Hello, everyone. This is Dr. Li Pu from Sacramento, California, USA, and I'm honored to moderate this ASPS Global Partner Webinar Series. Today, the topic is focused on how to optimize an outcome in breast and also gluteal augmentations. We have three global partners, countries from Spain, Romania, and also Norway, and I'm very honored to introduce our first speaker, Dr. Alexandra Daniel-Hermig from Romania. Dr. Hermig did training in Bucharest and also Paris and Brussels, and also did a fellowship at the Chango Memorial Hospital in Stockholm, and he's specialized in aesthetic and reconstructive breast surgery. Today, he's going to talk about breast augmentation. Dr. Hermig, please. All right. Okay, just one second here. Okay, just one second. Okay. All right. Hello, everybody. My name is Daniel Hermig. I'm a board-certified plastic surgeon from Romania. I'm going to talk to you today about breast augmentation and how we can master improved shape and stable results by making a comparison between the most popular dual-plane breast augmentation technique and the technique that we employ in our facility in Bucharest, which is the multi-plane technique. I have nothing to disclose. So, since their inception in the mid-60s, the popularity of this procedure has remained high. Breast augmentation using silicon gel implants is still the best leading cosmetic surgical procedure, with more than 1.7 million cases being performed each year across the globe. So, why do we still do it? Well, for many women, getting breast implants represents a major step, and very often a positive one. It has been shown that breast augmentation has the potential to enhance their self-confidence, to improve their perception of their personal body image, and to help them feel more feminine. Today, we're talking about 58 years of breast augmentation history, since Drs. Cronin and Gero performed this procedure for the first time. During this half-century period, plastic surgeons came across five generations of silicon gel implants, each one designed to improve the aesthetic outcomes and to limit the possible risk associated with these medical devices. Well, while manufacturers are constantly struggling to better themselves at developing optimal implant designs through finding the perfect silicon gel cohesivity formula and the ideal amount of fill, whereby finding the adequate amount of texturization and the safest means of producing it, all in an effort to limit capsular contracture and ALCL occurrence, plastic surgeons are continuously striving to provide patients with sound and efficient surgical techniques in order to deliver consistent and rapid recovery. In the beginning of the modern breast augmentation era, the philosophy around this procedure was more or less making a cut, dissecting a pocket, putting an implant in, and closing the incision site. Well, this approach has led to inconsistent results, which frequently required additional surgery and determined plastic surgeons to try to standardize the procedure as much as they could with regard to implant selection and tissue-based planning and to understand that unfortunately breast augmentation is not a one-size-fits-all procedure and that it requires an individual approach. No decision in breast augmentation is more important than selecting the implant pocket location, and this has everything to do with assuring optimal soft tissue coverage in every aspect of the implant, taking into consideration not only the immediate post-operative setting, but especially the long-term results. And how is this achievable? Of course, through thorough patient education, tissue-based planning, all in an effort to limit the irreversible tissue compromises that may occur many years after their procedure. Until the early 2000s, several implant pocket locations were described relative to their anatomical relation with the pec major. Each of these pocket locations can provide specific amount of soft tissue coverage in specific areas of the breast, and each location has a unique set of potential benefits and trade-offs. Initially, implants were positioned in a retro memory space between the parenchyma and the pec major, which made sense since this is as close as we can get to the plane of normal breast tissue. Choosing this plane led to very pleasant aesthetic results with an improved overall breast shape with minimal to no pectoralis animation deformity and a rapid post-operative recovery. Yet, in patients with soft tissue coverage, this pocket is likelier to show ripples, wrinkles, and implant edge visibility. Moreover, capsular contracture incidence is higher when implants are in place retro memory, and also diagnostic mammographies are more difficult to perform. Another variant of the sub-memory pocket is the subfacial pocket, in which the breast implant is positioned beneath the pec major fascia. The potential benefits with this dissection plane are somewhat debated, mainly related to the consistency with which the fascia can be elevated intact to assure full implant coverage, especially in its inferior part. Otherwise, lesser risks of lateral or upward implant displacement or minimal to no breast distortion with pectoralis major contracture are noted with this technique. On the other hand, interference with mammography or higher and higher rates of capsular contracture remain some of the trade-offs of when choosing this implant pocket. So, having understood the significance of soft tissue coverage led plastic surgeons to develop a new pocket which addressed this particular concern. And we had the traditional partial retro pectoral pocket, where all the origins of the pec majors were kept intact along the IMF. This pocket provides muscle coverage over at least the upper two-thirds of the implant, but does not provide muscle coverage infralaterally, so it assures adequate soft tissue coverage and it allows for more accurate mammograms to be performed. But lateral implant displacement over time and breast shape distortion with widening of the space between the breasts may be observed with muscle contracture. So, this led to the development of the dual plane technique, which was described in 2001 in the PRS journal by Dr. John Tebbets as a way to combine the advantages of both subpectral and subglandular planes while trying to limit their trade-offs. In dual plane breast augmentation, the implant lies partially behind the pec major and partially behind the breast parenchyma. So, this technique implies to partially alter the position of the pec major by selectively dividing its inferior origins along the IMF only with no muscle division along the sternum and by freeing the attachments at the parenchyma muscle interface. These maneuvers are performed at different times and to different degrees depending on the breast type and the implant soft tissue dynamics. So, a dual plane type 1 procedure implies a complete division of the costal origins of the pec major stopping at the medial aspect of the IMF 2 to 3 centimeters caudally from the nipple sternum line with no dissection in the retromemory plane and ipso facto with no gesture to mobilize the parenchyma muscle interface to preserve maximum muscle coverage. This procedure is selected for most routine breasts where all breast parenchyma is located above the IMF with tight attachments at the parenchyma muscle interface and the minimally stretched lower pole envelope. In dual plane type 2 procedures, all the pec major origins across the IMF are completely divided stopping at the lateral aspect of the sternum respecting the 2 to 3 centimeter distance from the nipple sternum line followed by the dissection in the retromemory plane to approximately the inferior border of the areola. The objective here is to perform more dissection at the parenchyma muscle interface to allow the muscle to retract more cranially. Therefore, the risk of having this highly mobile parenchyma sliding off the pec major and creating a double contour deformity in the post-operative setting is reduced. A dual plane type 2 technique is selected in scenarios where most of the breast is located above the IMF but with looser attachments at the parenchyma muscle interface, therefore with a more mobile breast tissue relative to the interior surface of the pec major. So this leads us to dual plane type 3 where the technical difference is that the dissection in the retromemory space is carried out until the superior border of the areola is reached. The pec major inferior release is done as usual and all medial pec origins along the sternum are totally preserved to avoid excessive upward retraction, visible superior muscle banding, and visible implant edges or traction rippling which we can see medially. On the other hand, keeping the sternal origins intact as in any dual plane procedure limits the possibility of narrowing the intermemory distance which sometimes may result in a fairly large gap between the breasts. The weakened lateral pectoralis flap will retract and minimize animation during muscle activity, but in rare cases there is a risk of getting animation deformity where either the breast or the implant will move with the pec muscle contracture. This does not happen to most women, but it's more significant significantly when we compare it to the subglandular approach. And last but not least, we have the multi-plane breast augmentation which was first described in 2017 by Dr. Konstantin Stan in the PRS Global Open Journal. This particular technique is all about tissue-based planning where one retro-pectoral pocket is designed to accommodate a form-stable implant and another plane is performed behind the gland to allow access for parenchymal manipulation and other ancillary procedures. So the first pocket is developed through an inframammary approach in the same manner as in any dual-plane procedure through a two-centimeter incision in the inframedial part of the pec major. The pocket is expanded in a regular fashion while keeping the inframedial origins of the pec major intact, but gradually weakening them from inside out to the level of the pectoralis fascia. All main sternal origins of the pec major are to be preserved. This dissection is followed by getting into Shasanyak's retro-memory space through a parenchymal tunnel created between the pec major and the posterior layer of the fascia superficialis. Two strips of parenchymal adhesions around this parenchymal tunnel are kept inframedially and infralaterally to avoid over-rotation of the pec major muscle, thus limiting any possible animation deformity. Once arrived at the level of the neck, the pocket is expanded to allow more space for replacement and repositioning of the special layer of parenchyma, which has major implications in breast pathosis. So having access to the posterior side of the gland allows us to perform important ancillary procedures like scoring, which is crucial while managing tuberous or lower pole constricted breasts, or when trying to accommodate high projection implants. This in conjunction when being able to coagulate the loose connective tissue on the posterior surface of the gland creates better premises for parenchymal adhesion to the pec major in order to prevent future breast pathosis. And also, partial splitting of the pec major may be envisaged to allow for further expansion of the retro-pectoral pocket in cases where high projection implants are employed. And of course, long-lasting resorbing repositioning sutures designed to relocate the laterally displaced parenchyma or to limit the bottoming out phenomenon and to improve projection and fullness in the cleavage area, especially in emtotic and pseudoptotic breasts. So to summarize, all the access to the retro-memory pocket provided by this technique offers better shape control through several ancillary gestures, notably scoring either in a horizontal or radial fashion, expanding the breast parenchyma to improve tissue dynamics in conjunction with accommodating a breast implant, especially in glandular or constricted lower pole breasts, or in patients necessitating high projection implants. Also, being able to coagulate this particular sliding layer of breast parenchyma using either diatomy or argon plasma as described in the popcorn technique creates the premises for better tissue attachment and repositioning of the parenchyma to the pec major. At this stage, another gesture that we have the liberty to perform is to partially divide the pec major, leaving one centimeter of muscle intact at its caudal border to further expand the retro-pectoral pocket. The classic procedure implies using up to three levels of horizontal scoring of both laps of breast parenchyma that will be reattached with slow reserving sutures to the supramedial portion of the pec major. Therefore, the intermemory distance is reduced and a better cleavage and more projection are obtained as in an internal lifting procedure. In terms of stability, here we have the BNA slides at more than one year after breast augmentation using the multiplane technique with 235 gram anatomic oval base microtain high projecting implants with internal lifting. So, good overall shape and symmetry has been achieved with no signs of bottoming out and good upper pole fullness is observed. Also, an improved aspect of the cleavage area with a reduced intermemory distance is noted. Another multiplane technique associated with internal lifting showed at 18 months after the procedure. So, here we have 165 gram anatomic round base microtain moderate projecting implant. We can notice the nice and stable shape with absent pseudoptosis for bottoming out, good overall symmetry, and the lifted appearance. So, to conclude, thorough patient education and tissue-based planning play a crucial role in achieving stable results. Dual-plane and multiplane techniques combine the advantages of using both retropectural and retromemory pockets aiming for greater tissue coverage, a more natural appearance, less wrinkling, faster recovery, and less risk of capsular contracture. The addition of glandular scoring, the popcorn technique, the glandular repositioning sutures, and the partial muscle splitting appear to be clinically beneficial in achieving a more immediate and long-term breast stability. And, of course, parenchymal manipulation with repositioning sutures and the keyhole approach to the retromemory pocket described in the multiplane technique may hold the key to reducing the intermemory distance and to limiting muscle animation deformity, which are sometimes bothersome with the dual-plane breast augmentations. The multiplane technique, as originally described, uses implants covered with micropolyurethane foam, but this technique can be employed with any implant, with any surface, but in these scenarios, we must pay special attention to the reinforcement of the inframemory foam. Thank you very much. This was my presentation. Thank you, Dr. Hermic, and any questions from the audience? I have a question to ask you, Dr. Hermic, and recently, at least in the U.S., people started doing more subglandular breast augmentations, and it's part of the reason why there's an improvement of the quality of silicone implants, and do you see something like this in Europe, and, you know, or is it still the same, like a dual-plane kind of breast pocket? Well, here in Europe, I mean, I was trained in Romania, in Stockholm, and in Australia. In Australia and Stockholm, they did dual-plane breast augmentation, and I think this kind of procedure fits this specific type of patients, because this patient, these patients don't have soft tissue coverage. I mean, you need to add the muscle in order to have, you know, pleasant aesthetic results. I think the paradigm is the same as John Debitz described it. You need to have good soft tissue coverage all across the implant. If you're fortunate enough to have a patient with sufficient amount of tissue to cover the implant just by the gland, that's great. You can do it, but still, in our experience, the trend is to try to put the implant behind the muscle and do a multi-plane, dual-plane kind of breast augmentation. Dr. Hermic, there's a question that they asked you. What's the key difference between the technique you presented and the one from John Debitz? What is the key difference between the technique you described compared to the technique from John Debitz? The retro-memory pocket is dissected differently. It's dissected in a keyhole approach. You get behind the retro-memory plane through a tunnel, three-centimeter tunnel, until the inferior border of the areola, and then you expand the pocket. The retro-glandular pocket will have the same surface as the, or, you know, one centimeter less than the retro-pectoral pocket. So, this axis behind this retro-glandular pocket gives you permission to manipulate the parenchyma, to move it more immediately, to coagulate it, and to play with it, you know, more easily. And, of course, the repositioning sutures are something that, in dual-plane, it's not described, and you do not have access to place them, and you do not squirt the parenchyma on the posterior surface of the gland. So, you don't have the premises to have a good adhesion, to have a stable result. This is what I think, actually. There's another question that they want to ask you about. Can you explain one more time about your internal fixation technique? Internal fixation. I think I already explained it. I mean, you have good access on the posterior surface of the gland, so it allows you to manipulate this parenchyma. You can coagulate it. You can squirt it. You can, I mean, you're squirting the posterior layer of the fascia, and therefore, you're attaching this posterior fascia to the pectoralis fascia. So, basically, you have the good premises for good tissue adhesion, which is in theory and also in practice, because we have rather stable results with this technique. All right. Thank you very much. Thank you very much, Dr. Hermig. We're going to move on to the next speaker. Thank you. Please stay on at the end. We'll have another questions section. So, our second speaker will be Dr. Amin Kalaji from Norway. He's from Norwegian Society of Plastic Surgery, and Dr. Kalaji is an immediate past president of Norwegian Society of Plastic Surgery and also currently director of Oslo Plastic Surgery Clinic. Amin has many leadership positions in ASAP, ISAP, East Press, and also MCAS. He's also the editorial board for ASJ and also Ascetic Plastic Surgery. Dr. Kalaji, today, is going to talk about the gluteal augmentation, and he's going to have a pre-recorded lecture. But he's actually on the air, and we'll be happy to answer any questions after his presentation. Please. Dear friends and colleagues, my name is Amin Kalaji from Oslo, Norway. I'm very delighted to share with you my experience today. This is a topic which ASPS has chosen for today, and let me share my screen with you. Now, you can see here, there are many lectures I have done for this topic. I have to say, I'm learning every time I teach from the feedback, from the discussion, and I'm looking forward today also to have it from you. The other thing is, this is just illustrating how important this topic is. This is today, like last month in Morocco, before in Washington, also in Dubai, life, Japan, this is ISAF's world, this was Argentina and Rome and here in France. This is only to illustrate how important this hot topic is and how much responsibility is relied on us as plastic surgeons for this topic specifically. This is a part of my upcoming book and there will be like 12 chapters about gluteal augmentation with fat. No disclosure and level of evidence is free. Outside the Hyalia Clinic, Jessica? That's right. She went into this clinic for cosmetic surgery and she would not come out Unfortunately, these stories of death are multiple, happened before a lot and still happening now. For the sake of the time, I will go like quickly through this. Even we think that this is mostly in the Americas and especially in South America in the beginning, but in reality, it exists everywhere. There is some like unofficial statistic in Europe and we know that if we go to the literature, like Conde Greene in the 16th, she showed that more complications are registered with buttock implants than gluteal augmentation with fat. This was echoed by Orange and also by Sino. Anyhow, all these like really they didn't mention a great study by Cardenas Camarena and he showed that there was 13 deaths caused by gluteal lipoinjection in Colombia. So both like macro and micro embolism. So this really created the task force and alarming news and we know all that ASAPS and also the ASERF like former task force, which came with the study 2017, which found that 32 fatalities in really highly accredited facilities in the United States. So just look here, we see like almost 280% raise from 2011 and more than 3000 from 2002. One death in 55,000 aesthetic procedure. Normally, if we calculate this for the gluteal areas, there will be one death in 3,400. Unacceptable. So we know that all these five major society including ASPS and ASAPS, ISAPS and ESPRESS and IFATS also issued many, as a matter of fact, a recommendation just not to put fat in the muscle or under the muscle. And they provide evidence that the death was reported from grafting in the muscle or under the muscle. And in no case, it was related to subcutaneous plan. Now, staging is one of the advice and to be mentally focused and also consider positioning, we will come to it later, also using of the cannula. And we as plastic surgeons should always give like information about the death risk. Also, we need to concentrate on doing it only in subcutaneous plan. And we need to be strictly adhere to this regulation. And also patient safety is number one should be for us as plastic surgeon. We see we come with our, came with our study, this like a safety study and prospective study. But still the stories are still coming, these two Britain and then Babras issued like memorandum to stop doing the procedure. So I was invited with Delvecchio as experts and he gave some recommendation. I will come back to it later at the end of the lecture. So especially for the young colleagues, which plan do you graft? Subcutaneously, muscle, submuscular or? I will come back to the answer at the end of the lecture. What is the location of greater sciatic foramen? And also what the appropriate cannula size you choose for or more than for? Which of the following is the safety factor? Constant motion of the cannula, large size, staging, staying above the muscle more than of the above. What is the appropriate volume? As much as possible, when desired shape or volume has been achieved, when fat is working out of the injection site or limit of 1800. These are the main positions of pine, brawn, brawn, deaf, naive and natural. We will come back to it. But very quickly about the main shape, we know all the A shape, H shape, D shape and O shape and C point, all almost agree about filling it here. And also the space here is more culturally related as a matter of fact. So in a discussion about what to use, machine or syringe, as we had it in St. Petersburg, I have to say, I mean, roller pump is good way to do it. We have like good publication from Abboud and also Delvecchio. But the syringe is also there and it has been there a long time, 60 or 10 cc. We have a lot of publication, Toledo has done it for 35 years ago. Also, there is our study here. Of course, they had this advantage if they were used incorrectly, and also the fatigue. This is also a good point raised by Delvecchio. But still, this is could happen also, even when you are using the machine now. So less tissue damage in my view, the syringe, because you don't have this power to cut all the septa, which is important for the circulation. It's also closed system and not time consuming. As a matter of fact, if you have good assistant, you really, really can make it good enough as the machine. Also external vibration, and Abboud, we'll see later, you can do it at the end. Also, three dimensional feeling is the most important. So it doesn't matter if you use syringe or if you use the machine, this is what is important. So syringe are not better or worse could be used, but both of them you need to use it really carefully. So these are the graphic areas around 400, as a matter of fact. And I love this test to show like generally this is like a preoperative assessment. We see here from where to take the fat and just as I draw or where I put the fat, where I take the fat and which area and how much is the C point. And this we see the operation table here, or this micro area again, no commercial interest. This is also you can do it as like AVL, grafting the fat with vibration. And this I love like let the anesthetist also note how from where you take the fat, how much you take and where to put in these five areas, I divide the buttock and the lateral to it. Now, see just an example here or another example. If we see here the difference between the side and the difference to the other side, here we just make also the grafting here, this after the liposuction here, these are the syringe would be 20 could be 50 also. And this is like also the massage at the end of the operation and we see here just one day after this is with the garment. So if we see here like I will try to give the videos all together. And we see here how we try here to make the, like put the graft. I stop have the graft really come with some Luteal, in fact Luteal here. So with important, I start here also with this. And we see here the retrograde, this is here I do the theropatic expansion and here like the grafting here. And this how much we do also the massaging at the end of the operation. And here I want to show you here the like retrograde grafting. See here is very important like to have the non-dominant hand and as here also like feeling the tip of the cannula. And once you are in the right position, so you start retrograde and graft at the side. This I think it's very good way to graft the buttock area. So this is also another example like to see how like buttocks, the lateral area of the abdomen. It's like about 360 as a matter of fact. And this is where the grafting is like helicopter use. You feel always the tip of the cannula in your non-dominant hand. And you see at the end of the operation, this is the canister. And this is also how we do it here. Now, this is also, and it was both combined gluteal and breast. And again here, what's important here is the micro area and the non-dominant hand should be really have like a feeling about it. This is how to do also the same. And the lateral view is really very important. See here, the cannula tip is always palpated by your other hand. So again, this is at the end of the operation. Now, of course we can do also in the L, and you see here at the end of the operation here. Like again, like you can do it, of course, there's some disadvantage and some advantage, of course, maybe it's a little bit quicker. And then we do the fat here, fat is coming here. And you see here how much also you can put. And also when the fat is squirting, it's better like to stop really doing the procedure. Now, I want to advise my colleagues, normally I'm a little bit hesitant to make an interview, but once it's coming to this procedure, so I advise all my colleagues really to go out and be active in social media, in television, because this is very important. There are so much unrealistic expectations out there. So look what we see in the social media. This before and after is totally misleading pictures. And you see this one, and like another also video, so another this one, like just only last week, it was with me here in Norway. And you see, this is extremely here, really, and I paid almost $80,000 for this. We give the wrong impression to our patient about this. Most of our patients don't want this. And what about this? Is this attractive in all cultures? The answer is no, definitely. So microwave, most of our cases, this again, some pictures, totally closed system we see here. And this we can also reverse the fat back, you see how much fat you put, etc. So this is some of the advantage here. These are the communications, they are really minor. And like some examples here, per operative here, see the canister, and before and after, before and after, before and after, before and after. These are really what our patient 95% really wish, not really the big, unharmonious back. So see our study here, these are like the ages, almost 30 years, not really very young. These are the indications, why they are wanting to do it also before and after, before and after, before and after, again, before and after. So choose with the patient all this, I mean, operation time, and also the grafted amount, as we also showed before. See here, some anatomical, like structures here, the sagittal section, this is, I stopped doing from this way, do it from above. This is very easy to tilt to the deep structure, this is when we have the, like the complication, and very important to avoid. Now, how to reduce mortality and morbidity? See a technique-related and a seizure-related duration, etc. So we need to work on it. So back to the question, do only subcontinuously. And know about the location of greater sciatic foramen, four millimeter or more, all these factors are really important. And please stop when the fan is working out of the injection sites. It's not a competition here. I mean, brawn is good. Jackknife is also good, but a long, if you take a long time, it will have like also deep venous thrombosis. Lateral is good. I mean, shall we forbid it? No, the answer is no, we should do it the good way with safety of our patient. And not only to be, oh, I didn't do it in the muscle, you need to be sure that you are not really injecting the muscle. This is very important. And we know, I mean, this report not accurate, because they say, oh, we didn't inject the muscular, but the specimen show that it is intramuscular. So we need to be very careful. It's about preoperative assessment, perioperative technique, and also postoperative. These are 20, my 20 recommendations. Please have a photo. This is my gift for you. If you can implement one or two or three or 10 or 20 of them, then we are in a good way to prevent or to reduce the mortality of this procedure. And it will be really my big pleasure. So gluteal augmentation, it's still augmenting and this is good, because this means that it's a good indication of it. High rate of mortality reported, though now, luckily, it's going a little bit down. Mortality related, we know that to muscular and submuscular, we need all to work on it. And this is also good news, as I mentioned, and some also reduction in the death in these cases. Lisa, I will invite you to the fourth Norwegian-American meeting and ICEF symposium in Norway in October. And this is Norway. Thank you very much. Thank you, Amin. Excellent lecture. And as always, I enjoyed your lecture very much. And so I have a question to ask you about is, what do you think we should change the public kind of concept about the gluteal augmentation with fat? Is this something we should call a gluteal contouring somehow? That's kind of a, I think that, you know, by discussing with Dr. Louis Toledo, etc. This is actually their original kind of idea. They think it's more should be like a called a gluteal contouring. The other thing is like about intramuscular injection. Okay, intramuscular. Should we do it? Or should I just completely avoid it? Because as you know, you put a fat into the muscle, you have better survival compared to put to the subcutaneous tissue. Should we do it? Yeah, go ahead. Yeah. Thank you. Very interesting questions. I will start with the first one. As a matter of fact, you are absolutely right. It's really not really but augmentation anymore. It's like I call it figure forming, like 360 grade figure forming. And this is what we like really need to convey to our patient that this is this what's about it's not about making a balloon. Like before, like when the implant was really a common procedure there. So you see no harmony between like the back and in front, etc. So I would call it 360 degree figure forming. I mean, it's not only the back, you have the thigh, you have also the abdomen. So that's definitely and this is one of the reason as a matter of fact, at least in our part of the world. And I have some some patient also from outside Norway from Nordic countries, and they really 95% they are aiming for this and not aiming to have like balloon, like buttocks. And this is what like what is killing us this what is in social media this as I showed before and after like photos that everybody will think that I will have this like a condition condition is like kind of need in our in our really practice. So for this patient, I really say okay, sorry, I cannot do it like this. Because it's, it's like it's like unrealistic. It's like also really at the end, what how much is attractive also, it's really not very attractive, not in all culture anyhow. So we need really to give definitely a new new definition about about this. And then as a plastic surgeon, also, it's very important. We don't want to kill this procedure. Because we know that like say in the 80s, when when it will start with liver suction, everybody will. So we are we have done this before, as a matter of fact, we have done it. Now what is added is like we are putting the fat what we are we are throwing out, we putting it in the gluteal area. So we need really to take care of this, that this will continue also in this safety like bath that way. Absolutely. About the second question, who this is, this is really very important. And this is what one of the big motivation for me really to be engaged in this. The problem is, I not do not say if everybody, every muscular injection will lead to death, I cannot say it. And nobody can say But as I'm saying here, like educate colleagues to discuss, I cannot say after all this evidence, go and do it in the muscle. This is the this is the bottom line. I mean, some colleagues, they still say and argue, okay, I do partially in the muscle. Okay, come on. You can do it yourself. But please don't tell anybody because we know all the specimen with all these five major societies, they find they found really the death is related to muscular and submuscular grafting. This is an evidence. So is all of the grafting in the muscle leading to death? No, of course not. But shall we advise? Shall we? I would not do it. And even not only not do it, you need to be sure that you are not doing it. And this is one of the, I mean, these 20 recommendations I put. So like choosing the incision size, choosing the amount, all of these, the positioning, the mobilization, all these is like a package, you know, we need to deliver to our patient to raise the safety and to take it back, you know, from that people just dying out, you know, from this procedure. Thank you so much, Amir, for your kind of comment. And we're going to move on to our last speaker, Dr. Miguel Bravo from Spain. And Dr. Bravo did the training in Madrid and in the European Board Certified Plastic Surgeon. He had prior practice in Vela, Spain, and he specializes in body contouring and gluteal surgery. Dr. Bravo is going to talk about the gluteal augmentation. Please go ahead. Thank you very much, Dr. Poo. Thank you very much all for being here today. Actually, I'm going to change after what you just said, I'm going to change gluteal augmentation to gluteal contouring. Gluteal contouring 101. Okay. Because you're right, because you're right. I think it is because, you know, in the US, 101 is like the first lesson of subject. And these would be like the basics of gluteal contouring. Thank you very much all for being here today for staying. And thank you, especially for the technical team, technical support for being there. I have no disclosures, so I'm going to move on to our next speaker, Dr. Miguel Bravo from Spain. performed yearly, but it's still far away from breast augmentation, right? So why bother, right? Let's just focus on breast augmentation and forget about the buttocks, right? But what I see when I look at these statistics, it's not just the numbers of the buttock augmentation, either with fat or with implants, it's the liposuction data, right? And why is that? Why I think it's the most important data in this report. It's because we are harvesting the raw material. We are harvesting the fat and just throwing it away. Why don't we use it, right? And I believe that this is not just a trend. This is not just something related to social media and it's going to go away and it's going to fade out. No, I think gluteal surgery is here to stay. And I have some of these reasons compared or with terms of business, right? We have a value proposition, which is very important. The physical attractiveness and the perception of beauty of a waist to hip ratio of 0.7 has been published and has been demonstrated to show more fertility. So it's a fertility display and it shows physical attractiveness. So it's not that female patients didn't request this before because they didn't want to. It's because maybe they weren't aware of these types of procedures, right? Also, as I said before, we have the raw material. We have the liposuction as one of the most frequent procedures. So we just have the fat there. Also the increased scientific knowledge and new technologies, which means a huge investment in research and development is also a key indicator in my opinion, that gluteal surgery is here to stay. Every time that the industry puts a lot of money in these type of new devices or these type of procedures, it means that it follows money, right? And last but not least, the public awareness and easy access to information nowadays with internet, with social media, that means marketing. Even though you are not actively doing anything, it's inbound marketing. So if you are publishing content, you're going to get the patients. And Dr. Kalayegi, Professor Kalayegi mentioned before King-Kardashian, and I think it's quite fun because I always compare the effect of King-Kardashian with the Pamela Anderson effect on the 90s, right? So nowadays, nobody or not a lot of patients are asking for that type of look that Pamela Anderson had in 90s. And it sounded crazy to have that type of volume, but now you saw that in the statistics, more and more women are having breast augmentations and they look at us normal. So with the buttocks, it's more or less the same. With King-Kardashian, that big effect blow everyone's minds and it started like, oh, I didn't know that we can actually do that. And more and more patients come in saying, I don't want the King-Kardashian look, but I want a bigger buttock. So that's interesting. And I think it's needed to have those type of figures sometimes to increase awareness about what we do and start looking for more natural surgery, right? As young plastic surgeons, and not only young, as I said, also more experienced plastic surgeons face certain challenges that I separate into internal and external challenges. Internal would be the lack of exposure during training, not only to the surgery, but to this area. So we are very comfortable with breast surgery, right? Because during training, almost I would say worldwide, we are in charge of the breast reconstruction, right? And we have a lot of cases during our residency of breast reconstruction and we feel comfortable when we finish our training in doing a breast augmentation. But regarding buttocks, unless you are doing sarcoma, reconstruction of that area or anything else, you are not getting so much exposure. And it's very difficult to find places with an academic point of view that are willing to share their knowledge if they are very focused on gluteal augmentation. Also the fear of other people's opinions. We are created to respect other people's opinions. We want to agree with the tribe, right? But when we are not only our tribe, we are open to social media and open to the world on TV or whatever, you are getting exposed to millions of different opinions. And it's very difficult to have a bad review of your work or have a bad opinion about what you do. So that type of feeling of, oh, maybe, I've been training in reconstruction all these years and now if I show that I'm doing buttock surgery, maybe my colleagues might think I'm not going the path of the light, right? But you just need to, don't worry about that, do your best work and that's the important thing. And also another important part of internal challenges that we face is that sometimes there are two types, the one that underestimates and the one that overestimates the risks of this procedure. So there are some john plastic surgeons saying, oh, I did a lot of lipofilling of the breast. I did a lot of fat transfer to the face. So why not doing it in the buttock? Well, the buttock is not the same as the breast and the face and it has a specific technique. And so that's underestimation of this procedure. And also there are other colleagues that might overestimate the risk, that might say, oh, no, I'm not experienced enough. I cannot do it, I think it's too risky, people are dying. I don't want to do it, right? So as with everything you have to move in between, right? And with the external factors that are challenges for us is the banning obviously of BBL or gluteal contouring in certain institutions and even countries. So I remember I was speaking with a colleague in the US and he told me, oh, I would like to go and visit you and see how you do that surgery. But the other day I wanted to do BBL and the hospital told me I cannot do it, that they are not going to allow me doing a BBL on the hospital. So for me, it was shocking, but that's external challenge for sure. And also the trivialization by some peers and other colleagues and media, obviously, and that's sometimes it's part of our own fault when we are using social medias and not so professional manner. And we have to be aware that we are talking and representing all the community of plastic surgeons when we are showing what we do in social media, right? So this is my playbook, the gluteal surgery playbook that I told you about. So we have these four different stages. The first one, the most important preparation before even talking with the patient about this surgery, you have to prepare yourself, know your anatomy, study hard, use the proper tools and obviously instruct your team about what you're going to do. And then when we have all the knowledge and we are deciding to do this surgery, some pre-op considerations, the whole body analysis, when to use just fat transfer or when we might need to add an implant. Also, don't be scared of using implants. And it doesn't need to look artificial or not harmonic, right? Instruct your patient and intraoperatively, obviously safety first, as Prof. Kaleiji said before, and also safety, your own safety, the ergonomics, especially if you are doing this surgery frequently or almost every day, ergonomics plays a huge role intraoperatively, right? And post-op, praise this part, the post-op as it deserves. It's really, really important. You need to learn how to deal with complications that you are going to have just as we all do, right? And obviously self-evaluate. Don't think that, okay, it's all done, I don't need to study more. Just always keep learning, keep self-evaluating yourself. Okay? As I said, know your anatomy, it's like study hard and visit other colleagues and just read all the literature about this topic, but also above all, first of all, know your anatomy, okay? And not only the classic anatomy or the classic point of view of the anatomy, like the Netter book, we all love Netter, we all love Grey's Anatomy, but we have to move forward. And we also nowadays with the technologies that we have and the virtual reality and all the animations that we can get from the internet and from different applications, different softwares, we have to also the dynamic anatomy of the structures, of the muscles, how it's going to affect to the implant, to the implant, if we are using an implant, how it affects to the shape of the patient. A lot of patients thinks that by doing a thousand squats a day, they are going to get that round buttock and that's not the case because of the shape of the buttock, because of the shape of the glutes muscle. So you just need to understand how it's going to move the body and that's going to be helpful for you to understand how some poses might give the look of a more rounded shape, just because they are crossing their legs or showing the hips in a different pose. And that's also very interesting and important. But don't stay there, go farther, go to the artistic point of view. This is really, really important. Don't just look at the image of a patient from an anatomy book, just go for the artistic point of view, try to learn how to draw the basic figure, the feminine figure, the human figure. If you are able to sculpt, even though you're not a sculptor, try to sculpt with some clay and it's going to help you get that sense of 3D image that you need to have during the operation. The next tool, the next rule is use the proper tools. So, and Professor Kaladji also mentioned this paper. I think it's really interesting and really important. One of the masterpieces about body contouring and parallel augmentation, the expansive vibration lipophilic technique. And it's not that you can not do it with syringes as Professor Kaladji demonstrated. It's that in my opinion and in different papers has been shown to be better to use this technique because it helps expand the tissue internally. So it's like the evolution of the safe lipo by Simon Wall and Michael Lee. And it makes sense. It's not only that it makes sense, it's published and you feel it when you're doing it. And since the first day that you use this technique, in my opinion, you don't want to go back to syringes. Also, if you have to use syringes and you have to do the Culliman technique and you're planning to infiltrate a thousand CCs of fat on each buttock, the nurse is going to kill you, first of all, then you're going to kill yourself because you don't want to do that ever again. So this makes things more comfortable and make things easier in my experience and in my opinion. Then also instruct your team. Provide written detailed protocols to everyone. Probably depending on where you're working, they might not ever see a body contouring procedure like this or fat transfer to buttocks. So make sure that you spend enough time with your team, provide written detailed protocols so they can study them and do not just settle with the OR team. Do it with all the staff, everyone that can be in touch with the patient or that they are playing a role in your team, they need to know about this procedure and how it's done, the complications that might be after surgery and all of that. And also do some real procedures if you can with your team so they are aware of the signs and what to do so that will make things move faster in case needed. Look at the body as a whole. So avoid looking at the buttocks as a separated area of the body and try to, when you're photographing the patient, take the pictures of the whole body or as much as you can. And this is the same with the breast, this is the same with the tummy. Don't look at it as separated parts. They are all one. So what you do in the breast is going to affect the waistline. And what you do in the tummy is going to affect also to the waistline. And if you are not doing liposuction, it might look like good for the tummy, but overall not enough or not what the patient is looking for. Also in combined procedures, when the patient is coming for a tummy tuck or breast surgery, it's an easy way to start doing fat grafting to the buttocks because the patient's priority is not the buttock. So you can start doing these cases and getting more and more experience by adding some fat to the hip dips with the tummy tuck. And that's going to help you gain confidence with this procedure. So when we decide to use implants or BBL or just fat transfer to the buttocks, and this is very, very important position for the patient selection, you have to understand and respect the patient priorities. So a term that I hate, even though I tend to use it is natural, like natural results. Natural is a highly subjective terminology. So what's natural for a 20-year-old Colombian girl is not natural for a 50-year-old girl from Norway, right? So try to understand what are the priorities of the patient, what are the look that they are looking for, and try to be on the same page. I always ask them the same question, and I think this might be helpful for you when approaching a patient on a BBL consultation. We are going, and I always tell this, we are going to improve both, but if you would have to choose, what would you like to improve more? The front shape, like in the front and from behind, that type of hip to waist, waist to hip ratio, or the view from the lateral to get that projection, but on the lateral view. And there's no correct answer, and all patients have different wishes, right? If the patient wants that lateral projection, just with that transfer, especially now that we are doing it always on the circutaneous space, we cannot get that type of projection that the patient is looking for. So in those cases, if the patient understand what it takes to have a buttock implant, then we might indicate and select the patient for a buttock augmentation. And also, we never use implants alone. We always combine it with some fat transfer, either to the hip dips, or either to the contour of the, where the implant is placed to make it soften, right? Unless the patient is like super thin, that if the patient doesn't have one cc of fat, then we might think about using just implants. 99% of the cases, we combine fat and implants. Instructor patient, I cannot highlight this enough. Spend enough time informing the patient. It's never enough, because nowadays they have a lot of information from social media, from internet, and it might not be as good as you want it to be. So make sure that they understand your protocols, that they understand the post-op recovery and what to expect. Pay attention to red flags in these patients for body dysmorphic disorder, obviously, as we all do in all our procedures, but mainly in these cases, we have to make sure that they don't have these type of problems. And as I said before, finish the consultation with that feeling of being on the same page with your patient, that you really understood what they are looking for, and then they understood what you can provide, right? And don't finish the consultation unless you are 100% sure of this part. Safety first, as Claudia mentioned before, there are some papers talking about this. I highly recommend you to look at them. There's some very impressive pictures of the fat transfer into the muscle and to the cava vein, and it's pretty impressive. So stay subcutaneous, stay safe, that's the mantra repeated constantly, and it will be okay. Also, you can use ultrasound guided fat transfer just to make sure in your first cases that you are placing the fat on the subcutaneous layer. Once you start gaining confidence and when you start getting more experience, you're going to feel that you are not going to need it unless the patient is really, really thin in that area, and there's a lot of atrophy of the muscle that can distort the anatomy. And do not forget agronomics. It's a very physically demanding surgery. You have to train and stretch daily, even on vacation as some of us are, because otherwise you are going to think, I'm not going to do this again because it's not worth it. It's like an aerobic fitness class. And try to increase proprioception, to increase the self-awareness of your body position in the OR. If you feel that you are not really aware of this, try to record yourself. That's a very good trick. Record yourself like just in golf, so you can see your swing. You can see yourself performing the surgery and notice some positions that you might not have been aware of before. Post-op is as important as surgery itself. So regarding the post-op, there are different protocols and there's no solid scientific data saying like two lymphatic draining massages are better than one or anything like that. But try to create your own protocol for these patients and adapt it to the settings where you're working and to your patients. In our case, we have a physiotherapist in our center that provide these massages. And we always instruct our patients to get more massages back at their home countries if they are traveling from other countries. And if they are able to do massage themselves or if in the place where they are going to get the massages, they have other devices like radio frequency, like external ultrasound or whatever, those might be helpful as well. But at least the massage, in my opinion, it's really, really important. It really makes a difference. And also compression therapy. That's also really, really important. We divide it in two stages. The first stage is like a belt and very lightly compressing pant. And then the second stage, the classic Colombian faja, the Colombian garment for the whole body. They're specially designed for BBL, obviously with a thinner layer of tissue in the area of the bottom. Regarding the complications, keep this mantra as well. Aim for perfection, avoid, identify, manage complications. Okay. Professor Kalaj, you also mentioned about this paper. I also recommend you to go through it from Sami Sino from when he was at NYU. And it's a great paper in my opinion, because it goes through all the complications that were published before. It's obviously underrepresented because the ones that are reporting these complications are usually like the more academic surgeons and the more trustworthy ones. So there's much more probably complications that we are not aware of, like in black market and all that. But when we are facing a complication, first of all, we have to avoid them, obviously, know what are the most common complications so we are able to avoid them, identify the complication when it's happening, have a proper diagnosis of that complication, and then manage it, face it. I think that's the most important recommendation or advice that I can give a colleague, a young plastic surgeon or resident. The patients usually, they get angry at you, not because of the complication itself, but because they get angry if you are not facing it, if you are just putting excuses and not really saying, okay, you had this complication, we are going to manage it, we are going to do whatever it's in our hands to fix it. I always tell the same thing as well, and I think it's a good thing to say. I cannot guarantee you that there are not going to be complications because that's something that we cannot guarantee. But what I can guarantee is that we are going to be here for you and to be there in case there's any complications. And make sure that you mean that because in case it happens, you have to mean that and you have to be there, okay? Regarding the summary of implant complications, it's higher than the fat grafting complications on the literature, being wound adhesions the most common complication in a buttock implant. And talking about the fat grafting complications, seroma is the most frequent one from donor side. And it's quite funny that the second one is under correction. So it's something important to tell our patients that certain part of that fat is going to get reabsorbed. So they might need to come back for a second round to get the result that they want. So these percentage of patients, they felt that the problem that they wanted to solve, it was not corrected. So I think it's interesting that the second most common complication of fat grafting, it's under correction. So try to put as much fat as you can, right? And then last, do not settle. Keep track of your patients. This is really, really important. Take all the pictures that you need, take all the photographs. Even though the nurses rush you or whatever, when you're a young plastic surgeon, make sure that you take all the pictures that you need for your records because you are going to want them in the future. I can tell you that. Also self-evaluate, be your worst critic. Otherwise, everyone is going to be your critic. So make sure that you are the worst one. And obviously stay humble. Honor your mentors. This is really, really important. And the best way of honor your mentors, in my opinion, is to be a good mentor for your colleagues and for other younger colleagues. And obviously, respect your peers. Plastic surgery is huge. It's widely, there's a wide variety of procedures. And I think we all deserve respect. And everything has a beautiful point and is worth respecting it. And obviously, share your knowledge. After you're getting some experience, please share it. We are looking forward to it. And last but not least, have fun. Otherwise, there's no meaning in doing anything, right? You are always welcome to Marbella. You see, we have nice views. You are always welcome there. Thank you very much. These are my details. So if you have any questions, feel free to touch base with me, okay? Thanks. Hi, thank you very much, Dr. Bravo and excellent lecture. There's a question from audience that asks you about where you kind of put your entrance side for infiltration. Yeah. So in my cases, I don't use ports. I think ports are useful if you are using energy-based devices like a phaser that can really burn the skin in the access point. In my case, I don't use phaser. I just use power assisted liposuction. And we don't use those ports. For the access to infiltrate the fat into the buttocks, I use the infraglutinal fold to access. And in the presacral area, so two above the buttocks, more or less, two below the buttocks. And with those ports, you are able to get access to all the different areas that you want to feel, especially to the hips area when they are in prone position, you can get a great access there. Okay, so we have- That's a great question. I see this. Yes. So we have a few minutes. Yes, so sad. We have a few minutes. We're going to have a general questions. I'm going to ask to each of you. And so my first question is asked for Dr. Hermick. And in terms of breast augmentation, and the experts like yourself, what do you think about it? What's new? If you can use a minute to say, what's new in breast augmentation with the implant I'm talking about? Well, I mean, I'm a young plastic surgeon and for me, everything is, I mean, I'm trying as much as I can. I've been trained with nano smooth textured implants, which I found it to be great, very easy to insert, very pleasant immediate results. But after several years, the results came back not as perfect as we initially thought. So basically right now I'm looking at the polyurethane implants, which I think they're fantastic, but my experience is too young to tell everybody that they're great. But there are people who have great experience with them. They have great results with them. And in terms of that ALCL, which has been related to polyurethane covering, well, that's not, people should read the literature more because the majority of the ALCL scenarios weren't exactly related to polyurethane coating. So for me, new in breast augmentation right now is this technique, which allows you to play with the parenchyma better than the dual plane technique, but not in all breast augmentation. In situations where you hesitate between doing the tiny PEXI and putting an implant in, or just trying to manipulate the parenchyma, do an internal lifting, put an extra projection or extra projective or projective implant to get a good shape without adding external scars. So this, for me right now, it's new. There's one more question from audience about your technique, Dr. Hermic. And can your technique completely eliminate emanation deformity? Well, I think no technique can do something 100%, but in our experience, the animation deformity is minimal, where non-existent, but I'm not going to say non-existent, but it's less. Good. All right. So a few more general questions about the gluteal augmentation of the fat. And this is something that I'm actually still thinking it may be debatable. Should we use ultrasound-guided injection? And if we have ultrasound, we might be able to put it into the muscle, right? Because it's much more safer. Should we do it? And because this is something that, in my opinion, if you put the fat into the muscle, the survival rate overall is better than actually putting the fat, such as in a tissue. Should we use ultrasound? Is this something like we should change our practice in the future? Go ahead, Dr. Bravo and Amit. Go ahead. Yeah, Miguel, please just go ahead. Yeah, so we've been using ultrasound and there's a very interesting paper, Conda Green talking about the ultrasound in PadGraft and in Badox. I think it's very useful and I think it really makes a difference. And not only in Badox PadGrafting, but I think nowadays with the new handheld ultrasound devices, it's changing amazing. I mean, it's great. When you get one of those, and those are not very expensive. There are different types and there are even wireless ultrasounds that are most easy to use in the OR. Although there are some models that have some lack because of the wireless. So it's a little bit tricky, but there are definitely, if you are able to use an ultrasound, use it. I think it's going to help a lot. And because most of the surgeons might say, oh, I inject subcutaneous or I see a lot of, well, not a lot, but some patients coming for buttock implants. And when you start dissecting the muscle, they already had a BBL somewhere else and you see the fat injected into the muscle. And when you tell them, they say, oh, they told me it was fully subcutaneous and all of that. Unless you are certainly sure with the ultrasound, you cannot tell 100% sure that you are in the subcutaneous layer. Neel, what do you say? Should we use ultrasound? Very good question. I mean, I agree with Miguel. And I would say not only if you are able to use it, I mean, it's the bottom line here, if you want extra safety, like measure. So means if you are say beginner and you really are not sure about like the injection plane, et cetera. So definitely I would advise you because it will not harm you anything. Maybe it will take longer time in the beginning and these are not very expensive and it will really give you encouragement and even will like save over, listen, I'm really sure 100% I didn't do it now. So this is, I think definitely. But again, the bottom line is always the feeling of the tip of the non-dominant hand. And it depends even if you use the machine, the AVL and like all our food, I also use it also, not only the Serango, only Miguel I use both of them. So, but it's really a good point like to increase our safety, especially now because of this death. And now the good news now, the death rate are a little bit going down. So we need really to continue this trend. And this is one of the safety things that can contribute to this. My second question is regarding the volume and how much you can put into each product. So a year ago, there's kind of a recommendation stuff from ASPS and they said it's like a 500 CC for each side. 500 CC for like every side of Caucasian women, like you would have a wider kind of a hip. It doesn't mean very much. It's like, what do you think? Should we push a little bit for the more, like for the 800 CC, 1200 something or should we follow like a society recommendation, 500 CC for each side? This is, if I might like start with this, very good question, Lee, because this is first, I mean, person related, even, I mean, during the same say race, say Caucasian or Asian, you have also a lot of differences. So I need to see to this two angles. Number one is what kind of fat are we grafting? I mean, and I have to say also some methods, like even some of this like AVL or APUD method, the fat is not really a hundred percent like pure fat. So it's like mixed more, say in percentage. And this is not negative or positive. It's not, it's only a fact. Then if you say centrifugate or decant the fat. So we need to know. So you say sometimes you are putting like 1,500, but as a matter of fact is half of it is liquid. So this is like kind of misleading. I mean, when we need to say about like the 500, I mean, my average is 400, but this is really pure fat after decanting. So this is, and when I use also myself, this is my experience, I use the machine. It's no way is the same. I, the fat is less really amount or the rate in the, inside this, like the injection amount. So this number one, number two, it's, it's really, I mean, we cannot say that is an amount. I mean, as I show in my questionnaire for our younger colleagues, I mean, when the fat is squirting out, so you just, you need to stop. It's no way, everything, you know, if you have elevator, which can accommodate like 10%, if you put 15, the 15 will die, not only the last five, you know? So this is the question. This is very important. So you have this, of course, perioperative expansion. Also I show, as I showed in my, like one of my videos, also it will create more space for the fat. You do also the massaging at the end. Also these also factors, it can also like increase the amount when you are putting, but don't force on it. And under correction, rather under correction in gluteal area than over correction. Then, I mean, the fat necrosis will be really evident. Yeah. Miguel, what do you think about the volume? Well, I, I think Dr. Koaji made a great point talking about the differences between the fat that is centrifuge and that it's like pure fat with the other technique. I think in, I don't remember the last case where I only crafted 500 cc on each bottle. I can't tell you. I think the mean in my cases, it's like 800, 900 per bottle, something like that. But you have to keep in mind that in these cases, using this technique, there's a lot of fat reabsorption. So in my cases, I prefer to oversize, to over correct, because I know certain part of that fat is going to get reabsorbed. And that's an advantage in my opinion. And I think that creating this type of discussion is always very attractive in the webinars. So I'm more dependent of the EVL technique. And I think Koaji is more dependent on the syringes and the centrifuge. But in my opinion, with the EVL, we are able to create more space. And with the syringes, if we are putting more volume, we are risking, especially we are placing it in the subcutaneous layer, we are risking a higher rate of fat necrosis that we are seeing in some cases. Some colleagues contacts saying, hey, I have this problem. And when you start talking with them, you notice that this is what happened, that with the syringes going, and being super afraid because they don't want obviously to go into the muscle, they are going so superficial with the syringes, putting such amount of volume that cysts form and the fat necrosis is there. So, and those are difficult cases to treat because those cysts, if they get infected or they get outside, they create a scar and it's a headache. Yeah. I mean, the last question that's specific to you is one audience asked, do you use lymphatic drainage in the post-op gluteal area for your patient? Not really. I mean, there is so far no need really to do it. And I mean, my limit for say liposuction is under three liters, like in any case. And for the gluteal area, as I like also make the decanting, good decanting, et cetera. So there's no need to, no indication for it. The only thing I just want to reply to Miguel is, I mean, if you are grafting this, I mean, you have the cannula, so really it doesn't matter if it's like, say a syringe or if it's machine, both of them are cannula. So you can still graft also very superficial if you do the machine. I use the machine, as I told you, the risk with the machine, if you go very aggressively, you are cutting everything, the septa, between the skin and the muscle, and there's no way on earth that the fat will survive. We have seen, and I have seen myself, many examples like putting 1500, 1200 in F and everything almost disappear after. So we need to be careful about like how much we put, and if you have also more liquid, of course the resorption will be also, as you mentioned yourself, also will be even more. But then I also have been also aware about, I'm conveyed from a colleague personally, that skin necrosis also has happened as complication when you put like 1500 or 1600 in each buttock. That's also one of the other complication. But as you said, also, it's really, these things not published like all this, we have dark numbers, dark complication there. So to me, I offer all my patients to redo it again, during one year for free. It's like guarantee, one year guarantee. I put it in the price in the beginning, and they are very happy. They come back to me, they don't go to other surgeon, and then they will do it. And often the second time is very, very limited. I have among certain area, et cetera. So again, this is nice discussion, only this is also my experience to discuss. Yeah. Yeah, I think that the syringes and the cannulas, sorry, the syringes and the cannulas are the same, the cannula itself, but the vibration is what changes. And with this device that has that power assisted liposuction on it, I think it really creates and helps expanding the tissue. And something that I also learned during this first years the differences in the skin quality, that's really determined. So there are patients that are so thick, that it's so difficult to expand that skin and put the fat on it, that you cannot even put 500 CCs on each side without the fat is creating through the holes. So a lot of patients that they just get big. Because just to reply, I will repeat it again, because I use always peripartic expansion exactly as you do with the same vibration cannula, but before putting the fat, I put it like before, I make peripartic expansion without suction. So it's exactly the same process before I graft. You see what I mean? So we are doing exactly the same thing. You are doing it when you are putting the fat, but I'm doing it before grafting the fat. So this I show in one of my videos. So we are doing more or less the same, like you do it exactly the same with the fat, I do it before grafting the fat. And it's not more time consuming? Like why don't do it at the same time? Or what do you think? I mean, because while I'm waiting for the decanting process, like do it also, I just, and in my view, it's much better to do it before than do it simultaneously, because then the tissue has time also to, how to say it, a little bit like expand, if we call it expansion, huh? So, and I do it also on the breast and really with great results, especially in a thin patient, as you said, huh? All right. So yeah, we're kind of at the end of this excellent kind of ASPS Global webinar series. And thank you so much for all the global partners and each one represent your country very well. And we had excellent lectures and also discussion. And I hope I'll see you guys in person and in near future. And welcome to Atlanta for ASPS meeting. And thank you very much on behalf of ASPS. Thank you very much. All right. Thank you and be safe all together. Bye bye. See you soon. Bye bye. Bye bye. Thank you, Leah. Bye.

breast augmentation

gluteal augmentation

dual-plane technique

multiplane approach

gluteal fat grafting

ultrasound-guided grafting

patient education

body contouring

complication prevention

anatomical approaches

vibration lipofilling

fat transfer

surgical outcomes

ASPS Global Partner Webinar

multiplane technique

tissue-based planning

intramuscular fat injection

subcutaneous fat grafting

post-operative care

expansive vibration lipofilling

ultrasound guidance

aesthetic surgery