Hello, everyone, welcome to the American Society of Plastic Surgeons International Trainee and Fellows webinar. My name is Dr. Oyur, I'm from Turkey, I'm currently a research fellow in the University of California, Irvine. Today we are with Dr. Brainerd Garcia from Argentina, Dr. Filippo Andrea Giovanni Perosso from Italy, and Dr. Richard Kwasnicki from the United Kingdom. Each and every presentation, if you have questions, please write down in the question section. We'll try to ask each and every presentation. And if you want to be a member of us, please reach out to Dr. Ms. Romina Valadez, and we are sharing her email address, and then we will welcome you to be part of the American Society of Plastic Surgeons. So now we are, first, we are with Dr. Brainerd Garcia from Argentina, and we will talk about microsurgical reconstruction in head and neck cancer resection, sorry, we are with Brainerd Garcia from Argentina. He will talk about a modified slant for prominent areas. Yes, Dr. Brainerd, we are with you. Okay, thank you, Dr. Oyur, for introducing me, and give me a moment, thanks to the organizing committee for having me in this series. Can you see my presentation? Yes. Okay. Today, I'm going to talk about the modified slant technique for prominent ears. As we know, prominent ears are a relatively common defect or alteration of the form of the ear, and there have been several methods described to correct this situation, including techniques that excise, bend, suture, cut, or score the auricular cartilage. This multitude of different approaches indicates that there is no one clearly definitive technique to repair this issue. So I have no conflict of interest, and the aims of this presentation are, first, describe how with minimal changes we could get a more natural result, and second, to show the outcomes of our experience with the adaptations of the original technique. The backbone of my talk is given by this article published by the current chief of the Plastic Surgery Department of the Italian Hospital in the ISAB's Aesthetic Plastic Surgery Journal in 2018. For a start, I would like to make a brief review of the evolution of this technique, which begins in the 70s, when Dr. P. Tanguy described the island technique based on the creation of a cartilage island to define the antihelix, its upper crust, and the triangular fossa, which would also correct the conquest scaffold angle. Later, in the 80s, Dr. P. Tanguy exposed an analysis of 300 patients with a follow-up of 1 to 15 years, in which he observed all the patients had a preservation of the aesthetic aspect as well as the cephaloauricular angle, and almost no early or late complications. Later that, in 2001, Dr. Bartowski, a surgeon from Poland, presented his results by using Dr. P. Tanguy's technique, and he observed good results as well, and he acknowledges the low visibility he found out of this technique in Europe and encouraged its application. Now withstanding, Dr. Da Silva Freiras, in 2009, offers an opinion about Dr. P. Tanguy's technique, and he saw that some patients developed subsequent deformities of the antihelix by using this technique, so he proposed the use of a diamond drill with a pinnacle point to trim the sharp edges of the island in these patients. Given this information, we can continue with the presentation. So it's time to talk about normal ear, but actually, in reality, there is no normal ear. We could say an ordinary, usual, typical, or perhaps natural, but never normal or standard. Because the ear is a complex composite of cartilage, skin, and fibrofatid tissue, with many intricate involutions and folds, but what we could say is that it's always composed of five critical elements, which are concha, tragus, antihelix, helix, and lobe, and other less determinate ones, such as the antitragus, Darwin's tubercle, or Simba conchae, among others. So these are some anthropometric measurements of the pinna that, in fact, we all know, so it would be a little boring to remember them, but we should keep in mind these two important elements, the long axis of the ear, which is sloped backwards at an angle no greater than 20 degrees to the vertical plane, and the distance from the antihelix to the head, which is 1.7 and 2 centimeters approximately in the upper, middle, and lower third of the pinna. Although there is great racial and gender variation, but it's important to keep this information aboard. In this case, we will mainly focus on the upper and middle third of the pinna, because they are closely related with the asymmetry of the ears. So prominent ears are defined by an underdevelopment of the antihelix, an overdevelopment of the auricular concha, or both of them. These two conditions can be objectified by observing a conchal scaphal angle greater than 90 degrees and a cephalauricular angle greater than 30 degrees. So these features are what make us look bigger when we look in the mirror, so they are very important. Let's start with the surgical technique. This technique could be performed under local or general anesthesia, or with a combination of both. First, the ear is folded back against the head, and the adequate size of antihelix is marked. Antihelix itself is taken as a reference to recreate the upper crust in this case. Then we go to the posterior side to the ear and infiltrate it with an anesthetic solution. This is mostly to perform a hydraulic dissection. For this, we use a mixture that contains 1% lidocaine and epinephrine solution. In ambulatory patients, we used to add one millimeter of 10% sodium bicarbonate for each nine millimeters of anesthetic solution, because we want to reduce the burning sensation and not overstimulate the patient. Afterwards, we resect a spindle-shaped skin pattern from the posterior side of the ear, and we can continue with undermining the retrovoluccular skin borders. These steps are quickly to perform, but at the same time, it is necessary to keep the delicacy of the manipulation of the tissues, because this is very important in the postoperative period. Next, we passed four 27-gauge striped needles through the ear at different points to show the previous marking which outlined the cartilage island. So, it's not necessary to hurry up at this point. You just need to put one by one, and then you will see the marking reflected behind the ear. This is the key of the procedure. Here, we create the three to four millimeters wide cartilage island with a 45-degree bevel incision to avoid sharp edges. This island is keeping attached to the anterior skin, so you never see what we do before. It is essential not to curve to acute angles at this point, because it will end up creating the opposite effect, what we want, and won't achieve a natural result. Sometimes, at this point, to recreate an antihelix and a concave scapula angle with equal dimensions to the contralateral ear, we excise one to two millimeters strip of cartilage from the lower border of the scapha. And finally, this diagram shows what would be the completely curved island. Well, to carry on with the procedure, here we look at the 45-degree angle to the island, in the border to the island, and the edges of the cartilage frame in the island are undermining five to eight millimeters on each side with a pericondylevator to allow the suturing of them without any tension. This is the video, and you could see that procedure, and the separation of the island from the borders, and how we can undermine the framing. Okay, after that, we suture the borders of the cartilage behind the island, and push the island forward to recreate a natural antihelix with the smoother borders. This video illustrates how it looks that step. In this case, as you saw previously, we just recreate the upper crust of the antihelix and note the complete subunit, aesthetic subunit. But we could design or enlarge the previous marking to make the island bigger. And this is the aspect of the new upper crust of the antihelix. Now, we placed and fixed the perforated drainage and proceeded with the closure of the reticular skin with a running suture. Most of the time with 5.0 polypropylene. Finally, we model the anterior and posterior aspect of the pina using wet cotton. And we also use a sponge gauze and head bandage. Okay. Here are the results. The photo on the left is an enlarged view of the pina in the preoperative period. And on the right, we have the results at 24 hours with minimal edema and almost no bruising. In this picture, the patient, who is actually myself, has prominent ears, mostly because the conquest scaffold angle is bigger than we'd expect. And then we can see the result on the right, one month after the procedure was performed. Here are other patients who were also treated with the modified eye-lighting technique, all of them with a slight smile on their faces on the right side, as me. And regarding the global outcomes, we have an acceptable operative time with an average of 103 minutes. Excluding my case, the follow-up had an average of 76 months, and except for the hematoma that I mentioned in this slide, that was drained in the operating room without subsequent consequences or complications, all of these events were treated in the outpatient clinic without sick wheels. In conclusion, this technique offers the advantage of gelling predictable aesthetic and symmetric results. And these simple and easy-to-learn modifications can be used in patients without ears, with prominent ears, in all age groups. And I would like to share this quote from Van Gogh, because I find it quite stimulating. Great things are done by a series of small things brought together. Apart from myself, no other animal was harmed during the recording of the video, including this presentation, so thank you so much. Thank you so much, Dr. Garcia. It was a nice presentation. Thank you. We are facing in a clinic with prominent ear very common, so it's very helpful for us. I'm checking questions. Please ask, if you have any questions, I'll ask to the presenters. And I have a question, if you can answer. I'd like to ask, what are the advantages of this technique that caused the cartilage overdose that only weakened or suturing? Can you explain it, please? Okay, yes. And I think there are two main advantages of this technique in front of others. The first advantage, I think, is that by cutting the cartilage and pushing the island forward and closing the borders behind the island, you can get more or an extra support for that new antihelix. And this situation is strengthened by the healing process itself and by the scarring process, too. So you could get more longest results or preserve your results over the time. And the second one would be, as this cartilage is cut in the full thickness, you will get the elastic forces loosened and the chances of recurrence will be less than in other cases. So I think that those are the main advantages of this. Okay, excellent. Thank you. And another question that brought up on mine, like treading the upper third of the pinna with this technique could make the lobe appear more protruded. So how can we avoid this? Can you give some idea to us, please? Yes. I can suggest that always, always before close the retrorhicular skin, you need to check or review the position of the earlobe and the relation to this earlobe, to the upper third of the ear. If you find the earlobe protruding forward, you can preset a fishtail pattern skin behind the ear, and then that situation could be corrected, or the earlobe could be positioned in the right side. So I think it's always a good practice to review before make the dressing, the final dressing, to check that before, sorry, before to close the skin, the retrorhicular skin. Excellent. And one of the questions from audience I'd like to ask, Cartavaggia doctor is asking to you directly, what's the purpose of not doing acute angle when you cut cartilage? Okay, when you make, when you perform an acute angle, by cutting the, by designing the island, you will get the massiest trait, or when you could observe the island too protruding, or with a sharp edges in front of the ear. So the situation was the doctor, Dr. Da Silva Freitas in 2009, mentioned a need to be treated with a diamond drill. So it's mainly, it's basically a complication of your procedure. If you don't take care about the angle, the bevel angle, you will get in a mistake when you perform this kind of surgery. Okay, excellent. So thank you so much for your presentation, we really enjoyed it. And our next speaker, Dr. Paroso from Italy, and he will give the presentation of microsurgical reconstruction in head and neck cancer, plus action, tailor-made flaps for composite defects. We are with you, Dr. Paroso. Good afternoon, everyone. I would like to thank AESPS and SIGGRAPH for this wonderful opportunity, Romina Valadez for the organization, and Dr. Oyur, the moderator for the introduction. Today, I will briefly talk to you about our experience with microvascular surgery in head and neck reconstruction, focusing in particular on the constant necessity to tailor the flap selection and dissection, according also to the particular patient, and the fact we have to address. So, microsurgical reconstruction should be the primary option in most defects of head and neck that need tissue transfer, because it permits a more aggressive tumor resection with low donor site mobility, and improved functional and cosmetic outcomes. The reconstructive needs following the ablative surgery for head and neck cancer are unique, and they usually require close attention to both form and function. So, the choice of the reconstruction, the reconstructive option, depends on patient comorbidities, any possible future treatments, including the radiotherapy, the donor site mobility, and more important, the constituents of the surgical defect. With multiple tissue types, often requiring to be reconstructed simultaneously, so we have to address the functional aspects, like restoring oral cavity lining, also maintaining the oral competence, and the function of speech and swallowing. So, in order to achieve all these results, the flap must be a good choice, both for the patient, but also for the surgeon. So, we have to reach a versatile design, adequate sign, renovation, if necessary, with a minimum donor site mobility, and also we have to find a consistent anatomy with a large and long pedicle, together with a two teams approach, if feasible. So, for all of these requirements, the chimeric flaps are, I think, the best option when advanced 3D reconstruction is necessary. So, starting from the ELT flap, which is, I think, the worst workers flap in soft tissue defects repair, is versatile, with minimal donor site mobility, it has also a long pedicle, it can be, as you've seen in our picture, it can be raised as a traditional facial cutaneous flap, also with facial lata, it can be designed as a double highland ELT flap, and also if we can follow other perforators, it can include a muscular part. Starting from the oral cavity, the defect can include the tongue, the floor of the mouth, the buccal mucosa, and the retromolar trigon, also sometimes extending to the tonsillar area. In this particular case, we have a resection of SCC carcinoma of the tongue, which was reconstructed with an ELT flap. Another case, in this case, an highland ELT flap has been de-epithelized, as you can see in the picture, to allow the inclusion of the remaining central portion of the ELT tongue, after the resection of an intestinal type adenocarcinoma of the floor of the mouth and tongue base, so this was an atypical resection. In another case, a thoracoglossectomy, SCC carcinoma of the base of the tongue, the reconstruction had to be addressed with enough tissue to provide the bulkiness and the anterior cover, so it was a challenging reconstruction from a functional point of view, considering that the posterior tongue allows normal movement of the epiglottis. In this case, a chimeric ELT flap with a fasciocutaneous and a muscular comprehens were able to achieve, according to our view, a good cosmetic and functional outcome. In this case, a sarcoma of the left midface, after the resection by the head and neck sargenosteum of the cheek and zygomatic arch, including the intraoral, as you can see here, corresponding mucosa, has been employed to resurface the defect chimeric flap with two different skin hyaline, one internal for the mucosal lining and another one external for the skin. The endoscopic view, as you can see here, show good internal healing with progressive reduction with the passing of the time of the bulkiness of the flap. Talking about maxillary defects, obturation is often very successful as the defect does not involve the anterior arch, the orbit and the nose, or if the defect is not too large to determine problem of retention and stability of the prosthesis. In our practice, usually, obturation is offered for class 1 to 2 defects, but composite flaps, or flaps including heart tissue, are preferred for larger alveolar and class 3 to 6 defects. The first case of maxillary defect that we can see today is a recurrence of adenocarcinoma of the left maxillary tuberosity. The patient underwent a left inferior maxillectomy with the resection of the masticatory space. In this case, no structural support was deemed necessary considering the posterior vellus was involved, so a chimeric ELT flap was elevated with vastus lateralis muscle positioned to fill up the cavity. All cases involving the loss or partial ablation of the maxilla should be multidisciplinary discussed, also because clear advantages in simplifying the surgery are possible, but this choice, I think, becomes more difficult as the defect becomes larger and more complex. So, in this case of malignant melanoma recurrence of the heart palate, we chose to use a custom-made prosthesis to support the ELT flap, mainly because of the poor prognosis of the patient. So, the next surgeons perform a subtotal right maxillectomy with inferior left extension. And we perform a reconstruction with a folded ELT flap for the oral and nasal floor lining. As you can see, the short-term result is satisfying. Instead, in a different patient, I think with a better prognosis, a similar extended osteomassillary extension with a fat would have benefit of an R-tissue flap like iliac crest or scapula or other osteos options. In this other case of squamous cell carcinoma of left anterior R-palate, a bilateral anterior inferior maxillectomy was performed. And the reconstructive choice was the medial femoral condyle with long-term repetilization, as you can see here in the picture, and reduced donor site mobility. Talking about composite maxillary effect, the successful reconstruction has to restore, first of all, a partial projection, but also it has to be the foundation for dental rehabilitation. So, in this case of bilateral dental defect, we decided to use a fibular free flap to replace the missing skeleton and mucosa. The follow-up results, as you can see, show adequate partial projection and oral competence. In cases of class IV defects, generally with a poor prognosis, as in this case of right maxillary SCC, with interorbital extension, a maxillectomy extended to the orbital cavity was performed. And as a reconstructive option, we chose the thoracodorsal angular artery, supplying the scapula tip and thyrus major, which were raised conjointly with the steratus anterior and latissimus dorsi, and provided an excellent result. So, you can see here the three parts of our flap, and the flap in position, with the bone fixed with the plates. And the problem in this case of orbital support is no longer present. The muscle to obliterate the oral fistula and line the nasal cavity is ideal. And also, the muscle can give support to the repair dura, in this case, preventing the spinal fluid leaks. This case, a left nasoethmoidal intestinal type adenocarcinoma was similar. The resection included also a large part of the cranial base, with a second teratio of the left orbital. The muscle of the chimeric ELT flap was positionate along the repair cranial base, and the orbital was obliterated with the remaining part of the flap. So, you can see here at the MRI, as the muscle is completely lining the cranial base and obliterating the orbital cavity. And of course, enough space will be left in the future after the tissue contraction for a prosthetic eye positioning. In this case, another case after the biopsy of squamous cell carcinoma in a particular position affecting the retromotor trigon. The neck surgeons perform a convo-cell resection including the tuber maxilla and the marginal mandibular branch. And we chose as a reconstructive flap the MSAP medial sura artery perforator free flap. Also because it is a thin and pliable flap with minimal donor site mobility, and it is ideal for small to medium size defect. It also, it is very important this thing, it permits to spare other flaps for more extended situations. So indeed, in cases of larger site defect or necessity of a composite reconstruction, we can still resort to the ELT flap. So, it's very important to keep in mind that we also have to think about the possible evolution of the disease in our particular patient. As in the aforementioned case, the patient underwent a recurrence of the carcinoma shortly after the end of the radiotherapy. So, we chose also in this case an ELT flap and not a fibula flap, although this kind of flap, the fibula, is the workhorse in mandibular reconstruction. You can see here the resective part with the sacrifice of the fracture nerve, which was completely invaded by the tumor. And so, according to the poor prognosis of the patient, we choose to reconstruct the osseous defect just with a prosthesis in place of the resected mandible. And the defect, as you can see, and I told you, was reconstructed with the ELT flap, and including a segment of fascia latae, which we employ to accomplish the static correction of the oral commissura, covering also the mandibular prosthesis anteriorly with a depitalized dermal flap. Besides, we also perform lateral tarsal strip chondroplasty to compensate the fascial nerve deficit. This is a case, instead, in which the fibula is ideal to reconstruct the mandibular bone after sarcoma resection, because it allowed the harvest of a long and thick piece of bone, permitting also the osteotomies for contouring and the osseointegration for the placement of the dental rehabilitation. The last case that I'm talking to you today is a case of Merkel-Sehr carcinoma of the left-hand face in an elderly patient. We chose, in this case, a radial flap, which allows importation of a large and thin pliable flap with excellent reliability. And this flap, in this particular case, allowed us to achieve an adequate static correction of the mimic muscle deficit of the left-hand face, including in the flap a piece of flexor radialis carpi tendum. So, although the disadvantage of this flap is the poor donor side aesthetics, in this case, the aesthetic result, as you can see here, of the donor side is acceptable. So, going to the conclusion, I think that the most important thing is the multidisciplinary preoperative planning to address all the possible reconstructive challenges, considering also the possible oncological therapies and the prognosis of the patient. We are confident about free flap options like ELT, radial forearm, MSAP, free fibula at our disposal to reach a versatile reconstruction with minimal donor side mobility. And of course, the chimeric option in particular represent the best answer to 3D reconstruction requirement thus improving also patient chances of survival. I would like to thank you for your kind attention and any questions are welcome. Thank you. Thank you, Dr. Peralzo. Those are great works that we are really impressed and a lot of like advanced technique. I'm checking questions from audience, not any. I'd like to ask some questions if you can answer, please. What about the use of local or pedicle flaps during this procedure? When do you usually resort to them, please? Can you explain? Yes, thank you for the question. I think that local flap can be, of course, used. There are a lot of options, particularly in endo-neck reconstruction and they can used if the donor side morbidity is low according to the site of the defect. And also if the size of the defect is small. So I think we have to think about the dimension and also the position of our defect. Of course, if we have a composite defect, so if we have multiple tissue components, it's difficult to use a local flap. So if we have to find bone, if we have to find a double lining, it's very difficult to use a local flap. Talking about pedicle flap, I think they are good options. They are the first type of flaps described in endo-neck and we use them for particular patient like elderly patients or in cases of salvage surgery. So we have to be sure about the type of the flap and we don't have the possibility to risk a too long a procedure for the patient. So I think every kind of flap has its particular indications according to the patient, to the defect, and also to the time of surgery that we are going to address. Excellent. Thank you so much for the answer. It explained actually what I asked. Also, I have a question. Since the operation that you are going, I mean, they need advanced techniques. So do you use usually like any additional technology, technological device to- Yeah. We have tried a lot of technology, along these years. I think sometimes some of these technologies are used by the endo-neck surgeons who perform the resections. So they use the, or sometimes they use the neuro-navigator. According to our view, the microsurgery, we don't use couplers. Sometimes we use the endo-shining gray, green to validate the perfusion of the flaps. If they are in a particular positions that we are not sure about the perfusion. I think the most important thing now is the possibility that the radiology give us to plan the surgery. So we have the exact dimensions of the tumor. So we can understand which kind of tissues we are going to rise with our flap. And also have a 3D view of our defect. So we can, before the surgery, we can plan our flap and be sure about the final result. Excellent. And we have a question from audience. Have you ever used coupler for reconstruction of facial bones? Sorry. So if we use the coupler for- Scapula, scapular bone. Oh, yes. Yes. We have, as in the case that I show you, in the case of the tip of the scapula, we use the scapula for a chimeric scapula flap, including the serratus anterior and also the latissimus dorsi for the maxillary defect. The only disadvantage, I think, of the scapula flap is that is a little bit more difficult to perform dental re-implantation after some time because it's a little bit more thin than the fibula flap. But yes, we used it. Okay. Thank you so much. Our next speaker, Dr. Richard Kovacniki from United Kingdom. And he will present wearable technology for patients having breast and abdominal wall surgery. We are with you, Richard. You are moved? Thank you very much. Excellent. Can you see my slides okay there? Yes we do. Perfect. Thank you very much. Well, thank you very, very much for having me. It's a real pleasure and honor to present to an international audience in such a great forum. So my name is Richard and I work in London. I'm a trainee in plastic surgery and I'm also a member of the executive committee of Plaster which is the UK's trainee association and so I'm the research rep on that panel as well. My email address is on there and I'd be really interested to hear from you if this stimulates any ideas or thoughts or any collaboration. Please get in touch with me. I'd love to hear from you. So it's less of a clinical talk and a little bit more technological. So I hope that's okay after all the great clinical slides you've just seen. I don't have any declarations. There's always been innovation in plastic surgery and just to mention a few, there was the whole era where often people think it started with innovation in surgical techniques after the first world war mainly to reconstruct soldiers with burns and these waltzing flaps have partially at least been replaced with free tissue transfer using micro surgery and now modern immunology means that we can almost take flaps from another donor and there's also a new era of tissue engineering which might even render these tissue transfers obsolete. But whilst innovation is still playing a major role in the development of plastic surgery there is increasing focus on the surgical process and I think there's an evolving balance between innovation and the use of the surgeon's instincts and artistic ability and the generation of reproducible results through evidence-based practice. And enhanced recovery after surgery has been one of the vectors for this across many specialties and this focuses on standardization and marginal gains in multiple areas of patient care in order to optimize the outcomes. There's also increased focus on personalized care and choosing the right operation for the right patient and while this still requires artistic vision from the surgeon it can be supported by data-driven decisions and predictable outcomes from pre-operative information about the patient. This personalized approach continues after the operation where the recovery of patients should also be individualized just like anyone's exercise regimen. Those meeting goals earlier than others should be pushed on and moved forward at their own rates. I'm a strong advocate for wearable technology and smart devices to facilitate this new paradigm in perioperative care and they're starting to appear all around us and I think it will really take off over the next few years. Two of the big drivers are advances in technology and that means smaller microchips, smaller devices, better communications such as Wi-Fi and Bluetooth and others and also the drive for more data and realizing how that data can benefit the patient and the healthcare system. One of the most simple and useful bits of data that we can collect is physical activity and this is usually measured using accelerometry which is measuring forces in one or more dimensions and this type of data is all around us already and the best example is a smartwatch but they're also inbuilt in smartphones and we're usually carrying those the whole time. Adding additional data to that information such as GPS or heart rate or O2 saturations can enrich the information but sometimes it requires more advanced technologies and some of these can give you inaccurate data. I don't know whether you get the same but on my social media feed I often see people updating with their morning jog or their exercise class on Strava or another platform and I think this data is really important to people. I think recording and sharing that data sometimes acts in a way to validate their effort that they're putting in and sometimes to want to share their healthy lifestyle choices or some people use it to compete against others on different circuits so the fastest lap around the park and in the last few years or last decade I've tried to use some of these technologies in various plastic surgery applications and I'm going to share a few of those with you and my experiences and how they might be able to help you. So my journey in wearables really started at the Hamling Centre at Imperial College in London and this is a really exciting unit, an interesting place where the surgical staff work alongside designers and engineers the whole time, you're with them all the time in your meetings and your design process and the main aim was to design lots of bespoke technology for healthcare applications. One of the first devices that I worked on there was this sensor called the EAR sensor which is a really lightweight eight gram sensor that you wear behind the ear and it measures activity and we initially put it on staff and patients in a gait laboratory and we realised quite quickly that we could quite accurately measure gait parameters and walking patterns just using this sensor and when we put a high-speed camera on the feet of patients wearing this sensor we realised that even more subtle parameters like the heel contact or the toe off could also be measured and so we wanted to take this a step further and we developed a scoring system for patients' mobility and their recovery and their mobility after lower limb reconstruction as well as some other orthopaedic applications such as after hip replacements etc. This is some data from a controlled subject and a patient or somebody walking and the three axes on the accelerometer you can see in different colours and you can see the healthy subject has a really firm heel strike, a regular walking pattern, whereas the patient is slower, they're unbalanced and they're just moving differently and this evolves over time more towards the control type pattern and that kind of information is really useful for the physiotherapist and probably could be used to personalise their rehab. It might also be interesting for the patient to get that information. We had a cohort of patients who are undergoing lower limb reconstruction, usually for open tibial fractures, and we started to use this data to track their recovery over a year and this was the first bit of data, objective data, that could actually show the differences in recovery for different types of injury in terms of their severity of fracture over time. So this is interesting and it made an interesting PhD and it was novel from a technological point of view but it was complicated and it required that engineering and technical support most of the time for all of the data and that element of it got me thinking, is that level of information necessary? Is that granularity of data really important or could we get similar information from something more simple? And I think the answer in most cases is actually yes. The recovery trends that we saw from the gait parameters were matched by general activity movements which are much easier to collect in terms of measuring them. So the question is, could we just use activity as a surrogate marker for recovery? And this is when we started our work in breast surgery and abdominoplasty patients and the first goal really was just to find out purely observationally, what do these patients do after surgery? Do they get back to their preoperative activity levels and do some of them do better than others and which ones and what were the factors which were leading to those things? Were some of the operations that we do, did they carry more iatrogenic trauma and morbidity than others? So this is just a quick video, hopefully it will work, just to show the setup. So we've got a basic laptop, we've got one of our research students and we plug in these devices, it's a little chip there that you can see and it goes into a silicone strap. They're pretty cheap, they're probably about a fifth the cost of an Apple watch, just to give you an idea. And they collect raw data and we send these out in the post to patients preoperatively along with some questionnaires and we get them to put them on and record some preoperative activity data and so we know what their baselines are. We do their operation and then we put the sensors back on them as soon as we can afterwards and we track them and then we let them keep them on when they go home, then they send them back to us, we plug them into the computer, use this bit of simple software which gets all the accelerometry data and then we get these recovery curves afterwards. So it's a pretty straightforward process and that's what we're doing. So we've collected data from probably 150 patients now in different types of surgeries and just to focus in on the breast surgery patients, the patients having breast and axillary surgery, our interest has really been in characterizing their upper limb dysfunction. The prevalence of breast cancer and just as importantly, the survival rates means that whilst curing is obviously the first aim, I think preventing the subsequent upper limb dysfunction is where the gains are hard to be had right now and this means that the patients survive their breast cancer but with minimal upper limb morbidity from their treatment. So this is some data from a group of women who've had treatment for breast cancer and we can see the general recovery in activity over time. So the x-axis is two weeks and the y-axis is showing their activity based on their 100% will be their preoperative levels. So you can see that the numbers drop on day one post-op down to less than 50% of what they were doing pre-op and they gradually recover but even at two weeks, they're still short of what they were doing pre-op and most of these patients have gone home on around day three. So a mixture of cases, not just all big cases and then we split the data to look at the operated side versus the control arm and you can see that in the blue, we can see a significant delay in the recovery of that operated side compared to the control. So these patients have two sensors on. If we just focus on one of those patients, we can see that the preoperative levels and these are the different hands, the right and the left hand or the operated and non-operated side. There's usually a difference of maybe five to 10% in terms of people's ratio of activity between their two hands and that was about that for this patient and afterwards that really splits. So the side that they had the operation on, certainly if they had axillary surgery, they don't do very much with for a few days and then they gradually work their way back towards their normal. So this is quite predictable and some people have said, well, why are you doing what we already know? But I think when we've got this kind of information, there are all sorts of possibilities for the next step in this research and then this sort of clinical and technological paradigm. I think, you know, in this patient, for example, would it be helpful to know that if they went home a couple of days after a mastectomy and their ratios weren't normalizing and we can get that information through Bluetooth or through Wi-Fi, then maybe that would give us an early warning score and we might be able to call the patient and just prompt an earlier appointment with us. Similarly, if their activity levels are going up really quickly and they're making a faster recovery than normal, then maybe we can step them up in terms of their rehab and get them going even quicker, back to work sooner, et cetera. Or on the flip side, if they're doing too much after their surgery, we might have told them in their post-op instructions not to move their arm too much, especially if they've had a latissimus dorsi flap or a lymphatic micro-anastomosis. Maybe we should be saying, look, you're doing too much, just slow down a little bit. There are also quite a few questions from a research perspective. So for example, mastectomy versus a DIEP reconstruction. I think most people would guess that there's going to be a difference in recovery, but we've never really measured it objectively. So what are the differences? And this graph shows that the objective recovery data in patients who've had the DIEP, so they're in red, is much slower, certainly in the first few days, than it is with the mastectomy patients. And that is even considering that the DIEP patients in this cohort, in general, were younger, fitter patients, more able to have a larger surgery. Similarly, looking at another important question, looking at axillary node clearance versus just a sentinel lymph node biopsy, although the data is not quite as split, we can see that in gray, we've got the clearances, and they take more time to recover. So if the oncological evidence to perform the procedure isn't very strong, should we be exposing these patients to this surgery? And then just touching on abdominoplasty, this is data that shows two weeks of activity data after the operation, and you can see that two weeks later, they're still at 50% or less of their pre-operative baseline activity levels. And I wonder whether this kind of information can be used before the operation to explain to patients what that recovery process is likely to be like, and maybe for different fitness levels, we can start to stratify those patients. It might give them a better idea of when they can return to work, or how long they'll need help at home, or when they'll be able to start looking after their kids. So help planning these things, or even for the health service to work out how long they have to provide carers for. And in some cases, I think this could be used as a baseline for an intervention, such as setting activity goals on an app, or through their trainer or physiotherapist. And we trialed this idea a few years ago of an intervention with wearable sensors, using the Nike FuelBand, which I don't know whether sort of exists as a new device anymore, but they're obviously similar devices which give you activity goals throughout the day. And this was really successful in patients with peripheral vascular disease. And we compared their walking distance over 12 months, their maximum walking distance using this device, and compared it to what their current standard of care is, at least in the NHS, which is a weekly supervised exercise class. And we found that this intervention was much better with the wearable than with the exercise class, and very cost effective as well. And so it definitely has potential in our plastic surgery cohorts. So just returning to those themes of modern plastic surgery, having now seen some of the use of the wearables, I think there are really many ways that they'll be able to help us achieve some of these objectives. And probably what I've mentioned in this talk is only really scratching the surface. But just to summarise some of our targets in our unit for wearables over the next few years, firstly pre-op. I think using pre-op data to predict the likely changes or challenges in recovery after major procedures will be able to help us help support our management decision process in that clinic setting. I think pre-habilitating the patient through feedback-enabled wearables, such as a Nike Fuelband or similar, will be able to optimise the fitness of patients for their surgery, and that could be really powerful too. Post-operatively, using a combination of wearables to give us continuous vital signs might help clinicians decide on when they can safely discharge a patient home, and also to tailor their further rehabilitation in their home setting, based on them meeting their recovery goals. Some patients, and some people have said that they want to do this, they might find that linking that activity data into their support groups through social media might be able to enhance their experience and improve their wellbeing. From a general point of view, a more research point of view, these wearables provide a whole new set of outcome measures for us, and they can add objectivity to the patient-related outcome measures. I think they're really improving now on the age-old unit outcomes, such as mortality and 30-day readmission, which probably, arguably, are becoming less fit for purpose in modern plastic surgery. Thanks very much, and thanks to all my colleagues at Imperial, and the contributions and funding of the NIHR, Royal College of Surgeons, and BAPRES. And as I say, my email is on there, I'd be really delighted to hear from anyone if they have any ideas, or wanted to copy and use some of these strategies in their own units. Thank you so much, Dr. Kowalsniki. It is nice, and for a feature, we are expecting a lot of change in technology, so it's one of the very important presentations that you made. And since we are good on time, I'd like to ask a question. In the market, there's a competitive market, so there's a lot of more advanced wearable stuff in the market presence. So why have you been using this particular device? Can you explain to us, please? It's a good question. I think because we're still towards the start of our journey in the wearable era in our research. What we wanted to do is make sure our data was as clean as possible, and if you give them a device like an Apple Watch, and they can see what they're doing, then it automatically acts as an intervention. It's a psychological intervention, and it changes their behavior. So what we wanted to do, at least at the start, to get the baseline information for these procedures and what their recovery trends were like, is we wanted to use a device which was completely closed. It didn't give any feedback to the patient. They didn't have to charge it. There was no worry about privacy. And so although it's a very, very basic sensor, it made it very easy to collect the data, and I think it tried to reduce the number of confounders that we might get in the dataset. So that's why we chose to use it. Yeah. So thank you for the answer. I'm checking, is there any question and answer? We have still time if anybody wants to ask questions to Dr. Kwasnicki or another speaker I've already presented. During that time, I would like to give a special thanks to Romina Valadez. She's an international manager in American Society of Plastic Surgeons. Thank you for organization, and it's very noble to share our knowledge all around the world. And I would like to notice that American Society of Plastic Surgeons, with being over 15,000 members, is the biggest plastic surgery community. If you want to become a member, please reach out to Romina Valadez. She will answer and help you out as soon as possible. Email address rvaladez at plasticsurgery.org. We're going to share end of the presentation also. And we will be happy to see you in the community. And it's a privilege to be a part of the American Society of Plastic Surgeons. I'm checking questions. Yes. Okay. In Q&A, you can see the email of Ms. Romina Valadez. So we don't have any questions yet. So is there any comment or speakers I'd like to hear just before I close the panel? Dr. Garza, you are moved. Yes. I have no any comments, but I want to thanks to the organizing committee for inviting me to participate in these sessions and the other panelists to share his outstanding knowledge with us. Thank you so much. Yeah. And Dr. Perozo, do you want to add any comment? Yes, I would like to thank all the attendees and the organization for this wonderful webinar and we are waiting for the next. Thank you. Dr. Kwasnicki, please, if you have any comment to us. No, I think there were great talks and I sort of apologize for putting in something without so many beautiful pictures of surgery, but I hope it was a sort of interesting extra or along the side, but no thanks. It's been a real pleasure. Look forward to the next one. Yeah. So thank you all for listening and for participation. Thank you for your time. And then it's a privilege to be a member of American Society of Plastic Surgeons. I really appreciate all attendees for your time and for your kindness and for your questions. So see you in the next panel. I really appreciate for your time and then for your attention. So thank you so much all. Bye.

plastic surgery

prominent ears

cartilage island

microsurgical reconstruction

chimeric flaps

Latissimus Dorsi flap

wearable technology

patient recovery

personalized rehabilitation

American Society of Plastic Surgeons

prominent ears correction

postoperative recovery

customized flap selection

patient outcomes

advanced techniques