Miller. I'm a plastic surgeon in Miami, Florida, and I would like to invite everyone or I'd like to welcome everyone to the ASPS International Master's Forum. Today we have some very distinguished speakers and the topics for lecture will be scrotoplasty, post-bariatric plastic surgery, and subfacial gel breast augmentation. Next slide. So we would ask that you submit your questions throughout the presentation using the Q&A feature at the bottom of your screen. We will answer as many questions as possible at the end of each presentation during the webinar and there will be the possibility to continue those questions by by chat if there are additional questions that run over that five minutes. Please note that today's webinar will be recorded and posted to the ASPS EdNet for ASPS members. If you're not an ASPS member and you wish to become one, please connect with Romina Valdez at the following email address. Today we are very privileged to have three distinguished speakers with vast experience and many years of experience in plastic surgery. We have Dr. Carlos Roxo from Brazil and we're going to be introducing them but with a little bit more detail prior to their talks but he will be speaking on post-bariatric plastic surgery making it simple, safe, and reproducible. Next we will be having Dr. Ruben Carrasco from the Dominican Republic who will be speaking about breast augmentation using a gel subfacial plane for these breast augmentations and then our third speaker will be Dr. Claudio Thomas from Chile who will be speaking on aesthetic scrotoplasty. So we'd like to welcome everybody to today's webinar. Please submit your questions via the Q&A icon at the bottom of your screen and with that we'd like to begin with Dr. Carlos Roxo who is a member, he's the head of the Brazil Plastic Surgery and Reconstructive Service at the Andaré Federal Hospital in Rio de Janeiro. He is a very experienced plastic surgeon who has a whole family of plastic surgeons that work with him and he's going to share his experience today on post-bariatric plastic surgery. With no further ado Dr. Roxo please. Okay I'm very honored to to talk with you and let me put my screen okay this is my city Rio de Janeiro and we are talking about post-bariatric surgery making it simple, safe and reproducible. I have no conflict of interest to date. I repeat this like a mantra, any surgery needs a provision. This provision will generate the team and this team is a very important thing that is systematization. Everything is linked to the time and brings safety to the procedure. So the no undermining approach is easier because it's a b-manual or b-digital marking maneuver. All markings are done in the day before surgery. This avoids distortion in sutures and creates a better provision for all the surgical team. It's faster because you can systematize all the surgeries, saving time in the operating room, avoiding the unpredictable and creating the possibility of two or three. Now I'm doing also four simultaneous procedures and this is very important without increasing operating time or surgical risk. And it's safer because if you don't undermine you cause less blood loss and there's no transfusion. You can pull more with less risk of necrosis of basins and it still has a better provision to exact the amount of tissue to be resected without distortion. So in real life, this is a classic example of systematization. Let's see. Red Bull team, 20 persons changing all the titers in two seconds. How is possible? This is systematization. And let's see in plastic surgery. This is my team, my daughter, my wife, my fellow from Italy, Luigi, my two residents. We are performing body lifting with brachioplasty and thigh lifting in four hours surgery, 24 hours releasing the patient home. And we can do it also in public. You see my residents in the public hospital doing thoracobrachioplasty, anchor abdominoplasty with neonphaloplasty and thigh lifting, three hours and 50. So it's possible, it's safe and the best is reproducible. So we published this paper and the idea is know about the adverse effects of combined surgical procedures on morbidity. And we measured the endocrine metabolic response in patients who underwent multiple body contouring surgeries after massive weight loss. It was a randomized study with patients who lost more than 30% of their body mass in this. And the conclusion was the combination of surgical procedures did not significantly affect the concentration of most biological stress markers. And this is very important. The variable of operating time was the most influencing increasing plasma concentration of stress mark. And the level of evidence was one. So let's go to the surgeon. This patient, we pull until the start of the genital. And so is my starting point, two fingers, that will be five, no more than six centimeters at the end of the surgery. Now we mark two points, one more aggressive and one less aggressive. And I go lateral and I pick like a tailor how much I can resect of skin. You see, doing this, I can go lower than the indian fold. I ask the patient to pull up and I mark, I connect the dots, the more aggressive and the less aggressive. I connect the inferior dots and we turn the patient. You see, imagine the bikini and tailoring. We just pull until the start of the intergluteal surgical. We grab and ask the patient to bend. And this movement will show us exactly the amount of tissue that can be resected, avoiding the descents. So we connect the dots. As we can see, this will not solve the problem. The patient needs to resect also this amount of tissue. So we draw the brow line and with the two fingers like tailor, we simulate that resecting this, can I resect the inferior? So we connect the dots. Imagine the scar result will be in the brow line and go to the other side. The important is the patient be standing up with the arms in the same position that she will be in the operating room. And this line will be tattooed to make the suture easy and symmetrical. Now we turn the patient and we are drawing the brachioplasty. My opinion, the best place to put the scar is in the brachial so we draw where we want the scar and with the two fingers we tailor the shape of the arm. When you have any doubt, we ask the patient to elevate the arm so the anatomy shows clearly where is the line of this dissection. And when you finish this, we connect the dots. We mark where is the points for the suture. And that's it. We go to the other. This is my patient number 900. She lost, she had 139 kilos and now she's 74. So it's 65 kilos. So this is how the patient was in the day before surgery. I use the Pentel, that is a pencil that do not erase. The patient can shower and it's easy to go to the OR with the patient already drawn. So let's go to the OR. We start in the patient prone position. I draw a line to the electrodes so the anesthesiologist knows exactly where he put the electrode. I tattoo everything and I incise the dermis, no infiltration, no undermine and no lipo. I incise the dermis with the co-braid and I come with the cautery in 45 coagulation mode. You see the telephone I control in my GoPro with the cell phone in the stereo bed. So we remove this flap and you see how easy, like sliding doors. I know exactly where the suture goes because I tattoo it with methylene, stereo methylene. So we're gonna suture in two layers. The suture team is now working and I go down and I come with 45 making like a rail and after making this rail I split the flap in two and my assistant do one half and I do another. So this time takes about 14 to 18 minutes. The rest is suture. You see the two flaps. I am touching here the obliquus muscle. I'm already in the abdomen. I'm sorry. And look how the team, the suture team is doing. So I don't need to finish here to do this. This is systematization. Look how it rotates. This tattoo is coming to here. Look how it gets oblique. Looks like I put an implant or put a fat grafting but not. It's just a planning. It's just a drawing. I resect the remaining tissue, the flap and we are putting a drain. This drain is going out in the mounds by the left because the drain in the abdomen is going out in the mounds by the right. So I know always in the left is the back drain. In the right is the right, the abdominal drain. You see the roundness that we achieve with suturing two plans, deep layer with the nylon 2-0 and intradermal and subdermal with PDS 3-0. I love to put glue because the patient can shower in the day after surgery. You see the symmetry. Now we are turning the cubitus. My concern is guarantee the tattoo points. You see the more aggressive line, the less aggressive line and tattooing the points to make the suture easy. So you see the original draw don't vanish even with the exception. Now I am incising only the dermis with the cold blade and I dissect, I incise with cautery 45 coagulation mode. Take care about the lymphatic ganglios here to avoid lymphedema because our incision is very low. So there's a lot of lymphatic ganglios here and I dissect from lateral to lateral. So I come in the middle between the more aggressive and the less aggressive line. We skeletize the umbilicus and this is a new approach I'm doing. So I see how deep is the skin and I cut. So I have now a perfect round umbilicus. We are doing the dissection until the schifoid appendix to provide the apexia. I don't believe in abdominoplasty without apexia and now I am providing the location for the umbilicus. I used to say to my residents the umbilicus is the signature of the surgeon. It was supposed to be the only part of the surgery that people will see. So we fixate the umbilicus so the umbilicus will not move from here. It's very important the umbilicus don't be less than 10 centimeters from the scar and the scar don't be more than five or six centimeters from the end of the genitals. So I'm just checking for adaptation of proposed and now I don't need to finish the placation. My assistant will do the placation. I came to the brachioplasty. So I dissect superficial six centimeters because the lymphatics are superficial and after this I go to the fascia because the lymphatics go down with this with the basilic vein and the cephalic vein and so the nerves are under the fascia. So it's important to be over the fascia. Now I'm giving a tip to you that we give two stitches one over the umbilicus another under the umbilicus in the poneurosis. We pass through the flap and in the subcutaneous we give the stitch and back and this will anchor the flap the abdominal flap avoiding the tension on the umbilical scar. This is very nice and very easy to do and this is how it gets. And let's see before and after 46 days. No adhesions, no asymmetries and you can compare how it improves the gluteus and the symmetry of the scars and you can cover everything. If you plan well you can cover everything with a nice underwear and the patient can go and can shower and this is the photo pre-op, the marking, the post-op. The marking, the post-op. Bikini pre-bariatric and post-bariatric. This is another case it's patient already we perform a body lifting with brachioplasty and we are performing mammoplasty with texia and implants. We always mark from the sternal fulcrum six centimeters and we go to the smaller breast always from the smaller to the bigger. So we draw the inframammary sulcus the axillary line this is the pitangue maneuver. We put our finger in the sulcus and point to our nose and we are going to transfer this measure to the other breast. And so now we are simulating the pecs marking and another thing I'm going to tell you is this line must have nine centimeters. Why nine? Because five of the vertical scar and four of the nipple areola diameter so it's ten to nine and this maneuver will avoid the dog ears. So I don't care about the size of the scar since the location is good as important the shape. The shape is more important. Now we are compressing the breast again the thorax and this is going to show me where will be the pocket for the implant. I like to put the implant in 100% of the patient in post-bariatric because I think they are too flaccid and the implant will provide more support. Now we are with the GoPro just checking for educational purpose and what we are going to do the first will be dissect the pocket for the implant. So we are making a pocket of five centimeters in the sulcus and always always in this patient sub glandular because a problem name it waterfall deformation that happens in post-bariatric if you put it submuscular or duoplane. So I suggest you put the implant always round implant because the implant rotates and always a sub glandular. So I suggest you also no bigger than 300. My favorite implant is 285 and now we are using a scissor. This is a very old case. In this case we used a polyurethane implant that we don't use anymore. We are now checking rechecking the marks of the nipple areola immersion and normally people say ah you don't need to do apex but of course I need to do apex because after the edema goes this breast will fold. It's very important the symmetry and rechecking everything. Now the hooks maneuver we put two hooks in the edges and this will show us exactly how to avoid the dog ears. We transfer this measure you see the old measure is exactly in the same double check just for educational purpose and we are going to do the schwartzman maneuver. You see my gopro this is a nice tool so you can control exactly what you are wanting to record. You don't depend anybody to film your surgeries. Now we resect all the inferior pole. What falls is the inferior pole. So I resect the inferior pole. I don't touch the superior pole. The implant's in position. We give a lot of tension suturing two layers you see and let's see the marking the vertical as I told you five centimeters no more than 5.5 centimeters because it's going to fall like or not. So I'm just showing you the symmetry that we achieved. This is not by chance this is because of the planning and let's see how this patient was in 14 days post-op. You see still with the glue the symmetry a nice symmetry you see this kind of the body lifting the shape and the brachioplasty is okay is 132 days post-op and so I like the patient with late results. So she came with 1165 days. I asked the incredible maneuver because everybody said oh you're gonna have a rippling if you put some glandular but I don't have any case of rippling and we measure everything as the patient came. I normally follow the patient five six sometimes ten years and this patient came back with 1,384 days pregnant. This is 38 weeks of pregnancy. You see the the color of nipaurella the abdomen and so we measure her during all the pregnancy and we keep on following to see what happened with the breast and what happened with the the surgery the body lifting and you can see the measures the 20 centimeters of the upper pole is still 20 the breast is heavy and what changed was the vertical. The superior pole don't change but the vertical change from 5 to 9 and 5 to 8.5 and here from 5.5 to 8 centimeters and from 10 to 13.5 centimeters and she came later after 100 days postpartum. I asked her to do the incredible hook to show there's no rippling and let's see the breast touching and let's see the measures what happened with the so 5 became 8 not 9 anymore 20 is still 20 sorry and 5 is still 8 and the good thing is that she's breastfeeding both breasts and she came back again with 600 days postpartum and see nothing happens with the breast it's better looking and let's see what happens 5 became 6.5 so it's 30 percent increase and let's see how she came for us and how she was 600 days postpartum and 2460 days after body lifting so this is her before bariatric before plastic marking after breast I take care with the background the same quality photos the same distance and this is her before bariatric after plastic wonder woman get pregnant and this is my team thank you very much I'm very honored to talk with you this is my family my daughter Anna my son Carlos my wife Claudia and the instrument thank you very much Okay, thank you very much, Dr. Rozzo. Excellent, excellent presentation. I'm going to ask if we can, we have some, I think we had some questions in the Q&A session, but I, in the chat, but I lost those questions. Do you know, Amy, if there, if I can see those questions? Yes, I will, I will repost them to the chat, Dr. Miller, and then you should be able to see it. Okay, in the meantime, I could ask you, what type of sutures are you using for the layered closure? Are they absorbable sutures, or are they sutures you're removing? Look, because the post-bariatric has a disabsorbable syndrome provoking, they are different from a normal patient. So, if you have a post-bariatric, you can, they have a problem with the strength of the scar. So, it's good to keep some non-absorbable suture in deep plane. In subcutaneous, I love PDS, but three zeros, please, because they are very strong. So, when you have PDS, I suggest you two zero nylon deep suture, or at least three zero nylon deep suture, and subcutaneous suture PDS. When you don't have PDS, do three layers. One layer deep suture three zero or two zero nylon, one intermedial suture of a vicryl, white vicryl three zero, and intradermal suture with the monocryl. But the monocryl, I have been having problems with, you know, like spitting stitches. So, PDS don't give me problem. And I love to put the glue, because it makes my life easy. The patient showers, don't need to make nothing. So, I love the glue because of this. The only problem of glue is because it's a little expensive. I think they could lower the price of the glue. Okay. Okay, great. Thank you. So, a question from Martin Iglesias, is the total body lift causes bleeding. How is her hemoglobin and albumin in the immediate and immediate post-operative period? In the immediate post-op is normal. Normally half a point. Okay. But after the first two second days, they have over-hydratation. How they know they are hemodiluted? Because if you wait the patient in the day before surgery, like I do, and you remove five kilos during the surgery, in the day after surgery, the patient maybe is heavier than in the day before. Sure. What is the explanation? This is hyperhydratation. So, they have hemodilution. So, normally a patient, I don't do surgery, less than 12 hemoglobin, and 37 women hematocrit. Never. So, they came to 11, no less than 10.5. But some of them, when the anesthesiologist over-hydrate, they can go to nine to eight, but they are asymptomatic because the number of matches is the same. So, don't medicate the exams. Give medication to the patient. So, the patient wake up, take a shower, go home, don't care about, don't worry about. I can guarantee, now I have 1,070 patients, real, and I have no transfusion. I do surgery overseas in meetings, and there's no problem. The trick is no undermining. So, you have a direct vision what is bleeding. So, you coagulate. And when you undermine, you pull up the flap and stop bleeding. You release the flap, you start bleeding. So, this is the big difference of no undermining. Yeah. Okay. Very good. And then Dr. Harald Tsai asks, is there a need for post-operative compressive garments? Yeah. I like not too tight, just like a glove. Okay. Because imagine you remove five kilos normally of this patient, and you give more mobility, and they are very strong. A person who weights 130 kilos and now is 70 kilos, still can move 130 kilos. So, if you can move and give more mobility, the patient must have something to restrain the mobility. So, I think the garment is good, just to keep the patient remembering that she is operating. Excellent. Excellent. Okay. Well, you have many congratulations here on the chat for a great talk, and we thank you. The Q&A time is up, but if anyone has additional questions for Dr. Roxo, they can communicate by the chat, and we thank you very much, sir, for an excellent lecture. It was my pleasure. Thank you. Thank you. Okay. So, we're going to be moving on now to Dr. Ruben Carrasco from the Dominican Republic. He is the president of the Dominican Plastic Surgery Society, and has been a member of their board of directors for over 12 years. He's very involved in the plastic surgery community internationally, and of course, in the Dominican Republic. He's going to be speaking about subfacial breast augmentation using gel implants. Dr. Carrasco. I think you're muted. Just unmute yourself. Thank you. Thank you, Dr. Miller. Thanks, everyone. Thanks, Romina and Amy. It's a pleasure to be here, sharing this scenario with Brazil and Chile with this talk about breast implants. So, I have a 15-minute talk. I'm going to be taking advantage of my time. As Dr. Miller said, my topic is breast augmentation placed in silicone gel implants in the subfacial plane. A long time ago, Pupils of Plato said that an artist is very special because he can conceive results even before working, start working on the clay. So, I think this is really what happens with plastic surgery, especially with some surgeries like the breast augmentation. For myself, breast augmentation is the ideal surgery because for myself, breast augmentation is the ideal surgery because you have an invisible scar, you have quick healing, you have an immediate result, and you have a fast recovery. And that is why breast augmentation and liposuction are always with a match in a contest in the global statistics, which one is the most common procedure worldwide. The latest ISAPS global survey that was published in 2020 says that the most common surgical procedures in women still remain breast augmentation, liposuction, and eyelid surgery. This is a very interesting survey because it says that despite many women has retired the breast implants concerning this anaplastic lymphoma related to breast implants, it is still one of the most common surgeries performed over the world. Sometimes it's liposuction, sometimes it's breast augmentation. So, if breast augmentation, it's a real common procedure and we do it so many times, we have to care about it and the techniques about breast augmentation. So, this study released in the official magazine of FILAB, which is Federación Latinoamericana de Cirugía Plástica, the Latin American Plastic Surgeons Official Scientific Magazine, published this study in 2020 reflecting data about the preference of plastic surgeons in Latin America and in Latin America about the implants. It was not surprising for me that most of the Latin American plastic surgeons prefer round implants, smooth or microtexture cover with a periareolar approach, and what I don't agree myself is that I don't prefer submuscular. I will prefer subfacial plane. So, why subfacial plane? This study published in January 2020 in an opera forum in London said that the Brazilian surgeons that pioneered the use of subfacial plane has demonstrated that the subfacial plane reduces the risk of capsular contracture. The rate is reduced a lot and also the post-operative pain when you compare this to other techniques like the subpectoral or submuscular techniques. So, the pectoral fascia, it's a defined anatomic structure with different thickness. You have a superficial layer and a deep layer. When we do the dissection, you can really see how thick is the deep layer which lies on top of the fibers of the muscle. When I'm talking about subfacial, I'm talking about this level of subfacial. So, you will leave the muscle entirely reddish and naked to create the pocket. It's very avascular. You don't have a lot of bleeding. When you are doing this many times, it will be very easy and it will be very comfortable for the surgeon and we will be very comfortable for the patient too. So, I prefer the periareolar approach, the periareolar incision because most of the women in Latin America and in Dominican Republic, they don't want to have a visible scar. So, I do the periareolar incision because I have demonstrated in these pictures that these incisions are invisible when you have completed the scaring process. So, this is one implant in the subfacial pocket with the periareolar incision and the other one which is just marked to begin the procedure. And this is one patient one week later on my office lying down on the examination table. You can barely see the scar in the periareolar approach. And this is another patient one month later. A little bit of dryness on the nipple areola complex, but mainly an invisible scar. About the pocket and undermining the subfacial pocket, I always mark this curvy line two or three centimeters around one inch below the original inframammary fold. This is very important in this technique and I place arrows in the marking because I have to detach that. I have to just undermine beyond the inframammary fold. This will produce a rotation of the nipple areola complex and that will give me long-lasting resorts over years as you will see later on the presentation. Of course, what I use in Dominican Republic for almost 20 years is cohesive gel silicone. Maybe I put two or three saline solutions 18 years ago, but after that all I have done is only cohesive gel silicone. The reason why I do the undermining of the inframammary fold is because you can have a nice inferior pole and a rotation of the nipple areola complex which will produce a nice shape and this shape will last for many years. Cohesive gel, it's very safe. It is already accepted by FDA in the Food and Drug Administration in the United States. In the Dominican Republic, it's well received in the health ministry department that has to see if this matters. Now because of the concern about anaplastic lymphoma, we prefer to have smooth or microtexture surface. I don't do 400 a lot anymore. I'm moving from 280 to 300, 350, sometimes 375. The PRS journal published last year that the anaplastic lymphoma is associated with textured surface breast implants. So that's why it is preferred to have smooth implants or microtexture. Myself, I will say that microtexture is another way to say smooth breast implants. When I have small areolas measuring less than 3.5 or 3 centimeters, like in this case, a very small areola, what I do is what I call an omega incision. The omega incision will be the per areola approach with two or three millimeters extended to medial and extended to lateral. This is not a problem because later on in this current process, this will be covered in the whole areola complex and you won't see those three millimeters inside or outside the areola. That's another view of the omega incision. So if it was three, I can make it almost four centimeters, the width of the areola, and that will be possible to place the breast implant as I'm going to show before. This is this patient with a very small areola. Two months later, you can not see it's an invisible scar. In the preoperative marking, I make sure myself to be very accurate with this new inframammary fold. One inch, three centimeters below the original inframammary fold, and I will detach that from inside the pocket when I'm doing the undermining. I never use a funeral bag, and biofilm is already demonstrated, has no strong evidence about the pathogenesis of breast implant-associated lymphoma. After that, a closure. I usually do four layers. The first one will be the pectoralis fascia and the deep layer of the glandular tissue. Another second layer of glandular tissue, a third one of subcutaneous tissue, and then the skin. Some cases. I admit the first cases, I was a kind of shy to do the detachment to liberate the inframammary fold. Then I was getting a little bit more confident about doing this to obtain this type of results. You can see the invisible scar. This is one month later. In a three-quarters view, look at the inferior pole. A nice resort with periareolar incision. The case you saw before, you can, even with the omega incision, you can't tell she has an incision in the areola. More cases. Here is a small omega incision. I don't care. I'm not concerned about this scar because I know that will vanish later. A three-quarter view. The omega incision, a small areola again. Another view. Look at this case. How I could make a nice shape and symmetry in both breasts using this technique. Some patients nowadays, they ask to a cleavage more prominent. I can't do that and I'm not very concerned about it because I know a couple of months later, this will have a natural look because after the swelling, the breast will descend a little bit with a nice natural look. Look at how I could manage here the asymmetry, the natural asymmetry in this case. Supernumerary nipple in the left side. The post-op picture can tell how far beyond I went down the original inframammary fold. I could even better the natural asymmetry of her breast. This is 10 years later with this technique. I have a video to show it 10 years later. I just took this video one week ago. The pre-op is 10 years before and 10 years later. Look at the inferior pole. 12 years later, look at this car. And this patient came, she was operated by me in 2007. So this is almost 14 years later. I put her a 300 grams breast implant and she brought this mammography which shows that the implants are in perfect shape. This is her lying on the examination table, 14 years post-op, raising arms, like Dr. Roxo said, doing the Incredible Hulk position, 14 years later. So to finish in the conclusions, the subfacial plane is very comfortable for the patient. No pain, no bleeding, a very low rate capsular contracture. You will have long lasting results, 10, 12 years, 14 years later. I want to say thank you to you guys and to the ASPS Association and the Global Series. Thanks a lot. Thank you. Okay. Thank you very much, Dr. Carrasco. Excellent, excellent lecture and learning every minute of your talk there. We have some questions. Let's see here. Where do you start? This is from Dr. Herouz Say or Say, I hope I'm saying it right. Where do you start dissecting the subfacial plane? And when you release the inframammary fold, is there any risk for a double bubble? I have seen double bubble in subpectoral and submuscular and it's one of the main concern because the implant will be fixed in the upper pole and you will immobilize the breast implant, but the skin is loose. That's why they later on invented, they created the dual plane to help the weakness of the, in that matter of the subpectoral. I never had a double bubble with subfacial. What I do is I just go directly from the periurelar incision to the fascia. You can see it very well. As I have been doing it for more than 15 years, when I get there, I already can identify the pectoralis fascia, the superficial layer and the deep layer. I just take the cautery and I open up a little bit of the fascia and then I put my, just I pull it with the devices in my equipment and with the cautery, I just do the dissection in the inferior sense to reach the inframammary fold. I admit when you get there, it's very stick sometimes even to the periosteum or to the inferior fibers of the pectoralis muscle. And that's maybe the hardest point of the technique. You have to undermine beyond the inframammary fold. Well, when you do it many times, it will be very easy to do it. After that, you release the inframammary fold and you get a nice inferior pull of the mammary gland and a nice shape of the breast. So can I ask when you incise, just to follow up on that question, when you incise the fascia, are you incising the fascia vertically or horizontally or what? Horizontally, the same way I did the periolar incision on the top. Okay, okay, great. And then- So I do it horizontally and when I close it, I make sure I will close with sutures vertically. So I will get the deep layer of the mammary gland and the fascia together in the first layer and I will do observable sutures. Usually I do bicryl zero in the deep layer. Okay, okay. And you get complete coverage of your implant when you're going- That's right. I make sure to get a complete cover and I've had a very, very low rate, almost close to zero of capsular contracture. And in a couple of cases that I had a capsular contracture, I had only a type two capsular contracture. That if you do massage and you just make some exercises, you don't need to take a patient to the OR to resolve that problem. Sure, sure. And the other thing is when we do a subpectral augmentation, the implants are typically riding high and we have to use these compression bands to keep them down. But I think the genius of this procedure is that you don't have to worry about that potential space because the fascia would prevent that from happening. Is that correct? That's right. You never use a compression garment in the top of inferior, the clavicles. That only you do it when you want to push the implant downwards. Right. But when you release the inframammary fold, sometimes there are some inframammary sulcus very tight and especially in the tuberous gland, you have to incise them from the inside a little bit of with the caltery to make some incisions in the inside with the caltery just to release the inframammary fold. That's the keystone of this technique. There are two keystone of this technique, finding the pectoral fascia, opening the fascia and leave the muscle naked. And the other thing is liberate the inframammary fold. Right, right. Interesting. Okay, excellent. Very good. I think we're going to move on to now. Thank you very much, Dr. Carrasco, excellent talk. And I might actually have to start utilizing that technique. That's really excellent. Thank you. Yeah, great, great, great, great lecture. Now we're going to hear from Dr. Claudio Thomas of Chile, who is a member of the Chilean Plastic Surgery Society and is also the current president. And today he is going to be speaking to us on scrotoplasty. So without further ado, Dr. Thomas, welcome aboard. I think you're muted, just unmute yourself. Again, good evening, everybody. I want to say thank you for this invitation, the Medical Society of Plastic Surgery. I want to share my presentation. And let's go. This is a very specific topic because during the last year, female intimate surgery have grown exponentially. Nevertheless, male plastic surgery of genital hasn't developed as much. Scientific publication about this topic are just a few. Dr. Thomas, we don't see your presentation yet. Would you like me to share my screen and share it? Or would you be able to share it? I share the, I'm sorry. I share the, maybe now. There we go, it's starting to come up. It's okay. Yep, and on the bottom, if you could just put it into slideshow. It's a slide. Look at, this is my presentation. Yeah, so on the bottom. Yeah, okay, I understand. Yes, it's okay now? Yes, it's okay now, we can see it. Okay, I'm sorry. Wes, just I say, this is a very specific topic and just a few of anatomic concept when I start. The scrotum is formed by two skin bags that union in the middle in a embryonary, scar that is the rougher. And the next level is the dactos and the dactos is the continuous of the superficial fascia. But in the dactos, we have some muscle and then in the middle part, the dactos join and make this, the tabique scrotal or septum scrotale that you make this union with the base of the penis. Then the both sacs are independent. And this is important for the surgery, but this also is important that is the innervation. For the anterior zone, the innervation is for the ilio-inguinal nerve and the femorocutaneous nerve in the anterior zone and the posterior zone, the posterior femorocutaneous nerve and the perineal nerve. That means that any section in transversal section can alterate the sensitivity and the activity of the dactos. The benign pathology of the scrotum and the typical consultation about this is lymphedema medians, rafesyst, idiopathic acinosis, amartomas, anxiokeratosis, alopecia, hypertrichosis. But this type of pathology is not for us. Is patient go to urologist or dermatologist. But scrotum ringless, that is very special. I speak about this in a moment. And scrotum laxity that the patient consult about this. This is fine because the scrotum ringless is more than a pathology, is a fashion in young people that don't like the scrotum small and with ringless and use botox for get a more laxative scrotum. And you can see this video on YouTube that is funny of the program, a user program is Saturday Night Live. And it's very special. But this publication from Cohen show that is what I speak, laxity. This is a problem in some men and the laxity can have some problems in sports when you use sport clothes and for practices sport. And also when you go to intercourse sexual intercourse. With Dr. Alfonso Navier, we published this article in an aesthetic plastic surgery recently in November last year. Is aesthetic scrotoplasty systematic review and proposed treatment algorithm for the management of botox on scrotum in adults. And the only publication that we get is this from Dr. Lorenzo that show a treatment of a young man that have problem with the laxity of the scrotum. But they proposed this, that is the areas of section and then a scar in the posterior zone and a transverse scar. This means that maybe a loss of sensitivity in this zone. I don't think this is a good surgery. This is this picture show the, and I draw that the scheme of the surgery and this is the result of the surgery. It's a good result. But I think functionality may be with a change. And this is what we find only due to publications, not publication about this. Dr. Alessandro Litalia and transversion in the union in the penis when the scrotum and the scar is in this zone. I don't like this zone for a scar because I showed the innervation and maybe you can change the sensitivity of this area and change the possibility, the movement of the ductus. And this is from Dr. Josep Maria Cos Calvet and it's a transverter resection, circumferential resection. And it's complete circumferential resection. This is the suture and you can see the result and look at in the bottom, you don't have any wrinkles. Why? Because this determine the innervation of the bottom of the scrotum. For this, we propose this algorithm from treatment. First, we left out buried penis, differential diagnosis like eroseli, varicoseli and others. And we go for the history of discomfort. And when the patient wearing those clothes, walking, doing sport on a sexual intervals. In the physical examination, we find penistrotal wearing in some cases on an objective increasing scrotal laxity. And then another problem, we don't find any definition about laxity of the scrotum. We define a scrotal laxity when this bottom of scrotal hanging one on two centimeters below the tip of the penis in flaccid position. The penistrotal wearing is another pathology. I don't speak about this, but we prefer this penistrotal junction set of plastic for the treatment. And for the treatment of the laxity of the scrotal, we use this vertical ventral skin resection. Horizontal resection with posterior scrotum is not good. And horizontal ventral skin resection, I think is the same. This is the scheme of, this is about, we speak to one centimeter. This is the weight and the treatment of the weight in this case and the design that we use for the treatment of the patient when this is the case. Old man, about 62 years old, he don't like the aspect of the scrotum and have trouble with the sexual integral. This is the physical examination intraperitoneally. In this video, sorry. I'm sorry. Sorry about the video is saying that the video is okay. Can you help me with this? Yes, Dr. Thomas, would you like me to share my screen and the video? Okay. Okay. If you could stop sharing yours. Oh no, I am looking, start? Yes. Okay, continue. Thank you. And you can see the design for trade the wedge and the marks for trade the laxity. And the marks was done with the passion stand. They said the plastic, when the wedge was straight and this is important. If you see again, I can stop in a moment. If you see this, this is the dardos and this is the septum scrotale and this is the dardos in the other side. The fist suture is made this to the septum and to the other area of the dardos for restore the natural anatomy. It's important. And then suture the skin. in the operation room and with a 6 month post-op, Patient was very happy with the result and For conclusion, the aesthetic treatment, both medical and surgical of the scrotum should be performed by plastic surgeons. More study and publication must be carried out, otherwise it will be an area absorbed by no specialist. The scrotum leaves using a vertical ventral resection design to ensure an aesthetic result with anatomical restoration and maintenance of dardos intervention and skin sensitivity. Thank you so much. And that's all. Excellent. Okay. Thank you, Dr. Tomas. Questions from the audience we're looking for right now, if we see them, Amy, if you could post them on the side, but I'd like to ask, are you using also your suture selection for this type of procedure? Are you using resorbable sutures or permanent sutures, especially for the rafae in the middle? I use a static fix for all. Okay. All, all layers, everything. Yeah. And no, no issues with hematoma. Have you, do you use any basal constriction before you start any injection with epinephrine? No, no, no. I read about the problem of the dardos with hematoma and you, you must be careful, only careful. If you make the resection and use a Viborag, okay, that's a problem with hematoma. I don't have a lot, very much experience about this because there are not many patients that consult about this. That's right. Yes. Yes. But I think it is important. We, we design this type of surgery because I think with the time more and more men come with us. Yes. Yeah. And I think the concept of a vertical incision, so you're finding that the sensibility is still good, that you're not losing any, any sensation. You saw the, the picture of Dr. Calvet. Yeah. The horizontal. Yeah. All, all, all around the, the bottom. And you look at the elevation of the bottom. Any, any wrinkling in the, in the bottom of the scrotum is because the elevation, total elevation. Sure. Yeah. Are the, are the urologists in your area, in your country, are they doing these types of procedures or is it mostly just plastic surgeons, but uncommon? I have many friends, very, very nice urologist. He made a plastic, urology plastic surgery. And I showed this and he, they say this, this is okay. It's very nice. But he liked it. I think it's okay because, because it's simple. It's not a difficult surgery. Yeah. It's very important that when you define the design, thinking that the left test always is more down, then you remember my picture about the design, the left side is more wide because this. And other thing is important. You need to start the suture all the time from the posterior to anterior zone. Then you don't need any compensation near to the rafae anal. No, this may be perfect. Then you can compensate near the penis. I see. Very good. Well, we'd like to thank our distinguished speakers for today. This is our first of our ASPS international master's forum. And we thank you all. And we thank all the participants and also our great staff at ASPS. And we look forward to having you and joining for the next one. Thank you so much. Thank you. Thank you. Bye bye.

ASPS International Master's Forum

plastic surgery advances

scrotoplasty

post-bariatric surgery

subfacial breast augmentation

Dr. Carlos Roxo

Dr. Ruben Carrasco

Dr. Claudio Thomas

capsular contracture

surgical techniques