor site is actually close to your thigh and posterior flank region. I find that fat to be the most favorable. You might call that the PAP or lumbar donor sites, but that is typically what I will use for fat grafting. It does require flipping the patient prone, but you can get these, sort of, nice, high-quality fat grafting. And I'll usually do one to two hundred cc's per breast on top of the implant in that subcutaneous space. So, you know, finally, I want to finish up with the idea of converting implants to flaps. That is a form of pocket conversion. You know, pretty straightforward. You're basically going to take everything down, take it apart, and then do a flap of some sort, most commonly a deep flap. Many of these patients will present with very unnatural-looking reconstructions. I find that they share a few things in common. The number one most common thing they share is radiation to the implant. The other, sort of, common thing is failure to create a three-dimensional shape. That is common in patients, first of all, that have a large amount of adiposity, but also in the submuscular position, there's just no way to create that three-dimensional shape. And then finally, this, this kind of situation here, this is where you have incongruence between the pocket, which is a submuscular pocket, and then the overlying breast skin, which is draped in another plane, and they are not in contact with each other. So, the obvious thing here is to remove that pocket, neither go pre-PEC with an implant, but in a patient with this type of donor site, we will convert her to flaps. So, steps in the plane conversion in flap-based surgery. So, remove the implant, the capsule, take everything out, suture down the PEC to the chest wall, recreate the mastectomy defect. I can't emphasize that enough. It's, it's often, you know, kind of, hurry up, let's get the flap going, I want to do the micro. You got to take time to recreate the mastectomy defect when you're doing these pocket conversions. Place drain, transfer the flap, usually use the internal mammary vessels via the PEC muscle, which has been sutured down, re-drape the skin, and close. So, here's one of those patients I showed. Here's another case I showed this patient earlier. So, in conclusion, for mastectomy patients, then the natural breast does not sit under the PEC muscle. I do not put flaps under the PEC muscle. I only put implants under the muscle if they were already there, and the patient is happy with them. I do convert a lot of patients from the submuscular implant position to the pre-PECteral, either flap or implant position, and the primary reason for that is just, is discomfort. So, thank you very much for the opportunity to speak today. Okay, we just hear a very nice presentation from Scott, and now we are going, we're moving to the Q&A session. I have a few questions for both Aparna and Michelle. First, I would like to say something. Perhaps we all know that the first implant-based reconstruction were pre-PEC. The first case ever reported in the medical literature was pre-PEC. So, this is a changing trend, you know, like in fashion world, you know, and we must realize that this is just possible because with the advent of the ADM, we know now that fat grafting is safe. During many years, fat grafting was considered bad, and that was increasing the risk of breast cancer relapse, and we know now that it's safe. So, all these, I mean, we are talking about pre-PEC breast reconstruction now, just because we know that fat grafting is safe, and because of the advent of ADM. But, I would like to ask Aparna. Aparna, I know that in many medical centers in the U.S., they are limiting the use of ADM because of costs. Huge costs at the end of the year are, I mean, million dollars of expenditures just because using ADM in breast reconstruction. Which is the situation in your practice? Do you have any kind of pressure from, I mean, from your institution to try to limit or to avoid the use of ADM? And in those cases, what are you planning to do? So, we are starting to, for the first time, to see some insurance denials. You know, I always tell our residents, you know, like, at Mayo, usually, it's a big institution. It's like a well-oiled machine. We don't run into these things. And I always say I don't have the luxury of practicing without thinking about much about what's going on in the back end. But it's not, I mean, it's becoming more and more common. I know our graduates who graduate, go outside, and they're like, oh, my God, my hospital said that I can't use this. They said I can only use this particular match. Like, one of our recent graduates who's in board collection literally told me his hospital told him that he cannot use match for Prefect. Now, that being said, we are not seeing it that often. I do think a lot of the insurances, like, especially private insurances, they have certain kinds of match, you know, brand names that they kind of approve. So, we, I, for the most part, have maybe had to do a couple of peer-to-peers. I've had to write some letters, but I haven't had anything turned down completely. But I do fear that we might be at that point. I do, on that note, I would say that this has put pressure on the match companies to come up with trials. Like, right now, we have two FDA trials that we are part of at Mayo for match. One is on a bioabsorbable match, which is antibiotic-coated. The site's live, and they're looking at it. And the second one is going to be on another is a low dermal matrix. So, I think once we have these trials in place, hopefully in time that we won't have to go to a transition where they deny it. So, that's where we are right now. And you also, we are still expecting a reduced, the reason of the cost of ADM, you know, like a new technology, you know, time, they're trying to reduce the cost, but ADM has always the same cost, you know. So, it's another thing that I would like to share with you, ladies, is that the fact that in some countries, just because of the cost, ADM was never, I mean, it was never available in the market. So, for instance, in Argentina, we don't have ADM. And for those cases, we use, in those cases of capsular contracture, and irradiated patient, and with animation problems, we use the endoscopic latissimus dorsi flap. So, we can provide the muscle coverage. And in that way, we can avoid, you know, all those problems related with breast animation, with rippling, and everything. And also in Europe, you know, and also in some centers here in Argentina, it's being used polyurethane-coated implants. The polyurethane, you know, the polyurethane behaves like, actually like an ADM, you know, it's like a scaffold for muscular ingrowth, they are integrated in the tissue, they actually increase the thickness of the flap. So, you don't have thickness, you don't have ripping problems that you'd be in the pre-PEC breast reconstruction. We can use shape implants, we use shape microtexture implants, they are not banned in this part of the world. I know that is a problem for you ladies, but that is the main advantages that will happen in this corner of the world. Regarding your presentation, Michel, I really like it. You know, your presentation really remarked how important is patient selection in breast augmentation. Breast augmentation in the U.S. and in Argentina and many countries of the world is the most common plastic surgery procedure, cosmetic plastic surgery procedure. But again, if you have patients with breast animation, we have patients with rippling going to glandular, you have patients with breast animation going to pectoral, it means that from the beginning, perhaps the technique was not well indicated because the plane conversion actually indicates that from the beginning was not the right indication. So, this reinforced the fact that in plastic surgery, no key fits every lock. So, we cannot indicate the same procedure and the same plane for all our patients. Patients have different BMI, they have different lifestyles, many of them they practice sports every day. So, you cannot consider the sub-pectoral placement of implants on them because actually you will have a problem in the near future. So, again, the fact that in the U.S. you are using a smooth implant, you know, if compared to other countries, the volume of implants are large and also high profile, right? So, that is a huge problem. And I would like to know, in your case, Michelle, if, I mean, how do you manage those patients, I mean, that feel not happy with your result? In those cases, if you are, your own cases, which is your policy, do you charge them? In order to keep the patient relationship patient and avoid, you know, in a malpractice, you know, process, do you avoid to charge the patient and you just charge the clinic fees? What is your policy? What is the policy of the, in general, of the American plastic surgeon facing these kind of difficult situations? No, I think those are great questions, and I appreciate you asking them. I think there are different practice models in this country, just like there are in other countries, yeah. In my practice model, we own our own operating room, and we pay our own anesthesia cost. So, when we, if you're a patient that comes and sees me, you get one bill that covers everything, your implants, your surgeon fee, facility fee, and anesthesia fee. So, that's the first thing, because it makes it easier for me, because I can control all those costs. The second thing is that we actually offer the patient at the time of when they pay for surgery at their pre-op visit, they can choose something that we call revision assurance, where they can pay, it's about $500, it might be $400 upfront, and that covers any revision that they might need for 18 months, excluding size change, because I would have them all back if I didn't exclude that. So, you don't get a free implant, but bottoming out, rippling, capsular contracture, animation, anything that you're super frustrated with, I will revise it at no charge, or if you don't buy the revision assurance, we bill you at, I think it's $1,200 per hour of OR time, and I can get that done in an hour. So, if you want to play the odds, you don't buy it, and then for most of my patients, I would say about 90% of them do buy that upfront, so then it's no more awkward conversations, they're not mad, and I'm happy to fix it for them. Wonderful, yeah, it always is good to keep a good patient relationship, doctor-patient relationship. It's tricky, because now social media controls everything, right? And they can post anything they want. Yeah, they can destroy you on the next day, you know, if the post could viralize, and you know, you are done, especially if you are working in a small town, you know, so it's a huge problem, absolutely. So, ladies, these two talks, and also Scott's talk has been really enlightening, and you know, in this part of the world, it's almost 10pm, and my family will kill me. So, ladies, I think this has been a very enriching webinar for all of us, and I would like to thank you very much for being here, and for sharing your knowledge, and I'm sure that many young plastic surgeons will, I mean, they will learn a lot from your teaching today, tonight, actually, in this part of the world. So, thank you, ladies, and hopefully, I would like to meet you in person sometime, yeah, next year in New Orleans, okay? Okay, good night. Thank you. Thank you, ladies, and have a nice evening, okay? Thank you very much for participating.

breast reconstruction

pre-pectoral implants

Acellular Dermal Matrix

capsular contracture

animation deformity

fat grafting

patient selection

surgical techniques

financial aspects

tissue expanders

submuscular to subglandular conversion

revision assurance policies

latissimus dorsi flaps

patient customization