Hello and welcome to our fourth ASPS Global Partners webinar series of this year. Today we're very pleased and honored to be hosting our friends from Croatia who are going to present three wonderful topics and I'm sure you'll find it interesting and very worthwhile. So a few ground rules here. Please submit questions through the presentation using the Q&A feature at the bottom of your screen as you see here, and please note that today's webinar will be recorded and posted to EdNet for ASPS members. So if you are not an ASPS member and wish to have access, please contact Ms. Romina Valadez at the address that you see on your screen at this point. So, I am Bob Murphy, and I have the honor of hosting our friends from Croatia, and a brief introduction. We have Dr. Sandra Smud-Orhodek, who is a plastic and reconstructive surgeon and assistant professor at the University Hospital Center in Zagreb in the Department of Plastic and Reconstructive Surgery. She has a very rich educational background, having trained in Sweden, England, Scotland, Greece, Hungary, Italy, and has extended her interest in cosmetic surgery and reconstructive surgery by publishing many papers in these areas. She's participated in both Croatian and international congresses with more than 15 congressional presentations. Her main interests are reconstructive surgery, vulvar cancer, skin cancers, soft tissue sarcomas, and microsurgery, and Dr. Orhodek will be presenting on one of those topics today. Also, we have Assistant Professor Zlatko Lajic, who is a plastic and oncological surgeon at the University Hospital in Dubrava, Zagreb, Croatia, and is a member of the bariatric team there, where he does a number of body lift procedures after bariatric surgery and abdominal wall reconstruction. He also works as a member of the breast team and is part of the National Referral Breast Surgery Center for all types of oncologic issues dealing with the breast. He's a longstanding secretary of the Croatian Society of Plastic and Reconstructive Surgeons and the corresponding member of ASPS. And last but certainly not least, we have Professor Rado Zik, a good friend, who practices through the entire gamut of plastic surgery at the Department of Plastic, Reconstructive, and Ostetic Surgery at the University Hospital in Dubrava, Zagreb, as well. He's president of the Croatian Society of Plastic, Reconstructive, and Ostetic Surgery and the European Society of Plastic, Reconstructive, and Ostetic Surgery. He's also an international member of ASPS. He's been involved with the European Board of Plastic, Reconstructive, and Ostetic Surgery in various capacities and has contributed to the exam process in the EU. He's also a member of the editorial board of the European Journal of Plastic Surgery and the Turkish Journal of Plastic Surgery. He has a number of publications, 160 papers in multiple journals, and will share his insights into his technique for reduction and reconstruction of large entotic breasts. So an exceptional faculty here to present for your benefit today. And without further ado, I'll turn the microphone over to Dr. Barhović. Esteemed colleagues, good afternoon and good evening. And thank you, Dr. Murphy, for the introduction. And I would like to thank ASPS for the invitation. It is a great honor and privilege to be here. I will speak about our experience in vulvar and urethral reconstruction after radical or hemi-vulvectomy. So vulvar cancer is rare. Is this something going on? Okay. So vulvar cancer is rare. It occurs in only 5% of cancer that affect women's reproductive system and in 0.6% of all cancer cases in women. It is two to three times more common in undeveloped societies. And most women who are diagnosed are over the age of 60, but approximately 15% of vulvar lesions occur in women younger or around 40 years of age. And this particular group of women do require plastic and reconstructive procedure, not only for reconstruction of genital organs, but also for giving them the possibility for intimacy. This pathology is associated with HPV infection, HIV, smoking, chronic irritation, and other still not clarified risk factors, therapy, surgery, chemotherapy, and radiation. The size and location of the lesion are the primary perimeters in deciding what procedure to perform. Early stage lesions are treated surgically and advanced stage lesions are treated preferentially with chemo and radiation. An essential part of treatment planning is staging of the disease. It is associated with curability and establishing indications for reconstructive procedure. Prognosis depends on the stage, based on the primary tumor, regional lymph nodes, and remote metastasis. Indications for vulvectomy are the following histopathological types, such as epithelial neoplasm of skin and mucosa that included invasive squamous cell carcinoma, basal cell carcinoma and adenocarcinoma, then Bartolin gland carcinomas, carcinoma and sarcoma of ectopic breast tissue, carcinoma of sweat gland origin, bands of tissue sarcomas, and other malignant tumors such as melanoma, lymphomas, secondary metastatic tumors, and unclassified tumors. Reconstructive surgical techniques would include grafting procedures, realignment of sundered incisions, use of local fasciocutaneous flaps, vascular pedicle flaps, or free flaps. But the ideal flap for reconstruction should provide functional preservation and good cosmetic outcome in both the donor site and the recipient site. There are various flaps used in this region, such as the gratis myocutaneous flap, grand flap, blue-tilt fold flap, ILT, myocutaneous flap from MTFL, or radial forearm flap. However, there are some disadvantages associated with each one. From 2008 until this year, we had 20 cases of vulvar lesion that required complex bi-secondary reconstructive procedure and had patient consent. That included three melanomas, Bartolin gland carcinomas, morbid spages, three sarcomas, and two invasive squamous cell carcinomas. Chemotherapy was radical bivocal excision, meaning radical vulvectomy or hemi-vulvectomy. Each operation has two stages. First is performed by a gynecologist. He sets the indication and performs radical or hemi-vulvectomy with the dissection of lymph nodes. And second stage is performed by us bi-secondary reconstructive surgeons, immediate or delayed depending on the type and stage, and where the patient needs chemotherapy or radiation. This is first case that we are presenting after initial surgical skin biopsy, but the histological result came as melanoma vulva, PT4B. So gynecologist performed bilateral inguinal femoral lymphadenectomy and hemi-vulvectomy. And we decided to do reconstruction using pedicle grasses myocutaneous flap. So this is our center flap markings, raising the flap, guarding the pedicle. Pedicle is medial circumflex femoral artery. Then we place the flap through the tunnel in the inguinal and we fix it to the vaginal introitus using sutures. And afterwards we do a skin grafting on the donor side. Gracilis is a good choice. It leaves a minimal functional deficit on donor area, has a good external cover and inner lining and scarring can be wearable hidden with clothes. So this is another case of pedicid disease. After radical vulvar dissection was performed, we did reconstruction combining a pedicle muscular gracilis flap with spadichne skin graft, primer skin closure, and use of local fissure cutaneous flaps. And this patient here, this is after extubation of lap barton gland because of relapsed inflammation, but the histological result came as desmoplastic tumor of small round cells. She already went through seven cycles of chemotherapy, but with poor therapeutic answer, as you can all see. So our plan was to do reconstruction after vulvectomy with the same REM flap. So radical vulvectomy was performed. A picture on the right is showing tumor specimen, a sizing 27 centimeters in diameter. So these are our flap markings, raising the flap, guarding the pedicle, inferior epigastric artery in vein. Then we put always polypropylene mesh to avoid weakening of the abdominal wall and postoperative hernia. And this is final result with good covering. But sometimes REM flap could be a little bit bulky and scarring is pretty big and there's always a possibility of postoperative hernia. And what about complications? So this patient already had radical vulvectomy with the dissection of lymph nodes. She was closed with primary intention and use of one local fissure cutaneous flap. What she developed was stenosis of the orifice of vagina. And in cases like this, where there is a need to reconstruct not only the vulva, but orifice of the vagina, clitoris, if there is any remaining after oncological part of surgery, then reposition a little bit of mouth of urethra. We like to use free forearm flap based on radial artery, comitant veins, and we use sensory branch of radial nerve as a graft for lateral clitoral crura. So initially we did resection of skin and subcutaneous tissue design local skin flaps. Vagina is narrowed in most cases. So one should perform resection of scar alter tissue of vaginal atritis. And we reposition mouth of urethra a little bit superiorly. Then we raise the flap and as the most was performed end to side to right femoral artery and great saphenous vein and picture on the right is showing neurography of sensory branch of radial nerve to lateral clitoral crura. And this is her final result. We had one flat failure due to venous thrombosis and secondary reconstructive procedure was using vocal fissure continuous flaps with satisfying, aesthetically satisfying result. And what happened here? So this is 18 months after reconstruction. She had bilateral gracilis muscular pedicle flap. And what she developed was stenosis of her of the vagina. So she wasn't able to perform normal women hygiene and her mouth of urethra was partially covered with this skin flap. So there was no normal urinary urinary flows. So she also had urinary tract infections. So what we did, we did wide vocal excision, resected the scar author tissue vaginal introitus, repositioned the mouth of urethra a little bit superiorly. Then we raised free forearm flap and as the most was performed to superficial femoral artery and great saphenous vein. And this is the outcome eight months after second operation with good functional and cosmetic outcome. So there must be adequate lining to keep the introitus and vagina patent to allow normal women hygiene and resumption of sexual intercourse for those patients that are sexually active and durable skin around the urinary meatus to prevent stenosis and to allow normal urinary flow. And the original reconstruction case of 53 years old patients, she was diagnosed with men three. She already had partial rubectomy in various county hospitals with partial urethral resection and reconstruction with Wolfcross SkinCraft, but always with positive margins and disease recurrency. So we had two options to do one more reconstruction of urethra or urethracutinostomy. The patient wasn't prone to stoma yet, even though she was informed about complication of incontinence. So we decided to do a reconstruction of urethra, supravaginal approach. We use free form flap. We designed it as a tube around the urinary catheter. Anastomosis was performed to superficial femoral artery and to site and great saphenous vein. We left the catheter for four weeks post-op. And this is final result eight months post-op with no mental stenosis. She went through testing, meaning urodynamics with video imaging. She was found incontinent, but interestingly, about one year after surgery, she said that she has developed this kind of sensation or feeling when she needs to go to the toilet. So in her state of mind, she's not 100% incontinent. And patient satisfaction and objective studies in the literature have demonstrated that urethral reconstruction using a radial free form flap is a good reconstructive procedure. So we had one flap failure, two vaginal and joint discontractions. We have no local complications of radiation therapy. Average length of stay on our department was 2.4 weeks and all patients were generally satisfied with the results of reconstruction. So in conclusion, there are various myocontinous flap methods, which have been reported for the immediate reconstruction of large ovary defects created by deforming reticle cancer surgery. In our opinion, Graz's myocontinous flap and radial forearm flap provide the best functional preservation with good external cover and inner lining with a good cosmetic outcome in both the reconstructed site and the donor site. They are speedy to lift and technically less demanding. And of course, our decision was also made considering patient's age, local amount of tissue, patient's condition and comorbidities, and most importantly, patient's attitude to the current problem. Thank you very much for listening. If you have any questions or comments, you can feel free to email me on the email listed below. Thank you. Thank you for a wonderful presentation and for the group, we will take questions at the end of all the presentations. So with again, our thanks, Dr. Orhovich, and we'll move on to Dr. Lagish. Okay. Good evening. Ladies and gentlemen, it's a great privilege to be here with you today. It's a great privilege to participate in this symposium and Dr. Lagish, thank you for introduction. I would like to present our modification of the component separation abdominal wall restriction, well-known procedure with a lot of modification and this is one of them. I come from University Hospital Dubrova, Zagreb, Department of Obstetrics and Gynecology, and I suppose in 2011, I started to participate in Washington, D.C. abdominal wall reconstruction and at that time, I met Coach Phil and Sandro Mardini, Marissa Hadidia, and all the guys involved in this procedure. And I started to do those kinds of procedures when I come back home to Grazia, to Croatia, to do modifications like this, adrenal hernia of all kinds, as you can see. Most of them with comorbidities and previous 5, 6, 7 procedures. As Dr. Butler advised, most of them were in Gate 1, with low risk of complications, not necessarily wound infection, and Gate 2, with comorbidities, smoker of AIDS, I.D. system of stress patients, and COPD patients. Some of them, not too many, or the last 50 patients before COVID, maybe only 2 or 3 patients with potentially contaminated and truly infected wounds. And what's the reason why plastic surgeons started to do that? The ingenious procedure published by Dr. Ramirez is a component separation. As you know, published in 1990, it's a bilateral innervated etherical rectus abdominus transversus abdominus internal oblique muscular complex. And it works only in the case of the intact and innervated rectus abdominus muscle. Transposed medially to reconstruct the central defect. It's possible to close around 14 centimeters wide and 25 centimeters long defect without mesh. And what's very important is, of course, to preserve intercostal nerve, because without that, even with intact rectus abdominus, the recurrence rate is as high as you don't have a rectal muscle at all. So, the procedure is, as you know, 1 cm line lateral fibrillina semilunaris. We preserve intercostal nerve. That's a plane of separation. Quite easy and ingenious procedure. That's open component separation and closure of course, for plastic surgeons, the problem, yeah, Dr. Ramirez, at that time, got a life achievement award in Washington, 2011, for, among others, for this procedure. And the problem for plastic surgeons is this one, undermining of a huge flap of the skin, it's cutting most of the periodical separators, and with a result like this. So, first, Dominion regularly modified that incision and that approach on this way, with additional bilateral subcostal incision, as you can see, 18 meters on both sides, at the inferior aspect of the ribcage, and doing the component separation through that incision. We call that peri-umbilical, PPS, peri-umbilical, peri-component separation, with subcostal, additional subcostal incision. Also, Charles Buckler did the modification like this, adding a bilateral transversal excess tunnel in the supra-umbilical area, as a matter of fact, at the middle of the laparotomy wound, and again, to separate longitudinal tunnels for anterior component separation. But it's quite difficult to visualize around the corner, you know, to do the component separation through that incision, in my opinion. So, most of the patients, for most of the patients, we have to think about the pancolectomy, 90%, more than 90%. Pancolectomy is, as a matter of fact, part of the procedure. And as Maurice advocated simultaneously pancolectomy against subcostal incision for the anterior release, I started to do that procedure without subcostal incision. Why? Because previous subcostal incision, as you can see, can compromise the circulation of the hypoxic zone 3 of the abdominal wall. It means the zone 3 supplied by the musculoprenic lower intercostal and lumbar arteries. And so, my idea was to escape that subcostal incision, if it's possible, and to do some kind of simple direct visualization, not around the corner, as I said, in butler's modification, or without, of course, subcostal incision. So, for the patient like this, subcostal incision is already a problem, and that idea I presented at, I think, abdominal wall reconstruction in 2019, yes, and showed that to Charles Barclay at the time, and also to Gregory, and published that procedure in Japan last year. And what's the point of the procedure? It's very simple. From the pancolectomy side, instead of subcostal incision, instead of the transversal incision of the middle of the laparotomy wound, I do, after pancolectomy, I do in the tenderloin position, direct visualization and anterior, compartment anterior composite release, without undermining of the periubilical region, without destroying the periubilical perforator, with a little help of the long hook, of course, 15 centimetre blade hook, and the knife with the long pen, it's possible to, under direct visualization, it's possible to do the release. After that, the other part of the procedure is usually described by many surgeons, maybe more than others, by Michael Rosen, which means rectal pollution, the best pollution of the mesh, you know, because you've got a vasculite tissue on both sides of the mesh, so I think really that rectal pollution is the best one, and if you can close the posterior sheath without tension, you don't have to go any further, you don't need the task procedure at all. That's as a matter of fact the oldest technique, rectal space, as you can see. Of course, you can go further and do the posterior rectal sheath incision, too, dividing that upon a rock sheath, and getting access to the plane between the internal oblique and abdominal muscles, and putting the mesh in that position, and fixing that, as in this article by Thelmonell from 2008, and fixing it with Reverbeam's needle, that mesh in this position. And, of course, it's possible to go even with stars, as described by Malicki in 2012, and do the complete star release, or just one division. On this side, you can see the posterior advancement you can get with the posterior compartment release. It means with rectal, you can get, as you can see, 7.5 centimetres, and with incision of the posterior lamella of internal oblique muscles, 8 centimetres on both sides, and with division of the transversal abdominis, 9 centimetres, and even 11 centimetres on both sides with complete star release. Of course, it's up to you, but for most of the cases, I don't prefer complete star release, and this procedure, incision of the mesh with the Reverbeam needle in this position, as you can see, this is the task, of course, and also possible, but for most of my cases, I use the standards, the gold standards of the American Health Society, and that's Reus Topper 1 repair, as you know, and for cases with, let's say, you get from the abdominal surgeons, in case, let's say, of the abdominal compartment, where they can make the primary closure, and they put a different patch on side, and they use also some kind of bags for that, substitution for different patch, transportation bags, and after the wax procedure and the bridge, I use the same technique, you know, from the pancreas side, again, not touching the bag at all, again, in the transverse position, again, lateral, inferior lateral tunnelling, we call this technique, and we do the anterior release, and after that, we remove the bag, and do, in this case, primary closure without mesh, of course, contaminated wound, which should be biologic mesh, otherwise, it would be exact mesh. And that's that. That's the bottom of the bottom surgery, thank you. Thank you, Slaco, again, some pretty impressive technique there for handling a very difficult problem, challenging cases there, so thank you so much for sharing. Now, moving on to, from the vulva, to the abdomen, to the breast. We'll turn now to Dr. Zick for his presentation. Hello, thank you, Robert, for the introduction. And so, I'll be speaking about the dermal cage inferiorly based dermal flap technique for reduction and reconstruction of large implanted breasts. So, we have no conflict of interest to disclose. So, what are large implanted breast challenges that we have to address? It's a long nipple to ugulam distance. It's a problem of vascularity to the nipple, large skin envelope, usually more fat than breast tissue. It's patient preference, which usually they want smaller breasts in a normal position with no or minimal ptosis. The scars will be long, and of course, the longevity of the results. For large endotic breast settings, we can have three possibilities. One is aesthetic operations, the second is prophylactic operations, and the third is breast cancer treatment and reconstruction. In Croatia, breast cancer treatment is also in the hands of plastic surgeons. So, we treat the patients from the beginning, and this is one of the good things because we do the mastectomies alone. As you know from Tom Bick's famous words, no key fits every lock to Patrick Maxwell's that there is no one perfect technique that is applicable to the demands of every patient, and plastic surgeons will continue to require more than one in their armamentarium. So, the first setting is that we have large endotic breasts and that we want to do a breast reduction remodeling or after massive weight loss, where we have endotic breasts because of the loss of the fat tissues. So, I think what's important in every breast reconstruction and reduction is to try and keep the vascularity of the breast tissues and the skin envelope. And I think one of the most important papers that will describe the vascularity of the breast was published by Elizabeth Wuringer in 1998, which describes the breast septum in which you can find the blood vessels and the nerves that come from the intercostal area and from the perforators from the intercostal blood vessels. Of course, you will also try to preserve the vessels from the internal mammary artery, from the lateral thoracic artery, and try to keep as much of the vascularity as possible. Techniques that preserve this septum are the inferior pedicle, septum-based medial or lateral pedicle, which is a technique I prefer for smaller and medium-sized breasts, and central mound techniques. The inferior dermaglandular pedicle was described by Ribiero in 1975 and then was modified by a series of surgeons. It's still popular, or it was in 2004 when Rory published this paper, where he found out that a large number of surgeons were still using it. It's applicable to almost all breast sizes. It can excise even 2,000 grams per site. It can be used in cases of gigantomastia, avoiding free nipple grafts. It has a relatively short learning curve, and it gets relatively good vascularity and sensibility to the neck. The problems with that technique is that it maintains the inferior thoracic part of the breast. It has usually poor projection. There is a possibility of the pedicle to displace laterally, and pseudoptosis, or bottoming out, is a very common complication in the long term. Of course, it also has a time-consuming depitalization, and there is tension on the inverted T-junction point that is known for an all-wise pattern type reductions. The pseudoptosis was tried to be resolved by Pennington in 2006 by placating the pedicle at the inframammary level. So, my question was, when I was doing this technique, when I learned the technique, was that during the standard resection of skin and ganglion tissues with the lower pedicle technique, there is a large areas of skin which we resect. So, I was thinking, how can we use this to reconstruct the breast, or to use this skin to fix the lower pedicle in our desired position, and to reduce the pressure on the lower pole? We published this paper in 2013, but we presented our first results in 2000 in our Congress in Split, where we presented it for the first time. So, what we do before the operation? We usually have preoperative mammographs if the patient is more than 35 years old, or if there is some familiar chance of having cancer. We do an ultrasound of the breast below 35. We give perioperative antibiotics, and for patients at risk for DVT, we give low molecular weight heparin. When breasts are inflated with saline with a mixture of marcaine, xylocaine, and adrenaline to reduce blood loss and postoperative pain. So, where are the incisions made? It's basically a standard inferior pedicle breast reduction, but instead of resecting the wings on the side, we keep them, so there is a little bit more of the epitalization. So, this is what we do. We try to keep the septum of the breast, and we also try to keep the lateral part of the breast tissues, where the nerves come in from the side towards the nipple. This is the Waringer septum. You can see it during the procedure. You can see the blood vessels here. You can see the blood vessels here, which are preserved. And the dermal wings, this is after the epitalization are kept. You can keep different amounts of tissues on the dermal wings, so you can have more tissue on the medial side or the lateral side as needed. And then you resect the upper parts as the same as in the lower pedicle technique, keeping the thickness of the skin flaps as desired. And then you basically can fix the lower part of the tissue as an implant with the breast, with those dermal wings, which we can put at, let's say, put the application up into the second or third intercostal space, and we can suture the sides to the breast wall, and then position this central mount the way that we want it, more laterally, more medially, depending on what result we want to achieve, and then we re-drape the upper part of the skin. These are some cases. You can see the before the operation, the drawings, immediately after the operation and early results here. Another patient which has a lower position of the breast, so the footprint of the breast is lower. This is the side view and the result after six months, where you can see the result of the tissues. Another patient, this is how it looked before, early result, result later, and then after six years, and after nine years, and you can see there is no minimal bottoming out, and the breasts are keeping their shape and position. In breast reconstruction, we even have larger problems in large endoptic breasts, because we remove all the breast tissues, we remove all the vessels, blood vessels, which go through the tissue, and we remove all the nerves going through the tissue. So, we have more redundancy of the skin, and skin reducing procedures usually further reduce the vascularization of the skin envelope, and we need to cover the implant when the pectoralis muscle is not enough by itself. Or, in case if you go for a suprapectoral reconstruction, which is more and more popular today, because we get better aesthetic results, the question is how to reduce the chance of wound dehiscence and implant protrusion. So, I think that the most important part again here is to preserve as much circulation as possible to keep the section in between the breast tissue and the subcutaneous tissue, keeping the vessels in the skin. The dermal pedicle of the nipple can be, in the skin and nipple sparing mastectomy, can be oriented towards the best preserved circulation. These are some of the techniques that were used to reduce the breast skin envelope, so we're cutting out a segment of the breast in the upper part, reconstruction with a DEP flap, or you can create a whole ptotic enlarged breast using a DEP flap, which you just put as a big, with a big skin island, and then you construct a ptotic breast, but this is mostly not so. So, as we said, direct to implant one stage or immediate breast reconstruction is becoming more and more popular. So, the task of additional covering the lower polar implant can be achieved either by using a cellular dermal matrix or autoderm or the inferior dermal flap. So, we have usually, we have a coverage of the upper part, upper medial part, using the pectoralis muscle and the lower lateral part using a cellular dermal matrix, or in case with this case, I will show you, we can use the dermal flaps to do the same. The question is, do we really need synthetic or biological metrics as an implant-based breast reconstruction? In such huge numbers, or is it just a trend in favor of medical device market? Do we have more natural and less expensive solution with the preservation of the dermis instead of using expensive substitute for covering the lower pole of the implant? And I would say that you know the reconstruction with the dermis is not something new or revolutionary and we can see that it was described by Zbostwik in 1990 and then some other modifications by Tansky and Rosato before in 80s and 76. And the basically is the covering, do we want to cover the implant or do we want to fix the implant in position? And we paper the paper in GAP Press for the dermal cage and fairly based dermal flap technique for breast reconstruction after mastectomy. And the position of the nipple arola complex can be either on the epithelial lower pedicle flap or on the upper pedicle's medial lateral upper depending on where the better circulation is. This is a case with a patient which had breast conservative surgery with irradiation on the on the left breast and on the left breast there was a newly described tumor. So it was decided that we do a complete skin and nipple sparing mastectomy on the left side and the same procedure on the right side for symmetrization and removal of the remaining breast tissues. So if you look at the 3D drawing this is what we do the same as I've shown you in the breast reduction. So you basically de-epithelize the lower part with the wings remaining. You can placate the lower part to have better projection and you have the medial and lateral wings which you can either cover the implant or even position it in place. So this is once you turn it around the implant you have the whole dermal part covering the implant in the lower part lateral and medial part. So it basically forms a cage about the implant. In this case what is drawn there the nipple arola complex is carried on the lower pedicle. So this is elevation of the upper mastectomy flap and then remove the breast tissue down to the pectoral fascia. Implant is in position covered with the de-epithelized wings and closed over the skin flap is closed over the implant. In this case because she had quite a bit of subcutaneous tissue there was no need to put it either in before below the pectoral muscle and so we could just cover it with the good skin that was well vascularized. In the end we are closing the incisions and bringing out the nipple at the highest point of projection and that way we have a good projection after the operation. Another case with one side of the breast was done with a reconstruction and the other one was done as a reduction. Again the nipple is carried on the lower pedicle the dermal wings are closed around the implant and the skin is rejaped and the nipple brought out. In this case we have the nipple on the superior medial pedicle other parts of the procedure are the same or a bilateral skin and nipple sparing mastectomy for extensive ductal carcinoma in situ with reduction of the skin envelope and lower de-epithelized dermal flap with nipple on lower pedicle as well. This is post-operative result at six months. Complications of course that we have them and the most common ones are nipple and skin necrosis usually partial usually epidermolysis and it just basically heals by itself. This is a case where you can see you had epidermolysis of the nipple so you have this patch here where the the color was lost and it's not symmetrical to the other side but can be solved with the tooing. Of course you can have wound dehiscence but it's a good thing because you that you have another layer below so in many cases you can just resuture it and there was no contact with the implant so you don't need to remove the implant. Infection can be also superficial or it can be deeper visible scars can be a problem because the incisions are quite large and there can be asymmetry of the results. In conclusion I can say that patients with large endothelic breasts need more preoperative consideration and planning. Preserving the circulation is essential and the patient will have longer scars as excess skin needs to be resected and this has to be communicated with the patient and the dermal cage technique is a possibility for both reduction and reconstruction of large endothelic breasts. Thank you for attention and from our team from University Hospital Dubrava in Zagreb. Again for the third time thank you Professor Zeker. Again some very very challenging cases and beautifully presented. Also enjoyed your historical review of the progression of the techniques and brought to mind several warm memories of having known some of those great professors in our past. So at this point I'd like to open for the last 15 minutes or so to our participants in this webinar to ask questions of our panelists by going to the chat section and we'll keep an eye on that. But let me start out with a with a question for Dr. Horvitz. Some beautiful cases a lot of thigh base flaps. What about gluteal fold flaps? What's your what's your feeling or experience in that with your vulvar defects that you're forced to reconstruct? Thank you very much for your question. Over the years we have used several gluteal fold flaps as unilateral or bilateral advancement or rotational flaps. They are also a good reconstructive option but for lower and mid thirds vulvar defects scarring is very good and women like it because it's very hidden. But for upper third defects gratis myocontinous flap would be a much better option. Thank you. Professor Vlažiš, can you explain a little bit about how you use the mesh, how you position the mesh, and with your mesh experience what's your recurrence rate for this technique? Yeah, thank you for that question. Most of the time I use total throttling mesh. I use the biologic mesh from the Human Origins, so the option is epoxy mesh, thermacol, and therapist, it's quite expensive, as I said multiple times, for non-contaminated wound healers, ultra-thin mesh, for contaminated, the option is, of course, to use biologic mesh, soluble mesh, of the porcine origin, also in retro position most of the time, and that's because it's vascularized tissue on both sides of the mesh. Talking about recurrence rate, in literature you can find, let's say, for the first recurrence, 25%, for the second, even 50%, for the fourth, let's say, up to 6-8 meters recurrence rate, which is only in techniques. For the last 50 patients in 2-3 years, I didn't see one or two recurrence using this technique. So, I think, yeah, I've got a picture of the intestinal lesion, of the intestinal lesions. But most of the patients follow-up, personal follow-up, are still in our research, and that's the reason why I think that the gold standard technique, especially... Moving to Professor Zieg. Again, a beautiful, beautiful use of the technique, a little more labor-intensive than some of us have with our, the way we do breast reductions and the like. One way you would think that maybe it would make it easier would be to use a cellular dermal matrix as opposed to the epithelialized flaps. Do you have any comparisons or any impressions of the advantage of this technique in your hands? The problem is that a cellular dermal matrix is, you know, not allowed in Europe from the human origin. So, again, the ones that we have, which are not human, are not very good in quality. The other thing is reimbursement from our national insurance company is not very high. So, using that cellular dermal matrix would be a very problematic issue for us because it would cost more than we would get from the reimbursement. So, that's why we try to find solutions which are more, less expensive, and I say from the patient. So, this is one of the reasons that we are using the dermal graphs more than we are using the cellular dermal matrix. But the results from the literature for many of these reconstructions are very good. So, no reason why not to use them when you can. Thank you, sir. You know, moving from the world of macro-microvascular to the world of micro, micro, and super micro and perforator flaps. Do you have any experience with the perforators in this territory of vulva reconstruction or any other insights you might lend to the audience in that regard? Well, I have to be very honest. Since 2008, we have had our own learning curve in this particular region. It is essential to say that we do not have many vulvar lesions per year because of its rareness. And even though there are several perforator flaps that could be used in this region, such as deep femoral or medium circumflex, external pudendal, internal pudendal, or perhaps medium thigh freestyle perforator flaps, they would provide probably thinner fissure cutaneous flaps with favorable reconstructive results and fewer donor site morbidities. So, I would say that this is still something that me and my team are planning to perform in the near future. Very good. Thank you. Thanks so much. Dr. Vlažiš, are there any patients that you would look at and say that they don't meet your selection criteria for this procedure? Are there comorbidities or something that would make them not candidates? And what is your technique for your post-operative regimen for helping to maintain the integrity of your repair? Thank you for that question. Of course, there are many patients for which I say no. Preoperative evaluation is the most crucial part in the selection of patients for the success of the procedure. You know, because I've got a problem with smoking. I insist on that to stop smoking at least three weeks prior to surgery. Of course, it's possible to do a wound iniquity test for that. Weight loss, of course, with a body mass index more than 35, is called a deficiency. It's three and a half times more than usual. We do spirometry for those patients to rank top patients. We do CT for all the patients to evaluate the position of the rectal muscle, the hernia, the content of the hernia, etc. For the patients with loss of the main, we do the botox too. Let's say 500 units diluted in 5 milliliters of saline. We do it on both sides of the external glute muscle. And the system of peritoneum is also, as described in the procedure, a general technique for stretching of the lateral muscle, same as the botox. But we don't use it. We use it just to judge the volume of the residual autosomal cavity. It is YCT. And of course, comorbid conditions, we judge very carefully with steroid use, low albumin. So, for all those patients, when we judge that the risk outweighs the expected benefits, it's better just to say no. Those are difficult cases, and we have to be objective about that. Thank you. Professor Dzik, what's your selection criteria? What are the patients that you find that this procedure is optimal for? And in your experience, what's the most problematic complication you might run into with using this technique? So, Mike, the criteria selection is basically that you would have the nipple to inframammary fold distance at least 12 centimeters. Because you want to keep the distance in the end for about 6 centimeters. But you still need some of the dermis to cover the lower pole and to use it. If it's too short, then it's not worth using it. So, this would be the major selection criteria. Of course, I think that, you know, it's not… The nipple distance is not that important, because the breasts have a different footprint. So, you basically have to look at the footprint where it is. And then from that way, you can decide, you know, how much distance you have from the blood vessels to the skin and to the edges of the skin. I think the biggest complication, I think, in the technique is necrosis. If you have necrosis of the skin or necrosis of the nipple full thickness. Because in that case, of course, it will be problematic. Many times I found that even when I had a full thickness, it wasn't very often. I got maybe one case of full thickness of the nipple. And one case where I had the nipple survive, but there was a necrosis of the skin on one side. Not a large one, but we had the dermal flap below. So, it actually healed in the end with a little bit of deformity. And you could put a skin graft there and then remove it maybe later. So, I think that was the biggest problems that we had with the technique. Very nice. Sorry, I interrupted. No, it's okay. That's about it. One more for you, Dr. Horowitz. Obviously, a problematic area to reconstruct. And is there one thing that you've learned from your patients that, given the nature and the anatomy here, one problem that you've heard from your patients that if you could do anything and improve our approach to vulgar reconstruction that we need to focus on and to try to advance our techniques and the science to meet our patients' expectations better? Well, they are not very concentrated about the scars. The most important thing is so that they can keep their hygiene, normal hygiene. The elderly patients are not sexually active anymore. So, they are not really focused about the vaginal introitus or the dilation of the vagina. But the younger patients do want some kind of soft and gentle and thin tissue around the vulva area. They do not want it to be too thick or too bulgy because they don't like it. They don't feel it's the right size or something like that. And the most important thing is complications, the length of operation. And elderly patients, obese patients, we tend to minimize the operation and to be as quickly as possible. So, keep it simple and to do the simplest result and the simplest result of the current problem. Always great advice to keep it simple and deliver a defined product. So, thank you for those insights. Yes. Well, we are at the top of the hour. And so, I want to take this opportunity again to thank our panelists for three exceptional presentations. And to remind our folks that this webinar will be now placed in our library for educational purposes moving forward. So, with our sincere thanks to the participants who watched this webinar and to those who will watch it in virtual fashion. But most especially to our friends and colleagues in Croatia for sharing their expertise with us today. Our sincere thanks from ASPS. So, with that, thank you very much. We hope to see all of you at PSTM in Boston. And we look forward to our next in our series of ongoing webinars with our international friends and colleagues. So, thank you all very much. Thank you. Thank you. Thank you very much.

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