All right, well welcome to the lab and as you make your way to your stations, you should be able to watch on the screens next to you. If you guys don't hurry up, I'm gonna start singing the Duke fight song And I'll sing the Georgia Tech song no one wants that Ramblin wreck Ramblin wreck Do you know we're playing today I did actually Mike works all right sounds like you're lying So welcome to the lab are you guys ready to have some fun So if if you can make your way to your stations you should be able to see on the screens What what's going on and what I'd like to do is a brief live demo of the lipid gems technique and Molly Pettit's here to help me from lipid gems and This is this is not hard, but there are some tricks to it I'll try to go through those with you briefly, and then you can get your your Your hands going on your own stations And we'll walk around and help With any questions that you might have but as far as the technique goes I want to start with the instrument tray So if you're looking from top down here I'm gonna put a little mark on the side, and I've already done that on this particular cadaver, but a marking pen I'm going to use 1% xylocaine with epinephrine and that's the next Implement we're going to use in an 11 blade We're going to make a small neck into the subcutaneous tissue And then we're going to inject tumescent, and if you're in the office. You're probably going to want to do the full 240 CCs And I'm gonna do that in the OR if I'm doing both sides, but I'm gonna do half that I'm gonna do 60 above the umbilicus and 60 below which is what I'll do here today Just for demonstration purposes, then we've got the catheters here. This is the 17 gauge Tumescent catheter and you can see that's blunt tipped But it's got ports on the side for infiltration of the tumescent and then after we agitate the tissue and wait for 10 minutes We're gonna go back with the 13 gauge liposuction harvest catheter and you see that's got a single port on the side, but again It's a blunt tip and you might try for like I did when I was learning how to do this to see if you can Get into the peritoneum. I can tell you you can do it, but it takes a pretty direct approach So obviously you want the angles to not be direct This is the liposuction Catheter here that's for harvesting notice It's got a little tab right here and what you can do when you come back is You can set that so that you don't have to hold the suction during the procedure and I'll show you that when we get Into that and then this is the collection syringe. This is a 60 CC it's got a little lure lock on the top here that allows us to to Transfer the fat and collect it in that tissue. So I've already got the I've already got the mark made we can switch back to the cadaver now And I started out with a Concentration camp victim here and I had him switch to a more North Carolina type patient for demonstration purposes But I like to be pretty far over on the flank and what we're gonna start with is just a little wheel of local Antiseptic this is a little bigger needle than I would use in the office, but this is what we have here Create a little skin wheel Thank You Molly and then I'm gonna take an 11 blade and we're just gonna go through the subcutaneous tissue So we're not going super deep with that And then we got our tumescent syringe let me see if I can make sure you can see that there and we're gonna put our tumescent needle on the tumescent syringe and then we're gonna go through and Again, I you don't want to go directly in obviously because that's the danger zone But you can stay pretty flat here and we're gonna inject this in a fan fashion So what I'm doing is fanning out as I come across Now the umbilicus is really tender. You don't want to go into the umbilicus but if you can stay below that and inject the the tumescent solution as you come across And then I'm going to come back and go above the umbilicus with another 60 cc's and I like to kind of feel where my needle is up in the skin here and just kind of keep an idea of how good a job I am of fanning out and In the office more is more is more The local anesthetic effect of the tumescent is important to the patients I Hand this to the back table and then I'm gonna gently agitate the tissue So we play the the music and get a little shake and bake going here and Then we've got in our as I showed you in the demo from the OR We've got the the shoulder or the knee draped down. We're gonna go ahead and start our scope In fact, we've already started that as a simulcast so Let's assume it's been 10 minutes and now we've got our catheter here you can see You can come back in a little bit of a close-up and it's got the this is the the harvest catheter the 13 gauge And it's got the side ports a blunt tip again And we're gonna go back through I'm gonna go ahead and insert this all the way in and then I'm gonna set the lock on the syringe This is as I mentioned. I don't know if you can close up on that syringe there from above looking down but But the little tab right here is what I'm going to set that on And so you see that locks nicely now It's inevitable as you go back and forth that you'll hit your your hand against an arm Against a wire or something to hang it down and you lose your suction, but you can come back to that And now we're going to go through and you can see the the fat starting to collect And I'm kind of following that same kind of fan like distribution that I did When I was coming through with the tumescent solution and the longer you wait the easier this is we didn't wait very long here just for Demonstration purposes, but you can see the collection of fat here You can see it doesn't take long to really fill your syringe and if you lose suction you can just reload it Again keeping a relatively flat angle And then I'm gonna Just get the air out of the syringe there a little bit I'm gonna come back over to Molly if you can look over here And we're gonna just connect our syringes there Make sure you got it connected so you don't shoot fat in somebody's face And we've come back in and you can make multiple passes here And I'm gonna reset the lock there. Let's let's assume that I've gone a little bit and I've lost my seal Well, then what I would do is just come out I'm all the way back Let's make sure we're all the way up at the top there and you go back right back in Then we can reset the seal and then you're ready to go again So and you can keep going, you know a lot of times in a Relatively thick patient you can get pretty easily 200 cc's of fat if you want it So I'm gonna come out and I'm gonna go back up above the umbilicus And we're gonna do the same thing we're gonna lock and then in that fan shape fashion And you can see again, it doesn't take that long to get a pretty full syringe, and we'll pass that back to Molly again here. So when we finish the fat harvest, and if I were doing a patient where I needed to do a couple different joints, I would repeat the same procedure on the other side. You can see, I don't know if you can shine in, but I've got a similar mark over here on the other side, and just repeat the process over there as well. So once the fat's harvested, I'll go ahead and put, I use a suture, just a simple suture with 3M nylon on each side, and then at the end, we'll put a little dry dressing over that and a clear wrap on top of that, and then we'll come over with an abdominal binder at the end, usually put a couple ABDs in between, just to give some compression at the end of the procedure. And I think that really helps. I have them leave that on for 48 hours. But really, that's about it for the harvest. It's pretty simple. We hand the cells off to processing, and then Molly will show us here with the cylinder how she sets that up. Thanks, Dr. Mormon. So this is the smaller of the two kits. We have two sizes. Typically, you're going to use the larger one in the OR, but since we're only going to do one joint, we'll use the smaller, which is called the 60cc, which you have at your So there's a waste bag that needs to be tightly attached. There's a little bit of lure lock, so just make sure that that is tight. Pass that down to the floor. That's where the saline and the debris will collect, and you have your other end that's going to pop into a bag of saline, which is already spiked, but just make sure that doesn't spill here. All right. So the system is primed with saline, and inside of each cap, you have a cutting screen. So inside the orange and the gray, you have different sized cutting screens, and that's what the fat's going to go through. So to fill the device, you want to have it with the gray end up, and that way it fills with no air, because when fat passes through a filter into air, the adipocytes can rupture. So we want to protect them from that pressure gradient, so we fill the device with saline. So all the clamps are open right now. It's just filling on its own. So you can see the saline went through the top here, so we'll close both of our clamps. Check for air bubbles. Don't see any. So then we'll take our fat, and we're going to attach. Just push and twist, not too tight, just until you feel it stop. We're going to open our—and this will be a loop video going around, so you don't have to remember all of these. So the bottom clamp's open, and then you inject your fat through that filter, and you can see it going into the saline. Usually we don't fill it more than about a third at the beginning. So then we're going to manually shake it, just like a martini, if anyone's ever made a martini. So you shake for two sets of 30 seconds, so—but you get the idea, 30 seconds. After 30 seconds, you open both clamps to allow that saline to rinse out the cell debris, the fragments from the adipocytes. Sometimes there's blood, oil, so you can start to see kind of like a lava lamp effect. Washes out. This washes out all the oils and impurities and really concentrates the good part of the cells that are hiding the pericytes. Then we do our second round of shaking, 30 seconds. Call that 30 seconds. Open the clamps and let it completely rinse out until you see this chamber become clear and the fat—and usually it starts out kind of like a strawberry-mango smoothie color and it turns out to be pretty bright yellow. Now no one wants smoothies, sorry. So once it's completely clear, you'll close both, you'll rotate it. So we put the fat into the orange side and we want to push it out of the gray because that's the smaller filter. We put a 10cc syringe on each end, just push and twist. Thank you. So now this is the fun part. So you open up your bottom clamp, which is going to your saline bag. You fill this bottom syringe with 10ccs of saline. Close both so the whole system's closed. And then this is important. So you use your fingers and your palm here to squeeze. And there's lipogems. That's it. And you do that as many times as you need to to get it all out. And just push the air out and you're ready to go. And oftentimes in a case, we'll have three or four of these decanting over on the side as Jason showed us earlier with the fat pad. And then these can be combined, as he showed you, into one syringe so that we think that the right amount for a joint is 10ccs. That's what the Italians tell us. I think Americans need more than the Italians. So I usually try to put about 15 if I can in a joint. Whether we get to too much, I put up to 30 in a joint and I haven't seen any harm. The patient said it was a little bit like walking on peanut butter for a while, but they didn't mind it. So I don't think you need to use that much, but 10 to 15ccs in a knee in an average size patient may be a little less than a smaller patient. And the same with the shoulder. In the shoulder, I've used 10 in the joint. I like to put it in the subacromial space too if we have a patient where we're doing an arthritic shoulder. But that's rough ideas on the quantity. So if you guys can go to each of your stations, we'll come around and help you with this. And I hope it's not hard, so we'll have some fun with it. Thanks.

lipid gems technique

lab setting

demonstration

tumescent solution

cadaver