IPRAS JOURNAL 8th ISSUE by MARIA PETSA

ISSN: 2241-1275

IPRAS Journal

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CONTENTS • President’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . 5 • General Secretary’s Message . . . . . . . . . . . . . . . . . . 7 • Editor-in-Chief’s Message. . . . . . . . . . . . . . . . . . . . . 9 • IPRAS Management office Report . . . . . . . . . . .

• Pioneers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• Senior Ambassador . . . . . . . . . . . . . . . . . . . . . . . .

• Humanitarian Works . . . . . . . . . . . . . . . . . . . . . . .

• Report on the 1st ISPRES Congress. . . . . . . . . . .

• Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• Surveys from 1st ISPRES Congress . . . . . . . . . . .

• National Associations’ & Plastic surgery organizations’ News . . . . . . . . . . . . . . . . . . . . . . . .

• Historical Accounts . . . . . . . . . . . . . . . . . . . . . . . .

• National & co-opted societies future events . . . .

• Certificate of Membership . . . . . . . . . . . . . . . . . .

• IPRAS website . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• Industry news . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• IPRAS past General Secretaries . . . . . . . . . . . . .

• IPRAS Benefits for National Associations & individual members . . . . . . . . . . . . . . . . . . . . . .

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IPRAS Executive Committee Meeting in Rome, March 2012

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WFW mission in Bangladesh, March 10th-March 17th, 2012

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WFW mission in Vijayawada, February 19th - 25th, 2012

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Historical Account of Serbia

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AIMS AND SCOPE

• To promote the art and science of plastic surgery • To further plastic surgery education and research • To protect the safety of the patient and the profession of Plastic, Reconstructive and Aesthetic Surgery • To relieve as far as it is possible the world from human violence or natural calamities through its humanitarian bodies • To encourage friendship among plastic surgeons and physicians of all countries

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PRESIDENT’S MESSAGE Dear colleagues, “The best way to predict the future is to invent it”. Words of the American scientist Alan Kay, expressing in the best possible way our emotions during the 1st congress of our new “daughter” Society, the International Society of Plastic Regenerative Surgery, ISPRES, in Rome.

Board of Directors

This congress was unique in many ways. The personal congratulations and blessings of Pope Benedict the XVIth for our Society, the unique setting at the medieval Palazzo de la Rovere, - our congress hotel right next to the Vatican, the enthusiasm of all the participants in this historical event, the creative potential of speakers and faculty members, the visionary ideas of the ISPRES founders and last but not least, the humorous philosophical remarks of Don Antonio Tedesco (Pope Benedict keeps teasing him: “Not Tedesco, Bavarese” – because of his subtle sense of humour which is considered to be typical Bavarian), when he revealed the secrets of the Pantheon to us. The congress ended as it started: With the blessings of Pope Benedict the XVIth.

President Marita Eisenmann-Klein - Germany

Prof. Marita Eisemann-Klein President of IPRAS

What a unique launch for this society of visionaries and pioneers! What great perspectives for the future! Solutions for up to now incurable health conditions! As if “We have removed the ceiling above our dreams. There are no more impossible dreams” (Jesse Jackson). And we, as plastic surgeons, hold the key role in this development. We are truly blessed! We should take advantage of this revelation – especially when our daily life becomes unpleasant and difficult. It will be an inexhaustible resource of energy and joy of life for all of us! Cordially yours

General Secretary Nelson Piccolo - Brazil

Marita Eisenmann-Klein IPRAS President

Treasurer Bruce Cunningham - USA Deputy General Secretary Yi Lin Cao - China Deputy General Secretary Brian Kinney - USA Deputy General Secretary Ahmed Noureldin - Egypt Deputy General Secretary Andreas Yiacoumettis - Greece Parliamentarian Norbert Pallua - Germany Executive Director Zacharias Kaplanidis - Greece

Prof. Eisenmann-Klein, IPRAS President thanks Don Antonio Tedesco for his support to 1st ISPRES congress

Don Antonio Tedesco guides the participants of 1st ISPRES congress at the St. Peter Cathedral

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GENERAL SECRETARY’S MESSAGE

Prof. Nelson Piccolo IPRAS General Secretary

Plastic Surgery presented the state-of-the-art aspects of Regenerative Plastic Surgery, in Rome this past March. Future meetings on the role of fat and pre-adipocytes are already scheduled up to 2014 and beyond. In my opinion, this event clearly exemplifies our role in this ever evolving Specialty: to foster constant evolution over solid principles and techniques. It is certain that Plastic Surgery has been around for centuries – and we know that for the recorded contributions that an uncountable number of people have made, contributing to its evolution, ultimately aiming for a greater benefit for our patients. I believe we continue to have this obligation – as an individual or as a group, Plastic Surgeons from all corners of the world have modified or created techniques that are the pillars of our specialty today. Parallel to these, several great ideas (occasionally minimally modifying a technique or observing a different way of doing the same thing) have yielded giant steps for Plastic Surgery as a whole. We are at a great moment for Plastic Surgery, worldly represented by IPRAS and its country and individual members!!! The 17th IPRAS Congress is coming up – Santiago de Chile, February 2013, when we expect a world of Plastic Surgeons to be present!!! It will be the ideal moment for you to come and present how you practice Plastic Surgery in your country, on your patients; to show that detail or that collective experience that you believe could influence on the way we all perform that specific procedure or technique. We also are most interested in how Plastic Surgery is practiced and thought in your country, as well as in the recent judiciary or legislative aspect related to patients or Plastic Surgery practice, which may have occurred in your area of the world. Please check our website www.ipraschile.cl , register and send your paper – our multilingual, multinational scientific committee is eager to evaluate and place your paper at the proper session, so we can all benefit from it. We are very much looking forward to meeting you and seeing what you have to tell us in Santiago de Chile. See you there,

Prof. Nelson Piccolo IPRAS General Secretary

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S HJ IOEUFR’ SN A E D I T O RI -PIRNA- C MLE S S A G E

No Key Fits Every lock

EDITORIAL

Dr. Thomas M. Biggs, M.D. Editor-In-Chief

It’s been my pleasure to make this statement in many countries over the past 30 years. I’ve rarely mentioned its origin, but all philosophical concepts have a practical origin. This phrase came about when one of my respected colleagues and dear friends discovered the joy of the free TRAM flap for breast reconstruction and made the statement that it was the “gold standard” of breast reconstruction. I did not disagree that it was a step forward, but we were seeing extremely satisfactory results with a potpourri of techniques (expanders, lat. dorsi flaps, implants, pedicle TRAM) depending upon the patient’s defect. We now come to a time when forward -moving surgeons have found another approach to breast reconstruction: the use of autologous fat. We recently concluded the first meeting of the International Society of Plastic Regeneration Surgery (ISPRES) in Rome. The room was packed and remained so during each of the three days. Sessions included the basic science of fat, stem cells, and other still-not-fully-understood components of fat. We were introduced to the positive effects on skin and scars and multiplicity of other benefits. Basic methods of fat procurement, preparation, and grafting were discussed. Cases involving volumes of graft exceeding 200cc or complicated cases involving extensive scarring or radiation damage could likewise be reconstructed by employing external expansion by the Brava® system to prepare the recipient site for the graft. Del Vecchio showed cases in which fat grafting was used to offset deformities involved with implants such as in fibrous contractures or implant edge visibility in very slender patients, or in patients with other thoracic deformities. Perhaps the most significant take-home-message was the certainty that the use of autologous fat can be employed to create a soft, normal-looking and sensate breast .This is a reconstructed breast with no incision, no sutures, no scars, and can be done as an outpatient procedure with no major complications and few minor ones, which are all easily corrected. A key question was asked by one of the basic science faculty members: “What do we tell the patient about the effect of fat grafting to the breast relative to the development of cancer?” The answer was a firm, “We do not believe it ever causes cancer. The fat is no different than the fat on a TRAM flap”. The meeting was extremely stimulating in the sense that we seem to evolve into a new and better way to reconstruct a breast. As a matter of fact, by creating a stromal/vascular scaffold, then seeding it with fat, we are engineering the creation of new tissue in the shape and feel of a breast….or…in other words, we’ve created a new operation. Of course we know “the greatest enemy of progress is the COMFORT ZONE” and therefore there will be many skeptics who will oppose this, but truth has a way of never dying. In cases of extensive and deforming scarring it was shown that the use of a needle percutaneously could, through multiple sites, break up the scar, creating a matrix which would be the site of fat grafts. This prompted the concept of Rigotti, “from cicatrix to matrix”. Roger Khouri described treating Dupuytren’s contracture with this same percutaneous interruption of the contracting aponeurosis and then by injecting fat into the area to prevent recurrence. Because of this we may see through the shadows a new approach to scar contracture in other specialties: orthopedics, surgery, gynecology, general surgery. As has been the situation in other areas, Plastic Surgeons, whose specialty is innovation, may once again be on the forefront of a huge evolutionary leap. We still believe that “no key fits every lock” but with what we experienced, it seems we have a new key and, based on the breadth and depth of its usage, it is not just another key, but a very GIANT KEY. Dr. Thomas M. Biggs, M.D. Editor-In-Chief

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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

January 2012 – March 2012

Mr. Zacharias Kaplanidis IPRAS Executive Director

The ﬁrst quarter of 2012 has almost come to an end and almost everybody’s thoughts and eyes are aimed towards the European Union, which continues to face problems related to economical development and high unemployment, mainly in the Southern countries of the continent. This ﬁscal “virus”, with immediate impact on the economies and unemployment levels of countries such as Greece, Ireland and Portugal, is now headed dangerously towards Spain and Italy.

Germany, whose export policy relies on a certain degree on countries such as Spain, Italy, Portugal and Greece, and could easily cross over to the more dynamic countries such as China, Russia, Brazil, India and, of course, the USA. At the time that this article is being written, very crucial elections are taking place in France, who, until now, endorses the German mentality

The leadership of the European Union is divided into two different philosophical groups. One side, led mainly by Germany, believes that total austerity and tight fiscal discipline is the solution to the problem, while the other side, which teaches austerity to a lesser degree and cutback on expenses and salaries, aiming though towards development and the reduction of unemployment. It is only logic that countries such as the Southern countries of the European Union, Greece, Spain & Italy, whose unemployment levels reach or exceed 22% (and are continuously rising), are the main exponents of this theory. Our belief and thesis to this skepticism, is that the best solution is not the obsessive and tight discipline and the strangulation of societies and economies, nor is the continuous resource spendthrift by financially undisciplined countries. We agree with the German mentality that a fiscal and structural change is necessary, but we disagree that everything must be done here and now. It is inevitable that the huge economic recession and the incredible unemployment levels, which rise to the degree of 50% among the youth (e.g. in Greece), will force an economic domino and social unrest and spread towards countries like

Executive Committee members from the EXCO meeting, Rome, Italy, March 8th , 2012

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of a tight and unconditional ﬁscal discipline. We have the impression that the Greek public will also send a message in its upcoming elections that it does not agree with the exhaustion of economies and societies. The European Union is basically the most powerful economy on the planet. It has the power and all the necessary tools to confront problems and to correct distortions in the economies of its members/countries. The solution to each “toothache” is not to “rip out the bad tooth”. This solution, and not the healing of the tooth, could lead to a loss of numerous teeth. I believe that under-disciplined countries such as Greece have learnt their lesson and this will be applied in the forthcoming general elections on May 6th. The two major parties, which have the largest amount of responsibility for the public wealth spendthrift, are anticipated to lose at least 40% of their political power and voters. Still, it is not a fair, nor proper, that ﬁnancial measures be taken to lead the Greek people towards poverty, followed by the Spanish people, the Portuguese and possibly the Italian. Believe me, I do not speak as a Greek but as an economist and an economist owes it to see things with realism and to foresee future developments. I would like to close this prologue with my comments of the European and International economy by expressing the hope that the leaders of the European Union and

the G20 will come to a bolder decision and see that the social and financial problems worldwide are mutually connected. NO COUNTRY STANDS ALONE. The international community of Plastic Surgery, after facing the PIP implant problem, is gradually finding its serenity. Naturally though, Plastic Surgeons from the above-mentioned countries are affected by the financial situation and, more specifically, in the field of Aesthetic Surgery. Apart from the financial development, the international community and the industry must invest in research and offer new products and services, which will cover the modern needs of the public. For example, I believe that more than 6 billion people in the world are interested, more than ever, in prolonging and improving the quality of their life. Sciences which deal with Regenerative Surgery, quality and active life and beautiful aging have much to offer and to gain in the near future. Countries, insurance companies, corporate companies, institutes and even political parties show a huge interest and concern for people’s good health and appearance, much over the age of 60 and 70. I don’t think it is necessary to analyze the financial, social and environmental benefits of such an evolution. I would just like to analyze that the field of Plastic Surgery could and should play an

1st ISPRES congress hall

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important role in such an effort and, therefore, I would like to welcome IPRAS’s initiative to create the International Society of Plastic, Regenerative Surgery (ISPRES), a society under the umbrella of IPRAS, targeting the development of new scientific channels and regenerative methods. The response to this new association was immediate and large (approximately 400 new members) and it peaked with the tremendous success of the 1st ISPRES Congress in Rome last March. Personally, I must admit that after 30 years in the field of congress organization, it is the first time that I have seen 95% of the congress participants attending the sessions all day through, for 3 consecutive days. This was the best example of the interest that is shown by Plastic Surgeons (who in majority are successful scientists) towards new horizons and new scientific methods of Plastic Surgery, in the field of Aesthetic and Reconstructive Surgery. Undoubtedly, the ISPRES congress is the threshold of a dynamic evolution of the art and science from which many people will benefit in the future. Concluding this report, I would like to congratulate the protagonists of this effort, and first of all the President of the Society, Dr. Gino Rigotti (Italy), the Vice President, Dr. Roger Khouri (USA), the General Secretary, Dr. Sydney Coleman (USA), the new Treasurer, Dr. Norbert Pallua (Germany) and all the Founding Members, Dr. Tom Baker (USA), Dr. Tom Biggs (USA), Dr. Jim Carraway (USA), Dr. Abel Chajchir (Argentina), Dr. Wanda Elizabeth Correa (Brazil), Dr. Dan Del Vecchio (USA), Dr. Emanuel Delay (France), Dr. Marita EisenmannKlein (Germany), Dr. Greg Evans (USA), Dr. Andrea Grisotti (Italy), Dr. Jose Guerrerosantos (Mexico), Dr. Brian Kinney (USA), Dr. Guy Magalon (France), Dr. Alessandra Marchi (Italy), Dr. Tim Marten (USA), Pope Benedict XVI blessing 1st ISPRES Congress Dr. Riccardo Mazzola

(Italy), Dr. Marta Markowicz (Germany), Dr. Maurizio Nava (Italy), Dr. Ahmed Adel Noreldin (Egypt), Dr. Neeta Patel (India), Dr. Nelson Piccolo (Brazil), Dr. Ewaldo Bolivar de Souza Pinto (Brazil), Dr. Jan Poell (Switzerland), Dr. Lee Pu (China), Dr. Rod Rohrich (USA), Dr. Peter Rubin (USA), Dr. Michael Schneider (Norway), Dr. Theodoros Voukidis (Greece), Dr. Andreas Yiacoumettis (Greece) and Dr. Kotaro Yoshimura (Japan). During the 1st ISPRES Congress, IPRAS had the opportunity to organize a Board of Directors and Executive Committee Meeting, which attracted a large number of participants (more than 25 representatives from respective countries). Issues discussed included the approval of the financial report of 2011, which was unanimously accepted, the future IPRAS economic resources and activities, the humanitarian activities and the resources which will cover their expenses, the future most important IPRAS events, such as the 10th IQUAM Congress and Consensus Conference in Athens, which is very important this year due to the PIP implant crisis, the IPRAS World Congress in Santiago Chile (February 2013). Also they discussed the financial and scientific support of smaller National Congresses, such as the 3rd Central Asian Plastic Surgery Conference in Uzbekistan in May 2012, the collaboration between IPRAS, ISPRES and ASPS etc. Furthermore, the General Secretary of IPRAS, Dr. Nelson Piccolo (Brazil), represented IPRAS at the National Congress in Argentina. The President of the IPRAS World Congress in Santiago, Dr. Patricio Leniz (Chile) and the President of the Scientific Committee, Dr. Wilfredo Calderon (Chile), also attended the Congress. IPRAS will also participate and will be represented at the very important 19th International Congress of FILACP in Colombia. We wish the Organizers every success. In conclusion, I would like to thank all the National Associations and all individual members that collaborated in order to publish one more, very interesting, IPRAS Journal, as well as the industry and all the sponsors for their support. Zacharias Kaplanidis IPRAS Executive Director IPRAS Management Office ZITA Congress

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PIONEERS

Dr. Lisbet Rosenkrantz Hölmich

Dr. Biggs: Reading your CV and your resume of your clinical and academic pursuits convinces me you are a very busy lady. Before we go into these matters please tell us a little about you….your education, clinical experiences, and a bit about your personal life. Dr Holmich: Well, I am a native of Denmark and have received all my training in Denmark. I received my medical degree in 1987 from Copenhagen University, my specialty in Plastic Surgery in 2006, and my Doctorate of Medicine in 2009 with my thesis: “Epidemiological, clinical and oncological aspects of silicone breast implantation”. My primary focus has been on effects of and complications to breast implantation, both reconstructive and cosmetic. The scientific studies include both register-based, clinical, and para-clinical studies. This has to date resulted in 43 published papers and more than 60 oral presentations at national and international scientific meetings and the above doctoral thesis. Dr. Biggs: I see you’re also involved with melanoma and its treatment. Dr. Holmich: Yes, we have quite a lot of melanoma in Denmark and I and my group are involved in all aspects of its treatment … from simple excision to massive resections and large flap reconstructions. Dr. Biggs: What are you doing about breast implants? Dr. Holmich: We are involved in all areas of interest here. As you know, Denmark has for years been in pursuit of better and better control of the outcomes of treatments, which fits right in with the extremely important move our specialty is making into evidence-based medicine. We are trying to determine the natural course and longterm effects of silicone implants. Dr. Biggs: Have you become involved with fat grafting? Dr. Holmich: Yes, for sure. I feel there’s no question that the future will involve fat grafting. I am a strong believer in “replace like with like”. Dr. Biggs: Tell us a bit about your private life. Dr. Holmich: I am a mother of 3 children; I am married to an Orthopedic Surgeon with a very busy scientific and clinical carrier. I like to do gardening, go skiing, bicycling and now, during the spring, I and a local group of women are training for the yearly 112 kilometer social bicycling race for women only. This is great fun! Dr. Biggs: Dr. Holmich, you are truly a PIONEER. You are engaged in a demanding, full time clinical practice, you are doing the equivalent of full time academic work (43 published papers), and maintain balance in your life. Congratulations on being our PIONEER….and good luck on that 112 Km bicycle race!

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SENIOR AMBASSADOR

Dr. Mark Gorney, M.D.

Dr. Biggs: Dr. Gorney, please give us a review of your educational background. Dr. Gorney: I received my B.A. from Harvard University in 1943 and then served a stint in the U.S. Army from 1943-1945. During that time I got my medical school training at the University of Chicago, graduating with an M.D. in 1947. I spent a year in internship in Paris, then returned to the University of Michigan where I trained in General Surgery and Plastic Surgery, finishing in 1956, with an interruption by a tour with the U.S. Navy from 1949 to 1951 (this time as an officer). After Michigan, I took a one year fellowship (1956-1957) at Tulane University in New Orleans. Dr. Biggs: That began your academic career. Tell us about that. Dr. Gorney: It began at Stanford, in Palo Alto, California, where I was appointed Clinical Instructor in 1957 and advanced through the ranks to become Clinical Professor in 1983, and then Clinical Professor Emeritus in 1993. I also received an appointment as Associate Clinical Professor at the University of California, Department of Plastic Surgery and, in addition, I was Chairman of the Plastic Surgery Residency Program at the St. Francis Hospital in San Francisco from 1976 to 1987. Dr. Biggs: Tell us about your significant electoral offices. Dr. Gorney: Well, I’ve had more than my share of those, but the most significant were: 1)President of the California Society of Plastic Surgery from 1978-1979 2) President of the American Society of Plastic and Reconstructive Surgery 1982-1983 3)President of The World Congress of the International Confederation of Plastic, Reconstructive, and Aesthetic Surgery (currently IPRAS ) in 1999. Dr. Biggs: During your time with the ASPRS you were active with medicolegal issues and subsequently became involved with the Doctors’ Company, the largest insurers of doctors against medical malpractice. What were your roles there? Dr. Gorney: I was the Executive Vice-President of Medical Services from 19872004 and I was a member of the Board of Governors from 1976-2006. Br. Biggs: I’ve read you CV and it’s huge. We don’t have time or space to put it here but I’m highly interested in your personal view of your life in Plastic Surgery. The best way for us to understand it is for me to include a letter you wrote me over a month ago which I shall reproduce now. Upon reading one can easily see why Mark Gorney was chosen as our Senior Ambassador.

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Dear Tom, It is now the occasion for this humble servant to respond to your inquiries regarding my career experiences. However, your young readers must accept that the words they read will be the contemplation and reflections of someone whose medical practice was in the past, not the present. As much as I would like to think that a reading of my adventures would be received with great enthusiasm, I fear that it is more likely to be an exercise in boredom. Nevertheless, I will try to pass along a bit of wisdom that is derived from many years of practicing our craft. In doing so, I ask that readers keep in mind that some day they, too, may be asked to pass along their retrospective experiences to the generation that follows them. When I was a young child I knew I wanted to be a surgeon, but it was not until I was in medical school and observed a cleft lip and palate repair that I was fascinated by the concept of learning how to change a deformity into something closer to normalcy. Fortunately, I was able to work with some of the most revered surgeons of the time relative to Plastic Surgery. It was like entering a whole new world and I was on my way. By the time I began my practice in San Francisco in the early 50s, cosmetic Plastic Surgery had become rather common and I found that, like reconstructive surgery, it gave me great pleasure to be able to enhance a person’s body image through the wonders of Aesthetic Surgery. As it would happen, as time went on, there were fewer and fewer reconstructive cases at home so, to satisfy my deep desire to put broken faces back together, I served for many years on volunteer medical teams that did charity work in third world countries where cleft lip/palate deformities, facial distortions and burns were too numerous to count. I guess one could say that the hundreds of people that my two hands made whole and the patients whose body image soared because I was able to help, resulted in my feeling a satisfaction that cannot be described with mere words. It can only be felt in my heart. Somewhere along the way I developed a zeal for teaching. To be able to pass the knowledge of my craft to the next generation, I served on the clinical faculty at Stanford University and University of California San Francisco, as well as holding the position of Chief of Plastic Surgery at St. Francis Memorial Hospital in San Francisco. Giving back to the Specialty that did so much for me was very important which is why I served for years in the leadership of Plastic Surgery, both nationally and internationally. If anyone is interested in seeing my CV, it is on my website so I won’t bore your readers with that information. Your IPRAS Journal readers might be interested to know, though, that I served as the US delegate to IPRAS for many years and served one term as its President. Two of the greatest honors of my career were to serve as an examiner on the American In reflecting Board of Plastic Surgery and as President of the American Society of Plastic Surgery. upon where Plastic Surgery has been during my years of practice, I think it is much like going from horse and buggy to space travel. While basic techniques are much the same, microsurgery, lasers, and imaging have made possible procedures unimaginable when I began practice. Who would have thought sixty years ago that connecting severed digits would become routine, and that a face could be transplanted from one human being to another? Who would have thought that a cleft lip could be repaired in utero? Astounding! I would not venture to guess what advancement will be made in the future, but I have no doubt that Plastic Surgery’s brilliant young minds will continue to amaze and make us proud. As far as whether or not our Specialty will merge with others who call themselves “Plastic Surgeons,” I would hope that our leaders, both in the United States and abroad, continue to set the bar high and demand that only those who meet our lofty criteria for excellence be awarded the distinction of wearing our worthy title. As many of your readers know, certainly the ones who have been around for awhile, my involvement with The Doctors Company offered many opportunities for me to help my colleagues avoid medical malpractice litigation by practicing sound judgment, appropriate patient selection, and patient safety. As a legacy to the Specialty, I collaborated with Dr. Phil Haeck in writing Risk Liability and Malpractice: What Every Plastic Surgeon Needs to Know. I hope your readers and all Plastic Surgeons will take advantage of this information. Let me close with a farewell from the heart. I’ve been fortunate to have lived to see much fascinating, scientific artistry created by the brilliant minds of my colleagues. Their curiosity about “what if” and their constant need to excel has resulted in immeasurable good for our patients, not to speak of what it has done to aggrandize Plastic Surgery. I treasure, personally, all those achievements. Although I won’t be around to see what further marvels for humanity our colleagues develop, I am confident that they will be developed and will continue to astound. My very best wishes to all. Mark Gorney, M.D.

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HUMANITARIAN WORKS Women for Women Camp

Chilmari, Bangladesh, March 10th-March 17th, 2012 The Location The March 2012 Women for Women mission by IPRAS took place aboard the Friendship/Emirates hospital boat located near Chilmari, Bangladesh in the Jamuna River. Chilmari is an upazila of Kurgram district in the division of Rajshahi and was once a famous river port during the Pakistani and British rule. It is located in the northern

part of Bangladesh, near the Indian border and is very inaccessible by roads and trails. Our team was able to reach the location with the help of the Mission Aviation Fellowship (MAF), a non-proﬁt organization that serves to help transport medical professionals to isolated and remote regions by air. The skillful former Air Force pilot transported us from Dhaka to the Friendship/Emirates ship in an Amphibious Cessna single-engine plane. The mission was hosted by the Friendship organization and patients were screened prior to our arrival by the in hospital physician, Dr. James. Patients traveled by boat, bus and on foot for up to 3 days to reach the ship. While patients and their families were receiving treatment, they stayed in a shelter located 20 meters from the docked boat. The boat was well equipped with two operating rooms, a postoperative unit housing up to eight patients and an outpatient clinic. The team was fortunate to live aboard a houseboat, equipped with individual bedrooms, two showers/bathrooms and a live-in cook, docked about 20 meters away from the Emirates ship.

The Team Our team surprisingly consisted of all blonde women. There were three surgeons: Team Leader, Dr. Alexes Hazen (New York, NY), Dr. Nicole Lindenblatt (Zurich, Switzerland) and Dr. Katie Weichman (New York, NY). The surgical team worked well together, utilizing only one of the two OR’s by working simultaneously on multiple procedures. The surgical team was supported

by two anesthesiologists; Dr. Christine Kufner (Munich, Germany) and Dr. Celine Olivier (Munich, Germany). The Operating room team worked together to deliver safe and efﬁcient anesthesia to our primarily pediatric patients. We were joined by a medical student, Nicole Strungmann (Munich, Germany), who worked meticulously on both documentation and scheduling, while making special connections with the patients and their families. Ann-Christine Woehrl (Munich, Germany) again accompanied the Women for Women team, photographically documenting the mission both intraoperatively and discovering deeper narratives outside the medical history. Joli the nurse and Shaheen, the technician, employees of Friendship, also joined us in the OR and were incredibly helpful both in the OR and in understanding Bangladesh culture. Additional postoperative support was provided by a 2 local nurses and, postoperatively, by a local physical therapist.

The Mission The surgical mission started on March 10th after our ﬂoat plan landed. Once we landed, we were greeted by the surrounding villagers, who ran to the river’s edge upon seeing and hearing the plane. We took a tour of both our houseboat and the hospital ship and then started patient screening. We saw 27 patients and scheduled 23 for surgery. The majority of patients displayed sequelae of ﬂame burns and secondary healed burn contractures on various parts of their bodies. We additionally evaluated several lower lip lesions and a cup ear deformity. Twenty patients were children, while only three were adults. The deformities ranged from hand and upper arm burn contractures to lower extremity ulcers from secondary Issue 8

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Visit to Chilmari

Despite our busy operative schedule, we were able to travel to the city of Chilmari after seeing our postoperative patients on March 15th. The trip was organized and supervised by Shaheen, who took us on the long trip by boat and tuk-tuk to the city. While in the city we saw a different culture than we had experienced in our rural area. The town had a large bustling marketplace with goods, fruits, vegetables,

healed burned contractures, to neck and face contractures. Most injures were secondary to ﬂame burns from lack of supervision rather than domestic violence, as seen in some areas of India on previous missions. Patients were all female and more likely to be accompanied by their fathers rather than their mothers. We started the operations the following day, on March 11th in the afternoon, after unpacking our copious supplies. These supplies were thanks to the generosity of New York University Medical Center, Memorial Sloan Kettering Hospital, Dr. Constance Neuhann-Lorenz and Dr. Nicole Lindenblatt. After a quick successful day in the OR we were able to journey to the nearby village to see where some of our patients and people native to this area lived. They were as excited to see us, as we were to see them. The village consisted of individual family huts, many goats, cows and small horses. The average family in the area has six children, so there were many children around excited to be photographed. We continued to operate until March 15th and did a total of 108 procedures on 23 patients. On March 16th we spent the ﬁnal day seeing postoperative patients and taking down splints and dressings. There were no complications and patients, families, and surgeons were ecstatic with the results. Postoperative plans including, hand/physical therapy and dressing changes were discussed with the local team at this time.

chicken and local ﬁsh, with cars, trucks and rice farms. We saw a game of cricket in progress, a local school and a local hospital. In addition, we saw many more goats and local children eager for us to take their photos. We did not buy anything but were thrilled with the rickshaw ride back to the boat at the conclusion of the trip.

Mission Overview

Our mission to Bangladesh was hugely successful! It was out of everyone’s comfort zone at one point or another but deepened our appreciation for family and illness on many levels. There is so much beauty in Bangladesh from the faces, to the vibrant colors in their clothing, to the peoples’ sense of family. We all learned a lot about others and ourselves and were grateful we were able to help. Thanks to everyone who helped to make the mission such a great success!

Sponsors

The mission was generously supported the following companies and individuals: • Adler Apotheke, Munich, Germany • BBraun Melsungen AG, Germany • Dermokosmetika Synchroline, Merzhäuser&Bolky , Germany • Hartmann Company, Germany • KVG Vertriebs-GmbH, Germany We are deeply grateful for all their support and trust. Alexes Hazen, MD Assistant Professor of Plastic Surgery Director of Aesthetic Surgery Center Institute of Reconstructive Plastic Surgery NYU Medical Center New York

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The 9th WomenforWomen Camp In Vijayawada, Andhra Pradesh India February 19th - 25th, 2012 The place The ninth WomenforWomen by IPRAS mission took place for the third time in the Salaja Hospital in Vijayawada, India. Vijayawada is the 3rd largest city in the state of Andhra Pradesh. The city is well-connected to other regions in India via roads, trails or air, which makes it easily accessible for our patients and WomenforWomen teams. The mission was hosted and diligently prepared, as in two previous missions by Dr. Lakshmi Saleem (Vice President Women for Women), who runs Salaja Hospital with a competent team of scrub nurses, nurses, anaesthetists etc. Dr. Saleem advertised the 3rd WomenforWomen mission with a short television clip (sponsored by Narasimha Rao, C Channel, Blue Cip Systems) and selected patients in her ofﬁce in Hyderabad and at Salaja Hospital. Salaja Hospital in Vijayawada is a privately run hospital with 2 operation rooms, an outpatient clinic, special dressing rooms and even a burn ward. The hospital is well structured, clean and offered our team a comfortable and friendly work environment. Coming to Vijayawada repeatedly enabled our teams to deepen the close ties with our female patients, some of which have been treated by WomenforWomen by IPRAS during all 3 missions. Our patients and surgeons were very satisﬁed with the progress that has been archived in a mutual effort. Vijayawada meaning “Land of Victory” clearly seems to develop into a successful project within WomenforWomen by IPRAS.

The team The team consisted of 5 surgeons, which enabled the team to conduct a vast amount of operations at minimum time by working simultaneously. Dr. Lakshmi Saleem (Vice President WomenforWomen Hyderabad India) and her husband Dr. M. Saleem (Hyderabad India), who kindly helped our female surgeons with the huge workload, acted as local coordinators during the mission. Further, the surgical team was made up of Dr. Constance Neuhann-Lorenz (President WomenforWomen, Munich, Germany) and Dr. Debra Reilly (Vice President WomenforWomen, University of Nebraska Medical Center) and Dr. Sarah Lorenz (Residents Program, Hospital Munich

Bogenhausen). Our surgeons were supported by 2 anaesthetists, Dr. Hanumantharurao, Dr. Lakshmi Narayana and 7 nurses. The team was accompanied by the photographer Ann-Christine Woehrl, who investigated the sad backgrounds and stories behind our patients with interviews and pictures. Ann-Christine Woehrl’s efforts helped our surgeons get a deeper understanding of our patients individual situations, besides the medical history.

Banner announcing the WomenforWomen Mission in front of Salaja Hospital

The mission The surgical mission itself started on February 20th, when, according to the WomenforWomen rules detailed screening, documentation and planning of the OT sessions was carried out. Forty-eight patients were screened and 34 patients operated on, with a total of 81 procedures. Most of our patients showed secondary healed burn scars due to acts of domestic violence, which functionally impaired them. The scars ranged from large surface post burn contractures to small ones, that destroyed the function of the hand or face. Rama Devi is 18 years old and mother of two children; she was burned by her husband over a year ago. When she presented to the hospital she suffered from severe post-burn scar contractures of both feet, ﬂank and the arm, which were surgically treated. Rama Devi’s sad story was followed closely by Ann-Christine Woehrl., who was honored with a grant for her documentary of WFW projects by “Stiftung Kulturwerk der VG Bild-Kunst“, Germany. Furthermore, the team saw very pleasing long-term postoperative results in previous patients. Nehaari presented with functionally and aesthetically pleasing results regarding the contractures of her neck and face and received another minor contracture release. The last day of the mission in Vijayawada was mainly used to change dressings and deﬁne the postoperative regimen with the local staff.

Visit to ASRAM College and Hospital

Dr. Neuhann-Lorenz examining a burn victim

On February 24th the WomenforWomen team visited ASRAM (Alluri Sitaramaraju Academy of Medical Sciences) Medical College and Hospital. The College is afﬁliated to Dr. NTR University of Health Sciences, Vijayawada and the hospital is a privately managed facility. The hospital accommodates a unit for Plastic and Reconstructive Surgery with Dr. Krishna as head of the department. The WomenforWomen team presented their project to the hospital’s management and inspected the large campus and OR tract. The management and the Principal of the hospital, Dr. K. Umamaheswara Rao, indicated their interest in hosting future WomenforWomen by IPRAS missions.

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Sponsors The mission was generously supported the following companies and individuals:

Team during surgery

Meeting with the team going to Jalhandar On the evening of February 25th the team of the ninth mission met members of the team of the tenth WomenforWomen mission, who were on their way to Jalandhar lead by Dr. Andrea Pusic (Memorial Sloan-Kettering Cancer Center, New York, USA). The teams exchanged supplies and instruments and discussed issues encountered during the missions. The photographer Ann-Christine Woehrl joined the next team.

Woman an girls watching over one patient

Meeting with Bridge to India On February 26th Dr. Neuhann-Lorenz and Dr. Lorenz met with Dr. Engelmeier from Bridge to India discussing future possible ﬁelds of action for the WomenforWomen project and ways of reaching out to the public to create awareness within the Indian society. A meeting via Bridge to India with Mr. Asaf Ali, CEO Cashmere Loom Inc., was organized on Feb. 27th to discuss options for a WomenforWomen camp in Kashmir provisionally for May, 2013.

Report From Second WomenforWomen mission for 2012, in Jalandhar, India - January 24th -31st, 2012 The trip to Jalandhar was our second WomenforWomen mission for 2012 and it was a great success! Dr. Chanjiv Singh was our very gracious local host and took excellent care of the team throughout the mission. He is a dedicated colleague with great energy and enthusiasm. Our team consisted of 3 North American surgeons (Drs. Andrea Pusic and Alexes Hazen from New York City, Dr. Nancy Van Laeken from Vancouver, Canada). Ann-Christine Woehrl was our mission photographer and a great addition to the team. Alison Price, our fourth year medical student, maintained meticulous docu-

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Whole Team: Including, Upper row left to right: Dr. Hanumantharurao (anaesthetist), Mrs. Valsala (nurse) and Dr. Saleem, Dr. Neuhann-Lorenz, Dr. Reilly and Dr. Narayana (anaesthetist). Lower row right to left: Mrs. Sita (nurse) and Dr. Lorenz

Braun Melsungen who donated vast amounts of resources. Lufthansa: Transport of resources Hartmann: Resources Adler Pharmacy, Munich Germany: drugs and ointments Dermokosmetika Synchroline, Germany: ointments and med. supplies Erbe Elektromedizin GmbH, Germany: Instruments KVG VertriebsGmbH, Germany, med. supplies Narasimha Rao, C Channel, Blue Cip Systems: Announcement of the mission on the local TV station BILD hilft e.V. ein Herz für Kinder Raghava Rao Nadella, Gopala Tube Well Works: dinner fort he team ASRAM College and Hospital: Lunch for the team Dr. Mohamed Saleem: Dinner for the team Mr.Ahmed sponsored the teams daily lunch at Salaja Hospital Not to neglect all our faithful and trusting friends who have made donations throughout the year. We are deeply grateful for all their support and trust.

Dr. Constance Neuhann-Lorenz, M.D. President WomenforWomen Dr. Sarah Lorenz, M.D. WomenforWomen Member mentation of patients and procedures and was an essential member of the team as well. We were also fortunate to have 2 delightful Indian surgical interns who acted as translators and general assistants. During our 5-day visit, we operated on 35 patients and performed 73 procedures. The majority of patients were women and girls, but 5 little boys were also treated. Most cases were burn-related, but there were also a number of congenital anomalies. There were no intra-operative or early peri-operative complications. In spite of a busy surgical schedule, we visited the beautiful Golden temple – which made for a perfect ending to the mission.

Dr. Pusic Andrea WomenforWomen Vice President

R E P O R T O N T H E 1 ST I S P R E S C O N G R E S S

International Society of Plastic Regenerative Surgery (ISPRES) The first congress of the newly formed International Society of Plastic Regenerative Surgery (ISPRES) took place in Rome, Italy, from March 9th to March 11th , 2012. ISPRES was created to promote the study of “Regenerative Plastic Surgery”, those forms of Plastic Surgery that take advantage of our own body’s ability to repair, remodel and enhance itself. We had an overwhelming number of abstracts submitted to the congress from every continent on a broad range of basic science, translational science and clinical subjects. This firstcongressofISPRESfocusedspecificallyonbridging the gap between basic and translational research and many forms of fat grafting. The scientific program highlighted adipose tissue-based technologies and procedures to help the attendees better understand how the human body can be enhanced, remodeled and restored through the manipulation of adipose tissue, adipose tissue-derived repair cells and growth factors. The abstract submissions were combined with presentations from a stellar invited faculty to create a diverse, exciting and informative program comprising of 90 speakers and 36 moderators. Interest in the Congress was so overwhelming, that registration ended in December, almost three months before the congress and over 200 people were turned away. The meeting rooms were able to accommodate a standing room only audience of 275 registered attendees from 55 countries.

Sydney R Coleman, MD Scientific Program Chairman of the Congress Secretary General of ISPRES The congress lasted three full days. The first day emphasized the mechanism of fat grafting, Stromal Vascular Fraction (SVF), Adipose Derived Stem Cells (ADSC) and growth factors. The second day explored many uses of fat grafting in clinical settings. The third day focused on clinical aspects of fat grafting to the breasts, with an instructional course in the afternoon. The opening session looked into the history of fat grafting and fat injection, beginning in 1908 and continuing to the recent past. The functional uses of transplanted fat were recognized by Plastic Surgeons over one hundred years ago. The second session was designed to answer specific questions about the science of fat grafting, SVF, ADSC and growth factors. Panelists explained the mechanism of

Opening Ceremony

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From the left: Dr. Roger Khouri (USA) ISPRES Vice President, Dr. Gino Rigotti (Italy) ISPRES President, Dr. Sydney Coleman (USA) ISPRES General Secretary, Dr. Dan Del Vecchio (USA), Dr. Marta Markowicz (Germany) IPRAS Executive Committee member

fat survival and gave insight into the process by which fat grafts and stem cells can potentially repair surrounding tissues. The longest session of the day, session 3, examined the SVF of adipose tissue. A panel composed of Plastic Surgeons with expertise in the area of SVF answered the questions “How many Stem Cells and SVF cells are in harvested fat?” and “What is in SVF and how can we be sure?” A discussion ensued on the methods of isolating SVF from fat currently in use and in development. The last section of the third session turned to the practical uses of SVF in breast procedures, supported by anecdotal evidence of success. Next, attention was turned to the practicalities of using SVF, specifically examining various scaffolds and matrices used as media for placement of SVF into tissues. The morning concluded with Session 4, a thorough examination of the potential for storage of SVF and adipose tissue and its associated problems. This session ended with a sobering look into the regulatory issues of tissue banking. After lunch, Session 5 explored the science of fat grafting, examining the scientific methods of determining how each step in the fat grafting process influences tissue viability and survival. Every attempt was made to include evidence-based data. Individual sections followed this on harvesting, refinement and placement of adipose tissue. Session 6 addressed the question, “How can we improve predictability and the effect of fat and SVF?” These talks related the presenters’ experience with lasers and additives such as platelet rich plasma to improve survival. Session 7 focused on safety issues of fat grafting, along with complications and their management. Particular attention was paid to catastrophic complications and infections. A panel followed, in which many of the experienced faculty related their worst and most common complications and how to avoid them. 22

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The last session of the day examined worldwide government regulations, judicial developments and ethics concerning fat, SVF and ADSC. Professional Society recommendations were also discussed. The next day focused on clinical fat grafting. Each session explored a different indication for fat grafting. Session 9 began the day with fascinating presentations on the effect of fat grafting on acute, subacute and chronic wounds. Compelling photographs were shown of fat grafts used in acute traumatic wounds, as well as non-healing ulcers and amputations. Fat grafts were shown to be successful in treatment of acute burns, therapeutic radiation damage, scar contractures, keloids and other scars. Remarkable healing was demonstrated in ulcers and fistulas treated with fat grafts. When possible, anecdotal reports were interspersed with scientific studies, which supported the specific indications. Session 10 returned to the science of fat grafting with discussions of the scientific background behind reverse expansion with an external vacuum to prepare for fat grafting and to culture fat tissue. Different methods of imaging to determine volumetric changes after grafting fat were discussed, aimed primarily at evaluation of breasts. Then a long section on the safety issues of fat grafting, specifically for the breast, began with the reports of studies of potential interactions of cancer cells with transplanted breast tissue. This was followed by many epidemiologic studies evaluating the occurrence or recurrence of breast cancer after fat grafting. The direction changed back to clinical presentations of fat grafting to the head and cranium, both aesthetic and reconstructive with Session 11. This was our longest session (over three hours), and was interrupted by lunch.

Pope Benedict XVI blessed 1st ISPRES Congress.

1st ISPRES congress opening ceremony. From the left: Dr. Sydney Coleman (ISPRES General Secretary), Dr. Roger Khouri (ISPRES Vice President), Prof. Marita Eisenmann-Klein (IPRAS President)

The ability of fat to create fullness was clearly presented, but the most fascinating observations were concerning the quality of skin after fat grafting. Most of the presentations showed dramatic improvement in the texture and color of the overlying skin after fat grafting to the face. Session 12 concentrated on corporal fat grafting, especially for the buttocks and lower extremities. Session 13 explored other conditions and diseases that have been treated with fat grafting, including scleroderma and vocal cord scarring and paralysis. The day ended with Session 14 in which future applications of fat grafting ADSC and SVF were proposed such as bioengineered breasts and the regeneration of nerves and muscles. The entire last day was devoted to the techniques of fat grafting in breast surgery, both aesthetic and

reconstructive. The Congress ofﬁcially ended with a panel discussing the clinical indications for reverse expansion. The remainder of the day was an instructional course given by the faculty members most experienced in the techniques of fat grafting to the breasts. The presentations on these three days were uniformly of the highest quality and the Congress was a worldwide sharing of knowledge, research and clinical experience previously unseen. ISPRES is planning the next Congress on June 13-15, 2013 in Berlin, then June 12-14, 2014 in New York City. To expand the worldwide impact of the meetings, the 2015 meeting is planned for Rio de Janeiro and the 2016 meeting in Asia. The attention of future meetings will expand to include regenerative technologies of every type with potential uses for Plastic Surgeons.

Next ISPRES congress will take place in Berlin, Germany, June 2013!! More information will be announced soon… at www.ispres-ipras.org

HOW TO APPLY FOR ISPRES MEMBERSHIP: You may apply for membership by visiting www.ispres-ipras.org “How to become a member” section. Please send us your application together with your short CV (not more than one page) and you will be informed shortly about your membership status and membership fee. For more information you may send your requests at Mrs. Maria Petsa (maria.petsa@iprasmanagement.com).

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SURVEYS Best papers of the Finnish Society of Plastic, Reconstructive and Aesthetic Surgery Congress (Íovember 2011)

Treatment of Severe Frostbites in Tampere University Hospital Background Frostbites have classically been treated by rewarming and delayed surgical debridement or amputation. However, patients who present within 24 hours of cold exposure may beneﬁt from a more aggressive therapy: rapid rewarming, antiplatelet agents and intra-arterial thrombolytic therapy (1-3). So far there is no national protocol or guideline for treating frostbite injuries in Finland. Based on literature review and promising pilot results, we have implemented a new protocol for frostbite patients in our clinic.

Protocol Treatment is started with rapid rewarming of the injured tissue by water immersion at 38 to 42°C. Peroral Ibuprofen 800mg every 8 hours is started simultaneously and tetanus prophylaxis is given. After 15 to 30 minutes of rewarming, cold injury is reassessed clinically and with hand held Doppler device. The frostbite is regarded as serious if, after warming, there is paresthesia, paleness or hemorrhagic blisters in the extremities or no doppler signal is heard from digital or proximal arteries. In these cases, an immediate angiography is pre-arranged. Intraarterial thrombolytic therapy is started for patients who have total or partial occlusion of arteries or serious vasoconstriction. Thrombolysis is continued for 24 to 48 hours. Peroral daily oral acetylsalicylic acid medication is started. Wounds and blisters are treated conservatively with daily dressing changes and mobilization.

Patients During the winter of 2011, two patients (a total of ﬁve extremities) were given thrombolytic therapy. The ﬁrst patient

Juha Kiiski1, Lauri Lindroos2, Janne Korhonen3 Hannu Kuokkanen1, Jouni Havulinna2

Dept. Plastic Surgery, Tampere University Hospital Dept. Hand and Microsurgery, Tampere University Hospital (3) Medical Imaging Centre, Tampere University Hospital (1)

(2)

had severe bilateral upper extremity frostbite: no blood ﬂow in digital arteries was noticed after warming. The patient received intra-arterial thrombolysis for 48 hours. The hands revascularized well and no amputations or revisional surgery was needed. The second patient had severe fourth grade frostbite in both lower extremities and grade-two frostbite in the left upper extremity. Angiography showed digital artery defects in the lower extremities and spastic digital arteries in upper extremity. After 48 hours of intra-arterial thrombolytic therapy, the circulation returned to the injured extremities and the patient did not need further procedures.

Conclusions Rewarming, ibuprofen, acetylsalicylic acid medication and tetanus prophylaxis should be given to all patients with frostbites. Patients with severe frostbites and compromised circulation of the injured extremities should be referred to centers with availability for immediate angiography and thrombolytic therapy.

References 1. Twomey JA et al. J Trauma 2005;59:1350-55. 2. Bruen KJ et al. Arch Surg 2007;142:546-553. 3. Jenabzadeh K et al. J Burn Care Res 2009;30(2):S103.

The effects of hypotension and norepinephrine on microvascular flap perfusion There is little definitive evidence about the dangers of hypotension and hypoperfusion in clinical microsurgery. Patients are always treated to maintain good tissue perfusion, and fluid resuscitation is considered the first option for this. Excessive fluid infusion can also be harmful and induce oedema and tension to the flap and sometimes vasoactive medication must be considered. Unfortunately, there is little data about the safety of vasopressors in microvascular surgery. As vasoconstrictors, vasopressors might impair microvascular flap perfusion. We studied the effect of hypotension on the perfusion of microvascular and superiorly pedicled rectus abdominis myocutaneous flaps in ten landrace pigs. Normovolemic hypotension (MAP 50 mmHg) was induced by high doses of sevoflurane. We also evaluated the effect of norepinephrine on flap perfusion when it was used for the correction of 24

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Leena Setälä, Kuopio University Hospital, Finland. hypotension. A sensitive monitoring method, microdialysis, was used to detect perfusion-related metabolic changes in the flaps and control tissues. We found that a moderate degree of hypotension or high systemic doses of norepinephrine did not affect flap metabolism. The finding is contradictory to some previous studies that claim norepinephrine is potentially harmful, but may be explained by very different models of investigation. At present, there are new clinical studies going on to confirm the safety of norepinephrine in microsurgery. Reference: Hiltunen P, Palve J, Setälä L, Mustonen PK, Berg L, Ruokonen E, Uusaro A. The effects of hypotension and norepinephrine on microvascular flap perfusion. J Rec Microsurgery 2011; 27(7):419-425

Autologous Fat Grafting, Adipose-Derived Growth Factors and Stem Cells Norbert Pallua, MD, PhD, FEBOPRAS, Professor, Head of Department Christian Opländer, PhD Biologist Department of Plastic Surgery, Hand Surgery, and Burn Center, University Hospital of the RWTH Aachen University, Aachen, Germany

Adipose-Derived Stem Cells For many years, the scientiﬁc interest has been focused on the possible use of embryonic stem cells in regenerative medicine, but ethical considerations and potential induction of tumors prevented clinical applications. The identiﬁcation of adult stem cells and the possibility to reprogram differentiated into pluripotent cells, which can differentiate into many different cell types, bypass and avoid

the ethical problems and decrease the risk of teratoma. Therefore, until the year 2000, stem cell research focused mainly on the use of adult stem cells, primarily obtained from bone marrow. Especially, the so-called mesenchymal stem cells, speciﬁc cells within a population of stem cells in bone marrow and blood vessels, are multipotent and involved in healing processes, but the number of mesenchymal stem cells, which can be obtained from patients for clinical use is limited.

Before Lipofilling

4 years after lipofilling

Before Lipofilling

6 years after lipofilling

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In 2001 for the ﬁrst time, the existence of stem cells within adipose tissue was reported. Further investigations have shown that adipose tissue has 300-500-fold the number of mesenchymal stem cells, compared to bone marrow. Adipose tissue as a stem cell source is promising and high numbers of stem cells can easily be isolated from liposuction, which provide 100 to 3000 ml of fat tissue without excessive complications and pain for the donor or patient, respectively. Therefore, the use of adipose tissue for stem cell isolation is superior to bone marrow, placenta, or umbilical cord as sources (1).

Outlook

The Yield of Stem Cells from Adipose Tissue

1. Witkowska-Zimny, M., and Walenko, K. (2011) Stem cells from adipose tissue. Cellular & Molecular Biology Letters 16, 236-257

Yet, the yield of stem cells from adipose tissue is dependent on many factors e.g. the patient, age, harvesting site and the harvesting procedure (2). Furthermore, the technique of cell isolation from adipose tissue, as well as conservation procedures and in vitro culture steps, may influence the number and also the behavior of the obtained stem cells (3-5). Therefore, one important challenge in the future will be to find the optimal isolation method for obtaining adipose-derived stem cells for clinical use. Another problem to mention is that adipose-derived stem cells isolated from the stromal vascular fraction of lipoaspirate represent a heterogeneous population with functionally different subpopulations of stem cells, which may influence the clinical outcome (6).

Effects of Adipose Growth Factors and Adipose-Derived Stem Cells One important characteristic of adipose tissue and adiposederived stem cells is the secretion of a variety of growth factors and cytokines (7), which can be beneficial for patients. Angiogenic factors, for example, can improve microcirculation of the skin significantly. Mojallal et al. in their experiments using a nude mice model, found a local increase of type I collagen fibers of murine origin after injection of human fat tissue, as a result of murine fibroblast stimulation by the grafted human fat tissue (8). Additionally, dermal thickness was significantly increased around the injection area. An improvement of skin quality and a marked disappearance of fine wrinkles have been found in patients after facial lipofilling due to the increased thickness of dermis and improved microcirculation (see Figure 1). By the same mechanism, the appearance of scars can be improved (see Figure 2). Nevertheless, long-term effects of autologous fat grafting are unknown. Recently, studies have shown that secreted cytokines such as interleukin 6 may promote migration and invasion of breast cancer cells in vitro (9). However, in vivo, long-term follow-up studies could not prove any higher incidence of recurrence of breast cancer after breast reconstruction with autologous fat grafting (10). 26

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The use of adipose-derived stem cells in regenerative medicine is very encouraging and many ongoing clinical trials are investigating the possible effects of adipose-derived stem cells on a variety of diseases such as Diabetes Mellitus, Crohn`s disease, myocardial infarction, liver cirrhosis and autoimmune diseases. In summary, we can expect that in the near future, liposuction will not be performed only for aesthetical reasons. but also as a necessary procedure in the treatment of a wide range of diseases.

References

2. Padoin, A. V., Braga-Silva, J., Martins, P., Rezende, K., Rezende, A. R. d. R., Grechi, B., Gehlen, D., and Machado, D. C. (2008) Sources of processed lipoaspirate cells: inﬂuence of donor site on cell concentration. Plastic and Reconstructive Surgery 122, 614-618 3. Oedayrajsingh-Varma, M. J., van Ham, S. M., Knippenberg, M., Helder, M. N., Klein-Nulend, J., Schouten, T. E., Ritt, M. J. P. F., and van Milligen, F. J. (2006) Adipose tissue-derived mesenchymal stem cell yield and growth characteristics are affected by the tissue-harvesting procedure. Cytotherapy 8, 166-177 4. Pallua, N., Wolter, T.P.,, Coleman, S. R., and Mazzola, R. F. (2009) Cryopreservatikon of Adipose Tissue for Autologous Fat Transfer Fat Injection: From Filling to Regeneration. QMP, 58-71 5. Wolter, T. P., von Heimburg, D., Stoffels, I., Groeger, A., and Pallua, N. (2005) Cryopreservation of mature human adipocytes: in vitro measurement of viability. Annals of Plastic Surgery 55, 408-413 6. Li, H., Zimmerlin, L., Marra, K. G., Donnenberg, V. S., Donnenberg, A. D., and Rubin, J. P. (2011) Adipogenic potential of adipose stem cell subpopulations. Plastic and Reconstructive Surgery 128, 663-672 7. Pallua, N., Pulsfort, A. K., Suschek, C., and Wolter, T. P. (2009) Content of the growth factors bFGF, IGF-1, VEGF, and PDGF-BB in freshly harvested lipoaspirate after centrifugation and incubation. Plastic and Reconstructive Surgery 123, 826-833 8. Mojallal, A., Lequeux, C., Shipkov, C., Breton, P., Foyatier, J.-L., Braye, F., and Damour, O. (2009) Improvement of skin quality after fat grafting: clinical observation and an animal study. Plastic and Reconstructive Surgery 124, 765-774 9. Walter, M., Liang, S., Ghosh, S., Hornsby, P. J., and Li, R. (2009) Interleukin 6 secreted from adipose stromal cells promotes migration and invasion of breast cancer cells. Oncogene 28, 2745-2755 10. Rigotti, G., Marchi, A., Stringhini, P., Baroni, G., GaliÃ¨, M., Molino, A. M., Mercanti, A., Micciolo, R., and Sbarbati, A. (2010) Determining the oncological risk of autologous lipoaspirate grafting for post-mastectomy breast reconstruction. Aesthetic Plastic Surgery 34, 475-480

S U R V E Y S F R O M 1 st I S P R E S C O N G R E S S

Mega volume fat grafting to the breast

Roger Khouri, M.D. Mega volume fat grafting is the grafting of 200 cc of fat or more to one breast. Successful efforts at fat grafting to the breast have been reported for years and many people are doing it today, but reports of successful grafting of 200 cc or more are essentially non-existent. In order to understand why, we need to go into the science of fat grafting. The two vital components to successful grafting, which control all aspects of this endeavor, are: 1) the fat graft/ recipient site interface 2) the interstitial pressure of the recipient site after grafting. It has been shown that a graft of a size greater than 2 mm will not survive the 48 hours it takes for the capillary rescue of the graft and that no graft will survive if it is at a distance greater than 2 mm from a capillary. It has also been shown that a rise in interstitial pressure greater than 7 mm Hg will cause the graft to choke and necrose. This is why the external pre-expansion is so important. It provides the space to accept the graft and the highly vascular scaffold resultant from the expansion provides ready nourishment to the desperate graft. During the ISPRES conference in Rome, I discussed my aspiration method. Using a 12-gauge, 12-hole cannula and a constant 300-mmHg low-pressure K-VAC syringe I transferred the fat with a three-way valve through a closed system, where fat ﬁlled bags were placed in a hand operated centrifuge which delivered 15-20 G for two to three minutes. From there, the fat was passed through the closed system to the operating ﬁeld, where they were available to a 3-cc syringe with a 15-cm 14gauge cannula. Grafting is done employing the “sprinkler system” (as is the aspiration) so there is no coalescence of grafts. It’s highly important not to overgraft, so we

use a special monitoring system to aid us in knowing when to stop. Undergrafting can be corrected, whereas overgrafting can cause a major loss of tissue. During the conference we showed cases of augmentation, congenital deformities, and reconstruction. In many instances the recipient area was badly deformed by previous surgery or other unfortunate circumstances, which were resolved by the use of Rigottomies and in cicatrices of a block nature the PALF (percutaneous apponeurotic lipofilling) technique allowed for the meshing of the block converting the cicatrix into a matrix, which acts as a scaffold for lipofilling. In this situation we are using tissue generation to supplant a flap. We discussed the use of the expansion device post grafting as a stent to maintain stability until the graft could support itself. The successful mega volume graft is similar to successful farming. The farmer must prepare his SOIL just as the Plastic Surgeon utilizes an external expansion device and rids the recipient site of deforming scar tissue. The farmer prepares his SEEDS just as the Plastic Surgeon harvests and centrifuges the lipoaspirate in a careful and gentle way. Then the farmer plants his SEEDS just as the Plastic Surgeon inputs his grafts. And finally, the wise farmed SUPPORTS his tender plantlings just as the Plastic Surgeon does. The concept of mega volume fat grafting brings two charges; respect the fat graft/recipient site interface and respect the interstitial pressure post graft. These two items make up the essence of success. Having utilized these concepts we create a stromal/vascular scaffold and graft the interstices…..and we have created a new operation…a 21st century appearance.

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Towards a More Scientific Approach to Autologous Fat Grafting

Lee L.Q. Pu, MD, PhD, FACS, FICS, Professor of Surgery, Division of Plastic Surgery, University of California at Davis, Sacramento, California, USA e-mail: lee.pu@ucdmc.ucdavis.edu Autologous fat grafting has been considered as a valid option for soft-tissue augmentation in Cosmetic Surgery. However, its result has often been considered poor or unpredictable and is largely surgeon-dependant. Less desirable outcomes after fat grafting are probably due to lack of “good” surgical technique that was poorly studied in the past. Recently, one technique of fat grafting has been popularized and used by many surgeons. However, whether recent scientific studies have supported the use of this technique remains largely unknown. In order to help Plastic Surgeons gain more insight to this valid fat grafting technique, the author conducted a critical review of the current literature on this subject. The MEDLINE database was searched for all studies related to fat grafting research between 2000 and 2009. A total of 33 articles were identified in the database and were used in this study. To better address the findings of the study, the fat grafting technique was arbitrarily classified into 4 essential steps to determine how the donor sites should be selected and how the fat grafts should be harvested, processed and placed. Although the viability of fat grafts harvested from different donor sites shows no difference in some studies, a recent study shows that more adipose-derived

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stem cells are found within the fat grafts harvested from the lower abdomen or inner thigh. Fat grafts harvested with low-pressure syringe suction and processed with centrifugation at 3000 RPM for three minutes clearly have better viability than those harvested and processed after conventional liposuction. In addition, viable adipocytes and adipose-derived stem cells, as well as angiogenic growth factors, can be concentrated within the fat grafts after centrifugation with the same setting. Several studies also show that the fat grafts injected should have maximal contact with the vascularized tissue in the grafted site; better survival is achieved if in a small amount is placed with each pass, using multiple passes in multiple tunnels and multiple tissue levels. The estimated overall survival of fat grafting with above techniques is about 40 to 60% or higher. It becomes clear that several basics in this established fat grafting technique have gained much of scientiﬁc support and should be followed, in order to achieve an optimal outcome for our patients. These basics include proper selection of donor sites, harvesting fat grafts with an atraumatic technique, processing fat grafts with centrifugation in an appropriate setting and placing fat grafts with a unique fashion as described above.

Delayed Fat Reconstruction in Breast Conservative Surgery Delayed breast reconstruction in Breast Conservative Surgery (BCS) is one of the most beneficial scenarios for this new technique. Both procedures of fat transfer to the breast (volumetric and regenerative) are combined in the reconstructive approach of defects after resection and radiotherapy due to BCS(1). Lipofilling technique has been used for many years in aesthetic surgery, improving the results of partial reconstruction in breast cancer patients. There are numerous reports on total breast reconstruction with repeated fat transfer sessions, but the technique is most frequently indicated in small defects and asymmetries. It is a simple and safe technique, which can be done incisionlessly and in an ambulatory setting. Rigotti et al demonstrated that fat transfer is more than a filler; it also enhances skin trophicity, which is always damaged (2) after radiotherapy. According to preliminary studies by Masetti(3), de Lorenzi(4) and Rigotti(5), fat transfer to the breast seems to be a safe procedure in breast cancer patients. Longer follow-up and more oncological series are urgently required to confirm these findings.

Carlos PestalardoAlberto Rancati Eduardo GonzalezJulio Dorr Instituto Oncologico Henry Moore, Buenos Aires, Argentina contact: rancati@gmail.com

A 42-year-old patient. Sequelae of Conservative Surgery + Radiotherapy

1. K. Clough, C. Nos, and A. Fitoussi, “Oncoplastic surgery for breast cancer,” Operative Techniques in Plastic and Reconstructive Surgery, vol. 6, no. 1, pp. 50–60, 1999. 2. A.M. Munhoz, E. Montag, E. Arruda et al., “Immediate conservative breast surgery reconstruction with perforator ﬂaps: new challenges in the era of partial mastectomy reconstruction?” Breast, vol. 20, no. 3, pp. 233–240, 2011. 3. R. Masetti, A. Di Leone, G. Franceschini et al., “Oncoplastic techniques in the conservative surgical treatment of breast cancer: an overview,” Breast Journal, vol. 12, no. 5, supplement 2, pp. S174–S180, 2006. 4. F. de Lorenzi, “Oncoplastic surgery: the evolution of breast cancer treatment,” Breast Journal, vol. 16, supplement 1, pp. S20–S21, 2010.

1 year Post-op. One procedure, transfer of 80cc of fat

5. Rigotti G Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant PRS 2007. 119(%) 1409-1422

Fat grafting in delayed reconstruction of soft tissue tumors resections Volume deﬁcit after soft tissue tumors resection might be aesthetically unpleasent. Reconstruction after radiotherapy is a challenging procedure.

Claudio Angrigiani, Alberto Rancati, Eduardo Gonzalez, Luciano Tessari Instituto Oncologico Henry Moore, Buenos Aires, Argentina contact: rancati@gmail.com

Clasically, ﬂap reconstruction with autologous tissue is the ﬁrstthought option for cutaneous restoration and volume repair.

A 55 year-old patient with scar retraction post soft-tissue sarcoma resection & Radiotherapy. Post-op after 9 months

Five clinical cases were reconstructed with serial fat tissue transfer. All cases received three procedures done every 2 months, with an average of 200cc each. We observed a high rate satisfaction for both patients and surgeons. Thirty per cent volume reabsortion was observed.

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“Fat Transfer in the Delayed Breast Reconstruction After Radiated Mastectomy” “Converting indication from Autologous Flap to Implant Reconstruction” Abstract Delayed breast reconstruction in radiated mastectomy has always been a challenge and, most of the times, the best result is obtained by flap reconstruction. It has been demonstrated that radiated breast tissue can be improved by fat transfer. The authors performed fat transfer in 13 cases of radiated mastectomy, that would be classically selected to autologous flap reconstruction. This method permitted an expander-implant reconstruction in patients that would otherwise be candidates for flap reconstruction.

Alberto Rancat, Carlos Pestalardo Eduardo Gonzalez, Luciano Vidal Instituto Oncologico Henry Moore, Buenos Aires, Argentina Contact:rancati@gmail.com

In the 13 cases of delayed breast reconstruction, the mastectomized patients (age range 32 to 64 years) received radiotherapy with a 6-MeV electron accelerator after mastectomy, at least 6 months previously to the ﬁrst fat transfer session. The authors injected between 50 cc and 200 cc of lipaspirated fat between the skin and the muscle in three sessions, every two months, and proceeded in between to the use of external expansion (Brava system). After three external expansionfat grafting sessions, a Natrelle MV or FV 133- expander, range 300-400cc (Allergan, Inc.,Irvine, Calif.) was inserted under partial pectoralis major cover. After 4 – 8 months, the expander was removed and a Natrelle Style 410 corresponding cohesive anatomic silicone implant was inserted; contralateral surgery was simultaneously performed when necessary.

Pre op. MT - Rt – Expander Implant – Extrution

All these patients had indication of autologous reconstruction due to bad local tissue condition and this situation was reversed by improvement of elasticity and fat thickness after at least two sessions of fat grafting and external expansion. We think that fat grafting with external expansion has an indication in patients with PMRT, where direct expanderimplant reconstruction is not a good option, due to lack of tissue coverage, previous failures or high complication rate and when autologous tissue reconstruction is risky or patient do not accept it. With this technique it has been possible to convert the indication from ﬂap to expanderimplant reconstruction by an ambulatory, 5-step procedure, with high patient and surgeon satisfaction.

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Post op. After 6 months; 2 fat transfers of 200cc each + Brava +Thoracodorsal ﬂap + expander MV 400cc + implant 410 MX 400cc

We have found this method reproductible, safe and with no complications.

Facial surgery and the use of adipose-derived stem cells Natale F. Gontijo de Amorim M.D. Full member of Brazilian Society of Plastic Surgery Luiz Charles Araujo de Sa M.D. Staff of Clinica Performa, Reconstructive and Aesthetic Plastic Surgery Clinica Performa - Rua Visconde de Piraja 351, sala 1104 (Ipanema) Rio de Janeiro - RJ - Brazil natalefga@yahoo.com.br The purposes of facial aesthetic surgery have been to lift and replace muscular and cutaneous tissues, attenuate wrinkles and folds, eliminate excess soft tissue. However, emerging concepts that optimize the results have to be considered, as the use of fat and adipose-derived stem cells for volumetric replacement. The aim of our new research is precisely volume replacement, not as a substitute for conventional surgery, but as an evolutionary procedure (volumetric replacement) that addresses a key point in the ageing process, which is the gradual absorption of fat

long-lasting result of fat grafting. The great problem of the fat graft is the high incidence of absorption, so the result is unpredictable. Because of this, we analyzed the fat obtained during liposuction and processed it using 3 methods: decantation, washing and centrifugation. With the last one, it was possible to isolate a layer rich in stem cells, known as pellet 1, 2. Based on our results, we began to use the best part of each method of fat processing; decantation, washed fat and centrifuged fat mixed in a sample (Cell-assisted lipotransfer) and used this technique in patients with Romberg syndrome, facial trauma sequelae and volumetric replacement after face lifting, in a total of 20 patients. After the liposuction, the fat is processed at the surgical room and injected into the drawing areas of the patient’s face at the same surgical time, without any overcorrection. It was observed that with the use of adipose-derived stem cells, we obtained a long-lasting result after 1 year of follow-up. In conclusion, when we join the surgical evolution with autologous fat graft and the use of adipose-derived stem cells, inﬁnite possibilities of new advances will become available to facial Plastic Surgery.

Preoperative and Postoperative (1 year after) aspect of cell-assisted lipotransfer without overcorrection

and the deﬂation of the face. When volume replacement is indicated, it is fundamental to understand the fat graft. Adipose tissue contains adult stem cells, multipotent cells. These adipose-derived stem cells have the ability to differentiate into new adipose cells and endothelial cells to promote neo-vascularization and release angiogenic growth factors. This could guarantee the

REFERENCES: 1- Conde-green, A., Gontijo de Amorim, N.F., Pitanguy, I.; Inﬂuence of decantation, washing and centrifugation on adipocyte and mesenchymal stem cell content of aspirated adipose tissue: a comparative study. J PlastReconstrAesthet Surgery, 63, 1375-1381, august 2010. 2- Conde-green, A., Baptista, L.S., Gontijo de Amorim, N.F. at cols; Effects of centrifugation on cell composition and viability of aspirated adipose tissue processed for transplantation. AestheticPlasticSurgery, 30:249-255, march/april 2010.

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Breast augmentation with own fat Amin Kalaaji, Cecilie Bergsmark Bjertness, Kjell Olafsen. Oslo Plastic Surgery Clinic, Oslo, Norway

Correspondent author: ami.kal@online.no

Introduction: Fat grafting has been a well-known clinical method for reconstruction of small defects and recently applied in face, breast reconstruction and breast augmentation as an alternative to breast implants.

Patients: Oslo Plastikkirurgi Clinic has, since 2008, carried out 38 breast enlargements with fat grafting on patients with hypoplasia mammae, asymmetry and in a few cases with mastopexy. The patients had to fulﬁll three criteria to become candidates for surgery: no use of foreign objects, existing fat to be corrected - not just a “donor site”, and a realistic expectation of volume increase of the breasts.

have removed unwanted fat. However, far from all patients obtained the desired volume. Furthermore, it is rather difﬁcult to calculate gained rest volume and some patients were disappointed by the resorption process, in contrast to the large breast volume seen directly after operation with the subsequent swelling. The method is still in the establishment phase. Factors like centrifugation, local anesthetics, cannulas used, preoperative expansion and injected fat amount still have an unclear effect on the ﬁnal result.

Conclusion: Provided that strict patient selection is applied, this method could be a good alternative for breast enlargement. A longer follow-up time and multicenter studies should be performed before ﬁnal conclusions can be made. Editor’s Note: This report points out the importance of pre-expansion in grafts of more than 200 cc to the breast. The recipient site is choked because of interstitial pressure.

Method: Fat was usually harvested from the abdomen, thigh, buttocks or knee. The fat was machine-centrifuged for three minutes and grafted in intersecting and parallel canals through small incisions using Coleman’s cannulas. A loose bra was used postoperatively. In recent patients we used a manual centrifuge and these patients (10 patients) are still under evaluation.

Before and 1 year after

Results: Average injected fat in left breast: 219 ml, right breast: 221 ml. Resorption rate was 40-60% in most cases, but 7 patients had more than 60%. Further injections were performed on three patients. Three more patients chose breast implants because there was not enough donor fat and/or because their expectation about breast volume with this method was not satisfactory. Two small cysts were observed.

174 ml right side, 150,5 ml left side

Before and 6 months after

Discussion: Patients obtained a natural feeling, better fullness in desired areas and 246 ml right, 246 ml left side

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Stromal vascular fraction isolation manual protocol. A cheap and easy way to control the production of adipose derived stem cells Radu Ionescu MD, Nicolae Antohi MD, Tiberiu Bratu MD

Fat and the discovery of adipose derived stem cells put Plastic Surgery in the frontline of new frontiers of science, the place where we, with our ability for public relations and safety of good practice in lipotransfer , we develop a powerful marketing tool, maybe too powerful, performing this type of surgery with a certain lack of knowledge and scientiﬁc data, a fact that can make the ADRC research to be stomped by a increased number of questions concerning the safety and efﬁcacy of Adipose Derived Stem Cells treatments. The main objective of this work is to standardize the protocol of Fat harvesting, SVF preparation and Lipotransfer.

Fat harvesting has to be performed using low aspiration pressure of 0.35 bar, a cannula of maximum diameter of 3mm, tumescent or super wet, buffer solution for inﬁltration- with a low dose of xyline at 37° Celsius (see photo 1) The Preparation of SVF is performed in the operation

room on using GMP devices and drugs, in approx. 60 min, on a standard protocol of 9 steps (see photo 2). The Collagenase used is Serva NB6, GMP approved

and inactivation of the collagenase is effectuated with Actovegin (Nikomed) and PRP. The lipotrasfer is effectuated with a 2-mm cannula, with no pressure on the plunger, micro droplets, for 1cc of fat transfer- SVF from 1cc fat. First the lipotransfer, after 20 min SVF with PRP, permits post traumatic lymphocytes and chemokine’s that induce hypoxia, who activate the ADRC and stop them from migration. A quantity10% of prp+svf will be sent to the lab to have culture probe.SVF was cultured in DMEM medium with 20% FBS . Cells were analyzed by ﬂow cytometer (FC 500 -Beckman Coulter), found to be positive for CD31, CD34, CD90, CD105 surface antigens. The cells viability was 91% when tested using 7-AAD on the ﬂow cytometer. Stem Cells CFU-F 1-5% of total SVF.

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Autologous fat transplantation improves wound healing We analyzed a case series of 8 patients with chronic leg ulcers, on which sublesional autologous fat transplantation was performed. After debridement of the ulcer, liposuctioned fat tissue from the abdominal wall (centrifuged at 150g for 3 min.) was transplanted below the wound and into the wound edges.

Thamm OC, Phan TQV, Thieme D, Averkiou D, Weinand C, Spilker G Clinic for Plastic Surgery, Rekonstructive- und Handsurgery, Burn Center, Public Clinics of the City of Cologne, Merheim Hospital, University of Witten/Herdecke

The ulcers existed between 8 weeks and 4 years before the intervention. After debridement, the wound size averaged 6.41 ± 9 cm2. After 6 weeks, the wounds have decreased by 72 ± 10%. The mean duration until complete healing was 12 weeks.

It is assumed that autologous fat transplantation improves healing of chronic leg ulcers. To prove this hypothesis a prospective, controlled, randomized, clinical trial is currently conducted at our department.

Chronic wound with exposed bone after bunion surgery before lipoﬁlling

Situation 22 weeks after first lipofilling procedure. The second lipofilling was performed after 12 weeks.

The role of LASERS in FAT management during complex surgical cervico-facial rejuvenation Dr Dana Jianu MD PhD, ProEstetica Medical Center

THE GOAL Our goal is to restore a youthful appearance through a surgical less invasive treatment with visible and long lasting effect. DETAILS OF THE SOLUTION 1. “AdipoLASER reJuvenation” of face and neck - a personal method of Dr. Dana Jianu; a simultaneous incisionless combination of 4 surgical techniques: fat graft, fat LASERlysis, liposuction and fractional CO2 LASER resurfacing. 2. It is known that fat grafts to the face improve skin texture and quality. FRACTIONAL CO2 LASER works in synergy with fat in this respect; in addition, it improves the metabolism of cells including the transplanted adipocytes due to a LASER PHOTOBIOACTIVATION REACTION (“LLLT”). 3. LASER PHOTOBIOACTIVATION is a possible optimizing factor for fat graft survival, opening new paths for research and clinical applications. 4. Experience: 50 cases with all 4 treatments and 150 cases with single or double procedures. 34

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13/07/2011 (before)

22/09/2011 (2 months post-op)

Large volume liposuction and fat transfer to the buttocks John Walker, M.D.

BACKGROUND AND METHODS

Postoperative

A single surgeon’s experience, using the same method, instrumentation, and technique, in a ﬁve-year cohort of 350 patients is described. Safety concerns, and results after the transfer of between 1000-2000cc of fat per hemigluteus, using a 5-level patient-evaluated satisfaction scale with an 83% response rate is described. A mean follow up of 3.5 years, with a maximum of 6 years, with an average of 1250cc per side.

Standard use of Ciproﬂoxacin, close follow-up, compression garments that are changed to a second stage garment at 2-3 weeks, with reduced pressure built into the garment over the buttocks. Arnica Montana, bromezyne for 1 week and massage of the harvest area, again with Retinols/Retinoic acid to increase subnormal vasculature that may increase amount of fat “take” and increase dermal collagen and elastin.

TECHNIQUE AND SAFETY CONSIDERATIONS Pre-Operative Patient selection: ideally, a non-smoker, no blood thinners (Aspirin containing compounds, green tea, etc.), no corticosteroids, arnica montana pre-operatively, preparation of harvest area AND donor area skin with massage and Retinols/Retinoic acid to increase subnormal vascularisation, and increase collagen and elastin content.

Peri-Operative Standard preoperative antibiotics: Ancef 1g IV 30 minutes prior, Chlorhexidine (posteriorly redressed a second time prior to injection once prone). The cells should still be warm when transferred, the total time of these surgeries is typically 90 minutes for a 5-liter harvest and 2500 cc transfer. Massage injected fat AWAY from the injection site before closing the sites close to recipient area. Reduced vacuum of -18 mm Hg, reducing cell rupture, warm sterile saline in the capture container for a soft landing and to provide an “auto-rinsing” medium. Fat is harvested rapidly, typically harvesting 5-6 litres at a time using 1:1 inﬁltration using warmed, standard Klein’s wetting solution. Graft preparation is simple sterile saline rinsing, decantation, and removal of infranatant. Fat is injected in a retrograde manner, avoidance of injecting “lakes” of fat, “lipostructural” threading, in multiple planes concentration in the gluteal muscles and also sub-dermal. Injection instrumentation is a personally designed 3mm “Inﬁltration type” cannula which has a blunt tip and radially spiraling 1.5mm holes. A “radial fan pattern” of fat injection, concentrating on injecting microdroplets, using a single, midline, mid sacral level injection site.

RESULTS AND CONCLUSIONS A postoperative satisfaction survey with median 3.5 years after single surgery: 83% response rate: Excellent =153/290 (56%) , Very Good=74/290 (27%), Good=55/ 290 (9%) , Fair=8/290 (3%), Poor=0 Fig A) Results of 1500cc per side, at 3.5 years postoperatively; Fig B) 1200cc of fat transfer per side at 3 years postoperatively 97 % of patients are female, 2% are transgender, and 1% are male. Age distribution: 56% are 35-50 yrs old, 35% are 25-35 yrs old, 94% of patients are Hispanic, although multiple race groups are represented, showing the efﬁcacy across these. Complications are low: 1 cellulitis, 2 gluteal infections, 2 chronic pain (> 1 month, all eventually resolved), 3 transient nerve complaints, 6 complaints of too small volume, and 2 complaints of shape being too ﬂat, total: 0.6%. Large volume liposuction and fat transfer to the buttocks with volumes of 1000-2000 ml, is a safe, reliable, predictable procedure with high levels of patient satisfaction and low complication rates in non-smokers, not on Aspirin compounds or corticosteroids aged 18-72 yrs old. Issue 8

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Proper facial fat redistribution or facial fat fantasies

Miodrag M. Colić, MD, PhD Autologous facial adipose tissue deposits represent a reliable source for volume replacement in different regions of the face. Fat excess is most often present in the submental and submandibular area, where it can be easily harvested by using standard techniques of superﬁcial syringe liposuction. In this manner, we can reshape these regions and, after careful manipulation, use that same fat to correct other facial regions where it is needed.

On the other hand, another less known source of facial fat tissue can be mobilized during certain ancillary procedures and later used for the replacement of the missing tissues in some other facial areas. Such sources can be Bichat’s fat pad, nasolabial fat excised during facelift, infraorbital and supraorbital fat pads. That adipose tissue is somewhat structurally different from the aspirated submental fat and therefore more complicated to insert in the other areas, especially because it cannot be inserted using standard techniques of fat injection. Those fat transplants are therefore introduced using various maneuvers with different instruments, such as tendon forceps, long blunt needles, ﬁne cannulas etc. The observed percentage of fat taking is not much different than that of the technique of structural fat grafting and even in many cases, decreased resorption is noticed, probably due to the more careful manipulation, immediate placement into vascular bed and no ﬁltration at all.

Prominent nasolabial folds before and after treatment with fat pads

One year after fat grafting of the nasolabial area

Orbital fat pads to be placed under nasolabial folds after subcision

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Histological specimen was taken during later facelift procedures, which showed clear incorporation of previously inserted adipose grafts into the surrounding tissues, with the visible border between the fat tissue and nasolabial fold adhesions. That means that even larger fat pads, like Bichat’s or the orbital fat pads, can be taken, if carefully placed under the previously subcised nasolabial folds.

“3L & 3M” integrated autologous fat grafting technique in Asian people with long time follow-up our experience Kai Liu, Dan N Zheng., Yun Xie, Bin Gu, Tao Zan, Shuang B Zhou., Qing F Li Ward II, Department of Plastic & Reconstructive Surgery Shanghai ninth people’s hospital, Shanghai Jiaotong University School of Medicine No. 639, Zhizao Jv Road, Shanghai, China 200011 drkailiu@126.com

In this report we present a modified Coleman fat grafting technique named ‘3L & 3M’ integrated fat grafting method, developed over the years for cosmetic facial contouring and cosmetic breast enhancement in Asian people. In our technique, fat grafts were harvested under low pressure with syringes, processed with low speed centrifugation. And then with low volume for each pass via multi-tunnel, multi-plane, and multi-point technique fat grafts, they were injected into the affected areas. Through glucose transport test and MTT assay, the fat grafts harvested with the integrated fat grafting technique have been verified to have significantly better viability compared with fat tissue harvested from traditional liposuction for body contouring. At an interval of 3 to 6 months, 378 patients who needed facial contour and/ or breast-size enhancement received 1-3 times of fat grafts injection. All patients were evaluated clinically and followed up from 3 to 9 years. Some of them were followed with sonography, mammography, or magnetic resonance imaging. Obvious improved facial and breast cosmetic contours were evident in most patients. More than 95.2% of the facial injection patients in this

series were assessed as very satisfied or satisfied by all observers (patient, surgeon, and layerperson). Only 4.8% of the patients were unsatisfied. While for the breast enhancement patients 80.3% were very satisfied or satisfied, and 19.7% were unsatisfied. Eleven patients (16.7%) developed liponecrotic cysts but only two patients decided to have the breast lumps surgically removed. In fact, the ‘3L & 3M’ integrated fat grafting technique significantly improves the survival rate of the transplanted fat. Autologous fat grafting is a safe and reliable option for facial contour and breast-size enhancement. However, more than one procedure may be required to achieve an optimal outcome. Editor’s Note: The author states, “the ‘3L & 3M’ integrated fat grafting technique significantly improves the survival rate of the transplanted fat”, but gives no evidence confirming this. In addition he states a 19.7% “unsatisfied” result in grafting to the breast. It’s this Editor’s opinion that mega volume fat grafting (as to the breast) carries unique requirements and we would be extremely disappointed with that high level of unsatisfied patients.

Severe upeyelid hollow patient with autologous fat transplantation

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NATIONAL ASSOCIATIONS’ & PLASTIC SURGERY ORGANIZATIONS’ NEWS

Brazilian Society of Plastic Surgery Dear Colleagues and Friends, We are very happy to announce the 31st JORNADA CARIOCA DE CIRURGIA PLÁSTICA that will be held in Rio next August from 1 to 4 . This has become a traditional meeting for worldwide Plastic Surgeons, who gather in the “Marvelous City “ to discuss the most exciting issues of our specialty while enjoying the ambience of charm and friendly brazilian hospitality. . This year we will focus INNOVATIONS ! More than ten outstanding plastic surgeons from different countries have already responded to our call , assuring tremendous moments of foremost advances on Plastic surgery for an audience of more than one thousand! FATGRAFTING ( clinical and research ) , BREASTRECONSTRUCTION UP DATING, FACIAL REJUVENATION, ORBITO-PALPEBRAL TOPICS, BODY CONTOUR AND COSMETIC BREAST SURGERY are the leading subjects. Come and join us! city!

In time,August shows the best weather in the

Cordially yours Paulo Leal President of the Regional Rio - Brazilian Plastic Surgery Society

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Knowhow and “Snowhow” from Finland The members of the Finnish Association of Plastic, Reconstructive and Aesthetic Surgeons would like to warmly thank IPRAS for the quick and accurate statements and actions taken with the PIP-Implant issue. We found the worldwide interaction in the matter very helpful and supportive, indeed. In the end, the research and publicity evolving from this PIP scandal increased the public awareness of non-authorized aesthetic services and health care authorities in our country are considering establishing a national breast implant register. All in all, the past year has been busy. We will share some of the benchmarks reached in our society. In 2011 a member survey was conducted on the subject of current working status (public, private or both), fields of interest, planned years of work ahead, past and future training and an estimation of the future need for fully trained Plastic Surgeons in the own area of activity. The reply rate was 60 %, but representative of all age groups, geographic locations and different areas of interest. In Finland, in the last few years the working opportunities for newly graduated consultants have been saturated. In a country, were s.c. General Surgeons don´t exist anymore, it is important to maintain a balance between demand and supply of Plastic Surgeons, otherwise (with an oversupply) work previously performed by GP’s or General Surgeons are shifted to Plastic Surgeons (incisions of infected tissue, minor amputations, primary sinus pilonidalis, small lumps, etc). The Finnish Society was unanimously concerned about this development and focuses on maintaining the reconstructive nature of our specialty. Thus, it was decided that the number of Plastic Surgeons trained in our country will be substantially decreased. The Finnish Society has 4 annual national meetings, the largest being held in November in collaboration with all other operative fields. The free paper session of 2011 was the busiest ever, with a large number of high quality papers and presentations representing both clinical and research subjects. The session was so popular, that the auditorium early filled up and only standing seats were available for late arrivers. The top three papers selected by a jury are listed below. The winning paper, by a resident, Juha Kiiski from Tampere brings new insight in the pathophysiology of frostbites and led to a clinical recommendation of early trombolytic intervention in severe frostbites taken up by all leading centers in the country. The past winter has been exceptionally cold and rich in snow so the number of frostbite injuries has been substantial and the knowhow by this young colleague turned out very useful. Another thing we are very good at in

this country is to keep air- and land traffic functional despite 30-50 cm of new snow/day. We call this “snowhow”, and are happy to share with friends from warmer countries, where already small amounts of snow will close down airports:) Top 3 papers from the Finnish National Society Meeting in November 2011 1)Treatment of Severe Frostbites in Tampere University Hospital Juha Kiiski, Lauri Lindroos, Janne Korhonen, Hannu Kuokkanen, Jouni Havulinna Departments of Plastic Surgery, Dept. Hand and Microsurgery, Medical Imaging Centre, Tampere University Hospital 2) Stem cell enrichment and take-rate of fat transferred to the breast. A clinical and radiological prospective study. Hilkka Peltoniemi, Asko Salmi, Raija Mikkonen, Susanna Miettinen, Kai Saariniemi, Hannu Kuokkanen Private Plastic Surgery Hospital KL Oy, +Vantaan Magneetti Oy, Cell and Tissuetechnology Center Regea, Tampere University Hospital, Dept of Plastic Surgery 3) The effects of hypotension and norepinephrine on microvascular flap perfusion Leena Setälä, Kuopio University Hospital. Like in many other countries around Europe, we are struggling with increasing numbers of post-bariatric patients demanding Plastic Surgery interventions for a skin that has become several sizes too big. In order to cope with that, a work group led by Leena Setälä wrote our recommendation for post-bariatric Plastic Surgery, inclusion and exclusion criteria. The document has been sent to the Finnish Ministry of Social Affairs and Health and it will serve as guidelines for operative criteria. The small Finnish Society cherishes the memories and good experience obtained from the 6th World Society of Reconstructive Microsurgery Congress held in Helsinki last summer. This over 700-participant meeting was a huge effort for a small group but also served as great stimulation for our members and the local society. If you happen to be in the neighbourhood later in the spring, please don´t hesitate to visit us again in Finland. There will be two international meetings,(in English), also this year: The Nordic Burn Meeting in Helsinki May 2325 http://www.nordicburn2012.org/ and The Scandinavian Association of Plastic Surgeons (SCAPLAS) meeting in Espoo June 14-16, http://npf2012helsinki.org. Happy to keep in touch, Susanna Kauhanen, Secretary susanna.kauhanen@hus.fi Tarja Niemi, President tar.niemi@sci.fi

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Report from German Society of Plastic Reconstructive and Aesthetic Surgery

PD Dr. Christine Radtke Reconstructive and Aesthetic Surgery Department of Plastic, Hand- und Reconstructive Surgery Hannover Medical School, Hannover, Germany

PD Dr. Christine Radtke is working as a senior physician and scientist at the Clinic for Plastic, Hand and Reconstructive Surgery at Hannover Medical School, under the direction of Professor Dr. Vogt. She joined the department in 2003, became board certified in Plastic Surgery and received her habilitation in 2009, followed by an additional qualification in Hand Surgery in 2011. In her scientific work, PD Dr. Radtke investigated, parallel to her clinical appointment, the potential use of different cell types to enhance remyelination and axonal regeneration after injuries of the central and peripheral nervous system. The studies included both in vitro characterization of the cell types as well as the in vivo use in animal models and the potential clinical transfer for cell-based therapies in patients. PD Dr. Radtke was awarded the 2012 von-LangenbeckPrize of the German Surgical Society (Deutsche Gesellschaft für Chirurgie, DGCH) for her research describing the effect of transplanted olfactory glial cells (olfactory ensheathing cells, OECs) in the injured peripheral and central nervous system to improve axonal regeneration, remyelination and functional outcome. Given the increasing number of degenerative neural diseases, traumatic spinal cord injuries and peripheral nerve lesions, the transplantation of myelin-forming cells represent a promising approach to improve functional

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PD Dr. Peter Vogt President of the German Society of Plastic Reconstructive and Aesthetic Surgery Department of Plastic, Hand- und Reconstructive Surgery Hannover Medical School, Hannover, Germany

outcome of the injured and diseased nervous system. This work makes an important contribution to the potential use of cell-based transplantation strategies to improve regeneration in the peripheral and central nervous system after injury and illness. Since August 2007, PD Dr. Radtke is in charge of the working group “Peripheral Nerve Regeneration” at the Research Laboratory for Experimental Plastic Surgery with the continuation of the theme of the previous studies. In 2009, the DFG research group FOR 1103 application was granted and since 2011 her work is further supported by “Plus 3 Program” for outstanding basic scientists by the Boehringer Ingelheim Foundation. The von-Langenbeck-Prize ceremony of the German Surgical Society will be held in April 2012 at the Annual Meeting of DGCH. PD Dr. Peter Vogt IPRAS congratulates her cordially on this prestigious award! We are proud that this kind of epoch-making research is done by Plastic Surgeons. Many research groups in this ﬁeld are based in Germany. We look forward to their contributions for the 2nd ISPRES World Congress in mid-June 2013 in Berlin! Prof. Marita Eisenmann-Klein IPRAS President

HOPE AFTER FIRE - A Project for Reconstructive Surgery for Correction of Post Burn Deformities

A joint initiative of Ganga Hospital and Rotary Club of Coimbatore Metropolis, Coimbatore, India. In developing countries and due to the inadequacy of infrastructure for primary surgery in burn injuries, the incidence of post burn deformities is on the higher side. These deformities mainly affect the hands and the face. They affect the quality of survival for the individual. It also adversely affects the return to gainful employment and is a serious economic burden to the society.

As a measure to correct this problem, an unique initiative is being undertaken by the Department of Plastic Surgery, Hand and Microsurgery and Burns of Ganga Hospital in Coimbatore, India. The project termed “Hope after ﬁre” is a joint initiative of the hospital and the Rotary Club of the Coimbatore Metropolis. The scheme was launched on 10th March 2012 by popular ﬁlm actor Mr. Suriya in the presence of Dr. Mathangi Ramakrishan, Past President of the National Association of Burns of India. The interesting evening included a fund raising musical event. Dr. S. Raja Sabapathy, Chairman of the Plastic Surgery Department of Ganga Hospital, gave a series of lectures to the public and Rotarians and so far has managed to collect Rs.2.5 million (USD 50,000) for the project. With this, the department will be able to perform free surgeries for post burn deformities. The launch and the surgeries done have created a very positive impact among the public on the role of Plastic Surgery in Burns.

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Nicaraguan Association of Plastic Surgery Report

Meeting its objectives to promote continuous updating among its members, the Nicaragua Association of Plastic Surgery held a Symposium of Breast Surgery this past 16th of March. The Association had the honour to receive Dr. Silvia Espinosa, the Chief of the Plastic Surgery department and of the School of Plastic Surgery of the General Hospital in Mexico as a guest Professor,. The conferences took place in the morning and during the afternoons several mammary surgeries took place on patients with low incomes. The ANCP managed the fulďŹ lment of such surgeries in a private hospital to be completely free for the patients thanks to the generous support we received from the hospital, Hospital Salud Integral. Dr. Sandra Gutierrez President of the Nicaraguan Association of Plastic Surgery 42

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17th Annual Meeting of Pakistan Association of Plastic Surgeons Report The 17th Annual Meeting of Pakistan Association of Plastic Surgeons was held in the ancient city of Bahawalpur, from February 16th to 18th, 2012 with a very catchy theme – ‘Bridging the Gap’. Hosted most graciously by Quaide-Azam Medical College, this meeting was attended by more than 200 delegates. Bahawalpur lies in the southern part of the state of Punjab in Pakistan, on the western rim of the Thar Desert and used to be one of the princely states of the erstwhile Rajputana; it is a city of forts and mahals. The aura still remains princely and the guests are treated like ‘baratis’ and no less!

DAY 1 The conference started with a daylong operative workshop on hypospadias, conducted jointly by Mr. Aiver Bracka of UK and Dr. Obaidullah of Peshawar. Eight patients were operated on by Mr. Bracka’s own technique and both Stage 1 and Stage 2 were demonstrated in different patients. A lively interaction with the delegates from the OR ensured that they were made aware of every bit of the details of these procedures. The beautiful slit-like meatus, which Mr. Bracka would invariably produce, is hard to achieve by any other method of hypospadias repair.

DAY 2 INAGAURATION The conference was inaugurated by Prof. Faiz Mohammad Khan, the most senior Surgeon with a keen interest in our Specialty. The Chairman of the Organizing Committee, Dr. Muhammad Mughese Amin, welcomed the delegates to the meeting and the Principal of Quaid-e-Azam Medical College, Prof. Md. Usman Ghani welcomed us to his Institution

Session 1 Aesthetic: Dr. Md. Riaz Malik of UK, who discussed his experience of 287 face lifts, including 17 males, delivered the first academic lecture He also at times added a few reefing sutures in between the principal sutures to reduce the bunching up of SMAS. For those necks which were not adequately addressed by MASC lift, he would add an open neck lift with lipectomy and platysmal reefing. Mr. Aivar Bracka then spoke on ‘Penile lengthening and augmentation’ and felt that this surgery was being done to individuals only to let them have a change in self- perception, but not without body image counseling. While comparing the costochondral graft and the Turkish

delight for nasal dorsal augmentation Dr. Kanwal Yousaf of Islamabad in a study of 55 cases undergoing 33 primary and 22 secondary rhinoplasties felt that, while both offered satisfactory results, the Turkish delight had the advantage of the ability to mould the shape of the nasal dorsum after completion of surgery and even after splint removal. Dr. Md. Adil Abbas Khan offered a new technique of breast reduction and mastopexy, in which he combined a central mound pedicle, dermal wings and placation of the infra-nipple dermal ﬂap to reduce post operative pseudo-ptosis and produce a pleasing visual result. Having performed this procedure in 35 cases, the authors showed some very exciting long-term results. Dr. Tajammal Ahmed Chaudhry talked about rhinoplasty in patients with long skin sleeves, with thick and sebaceous skin and he based his observations on a series of secondary rhinoplasties that he performed in these patients.Dr. Md. Adil Abbas Khan then presented a method of modiﬁed open tip rhinoplasty for primary adult unilateral cleft lip nose correction in 32 adult cleft lip noses. The authors of this paper used rolled up praline mesh for alar base support and the pre- and 12-month post-operative frontal and basal images – traced on digitized pad by 2 surgeons were analyzed, using the ‘Symnose’ analysis program. The functional outcome and patient satisfaction were assessed using the validated Nasal Objective Scale (NOSE) and Rhinoplasty Outcome Evaluation (ROE) questionnaire respectively and objective improvement of nasal aesthetics and function were documented. Mr. Md. Riaz Malik presented a technique of lower eyelid blepharoplasty with cheek lift, in which the orbital fat was draped over the lower orbital margin, the loose orbital septum was plicated, a SOOF lift was performed and a canthopexy and a cheek lift suture were added, in order to rejuvenate both the lower eyelid and the midface. Prof. Fareed Mohammad Khan, while deliberating upon Breast Augmentation, traced the history of the procedure from 1895 and that of the implants. Stepwise he discussed the clinical examination, superior pole pinch, the markings, the breast dimensions, the choice of implant, the available software to predict the appearance of the breast after surgery using implants of various sizes, the choice of route of implant introduction, the level of implant placement and the aftercare. In a sponsored session, the German company Polymedics introduced ‘Suprathel’, an innovative synthetic skin substitute, which is being used as a single application in burns to reduce pain, infection, nursing care and to allow epithelialization to progress undisturbed; as the dressing is transparent, the wound can Issue 8

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constantly be monitored. Its ease of use and patient and doctor’s convenience makes it a valuable in burn units. However, its price will not allow it to be very frequently used in our sub-continent.

Session 2 – Cleft Lip & Palate: Prof. Ashraf Ganatra of Karachi started this session with a lecture on ‘Advancement in Cleft Lip Surgery in Pakistan’ and showed how both qualitatively and quantitatively this surgery has improved over the years and, particularly, after 18 Smile Train centres have started functioning in the country. Prof. A.K. Singh of India then presented his protocol for the management of hemifacial microsomia and showed how, with judicious use of distraction osteogenesis and by adding a growth centre, using a costochondral graft to replace the missing condyle in children, he manages to either achieve symmetry or minimize the asymmetry and how the final bi-maxillary surgery in adulthood is made simpler by managing the childhood effectively. He advocated ear reconstruction at 6 years and treatment of facial clefts at 3 months. Dr. M.M. Bashir while comparing the use of sutures only and cartilage grafts+sutures in treating secondary unilateral cleft lip nose deformities in a randomized trial comprising 60 patients concluded predictably that graft+suture technique improved tip projection more than sutures alone. Dr. Asad Awan shared his early experience of modified L-shaped rotation incision and Tajima incision in the repair of incomplete cleft lip. He was of the view that deficiency of the nasal floor and stenosis and asymmetry of the nostril can be avoided by this simple modification. Mr. N.B. Hart looked back to 1998 when a Plastic Surgery team from Hull, England– the Overseas Plastic Surgery Appeal, first visited Bashir Hospital in Gujrat, Pakistan to operate on the young and disadvantaged patients of CLP, other congenital anomalies and post burn contractures. Gradually, the number of Surgeons in the visiting team has gone up and now they are visiting twice a year. Local Surgeons, Anesthetists, nurses and OR technicians have been inducted and together they can now operate on 100-130 patients during each visit. Over 2000 patients have been operated to date, he added. Dr. K.S. Krishna Kumar then mesmerized the delegates by his ’How I Do It’ presentation of Bilateral Cleft Lip. Starting with the basic anatomy and the principles of the planned repair, he demonstrated step by step the markings, incision, flap elevation in the lip, alveolus and palate and then finally showed the sequence of closure from palate to alveolus to gingivo-labial sulcus to finally the lip and the nose. This single stage nose, lip and gingivo-palatoplasty of alveolus and anterior palate was greatly appreciated by everybody. Dr. Tahir Sheikh offered a technique to correct the saddling of the ala on the cleft side by anchoring the

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two alar cartilages blindly using sutures passed through hypodermic needles and thus avoiding an incision on the non cleft nasal vestibule.

Session 3: Dr. Tariq Iqbal of Islamabad started this session with a very well organized lecture on ‘Acute Burn Care – Past Present and Future’ in which he emphasized the importance of the concept of early escharectomy and grafting and the role of newer dressing modalities and skin substitutes. Dr. S. Bhattacharya of India then presented his concept of negative pressure dressings and emphasized that this extended way beyond the commercially available VAC. Lt. Col. Shahid Hameed presented an excellent review of propeller flaps used in reconstruction of defects in the lower third of leg in 15 cases. Perforators were dopplered in the vicinity of the defect along the course of the three major leg arteries and the most favourable one was chosen for coverage. They were easy to harvest and needed no micro-surgical hardware to execute. Dr. Zia ul Islam of Karachi then presented the use of pedicled TAP flap for axillary defects and laid special emphasis on sequencing this surgery properly, as not all defects require the TAP flap to be elevated as an island. He first raises the flap as a hatchet and if that does not fill the defect, the flap can be islanded and advanced as a V-Y; if even this is not covering the defect completely, the distal perforators can be ligated and the flap then is transposed. His flap planning and ‘cut as you go’ method of flap elevation was very logical and very well presented.

DAY 3 Session 1: Mr. Aivar Bracka started the proceedings of the day with an outstanding lecture on ‘Reconstruction of the Glans’ and showed how in Balanitis Xerotica Obliterans only debridement and split skin grafting can produce an aesthetically pleasing glans. Chemical and thermal burns of the penis also can be treated similarly. In cases of partial amputation of the penis, he insisted on dissecting the corporal heads, bringing them together and covering them with split skin graft to get a glans-like appearance. Dr. Humayun Mohammad of Islamabad spoke on ‘Hair Transplant Surgery – a Procedure or an Art’ and talked about every aspect of this surgery – patient selection, toning down their expectations, choosing the correct donor site, technical details of the bench surgery, choice of hair grafts to choose a particular site, direction of the hairs as they would come out of the scalp and the common mistakes that occur in this surgery. Prof. A.K. Singh of India deliberated upon the surgical correction of hypertelorism and discussed the operative steps in great detail, the osteotomies, the resection of the excess bone between the two orbits, the low lying ﬂoor of the

anterior cranial fossa and bone grafting of the defect in the cribriform region, the use of pericranial flaps and calvarial bone grafts etc. His presentation generated a lot of interest amongst the audience. Dr. Mahesh Kumar of Hyderabad, Sindh presented a large volume of work on the use of fasciocutaneous flaps to cover leg wounds with exposed bones – 82 patients in 4 years – and showed a bias for the reverse sural flap for covering a wide range of defects over the Achilles tendon, heel and malleoli.

Session 2: Prof. Muazzam Tarrar of Lahore started this session with a very well planned lecture on ‘Lower Limb Reconstructions’. He categorized the defects into upper, middle and lower thirds and then offered reconstructive options for each. He then offered options for lower third + foot, heel and lower third + heel defects and showed some judicious use of chimeric LD + Serratus Anterior flap for combined defects in the latter two situations. Dr. Md. Sarmad Tamimy presented the concept of ‘Free hand Perforator Flaps’ in which he harvested perforator flaps without prior Doppler. Dr. K.S. Krishna Kumar of India then presented the management of complex and mangled limb trauma with loss of multiple tissue elements and cautioned that though at first appearance these limbs may look like non-salvageable, if sensation to the sole of the foot can be assured, every effort should be made to preserve the limb. Dr. S. Bhattacharya of India, presenting ‘Vascular Injury in Lower Limb Trauma’ called it a true Orthopaedic emergency, as the patient is threatened by multiple problems – tissue viability, progressive blood loss, progressive ischemia and compartment syndrome. Dr. Rana Hassan spoke on ‘Free Fibular Flap for Ling Bone Reconstruction’. Dr. Mamoon Rashid, while deliberating upon phallus reconstruction, presented his mammoth series of 153 cases – mostly wheat thresher accidents, burns, industrial accidents, microphallus and, on 7 occasions, gender assignment. He offered a very

useful classification based on the site of external urinary opening and suggested a reconstruction for each of these conditions. He felt that the aim of reconstruction should be to have a penis with normal appearance, with a urethra in the centre, allow micturition in standing position, with adequate protective sensations to retain a stiffener, possess both tactile and erotic sensations and preferably be reconstructed in a single stage. Glans reconstruction is very important when this surgery is being done for gender reassignment. Dr. K.S. Krishna Kumar of India then presented a very exhaustive account of Brachial Plexus repair – stressing mainly the principles of repair, their justification and also the surgical steps. Dr. Uzair A. Quazi of Islamabad showed a series of 15 patients with Romberg’s Disease in whom he had used free adipofascial scapular flap as filler to correct the facial asymmetry and soft tissue deficiency. In the next 6 patients he chose the ALT flap and got equally good results and wondered whether a hidden donor site and more abundance of soft tissue made this flap a better flap for treating patients with Romberg’s Disease. Co. Irfan Ilahi of Islamabad presented a 15-year-old child with electric burns involving both upper limbs, in whom he performed an ALT flap cover in both the sides after debridement. Dr. Fazal ur Rehman of Karachi presented their first double toe to hand transfer and discussed the steps of surgery and his result. Col. Rizwan of Multan discussed the challenges faced while performing replantations and revascularizations in the paediatric age group, as he presented his series of replantations and revascularization of both upper and lower limbs. Dr. Saood from Prof. Tahseen Cheema’s unit in Bahawalpur presented a case of a cleft hand and discussed in brief the various types of clefting. Dr. Mughese Amin and his team made a wonderful effort to bring a host of specialists from Pakistan, UK and India to this conference in Bahawalpur and because of his untiring efforts the conference was a huge success. The social events planned for the spouses and the cultural evenings were simply magnificent!

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HISTORICAL ACCOUNTS

The Israel Society of Plastic and Aesthetic Surgery

Yoav Barnea, MD; Ami Barak, MD; Yaron Har-Shai, MD Members of the Israel Society of Plastic and Aesthetic Surgery Plastic surgery in Israel emerged during the War of Independence in 1948, when Dr. Jack Penn, head of Plastic Surgery at the University of Johannesburg, along with a medical team, made several trips to Israel in order to treat war casualties. Dr. Penn was assisted by Dr. Leo Bornstein, who was the founder of Plastic Surgery in Israel and, together with Dr. Bernard Hirshowitz, Dr. Tzvi Neuman and Dr. Isaac Kaplan, are recognized as the pioneers of Plastic Surgery in our country (Figure 1). The first Plastic Surgery meetings in Israel were held in 1965. These meetings were informal professional gatherings at which doctors exchanged ideas, experiences, and research projects. They were usually held in the major medical centers of the country; that is, Jerusalem, Haifa and Tel-Aviv. However, it was not until 1973 that the Israel Society of Plastic and Aesthetic Surgery (ISPAS) was officially founded and the regulations for the Society were established, including guidelines for the Society’s activities, organization of conferences, official residency programs in Plastic Surgery and formal elections of President, Secretary and Treasurer. Dr. Leo Bornstein was the first elected President of the Society. Following his active intervention in treating war wounds during the 1948 war, he specialized in Plastic

Founders of the Israeli Society of Plastic and Aesthetic surgery. Standing from left to right: Tzvi Neuman, MD; Bernard Hirshowitz, MD; unidentiﬁed member of Israeli Medical Corps of the Israeli Defense Forcces. Seated, from left to right: Isaac Kaplan, MD; Leo Bornstein, MD; Jack Penn, MD.

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Surgery with Dr. Joe Tamerin in New York. In 1950, he founded the first Department of Plastic Surgery in TelHashomer, Israel. The ISPAS original emblem, first designed in 1956, was inspired by the writings of the Bible, under the advice of distinguished biblical scholars. The words in the emblem were selected from the book of Isaiah and reflect the philosophy underlying Plastic and Reconstructive Surgery as envisioned by its pioneers: In the English translation, they say, “Every mountain shall be made low, the crooked shall be made straight and the rough places plain.” The figurative design includes a budding tree stump surrounded by an entwined serpent, symbolizing life (Figure 2). With the passage of time, the practice of Plastic Surgery in Israel has undergone significant changes and attained a high level of achievement in the areas of both Aesthetic and Reconstructive Surgery. The official ISPAS emblem was updated (Figure 3). Regrettably, the ongoing military conflicts surrounding The previous emblem of the the region have been a major Israeli Society of Plastic and factor in the acquisition of Aesthetic surgery. significant experience in the treatment of war trauma and burn patients. Currently, the Israel Society of Plastic and Aesthetic Surgery have 148 members. We have approximately 50 Plastic Surgery residents in training, working in 8 hospitals with a fully recognized teaching program around the country. The ISPAS holds an annual professional meeting in November, with attendance of Plastic Surgeons, nurses and paramedical Plastic Surgery staff. Moreover, every 2 years the ISPAS holds an international symposium on Plastic Surgery in Eilat at the Red Sea, in collaboration with our American colleagues. This is a very unique meeting, with topics on aesthetic and reconstructive issues and distinguished key-note speakers. The ISPAS moderates the residency program and is responsible for the Plastic Surgery Boards examinations (written and oral). The ISPAS newly elected officers are: Amos Leviav, MD Chairman, Anitta Vilan, MD Secretary and Ori Shulman, MD Treasurer.

History of the Italian Society of Plastic Surgery Presented at the RACS AGM Plenary Session “75 Years of Surgical Progress” on the 13th of May, 2002. Riccardo MAZZOLA, M.D.

SICPRE External Relations IPRAS Historian

The Italian Society of Plastic Surgery was founded in 1934 by Prof. Arturo Manna. Arturo Manna (1886-1972) was a General Surgeon from Rome with a particular enthusiasm for reconstructive surgery (ﬁg.1). When the French Society of Plastic Surgery (Société Française de Chirurgie Réparatrice Plastique et Esthétique) was established at Paris in 1930 by Charles Claoué and Louis Dartigues, he actively participated in the meetings and conceived the idea of creating a similar organization in Italy. On June 10th, 1934 in the lecture hall of the Royal Surgical Clinic of Rome, Prof. Arturo Manna established the Società Italiana di Chirurgia Riparatrice Plastica ed Estetica). Founding members were Arturo Manna,

Prof. Arturo Manna (right), founder and President of the Italian Society of Plastic Surgery, with Prof. Frantisek Burian (left) in Prague on July 1935

appointed President, Roberto Alessandri, director of the Royal Surgical Clinic of Rome, Vice-President, Riccardo Galeazzi, ophthalmologist, Secretary General and Vincenzo Di Filippo, Treasurer. On that occasion, Manna announced the publication of a bi-monthly journal, specifically devoted to this discipline. The first issue of “La Chirurgia Plastica”, as it was named the journal, appeared on January 1935. The International editorial board included R. Asis (Madrid), G. Bankoff (London), J. Bourguet (Paris), F. Burian (Prague), M. Coelst (Brussels), L. Bourguet (Paris), A. Davis (S. Francisco), J.F. Esser (Monaco), J. Maliniac (New York), G. Sanvenero Rosselli (Milan), E. Sheeahn (New York). “La Chirurgia Plastica” lasted until the end of 1941 (7 years), when it ceased its publication definitely, due to the WW2.

The cover sheet of the ﬁrst issue of “La Chirurgia Plastica”, the ofﬁcial journal of the Società Italiana di Chirurgia Riparatrice Plastica ed Estetica.

The ﬁrst Congress of the Italian Society of Plastic Surgery, held in Bologna on October 24th, 1935. Prof. H. Eckstein, honorary guest, delivers his lecture (left). Prof. Arturo Manna, President, (right).

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The first Congress of the Società Italiana di Chirurgia Riparatrice Plastica ed Estetica took place on October 24th, 1935 under the Presidency of Arturo Manna, at Bologna Archiginnasio, as a tribute to Gaspare Tagliacozzi, founder of Plastic Surgery, whose wood statue is preserved in that building. Prof. H. Eckstein from Berlin (fig. 3), Louis Dartigues from Paris and Charles Claoué from Bordeaux were the International honorary guests. The second Congress took place in Rome on October 20th and 21st, 1936, the third in Turin on October 23rd and 24th, 1937 and the fourth in Rome from October 20th to 22nd, 1938 with an important international participation. All of them were under the presidency of Arturo Manna. Due to the advent of WW2, the activities of the Society of Plastic Surgery ceased. They were resumed on 1950 with a memorable Congress, the first one postwar, held in Bologna in October 1950, under the Presidency of Gustavo Sanvenero Rosselli, having Jerome P. Webster as honorary guest. On that occasion Webster presented his book “The Life and Times of Gaspare Tagliacozzi, surgeon of Bologna”, a complete and well documented study on Tagliacozzi’s life and legacy. In the same year, the Italian Society of Plastic Surgery appointed Gustavo Sanvenero Rosselli, as President (fig. 4). He maintained that position until 1971, when he was replaced by other Italian Plastic Surgeons. In 1967, the Society endorsed the fourth International Congress of Plastic Surgery of the IPRAS (at that time named IPRS), which took place in Rome on October 1967, under the Presidency of Gustavo Sanvenero Rosselli. On 1976, the name of the Society was changed into Società Italiana di Chirurgia Plastica and more recently (1986) into Società Italiana di Chirurgia Plastica Ricostruttiva ed Estetica (SICPRE). The logo is represented by the renowned image of the arm flap nasal reconstruction, as it appears in Tagliacozzi’s book (fig. 5). The current Board of Directors includes: Michele Pascone, President; Enrico Robotti, President-elect; Francesco Conte, Past-President; Paolo Palombo, Secretary; Francesco D’Andrea, Treasurer.

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Gustavo Sanvenero Rosselli (1897-1974)

The Society, which has 480 full members and 750 associate members, fosters a Humanitarian program by establishing two fellowships for young Plastic Surgeons. The aim of this project is to organize surgical camps in developing countries where Plastic Surgery does not exist, for treating sequelae of burns/traumas, cleft lip and palates, etc. The ofﬁcial journal of the Society is the “Rivista Italiana di Chirurgia Plastica – Clinical and Experimental Plastic Surgery”, established in 1968 and published in English. In 2012, the Society celebrates its 61 Annual Congress in Palermo from September 24 to 27, under the Presidency of Francesco Conte. For more information visit the Society website: www. sicpre.it

History of Plastic, Reconstructive and Aesthetic Surgery in Yugoslavia, now Serbia Plastic and Reconstructive surgery has rapidly developed in Yugoslavia immediately after World War II, when centers were formed to primarily treat wounded patients with war injuries. A great number of war and peacetime invalids, as well as persons with congenital and acquired deformities of tissues and organs, brought up the need for the foundation of such a center in our country. As no specialists in Plastic and Reconstructive Surgery existed in the country, upon the initiative of the head of the Medical Service of Yugoslav Army, General Dr Gojko Nikolis, an agreement was made with the British authorities, under which a team of specialists was sent to Yugoslavia to treat the wounded, primarily those with injuries of the face and jaws. The first team of British specialists, comprised of a Surgeon - specialist in Plastic and Reconstructive Surgery, Anesthesiologist, Oral Surgeon, one nurse and one scrub nurse who arrived to Yugoslavia by the end of 1945. These specialists were close assistants of Mr. Harold Gillies, an internationally known expert in Plastic Surgery. The team had already achieved great experience in the treatment of war injuries. The task of the team was to treat wounded Yugoslavs, applying methods of Plastic and Reconstructive surgery. Until that time, our wounded were treated in the Allied Forces Hospitals in Italy. During 1946 three more teams of British experts were exchanged, with the main task to train our Surgeons, Anesthesiologists, nurses and technicians to work in Plastic and Reconstructive surgery. During that time Major Dr Vinko Arneri with his colleagues and physicians of other specialties were educated. With permanent and generous aid from the members of the British team they quickly became qualified for independent work and in July 1946, upon departure of the British specialists, managed to take over the complete activity in the field of Plastic and Reconstructive Surgery. Besides the treatment of war wounds sequelae, the activity was gradually transferred to the surgical treatment of defects of other etiology. Until 1948 the major part of surgical treatment covered reparatory and Reconstructive surgery of maxillofacial war injuries, as well as Plastic Surgery of various scar contractures on extremities. Gradually the specialist activity was widened, introducing operations not performed by British physicians. Also, civilian patients began to be treated (injuries at work and congenital anomalies). By the end of 1946 the II Surgical Department of the Central Military Hospital of the Yugoslav Army gained the title of Department of Plastic Surgery and Major Dr Vinko Arneri became its first head. Although the treatment of wounded and civilian patients was the main activity of the Department in the first stage (1945 / 50), educational activity was not neglected. It was conducted in the form of courses for nurses, medical technicians and physicians and intended to teach them

Miodrag M. Colić, MD, PhD specific treatments and care of patients in this surgical branch. At this time the physicians specializing at these courses passed specialist’s examinations, upon which they became the first specialists in Plastic and Reconstructive Surgery, besides Dr. V. Arneri who already possessed this title. When the Military Medical Academy was founded, the Department of Plastic and Reconstructive Surgery was upgraded in 1950 to Clinic for Plastic Surgery. Because of the significance of burns in war medical activity a specialized Department for the treatment of burns was formed within the Clinic in the beginning of 1954, with special staff and surgical theatre. Due to the increasing number of children being received for treatment of congenital malformations, a pediatric department was formed within the Department of Plastic Surgery, as well as the Section for plastic-surgical prosthesis. The Clinic for Plastic Surgery and Burns of the Military Medical Academy gradually became a well known institution for postgraduate studies, such as specialization in the field of Plastic and Reconstructive Surgery in Yugoslavia. So far, about 100 civilian and military physicians have specialized at the Clinic. Except for a small number of specialists working in Ljubljana, the specialists from other parts of former Yugoslavia conducted their specialization in Plastic Surgery at this Clinic and Belgrade University Clinical Centre. Among them were also physicians from other countries. Those specialists returned to their regional hospitals and formed clinics or departments for Plastic Surgery and burns in Belgrade, Novi Sad, Nis, Sarajevo, Skopje, Split etc. in former Yugoslavia. Later, the Section of Plastic and Maxillofacial Surgery was formed in the Serbian Medical Association and has been successfully collaborating with respective sections in other republics and provinces in former Yugoslavia through Yugoslav Association for Plastic and Maxillofacial Surgery. The members of the Association have participated in all significant meetings held in our country and abroad and submitted a great number of papers. It should be emphasized that Yugoslav Plastic Surgeons conducted a series of lectures in recognized centers of Europe and the USA. Prof. Dr Vinko Arneri was a co-author of the following worldwide known textbooks in Plastic Surgery: 1. J.M. Converse: “Reconstructive plastic surgery” W.B. Sounders Company, Philadelphia, 1977 2. J.N. Barron: “Operative plastic and reconstructive Issue 8

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surgery” Churchill Livingstone, 1980. 3. Charles E.Horton: “Plastic and reconstructive surgery of the genital area” Little, Brown and Company, Boston, 1973. Zora Janžeković from Maribor, today Slovenia, was the ﬁrst to describe early tangentional excisions as primary treatment of deep burns in the 1970s. The Clinical

there and passed the final examination after completing five (now six) years of training. Nowadays in Serbia there are Clinics and departments for Plastic Surgery and Burns in all major cities (Belgrade-2 specialized hospitals and 2 departments in general hospitals, Novi Sad, Niš, Kragujevac, Kraljevo, Ćuprija, Užice, Priština, Mitrovica, Subotica, Zrenjanin, Pančevo). Numerous private Plastic and Aesthetic Surgery clinics exist today all over the country. It is the responsibility of the national Society to have the complete control of their work and the quality of the service. Today Serbian Plastic Surgeons are joined in the Serbian Society for Plastic, Reconstructive and Aesthetic Surgery (SRBPRAS, before YUPRAS), which was established in 1996. The firstPresidentoftheSocietywasProf.DrBranislav Pantelić (1996-2001), followed by Prof. dr Miodrag M. Colić, (2001-2009) and Prof. Dr Marijan Novaković who was elected in February 2009. The Executive Board of

Marshall Tito’s visit to the ﬁrst plastic surgery hospital in Yugoslavia

Center of Ljubljana was one of the major institutions of Plastic Surgery and the late Dr Marko Godina was a world renowned microsurgeon and one of the fathers of replantation surgery. The Karapandžić ﬂap for the reconstruction of the lower lip defects after tumor resection, found today in all major textbooks, was designed and published by Professor Miodrag Karapandžić, former Director of the Clinic for Burns, Plastic and Reconstructive Surgery of the Belgrade University Clinical Center. This institution was established in 1985 and at that moment united all the signiﬁcant Plastic Surgery names in Belgrade and played the leading role in Clinic for Burns and Plastic Surgery in Belgrade

Prof. Vinko Arneri

Sir Harold Gillies

the education of new generations of Plastic Surgeons in Yugoslavia for a long period of time. With the capacity of 80 beds, it is also the largest one. Specialization in Plastic Surgery was conducted at the University centers, mainly at the Universities of Belgrade, Novi Sad and Nis. All educational activities were conducted mainly in those centers and in Military Medical Academy. Board certiﬁed Plastic Surgeons were trained 50

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the Society has 12 members. The Society is a member of IPRAS, ESPRAS, BAPRAS, EURAPS, EQUAM, EBA, IBA, MBC etc. The Society members actively participate in most of the major Plastic Surgery conferences all over the world. The International Society of Aesthetic Plastic Surgery (ISAPS) has currently 32 members in our country and Miodrag M. Colić, MD was the ﬁrst ISAPS National Secretary for Yugoslavia and Serbia afterwards, followed by Mićo Djuričić, MD. Prof. Dr Miodrag Colić entered the Board of Directors of ISAPS in 2004 serving two terms as a National Secretaries Chairman (2004-2008) followed by two terms as a Secretary General of ISAPS (2008-2012). He is also one of four European representatives to IPRAS. The Yugoslav Society hosted the 2nd Balkan Congress for Plastic, Reconstructive and Aesthetic Surgery and ISAPS Mini Course in May 24–26, 2001 in Belgrade. It also hosted the ISAPS Course in Sveti Stefan in 2005 which will be remembered for having almost 40 Faculty members. After the separation of Montenegro and the ﬁnal establishment of the Serbian Society it hosted two National Congresses in Belgrade, in May 2010 and 2012, as well as numerous educational courses.

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SUPPORT LETTER FROM BOARD OF TRUSTEES MEMBER

Dear colleagues and friends of IPRAS, I have always been certain that the only way forward is to have our eyes looking to the future, confident that plastic surgery will carry on thriving, absorbing new technologies and techniques. I have accompanied our society since its first steps, and I am glad to see visions transformed to reality! It has been my hope that IPRAS and its national societies will continue to be the forums where innovation will be presented, where the inquisitive mind will find others equally curious, so that plastic surgery may evolve within the framework of two principal objectives: to generously pass on knowledge to the next generation, and to assure safety to our patients. I am particularly happy that the upcoming IPRAS World Congress is to be held in beautiful Chile, in our continent of South America, where plastic surgery has made giant steps of development. I invite you all to add this important event to your plans for 2013 and to take advantage of the opportunity to attend one of the most important scientific gatherings for plastic surgery.

Ivo PITANGUY 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 (and patron) 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

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NATIONAL & CO-OPTED SOCIETIES’ FUTURE EVENTS 15 - 18 May 2012

11th SRBPRAS Congress

Location: Belgrade, Serbia - Venue: HYATT Regency Belgrade E-mail: info@srbpras.rs - URL: http://www.srbpras2012.org 18 – 20 May 2012

Controversies, Art and Technology in Breast and Bodycontouring Aesthetic Surgery, CATBBAS I Location: Ghen, Belgium - URL: www.coupureseminars.com - E-mail: seminars@coupurecentrum.be 22 - 26 May 2012

XIX International Meeting of FILACP

Location: Medellín (Colombia) - URL: http://www.filacp2012.com 29 - 31 May 2012

3rd European Congress on preventive, Regenerative & Aesthetic Medicine (ECOPRAM) Location: Istanbul, Turkey - Venue: Harbyie Military Museum - Contact: Irene Katti Telephone: +302111001783 - Fax: +302106642116 E-mail: i.ka@zita-congress.gr - URL: http://www.ecopram2012.com/ 05 - 07 June 2012

17th Meeting of the Euro-Mediterranean Council for Burns and Fire Disasters (MBC) & 25th Anniversary Commemorative Meeting Location: Palermo, Italy - Contact: Prof. Bishara Athiyeh - E-mail: batiyeh@terra.net.lb 16 - 17 June 2012

1st Seoul Rhinoplasty Forum

Location: Seoul, Korea - Venue: Seoul St. Mary’s Hospital E-mail: aid@pentaid.com - URL: http://www.srf2012.or.kr/conference/1st_html/ 04 - 08 September 2012

ISAPS 21st Congress

Location: Geneve, Switzerland - Venue: CICG URL: http://www.isapscongress2012.org/ 09 - 10 September 2012

IPRAS Course - “State of the Art” of Fat Transplantation in Regenerative Plastic Surgery & Microsurgery

Location: Sinaia, Romania - Venue: Casino Sinaia, Romania Contact: Nikos Antonopoulos - Telephone: +30 2111001782 - Fax: +30 2106642116 E-mail: n.an@zita-congress.gr - URL: http://www.roaps2012.com 11-12 September 2012

The XIIth Congress of the Romanian Association of Plastic Surgeons with Co-organization of Hungarian Association of Plastic, Reconstructive and Aesthetic Surgery Location: Sinaia, Romania - Contact: Nikos Antonopoulos E-mail: n.an@zita-congress.gr - URL: http://www.roaps2012.com 12 – 15 September 2012

LaserInnsbruck 2012

Location: Innsbruck, Austria - Venue: Faculty of Catholic Theology of the University of Innsbruck Contact: George Koliopoulos E-mail: congress@laserinnsbruck.com - URL: http://laserinnsbruck.com/

NATIONAL & CO-OPTED SOCIETIES’ FUTURE EVENTS 12 - 16 September 2012

10th National Congress of the Northern Cyprus Turkish Society of Plastic, Reconstructive and Aesthetic Surgeons Location: Girne, Cyprus - Venue: Merit Crystal Cove Hotel - Telephone: 0090 3124661466 E-mail: kongre@bilkonturizm.com - URL: http://www.kktcplastik2012.org 13 - 15 September 2012

43. Jahrestagung der DGPRÄC / 17. Jahrestagung der VDÄPC Location: Bremen, Germany - URL: http://www.dgpraec2012.de 10 - 13 October 2012

2nd World Congress of Plastic Surgeons of Lebanese Descent Location: Cancun, Mexico - Venue: Convention Center Cancun URL: http://www.congressmexico.com/LSPRAS2012 26 – 30 October 2012

Plastic Surgery THE MEETING Location: New Orleans, USA - E-mail: registration@plasticsurgery.org URL: http://www.plasticsurgerythemeeting.com/ 1st November 2012

The 1st IPRAS International Trainees’ Meeting Location: Athens, Greece - Venue: Royal Olympic Hotel Contact: Mr Nikos Antonopoulos - E-mail: n.an@zita-congress.gr - URL: www.iquam2012.com 01 - 04 November 2012

10th IQUAM CONSENSUS CONFERENCE Location: Athens, Greece - Venue: Royal Olympic Hotel Contact: Nikos Antonopoulos - Telephone: +302111001782 - Fax: +302106642116 E-mail: nikos.antonopoulos@zita-congress.gr - URL: www.iquam2012.com 4 - 8 November 2012

Lucknow, India: 47th Annual Conference of Association of Plastic Surgeons of India E mail: apsicon2012@gmail.com - Central Helpline: +91 9651 06 9277 - URL: http://www.apsicon2012.com/ 08 - 10 November 2012

Marrakesh World Aesthetic Conference Location: Marrakesh, Morocco - Venue: Palmaraie Palace URL: http://www.mwac2012.com/ 14 – 18 November 2013

49th Brazilian Congress of Plastic Surgery Location: Porto Alegre - URL: http://www.cirurgiaplastica.org.br/

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IPRAS WEBSITE

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JOIN YOUR COLLEAGUES The first website that gives you the opportunity to upload your scientific profile for free!!

IPRAS Journal

Now it is very simple to upload your scientific profile and gain the benefits of being under the IPRAS umbrella. Try it…!! Sign up on www.ipras.org and follow the following steps: 1. Create an account by clicking “Member’s login” on the top right-hand corner and then select the “Create new account” tab. 2. Fill out your “Username”, “Email” and “Password”, as required. 3. Select the option “Doctor” and your country, under the section “If you are a doctor, complete the following”. 4. Once all account details have been added, click on “Create new account” button. Then you click on “EDIT” and then on “DOCTOR PROFILE”. This is the section where all the information of your scientific profile can be uploaded. You may complete the fields with the information that you prefer such us: Personal Picture, Hospital Position, Affiliation, Special Field of Interest, Contact Details, Memberships, Topics of Special Interest, Publications etc. At the “EDIT” section you may proceed to the appropriate corrections at your account such us to change your password or to update personal information. When you complete the aforementioned steps there will be one last step remaining for your details to be uploaded on the IPRAS website. The application must be approved by the National Association you are a member. The application will

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be sent at the Association of the country that you have declared, ensuring that only IPRAS members of good standing and high ethical principles are able to upload their personal details. As soon as your Association verifies you as a member, your profile will automatically be uploaded at the website’s, “Find a doctor” option in the “Members”section. It is also up to you to decide whether your profile will be classified as “private” or visible to all visitors of the IPRAS webpage. Our aim, besides facilitating communication among colleagues, expands to allowing patients to verify the good standing and high ethical principles of the doctors’ profiles hosted, allowing them to choose qualified IPRAS members for needed procedures. In conclusion, I want to emphasize the usefulness of the IPRAS website FORUM. A section you will gain access to, as soon as your profile has been accepted and uploaded. Only verified plastic surgeons can use it and read its contents. Therefore, you will have the opportunity to exchange ideas, news regarding plastic surgery techniques, news from your National Association, alerts and all other information you would like to share with your peers. Don’t miss the opportunity to make the IPRAS website twice as useful to you! If you face any difficulties please do not hesitate to contact me at: maria.petsa@iprasmanagement. com . Always at your disposal! Maria Petsa IPRAS Assistant Executive Director

INDUSTRY NEWS About the RESTORE Procedure

March 19, 2012

Cytori Breast Reconstruction Cell Therapy Trial Results Published Zug, Switzerland and San Diego, CA – Cytori Therapeutics (NASDAQ: CYTX) announced today the publication of RESTORE-2 trial results in the peer-reviewed European Journal of Surgical Oncology. RESTORE-2 is a 71 patient multi-center, prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of the breast after cancer surgery. The majority of patients underwent radiation prior to the procedure, creating an unfavorable ischemic environment for which breast reconstruction with ADRC-enriched fat grafting appears to be ideally suited. Key findings of the trial were: • High rates of investigator (85%) and patient (75%) satisfaction with the overall treatment results at 12 months; • High rates of investigator (87%) and patient (67%) satisfaction with overall breast deformity (based on functional and cosmetic outcomes) at 12 months; • Improved breast contour at both six and 12 months, demonstrated by blinded MRI assessment; and • No local cancer recurrences or serious adverse events related to the ADRC-enriched fat grafting procedure. “Following cancer treatment, the patient’s breast tissue can suffer from radiation injury, scarring and tight skin,” said Consultant Plastic and Reconstructive Surgeon Mrs. Eva Weiler-Mithoff, co-principal investigator for RESTORE-2 at the NHS Glasgow Royal Infirmary Hospital. “This new technique is exciting because it may offer the opportunity to resolve some of the most difficult to treat conditions where other approaches, including fat alone, do not achieve satisfactory results.” ADRC-enriched partial mastectomy breast reconstruction is marketed in the EU as the RESTORE Procedure and represents an innovative treatment option with significant cost savings potential. The procedure can be performed on an outpatient basis. Satisfactory results can be achieved in a single procedure for the majority of patients. In contrast, competitive approaches are more costly with lengthy hospital stays, require repeat procedures and increase the overall burden on the healthcare system. Furthermore, because of these limitations, physicians are often reluctant to recommend reconstruction for patients with partial mastectomy defects and radiation-induced damage in the breast. Each year, approximately 450,000 European women are diagnosed with breast cancer. Of the newly diagnosed breast cancer cases, 7080% are eligible for breast conserving surgery, where only a portion of the breast is removed rather than the full breast. In the European G5, there are an estimated 1.25 million women who have undergone partial mastectomy. The majority of these patients are left with a sizeable volume defect, scarring and often radiation damage. “Given that there is no widely accepted reconstructive option available today for partial mastectomy patients, this procedure could well address this substantial unmet need and help complete the overall cancer treatment,” said Marc H. Hedrick, president of Cytori. The European Journal of Surgical Oncology is the official journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

During the RESTORE Procedure, fat is taken from the patient’s stomach, hips, thighs, or other areas by liposuction. Some of the tissue is processed in Cytori’s Celution® system to extract the patient’s own regenerative cells which occur naturally inside the tissue. The extracted cells are then combined with the remaining fat tissue, forming an ADRC-enriched fat graft that is injected into the breast to restore its natural look and feel. In addition to providing an entirely natural reconstruction, the procedure is minimally invasive with the potential to reduce scarring. The Celution® system is not commercially available in the United States.

About the RESTORE-2 Trial RESTORE-2 is a 71 patient European post-marketing trial primarily intended to measure patient and physician satisfaction in reconstructing the breast utilizing the Celution® system. The trial took place at the following sites: Hospital General Universitario Gregorio Marañón in Madrid, Spain, Glasgow Royal Infirmary in Glasgow, Scotland, KU Leuven University Hospitals in Leuven, Belgium, Azienda Ospedaliero Universitaria Careggi in Florence, Italy, Instituto Valenciano Oncología in Valencia, Spain, Norfolk and Norwich University Hospital in Norwich, England, and Jules Bordet Institute of Cancer in Brussels, Belgium.

About Cytori Cytori Therapeutics is developing cell therapies based on autologous adipose-derived regenerative cells (ADRCs) to treat cardiovascular disease and repair soft tissue defects. Our scientific data suggest ADRCs improve blood flow. As a result, we believe these cells can be applied across multiple ischemic conditions. These therapies are made available to the physician and patient at the point-of-care by Cytori’s proprietary technologies and products, including the Celution® system product family. www.cytori.com

Cautionary Statement Regarding Forward-Looking Statements This press release includes forward-looking statements regarding events, trends and business prospects, which could affect our future operating results and financial position, such as our expectation of increased hospital and patient availability, and our expectation of acceptance of the treatment for lumpectomy and radiation scarring. Such statements are subject to risks and uncertainties that could cause our actual results and financial position to differ materially. Some of these risks and uncertainties include regulatory uncertainties, the perceived quality of our clinical data, physician and patient acceptance of our technology, and other risks and uncertainties described under the “Risk Factors” in Cytori’s Securities and Exchange Commission Filings, including its annual report on Form 10-K for the year ended December 31, 2011. Cytori assumes no responsibility to update or revise any forward-looking statements contained in this press release to reflect events, trends or circumstances after the date of this press release.

EU Stefanie Bacher sbacher@cytori.com +44 77 0202 7053 (mobile)

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IPRAS PAST GENERAL SECRETARIES

Tord Skoog (Sweden) 1955 - 1959

David N. Matthews (U.K.) 1959 - 1963

Thomas Ray Broadbent (USA) 1963 - 1967

William M. Manchester (N. Zealand) 1967 - 1971

John Watson (U.K.) 1971 - 1975

Roger Mouly (France) 1975 - 1983

Jean-Paul BossĂŠ" (Canada) 1983 - 1992

Ulrich T. Hinderer (Spain) 1992 - 1999

James G. Hoehn (USA) 1999 - 2006

Marita Eisemann-Klein (Germany) 2006 - 2011

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International Confederation for Plastic Reconstuctive and Aesthetic Surgery

IPRAS BENEFITS FOR INDIVIDUAL MEMBERS • Immediate information about safety warnings on devices, drugs and procedures • Information regarding the proper use of all materials, substances and techniques related to Plastic, Reconstructive and Aesthetic Surgery through IQUAM (the International Committee of Quality Assurance and Medical Devices in Plastic Surgery) General Consensus statement, with an update every 2 years • Free electronic receipt of the IPRAS JOURNAL • Information regarding harmonization of training • Information regarding accreditation of Plastic Surgery Units • Promotion of Patient Safety and Quality Management (in cooperation with WHO) • Protection of the Specialty and Promotion of its image world-wide • Promotion of Individual Members of National Associations by uploading their scientific profile on the IPRAS website • Exchange of ideas, views, thoughts and proposals though the IPRAS website and its FORUM section • Certificate for Individual Members to display their IPRAS Membership • Regular updates on necessary information and the right to participate in all events organized by National Societies and IPRAS • Strengthening ties of professional cooperation and friendship with colleagues beyond national borders all over the world • Information regarding the developments of plastic surgery worldwide

International Confederation for Plastic Reconstuctive and Aesthetic Surgery

IPRAS BENEFITS FOR NATIONAL ASSOCIATIONS • Association support for educational and research purposes • Association legal & ethical advice according to international law and practices and assistance with crisis management • Promotion of local or regional events through the official IPRAS management office • Promotion of local or regional news and a Historical Account for the Association through the IPRAS Journal • Free shipment of copies and electronic receipt of the IPRAS Journal • Immediate information and advice about safety warnings on devices, drugs and procedures • Information regarding the proper use of all materials, substances and techniques related to Plastic, Reconstructive and Aesthetic Surgery through IQUAM (the International Committee of Quality Assurance and Medical Devices in Plastic Surgery) General Consensus statement, with an update every 2 years • Promotion of Patient Safety and Quality Management (in cooperation with the World Health Organization - WHO) • Information regarding harmonization of training • Information regarding accreditation of Plastic Surgery Units • Protection of the Specialty and Promotion of its image world-wide • Information and reports about events organized by other National Societies and IPRAS

8th Issue April 2012

IPRAS Journal Management Editor: Editor-in-Chief: Editorial Board:

Page Layout: E-mail: Post Editing: Photographer: 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 Accounting Director: George Panagiotou E-mail: george.panagiotou@zita-congress.gr Associations Management Director: Dimitris Synodinos E-mail: dimitris.synodinos@zita-congress.gr Commercial Director: Gerasimos Kouloumpis E-mail: gerasimos.kouloumpis@zita-congress.gr

Next issue: July 2012

IPRAS Thomas Biggs, MD Marita Eisenmann - Klein, MD Andreas Yiacoumettis, MD Christian Echinard, MD Constance Neuhann-Lorenz, MD Zacharias Kaplanidis, Economist Diastasi info@diastasi-print.gr Athena Spanou, MD Julian Klein

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. Not for sale. Distributed for free.