Welcome, everyone, welcome. This is Dr. Horacio Mayer from Buenos Aires, Argentina, an ASPS international member. I'm more than happy to be here tonight, participating in this wonderful webinar on breast surgery complication. This is part of the ASPS Global Partners webinar series. And today we have three wonderful speakers. Before starting, I would like to remind to all of you that you can submit your questions through using the QA feature at the bottom of your screen. We will answer all your question at the end of the session. All the webinars will be record and will be posted at the ASPS at net and the ASPS members. So, and also I would like to remind to all of you that if you still know you are not a member of the ASPS and you're interested in becoming a member, you could contact Romina Valadez at rvaladez at plasticsurgery.org. So, our first speaker is Dr. Bob Basu. Dr. Bob Basu is currently president elect of the ASPS. He has a very busy aesthetic practice in Houston, Texas. And he has been listed as one of the top 100 plastic surgeons in the United States by Newsweek Magazine for four consecutive years. And he's also a co-author of the textbook, "'Cosmetic Breast Surgery' by Femur Publisher. Dr. Basu will be talking about managing and preventing implant malposition in breast augmentation mastopexy. So, welcome Bob and thank you for being here tonight. Thank you, Dr. Mayor. Great to see you and great to be with everyone online through the Zoom. Since we're on a tight schedule, I'm gonna go ahead and share the screen so we can just jump in. One second there. All right. And let's start it. There we go. Okay. Horatio, you can see the screen okay, correct? Yeah, we can see the screen. Wonderful. Well, thank you. So I'm gonna, as Dr. Mayor was saying, I'm gonna be talking about managing and preventing implant malpositions in cosmetic breast augmentation mastopexy. And these are my disclosures. The only relevant one for this is that I will share some of the diagrams from a textbook that I received royalties from Femur Publishers. So, common things that we hear are common complications from augmentation that we, augmentation mastopexy that we hear from patients. Patients come back, they're complaining that the breasts are not sitting high enough. My breasts are sagging back down. I paid all this money and I see no difference. My breasts still fall to the sides. Doctor, one side hangs more than the other. Why am I not healing underneath the breast, specifically the inverted T-junction? And why have my scars widened after my augmentation and lift? So, these are common things that our colleagues and I hear with augmentation mastopexy procedures. And I think there are a couple of exacerbating factors that are making this worse in the United States and around the world because of ALCL concerns, the absence or fallout of textured implants. And we're using more smooth implants in many markets. We have the weight loss revolution with the GLP class of medications where patients are losing weight and we're seeing an exacerbation of poor soft tissue support, which we're gonna spend some time talking about. And of course, the more common use of larger implants in certain markets puts more of a weight effect on tissue. So, I do a lot of revisional surgery on my practice. And when I kind of get the history, it still amazes me how under-discussed the importance of tissue quality is in consultation. So, I think it's very important to talk about the importance of tissue quality and soft tissue support, whether we're talking about a primary augmentation case or a revisional procedure or an augmentation mastopexy, because ultimately, all of us as surgeons are working with the tissue that the patients provide or give us. So, a question that I ask all cosmetic implant patients is, what is it that holds up your breast whenever we do these procedures? And the answer to that question is, it's their tissue quality. And so, another question that I ask is, what do we do when your tissue is too weak to support the breast implant where you want it to sit? And in this photo, you can see the patient's holding her breast up or where she wants her upper pole to be, but she's already had an implant elsewhere and you can see where the breast is sitting. Not a bad result, but she wants a higher, tighter look. And the answer, I think, for these patients who have weak tissue is the internal abroad technique using a resorbable mesh. So, my evolution in terms of primary and revisional augmentation mastopexy, what I no longer do, when I'm talking to patients about augmentation mastopexy, whether it's a primary procedure or a revisional procedure, I no longer trust the patient's tissue quality when I'm talking about primary or revisional breast surgery, plus minus whether we're doing a mastopexy. Now, that doesn't mean I'm always utilizing or always advocating for resorbable mesh, but we have that discussion that it's an option on the table because in that discussion, it allows the patient to realize that we are all working with their tissue quality and there's some inherent limitations. The other thing that I'm gonna touch base on in this presentation is that for large volume goals, when patients want large volume results, I no longer recommend a one-stage augmentation mastopexy in the following two categories, in the category of severe grade 3 ptosis or in the scenario where they have grade 2 or grade 3 ptosis with that two breast breast deformity, that conical breast, and we'll go over some examples. Now, I'm presenting some of these very severe, complex, revisional cases and talking about pocket control because a lot of the lessons can be applied whether you're doing a primary case or you're doing a revisional case or you're doing an augmentation or augmentation mastopexy. Now, in these revisional cases for pocket control, you can always take a wait-and-see approach with capsuloraphies, but there's always potential risk for malposition and, of course, patient satisfaction if the implants drop, they're not happy. You can always utilize internal sutures that have been used for decades, but is the tissue really strong? Perhaps internal capsuloraphies with suture techniques can work if you're using smaller implant sizes, but I will argue that weak tissue, inset to weak tissue does not create strong tissue. It's still weak. So I often look to resorbable surgical mesh because it allows us to prevent or treat inferior malposition or bottoming out. It can help treat lateral malposition and it can help deal with fold weaknesses and I think it's a really good tool to help us achieve predictable outcomes, particularly in very complex cases. Now, there are different meshes out there and the focus of this talk is not to talk about the specific mesh dealer's choice, but in the United States and around the world, I'd definitely recommend advocating for informed consent for mesh use. In the United States, utilizing any mesh product is off-label, so I encourage you to use the ASPS-endorsed forms when obtaining informed consent and, of course, name the surgical mesh of your choice in all your documents. Now, the one thing I'd like to emphasize, and if you take home one thing for this presentation, is the importance of two-point fixation. We're all plastic surgeons on this call and we're well-versed in multi-point fixation in our maxillofacial experience or a hand surgery training. Well, the same applies to breast surgery. There are a lot of different presentations using resorbable mesh, but I will advocate the importance of two-point fixation. And the first point is the upper fixation point and the upper fixation point, as this diagram show, I advocate for upper fixation as something very strong. This can be the inferior edge of the pectoralis major muscle if you're doing a dual-plane placement. If you're an advocate for a subfascial technique, then the pectoralis fascia can be also a great strong anchor point for upper fixation. For inferior fixation, this gives us an opportunity to raise the fold if the fold has been lowered in previous surgery, if it's stretched out. You can address fold asymmetries and create essentially a neofold crease, or if you just want to reinforce the fold to maintain the implant position. So again, two-point fixation. Now, I'd like to go through a three-step process that I like to review in terms of how I use surgical mesh. So first, we talked about upper fixation. Ready? Okay, so what we've done is upper fixation of the galloflex to the inferior edge of the pectoralis major muscle. We took four big bites to the capsule and the pec major muscle. You can see that's good fixation. That's not going anywhere. So that's our upper fixation point. Our lower fixation point will be the chest wall. Now again, in this example, I'm doing a side change dual-plane placement. But again, if you're a subfascial pocket person, you can absolutely do upper fixation to the pectoralis fascia. And the second step is I typically use a rectangular 10 by 20 square sheet and in this case, I'm utilizing a resorbable mesh of P4HB. And I orient it in the up and down axis. So the 20-centimeter axis is oriented horizontally. I'm sorry, up and down. And so how do we know how much to trim? All right, now what we've done is we've put a sizer in. She's gonna get a S high-profile 485 Allergan Sizer. And I've got the inferior edge of galloflex. But how much should we trim? If you make this too short, it'll blunt the lower pole. If it's too long, you're not getting the support. So what I actually do is I estimate. I know I've marked the chest wall where I want the fold to be. I actually put this down here and my index finger is pointing to where I want that fold crease to be. And I kind of estimate where my inferior edge needs to be. I take a surgical marker and I put a little dot right there, bring it out. And that's kind of telling me where that inferior edge needs to be. And I'm gonna trim the galloflex so it's a perfect fit. Now that redundant component that I'm trimming, don't throw that away. Because I can use that piece resourcefully and actually create a lateral sling for lateral support, which we'll talk about in the next slide. Ready? So the third step is really to complete the inferior fixation sutures. I typically place two max three sutures anchoring the resorbable mesh down to my neofold. I will not tie those sutures down. I call those parachute sutures so that I can actually introduce the implant. So I use any kind of funnel, like a Keller funnel. And I basically glide the implant using a funnel underneath the subpectralis major or subfascial pocket. And then underneath, of course, the resorbable mesh. And then ultimately, once the implant is in place, you're satisfied with the implant position, I simply tie them down and you're essentially done. Now, when you've completed that, it is very important to sit the patient upright to verify fold position. Make sure you have full symmetry and make sure your upper pole volumes are symmetric. If it doesn't look right on table, it will not look right weeks later after surgery because many of these resorbable mesh are not forgiving. Make sure that you do not have blunting of the lower pole and you make sure you have proper mesh tension. So it is very important that you sit these patients upright to confirm implant position. Now, what about lateral pocket control or correction of lateral malposition? As you can see in the center picture, this is a picture of someone who has large implants that have fallen to the side. She has severe lateral malposition. Now, before resorbable mesh, we would all do lateral capsuloraphies. There's the thermal popcorn technique. You can use lateral sutures. You can use capsular flaps. But the challenges are oftentimes in severe cases, you can get indentations, anchoring sutures could potentially create chronic pain issues and longevity, especially with large implants. Remember, glycating weak tissue to weak tissue does not create strong tissue. Now, after resorbable mesh or use of a resorbable mesh, I will still do a lateral capsuloraphy, but mostly a popcorn technique to contract the lateral capsule. I reserve suture techniques only for the most severe cases with implants going into the sub-axillary space. But I use a resorbable mesh such as P4-HB as a lateral onlay graft to help to reinforce, strengthen, and hold the lateral pocket position. So I want us to take a look at this diagram. And here you can see I'm using that extra redundant piece of resorbable mesh that I trimmed early in the video. And I basically laid in essentially like a taco shell in the lateral pocket, overlaying into the lateral gutter. These yellow arrows essentially show that I'm anchoring at three points down to the chest wall. I typically use either a 3-0 PDS or a 2-0 PDS. So in this case, I've achieved lateral support by doing a thermal contraction technique or a popcorn technique. I reserve the suture technique only in severe cases where I have to close down a lateral dead space. And then I'm using this P4-HB resorbable mesh as an onlay graft essentially with two or three deep chest wall tacking sutures. And ultimately then I will inset this lateral border to the anterior P4-HB for complete lower pole coverage. Let me show you what I'm doing with this video here. All right, so we've done the inferior sling with our P4-HB. This is the lateral. Remember we put in the gutter? The anterior edge of that lateral sling, I'm gonna just inset it together like that. I'll trim this, inset the edges, and now you have full coverage inferiorly as well as inferior laterally, as well as laterally to give support. So this implant will no longer fall this way. It will no longer fall this way. So basically I'm taking the anterior border of this lateral piece, and I'm insetting it to the lateral border of the inferior piece. This is just using one piece and using it resourcefully so you're not using multiple piece because the costs do go up. All right, so let's go over a couple of cases. So first case, and I wanted to present the most complex cases because if it works in these very complicated cases with long-term follow-up, then you'll feel more confident using it in more simpler cases or primary cases. 48-year-old female with 25-year-old implants. She has Baker's class IV capsule contracture, ultrasound-confirmed ruptured gel implants. You can see she's got a waterfall effect with poor soft tissue support. She's got ptosis. With the arrows that you see that I've drawn in the chest wall, she has an underlying fold asymmetry, and she wants to restore upper pole volume, and these blue dashes show where she wants her upper pole cleavage to be. In a simple revisional augmentation mastopexy, depending on her tissue quality, I can't just achieve that with long-term results based on her tissue, so I utilize resorbable mesh. So in this case, this is what I call the half-time show where the left side's completed, the right side is her before. In this case, I performed an implant exchange. I used a resorbable mesh with inferior and lateral support, did a full mastopexy utilizing a cohesive ultra-high-profile 525 implant, and this is fine. This is the intraoperative view, but it's important to look at our long-term outcomes, and this is a four-and-a-half-year follow-up where we've maintained her upper pole volume. She no longer has the waterfall effect, no longer has lateral malposition, and I do believe that when I'm using a resorbable mesh to hold up the implant, it takes the weight of the implant off a weak skin envelope. I am seeing that my mastopexy scars heal much better. The number of revisions I need to do around the areola or mastopexy scar has drastically decreased ever since introducing resorbable mesh in my augmentation mastopexy practice. Here's another case, case two. This is a 58-year-old with 15-year-old implants. She has high-profile 600cc subglandular implants. She's done multiple augmentation mastopex, augmentations before. She presents to me with Baker's Class IV capsule contractor. You can see the obvious indentation from the capsule contractor effect here. My office ultrasound showed that her right breast is indeed ruptured. She has very thin tissue. Add on to that, she has a 20-pack-a-year smoking history, and she's lost 20 pounds using semaglutide, so very thin tissue. In this case, I did a revision augmentation with an implant exchange. We removed a ruptured right implant with total capsulectomies for her capsule contractor. Because of her capsule contractor, I performed a site change to a dual pocket for a neopocket, and then resorbable mesh with P4-HP with inferior lateral support, and again, a full mastopexy, and this is her 1.5-year follow-up with very weak tissue and a smoking history. Case three is a 29-year-old female who's undergone a subfascial breast augmentation approximately three years ago. She presents to me with right breast capsule contractor, type III. It's not causing pain, but it's tight. But she actually likes the side that's pathologic. She wants upper pole volume. She wants to go larger, but has very weak tissue. So in this case, we discussed her options. She opted for resorbable mesh. I performed a revision augmentation. Again, a site change to a neopocket, in this case, a dual plane, and opted for larger cohesive implants and used resorbable mesh, and this is 2.5-year follow-up. And the fourth case is, I think, the most complex. I think this is as complex as it gets. This is a 50-year-old who's had multiple, multiple previous augmentation mastopexies. She's had a 60-pound weight loss, a severe waterfall deformity. She's got lateral malposition, as you can see from the photo from the bottom, extensive striae, poor soft tissue support. She's got a wide gap between her breasts, and she currently has intact textured implants. So I consider this a very complex aesthetic case. So in this case, let's go to the OR. Hey, everyone, we got a really complex case. Let's take a look together. So you can see she has large implants, huge gap between her breasts. This is what, almost, it's not almost, it is 10 centimeters, 10 centimeters of distance in between the breasts. These implants are falling to the side. She's got super thin tissue, you can see right here. She's already undergone previous augmentations with lifts. You can see the scarring at the bottom, all these indentations. So what we're gonna do today is take these large implants out, we're gonna put new implants back in. It's time for the internal bra technique. You can see how weak her tissue is right here. She needs support. So we're gonna do internal bra technique to support inferiorly and laterally so that her implants sit up here, bringing her cleavage back closer where she wants it to be. We're also gonna revise her breast lift and take out these old scars and make her breasts look a lot better. Here's her 18-month follow-up. We did a revision augmentation with removal of her intact textured implants, placed a new cohesive smooth gel implants, again, resorbable mesh with inferior as well as lateral support with multi-point fixation and a full revisional mastopexy, and this is her result with a 18-month follow-up. So last thing I wanna talk to you based on is avoiding a 2.0 or revision surgery in the cases of severe great thretosis with or without tuberosity. And what am I talking about? I'm talking about these type of cases that I'll walk in to our offices for consultation. So for patients, these patients, when they're seeking very large augmentation results, full upper pole volume, full cleavage, I no longer will offer a one-stage augmentation mastopexy. In these cases, I divide it into two-step approach. Step one will be a mastopexy, excuse me, oftentimes with a lateral reduction. And then step two, we discuss two options. It can be a breast augmentation with an implant with resorbable mesh with or without fat transfer, or if they're okay with their current volume, they just want a conservative augmentation, then a breast augmentation with fat grafting is also a great option. And just to show you one example, I know we're almost out of time. This was a result from a two-stage approach. Step one, I did a superior medial pedicle mastopexy with a small volume lateral reduction. And step two, an augmentation with a cohesive gel implant with a resorbable mesh, but I did also perform fat grafting to the cleavage, and this is her about one year healed result. So final thoughts, I think it's very important to discuss the role of tissue quality with all our breast patients. Consider resorbable mesh. I think it provides a reliable long-term pocket control. I think it can be a great modality to help prevent lateral and inferior malposition and provide much needed soft tissue support in challenging cases. And I do think when you're getting the additional support of the implant and taking that weight off the skin envelope, particularly in poor soft tissue support cases, I think it helps to improve mastopexy scars and healing, and it helps to take that tension off, particularly at the triple point, because we all know we all have challenges at the inverted T-junction. So I think this is one way to take that weight off of tension points. And if you're going to utilize resorbable meshes, I would advocate you consider two-point fixation, upper fixation to the inferior edge of the pectoralis major muscle, or the pectoralis fascia and inferior fixation to your inframammary fold or to the chest wall. Thank you very much. It was an honor to present, and I will hand off the baton to Dr. Maia. Thank you very much, Bob, for this enlightening presentation. As I said before, all the questions will be answered at the end of the session after all presentations. Our next speaker is Dr. Gabriela Garcia-Norris, who is an assistant professor at Emory University in the Division of Plastic and Reconstructive Surgery. Gabriela completed her general surgery residency at NYU, during which time she also undertook a research fellowship at the Memorial Lung Catering in lymphedema surgery for two years. She then went on to complete Plastic and Reconstructive Surgery Fellowship at Emory in 2021. Following this, she completed a fellowship in reconstructive microsurgery from University of Pennsylvania. She's double certified, board certified in general surgery and plastic and reconstructive surgery, and her research interests encompass outcomes, research in implant and autologous breast reconstruction and quality improvement. And also she currently serves as the QI officer of the Plastic Surgery Division. She's also the Medical Student Clerkship Director for Plastic Surgery at Emory. Gabriela is presenting tonight about the management and the prevention of mastectomy, flap ischemia and necrosis. Thank you very much, Gabriela, and welcome. Good evening, and thank you so much for giving me the opportunity to present. I'm going to share part of my screen and see if everyone sees it. And we're going to gear this presentation a little bit more towards the reconstructive aspect of breast surgery, which is about 70% of my practice. I wanted to discuss the prevention and management of really mastectomy, skin flap, necrosis and ischemia. And I have no disclosures. So really, why is the skin envelope important after a mastectomy, whether a skin sparing or nipple sparing mastectomy? And that's because really we have to remember that the skin is there and it's left behind to enhance the reconstruction and to improve a better or more cosmetic result. And really the management and prevention of skin necrosis ends up falling upon us as plastic surgeons to a certain degree. I wanted to bring this study to your attention and really evaluated the benefit of preoperative vascular mapping and MRI before and after a mastectomy. And what they did was they really mapped the perforators that were there after a nipple sparing mastectomy and noted that even though most of the really blood supply to the breast is gone with the mastectomy or through the breast skin, the residual vascularity is mostly derived from the internal mammary perforators, the fifth intercostal artery perforator or ICAP, and then the subdermal plexus. And that's why it's really important to plan with your breast surgeon what their incisions are gonna be in order to try to prevent them from, for example, doing a much larger incision and compromising some of your blood supply. Because you really do not want to be left with this or this, or this, because you're gonna be left with a lot of increased infection rates, reconstruction loss, patient dissatisfaction rates, and there's multiple studies that prove all of this. So really how often does mastectomy skin flat necrosis occur? Literature out there poses it as about 18 to 30% of all mastectomies. And this study really posed an important question. What is it that we're calling mastectomy necrosis? Is it defined by the area, by the timing of which we're going back to the operating room about, is it defined by really, are we doing the breedments intraoperatively? Are we doing the breedments postoperatively? Are we doing small procedure room to breedments? Or is it defined by the depth of the necrosis, by full thickness versus partial thickness necrosis? Is it defined by the physician? You can see this table comparing physician definitions of necrosis by the type of necrosis versus patient definitions of necrosis. But really at the end of the day, when we have necrosis, we have to look at what our risk factors are. And we're going to define some of the risk factors. Our main risk factor obviously is our breast surgeon. We can only work with the canvas that we are given. And if we do not communicate with our breast surgeons, if we do not have a very good understanding of who we're working with, sometimes we're left with the results that we just showed. Then we have the breast skin. An elderly, thin patient will be at higher risk than a very young, heavier set patient that has a nice layer of subcutaneous tissue. Patients that are smokers that have very long, thin flaps. Patients that have, or mastectomies that have traction injuries, whether by retractors or thermal injuries by bovie electrocautery or other thermal devices. And finally, radiated skin, which doesn't ever react really like normal skin. So how thin is too thin? This study really examined pathology specimens in breast reductions, and had the pathologists evaluate the thickness of the subcutaneous tissues, starting at the measure of where the dermis ended and where the breast, really dermal glandular tissue started. And they basically correlated that with age, BMI, and specimen weight. And they noted that there was really no correlation between BMI, age, or breast specimen weight and the thickness of the subcu, but there was a consistent layer throughout and very distinct layer, as marked by this red arrow, of non-breast tissue with a median thickness of about one centimeter. So really what we want in your mastectomy flaps is approximately one centimeter of thickness to have a healthy layer of mastectomy. So really how do we predict and prevent skin flap necrosis? And what tools do we have? All of us use clinical examination, right? It's the most available of our tools. We look at color of the skin, capillary refill time, dermal bleeding, et cetera, but that's sometimes not fully reliable. And there's more objective measures that are listed below and that we'll go through that are nice tools to have in the operating room or outside of the operating room to guide us with this. I'm a huge fan of sphyangiography. Here at Emory, we use it in a lot of our patients, and it uses a near-infrared camera with a fluorophore ICG, and it's allowing us to have a very nice quantitative and qualitative analysis of tissue perfusion in real time and an objective measure of tissue perfusion. And I could not speak about sphyangiography without really looking at the work that was done in the past by some of my mentors here at Emory that really did some of the first analysis of mastectomy necrosis with the use of sphyangiography and really posed a positive predictive value of this methodology and really the negative predictive value of it. This other study, really, they looked at a prospective cohort of women with skin-sparing mastectomies over two years, and they looked at skin flap perfusion intraoperatively, as you can see here, depicted on sphyangiography, and followed those people postoperatively, right, and took clinical images, clinical photographs, and then transposed them or superposed the images and looked at areas of hyperperfusion and areas of superficial epidermolysis or necrosis and noted that really when there's a skin perfusion score of less than 25% on SPY, you had a higher rate of approximately 90% of necrosis over time. And then when the perfusion was more than 45%, then approximately 98% of the time, the flaps would survive. But also what they did was they found this perfusion cutoff score of about 33%, which is used in multiple other studies since then, right, that gave you, designed this score where we can expect more accurately to either remove skin or leave skin behind, right? And then they defined that this is actually really cost-effective because it saved patients an average $610, you know, based on all the reoperations that they would have for perfusion-related complications. So really sphyangiography has been demonstrated when you look at hyperperfused areas to be highly sensitive, highly specific, very good positive predictive and negative predictive value. And it allows us to have feedback in real time in the operating room with evaluation of mastectomy, hyperperfusion, which ends up in sometimes necrosis, right? Same thing here, areas of hyperperfusion that end up having a clinical result of, you know, superficial or more severe necrosis. And this is not only useful in autologous reconstruction where we do a lot, but it's also useful in implant-based reconstruction. This is pre-implant placement after a mastectomy. You see an area of slight delay in hyperperfusion. Once the implant is placed, there's more pressure on the mastectomy flap and this area is more evident, right? But ICG is not the only thing that we can use. This study by Dr. Roark looked at really tissue oximetry, measured that in about 10 patients and noticed that in the one patient that had a mastectomy necrosis, there was much reduced saturation of O2 over in the skin. And so he posed this as a possibility intraoperatively or even postoperatively as a method of evaluating the possibility of ischemia or necrosis. There's new technology like FLIR technology, which is used more at Penn that looks really also at saturation of O2 in the tissues or really colorimetric saturation. And this is a study that looked at multiple patients. This I thought was the most interesting after a free flap reconstruction. At day two, you can see already that there's like hyperperfusion here, but it's not clinically relevant until day four. And finally, day 20, where you actually have to go in and do debridement for this flap. So there's multiple methodologies. This last one that I wanted to pose to you is a new measure that we're using at Emory. It's called SNAPSHOT, and it looks at tissue oxygen saturation in the superficial tissues. And it's not invasive. It is a little bit heavier than the FLIR camera because it weighs about 10 pounds. But when Dr. Jones looked at this study where he compared nipple-sparing mastectomies or skin-sparing mastectomies with implant reconstruction with FLIR and with the SNAPSHOT technology, some of the FLIR images would have predicted that the entire area of the mastectomy would have died post-op, whereas the FLIR technology allowed us to keep the implant and the skin in and therefore not over-reset this area. So I think that's new technologies that are emerging and that are things to think about in the future. But the true benefits really come when decisions are made intraoperatively based on findings that will improve patient safety and reduce complications. For example, here, you have a patient that's going to undergo a mastectomy. We're choosing a periareolar mastectomy, but she has a very large scar here from a previous biopsy. And intraoperatively, when in setting the flap, we have an area of hypoperfusion, which would result in necrosis based on SPI. So then what we did was we resected that area and we ended up with a pretty good result. Now, inversely, when you have previous scars and you think you're going to need to resect this large area, you can also SPI and realize that you have very good perfusion in this, and you can end up with a nice reconstruction with an implant in this case. So now what do we do when we're faced with poorly vascularized flaps, either intraoperatively or postoperatively? Step number one, if you can, you can excise the compromised skin, if possible. You can do it intraoperatively, or here, for example, at one week postoperatively, then at two weeks where you have more defined necrosis, and then intraoperatively once you've resected all the areas that you needed. You can use a better perfused area. Here, this is an implant-based reconstruction where we did an inferiorly-based perforator flap to decrease the tension of the mastectomies. You can adjust your prosthesis. You can switch to a tissue expander. You can decrease the fluid in the tissue expander. When you have an area that's going to be too large and you do not have any other tissue to rearrange it from, with, for example, a subtotal mastectomy, you can convert to a latissimus reconstruction, a Tdap, an LTAP, or other local perforator flaps. If the skin looks terrible after a free flap and you still haven't deepithelialized everything, you can unbury the flap and then convert that to a partially buried flap and have still a pretty okay reconstruction. And finally, you can convert to a delayed reconstruction. Now, what if it's post-op that you will notice these signs of hyperperfusion? We have several tools in our armamentarium. Everyone knows about nitropaste. It's been proven to reduce markedly mastectomy necrosis after a mastectomy and even nipple areolar reconstruction, sorry, nipple areolar complex necrosis. But really, this new tool that is DMSO or dimethyl sulfoxide has been proven really in Europe and now in the States to help with saving some of these nipples and even mastectomy skin. This is a study by Penn that looked at really 11 patients and noticed intraoperatively that these patients had signs of ischemia and whether on day zero or on day one, they decided to start treating with TID-DMSO, either topical, in gel, or in liquid form. And they were able to save all of those nipples and the mastectomy skin. And these are pretty compelling pictures. So just things to take into account. And how do we actually manage the necrosis once you have necrosis and you've tried all these other tools? It really depends on the location, the size, whether you have an implant or autologous reconstruction, and really the depth of the necrosis. And the trick is when you have autologous reconstruction, when you have nice tissues underneath this skin that is struggling, early conservative management is really much, much better followed by late scar revision. And your options are nitro paste, DMSO, hyperbaric oxygen therapy, wound care, debridements, et cetera. But really let's look at some examples. Here's an area of superficial epidermolysis a few weeks later, and her final result after reconstruction. This is another patient with autologous tissue reconstruction, a larger area of necrosis, the same full thickness after we waited a little bit. Another patient that had a very large area of autologous reconstruction of necrosis after we waited a few weeks, if not, you know, a couple of months, and after her final reconstruction and tattooing. What if it's partial thickness? Partial thickness actually heals much better. It looks terrible, but it does heal much better without mostly doing anything at all. What if we have an implant in a very large breasted obese individual where we have done a Weiss pattern skin reducing mastectomies? Sometimes we're able to debride and keep all this area intact. Why? Because we have an inferiorly based autodermal flap in those patients and we're okay with leaving the necrotic area to heal slowly over time, debride it at a later time and finish with an acceptable reconstruction down the road after we left it to secondary healing. So when you have really a good layer of tissue beneath that is covering the implant, you can get away with a lot. Now darker and larger and deeper skin necrosis really don't do as well and have a tendency to contracture and so earlier, you know, more aggressive approaches are preferred. This is an example of early debridement and skin graft with a finalized reconstruction. This is another example of a patient that needed to undergo neoadjuvant or adjuvant therapy and later on radiation had a debridement skin graft after her finalized reconstruction. When you have really full thickness necrosis like this and a patient that really needs to continue her adjuvant therapy pretty quickly, you really need to be more aggressive to breed those areas, try local flaps and really let everything heal so that the patient can move on with her cancer treatment. Again, when you have areas that are large, you have to debride and be more aggressive and find localized options and sometimes when you have a prosthetic implant, switch it to a tissue expander, decrease the volume, right, and debride everything that you can and close what you can and come to fight another day. Implant-based reconstructions, they call for more aggressive management, right? If you have necrosis, you do not want to have an implant infection, you don't want pseudomonas or any other bacteria in there and so you're going to go with local flaps. If you have an area of very large necrosis, what's going to happen is you're going to try to recruit a latissimus, a Tdap, an LTAP and come to fight another day. Again, large area of necrosis where we recruited latissimus flaps. This is another area, again, another example with an exposed implant where, again, we recruited latissimus flaps. And then finally, to conclude with this, when you look at secondary healing, especially in autologous reconstruction, you just have to be as patient as possible, let everything heal and revise it later to have a better reconstruction down the road. So really, in conclusion, prevention is key. You have a lot of tools in your armamentarium, whether fancy tools like SPI or more available tools like DMSO, which is available on Amazon. You can do local wound care for smaller, more superficial areas of necrosis. When there's full thickness necrosis, if it's an autologous reconstruction and if it's a small area, you can basically just let it heal or if you have any soft tissue covering the implant too. If it's full thickness necrosis and adjuvant therapy is needed or there's an implant underneath there, you need to be more aggressive. You need to either skin graft or use local tissue to rearrange it and to cover that implant and to try to avoid the risk of distortion of the shape. I want to thank everyone for letting me present today and giving me this opportunity. And this is my email if you have any other questions after today. Thank you. Thank you, Gabriela, for such a nice overview on all the current techniques in managing this such a difficult complication, which is the ischemia and necrosis of the mastectomy flaps. Please don't forget to submit your questions that after Dr. Luskin's presentation, the speaker will be answering your questions. We already have some of them. Our next speaker is Dr. Albert Luskin. Dr. Luskin is a professor and chief of plastic surgery at Emory University Hospital. He earned his medical degree at Harvard Medical School and completed his training at Emory. He specializes in reconstructive anesthetic breast surgery, as well as abdominal wall reconstruction. He has a busy clinical practice and he's devoted to his patient and to advancing technique and technologies to improve outcomes. He's a member of local and national plastic surgery society and is a speaker on numerous breast surgery meetings. His contributions to the field include more than 250 scientific articles and numerous book chapters focusing on breast and abdominal wall reconstruction. Tonight, Dr. Luskin is going to talk about again the management and the prevention of complication following oncomplastic reconstruction. Thank you very much, Dr. Luskin, and welcome. Thank you. Thank you, Dr. Meyer, and great talks by Dr. Garcia and Basu. That was awesome. So I thought I'd talk a little bit about managing and avoiding complications in oncomplastic breast surgery. These are my disclosures. They won't impact this talk. You know, I think a lot of you are familiar with oncomplastic breast reduction techniques and the benefits of that. Breast reduction techniques is when the cancer gets removed in a patient like this with a low pole breast cancer. She has large breasts. This is what it looks like after the resection. And then we just do a superior medial breast reduction in this situation and reconstruct that defect nicely and try to minimize or avoid complications. And this is a very accepted concept. I think there are a lot of advantages to this. I'm not going to go over any of those, many of them, because this is about complications. Most are not going to talk much about technique because it's complications. But if anyone has questions, I'm happy to take them. Whenever we're doing something extra, like in a patient, for example, who's getting a lumpectomy, we're doing additional surgery, we need to kind of weigh the risks and the benefits of that approach. And once we start looking at long-term data, it's really important that we look at complications as well, because that's going to impact potentially additional treatment that might impact survival in this situation. So it's important. This was a meta-analysis that we did a long time ago, looking at a bunch of things. But complication rates showed that oncoplastics were slightly less than BCT by itself. But to me, this is really kind of not necessarily the case. And it doesn't really make sense. And I think the point being is that if you look at poor cosmetic results after BCT alone, it's close to 30%. And those numbers get thrown into any complication when you're looking at BCT. Because in reality, we're doing more surgery, right? We're doing, we have longer scars. We potentially have donor sites if you can do a flap. And you're probably going to have a little bit higher complication rates compared to breast conservation therapy alone. And so what we're seeing is a shifting up front of the complication profile, because we're avoiding some of the back issues and just having a slightly higher complication rate up front. But patients are happy. You look at patient satisfaction, it's close to 90% versus close to 80 for BCT alone. And so I think that's important for us to realize that patients will tolerate slightly higher complications for more additional surgery as long as long-term they obtain a better result. The actual complication rate is not really that high. You know, you can have about 4% or 5% dehistance rate, fat necrosis, infections low, and then necrosis. Obviously, we're going to talk about that and how to try to avoid it. As in breast reductions, and a lot of what I'm saying now can be applied to breast reductions. I'm going to talk a little bit more about why it's important for oncoplastic reductions to try to minimize things like this. We see the same problems that we see with breast reductions. I do tend to be a little bit more aggressive with these patients. You know, on a regular breast reduction, I might just let that heal secondarily. But if you have chemotherapy or radiation therapy, you need to start, then I'm more aggressive and I go back in and I really try to get that closed. How can we avoid that? There are a bunch of different ways you can avoid it. We've started using Bridget, which is a skin modulation device. It takes the tension off the vertical. There has been some data out of UT Southwestern, which shows a 91% reduction in open wounds, especially at the T-junction. And the scars are smaller when you use the Bridget and the vertical scar. We've also started using silk tape, which is a woven silk mesh that we feel might help. So we're trying everything we can to try to avoid some of that T-junction breakdown and try to minimize complications. I think it's really important in these patients that you do that. If you look at what causes them and what's increased risk factors, BMI over 30, you know, the usual problem for increased wound healing. Problem for increased wound healing, but our average BMI for oncoplastic patients is 34. So this is by nature, a group that has large breasts and has high BMI. So we're really not going to be able to fix that. So we just need to do everything we can to minimize it. Things like skin necrosis. There's a patient who had an oncoplastic reduction and lost some of that skin. We ended up doing a skin graft because she needed to go to radiation therapy. And as you can imagine, that's what she looks like after radiation therapy. So she ended up getting latissimus flap. Her final result was fine, but this is not really breast conservation, right? We've done a lot more surgery and now we've done a flap. So we really need to try to avoid skin necrosis at all costs. I think it's important when the breast surgeon does their resection, if they're going to cut on your Y's pattern markings, that they don't raise mastectomy skin flaps. If you can raise breast reduction flaps until you get to where the cancer is, that's going to result in the flaps doing so much better. So these don't need to be mastectomy thickness flaps. And I think it's important to talk about that with your breast surgeon, because that's really going to increase your risk of complications. If you have healthy flaps, reduction style flaps, you can do anything you want underneath those flaps, and you're going to get a nice result. Now, sometimes you don't have a choice, and I recognize that because it's a cancer operation. So a patient like this, we come in and the cancer was close to the skin and we have really thin skin flaps. But there are things you can do, right? So we did a superior medial pedicle for the nipple. We tailor tacked it closed. And then we did on-table spy angiography. And so where I thought it wouldn't light up, it didn't. And as long as you're going to have a plan B, we preserved a small little lip of skin. We hadn't taken that skin, so we cut out the thin skin. We placed a little fasciae cutaneous flap where that was. And there she is two weeks post-op, and that's going to tolerate radiation therapy so much better. Same in this patient, exact same thing. And you can see at five years after radiation therapy, she's done really well. So these are some of the things that we can do to try to minimize complications. Previous scars will affect your decision-making. I don't want to do a Weiss pattern scar in a patient like this who has that previous lumpectomy scar. So we're going to go ahead and resect the breast surgeon, resect the cancer. We do a vertical mastopexy. And despite having a scar there that potentially would increase her risk, she ends up doing well because we chose a safer operation for a higher risk patient. All right, so nipple necrosis, no one likes to see that. You know, we all do see those in our breast reduction patients, but I think these patients tend to be a slightly higher risk of nipple necrosis because sometimes the tumor resection interrupts the blood supply, even more so than just a regular breast reduction. You can try to double pedicle if you're worried about it. This was a resection that was close to the nipple. So we ended up doing an inferior, kept them attached superior laterally and try to keep as wide a base as possible. This was a patient that was really thin after tumor resection. And so what I did was I kept that superior lateral pedicle as wide as I could. And if you'll note, we did not cut out the circle for the wise pattern because if that nipple doesn't light up on angiography or on clinical exam, then you'd rather not have cut out your circle. And this way you can do a reconstruction later or you can just do a breast amputation. This situation, it did seem to be viable. So we inset the nipple nicely. Dr. Garcia spoke about that. So I'm not gonna talk about it. And then remember, if you worried about complications in a higher risk patient, it's okay to just keep it safe and do a breast amputation. And you can always reconstruct the nipple later like we did in this patient. She had previous scars. She was actually a smoker and ended up doing well with a relatively conservative procedure. What about hematomas? So no one likes to get hematoma, but unfortunately we do see those. I typically, the way I manage hematomas, I evacuate them if they're expanding or if it's compromising the skin or if it's tight. If it's not any of those, we tend to observe it and then just try to drain it in clinic or aspirated. And sometimes if it's small enough, it will resolve by itself. This was a study we did on TXA and breast reductions. And you can see here on the left, the hematoma rate after breast reduction was significantly less in the patients we gave one gram of IV TXA2 before the surgery. So that's something we've started doing in oncoplastic patients now too. And we're gonna look at that data soon. The other thing we currently do is we spray with a microporous polysaccharide, potato starch, it's called Arista. And we just spray three grams after we do the resection. And there has been some studies on mastectomies, breast surgery showing less strains, less seromers. So we're still looking at that and I think it's helpful. The auto-augmentation techniques, I'm not gonna go over in detail, but these are when we use breast tissue to fill defects. You can either have an extended primary pedicle, like on top, or you can have a secondary pedicle, like on the bottom. And we've used this in a third of the time. And it's really important when you do this, for example, that that tip has a good blood supply. So you can see how attached it is inferiorly. So I've really resected, lifted it up very little. I've attached it to a superior medial pedicle, but it's still all attached as much as it needs to be. And that's gonna maximize the blood supply of that tip. And if you're worried about it and you don't wanna do a extended pedicle, you can always add a second pedicle. Keep that short and have a nice wide second pedicle and use that to fill a defect. It's become very useful. And we have looked at complications and outcomes. You can see it here at the bottom. Fat necrosis rate symptomatic is the same, whether you do an extended or secondary or a regular oncoplastic. And I think that's important because you don't want fat necrosis in these patients who've had breast cancer. A little bit about timing. I think timing does impact patients. If you do your immediate reconstruction, your complication rates a lot less. So that's at the time of lumpectomy. If you wait until after radiation therapy, the complication rates much higher, right? And obviously that's a previously radiated patient like this one. We try to avoid this if we can because their results never gonna be as good as much harder to get good symmetry and your complication rates even higher. So why is it important to minimize complications? Well, we're doing more surgery, it's more costs, but then these are breast cancer patients. We really need to not do anything that's gonna interfere with appropriate cancer management. And I'm not gonna get to surveillance because we really just don't have time. But people have looked at the delivery of chemotherapy and you can see the number of days to chemotherapy is the same, whether it's oncoplastic or lumpectomy by itself. So that's a good thing. And if you're gonna be doing this, speak with your medical oncologist about it. If you look at radiation therapy, it's slightly higher in the oncoplastic group, but not significant. But if you have complications, then it does start getting significant. So if you have complications, it's 72 days versus no complications is 54. So radiation oncologist is not gonna be very happy and there might be a survival impact if you're having to delay radiation therapy. This was another study, which is a nice one that showed and you can see the major complications resulted in a delay in radiation therapy up until seven weeks versus 15. So you don't wanna get up to 15, that's too long. Interestingly, again, chemotherapy was not impacted. And I think the reason being is people are a lot more likely to start chemotherapy with the small delayed healing, but you really don't wanna start radiation therapy. So do everything you can to minimize these complications and minimize any delays in adjuvant therapy. Complication does contribute to reoperation in 5% of the time, or sorry, 8% of the time. But more importantly, the most common reason for reoperation is aesthetic. So we wanna do what we can to try to avoid any revisional surgery and keep that ipsilateral side larger. If you anticipate radiation with the small amount of fibrosis, you're gonna minimize the need to go back and revise the opposite side, which is the most common reason for reoperation in these patients. So I just wanted to kind of give you a little bit of my perspective when it comes to complications with oncoplastic reductions, because I think the stakes are obviously a little bit higher than breast reduction by itself. You really don't want them to impact adjuvant therapy or surveillance. Patients will tolerate complications upfront as long as it improves the overall result, but really keep them in mind and try to minimize them as much as you can. And it requires close working with the team to ensure that it's in the patient's best interest. Thank you very much. That is my email address, and I think I've left a few minutes for some questions, but I appreciate the opportunity to chat with everyone today. Dr. Mayer. Thank you. Thank you very much, Albert. Very, very nice presentation about how important is nowadays oncoplastic breast surgery. We know that a patient who had actually an oncoplastic procedure, the impact in quality of life is tremendous, especially if that patient is undergoing radiotherapy. We're gonna start our session, our Q&A sessions. Please, if you still have any questions, you can submit it through the Q&A button function at the bottom of the screen. We're gonna start with a question for Dr. Basu. Bob, very nice presentation indeed. We all know that the size of the implants varies largely depending on the country. In Argentina, for many years, for instance, the average size was around 300. So I would like to know in your practice, which is the average size of breast implant in your practice? And also I would like to do a comment about the type of implants, of course. As you really pointed out, in the US, you don't have a microtexture implant or polyurethane implants. So you can only work with a smooth implants. So in those cases, stabilization is much difficult and a mesh is mandatory. So in Argentina, also in the last years, we are noticing a reduction in the size of the implants. And nowadays, ladies are requesting around 200cc implants. So I would like to know in your private practice in Texas, which is the average size? Okay, so let's talk about size first. First, even in the United States, there's a lot of heterogeneity in terms of size selection based on regional cultural preferences. I will tell you that it is true. Everything is bigger in Texas. And I think this does apply to implant size selection. Most of my aesthetic practices or visual breast surgery, at least the breast portion of our practice are moms and professionals, and they still tend to want larger implants. I would say prior to these recent cultural shifts, I would say the average implant size is probably between a 400 to 550 range for augmentation or vision augmentation maxis, which is on the larger side, even in the United States. That being said, recently, we are seeing a downshift in more goals that are more conservative. And we see that based on the photos, the wish pictures or their desired goals that the patients are bringing in. So we are seeing a downshift in size. I think, Horatio, you mentioned something about in the United States how macro-textured implants have fallen out of favor because of obvious reasons with the concerns of ALCL and so forth. I think with the smooth implants, we do miss this Velcro type of effect that perhaps the macro-textured implants provided, and I know colleagues around the world that are still using those implants that are no longer available in the United States would probably comment better. Without that Velcro effect, then I think it sets it up for more malpositions. But I think the reason why we're seeing an increase in malpositions is we're seeing Americans, and we have and continue to have an obesity epidemic in the United States. And as patients are getting healthier with weight loss, whether it be previously with surgical weight loss, now it's the semaglutides, it's the terzapatides, it's the GLP-1 category of medications. I mean, it's almost 70% of the cosmetic patients that I see in my practice have been on one of these medications that have lost anywhere from 10 to I've seen patients lose up to 200 pounds on these medications, and with the right proper therapy, they're losing weight. But that is negatively impacting tissue quality. So previously, it would be postpartum breast, massive weight loss breast, or someone that's just born with weak tissue. Now we're adding on a whole spectrum of patients that are losing weight, and that is having a significant impact in tissue quality. Hence, I think it's important to have a discussion about tissue quality and their expectations of what we can achieve for them just with their tissue alone. Now, not all patients will opt for resorbable mesh. This increases the cost, this increases the complexity, but at least it's important to have a discussion about the limitation of what we can achieve with their tissue alone. Great. Thank you, Bob. There are some questions from the audience. We have a question from Dr. Alan Baez. Dr. Alan Baez would like to know if you use trains, and if you use them, for how long? That's one question for you, Bob. Okay, so for resorbable mesh products, I no longer use drains. Prior to the availability of resorbable meshes, I used to use ADM products, in which case I would use drains. But with resorbable, the only time I will use a mesh product, I'm sorry, only time I will use a drain in these revisional cases as I'm dealing with a really bad capsule contracture. We've all seen them. They're calcified, chalky, there's this weird cottage cheese type material. Okay, I worry about the post-inflammatory effect of doing a total capsulectomy, or if I'm dealing with a really bad implant rupture. Besides those scenarios, I will not utilize drains when I'm using resorbable mesh at all. Perfect. And we have also an anonymous question. A doctor would like to know if besides Galaflex, do you have experience with any other type of resorbable mesh for these cases? I mean, if you ever use any other type of mesh. I'd love to hear what Bert and Gabriella, their experience with mesh, and see what their thoughts are, and then I'll answer if they wanna chime in. Okay. I can jump in there. I think a lot of the resorbable meshes are similar, maybe some slight variations in properties, advantages and disadvantages of each. I've tried P4HP, I've tried TigerMesh, Durazorb. I think they all will provide you the soft tissue support that you need, and very similar experiences to Dr. Basu. Okay, perfect. I would say a similar answer to Dr. Loewsken. I mean, I prefer to use P4HP just because I like the fact, and there are different types of meshes. One of the problems with using the standard P4HP is palpability. In a thin skin patient, sometimes you can feel some of the mesh or where I've inset it with a PDS suture. But I like the fact that it's gonna stick around for about two to three years. It is a resorbable mesh. There are other mesh products, such as products that are made with PDS. I have utilized the PDS or PDO mesh products before. I'm not keen on them because of the lack of longevity. We typically know, we know that PDS mesh typically start, or PDS as a suture typically starts dissolving between three to six months, it's gone. And that makes me a little concerned, particularly in complex or visual cases, in terms of the longevity of the results. So I have not, to be honest with you, I've tried the Durazor product mesh before, and I have seen one or two recurrences. And so I've had to bring them back to use a different mesh product. There are other products that are out there. I believe Dr. Loewsken said there's this Tiger meshes, and in other countries, there are different products. I think the important thing here is that it's not the mesh product necessarily, but more so how are you utilizing it? And that's where I tried to emphasize, I think it is important to have proper fixation. I see presentations around the world where the mesh is just being put in and maybe sutured in one place. And I think there's a missed opportunity. And I thought about this, about fixation when I was on vacation, I saw a hammock with two palm trees, right? You'd never lie on a hammock that's only tied to one palm tree. You need two point fixation, right? So it's stable, it holds you up. And so that similar context applies to what we do in implant surgery. So I do firmly believe in multi-point fixation. That's more important than the product you're utilizing. Okay, great, Bob. Gabriela, regarding your presentation, we are moving. I would like to know, in, I remember this is a global partner webinar series. So just to show the difference with the different countries. In Argentina, there are some medical centers. I mean, in Argentina, like in the US, the breast surgeons perform the mastectomy and their plastic surgeon perform the breast reconstruction. In Argentina, also some breast surgeon are also doing the breast reconstruction. Something similar is happening in some countries of Europe. So my question is about, you were talking about the importance of the flap thickness in order to ensure, to avoid ischemia of the flap. Which is the protocol at Emory? The breast surgeon infiltrate the flap with the adrenaline solution or just performs the mastectomy using cautery? That's a great question. Some of our breast surgeons do, and you can see the slide with a lot of mastectomy flap necrosis complications come from mostly those breast surgeons because we cannot really rely on clinical exam or on really any objective measures such as biongeography when they do that. So I've advocated with the breast surgeons that I work with for just fovea electrocautery or other thermal devices that they use, but to avoid tumescent, especially for nipple sparing mastectomy. So yes, I agree. It is very hard to have any predictability of any type of necrosis when you have tumescent solution on board, even after really more than 20 minutes most of the time. Yeah, yeah, absolutely. We all know that a good breast reconstruction starts with a good mastectomy, right? So if the mastectomy was carried out with a tumescent infiltration, we cannot judge the real thickness of those flaps. The other question for you is, in those cases that you have a full preservation on the nipple arola complex, the full skin envelope, and you are going pre-pac, and your SPI was right during the surgery, but afterwards you start noticing some ischemia of the flap. Which is, what would you do about, I mean, all the measures that you mentioned, and they were great, that about using DMCO ointment or nitroglycerin ointment, do you prescribe antibiotics, or you do not prescribe any of that? I don't prescribe- Considering that you have the breast implant The breast implant immediately below the skin. I don't prescribe antibiotics unless I actually have full thickness necrosis, and then we're treating with silvadene before going for an early operative debridement to try to avoid an infection. But I do not prescribe antibiotics if the skin is threatened, I do preventive measures very aggressively. And that study from Penn really looked at using DMCO four times a day. And what I do is really, especially for nipple-sparing mastectomies, I'll send the patients on NitroPaste for one day because the operating room doesn't allow us to use DMCO because it's not FDA approved, so we can't bring it inside the operating room and use it there. But we can put it on when the patient arrives at home. And like I said, you can order it from Amazon and it arrives overnight. So it's a very, very good tool. And then I bring the patients very rapidly to my office within 48 hours to see how things are progressing and if I need to go for an early debridement or an early closure to try to avoid losing the reconstruction and the implant versus just continue to nurse it along. And most of the times really nursing it along, even in nipple-sparing mastectomies in very thin patients, I've been very lucky with the use of DMCO. Great, right. Thank you, thank you very much. And there is another question. The last one from you, Gabriela. This is from Dr. Leonardo Stella from Brazil. He says that, he's asking if you have ever used heparin, local heparin injection in the area of venous congestion because he had good result injecting heparin in those areas. Do you have any experience with that? I don't, and that would make me a little nervous because if you're thinking about areas of initial congestion, you're thinking within the first 48 hours and that's the time where really your initial clot is forming too. So if you've gotten good hemostasis and you don't mind doing small injections, then maybe that's a possibility. I don't really know what the mechanism would be because physiologically what you want is vasodilation and all of the tools that we discussed really create vasodilation. So unless you're actually spraying the heparin in the wounds I don't really see how that would be more helpful and wouldn't result in some complications like hematoma down the road. Okay, perfect. Also we are for the interest of time and we need to finish the webinar. We have a last question for Dr. Luskin. The last question comes from Mexico, Dr. Omar Alberto Perez Benitez. He would like to know if what you, Albert, think about waiting and do a delay reconstruction in a patient who will need radiotherapy knowing the damages this treatment does to the endothelium, thrombosis and muscular damage. Would you opt to wait or do an immediate reconstruction despite of the radiotherapy? Yeah, thank you. No, I mean, I think that's obviously a reasonable question and some people might choose to do that but there've been multiple studies that have shown complication rates just go up significantly if you wait. So 100% of the time, if I see a patient who needs an oncoplastic reduction I wanna do it immediately. Complication rates are lower, patient satisfaction rates are higher. The only ones I do delayed are the ones that I didn't get to see immediately and they come in with a deformity and then we have to do a reduction and I do that very sometimes begrudgingly but always conservatively and try to minimize any undermining and things like that. But no, I would much rather do it immediately. Totally agree, totally the best opportunity for sure. Well, I would like to thank everyone. We have over almost 100 attendance tonight and this is because of you. So I am very grateful to Bob, Bert and Gabriela for your wonderful presentations and I would like to invite to the next one next month to a new Global Partners webinar series. Thank you very much again and have a nice evening. Bye-bye. Night, thank you. Bye. Thank you.

breast surgery complications

implant malposition

internal bra technique

mastectomy flap ischemia

oncoplastic reconstruction

breast augmentation mastopexy

sphyangiography

NitroPaste

skin modulation devices

breast implant trends

plastic and breast surgeons