2014-01-14   Advances in Quality Patient Care and Safety 30th Annual Scientific Meeting

Anna Galęba 1), Hassan Nurein 2)
1) Private Practice of Aesthetic Medicine and Anti-Aging in Warszawa and Poznań. Wellness Chanel in Konin, Poland
2) Private Cosmetic Surgeon Harley Street, London. Aesthetic Beauty Centre, Newcastle, United Kingdom

On the 14th of January 2014, the American Academy of Cosmetic Surgery held a congres on cosmetic surgery but there were also presentations on aethetic and anti aging medicine - The Future of Cosmetic Surgery: Advances in Quality Patient Care and Safety - 30th Annual Scientific Meeting. This congress took place in Hollywood, Fort Lauderdale in Florida. This was situated at the proximity of Pompano beach which is on the Atlantic ocean. Fort Lauderdale has 140 thousand people and is next to Miami which is one of most important centres for international trade, finance, culture, media, art and tourism. In 2008 „Forbes” magazine described Miami as the cleanest city in the United States (US), considering all year clean air, drinking water and streets as well as its recycling programe and green areas. Miami is considered to be the richest city in the US and the fifth richest in the world in terms of inflation. Port of Miami, also known as „the world capital of cruise liners”, anually hosts the largest numer of cruise liners compared to all other ports in the world. Miami is nicknamed „the capital of Latin America”, as it is the second city in the US with (after El Paso, Texas), where more than 60% of the population have spanish as their first language. In Miami live the highest number of Cuban americans than any other place in the US.
The event took place at The Westin Diplomat Hotel in 8 large halls and 17 other smaller rooms. Most delegates were from the USA, however there were many international delegates especially latin america but also from Europe and Asia. Among the participants there was no shortage of guests from Africa and even distant Australia. During the congres there was more than 120 companies that presented surgical instruments, beauty equipment as well as antiaging products.

30th Annual Scientific Meeting, in Hollywood

The congres lasted 6 days. Events took place daily from 7 AM to 6 PM. On the 14th of January there were full day workshops on various topics: Regenerative Stem Cell Therapies, American Society of Hair Restoration, International Society of Cosmetogynecology (ISCG), Advanced Concepts in Breast Surgery and American Society of Cosmetic Laser Surgery. Delegates had the choice to attend one of these. On the same day there was a spanish symposium „IESM/Spanish Symposia”. This symposia was divided in 4 sessions and was presented in spanish. Delegates were mainly from Argentina, Mexico, Brasil, Venezuela, Paraguay, Colombia, Puerto-Rico, Chile, Domenican Republic as well as from the USA.

FloridaThe Westin Diplomat Hotel, Hollywood

There were daily early morning workshops that took place before main presentations, usually 4-5 topics for the delegates to choose from depending on their interests.
Workshop topics included, Transgender surgery; Gynecomastia management; Body contouring; Your first 100 breast augmentations; Facial anatomy 101; Avoiding breast surgery comlications; Cosmetic dermatology for ethnic groups; Hands-on ultrasound workshop; Facial surgery; Oncoplastic issues in cosmetic surgery; Comlicated rhinoplasty; Breast; Cosmetic issues in ethnic skin; International medical missions; Penile cosmetic surgery; Clinical problem of fillers/toxins and Scars and wounds.
The general session started everday at 9 AM. There were frequently simultaneous sessions and delegates had to decide on which one to attend to. The sessiona were grouped into topics the most important ones were: Lasers, ultrasounds & radiofrequency; Aesthetic invasive and non-invasive technology energy source: machines go head to head in an open presentation and debate format; Healthy aging; Applications of lasers, fillers and toxins; Cosmetic surgery and care of the post bariatric surgery/massive weight loss patient part I and part II; Infection prevention in ambulatory settings; Cosmetic gynecology; Comlications of facial cosmetic surgery; Choosing /using technologies:clinical outcomes; Noninvasive body contouring; Cosmetic surgery, the future of the specialty; Live patient demonstration - toxin, fillers, lasers and energy devices - part I and part II. Etics and cosmetics surgery; Difficult cases and comlications stump the experts; Spider veins and teleangiectasias; Facial anty-aging; Complex facial concerns; Pain management and anesthesia; Managing patient expectations; Patient safety initiative: non and minimally invasive procedures: are they as safe as claimed?; Complications of energy sources and many others.

Live patient demonstration - toxin, fillers

During the congress there were also sessions and workshops not only on our professional work in the office and treatment rooms but also our work with patients in a business sense. „Practice Management Symposia” took place on 17-18 January, lasting most of the day. There were presentations on most offective use of resources for directing and converting patients towards treatments and how to create a succesful business by using the right marketing approach: Jennifer Deal, Director of Marketing, Southern Surgical Arts from Chattanooga, TN, USA and Paula Manly, Manager of Tulsa Surgical Arts, from Tulsa, TN, USA. On Friday there were the following sessions; Research and discovery: how patients find you; Much ado about something: how do patients make the big decision in the first place: and The point of first contact: what’s it like to be a patient in your office? However, on Saturday: Making the final decision: consultation and closing; Cross-sell and customer Loyalty; Build a successful team: lead the team and last session Secrets of the trade: practice survival training.
All the above sessions ended with discussions by the delegates, where they had to be frequently be interrupted due to lack of time and lenght of each session. Below is a summary of the most interesting sessions attended by the delegates.
The doctors Steven Gitt (MD, FACS; North Valley Plastic Surgery & the Phoenix Stem Cell Treatment Center) and Mark Berman (MD, FACS and Elliott Lander, MD, FACS; the California Stem Cell Treatment Center) from US, presented Early Positive Results of a Multi-center Pilot Study Investigating the Beneficial Effects of an Autologous Adipose Derived SVF Human Stem Cell Solution in a Variety of Injuries, Illnesses Conditions. Where Do We Go From Here? This is the summary of the speech. We have treated a wide variety of illnesses, injuries & medical conditions within an IRB approved multi-center pilot study. We are investigating many unique diagnoses employing the Time Machine™ centrifuge & incubator system for stem cell cleavage & separation into Stromal Vascular Fraction (SVF). All patients have intravenous deployment of their own autologous SVF harvested by mini-liposuction procedure under local anesthesia. For joint & spinal pathology, SVF is directly deployed into joints & to within 1mm of spinal pathology under fluoroscopy. Pulmonary patients receive small volume nebulizer deployment & Neurologic patients IV Mannitol prior to IV deployment. Pain management, Orthopedic & spine surgeon affiliates participate in certain deployments. Early results have shown in excess of 70% of arthritis & autoimmune disease patients have shown positive response manifested by clinical & functional improvement. Other cases such as ALS have shown a 40% response rate but are included on compassionate basis. A wide variety of patients have been enrolled in the study, including Parkinsons, Multiple Sclerosis, Cystic fibrosis, renal failure, rheumatoid & osteo-arthritis, cervical, thoracic, & lumbar arthritis, DJD, disc disease. Lichen sclerosis, COPD, pulmonary fibrosis, cardiomyopathy & CHF, neuropathy, peyronies disease, Diabetes Mellitus types I, II, Macular degeneration (dry type), Retinitis Pigmentosa, Optic Neuropathy, as well as any/all autoimmune diseases. Patients are initially seen in consultation. They are treated in a single session & the Stromal Vascular Fraction is deployed immediately after harvest. PRP is added to all peripheral joint deployments. Baseline functional status is assessed prior to deployment & re-assessed at regular intervals. Dramatic results have been seen in many cases, including Parkinson’s patients entering complete remission, MS patients showing dramatically improved functionality, POTTs disease with complete resolution, cardiac patients with improved ejection fraction being taken off the transplant list, improved serum creatinine levels in renal failure patients, patients with improved mobility, decreased pain, & able to avoid joint replacement. Improvement in a wide variety of autoimmune disease cases has also been seen. Specific cases will be reviewed. There have been absolutely zero major adverse events across our entire study patient pool at all sites. We intend to initiate much more narrowly focused, prospective, double blind, randomized studies. Our goal is to prove the safety & the beneficial effects of a mesenchymal, lipid derived, autologous stem cell rich solution in humans.
Dr. John V. Tedesco (D.O., FACOS from Wesley Chapel, Florida, US), had speech on the topic Special Considerations in the Post-bariatric Patient. This is short abstract of the speech. Post-bariatric body contouring helps correct the majordeformities often caused by assive weight loss. Surgical correction of these body deformitiescan significantly enhance physical and psychological changes of weight loss. Recommendations oimprove risk: Wait 12-18 months after bariatric surgery to consider bodycontouring procedures, and ensure the patient’s weight is stable for 30 days. Stage multiple procedures if the OR time can be expected toexceed 5-6 hours. This reduces risk andimproves outcomes. Make sure co-morbidities are controlled and obtain medicalclear- ance. Provide DVT prophylaxis including SCD’s and peri- operativelow molecular weight heparin (LMWH). Provide antibiotic prophylaxis within 60 minutes prior tothe procedure and not lasting more than 24 hours post-op. Monitor nutrition and provide vitamin supplementation. Remember these patients are overall high-risk and maintainhypervigi- lance for complications.
Doctor Sumita Shankar (MD, Plastic Surgery from Hyderabad, India) had speech on the topic Role of ‘Slide Swing Plasty’ in Oncoplastic Reconstruction. This is the summary of the speech. Slide Swing plasty is a very usefool tool for closure of round, oval or semicircular defects. We produce round defects after removal of various lesions from small to medium and some large size. It is sometimes a great challenge to cover these defects with best aesthetic outcomes and results. To have a good aesthetic result, I would place the following criteria: Trying to cover the defect with approximation with minimum scarring; Local Tissue cover if the defect is medium to larger size if possible; The final placement of suture line along the RSTL (Relax Skin Tension Lines); No Distortion of any important surrounding parts such as lips, eyes, eyebrows etc., and Faster healing possible with best aesthetic results.
‘Slide Swing Plasty’ is a very easy to perform flap where adjacent local tissue is rotated and swung on to the defect. And the wound is closed primarily. It is a modification of Limberg flap. A tangent is drawn along the side of the defect where a proposed flap is raised. Flap is drawn from the point of tangent to the level of the defect and with a diameter smaller than the defect. The Criteria for the success of this flap is that the defect should be pinchable. The Surrounding skin should be lax and the final lines should not distort any important structures around it. Advantages of this Flap: Small, Medium, Large defects; Best Aesthetic Outcome; Safety; Universality; Adaptability; Rapidity; Local Skin Texture and Sensibility; Choice of placement and orientation of Scar; Short Recovery time; Easily Reproducible. Unpleasant Outcomes : Poor Selection; Wound Dehiscence; Edge necrosis; Dog Ears; Distortion of surrounding tissue. Conclusion: It can be a very useful flap in a common day to day practice for covering the defects after mole removal, removal of other smaller skin lesions such as Basal cell Carcinoma, Squmous Cell Carcinoma, Melanoma, Amputation Stumps, Bedsores, Pressure Sores, Vascular malformations, other Post- infective and Post-traumatic defects.
Dr. Elen Carolina de Masi (MD, from Curitiba Parana, Brazil), had speech on the topic Growth Factors (VGF, VEGF, IGF, FGF) in Skin Wound Healing in Rats. It was the common work of several doctors - Antonio C. Campos, Flavia D. J. de Masi, Marco A. S. Ratti, Isabela S. Ike, Roberta D. J. de Masi. This is the abstract of the speech. Introduction-the Platelet Rich Plasma is a blood product fresh and contains large amount of platelets with anti- inflammatory and regenerative. Platelets are a large number of growth factors and cytokines, which are fundamental in tissue healing. Growth factors are proteins that stimulate and activate cell proliferation such as angiogenesis, mitogenesis, gene transcription, among others. Objective. To assess the value of growth factors in wounds and changes achieved by analyzing the results, improvements proportionate to the healing process. Method. We used 45 male Wistar rats that underwent skin incision on the back. The Macroscopic and microscopic evaluations were performed on the third, seventh and fifteenth day of the experiment, after the removal of material involving the entire wound (excisional biopsy). For microscopic morphological analysis was used hematoxylin-eosin, evaluating inflammatory process; vimentin evaluate vessels, and fibroblastose Picro with Sirius Red collagen evaluated. Results. The wound infiltration with epithelial growth factor and vascular showed faster healing. In Microscopy showed intense inflammatory reaction in the wound control with p<0.05. In wounds with growth factor was greater maturation of the scar due to the higher concentration of fibroblasts and vessels with p<0.05. Conclusion. The results of this study indicates that the use of growth factors as both epithelial vessels compared to control wounds, promotes less inflammation and accelerates the healing process, develops greater angiogenic activity, accelerates fibroplasia and maturation of healing.
Dr. Adrian Gaspar (Prof., MD, Gynecology Department, Faculty of Medicine, University of Mendoza, Argentina) had speech on the topic Treatment of vaginal atrophy using carboxytherapy. It was the common work of several doctors - with the dr. H. Brandi and dr. V. Gomez Diez from Argentina. This is short abstract of the speech. Objective: to show our experience in the use of carbonic anhydride (Carboxytherapy) in the treatment of hypotrophy and atrophy of the vaginal mucosa. Patients and methods: we selected two groups of patients (Case and Contro l). Symptoms of study and treatment: vaginal dryness and dyspareunia. Case group (16 pat ients, average age 57 years) was treated with vaginal carboxytherapy. Carbonic anhydride is administered two times a week for 12 weeks through a handpiece designed for this purpose. Control group (20 patients, average age 54 years) received topical estrogen the rapy with estriol, a daily application of 0.5 mg per day for 2 weeks, and then followed by three times a week for another 2 weeks and finally twice-weekly applications for 4 more weeks. Results: monitored by vaginal biopsies and clinical evaluati on. There was substantial clinical improvement and significant differences in biopsies before and after treatment in the case group patients compared with the control group patients. Conclusion: the application of vaginal carboxytherapy in women with signs or symptoms of hypotrophy or atrophy of the vaginal mucosa, showed a marked improvement, not only in the epithelium, but also in the lamina propria, compared with the control group. This is in contrast to the documented effects in the epithelium observed with the use of topical estrogen therapy. We also observed a marked comparative improvement in terms of the sexual discomfort problems reported by the patients.
Doctor Bob Tahara (MD FACS Allegheny Vein & Vascular Bradford, PA, US) had speech on the topic Avoiding the Alligators Common Complicating Conditions That Can Accompany Spider Veins. This is the summary of the speech. Superficial varicosities and spider veins are the source of significant patient concern and drive many patients to seek options for cosmetic treatment. Both patients and medical professionals frequently do not recognize the other potentially far more complicated conditions that coexist with this superficial and cosmetic disease. Specific examples of these complicating conditions include frank venous insufficiency, deep vein thrombosis/ post thrombotic syndrome, and more proximal iliocaval venous occlusive disease (May-Thurner Syndrome).
A complete initial evaluation involving a directed history and physical will often identify patients at risk for more complex disease patterns. Specific history items that are critical to this include a history of leg edema, classic venous symptoms of aching/heaviness/itching/burning, any history of DVT lower extremity venous ulcer, and/or a bleeding varicosity. Specific exam findings include any demonstrable edema or venous skin changes (i.e. CEAP Class 3 and above). Marked asymmetry (particularly when involving the left side) should raise the suspicion for iliocaval occlusive disease and/or antecedent DVT Port wine stains should raise the suspicion for Klippel-Trenuarany Syndrome. Imaging should nearly always include a complete venous duplex with avoidance of more complex imaging such as CT venography and/or MR venography unless there is clinical suspicion of more complex disease and need for operative planning.
Venous duplex evaluation should be performed by a technologist experienced in venous disease to ensure a high quality exam and eliminate common technical errors that are frequently seen when such an inadequate or inaccurate reflux assessment, inadequate or inaccurate venous anatomy, and identification and characterization of chronic DVT/venous scar vs acute DVT. Physician interpretation should be performed with a critical appraisal of the technical quality of the study and not simply repeat back the technologist's observations.
Iliocaval occlusive venous disease is more frequently observed in patients with complicated or severe venous disease than is commonly appreciated any may be compressive from the overlying iliac arteries, post-thrombotic, fibrotic (from surgery/trauma/radiation), or some combination of any/all of the above. Up to 25% of the population may have anatomic predisposition to the compressive variant of this based on both cadaver and CT studies. Duplex ultrasound can suggest this diagnosis if the common femoral vein waveforms are dampened or monophasic but a normal study does not exclude the presence of this condition. May Thurner Syndrome is a well characterized and specific subtype involving compression of the proximal left common iliac vein by the crossing right common iliac artery. Treatment of high grade iliocaval stenosis commonly involves evaluation with venography and intravascular ultrasound followed by large diameter stent placement.
Identification of these complicating conditions in patients with primarily cosmetic complaints is an opportunity to avoid further disease progression, morbidity, and adverse outcomes in this population.
Dr. David Angeloni (MD, Irvine, CA, US) had a speech: A Comparative Overview of SVF Characterization Studies Using NIL, SAL, and Enzymes. This is short abstract of the speech. Adipose tissue represents a versatile and abundant source of adult mesenchymal stem cells (MSC). The role of the physician in serving as chief procurement practitioner for adipose derived stem cells (ADSC) requires improving efficiencies such as procedural times from harvesting to deployment while minimizing costs and maintaining a high standard of care. This is critical for any regenerative center which strives to remain “profitable” and still yield an adequate amount of viable ADRC’s with minimal effort and costs in a point of care model. To date there are several methods and devices that attempt to address these concerns, however, many of these methods and devices have overlooked using cells released into the aspirate via mechanical dissociation during tumescent liposuction. In this talk I will review and compare recent published and independent studies which have looked into quantifying and characterizing these cells and equating them to what can be normally yielded by a standard collagenase process.