Hello, everyone. My name is Dr. Ashley Amalfi. I am a board-certified plastic surgeon in Rochester, New York, and I'm so excited to be your host and moderator today for this ASPS Global Partners webinar series. We have had an awesome series of lectures brought from some of the masters of their trade to you all over the world, and so we are so excited to bring you our speakers tonight. Please remember that even though we can't interact with you on the screen, we would love to interact with your questions. So throughout the presentations, please go to the little Q&A box at the bottom of your screen, type your questions in, and we will be sure to answer them at the end. We are going to take questions after all three of our speakers go. And remember that if you're unable to watch all of this tonight or you have friends who you think would love to watch this, all of this ASPS content will be recorded and kept for you on ASPS EdNet, so you can go there to get your credits and watch these amazing speakers. So I'm so excited for the panel we have tonight. So continuing this cosmetic focus, today we're focusing on lower body circumferential contouring. So this is such a niche topic, and we are looking at the masters of these topics here. So we have Dr. Jeff Gusanoff, Dr. Jennifer Kapla, and Dr. Ahmed Afifi, who are going to be with us today. We're going to start with Dr. Jeff Gusanoff. So Dr. Gusanoff is someone I know very well from his history and roots here in Rochester, New York. He earned his undergraduate degree at Johns Hopkins and then completed his residency in plastic surgery at the University of Rochester, which is where I met him when I was a young plastic surgeon wannabe, looking up to Dr. Gusanoff. He did a fellowship in body contouring surgery at UPMC. He's won numerous academic awards, written several peer-reviewed articles, book chapters, and textbook. And he truly is an expert in advanced body contouring and foot backcrafting surgery. So tonight we are so excited for him to talk about his lower body lift and buttock auto-augmentation. So please put your little questions in the chat, and we welcome Dr. Jeff Gusanoff. Thanks, Ashley. I really appreciate that, and I want to thank ASPS for the opportunity to present tonight or morning, wherever you are in the world. These are my disclosures, don't really have much impact today. There's a lot of things to consider when doing body lifts here. So there's the saddlebags, residual deformities, staging of the procedures, auto-augmentation or to not auto-augment, and then gluteal cleft elongation is a problem with body lifting that I want to address as well. So a lot of things to cover in a short amount of time. Outer thigh considerations are really important. Some people present with global adiposity of the thigh and looseness. In the middle here, you see the large pannus with saddlebags going out to the sides, global adiposity as well, and then some people have more isolated deformities such as just the saddlebags or inner thigh looseness that are sometimes a little bit easier to deal with, especially at lower BMIs. Now, when you have a high BMI or global thigh adiposity, you have to really decide whether this is the right patient for surgery. High BMIs can be associated with lymphedematous changes, and these may not be ideal candidates for any kind of procedure except for weight loss. There's lots of different body types. So there's the apple shape and there's the pear shape. So some people carry their weight in different locations, and so they may carry most their looseness after weight loss centrally, and some people carry it more in the hips and thighs. Managing patient expectations is really critical. We go over a very detailed list of complications that they may experience after surgery, and the one you really need to be careful to mention is leg swelling or chronic lymphedema with any circumferential procedure. It's also very important to document what their ankles look like before surgery because if they do have swelling, you want to be able to go back and look at what they look like. A lot of people have lipedema or residual adiposity down near the ankles, and you want to be able to document what they look like because when the rest of the body is smaller, those areas may start to actually appear larger to the patient even though there's no difference. This is a saddlebag deformity here. You can see this patient came in. We planned an extended paniculectomy operation and took off a lot of tissue, but you can see that she's still left with these lower saddlebags. So it's really important to point out other areas and how they'll be impacted by your operation so you can manage their expectations after the procedure. This patient was disappointed in her result even though we took off a lot of tissue and made a significant impact. For saddlebags, there's less benefit the further from your resection line. So the more you lower your scar, the more of an impact you're going to have on that saddlebag. To correct the problem, you need to resect more of it directly. So if you plan your incision high and you think you're just going to be able to lift it, gravity is going to fight you significantly. You can abduct your legs for marking as well as intraoperatively to help get some extra tissue out. And then judicious liposuction of residual areas may be very helpful, or they may not be helpful. We'll discuss a little bit of that later. Direct incision is another option. So the vertical scar going up and down to directly excise that saddlebag. This is an example of some of the saddlebags we face here in Pittsburgh. You can see the markings here. And then on the front side, we use the Hoyer lift to resect the rest of the tissue and came up with a really nice result for this person functionally. Here's another saddlebag, really significant ones extending and pulling the buttocks down. Here's the planned markings. You can see you have to really lower the upper incision to get the saddlebag out. And so you really commit to the lower incision first when you do this operation because you want to get that saddlebag out and then lower the upper incision based on towel clamp tension to determine when you know how much you can take out from above. So she did have a little bit of delayed healing laterally. This is very common. We use permanent sutures laterally on these cases because there is a lot of tension out there. It takes a little while for this to heal in. Another patient came in significant saddlebags. You can see the planned incisions here are going below the saddlebag. We have to lower the upper incision to accommodate for that. We're going to do debulking liposuction of the inner thigh at the same time and then come back in a staged fashion and address the inner thigh in a second stage. It allows us to also fix any delayed wound healing or areas like that when you have a second stage. But despite even doing all that, you can have residual deformities. And so this patient came back for touch-up liposuction of different areas to help improve even more. So residual deformities are always a problem with massive weight loss body contouring. Another patient with saddlebags, you can see the planned incisions here, probably needed to lower that upper incision even more. Despite taking out this tissue, she ended up with delayed wound healing on both sides. The tenets of plastic surgery are you have to get control of this wound. So we get it nice and clean, granulating, and then make sure it's loose enough that you can reclose it. Now, with the pinch test, it seems to come together rather easily. And that's a good test. However, once you cut these areas out, they tend to get larger. And you can also be surprised by hidden cavities, such as seroma cavities that can make things very complicated very quickly. So you need to be prepared for that. And then you can reclose it. And we made, you know, a pretty big improvement in terms of her wound healing and speeding things up. Still had a little bit of delayed healing that healed in secondarily. You know, really is a full six months of healing with any of these areas that are really slow to heal. Then, you know, I thought she'd had enough, but she wanted her inner thighs done. So she came back, had the inner thighs done, and that was challenging recovery as well. But she did well, and she was happy. For lateral thighplasty key points, lower your scars to capture those thigh saddlebags. It may be a trade-off for capturing back rolls. And it's a good opportunity for medial thigh liposuction. So again, staged approach, lower body lift, debulking liposuction. The tissues are going to relax and rotate down and in as your lower body lift relaxes. And then you can come back in that second stage and clean out the middle thigh. Lower body lift plus abdominoplasty creates a dramatic initial improvement in contour and tissue relaxation over time allows you to come back and tighten any laxity. It's an easier recovery and less operator stress. And the important thing to note is the lower body lift, lifting the buttocks first before your inner thigh operation cleans out the thigh gap. If you do the medial thigh lift first and pull in that loose buttocks tissue, they will not be happy. So you always have to simulate that lift of the inner thigh to see whether or not you're pulling in loose butt tissue because you may make the thigh gap worse. Really important point. Just another stage procedure, outer body, lower body first going all the way around and then staged inner thigh. And this is a long-term, I think three-year follow-up on this patient. Recurrent saddlebags are a big problem. Even though you take out a ton of tissue and you liposuction the residual saddlebags, these things can still come back as if you didn't even touch them. We published this in ASJ. It's a good paper to look up. We looked at 79 patients with saddlebag deformities and we rated them before and after surgery to see how the saddlebags changed. Scores improved slightly after surgery, but long-term results were largely unchanged from pre-op, surprisingly. We have a Pittsburgh rating scale for just about every deformity. This is our saddlebag rating scale that we created. And we had 170 patients, 79 met inclusion criteria, average age of 45, BMI 28. The pre-op score, no correlation with BMI or Delta BMI. And then we look at their short-term and long-term, really no difference. There's an improvement slightly short-term, but by long-term, you know, they're pretty much back to where they were. So even though you can see a nice improvement, it tends to come back. So here, initially a nice improvement, but then it settles down over time. And then when we looked at liposuction of the residual saddlebag, same pretty much panned out. So no major difference when you do liposuction versus no liposuction. You can see here, it just tends to settle down over time. Scar migration. So short-term, 97% have descent of the scar, which probably contributes to this situation. Long-term, no patients had further descent. So it's usually an early phenomenon of that scar coming down. And then usually once that has settled, you know, there's no going back on that. But now I'm going to transition to buttock auto-augmentation. So what's nice about auto augmentation is you have a robust blood supply. You need minimal deeper delialization. You can maintain buttock projection and your major complication is really minor wound healing for most of the cases. It occurs at the scar and it can be easily revised once you get control of the wound if it's a problem. We published a paper on this in PRS and you can see here the flattening you can get when you don't auto-augment. So we wanted to compare perceptions of both the patient and physicians with these types of cases. We looked at 97 patients, 42 had auto-augmentation, 55 had no auto-augmentation. The major complication again is wound dehiscence. And the bottom line is both groups are satisfied with the result. So the patients are happy and they're happy if they had it auto-augmented or they're happy if they didn't. Whatever they chose, they're happy with. Both groups would have surgery again and recommend it to a friend. However, surgeons repeatedly rank the aesthetics of an augmented buttocks higher than a non-augmented buttocks. But it's really what the patients want and what they're going to be happy with that's important. There's a lot of different designs. There's these, Rob Santino described these island flaps that you can do, which is similar to what we do in our practice. There's a mustache flap, which is also a little bit similar where you rotate that tissue down into a pocket that you create with the lower gluteal tissues. And then there's the transposition gluteoplasty where you're actually doing a lot of suturing. I tend not to do a ton of plication sutures within the mound because if these rupture, you can get asymmetry in your buttock shape and contour. This is a video I want to play just showing the markings because I think this is pretty important. So you can listen here for a few minutes. Dr. Gusanoff I don't hear any audio on your video. Oh I'm hearing it on my end I'm sorry. That's okay but if you want to just talk over it go ahead but we see it beautifully. Okay so yeah so basically you want to really design a gull wing pattern and then the lateral extent is sort of where the sinusoidal curve is of the hip and then the bottom is really a pinch test to kind of estimate that. I then use six centimeter bars to orient the tissues. You want your upper incision to be about the same length as your lower incision so you're not forcing tissues in and creating that gluteal elongation. We measure out to about the fourth bar here so six centimeters out four bars and that's usually mid axillary line and that's when we would flip the patient as far as that. Now I mark out to the third bar for the auto-augmentation and then I only mark like a J pattern to de-epithelialize because you really only need the outer rim of dermis to tack the flap down when you rotate it down that 45 to 90 degrees whatever you can get in terms of the rotation. So I'm just going to mark here what's going to be de-epithelialized and then we'll move this along here and then it just gets merged into the front. So here we're planning a fleur-de-lis abdominoplasty for her as well. I usually mark that pubic area six centimeters above the vulva commissure and then everything here is really estimated and determined intraoperatively in terms of the vertical excision and everything else. So this just sort of shows the tentative markings by pinch and then again we estimate everything and check everything in the operating room again. So the important thing is to know that the incision pattern always looks higher on the table once the patient is prone. So here you can see when you put the patient prone that whole pattern rotates up so you have to be very careful to to you know follow your pattern. It's really important you have to commit to your upper and lower incisions at the same time and then the buttocks projection will descend with time and then again beware of elongation of the gluteal crease and wound healing problems we'll go over in a minute here. I'm going to move through some of this quickly just in the interest of time but you can see in this pattern I designed that upper incision way too straight so there's a major discrepancy in the upper and lower incisions here. All right it's going to force tissues medially we dip that lateral edge of the flap rotate it down and then secure it with some braided poly like a polysorb suture and then we lift everything up over top of that to get nice projection that usually should be directly opposite the mons or pubic symphysis area. Another patient little showing the the mounds here there's a one-year post-op and this patient you can see here nice initial results but then you can see that everything's going to settle over time and she developed this elongation of the gluteal cleft and it was bothering her so how do we fix this? We basically de-ep it and then roll it like a cigarette on itself and bury it and close the skin over top for filler so instead of fat grafting it or anything like that you use the dermis to roll it in on itself and then close the skin on top of that and it gives you basically a straight line scar so it looks like they had spine surgery or some sort of back surgery instead of a deep cleft in that area. So this just sort of goes through that elongation and the risk factors for that including a lower pattern length discrepancy and significant back laxity. This patient has all those things going on so a lot of elongation of the gluteal cleft. So let me just move through this in the interest of time these are some long-term follow-ups so you don't have to auto-augment everybody but they can get some flattening which is sometimes not very desirable to the surgeon but again if they have this like shelf in the back those are great patients to cut that shelf out and they'll get a really nice contour afterwards without any auto-augmentation. When they're super flat like this they end up even flatter they can end up with bad stretch marks and things like that so be careful with this patient population. Same thing here you can always lipo fill a non-augmented lower body lift but it's difficult to find enough fat in these patients. This is three weeks after a lower body lift you need to be careful with bending over if they do dehisc then we wash it out close it over a Penrose drain and we do this in any kind of setting the office the ED if it needs to go the operating room you can do that. I used to use permanent sutures but it doesn't really help you they still get wound breakdown back here especially in auto-augmentation it's the biggest problem with this operation. So in summary manage patient expectations with saddlebags auto-augmentation is my procedure of choice for massive weight loss patients. The biggest risk is wound dehiscence which can be usually managed conservatively and then thoughtful surgical planning can avoid gluteal elongation. Thank you very much. Thank you so much Dr. Yusnoff that was wonderful the video is great and when you started talking I think everyone totally understood what was going on so I don't think anything was lost there. I'll reserve my questions for the very end but thank you and thank you for being so honest and showing complications I think that's so reassuring for everyone to see when you're doing these sort of difficult cases that even in the best hands these are just really challenging patients so thank you so much. So our last presenter is Dr. Ahmed Afifi he's a cosmetic plastic and reconstructive surgeon in Madison Wisconsin. He received his medical degree from Cairo University School of Medicine he's been in practice for more than 20 years. Dr. Afifi is the associate professor for the department of surgery at the University of Wisconsin School of Medicine and Public Health in the plastic and reconstructive surgery division and without further ado we are so excited for your talk Dr. Afifi. Thanks Ashley I hope you can see my my presentation and can hear me well. I hear you and now I see you sharing your screen so you're great. Great so thanks to the ASPS staff Devin Romina you guys do all the heavy work and we're actually doing the fun part and it's an honor to share this with Ashley and Jennifer and Jeff they've been friends and colleagues for a long time and I've learned from all of them. So lower body lifts. So these are my disclosures they're unrelated to this talk. So this is my practice 14 years ago and it's probably similar to yours. Most of my abdominal classes were being supine only abdominoplasty. I think that's a long time ago there's my practice now. The vast majority of patients were starting prone. I think this has we first started prone for the liposuction which prompted us to do the extended abdominoplasty and now the lower body lift. The last statistics from ASPS were released yesterday and they show a significant increase in lower body lifts. So what is the real complication rate of lower body lift? I think Dr. Gosanoff showed us some very honest results and the complication rate. We'll publish we're submitting this work soon. We did a meta-analysis of all the published literature and 39 articles over 1,200 patients and the mean complication rate was around 36 percent with the wound distance of 17 and the seroma rate of 14 percent. And when you're considering these numbers consider that this is the literature from the most experienced surgeons in the world and that the vast majority of retrospective articles would tend to under-report the actual complication rate. I would say my complication rate is at least as high as this and and that most lower body lifts have an even higher complication rate. So how can we decrease the complication rate? I'll talk about four things that I'm doing I've done to improve my outcome. The first thing is auto-augmentation and Dr. Gosanoff has mentioned this. When I look at lower body lift to me there are two big categories. The one is auto-augmentation which I was trained to do and I've done them for many years and there are many different ways to do that. So there's a patient of mine again I do an auto-augmentation with a purse ring luteoplasty and fat grafting and you see her outcome. I would say there's a nice outcome with a smooth elevated buttock and you can barely see the scar under this ring. Here's another patient again my preference was to do the purse ring luteoplasty as described by Hansted. Dr. Gosanoff he showed us many different ways of doing it. I've actually tried most of them and I settled on this one as my preference and again nice outcome with a very well healed scar. But there's another approach which is to do just a lower cut, upper cut and just close with no undermining and no auto-augmentation and Dr. Gosanoff showed us this number. Auto-augmentation in their practice more than doubles the complication rate. Now when you're looking at these numbers consider two things. Number one is that these are very experienced surgeons. Their outcomes are probably better than most surgeons. Number two they do have a much more challenging patient population than most of us. So our meta-analysis showed that auto-augmentation does increase the risk of seroma, bleeding and return to the operating room. I was getting a lot of seromas personally with these patients. Sometimes they would just go away with repeated aspirations. Sometimes I would go to the OR. Sometimes they would lead to adhesions. It was just too much work for me and headache for the patient. So I'm trying to switch more to not doing an auto-augmentation. So there's a more challenging patient with a higher BMI and a significant amount of weight loss. And in spite of that I just do a simple cut, cut, close, no auto-augmentation, no undermining and you see that she can heal very well afterwards. I'm always doing this in most patients right now. Here's a thinner patient. She's really bothered by her infrabutter crease. She wants to completely eliminate it. It becomes a very simple procedure to just do it and you can see how well she heals. So I've gone from the beginning of my practice which I was doing an auto-augmentation in everyone, because that's what I was trained to do, to being more selective. And now I'm being more and more selective and I rarely do auto-augmentations anymore. So change the sequence of body contouring. And the large part of this is because of this technique. This just came out. I published this, came out in PRS this month about fat grafting to the breast, which I do a lot for both aesthetic and reconstructive breasts. I'll explain in a second how this is related to lower body lift. So when I see these patients, most of them, they need surges all over the body. I personally do not do all of them in one surgery. Most of these patients in my hands will go to the operating room three or four times. And we were always taught to start with the abdomen because that's the biggest area of concern and that's what most surgeons are most comfortable with. And I still do that in most patients. I do a lot of lower body lift in most patients, one stage as the first procedure. Like this patient that you see here, just a lower body lift with the breast surgery, one procedure. And this patient that I showed you, I started with the lower body lift. So I do a lot of that. However, one of the principles of body contouring is to not do vectors that are opposing each other. So when you look at this video here, with the patient in a flexed position, in a prone and flexed position, you'll see that it's quite tight. Once I level the bed, the laxity becomes much more. So what does this tell you when you have a patient after a lower body lift in a semi-sitting position? You see the laxity has just gotten so much more by just leveling the bed. So what does this tell you about your opposing tensions when you're doing a lower body lift on the front and the back? And again, we're usually starting with the abdomen because most of us are more comfortable with the abdomen. I think that was 15-20 years ago. Most of us are very used right now to doing lower body lifts. I'm not sure there's any more complicated for most people listening here than an abdominal plasty. So why do I try to separate the posterior body lift from the front because of opposing tension? And now I usually start with the posterior lower body lift, which is the buttock lift, and the breast. And I actually leave the abdomen to a later stage. Why do I do that? It's because with the breast surgery and with the buttock, I raise the IMF, I raise the breast, and I raise the buttock. Dr. Kaplan just told us about the power of pulling upwards. And Dr. Kosanoff, in his talk, he said you have to pull up before you pull down. It's the same principle what Jeff just showed us about pulling the thigh and the butt up before pulling down with the medial thigh lift. It's the same with the facelift that we start with pulling this mass up before doing the neck. It's the same thing here. So I raise the breast, often with raising of the IMF, some form of a reverse abdominal plasty, and this allows me to shape the buttock and the breast so I can come back with the second stage and do breast fat grafting. I'll skip through this because I know we're running behind. So I like raising the IMF in many of these patients. I do a lot of reconstructive breast surgery, so I've gotten familiar with this approach. And you see here is a patient, there's, again, they're separate from this talk, but just just showing the power of a reverse abdominal plasty with raising the IMF. She comes wanting a breast lift. The nipple is already too high in relation to the IMF. But however, I raise the IMF, reverse abdominal plasty, and now I can raise the nipple even higher. So you can see that we can get her from here to here. I did not do an abdominal plasty on her. This is just the reverse abdominal plasty and the liposuction. So I start with the posterior lower body lift and the breast surgery because I want to position the breast and the buttock in the right position so I can come back later and do the buttock and the breast fat grafting with the abdominal plasty. And the other thing I would mention, it's not written here, Dr. Kosanoff just mentioned the recurrent saddlebag and lateral trochanteric plasty. When I separate both of them in that lateral area, it gives me another take to actually resect it again with the abdomen. And I have, I have just to emphasize so no one is confused, is that I do not do this in everyone. But if a patient is going to commit to having three or four surgeries with me, then this is my preferred approach. So the first surgery, I do a posterior lower body lift, breast lift, raise the IMF. We do this surgery, we get her to here. In the second surgery, I'm doing a fleur de lis with the arm and fat grafting the breast to get her bigger and fat grafting the buttock if needed. So oblique flank plasty. Dr. Kosanoff just mentioned, the closer your resection line to the area of concern, the more effective you will be. So this was published by Dr. Hurwitz, and I first heard about this around seven or eight years ago. And basically, there's the difference between a lower body lift and an oblique flank plasty. So lower body lift is a transverse excision, oblique flank plasty, it goes along the exact area of the concern, which is right along the flank. Now the obvious drawback of that is that the scar cannot be hidden by swimsuits or underwear. Again, but if the patient's biggest concern is that, you can put the scar right there. Now, I was hesitant for a long, long time to try this because I did not like the idea of a scar. This is one of my first patients. I saw her for breast reconstruction. She has breast cancer, previous implants done elsewhere. So I was doing a DIEP, a free flap reconstruction to the breast, together with implants under the free flap, doing a mastectomy, removing the implants obviously, and she wanted me to take care of the flank. And she had multiple tattoos there. So I told her, I'll do the flank plasty for you. However, you'll promise to tattoo the scar. Eventually, that's what she looks like. So there's three months after the flank plasty, and there's what she looks like 15 months after the flank plasty. So there's free flap to the breast with implants underneath, nipple tattooing, and I'm doing the flank plasty. She never got the tattoo because that's what the scar looks like at 15 months. Here's another patient. Again, I did this with a fleur-de-lis and you see on the front and on the back, again, not the most, not the ideal location of a scar, but patients do not seem to care about that at all. So I started doing more and more of these and then became more clear to me that the indications of an oblique flank plasty, we published this this year. And when I compare a lower body lift to an oblique flank plasty, a lower body lift definitely has a better scar than oblique flank plasty. There's no, no, no, uh, discussion, no debate about it. There's a patient after a lower body lift, again, with the right underwear, you cannot see the scar at all. Healing. I think there's to me, the biggest selling point of the oblique flank plasty is that the healing is so much better. Why is that? We all know that the dermis of the back is the thickest dermis in the body. The healing is so much better that dermis is not in a sweaty macerated area. The healing of an oblique flank plasty is so much easier than a lower body lift. A waist reduction in lower body lift is limited. It's mostly by your liposuction. Look at the literature. So these are patients from the literature, not my patients. If even after a lower body lift, they still do have a bulge at the area of the flank. Here's another patient after a lower body lift, still a significant bulge in the flank. With a flank plasty, I just showed you the significant improvement in the waist and the flank. The butt aesthetics. So again, principles of body contouring, the closer you are to the area of concern, the more effective it will be. So to me, a lower body lift is more effective at the infrabutter crease. Like this patient here, there's her biggest concern. I do a lower body lift to smoothen out this area. Perfect scar. You cannot see it. However, when you see a patient like this, at first I thought that I do not really change the buttock with an oblique flank plasty. I thought it's too far away. Until this patient came after the oblique flank plasty and told me that her buttock is so much better. I was like, this could be a placebo. And then I went back and looked at the pictures and then I realized why she's saying the buttock is so much better because there's what she looks like two weeks after the flank plasty. I'm showing you the early results. So you wouldn't think it's from weight loss. There's just two weeks after the procedure and you see very easy healing and no elongation of the infrabutter crease. In fact, it actually usually shortens the infrabutter crease. And there's what she looks like six months after the oblique flank plasty. Buttock fat grafting, you can be much more liberal with it. The trend all over the world right now with buttock fat grafting, it's much easier to do with an oblique flank plasty. So here's a patient with an oblique flank plasty and I'm doing all the buttock fat grafting and I can really correct the C point there. Anterior midline laxity with an oblique flank plasty. I'll show you this patient and this will explain the point. So there's a patient who I saw for a lower body lift and afterwards for an upper body lift. And there's what she looks like. I would say there's significant improvement, but she had two concerns. Number one is that this residual area in the flank was still bothering her. And number two is that she still had some anterior midline laxity. So an oblique flank plasty, I do not think it will substitute for a fleur de lis. If you need a fleur de lis, I don't think there's any way to get away from it. But patients who are borderline for a fleur de lis, the oblique flank plasty can actually correct this area of concern. So you see me here when I'm simulating the effect of the oblique flank plasty on this patient, that it actually does improve the anterior midline laxity. So that's what I do on her. That's her request. And you see her after the oblique flank plasty after a previous lower body lift. So this after a lower body lift and after the flank plasty, you can see the big improvement in the waist. Finally, I would say perioperative care. Nutrition is a big issue in these patients and it's a complicated thing. All of these patients, I have them take one of these nutritional supplements. I have no conflict of interest. There's what's available in the USA. I'm not sure what's available in other, in the rest of the world. So in conclusion, lower body lifts have a high complication rate, large variation in technique. Personally, I avoid auto-augmentation. Second, I separate the posterior from the anterior lower body lift, but I have to emphasize this is only in patients who are committing to three or four surgeries. Still, the vast majority of my practice, our patients were coming in wanting one surgery, a circumferential lower body lift in one surgery. And that's still the majority of my practice, single stage anterior and posterior. However, in the right patient, I do separate the front from the back. Oblique flank plasty, again, it is not superior to a lower body lift. It's another option. I still do more lower body lifts than oblique flank plasty. And finally it's pre and post-operative nutrition. Again, thank you for giving me the opportunity to speak to you today. Thank you so much, Ahmed. That was amazing. And that flank plasty is really, really interesting. I'm excited to hear the other speakers talk about that. If everyone wants to jump in for a quick question and answer, we have a few questions from the audience and I think that they'll keep rolling in. I know, I know we're getting close to time, but we're going to give a good 10 minutes to question and answers here. The first question was for you, Dr. Rafifi. It sounds like the flank plasty has evolved from your concern for tension when you're doing the anterior and posterior resection at the same time. I'm wondering how that relates to the way that you do your surgeries, Dr. Kaplan, Dr. Gusanoff, because one of the questions for the audience is, how do you really flex your patient when you're doing the abdominal plasty portion of the circumferential body lift? Or do you not do that because that tension that Dr. Rafifi was talking about is, is really a concern. And that's what the, that's what the question is about. So I actually jackknife the bed when I do the buttocks. So it simulates a little bit of the flexion when you flip the patient over. It also has you set the tension for the lower body lift with a little bit more, you know, you're, you're, you're closing it somewhat tight, but when they technically stand up straight, then hopefully it's a little bit looser back there. But you have to be careful when you jackknife the table, make sure you do some reverse Trendelenburg to raise the head so that there isn't a lot of pressure on the eyes during that portion. But I try to, it's not the same amount of flexion as when you're doing the abdominal plasty, but it's, it's a little bit. And when you have issues with healing, do you find that then they're more anterior because you are a little bit looser when the patient starts to stand up postoperatively, or do you think it's equally the front and the back where you're having wound healing issues? Oh, it's definitely the back. It's definitely, it's definitely the lower body lift incision. I think cause they're like sitting on it after surgery. They're sitting on it during the operation. After you've just operated on it, if you're auto-augmenting, you're undermining that lower flap. So there's less blood supply to that incision line. Sure. All the things. The other question was a very specific question about the elongated gluteal cleft, Dr. Gusanoff, that you were chatting about. Is there anything that you can do preventatively or any tricks that you've learned about that the marking and incision placement that would reduce the risk? I know you talked a little bit about the equivalent lines, the upper end and lower incision being equivalent. But there someone was just asking if you have any other tips to avoid that complication. No, I mean, I think sometimes your hands are tied because the, when you design that going in, it, it may be like in such a loose gluteal cleft that you're going to end up putting most of that incision in that, that cleft because it is just descended so low. You need to lift it to get it out. It's really just trying to keep that upper and lower incision as even as possible. So really, really diving in. If you know that you're, you have so much descent and looseness of that cleft that your lower incision is going to be coming way up like this. So you've got to try to balance those two as best as you can. Any tips from anyone else on that question? Do you guys do the little cigarette, the rolled dermis that Dr. Kusinov, I'm not going to be able to get that out of my head, that he explained to kind of fix that. I didn't know it, but I like it. It depends on the gene style, right? Ashley. So if you, you know, if the low rise genes are in style. If they come back, we're doomed. They bend over and they're gone. What are the high rise genes, whatever they're called. Yeah. I mean, that's, that's in right now. So it's golden. Yeah, that's perfect. That's perfect. There was a specific question about drainage. One of the, one of the viewers said that he has trouble with some fat, liquefied fat that drains through the incisions. I'm not sure how you guys feel about that fat necrosis. And if you see that, and if you have any questions about that, I'd love to hear from you. How you guys feel about that fat necrosis. And if you see that and if you have any tips to prevent it. So on the back incision, I've kind of transitioned from using a running barbed suture in the superficial fascial system. Cause I feel like it just can cut off the blood supply to too much fat. So I've gone to using just interrupted like two O polysorbs or whatever, two O braided, absorbable suture to close that and get the superficial fascial system together. Can you still get fat necrosis? Yeah. If you cut off the blood supply and it dies, then yeah, it's a problem. The flaps though are usually very robust and we don't see a lot of fat necrosis of the flaps cause you're not undermining it on a pedicle to rotate it down. So fat necrosis is not really an issue of the flaps. It's really the incision line, deep sutures and that fat. Is everyone else using braided, using barbed suture or just throwing individual sutures or? So I use a barbed suture for the dermal closure, but the deep closure, I use a regular Vicryl and I would say number one, to avoid any problems with that is no undermining. If you're just doing a straight line resection with no undermining, the healing is so much better. And number two is a subscarpal plane of resection will usually work better. And we've shown that in our meta analysis. So people who resect suprascarpas trying to preserve the scarpus fat, that's when you're into trouble. But if you resect the scarpus fascia, and then you're having scarpus to scarpus closure, that's a much more secure closure. Let's go through the whole panel for one last question. Everyone always likes to know about, I think two big questions come up. How much surgery do you do in an outpatient setting? What is your threshold for admitting patients? Or if you're in an ambulatory surgery center, what are some guidelines for surgeons regarding that? And then number two, what's your DVT protocol for VTE prophylaxis in this population? Whoever wants to start can start. So I do all my patients in the hospital. So they all stay overnight. Anything abdominoplasty or greater stays overnight. If I do a lower body lift going around and I will sometimes keep them two nights in the hospital just to make sure their pain's under control and everything before they get out and they have help getting in and out of bed and getting comfortable with that whole process before I send them home. So it's usually one to two nights. And then I give DVT prophylaxis. I give sub-Q heparin before surgery and I keep them on a Q8 afterwards. And I only send them home with something if they have that need or recommendation from, you know, high Caprini or something like that. So most of my cosmetic patients are done outpatient. So they go home the same day. I would say it's much more convenient for them to spend the night. If I had that option, I would have definitely done it for all my abdominoplasty. If there's a component that's covered by insurance, then I do keep them overnight, which again, it's much easier for them and their families. So all my surgeries have to be done in less than six hours and preferably less than five hours, no blood transfusion. So I'm very careful about being completely dry, lots of tumescence. And all my patients, similar to Jeff, I give them Lovonox with induction of anesthesia. If they have any other predisposing factors, then we would give them anticoagulation for further two weeks. Fantastic. Well, thank you all for staying just a little bit later. Thank you to all of our panelists, Dr. Apifi, Dr. Gusanoff and Dr. Kapla. And to all of you from all around the world for tuning in or watching this on demand, we will have many more global seminars to come. So we are so excited for what's to come and grateful to all of our participants today for sharing their amazing results and knowledge. So thank you all so much and have a wonderful night.

body contouring

lower body circumferential contouring

buttock auto-augmentation

gluteal cleft elongation

oblique flank plasty

surgical planning

complication rates

post-operative care

lower body contouring

body lifts

gluteal elongation

auto-augmentation

patient management

perioperative care

preoperative planning