Hello and welcome! We have prepared an exciting session for you. Before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming and video recordings. Also, please note that this session has a corresponding forum discussion taking place right now on the PSTM 23 conference platform. If you have questions for our faculty, please feel free to submit them there. Please note that chat records may be recorded. Thank you for your participation and enjoy! Hi, my name is Megan Gruber. I am in private practice in Tampa, Florida, and my practice is almost 100% aesthetic. And I do most of my surgery in my office with the patients completely awake. So today my presentation is going to be about using the fact that patients are awake to improve your outcomes and the reliability of surgery and also to increase patient safety. I have two disclosures, but neither one should impact any of the information in this discussion. I have a media contract with TLC Discovery Productions, and I am a consultant for Apix Renuvion. So why would we ever want to do surgery on patients who are fully awake? In the past, doing surgery on fully awake patients was the domain of the non-surgeon. We would do little things in the office and maybe some liposuction, mostly touch-ups and mole removals and smaller procedures in the office. But in general, it was much easier and simpler to have somebody be asleep. These days, with the changes in reimbursements and especially with cosmetic surgery and the expense of using the outpatient surgery centers, there's been a resurgence of interest in doing patients while they are fully awake. I also find there's a subset of patients who just don't want general anesthesia for a variety of reasons, whether it's nausea, vomiting, memory problems, hair loss, or real medical indications. There's just an unserved subset of the population who would like to avoid general anesthesia for whatever personal reasons. So for all those reasons, I have found that there is a large demand for patients to stay awake during surgery. And so it is up to us surgeons who could otherwise put patients asleep to bring our expertise and knowledge to this realm, which really has been relegated to our colleagues who are non-surgical. I found that patients moving can actually be a benefit rather than a difficulty. So you can get to difficult to reach areas. You can have the patients move and bend their knee to get into the inner thigh. Axilla is an area that's difficult when patients are asleep. That's relatively easy to deal with by just having patients, you know, raise their arm, move to the side a little bit. And so for those reasons, I think there are benefits that we haven't explored as surgeons to having the patients be awake and able to follow commands. Another benefit is that the dermis and the muscle fascia remain sensate the way that I anesthetize the fatty areas. And this will allow me to stay in the proper plane and avoid any unnecessary damage during the liposuction portions to the skin and to the muscle fascia. Patients being able to stand up in front of the mirror and see the results really is a benefit to both the patient and the surgeon. And that with lipo especially, you can get a fast learning curve dealing with the loose skin. The effects of gravity are easy to learn when you can stand the patient up during the surgery and correct anything that you see immediately. Also, having the patients involved and invested in the results really helps with satisfaction and realistic expectations. So the patients see how their skin is responding. They see the limitations of the liposuction portions of the surgery, and they understand why we need to make an incision, you know, in a certain place or why they need an extension of their incision, which might be longer than they were asking for. So it really leads to really good patient satisfaction levels, which is in the end what we're all looking for in our techniques anyway. So in terms of incisional surgery, I think we should try to use a more dilute lidocaine mixture than standard. And that 1% really is not necessary to provide anesthesia adequately. And if you want to maximize your surface area that you're going to be working in without general or a sedation, then you need to use more volume. So we want the volume to be less concentrated. And in the opposite way, when you're doing lipo, you can get away with using a slightly more concentrated lidocaine and less volume of it. So I don't usually do a tumescent liposuction. I just use a probably what would be considered a semi-dry formula where I use about a one to three volume of numbing fluid. So I don't think that tumescence is necessary to provide the anesthesia for lipo. And in fact, I think that if you use less volume, that you can maximize patient comfort while minimizing shape distortion and minimizing fluid shifts. So when patients are awake, I do think that there are a few things that you should keep in mind. And we've developed a few techniques along the way that have really helped us. So preoperatively, we carboload the patient so that they have enough energy to get through a long procedure. We do use the epinephrine in our tumescent fluid. And it's stressful for the patient. So a combination of that epi and their natural cortisol levels can make them hypoglycemic. Also, because we're not using an IV, we have the patients hydrate really well the night before and the morning of the procedure. We've also found that limiting narcotics and not using any kind of sedatives has really improved patient cooperation. And it tends to make the patients more accepting of any small discomfort they might have. And finally, reassuring the patients is really important. It's important to let them know that you're going to be aware of their discomfort, should they have any, and that you will be patient with making sure that they're comfortable at all times. The prep can be very cold for awake patients. And so it's important to warm the prep solution and to dry them really quickly. Intraoperatively, we use a distraction technique called tapping, which I will show you a video of. And also, we touch up areas with quarter percent lidocaine on a 14-gauge Klein needle. It's really important that you watch your own anxiety level. We're not always used to operating on awake patients. And in the operating room, when things go wrong or you're frustrated about something, it's not always that important that you keep your mouth shut. But when the patients are awake, you have to keep your cool at all times and make sure that your anxiety level is low so that everybody in the room feels very calm. And finally, when in doubt, 50% nitrous oxide is really useful. It does provide analgesia without anesthesia, so you don't need your facility to be accredited for anesthesia to use the nitrous oxide. And this can just allow some patients with high anxiety or low pain thresholds to get through the more painful or uncomfortable numbing portions of the procedure. So in the next video, I'm going to show how we do our standing prep. It's fairly typical. We do add in the washing of the bottom of the feet because the patients are going to be completely on the table and we want them to be able to bend their knee and move around. Also, you'll notice that on the bed, there's a sterile absorbent pad. This is important if you're doing liposuction. And also we use sterile drape tape for patient modesty and make them a sterile bra and panty. Our patient is kind enough to let us walk through the whole procedure. And I'm going to show you everything from the prepping and how we position patient on the table and how we keep things sterile when they're awake. And that's really, you know, the most important difference between awake and asleep is just that you have to consider all these different things with patient and sterility that you usually don't have to consider when patient's asleep. First thing we're going to do after the markings, of course, is do a standing sterile prep. So that'll be the next thing that I show you. Okay, so our patient came in and we brought her back. She went to the restroom, we did a pregnancy test, get her all naked, the bonnet, all of that. We did an antibacterial nasal swab, an antiseptic mouth rinse, vital signs, we gave her medications, we reviewed her medical history. Dr. Gruber met with you, went over everything, and now we're going to do your sterile wash. We use a chlorhexidine sterile water mixture. It's going to be very cold. And then we'll get you on the bed and get started. Very good. The next video will show my technique for wide area local anesthesia for your awake patients before doing an excisional surgery. I use a setup that's quite similar to that for liposuction infiltration, but I don't too mess with the fluid. I use much less volume and I use a more concentrated solution than would be used for your typical liposuction. The recipe is shown here on the slide. And I'm using about one liter of infiltrate for every three liters of aspirate. So if I'm going to take out a liter of fat, I'm only using about 300 cc's of infiltration fluid. So our patient today is wide awake. Say hi. No sedation, just some Percocet, antibiotics, and a little pro-methadone. So I'll show you how to do the numbing. And this is with half percent lidocaine for the injection. So we're going to have the assistant come in. Tapping method relaxes the patient. Numbing, half percent lidocaine. Everything okay so far? Oh, good so far. Awesome. And now I'm going to just have her raise this knee and twist your body away from me. So we can get to the lateral breast here along the mid-axillary line. So that is the injection site for the lipo. And now I'm just going to make the cannula insertion site. Any pain with this? No, not yet. Can't feel it. Not yet! I'm anticipating some pain. So this is a 14-gauge Klein needle. And I'll show you the speed of infiltration. If you can just take a picture of the infiltration pump. It is at a rate of 0.6. And you can see the red line there. That's extremely low. It's not even a level of 1. Okay, and here's what that looks like. Very slow. That's very important for not causing pain. Alright, so we're going to also do the tapping at this point. And this is a little cannula insertion. How does that feel? Fine. Okay, so no numbing there. Just only in the skin. It's going to feel like fluid and weird coming in. How's that? Fine. Feels okay. Good. See, this is the numbing going into the fat layer. And there's no anesthetic at all in there. It's just going in. And she's totally fine. Can you describe the sensation at all? There's a little fullness. But it's not even cold. I expected it to feel cold going in. Uh-huh. Yeah. Okay, good. And I'm going to show you just a little bit of technique how to numb the breast with Tumescent fluid. How are you doing? Wave to the camera. Hey! Okay, so it's great to put the fluid underneath the breast. You don't want to try to put it through the breast tissue. So we put it underneath the breast on. Does that feel okay? Yes, ma'am. Do you feel pressure? Yes. Do you feel sharp pain? No sharp pain. Okay. You can be honest. We want this to be real. Not sharp pain right now. As you can see, I'm going all the way under the breast, across, over the pectoral muscle fascia, and underneath the breast tissue. Try to go through the breast tissue first. It's going to hurt a lot, right? So we want to always be aware of what would hurt the awake patient. So here you can see I'm coming to the middle where there's a lot of feeling. Does that feel different over there? Yeah. Or it all feels pressure? Pressure. But it's more intense over there. Okay? The next video will show the extent of the lipodissection that I do prior to doing the skin excision. So you'll notice that liposuction will create a very hemostatic field. Both the avulsion technique of removal of the fat as well as the use of epinephrine in your numbing solution will create a very bloodless field for you. And it's really important to use this advantage to make sure that your excision is quick. So if you thoroughly lipo your flap and don't skip the areas to be excised, you'll spend much less time on the excision because you'll be able to do it with scissor and not have to stop for cauterization of any vessels or tying vessels off. So I've finished the lipo, and now we did the tummy tuck dissection completely awake, right? Yes. And wave to everybody so they know you're awake. So come on down. We'll show you everything here. So everybody knows how to do a tummy tuck already, but I'm just going to show you what the dissection looks like so you can see it's not like a mini. Come around. All right, I'm going to hold those up. Okay, so here's the umbilicus, and this part above is all dissected with lipo. So it's very mobile, but you can see here. Can you see in there? It's dissected with lipo. You don't have to dissect it with a cautery. So then we're going to bring it all the way down, and you can see she's flat and not sitting up now, but that's going to reach perfectly. Very long torso, so she's got a lot of territory here where we can make a nice flat abdomen. Once your liposuction is complete and you've been able to mobilize the flap with the lipo dissection instead of using electrocautery, you will be able to move the flap, remove the excess skin without elevating that flap off of its vascular supply. So in this way, you've created a vascular robust flap without disconnecting from the underlying fascia, and this type of flap also needs less drainage because it has connections similar to what quilting sutures will do for your flap. So you have the benefit of being able to remove the flap quickly and painlessly with scissors instead of electrocautery and also not having to drain the technique. Okay, so we have completed the skin removal, and as you can see, it's basically like a regular breast reduction or breast lift. That's basically it. So we're just going to irrigate with some antibiotic solution and tailor-package shut. So the second breast has been reduced with lipo and she's still awake and now we're just detaching the inferior part of the pedicle. So this portion here has been liposuctioned. You can see there's no breast tissue or fat on the inframammary fold. So this is the old inframammary fold and the new one's going to be up here about an inch and a half or so up. So we're gonna just close this up and I'll show you a little bit more. Okay, today we are doing the awake body lift. So here we have her back and I'm just dissecting the posterior flaps. Right? Can you wave for us? There you go. There you go. Okay, so she, how you doing under there? Good. Okay, so I don't know if you could see this, but hold down here. Let's see. Can you see the dissection here? Yep. Basically lipo has dissected it for us and there's just tiny amounts of bleeding. Really for a posterior body lift, very little blood loss at all and I'm not using a bovie yet as you can see. I'm just doing the dissection with scissors and that keeps it a lot more comfortable for the patient and comfortable for me because no smoke. But that's basically it for the posterior dissection. That took about what, five minutes? Which is much, much faster than if you're doing it with just the bovie alone. All right, I'm just gonna sew the dermis and then we'll show you the tummy tuck. Okay, so here you can see the nice dissection that the liposuction does for you, which allows you to just really painlessly come through this. So again, you can see that the point of dissection is sort of already out from the lipo and you can see it very clearly. Hey, here we are. Are you feeling okay? Yeah. You were snoring, so I guess that's okay. No, I'm sorry. No, you're good. We like snoring. It means you're comfortable. So again, the whole dissection should be able to be done bloodlessly. Pretty nifty to do a bloodless armpit dissection, I'll tell you that much. That's a heck of a wax. That's a heck of a wax. Here is the entirety of his dissection. Can you wave to everybody? Hey! Pretty cool, huh? I think it's cool. We are all tacked shut here, and I'm gonna start closing it up. So we're just gonna take some stitches here and close you up. So, this side's loose, this side's tight. Alright, can you see it? Are you okay? Are you hanging in there? Okay, you can come take a look at this here. I'm sorry. Alright, so there's blood loss. There's hardly any. Yeah, you saved a tattoo. I did, I didn't cut it at all. Tattoo saves, and then your daughter's name, see? It comes right there. That's a good answer. That's a good answer. Oh yes, good. Today I'm doing an awake thylate. It's just totally awake. Wave hi to everybody. Doing okay? Yes. And pain so far on the scale of 1 to 10? Zero. Zero? Oh my goodness. Are you feeling anything under there? Not at all. Zero? Zero. Just hugging, huh? Yep. That is amazing. That's it. Alright, it's totally off. Wow. The skin's totally off and all we have left to do is close it up. Okay sign. Okay. With the light. Yay! Yay! We just finished our awake thylate. So, hi! Hi. And you can see the skin there, right? That's what we took off the right leg. Alright, so now we're going to get you up. Just sit on the edge for a minute because you've been laying down for a while. You okay? Yep. Okay. Wow. Much better. Looks good. Looks very good. Hello and welcome to our panel on ABCs of anesthesia and body contouring. My name is Omar Bates. I'm a plastic surgeon in Orlando, Florida. My focus is mostly on post-bariatric or post-weight loss body contouring. I'd like to thank the Society for inviting me to give this talk. I have no relevant financial interests to disclose. So the objectives today of this panel are as follows. My focus will be to identify safe practices in anesthesia with body contouring. I do most of my procedures under general anesthetic in the OR as opposed to the other panelists here today. And so we'll have some interesting discussion afterwards. So you know, goals after surgery, especially when talking about general anesthesia, we want patients to get up and walk early. We want a rapid recovery. We want to decrease the length of stay, whether that be in the recovery area and certainly in the hospital as that increases costs. And certainly we always want to keep our rate of complications low. And so one of the main medications that we use for post-op pain control are opioids. And unfortunately, opioids have the following side effects, which we all know, respiratory depression, they can increase length of stay, they can cause nausea and vomiting. And as we all know, again, they can cause a delay in recovery of bowel function. And these are wanted effects. So how do we mitigate that? So we use non-opiate alternatives. So this is a quick list of medications that we can use pre-op, post-op, or pre-op, intra-op, and post-op. And we'll kind of go through all these categories here. Mainly we'll talk about NSAIDs, Celecoxib or Celebrex, which is a special type of NSAID. Acetaminophen, this says IV, but we can certainly use that PO. Ketamine would be intraoperatively, gabapentin. Liposomal bupivagine, which we'll focus on during this talk. And then other local anesthetics. So NSAIDs, commonly used ones will be ibuprofen and naproxen. These will inhibit the cyclooxygenase enzyme and decrease inflammation, decrease pain. A main, this is not used very commonly in my practice, again, because I do a lot of post-bariatric contouring, and a relative contraindication is a history of bariatric surgery due to the risk of ulcers. Other contraindications are a known allergy and pregnancy, or especially the third trimester. So Celecoxib, as I said, is a special type of NSAID. It is a selective COX-2 inhibitor, but does affect COX-1 to a lesser degree. I do tend to use this in weight loss patients. Certainly a short course, I found it's well tolerated. I do generally touch base with the bariatric surgeons before prescribing this, and most have been pretty open to 10 to 20 tablets for patients. Again, it's a short course, and we've not found any incidents of increased complications. This has not been studied, so anecdotal data. Again, contraindications, pregnancy, or allergy to sulfonamide drugs. Our next class will be neuropathic agents. These are medications like gabapentin or pregabalin. These will inhibit neurotransmitters, and so they can have epileptic properties, but we certainly are using them for their anti-nociceptive or anti-pain properties. Really very minimal contraindications. It's a known allergy. It can be sedating. I'll cover that a little bit later on, especially in older patients, and especially at higher doses. So that is one to be a little bit careful of in older patients. Next we have our muscle relaxers. Commonly used muscle relaxers will include methocarbamol, or Robaxin is the brand name. Another one is cyclobenzaprine, also known as Flexeril. So these will block transmission at the neuromuscular junction and help with muscular pain. I find this very useful, for example, in a tummy tuck. Not so much for the abdominal symptoms, but more so for the back when the patient's hunched over for the first few days after a tummy tuck. I find that that can be helpful for some of the back spasms that patients can get. Somewhat of a long list of contraindications, but again, for the most part, pretty well tolerated. Generally be careful in patients with cardiac issues. So again, this will be what my talk is focused on, to a large degree, is liposomal bupivacaine or Expirel. This is delivered using a multivesicular liposomal compound. It does come in two vials or two sizes, the concentrations being the same. Once the first vial is a 10cc vial, this is usually a small surgical site. Generally for plastic surgery operations, we'll be using the larger vial, the 20cc vial, which is 266 milligrams of bupivacaine. So what is a multivesicular liposome? Essentially, it's 20 cc's will have 750 million liposomes. These liposomes will release the medication over an extended period, and the way to get analgesia is to obtain full coverage of the surgical field with the liposomes. So the 266 milligram version can be expanded. You can use normal saline or lactated ringers, and you can do that using a volume of 280 cc's for a final mix of 300 milliliters. You can also mix it with plain bupivacaine. You just have to make sure that the ratio of plain bupivacaine to Expirel does not exceed 1 to 2. So keep in mind that Expirel, 266 milligrams, has 300 milligrams of bupivacaine. So when you do your calculations, that means you can only put in plain bupivacaine in a maximum of 150 milligrams. So if you're using a quarter percent mixture, that's 60 cc's. If you're using a half percent mixture, that's 30 cc's. I'll generally use 30 cc's of a quarter percent mixture. So that keeps me at about 75 milligrams. So again, how do you use it? You're going to dilute it in your mixture of choice. You can inject it several different ways. You can do a field block, a specific nerve block, or you can do a subfascial or regional block, and I'll go over those. The nice thing is it's an intra-op injection, and no need for any pumps or catheters like the On-Q pump. So you want to inject 1 to 2 cc's per site, and you want to inject in small areas a couple of centimeters apart to cover the whole area. You can inject above and or below the fascia, you can inject into the subcutaneous tissue, and generally the recommendation is to use a 25-gauge or larger needle to not damage the liposomes. So in the breast, generally what you want to do is do a PECS-1 and a PECS-2 block. A PECS-1 block is performed by infiltrating between the PEC major and the PEC minor. A PECS-2 block is performed by infiltrating between the PEC minor and serratus anterior. So we're going to inject Xperl into the breast here. I've diluted this in 230 cc's of saline for a total of 250 cc's, and here I'm doing essentially a PECS-1 block. I'm injecting between the PEC major and PEC minor. I'm staying parallel to the chest wall. I'm using a large bore needle, I like a spinal needle because I don't have to stick patients as many times and I can reach a little bit farther with that. And generally in the chest or breast, I will do 20 cc's in that PECS-1 plane, and then right here I'm putting 5 cc's into the serratus to do my PECS-2 block. So in this diagram you can see the various types of blocks you can do. You can do a classic tap block which will be T10 to L1, that's the yellow outline here. A costal tap, T6 to T12, that's this. smaller longer oval. You can do a bilateral four point tap block that's the blue semi ovals here along with a larger semicircle here. Rectus sheath block is going to be this gray diagram here and then the quadratus lumborum block which is the kind of larger oval in purple. Generally I'll do kind of a rectus sheath block and I'll show that in a minute. You can do this under ultrasound. The nerves typically lie between the internal oblique and transversus abdominus muscles. If you are only doing an abdominoplasty you could do this in this technique and then just flood this plane with your expirale. So this is the same patient we've done the breasts on. Again we've diluted the expirale with 230 cc's of saline so I've got 200 cc's left to use on the abdomen. I'm going to use again that same large bore needle. I'm going into the fascia. I typically inject on the withdrawal and the goal again is to get one to two cc's every one to two centimeters and flood the entire subfascial point. I like to do this before I placate. I think otherwise you don't get the entire fascia and I feel like it gives better pain control post-operatively. So the benefits of expirale improve pain control, decrease opioid use, decrease post-operative nausea and vomiting, and shorter length of stay. For me this is really revolutionized my practice whereas in the past I might keep a patient overnight for that first 24 hours to help with pain control. My patients now go home the same day. So the patient who we just watched the videos for went home on post-op day zero. You can see here liposomal bupivacaine versus plain bupivacaine versus the on-cue pump versus controls. Expirale or liposomal bupivacaine came in at significantly smaller doses of outside narcotic use compared to all three other groups and they were all statistically significant. A few quick warnings. You have to be careful and use it with other local anesthetics. So I will tumess the abdomen and then use lidocaine and my tumescent but you can use that 20 minutes later and again also you know you're tumescing the subcutaneous space whereas you're injecting the subfascial space so in theory they're not exactly the same site. And then this is metabolized by the liver so use cautiously in patients with liver disease. So multimodal pain therapy. We'll go through that somewhat quickly. Pre-op again we talked about NSAIDs or cellococcus have been bariatric patients. Intra-op we can use our bupivacaine, liposomal bupivacaine. And post-op again we can use a whole variety of drugs. So this is our patient from two days. She's post-op day two. Same patient I injected. And tell us about your pain. My pain level is like five. Okay and what medications have you been using? Gabapentin, Robaxin, and Tylenol. Great. You can see the bruising here. Have you taken any narcotics? Have you needed any narcotics? Okay. And pain's been pretty tolerable? Yes. All right. If you had to point to the place where it's the worst where would you point? Right here. Right there. Okay. All right. And to the sides. And the flanks. Where would the liposuction? Okay. All right. Great. Thank you very much. Thank you. So again, a whole long list of adverse reactions. Many of these are pretty typical post-op and in general. So I don't think there's really any fears about using this. So again, we talked about ERAS slightly earlier. And so really this was developed to create a patient-centered protocol that's multi-modal, multi-disciplinary, and evidence-based. And so I encourage you if you're at a hospital or operate at a surgery center to get a group together. It typically takes five to seven people. And these may be, you might only have one surgeon, one anesthesiologist, or CRNA, depending on where you operate. And then a nurse in each of these sections. But it's good to sit together regularly and discuss, sorry, discuss processes and outcomes and how we can improve post-op pain. So again, this is an example of an ERAS protocol. We do allow patients to drink clear fluids up to three hours before. And sometimes we'll allow them to even have a drink the evening of and then the morning, or the evening prior and the morning of surgery. Again, this is all evidence-based. So the ERAS Society is a non-profit society. It helps develop programs. It is again evidence-based. And a lot of the things we just went through now, like I said, carbohydrate drinks, minimally invasive approaches, managing fluids pre-, intra-, and post-op, and then early mobilization. So in general, we want to improve overall recovery with decreased use of narcotics and decreased post-op nausea and vomiting. This does lead to increased patient satisfaction, decreased length of stay. And then, as I said before, expiral can be a very useful adjunct and can be an integral part of ERAS protocols. Here are my references. Thank you very much for your time. We have to take questions and have a discussion later. Good morning, everyone. This is Spiro Theodore from New York City. First of all, I'd like to thank the organizers for inviting me to talk at Plastic Surgery the meeting on Austin, October 26-29, regarding Brazilian butt lift under local anesthesia, a paradigm shift in the safety in plastic surgery. Here are my disclosures. So local anesthesia for butt lift. Obviously, we all are very aware of the current situation of the high-profile deaths that have occurred during Brazilian butt lift, and I can tell you right now that the work of Daniel Del Vecchio in this realm has been quite critical and important to my learning and as well as my partner Chris'. I have to say that we've been doing this for a very long time. Back in the day when we started doing liposuction under local anesthesia using laser, as well as radiofrequency, and the demand for having a butt lift without anesthesia really generated from our patients. So we published this in the PRS and described our technique and we'll go over it today. So obvious thing that no one knows is that Brazilian butt lift is not really Brazilian. It wasn't invented in Brazil. It was invented in the United States of America by a surgeon in California who had a Brazilian patient who he talked about and it basically stuck. So here I have a patient of mine speaking in Portuguese and she's very happy and excited and here's what's important. She doesn't want a big butt. So Brazilian butt lift does not mean necessarily a big butt. It means she wants a little better shape, a little better lifting, and nothing beyond that. So if you're looking at patients that come in for liposuction, as you know the buttock drops with age, so just putting some extra fat that you're gonna throw away probably anyways and shaping them and lifting them is something you can offer all your patients. So it's a misnomer or Brazilian butt lift that's for a large volume but lifting it's not. This can be used in every operation. Once you realize that you have the ability to do this under local, all of a sudden you're looking at every buttocks differently, you're discussing with your patients what they need. In this case she just wanted a little better shape, a little rounder shape, so we're gonna be marking her accordingly. So first I'm marking the infraglutial crease. With age you have buttocks are actually dropping, sagging, so the infraglutial crease gets longer. If you see patients that are younger, the infraglutial crease is shorter. So that goes also with the banana roll. The banana roll is basically a function of buttock sagging, so therefore we should never actually try to aspirate it. Instead it's a function of elevating and lifting the butt. So here we actually mark the the midline and basically the C point according to Dr. Tino Mangetta and that right there, that point right there, and we make sure that we give her what she needs. And the majority of the volume here is gonna go in the lateral aspects because she's pretty happy with the projection. She just wants a little more rounder, a little more lifted buttocks. Those are decision points that are hitting quite well. Typically patients that come in are two categories. Either the ones that are coming in for a butt lift or the ones that are coming in for liposuction, different areas of their body that also want to have a lift, but it's a secondary thing. It's important to make the distinction because if the patient comes in and wants a buttock lift or wants volume-volume enhancement and you're not able to give it to them, then they're not going to be happy. So you got to be very clear as to manage expectations at that point in that case. Patients that actually come in that want liposuction of their flanks, their abdomen, and as a secondary procedure perhaps, hey why not actually increase my buttocks as well, the lift, the shape. They'll be happy with anything you do with them. So it's a different type of conversation, but you have to prepare it for them. And it really goes along the lines like look, you're taking the fat out, bra roll, flanks, right? I'll put it here, otherwise I'm gonna throw it away. It's a good opportunity for us to lift your butt a little bit, give it a better shape, and therefore different discussion. So categorically, very important to manage that conversation and very important to manage the expectations as to what you can do. The reason being, if you have a skinny patient like this one, the amount of butt lift you can get and the size you can get is directly related to the amount of fat they have. So you have to point those things out and always like we always do in plastic surgery, under-promise and over-deliver. So here are the markings that we do. Here are the markings. All the markings usually typically go on the belly button so no one can see them. We don't necessarily put markings anymore in the pubic area because everyone's shaved nowadays. And here she is ready for surgery. So here's the animation, the actual technique itself, right? As you can see, the first thing we do before we even actually start is determine to put the patient in the lateral decubitus position. And hold on a second. And let's start off with the markings and the definition. As you know, when they're in the lateral decubitus position, they have some sagging. So you got to take that in consideration unless they're very young, and that's not the case. So here we go with the injection calipertumescent. You pop in through the SFS, you go directly over the muscle and inject that area. It's very easy to inject. Then you put them in the pearl position and you actually inject in this direction here to get the medial part of the buttocks. But the truth is, the majority of the fat grafting you're doing tends to be lateral and infralateral gluteal areas. Not as common to put a lot of fat in the medial areas. Then you come from infragluteal crease, as you can see incision. Same thing here. And you're able to inject this fluid without any pain. Now the question is, why no pain, right? Here's how it works. We described this in another publication of ours regarding local anesthesia with smart lipo, but the principles are the same. Most of your nerves are in the superficial area, right in the dermis. And that's where all the arborization occurs. So as you go down, you can see that the trunk of the nerve is thicker, less branching. So first you go in with a 10cc syringe with 30 gauge needle and you inject, you inject. Then you open up that incision and you push through, down through the SFS. So here we go. She's in a lateral decubitus position. I'm injecting deep. I'm not creating a wheel. The wheel hurts a lot. I'm going directly down, popping through the SFS after I put some of the local deeper. That way I get to the core of the trunk of the tree, the core nerve, which is just above the muscle. And I'm actually if, you know, putting all the fluid there and letting it slowly rise and also do my hydrostatic dissection. Here I'm making a little 14 gauge needle hole. I don't use a scalpel. The reason is in nature, usually circles heal better in a circular fashion. So I use a 14 gauge needle, not a line. Younger patients especially. So the next step is you actually go here with your temesin cannula. You inject deep and you pop through the SFS. You'll feel it go pop, patient might jump a little bit, and then you directly go deep and you layer the fluid deep. And that's, this is where they have no pain. And this is what's critical to do when you're doing under local anesthesia. No puderange, no wheels, all the fluid goes deep and it slowly rises to the top. So by the time you get to the superficial area, there's no pain. If you're able to do this in this direction, most patients will tell you that, hey, this hurt less than a dental injection. So here we go. The last part we do is a superficial part, just to make sure we have adequate anesthesia on the dermis, on the epidermis. And once we test that, we're good to go. And here is an animation of what that looks like, this method of injection under local. As you can see, hydrostatic pressure, you're not shoving it back and forth. A lot of the bleeding, the bruising that you hear, that you see in patients post op, is directly related to this step of the procedure, because you're disrupting the blood vessel. So careful, slow, deliberate injection. Here's a patient, popping it right through. Boom, right there. And now I'm just letting it hydrodissect. She's awake. She's talking. Typically, I might give them a Vicane Evaluant just before the surgery, about 20 minutes before, a half hour before. But no other sedation, no IV. She's saying, giving us a thumbs up that she's good. So this position, you're right over the fascia, and it's there, and there you see that it doesn't hurt. So step one, you can do the actual aspiration. So if you don't want to give a value of Vicane, that's fine, but you know, the oral sedation might calm them a little bit. But again, as you can see, she's pretty happy. So now, you've aspirated all the fat, and now you're going to do the aspiration. So you're going to do the aspiration, and then you're going to do the aspiration, and then you're going to do the aspiration, and then you're going to do the aspiration, and then you're going to do the aspiration, and so now you've aspirated all the fat, right, and now you're injecting using Dr. Del Vecchio's method on EVL. Apologize for the music, but you know, I have patients pick their own music, and they get happy with that as well. It takes their mind off what's going on. So injecting above the muscle, and moving along, as you can see, very safe. Here's the best safe about this operation. If you hit the muscle, patient's going to jump off the table. So it's practically impossible to penetrate the muscle here, so it is the safest way to do it. So that's why, you know, doing local anesthesia for BVL, you don't come in this situation where you penetrate the muscle causing all the problems that they're causing, right? You can use a basket can, whatever you want to do. So here are some of the results. This is right on the table, right, as you can see, you know, better shape. 500 cc's a side, you can do quite larger volumes. Luckily, the only constraint you have, the only constraint you have is basically lidocaine, right? So you want to stay under that, you know, the recommendations, and not go over the toxic levels, but the fact is they're awake, and they're best neurological monitor possible for you. Same thing here. There's another result, 350 a side. There's a patient that comes in and, you know, they might be concerned about their flanks or their other areas, but you turn almost every case into a butt case. And it's not a bad thing. They appreciate it. She's a younger patient, as you can see from her infraglutinoid crease, it's a lot shorter. Here's another patient, 500 cc's with cellulite, multiple operations in the past, laxity. So yeah, so instead of like trying to pull her up, she doesn't want another operation on her body lift or anything like that, you're just filling everything up. Same thing here, 400 cc's in area, as you can see, support of the infraglutinoid crease, you go past that border and recreate that column to support the buttock. Here's a skinnier patient, really skinny patient, 400 cc's a side. As you can see, again, the infraglutinoid crease is long on the left. That shows there's buttock ptosis, and you see the elevation right here. So here's a pre-op patient, and here's one year out, as you can see that she still maintains her shape. Usually at two to three months, that's the shape you're gonna get. That's what I'll tell patients, expect that at two to three months, you should be okay. After that, whatever, you're not gonna have a lot of change after that. So when they ask you, hey, when's my final result? You say, look, two to three months you're good, and after that, you're all fine. So whatever you're gonna lose, you're gonna lose during that period. As you can see, again, the average numbers are 60 to 70% retention. As you can see here, she's retained just fine. It's a one-year post-op. So here is our, one of our patients, two years post-op. So with the one you saw in the previous slides, well, I'm not sure why it's upside down like this, but you know, as you can see, it's a video. I like to do the videos because videos don't lie. Let's see if we can get the next one. Here you go. You can see the tattoo, same patient, same situation, two years post-op, and the projection actually holds up. So these are skinny patients. BBL doesn't have to be a big-volume operation. Every patient that comes in your office that's over a certain year, over 30 years old, as kids, are showing buttock ptosis and laxity is a candidate for this. If you're able to do another local, you don't think about it twice. Same thing here, pre-op and two years post-op. So safe subcutaneous buttock augmentation under local anesthesia. You know, I'd like to thank Dan for doing all the pioneering work regarding safety, but you know, doing a buttock BBL under local should not be an issue, should be in every surgeon's operatorium, and is literally the safest operation amongst BBLs out there. So thank you for your time.

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