Scientific Abstract Presentations: Global Partners Session 1 (Not for CME) Friday, September 27 Fri, Sep 27 8:00-9:30 a.m. PDT

Introduction Scaffold guided breast tissue engineering (SGBTE) is a concept which uses additively manufactured scaffolds which are implanted to regenerate soft tissue. SGBTE has the potential to transform reconstructive and cosmetic breast surgery where implanting permanent silicone implants is the most common method used. Complications from permanent prostheses are well reported and include capsular contracture, rupture, and development of Breast Implant Associated Anaplastic Large Cell Lymphoma. Our SGBTE approach involves implanting a porous and bioresorbable breast scaffold made from medical grade polycaprolactone (mPCL) which is filled with autologous fat graft. Over time, the body acts as a bioreactor which supports the regeneration of soft tissue, whilst the scaffold resorbs leaving an autologous tissue engineered breast reconstruction. Our research group have extensively investigated SBGTE preclinically and have performed a first-in-human trial for pectus excavatum correction.(1-3) The purpose of this study is to demonstrate the safety and clinical performance of implanting mPCL breast scaffold in a clinical trial for breast implant revision or congenital defect correction surgery.

Methods An open label single arm clinical trial assessing the use of mPCL breast scaffolds was conducted (Ethics Approval: HREC/2021/QRBW/79906) (ClinicalTrials.gov ID NCT05437757). Inclusion criteria were adult women requiring breast implant revision or congenital defect correction surgery. These patients underwent a capsulectomy and removal of implants if required, then insertion of a sub-glandular 150-200 ml mPCL breast scaffold which was filled 50% by volume with autologous fat graft. Key endpoints were safety measured through an adverse device event rate, and performance measured through patient reported outcomes (BREAST-Q) and radiological outcomes with magnetic resonance imaging (MRI).

Results This first-in-human procedure was successfully performed in all recruited patients (n=19). Six patients (n=6) have completed their 12-month follow up. To date there have been no device related complications or stopping criteria triggered in the trial. Preliminary performance analysis was performed on 11 patients who had sufficient follow up (2-months post-operative). Mean patient reported quality of life scores demonstrated improved breast satisfaction, sexual well-being and psychosocial well-being with implanted scaffolds compared with their baseline. There were also improved scores compared to 1-year published outcomes as a reference. MRI demonstrated good soft tissue retention at 2-months post-operatively.

Conclusion Preliminary findings suggest implanting mPCL breast scaffolds is safe up to 12 months post-operatively. There is improvement in patient reported outcomes and radiological evidence of soft tissue retention at an early time point. Longer term outcomes are yet to be determined as they have not been assessed.

Conflict Declaration This trial is sponsored by BellaSeno Pty Ltd. All authors have no financial interests in the company. All authors have no other conflicts of interests to declare. This trial is independently monitored.

References (1) Chhaya MP, Balmayor ER, Hutmacher DW, Schantz JT. Transformation of breast reconstruction via additive biomanufacturing. Scientific reports. 2016 Jun 15;6(1):28030. (2) Cheng M, Janzekovic J, Mohseni M, et al. A preclinical animal model for the study of scaffold-guided breast tissue engineering. Tissue Engineering Part C: Methods. 2021;27(6):366-377. (3) Cheng ME, Janzekovic J, Theile HJ, et al. Pectus excavatum camouflage: a new technique using a tissue engineered scaffold. European Journal of Plastic Surgery. 2022/02/01 2022;45(1):177-182. doi:10.1007/s00238-021-01902-5

Introduction Bariatric surgery has become an increasingly popular procedure for the treatment of morbid obesity and its associated comorbidities1,2. The increase in bariatric procedures has consequently led to augmented demand for post-bariatric body contouring procedures2. Medical literature provides plenty of articles addressing body contouring after bariatric surgery; however, there are only a few studies related to cervicofacial deformities and facelift outcomes in post-bariatric patients. The resulting excess skin leads to an appearance of accelerated facial aging3, which is psychologically debilitating and negatively affects self-esteem. Facelift surgery (rhytidectomy) is the mainstay treatment, and the efficacy of superficial musculoaponeurotic system (SMAS) plicature in this subgroup comes into question, due to impaired wound healing. This study intends to compare aesthetic results and self esteem variation in patients subjected to rhytidectomy with and without SMAS plicature.

Methods This randomized, single center, clinical trial recruited 29 post-bariatric women, from March 2018 to March 2020, who were randomly assigned to rhytidectomy either with or without SMAS plicature. Self-esteem was evaluated pre- and post-operatively and compared between groups. Patient satisfaction was also evaluated through a study-specific scale. Expert evaluation was conducted to assess for a satisfactory aesthetic result.

Results Improvement in self-esteem was observed in 54.5% of the patients in the control group, as opposed to 26.8% in the intervention group (p > 0.05). Contrast between groups was further investigated by stratifying patients according to self-esteem levels, revealing that the intervention group had 57% of patients with higher self-esteem. Subsequent statistical analysis revealed that patients with higher preoperative self-esteem had a decrease in postoperative scores (p < 0.05). Expert assessment of whether the patient had undergone plicature was wrong in 43% of the cases in the intervention group, as opposed to 36% in the control group.

Conclusion The results demonstrate that there was an improvement or maintenance of self-esteem in more than half of patients, which is consistent with the available literature4. There was no difference between pre- and post-operative self-esteem between groups. However, improvement or maintenance in self-esteem perception was observed in the majority of patients, with preoperative self-esteem influencing postoperative perception. Patient satisfaction with the procedure was expressive. As for expert evaluation, results of the intervention group were rated higher, but experts could not correctly assess whether plicature had been made.

References: 1. Trus TL, Pope GD, Finlayson SR. National trends in utilization and outcomes of bariatric surgery. Surg Endosc. 2005;19(5):616-620. 2. Poyatos JV, Balibrea JM, Sales BO, et al. Post-bariatric surgery body contouring treatment in the public health system: cost study and perception by patients. Plast Reconstr Surg. 2014;134(3):448-454. 3. Sclafani AP. Restoration of the jawline and neck after bariatric surgery. Facial Plast Surg. 2005;21(1):28-32. 4. Jacono A, Chastant RP, Dibelius G. Association of Patient Self-esteem With Perceived Outcome After Face-lift Surgery. JAMA Facial Plast Surg. 2016;18(1):42-46. doi:10.1001/jamafacial.2015.1460.

Background:

Gluteoplasty is a procedure that has experienced rapid growth in recent years within aesthetic surgery (1), however, the risk of potential associated complications has generated concern among plastic surgeons to such an extent that a task force has been created to deliver recommendations with the aim of increasing the safety of this type of interventions (2, 3). The term "Hybrid Gluteoplasty" refers to the combination of different techniques in the same surgical intervention to obtain the best aesthetic results(4, 5). In the present work, we describe the surgical technique that seeks to improve gluteal volume and projection, along with the remodeling of adjacent structures to achieve a better body contour, following strict safety parameters in order to minimize potential complications.

Methods:

Between 2016 and 2023, 253 patients underwent surgery. Gluteoplasty was performed with intramuscular implants, liposuction of the areas with lipodystrophy and lipoinjection in the adjacent tissues. patients have been followed up to date and associated complications were recorded.

Results:

Of the 253 patients, 240 were women, 4 were transgender women, and 9 were men. All implants used were made of cohesive silicone gel. As far as the implants shape concerns, 125 anatomical and 128 round were used. In terms of complications, in general there were 32 (12,6%): 23 of them (9%) where wound dehiscenses and just required local management, 8 cases (3,1%) were implant rotations (all of them anatomical implants), 1 case (0,4%) was an herniated implant, 2 cases (0,8%) presented seroma and 2 cases (0,8%) implant pocket absceses (that required explantation). We had no cases of fat embolism.

Conclusions:

By combining the placement of intragluteal implants, liposuction of areas of lipodystrophy and lipoinjection in adjacent areas, the hybrid gluteoplasty improves gluteal volume and projection while providing better body contour, which ultimately determines better aesthetic results. By avoiding risk areas during lipoinjection such as the central gluteal area, the feared risk of fat embolism decreases, giving the procedure greater safety. In the present study, there was only the occurrence of local complications, the vast majority of which were successfully resolved with local management, but no event of fat embolism or mortality associated with the procedure occurred.

References: 1)https://www.isaps.org/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2022-full-report-and-press-releases/ 2) Villanueva, Nathaniel L et al. "Staying Safe during Gluteal Fat Transplantation." Plastic and reconstructive surgery vol. 141,1 (2018): 79-86. doi:10.1097/PRS.0000000000003934 3) Mofid, M Mark et al. "Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force." Aesthetic surgery journal vol. 37,7 (2017): 796-806. doi:10.1093/asj/sjx004 4) Godoy, Paulo Miranda, and Alexandre Mendonça Munhoz. "Intramuscular Gluteal Augmentation with Implants Associated with Immediate Fat Grafting." Clinics in plastic surgery vol. 45,2 (2018): 203-215. doi:10.1016/j.cps.2017.12.004 5) Cárdenas-Camarena, Lázaro, and Héctor Durán. "Improvement of the Gluteal Contour: Modern Concepts with Systematized Lipoinjection." Clinics in plastic surgery vol. 45,2 (2018): 237-247. doi:10.1016/j.cps.2017.12.005

Breast reconstruction is an integral part of Breast cancer surgery. Patients with large and ptotic breasts can be a challenge to reconstruct. The authors will present different possibilities for the reduction of the skin envelope during skin and nipple-sparing mastectomy and reconstruction in these patients.

INTRODUCTION Currently, aesthetic procedures in particular fillers and injections are very popular and sometimes can sadly be perform by untrained and unlicensed personal, mostly because of rapid results and low cost. For these reasons patients can be seduce or deceived the used of industrial substances such as the application of biopolymers. These substances can, in short and long term, lead to numerous complications, with severe deformities, skin necrosis, death and chronic illness like iatrogenic allogenosis. Therefore, surgical techniques have emerged to address this issue, we are presenting our approach through tumescent infiltration with selective removal, this concept is based on the tumescent state and hydro-dissection that Dr. Joseph P Hunstad introduced.

OBJECTIVE To describe clinical characteristics and progression of three patients diagnosed with iatrogenic allogenosis who underwent a removal of biopolymers through tumescent infiltration with selective removal at a private medical center in Santo Domingo, Dominican Republic.

METHODS This is retrospective study, in a single-center with one surgical team, including cases of three patients diagnosed with iatrogenic allogenosis that underwent an selective biopolymer removal through tumescent infiltration at the Espaillat-Guerra Seijas Plastic Surgery Center in Santo Domingo, Dominican Republic, during the period from April to May 2022. It was reported following the guidelines established in THE PROCESS framework for surgical case series. RESULTS: Three patients diagnosed with iatrogenic allogenosis were reported, all of them being women with an average age of 38 years. They all exhibited common symptoms, such as itching, hyperpigmentation, edema, localized pain and high temperature of the gluteal areas. No complications were recorded during the surgical procedure. The patient with the largest tissue extraction had a measurement of 12 x 6 x 2.5 cm. Histopathological findings revealed necrotic connective tissue with granulomatous reaction to a foreign body, specifically silicone, and in one patient, both silicone and hyaluronic acid were found. Post-surgical management included pharmacological and non-pharmacological treatments, resulting in an effective improvement with no complications reported.

CONCLUSIONS The selective removal of biopolymers by tumescent infiltration (Clime technique) in patients with iatrogenic allogenosis offers benefits such as the decreasing of health risks, removing the substances but avoiding the removal of large amounts of healthy tissue, restoration of a natural appearance, and patient well-being, thus prioritizing safety and health, ultimately improving long-term quality of life.

Migraine headache is a frequent cause of discomfort and disability in patients, producing significant economic costs and downtime in treatments that do not offer a solution. Extracranial nerve decompression surgery is presented as a definitive option for this disease. This study aims to demonstrate our experience performing nerve decompression surgeries on patients diagnosed with migraine headaches in a developing country from November 2017 to November 2023. The method used for this study is a retrospective analysis, following the guidelines described for validating pain trigger points 1. To this end, a universe of 400 patients evaluated in our private practice is taken into consideration, all with a diagnosis of migraine headache, referred by a Neurologist, submitted to the assessment, using the application of local anesthetics and/or botulinum toxin, for the identification of trigger points at the frontal, temporal, and occipital trigger points in addition to intranasal decongestants for the nasal point in some patients.
In addition to the evidence, the use of Doppler ultrasound is an invaluable tool when selecting candidates for surgery performed by the principal investigator, avoiding any risk of variation in the diagnosis and treatment,3,4. From this number of evaluated patients, 250 are optimal candidates for extra nerve decompression surgery. These patients are classified according to sex, trigger points, and different comorbidity such as arterial hypertension and diabetes and excluded for this propose if Medication-overuse headache diagnoses are present The patients were managed through a daily report using a mobile application, MigraineBuddy (available free of charge), based on the Migraine Headache Index. The surgery was performed on 220 women and 30 men aged 17 to 71. Of the total number of patients who underwent surgery, 50 (20%) obtained an entirely positive result, 177 (70.8%) obtained a significant improvement, 20 patients (8%) reported a partial improvement, and three patients (1.2%) did not show any improvement with an average follow-up of 700 days. This study shows that the surgical approach for migraine headaches is replicable in developing countries based on the literature in this field, correctly diagnosing and selecting patients and carrying out the appropriate surgical protocol. The overall procedure is highly successful worldwide when performed by plastic surgeons who are adequately trained.

References: 1.⁠ ⁠Janis JE, Dhanik A, Howard JH. Validation of the peripheral trigger point theory of migraine headaches: Single-surgeon experience using botulinum toxin and surgical decompression. Plast Reconstr Surg. 2011;128:123–131. 2. Burstein R, Blake P, Schain A, et al. Extracranial origin of head ache. Curr Opin Neurol. 2017;30:263–271. 3. Shevel E, Spierings EH. Role of the extracranial arteries in migraine headache: a review. Cranio. 2004;22:132–136. 4.⁠ ⁠American Society of Plastic Surgeons. Policy statement: Migraine headache surgery. Available at: https://www.plasticsurgery. org/Documents/Health-Policy/Positions/ASPS-Statement_ Migraine-Headache-Surgery.pdf. Accessed May 3, 2021. 5.⁠ ⁠Group GNDC. Global, regional, and national burden of neurological disorders during 1990‐2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol. 2017;16:877–897

Methods: We report a retrospective study of 25 patients treated in our unit for acute ankle wounds between 2008 and 2022 and who underwent superficialis temporalis fascia (FST) free flap reconstruction. There were 19 males and 6 females. The mean age was 38 years old (5 to 62 years old). The location of defects was: Medial malleolar (12 cases), Achilles tendon (8 cases) and dorsum of the foot ( 1 cases). The mean surface area of the wounds was 36 cm2. 16 cases were post-traumatic with 4 cases involving crush injury. The remaining 9 cases involved wound complications from orthopedic reconstruction with exposed or infected hardware.

Results: Operative times ranged from 3.5 hours to 5 hours. All flaps were performed with end to side anastomoses in both arterial and venous positions (posterior tibial in 21 cases and dorsalis pedis for the other cases). Immediate STSG's were performed after the revascularization of the FST. Occlusive dressings were used for 5 days and flap monitoring was done by Doppler exam. Ankle mobility was limited by splint or cast. There were no microvascular complications and no flap failures. One skin graft failure requiring repeat STSG and one donor site alopecia (2 cm width) occurred. Minimum follow up is one year. All wounds healed primarily with no subsequent breakdown. All patients considered the scar at the donor site as invisible or minimal.

Conclusion: For us the FST flap has many advantages. It is thin, pliable and results in a very hidden scar at the donor site. This flap is our first choice in the management of small wounds around the ankle. The only limit is the surface area of the FST which can be appropriate only for small defects.

Introduction Functional deficits after nerve injuries pose a major clinical problem. This highlights the importance of implementing methods in preclinical research allowing for comprehensive quantification of functional recovery. In the evaluation of sensory recovery after nerve injury, a response to tactile stimulation can erroneously be allocated to regeneration of the injured nerve, disregarding the process of collateral spouting of adjacent uninjured nerves into the denervated skin. In the rat sciatic nerve model a significant influence of collateral sprouting of intact nerves on the development of neuropathic pain could already be revealed. Our project aimed to analyze and correlate sensory and motor recovery and investigate the contribution of collateral nerve sprouting in a rat model of median nerve injury and repair.

Material & Methods Male Wistar rats (n=10) underwent transection and reconstruction of the median nerve with epineurial sutures in one forelimb. In the contralateral forelimb, 15mm of the median nerve were resected and the nerve stumps were coaptated to surrounding muscles to prevent regeneration. For 12 weeks after surgery, mechanical allodynia, grip strength and gait behavior were assessed weekly by means of the Von Frey Test, the Grasping Test and the CatWalk gait analysis system. To analyze the effects of collateral sprouting, Von Frey Monofilaments were applied to predefined test areas considering the sensory innervation of the forepaws: Medial and lateral areas selectively innervated by the median and ulnar nerve and the central area non-selectively innervated by both nerves.

Results One week postoperatively, early mechanical allodynia was evident in the areas of the forepaw selectively innervated by the ulnar nerve and the overlapping area innervated by the median and ulnar nerves. Subsequently, mechanical allodynia developed in the areas of the paw innervated by the median nerve. This was associated with a significant decrease in grip strength and Print Area. From week 6, mechanical allodynia increased in the median nerve innervated territory, which was associated with regeneration of grip strength and Print Area. Mechanical allodynia persisted in all areas of the forepaws until week 12. The results of the functional tests correlated significantly and revealed a marked effect of nerve reconstruction on functional outcome.

Conclusion Collateral sprouting of uninjured nerves and regeneration of the injured nerve contribute differently to sensory reinnervation after nerve injury. The use of functional tests to evaluate motor and sensory recovery provides profound insights into the interaction of these processes and adds to the understanding of the development and maintenance of neuropathic pain.

Introduction- Locally advanced breast cancer(LABC) is heterogeneous ranging from local involvement of skin to peau-d'orange, and/or extensive lymphadenopathy. In India, 40% present as LABC. Neoadjuvant chemotherapy (NACT) is standard but 10-15% don't respond. Surgery necessitates extensive resection and reconstructions. The reconstruction of extended breast skin defects resulting from complex-mastectomies (multiple procedures) can pose a surgical challenge for reconstructive plastic surgeons. Herein, we present our institution's experience in tackling such extremely complex post-mastectomy defects. We evaluated their long-term outcomes. Methods- A prospective series of non-metastatic BC patients who underwent large resection and reconstruction between 2016-2021 was retrospectively assessed. Results- Of 63, 44 were LABCs, 6 oligo-metastatic, 10 local recurrences and 3 oligo-recurrences. Median age was 45 years. All had cT,cN2-3 disease. Standard NACT was administered in 56 (88.8%), 1 received endocrine therapy. Of these, 41% progressed, 42% had partial response and 16% stable disease. Six patients were operated first for ulcero-proliferative disease. Median clinical and pathological tumor size was 10cm(1-20cm) and 7.2 cm(0-20cm) respectively. 43% were TN, 35% HR+ and 22% HER2+. Reconstruction method was LDflap-29, FALT-26 and free-TRAM/DIEP-8. Morbidity was seen in 9/63(14.2%) patients. At median 18 months, 43(68.3%) recurred-5, 26 and 12 local, distant and both respectively. Free flaps [anterolateral thigh flap (ALT) variants, deep inferior epigastric perforator flap (DIEP) and tensor fascia lata flap (TFL)] were used in 34 patients whereas pedicle-flap based reconstruction [latissimus dorsi flap (LDF) and vertical rectus abdominis muscle (VRAM) flap] were performed in 29 patients. The following ALT variants were used for reconstruction: ALT only (n=19), ALT+TFL (n=4), ALT+ vastus lateralis (VL), (n=4) and ALT+ anteromedial thigh (n=1). The mean longitudinal and transverse dimensions of the included flaps were 23.211 ± 7.197 cm and 8 cm [IQR, 12-15] respectively. The mean flap area was 162.5 cm2 [IQR, 258.2 - 445.2]. The overall complication rate in this cohort was 25.6%. Hemoglobin (p= 0.002) and albumin (p=0.005) levels were associated with increased incidence of flap excision and debridement. On Cox-regression, TN-status(HR-2.44,1.02-5.8,0.043) and non-receipt of post-operative radiation therapy(HR- 2.68,1.28- 5.58,0.008) predicted recurrence. 20/63 progressed before radiation. Time-to-recurrence was 5 and 9.8 months for locoregional and distant metastases. The DFS and OS at 3 and 5 years was 26.4% (25.07-39.73) and 38.6% (23.9-53.3) and 21.1% (19.69-35.21) and 35.4% (20.7-50.1) respectively. Conclusion- Curative resection with negative margin is desired in non-metastatic breast cancers, caution is needed in those who progress on chemotherapy and need large resection and reconstruction. Surgery needs to be backed by post-operative radiotherapy and further systemic therapy. Oncoplastic reconstruction with a combination of free and pedicled flaps are feasible options for reconstruction of extended breast skin defects resulting from multiple mastectomy procedures.

Introduction: In recent years there has been an upsurge in pre-pectoral immediate implant based reconstructions, necessitating the use of a larger ADM for implant coverage (1). Former studies found a potential increase in rates of infection, flap necrosis and seroma in breast reconstructions using ADM (2). Yet, to the best of our knowledge, there is no data showing whether this increase is explained by the body's reaction to the mere presence of ADM or its size. This study aimed to examine the potential correlation between the size of ADM used and the incidence of postoperative complications.

Methods: A retrospective, single center analysis of 229 women (297 breasts) undergoing immediate breast reconstruction with human acellular dermal matrix. Breast reconstructions were stratified into two cohorts: Small ADM - those using an ADM smaller than 130 cm² (n=91) and Large ADM - those using an ADM larger than 130 cm² (n=206). Data regarding demographics, co-morbidities, surgery and outcomes were collected and analyzed. Seroma was assessed by time to drain removal.

Results: The Small ADM cohort had a significantly lower resection weight compared to the Large ADM cohort (mean= 401, 627 grams, respectively), lower BMI (mean= 23.4,26.94 kg\m², respectively) and more neo-adjuvant chemotherapy (37.4%,23.3%, respectively). There were also significantly more subpectoral reconstructions in this cohort (67%). There was no statistically significant difference among the cohorts in time to drain removal (mean= 13.34, 14.09 days, respectively). Logistic regression demonstrated a trend towards an increase in infection rate in the Large ADM cohort (OR = 5.40, p-value=0.06). Infection rate was significantly higher in patients with a larger resection weight (OR = 1.001) and reconstructions using macro-textured implants (OR = 20.53). There was no significant difference in other major complications (12.1% in the Small ADM cohort VS 21.8%).

Conclusions: The incidence rates of seroma and other major complications were not significantly affected by ADM size used in breast reconstructions. Although results showed a larger ADM size may be associated with an increase in infection rate, they were not significant. The findings of this study suggest that the potential increase in rates of postoperative complications previously seen is rooted in the presence of ADM and is not affected by its size. This provides additional evidence maintaining the efficacy and safety of ADM use in pre-pectoral breast reconstructions.

References:

(1) Ostapenko E, Nixdorf L, Devyatko Y, Exner R, Wimmer K, Fitzal F. Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction: A Systemic Review and Meta-analysis. Ann Surg Oncol. 2023 Jan;30(1):126-136. doi: 10.1245/s10434-022-12567-0. Epub 2022 Oct 16. PMID: 36245049; PMCID: PMC9726796.

(2) Chun YS, Verma K, Rosen H, Lipsitz S, Morris D, Kenney P, Eriksson E. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg. 2010 Feb;125(2):429-436. doi: 10.1097/PRS.0b013e3181c82d90. PMID: 20124828.

Objective: Lymphedema is a debilitating progressive condition owing to the accompanying cellulitis and angiosarcoma, which suggests lymphedema associated immune dysfunction. However, the immune status of peripheral T cells during lymphedema remains poorly understood. Hence, we investigated the circulating T cells in patients with lymphedema, post-LVA and healthy controls (HCs).

Methods: Peripheral blood samples from 21 patients with secondary lymphedema before LVA and 12 months post-LVA and 20 HCs were collected. We assessed the results of LVA as the extremity lymphedema (EL) index. In this study, we investigated the profiles of immune checkpoint molecules (PD-1, Tim3) in T cell subsets and comprehensive T cell receptor (TCR) analysis with calculating TCR repertoire as the diversity index (Simpson's index). Furthermore, we collected lymphatic fluid from two patients (primary lymphedema and lymphatic leakage from thoracic duct after hepatic cancer surgery) and analyzed T cell profiles and TCR repertoire.

Results: The EL index decreased in p-LVA compared to that in lymphedema, with a mean of 244 and 263 (p < 0.05). The PD-1+ and PD-1+Tim3+ expression assays on CD4+ T cells (%) showed significant upregulation in lymphedema compared to that in HCs; 33.2 and 19.8 (p < 0.01) and 1.1 and 0.5 (p = 0.04), respectively. However, the PD-1+ and PD-1+Tim3+ expression on CD4+ T cells in post-LVA were 27.7 and 1.1, respectively, which significantly decreased compared to that in lymphedema (p < 0.001 and p < 0.01, respectively). The Simpson's index was 72.7 and 202.8 (p < 0.05), which decreased in lymphedema compared to that in HCs; however, Simpson's index in post-LVA increased to 261.8 (compared with lymphedema; p = 0.05). The Simpson's index of lymphatic fluid was 9 and 1216 and blood was 386 and 237, respectively. The shared TCR percentage between lymphatic fluid and blood was 7 %.

Conclusions: Previously, the immune checkpoint molecules upregulation and TCR repertoire downregulation indicate immune dysfunction. In this study, immune checkpoint was downregulated and TCR repertoire was upregulated during post LVA. The observations suggest the distinct immunosuppressive status of patients with lymphedema and status relief through LVA, which might be related to the reduction from the accompanying cellulitis and angiosarcoma through LVA. The shared TCR between lymphatic fluid and blood was small part of itself. This study suggested the presence of specific T cell flowing to lymphatic channels and the flow is obstructed in patients with lymphedema. This study highlighted the peripheral T cells in lymphedema and new value of LVA additionally the effect of downsizing of edema.

Aesthetic medical treatment has gained popularity in recent times. This growth in demand is expected to continue. In view of the demand and the potential financial gains, a lot of non-medically trained personnel are venturing into this field. The demarcation between procedures that can be performed by medical and non-medical practitioners or even amongst medical practitioners are beginning to be blurred. The cost to the public of non-qualified, untrained practitioners performing aesthetic procedures can be catastrophic.

In view of this, the Ministry of Health Malaysia together with various stakeholders embarked on formulating and implementing a formal guideline and credentialing process for aesthetic medical practitioners in the country. This is a step to regulate the aesthetic medical industry to ensure Malaysians seeking aesthetic treatment will obtain the correct treatment, done in a safe facility and performed by a qualified medical practitioner.

Here, we will share our experience in formulating the guidelines and its implementation thus far.

Objectives: We use superomedial pedicle technique at our centre and propose deep lateral pillar suture to narrow the breast and achieve good projection and not to leave extra skin inferiorly to avoid bottoming out. Using diluted LA infiltration reduces the bleeding and thus reduces operative time and overall complication rates.

Introduction: Symptomatic enlarged breasts are both a physical and mental debilitating condition for the young female. Common physical symptoms associated with this condition are bra strap marks, skin rash and neck/shoulder/back pain. Breast reduction surgery offer relief to these symptoms and also significantly improves the self-esteem and reduces the emotional stress. Several breast reduction techniques have been described; commonly used ones are inferior pedicle and superomedial pedicle technique.

Materials / method: The aim of the study was to review all breast reductions carried out between March 2018 to March 2023. All cases are performed under GA combined with diluted LA infiltration at the incision line and in the breast parenchyma. We use superomedial pedicle technique at our centre and propose deep lateral pillar suture to narrow the breast and achieve good projection and not to leave extra skin inferiorly to avoid bottoming out.

Results: 500 cases were performed at the ASC as a day case procedure from March 2018 to March 2023. The mean age was 39 years. 488 cases had superomedial pedicle with wise pattern reduction and 12 patients needed breast amputation with free nipple areola graft. The mean weight of reduction was 650 gm per breast and largest reduction was 4kg for each breast. The surgery time ranged from 25-60 min. The follow up period ranged from 6-24 months. Most patients were satisfied with the outcome. 12 cases has post operative hematoma requiring evacuation. 14 % of cases had some minor suture line delayed healing / breakdown.

Conclusion: Breast reduction is a safe day case procedure with minimal complications and aesthetically pleasing outcome. Using diluted LA infiltration reduces the bleeding and thus reduces operative time and overall complication rates.

Background and objective. The viability of the nipple areola com- plex is a vitally important aspect in breast surgery. In previous studies, with the use of 3D mammography, we presented that the revasculariza- tion of the NIC after mastopexy is not ad-integrum and that there are dif- ferent vascular patterns in some patients after undergoing breast surgery. There are methods to evaluate tissue circulation, not only before surgery, but also during the intraoperative period, such as: colorimetry, indocya- nine green, and thermography. Our objective is to present the use of thermography as a predictor of vascular compromise of the nipple-areola complexNIC during mas- topexy. Methods. A prospective and observational study was carried out in 37 patients (74 breasts) who underwent mastopexies. Temperature was obtained using the Flir one pro® model 435-0004-03 portable thermal camera for smartphones (Apple® smartphone,I-phone12 version 16.1.1, evaluating temperature differentials in 3 stages of breast surgery: initial, intermediate and final. Results. The average temperature between initial and final in patients with clinical signs of vascular compromise of the nipple-areola complex was greater than 4 degrees. Rest of patients, with nipple-areola complex without clinical signs of blood flow changes, a differential between the initial and final temperature of <3.1 degrees was found. Conclusions. In our experience, thermography can serve as a predictive tool of vascular compromise of the nipple-areola complex during breast surgery.