Good evening and thank you for joining us. My name is Karen Wadlow. I'm the Commercial Education Manager for Mentor and I'm honored to facilitate tonight's webcast. Before introducing Dr. Brian Thornton, our speaker for the evening, I wanna run through just a few tips to help make the webinar most successful. Your engagement is what's truly going to make this event the most relevant to you. So please participate throughout the program by submitting any questions you might have. We will have approximately 15 minutes for Q&A at the end of tonight's talk. If you have a question at any time throughout the program, please just type it into the bar at the bottom of your screen where it says enter question here and then hit submit. That's all you need to do and your question will be received in the queue and held until it's time for the Q&A session following the presentation. Please know that we will do our very best to answer all questions received, but we do have a hard stop at the end of the hour. For the best viewing experience, please ensure you've maximized your bandwidth. You can do that by closing out any additional programs or browsers you might have open. And finally, if you experience any technical difficulties during the broadcast, please call 866-330-6655 for assistance. Again, the number is 866-330-6655 and someone will be available to assist throughout the broadcast. Tonight, we have our fifth and final webinar of our Spring Into Knowledge series, and we're extremely fortunate to be joined by Dr. Brian Thornton to bring our series to a close. Over the next hour, Dr. Thornton will share key insights on how to navigate breast reconstruction in the pre-pectoral space. Dr. Thornton is board certified by the American Board of Plastic Surgery and a member of the American Society of Plastic Surgeons. While attending the University of Louisville, he completed medical and graduate school and received his MD and PhD in microbiology and immunology. He completed an integrated residency in plastic and reconstructive surgery at the University of Kentucky and completed an MBA at the University of Louisville in 2013. He's also authored numerous scientific publications, invited seminars and textbooks. Dr. Thornton is also a frequent editor of several journals, including the Journal of Plastic and Reconstructive Surgery, Journal of Plastic and Hand Surgery, Aesthetic Surgery Journal, and Journal of Surgical Oncology. He serves on clinical faculty at the University of Kentucky and has been a visiting professor of plastic surgery at multiple academic institutions. He's the past medical staff president of Norton Hospital, the vice chair of surgery for Norton Hospital, and his educational background in both medicine and business make him a strong partner serving on multiple committees. His private practice, Thornton MD Plastic Surgery, focuses on the reconstructive needs of breast cancer patients. Dr. Thornton's expertise and passion for helping breast cancer patients has inspired him to combine art and medicine into his practice by providing creative solutions to his breast reconstructive patients and helping them to fulfill their expectations and enhancing their outcomes. He's been awarded the Patient Choice Award for patient care. He's received multiple compassionate doctor recognition awards, and he's been voted top doc by his peers. With accolades and achievements that could go on and on, I also would like to mention Dr. Thornton's devotion slash Tenga yoga in his spare time, and of course, his dedication to keeping up with his five-year-old twins. Dr. Thornton, we're grateful you've taken the time to join us this evening, and it's my pleasure to turn the presentation over to you. Well, thanks, Sharon. That's awful nice of you on this really kind of cold and dismal day here in Louisville, Kentucky, and thanks to all you guys for showing up and taking times out of your life away from your families. I want to thank Mentor for having a really fantastic spring into knowledge. The last anchor, as Jaron pointed out, with Dr. Nasralli starting several weeks ago back on April 15th in the midst of the COVID outbreak, and followed by Dr. Amalfi, as well as Dr. Garcia just a couple of weeks ago. Those lectures, as well as mine, are available through the J&J Archive, and so if you would like to get access to see those at a later date, including my lecture, just reach out to your rep, and they can make sure they get you the correct way to point your compass to get access to those. Tonight, our discussion is about something I'm very passionate about, and that's really about moving the standard submuscular reconstruction into the pre-PEC space. And so I think for lots of us over the last four or five years, and for me starting with pre-PEC reconstruction starting in 2015, I've been so happy in a different way thinking about breast reconstruction. I think somewhere between nipple sparing mastectomy and now the pre-PEC space has really just changed my practice compared to where I was 15 years ago when I first started out. But I had a significant number of patients who had had submuscular reconstruction over the first 10 years of my practice, which as my pre-PEC role immediate reconstruction kind of really got cemented, and I understood how to get away with it and the right techniques, it really made me start thinking about patients that I was seeing in long-term follow-up who hated their submuscular animation, the stiffness of their breast, the less natural way it filled, and that led us to start thinking about this concept of conversion is how we refer to that in the office. So tonight I'm going to go through with you what our current algorithm is, how to think about that, kind of the nuts and bolts is the way I like to think about things that you can start to use in practice maybe tomorrow or depending on how you're going about your COVID day. I have a little key emblem because I do think it's important that I've learned some things the hard way that I'll point out. And so whenever you see the little key in the upper right-hand corner, that may be something that you want to think about or take a little bit of a note for. My disclosures, both mentor and MTF. So what our practice does is we're really focused on the needs of our breast reconstruction patients. I'm happy to be a part of, but not employed by a giant hospital organization called Norton Healthcare that really does a tremendous amount of breast cancer work. I'm not the only plastic surgery in the system, but I've really kind of focused on taking care of a lot of referrals for their breast cancer needs. And our system does more breast cancer treatments than all the rest of the hospitals in our state of Kentucky combined. So we're a very busy organization with a tremendous throughput. As a result, year to year, we do a lot of two-stage breast reconstructions. I don't do a lot of direct to implants. We do about a hundred patients, almost 200 breasts. Most of those are immediate reconstruction and the majority are delayed. So this has been what has really been my career over the last 15 years or so. And I'm quite proud of that. And so when I came out of training, we knew that there were advantages, or I was taught that there were advantages of submuscular reconstruction. The significant advantage was mostly about increasing soft tissue coverage over the implant and more vascularized, the pectoralis major muscle, maybe would protect your skin flaps against viability concerns after mastectomy. Maybe it would camouflage rippling and wrinkling of our implants at the time. And of course, just more vascularized tissue resulted in a better experience. So that's what I was taught and many of us were taught over many, many years. But there are significant disadvantages in my mind. I think it took me a while to really understand the pain aspect of this. We know that patients will have an acute pain problem, certainly in the first couple of weeks or a couple of even months after undergoing submuscular reconstruction, different than the standard augmentation patients. But patients will also have chronic pain associated with their submuscular reconstruction. There's been a hard to figure out a number of that. In my estimation, it's maybe somewhere of one to 5% of patients will have a chronic pain. Now they don't describe it as pain. They'll just talk about things hurting if you ask them in long-term follow-up. I still had problems with implant visibility and meaning rippling and wrinkling of my implants when it was in the submuscular space. So if the muscle was providing me that much soft tissue coverage and preventing that problem, I still had that as an issue. I also think now in hindsight that the muscle contributes to malposition. We know part of what we do as plastic surgeons is to control scar and fight gravity. Well, we're maybe controlling scar and breast reconstruction but it's hard to fight gravity. So I think the problem with the muscle and gravity was constant driving the implant, not quite inferior, not quite laterally, but inferior laterally to continue to get that implant out of its place resulted in kind of pocket distention problems, lots of soft tissue problems in that space. And of course, the big thing is simply this. My patient in that first photograph have a pretty nice looking reconstruction, I think, right up until she does this. So animation is not normal. There's nothing normal about the way this patient's reconstruction looks. And so that really got me thinking about what am I doing for my patients and what could I do better? And initially that led to me in the immediate space, like I said, in 2015, doing above the muscle reconstruction, but really in about 2016, 2017, I started thinking about my current patients with their submuscular reconstruction, like the lady I just showed you. So this is her and a little brief history of her. Back in 2012, I met her. She was a 41-year-old BRCA2 positive patient. She had a history of a wise pattern mastopexy and had submuscular augmentation. So she's interested with it. She understands implants. She's kind of cares about her breasts, but there's certain things she doesn't like about her breasts, including specifically the BRCA2 gene. So through about five surgeries, which was my deal in 2012, I tell patients they're looking around five surgeries with mastectomy, submuscular expander placement, followed by exchange to silicone implants, followed by a bunch of fat grafting. And then ultimately in the middle of the fat grafting, we did do a circumareolar mastopexy to kind of address a widened areola problem that she was not happy about. So again, I think she has a fantastic result in repose, right? But this is the issue, just like we saw in the video. And so for me, this is no longer acceptable. Patients are not happy about the result of this. They certainly don't think about their breasts feeling naturally and continue to make us think about what are the other possibilities. And that's created what we think about as the prefectural conversion algorithm or how we go about addressing that in the office. So I'd like to share with you the complete setup of how we address it in the office, OR experience, how we do it in the OR and our post-op follow-up to kind of give you a nuts and bolts of at least one person's experience. So the first thing, most of these patients are coming to us either from word of mouth, which is increasing, or just our long-term follow-up of our submuscular patients. Typically for our submuscular patients and really all patients, we'll see them once a year for the first five years. After five years, we typically will see them every other year. And then through about year 15, we'll get back in front of them once a year. So as patients are coming around and maybe talking to my physician assistant or myself, we'll schedule them a sit-down appointment with me to simply talk about prefectural conversion. We'll allow about 60 minutes for that time slot for those patients as they talk to us about it. And there's some key things we need to understand. The first is, what do they have? Because obviously this makes a big difference if you know type of implant as far as size, saline or silicone doesn't make any difference, but there'll be a really important understanding about that volume of the implant in a moment. Of course, more and more patients that are having reconstruction done by other individuals in our community or region or Washington Shore, as I like to say in my office, after they have talked to other patients who have undergone conversion, and we may not have any of this data as far as what their implants go. Now, obviously we take photographs in the normal preoperative space for this. And then we really try to address with them what changes are they interested in? And then particularly, this really revolves around the implant itself. So one key lesson, as you see down there highlighted, is the fact of this, a submuscular device of the same volume. So let's pick a number, 500 cc submuscular silicone implant. If I take that implant and move it to above the muscle, they're gonna look bigger. There is some blunting effect in my opinion of the muscle itself that really kind of squishes the implant down and thus kind of distorts its size or volume of the device. So we learned the hard way, if they wanna be the same size, I need a smaller implant. If they wanna be bigger, I need a little bit bigger implant, but I can't use the same implant and expect them to look exactly the same. So understanding that kind of need of the patient and fundamental change was really a steep learning curve for us in the very beginning. It didn't take very many cases for us to understand the difference. So understanding that volume is really critical and understanding what the patients don't like as well. As we moved into this, this became an outpatient surgery for us. So we do all these as outpatient surgery, which is critical right now, at least for our institution. That's the only surgery that we're still currently allowed to perform. We allow for about one hour per breast currently. That's probably a little bit longer than what we need. I would suggest in the beginning, you might allow for an hour and a half or so for the surgery per breast. A lot of that's because I do have a physician assistant who works with me in the OR and is doing a lot of the back table work that we'll discuss in a moment. So minimum of an hour for us, maybe longer if this is the first time you've tried this. We are COVID-19 testing all our patients, at least in the state of Kentucky, which is an interesting thing as well. We do provide obviously pain medicine for these patients after surgery, but we do not prescribe antibiotics. So they'll get their normal perioperative dosing of two grams of Kefsol. We do provide a antibiotic solution, a la Bill Adams, with Kefsol and genomycin and betadine since bacitracin is no longer available. And so that's kind of the normal setup for their outpatient surgery. The next question or key is what do you use? Do you use an expander or do you use an implant? So in the beginning, I'm very comfortable with an expander, a lot of two-stage reconstructions. So I went with what I did and knew well, which was the expander. So for the first four to five of these patients, we fell back to an expander. My current thought process is if they did not get good filling of the soft tissue envelope, there's lots of weird skin changes or a variety of things. Those patients might still do better with an expander, but boy, is it difficult to talk to a lady into putting an expander in them one time, let alone two times. So rarely, rarely today will we put expanders back in patients, but I think that's always a good opportunity. Certainly if they want a large volume change, especially in the up direction, they've got a 300 CC implant, they've decided they want bigger. I think that may be a safer way to go about that. And again, allow patient input, which is one of the more valuable aspects of having an expander. My real reason is only if they didn't get good soft tissue stretch. If the lamella of the skin and the device are not well-developed, I think an expander can help do that better than the implant. If we're gonna use an expander, I prefer the Mentor Artura high-profile tissue expander. It fits my needs very well. It's my go-to device, obviously, in immediate reconstruction, the pre-PEC space as well. And then from an implant standpoint, I'm so happy to be a part of Mentor, and I've seen really an explosive growth in their implants, really focused on the needs of my recon patients. For many years, I think the focus was on both recon and augmentation, but with really the advent of the extra gel implant, which is the workhorse in my practice, I've been so happy with the results and the experience with that device. So for our patients, we're almost exclusively using the extra gel breast implants, whether it's the moderate or high-profile device. Incisions. Well, again, a key should have been placed here because what we have learned is if patients have a traditional incision, I wanted to honor that. I had a really difficult time wanting to put a different scar on a patient's breast, but learning the hard way, and I think Allen Gabriel published on this not too long ago, those traditional incisions have a high risk of healing. As we talk about my complications, it's exactly what we run into. So today, if women do not have an IMF incision, just a traditional incision with loss of the nipple, I tell them that the advantage of that is simply safety or simply speed in the OR for me, but a high risk of healing complications associated with it. So we prefer the inframammary fold incision for these patients, even if they have a traditional incision. Another learning point is really the BOVI. So I'm a kind of 35 COAG, 35 cut guy on a blend. And what we realized is, you're really recreating the mastectomy space. And in some ways it's more challenging because that space is very thin, but in holding the skin is an absolute real possibility, even in the best of hands. So we turn down the BOVI to about 30, 30, maybe 25, 25, whatever you feel comfortable with to lessen that thermal injury to the skin flaps, again, to minimize complications post-operatively. If you've not seen or used these impurity light retractors, I think they're some of the best things I've worked with in a long time compared to that kind of standard lighted breast retractor that all plastic surgeons have used for augmentations. The light source is better, which is fantastic, but it's really the adaptability of the blades of the impurity device that make it easy from kind of a very wide device that's short as you get started to that kind of longer paddle that you see pictured in the middle. So I have no relationship with impurity, but I really think their retractors are fantastic. The next question is, you've got your surgery going, when do you remove the current submuscular implant? And I get that question a lot, and I think the answer is when it doesn't work well for you. I think in the beginning of the dissection is you're kind of from that inframammary fold arcing up over the breast kind of where the nipple should be or maybe is. It helps to have the implant in place because it provides a secondary force for you to retract against. At some point, as you crest over the top of the implant, then it becomes very difficult and is in the way. So my experience has been somewhere about halfway through the surgery or just when I'm so frustrated I can't stand it anymore, we'll start talking about taking the implant out. I think at the beginning, leave it. It provides a very easy source to kind of use as a force to provide counter traction during your surgery. The next question is, well, where do I take it out or how do I take it out? And what I've learned is instead of removing all the old capsule or dermis or dermis capsule, depending on what they have, which is what we used to do, we really wanna make a little bit of a capsulotomy, so to speak, about midway between the inferior border of the pectoralis major all the way down to the inframammary fold. The reason we do this is one, it's easy to get the implant out of this, obviously much better than bringing it through the bloody pectoralis major muscle. But the real issue is it's nice to have that dermis or capsule in order to secure the pectoralis major muscle back down to the inframammary fold. One of the things I didn't understand until I started doing really conversion more than anything was my historic submuscular patients had a blunted or lost inframammary fold. Many of us did our Ryan flaps or internal Ryan flaps to kind of sharpen that crease to make it look much more natural and breast-like. But I think the real reason why that crease was lost or a blunted wasn't about our breast surgeons or anything else. It was simply the origin of the pectoralis major muscles really along that crease or along that fold. And if you lose that force, it allows the skin again to follow gravity and drift down. So I think it's terribly, terribly important in these patients to resecure their pectoralis major muscle back down to the fold. But sometimes that can be very difficult to get all the way down and or hold a suture. So this kind of midpoint removal or opening of the capsule or dermis to fetch out your implant allows a lot of this extra soft tissue to be able to get down to the inframammary fold in case you can't get the inferior border of the muscle back where you want it to be. Another really important learning point is limiting lateral dissection, right? Just like augmentation, once you get lateral, it's so easy to do. You want to just sweep it. It's exhilarating. There's no big blood vessels or perforators like there is along the kind of medial line of the breast. But what you're doing by over releasing that is again, allowing lateral displacement of the implant in the future. So for us now, we'll measure the width of the implant that we're going to put in the patient, put some dots on the patient's lateral aspect of their breast to understand where that is, and usually not try to over dissect that area and more finger dissected once we've got the implant in place. Again, no muscle force, right? So the muscle is not going to be driving the implant out laterally. It's really a function of gravity or maybe over dissection. So really spending some time thinking about that approach and limiting the taking down of the capsule laterally, I think is really, really critical. One patient, we didn't dissect it enough. She did have a little animation tug in the lateral aspect of her breast. She didn't want a revision or any change to that, but I felt like it is possible maybe to leave it too tight laterally as well. Over dissecting is a much bigger problem to fix. So this is our pectoralis major muscle. You can see with my mouse pointer here, the capsule of the muscle. So the muscle may be up here a little bit distance. This is towards her head. This is towards her foot. This is her inframammary fold. And this is basically showing a running 2-O-Vicryl that we do. So we use a running locking 2-O-Vicryl on a pretty good size needle. It's a CP2 needle just to make it easier to turn inside that space. And the first couple of these that we were doing and using an expander, we had the opportunity obviously to go back, take out their expander and look at the implant. And we quickly noticed that a lot of times the muscle was no longer back to the inframammary fold. If you think about the force that patients are generating, getting out of bed, pulling themselves off, exercising, whatever they're doing, it's a tremendous amount of force and requires a fairly stable repair. So in my opinion, or where we are now with this, is we do a running locking 2-O-Vicryl and then we do another one over top of it. We're really trying to define the inframammary fold, really hold that into place really well. And I think this has helped us to some degree. Unfortunately, we don't have the experience because we're not going back when we're putting in so many implants to really understand this, to see if that's helping. And this may evolve in time. ADM selection. So we are currently wrapping our expanders or mostly our implants in a dermis, which we'll talk about in a second. The question is, what dermis do you use? Obviously, as I disclosed, I'm an MTF guy, I typically like the FlexHD pieces. And we've realized that if you're going to use a FlexHD kit or device, we want a large piece of dermis depending on the size of the expander. So 600cc bigger expanders, they'll get two large pieces. If it's less than 600cc, we'll use a medium size. This works because it's taking care of a scarce product such as dermis and cost-wise, we're not really running up the cost for our healthcare institution as the large pieces are very expensive. The same concept is basically happening when we're choosing the extra gel implants. Around 600cc, again, is the cutoff for whether we want a smaller piece or a larger piece, that is a medium piece, I should say, and a large piece. So that may be helpful, kind of guiding you as you're thinking about doing this. Obviously, the problem with the pieces is we want it to be one, and how do you make two into one? So we've come up with three different ways of doing this. Originally, we were using this device used by our orthopedic colleagues in our institution called a GraphMaster or GraphPrepStation. You can see it has this little piece of the dermis is in this little adjustable clamp. There's another one that's over here holding it up, and it allows my PA right here to sew the two pieces together to kind of create one seam. Well, the problem with this is it's in high demand. As you can see here, the paint was chipping off of it, so they actually kind of cleaned it up for us. This is one only mine. And then, of course, our sterile supply people lost one of these posts, and my health care institution wasn't going to give me $10,000 to buy another one of these. So that went away, and that got us to this. I think this is currently what we're using the most of. It's basically the dermis, again, suspended by two silk sutures on two of the wire baskets that hold your instruments. My PA really loves this technique because now it allows her to flip the dermis over back and forth instead of having to move herself around the table or move the graft prep station around the table. You can also use it over a big bowl on the back table as well. We found the struggle with this can be, though, you're working your hands down inside the bowl, almost like a laparoscopic surgery, and again, that adds time to the case, which I'm a little intolerant of sometimes, but definitely more complex and a little more difficult as well. We believe in a partial wrap concept, so you can see this is the dermis kind of strung together. We use a CP3 blue-dyed needle just to be able to follow that. It almost kind of creates a midline of the expander or the implant itself. Then we use a purse string on the posterior aspect as well, so the pleats are kind of not palpable and they're on the posterior side of the device. I do think it's important in a prepack, whether it's immediate reconstruction or conversion, to have something posteriorly. I do think both superiorly and inferiorly, the dermis binding to the pectoralis major muscle is a strong force of holding up the device, whether it's the expander to the implant or straight out of the box to the implants. If we do the expander, we'll typically cut these little holes in the dermis to bring out our tabs to be able to secure that to the patient's chest wall. I think there are some key things that we have learned along the way just in breast reconstruction and that's basically what this is getting to. We do mark the sternum of where we want to put, especially for our expanders with tabs, where those are going to be. Especially for the bilateral cases, I think this is a really important moment because it allows us to get those most medial tabs secured to prevent misalignment in the vertical space of the devices, whether it's implants or expanders. We typically are not sewing down our implants in this space. We like to have a really tight fit and pocket, a lot of glove in hand, but for the expanders, I think that's really important. For the expanders, if we're using those for patients, we will use them as an air filled device as they come from the company. So we sometimes will add air, rarely will we take air away and we do secure the expander with an OPDS on a CT2 needle just to be able to control its orientation. We do use a 15 French drain, usually just one drain for these patients is all we have felt necessary. You're needing a drain for two reasons, in my opinion. You're recreating the mastectomy space. There's no doubt going to be some weeping of fluid as a result of that. And of course you're wanting to hold things until the dermis fully integrates itself. So typically we'll use a 15 French channel drain, exited far away from the skin with a bio patch over top of that. For our closure, we prefer kind of the Dermabond advanced topical skin adhesive, and that's really the only dressings we're currently applying. We do ask the patients to wear a sports bra, and I think we'll talk about that next. So as the outpatient procedure performs, this is kind of our routine postoperative follow-up for these patients. So we do ask them to wear a sports bra, and I think that's critical for a couple of different reasons. One, we're trying to minimize shear of skin over the dermis until it incorporates. We're also trying to support the devices in their home. Initially when we moved kind of away from the expander for these patients into just the implants, we were securing the dermis in a couple of key points, kind of like tabs, if you will. We haven't done that in a long time, and I'm not sure it's because the bra is helping or really limiting the pocket space development, which is probably more key, but we do ask them to wear a bra around the clock for the first four weeks, except for showering, and they're allowed to shower in the first 24 hours after surgery. They can drive whenever they're off narcotics, because that's obviously a big point of question for most patients, and that's happening in less than a week for the majority of our patients. So most of these patients have been through a drain experience, have certainly been through our practice to some degree, and so if they stop taking pain medicine the next day, they're okay to drive from my standpoint. The one big no-no is I don't allow them to submerge underwater, as I call it, for the first four weeks after surgery, which means no hot tub, no bathtub, no swimming pool, excuse me, until they're cleared for follow-up, and really no heavy lifting. I think the heavy lifting is not about the implant and the prepack space. I think about that so much in my immediate reconstruction today, but it's really about trying to get their muscle to scar and heal back to the inframammary fold and limit that torque or tension across that double repair with the 2-O-Vicol. As I talked about, I think the drain is really important, and the follow-up for us is really based, the first follow-up is based around the drain. Most of these patients, as I said, have been through a drain experience before, so we typically will tell them that when the drain is ready to come out, 30 cc's for the last three days in a row, give us a call and we'll take the drain out. Generally speaking, that's happening about two weeks after surgery. Occasionally patients will get it out at one week, and occasionally we'll have them out at three weeks. Three weeks is an absolute for me. The drains always come out at three weeks, just because I think the risk of infection starts to outweigh the benefit of the drain in that experience. The first follow-up will be with my physician assistant, and it's simply for drain removal. The second follow-up with them is going to be about eight weeks, and that's with me. I like to, so they'll actually come back around four weeks to have the restrictions lifted. Again, that's with my physician assistant, and then I like to see them at eight weeks. Eight weeks is important for me, because at eight weeks we're going to really start seeing about, are there anything else that they have problems with? It's mostly around the rippling and wrinkling concern that can be transmitted from the implant through the skin, and so I want to have that discussion with them, and based on what's happening with them, we'll either move them out to their long-term follow-up, or schedule them for surgery at that visit. The majority of our patients are going on back into their one year, or what we refer to as the long-term follow-up plan. So our normal routine for follow-up, one to two weeks, or whenever the drains were to come out, again at a month to relieve them of restrictions, make sure they're not having healing infection issues. I see them at eight weeks to talk about surgical decision making, and if they're done, they move out to one year. If they go back to surgery, we kind of repeat the process, although they probably won't have a drain at that point in time. So again, this is her. So this is her, and the upper part is all preoperatively with her submuscular reconstruction, and now this is her after undergoing conversion, and if you look at her, you know, maybe the breast is a little more low and natural, which not all patients are wanting in their reconstruction, but what they're really wanting is softness to the touch of their breast. I think it's also fascinating to notice that I dropped the implant 90 cc's, or whatever the math works out for that, it's less than 60 cc's, but the volume of her breast is still very similar, which was one of her goals, right? So we went from this kind of firm, fixated breast that moves, obviously, to a softer, more natural breast. One of the most incredible experiences I had with one of my long-term patients, who I again saw at that eight-week mark, many of my patients keep talking about, oh, they feel so much more natural. So I simply asked her, Sherry, what does it mean when you say they feel more natural? And one of the oddest moments in my career with my chaperone presence, she stood up, she asked me to stand behind her, and she put both of my hands on her breast, and she said, doesn't that feel more natural? Now I've got lots of things going through my mind, and natural may not be one of them, just wanted to hurry up and get out of the room, but it really started to show to me about what patients are thinking about their submuscular reconstruction. This week in the office, I saw somebody who's eight weeks out from her follow-up, and she talks about how her husband, Jeff, thinks they feel more natural, how they moved, which was a big change for her. I did her initial reconstruction in 2008, non-nipple sparing, kind of the early prototypes as I like to think about it, but a big change for her, much more softness, so many things that she forgot about, as she described, making my breasts feel more natural and more normal. So I think that's the real key with this, right? As I talk to patients about the opportunity for conversion, I ask them what they don't like about their breasts. They can't tell you that they don't feel natural because they've gotten used to whatever the submuscular reconstruction may feel like to them, but that's what they're really searching for, and hopefully you'll be surprised, as they will too, about how different their breasts feel after undergoing conversion. And of course, I think the biggest thing is this, and the real beauty of this patient is she was young, she was very breast-centric, she didn't like the size of her areolas, which led to this crazy idea of me doing a circum-areolar mastopexy, which I know more and more of us are doing, but she was so uncomfortable being intimate with her husband with the animation of her breasts, she refused to unless the lights were off. And she's a beautiful young woman married to a fantastic pilot, and it was very just not comfortable for her. And we changed all that in a very straightforward, roughly two-hour surgery, and in my opinion gave her a better result. Now there can be some complications with this, and certainly I've learned this the hard way, and first of which is that. So this is, again, a former patient of mine who we were honoring. She was scarphobic, if you will. We knew we were having problems with the traditional incision, that's her areola tattoo at the above, way before nipple spraying mastectomy. And on her right breast, along the kind of most medial aspect, she started having healing issues. And so back to the operating room, washed her out, back to the operating room, downsized her implants, did this kind of aggressive closure to try to get it to heal, and you can see by the soupiness that I'm just losing ground, and she ultimately lost the implant. So that really drove me, for all patients, to say, if you're not okay having a new incision in the crease of the breast, I don't think I can do this surgery for you. I don't know that that's an absolute. I think some patients have very thick tissue along the scar, and that may be safer to do. Certainly it's more easy to approach this surgery through that traditional incision, and I think more humane or the right thing to do to not put a second scar on the breast. But it's not worth this complication. Another lady with the same sort of complication, we were honoring the traditional scar across the face of the breast. She had a little breakdown somewhere or the other, ultimately had an infection of that device. She's the only patient that we've had an infection that didn't have healing issues, did lose the device, and we will plan to put that back in. I think the one thing that's concerned me the most, but I've seen very rarely or very little of that, is still rippling and wrinkling of the implant. Obviously that was the big goal of doing submuscular reconstruction, that we would minimize that problem with the healthy, beefy nature of somebody's pectoralis major muscle. And we all know sometimes the pectoralis major muscle is very thick, sometimes it's very thin, and there's very little of it laterally like what we see in this picture as well. So she did have rippling in her submuscular space, but she certainly had rippling in the prefectural space as well. So I think you really have to be thinking as you're talking to these patients about what else might they expect. In particular, I think besides the normal complications, which are terrible healing and infection issues, it's really about the rippling and wrinkling that may lead to more surgery. So if I have fat grafted them in the past, I have less concern about that. I think the extra gel device has certainly allowed us to see less of that, and we only have a handful of patients, two to three of these patients that have worse or similar rippling and wrinkling issues as they did submuscular. Obviously this is fixable with autologous fat grafting and surgical treatment for that, but it's something to be aware of as you're having these conversations. So then who is the patient to do the right move on, right? That's the way I think about it, or if I were out there listening to this broadcast, who am I thinking about in my practice that would want to benefit from this procedure? And I think it really starts, one, with that IMF incision. That's key to me, in my opinion. Gabriel showed exactly the same thing we were experiencing, that the traditional incision had a much higher risk of complications. So use the inframammary fold incision. Be generous with that. We have found that it almost takes the same size incision as the implant that you're going to put in it if you're using non-expander, so a gel implant, especially in the fact that the dermis-wrapped implant doesn't insert easily through the incision, right? You've got a restrictive force, the dermis, preventing the implant from doing its normal kind of amoeba movement into the breast, so generous incision. It hides well, it camouflages well, and really the goal of this isn't the new scar, it's really relieving animation. The second issue is to really think about implant volume, as I described. The patient that I showed, she went from a 535cc device down to a 465cc device and had similar volumes. So one, understanding what the patient wants and then executing that, and I usually have a discussion with them of this is what we're going to do and why and what we've noticed helps them to get buy-in with that. I don't think we've done a case yet where a patient's been unhappy with the implant volume we picked, and I know we haven't gone back to revise somebody simply because the implant was too big, too small, or just not the right size. Animation relief is the key. As I tell patients, they'll talk to you about pain and discomfort, and we certainly have seen most patients who have some sort of discomfort or chronic pain associated with their submuscular device, all that goes away and they don't have discomfort anymore. But as I tell patients, I don't know why you have pain. Operating on pain is never a pleasant experience because I don't know why you have it and I don't know how to fix it. If the goal of conversion for you is to relieve you of pain, this may not be the best surgery for you. If the goal is to get rid of your animation, we got a win-win-win situation, and I hope it gets rid of your discomfort as well. So understanding what the expectation is is always critically important. Expander versus implant, I think it's a little bit about what you're comfortable with and maybe at some point what the patient needs. As I said in my experience in the beginning, I really felt like it was just more comfortable for me to use the expander, and that's exactly what I did. As terrible as it is to put expanders back into patients again, but I did have some patients as we continued to progress in our experience that just benefited better from the expander. You can get away with a lot better soft tissue filling with an implant and may not need an expander, but that may take a little time for you to understand. Simplistically, if you think about it, the problem in the submuscular space, whether it's the expander or the implant, is really filling the breast space up is very difficult, right? It's not about expansion, it's simply filling the space. The muscle prevented or inhibited that to some degree. Today with conversion or pre-pectoral reconstruction, the results are better because it's like an augment. We're simply filling in the space where the breast used to be with a device, be it big or small. Depending on your comfort level is how I would recommend starting with an expander or starting with an implant. You can't go wrong with an expander, but it may put patients through a second set of torture in their life. Limiting that lateral dissection is so critical. We learned that the hard way in a couple of patients. Some of them during surgery, I had to go back and try to do a lateral capsuloraphy or try to provide some soft tissue support out laterally. You should be able to put the implants in the breast and that's the way they look like an augment and that's the way they continue to look. And that's what our experience has been after I didn't make too big of a space. The implant should not move around in there. Now the implant, skin envelope, hopefully the nipple, all moves as one like a normal breast should. But if you make too big of a space, because that's kind of what the mentality of the submuscular expanded implants been, I don't think you're going to be happy with the results. You will likely see more rippling and wrinkling. And again, you're going to see that kind of lateral rolling off of the implant, which a lot of women are not very happy with and uncomfortable with. And the big problem is that kind of gouging out in the central portion of the breast that you can fat grafts and a variety of things, but really just leave the implant where it should be. Don't over-dissect that lateral aspect of the breast. So that's moving it, moving it from the sub-pectoral to the pre-pectoral conversion. It's been a rewarding experience for our patients who are undergoing that, much more rewarding than your immediate patients who have no idea about submuscular reconstruction. They've just been told they're going to have pain for four weeks because they don't understand the difference. But my submuscular patients have really taught me so much about the benefit of pre-pectoral breast reconstruction. And it's just such an important thing to be able to offer your patients. It's rewarding to them. It's rewarding to us financially. It's rewarding as well. There are some CPT codes, especially about reorienting the pectoralis major muscle from the orthopedic side that are very valuable for this and a good RVU or generator of cashflow for your practice. So fantastic opportunity for you and your historic patients to really move the bar better and pre-pectoral reconstruction. And with that, I'll turn it back to Jaren. Thank you, Dr. Thornton so much. That was a great presentation. A lot of information that I'm sure our listeners have taken in, and we have some questions that have come through. So if you're okay, I'm just going to dive right in and start asking you some of these questions here. Dive away. First one, you actually kind of ended on it. So I'll start with that one. You were mentioning CPT codes and coverage. So are you able to elaborate a little bit more on the CPT codes that you're using for the procedure? And do you find that the procedures you're doing are generally covered by the insurances? So far, the procedures have been covered, which is always amazing and surprising. I think it falls back to the Women's Cancer Right Act associated with breast reconstruction in 1998. I think the real critical code besides the normal removal of an intact, or if the implant's ruptured, the immediate placement of an implant, the codes escaped me off the top of my head. But the unique code that's rewarding financially is a CPT code. Here we go. Write it down. 23395. 23395. That's an orthopedic code, mostly in the upper body side, which is really about movement of the pectoralis major muscle. So Maurice Nohabedian forever ago gave me that code one day when we were talking about pre-pectoral reconstruction. And then we were talking about moving the muscle back and how does that work. And so it's a fantastic code. The insurance does pay for that. The last time we looked, it can generate around $500 to $1,000 per breast. You're going to take a discount on the second breast, but really isn't a significant code because it's a lot of work to get the muscle back down to where it needs to be. Very helpful. Thank you for that. I have a couple of questions that I want to ask that have come in specifically around product. And you mentioned in your presentation that you utilize the Artor Tissue Expander. So can you tell us a little bit about whether you choose a smooth or textured expander and the tab utilization? Are you utilizing all the tabs when you're doing pre-peg? Yes. So texture has kind of gone to the wayside in the day and era of COVID, I guess. So I've been a big fan of smooth devices for a long time, including the expander space as well. Initially, before we were so aware about lymphoma of the breast associated with, especially the macro texturing devices, I had concerns that one day the FDA may just remove all texture from all companies. And at least in the expander space, we only had texture. So I'm always appreciative of mentor way ahead of the game, thinking about smooth tissue expanders. I think the other thing at the time I was thinking is, we were using texture to hold devices. And if expanders had tabs, which I felt like were stronger at holding the position, why did I need tab and texture? And so as a result, obviously became a big fan of the tabs. Currently for the Artura devices that have five tabs, kind of a three, nine, whatever it is down off the midline of the six, I'll use those four tabs. So I typically don't sew in the six o'clock tab, but I'll use the three, the nine and the other two when it's easy to get to or safe. Sometimes that space can be very difficult to find, to throw a needle through, especially that OPDS on a CT2. And so those are my preferred or go-to devices. I put in four tissue expanders today. And the first lady was very difficult to get to all four of those tabs. And so on one side, both sides actually only put three. I think the more the merrier. And I also think that because there's less time messing with the muscle itself, especially for some muscular reconstruction, it takes 30 seconds to sew in some tabs. And if it minimizes misalignment of your devices, your expanders long-term, your patients look better, they feel better, and it makes you look better as well. So that's my kind of thoughts about that, Sharon. Very helpful. I'm going to stick on the subject of product for a moment and shift to implants. And just want to ask you a little bit about what changes or other considerations did you find you had to make when you started doing more conversions from sub-PEC to pre-PEC? You were great at showing us your choices of implants. Has your choice shifted since you're doing more pre-PEC? Well, I think it's shifted in the fact that we have, and it's not related maybe just to pre-PEC, Sharon, but it's related to the fact that we just have more devices, right? We have extra gel in two lines, and then we have the kind of standard gel in four to five different lines. And so it used to be way back forever ago, all we had was high-profile. So every expander was changed by a high-profile device, and really they didn't fit that well all the time. I was fortunate to be the first in the country to use an ultra high-profile device, thought it was going to be the best thing since sliced bread, and it was in some applications. So now I find the biggest struggle for my office staff sometimes is really the debate about what is the right device. I'm not a person who comes to the OR with 40 different boxes of implants and lots of different sizers. I come with an algorithm of what we're going to do. And so the hard part for my staff now is to think about they have an implant that's this base width, it's this volume and this profile. She wants to be the same, she wants to be bigger, she wants to be smaller. How do we fit those same characteristics? And she feels like the breast may be too wide or maybe too narrow. So it's really a lot of kind of going back through the catalog, if you will, of really understanding the dimensional characteristics of the device that helps us kind of narrow the focus down on what we're using. Now with that said, we still mostly use extra gel just in the two lines of moderate, plus, and high profile. I don't think we use very many of the non-extra gel devices anymore. Not that they're bad devices, they just tend to cause a little bit more rippling and wrinkling than what we see with extra gel. Thank you for that. I'm going to switch gears again and talk about a couple of specific patient profiles. If you could maybe comment on how you're handling a patient who's obese, diabetic, or maybe a smoker, both in the immediate reconstruction or in the conversion scenario? So for the immediate reconstruction patients, you know, for those patients, I tend to rely heavily on a website called Brascore.org. It was developed based out of the NISQIP data, looking at patient characteristics that increase risk of complications associated with breast reconstruction. So it pulls from NISQIP, TOPS, and I think it's the MROC database, all on a very free, straightforward, easy to use website called Brascore.org. You put in the patient's height and the weight, so it's calculating BMI, put in the age to stratify that risk, and a variety of other things, knee or adjuvant chemotherapy, smoking, hypertension, all the risk factors. So at least for the immediate reconstruction patients, that's the algorithm we use. We put that in their chart, we give them a copy, we review that with them. It shows not only for expander and direct implant, but it shows across microvascular reconstruction, latissimus flap, and pedicle trams as well. For most of those patients who may be higher than a BMI of 35, smokers, et cetera, that's usually a starting point where I'm not very excited to offer them immediate breast reconstruction. And with that said, I saw a patient yesterday who had a BMI of 36, but she's 34, and she's small breasted, and she has an amazing breast surgeon who's going to do nipple sparing mastectomies on her. So to me, that's using the algorithm or the Brascore website to add to my 15 years of doing this to kind of give them a better gauge of what I think their percentile rank of complications are. So there's really no absolutes. I think an older patient who smoke and obese, that's a non-starter, they need to have delayed reconstruction. Now the pre-pectoral space, I'll be honest with you, I don't, well, I think we have done a couple of smokers, but they behave very differently, right? You have to be thoughtful about what's happening again with you recreating the mastectomy and being very diligent about that surgery. It's, I like music in my OR, I like to laugh in my OR, but I hate that first 30 to 45 minutes of each breast because it's very delicate and it's so easy to get through the skin, which has happened to me quite honestly on several different occasions. So time will get you better at that, understanding that, it'll make you maybe appreciate the breast surgeons and what they do a little bit as well. And certainly I think the smokers will have a little higher risk of that, but that's mostly an iatrogenic or my injury caused by the patient, not what they're bringing to the table. I don't think I would have any concerns certainly in somebody who's obese and converting them, they're kind of behaving almost in a delayed fashion as well. And I would probably argue in the same of a smoker. It's so complicated and confusing with e-cigarettes and a variety of things. And keep in mind, I'm in Kentucky, which is home to the Burley Belt to some degree. So we have a significant smoking population here in the city. I have one patient who had breast cancer five, six, seven years ago, had reconstruction submuscular by somebody else, has a pretty reasonable result. She wound up being tested and is BRCA positive or high-risk genetics. She underwent nipple sparing mastectomy four months ago. Turns out she was smoking. I had no idea or totally had missed that. And so we're planning on doing her expander exchange and implant on her last reconstruction, at least the one I did, and a conversion on the contralateral side. And I just don't have a lot of concern associated with her nicotine use, to be honest with you. She needs to know she's at higher risk. I typically still recommend to them that they should obey the CDC guidelines of four weeks of no smoking prior to surgery and for four weeks no smoking after surgery to help lower that risk as low as possible. They understand the risk and complications associated with smoking, which to me means if they show up with healing, certainly if it leads to infection, it's multiple surgeries. And in my opinion, if they have an infected implant, I take the implant out, wait a couple months and come back and start over again. And smoking contributes to that. Great. So sticking on the subject of patient types, let's consider a patient with fewer comorbidities, but maybe somebody with a thin, soft tissue envelope. What would your advice be there for breast reconstruction in that patient? Well, I think that's a really good question, Jaren. I think what you may wind up getting into is the problem of soft tissue, rippling or wrinkling of the implant through the soft tissue, not to mention a really difficult surgery. So I think if you're concerned about that or you're dabbing your toe in this concept of converting patients, maybe a better thing to start with those patients would be to fat graft them preoperatively, right? I certainly, in the submuscular time of my career, did get some improvement in animation with just a lot of fat grafting. It obviously never got rid of it. It would help camouflage it to some degree, but maybe that's enough for some patients. I think the real key of maybe trying to consider fat grafting them before conversion would simply be to increase the soft tissue thickness. And that's going to pay the two dividends. One, provide possibly an easier dissection plane for you to recreate that mastectomy space. And in particular, limit the amount of rippling and wrinkling postoperatively. Because in my opinion, those patients may be looking at two or more surgeries regardless. Why not just fat graft in the beginning that makes your job a little easier and you still may be done with two and look kind of smart. You know, you might be able to get away with it with a thin skin flap, but I think you really have to set the expectation of those patients may need future fat grafting to kind of camouflage any inconsistency in the device or position. I had a feeling that answer might lead into a couple of the other questions regarding fat grafting. So you actually did answer a couple more on the list. And really the final one along those lines would be, have you noticed any differences in the amount of fat grafting you're having to do in a pre-PEC patient versus a subpectoral patient? Well, I think for the conversion patients, that's hard to understand. So many of those were my patients. I fat grafted them in the past. We did one surgery, they were successful except for the obviously the picture I sold and they didn't need more fat grafting one or otherwise. So that may not be the best patient to understand that. And I think currently with our immediate reconstruction patients, it's been a really eye-opening experience, especially with extra gel devices. You know, as I showed you and as I used to tell patients in 2012 and even through probably 2016, you know, you're looking at two to five surgeries, the expander, the implants and fat grafting to follow to get a good result or whatever you might think the result might be. Today, we're down to less than three surgeries. We tend to fat graft at exchange now, which has really driven that forward. I think with extra gel, we're just seeing less rippling and wrinkling as well. So predictably, as I talked to two patients today about reconstruction, you're looking at expander exchange, you're looking at the expander followed by the exchange, and then maybe additional fat grafting based upon your needs. And they don't quite get all that in the beginning. They're more kind of concerned understandably about cancer, but I'm trying to get them to understand they're looking at two to three surgeries in my experience to get a result that used to take me five to six surgeries. Perfect. I can't believe it, but we have about five minutes left. So I think we may only have time for a couple more questions. So I'm going to try to hit on some that I'm seeing a theme, I'm seeing them come up a couple of different times. One of them is regarding putting air in the expander. Can you comment at what point you exchange out that air from saline? So yeah, so one, the air is permeable to your expander. So any of you who have expanders in your office, you know, over time it deflates and it kind of gets squishy, right? So if you do nothing, depending on the size of the device, it may take a month to two months before all the air escapes your expander. For us, we'll start expansion around two to three weeks, assuming there's no complications or issues. We started going very aggressively with 180 to 240 cc's in that first timeframe, really to shorten the expansion cycle down. We did realize that was creating quite a bit of weight and load on the device, almost like a direct implant causing maybe some movement of the expander or breaking loose from its moorings of its OPDS securings. So today we tend to go slow in the beginning. After about four weeks, we start going a little bit faster with their expander and start sucking the air out at four weeks. So in that first month, they're going to have an air liquid interface. Tell your patients they're going to slosh a little bit because that's what they may notice. After four weeks, we tend to start withdrawing the air and putting in larger volumes of fluid again to shorten expansion time down and also just to get the air out of the device as well. If you're going to fill air into the device during surgery, which may have been part of your question, Jaron, we do do that occasionally, especially for maybe a large skin envelope that we're trying to get good coaptation of our dermis up against the skin flaps. We'll typically do that in the operating room. I do believe you should use a filter. So we'll use a 22 micron filter that most ophthalmology centers will have because it will filter out any bacteria that's in the air. There is bacteria in the air in your ORs, even though they're a highly efficient suite as far as moving air across them. And so it concerns me a little bit about just pulling a syringe of air out and inject it inside of a sterile device. Thank you very much. We did have a couple of questions and I know this, we may not have anything definitive because pre-pectoral breast reconstruction is still considered a bit of a newer trend. But what are the longer term implications that you've seen or that you anticipate as a result of converting to pre-pec? Anything like bottoming out or patient maybe might need a lift sooner or malposition, anything that you can share would be helpful. I think that's always the concern. Anytime you change, what is it that's going to happen next year, five years, 10, 15 years down the line? And to your point, we're not sure about more than 10 years because that's really where the good data currently exists in pre-pectoral reconstruction. I do believe that the muscle contributes to more malposition than pre-pectoral space. We do have a study ongoing with a colleague at Stanford where we're really measuring patients, obviously preoperatively at the end of their expansion, at the end of their second stage, as well as at one year of the nipple sparing only patients to see in particular, is the distance from the nipple to the fold increasing or not? Because if there is going to be bottoming out, we should see that being stretched over time and doing this now going on five years in immediate breast reconstruction, we're simply not seeing that. And again, I'm not sure if that's related to dermis. I don't use dermis in truth and disclosure for all my immediate reconstructions where I might for all my immediate reconstruction, but I don't typically for delayed reconstruction patients. They don't seem to experience any more bottoming out than those who have dermis. So the dermis may or may not be contributing to soft tissue support. I think, as I try to explain to patients, everybody's fighting gravity. I just don't want the muscle helping me to fight gravity is the problem. So offloading the muscle, I think, is really going to minimize that problem long-term, but we simply don't know. We don't know that we're not going to run into some big problem 10 to 15 years from now. I just can't imagine what it's going to be because they hold up so much better than the bottoming out or lateral displacement of my submuscular patients. Thank you very much for that. I can't believe that we are at the top of the hour and we really do have a lot more questions to ask. I did try to bundle some that were asking similar things. So hopefully we were able to address a lot of what was coming through, but I really just want to say thank you so much to you, Dr. Thornton, for taking some time to be here with us and provide us with the knowledge for pre-PEC breast reconstruction. This is really an area that a lot of surgeons are wanting to learn more and more about and do more and more of. So this was extremely helpful and I want to thank our listeners as well for taking time out of your days to be part of this. You'll be receiving an email after the presentation and it will have a link to a survey. We do ask that you take a few minutes to fill that out. That will help us make sure that we continue to bring you educational content that's relevant and what you want to hear. So thank you in advance for doing that. And again, Dr. Thornton, just thank you so much for being here with us and I hope everyone has a great week. Bye everyone.

breast reconstruction

pre-pectoral space

submuscular transition

natural breast appearance

surgical techniques

acellular dermal matrix

fat grafting

patient selection

implant choices

CPT coding