Hello, everyone. I'm Dr. Steve Williams, Vice President of Membership at ASPS. I want to welcome you to the ASPS Global Partners webinar series. We've got a really great one today, Reconstructive Lessons in Breast and Hand Reconstruction, What We've Learned. I want to, again, say thank you to our panelists, and thank you to the viewing membership out there. We are going to have three separate presentations, and then we will have a Q&A at the end. So I want to introduce our speakers. The first will be Dr. Ruth Waters. She is a consultant plastic and reconstructive surgeon in Birmingham, England. Her specialist interests include microsurgery and breast reconstruction, and she is president of the British Association of Plastic Reconstructive and Aesthetic Plastic Surgeons. Secondly, Dr. Sean Carroll. He's a plastic and hand surgeon at St. Vincent's University Hospital. He is a professor at the UCD Medical School and director of the microsurgical training at RCS. He is also the vice president of the Irish Association of Plastic Surgery, the IAPS, and the Irish ICOPLAS representative, and he is a member, obviously, of IAPS, ASPS, and ASSH. And then finally, Dr. Marzia Sargarello. She's an associate professor of plastic surgery at the Catholic University of Sacre Coeur in Rome, Italy. She is the chief of the Department of Plastic and Reconstructive Surgery of the University Hospital at A.A. Gemelli, Rome, Italy, and founder of the Center for Surgical Treatment of Lymphedema at the same hospital. She focuses her activity on breast reconstruction, aesthetics, and post-oncologic reconstruction, microsurgery, and lymphatic surgery. She is the author of approximately 150 peer-reviewed articles and numerous book chapters on reconstructive and aesthetic plastic surgery. So as you can see, we have a really great panel, and I'm going to let the speakers get right into it. Thank you. All right. Hello, everybody, and thank you for that introduction. So I'm going to start sharing my screen now and tell you about what I'm going to talk about to you. Here we go. All right. Okay. Okay. There we go. Okay. So it's a little slow at moving at the moment. Okay. Sorry about this. Let's stop moving on. Dr. Carroll, you can always just navigate. You can advance by using the arrows down at the corner on the left-hand side. Okay. Okay. Brilliant. Thank you very much for that tip. Right. Apologies for that. Okay. So my talk today is about shared decision in breast reconstruction. So I've chosen this topic because it's something that has become quite dear to my heart lately, and I hope I can share my enthusiasm with you today. So shared decision-making is what it says, really. It's a process in which we as clinicians can work together with our patients to talk about their tests and treatments, how we're going to manage them, and give them the evidence for why we're going to do that. Now, you might say, well, obviously that's what we always do. Why do we have to call it this particular thing? And I think the reason for that is because sometimes this very obvious thing gets lost in the hurried clinics that we have to do and our busy lives. But there is now very clear evidence that this is the way we should treat our patients, because we know that doing it this way will improve the knowledge of our patients. It will give them a better idea of how they can choose, and the participation that they give in their decision-making leads to a better outcome. So in the UK, we have statutory bodies that regulate us, and one of these is the General Medical Council. And I've just done a cut and paste for some of the advice that they give to us. And actually, this is more than advice. This is what we must adhere to if we're not to fall foul of the law and of what they say we must do. So again, if you look at this screen, it's all pretty obvious. I hope we would all try and do this. We want to be polite and kind to our patients, treat them with respect. And it emphasises this working in partnership with our patients, sharing with them the information, allowing them to make decisions about their care. And that should include all the negative things as well as all the good things that we hope for them. And it should also encourage them to take responsibility for what they're choosing and what we're going to do for them. So what else do we know? Well, also in England, we have the Royal College of Surgeons of England, and they also give us guidance. They tell us about best surgical practice. And again, this is cut and paste from a big document, which tells us how we should look after our patients. So in this instance, they're saying that when we're seeking consent from our patients, it's not just signing a form. It's this whole process that leads up to it. It's enabling the patient to make their decisions. And it should be then, consent should be considered like an informed request. You know, the patient is saying, I understand what you have told me. You've given me the time to think about my options. And now I'm requesting that you do this particular thing for me. So that's the deal that we should aim to make with our patients. And in terms of breast reconstruction, we also have a body in the UK who are referred to as NICE, great name. So NICE stands for the National Institute for Clinical Excellence, and it publishes guidelines for all sorts of things. And we have taken here the advice that comes from the breast cancer document with regard to breast reconstruction. And this is what we must do. So this is not, you know, again, it's not a nice thing. It's not options. This is what we must do if we are looking after these patients. And you'll note, it's very specific. It says all women must be offered the possibility of immediate reconstruction or delayed reconstruction. And whether we do that or not should not just depend on whether we can offer it in our hospital. If we can't, then we must make sure that they get somewhere where they can have it. It says all women who are being advised to have a mastectomy, again, should be offered immediate reconstruction. And if they're going to have radiotherapy, the issues around that should be discussed. So all the benefits and risks of these things need to be told to them so that they can make their choices. And we all know that some women having breast cancer surgery will say, do you know what? I'm fine. Just do the mastectomies and I'll get on with my life. And at the other end of the spectrum, there are women who say I'm not having anything done unless you tell me how you're going to put me back together again. So we have to find out which kind of person they are and what really matters to them. So in the UK, before COVID hit, we had not the best situation. We were not living up to that ideal. We were not offering women these things that we should have been doing. These are some newspaper magazine cuttings I made a couple of years ago before COVID was ever a thing. And so it wasn't great. Then, as you can see, not all women were offered what they should have been offered. They were denied these things or not told about them. Then came COVID and oh my goodness. So we went into crisis mode and pretty much all breast reconstruction was stopped in the first wave. Some of us got going a little bit between the two waves that we've had. But again, in the second wave, it all stopped. So now we already had a waiting list for breast reconstruction. Now it's much worse. The women who have mastectomies during that time are now added to the waiting list and we are trying to recover the situation and get back to where we should be. So let's think about this. So what is the patient's role in the decision making? And I put this slide together to show, really to give you a flavor of what I feel these women go through. So these two slides at the top here show you have a woman, often a young woman, living her life, maybe looking after her children, maybe having a busy job, maybe doing both. And suddenly she's told that this small lump in her breast that is not painful and is not troubling her is something that might actually kill her if she doesn't have the right treatment. And then we tell her about all the treatments that she can have. And these are pretty grim. You know, there are things like chemotherapy, where you lose all your hair, surgery, where you become disfigured, and radiotherapy, which has consequences that sometimes aren't pointed out to them. This is angiosarcoma as a consequence of radiotherapy, which is a pretty much always fatal complication. This is a thing called morphia, where the reaction to the radiotherapy is where the breast becomes red and painful. So they go from being this person living their normal life with no symptoms to speak of, to someone having to deal with all of this. What is our role as a surgeon? Well, we've got to do our best to make sure they're cured of that disease. And we need to explain everything about all those options that are available to them. And then we have to say how we can put them back together again if they're having surgery. So it's really important that we understand that patient as a person, their personal circumstances and what they have to do in their normal life. And the thing that we hang everything on in terms of shared decision making are the benefits, risks, alternatives, or doing nothing. And all of this has to be explained. So we have to work with the patient to go through all of this. And we have to bring in people like their family and their friends who are going to support them, our nurse specialists, everybody around them. You can help them in their choices and looking after them and getting them on their way to recovery. So what are the specific things we might consider in terms of breast reconstruction? Well, the first thing is, if we're going to do a mastectomy, should we do the reconstruction straight away or not? So what are the advantages of doing it straight away? Well, we all know that it's easier to get a good result. So here we have two women. This woman at the top has had a delayed reconstruction after mastectomy. Both these women have had diephylapse. So using diaphylapse, we know we can match the volume and shape reasonably well. But at the end of the day, it's not quite as good. We have this big scar running along the top. And you can see there is a difference in the color of the skin as well as the scar. Whereas this lady at the bottom has had an immediate reconstruction of her right breast when she had her mastectomy. The whole skin envelope is maintained. And, you know, the cosmetic outcome is that little bit better. But also it reduces the number of operations that she requires. She doesn't spend any time with that gross asymmetry and ends up with a nice result. However, we have to think about that. You know, we have to talk to her about all the things that she requires for her treatment and then all these issues around reconstruction. And if we're going to do it as an immediate reconstruction, that's done in a small timeframe. So it's much harder, you know, it's much harder to achieve what we want in that shared decision making because we have that time pressure on us. So what about therapeutic mammoplasty? So some women, fortunately, don't require a mastectomy. They can have a wide local excision. And this is sold as something as, yeah, yeah, you don't need to lose your breast. Everything, you know, we can do this without you having to do that. But we have to think, what are the consequences of that wide local excision? Is it as good as we are selling it to be? So here, for instance, is a woman who had a wide local excision. This is sold as a breast conserving procedure. But you can see that after her surgery and radiotherapy, again, she's left with this gross asymmetry. And over here on the left is when we then later on try to adjust this for her. And you can see that we've reduced the right breast and we've uplifted and reshaped the left breast. But it's not ideal because we haven't achieved perfect asymmetry because of the effects of the radiotherapy. And it's much more hard, much more difficult to do. So an option we can offer them is therapeutic mammoplasty. So in this instance, we remove the tumour as part of the breast reduction. We do a breast reduction on the other side and we get really nice symmetry. And then she can have a radiotherapy and doesn't need any more further surgery. And she can get a nice result. So although this is sold as breast conservation, we have to be mindful that there's a better way of doing it. And this is what we can offer our patients. So what about risk reducing mastectomy? So some women are at such high risk of getting breast cancer in their lifetime, such as those who carry the BRCA gene mutation, that they will choose to have their breast removed before they have breast cancer. And this, I believe, should be their choice. Any woman in this situation should be able to come to us and say, tell me what I can do. How can you monitor my breast? Is it possible for me to live with it for a while without having surgery? I may choose to get married or have a family and then have the surgery. Or maybe, do you know what? I'm in my 20s. I don't want to live with that risk. I want to get on with it now. And I believe that that should be their choice. Some people, however, put arbitrary restrictions on this, such as your risk has to be more than 30% for us to offer it to you. Why would you say that? If your risk is 29%, are you going to refuse that treatment? I think these arbitrary restrictions should not be there. And as the patient's over 50 years old, is that really something that we should say to them that you're too old at 50 to have this done? But this is what some women are told. Also, some women are told that they can only have this surgery if a clinical psychologist agrees with it. Now, actually, our guidance says that women should have access to a clinical psychologist, but it should not be mandatory. And it should be an option for them. And certainly, whether they have the surgery or not, in my opinion, should not depend on what the clinical psychologist says to them. This woman had breast cancer in her left breast initially, and had a direct flap reconstruction. She was not offered the option of contralateral mastectomy at that point. And a few years later, got cancer in her right breast, and again wanted autologous reconstruction. So she was given an SCAT. Now, you can see she has a reconstruction on this side, which is acceptable. A reconstruction on this side is acceptable. But together, they're not acceptable. They're not symmetrical. And in my opinion, women who are having a direct flap reconstruction on one side should always be offered the option of a contralateral risk-reducing mastectomy on the other side for this simple reason, that you could achieve a great result and not leave them having to have follow-up and mammograms for the rest of their lives. Simultaneous symmetrization is another option that's often denied. So this woman has had a left breast reconstruction with an implant. This was becoming uncomfortable because she'd had radiotherapy. So she elected to have that change for a direct flap. And we offered her symmetrization on the other side. So immediately, everything's sorted out for her. She has a nice symmetrical result and is comfortable. I think it's not great to offer somebody a unilateral breast reconstruction if you can't achieve symmetry. And if you can achieve symmetry by doing one of these things, I believe that that should be offered and part of your decision-making process. So these are just examples of where I think it's possible to go wrong and dictate to women things that they might not choose if they are given all the choices. So I would say create the right environment, establish a good rapport with your patient. And finally, I would like to thank these two people for inspiring me down this path when I came to an American Society meeting a couple of years ago. Terry Cootey, a patient educator advocate, and her surgeon, Minnis, who works in Texas. And together they've produced a thing called the Breast Advocate App, which I would recommend everybody to have a look at. So thank you very, very much. I'm going to stop my screen sharing now and I'm very happy to take any questions. Dr. Waters, thank you for that excellent presentation. I think it's such a timely thing to consider as surgeons as we perfect our techniques and expand our knowledge, sometimes we forget about involving the patient in the decisions we make. And I think especially in breast reconstruction, that's something that can be really at the forefront of considerations because it can be very personal, obviously, for each individual patient. Have you found at your institution that physicians are given the appropriate resources and time to have these extra moments with patients to really understand what their goals and desires are? I think that's a great question. And of course the answer is no. You know, at the end of the day, you always want more and you always want to do that better. We try and give them, after their first consultation, we let them have another consultation with a nurse specialist, and we always see them at least once again before we go ahead with what they do. And we like to feel they have open access to us to ask further questions and make decisions if they possibly can. But you never really feel that it's enough. You never really feel that in a busy clinic, you're doing justice to the ideal that you would live up to. But I don't think that's a reason to stop trying. Of course not. There's a question from the audience, and I think this has to do a little bit with timing and resources. The question is, in terms of contralateral symmetry for the non-oncologic, the non-cancer breast, when ideally are you offering patients contralateral surgery? And then again, forwarding this concept of this shared partnership and decision-making, how do you structure that within your own practice? Or what do you advocate for others to structure in terms of those ongoing considerations? Because breast cancer reconstruction, it's not this one finite point. It tends to evolve over several years. And some of us have had patients for a decade that we've been kind of helping them along with their reconstructions. How do you manage that? And what's the timing look like? Okay, so as always, it's important to find what matters to the woman. So if, say, she has very large breasts and you know you can't possibly match the size of the other breasts with the reconstruction, you have to explain that to them and offer a reduction. But some women don't want their normal breast touch. Some women will say, well, you know, this has got no scars on it, it's got the normal sensation. I don't want you to touch it. And so then you either have to say, well, you know, we'll do our best to match it, but it might not achieve it. Let them live with it for a while and see what they want. So then you may have to do more to augment it. So if you've done a DIP, maybe you'll come back and do a little bit of lipomodeling for them. If it's, you know, an implant reconstruction, maybe put a bigger implant in or whether, but so then you're right, then it becomes a process, you know, and as the years go by and things change, maybe having lived with it for a while, their opinion changes, maybe they then say, actually, yeah, let's reduce it or uplift it. So you're right, it doesn't, although you try and achieve your very best in the first instance, yeah, we keep our patients under follow-up and keep an eye on things so that they can have further modifications later on. And then one last question for you, Dr. Waters, and again, I appreciate your expertise on this. Have you found that resources on the internet, for example, have served to help inform your patients or have you found that in some ways to be more harmful in terms of the questions they ask, the, you know, the research that they've done, their preparation for the process that really, this kind of extended process that really is breast reconstruction? Yeah, I think, you know, there is good and bad out there on the internet. And I think it's, as to be fair, most people are gonna look on the internet and I think it's good to obviously tell them what your views are, but you can always direct them to the bits that are out there on the internet that are better, you know, you can say, right, you've seen that, but maybe take a look at this, what this person has said, and that's where I think, you know, things like that breast advocate app that Minnis and Terry have produced is so valuable because you can direct them to something that is out there online that they can pick up and look at. So, yeah, I think, you know, these days, you can't deny the internet. They will come with some views already established and you need just to direct them to the good bits. Yeah, so I've known Terry Coutier for a very, very long time, she's done wonderful work. So I think that, you know, I appreciate you giving credit to the two leaders in the field. Thank you very much, Dr. Waters. Thank you. All right, I think if I'm correct, we're going to move on to our next speaker who we previously introduced. We are going to be talking about Dupuytren's disease and some novel considerations. Dr. Carroll, are you ready? Yes, indeed. And wonderful. Thank you very much for inviting me. I hope I have that on slideshow now. And thank you very much, Romney and Laura for putting it together and Steve for doing the introductions. Dr. Carroll, we're not able to see your screen quite yet. Okay. Now you can. Yes, if you just want to start slideshow will be ready to go. So that slideshow on. Yes, just play from start. Good left hand corner, tap left hand corner, where it says play from start. Excellent. Okay, ready to go. Thank you. Thank you. So without further ado, just as my own personal experience and over 2500 cases over the course of the last 21 years, primarily due to the Irish gene that occurs, that makes a lot of patients have duplications. My breakdown is 80% operative, approximately 15% cordotomy, and a very small percentage of collagenase treatments. This is Baron Jupitron, whose name it was to give to the disease, and his statue is right beside Notre Dame in Paris, and every year the students paint him up, and then a month later, he's restored and it happens again and again and again. It is a connective tissue disorder. There is to that is due to micro fibroblastic activity in the palmar fascia. It is a joint of the palms of the hand with cord and nodules. It can be occasionally confined to fingers. But both cause progressive flexion deformity and skin tethering. As we know, it's mainly on the ulnar digit side, and frequently bilateral. This is a special anatomy, and this is the area in which the Jupitons occurs frequently, and then moves towards the distal end of the palm and into the fingers. This is a picture of the Jupitons as both thickening of the tissue and nodular, and this is just a classic photo of what the Jupitons will look like. So, this again becomes more complex when you move into the digit, and one really does need to know where the spiral bands are, whether the pre-digital bands are clelans, and have a reasonably good knowledge of that anatomy, and allowing you to do this will minimize the amount of injuries one does, of course, of the Jupitons fasciectomy. Over 2,500 cases, I've divided 10 nerves, and I think that's not an unreasonable amount, but as I keep on saying to my patients, that doesn't mean that you're not going to be 11, because it just can happen in the blink of an eye, and clearly hugely embarrassing. The diagnosis is mainly straightforward. One has to be aware of age, onset, medical history, family history, an assessment of the activities of daily living, and to bring all of this together with making a plan for any procedure that might be done. Bilateral disease is very frequent. Oftentimes, what happens is that they present at different times. When you operate on one, they'll be back five years later for operation on the other side, or indeed, a recurrence on the side you've already operated on. The diagnosis of a flat tabletop test is absolutely mandatory, and if anyone comes with Jupitons that isn't painful, then if the patient has a negative flat top test, as in the bottom picture, then that patient does not require any treatment at present. The Tibiana scale has often been discussed. It doesn't really help me as a clinician to assess them with regard to Tibiana. It doesn't mean that I'm disregarding Tibiana and what he has done, but it isn't something that I use on a regular basis. My own approach is that if a patient comes in with minimal, mild or minimal complaints and without any obvious cords and failing a flat tabletop test, that's one to observe and to let the patient know when they fail a flat tabletop test, then they can come back to me. Moderate is defined by myself as isolated palmar cords, and with an isolated palmar cord, then a needle chordotomy can be performed or indeed a local fasciactomy, which seen pictures of severe Jupitons, and the only procedure that can be done with them is a palmar and digital fasciactomy of a number of various types. I've often thought that if you, before you do a huge number of particular procedure, and if after doing that number and you're still doing the same things when you first started, there's something wrong. So I've always tried to change things and move things along and think about how best to do these procedures and I hope that in the course of this presentation that will become obvious. I dislike collagenase. We know it's pulled now and it's not available for Jupitons, it's used for cellulite, and obviously that's going to be far more profitable than doing it in Jupitons. But just the logistics of collagenase usage and having to see them 48 hours, it just didn't sit with my practice, and yeah, and I just did not use a lot of it. I put up radiotherapy, and I could talk with relative anger with regard to radiotherapy and treatment of Jupitons, it still occurs, and I really feel that it can work, of course it can. But years later, when the patient comes along with radiotherapy and treated Jupitons, this quality of the skin is poor, the quality of the fat is poor, and it makes an operation that can be relatively straightforward, very difficult. So radiotherapy is not on my radar when it comes to treating these patients. I want to talk to you about needle chordotomy, and I have to change that. Okay, so everyone's going to say he's using a blue needle, yeah, I am. I've changed to an orange needle, but what I use is a three-dimensional expansion idea, so I do the chordotomy from one side and do as much as I can. Subsequent to that, I will move to the other side and do a chordotomy from above and on the other side. And again, right here and now in the palm of the hand, away from the metacarpal phalangeal joint, you are nowhere near the nerves. The nerves are both radial and ulnar to that, and you are sitting on top of the tendon. So you have no worries as to injuring the neurovascular bundle, it just doesn't happen. Again, I do this from the other side and do that for the time that the cord dissolves. Once you break down the cord, you can't feel it anymore. And even towards the upper end of the palm of the hand, you really are nowhere near the neurovascular bundle. And then, yeah, we don't need to do that. We will just go to the next slide. And that is the end result of that. So occasionally, just like here, there might be a break of skin, but nothing that will not heal of its own accord. Minimally invasive fasciactomy is something that I've worked a lot in. So this is a chap who has a cord here and here and here. This clearly has to be opened on a regular basis, but one can be a little bit creative here. So a incision here with a Z-plasty, excise or divide the cord here, dissect it from below and then from above, dissect it from, as we see here, I'm dissecting the cord from underneath. Again, you're nowhere near the nerves. And if you stick with that particular cord, you can just do an operation like this and there's minimal scarring. Scarring in the palm is not a good thing because the scars themselves, regardless of what you do, can occur, can cause contraction of itself. And here we have the end result. Not a great photograph, I admit, but the scar is here and the scar is here. There is no scar here. And our rehab occurs far quicker with minimal scarring. Typical in other Dupuytren's, and this is the limited regional fasciactomy that we talk about, incision made here and here. And you can see that just in this area, I have removed the Dupuytren's. I use a Z-plasty in this area to access the next ulnar cord. So minimizing scarring in the digit, you really do just have to open it and Z-plasty it because it's just too difficult with the nerve. I want to show you this. So clearly identifying the nerve, which is here, is key. And one can do this without removing significant amounts of fat. Fat is good for the recovery. And a lot of people have talked about fat grafting with regard to post-Dupuytren's. Well, my view on that is if you take out the fat, sure, you might need fat grafting. But if you leave the fat there, as I have now, you're just taking out the cord. Then the fat remains and the requirement in volumizing it is reduced. So again, the Z-plasty here in order to safely remove all the tissue without injury to neurovascular bundle, very important. I'm just wondering about time and halfway there, I'm doing fine. And the same goes for here. Okay. Yeah, that's the same. I have to change that slide. But Z-plasties are key. You have the palmar crease here and you design your Z-plasty so that the transverse limb of the Z-plasty fits exactly into the palmar crease. The same is here for the crease of the PIPJ. And it sits just very easily and works nicely. Another picture from my cohort. And then Z-plasties here, Z-plasties here. It does happen in the thumb, not infrequently and very often on the radial aspect of the thumb. One gets a significant cord which affects the range of movement and whatnot and unpleasant when lifting things. And this can be fairly easily removed. I'm going to just show you again. No, I'm not. I'm not sure what happened there. So we'll skip. We'll skip. Again, looking at palmar fasciatomy here. And you can see that this is significantly flexed. The little finger is the most difficult hand or digit to operate on. Why? Because the digital nerves are really, really small and it's so, so easy to divide them in a heartbeat. So you have to be very, very careful. And utilizing any remote access in the digit or indeed in the little finger is really not something that I would be confident in doing. Again, I point out that keeping fat in situ is a very, very important aspect of it. Having the isolation and eyes on the neurovascular bundle where you can then just dissect distally and proximally. The teaching has always been to start proximal. And that's what I started off initially. But quickly, one can find the neurovascular bundle at the level of the PIPJ. And very easy then to take that as a direction, both proximal and distal. So saving or minimizing the risk to the neurovascular bundles. Around about here, you can see the digital nerve running in there. There is this spiral cord that can cause havoc. One has to be aware of that. And follow the nerve so it's not happening. Again, zeppelastes to close. Look at what I'm doing here. I'm moving here. Look at all that fat that is staying in situ. That's key. And probably things that are not taught enough about is maintenance of fat. And I'm the first person to admit that when I started off, I would consider a Jupiter trans operation being excellent. Because I had cleared out the whole thing. But that's not good, I have to say. Okay, so again, the zeppelastes. Now, this may be a little bit old-fashioned. But I haven't changed this in 20 years. And it works at splint. And you have soft tissue or soft dressings. And a very relaxed spiral dressing over the arm and the whole arm. This patient will next be seen a couple of days later by my hand therapist. We put splints, my splint, for five to seven days. Depending on logistics. Sutures out at two weeks. Nighttime splint, eight to ten weeks. And hand therapy will be determined by recovery and how the hand therapists feel about it. I do have to say this, that you can be a really good hand surgeon. But if you don't have really good hand therapists, then your results will be fairly poor or average. If you are even a bad hand surgeon and have good hand therapists, I still feel that one can manage to have pretty good results. So hand therapy is really, really important. The other issues are dermal fasciactomy. Which I don't think it really happens very, very much now. Presumably the reason for that is early presentation rather than the change of requirements. Occasionally one has to do it. But I would imagine that in that 2,500, I probably have done some more skin grafts. But maybe about 10, 15. Fat preservation is really important. And therefore not requiring fat grafting. And watching out for nerve damage. I think it's really important as well to point out that once one extends a finger that has been held in flexion for four or five years. And you do a good clean out of the jupitons. And you extend the finger. The finger after you take the tourniquet off will go white. The first thing one does is take the dressing away. Take the splint away. Let the finger go back to the normal position. And I can guarantee you that that finger will pink up. So therefore there is no good reason for a finger to actually develop vascular injuries. If you are sensible with them, keep an eye on them. Don't let them be discharged from your hospital until such time as you recognize that all fingers have gone. Go back to their normal pink color. And I want to say thank you very much indeed. And happy to answer any questions as recorded. Great. Thank you so much, Dr. Carroll. Really interesting. One question. I remember when I was doing more Dupuytrens than I'm doing now. And the collagenase wrapped, banged on my door. And doc, if you're not doing collagenase, you're going to get left behind. It's the new thing. You have to be a surgeon. You have to get in front of this. How do we as physicians figure out the best ways to integrate certain technologies for hand surgery? The hand is such a unique part of the body because there's so much function in such a small area. We want to be innovative. But how do we separate the things that aren't going to work from the things that do? Safely. So, yeah, you're right. The hand is unique. And if one looks back at the history over the course of the last hundred years, there has been significant improvements in all aspects of the nature of treatment. I have to say that the large majority of the nature of that treatment has been the postoperative hand therapy involved, which has blossomed and then become so much more scientific. And I think that that is probably one of the areas where it has led to more significant improvements than probably what we do surgically. Sure, there have been changes, but the basics remain very, very similar. And there isn't a scope in hand surgery, in my view, as there is in other general surgery and in the breast reconstruction, because it's a confined area and there's very, very little that you can change. But little steps can make big differences. And the preservation of fat, in my view, is a key issue with regard to Dupuytren's. Collagenase, well, you know, it's had its day pretty much. A lot of people used it. I used it in my time to a small extent. I get the sense now that it's falling out of favor. I might be wrong in making comments with regard to the U.S., because I'm not entirely certain. But certainly in Ireland, I think that it had been used and had fallen off and then it was pulled anyway. So, yeah, innovation in hands is slow, but there have been significant improvements. Wonderful. We have a couple of questions. One of them, with the low rate of dermatofasciectomies, how do you manage multiple recurrent diseases? So when that patient comes back with recurrence in the same zone of the hand, what are you offering that patient? Okay, so it goes back again to how bad the patient is, how old the patient is, what the patient does, any comorbid problems, and the quality of the skin and what the expectations are. In that circumstance, yes, if you have so much Dupuytren's disease and it's penetrating into the palm of the hand, the skin, and that skin clearly needs excision, that can happen. You have to then, in that case, use a skin graft. But again, it's not very, very often. If you put those incisions in the right way, do the Z-plasties in the right way, we know that we can pretty much ignore previous scarring of the hand for whatever reason. I mean, it's basically because of the incredible blood supply to the palm of the hand. So my approach wouldn't be all that much different to a primary presentation unless there was obvious skin the quality of which would not be viable post-surgery. Thank you. One last question. For your anesthetic for pain control, are you using, what type of pain management are you using? Is it straight local? Are you using bare blocks, general anesthesia? Right, so the whole menu is there. I do most of mine under block. I am moving into a wallant. General anesthetic is very rare. It's only happens when people are exceedingly nervous and whatnot. Post-operatively, everyone gets another block, a local block, which works very, very well. And then it's oral medication. So nothing fancy, but my feeling is that patients for the most part don't remember six months later that they were in a huge amount of pain. So, you know, it is well controlled. Wonderful. Dr. Carroll, I really want to thank you for your time and your expertise in this field. Your results are great and we appreciate you sharing your knowledge. Not at all. It's been my pleasure and enjoying the meeting. Thank you very much. We're going to move on to Dr. Salgarello. So I'm going to just pop off here and Dr. Salgarello, thank you very much. Thank you. Thank you very much for the invitation to participate to this webinar and representing SIGPREP. And I start to share my screen to share my experience on autologous breast reconstruction using lateral thoracic perforator flaps. And I have no disclosure. And first of all, a few words about SIGPREP, the Italian Society of Plastic Reconstructive, Regenerative and Aesthetic Surgery, founded in 1934 and representing 1,200 members. SIGPREP is always looking to encourage innovation. And for this purpose, SIGPREP runs a range of activities among which the annual CME training programs, the guidelines to regulate diagnosis and treatment and clinical trials in cooperation with the Italian Ministry of Health. And in 2013, SIGPREP and ASPS signed the agreement. And SIGPREP was the guest nation at the Plastic Surgery, the meeting, 2018. I had the privilege to be there and present in Chicago. And then the greetings to ASPS from Francesco D'Andrea, our president, and Stefania De Fazio. She is the leading actor of the international liaison SIGPREP-ASPS and from all the executive board. So coming to the subject, the COVID-19 time is a time of global public health emergency and our breast cancer patients are at high risk of COVID-19 because of the immunodepression, poor functional status, frequent hospital visits. So many of us are to resettle our therapeutic algorithms. And the need of breast cancer patients are to minimize exposure to COVID-19 without compromising the oncological safety. And our reconstructive priorities are to achieve a satisfactory result by adopting the easiest technique, limiting operating times, the risk of complication, hospitalization, a number of post-op consultation. We did a lot of changes. And our reconstructive changes in autologous breast reconstruction, we did the less free flaps and we did more local pedicle perforator flaps for total breast reconstruction. This patient was operated in the first Italian lockdown from March to May, 2020. And we couldn't do free flap at that time. And she was a patient with previous lumpectomy and radiation treatment. And then she had the cancer recurrence requiring nipple sparing mastectomy and autologous reconstruction. And we did the reconstruction with the Leica flap. And this is the post-op. And the historical background of the lateral thoracic perforator flaps comes from the paper by Mustafa Amdi and 2006, 2008. And recently, Stephen McCulley give more details about lateral thoracic artery perforator flap. And the lateral thoracic area is a watershed area of different potential perforator flaps, which can be harvested in the same orientation of the axillary role. And they're used for partial and total breast reconstruction. In the last three years, we refined the planning and the execution of these flaps, expanding the application and making the surgery easier and faster. This is our evolution. We started using local perforator flaps for partial breast reconstruction. Nowadays, we use a lot local perforator flaps for immediate total breast reconstruction and delayed total breast reconstruction. These are the indication to local perforator flaps for partial breast reconstruction. First of all, after breast conserving surgery for the patient not amenable to tissue displacement, also for delayed partial breast reconstruction after breast conserving surgery and radiation treatment for the deformity that are not amenable to fat grafting, but also for some complication after post-mastectomy reconstruction, for example, for some implant salvage. This is a classical LICA flap for immediate partial breast reconstruction after breast conservative surgery, which implies some ischemic cesion in the inferior quadrants and the LICA was used to replace. And these are the indication to local perforator flaps for total breast reconstruction. Basically, the need of autogenous reconstruction and the reluctance to use the free flaps to reduce the extent of surgery and to reduce the surgical time. For example, for mastectomy after breast conserving surgery and radiation treatment, but also for mastectomy in the lax and thin patient, in the weight loss patient, for the obese patient, not candidate to implant reconstruction, and for those patient who dislike implant reconstruction. Lastly, for autogenous reconstruction in the thrombophilic patient, or after failed free flap, or when there is a poor abdominal donor or a poor thigh donor site. This is a case of a patient after skin-sparing mastectomy and implant reconstruction and contralateral mastopexy, augmentation mastopexy. But because of chronic pain, she has to get rid of the implants. And we did delayed total breast reconstruction with the LICA flap. This is the ICG angiography. We don't do it routinely. And this is the post-op after six months. And we also did the explantation of the contralateral breast. And the modern approach to this flap is the ultrasound-based harvesting. So we always do the pre-op ultrasound examination. It has to be done by an expert, but at the beginning of our experience, the expert was the radiologist. But nowadays, the operating surgeon, the plastic surgeon does the study to get as more information as possible. Because with all of this information, we can do a kind of ultrasound-based flap design. And also the knowledge of everything about the perforator speeds the surgery and makes the flap elevation safe. Basically, we are using LICA and TAP for total breast reconstruction. And we do our color Doppler sonography examination. We research for the perforator vessel in that area, especially for the location of the facial emergence point. And we mark it. We pay attention to the side and also to the branching in the subcutaneous. So for example, in this case, this is the end of the latissimus dorsi. We can see the thoracodorsal vessels and the TAP emergence point. But we also see the LICA, which seems to be very good with a good subcutaneous branching. So we have to choose in between these flaps. This is a case of a patient after breast conserving surgery and radiation treatment, experiencing a recurrence of the cancer in the right breast, needing mastectomy and autogenous reconstruction. This is the LICA flap. And this is the pre-op and post-op and one year post-op. This is another case of LICA flap used for delayed bilateral total breast reconstruction. This patient already had nipple sparing mastectomy, bilateral implant, and she experienced many recurrent implant infection. So she wanted to get rid of the implants. And we did LICA flap for both of the breast. And this is the result after six months. We can also give a flap weight prediction if we consider our flap as an elliptical cylinder, which can calculate the elliptical cylinder volume with the formula. We know A and B, but we also can measure A, the height, because we can measure the thickness of our flap with the ultrasound. And if we consider the flap volume equal to its weight with this formula, we multiply A by B by the height by pi, and we can have the volume and the weight. So this is a case of right mastectomy specimen weight about 220 grams. The LICA is calculated about 200 grams. And this match the mastectomy specimen. This is another case, patient with small breast needing nipple sparing mastectomy on the left side, asking for autogenous reconstruction without any surgery on the right breast. We planned this LICA flap, 60 grams is the prediction of the weight, and the mastectomy specimen was 70 grams. And this is the result. But now I want to drive your attention to the pedicle. The LICA pedicle is not skeletonized. And as the LICA flap is very close, it can reach the breast without skeletonizing the vessels, the perforator vessels. This protect the vessels from twisting and from the excessive traction. We do facial incisions to mobilize the flap pedicle, and both of these maneuvers increase the flap reaching and the movement of this flap is through rotation, as we can see here, but also advancement. So first of all, we verify the best LICA flap rotation. If counterclockwise as in this flap, not that good. We do the contrary, this is the clockwise rotation, and this seems to be fine. But also there is an advancement thanks to the fact that we don't dissect the vessel too much. And we call this translation, the summa of rotation and advancement. Well, as the pedicle dissection is minimal, the lateral intercostal nerve is usually included in the pedicle and also some peripheral branch of the lateral thoracic artery and vein to augment the perfusion of our LICA flap. This is the other option, tap flap for immediate total breast reconstruction. This is an obese patient needing lipospermial mastectomy. This is the flap, this is the pedicle, and this is the post-op. And the tap flap really requires to dissect the perforator vessels and often also the thoracodorsal vessels to reach the defect. So the movement of this flap is to the transposition of the thoracodorsal pedicle and the flap advancement. Sometimes propeller rotation when this perforator is very close, but it's rarely the case. And this is a case of tap flap for the late total breast reconstruction. We did the ultrasound, we found these two perforators, two tap perforators, these two. And we did the section of the flap with the skeletonization of the two vessels. And the flap fever is higher in this case along the thoracodorsal vessel. So the surgery takes a little bit longer. And the choice between the tap flap and the LICA flap for breast reconstruction is very, very often very easy. Usually a good diameter of LICA exists and the ultrasound provide us all the information. And we know that the LICA is close to the defect and there is no need to skeletonize the vessel and we can have a good movement of our flap. So we can conclude that the LICA flap harvesting is easy and quick. So the choice between these two, the winner for us is the closest. So we choose the LICA flap whenever a good perforator is present and the tap flap represents our secondary choice, second choice. Of course, we can add a small pre-pectoral implant or we can use fat grafting in a second surgery in case the patient want to have more volume. So these are my conclusion. Autogenous total breast reconstruction with local perforator flaps is easy and effective. And we increase this technique in our practice, especially in this last COVID time. And the ultrasound increased the safety and possibly it should be performed by the operating surgeon. This option is good for partial, but especially for total immediate and delayed reconstruction in our hands. And it could be combined with a pre-pectoral implant in case it's needed, or we can add fat in the later surgery. So now it's the end of this presentation and we are here for a question and answer. Thank you very much for your attention. Dr. Salgariello, thank you very much for that fascinating presentation. You know, I thought it was very interesting that part of this expertise, part of this development came out of COVID, came out of the restrictions that Italy was facing from some of the larger, longer operations like deep flaps. Do you see a return to, or a decrease in usage of the light cap flaps as COVID begins to wane? Or is this something that you think is a permanent change because it's been so successful? I think it's a permanent change because it made our surgery easier and the recovery of the patient very, very quick and also reduced the operating time. I think we learned a lot from this experience and we are now widening the application in many, many cases. So for autogenous, DAP is the first choice, but whenever we don't have enough tissue in the abdomen, probably the second choice is becoming the light cap flap. That's great. A question from the audience, in terms of both harvesting and donor site closure, are there things that you think about in terms of how you manage the donor site? For example, do you use drains to manage seromas? Are you finding that there's a lot of tension there? Or you have hypertrophic sparring from that area? And do you have tips about insetting the flap in terms of anchoring the flap with sutures or the pectoralis or deeper structures? Okay, very good question, both of them. Well, for the donor, we don't do very wide dissection, but we interrupt the superficial fascia system a lot so with the subcutaneous incision in the way we can close without tension, but we avoid big undermining and we don't experience seroma. That's very interesting, very different from the lat-dorsi operation. And about in the insetting, the key is to have the proper rotation. And then we usually, if we have the envelope, we just put the flap inside the envelope. If it is a nipple sparing mastectomy and the immediate reconstruction, if it is a delay, we use the flap for the inferior pole. And if we have some lack of tissue in the upper pole, we can advance the upper flap, but we don't fix the flap on the top of the pectoralis measure. We just close the skin together with the local skin. You know, I also, I was really struck by the analysis you had in terms of trying to match the flap with the oncologic resection in terms of measuring the amount of volume you would need. What do you think the maximum size of a LICAP flap would be? Or, you know, what is the largest volume you've replaced? Okay, good question. Well, I think the large volume, the largest volume is 25 by 10 and the volume was 500, which is with a big, big axillary role. So yes, very, very interesting. We use it for a failed VIP. It was enough, incredibly. Well, I want to thank you for, again, a very impressive body of work and some real innovations there. I think that the results speak for themselves and the efficiency in terms of surgeon's time and patient outcomes and donor site morbidity, all those things is really impressive and a nice step for breast reconstruction. So thank you very much. Thank you for the invitation. Thank you. Great. Well, I want to thank all of our panelists. I know we've run a little bit over time-wise, but I really want to say thank you to Dr. Salgarello, Dr. Waters, Dr. Carroll for taking their time and sharing some of the insights they've encountered and developed both in hand surgery and in breast reconstructive surgery. And, you know, I'm always amazed at kind of how much expertise is out there and really kind of what people are able to achieve. And it's, you know, it's very humbling to really understand the achievements that these plastic surgeons have made for their patients. So I want to thank everybody very much for taking the time to share that with us. Thank you. Great. All right, Laura and Romy, I'm going to turn it back to you. Thank you very much, everyone. And we look forward to seeing you in the next one of these presentations and we'll make sure we get the word out. So thank you again for attending.

breast reconstruction

hand reconstruction

shared decision-making

Dupuytren’s disease

needle chordotomy

fasciaectomy

local perforator flaps

LICAP flap

TAP flap

patient outcomes