Manager at ASPS. Before we get started I would like to talk to you about ASPS and on behalf of the entire ASPS leadership, we thank you for your participation today. ASPS is the largest plastic surgeon organization in the world with over 12,000 members and subscribers, including plastic surgeons, residents, medical students, and other members categories. ASPS provides lots of opportunities for members to become and remain engaged with the society. We currently have 50 global partners. The International Visitor Professor Program conducts virtual visits to international plastic surgery institutions. The International Residence Forum offers opportunities to contribute to ongoing projects and develop new projects specific to residency training and beyond. In addition to the research grants, the Plastic Surgery Foundation also includes innovative global health initiatives through our global volunteers and plastic surgery and share programs. GAP is the new PSF pilot program to build international union and foster exchange between the U.S. and global partners training programs. The Plastic Surgery Education Network, ASPS.net, is the online learning center developed by the American Society of Plastic Surgeons with the cooperation of several plastic surgery specialty societies. ASPS.net offers fresh content in all areas of plastic surgery every month. The ASPS Education Network offers more than 90 self-assessment models for practicing surgeons and residents alike. Each model provides journals, article readings, presentations, videos, and tests that covers all aspects of the specialty. Program directors are welcome to enroll their residents in the ASPS Education Network, REC, and review transcripts to track progress. And this slide shows a few highlights of the PRS journal that is included with your subscription. And the PRS Global Open, which is also included with your subscription. On the screen are some of the benefits of international membership at ASPS. We had a very successful annual meeting in October in Austin and I hope you can all attend the Plastic Surgery Meeting in late September this year. There are so many benefits to membership in ASPS for all our international colleagues including a subscription to PRS journal and a member discount to Plastic Surgery Meeting. To learn more or to join the society, we have QR codes with discounts for residents and practicing plastic surgeons on the screen. I will also share my contact information on the chat in case you have any questions for me. And now I would like to introduce you to our moderator today, Dr. Ahmed Afifi. Dr. Afifi is a cosmetic plastic and reconstructive surgery specialist in Madison, Wisconsin. He received his medical degree from Cairo University School of Medicine and has been in practice for more than 20 years. Dr. Afifi is an associate professor in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health Division of Plastic and Reconstructive Surgery. Welcome, Dr. Afifi. Thank you, Amina, and thanks to the ASPS for putting this together. A few notes before we start. So part of this recording, part of this panel will be recorded. I would encourage you to use the Q&A option in your Zoom meeting, submit questions. We'll try to get to all of these questions towards the end of this meeting. And thank you again, this should be a great panel. So last year during the ASPS meeting in Austin, we put this panel together and all four of us spoke and we had such great feedback. So we decided to bring the band back together for a one hour summary and highlights of abdominoplasty. We have three fantastic speakers between them. I think they've changed the way that the whole world thinks and performs abdominoplasty. So Dr. Saad from Barcelona, Dr. Fabio Nahas from Brazil, and Dr. Jamal Seneuva from Istanbul. They're very diverse, experienced faculty and friends. So without further ado, we'll have two recorded presentations, and then Dr. Jamal will give his talk live, and then we'll all join together for the panel. Hello, everyone. My name is Ahmad Saad. I'm a plastic surgeon in Barcelona, Spain. Today I'll be sharing with you my experience with abdominoplasty. I have nothing to disclose. Now the key for success in abdominoplasty like everything else in medicine is to first make a proper diagnosis, and then deliver results respecting patient's anatomy and wishes. Now, in order to make a proper diagnosis, we have to evaluate the three layers of the abdominal wall, the skin, the subcutaneous fat, and the muscles. Now let's start with the skin. The first thing we have to look at is the skin quality, of course. Then we have to look at where is the excess skin? Is it only in the infra-umbilical area? Is it in the infra- and supra-umbilical area? The second variable to evaluate is the extent of skin contraction. Is it mild, moderate, or advanced? Now years ago, the only way to address any level of skin excess was direct excision. Nowadays, we have some tools at our disposal that can help us improve the skin laxity in a less invasive way. I use the Renuvion, which is a radiofrequency-based technology that delivers radiofrequency to the subcutaneous tissue, heating that tissue to 84 degrees Celsius, and when properly used, can deliver really good results and acceptable risk. For example, this is a patient. You can see her skin excess, and she came to see me for a liposculpture, high-definition liposculpture. I cannot do high-definition liposculpture without addressing that skin excess. That would look so odd, and if she saw me years ago, I would have proposed a mini-abdominoplasty or even a full abdominoplasty. Now we did the high-definition liposculpture, and we used also the Renuvion, the radiofrequency technology, and you can see the level of skin contraction that we have achieved, and you can see the improvement, not only the anatomy because of the liposculpture, but because of the improvement in the skin tension, and one index that can tell you the extent of improvement is the shape of the umbilicus. Here's another young patient. He lost 25 kilos, and he came to see me for a paniclectomy, but he was very concerned about the scar that he's going to have at this young age. We decided to proceed with a high-definition liposculpture in addition to using that radiofrequency technology, and you can see the result and improvement that was achieved. Another patient with moderate skin excess. This patient, if I didn't have any technology at my disposal, I would definitely offer him a paniclectomy in addition to the liposuction, but we chose to take the risk and try the radiofrequency, see how much skin contraction we can get in addition to his high-definition liposculpture, and the result, as you can see, is very satisfactory. Now, when the skin laxity level is moderate to high, then we have to think of other options, which is basically one option. It's the skin excision. Now, skin excision, if the excess skin is only in the infraumbilical area, we can try to, we can do a mini-abdominoplasty. If the skin excess is all over the abdomen, we should think more of an abdominoplasty. Now, let's go over the marking of the skin. In the preoperative area, while the patient is standing, I go six centimeters above the bifurcation, and it's very important whenever you're doing your marking to use your left hand to pull the skin up, so that you avoid a high-riding scar. So, you pull the skin up, and with your right hand, you mark where you want your scar to be. Here, you mark the xiphoid, and you draw the midline from the xiphoid passing through the umbilicus down to the belly button, and you can see in this patient she has an umbilical hernia. Then, you measure the arm from the midline to the most lateral part of the scar, and you reflect that up towards the umbilicus. And here, you complete your drawing, and always, whenever we start, we make small holes in this, in the inframedilical area to do the liposuction. That's how we do the deep liposuction to all the abdominal area, and once the deep liposuction is complete, we disconnect the umbilicus from the skin flap, we do our suprapubic incision, and we undermine in an inverted V area, all this area that you see here, in order to expose the diastasis, and do our placation, and I'll show you how I do the placation in a little bit, and of course in a patient like this, we fix the umbilical hernia before we do the placation. Now, whenever we're talking about fat, we have to understand that we have two fat layers and the subcutaneous area. We have the deep fat layer and the superficial fat layer. Invariably, whenever we do an abdominoplasty, we always do a deep fat liposuction. Even if the patient is skinny, does not have much fat, this liposuction helps us open up the plane and dissect the subcutaneous tissue, and it helps a lot with hemostasis as well. Now, the superficial fat layer is addressed whenever we're doing high-definition liposculpture, and I'll touch on that a little bit. Now, here you can see in the operating room, addressing the deep and the superficial fat layer is very different. Here you can see the cannula and the deep fat layer, you can see the fat how it comes, it's yellow, it's soft, and the layer is very easy to access. In contrast to the superficial fat layer, which is more fibrous, it's harder, and you address this layer only whenever you're doing high-definition liposculpture. Now, let's talk a little bit about diastasis. Whenever we're evaluating for diastasis, we have to see, is the diastasis only below the umbilicus, or it's pan-abdominal, from the xiphoid to the pubis. Now, how do we correct diastasis? Now, diastasis does not only happen in the horizontal vector, it does happen in horizontal and vertical vector. So, I do a figure-of-eight suture that is with an inverted knot, because I think this can address both horizontal and vertical vectors, and I put many of these sutures from the xiphoid down to the pubis. I use a heavy, like a number one, non-absorbable braided sutures, like Etherbond or so. Now, in this patient, she only had the diastasis in the inframedical area, we did the mini-abdominoplasty with placation only from the umbilicus down to the pubis, and we placed a very low scar, and you can see the improvement on her profile. In a patient like this, she has full diastasis from the xiphoid down to the pubis, we have to do a full abdominoplasty with complete placation from the xiphoid down to the pubis, and you can see her scar. This is a few weeks after the surgery, you can see her scar still red, you can see here the three-quarter view. Another patient, this is three months after the surgery, full abdominal placation, you can see the scar, still in the healing process. Another patient, here you can see the scar, it's still red, still a few months after the surgery. Here's a patient who's three years after the surgery, had full abdominal placation, and you can see the scar, how it's well located, it's low, it's along the bikini line, and it healed nicely, and you can see the improvement in the side view, and this is the three-quarter view. Now what do we do if patients want high-definition liposculpture? I divide that into two stages. Stage number one, we do the deep liposuction and the abdominoplasty, and I tell the patients, come see me in a year where we can do the high-definition liposculpture. I do believe it is dangerous to do superficial liposculpture on a patient where you've done the sections for a full abdominoplasty, so that's why I divide them into two stages. For example, this is a patient who lost a lot of weight. He saw one of my colleagues who did his abdominoplasty, and then a year later came to see me for high-definition liposculpture, and this is his result. Now post-operatively, I leave two Jackson Pratt drains, and I insert them from the pubic area. I'll pull them up within 24 hours after the surgery. We use the compression garment for a total of three weeks, give the patients antibiotics for seven days, pain medication, early ambulation, and we give them DVT prophylaxis according to the recommendation from their Caprini score. We start the post-operative care with the post-operative massage at day five to seven, and I hope you enjoyed the talk, and I'll be happy to answer any questions you have. Thank you very much. I'd like to thank for the invitation of the organizers of this web meeting in which we will present what have I changed in abdominoplasty, but focusing on high-definition placations, which will be very much what we're doing in the operating room. These are my disclosures. So this is the abdominal definition liposuction. We have done many cases of this combining with abdominoplasty, but this presentation is just to demonstrate the effect of muscular placations and mobilization on the fine contour of the abdomen. So we're going to show the muscular definition effect. So in the following cases that we're going to show in this presentation, no liposuction was performing in any of the patients. These are the values, the percentage that each characteristics of the abdomen will contribute to the beauty of the abdomen, and you can see that the central midline depression and the semilunar lines correspond to 32% of what people think is beautiful in an abdomen. So these are the most important lines that give a look of a good cosmetically appearance of an abdomen. So we have a classification in which different placations are done, and I'm going to explain you each one of them. So type A are patients who present rectus diastasis secondary to pregnancy. So it is a fusiform deformity, and the placation is enough to bring a more projected abdomen to a very flat abdomen. But not only that, the rectus placation will create a dimple in the midline in the upper abdomen. So you can see even in patients with higher BMIs, we can see this dimple formed and more defined muscles in the abdomen. Now, the placation when we're doing the medial edges, bringing those medial edges together to the midline, we have proved that it works with nylon for six months follow-up, with PDS in a six-month follow-up, and it is a long-lasting procedure with more than five years. As you can see here in the pre-op, in the post-op, in the upper abdomen, in the pre-op, here and here, lower abdomen. In the three-week post-op, you can see some edema in both of these pictures. This is on my left side, we have the upper abdomen, and on the right side, we have the lower abdomen. But then, 80 months post-op, or more than seven years, we can see that there is no diastasis. So it's a very important technique to correct rectus diastasis and it is a long lasting procedure. Now, what happens if the patient has a pregnancy? This patient had pregnancy two years after the placation. And as you can see four months after delivery, there is no rectus diastasis, no recurrence of rectus diastasis. So here is the patient, the pre-op, one year post-op and four years after delivery. And you can see that the patient has exercised. So we had a rectus hypertrophy after physical training in a natural way because the placation was performed on the medial edges of the rectus muscle. So if you do a very wide placation, the muscles will rotate to the inside of the abdominal cavity and we lose this aspect. So it is important to make the placation on the medial edges, as you can see also in this case and also in this patient right here. Now, we have done, we start to use the triangular sutures that shortens the aponeurosis in its longitudinal aspect by 8%. We have proved in this study and it is a very interesting technique because as we know, the deformity is not only in one direction but it is rather multidirectional deformity. We have an expansion in the longitudinal area and also on the sides. So we have already done another study with 15 patients in each group in which we did a continuous suture which was faster and had no recurrence. We used GRIO, which is a barber suture and we had recurrence in two cases with no clinical repercussion but I don't like to have recurrences. And when we use the two-layer technique, we had 40 minutes more in our placation. So continuous suture was faster. So what do we do nowadays? We do two layers. The first one we do from three to four triangular sutures above and below the umbilicus. And also we do a continuous suture interlocking every two passes. So here is the triangular suture. We go very close to the midline, to the middle edge and then we make a triangular shaped suture, more trapezoid-like suture. And then it shrinks longitudinal and also we correct the diastasis at the same time. You will see again, we pass in the middle, wider in the upper part and shorter and closer to the midline in the lower part. Now, this is the second layer in which we do a continuous suture anchoring every two passes, interlocking every two passes. So it's a very fast way to do that. And it's very easy to achieve. So you can see that this patient has a very longitudinal excess of the musculoponeurotic layer. And with that kind of suture, we correct the diastasis and also we shrunk the longitudinal distension of the abdomen in a two-year post-op. Now, if the placation of the anterior rectus is approximating the middle edges of the muscle is not enough to correct the abdominal laxity, we should do another placation to complement, to improve the tightness of the abdomen. So that's a type B patient. So if you do the correction of rectus diastasis, there is still laxity, we do the application on the external oblique muscle aponeurosis. So the distension of, as I told you, the distension of the myoponeurotic layer of the abdominal wall is also longitudinal, as you can see in this pregnant lady. We have two twins here, and this one has had a baby. This one did not have a baby. We can see the vertical elongation of this abdomen. So we have to take care of that by doing the L-placation in which we have bidirectional placation when vertical to reinforce the correction of the rectus diastasis, and also a lateral branch to decrease the vertical aspect of this excessive laxity of the abdominal wall. So which are the advantages? We do the placation right on the lateral edge of the rectus muscle. So we preserve the fine contour. We don't make any depression in the rectus muscle. We rather do a placation right in between the external oblique muscle and the lateral, the muscles of the flank and the rectus muscle. So we allow them to, their hypertrophy without any placation there. So it reinforces the area of the umbilicus which is not placated in our placation. It helps to define the waistline because we create two vectors down and towards the midline. And it also corrects the vertical elongation as I told you. So when we do this placation, we kind of create this dimples here, these circles in these areas. So this is the placation of the rectus abdominal muscle performed, and then we have some laxity around the umbilicus where we don't do any placation. And what we do is a placation laterally to the lateral edge of the rectus muscle on the external oblique aponeurosis in an L shape. So that, so this is the placation marked and you can see that we do have a one centimeter from one to two centimeter with it in this placation. And these are the vectors, and we will decrease the vertical aspect of this abdominal wall. Now, these are the vectors. You can see it's down towards the midline. So we help to increase the waistline by doing that. So they also can go beyond the umbilicus as you can see. Now, when we do the placation, you can see that the abdomen is much tighter. This is the L, and you can see that it's tighter. And also that the vertical, the horizontal placation will create really these vectors. And also we can see some plagues of the fascia. As you can see due to the shrink of the vertical aspect of the abdomen. So here we have the pre-op, and here we have the post-op much tighter abdomen. Now, these are some examples which you can see some demarcation of this semilunaris line. And also in men, we can do that, but without doing the horizontal branch of the L, only a vertical placation in that area. You can see those dimples right here. And if you see this patient in the pre-op, post-op, and long-term post-operative, you can see that we have those L placations very defined. And this is a long-lasting procedure, as you can see in 19-year post-operative showing these dimples right here. Now, I ask you to pay attention in the insertion of the recti muscles. So this is type A, in which we have a fusiform deformity with the recti muscles coming together to the midline. And in the C type of deformity, we have a lateral insertion in the costal margin. So we have to do the medial advancement of the recti muscles. Type C is a congenital deformity. When general surgeons recognized it, they called the epigastric hernia. However, it was never recognized by plastic surgeons. If the placation is performed after repeated contractions, vertical contraction of the recti muscle, it may occur what we called the violin string effect, leading to recurrence of rectus diastasis. So this is the anatomical aspect. We try to put these two chords together. They're gonna go with vertical contraction of the recti muscles. They're gonna go back to their original place, showing a recurrence after some months. So to reattach the insertion of the recti muscles towards the midline would be way too aggressive. So we decided to advance the recti sheets, bringing the rectus muscle to a different position. And when they contract, they will not recur. So we did an anatomical study with the rectus undermining. We measured the tension to bring this pulmonary edges towards the midline. There was a decrease of tension. So we have created this technique based on that study in which I opened the anterior rectal sheet. I undermine the posterior rectal sheet all the way towards the lateral aspect of the recti muscles. I do the placation invaginating the linea alba, and then I anchor the anterior rectal sheet in the posterior sheet, bringing together these two sheets where the muscles are located. So what we do then is to open as close as you can to the linea alba, the anterior rectal sheet. So we open that towards the costal margin, and you can see the muscle here. We just release the muscles bluntly. It's a very easy technique for those who are used to do tram flaps. And we open, and then we go down all the way to the linea archiata, arcuate line. You will see that there are very few bleeders, very little perforators that sometimes we have to cut them, but usually we do that with blunt dissection with the finger, very few bleeders. As you can see one there, very few bleeders. And only in the lower part, we have to be a little bit more careful with the inferior pigastric artery and vein. But then, as you can see, we undermine all the way to the lateral aspect of the rectus muscle. You can see I'm gonna put my hand down there so that you can have an idea of how far we can go. And then we make a placation of the posterior rectal sheet. And you can see that I will show you that we pull it up so that you have no risk to grab a bowel. And we do these inverted stitches. Now we have done the posterior placation, and then I do a three-step placation, trying to recreate the local anatomy, bringing the anterior rectal sheet towards the posterior sheet in the midline. So it's a three-step suture. As you can see, we have one, two, and three. And then we do this placation. And that's the technique to correct this deformity. You can see at the end of the operation. Now, this is the pre-op of a patient like that, and we can do a very good correction with that. And also for men, it is very interesting that when we advance the recti muscles, you can see here the distance between the lateral edge of the muscle and his waist edge. And then after doing that, it increases in length. And also it brings down the upper abdomen. So in summary, when we do the placation, if there is good tension, okay, you can close the patient. And if there's still flexicity, we do the out-placations on the lateral aspect of the recti muscles. Now, if there is a lateral insertion, we do the advancement of the rectal sheet. So it is possible in patients with low BMI to improve muscle definition by correcting adequately the myoporoneurotic layer. And we should be very careful with the association of these techniques with HD liposuction, but it really may enhance results. So if we do limited undermining tunnels, trying to preserve the perforators of the rectal sheet, we can go ahead and do a liposuction as in a high depth liposuction. We can do that safely. Thank you. Can you see that? Yes, we can see it well, yes. Great. First of all, thank you, Professor Rafifi and the ASPS for this invite. My name is Yaman Shaniwa. I'm a plastic surgeon, prior practice in Istanbul, Turkey. So today I'm going to present my 3D abnormal plastic technique. I have books and chapters related to the subject. As you know, the abdomen and the body is not two dimensional, but three dimensional. And the purpose and the planning of the surgery should be three dimensional. So we gained a lot of experience with advanced body contouring surgery with liposuction and understood the importance of light and shadows. And the black and the white, you know, images, which has the dark and gray zones and the white zones, like, you know, rhomboid negative spaces, occlusal negative spaces, pectoral fullness. And we learned a lot of things about that. So an example about that. So this gentleman, early post-op appearance of this gentleman, natural result can be seen, and the later result we see that, you know, natural result can be achieved by, you know, this approach and the education and then this knowledge. And we can now transfer this knowledge and experience to the excision body contouring. So beautiful female body and abdomen has two rectus colon, epigastric belly, parietal shadows and the deep waistline. And poor planning will result with a natural result and the complication. And also ladies without children and overweight ladies or men can be considered as a bad patient. And poor general health and smokers also are bad candidates. So marking is important. After years, I found this, you know, easy way for marking. I asked my patient to pull everything, the soft tissue up. And I imagined the perfect location of my scar because of this, you know, adhesion zone on the inferior part of this anatomy. So there will be no scar migration. The skin ellipse is going to be marked. The future suprapubic fullness will be protected during the surgery and the lipodeposit area will be marked. And then we will ask our patient to sit and we will follow the extent of the excess skin. And we will extend, if necessary, the corner on the markings. By doing this, we will avoid and prevent all the dogged formation. And the resultant scar should be between the aesthetic abdominal unit and it should not invade the leg aesthetic units. It should be between these two aesthetic units. And two weeks after the surgery, you see that the scar is not migrated and the predictable location of the scar is achieved. So the surgical technique will be lipo-abdominoplasty. And I'm using the ultrasound technology for liposuction. Since this technology is very selective, it will protect the delicate tissues like connective tissue, lymphatics, and perforators. When we remove the fat tissue, which is not stretchable, the remaining tissue called tissue matrix will be much easier to advance and the aesthetic result will be better. So this is the technology that we are using. After the ultrasound energy is given, you see the appearance of emulsified fats. And after gentle lipo-aspiration, the preserved structures can be seen in this picture. The animation of our surgical technique, again, marking the semilunar, semicircular area is protected. Klein solution is going to be infiltrated. Ultrasound application, liposuction, according to the high-definition concept, and then elevation of the flap, which will be much easier. Just the skin excision site will be elevated and above the umbilicus, a tunnel will be created. The application will be made with non-resorbable stitches. The umbilical stalk will be fixed. We will put the patient in a semi-sitting position. And after progressive tension sutures, we will create the new umbilicus and we will do the closure. Let's see the video. Client solution, one milligram adrenaline per liter. To be deliberately infiltrated and then the setting of the device. Ultrasound application, again, the negative spaces will be targeted. The rectus columns will be protected. You see that two fingers application of the ultrasound is enough, very gentle. Because the fat is emulsified and fragmented, the liposuction will be much easier and more gentle. Again, keep in your minds that where to protect, where to create, you know, shadows. The epigastric VLA will be addressed. I finished the right side by liposuction and the left side has not been, you know, liposuction started. And then I'm using 30 degree Concord cannula. I go up to the axilla, I go not to the flanks and the end of the liposuction that you can do the comparison. And then the incision of the skin with your scalpel will be clean and sharp and, you know, fine. And then you can use Colorado needle for your derma. At this point, it's important to recognize the campyl fascia and deeper than that, you need to recognize the scarpa fascia. Then you will protect the suprapubic fat island in order to get rid of the dead space at the closure and also keep the aesthetic fullness in this area. And then you see that my assistant and me, we are using our fingers, not retractors. You should avoid all the pinching to your flap and you need to see your tunnel that you created with your liposuction. The shiny surface on the abdominal wall should be protected. All the perforators is coagulated. And at this point, I asked my anesthetist to have a normal blood pressure that I do a couple of times, the hemostasis. And also I like to do the irrigation with betadine solution. And then we start the duplication. I'm using double arm, non-resorbable stitching material. I start from my xiphoids and I like to do cross suturing and each three, four centimeters of my duplication, I lock my suture. And if something happens to one segment, the remaining segment will be protected. And when I'm doing my bites, I try to bite the rectal fascia, okay? The anterior, maybe posterior rectal fascia can be bite, but not the muscle. And you see that, you know, when you pull your suture material, you have a nice plication. And then after finishing my plication, my assistant helped me with my progressive tension sutures. We are using two ovicryl, not from the derma. You need to avoid the dimple, you know, but you know, you can get some connective tissue to the abdominal wall. Three to four sutures, progressive tension sutures is enough to avoid the tension around the umbilicus. And three to four progressive tension suture below the umbilicus. And for closure, I'm using V-lock suture. It's barbed suture. I start from my lateral corner and then I try to bite the superficial and deep fascia, the gamble and the scarpa. Of course, you know, be careful with your drain. And with the same suture material, when I approach the midline, I become superficial. And from derma to derma. So those are deep dermal stitches. And when you pull it, you will get a nice closure. And then it takes really, you know, five minutes per side. And we are using this Lapwood instrument to estimate the amount of excision. And this is how we do the closure with barbed suture. And for perfection, we are using three, four monocreate, one by one, various stitches. And surgical planning after years, I divided my patient according to the abdominal deformity. The first group of patient are skinny patient. In those patients, you are okay to do some medialization of your flap. So we have a couple vector of your flap and you do your closures. You can do, you know, medialization, lateralization or vertical closures. So again, in those skinny group, so you are okay to do medialization. This patient, you know, six months after the surgery. Even those patients doesn't have much fat. I like to do some tunnelization with ultrasound and the lipo aspiration. I do tunnelization to avoid the tension in the closure. So this is the six month result of this lady on the oblique view. Sitting position, the gross pinch of the patient, sitting position before the surgery and after the surgery. The pinch test. And this is the video of this lady six months later that, you know, even we did extensive application of the ultrasound. We protected the rectus or firmness or the definition, epigastric belly definition has been achieved and the surface is smooth. Another patient of this group. So this is skinny patient. Eight months result. I did tongue and groove shape umbilical reconstruction. Oblique view of this lady. You see the dimension, anterior-posterior dimension has been reduced. The nice muscle application has been achieved. The pinch test before and after. She was mother of two children and after the surgery, she become pregnant again and delivered a third baby while she remained the aesthetic outcome. Another patient in this group. So this patient had scars, the vertical infrared umbilical scars and some transverse scars before the surgery. So with this approach, this is, you know, getting two birds with one stone. So this is the early post-op, I think, you know, two months post-op images of this lady that when you turn one part of flash off, you can get, you know, this shadow images. So this is her couple months later on, the quality of the scar and the pinch test. So the second group of patient, patients who has some fatty deposits with laxity. So those are more good candidate for, you know, three-dimensional approach and result. So this is months later on, before and after that, you know, shadow images show you the nice definition on the rectus columns and the, again, the negative spaces that you mentioned, the soft muscle negative spaces, seen in negative spaces and the deep waistline has been restored. Public view of this lady, natural view and the pinch test before and after the surgery sitting position of this lady, the back view. The same group of the patient, this lady has more fatty tissue, more BMI. And then this is, you know, 10 weeks after the surgery, you see that the waist has been deepened and the shadow images, we created nice definition anterior-posterior dimension. The gross pinch test, you see that how diminished is sitting position 10 weeks later, the video of this lady 10 weeks later. And then, you know, in my series, I don't have any major complication or even minor complication, you know, we don't see in our practice. So you see that, you know, how nicely, how gently we reduced the fat layer, fat thickness. So this third group of patient, are patient with severe laxity and severe epigastric laxity. In those patients, to avoid the increase on the laxity on the epigastrium, we advise to lateralization of your flap. And by doing this, this is two months after the surgery, you, at least, you know, you protect the increase of the laxity on the epigastrium. I call pillory type of CAPE abdominalplasty, this group of patients, two months later results that, you know, you can get also some definition sitting position. This group of patients have more severe deformity. So you need to do extended abdominalplasty and the closure should be vertical. And the surgery will start on the prone position and we will do ultrasonic application on the flanks, on the waist, low handle. And then we will start by our excision and we are doing the closure on the back and then we turn the patient and we finish the surgery on the anterior part. And with the vertical closure, you see one year result. Again, tongue in groove shape, mycoplasty has been completed. One-to-one images, you know, the distance between shoulders, the width of the leg is equal. So it's a nice transformation one year after the surgery. With the control of the whole layer, superficial pit layer, deep pit layer, intermediate pit layer is under control and the nice, you know, muscle tightening has been achieved by doing just vertical midline application. So the nice, you know, woman line has been achieved. This lady comes from Gulf area, even in this, you know, dark skin type, we've been able to get, you know, good scar. So if the patient has epigastric hernia or digastric hernia, diastasis, so again, we will do this cross application. I call it French corset. And then it's three centimeters. You will do this interlocking. And I didn't use in my, you know, practice, not a material, you know, any foreign material in the patch. So this is because she comes from abroad. She sent me this early pictures that you see the diastasis has been corrected. The patient, if the patient asks me, you know, this, you know, high definition of the plastic, which has, you know, this, you know, severe deformity patients with high body mass index. So I stage my operation. The first operation will be excision with debulking. This is the result of the first operation. And then on the second operation, you are okay to do high definition. I shift the pectoralis, and then I give her, him some, you know, pec appearances. Again, the shadow images, you see that nice result has been achieved. In 2021, I was invited to this Russian Turkish Congress. I did live surgery. This is the case, tall lady. This is my marking before the surgery. And I did my surgery on November. And then six weeks later, she sent me a postcard without any complication. The surgery lasted two hours with question and answer. And again, you know, even it wasn't my home theater. I was able to get good results. And 2022, during the ICFs world meeting in Istanbul, I did live surgery. This is my team. Our friend, Mustafa Hamdi, did the breast surgery. My patient, Mustafa is sick. And I did, you know, abdoplasty. And the three weeks, three months later, three months later, you see that, you know, we achieved some shadows and the nice result. It is, you know, huge abdominal deformity patients. Again, the surgery lasted two hours. Postoperative care, nothing fancy. If I do a lot of, you know, liposuction, you know, large volume of liposuction, I don't hesitate to put drain. Otherwise, no drain needed. This is, you know, very early post-op results. And it's very gentle, very smooth. And we ask our patient not to do any gym for a month, but, you know, sometimes they don't obey. So this is a lady two weeks after the abdoplasty technique that she's been ice skating. And the good result, excellent result in Moscow, they asked me, I showed them. This is my, you know, very good result. This is one year post-op that you see that, you know, good fullness of the rectus colon has been protected. Good shadows, predictable space, negative space has been created. And this is the video. Smooth surface, no induration, no sensorial disturbances, no discoloration. This, you know, technology is very sophisticated and very gentle. And this is my excellent result, maybe, because she won the competition. So in 2023, I believe that our approach to the abdominoplasty should be three-dimensional. And it's easy, you know, just think it and just plan it. And it's, you are a good surgeon, and I'm sure you will able to get good result. Thank you. Thank you, Dr. Geniova. This was excellent. I myself have learned a lot from all three of these talks. I think we might have lost Dr. Saad, but thank you both, you and Dr. Nahas for being here, and we'll see if Dr. Saad can join. So we have a few minutes here for questions. So I'll start with you, Dr. Geniova. So I think a common question is, how much liposuction do you do, and in which plane? So do you have any guidance on when do you say there's enough liposuction, because definitely, if you do a lot of liposuction, you will jeopardize the flare. And are you being in the deep fat, like subscarpus, or in the superficial fat? So, thank you for the question. It's not about, you know, how much later. This is, you know, aesthetic outcome. You need to see the good result on the table. Some patients are very fatigued, so you don't need to reduce a lot. You need to check the neighboring aesthetic unit. The neighboring aesthetic unit thickness will give you a good result. The neighboring aesthetic unit thickness will give you the estimated amount of liposuction. So I start with the deep liposuction. This is, you know, this is close to the fascia, on the deep compartment. And for negative spaces, flanks, you know, waist area are very forgiven. You are okay to do kind of aggressive, or, you know, large volume of, you know, liposuction. And then you go to the superficial. If necessary. And then you'd go to the intermediate level. Negative space means it's a three-dimensional space, room, that you need to address all three layers, superficial, deep, and intermediate. If you are going to create a line, you need to address in one line, three layers also. On the epigastrium, I don't aspirate much, okay? I just thin out. I reduce the thickness on the epigastrium. And then I create a belly on the epigastrium. So it's not about math, you know, how much later. It's about what you see, you know, on the table. You need to achieve the good aesthetic view, observation on the table. And of course there will be a swelling, you know, wound healing process. But at the end of a couple of months, you will arrive to this level. Yes. So these were beautiful, really, truly, those three-dimensional results. Do you think that the plications, the tension suture, the quilting sutures, that if they're placed correctly, they can contribute to the three-dimensional results if you place them strategically along those lines? So it's not predictable, really, Ahmet, you know. I saw a lot of friends, colleagues, they are doing on the infra-umbrical area like Jean-Francois Pascal, Ozan. In order to reduce the tension on the closure, they try to put a lot of quilts and sutures to avoid the dead space and also to reduce the seroma rate, whatever. I don't think, in my practice, I don't use it. I don't think it's necessary, okay? So when I see a lot of dimples on the first day, it's not nice, so you don't need that. But progressive tension suture is important, of course. It will give you the opportunity to deepen the epigastric valley also, but avoid the tension around the umbilicus and avoid all the complication on the pubic area. You know, quilts and suture is not the best idea, but Fabio is a great surgeon. You know, he's my mentor, one of my mentor. To try to tighten the abdominal wall is an advanced technique, is an expertise. And in my patient, I don't see much of weakness on the lateral abdominal wall. So I don't address it. But, you know, if you feel with your patient that there is a weakness on the abdominal wall, of course you need to do some kind of application. All right, so I'll go to you, Dr. Nahas. And again, thank you very much for joining us. I know that you're traveling and that you're not in Brazil right now, so I really appreciate you taking the time. But look, I don't think there's anyone who has contributed to the science of abdominoplasty in the world today more than you, Dr. Nahas. So you've mentioned that placation works with both nylon and large PDS sutures. So what do you use? Now, now can you hear me? Can you hear me? Yes, I can hear you. So, you asked me whether... Can you repeat the question? You have shown, through your studies, that both nylon and large PDS sutures work. Ok. So, what do you use? I use mostly nylon for the applications, because at the end there was not a lot of benefit of using some absorbable sutures. Most of these sutures will be in the deep layer and will not be palpable. But it doesn't matter which you can use both on the availability and on the surgeon's preference. So, you can use both of them. We have proved that they in around 70 years follow-up, we have studied both nylon and PDS and they both work very well in the long-term post-operative. And still mentioning what Chemal said about placations. Actually, I did not reinforce the lateral aspect of the ... What I do is instead of doing a very wide placation in the midline to reinforce the abdominal wall as a whole, I prefer to leave space for the rectus abdominis muscle projection. So, instead of making a very wide placation, rotating the midline, thus decreasing the distance between ... I prefer to do the L-placation in which the placation will not compress the rectus abdominis muscle, nor rotate it towards the inside of the abdominal cavity. So, I'm just trying to improve the whole tonus of the abdominal wall. That's why I do the L-placation. Also, as a side effect, I'm going to have an increase in the waistline definition. And also, I can promote reduction of the abdominal wall. So that you can understand that we don't do that for increasing the tension in the lateral aspect, but rather, we increase the tension of the anterior abdominal wall by doing that. So, thank you for introducing this L-placation. Definitely, for me, there's one of the take-home messages from this panel, is this L-placation. My question to you about it is how high up do you go? Do you go all the way to the costal margin? And to do this L-placation, does that mean you have to do more subcutaneous dissection to get to the lateral? That's a very good point, Amed. When I started, as I have shown, I did a very wide undermining. But now, what I'm doing, I just do two tunnels right over the ciliary line towards the costal margins. But I go all the way up to the costal margins. So, I leave all those perforators from the rectus abdominis muscle inside. I don't cut them. Yeah. So, we have a question... I do a midline tunnel and a midline for a median tunnel, and I do the L-placation. So, you have three tunnels, basically. We have a question from the audience, and I know, Dr. Nahas, that you are doing a lot of research about this. The question is about post-operative garments. So, I'll start with you, Dr. Nahas, and then we'll go to Dr. Geniova for the same question, because I want to know how you control the swelling, because I'm looking at your earlier results, Dr. Geniova, and they're not swollen. So, Dr. Nahas, tell us about garments and the research that you are doing right now. Well, I did six... I published six papers so far. The first one is on the increase of the intra-abdominal pressure. And I have shown that there is an increase when you put the garment, the operation increases by three times the intra-abdominal pressure. So, I thought, well, maybe that will prevent the blood coming from the femoral vein. Not prevent, but will prevent the blood inside the vein. So, I did a study with Collor Doppler, that was the second study, that I have demonstrated that there is a decrease in the speed by 30%, an increase in cross-section of the vessel by 30%. So, that means phases. So, I think that that would be related to the increased risk of thrombus formation, because of the decrease of the speed of the blood in the lower limb vessels. So, I thought... Well, well, we have basically some reasons. The stabilization of your placation. Why do we do the... Why do we use garments? The stabilization of the placation is one of the reasons. The decrease of edema and a comfort for the patient. Right? So, I did some studies in each one of these issues and I found out that there was not an increased risk of rectus recurrence, rectus diastasis recurrence. The second one was that there was not an increase in seroma formation if you don't use garments. The third one was about edema. There was an increase in the first week and then in the group without garments. But then after the third week the group with garments we had an increase in edema after the third week. And then the comfort shown that there is more comfort for the patient in wearing compressed garments but after the operation people that did not wear garments said that there was no discomfort. So, it's more a psychological way of dealing with that. And also we did a fourth study a sixth study trying to evaluate the respiratory, the ventilatory function of the patients. And there was very good result without garments so that we don't have the restriction of the ventilation after the operation as that can cause also a connectasions. So, it was very possible to demonstrate that not using compression garments is feasible and the only thing that we need is comfort for the patient. So, I believe that we can use a different type of compression garments that will not increase that much the pressure and will give the comfort to the patients. So, I may come in the next future, in the near future with a different type of compression garments. Great! Dr. Sanjuva, what do you do? So, we are wearing garments but not tight one. So, the garments should be very moderate pressure. And when we apply the garments, we leave the inferior part of the garment open, okay? From the belly level, we don't close it. And the garment has three rows of closures and then the early period, because of the swelling, it's a large one and then gradually you can tighten up. After the fifth day, I evaluate the vascularization, the blood circulation on the suprapubic area. If everything is okay, I'm good to close it. During the operation, not only for abnormal plastic, but you know, in every cases, we are using the external pressure device. It's a must of your surgery, plastic surgery, in order to avoid the risk of DVT, which comes with the garment application. The garment is okay, you know, it's like liposuction, but it doesn't help the aesthetic outcome. It avoids the swelling and it can reduce the risk, the chance of bleeding. So, I think, you know, because of the garment, we reduce the tension on the blood circulation. So, it's helpful, but sometimes it's dangerous. So, you need to adjust and you need to control. If the patient complains about something related to the garment, we change the garment. We adjust all the time and we control the garment, but we don't close the lower part of the garment. Great. So, we're running out of time, so I'll ask you a quick question, Dr. Sanjeeva. So, you mentioned lateralization, a lateral vector of the flap. Thank you for mentioning that. This was described by Dr. Lockwood probably 25 years ago, but that maneuver is rarely, rarely used, and I do think it's very helpful. My question to you is, when you're doing that, you do end up with a longer dog ear. So, do you keep chasing it? Do you do an extended abdominal plasty in these? What do you usually do? So, you may have, of course, longer incision, but it's okay to get rid of the dog ear. Dog ear is under your control. You can see it. Even the elongated incision sides, you are able to correct the dog ear, and then if dog ear happens, it's a very minor one. So, don't hesitate to elongate, and don't hesitate, if necessary, lateralization of the flap. Can I add something to my liposuction technique? Yes. So, you can use the classic conventional liposuction device, but sweeping motion, it's forbidden, okay? You don't need, you cannot do sweeping motion. The liposuction should be, you know, back and forth, you know, it should be very direct, in a direct version. So, and also, laser liposuction, it cannot be used in this purpose, and also some rotational power assistive system cannot be used. It's forbidden for this, you know, approach. Classical, yes. Ultrasonic is gentle, and it will protect all the vascular system. So, only lateral torsical system, intercostal system, and the superior epigastric system is used for your flap, you know, vascularization. So, all the perforators coming from those systems should be protected. These are very important tips. I think if there's any trainees here who are listening to us, so liposuction, these are very experienced surgeons. I think we all do liposuction with the abdominal plasti-flap, but there's a learning curve for it. It has to be approached with caution. So, we're already 13 minutes over time, and I have enough questions. I think when we were in Austin, this panel discussion was around 40 minutes of questions, and we all learned a lot. But I think to respect everyone's time, we'll have to wrap things up. Again, I thank you very much. I know it's already late in the evening in Istanbul, and Dr. Nahas, I know that you're traveling. So, thank you both very much for taking the time for this. I myself learned a lot. This was a lot of fun. Thanks to the ESPS, and Davin, and Romina, and everyone for putting this together. And hopefully, we'll see all of you in future meetings. Thank you, Ahmet. Thank you, everybody. Thank you. I just would like to point out something that I didn't mention, which is the when I measure seroma formation, I did operations by placing QT sutures. All of them. And then I had a sematoma. So, this is important for you. If you are planning not to use something, any compression garments, you should do that. Okay? That was the only thought that I would like to mention. And thank you very much. I'm in Miami, and I just came out, and they're playing in there. I'm following that. Okay. Thank you very much. Enjoy the Miami Open, and hope to see you all soon. Thank you very much. Thank you. Thank you. Goodbye.

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