IPRAS Journal, 1st Issue, July 2010 by Zita

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IPRAS JOURNAL

Aims and Scope

he purpose of THE IPRAS JOURNAL is to provide a rapid reporting of things of interest to IPRAS members. This includes all members

of national societies who participate in the IPRAS organization. Because of the broad umbrella of IPRAS this includes matters of interest across a broad spectrum of sub-specialties including burn surgery, microscopic and reconstruction surgery, hand surgery, craniofacial surgery, and aesthetic surgery. In many instances it will include matters of interest to all specialties of plastic surgery combined. Matters of interest include, but are not limited to surgical techniques, patient care, patient safety, recognition and treatment of complications of surgery, humanitarian contributions, and schedules of pending meetings. Authors are encouraged to submit manuscripts for publication which will be evaluated by a peer review process. Letters to the Editor are encouraged and will be published if deemed contributory to the aims and scope of the Journal.

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I IPPRRAASS J JOOUURRNNAALL

General Secretary’s Message

Dear colleagues, with great enthusiasm we introduce the first issue of the IPRAS Journal to you: it is the expression of an atmosphere of awakening, of new chances, new visions. A reliable cooperation within the Board of Directors and the Executive Committee has stood the test of time since 2007, but in the beginning of 2010 we experienced a remarkable reinforcement: a dedicated enthusiastic young and yet experienced team under the leadership of Zacharias Kaplanidis, our new Executive Director, joined us. Together we opened new doors, crossed borders, expanded our humanitarian activities, developed visions. New concepts for congresses were developped, new cooperation partners found: together with the European Society of Prevention, Regeneration and Anti-Aging Medicine under the leadership of Professor Christos Zouboulis we designed an interdisciplinary holistic format for our congresses that will open our eyes for the achievements of other specialities, - insights that will result in benefits for our patients. The reaction of our colleagues, who we invited to join us on the faculties of this year’s events, was overwhelming: famous plastic surgeons from all over the world will join us in Bratislava for the IQUAM Consensus Conference. And CEN, the European Committee for Normalisation, will hold its first conference on European Standards in Aesthetic Surgery together with us in Bratislava. The Panafrican Section Congress in Nairobi and the Panarab Association Congress in Doha also will offer a unique scientific program. Besides the titles of the invited lectures we have received so many excellent abstracts, an impressive demonstration of the research activities going on in plastic surgery throughout the world. And when we were in search for a communication manager again we were fortunate: Tom Biggs, a unique ambassador of plastic surgery, a true cosmopolitan and citizen of the world, joined us to become the editor of our new journal - the IPRAS Journal. Four times a year it will inform you about our activities, new developments, striking news, but also about benefits of membership, new chances for cooperation and demonstration of solidarity. But this Journal is not meant to be a one way communication instrument from us to you. We want all of you to develop it to blossom. As Verena Kast, the Past President of the International Association of Analytical Psychology says: “It is possible to create new values: we can transform the current culture of dominance, in which it seems to be valuable to dominate or suppress others into a culture of relations, in which it is valuable to solve problems together in a better way and to experience joy together. Good self-esteem then does not result from feeling superior to others but from the joy of creating something together.” Cordially yours Marita Eisenmann-Klein Prof.h.c. Dr.med. Dr.h.c. General Secretary International Confederation for Plastic Reconstructive and Aesthetic Surgery Direktorin der Klinik für Plastische und Ästhetische, Hand- und Wiederherstellungschirurgie Caritas-Krankenhaus St.Josef, Regensburg, Germany phone +49-941-782-3111, fax +49-941-782-3115

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II P PR RA AS S JJ O OU UR RN NA AL L

Editor-in-Chief’s Message

EDITORIAL

Welcome to the IPRAS JOURNAL. This is a periodical that will serve to bring you closer together in the wide world of plastic surgery. Our field is broad and varied, but we all have one thing in common: We’re dedicated to excellence, progress, and the well being of our patients. It is our desire to present to you a vital piece of communication on a regular basis so as to allow us all to focus more acutely on these goals. Our plan is multi-faceted. Our intention is to have the journal a review of previous meetings, both active and endorsed, and a summary of future meetings on our calendar. We’ll have a report from our Executive Director, Zacharias Kaplanidis. Also you will have regular updates about Humanitarian mission from Constance Neuhan-Lorenz, Cristian Echinard, Nelson Piccolo, Jan Poell and other humanitarian team members. Of course regular editorials from our Secretary General, Marita Eisenmann Klein. To be in continuous support of up to date scientific positions we’ll have at least one article per issue on an item of current interest written by a prominent member in that field. As we progress we’ll have a larger and larger collection of pertinent articles, accepted after undergoing a thorough review process by peers. Instructions to authors as to the process of manuscript creation and submission will be posted on the IPRAS website Each issue will have an interview with a “Pioneer” in a new and emerging pursuit in our specialty. Knowing that our Founders set up the organization to encompass the pillars of our specialty, Reconstructive Microsurgery, Hand, Burn, Aesthetic Plastic and Craniofacial Surgery, the planned interviews will incorporate all these interests, as well as some cross over pursuits such as IQUAM. Understanding that the future of any organization lies in the hands of its younger members our plan is also to feature a piece in each issue our “Star on the Horizon” about one of ours in the younger age group. We’ll feature a Safety and Warning section alerting members of recent items worthy of caution. Knowing full well the rapidity of change in all areas of endeavor we’ll work with the Website Committee to promote an interactive arena where members can go for comments or advice. Lastly, we want the IPRAS JOURNAL to be user friendly and rapid in its response to events of interest. We’ll strongly support a Letters to the Editor section and the Editor will respond when called upon. Your Editor-In-Chief is tremendously pleased, honored, and excited to be part of what is bound to be a significant arm in this revived body of this largest and to be most significant organization of plastic surgery in the world. Welcome to the IPRAS JOURNAL.

Dr Thomas Biggs Editor in Chief’s

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II P PR RA AS S M MA AN NA AG GE EM ME EN NT T O OF FF F II C CE E R RE EP PO OR RT T

IPRAS Management Office Report 01 January -31 June 2010

Dear Members, From the first of January that we started working for IPRAS we are really enthusiastic and full of energy in order to achieve the goals of this year. Many honorable plastic surgeons are involved in IPRAS and serve its mission. But our goal for this year is all the members of IPRAS to get involved and be an active member of this Global Confederation. We want to welcome the new editor of the IPRAS Journal who as you all have noticed from this first journal is the amazing and always full of energy Tom Biggs.

friendship among plastic surgeons and physicians of all countries all over the world. Particularly, the construction of the new IPRAS website satisfies the demands of this interaction with IPRAS members in the following ways: First of all every plastic surgeon has the opportunity to upload his/her profile, contact details, specialty as well as a link to his/her personal website on IPRAS website. A particular procedure has to be followed. We have sent to all of you the instructions. However, you may find all the instructions by visiting the IPRAS website (www.ipras.org).

Welcome Tom!

In that way the plastic surgeons can promote themselves through every patient who will visit the Every three months our visitors find a new issue of the IPRAS website. Every plastic surgeon profile may be IPRAS Journal. Our first priority is the continuous found by search through country and Specialty. One communication with our members in order to update important notice is that the IPRAS website soon will them with the latest news about IPRAS, to inform get approximately 2.000.000 visitors them about the latest innovations in the Our goal annually. This is an opportunity that field of plastic surgery or even to spread all of you have to take into serious for this year serious alarms like the P.I.P. alarm consideration. without delay. is all the members Till now we have collected the mailing list of 60 associations in order to achieve this target. So, for those, who have not yet sent the mailing list of their members, be so kind and help us to accomplish a more efficient communication.

of IPRAS to get involved and be an active member of this Global Confederation

This means that we would like to achieve a constant and a direct interaction with IPRAS members. National Delegates as well as the individual members of every association are able from now on to be active members and promote the art and science of plastic surgery, to encourage education and research (especially in sections of IPRAS which need support like Pan African Section), and to encourage

Furthermore the new IPRAS website gives the opportunity to its members through the “forum” to exchange ideas, thoughts and experiences. So don’t hesitate to use the multifunctional and multipurpose IPRAS website!!

You may also download the guidelines for the Associations who are interested in sending their bids for IPRAS world congresses. Every Association can find a fully updated list of logistics and criteria that every country must have in order to proceed to bid for a world congress. An important notice has to be underlined. The last day for accepting the bids of 2017

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IPRAS World Congress is on 24th of September. Regarding 2010 budget the Management Office, in cooperation with the General Secretary Marita Eisenmann-Klein and our Treasurer Bruce Cunningham, elaborated and issued a realistic budget. New ways to increase IPRAS income have been found such us companies advertising through IPRAS website, income from the future events. We are quite confident that IPRAS will succeed in increasing its annual income as well as its activities.

Furthermore IPRAS in order to promote plastic surgery specialty in Africa as well as in Arab Countries the General Secretary travelled Egypt, Qatar, Nairobi and Kuwait in order to promote together with the IPRAS mission, the aim of both congresses (Pan African congress in Plastic and Reconstructive Surgery and 12th Conference of Pan Arab Association of Plastic Reconstructive and Burn Surgery). Another conference with a significant importance will take place in Bratislava. The “9th IQUAM consensus conference” will take place in parallel with the “CEN meeting” in

Promotion of IPRAS and its mission has been performed by the General Secretary Marita Eisenmann-Klein all over the world. She participated in congresses in:

order to declare a general consensus regarding safety rules towards plastic surgery procedures.

• Egypt, Sharm el Sheikh, 17 - 20 February 2010, National Congress of the Egyptian Society of Plastic Surgery

20 Biennial Congress of ISAPS in San Francisco, 9th IQUAM Consensus Conference Bratislava, Annual ASPS Congress in Toronto, International Congress of Plastic, Aesthetic Surgery and Cosmetology of Georgia, along with the Third Congress of Plastic Surgeons of Armenia, Panafrican Section Congress in Nairobi, Congress of OSSC in Tokyo, Congress of the Korean Society of Plastic and Reconstructive Surgeons in Seoul, Congress of the Brazilian Society of Plastic Surgery in Vitoria, Congress of the Panarab Association of Plastic Surgery in Doha. In conclusion we would like to thank you for your cooperation with the Management Office. We are always at your disposal for any kind of productive collaboration. Please don’t hesitate to send us your comments. Proud to be an IPRAS member!!

• Brazil, Goania, Goias 10-13 March 2010, Jornada Centro Oeste de Cirurgia Plastica • China, Shanghai 14-18 April 2010, First ChineseGerman Plastic Surgery Conference • Beijing, 17-18 April 2010, 1st China Medical Women’s Congress • Uzbekistan, Tashkent, 12-14 May 2010, 2nd International Central Asian Conference of Plastic Surgery • United Kingdom, Manchester, 27-29 May 2010, Annual meeting of EURAPS • Panama, Panama City, 1-4 June 2010, XVIII Ibero Latin American Congress of Plastic and Reconstructive Surgery • Turkey, Istanbul, 21-25 June 2010, International Society of Burn Injuries • Russia, St. Petersburg, 24-26 June 2010, International Plastic Reconstructive and Aesthetic Surgery Congress dedicated to the 200 Anniversary of N.I.PIROGOV 6

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The General Secretary will attend the following congresses later this year:

Zacharias Kaplanidis IPRAS Executive Director IPRAS Management Office Zita Congress Tel: +30 2111001770 - Fax: +30 2106642116 e-mail: zacharias.kaplanidis@iprasmanagement.com URL: www.ipras.org Don't forget to visit the new IPRAS website!!!

IN LOVING MEMORY

Obituary Robert M. Goldwyn Plastic surgery has lost a giant. Robert M. Goldwyn passed away. Robert M. Goldwyn has been my hero since the early days of my residency: unforgotten his editorials in Plastic and Reconstructive Surgery, - full of wisdom, a unique sense of humour and a modesty, that reflected his greatness. His book on â&#x20AC;&#x153;The Patient and the Plastic Surgeonâ&#x20AC;? is a perfect example of his outstanding talent to take a patient by the hand and guide him or her through the treatment. Working with Albert Schweitzer made him one of the first promoters of humanitarian responsibility in plastic surgery. Whatever he did he did it with love, - for his patients, his colleagues, his trainees and last but not least for his wonderful family. Robert M. Goldwyn was our editorialist and the first Hinderer Lecturer of IPRAS in 2007 in Berlin. Those who listened to him realized: he is one of the greatest we ever had in plastic surgery. Bob Goldwyn will be forever in our hearts. Marita Eisenmann-Klein

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HONORARY AWARD

Honorary Award Robert M. Goldwyn, M.D.

Dr. Goldwyn was born in Worcester, Massachusetts in 1930. He attended Worcester Academy, Harvard College (A.B. 1952) and Harvard Medical School (M.D., 1956). He did his internship and residency in general surgery at the Peter Bent Brigham Hospital in Boston from 1956 to 1961. During this time, he was the Harvey Cushing Fellow in Surgery at Brigham Hospital and Dr. Albert Schweitzer’s surgeon in Lambarene, Gabon. His plastic surgical training was at the University of Pittsburgh Medical Center from 1961 to 1963. He returned to Harvard Medical School, became Senior Surgeon at the Brigham Hospital and at the Beth Israel Hospital, where he was Chief of the Division of Plastic Surgery from 1972-1996. Since 1979, he has been the Editor of Plastic and Reconstructive Surgery and has authored or o-authored more than 300 articles and has edited several books: The Unfavorable Result in Plastic Surgery: Avoidance and Treatment (now in its third edition), Reconstructive Surgery of the Breast, Long-Term Results in Plastic and Reconstructive Surgery, Reduction Mammaplasty. He has written The Patient and the Plastic Surgeon (two editions) and The Operative Note, a collection of his editorials, as well as a book for the general public -- Beyond Appearance: Reflections of a Plastic Surgeon. With J. Saxe as translator, he wrote an introduction to G. Baronio’s Degli Innesti Animali, 1804 (On Grafting in Animals) and for the first complete English translation by J. H. Thomas, a facsimile edition, of G. Tagliacozzi’s De curtorum chirurgia per insitionem, 1597, (On the Surgical Restoration of Defects by Grafting.)

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Dr. Goldwyn was President of the Massachusetts Society of Plastic Surgeons, the New England Society of Plastic Surgery, the American Association of Plastic Surgeons, which made him an Honorary Fellow, and the Harvard Medical Alumni Association. In 1972, he founded the National Archives of Plastic Surgery, housed at Harvard Medical School and has since served as Chairman of the Archives Committee of the Plastic Surgery Educational Foundation. He was a founding member of Physicians for Social Responsibility and has written articles on world peace, opposition to chemical and biological warfare and on medical ethics. He has been Visiting Professor to more than 70 institutions, universities and hospitals in this country and abroad and is an honorary member of more than a dozen national and international societies of plastic surgery. His other awards include the Diffenbach Medal, the Honorary Kazanjian Lectureship, Clinician of the Year of the American Association of Plastic Surgeons, the Special Achievement Award and the Presidential Citation of the American Society of Plastic Surgeons. He has also received recognition for his teaching and writing. In 2007 he was the first Hiderer lectures of IPRAS.

SURVEY REPORT

Personal recollections of a life dedicated to plastic surgery

ike most surgeons of my generation, it was difficult to learn plastic surgery in a single department. In fact, in Brazil this medical specialty did not even exist. Therefore, I endeavored on a long journey through numerous centers in the U.S.A. and Europe, which would last the better part of the 1950´s. I was granted a scholarship by the Institute of International Education and was privileged to be a resident in the surgery department at Bethesda Hospital, Cincinnati, Ohio, under the supervision of Prof. John Longacre. A rotation to several other services led me to the Mayo Clinic in Rochester, New York and to Dr. John Marquis Converse. In Europe, I visited with Dr. Paul Tessier who was then fully occupied with the creation of the specialty of craniofacial surgery. Dr. Marc Iselin took me in as an “assistant étranger” at the Hôpital Americain in Paris, where I was taught the finer details of hand surgery. My stay in France included the Maison Departamentelle de Nanterre and also the Faculté de Médicine de la Univesité de Paris, under the supervision of Prof. Aubry. In England, I was invited to be a visiting surgeon by Prof. Kilner in the Churchill Hospital, Oxford. I then stayed at the Park Prewet Hospital in Basingstoke, under the supervision of Prof. Harold Gillies. Finally, Sir Archibold MacIndoe was very kind to accept me as an observer at the Queen Victoria Hospital, in East Grinstead. This extensive learning experience also included the acquaintance of the following surgeons: Prof. Rangell in Stockholm, Sweden; Dr. Schmidt, in Stuttgart, Germany; Drs. Tubiana and Morel-Fatio in Paris; and Dr. Malbec, in Buenos Aires, Argentina. Once I returned to Brazil I founded the first Service in Hand Surgery in Latin America, at the Santa Casa General Hospital of Rio de Janeiro (a charity institution founded over four hundred years ago by the Portuguese missionaries). I also became head of the Department of Burn Injuries and Trauma Surgery. However, I soon realized that it was difficult to practice what I had learned, because surgeons at that time did not give the necessary importance to plastic surgery. To

further the cause of this nascent specialty, I decided to become involved in the training of young surgeons. Here are a few of my recollections that guided my first steps: Sir Harold Gillies emphasized the importance of commitment to research. He stated that “research is the result of observation. The more one observes, the more one accumulates experience and improvement. From then on, one has the chance of finding ‘the key’, which is an original technique that will help minimize difficulties and will bring solutions to even the hardest cases. Other than that, there are no miracles!”. Marc Iselin showed me the French spirit, the Cartesian side of life and the curiosity without limits. McIndoe was an outstanding surgeon, and taught me his knowledge and the technique of aesthetic surgery. Kilner showed me how to operate on cleft lips and other types of congenital deformities. Looking back on these giants of plastic surgery, I can affirm that the progress of humanity only occurs when the ones that follow us are capable of improving our results. To teach has been my perennial mission since those early days. The practice and teaching of plastic surgery became a reality in 1959 when, together with a close group of collaborators, we founded the 8th Ward, later to be called the 38th Ward, of the Santa Casa da Misericórdia General Hospital (SCM) in Rio de Janeiro. In this charity institution, poor patients from the city, and from other states of Brazil, come to seek a remedy to their problems. There was no shortage of people of all ages bearing congenital and acquired deformities, and our difficulty was to attend to these patients within the limits of a meager institution. The opportunity to create an academic course occurred in 1960, when this public infirmary was affiliated to the Pontifical Catholic University of Rio. This was the beginning of our Post-graduation Course in Plastic Surgery. Much later,

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we would expand our academic ties with the Carlos Chagas Institute of Post-Graduate Medical Studies. Since its beginning, it has been emphasized that surgeons that train in plastic surgery should be taught that the specialty involves a broad commitment to both reconstructive and aesthetic surgery. The graduation of the first class of residents was in 1962. A tragedy of huge proportions occurred on December 17th, 1961, when a circus full of children, the Gran Circo Norteamericano, caught fire, taking the lives of more than 500 people, and leaving over 2,500 victims. This was to be the largest indoor fire ever. Together with my first team of trained residents, the burn victims received a comprehensive treatment. This event aroused the interest of the Brazilian community to the social importance of plastic surgery. In 1963, the Ivo Pitanguy Clinic was founded and was integrated to the Plastic Surgery Department of the Pontifical Catholic University. In this manner, we were able to give our residents training both in the public service as well as in the private setting. In 1964, the first extension course in Plastic Surgery, sponsored by the University of Brazil (now the Federal University of Rio de Janeiro) was held at the Clinic. This initiative served to attract the interest of the academic medical community to the many aspects of plastic surgery. The Ivo Pitanguy Study Center was then established, with the aim of aggregating the cumulative experience of the 38th Ward of SCM to the private clinic, significantly enhancing the scientific research of the post-graduate students, and thus becoming a valuable instrument for clinical research. The duration of the post-graduate course in plastic surgery is three years (1,890 hours), with full-time academic, clinical and surgical activities. This is done in a rotation system, divided in 18 blocks. External rotations (ie. in other hospitals outside SCM and the Clinic) are done for a period of two months in specialized areas of plastic surgery: reconstruction following oncological surgery (the National Institute of Cancer); microsurgery (the Hospital dos Servidores do Estado, a state hospital); pediatric plastic surgery (at the Jesus Municipal Hospital); burn care and rehabilitation (the Andaraí Hospital); craniomaxillo surgery (the Santa Cruz Hospital). This program has graduated young surgeons from all states of Brazil and more than 40 countries, and was officially approved by the Brazilian Society of Plastic Surgery in 1973 as a formal training program. Up to December 2009 our course has graduated 542 young plastic surgeons, has received 758 fellows and has hosted over 5,000 visiting surgeons from all over the world. Through my personal efforts and the collaboration of the teaching staff and residents, working in the Ivo Pitanguy Study Center, scientific papers have been regularly published in the Brazilian medical community and in foreign

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publications: • 980 articles published in Brazilian and international literature • 54 book chapters published in Brazilian and international literature • 15 books • 48 prefaces published in Brazil and other countries • 1,978 conferences in Brazil and other countries. A final contribution to the training of our specialty was the creation of the Alumni Association of Prof. Ivo Pitanguy (AExPI) in 1974, with the aim of congregating present and past residents, in regular scientific meetings and continuous exchanges. International meetings have taken our school of plastic surgery to Berlin, Athens, Casablanca and Rome. Regular events have occurred in Brazil, and have proven to be valuable to the exchange of scientific ideas and to renew old and new friendships. In my almost 50 years of experience in teaching, I have accompanied the evolution of the International Confederation of Plastic, Reconstructive and Aesthetic Surgery (IPRAS), attending each and every one of its meetings. Our goals are the same: to emphasize the importance of training in all fields of plastic surgery, in its broadest sense: aesthetic and reconstructive, following sound basic surgical principles, which are then further developed into new and innovative procedures. As a final word, I should state that the strength and the will to spread the knowledge that I have acquired has come from the interaction with my pupils and peers. The field of knowledge that we have pursued deals with human being’s most intimate desires and the never-ending quest for harmony, well-being and identification with one’s own self image. I congratulate IPRAS, its leaders and its members in pursuing our common philosophy, which is train surgeons who will be capable of practicing plastic surgery, with its diverse and multiple subspecialties, taking our experience to the world. This has been motivated by love for the human being and the sharing of knowledge, which, it is my belief, is the true meaning of the Hippocratic oath, the essence of medicine.

Ivo Pitanguy, MD Founding member I.P.R.A.S. Head-Professor of the Plastic Surgery Departments of the Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Institute of Post-Graduate Medical Studies. Member of the Brazilian Society of Plastic Surgery, the National Academy of Medicine, and the Brazilian Academy of Letters. Visiting Professor, I.S.A.P.S. FICS, FACS.

INTERVIEW: PIONEERS

Dr. Roger Khouri

Dr. Biggs: Jose Guerrerosantos and Abel Chajchir and others have been using fat grafting for years but it’s never caught on in routine clinical practice. You seem to have developed something with which you’re having significant success. Can you explain this? Dr Khouri: Well, those men were great pioneers, as is Juan Cardenas from Colombia, Gino Rigotti from Verona, Emmanuel Delay from Lyon, and Syd Coleman from New York. My particular contribution has been in high volume grafting to the breast, which is different from the face or the buttock. Dr Biggs: How is it different? Dr Khouri: The face is a highly vascularized area requiring small volumes whereas the breast is just the opposite. Dr. Biggs: I’ve heard you speak and seen remarkable long term results. How do you account for this? Dr Khouri: Think of the farmer. What does he do for a successful crop? First he has to make sure his field is large enough to accept all the seeds he wants to plant. He also plows it so as to have a recipient site suitable for the plantings to survive. He can’t just throw seeds on hard dirt or cram tight large quantities in a small plat and expect them to survive. Second, he acquires his seeds or his plantings and he does so in a fashion so as to render as little damage as possible. After that he prepares the plantings, getting rid of leaves and debris that will interfere with survival and growth of the plants. Third comes the planting. He carefully sows the seeds in a manner that is optimal for growth. He knows he has to disperse them in the plowed field, such that each seed is surrounded by good soil. Seeds trapped in clumps die instead of sprouting.

Fourth, he protects the vulnerable plants or seedlings until they’re sufficiently stable and can survive on their own. This is simply the process of a successful farmer and exactly what we do. Any deficiency along this orderly series of steps and the process will fail. Each of the four steps has to be optimized since the deficient one will be the bottleneck and cause failure. Because of this “weakest link” phenomenon, maximizing one step will not overcome the rate-limiting effect of the deficient one. Dr. Biggs: That’s a clear approach, but what do you do specifically to follow this process? Dr Khouri: For recipient site preparation I use the Brava™ system (an externally applied bra-like device that uses negative pressure to expand the breast and increase its vascularity). I get my patients to wear it for about three weeks, ten hours per day; most women get used to sleeping with it. We have absolute proof that this significantly increases the space and the vascularity into which we put the grafts. We have many pre and post Brava™ MRIs to show it. Dr. Biggs: How do you decide when the patient is ready for grafting? Dr Khouri: For cosmetic breast augmentation, I like to see the patient at least double her original breast volume and preferably triple it. Our series has shown that the single most important determinant of final long-term breast augmentation volume is the pregraft volume increase generated by expansion with a linear dose response curve and a 0.8 slope. This means that the final breast augmentation volume is usually smaller than the breast volume the patient achieves herself through Brava wear. This is important as it makes the patient responsible for her outcome. The larger she presents at the time of surgery, the larger her augmentation. Compliance is a major issue here.

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For a good expansion, the patient has to be compliant with the wear of the device and her tissues have to be compliant. Breasts pre-expanded by previous pregnancy and breast feeding will expand better than the tighter AA cup of a young nulliparous woman which in turn will expand better than the radiated mastectomy defects. Dr. Biggs: Ok, now that the recipient field is well prepared, what do you do to acquire the fat seeds for grafting? Dr Khouri: We feel it’s imperative to be as atraumatic as possible. We use a special syringe with a spring that maintains a constant vacuum suction of one-third atmosphere (250 – 300 mmHg). Others have shown that anything over one half an atmosphere damages cells. We also found that, while amply compensating for the lower vacuum force, increasing the number of holes in the cannula improves harvesting efficiency. Our preferred cannula is 12 gauge (2.7 mm), with twelve 1x2mm side holes. Dr. Biggs: What do you do to prepare the fat for grafting? Dr Khouri: I don’t use a centrifuge. Instead I use a hand operated spinner that spins at 300 RPM creating a G force 100 times lower than standard centrifuging. By preparing the fat this way we create loose slurry rather than a compacted paste and therefore we avoid injecting clumps. In order to further protect the seeds, I use a totally closed system so that the fat I suction in the spring loaded syringe goes through a valve directly into a bag that’s put into the spinner; and after spinning we drain out the sediment fluid and accumulate the fat to be injected in the bags. We graft the fat directly from these bags by connecting them to the injection syringe with a tube and a special non-clogging valve. So it’s a totally closed system throughout the entire process that is protected against room air contaminants and drying out. This way we also avoid having to constantly disconnect the cannulas, switch syringes, transfer fat from syringe to syringe, and accumulate racks on the side table. When I started fat grafting the breast five years ago the method then was inefficient and a bilateral augmentation used to take me in excess of 4-5 hours. This was prohibitive, I had to streamline the process, I therefore developed this closed system to predictably perform the procedure in less than two hours. Dr. Biggs: You’re now ready for grafting. What special techniques do you use? Dr Khouri: At this point I employ the brilliant concepts of diffuse microdroplets grafting popularized by Syd Coleman. I inject the fat while retracting a

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gently curved 15 or 25 cm long cannula connected to a 3 or 5 ml syringe. The cannula is 14 Gauge (2.4 mm) with a single side hole and essentially leaves no scar at the entrance site. That way, going through multiple puncture sites, fanning out in multiple angles and at multiple depths, I leave behind thin rows of fat that create a three-dimensional weave. Other than the gland itself I inject everywhere being careful not to inject anywhere in the same place twice. I need about 1,000 cc. of aspirate to inject 350 cc into each breast and expect a decrease over time of about 10-20 %. While it is very tempting to keep on filling the breast with more fat, it is crucial to avoid overgrafting. I gauge the amount of fat I can safely graft by the amount of space the patient has given herself through external Brava expansion at the time she walks into the operating room. Grafting beyond the capacity of the recipient leads to crowding, increases interstitial pressure and eventually leads to total graft failure. It is important to stay well below the level of increased tissue turgidity. In a well-expanded breast I can diffusely graft 400 – 500 ml of fat and keep it soft, something one could not achieve without Brava expansion. Dr. Biggs: What’s your post op regimen? Dr Khouri: It’s very simple. Many patients are done as outpatients and they go home with a small bandage to deal with the minimal oozing from the multiple injection sites, and the next day I put them back on the Brava for six weeks, though the 10 hours per day regimen is not that stringent at this stage. Rigotti has shown the necessity of this. He feels, and I agree, that this phase has massive importance not only in acting as a stent to immobilize the grafts, but also by holding the space open, acting like a multitude of tissue chambers like the ones experimentally demonstrated by Wayne Morrisson to stimulate fat growth. There’s a gentlemen’s argument going on as to what actually incorporates the eventual grafted tissue… In the traditional engraftment hypothesis, the injected live adipocytes survive by plasmatic imbibition untill they revascularize in a mechanism similar to skin graft survival. Others, including Gino Rigotti, hypothesize that all the injected fat cells die and that the endemic mesenchymal stem cells present in the injected lipoaspirate step up to their regenerative role and differentiate into new fat. While I do not have the pretense to know what is really happening, I favor the traditional engraftment hypothesis because it conforms to well-established

surgical principles. However, it is very likely that to a certain extent, both mechanisms act together in concert. Bottom line, I’m a clinician…. I know how to make a skin graft work but can’t get into the complex detailed cellular and molecular biological pathways of what really makes it work. I simply know that by conforming to the surgical principles, it works. I like to think of myself as the good farmer who empirically found a way to promote the survival of large amounts of fat while leaving the complex basic scientific elucidation to the non-farmer laboratory scientists. Not knowing the molecular mechanisms behind seed sprouting does not prevent the good farmer from having a successful crop. Dr. Biggs: The ASPS was against fat grafting to the breast. How do you deal with this? Dr Khouri: They were against it for two reasons. One was efficacy, the augmentations published by Bircoll in 1987 were modest at best, while the augmentations we can predictably achieve today with our technique are comparable to implant augmentations. Second was micro calcifications interfering with the diagnosis of cancer on mammograms. Radiologists are outspoken now as to the fact that our flaps and reduction mammoplasties also cause calcifications and that they now have the understanding and the tools to tell the difference between cancerous calcifications and fat necrosis calcifications. What makes me especially happy is I have four female radiologists in my series. Knowing the alternatives, these intelligent and wellinformed women selected fat grafting. Regarding cancer, Gino Rigotti has over 1,000 patients in his series and has seen very little cancer. He has a controlled series recently approved for publication in APS that compares two groups of patients both in a high likelihood for cancer (post op mastectomy for cancer) . He found very little difference in the grafted cohort than the non grafted. This gives us scientific support to what was before anecdotal impression. Dr. Biggs: How do you see this work affecting breast reconstruction? Dr Khouri: I’ve done hundreds of free flap breast reconstructions. In these, I take a block of tissue, divide it from its original blood supply, and reconnect the blood vessels at the recipient site. With Brava external expansion and fat grafting I have moved towards a radically new concept: tissue regeneration instead of tissue transfer.

The “holy grail” of tissue engineering is a three dimensional vascularized scaffold that can be seeded with cells. Current tissue engineering is limited to a few cells thick sheets because of our inability to provide bulkier constructs with the functional vascular network needed for their survival. Brava external expansion generates in situ a huge three-dimensional scaffold that is very well vascularized. Seeding this large three dimensional framework with fat microdroplets generates, just where it is needed, the tissue equivalent of a transferred distant flap without any incision, any foreign material, or any vascular anastomosis. The degree of patient satisfaction with this regenerative approach, is much higher than the autologous free flap. Our post mastectomy patients truly feel they have recovered the breast that they lost, it is sensate, it is like their breast has gradually grown back again… Dr. Biggs: What are the important points you’d like the reader to take home after reading this interview. Dr Khouri: I want them to know fat grafting is real and it works. It’s minimally invasive, has minimal complications, leaves no scars, and is useful all over the body. In the breast it’s aided massively by the Brava system and can be used in all forms of breast problems….augmentation, correction of deformities, and total reconstruction. It probably won’t replace the breast implant for augmentation but is especially effective in the otherwise impossible congenital deformities, in the patient with severe capsular contractures and in the post irradiation deformities. We’ve seen numerous patients relieved from constant pain and some actually having regained sensation in previously numb areas. Something we’ve not mentioned is the improvement in the donor site. Virtually all of our patients have commented on their joy at seeing improvement in their hips, thighs, and abdomens. Dr. Biggs: Do you think this is a passing fad in plastic surgery? Dr Khouri: I think fat grafting will become one of the primary tools in not only the plastic surgeon’s armamentarium but in that of all surgery. The neoangiogenesis and possibly neoneurogenesis will become a great asset in many cases…..and many lives will be made better, but isn’t that our role as physicians? Dr. Biggs: Thank you, Dr Roger Khouri.

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INTERVIEW: STARS ON THE HORIZON

Dr. Ozan Sozer

Dr. Biggs: Dr. Sozer, we’re seeing your name more and more as a speaker in various parts of the world and seeing publications by you. Tell us a little bit about your background and what you’re doing now that has attracted so much attention. Dr.Sozer: I’m originally from Turkey but came to the U.S. after medical school. I did a full general surgery training at the University of Texas in Houston, a year of microsurgery fellowship at St. Joseph’s then two years of plastic surgery also at St. Joseph’s in Houston. I returned to Turkey for two years working with Onur Erol, then emigrated permanently and began my practice in El Paso, Texas, where I work now. Initially my practice was general in nature….I covered every emergency room in the cityand did general plastic surgery with a lot of free flaps, but gradually evolved into more and more aesthetic surgery, especially body contouring. Dr. Biggs: Why was body contouring so significant ? Dr. Sozer: There was a lot of demand. The Hispamic culture is very much into aesthetic surgery. The women have early pregnancies and lose their figures. Dr. Biggs: What is it about your body contouring work that’s attracted so much attention? Dr. Sozer: I can’t answer that exactly, but I do know that as I did more and more I found that I could work efficiently and with team effort do more and more at one sitting. Dr. Biggs: What do you mean,”more and more” ? Dr. Sozer: I began doing liposuction with all my abdominoplasties. I found if I left 1.5 to 2.0 centimeters on the flap I could suction the whole flap. Dr. Biggs: Did you preserve the perforators ? Dr. Sozer: No, but I was careful to leave that fat on the flap. No superficial liposuction. I’ve done over 200 that way and have never had any necrosis. 14

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Dr. Biggs: What els do you do that’s different. Dr. Sozer: I do a breast reduction or mastopexy then an abdominoplasty along with appropriate liposuction. Then, when things were going smoothly I move to the hips and thighs. If I were doing a total body sculpting I would begin with the patient in the supine position before doing the anterior body. Working as a team, two surgeons, each with an assistant, we operate simultaneously. I also follow the teachings of Jean Francois Pascal and am careful to leave the lymphatics intact with my initial incision in abdominoplasty…. I incise in a cephalic direction. This is very important and avoids seromas. D. Biggs: Were you doing things differently with the butrtocks ? Dr. Sozer: Yes, definitely. I do a myocutaneous flap based inferioly and fold it over to give fullness to the mid portion of the buttocks. I have some drawings to demonstrate this (see drawings ). Dr. Biggs: How about the arms? Dr. Sozer: Again like Dr. Pascal, I do a complete liposuction then excise redundant skin. Dr. Biggs: And the thighs ? Dr. Sozer: I follow the teachings of Lockwood. I do a liposuction followed by skin excision, then anchor to the periosteum of the pubis. Dr. Biggs: What do you see in the future for body contouring ? Dr. Sozer: More of the same with team work creating more surgery in less time using the team approach, then add in lipografting where indicated. With the great rise in obesity I feel this is a field that can only grow. Dr. Biggs: Thank you Dr. Sozer.

SURVEY REPORT

The status of body conturing for the massive weight loss patient Joseph P. Hunstad

ody conturing for the massive weight loss patient has become an area of keen interest and innovation for plastic surgeons. In reality, it has assumed the status of a subspecialty in itself. For patients to experience the great success of massive weight loss from either self determination or bariatric surgery and yet be faced with the body sequelae of loose redundant skin, hygiene problems, and an overall disturbing appearance has created a great deal of patient derived impetus towards the creation of safe and effective methods to rejuvenate the massive weight loss patients' body. When patients experience the success with weight loss, yet are presented with their body which often resembles a melted candle, they are very disturbed and motivated to seek care to correct this. The keystone procedure for all post massive weight loss body contouring procedures is the body-lift itself. The body lift, refer to by some as a belt lipectomy or circumferential abdominoplasty, achieves a circumferential body rejuvenation that dramatically improves the contour and shape of the abdomen, flanks, and buttocks. The body lifting procedure also improves the tone and shape of the anterior thighs and when properly utilized can improve the buttocks ptosis and atrophy as well. This technique has improved dramatically since the original description by GonzalezUlloa. Instead of a panniculectomy or gross resection of tissues, attention to detail and focus to achieve the maximum aesthetic result and contour has been implemented by many plastic surgeons who focus on post bariatric body contouring. Elements of this procedure that have enhanced the final result include a very strong myofascial plication which returns the abdominal wall musculature to a point that achieves a beautiful silhouette enhanced waistline and a flattened abdominal contour. Concurrent liposuction, when indicated, throughout the areas of residual fullness further enhances the final shape and outcome

delivering an enhanced silhouette and shape. When abdominal expansion has been significant, not only vertically but in a transverse plane, a fleur de leis type procedure also provides outstanding circumferential tightening. A common denominator to post massive weight loss body contouring is that "Patients tolerate a long scar for an excellent result." This fact has been documented and demonstrated by plastic surgeons performing these procedures globally. When patients look excellent in clothing, the underlying incisions become inconsequential. Once the foundation or keystone for all body contouring procedures following massive weight loss has been completed, the other areas need to be addressed. The treatment of the arms by extended brachioplasty which can even include the forearm, the entire arm, the axilla, and including the lateral redundancies and fullness of the chest and breast area can be safely performed to achieve a smooth even contour with delivery of markedly improved tone and shape to the arms. It is gratifying and impressive how many patients who have undergone brachioplasties feel comfortable in wearing sleeveless attire because of the shape of their arms has been so improved. The breasts often are extremely flaccid, flat, and long. Usually, with a complete weight loss patient, an implant is necessary as well as a full mastopexy. Techniques that utilize the redundant tissue, particularly in the lateral chest area and breast area for autologous breast augmentation have become increasingly popular and are desirable because the tissues rotated into the breast are well vascularized and create and autologous augmentation. Results with this procedure have been quite significant and gratifying for both the surgeon and the patient. The upper back area remains a significant challenge because of the forces that are put into play with the body lift and lower abdomen are not transmitted to

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the upper back because of the strong midline zone of adherence. The upper back lift also coined by some as the "bra-line back lift" has been highly effective in completely contouring the entire back removing the lateral folds and rolls and excising redundant skin from the inframammary fold in the anterior axillary line from one side completely across the back to the other. This technique creates a dramatic improvement with complete elimination of redundant rolls and folds providing the patient with a smooth lateral silhouette that is attractive and allows patients to wear form fitting clothing which previously was simply impossible. The inner thigh lift is usually not an adequate procedure for the massive weight loss patient. A vertical thigh lift, however, can provide a dramatic improvement in the contour of the thigh with a final incision line in the inner aspect of the thigh often going down to or even below the knee. Concurrent liposuction can be performed particularly for patients who have under experienced incomplete weight loss and this can be done in combination with a vertical resection. The vertical resection can be 'spiraled' upward as well joining the body lift incision to give further lifting and tightening of the superior anterior thigh. The thigh lift can even be extended below the knee contouring the calves as well. A notch at the level of the knee or Z-plasty is necessary to avoid a scar contracture across this joint just as one place as a similar notch or Z-plasty across the axilla or elbow when performing and extended brachioplasty. The buttocks is an important area for consideration. With the traditional body lift or circumferential abdominoplasty, all redundant tissues across the buttocks were excised and the buttocks achieved excellent elevation but frequently was noted to be somewhat flattened and atrophic. Instead of discarding this buttocks tissue, it can be deepithelialized, elevated, and rotated as a variety of flaps or sutured at the level of the superficial fascia to create a central mount, all of which add volume to the buttocks. The lower buttocks skin is an elevated and a pocket created above the gluteus muscle to accommodate this autologous tissue. This achieves a buttocks lift with simultaneous return of volume correcting atrophy and projection with lift being correcting ptosis. Finally the face, which is addressed more unusually than the other areas following massive weight loss, can occasionally be the number one focus of patients who would like to see this improved initially. All of the current methods of facial rejuvenation can be employed successfully to eliminate platysmal bands correct the laxity and fullness of the neck, tear trough, marionette

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line, strong nasolabial folds, tear troughs, and create rejuvenation with the currently available methods of forehead, eyelid, facial, and neck rejuvenation. Timing is an important question when it comes to caring for the massive weight loss patient. For those patients, who wish to undergo all the procedures for the body, breast, arms, back, and thighs, this procedure is often staged. It has been performed as a single procedure, but is somewhat controversial because the length of time is very significant, often extending for greater than 10 hours and requiring simultaneous work by a number of teams. More typically, particularly in a private esthetic practice, these procedures are staged. Most commonly, the body lifting is performed initially, which is the keystone of post massive weight loss body contouring. At a second stage, the arms, breast, and thighs can be addressed safely in a single setting. The back can be performed with the body lift or in combination with other procedures. The facial rejuvenation is usually performed as an isolated procedure because it can often involve all aspects of facial rejuvenation of the forehead, lids, face, and neck. Having performed my first body lift at 1988, I have seen an incredible evolution in post massive weight loss body contouring with wonderful contributions by thoughtful and clever plastic surgeons worldwide. Techniques are continually been conceived and advanced for our consideration to further improve patients results and safety. I apologize for any exclusion but would like to acknowledge physicians who have recently contributed to this field. Dr. Ally, Dr. Hurwitz, Dr. Rubin, Dr. Pitanguay, Dr. DeSouza Pinto, Dr. Hebel, Dr. Suldahna, Dr. Graf, Dr. Matassaro, Dr. Saves, Dr. Lockwood, Dr. Richter, Dr. Pascal and Dr. Downey. Joseph P. Hunstad M.D., F.A.C.S. TAD

SU ER S RV VE EY Y R RE EP PO OR RT T

Current Status of HA Fillers and Radiesse (next report on permanent fillers and toxins) Brian M. Kinney Introduction Fillers are becoming increasingly important to the practicing plastic surgeon. Cosmetic non-invasive, minimally invasive procedures have grown 99% from the year 200 to the year 2009 in the US according to statistics from the American Society of Plastic Surgeons in a news release of April 27, 2010 (http://www.plasticsurgery.org/ Media/Press_Releases/ASPS_Reports_Cosmetic_Plastic_ Surgery_Down_In_2009_Up_69_In_First_Decade_of_New_ Millennium_.html). Injection of botulinum toxin type A leads the way with 4.8 million procedures. While accurate statistics are not available in many countries, it is safe to say the interest has exploded worldwide. This trend predates the worldwide economic downturn that started in late 2008. In my clinical practice patients prefer to avoid surgery if possible and begin interventions at a younger age. The public acceptance of cosmetic surgery has reached 48% as reported by the American Society for Aesthetic Plastic Surgery in a March 9, 2010 press release (http://www.surgery.org/media/newsreleases/almost-half-of-americans-approve-of-cosmeticplastic-surgery-regardless-of-income). We all know this is true; now we have new data to confirm our clinical impressions.

ASPS Statistics (April 27, 2010) Botulinum toxin type A Soft tissue fillers Chemical peel Microdermabrasion Laser hair removal

4.8 million 1.7 million 1.1 million 910,000 893,000

Meanwhile cosmetic surgical procedures decreased 9 percent year over year and are down 20 percent since 2000. Breast augmentation Rhinoplasty Eyelid surgery Liposuction Abdominoplasty

289,000 256,000 203,000 198,000 115,000

The competition in the filler market has gone from active to torrid. Many plastic surgeons may simply choose a product based on advertising, price, or personal preference. Average results may be obtained by injecting any of perhaps a dozen products; however, understanding fine details is the difference between those average results and excellence in clinical outcomes, complementing our surgical results and growing our practice. Making an intelligent choice based on logical clinical analysis, patient anatomy and filler chemistry is far more difficult than it would first seem. Not only are average results “average,” but they may be obtained with a modest amount of effort. Excellent results require much more. When only a few preparations were available, the choices were not so bewildering. Now they potentially are and command our attention. While ten years ago, a few countries like Italy enjoyed the benefits of a dozen or more products, now most plastic surgeons in the world are beset by as many as several dozen choices. Hyaluronic acids (HA’s) dominate our clinical use for good reason - they really do work well, they’re similar to naturally occurring HA and are generally safe. In a brief overview, it is not possible to discuss all of them in detail. Here is a quick reference for commonly available and widely used fillers. Adverse Events Common to All Injectables Minor adverse events common to all injectables like pain, erythema, tenderness, itching, bruising and asymmetry that occur in the low single digit rate, generally less than 5%, are relatively straightforward to manage. Treatment may range from ice and makeup to a minor touchup injection 10-14 days later. Significant adverse events common to all injectables like nodule formation, hematoma and inflammatory reaction/ skin slough are much rarer, less than 1% to less than 0.1%. Treatment for nodule formation generally includes either hyaluronidase or steroid injection. Hematoma often responds to simple massage or needle aspiration. Inflammatory reaction may potentially leave a permanent scar and requires multi-modal therapy, often consisting of hylaronidase, steroid, antibiotics and rarely incision and drainage with healing by second intention. Issue 1

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Company Q-Med AB (Uppsala, Sweden) Family of Three Products

Perlane – this product is chemically identical to Restylane, but contains larger particles and only 8000 beads per ml. Generally it is injected deeper than the mid-dermis and clinically may last longer than nine months. A preparation containing lidocaine is now available.

Restylane – this is the product launched in 1996 in Europe that pioneered and popularized HA fillers. Long considered the gold standard, there are many other competitors in the marketplace today. It was approved in the US in 2003, and in China in 2009. Like all the currently available products this is a non-animal stabilized hyaluronic acid (NASHA) cross-linked with 1, 4 butanediol diglycidyl ether (BDDE), which contains 100,000 gel beads per ml, is hydrophilic and its metabolic by-products are water and carbon dioxide. Like all the HA’s Restylane’s breakdown is isovolumetric, thus it retains much of its initial volume during degradation, which takes about nine months in the nasolabial fold. Over 11 million injections have been carried out around the world. A lidocaine-containing preparation is now available in most locations.

Macrolane – this is based on Q-Med’s NASHA technology and was approved in Europe at the end of 2007, the Middle East and Asia in 2009. It is specifically marketed for body shaping where there is less tissue cover (the VRF20 preparation) and more tissue cover (the VRF30 preparation). Follow-up treatment is recommended at 9-12 months with about 50% of the initial injection volume advised. Breast injection is an exciting new application; however after several years, the cost may exceed that of breast augmentation surgery.

RESTYLANE® - INDICATIONS AND SUMMARY TABLE Product Concentration (mg/g)

Restylane (small particles) 20

Perlane (large particles) 20

Macrolane VFR20 VFR30 24

27 Superficial and mid dermis 9

27 Superficial and mid dermis 9-12

22 - 25 Subcutanoues tissue / not in the face 9-12

Cross-linking (percent) Needle (gauge) Indication Duration (months)

Company Teoxane (Geneva, Switzerland) Teosyal Family of Seven Products By precisely controlling the chemistry of their various preparations, Teoxane has created a family of HA’s for a variety of clinical indications. The cross-linking is BDDE like the Q-Med products. They have sold over 1.5 million syringes since the company’s founding (personal communication with the CEO, April 12, 2010) and clinical use is accelerating. Widely available in Europe,

clinical trials will likely begin in the US late this year or early 2011. Like other HA’s progressive absorption results in the end products water and CO2 and it can hold up to 1000 times its weight in water. With so many products it may be a bit daunting to know when and how to use each. Start with just a couple and learn them well before trying all of them on a regular basis.

GAMME TEOSYAL® - INDICATIONS AND SUMMARY TABLE TEOSYAL® Product

Meso

First Lines

Global Action

Touch Up

Deep Lines

Kiss

Ultra Deep

Concentration (mg/g)

Cross-linking

None

Needle (gauge)

Rehydration/ superficial dermis

Superficial crow’s feet/ perioral

Mid dermis/ facial wrinkles

Deep injection/ wrinkles

Deep injection/ lip contours and volume

Deep injection/ wrinkles

2-3

6-9

9-12

Indication Duration (months)

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Merz Pharmaceuticals (Frankfurt, Germany) Belotero Family of Three Products – Intense, Basic and Soft These products are described as being made with to a monophasic gel with different zones of HA chain Cohesive Polydensified Matrix (CPM) technology. The density. Satisfaction rates in the nasolabial fold were first cross-linking with BDDE creates a monophasic gel 81% at six months and 66% at nine months in a study of adjacent strands of stabilized HA. The second crossof 114 subjects published in July 2008. linking step is also carried out with BDDE and leads

BELETERO® - INDICATIONS AND SUMMARY TABLE BELETORO® Product

Soft

Basic

Intense

Concentration (mg/g)

22.5

25.5

Cross-linking

Needle (gauge)

Superficial dermis

Mid dermis

Deep dermis

3-6

6-9

Indication Duration (months)

Allergan (Irvine, California, USA) Juvederm Family of Products This is the only HA product cleared by the FDA for a 1-year duration. The formulation has a smooth consistency, high concentration and high degree of

cross-linking. In addition, it has gained great market share in the US in a short time due to high physician and patient acceptance.

JUVEDERM® - INDICATIONS AND SUMMARY TABLE JUVEDERM® Product

Ultra

Ultra Plus

Concentration (mg/g)

XC (lidocaine .3%) Ultra and Ultra Plus 24

Cross-linking

6 and 8%

Needle (gauge)

Superficial and mid dermis

9-12

9-12/ 12

Indication Duration (months)

Mentor (Santa Barbara, California, USA) Prevelle Family of Products This is the newest family of products on the market with only the Silk variety available in the US. Prevelle Shape (Puragen) was approved in the EU in 2006, while Lift was approved in the EU in the fall of 2009 and is just beginning to reach clinical practice now. The particle size is much smaller and allows for a

lower extrusion force (ease of injection) and smoother contours. While not studied in the tear trough during formal clinical trials, early clinical reports have been favorable. Prevelle Lift is unusual for an HA in that it has a very high G’ (modulus of elasticity) making it very firm like Radiesse.

PREVELLE® - INDICATIONS AND SUMMARY TABLE PREVELLE® Product

Silk

Shape (Puragen)

Lift

Consistency

Soft

Moderate

Firm

Concentration (mg/g)

5.5

Cross-linking (percent)

3 (double cross-linked)

Needle (gauge)

Superficial and mid dermis

4–6

Indication Duration (months)

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Calcium Hydroxyl Apatite in a Glycerin, Carboxy Methylcellulose Gel Carrier Bioform (San Mateo, California, USA) Radiesse This injectable is unique compared to the HA products as it contains calcium hydroxyl apatite in a carboxy methylcellulose gel carrier. Studied since the early 1990’s

and used since 1996 in urinary incontinence, it received FDA approval in the US for subdermal implantation in facial wrinkles and folds in December 2006.

RADIESSE® - INDICATIONS AND SUMMARY TABLE RADIESSE®

Radiesse

Consistency

Firm

Concentration (mg/g)

300

Product (percent)

30% Ca HA 70% Gel

Needle (gauge) Indication

25 - 27 Mid and deep dermis

Duration (months)

12 – 24

Summary While all the fillers may produce aesthetically pleasing results, it may not be possible to achieve clinical expertise in them all. Pick a few of them and learn them well. Understand their chemical characteristics, their handling properties and how patients respond to them. Be aware of complications and follow patients

just as carefully as after any surgical procedure. Patient satisfaction rates are extremely high, the risk to benefit ratio is great and they add a significant capability to your clinical practice as patients shift towards earlier, more subtle intervention and natural, less noticeable results.

Next issue update toxins and permanent fillers Contura (Soeborg, Denmark)

Allergan (Irvine, California, USA)

Aquamid – this is a soft tissue volume filler, nonabsorbable hydrogel containing 97.5% water and 2.5% cross-linked polyacrylamide. It does not degrade over time, becomes fully incorporated into the tissue and stimulates a connective tissue reaction. Results will last for years, whether aesthetically pleasing or not. A five-year study indicated high satisfaction and it received a CE Mark in 2001 for facial augmentation. It is currently being studied in the US.

Botox toxin A

Suneva (San Diego, California, USA) Artefill – this is a polymethylmethacrylate fillers consisting of microfine beads in a carboxymethylcellulose carrier gel.

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Merz (Frankfurt, Germany) Xeomin toxin A

Ipsen Company (Paris, France) (UK subsidiary) Product Dysport toxin A

Mentor (Santa Barbara, California, UA) Purtox toxin A Brian M. Kinney, MD, FACS, MSME Clinical Assistant Profecor of Plastc Surgery USC Scool of Medicine Los Angeles, CA USA Parlimentarial, Board of Directors, IPRAS

SURVEY REPORT PLASTIC AND RECONSTRUCTIVE SURGERY, October Supplement 2004

It’s Not How You Say It But What You Say Robert M. Goldwyn

Two recent comments in the media that I should have forgotten have stayed with me. The first was calculated gibberish from a government official speaking about the schedule of airlines at the beginning of this year in response to fears of Y2K mishaps: “There will be no delays, although there will certainly be slowdowns.” The second comment was from the surgeon who did an emergency quintuple bypass on television host David Letterman: “Dave has the heart muscle of a 22-year-old man.” I hope that Mr. Letterman, age 52, was duly encouraged. Telling the truth is not always easy, for several reasons. The first reason is that one may not know it. The second is that one may not want to say it. The third is that the listener may not want to hear it. If we do know the truth and are reluctant to voice it, then we devise ways to tell the truth the way that it almost is. For example, let us consider the situation of a 65-year-old woman presenting for a face lift. Although her anatomy is suitable, her personality is not. She is extremely hostile, demanding, unrealistic, and perfectionistic –the type who never accepts the first table offered, even in the most plush restaurant. How do you extricate yourself from being her surgeon if that is your choice? “Mrs. Killum, from a technical standpoint, you are ideal. However, you are an obviously difficult, if not inpossible, human being-too wearing on my nerves with which to have to deal.” “Mrs. Killum, you have clearly enunciated your expectations, to which you are entitled. I am just a simple plastic surgeon, one whose humble skills and ordinary hands would be inadequate for the great challenge that you have presented me.” “Mrs. Killum, my secretary, Ms. Gizzard, has just handed me our astrological printout. Your zodiac and mine are incompatible. You are a Tzoris and I am a Mitzah. The heavens would clash and disaster would ensure if we embarked on this surgical adventure. Oh, dear Lord, how could this have happened when I wanted so much to be your plastic surgeon?”, said as you put your head in your hands and begin wailing. “Mrs. Killum, scheduling at the hospital has become infinitely difficult. I do not think that I could fit you in until Y3K,” said as you begin to chuckle, then laugh violently, gasping for breath-all signs of sudden insanity. “Mrs. Killum, I specialize in Modigliani-type faces. Yours is not shaped like an almond, but more like a pecan or, from the side,

a filbert. My esteemed colleague (here name someone whose malicious remarks led to your being sued), Dr. A. Sassin, is an expert. See him, but only him. He is a very modest man, the type that at first will refuse to operate on you, but do not give up. Insist on his devil-I mean- God – given skills. “Mrs. Killum, I am terribly sorry that you came for this consultation at the end of my career. My secretary should have told you that today is my last day in practice. Although I would have enjoyed operating on you, I will have to be thankful for just the privilege of having met you. Alas!”, said with a wistful look at the diplomas that line your walls. “Mrs. Killum, although your face is not as tight as you would like, it is not as loose as it could be. Believe me, I have seen much worse. You are in what we would call the ‘Middle Period’ (here you are an amateur Egyptologist), the transition between facial maturity and facial senescence. You are certainly not in the last throes of aging. Do not rush into an operation. I would recommend strongly that you begin facial exercises – for 2 years at least- to set the stage for ‘the operation.’ Timing is the essence of success. Knowing the proper moment for the knife to strike requires experience. I am so glad that you came to me. The kind of advice I am giving you, you would never get from anyone else.” “Mrs. Killum, you are an excellent candidate for a face lift. I recommend it strongly. I already have discussed with you the details of the procedure, but I have not gone into complications. Unfortunately, they do occur. I have had my share- oh, have I had my share! Everything, and I mean everything, from paralysis of the nerves of the face to sudden, almost catastrophic bleeding and very, very unsightly scarring. I would not want to give the impression that these complications are common, but when they happen, it is a disaster!” You conclude by shaking your head as Mrs. Killum pushes back her chair and flees from the office. The astute reader has probably wondered why I have not mentioned another stratagem: Increasing the fee beyond even exorbitance. The problem is that Mrs. Killum might eagerly pay it. Originally published in Plastic and Reconstructive Surgery in November 2000 (Plast. Reconstr. Surg. 106: 1421,2000)

REFERENCE 1.Grenson, S.L. Letterman has quintuple bypass. The Boston Globe. January 15, 2000:A3.

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HUMANITARIAN WORK

Women for Women

…is a charity programme supported by female plastic surgeons whose goal is to help women suffering from disfiguring or socially excluding injuries and trauma, with the goal of enabling such women to continue on to lead happy and prosperous lives despite their injuries and trauma they have suffered in the past. The programme was developed by the Secretary General of IPRAS, the International Society for Plastic Reconstructive and Aesthetic Surgery, Marita Eisenmann-Klein, MD and the Chairperson of Quality Assurance of IPRAF, the International Plastic, Reconstructive and Aesthetic Surgery Foundation, Constance Neuhann-Lorenz, MD. Women for Women’s first mission was conducted 2008 in Jalandhar, followed by missions in Kulu, Palampur and Lucknow in 2009. The first mission in 2010 took us to Vijayavada, India

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Domestic Violence The United Nations General Assembly defines “violence against women” (VAW) as “any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.” Women in India often cannot escape domestic violence when they are subject to it, as they do not have the means to live alone, and their in-laws will not support them once they are married. With no means to support herself or her family, an Indian woman facing domestic abuse is stuck in a vicious cycle from which she cannot escape. There is a social stigma attached to divorce and separations, which means that women who are the subject of domestic violence will face pressure from their families not to leave their abusive spouse.

Facts and Figures In India, 35 percent of women in the age 15-49 have experienced physical or sexual violence at some point in their life. At least one in seven of married and divorced women have suffered injury as a result of spousal violence. Paying and accepting dowry has been illegal in India for 40 years but it is still rampant. Indian Government statistics show that husbands and in-laws killed nearly 7,000 women in 2001 over inadequate dowry payments. BBC article on dowry deaths Acid violence Acid violence seems to be almost unique to South Asia, with most incidents occurring in Bangladesh, India and Pakistan. Part of the reason is that acid is cheap and widely available. Many Indians use concentrated acid to sterilize their kitchens and bathrooms, as Americans would use bleach. The acid attack phenomenon is becoming increasingly common and widespread, with neither class nor caste nor creed nor any other variable serving as protective barriers, and with triggers ranging from unrequited love and marital discord (often over trivial matters) through family feuds and property disputes to enforcement of social diktats of various kinds. Local Support Through IPRAS, Women for Women is able to profit from a well functioning network of delegates in the entire world that help them with the organization and coordination of each mission on sight. Due to the worldwide Network of IPRAS, the local delegations play a crucial role in the process of selection as well as the selection criteria for the patients. The local coordinators also play a major part in helping

the foreign team of doctors to prepare for possible challenges and working conditions in the countries. How can you contribute? Your funds are used for patient care only. We are self administrators. Donate money by financing travel expenses, instruments and medication. Offer other support by fundraising. Donations to: Women for Women K.Nr. 1384181 BLZ: 70030300 IBAN: DE 8170 0303 0001 3841 8100 BIC REUCDEMMXXX Bankhaus Reuschel For detailed information on how to contribute please contact: info@womenforwomen-ipras.org How to participate We are thankful for every helping hand that wants to join our mission. If you are interested in participating, you can either: • Join the team of Doctors • Help spread the word • Give organizational support If so, please send a short letter of motivation and a CV with photo attached to info@womenforwomen-ipras.org Dr. med Constance Neuhann-Lorenz, MD Plastic Surgeon, Munich - Germany President Women For Women e-mail: dr.c.neuhann-lorenz@tonline.de dr.neuhann-lorenz@tonline.de

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SAFETY

WARNINGS

AND

CAUTIONS

Warning published by the German Federal Institute for Drugs and Medical Devices (BfArM)

Affecting Silicone gel filled breast implants produced by the French company PIP (Poly Implant Prothese) French and German Health Authorities (Afssaps and BfArM) informed IPRAS in April that the French Health Authorities found out during an inspection that most of the breast implants produced by PIP since 2001 are not filled with the specific Silicone gel which should be used for this application. Therefore these implants do not fulfill the requirements outlined in the European Medical Device Law e.g. 93/42/EWG. At present French Health Authorities investigate whether the use of this material affects the safety of these implants. Afssaps and BfArM recommend that plastic surgeons who inserted implants produced by PIP should inform their patients and should stop using these products. Patients with PIP implants should contact their plastic surgeons.

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IPRAS WEBSITE

IPRAS Compliments to Individual Plastic Surgeons

www.ipras.org Ï

ur redesigned website which can be found at www.ipras.org offers a great opportunity for the plastic surgery community to project our objectives, principles and values to a wider audience. In order to do so, we redesigned our website to be efficient, modern, unique and – free of charge. Also, we have taken into account the public’s and potential patients’ needs for more information regarding plastic surgery while it is easy to navigate. Plastic surgeons from around the world can exploit opportunities that IPRAS website offers, free of charge as they will be able to promote themselves and their work to potential patients through the information that the plastic surgeon has uploaded. The information that they can upload can be their contacts details, their scientific status their specialty and they can also provide a link to their personal website. You can register online and benefit from this free and effortless promotion of yourself. After you apply for registration your National Delegate, who has the updated list of his Association members will be able to identify you as a member. The advantages that you are able to gain by uploading your scientific status at the IPRAS website are: • Your colleagues from all over the world will have the opportunity to find your profile and your contact details on the IPRAS website • Potential patients, looking for a specialized plastic surgeon can search through “Find a doctor” section at IPRAS website by choosing country and specialty.

In that way, they will be able to find all the plastic surgeons who have uploaded their profile and have chosen their particular specialty. • By uploading your scientific status you will be able to add a link to your personal website as well as a link of the clinic that you are employd. Thus, this is an excellent opportunity to promote yourself and your clinic. • You will be recognized as an IPRAS member and you will have the acknowledgment of IPRAS. Besides of having your profile uploaded every registered plastic surgeon will have the opportunity to participate to the IPRAS forum. In this section of the site you will be able to: • Exchange views, thoughts, ideas with your colleagues as well as to chat with them on several and diverse issues. All registered plastic surgeons will be able to follow the discussion and participate on it. • Every plastic surgeon can inform about events that will be interesting for the rest of his/her colleagues. For example National Meetings. • Upload any information, innovation and development regarding plastic surgery. • Upload safety regulations etc Lastly, from IPRAS new website you will be able to find all the future events with or without the endorsement of IPRAS, all the IPRAS journals, latest news at the field of Plastic surgery from all over the world, our Humanitarian work, news from WomenForWomen and more. Support our effort and help us to make IPRAS stronger!! Issue 1

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IPRAS PAST MAJOR EVENTS

What a moment

Thomas M. Biggs “What a great moment” were the ﬁrst words said by Secretary General Marita Eisenmann-Klein when she opened the General Assembly of the 15th World Congress of International Confederation for Plastic, reconstructive, and Aesthetic Surgery in New Delhi, India, in the Ashok Hotel on 1 December, 2009. And what a moment it was. It was the ﬂowering of a reorganized, rebuilt, and newly inspired IPRAS. Under the leadership of Marita and with the support of the new Executive Committee including Bruce Cunningham as Treasurer, Brian Kinney as Parliamentarian, and Manuel Garcia-Velasco, Fu Chan Wei, and Daniel Marchac as Deputy Secretary Generals, and the management skills of Zacharias Kaplanidis and his Zita Congress S.A., IPRAS has a new face, the proper offspring of the Founding Meeting which was held in Uppsala, Sweden ,in 1955 under the leadership of Tord Skoog.

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The meeting in Delhi was preceded however by two outstanding meetings in the months prior. The first of these was the ESPRAS meeting, the European Section of IPRAS, held in Rhodes, Greece, 20-26 September under the guidance of Andreas Yiacoumettis who was elected the new President of ESPRAS. This outstanding conference brought more than 1,000 plastic surgeons and 300 accompanying people to this beautiful island and in addition to a scintillating social program included 700 free papers, 24 round tables, 35 Master Classes, and 24 Keynote Lectures. Epitomizing the broad range of excellence were many items including an outstanding lecture by Maria Siemenow on Face Transplant which brought together the union of finite facial anatomy, the science of the immune mechanism, exquisite surgical skills, and the orchestration of effective teamwork, all designed around the benefit to the patient…or…an excellent expression of plastic surgery in the 21st

Century. Added to that and the many other presentations was a “debate” between Roger Khouri and David Ross on breast reconstruction employing traditional approaches versus the newer fat grafting methods. In addition to all these the organizers set apart an entire day and created a cruise to the ancient Island of Kos, the site of the Asclepieron and the birthplace of the Hippocratic Oath. This outing included 950 participants with all the physicians renewing their oath in a dramatic ceremony. After Rhodes the Asian Pacific Section of IPRAS held their 10th International Conference in the Hyatt Regency Hotel in Tokyo from October 8-10. Under the guidance of Motohiro Nozaki, President of the Japan Society Plastic and Reconstructive Surgeons a similar sensation was created with many free papers and panels along with Invited Lectures by Ted Huang, Kiyonori Harii, Kwan-Chul Tark,Marita Eisenmann-Klein, Yu Ray Chen, and Andrew Burd. In addition there were 19 keynote Lectures. The Special Dinner included a show of fabulous classical Japanese performers who graced the audience by their presence after the show. When it came time for the Main Event in Delhi all members were ready. The Opening Ceremony was held in a beautiful, spacious auditorium, filled with the 1,000 physicians and their guests. Welcoming speeches were made by significant dignitaries including Prof. Kiran Walia, Minister of Health and Family Welfare, Suresh Gupta, President of the World Congress of IPRAS, Bahman Daver, Co-President of IPRAS 2009, G. Balakrishnan, President, Association of Plastic Surgeons of India, and of course by our Secretary General, Marita

Eisenmann-Klein. A welcoming speech that cannot be forgotten was made by Rajeev Ahuga who . by the force of his conviction, and the assurance of his personal estate, made it all happen. Without doubt one person cannot do it all alone and he was aided by a collection of hard working and dedicated colleagues, but when the years have passed and much is lost in our memories the one thing that will remain will be the magnitude of the contribution made by Rajeev Ahuja. The faculty came from around the world, presenting 669 papers and 21 Master Classes. Attendees came from 73 countries. The General assembly included the report of the outstanding Women for Women project, a unique thrust of humanitarianism, originated by Marita and Constance Neuhann-Lorenz and others. The Hinderer Lecture, given by Ian Taylor, kept us all expectant with the title: Keeping Abreast, and we were not disappointed. A touching report of work being done in Bangladesh and Afghanistan was made by Christian Echinard. Realization of the magnitude of IPRAS on the world scene was made by Marita Eisenmann-Klein, our 10th Secretary-General when she looked out at the General Assembly on that Tuesday, the 1st of December, 2009, and said,”What a great moment”. This GREAT MOMENT was the rebirth of a powerful IPRAS, and its claiming of its place as the world’s leading plastic surgery organization.

Thomas Biggs 1315 St. Joseph Pkwy, Hïuston, Texas, 77002 e-mail: tbiggsmd@aol.com

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FUTURE IPRAS CONGRESSES & EVENTS

“Don’t loose the opportunity to contribute to the consensus statement regarding safety regulations on plastic surgery procedures and devices”

Organizing Committee

Scientific Program Topics

Chairman: Fedeles Jozef Slovakia Neuhann-Lorenz Constance Germany Duskova Marketa Czech Republic Gulyas Gustav Hungary Palencar Drahomir Slovakia Garcia-Velasco Manuel Mexico Kaplanidis Zacharias Greece Hulin Ivan Slovakia Lascar Ioan Romania Mandrekas Apostolos Greece Scharnagel Erwin Austria Evstatiev Dimitrie Bulgaria

• Breast augmentation, reconstruction and the status of breast implants register in the country • Current status of other techniques for breast reconstruction and augmentation - tissue transfer, fat grafting, other injectables for breast augmentation • Suspension materials • Stem cell therapy • Tissue engineering • Wound healing • Shock wave therapy • Injectables (lipolysis) • Botulinum toxine • Injectable fillers • Microcirculation, high resolution ultrasound, science in antiaging medicine • Exchange ideas that will foster innovation in plastic surgery • Innovation in suture materials • Standard for aesthetic surgery services

Scientific Committee Chairman: Daniel Marchac France Co-Chairman: Brian Kinney US Eisenmann-Klein Marita Germany Neuhann-Lorenz Constance Germany Cunningham Bruce US Prantl Lukas Germany Yiacoumettis Andreas Greece Kubiena Harald Austria Yilin Cao China Piccolo Nelson Brasil Manfred Frey Austria

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Contact 1st Klm Peanias - Markopoulou 19002 Peania, Attica, Greece Tel:+30 211 1001781 Fax: +30 210 6642116 Contact Name: Katerina Zerdeva Å-mail: katerina.zerdeva@zita-congress.gr Web: www.iquam2010.com

“Support IPRAS, support our African Colleagues, join us in Nairobi!”

Organizing Committee

Scientific Program Topics

President of Organizing Committee: Githae Bernard Kenya Chairman: Badran Hassan Egypt Co-Chairman: Abdulwahab Aref Egypt Agbenorku Pius Ghana Fouad Ghareeb Egypt Kaplanidis Zacharias Greece Khainga Stanley Kenya Mitich Badreddin Algeria Mugwe Winnie Kenya Nangole F.W Kenya Nnabuko Richard Nigeria Rida Franka Mohammed Libya Wangeri Kimani Kenya Yiacoumettis Andreas Greece

1. 2. 3. 4.

To be confirmed: Lamont Alastair South Africa

Scientific Committee Chairman: Marchac Daniel France Co-Chairman: Githae Bernard Kenya Zaidi Mustafa Libya Abdulaziz Nefzi Tunisia Al-Basti Habib Qatar Biggs Thomas US Evans Gregory US Goran Jovic Zambia Holle Juergen Austria Kadry Mohamed Egypt Kouppas Andreas Greece Madaree Anil South Africa Papadopulos Nikolaos Greece Piccolo Nelson Brazil Reilly Debra US Tazi El Hassan Morocco Zaki Mohammed Sobhi Ahmed Egypt

Fat Graft Instructional Workshop Burn Wound Care Guidelines for flap surgery Principles and latest advances in microsurgery 5. Panel on Humanitarian Projects 6. Rhinoplasty 7. Facial Rejuvenation 8. Body Contouring 9. Breast Aesthetic 10. Breast Primary and Secondary Reconstruction 11. Preventive,Regenerative and AntiAging Medicine A. Cardiology Pre-Clinical and Clinical Studies on Applications of Human Myoblasts in Regeneration of Post Infarction Heart TBA B. Orthopaedic Common ageing-associated bone and joint diseases and their treatment TBA

C. Urology Prostate Cancer - Prevention and Treatment Kidney Stones Kidney Stones - Prevention and Treatment Testosterone and PDE5 inhibitors in the aging male Dr. Christian Chaussy, Germany

D. Gynecology Breast Cancer, Gynecologic Tumors and Hormones TBA E. Oncology Tumors Of The Abdomen TBA F. Dermatology Aging Skin TBA

Contact 1st Klm Peanias - Markopoulou 19002 Peania, Attica, Greece Tel:+30 211 1001782 Fax: +30 210 6642116 Contact Name: Nikos Antonopoulos Å-mail: nikos.antonopoulos@zita-congress.gr Web: www.pacprs2010.com

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With the support of Euro-Mediterranean Council for Burns and Fire Disasters and the European Society of Preventive, Regenerative and Anti-Aging Medicine “Be there and catch the challenges!”

Scientific Committee

Organizing Committee

Chairmen: Al-Basti Habib, Qatar (Member of PAN ARAB & GCC) Khalid AL-Hammdani, Qatar (Member of PAN ARAB) Co-Chair: Eisenmann-Klein Marita, Germany (General Secretary of IPRAS) AL-Jaber Hamad, Qatar (Member of PAN ARAB)

Chairman: Al-Basti Habib, Qatar (Member of PAN ARAB & GCC) Co - Chair: Musleh Al Abdulwahab, Qatar (Chairman Qatar Health)

Members of PAN ARAB Association: Rida Franka Mohammed, Libya (General Secretary PAN ARAB Association) AL-Tamimi Noora, Qatar Bishara Atiyeh, Lebanon El-Khatib Hamdy, Qatar Kaladari Saeed, Qatar Seif Makki Ahmed, Qatar Talal AL-Hetmi, Qatar Members of PAN ARAB & GCC: Chonah Thomas, Oman International Members: Ahuja Rajeev, India Chajchir Abel, Argentina De Mey Albert, Belgium Firmin Francoise, France Foustanos Andreas, Greece Mutaz Habal, US Ninkovic Milomir,Germany Pallua Norbert, Germany Zouboulis Christos, Germany

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Members of PAN ARAB Association: Rida Franka Mohammed, Libya (General Secretary PAN ARAB Association)

Araji Zakaria Y., Iraq Khalid AL-Hammdani, Qatar Zaidi Mustafa, Libya

Members of PAN ARAB & GCC: Chonah Thomas, Oman Eed Mohammed D. Ali, Saudi Arabia Numairy Ali, Emirates Saeed Tarik, Pakistan

International Members: Eisenmann Klein Marita, Germany (General Secretary of IPRAS) Kaplanidis Zacharias, Greece

Social Committee Chairman: Saed Kaladari Members: Khalid A. Haji Attalla Hamouda Ali Shaker Mahmoud AL-Sharkawi Mahmoud AL-Thalathini

Contact 1st Klm Peanias - Markopoulou 19002 Peania, Attica, Greece Tel:+30 211 1001780 - Fax: +30 210 6642116 Contact Name: Gerasimos Kouloumpis Å-mail: gerasimos.kouloumpis@zita-congress.gr Web: www.panarabprs2010.com

“The world’s best reconstructive and aesthetic surgery in one meeting” Organizing Committee Organizing Committee Chair: Dr. Don Lalonde Scientific Program Chair: Dr. Peter Neligan Local Host Committee Chair: Dr. Richard Warren Finance & Sponsorship Committee Chair: Dr. Gordon Wilkes International Relations Committee Chair: Dr. Ronald Zuker Executive Director CSPS, Committee Coordinator: Ms. Karyn Wagner

Scientific Program Committee Chair, CSPS Scientific Program: Dr. Patricia Bortoluzzi Pediatric Plastic Surgery: Dr. Louise Caouette-Laberge General Reconstruction: Dr. Kenneth Murray Hand Surgery: Dr. Douglas Ross Aesthetic Surgery: Dr. Walter Peters Craniofacial Surgery: Dr. Christopher Forrest Breast Surgery: Dr. Peter Lennox Burn Surgery: Dr. Edward Tredget Microsurgery: Dr. Steven Morris Basic Research: Dr. Michael Neumeister Clinical Research: Dr. Andrea Pusic

Scientific Program IPRAS 2011 Vancouver Scientific Program will offer: Scientific Program tracks including: • Aesthetic surgery • Reconstruction • Research • Education • Administration • Free Daily Master Classes • Invited lectures by established experts • Sessions highlighting young surgeons • Daily plenary sessions & panel discussions • Specialized subspecialty sessions • Session featuring Best National Society Meeting Papers • Video sessions • E-posters • Further information will be posted here as it becomes available. • Facilities at the Vancouver Convention Center are state-of-the-art.

Contact IPRAS 2011 Vancouver 4-1469 St. Joseph Blvd. E. Montreal, QC, H2J 1M6 CANADA (T) +1 514 843 5415 - (F) +1 514 843 7005 Web: www.ipras2011vancouver.ca

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CO-OPTED SOCIETIES FUTURE EVENTS

“Latest news in aesthetic surgery education worldwide.” ISAPS - 20th Congress - San Francisco, CA - August 14-18, 2010 Location: San Francisco, California, USA Venue: San Francisco Marriott Hotel Contact: Catherine Foss Telephone: 1-603-643-2325 Fax: 1-603-643-1444 E-mail: isaps@sover.net URL: http://www.isapscongress2010.com/

National Associations Future Events 14 - 18 Sep 2010 Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Asthetischen Chirurgen, Annual Congress of the German Society of Plastic, Reconstructive and Aesthetic Surgeons Location: Dresden, Germany URL: http://www.dgpraec2010.info 01 - 06 Oct 2010 PLASTIC SURGERY 2010 Location: Toronto, Canada URL: http://www.plasticsurgery.org 31 - 04 Nov 2010 The faces of Jerusalem Location: Jerusalem Venue: The David Citadel Hotel Contact: Mr Sigal Avidan Telephone: 972-3-5639518 Fax: 972-3-5639599 E-mail: sigal_a@edan.co.il URL: http://www.facesofjerusalem2010.com 11 - 13 Nov 2010 Congress of the Korean Society Location: Korea URL: http://www.plasticsurgery.or.kr

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IPRAS Journal Management Editor:

IPRAS

Editor-in-Chief: Thomas Biggs Editorial Board:

Page Layout: e-mail:

IPRAS Management Ofﬁce ZITA CONGRESS SA 1st km Peanias Markopoulou Ave P.O BOX 155, 190 02 Peania Attica, Greece Tel: (+30) 211 100 1770-1, Fax: (+30) 210 664 2216 URL: www.ipras.org E-mail: zita@iprasmanagement.com Executive Director: Zacharias Kaplanidis E-mail: zacharias.kaplanidis@iprasmanagement.com Assistant Executive Director: Maria Petsa E-mail: maria.petsa@iprasmanagement.com Director of Accounting: George Panagiotou E-mail: george.panagiotou@zita-congress.gr Congress Organizer: Gerasimos Kouloumpis E-mail: gerasimos.kouloumpis@zita-congress.gr Director of Marketing: Kostas Chamalidis E-mail: kostas.chamalidis@zita-congress.gr

Next issue: October 2010

Marita Eisenmann - Klein, MD Andreas Yiacoumettis, Prof. Constance Neuhann-Lorenz, MD Zacharias Kaplanidis, Economist “In Tempo” Athens Greece panos@intempo.gr

DISCLAIMER: IPRAS journal is published by IPRAS. IPRAS and IPRAS Management Office, its staff, editors authors and contributors do not recommend, endorse or make any representation about the efficacy, appropriateness or suitability of any specific tests, products, procedures, treatments, services, opinions, health care providers or other information that may be contained on or available through this journal. The information provided on the IPRAS JOURNAL is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on this journal is for general information purposes only. IPRAS, IPRAS Management Office and its staff, editors, contributors and authors ARE NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT YOU OBTAIN THROUGH THIS JOURNAL. NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING YOU HAVE READ ON OR ACCESSED THROUGH THIS JOURNAL. While every effort has been made to ensure accuracy, neither the publisher, IPRAS, IPRAS Management Office and its staff, editors, authors and or contributors shall have any liability for errors and/or omissions. Readers should always consult with their doctors before any course of treatment. ©Copywright 2010 by the International Confederation of Plastic, Reconstructive and Aesthetic Surgery. All rights reserved. Contents may not be reproduced in whole or in part without written permission of IPRAS.