Greetings. Good morning. Good afternoon. Good to our friends in Russia. I'm excited here to be able to welcome three of our young promising and rising stars within the Russian Federation to participate in our asps global partners webinar series today. I'm Bob Murphy hopefully known to many of you here, and the title of our, of our webinar today is aesthetic reconstructive and regenerative medicine challenges and plastic surgery of you from the Russian Federation. Today we are, we are going to be broadcasting in English, but have colleagues in Russia, who will hear this in a delayed fashion. The video. There's been some, some platform issues, so that we will proceed with the webinar now, but our colleagues in the Russian Federation, and our may need to access this at a different time to meet you if you could be so kind. Good afternoon, colleagues. Good afternoon, good evening, depending on your geography. I am delighted to welcome you to today's event. Today we are addressing three rising stars in the Russian sky. Unfortunately, today's event will be in English. You will have the opportunity to familiarize yourself with the voiceover after the event. Unfortunately, we encountered problems with the platform and were not able to fully include a synchronous translation, so the translation of the event will be available later via the links. Thank you very much, colleagues, and the event continues in English. So we'll get on with our webinar now our first speaker is a gentleman that I'm privileged to call a friend for many years. Dr Constantine Lipsky, who I met when he was president of the Russian Society of plastic and reconstructive and aesthetic surgeons. Dr Lipsky has a tremendous knowledge base and interest in rhinoplasty and is actually the co founder and member of the rhinoplasty Society of Europe. He is also a member of the editorial board of the annals of plastic reconstructive aesthetic surgery, and the author of more than 200 publications. Currently, a working department plastic reconstructive surgery cosmetology and cell technology is the Russian National Research Medical University and associate professor there. So it is my privilege and pleasure to introduce my friend, Dr Constantine Lipsky. Thank you so much. Sorry, time to share my screen. Just a moment. Okay. So, um, it's a pleasure. It's great pleasure for me to be with you today and we are starting from the first report which will be about secondary rhinoplasty but first I would like to say some history because we are. We are having together history. That's mean that there's our Alexander, the second and the president of the very good friends and the pen friends of course. As you can see the, the conversation between several years leads to proclamation of emancipation of slaves and in Russia. It was liberation of service. So it's a long, long time tradition. But another tradition that we have, we have a lot of guests usually from the United States and here you can see. And, of course, a big who came to us, just after the 911. This is a September of to one. My presentation will be about secondary rhinoplasty, and I want to share with my experience in that field. Of course, nowadays, secondary rhinoplasty it's a common operation but of course I like to say that we should do rhinoplasty only once a life. And all that operations. Steric operations and plastic operation of course can be done several times but this is a idea but I used to show this patient because this patient is. Mistake of attitude because she was suffering from headaches which was suffering from problems mental problems and some psychological problems, but the main idea was that she was ill, and their idea of who this was of course the inflammation. But this was not diagnosed, it was not possible to diagnose this, and she was treated only in two years, when she was in our clinic. And we of course, open the inner valve, we open the external valves, you can see how small septum was left for this patient and of course, we achieved a good result for breathing and, of course, she, even the eyes on the picture you can see that they become more happy. Of course, nowadays secondary rhinoplasty it's always a ring, but we're using grips, I think in about 60% of our cases and I think this is a stable percentage. Well, I will start with one patient which is called my mistake but it's not my mistake but she asked me to make her nose, which was before this previous operation. You can see how it looks like, hump, but before it was a bit longer. So the doctor just shortened the nose, and she asked me to do the same. Of course, we need to separate the synahia and to make the septum stable and this was the result after this first surgery, but of course, this is not acceptable. And the doctor understood it and asked for one more revision. This is obvious that this was a short nose, but of course, she was not happy. So what we did next, of course, we did a secondary reconstruction, but it was much more easy because we just shortened the nose and the result was like this. So this is a good example that we should take care of, not only what our patients are saying to us, but of course, of the main idea of the surgery to make the nose breathing and to make the nose more beautiful. Well, some other patients which we have. This was after the previous operation and you can see that there was a big subtle deformity because the septum was absent and we did the reconstruction of the septum. And nowadays we are doing some camouflaging with some, there is a small defect which we were taking care of last week. Always very difficult to take care of patients with thin skin and this lady was underwent some reconstruction, but with this light subtle deformity and light subtle deformity. So we also took rib and recreated the cartilaginous septum with such a result, even with the thin skin, you see, we can achieve good results. Another lady, opposite picture, you can see how, what is the deformation of the nose, it is very short and the projection of the tip is not prominent, is not in proper position. So this was also a problem inside, you can see there was a lot of scars, also. So we took a rib, we did the reconstruction of the whole structure. And this was a result of the operation, which we got six months after surgery. Another lady, also secondary procedure, very strange nose. It was done somewhere in another clinic, but what we were able to do, I will show you. This was also problems with synechia, you can see that the arteriole was collapsed and collapsed on some space of the tip of the nose. This is a multiple fragmentation of the bones, I think was a result of osteotomy. So the result, which we achieved in six months after surgery, you can see that the nose became more beautiful, of course, the patient was very happy to have a breathing and short nose, not like she had before. Another lady, this is not a chronic disease, this was just a previous several rhinoplasty, which leads to inflammation, which leads to cartilage problems. And you can see how small the nose is, how small the nostrils are, and the shape of the nose, of course, was not like it should be, and which can breathe properly. You can see it here. So this is inside you, you can see that everything is blocked, the airwaves are very narrow, and of course we, and this is arteriole, well, you can see that it's just closed. So what we did, we did the reconstruction, there wasn't enough skin because you can see the shape of the skin was like it was the waves. We put these activators for the nose, silicone activators, because the scarification was very big and usually we are using them for two or even more months, that helps a lot to prevent scarification in such kind of situations. That looks nice from the bottom. Another patient, you can see that it's a very, very small deformities, aesthetic deformities, but you can see that the inner valve is very narrow. Of course, the first indication was bad breathing. And we were taking care of this, and of course she wanted to have symmetrical nostrils, but sometimes these ladies, they are very strict with us because, you know, of course, scarification and the procedure which was made during the first operation seems to be a big start. A starting moment for such kind of things. Of course, there were collapses of the valves, you can see also syneches. So we made the reconstruction of the whole framework, we put some rim grafts, we recreated the inner valve. And the result was, for me, quite acceptable, but a little bit asymmetry was present. And she was, of course, she was saying that she didn't like the result of the operation, but the breathing was excellent and you can see that the situation became much better. And the profile. And the profile. Another lady, she underwent septoplasty, you can see the deformation of the nose, all the soft tissues went in, of course, all the framework needs to be reconstructed. And you can see how the deformation inside the nose, we took it, it's A3. And the result of operation, which is also was for the first time was a little bit asymmetry of the nostrils, but this is the main issue, the main problem of secondary operations, and this, we should also tell them because this situation can be, say, so even one year after surgery until it will be solved. The profile is very good, and the projection became much better. The opposite, again, opposite situation, the lady was not breathing properly after the first operation, but she likes her nose. In that case, of course, we should take care of the structure of the nose, take care of the stable result. Of course, it's a bit more difficult situation. And you can see what was the problems, which were left from the previous operations, you can see conchobolosa, and perforation of the septum, not too large. And this is a result of the operation, you can see that we didn't change a lot the shape of the nose, and this was the main idea of that lady that we will not change the shape. In other situation, big deformity, also in the case which was operated previously, and what we've done, we've just recreated the normal appearance of the nose, which the lady wanted. Like, nowadays it's normal to make a model of the future result of the operation, and this is very acceptable in Russia, I don't know how it works in the United States. Another lady, also deformation of the septum, also was septal, some sort of septal operation, septal deformity of the cartilage part of the nose, also the rib, and we achieved such a result, which was, to my mind, very good for her face, and of course she was very happy. Secondary rhinoplasty is a special issue, because in my opinion, we should do only straight and only good angles, I mean, not too creative, more feminized nose. But here, of course, you can see another one, which was also as a result of the previous operation, there was a big absence of the cartilage, how it looked like after surgery, this is profile. I think this is all that I wanted to tell you, I hope I didn't spend too much time, but the main idea, which I'm always saying that we are doing the rhinoplasty not for five, not for 10 years, but we are doing this for the whole life, so we should think carefully what kind of procedures we are using, what kind of materials, and of course, what kind of methods we are using. Because as many tools you have in your toolbox, like Dr. Tarumi told, he's actually in Istanbul, the better surgeon you can be. Thank you so much. Thank you, Konstantin, pretty remarkable results for secondary rhinoplasty, always a challenge. I'm impressed by the degree of septal issue that you've had to reconstruct. So two questions. Do you find that some of your colleagues use one technique that leads to the ovary section of the septum? And the other question is spectacular results using rib cartilage, what's your long-term experience with maintenance of that result? Thank you so much for answering the first question. What kind of procedures are they using? I can't say that this is some sort of procedures, but for sure, the septal work, when they left a very small strip of cartilage, which is not able to have a stable position of the septum, it can be one of the reasons. Maybe the strip is very short. And another problem, the angle, which is anterior angle, which is always about 90 degrees, but it should be covered, like an arch, because, of course, you all know that arch is much more stable than an angle. So that's why I think if we are taking care of those two points, of course, such problems will not exist. But, of course, we need time. And concerning the other question, long-term results, of course, we have some information, we are taking care of them, and we now know how to treat them. Of course, we are doing the sensibility for the antibiotics of what we are finding in noses, but the type of bacterias they are sometimes very different. We can have staphylococcus, we can have staphylococcus fecalis, we can have even Escherichia coli, which we can find in the nose. So it means that, well, nowadays we are cleaning the hands, all of us, because of the COVID, but in the previous times, of course, maybe it was not like this. I mean the patients, of course. Very good. Well, again, congratulations there. Just wonderful results, Konstantin. Beautiful results. Turning to our next presenter, now I'd like to introduce Dmitry Melnikov, who is Chief of Reconstruction and Plastic Surgery at the Institute of Plastic Surgery and Cosmetology and Senior Surgeon at Sechenov University, and he is also the Vice National Secretary of ISAPS. His fields in plastic surgery are microsurgery and breast reconstruction, breast oncology, and lymphedema. So can we move to Dr. Melnikov's presentation, please? Hello, everybody. It's a big honor to be here, and a little bit nervous in such company. So my talk will be about the modern trends in breast reconstruction, and it's a pretty complicated topic to talk, and I hope I will be on time. So I try to focus top five trends in breast reconstruction for me now in our routine work. Trend number one, it's more reconstructive procedures at all. Trend number two is more complications. Trend number three, it's more free flaps and less trend flaps and other kind of flaps. Trend four, it's more LD flaps, and trend five is education. And I will talk more about one of these trends. So about more reconstructive procedures, everybody knows the stats. And in Russia, we have the same. We have more breast cancer diagnosed, and we have more surgery done by year, and we have more patients for breast reconstruction. And a lot of trends we have everywhere, and everybody in all departments, we have more breast conserving surgery, we have more prophylactic mastectomies. So we have more and more reconstructive procedures, and most of them are with the implants. So in oncology, in breast reconstruction, we do everything like mediate reconstruction, breast conserving surgery, direct to implant reconstruction, perpetual, oncoplastic reductions, prophylactic surgeries, meshes, ADMs, everything is possible, and everything is routinely done in Russia, in our department, everywhere. But we have the main paradigm shift, and the reconstruction became more aesthetic, and patients' expectations of the patients are higher and higher. And you know, sometimes it's impossible to understand, reconstruction has been done, or this is just a static procedure. Like this lady on the video, it's my patient after the prophylactic mastectomy with a DTI implant reconstruction without any mesh, fat, or something else. So today, breast reconstruction is a natural shape, it's a proportion, it's a symmetry, it's a natural feel, it's a freedom feeling, it's a feeling to be free from the cancer for our patient, it's less cost, and always a controlled breast management and some kind of operations. So we became more aesthetics, and it's very, very important for oncoplastic surgeons, for oncoplastic surgeons as well. And it's very important, and I will talk about later, the social media influence. Now the patients put their pictures on Instagram, they share, they compare the pictures, they make accounts or something else. So now you can't do ugly breast reconstruction and say, that's okay, that's affordable, something else. The level of expectations, the level of breast reconstruction became more high and higher. And we still have very big controversies about the breast reconstruction. It's a radiotherapy, because when you took part in some kind of oncological meetings and you see the trends, you know the trends in breast oncology, there are a lot of radiation. So a lot of patients did the radiotherapy after the breast surgery, and the radiation affects the result, affects very strong, and it's a keystone of the breast reconstruction. And the rate of complications are very, very high. If the breast has been radiated with the implant, with the flap, it doesn't matter. So it's very important to understand, do we really need a breast reconstruction now at the moment, if we understand that the patient will have a radiation and radiotherapy? I think that's very, very important. And in our meetings, we talk with oncologists and sometimes say like, maybe sometimes it's better not to do a breast reconstruction, complete all the treatments, and after that go back to reconstruction to have the result. Because, you know, there's a bad trend today is to reconstruct everything and all the time, no matter how deep the radiation will be, just reconstruct everything. I don't think that's good. I don't think that's a goal. And the trend, too, is going from the trend number one. We have more reconstructive procedures, and we have more complications. All of these ladies, I will show you, they came to my office, they came, they Zoomed with me, they sent the pictures, and all of them are with a breast reconstruction that has already been done, and they quit from the breast reconstruction, that this is the final result. And they are not happy. They are not happy on the picture on the right, on the left. All of them are not happy. It's not good, that's not aesthetic, that's not symmetrical, that's really bad results of the reconstruction. And we have them more and more. And you know, I try to analyze why this happens. And I had a big talk about this, about the complications and the reason of complications. And I think that the main reason is that a lot of, in Russia especially, a lot of oncoplastic surgeons, oncological surgeons, they shift their work more to aesthetics and reconstructive procedures. And I think that's a big problem. You have to be a full plastic surgeon to do a nice reconstruction, especially if we're talking about the contralateral breast management or surgery or something else. So the complications like this with the implants, all these complications are the problem, are the modern problem of breast reconstruction, I think worldwide. So if we go back to this picture, and you'll see that the amount of the breast reconstruction surgeries with the implant are high and high in Russia, in the United States, because it's easier. We have more implant-related complications. And that's very important for me. When we're talking about the implants, now you know, all of you know this trend about the LCL, breast implant complication, breast implant illness, ATC, and aesthetic patients and oncoplastic surgeons, oncoplastic patients, we have the same. And we have always talked and explained to patients that if you have some kind of implant, you're possible in danger with this implant. You can have a capsule contracture. You can have a rippling. So you can have some situation to do revision surgery or something else. That's why we, and this is the trend number three. We really believe in the deep flap, we really believe in autologous reconstruction. In my department, we have done more than 400 flaps, deep flaps. That's not too much, but we do routinely like twice per week. And I think that's deep flap is the golden standard of breast reconstruction today. Why? Because we replace like with like, like was written in the basic books of plastic surgery. This concept is very important concept for the patients. That's one stage surgery. This is easy flap. If you do it recently, that's really easy and nice flap. And the patient has a lifetime result. The most important thing for the breast reconstruction, reconstructed breast is soft. And in my practice, we do mostly secondary reconstruction, and sometimes there are no option except the flaps. So about the flaps, I really believe that it's not the complicated flap. And if you have some tips and tricks, and you have some management of your surgery, you could do it with a high predictable result. It's a constant anatomy, it's big vessels. It's not real microsurgery. And the flap quality is very close to the contralateral to healthy breast. Maybe this could be complicated by time. But as I said, if you find the right patient, if you work as a team by two teams, for example, that could be really fast. For example, the most important things is a patient selection, pre-op planning, optimization of operation room space, surgical team optimization, doing the procedure in the right fashion, right equipment, good anesthesia support, and vascular complication prophylactics. For example, this lady for me is ideal for the flap. There is no any options because all the surgery you can do except the flap, that will be two, three or four stages procedure. You can do it in one time. You can do just like abdominoplasty, use this flap, reconstruct the breast, do a reduction. In one surgery, you solve like three problems. That's very nice for her. About the planning, we do all the time planning. We do MRI, not the CT angio, but we do the MRI angio. And it gives more, that gives less time to find the perforator and that gives a better navigation. So you can see the picture and not only in perforator locators, but to understanding the vascular anatomy of the body of the current abdominal wall. Because every abdominal wall, the vascularization is unique and you have to understand it. If you understand it for each patient, it's very personalized. You will have a nice DF flap without any complications, without any fat necrosis or something else. So about the operation room optimization, it was, this video has been done not a long time ago. I got knee problems and you see, you have need to space, to move around the patient, to do it easily, to work with the teams. It's very important. You can save a lot of time. Even on this slide, I do a vessel anastomosis. And if you took a look on the left, the clip was very close. And if you feel yourself a little bit uncomfortable, that's very important in microsurgery. I have a lot of people who are listening for me and know this, but we have to point it again that the microsurgery, the micro stage could be a nightmare. Another trend, I think it's very important to respect the anatomy of the abdomen. So we do in most cases, minimal excess DF flap when the incision is very small, it's like a 4.5 or 5 centimeters. And you can easily harvest the flap. You can easily harvest the pedicle with a sufficient length. And you can stay, can't stay intact with the motor nerves. That's very important as well. And everybody knows about this, there's the DF flap result. And the trend number three, yeah, you have to learn microsurgery. And trend number four is a LD flap. You know, it's, I think it's a forgotten method, but it's very nice to solve some problems. And we do more and more and more LD flaps. Like I already said, we have a lot of secondary patients and the difficulty of the volume of the skin is a big problem. And in a two-stage procedures with the tissue expander, LD flap, and after that, the change for the implants on the both sides, you can have very nice result. And it's really good for the patient and they accept it very well. Like in this situation, you know, see the complications after the breast reconstruction with the replink, with the capsular contracture, with the volume loss on the axillary area. So I think that the LD flap is a nice solution, especially when you do it with a mini incision and you took the very small part of the skin and put it and create the new shape of the breast and you create a pocket by your LD muscle to cover the implant. Like in this situation, when you have the defect of the prophylactic mastectomy, there's the patient of mine, but I'm absolutely sure that a lot of surgeons had these problems, unfortunately. And we harvest the LD flap with a mini incision. There's the look of the patient of the back for the first 24 hours. And that's the back for six months. You see very nice shape of the breast and recover the defect. And I think that breast, the shape of the breast and the softness of the breast is much more better from the right side. There are no any flaps and there are no any ADMs. Going further, I'm absolutely sure that the LD flap, if you harvest from the small incision or sometimes we do it endoscopically, you can harvest a big amount of muscle tissue and you can create a nice pocket for the implant. And the complications rate in years are much more less than if you just put the implant even with the mesh or alloderm or ADMs or something else. So there's the muscle I really like. You can have a big amount of this tissue. It's not complicated to position. And it's very important. You can create very nice shape in the axilla. In a lot of patients in Russia, we have this problem with the hollow axilla. And after the harvesting from the lymph nodes and lymphadenectomy, and you see the incision is very small. But if you don't touch the skin, don't harvest the skin, the contour of the back is always nice. I mean, in 100%. There's the result after the revision surgery with the tissue expander, with the changing to the implant and the LD muscle with this mini incision and revision surgery on the left. And the trend number five, I think it's very important now in 2021. It's a social media communication and education. We try to educate our patients. And I really believe that Instagram is very important tool now for plastic surgery, for education at first, not the promotion, but for education about complications, about staging, about ability of reconstructive surgery. And that we can have from our patients, the real look and understanding what we can do and what we can't do. That's very important for me and really believe in it. And I think that patient education is a way to success and real expectations before the surgery is the key to have your surgery nice. Thank you so much. And I'm ready for the questions. Well, thank you, Dimitri. I mean, that was a beautifully presented academic discourse there about one that I would love to share with my residents and trainees. It was beautifully done. Your institution, you say about experience with about 400 DIEP flaps, is this becoming the gold standard across the Russian Federation now? Or do you still think I saw a flattening of the microsurgery procedures and an acceleration of the prosthetic procedures, which does reflect the global experience? But do you think there's more acceptance of the DIEP and the autologous reconstruction with results like you've been able to generate? You know, it's not in my institute, it's my department. So it's mostly my cases. And I strongly believe that we will have more micro reconstructions in future. But, you know, in Russia, most of the reconstructions are done by oncologists. And you have to learn micro. So that's the main problem. But year from year, from the meetings, we have more and more surgeons doing DIEP flaps and we have more discussions. We have more promotion of this. So I think that that's the real gold standard in the whole Russia. I don't know, maybe I'm a dreamer, but I really believe in it. Well, those type of dreams are exactly why we're here today, is to get, you know, the global brotherhood of plastic surgery, to be able to educate the patients, like you say, educate each other and get the best results from our patients. So congratulations, wonderful job and continued success to you, sir. Moving to our last presenter of the day, Vyacheslav Vasiliev. And he will speak to us on regenerative medicine. Vyacheslav Vasiliev has been in practice in plastic surgery, post-oncologic reconstructive surgery since 2007. He is a member of the American Society of Plastic Surgeons since 2017 and an international society of plastic regenerative surgeons, as well as the Russian Society. So we're looking forward to Dr. Vyacheslav Vasiliev's presentation, if you would be so kind, sir. Hello, Dr. Murphy, thank you for your kind presentation. And it's an honor to me to be a part of this exciting event. So can you see my presentation? Okay, it's moving. So the injectable adipose therapies are changing paradigm in aesthetic, reconstructive and plastic surgery today. And as fat grafting becomes more and more popular procedure, we can see a lot of methods for harvesting, processing of the fat, and eventually a huge variety of final products that all have different properties. And the issue is which method we choose and for which indication. So, slide, sorry. Okay. So the answer for this question was given by Daniel Delvecchio and Rorich in 2012, and they stated that there is no ideal method for fat processing and there is no ideal product and we can modify our technique depending on the clinical needs. So let me share with you my experience. I've been focused on fat injections and regenerative surgery for the last 11 years, and today I'm using just four products. And the first one is Milifet. As you know, Milifet is the material which has big particles and we get it with a cannula with side holes from two to four millimeters in diameter. For the Milifet processing, we use sedimentation for 15 minutes or more. And the other product is microfat that we get with cannula with one millimeter in diameter side holes and the greater type cannula. And we centrifuge microfat according to the Coleman protocol. The next product is nanofat, which we obtain by means of micronization. It's a standard technique proposed by Tanar. And the last product is stromal vascular fraction that we obtain with collagenase digestion. So, first of all, we need to understand which units of the fat of the lipaspirate, of the fat graft, possess different biological effects. The adipocyte and extracellular matrix are responsible for volume for the tissue structure. And this is a matrix. And without this matrix having preserved, we cannot achieve volume during the fat grafting. The stromal vascular fraction is an engine of the fat grafting. And these cells provide neodymogenesis, neoangiogenesis, and some other well-known regenerative effects. So, when we micronize fat with inter-syringe dissociation, we almost kill all the adipocytes and completely distract the tissue integrity. With that, we decrease the volumizing capacity of our fat graft to zero. This material doesn't have any volumizing capacity. Maybe some, a little bit of capacity. I will talk about that later. And to get rid of the residual connective tissue, if we are planning to inject through tiny needles, we need to filtrate this. So, here you can see our data on the particle sizes, depending on what cannula we used and what processing method we used for getting the product. This data gives us an idea which injection cannula should we use for different types of products. And here you can see the cell content. And as we get more aggressive with liposuction and processing, we destroy more adipocytes and distract tissue integrity and decrease the volumizing capacity of the material. On the other hand, the SVF cells are comparable in all these materials. So, we can use all of them in order to get regenerative effects. So, these are the nice pictures from electron microscopy that shows that the more aggressive we are with processing, the more damage we actually do to our fat graft. So, just an idea. And we can compare it with building blocks, bricks and plaster, for example. And here you can see in which indications we use these different kinds of products. Increased volumizing capacity of the fat graft is centrifuging. We use the standard Coleman protocol for centrifuging, and this makes fat more dense and actually kills additionally some of the adipocytes. But despite of the additional adipocyte damage, the change in the density makes this material more in terms of volumizing capacity. This is important, in my opinion, when we speak about facial fat grafting, where we need to place the volume precisely in the very small areas and we don't need to augment all face. And as this material fixes better in the recipient side, it's easier to get more stable and consistent results with this kind of fat. On the other hand, loose fat that we get with sedimentation is more logically to use in big volume fat transfer, for example, in breast augmentation, buttock augmentation, etc. Because in such a situation, we have to fill the recipient side completely. Loose fat helps us to avoid fat collections and helps to distribute fat more evenly within the recipient side. Here you can see the standard protocol for collagenase digestion. And on this slide, I try to compare NanoFET and SVF. These two materials have the same biological effects, maybe, and used for the same indications. But NanoFET is not a pure cell suspension. It aggregates, it has residual oil, it has tissue debris. So if we count the number of SVF cells with automated nuclear counter 200, for example, that we use in our practice, we can see that the number of viable cells in the NanoFET was from 500,000 to 1.5 million. And the viability is a little bit less than in SVF. And this data correlates with the publication of Dr. Lu, who actually counted the number of SVF cells by the other method, by DNA quantification, and they counted that the number of cells per one gram of NanoFET is about 7 million. I'm sorry. And for the SVF, we can control concentration of cells per one milliliter of the product. And this is important, especially when we speak about some scientific investigations where we need to investigate those dependent effects. In the NanoFET, we have a given concentration. We cannot change it. And the other important advantage of the SVF is that it is pure suspension, so we can use it for IV, for intrathecal, or other types of procedures. And here you can see the injectability and fluidity of the different products. This data was published before, so we don't need to explain this. I don't need to explain this. So now to the clinical examples. This is a standard body reshaping procedure with a FET grafting. This is the result of two FET grafting sessions. Actually, for me now, the FET grafting is the only method I use for breast reconstruction, and the results are encouraging, and I actually don't use any other methods now. This is a long-term result for management of tuberose deformity of the right breast after two sessions of FET grafting. And here, six years after the second procedure, you can see how stable the result is. And by the way, this patient hasn't had any palpable lumps in her grafted breast. MicroFET, centrifuge microFET, as I mentioned before, we use for aesthetic and reconstructive facial FET grafting, lips augmentation, infrabrow augmentation. In such severe cases when the recipient site is damaged, and especially when we deal with radiation-induced fibrosis, it's better to use centrifuged FET, I mean dense FET. Otherwise, the material is going to leak out from the recipient site. So stage by stage, all six stages have been done under the local anesthesia. We reconstructed her left side, left half of the face. And together with that, we observed some regenerative effects as improvement on skin sensation and improving of the movements of the left half of the face. Chronic radiation wounds, in such cases, it's better to use dense microFET, chronic venous wounds as well. Sniff technique is, I think, the most efficient one to deal with atrophic skin damage. For example, such atrophic scar have been treated with two sessions of intradermal FET grafting. And in this case, I also infiltrated skin around the scars with nanoFET together with intradermal microFET injection. And I'm not sure if nanoFET gives some benefits, but in such cases, I'm trying to combine both products. In this case, we have exposed bones and it's not possible to inject structural FET in this area. So again, we combined microFET and nanoFET. Very helpful for me to use superficial nanoFET injection when we speak about infraorbital FET grafting. And in this case, I placed with the same cannula superficially 1.5 cc of nanoFET and two milliliters of microFET deep to the orbicularis oculi. And here you can see the result. And I think that in some cases, superficial nanoFET placement has to be performed. Otherwise, we cannot get rid of the tear trough. And actually now we do in routine endoscopic nanoFET injection for treatment of internal chest wall defects. We use it as a separate procedure or in combination with other methods. We also have done a study which was published on clinical trials. You can see the number on the treatment of radiation-induced rectovaginal fistulas. And in this, the protocol was to inject microFET into the deep planes of the rectovaginal septum and injection of the stromal vascular fraction submucosally. And here you can see the result. It is complete spontaneous healing of the rectovaginal fistula two centimeters in diameter. And this method is now a routine in our practice for solving such complicated, such challenging problems, which often cannot be solved even with microsurgery. And the efficacy is close to 100%, like 98% in our practice. And our pilot study has been completed and it's going to be published soon. The endoscopic SVF injection, of course, we use in the same patients when we have radiation damage of the sigmoid or rectum proctitis. And this is the result after just one injection. The structure of the intestine has completely restored. And of course, knee arthritis, for that we use both SVF and nanoFET. And to conclude, these four products for me now fulfills all the clinical needs that I meet in aesthetic, reconstructive and regenerative procedures. And I think that it is crucial to understand how different harvesting and processing methods impact the biological and physical properties of the final products. And after that, of course, the choice of materials or combination of the products depends on the particular clinical situation. Do we need, whether we need to augment to get volume or to have just a regenerative effect? And which area, which anatomical area do we deal with? And, of course, the status of the recipient side is very important when we choose the product to be used. Thank you very much for your attention. Thank you very much. Thank you. If you could, in the interest of time, since we're running close, but this was such a spectacular presentation. In your clinical hands, what's the most important factor in maximizing your volume? Well, as I said before, I think that here we can think about regenerative triangle. This is a famous framework. First of all, we need to think about the preservation of the adipocytes and extracellular matrix. And the more particles we have, for example, millifat has more volumizing capacity, the better volume retention we're going to have. The second point is the densing of the fat. I mean, how we can make fat more dense. There are two ways, centrifugation or filtration through the meshes. And the last thing is, I think that the less important is how many SVF cells we have in our fat graft. So first, the preservation of adipocytes and ACM. Second, how dense the graft, and less important, the SVF concentration. Well, thank you so much. And I have to say that I am sincerely astounded at the quality of the outcomes that you've all presented in some very, very challenging circumstances. And my hat is off to all three of you. And I've learned so much, and I know that our participants have. And what I'm even more excited about is this being one of the first steps for exchanging between our two countries and globally, even more, some of the beautiful work you've done, and the chance to spread it among both our colleagues and trainees. So I thank you all. This has been a wonderful presentation by our colleagues and friends from the Russian Federation. We hope you've enjoyed this version of our webinar series. We look forward to having you on other webinar series going forward, and hope especially to be able to welcome many of you to Plastic Surgery, the meeting in Atlanta, Georgia, in October. Until then, be well, be safe. Again, our sincere thanks to our panelists, and have a good day. Thank you. Thank you so much.

plastic surgery

secondary rhinoplasty

breast reconstruction

regenerative medicine

microsurgical techniques

DIEP flap

fat grafting

interdisciplinary collaboration

international collaboration

surgical outcomes

aesthetic medicine

reconstructive surgery

DIEP flaps

knowledge exchange

Russian surgeons