All right, great, great job, Jason. If you can switch the slides over to mine, I'd appreciate it. And what I'm going to do, just in the spirit of, I'm an old offensive lineman, so I believe in grass drills, so we're going to do some reps. So I want to show you the setup from the OR, because I think that's important, and then Jason has asked me to do a live demo over in the lab as well, and we'll do that. But I think the setup's important, because you can totally simulcast when you're doing these cellular techniques, at least with the adipose, and I want to show you that. Because a lot of you are going to be working with PAs in the OR, and they can do the harvest while you're starting a scope. I'm working with residents and fellows, so I'll usually have them doing the scope while I'm doing the harvest, but you can simulcast, and that can really cut down on the time required for the procedure. The other thing is that, as I mentioned yesterday, and has been mentioned today several times, in primary care ortho, and in primary care sports medicine, and also in orthopedics, we don't really learn liposuction techniques. And it's not hard, particularly the way that I do it. I'm too many downs with no helmet, so I don't do anything that's complicated. But there are some certain tricks that I've learned over time, and I had the privilege of doing the first lipogems case in the U.S. with Carlo Tremolata about four years ago, and my technique has evolved based on experiences. And as you all know, experience comes from screwing things up, and then that leads to wisdom. So I'll share that, what I've learned as far as that goes. So these are my disclosures, which we went over yesterday. So this is our technique. So we're going to put a little wheel of lidocaine in the skin. I'm not so sure that the local anesthetic controversy is real. It's a little 11 blade making a nick into the subcube, because our cell samples have shown viable cells, and we're putting a giant amount of tumescent in the abdomen that's laced with 1% lidocaine. So here we are injecting the tumescent, and we're going to do it in a fan-like fashion. And this is what the plastic surgeons will tell you. If I'm doing it in the OR, I'll do 60 cc's above the umbilicus, 60 below. You want to use about twice that if you're doing it in the office, just because of the anesthetic, the need. So then we're going to inject across the abdomen, below the umbilicus. Now in thin patients, it's difficult sometimes to get all you need from the abdomen. That's why you hear people talking about the buttock. The love handles and guys are just about always a good source for fat, but almost always I'll use the abdomen. I like the supine position. You notice that the knee is prepped out as well below here. You notice that we're simulcasting. In this case, we've got a resonant start in the scope. We've agitated the tissue, waited 10 minutes, and now we're going back with the liposuction catheter. And this has got a little lock on it, and we're going to follow that same path we did with the tumescent injection. Now one of the questions is how long do you wait in the office? Maybe a little bit longer, because you really want to be well anesthetized, and the fat a little further emulsified. So maybe 15 minutes in the office. But you can see we fill the syringes up pretty quick here, and with lipogems, it's about five to one. So if you harvest 100 cc's of fat, you're going to get 20 cc's. If you're only doing one knee and you need 10 cc's, you might get away with just doing 50 cc's. So this is a little video that I made with a couple of our fellows when I was in Durham. This is a person we're going to inject both knees in, so we've got the abdomen prepped out. We use a lap drape system there, and sometimes we use Ioband around it. It's not totally necessary. So here we've made the little 11-blade neck. Now we're going to inject. One of the concerns you've got, like I did, is are we going to get into the peritoneum? They challenged me when we were doing a cadaver to even go straight in, and we didn't get into the peritoneum. It's a blunt-tip catheter, so it's very unlikely. But here we are. We've harvested the fat. Now we're going to go ahead and we're going to clean up the joint. A lot of times this will time up about right, so you get in, get your scope done, get everything cleaned up. Depends on if it's a resident or a fellow doing the case on the 10-minute part. Then we're going to go back, and we're going to set this lure lock on the syringe, and then we're going to follow back and forth. Now you'll notice there's an abdominal incision here. This patient had had a hernia repair. Be careful about abdominal incisions, and be careful about umbilical hernias. You obviously want to be very, very careful. I've done it in all those categories before, but just being somewhat gentle and careful. Now if you lose your seal, it's no big deal. Just go back, reset it, and you can go right back in. Set your lure lock again, and it's inevitable your hand will hit something and you'll lose that seal. You also notice that the material's a little red or a little pinker as you go further in. So now we're going to process this, so we're going into the canister, and you can see the fat. There are multiple washes with the lipogym's technique, and there are also two filtrations as you inject the cells, so not only are you going through the process of the agitation, but you're also filtering this. This is Brad Wilson, who was my assistant for 20 years in Durham, and Brad was a real pro at this. We've got a team trained up on this in Charlotte now. The reps are fantastic to come in and help you in the OR. We've got Molly Pettit here with us today in the lab. She'll be helping with not only the processing, but also the technique. So use the resources here so you can get your questions answered. That's the waste bag on the floor. With lipogym's, again, it's about five to one, so I try to get about 120 cc's of fat. We're doing some studies, so we're sending samples off and other things, and oftentimes we're doing a couple joints. If you have them under general for the scope, why are you using lidocaine? We still need it to emulsify the fat. I guess we could get away without that, but that's a standard two medicine that the plastics people have used. It's also got epinephrine in it, which I think helps to minimize the bruising a little bit. I think that's probably the main reason, plus post-op pain relief. It gives them some post-op pain relief, but it wears off. But it's the epi that stops, presumably, the hematoma. How long do you wait? They keep telling me to wait and wait and wait, and the longer you wait, the better before you go back. So before you'll actually go do the lipoaspirate, what's your minimum amount of time to let the two medicines set? My patients are similar to what I know yours to be, so I have a hard time waiting more than 10 minutes. We start the timer, and I've never had a problem with waiting 10. They tell me if you wait a little longer, it's better. Sometimes when we have waited longer, I haven't really noticed a big difference, but I think in the office, it would be better to wait a little bit more time. What about really thin patients? In an athlete, sometimes there's like 5-6% body fat, and I've tried going to love handles, and it's just really fibrous. I found it to be really fibrous tissue. So did you go to the leg? Well, they tend to be more fibrous. Yes, and would you go to a different spot? Let me hit a couple points here, because I don't want to miss them. First of all, the Italians think it's important to dry up the joints. So I've dropped the spinal in, and I've closed the portal, and I've got suction on here. And once you get inside the air bubble, you can actually see fine, dry, even if there's a little bit of bleeding. And then we want to inject into the worst compartment. Most of them are going to be medial, of course, and you see this patient here, and then you see us doing the injection. I think it's important to close the portal before you start the injection, otherwise you'll lose some of the lipid gems on the floor. I also have the suture ready for when the scope comes out, so again, we don't lose it. And then I think it's important to distribute the cells. This is the other knee. So just going in super patellar to do the injection over there as well. This is the abdominal binder. I learned this the hard way. It's important to keep compression on the abdomen for 48 hours. That won't eliminate, but it will minimize the bleeding and the swelling from the procedure. So, yeah, let's go over questions now. Yeah, so just sites for someone who's very thin. Okay. In a very thin patient, we've had two football players, we had to use their glutes. And it's very helpful in those scenarios to have ultrasound available to find the fat stripes. But the truth is that I have not gone to that recently, even in very thin patients. If you use both flanks and you come across the abdomen, you do a good job. If you're in a thin patient, I think you need more tumescent than in a larger patient. And then both sides, 60 cc's above the umbilicus from both sides, total of 120, 60 below as well. And I've been able to get enough fat to do the procedure with that. The good news is in most of those thin folks, you're really just doing one joint. You know, when you get into my category where you've got an old guy that's an old warhorse and you're trying to do a shoulder and two knees, they're usually going to be a little heavier and you'll have more leeway. But even in the athletes, I've been able to get away with just using the abdomen, which I think is a lot easier because you're already set up for a scope, whether it be the shoulder or the knee. Other questions or comments? I think the local anesthetic thing is a little overblown for fat because our samples are showing good cell culture growth and the viability of the cells is over 90%. That's even with a large amount of lidocaine with epi in the abdomen. So I don't, I think that may be overblown. Ken, do you have a question? No our algorithm for that, I've been fortunate in Durham, I had Blake Bajas, who's a superb ultrasound primary care sports medicine doctor in Charlotte. I've got Dave Price and Kevin Burrows and our algorithm, and this is arbitrary, but I think it's holding up and it makes sense to me. If a patient has mechanical symptoms, so if they've got locking, clicking, popping in the knee, I'm going to scope them and do them in the OR and do the injection there. If they do not have mechanical symptoms, I send them to Dave and to Kevin and they do them in the office. I think that's a reasonable way of doing it, but that hadn't been studied, that's a little arbitrary. Yes? Yeah, hey T. Your 120 cc's of lidocaine, is it 1% or are you diluting it out? The two medicine, Molly, can you help me with that? So I'm going to go from the mic, can you repeat that one more time, 500 cc's of saline. Fifty cc's and 1% in the OR, or 2% in the office, and one amp of epi in a 500 ml bag. That's all invisible to me because this is happening on the back table while we're starting our scope, but that's a standard two medicine solution. Yes? Are you aware if, I don't think that I have hospital privileges for this, and I don't think it falls under the guidelines for orthopedic surgery, has that been an issue that you're aware of? No, it hasn't been an issue for me. I'm not sure if I'm going to get challenged on it next week now, but you know our privileges that I signed off on are very broad, they're things I would never dream of doing, and I think when you're talking about tissue harvest and biopsies and other things, which are already in our scope of operations, I don't think anybody's going to challenge us on liposuction. Carl, do you have an answer to that? Yeah, that's a good point. I mean, the hand surgeons are harvesting fat all the time for their grafts and things, so it's probably well within our scope. Do you have a question? Yeah, if you do flow cytometry on your end product, what kind of cell numbers are you getting, and can you differentiate between MSCs and hematopoietic stem cells? Yes, and I think it's one of the advantages of fat. You're not getting as many of the hematopoietic cells. In our sample analyses that we were doing, we were sending them 10 CCs, similar to what we would be injecting in the OR, and they were getting multiple millions of adipose cells, and that's the overwhelming cell population that comes. They did get between 50 and 100,000 mesenchymal stem cells. Now, Arnie's not here, so I'll say it out loud. Mesenchymal stem cells, and then the cells did grow out in culture and multiplied, so I don't know if that actually happens in the knee, if they grow out like they do on the agar plates, but I know that you are injecting stem cells much slower than we've been led to believe, so we'd like to get multiple millions of concentrated stem cells to inject. That's not what we do get, but there are 50 to 100,000 from the fat with this particular processing method, but multiple millions of adipose cells. Yes, Jeff. Are you putting them in any unloaded races or anything like that afterwards? Yeah, I think that's a very important point. As has been alluded to multiple times during this talk, don't forget what we learned before about alignment, so if somebody's got a terrible varus deformity, kissing lesions, Kellgren-Lawrence IV, I don't think they're a great candidate, to be honest with you, but if I am dealing with a patient with a medial compartment or a lateral compartment problem, I'm going to try to unload that with a brace, and I also put people on crutches for 10 to 14 days. That's a little more conservative than you've heard, but that's what I've been doing. In the early days, I think people came in a little more swollen, a little more uncomfortable than I really want them to be, and I don't see that when I put them on a short period of immobilization. Probably just settles down some of that bone marrow edema a little bit and all that's subchondral that you don't necessarily see with the scope. Yes. Do you ever do any subchondral injections with the fat, as they mentioned earlier, with the bone marrow? I'm getting ready to start. I think that makes a lot of sense because all these people have bone marrow edema in the compartment, and I have not done that, but I love the idea. Now, I'm not sure what the right cell is for that. Would that be fat or would that be marrow? It makes sense to me that marrow would be a better injection there, but who knows? But I do believe that that makes a lot of sense in these people with a lit up MRI where they've got a lot of subchondral edema that we want to treat that as well as the joint problem. Yes, Bill. Our PMR guy says about a low inflammatory diet or no NSAIDs six weeks before the fat harvest. You heard anything about that? I haven't held up to that. I don't think that the trauma of this is such that it's that big a deal, even if they're all non-steroidals, but some people get a lot more bruising than others, and I suspect that those are the aspirin and non-steroidal folks. It's been benign. I haven't had any problems related to that. Brian, how we doing? I'll just take one question. Yes. Are you using an ABN for billing, or is this ... What's your billing process? Yeah, I'm out of the ivory tower now. Jason and I had similar situations when I was in Durham. I wasn't actually billing the patients in the hospital. I told them they couldn't bill them either, and we were trying to just follow their outcomes, which I didn't do a very good job of either. But now in Charlotte, I'm in the real world a little bit more, and we set up a system where the hospital's billing 1,000. The kits cost 1,000 or a little bit more, and I'm telling the docs that they're going to get 1,000. So we're charging 3,000 like Jason is, and I'm trying to standardize that across our enterprise. We got 200 docs and herding some cats there, but I think that'll ultimately be where we land. All right, so 9-11.

liposuction techniques

orthopedic procedures

harvesting fat

simulcasting

patient selection