DARRYL J. HODGKINSON
M.B. B.S. (Hons), F.R.C.S. (C), F.A.C.S. F.A.C.C.S.
DIP. AMERICAN BOARD PLASTIC SURGERY
Cosmetic Plastic Surgeon
24 February 2016
ICAPS 19th Scientific Meeting New Zealand 17 February 2016 to 22 February 2016
I was given the task relieving Dr Stephen Gilbert of being the scientific chairman for this meeting as Dr Gilbert was the convener for the New Zealand meeting. With the endorsement of Stephen I decided to alter the format of the presentations along with those similar types of meetings such as the North American Alpine Workshop and other boutique meetings such as the Rocky Mountains Plastic Surgical Meeting. Each participant was asked to present a seven minute presentation to be followed by three minutes discussion under four categories. The four categories were:
Day 1 and Day 2 were held at the Hilton Hotel in Auckland
Joe Hunstead opened the session with a talk on making a Maloof chair. This was a woodworking carpentry skill Joe attended and with time produced a beautiful rocking chair which at least his family seemed to enjoy.
Daniel Knutti an experience aviator flew his plane to 79 degrees north to an old Russian outpost. This required special planning to be so close to the Arctic circle and the continuous summer meant they experienced full daylight at midnight.
Russell Walton took us on a tour of his office him being a keen collector of medical memorabilia including a charming collection of porcelain medical examination figures.
Bryan Mendelson had a harrowing experience after removing a submandibular gland in a HIV positive patient. Only his immediate response saved this patient's life. He emphasised the potential catastrophic bleeding which can occur from submandibular gland resection in association with face lift and neck rejuvenation surgery.
Darryl Hodgkinson showed his recent accident which occurred during the 2015 Sydney to Hobart Yacht Race which required a medical evacuation after he fractured ribs, thoracic vertebrae and had a haemothorax in this very rough ocean yacht race.
Anna Bandinanaz opened our eyes to quantum physics as it may relate to our personal interrelations and emotional responses.
Richard Halley-Stot and avid wildlife photographer took us on the Wildebeest Migration of East Africa accompanied by graphic and inspiring photography taken by himself.
Stephen Gilbert discussed his involvement with the financial vicissitudes of private hospital directorship.
Jose De La Pena inspired by Dr Ortiz Monasterio has reached out to young plastic surgeons empowering youth and he showed how he has continued to integrate technology and new advances into his extensive practice in Mexico.
Tom Roberts emphasised the beauty and youth of the 0.7 waist to hip ratio and showed that his combination of liposuction and lipoinjection gave an ideal and youthful aesthetic relationship.
Then a guest lecturer was Tarisi Vunidilo an anthropologist from Fiji and a lecturer in Pacific Studies at the University of Auckland. She traced the migration of the Melanesian, Micronesian and Polynesians across the vast Pacific as they colonised the many island nations. Etymological studies allows for us to follow this vast extensive migration over tens of thousands of year. New Zealand was only colonised in 1300 AD. The boundless Pacific was transversed by skillful celestial navigators transporting up to 300 migrants in long wooden sailing canoes.
Bryan emphasised the difference in facial ageing from descent of the jowl versus descent and displacement of the buccal fat pad. He is exploring the vascular anatomy of the buccal fat pad as well as its fascial attachment and its potential for manipulation in facial rejuvenation surgery.
Russel presented a challenge case of a chyle fistula after breast augmentation which he successfully treated. This was an extremely rare case.
Abel showed a 10 year history of buttock augmentation with gel implants in the subfascial plane. Positioning is critical and incisional placement integral to preventing displacement of the implant and dehiscence of the midline gluteal incision.
Darryl is utilising the cut Lore's fascia as a vehicle to elevate the neck platysma and readjust excess tissue at the mandibular angle after neck elevation. The modified Fogli approach continues to be expanded.
Anna showed dramatic results from combining fat injections and fractional laser with facial rejuvenation.
Stephen Gilbert presented a case of a staff member who had been performing injections for him and then after a face lift she now became a strong referrer of patients for facial rejuvenation surgery.
Richard uses a perioral dermabrasion for severe mouth rhytids and combines this with a Lumens laser to improve the "golf course weather beaten face".
Daniel gave a long term follow up of a patient on whom he performed one of his first TRAM flaps and 20 years later after reconstruction of the opposite breast retains a nice symmetrical result.
Tom discussed fat injections for the sunken eye and introduced the term "gaunting" which occurs as the face deflates and becomes sunken with age.
Joe showed a total body rejuvenation by Fleur-de-lis body lift for that "melted candle" look. He combines liposuction with these cases and emphasises the blood stasis of these tissues which potentially predisposes to deep venous thrombosis and tissue necrosis.
We then had two guest lecturers Zein Shubailat Gaith's son who works for Microsoft gave us an exhilarating discussion of the effects of technology which will be occurring on our lives. The evolution of the internet of things (IOT) BIGDATA and augmented and virtual reality will ever increasingly impact on our daily and professional lives.
Mike Klaassen a New Zealand plastic surgeon from Parnell who has a vast knowledge of the history of plastic surgery spoke about the four Knights of plastic surgery from New Zealand Gillies, Mackindoe, Pickeral and Manchest all of whom were knighted for their contributions to plastic surgery during the 20th Century.
We then transferred to Queenstown and on Day 3 was Tips
Gail Shubailat gave a very personal account of a heroic reimplantation of an arm which took nearly 30 hours then a reunion 30 years later of the patient a young woman who then had become a very successful Professor of Linguistics in the United States.
Jose uses laser a Nd:YAG to sculpt the face in his face lifting especially for the fatty faces and feels that laser reduces morbidity and less down time for his rejuvenation patients.
Stephen uses a yankauer sucker to assist in positioning of his polyurethane breast implants.
Darryl uses the post auricular SMAS and perichondrium as a cover for nasal tip reconstruction in secondary rhinoplasties where the dermis has been very badly damaged and any reconstruction will show through the skin postoperatively.
Daniel explained to us the Cross-punch technique for hair transplanting giving a thicker and a curlier look to the final result.
Tom showed his results with lip lift which extended into the nasolabial fold.
Russell explained how he defines the inframammary fold preoperatively and also how he uses blunt needles to inject anaesthesia into the face before facelift reducing bruising.
Richard told us about PCT (Pro calcitonin) which is very accurate in detecting clinical infection and he also showed us how he deals with a superior vertical epigastric scar when he performs an abdominoplasty.
Joe showed his technique for submandibular gland resection in combination with face lifting.
Anna uses the a Costogrande needle for forehead and cheek elevation showing multiple threads pass through the mid face especially helpful in ectropion repair cases. She also showed an endo ribbon for a mid face elevation.
Gaith showed a video of his technique for periosteal/perichondrial dissection and spreader flaps in open rhinoplasty. He uses a turnover flap for the lower lateral cartilage refinement.
Stephen had a patient with persistent unrelenting back pain after body lift.
Daniel presented a case of frontal branch palsy after removing forehead threads.
Jose had a case of paradoxical fat hypertrophy after Coolsculpt.
Russel showed a very persistent double bubble case.
Gaith had a very threatening medical practitioner on whom he did a secondary rhinoplasty and this patient was threatening to his family, aggressive BDD patient.
Richard showed a secondary breast implant case with increasingly large implants the patient refusing mastopexy ‘’a boyfriend who should not know’’ was in the background.
Anna showed a pyogenic granuloma of a breast which occurred the patient requiring steroids as she had an undiagnosed immunodeficient disease.
Joe showed a case of dehiscence of a breast augmentation case which he nursed along with the patient eventually becoming very supportive.
Darryl finished the session showing another example of male BDD rhinoplasty and explained that preoperative psychological testing with a BDDQ was a screening device and emphasised the need for psychological evaluation in patients preoperatively.
The four day sessions ended there being a myriad of subjects covered and the discussions continuing during the very successful social programme of the 19th ICAPS Meeting.
DARRYL J. HODGKINSON
Report of the Secretary General Gaith Shubailat
ICAPS 2014 in Vienna was hosted by the pioneer member Professor Juergen Holle and Inge at the Sacher Hotel from May 10-15. It was attended by the following:
Sporting Activities: On Saturday May 10, a golf tournament was arranged by Jurgen on a nice sunny warm day. Participants were Gaston, Bernard, Jurgen, Stephen, Margaret and Leslie. Leslie was announced winner of the tournament.
Scientific activities under the efficient chairman of the scientific committee Stephen Gilbert occupied the mornings of May 12, 13 and 14.
Cultural activities included a visit to the Spanish Riding school upon the invitation of its director Madam Elizabeth Gurtler, who is also the owner of the famous Sacher Hotel; followed by attending Mozart’s “ Le Clamenza di Tito” at the Vienna State Opera House . Guided tours of Castle Schonbrunn, a lecture on the culture of Vienna by Mr. Daniel Uchtmann followed by a guided tour of Kunsthistorisches Museum, the National Gallery showing highlights of Austrian Art history. A visit to the Baroque Castle Belvedere built by the most famous soldier Count Eugen de Savoy.
One of the best highlights of the presentations was a terrifying video show by Daryl Hodgkinson on how he won the Sidney-Hobart Yacht Race in 2013.
The Business Meeting
Held on May 14 when our outgoing president Onur Erol handed the batton to our new president Gaston Maillard. Elections of the board resulted in the following appointments:
Location of next meetings:
New Candidate Members
Candidate Harry Fok was voted in as full active member of ICAPS…congratulations Harry
The following short list of names were suggested as possible new candidate members:
|1||Paulo Amaral and Katia, Brazi||Carlos Uebel|
|2||Jeorge Herrera. Argentina||Carlos Uebel|
|3||Luiz Heridia, Argentina||Carlos Uebel|
|4||Celso Bohorquez, Columbia||Pierluigi Canta|
|5||Gianluca Capiglio. Italy||Pierluigi Canta|
|6||Joachin Von Finckelstein, Germany||Bernard, Carlos, Gaith, Gaston|
|7||Thomas Rapple, Austria||Pierluigi Canta|
|8||Arturo Montana,Mexico||Carlos Uebel|
|9||Brent Tanner, UK||Woffles, Jurgen|
|10||Nuri Celik, Turkey||Woffles, Jurgen, Gaith|
|11||Vakis Kontoes, Greece||Woffles, Jurgen|
|12||Wu Sufan, China||Woffles|
|13||Massimilino Ferri, Italy||Catherine|
|14||Henry Mentz, USA||Alfonso|
|15||Kai Uve Schlaudraff, Switzerland||Jan Poell|
|16||Des Fernandes, Capetown, South Africa||Gaston|
Members sponsoring new candidates are requested to contact them and explain to each that their names will be recommended to the board and that since membership is limited to a maximum number of 50, then the board will make a decision on whom to invite next year considering the constriction of available positions.
HISTORY CULTURE SCIENCE
ICAPS VIENNA 10-14 MAY 2014
SYNOPSIS OF CULTURAL AND SOCIAL PROGRAMMES
Twenty three members attended our 14th meeting held at the historic privately owned Sacher luxury hotel in the centre of Vienna. Many celebrities have stayed here before us and their signed photographs line the walls.
Our thanks to our local host Jurgen Holle for his excellent organisation of a rich cultural programme which included visits to the see the Lipizzaner horses performing in the baroque Spanish riding School, Mozart’s “La Clemenza di Tito” at the Vienna State Opera, the baroque Schonbrunn Palace once the home of the Habsburg Imperial Family, the Gustav Klimt and Shiele master pieces at the Belvedere Palace and culminating with wonderful Austrian cuisine, wine and in the heurige or vine yard area of the Vienna woods. Of course there was much fine dining at other restaurants where we were at risk of ‘death by chocolate’ and many ladies took advantage of the excellent spa at our hotel with Bernard being the only male to have been noticed on the exercise machines.
On this occasion the meeting was preceded by a golf tournament hosted by Jurgen at his club Schlos Schonborn, 40 k out of Vienna, where the club house was actually a substantial castle. This was won by Leslie Kuek who has now been elected captain of golf for ICAPS.
It was quite a shock to have to start the academic program on the Monday and this ran from 9-12.30 each day till Wednesday. A highlight of this was a lecture given by the prominent Viennese historian Daniel Uchtmann on Vienna culture and history attended also by our partners. This was followed by a Lifestyle talk from Darryl Hodgkinson on how to win the Sydney Hobart yacht race which had us all seasick before lunch. He showed how plastic surgical principals of thorough research, sensible appraisal of one’s ability, making a sound plan of action, gathering a loyal and well trained team around you and then making your best effort applied just as much to winning an off shore yacht race as achieving a satisfactory plastic surgical out come.
As Sir Harold Gillies liked to say you must have a life boat for any complex plastic surgical procedure that might go wrong.. The difference is that the plastic surgical operation could be fatal for the patient whereas the boat race could be fatal for the surgeon/sailor if either were not conducted properly. It is a matter of taking well calculated risks against the sea as opposed to against the blood supply.
The ACADEMIC programme was designed to use the papers offered in the most logical sequence with each member being allowed 10 minutes presentation and 5 minutes discussion time so that everyone had the same opportunity to speak. This worked well and I am grateful to everybody for keeping to time in fairness to their colleagues.
Jan Poell who had to leave the meeting early kicked off with an update of his short scar breast reduction which he had first shown us at ICAPS Bordeaux. This involves taking out the excess skin around the areolar, liposuctioning the upper pole extensively to give a circumvertical scar only even in the largest breasts.
Maarten Fechner won the prize for being exactly on time in delivering his ground breaking talk on a study of 3-D anatomy of the face using the CM3600Xp Cryotome which shows potential for training young surgeons in the appreciation of the spatial relationships of the anatomy of the face and hand but is at present still in the research phase.
The programme was otherwise organised in the usual order starting with the face and proceeding to breasts and body.
Most papers were offered on the face and these were divided into normal anatomy, fillers, my experience and preferred technique, and face lifts with augmentation.
Martin Flechner, Woffles Wu and Bryan Mendelson set the scene establishing parameters of facial anatomy and Asian beauty. Woffles in his urbane way pointed out that the new Asian ideal is not to be more Caucasian but rather to be Pan Asian which means having a narrower more oval face but not the higher arched eyebrows thin nose and high cheek bones of the Caucasian ideal that once was. The Caucasian ideal is also moving more to the Pan Asian look with lower eyebrows, narrow chin and prominent but softened cheek bones.
Bryan Mendelson showed how a subtly filled lateral eyebrow enhanced beauty and youth. He prefers to use hydroxyl apatite crystals laid on the supra orbital ridge to achieve this rather than fat which can drop this area rather than fill and lift it. He commented that good looking male film stars tend to have broad flat fore heads but women may be considered attractive with narrow ( Angelina Jolie) or wide (Grace Kelly) foreheads and in some temporal filling may be beneficial. The trick is to make the right cosmetic judgement.
In the FILLER section Jose Abel de la Pena made a plea that plastic surgeons should take seriously shaping the face with hyaluronic acid as it is a precise technique requiring good aesthetic judgement and should not be left to untrained practitioners or we shall loose the market for facial rejuvenation. He showed very elegantly how judicious use of filler could reshape a nose and chin getting a good aesthetic result without intrusive surgery and minimal problems.
However Stephen Gilbert showed a case of recurrent granuloma in the cheeks of a 65 year old woman who had had hyaluronic acid injected into her face a year before with out a problem but on reinjection developed bilateral inflamed areas settling with conservative treatment and hylase on one side but not so well with local steroid on the other and leaving distinct hollows on both sides,
The expert opinion was that this must be due to infection with sub clinical bacteria in a biofilm rather than hypersensitivity.
Further reasons for caution with HA fillers was given by Jan Poel with a case of tip necrosis in the nose and by Leslie Kuek with a case of injected “bone powder” causing quite extensive dorsal skin necrosis. Tim Marten emphasised the benefits of immediate hyperbaric oxygen treatment as well as hylase injection.
After a brief coffee break Rolf Norstrom chaired the session on the PREFERRED FACE LIFTING TECHNIQUES of experienced surgeons Jurgen Holle, Alfonso Barrera, Daniel Knutti and Hans-Leo Nathrath who all showed good results while manipulating SMAS rather differently.
Jurgen preferred a high SMAS with full release of the retaining ligaments transferring it vertically, with a short post auricular scar and lipofilling with a sharp needle.
Alfonso suspends the SMAS to the malar periosteum and freeing the submental tissue with a liposuction cannula suspends it with a mastoid to mastoid Gianpapa style suture . He can disguise a pre sideburn scar with hair transplants but this is seldom necessary.
Daniel likes minimal skin undermining and fixation of the SMAS to the firm parotid fascia and has shown with marker clips that in his hands there is only a 5mm slide of the SMAS over 6months.
Hans-Leo, working with ICAPS Member Gossi, and using contrasting techniques on either side showed that a Daniel Baker type SMASectomy was less effective than SMAS advancement. He also showed a long term result of open subperiosteal facelift which resulted in a marked change of appearance of the patient and needed correcting by preperiosteal methods.
On TUESDAY FACE LIFTING WITH AUGMENTATION was the first topic. Catherine Bergeret-Galley showed excellent results of simultaneous face lifting and Lipostructure which she had learned from Tom Roberts,. She put in up to forty cc or more of centrifuged fat especially defining the jaw line, enhancing the malar mounds and dramatically reducing dark circles under the eyes.
Onur Erol showed how adding suspension sutures to a 3D volumetric facelift with SMAS plication, could reduce the redundant skin under the chin and give a more permanent lift to the lateral brow. These techniques can be used with Lipostructure with or with out a face lift.
Bernard Cornet de St Cyr again demonstrated the need for a short upper lip in a beautiful face and showed his technique for achieving this with the modified bull horn excision of sub nasal tissue hiding some of the scar well above the nostril sill. He also told a cautionary tale of the dangers of trying a new technique on a demanding patient whom you were trying particularly hard to please_____ in this case using silhouette sutures which resulted in marked asymmetry and dimpling and then a temporary complete one sided facial palsy when he tried a quick fix with a superficial mini lift under local anaesthetic.
Tim Martin and Bryan Mendelson discussed the benefits and precautions of precise subcapsular partial submandibular gland excision to give a clean neck in selected cases. Tim showed with very clear anatomical pictures how by approaching the gland from the medial aspect through a submental incision set back another centimetre from the usual position avoided the nerves and blood vessels lying on the lateral surface of the capsule.
The risk of a postoperative haematoma is thus minimised in experienced hands but this is not an operation for the inexperienced post conference enthusiast.
We then proceeded to the NOSE section in which Gaith Shubilait showed his technique for primary open rhinoplasty talking to a beautifully photographed video taken in a bloodless field provided by his anaesthetist with hypotensive general anaesthesia down to 80mgs and local anaesthetic with adrenaline. His principals were sub mucosal separation of the upper lateral cartilages from the septum starting with a midline dorsal periosteal incision and then turning in the excess upper lateral cartilage as an auto spreader flap. He used mattress sutures to straighten the septum and made a point of anchoring the dislocated quadrilateral cartilage to the nasal spine with a suture placed through a drill hole.
Abel discussed the Metzino nose where there is a superabundance of skin and soft tissue but a fragile cartilaginous supporting structure. To give this a more defined shape required thinning the soft tissue and strengthening the support with spreader and columella strut cartilaginous grafts. The spreader grafts frequently extended sub periosteally over the nasal bones and he built up the premaxilla with diced cartilage. A tip graft was also usually needed.
Next was the BREAST section in which Gaston-Francois Mallard first discussed the current situation with PIP implants outlining the history of how the European regulatory commission of which he was a member had been duped by the manufacturer by substituting at the time of inspection medical grade silicone for the cheaper industrial grade they were actually using. However there is no pathological evidence that this cruder silicone was actually harmful and the issue is more with a 25% rupture rate and silicone seepage not unlike the fragile Dow Corning liquid silicone ones of yesteryear. 400,000 had been sold. The owner of PIP is now serving a four year jail term in France and had to pay a fine of $75,000. The company has no money to pay any compensation. In Holland at least the government has paid for removing and replacing the implants.
Carlos Uebel, the current ISAPS president, then followed with a very nice video presentation of his preferred breast reduction technique using the Pitanguy inverted T pattern and a lateral dermoglanudular pedicle. The results were pert and youthful not unlike those on the female statues adorning Vienna. Crucial points were making a central tunnel into which the breast parenchyma could be advanced upwards and secured to the pectoral fascia and sewing the lateral pillars together to help hold it there and narrow the breast.
Harry Fok presented a perplexing case of late expanding organised thrombus in a breast associated with a smooth implant with no associated trauma.
On our last scientific morning Joe Hunstad showed how body contouring for massive weight loss patients has come of age. He achieved an excellent shape with good quality scars using circumferential tumescent liposuction with large volumes of very dilute lignocaine and adrenaline and a fleur de lis designed abdominoplasty.This got rid of that annoying boggy loose supraumbilical excess of fat and skin seen after the standard lipo-abdomino plasty. He did not have to transfuse his patients who ended up with a haemoglobin of 11or 12 gms and went home the next day. Using the oral anticoagulant Xarelto Joe had avoided VET or haematomas in all his patients.
Pier Luigi Canto then gave a very elegant review of his results of intramuscular buttock implantation emphasising how these must be smooth walled to avoid future seromas. He captured our attention with slides of the latest female underware accentuating the buttock rather than the breast, presumably to catch the male eye.
Tim Martin then concluded our scientific meeting with an invited talk on lipo filling around the orbit to rejuvenate a tired face demonstrating how this is really an artistic art form rather than a matter of technical specifics. In other words we are really now sculpturing the face rather than tightening it, essentially doing at least 5 rhinoplasty type operations and the artist in us must determin where and how much. This not unlike Sir Harold Gillies transferring tube pedicals to the face and then crafting them into a new face.
Finally Rolf Nordstrom of Finland gave us a video summarising his life in plastic surgery to date. At this time he is making a significant change in his lifestyle having sold his clinic operating company. We await with interest a follow up on how he is coping with his new freedom from administration.
The academic day concluded with the business meeting and sincere thanks to Jurgen and his able secretary and tour guide EVA for providing us with an oustanding time in Vienna, the European capital of HISTORY CULTURE AND MEDICAL SCIENCE.
7-11 May, 2013
May 7-11, 2012
NAPOLI - ITALY
9-13 JUNE 2010