Welcome, everybody. We are going to wait a little bit, just a few minutes to have an opportunity for everybody else who's interested to check in as we're opening up the webinar. So we'll just wait a couple minutes. Okay, so in the interest of time, maybe we'll get started because we have a really exciting set of panelists that are going to speak today. This is the ASPS Global Partners webinar series, and tonight we have the distinct pleasure of introducing our Latin American colleagues. And the topic for today is going to be really quite broad, which is amazing and speaks to the diverse talent and the breadth of experience in Latin America. So we'll be exploring the spectrum of plastic surgery in Latin America. It will be innovations and experience in reconstruction and aesthetics. Next slide, please. Just a couple of quick housekeeping rules. We do want this to be a very interactive webinar, so please feel free to submit any questions you have through the question and answer feature at the bottom of the screen. What we'll do, because of the diversity of the topics that we'll be talking about, we'll have each of the speakers present and answer questions after each of their presentations. And again, everyone is just to be aware, we are recording this webinar, so it will be available to ASPS members in the future. Next slide, please. So again, it is my honor to be a part of this wonderful webinar series, and we really do have a very elite group of panelists that we'll be talking about a lot of different topics, which really, again, reflects the expertise in Latin America. One of our first speakers, Dr. Linda Rincon, she is representing the Venezuelan Society of Plastic Surgery, of which she was a previous president of that society. She does a breadth of plastic surgery, but is the Director of Breast Surgery for the Bureau of Latin America Federation, and she also holds a professorship title at the Universidad Central de Venezuela. Next, we also have Dr. Marin Colombo, who is representing the wonderful, beautiful country of Argentina. He is the current president of the Argentinian Plastic Surgery Society, and again, has had an extensive experience, both in reconstruction, as well as in aesthetic surgery. He trained in the United Kingdom, and again, works in the, both in breast reconstruction, as well as aesthetics, as well as microsurgery. And then our final speaker, last but not least, Dr. Hector Duran, who is representing Mexico, and again, he is a plastic surgeon with a diverse skillset, who will be talking about his experience with aesthetics. He is a member of multiple societies, obviously the Mexican Society, but also he is an international member of the ASPS, of ASAPS, and again, we are honored to have such a wonderful, elite, kind of specialized group leading the way in Latin America. So, without further ado, I present Dr. Linda Rincon. Okay. Can you see my screen? Yes. Okay. So thanks, American Society of Plastic Surgeons Global Partners, to invite us to discuss these interesting features that we are going to share today with everyone. Capsular contracture versus muscular contracture. First, we want to make some definitions about which is the foreign body reaction. Every time a foreign body gets into the human body, it will appear some kind of reaction because of the foreign body itself or because some bacterial relations or with local cellular immune response. But it's very interesting to know that there are five different phases who appears in the foreign body reaction. The first one lasts for hours. The second, three weeks. The third, six months. The fourth, until 12 months. And the fifth will last more than 12 months. But it's not necessary to come in a row. Maybe they can go to the third phase depending on the stimulus or reason or any reason, particular reason. And in some cases, it will go to the last phase, number five. When we have a number five phase with a fibrous capsule formation, that is the problem that we can manage in our surgeries because they will not be reversed. So we will have to pay attention to that. Which is our foreign body? Our foreign body would be our implants. Many type of implants, devices, and the way we use the implants into the body in the different pockets. Subglandular, subfacial, biplanar, or subpectral. We want to talk with the subglandular and subpectral who are the most common here in Latin America. If we have a subglandular pocket with a smooth surface, we can have a fibrotic reaction capsule between 13 and 20%. So when we have subglandular pocket, we have three layers covering the implants, skin, gland, and subcutaneous tissue. In that case, we can talk about Baker's scale. Baker's scale would go from one grade to fourth grade. And it will match with the phase three or phase four and five, depending on the grade of clinical appearance of firmness. And in that case, we have to do a lot of strategies to solve the problem. We can use ultrasound, leukotriene inhibitors, vitamin E, closed capsulotomy, open capsulotomy, change the implants, or change the pocket. The usual leukotrienes are very active in chronic inflammation phases. But what happens when we have a submuscular pocket? We have another layer covering the implants. And with that, we can decrease capsular contracture down to 3% more or less. And here, how do we be sure if it is capsular or muscle thickening? We don't have the certainly answer for that question. So here, clinically, it's very difficult to determine which is the problem inside the breast. If it is the capsule, or is it a muscle problem? If the patient is arthritic, maybe we can suppose that it has a mechanical distortion of the breast. But we are not very sure if inside there is a capsule. So we decided to make a research and study the implication of personal history in the development of muscle contracture or periprosthetic capsule in breast surgery associated with implants. And in that period, we choose 66 patients who went for breast surgery and choose 21 who had previous breast surgeries with implants. We took a little piece of the capsule to send it to osteopathological studies. We fill up a file with a lot of personal history of immunological disorders, problems with scars, previous traumatic around the post-op period, muscle issues, hemorrhagic problems. We fill up a file with a lot of personal history of immunological disorders, problems with scars, previous traumatic around the post-op period, muscle issues, hematoma, seroma, or infection associated with the previous surgeries. And those are the variables that we want to study. And we describe the macroscopic features of the capsule around each patient, which is the color, the thickness, the surface, and which is the muscle, which will be soft or thick or those things. So we determined that we have 34 implants with a small surface and eight with textured implants. So 34 were sub-pectoral and others were sub-facial and retrogranular. And we determined two histological patterns, one chronic and stable and one chronic active. That will match with chronic stable with a phase three of inflammation and chronic active with a grade four and five. But this is interesting because some of the cases that we are facing in our consultancy, maybe we can relax between these inflammation issues. So in this phase, we can reverse, but in this other, we cannot reverse the inflammation because it is a fibrotic capsule with chronic inflammation. So this is the results mainly to explain to you that they are two different histological patterns and we are not sure clinically, which is the one we are facing in our office. So firmness was related very, very close to the muscle contracture. And the chronic active pattern, which the capsular contracture not always appears with firmness and the chronic active pattern, the capsule contractures appears to be related with sub-glandular pocket, implants rupture, implants leaking, macrotextured implants, PAP implants, immunological stories and mechanical trauma. So this is the slide most important for everyone because here we determine in our results, which is the main important clinic association to the firmness. So early firmness is more associated with muscle issues than capsular contracture. Of course, when we are using sub-muscular pocket and real capsular contracture is associated with sub-glandular pockets, implant ruptures, implant leakings, and the things that I have discussed. So when we are treating a patient with firmness in the post-op period between one month and one year, we have to think about muscular issue. And we have to make an accurate diagnosis as soon as we can, because we have to treat the muscle with bodily toxin, physical methods, kinesotaping, muscle relaxing drugs, leucotine inhibitors in most cases. And this is the important thing, the shock waves therapy, that is what I want to show to you. Because shock waves is an electrophysiological physiotherapy that helps the muscle to relax and helps a lot to change the behavior of the dynamic of the muscle. So early firmness associated with other things, with trauma, hematoma, infection, or radiation, we have to think in an inflammation response and not in the muscle. So we have to go with leucotine inhibitors or surgery if that is necessary. And if we have a patient with firmness more than one year post-op, we have to think in another cause, and we have to go to the OR. And we have to make the revision, we have to improve the muscular technique, if that is, or change the pocket. We have to change the implant surface or implant type and shock waves in the post-op. That's the way we do it. But some patients does not attend the consultation on time. They have the firmness and they consult late. So the problem may advance and we could see a double cost of firmness associated. But how can we know if it's a capsular inflammation problem or a muscular contracture? We have to go to OR and do the revision of all the things we know. So if we see capsular contracture and muscle sickness during surgery, we cannot be sure which condition came first. So we made some changes in the submuscular pocket. We kept a window open and we cut the costal fascicles of the muscle to maintain the muscle relaxant. And since actually submuscular pocket is very common, we have to manage firmness well to avoid further complications. We have to make the diagnosis as soon as we can. Use an ultrasound because it will help a lot to determine which is the muscle thickness or it's an inflammation around the implant. Because the treatment will change. Early firmness helps the muscle. Late firmness, we could think in other things and go to the OR. So finally, we need to think in a new scale of firmness, not in the Baker scale, when implants are in submuscular pocket. To do an accurate diagnosis and decide treatment in time. We need to adapt concepts to our reality. Right concepts can help us solve problems in time. Thank you very much. Q&A. Thank you so much. That was a wonderful talk with a lot of information in a very short timeframe. I do not see any questions in the Q&A. So maybe I'll just open up some questions of my own. And then everyone in the audience, please feel free to send some questions to the Q&A function. Dr. Ricone, when you give the Botox to the muscle, how much Botox are you administering? How many units are you injecting? And where do you target the muscle? Are you trying to inject sort of diffusely in the muscle? Or do you focus maybe towards the attachment and the humerus? And how do you avoid injuring the implant? Yeah, we do that with ultrasound help. Okay. And with a very short needle. And from the region of the muscle here near the shoulder, we can be sure that we are having the muscle fibers. And we start from the region of the muscle through the middle of the breast. Like 25 points of 0.2 botox. Okay. And we have to repeat that twice a week for the first week. And then we can do, depending on the response, we can do it two more times one week after that. And it is very interesting that we have a good response. But prior to that, we use the shock waves. Because shock waves are less invasive. And the physiotherapy has a lot of experience now doing that. And it will help very good. Wonderful. We have a question in the chat. The botox injections, how many sessions do you do for the muscular contracture? Is it once a week, but a total of three sessions? Or can you do more than that? Yes, the first week will be twice a week, like Monday and Friday. And then we wait a week just to know how the treatment, the first initial treatment responds. And then we repeat one session a week. And just two more. I mean, no more than four. We don't need more than four. So first, we try with the shock waves and help at the same time, if the first two sessions of shock waves doesn't work any longer, we associated the botulinum toxin. Fantastic. And then maybe just one last question before we move on. When you are using or selecting your implants for reconstruction, and you've gone back for capsular contractures, I know the concern for the ALCL is a big issue, but it seems to be very rare in Latin America. Have you had any experience with identifying ALCL? And maybe is there an association of indications with capsular contracture and the ALCL? Okay. This is a very interesting question because here in Venezuela, we have been using a smooth surface from 25, 30 years. So we don't really have that issue in our practice. The problem with the liquid around the implant. So here they are just two cases of ALCL and they are related with the texture. Both cases had macro-textures implants. So the capsular contracture are associated with muscle pocket, submuscular pocket. It is very, it's very real in our experience because we detect as soon as we can, the muscle issue and we treat it. So we don't let them go further. Wonderful. Thank you so much Dr. Rincon again for such a wonderful presentation, and sharing your experience. Next, we will have Dr. Maran Colombo present on his experience. Dr. Colombo. Hi there, Edward. I'm fine to give my presentation, but apparently it was Dr. Duran who was going to give his presentation. Go ahead, brother. Go ahead. Don't worry. Okay. So... Sorry, I apologize. I'm going to share my screen. Okay. Changing subjects now, going from... Well, still impressed. Again, same as Linda Rincon, I'm thanking the ASPS Global Partners for this invitation, for letting us presenting experience in South America, and sharing with you what's part of our experience. I think Latin America is an area of the world that plastic surgery is going on and going on, and there are lots of plastic surgeons working with some difficulties, but trying to innovate in plastic surgery. So what I'm going to try now is give you my experience. I'm especially interested in breast reconstruction. And this is my presentation on risk-reducing mastectomy, evolution to one-step reconstruction, what has been our practice with this, and I'm going to share it with you. I'm a speaker for Polytech, and everything started with William Halstead in 1907. He introduces what was a new idea at that moment, he had to be in 1907, and seeing that breast cancer can be treated by surgery, that was a completely innovation for the time. He presented this in Annals of Plastic Surgery, and to mention, there's a phrase there in his publication that mentions, and started mentioning, giving entity to plastic surgery, beware of the man with a plastic operation, he was probably concerned about that reconstruction can hide the evolution of breast cancer. But here he is, mentioning plastic surgery in breast reconstruction. And from there, mastectomy techniques evolved in 1970, Madden with a radical mastectomy, huge step in 1980, Veronesi with a breast conservative surgery and radiotherapy, Siebenkroll, in what we think is a huge advance for reconstructive and reconstructive surgery outcomes, with a skin sparing mastectomy, and what is for most of us that do breast reconstruction, from 2002, nipple sparing mastectomy. And the man with a plastic operation also evolved, a huge evolution in what was first this very, the first silicone implants, to modern and new type of breast implants in shapes and surfaces, expanders with one, two valves, and what is now probably for me the gold standard in mainly unilateral breast reconstruction, that is the autologous TF flaps. But we not only are treating breast cancer, but what we are doing now, trying to avoid and prevent breast cancer with surgery. Here is where risk reducing mastectomy comes. First with oncological patients, in contralateral risk reducing mastectomy, and then in high risk patients, what is the bilateral RRM. This kind of practice, statistics of the American Society in 2017, show that there is a steady increase in this kind of practice. And that's why in 2016, the American Society of Breast Surgeons came with this consensus, trying to see and to put some order in what was going on with this kind of practice. First of all, trying to see if this was something that has, needs to be done. And they came with that breast cancer in average with women, without any other previous history, is probably not very high, the possibility of having a contralateral cancer, one to five in 10 years, but completely different if you have genetic markers, or if you have a strong family history. Here, the cumulative lifetime possibilities increase, with markers and with strong family history. So they came with this resume, summary of who will probably benefit of contralateral prophylactic mastectomy, they call it that way. And this will be patients with a definite with genetic markers, positive genetic markers, and patients with significant history, family history, even if they don't have genetic tests. And patients who may benefit from the contralateral prophylactic mastectomy are, who have negative markers, but even with that, a strong family history. And also patients who desire symmetry, and this is where we evolve in breast reconstruction, symmetry after reconstruction, and patients who are extremely anxious about the possibility of having a breast cancer. What is the surgical options for risk-reducing mastectomy? There's no objectively defined single technique for this. There's no randomized trial evidence showing that one technique is better than the other one, and all the data we have is from cohort studies. So what are the important decisions on what kind of procedure we're going to do with these patients? We have to define the type of mastectomy we're going to do. We have to define which is the best incision location, and which one is the best reconstructive procedure. So with these three possibilities, we start with deciding what kind of mastectomy. And we know that nipple-spare mastectomy, as we said before, combines the removal of all at-risk tissue with the best aesthetic outcomes, and preserving all the skin and the nipple areola complex definitely makes a huge difference in this kind of mastectomy. So is this procedure a safe procedure? This paper published in JAMA, a multi-institutional study showed that the prophylactic nipple-spare mastectomy resulted in a significant reduction in breast cancer events in patients with genetic, positive genetic markers. What about the oncologic safety? Are there recurrences with nipple-spare mastectomies? Well, this paper also published in PRS showed that rates of local-regional recurrences are low within nipple-spare mastectomy. And obviously, as one can expect, significantly more often in therapeutic nipple-spare mastectomies. What about cosmetic results? Another paper, PRS, recent paper measuring breast Q, and the authors noted that there is a higher median post-reconstruction scores with nipple-spare mastectomy group compared to any other mastectomy type. So we have to define the ideal kind whenever it's possible of mastectomy, nipple-spare mastectomy for this kind of procedure. Then we have to decide what's the best incision for this. And this meta-analysis paper with 49 studies reviewed, published also in PRS, showed that definitely the most used incisions are inframammary and radial lateral or mid-lateral incisions compared to periurelar or previous scars or endoscopic. Both inframammary and radial, almost the same. And when it comes to seeing what the complication rates are the periurelar incision definitely has the higher incidence with a lower in the inframammary and radial, the same as with a total complication. Periurelar definitely has a higher incidence of complications compared to the inferolateral and inframammary fold. But can we use this, probably the sub-mammary incision that's at the moment the most used incision in all patients? Well, this paper showed that if the distance you have from the mid-clavicular to the inframammary fold is long, the ischemic complications, when the distance is more than 30 centimeters from the mid-clavicular to the inframammary fold, the ischemic complications increases 3.8 times. So deciding the type of incision depending on the type of rest, it's important. Now we have to decide what kind of procedure, reconstructive procedure, that's the third step on this, is again, the same meta-analysis that we presented before shows the evolution in the last years, as from 2013 and coming to recent years, the direct-to-implant procedures are getting more and more common, more popular, compared to two-stage procedure, expander and implant exchange after that. And the total decision always changes depending on definitely the experience of every center. So what is our evolution and how has been our evolution to what we are doing now? This patient shows what we started at the beginning when we're doing this kind of procedures. Every time we could, and it was possible, nipple sparing mastectomy, and initially we started using lateral incision. This kind of incision was an incision we selected because it will give us the possibility of a good access for the breast mastectomy and to the axillary if we're gonna do a sentinel lymph node biopsy. You can see that you have a very good access definitely to do the mastectomy, and from there to the axilla. We, at the beginning, started using, the type of reconstruction was a direct to implant, definitely because you have the skin envelope, completing skin envelope, using anatomical textured implants in a retro-pectoral position. We tried different incisions also, and in this patient with a genetic markers negative, no oncological, she had a strong family history of oncological problems, but she didn't have any cancer at the moment, but difficult examining breasts and extremely anxious. We tried in this patient to do a small mastopexy using a silicone marrel in the superior edge, and as shown, the incidence of complication using this kind of incision increases. This patient was an example of this. Fortunately, she finished everything without any problem, but we, after that patient, we are not using, we don't use the period incision anymore. In this case, a reconstruction with anatomical periuretic implant in a retro-pectoral position. We then started combining, and this patient shows on the oncological side, we still use the mid-lateral incision to have access to the sentinel load, but on the contralateral risk-reducing mastectomy, we started using the inframammary incision that gave a much better cosmetic result. The mid-lateral is an incision that you can see it, the inframammary is a much covered incision. And as from there, we started following Dr. Roy De Vita from Italy who presented, we saw his presentations with pre-pectoral reconstructions and the combination with polyurethane in a pre-pectoral pocket, it started to be for us our next evolution step. From then on, we started combining and we saw that the inframammary incision was a very good incision cosmetically, so we started doing the mastectomy, doing the same submammary incision, and as from there on, combining with a separate axillary incision for the sentinel load biopsy. This was a very important step and you will see afterwards in the results in which we separated pockets from the mastectomy and the axilla, and we reduced the high incisions that we were having of seroma when we combined pockets. And again, using pre-pectoral and pure polyurethane implant in that. I'll show you the sentinel load biopsy with a completely different incision, separating axillary incision for the sentinel load. This is just to show you the mastectomy. We do our own mastectomies, we don't do it with breast surgeons, we do our own mastectomy, gives a completely different result. That's with electrocotheroid, with a bovie separating the muscle from the breast, and the breast from the skin, we try not to use the bovie to avoid thermal injuries for the skin, so what we do is we dissect, as we showed, again, we saw from Roida Vita in Italy, and we dissect the breast with scissors separating the breast from the skin, and even an adequate skin flap at that time. Images to see the pocket, the polyurethane implant, and drains, drains are used for five, six days at least, and both sub-mammary incisions showing the symmetry that you can obtain with this. This is a patient that we just saw, pre- and post-op, pre- and post-op, front, oblique, and lateral view. You cannot see the incisions. Another patient, the same, a right breast cancer, oncological and sentinel node biopsy through a separate axillary incision and sub-mammary incisions for the skin-sparing mastectomy on both sides. Those are polyurethane pre-pectoral implants. And another patient exactly with the same procedure. Older patient, pre-pectoral implant on both sides. Just to show you another patient, she had a nipple-sparing, skin-sparing mastectomy on the right breast because of the proximity of the tumor to a nipple area complex, and a contralateral risk-reducing mastectomy. Reconstructed nipple area on the right side, and on the left side, both with a sub-mammary incision. This is just to show how it moves, how it feels. Polyurethane implants, they're meant to be tougher or more rigid, but at the beginning, they can be, but with time, they move completely naturally. So in our experience with this procedure, as from November 2018 to January 2021, recently, last patients, we operated on 39 patients doing this procedure. Bilateral for high-risk were 16 patients, and oncologic mastectomies with contralateral RRM in 23 patients. Ages went from 27 to 71, with a mean of 48. Usually these kind of patients are younger than breast reconstruction for oncologic reasons. And this is the interesting part, complications. All of the non-oncological breasts, high-risk or contralateral, we didn't have seromas at all. Zero case of seromas on this guy, on these patients. On the other side, on the oncological breast, with sentinel node biopsy, when we use the same incision for the nipples, perimastectomy, and sentinel node biopsies, when the pockets were connected, we saw the seroma incident was quite high. Seven of nine of our patients had a seroma. One of them finished with an extrusion. But when we started using a separate incision, we had zero incidents of seroma. Extrusion we have in two patients, as we mentioned before. One was because of a previous vertical scar cosmetic mastopexy, and this patient, we did a nipple sperm mastectomy. And as from there on, we are quite, we have to be very careful in the thickness of the skin flap that we're leaving. But if they have previous scars, and we decide to do this procedure, we now use, we put the implants in a retropectoral position. And the other extrusion that we had was because of one of the seromas in patients that didn't have a separate axillary incision from sentinel node biopsy. Rippling was not a complaint, and this is something that everyone can ask about rippling. Yes, what we saw was palpable in the upper border of the implant, in the anatomical polyurethane implant, in four patients. And these were more older patients and thin skin, with thin skin. And we also saw in three patients skin redness, that's something that is seen in polyurethane implants, and that results with an intramuscular serine injection. To finish, we don't use ADM or mesh. We know the pros of the ADM. We know the cons, it's more expensive. There are no long-term data on its outcomes as yet, and increasing complications as rates of seroma. We think that polyurethane implants replaces all the ADM benefits. It's a cheaper construction with all the same benefits, less mechanical shift, less capsular contracture, less rippling, less seroma. Conclusion, RRM requires a fully informed discussion of benefits and risks. Each case requires its own technique selection. Nipple sparing is an oncological safe procedure, has proved to have the best aesthetic results. The sub-mammary and radial incisions have the lower complication rates. Incision selection depends on the breast size and the ptosis. There's a steady increase in direct-to-implant reconstruction. There is a steady increase in pre-pectoral reconstruction. Obviously, you don't have animation distortion that is one of the contrasts of using the retro-pectoral. Polyurethane implants have all ADM benefits and finished to be a cheaper reconstruction. And with previous breast scars, nipple sparing mastectomy has a higher incidence on skin necrosis. And definitely, this is for us the most important conclusion, separate incisions for sentinel node biopsy to avoid connecting pockets and seroma. Thank you very much. Questions and answers. Wonderful talk and really beautiful and amazing results, Dr. Colombo. It's very, very nice. We have a question from Eric Chang. I have a twin brother named Eric Chang. I don't think it's the same person though, but he was wondering about, again, the risks and increasing incidence of ALCL, whether that has affected your choice of implants. Have polyurethane implants been associated with ALCL? Have you seen cases of ALCL? Okay. I'm in Argentina in head of the ALCL committee and part of the board with the international board. So I'm very concerned about ALCL. That changed my practice in cosmetic surgery initially. Like seven years ago, I started using, back again, I used to use textured and then started using smooth implants. Now I'm using, for both, I'm using microtextured implants from Polytech and I'm using polyurethane implants, both in cosmetic and in reconstructive surgery. Polyurethane implants, there are very few cases described, very few. And most of them were related to the brand that used to produce them before. It was a Brazilian brand, Silimet. And they were, the way they were manufactured was a different way that the German polyurethane implants have. There are two cases described with polyurethane implants in Australia and in Europe. And I think that the benefits are so great of what they give you compared to what is the risk of ALCL that obviously we give and make them sign a consent information about all this to the patients. And we explain them. The risk of going back to the operating room because of displacement, because of capsular contractions are so higher compared to the risk of two cases that I think I'm going to still use to keep using them as I'm using it. Wonderful. I mean, you've gotten amazing results with your approach, your technique. So it's great. I mean, I'm sure it's probably publishable, you know, with the breast Q and patient satisfaction. It's just a remarkable results. Thank you. In the interest of time, shall we move on to our final speaker, Dr. Hector Duran? Okay, thanks. I'm sharing my screen. Are you seeing it? Great. So my name is Hector Duran. I'm a plastic surgeon in Mexico. And this lecture is not as rigid, it's more pragmatic. I'm gonna give you my insights and own opinion on what is the next Latin American trends in female liposculpture. Because I want to share with you what has been changing in the last three years. And it's been a lot of changes. So I have no disclosures. So Latin America is known for body contouring surgery. And of course we do a lot of it. And Latin females were known for voluptuous bodies. I mean, everybody thinks like a Brazilian and like a Mexican, like a Colombian girl. We all think about a big, big curves and that's okay. But this trend or this stigma is changing. And you gotta know the trend is changing right now. So I call it the needle effect, the scale needle effect. And since the first there was a need or a desire for voluptuous body. But since we have been changing the last three to five years these changes for a desire for higher definition. Of course, we cannot forget Dr. Alfredo Hoyos who with his high definition and amazing results set a trend that everyone wanted to. And the girls were responded to. So this is what I call a needle effect. If you had measured something in analogic scale like this you will know that instead of giving exactly the right weight, it goes up. So this is why I call the scale needle effect because if something new happens everyone wants to go like this to this new trend. But after a while, the needle starts to balance and then it keeps on the needle. So that's what I think is happening right now. So we've seen a lot of girls right now that are not looking for very high definition but they don't want also to be voluptuous. So what's in the meat? So of course this has been a changing trend as we get more changes in the liposculpture technique. Yes. And for example, we were at first going out with the first results as we so much of us learned which was this kind of flat tummies without any silhouette. Then we started to go with a little more and then to finally to bring very big high definition to these girls. But nowadays these high, very high definition girls are not looking for it. Even we have some patients that are looking to erase that effect. Why? Now what are these new trends? Well, the Latin American girls are looking now for a more balanced outcomes. And what it means is, well, it means like a high definition in the front. And I use my technique which is called a lipocontour for giving the high definition. But nowadays they're not looking for this so high definition. Right now, this is something that not everyone are looking for but also it's not a great result for every patient. Because in Latin America, we see some, and especially in Mexico, we see so many patients that are overweighted. So giving a high definition result in an overweighted girl doesn't look so good. You know, it looks false. So, and in the back, they are looking for again, big results. And this is high definition. But nowadays, as I was talking about you, where the girls are looking for a more soft definition like a contour. And what I mean with a soft definition? Well, they don't want flat, they don't want so high definition, but in the front, especially in the tummy, they want something like this, more soft silhouette, something more refined, something that looks great, but it's not screaming, I had liposuction. So this is very important because I think you will be seeing this trend in the next four or five years in USA. And this is the kind of results I want my patients to have, but also what my patients like. And I was not like having deficiencies doing high definition, but my patients ask it for a less higher definition. So, but in the back, they are asking these big butts and it's okay, it's something that you have seen, and, but it's very different. The butts are not getting so big enough, but they're getting, they want this very good relationship between the waist and the hips. So they're looking for this between 0.7 to 0.6 relationship. Of course, they don't come to the consultation asking for that, but I, they talk to me and I have to get this transition. So this is a patient of mine that I agreed to, she's a Chilean girl and she asked me for that kind of body. And this is like a very soft definition, like a sculpture in the front, but also a very volumized, buttock. So with a small waist. So I think this is, will be the trend that it will be, we will all as plastic surgeons be seen. And other trends that are also I have seen coming is with the resection of the skin associated with the lose weight, the patients that are losing weight. And I don't mean massive weight patients, but that kind of patients that was overweight and not too much and then lose skin or the ones who were pregnant. And I, what they are asking now is the resection or the, of course, they're not looking for the resection, but for the firmness of the tummy, but also combined with a more flat tummy, but not flat, but again, they're looking for a new as with the high definition pressure, they're looking for this new kind of definition. And let me tell you something, having a resection surgery as a mini tummy tuck and tummy tuck combined with a high definition is kind of risky because you can alter the irrigation, but it comes very, very good with a soft definition. And it's something nowadays I'm offering to my patients, resection surgery and soft definition, and it's coming a good trend. Also, I want to everyone to listen to me because I think that mini tummy tuck or mini lipectomy will be set as a new trend and something we will see more often than lipectomy. And it can be done because we are seeing more, less overweighted patients with troubles from pregnancy, but they're not, they haven't lose weight because they gain weight, but for the pregnancy. So these are kind of a skinny girls that has this kind of troubles and looking for not so big incisions, but also they want this kind of not like tummy, but with a silhouette. And of course, what I have previously told you, small waist and a more rounded butt. And this is the kind of patient we're seeing very often. Nowadays, very different what I was seeing five years, and I think other plastic surgeons in Latin America are also seeing this. The skinny girl with two or three pregnancies and with, of course, some hernia, but also with a C-section. And then what some plastic surgeons become a little bit, they get a little bit like feel forced to have a lipectomy, but the height of the umbilicus and the abdomen line is very high. So they are not, this kind of patients is also, are not also fit for like a regular tummy tuck. So this is the kind of patient that we can set this mini tummy tuck with the hand of lipo, softly finishing lipo. So I think this will be the trend. And of course, in some patients, of course, they're not fit for regular, sorry, mini tummy tuck. And this kind of patients will need for very long or the regular tummy tuck. But again, patients are not accepting now the regular tummy tuck, but they want the regular tummy tuck with a silhouette, with the definition. And again, you can do it with soft definition, and be very calm, because if you know how to do it, it will be very beautiful results without any compromising the irrigation, of course, in selected patients. These are some other examples of what I'm talking about. So as you can see, there's a lot of change in this kind of patients with a regular tummy tuck and the soft definition they're looking for. But even if you believe it or not, let me tell you something you will agree with me. Bad outcomes are never going to be a good trend. And if you deliver this kind of high kind of definition, but without knowing the anatomy, knowing the techniques and bringing bad results without symmetry and not a good outcome, okay, you're not gonna be a good trend in your practice. So hopefully you enjoyed this, my point of view. These are some of the publications of the lipocontrol technique. And thank you so much for the invitation to ASPS. Yes. Thank you, Dr. Duran. Again, amazing, beautiful results. I don't think there were any questions in the chat, but how much fat are you injecting into the gluteal region when you're doing the liposuction? How much do you take off of the abdomen in order to create the definition? It sort of does make sense if you're doing the high definition contouring, what you are able to remove, you can then use to augment another area. So I was wondering what the relation ratio is of what you remove to what you inject. Thank you so much. I don't have a goal in the definition in the tummy in milliliters or volume. I just want the silhouette become visible. The difference between a high definition and a soft definition is not so subtle. And there are some very good goals to achieve, but the main difference is Alfredo was talking about lines or negative spaces. And it's kind of it, but it's not about lines, but areas that we have to, because we don't want a very high definition, but an area of depression, again, and then the negative, but not a negative line, but a area. So I think that's the main goal. Also talking anatomically, I try not to go near the dermis. In the soft definition, you keep your cannula very profound, very, well, profound next to the muscle and in the deep subcutaneous fat. And answering your question about the fat in the buttock, I usually put between 400 to 800 cc's per buttock and to the sides. Beautiful results. Again, if we have time for maybe just one more question. Inpatients, or sorry, there's some questions in the Q&A. What technique do you use when you do the liposuction and the high definition and the soft definition? Is it wet, tumescent? What is your tumescent solution? Super wet. I want to tell, to think about myself that it's tumescent, but the reality is when I feel it like, okay, I stop constantly and thereafter I recall the volumes and I see I'm doing super wet, not tumescent. Thank you. Does anybody have any other questions? Dr. Alan Yepes asked about how do you avoid damage to the skin, particularly around the flanks? Are you also staying deeper, closer to the muscle to avoid traumatizing the skin? Well, Dr. Alan Yepes is a expert from Mexico. I know him and he's a very good friend of mine, but yes, I try to go deep, but the sides are not very, there's almost no thickness, but yes, I lower my cannula. I usually do my liposuction with five millimeters cannula, but at the sides, I try to do it with four. I never use three. I would like to, but sometimes I feel it's like a little bit bending, so I don't want to feel unsafe. So I prefer the rigidness of the four, but yes, I don't, I'm not trying to go close to the dermis. So the way I do this is with the tumescent solution. Yes, in the sides, I put a little more, try to put a little more of volume than at the fronts. Wonderful, thank you again. If there's some time, maybe we can have all the panelists return back. There are some additional questions for Dr. Rincon regarding the use of the leukotriene inhibitors. How long do you treat patients for and how effective have you felt the leukotriene inhibitors are, particularly in patients who have had post-operative radiation? And then maybe Dr. Kolombo can even chime in on what his experience has been with some contractures and reconstruction with the polyurethane implants. Okay. We use leukotriene inhibitors for twice a day for the first two weeks, and then once a day for the next six weeks, a total of two months, okay? Like the first two and then six. The first week, the first two weeks, twice a day, okay? And the last six weeks, once a day. So before getting the treatment, we have to be sure that the hepatic analysis are in the well stage. And then after the end, we have to do another lab to check the hepatic function, okay? That is very important. And the response is wonderful. We have been using that originally in our practice with a very, very good result. Wonderful. Dr. Kolombo, any thoughts on the contracture and the different types of implants that you use? Yeah, well, as published, my experience is when I change the implant surfaces like five years ago and started using smooth implants, obviously my concapsular contractures raised a little bit, not much, but raised compared to textured implants. And I used to use mainly the retro-pectoral space. And I always said that I'm not sure about that. There is a huge difference between surfaces in a retro-pectoral space or pocket with a smooth and textured. But the implant that definitely changes the capsular contracture rate is the polyurethane implant. I used it as a rescue in patient that had once, twice capsular contractures previous history and changed to polyurethane implants. And they have no capsular contracture anymore. Even if it's in the pre-pectoral, in the retro-pectoral plane, whatever, I haven't seen capsular contracture with it. The thing with polyurethane implants, as I mentioned, especially with the thin skin patients, is that sometimes, and especially in an anatomic polyurethane implants, you can feel or touch the upper border of the implant. I would say that's probably the only con of the polyurethane implant. The rest, all benefits. It doesn't move. You put it there and it stays there. Even if you do a bigger pocket, a smaller pocket, whatever you do, the implant will give you a hand with that. I know that you cannot use it in the States, but if you listen to or you read to Elisabeth Holfilney when she used to use them, and she always say that those were the best implants I ever used. And that's it. I mainly use them. The only reason why I don't use them in all patients is because they are a little more expensive. Wonderful. Dr. Duran, some technical questions about your technique. Do you do these procedures under general, IV sedation, local? And can you give some technical aspects in terms of maybe some of the landmarks that you use for creating those nice silhouettes and what kind of cannula size you use, or if you use like one of the vaser or different vibration assisted or micro air assisted lipocannulas? Yeah, thank you. I did it for 12 years under regional anesthesia. Nowadays, and that is almost eight years, general anesthesia is more, the hemodynamics are much better with it. Yeah. Also I use almost 99% of my procedures with micro air and only 30% of my procedures with a vaser. And about the landmarks, I was reading that question and this is very, very good question. The question was where I supposedly have to put the lateral lines if I'm doing a tummy tuck. And this is because some plastic surgeons tend to put it where it's supposedly to be, which is a linear outlet. But then when you do the closure of the plicature, then this goes next, more closer. So it doesn't fit no more. So that's why I try to do it at the end. And once I have the plicature and the resection of the skin, then I close. Then I do a couple additional incisions in the inguinal crease. So then I should, now I see where it should be. Then I do these areas, these negative areas. Wonderful. And then maybe just one more question for Dr. Colombo. When you have a patient who is not a BRCA carrier, but has a strong family history, what is the age of when you would do, your procedure with the reconstruction? Is there a limit in terms of how young you would go? And then just from my side, is this something that is covered by insurance down in Latin America? On some areas of the world, insurance companies will cover risk reducing surgery with the reconstruction, but in some areas of the world, it's not covered by insurance. Okay. So insurance related, there are not all of them, but there are many insurance companies that they only cover this kind of a procedure if patients have a positive genetic test. If they have a positive genetic test, yes, they will. Both as a risk reducing procedure for bilateral procedure and for contralateral. In the contralateral case, only in those cases, amazingly, I don't understand why, but they don't cover, if they don't have a positive genetic, even if they have a breast cancer, they won't cover the procedure on the other side. And the other question was, what's the age for starting with this? And I think usually when somebody comes to consultation with this problem, they come because they are concerned, or the patient, the young patient, or they're with a strong family history. Usually there is something that they're anxious about this breast cancer thing is something that makes the family anxious. So it will definitely depend on after talking, after explaining them the possibilities and the chances and the options and everything. The question is when, that's I answered one of the questions there in the same way, is something that you discuss with the patients. And that mainly depends on the anxiety. I haven't seen this, probably if I remember my younger patient, it was a 25 year old patient. I did a bilateral risk reducing mastectomy and reconstruction as I showed. And it's difficult to think in a young woman to remove her breasts, but this depends on their anxiety. And options they have definitely. Wonderful. Thank everybody again so much for this wonderful webinar. And I'd like to thank the SPS, Laura Weber and Romina Valdez for coordinating such a wonderful panel of just a tremendous experience with such wonderful results. Thank you everybody for your time and for the wonderful webinar. Thank you, Edward. Thank you to everyone. Thank you to everyone for being there and listening to us until this time of the day. And thank you, Edward, for the great monitoring and the great panel management. Okay. Thank you. Thank you guys. Hope to see you guys in person sometime soon. Hopefully. Hopefully. Thank you, Romina. Bye bye, friends.

plastic surgery

breast reconstruction

aesthetic surgery

liposculpture

capsular contracture

muscular contracture

nipple-sparing mastectomies

sub-mammary incisions

polyurethane implants

mini tummy tucks

anaplastic large cell lymphoma

Latin America

breast surgery

risk-reducing mastectomies

liposculpture trends

body contouring

patient safety

aesthetic outcomes