Welcome everybody. Glad and grateful for you guys to be here and be able to have the opportunity to present with my brother and give you guys some feedback on the reconstructive portion of breast reconstruction and reconstructive plastic surgery. I'm going to briefly tell you guys who I am. I'll give Faris an opportunity to introduce himself and we'll get into the presentation. So my name is Asad Samra. I've been in practice for nearly 15 years in the Amamut County and Middlesex County areas. We share offices in Holmdell and in Olbridge. I did my training in Houston, Texas at Baylor College of Medicine. And I spent quite a bit of time at MD Anderson getting involved with breast reconstruction, both implant and tissue based. And I've been in practice with my father and now two of my younger brothers. Yes, I'm the older brother. And we're very fortunate to be able to work together and breast reconstruction is a passion of both mine and Faris's. And one of the joys is when we get an opportunity to work together and hopefully make an impact on a patient's life. With that, I'm going to let Faris introduce himself and we'll get going. Thanks, Asad. Thanks, Kayla for putting this together. My name is Faris Samra and I am Asad's little brother, saying that for a long time. I trained at the University of Pennsylvania in plastic surgery. And I did a dedicated fellowship in complex cancer reconstruction at Memorial Sloan Kettering Cancer Center. I joined the practice in 2019.  And so we're going to talk about sort of all aspects of breast reconstruction today. And we're going to sort of go back and forth, but it's going to start off with the slides. Great. So, when discussing breast reconstruction, arguably we need to set the stage, what are the goals of reconstruction. And arguably one of the basic goals is to restore the patient's appearance in clothing, to free them from wearing a prosthetic, and to produce symmetric aesthetic appearing breasts, and to ideally remove the constant reminder of having had previous breast cancer or prior malignancy. As the techniques in breast reconstruction have enhanced and improved with time. The goals have somewhat become a bit more sophisticated to get ourselves a little bit closer to not only restoring appearance and clothing, but to restore appearance in less and less clothing and whether that be in a bathing suit or that be in a bra or potentially even with no clothing at all. And hopefully we will show you guys through this journey of breast reconstruction how we're getting closer and closer to that goal. Reconstruction can be done after a breast has been completely removed otherwise known as a mastectomy. However, it can also be done after a portion of the breast has been removed otherwise known as a lumpectomy. And there are different techniques that can be done, typically referred to as oncoplastic techniques again on co being Latin root for cancer and plastic surgery. So plastic surgical techniques for cancer related issues. An example would be an oncoplastic breast reduction in which, for example a patient would have a lump removed from their breast. The patient already was a appropriate candidate for a breast reduction. And after we get clearance from the breast surgeon and the pathologist that the tumor has been removed, we would then perform a breast reduction on that patient. Sometimes that lumpectomy can be combined with the breast reduction. Other times that breast reduction will be done as I mentioned before after the fact. Reconstruction, if the patient doesn't need a breast reduction but other contouring procedures for the breast such as a breast lift, or potentially a breast augmentation, those are things that can be done. And if there are smaller contour issues of fat grafting can be done to improve those irregularities. Fat grafting is a procedure in which we perform liposuction, typically on the abdomen to harvest fat. And once we take that fat we collect it and re-inject it into the breast to have that fat now live there. I just want to go through this example of a patient that had fat grafting. Yes, this is a patient who had a lumpectomy and standard of care when you have a lumpectomy is typically lumpectomy radiation. And radiation can serve in a way to almost shrink wrap a defect of that lumpectomy. So the skin can get tight, fibrotic attached to that that defect, and it can leave patients with a noticeable permanent indent where that lumpectomy was done.   But through that procedure, and you know what you can clearly tell as a relatively thin woman, we're still able to harvest some fat injected into the area of the breast and improve upon the aesthetics of the breast and remove that indentation. Exactly. You know, I think that this is also a great opportunity to to focus on a comment that Faris had just made about insurance approved liposuction, and I think it is very important for everybody in our audience to understand that breast reconstruction has become a right by federal law. And that is a by right, I mean that it is an insurance covered benefit in healthcare, not only for reconstruction of the breast that had cancer, but also for the opposite breast that may need some sort of adjustment to improve symmetry. So said more plainly, if a woman has had a mastectomy or a lumpectomy on the right side, and they now need some sort of a lift or reduction, or addition of volume otherwise known as an augmentation on the left side that left sided procedures also covered by insurance. And that's something that I find still surprising that women are not aware of that and I do think it's important that our audience knows about that. Moving into total reconstruction of the breast or reconstruction after a mastectomy, there are typically two main ways of discussing breast reconstruction. One is doing autologous reconstruction, which is using the tissue from the patient from a different body as the cartoon or image down on the bottom right shows that's an example of taking skin and fatty tissue from the lower abdomen, similar to the tissue that would be removed in the tummy tuck, and that tissue is then transplanted up toward the breast. And we're going to get into that a little bit more in depth, a little bit later into this presentation. The other way of performing breast reconstruction and arguably one of the more common ways nationally that breast reconstruction is performed is using breast implants, whether implants being placed immediately at the time of mastectomy which is referred to as a direct to implant, which is not as common as a staged reconstruction in which at the first time any of mastectomy and temporary implant called the tissue expander is placed, and then at a second procedure the expander is removed, and an implant is placed. We're going to go through the different pros and cons of these procedures so hopefully give you guys a better understanding of these types of reconstruction. So starting off with implant based reconstruction, as I mentioned to you moments I just want to interrupt you real quick, just to point out that it's not arguable about 80% of implants, I'm sorry 80% reconstruction in this country is done with implants. So it's, it's far more common than autologous. And there are reasons for that that we'll talk about but most women in this country end up getting implant based reconstruction. Yeah, and, and I, I agree and I appreciate that percent that percentage because it is important for you guys to know that. Construction as I mentioned is often performed in two stages, where at the time of the mastectomy, a tissue expander, which is pictured here to the right on the screen, otherwise referred to as a temporary implant is placed in the breast. And then, as an outpatient that expander will be filled with saline through a port if you can see my pointer here. So that port is findable using a magnet on the outside of the patient's skin, and then we can pierce through the skin with a needle into that port and then add some saline into the tissue expander. Because the skin of the breast is quite numb after a mastectomy, typically the placement of that needle into the tissue expander is not painful at all and in fact most patients don't feel it at all.  And again in an outpatient setting meaning day surgery the expander will be exchanged for an implant. Historically, all tissue expanders had been textured and the texturing is in reference to the surface of the implant. And that texturing was done because of the fact that we wanted the implant to stick to the soft tissue that it was placed in, so that the expander did not rotate or move around, especially as the expanders that we use today tend to be shaped. And by shaped I mean that they fill more preferentially on the bottom portion of the breast, rather than just as a circular expansion. It's more on the bottom of the breast and less on the top of the breast. Nowadays we have suture tabs and you can see these little tabs that are coming off of the expander in this image and those suture tabs allow us to suture the expander into place. And therefore we are using smooth tissue expanders rather than textured being that we have these tabs. And as we'll discuss a little bit later there has been a concern raised with the use of tissue, sorry implants that are textured, due to a rare form of a malignancy and again we'll discuss that in just a moment. Once we're exchanging the expander for an implant, we're typically having a discussion with our patient of silicone versus saline implants. The vast majority of patients are getting silicone implants in the setting of breast reconstruction, as those implants are typically softer and therefore feel and look more natural than the saline counterparts. So today comes in a cohesive or a highly cohesive form of silicone, which basically means that should there be an unexpected rupture or tear in the shell of the implant, the silicone does not leak out. And so in the past in the 1980s and 90s when there was concern of silicone leaking out of implants. We don't have that issue today as there is a higher cohesivity or gel like nature to that silicone. And so the silicone again does not leak out. In addition to which the implants have gone through extensive research to look at whether there is in fact any concern related to safety and the placement of silicone implants. And after approximately 10 years of exhaustive research there has been concluded no link, if you will, between silicone implants and the connective tissue illnesses and disorders that women had. We touched upon the concept of texturing and smooth as it pertains to expanders and similar to not really using texture and expanders. We're not really using texturing or in the implants as well but deciding to use smooth implants. There are anatomical versus round implants. If we were to use an anatomical implant as pictured here again flatter on top and lower, fuller on the bottom. The issue is that that could rotate and therefore would need to be textured and so again we come back to the fact that most of the time now we're not using textured implants so we're typically using a round smooth shelled silicone device in the setting of breast reconstruction. We had some patients that have asked about having saline just because they felt more comfortable emotionally or mentally with the idea of having saline. And so saline is a choice but by and large we're using some form of silicone, typically, you know this gummy referring to a gummy bear and how that candy once compressed can spring back up to its normal shape and size. The same concept is with the silicone implants today that it is cohesive and so it holds its shape stays within the shell of the implant while still being soft and providing good structure to the breast. First, why don't you walk us through this implant based patient here. So this is a patient who you can tell a skin skinny relatively small breasted had left breast cancer had a tissue expander placed and you can see that in the photo on the top right of the screen and expanders often are not the most comfortable. They can be tight, they can be a little shiny they can be a little bit higher place than you may want them or not exactly perfectly positioned. And that's part of why we do this is a two stage procedure because it allows us an opportunity to allow the skin to recover. Heal from the mastectomy and then have an opportunity to come back and really refine the appearance at that second stage when we take the expander out and put in an implant. And that you can see was done in the bottom two photos. It's important to note in this patient that because she was small breasted and sought to be larger breasted. She had an augmentation of her right breast. And again as Assad pointed out, at the beginning of the talk that that's part of the federal law that she had an augmentation of her right breast. So the augmentation of her right breast, not only gave her an overall better aesthetic, but it also allowed for her to have better symmetry because it's easier for an implant on one side to look like an infant on the other, compared to an implant looking like a natural breast. And she has a very reasonable result that she's happy with. This is an example of a patient that had both breasts treated with mastectomy, eventually placement, or at the time of mastectomy placement of tissue expanders, the middle photograph shows the patient having those tissue expanders filled with ceiling, and then ultimately those tissue expanders were exchanged for silicone implants. And you can see her results on the right side. Her next step would be a nipple and areiola reconstruction, which we will touch upon as well. Right now, if I can just have you go back actually to that last patient. One thing that's important to talk about with implants. And it's not as a ton of experience with this is fact grafting and we talked about fact grafting a little bit when it came to lumpectomy defects, but fact grafting is also a wonderful adjuvant treatment and implant based reconstruction. And this is a patient that I think actually would really benefit from that, particularly on her left upper breast photos a little bit washed out but you can appreciate there's a little bit of hollow there. And some fact grafting in that area would really help to smooth out that transition. This particular patient is just not bothered by it and of course we're not going to, you know, force patients to do anything they don't want to do. But I don't know if you want to talk about this on any other adjuvants or fact grafting and implant based reconstruction or something like that. Yeah, I know I appreciate you bring that up and so you know as far as said, probably almost with every time that I go back into the operating room to exchange expanders and place silicone implants. As we would go from this middle photograph to that photograph on the on the right side. And performing fact grafting at that time to try to help soften the contours around the implant to help soften that transition from the upper chest to the breast itself, and perhaps addressing some of the concerns of rippling, which is the visible ripple that can be seen in actually infant patients. And so fact grafting has arguably, in my practice gone from a, we could do this to just about we're almost always doing this, as I think it's slowly becoming a part of the standard of care and options available to treat patients patients going through breast reconstruction. And at that point, a question was asked about the infection rate of fact grafting. I think the infection rate is very low, but they're the success rate or the take rate is not 100%. What I mean by that is generally speaking about 60% of the fat that we transfer survives the journey and that means that it gets revascularized by the tissue that you put it in, it lives and it, you know, continues to be a part of you. And does what you want it to do as far as adding volume and improving contours and things like that, about 40% of it doesn't really survive the insult from the liposuction damages those fat cells, enough that when you transfer it it doesn't survive that journey and your body just absorbs that fat over time.  But fact grafting is very safe. Women often are worried about fact grafting increasing cancer recurrence or things like that. That's just been done on that and is not borne out to be concerned from a recurrence for cancer. Correct. In addition to which the radiology modalities of mammogram and tomography and MRI are very well suited to be able to pick up what looks like fat or even fat hardening otherwise known as fat necrosis versus any sort of a concerning lump that's forming. So there really isn't a concern associated with fact grafting and malignancy. So our next slide basically is to show you guys a woman in her preoperative setting having the need for bilateral mastectomy, then went through implant based reconstruction and you can see her horizontal somewhat diagonally if you will positioned scar that was done for her mastectomy. She had had a previous procedure in which there is scarring done around her areola and coming down to the fold of her breast which you can also see slightly in these post operative pictures, but the mastectomy incision was made across her breast. And after her implants were placed, she had a nipple and areola reconstruction done with 3D tattooing. So despite the appearance of projecting nipples that you can see on that right image. Those are actual flat 3D tattoos, which have become a incredibly popular way of reconstructing the nipple and areola, especially in women that have done implant based reconstruction. The nipple reconstructive procedures require that there be a significant amount of fatty tissue under the skin to create the projection of a nipple. And in the setting of implant based reconstruction, usually there's a very thin fatty layer underneath the skin before the implant is there. And so one of the difficulties in implant based reconstruction is in fact creating a projecting nipple and 3D tattooing has arguably been a way to solve that problem as with a single session or potentially a single session with a touch up session. Our tattoo artists are able to both create the areola and the image of a projecting nipple giving completeness to the reconstruction. And the only thing I would add to that aside is that in my experience, a lot of patients that have had bilateral surgery done are even more likely to just have tattooing, because they're they're not trying trying to obtain symmetry to their natural nipple on the other side that has some projection to it. And a lot of women like you said especially that have had implant based reconstruction. Look forward to not having to wearing up not having to wear a bra, not having to worry about their nipple showing through shirts, and that sort of stuff and so having just tattoo nipple reconstruction really accomplishes the goal of changing how your mind's eye looks at a breast without some of the risks like you, you talked about, as well as the negatives of you know having to make sure that your nipples don't show. Your headlines aren't always on as patients have upset to me. So, another example of a patient with larger breasts that underwent bilateral mastectomy with placement of tissue expanders and you can see those expanders are full up to that top right. And as we come down to the bottom pair of photographs, the implants have been placed, and that patient has gone through a niplinarial reconstruction and tattooing. In this particular patient, she did have nipple flaps, if you will, or the procedure done to create the projection of a nipple, and then tattooing was done on top of it. You could arguably appreciate that there isn't on this kind of angled view of significant projection of the nipple, which again is not objectionable as far as I mentioned sometimes it can be a bit awkward if there's always a protruding nipple as it pertains to particular clothing that's being worn. But it this is to really demonstrate that even though there can be thin fatty layers in implant based reconstruction. There are times and occasions where we are able to create a projecting nipple if that's in case with the patient. In fact, rather what the patient wants. Not all mastectomies remove the nipple. And this is a patient of mine that had bilateral nipple sparing mastectomies. And in this setting the incision for the mastectomy was done along the bottom of the breast or along the fold of the breast. And therefore this patient was able to not only keep her nipple and areola, but ultimately after her reconstruction was done, you could make an argument that she simply looks like she's had a breast augmentation and didn't actually have to go through breast reconstruction, where in fact her breast is entirely made up of a silicone implant. And these are some of the advancements that have we have made as a group of breast surgeons and plastic surgeons in understanding and better stratifying which patients can be treated with nipple saving or nipple sparing procedures and therefore placing scars in a different area of the breast. This case also brings up a discussion of advancements that have come up in terms of where these implants and or tissue expanders are placed in reference to the patient's chest muscle. And so through an elaborate and or exhaustive discussion of the reconstructive process since the 1960s and 70s until now. So, the highlight points are that initially, we only had implants that were placed above the chest muscle, which was unfortunately fraught with a lot of infection as the mastectomy skin tends to be pretty damaged from a perspective of blood supply after that surgery is performed, and therefore the mastectomy incision would break down. The surgeons at that time then attempted to try to find better blood flow tissue to cover the implant and started to go underneath the muscles of the chest wall and in fact potentially also underneath the muscles of the upper abdomen and the side of the chest. The issue was that the implants needed to be very small to be able to accommodate that tight space and therefore we were able to accomplish a meaningful reconstruction in women that either had and or wanted fuller breasts. Tissue expanders allowed us to come up with a way of solving that by placing tissue expanders in that under the muscle space and then stretching out those muscles to eventually swap it out for an implant. Fast forwarding until approximately five to 10 years ago, we now find ourselves going back above the muscle with the technological advancements of something called spy camera, which allows us to assess the blood supply of the mastectomy skin up to the level of the incision in the operating room, giving us a real time view of how things are healing and how well we expect them to heal. And that has allowed us to now not touch any of the muscle on the chest wall or upper abdomen or lateral chest which has greatly reduced the pain and bleeding complications of patients after surgery and arguably putting the volume where it quote unquote belongs, which is right underneath the mastectomy skin. This patient is one that not only had a nipple sparing procedure but also was able to have an above the pack or a pre pack reconstruction. And so if any of our audience members have heard of the concept of a sub pack which means below the pack muscle, or a pre pack which means above the pack muscle. What we're referring to again as the placement of that implant and again this is an example of a patient had a nipple sparing procedure in the pre pectoral space. So the benefits of the implant best reconstruction are arguably less surgery. There's one night in the hospital. A three to four week recovery. That's easier as the surgery is only limited to the breast, and in a bilateral reconstructive setting, we can get really good symmetry. Conversely, some of the negatives of implant based reconstruction is that the process can take longer as expansions can take time, and the expander itself can be uncomfortable as it is a relatively rigid device. There can be some size limitations with currently us being unable to create breasts, much larger than approximately 800 ccs as we're limited by the available size of implants. There is some discussion on the horizon of creating larger implants for women that are naturally larger and would like to stay larger, but currently there are some size limitations. There can be implant maintenance, and that is to say that the implant is a medical device that is not intended to last forever. That being said, that does not mean that there is any specific timeframe for when implants need to be changed. I'm often asked by patients that is it true that I need to change my implants every 10 years. And the answer is simply no that is not true that that is an extrapolation of the warranty that has been given on implants by the implant manufacturers, specifically for the cosmetic patients. Because cosmetic patients purchase their implants, and therefore this is a warranty for them. Should there be anything that is considered a manufacturing problem with their implants. Despite the fact that there is no specific timeline for implants maintenance. The reality is that it is likely the younger the patient that they would need to address their implants in the future, whether they want to be smaller they want to be larger, their implants have started to droop of it with time. There can also be a tightening of the scar capsule around the implant refer to as capsule contracture. And those are examples of reasons of why someone would want to exchange their implants in the future. Infection risk, as presented in this example of a photograph here of this patient who unfortunately has an infection. We cannot fight infection and arguably if there is any sort of possible seating or introduction of bacteria at time of surgery, or time of expansion implants can harbor infection. And so we take the prophylactic and or preventative measures of infection very seriously in implant cases where we treat our patients with IV antibiotics, we wash the space where the implant will go with antibiotics. We have the implant itself in antibiotics, and we have been using a device called the funnel or the Keller funnel, which is a way of introducing the implant into the breast, without ever touching the implant. And so the implant is poured into the funnel, and then the funnel is used, kind of like a baker's funnel if you will the funnel is used to introduce the implant into the breast pocket, without even touching it. And those are always to try to reduce the risk of infection. Radiation is a very common part of breast cancer treatment nowadays, and radiation and implants typically don't play well together in the sandbox, especially if the patient has had some significant skin changes as a result of radiation. And so radiation may be a reason that we need to consider doing a different type of reconstruction, or changing the trajectory of our reconstruction from an implant based reconstruction to a tissue based reconstruction which we'll get into next. There can be poor symmetry, where as you can see in that picture on the right the patient has a natural tautic otherwise known as droopy breast, and now they have a higher perky implant breast. So there can be procedures done to lift to that right side and improve symmetry, but it can be difficult sometimes to get implants and natural breast tissue to match, especially out of clothing. There can be concerns related to implant issues, and there can be numbness. So what I want to add to you is at what you said was with regards to implant maintenance. I think that everything you said is totally accurate. You know we generally tell people implants last 10 to 15 years, but that does not mean that it's like you know you drove your car for 3000 miles and you have to have an oil change and so we're going to schedule your implant surgery 15 years from now or whatever. This means that after a certain amount of time you're at an increased risk of having some issue with your implants. And so you may need other surgery down the road and implant warranties are themselves improving the implants that I use are warrantied for 20 years made by a company called Cientra and implant technology is improving and so that is also helping to give patients better results.  It's very important for them to know that these implants will likely not last the rest of their life, and they may need two or three more surgeries throughout the rest of their life for their implants but if I have a 68 70 or 60 to 70 year old patient that is having breast cancer. It may last the rest of their life and truth no one knows how long the rest of their life is, but you know implants may last them as long as they need it just, you know, no one really knows but you know implants are not lifetime devices is basically the bottom line. That's right. That's right. The next slide is to demonstrate to you some of the effects of radiation on breast and implant based reconstruction. This patient had left breast cancer that was treated with mastectomy. You can see the effects and discoloration on her breast skin after she has had radiation. And then, as far as had mentioned to you guys before that can result in a tightening of that breast skin envelope.  And then perhaps this is not as obvious when she's in a bra and this breast is lifted up a bit, but you can see it a bit more obviously when she's out of clothing. So the implant concerns that we wanted to make you all aware of are some that are related to recent findings of something called breast implant associated. This is AL or anoplastic large cell lymphoma, which is a very rare lymphoma that appears to be associated with textured implants only the incidence of ALCL amongst people who have textured implants varies pretty drastically from one in the 30,000. But this being a textured implant problem resulted in myself and my partners and the vast majority of surgeons that I speak to, not offering textured implants at all, neither in the setting of the placement of a tissue expander, nor in the insertion of the more permanent breast implant. In addition, there is breast implant illness, which is a poorly defined syndrome or if you will conglomerate of symptoms that have a pretty drastic range of overall not feeling well or hair loss or itchy, dry eyes and kind of almost immune oriented type of symptomology. And the interesting challenge that we faces plastic surgeons is that when people ask us about breast implant illness, the science the data that's out there scientifically cannot seem to find a link between breast implant illness and breast implants. There is a relatively significant presence on social media, Instagram and Facebook of women who have expressed having had these symptoms, and that once they've had their breast implants and capsules removed that they found that their symptoms have improved. And that has given a lot of credence to breast implant illness, perhaps just not being realized yet scientifically, but actually being a quote unquote real, if you will. The other interesting challenge is that there's also a social media presence of people who've had their breast implants removed, because they believe that they had breast implant illness that now have persistent symptoms even after their implants have been removed, which again, is creating a little bit of a confusion as to is breast implant illness real or not real. Suffice it to say that I think that breast implant illness may in fact be a real thing for a population of patients that unfortunately to date is very difficult to determine or define. Some people feel that perhaps those that are currently dealing with autoimmune issues that perhaps they shouldn't have breast implants placed. But again, there is no good data that would prove that that is in fact a real recommendation. Lars, do you have any thoughts on breast implant illness or else to y'all. No, I think you defined it pretty well I mean I when it comes to breast implant illness. You know I basically just tell patients that the range of symptoms is so drastic, you know from foggy brain anxiety tingling in their fingers diarrhea dark circles under their eyes everything that it just makes it very hard to really study. And so, and then I think that you, you said it better than I think I've ever told the patient as far as, you know how there are people who have their implants out and they feel better and I'm happy for those people. And the people who have their implants out and they feel lousy still and I'm very sad for those people, but it leaves us not really knowing what to make of this. And so I always talk to patients about it because I'm, you know very full disclosure and I want them to know from me and not think that I'm trying to hide anything from them. But I think that the jury's out on breast implant illness and I agree with you I think that there's a sub, a small subset of patients that have a lot of autoimmune issues that pretend potentially shouldn't have any foreign body, you know if possible know, you know knee replacement played in their wrist or shoulder or anything, let alone a breast implant and I think most people do fine with it, but you know we're still trying to learn more. Great. Okay. Well, I'm going to now actually turn over the lead to Faris to walk us through autologous based or tissue based reconstruction. Very good. Hopefully that's working for everybody. So, I'm going to talk about autologous reconstruction. And this is when you use your own tissue. And this can really be done at any time. It can be done at the time of mastectomy. It can be any done anytime afterwards assuming the patient is a good or safe candidate for it. It can be done after implant reconstruction so women who have implants and already. It's not like you've, you know gone down some path and you're, you know, destined or doomed depending on how you look at it to have implants for the rest of your life. This is typically the most common source of where we take tissue from because it gives us typically the most volume and similar type of tissue to a breast, but thighs can also be an option and women who have skinny bellies but are larger on their bottom. So this is just a little schematic of what this is and, and it's, it's like a tummy tuck but I emphasize the like it it's not really the same thing as a tummy tuck.  So our goal is going to be to give you the flattest tightest belly possible with the lowest scar that you can hide in, you know the smallest bikini.    And you can see in this schematic here that we identify those blood vessels, then we dissect them through the six pack muscle to get down to where the base of those blood vessels are which is down in the pelvis. There are three branches on a tree.  And then we completely remove it from the body, which you see here so this is very similar to someone having a kidney transplant from one person to another. It's completely separated from the patient. And then if in the chest, we take a small little segment of rib out, where we find some blood vessels that pass underneath that rib, and then using a microscope or a loop magnifying glasses, we sew these blood vessels together to reestablish blood flow in this tissue. And this allows for that tissue to now be living and healthy on your chest, so that we can shape a breast out of it. And briefly one other thing that is worth pointing out here is that your belly doesn't know it lives on your breast anymore, or that it's no longer on your belly and it lives on your chest and so with that weight gain will fluctuate with your breast sensation can be built up in your breast and I'll talk a little bit about that in a second.  You can see that she hasn't not so beautiful scar that is you know, relatively high for tummy tuck purposes. But scar from hip to hip scar around her belly button, but quite good symmetry in matching her other breast in a unilateral setting. Here we go. This is a patient who had bilateral mastectomies. And you can see here that her nipples were removed and in the area where her nipples were is again skin from the belly. Her scars a little bit lower based off of where her blood vessels were and how much her skin stretched. And also excellent symmetry in a bilateral reconstruction. One way one place that deep labs differ from implants is that if you're having just one breast reconstructed. You know, skin and fat from the abdomen in the form of a deep flap can look a lot like a natural droopy breast on the other side which you know is similarly scan and fatty tissue or breast tissue. So in a woman like this where you do a unilateral reconstruction and she has had her scarring limited to around the areola. You can imagine that if she had nipple reconstruction and tattooing done on her left side that her symmetry would be quite good and almost difficult to perceive. She recently had a patient that we did a unilateral breast reconstruction on with the deep flap on how did her symmetry work out how she feeling about it. It really worked out great, especially to similar to this picture. Her unoperated breast was a bit droopy after having had about three children and breastfed, and she wasn't really interested in doing anything to change that breast in terms of having a lift, or any modification to it. So we had delayed her reconstruction and you may get into that a little bit we delayed her reconstruction by having a tissue expander placed initially, and that expander looked quite high in relationship to where her other breast was. And then as we transitioned her to the deep flap reconstruction we were really able to very significantly match and improve her symmetry and she's looking great. This is a patient that actually did not have breast cancer and it's an interesting opportunity for us to talk about prophylactic breast reconstruction. This is a woman who had genetics that predisposed her to increased risk for breast cancer. She's only about 40 years old but she had a sister who died in her young 30s from breast cancer. And she therefore sought out prophylactic mastectomies to reduce her risk of developing breast cancer that could be a life-threatening event. And so when she presented to me on this photo on the left, she had recently had massive weight loss surgery, she had these very droopy breasts and again as a young otherwise cosmetic inclined woman. And what we did is we first staged her with a breast lift, and that allowed us to put her nipples in a more acceptable cosmetic location and give her a better shape and definition to her breast.  And then we did a nipple-sparing mastectomy similar to how Saad presented that patient with the implants that, you know, great at the end of the implant section. But we reconstructed her breasts using deep flaps. And you can see that there's a small triangle of skin at the bottom of her breast here that is from the belly. And she brings some amount of tissue, skin tissue from the belly with us because we utilize that for monitoring. I tell patients it's like a canary in the gold mine, it lets us know if there's any problems. And so by that skin looking healthy and happy, we know that the tissue underneath is healthy and happy. And then in another patient that I did a similar procedure on, this one had breast cancer, but I similarly did a nipple-sparing deep flap breast reconstruction. You can see her skin paddles again from the belly, the skin from the belly that was transferred up to the breast. At a separate surgery, I can go back and try to aesthetically refine this further and we can remove those skin paddles. And so here you see her after having that skin from the belly excised.  She had no skin paddles from the belly, she kept her own nipples, and if anything she just has a larger fuller breast that's been a little bit lifted. And she has a scar from hip to hip, which, you know, again is sort of similar to a tummy tuck, it's not the best tummy tuck result, but definitely a very acceptable one.  She had the bruising of her right breast from her biopsies.  She's similarly a young 40-year-old woman. This is going to last her the rest of her life. And she has a flatter belly and fuller breasts. And so that's something that, you know, she felt was a really good option for her. This is something that you can do, like I said, at any time though. So there are women who didn't have reconstruction and decided that, you know what, this was harder than they thought and they don't want to be stuck to wearing prosthetics. And so we can do a deep flap reconstruction afterwards. They can be women who failed implant reconstruction, whether that means they got an infection or had some sort of complication that was no longer successful in the implant world.  And like Asad mentioned previously, who have tissue expanders in. And, you know, a lot of the cases that we do with the breast surgeons that we work with at Bayshore and Riverview, who are fantastic, we often typically put expanders in first. And that's because that allows us to make sure that patients don't need any form of radiation, any form of chemotherapy that we're not going to delay any of their cancer care from a reconstructive perspective. And it keeps all options on the table. It allows them to still be a candidate for deep flap it allows them to still be a candidate for implants, whatever the patient wants and is best suited to them. And it allows us to get the cancer out because that's all the patients are really worried about at the time of receiving a cancer diagnosis and cure them of their cancer and then we can think about the reconstructive that's best suited to them. In a, you know, sort of more comfortable and less urgent way. This is a patient who had expanders in, and then we switched her to deep flaps and so you can see here this is a up and down vertical incision and expander that's in place and then this circle of skin where ultimately she had nipple reconstruction and tattooing. This is belly skin.  But if you want to worry about implant maintenance or infection concerns or those sort of things. And in patients who get radiated and have a lot of damage from radiation deep flaps are great because they bring in non radiated healthy tissue. You know this is tissue from the belly that has not been radiated and it's soft it's supple and it looks and feels a lot more like a breast. And it can allow patients to have a very acceptable result. And one of the things that it's always how to speak construction is that it's all natural it's it's all the patient it lasts for the rest of their life. One thing that we do that there are a few doctors, frankly in the country that do is we also hook up nerves. And what I mean by that is when we are dissecting the tissue out in the belly. We will find the nerves that provide sensation to the skin and fat of the belly. And then we will also find a nerve in the chest. We use a nerve graft which comes off of the shelf and doesn't have any mobility to the patient as effectively an extension cord to connect the nerve in the chest to the nerve in the belly of the tissue that we transfer. And this is meant to guide the, the nerve to grow into this tissue that we transferred to try to help maximize the sensory outcome of the reconstructed breast. I tell all my patients that I'm not trying to misguide them or mislead them into thinking that it's going to feel like their breasts did before they had a mastectomy. You know the the amount of nerves that are cut when a mastectomy is performed is innumerable. And we're basically hooking up one again to use that tree analogy one tree trunk of a nerve, trying to guide the nerve to grow into this tissue.  And so it takes months to years to really see the impact of this nerve surgery to see the maximum impact of the nerve regeneration and the sensation returning. And this is something that you know we've been doing for over a year now and, and, you know, we're excited to be one of the few people around here offering this. And our patients seem to really like it. And it seems like our patients, you know, are starting to develop sensation and more than anything I think that they love that they're getting the most cutting edge form of reconstructive surgery that you can get anywhere in the world at any high level academic center in the comfort of their own home and at one for hospitals like Bayshore River view. So I know we recently did a patient of yours that we did resensation on. I know she wasn't too long ago so not sure how much sensation she's had back but what's her experience been like. Yeah, yeah agreed it is a little bit early, but she definitely is encouraged by the fact that she has the best shot of getting sensation back and there does seem to be some early signs that on the periphery of her flap. That she's getting some sensation back and so that's, that's really promising and I agree with everything that you said that this is you know the the kind of the next frontier is not only creating the appearance of a breast but here we say like the function of a breast which is to have a breast that not only looks hopefully natural but feels natural not only to the person touching but to the person being touched. So the way that I have had it explained to me and I tell patients is that the goal is, is to have it so that when a patient who's had this procedure done hugs their loved one whether it's a child spouse and parents whoever. They feel that foreign body between them, they feel that it is a part of them, and it's just an extension of them and I think that that takes time again because nerve growth takes time but is a wonderful thing to restore to patients to really help them close the door on their breast cancer and and the journey that they've gone through. One of the bits of autologous reconstruction is that you don't have to worry about implant maintenance you don't have to worry about you know I've had my implants done 20 years ago, you know I'm not really happy with how these things look or the shape or the feel and you don't have to worry about things like that infection is much less of a concern we talked about symmetry and, you know one side versus two sides, of course, most women who are candidates for the surgery have some extra tissue that they're more than happy to give up. So you get the improved contour at the donor site. And there's been a lot of studies done when I was at the University of Pennsylvania that showed that there's really better long term satisfaction with this procedure. Of course, there are trade offs. And, and this is a much bigger story.  Unlike, you know implant based breast reconstruction which typically one night in the hospital oftentimes, frankly, we can do an implant based breast reconstruction, a patient have no nights in the hospital. But in this setting you need at least two nights in the hospital you need 48 hours of monitoring, and you're looking at at least really a six week recovery. And that's because there's now surgery both in the belly and surgery in the breast in both situations, and we need to make sure that both sites heal. We don't want you to get a hernia we don't want you to have wound healing problems. And so it's just a little bit longer of a journey. You know, very technically challenging surgery. And so you have to have someone who is confident and capable and experience. This is something that I did every day, you know in residency and then every day, even in more intense way and fellowship. So I've done hundreds of micro surgical and astimoses. We've done, gosh, I think over 40, since I joined our practice. And it's something that we're very comfortable and good at but not everybody is. And I think that going back to the statement that we made at the very beginning I think that plays a significant role in why 80% of women get implant based breast reconstruction and that's because implants are easier. It's a lot harder to do it's a lot more challenging for the surgeon, and it's also more challenging for the patient. And so the tissue that we connect the biggest concern that we have is that those blood vessels that we have to so are typically about two millimeters in size. And so if a blood clot forms in one of those blood vessels and blood flow either can't get in or can't get out of the tissue that we had transferred, and either way that tissue won't survive. And so it becomes an emergency that we have to deal with, no matter what time of the day or night it is to try to fix that problem. Fortunately, that problem only happens about 1% of the time, and so those odds are pretty good. If it is to happen we can fix it usually about 50% of the time. I keep patients in the hospital for 48 hours because if that problem is going to happen it typically happens right away. And that window of time that you're worried about and in which you can actually make a difference is usually the first 48 hours. So, around 48 hours out from surgery my patients have in walked showered, you know, and the pain is well controlled. Most of my patients don't take any narcotics, and they're ready to go home. And so most of my patients go home at around 48 hours after surgery.  And so sometimes patients are not a candidate for this. And like I said before there are risks at the second surgical site. And that's, that's pretty much it. So I know there's a couple of questions let's see what is going on here. I'll ask if I want to answer it the first one is if you learn that you have cancer. Do you have to go to a breast surgeon before a plastic surgeon, or can you go straight to a plastic surgeon. I mean of course you can go to a plastic surgeon, but ultimately that plastic surgeon is going to need to get a breast surgeon involved in your care. And that's because we as plastic surgeons, we don't do mastectomies. We don't remove the breast cancer and do your lymph node dissection if necessary.  And these are multi disciplinary conferences where there are breast surgeons plastic surgeons radiologists medical oncologists genetic specialists, everything's a very multi disciplinary approach to make sure that we're providing patients patients the best care. And it's important that you know you have a good team and you're lucky that at Bayshore Riverview we really do have wonderful breast surgeons I mean I trained some of the best institutions in the country arguably the world Assad, I know the same. And we can tell you that you know the breast surgeons at Riverview and Bayshore and namely Dr Kamal and Dr Campo are wonderful. They take wonderful care of patients. They take wonderful care of your cancer and they work in a great multi disciplinary way. And we're very lucky to have them. I agree to I just I guess to reiterate what you said, I guess, the way you asked your question, you do not have to go to the breast surgeon first that does seem to be the more common pathway is the breast surgeon evaluating the patient determining the benefit or need of lumpectomy double mastectomy, and then the breast surgeon getting us involved in the reconstructive setting, but you could come to the plastic surgeon to discuss reconstructive options, but then as far as mentioned, we would definitely want to get one of our breast surgery colleagues involved. Next question fire was, do you recommend a double mastectomy if you are predisposed to cancer.  So is that something you can do and would insurance cover it. Yeah, so if you are someone who is genetically predisposed to breast cancer your BRCA positive or there are other, you know, genetic mutations as well. You may be at significantly higher risk of developing breast cancer, and that may result in insurance, approving mastectomies as a general statement. I don't ever recommend patients get a double versus a unilateral. I don't think it's any of my business. I think that that is a decision that is very personal to the patient. And I think it's a decision that needs to be had between the patient and the breast surgeon. There is lots of data that having a double mastectomy in patients who have even had a unilateral breast cancer does not significantly reduce their either recurrence rate or mortality from breast cancer, compared to having a unilateral mastectomy. What I do tell patients is that if you had a unilateral mastectomy you didn't have the other one, you of course need to continue to have regular screening and sometimes it has to be even, you know, higher risk screening of the other breast. And sometimes the anxiety of that is not worth it to patients. And so I think it's very personal between the patient and the breast surgeon. I think that, you know, from a reconstructive plastic surgeons perspective I just have to educate patients on what are your options, what's going to look better. What, you know, like we talked about already today if you have a unilateral mastectomy and a unilateral implant reconstruction, there's going to be some challenges with symmetry. So if you have a bilateral, your symmetry odds are going to be better. I think those are, those are discussions that again we have to have as a, as a joint effort and as a team. Yeah, I agree. You know, I think the only perhaps things I can add is predisposition to breast cancer can be different things today is that there are very sophisticated tests that can be done to delineate the genetic predisposition, and how high those risks are would ultimately be answered by either a genetic counselor and or the combination of the genetic counselor and the breast surgeon. So it would be difficult for us to recommend mastectomy to anybody, but rather perhaps as far as the saying is discuss the options for what we can do to reconstruct a mastectomy or a lumbeck to me. That would be a defect. Insurance could certainly cover these things. Again, probably starting with the genetic testing and then counseling. Last question on this thread was what are the complete recovery times for these various options of surgery. And to tell you that, you know, typically complete, perhaps is maybe the key word that you were asking, and the truth is that we tend to talk about recovery times and typically generally four to six week windows. And by that I would say that an implant based reconstruction we would say, depending upon where you're counting from are you counting from the time of mastectomy are you counting from the time of removing the expander and putting in the implant. So if you're counting from that second procedure, that might be just like a two week recovery, because a lot of the work has already been done. But if you're counting from the time of mastectomy well then you might be looking at a several month recovery. As there's the mastectomy then there is the placement of the expander, followed by expansion, and then a second procedure to exchange your expanders. And that arguably depends upon where you're where you're counting from as far as had mentioned with the autologous based reconstruction, usually about a four to six week recovery window, and that's for most of the recovery to happen and so that then the patient doesn't necessarily need to worry about some of the immediate post operative concerns of infection or wound healing problems. So there are continued changes over the course of several months after that with the breast getting softer the scars getting lighter. And so you could arguably say that complete quote unquote recovery, maybe more in the order of one to two years. I don't know if you want to add anything to that for you know I think that what you said is accurate I think that it's one thing to just keep in mind that if you are going down the road of implant reconstruction. And generally speaking you're having at least two surgeries right the expander place at the time of mastectomy. Usually there's around a three month gap between that surgery and the implants being placed. But like you said that second surgery is an outpatient procedure it's very well tolerated there's very little downtime. And like you said just a couple of weeks and you're basically back to normal. There's no reconstruction, especially because of the abdominal composure components to the surgery. There is a much bigger recovery period up front. But you may never need to have another surgery after that. Generally speaking, I do do one more surgery, which is sort of an aesthetic refinement procedure, like you saw in that woman who had the nipple sparing reconstruction and we took out the skin from the belly to maximize the aesthetic so I would say otherwise your numbers are all on point. And again, you know, talking about sensation that adds a lot of time and so you know it just depends on what you're describing is complete. And the last question that's had was, do you know the likelihood of women who develop wounds from these surgeries and also what are the likelihood of infections for all of these surgeries. So, you know, I'd say that the likelihood of infection is very low. By that I would say between 5% or less. It can be specific, or those numbers may change based on the particular procedures or particular medical history of the patient. So let's talk about wounds as we want you guys to know about some of the potential complications associated with these procedures. The likelihood of developing wounds that are more significant than just a little bit of scabbing that would be healed with just a blood flow is fairly low that that would happen, especially with the advent of the use of the spy camera which is that camera that we talked about that can be used to assess blood flow when we're doing either implant or tissue based reconstruction in the setting of the tissue because it's just more surgery. Maybe there's a little bit more of a chance that you might have a wound healing problem along the incision along the abdomen. For example, but again usually those things heal with just some nursing care and by nursing care I mean bandage changes and antibiotics, ointments, or, or something like that. It's, I would say arguably relatively rare that we would have to do anything surgical to those things. Yeah, I think that's accurate. I mean I think that the in the concern with infection is inherently higher in implant based breast reconstruction. And that's primarily because your body can't fight an implant infection the way it can fight an autologous infection because it's known implant if it gets seated with bacteria there's basically no curing that unless you take the implant out. If you use your own tissue, you know, tissue that has blood flow means that that blood flow is bringing antibiotics and it's bringing your immune system it can fight that infection. And so, I think those things are real we take infection very seriously in our practice obviously. And so, inherently we're a little bit more worried about it when we're dealing with implants because it becomes a harder fight to have if there's a problem. But the rates are generally low I think the data rates on on implant infections can be as high as 15%. I think that's a little bit high. I think that you know closer to like what Assad said around 5% is probably more accurate at least in our experience. And then it's just not something you really worry about that much with autologous reconstruction.


Model 155 is about interlocked functions. We have discussed some interlocked functions previously and we have seen that through atomic operation we can increment or decrement our control variables. In that we have discussed functions interlocked increment or interlocked decrement and with the help of these two we perform atomic operations and increment our shared variables or decrement them. Apart from this, there are many other interlocked functions through which we can perform atomic operations on any shared variable. There are various kinds of atomic operations. They are used in various algorithms such as mutual exclusion or concurrency control and to enforce it we use those algorithms and in those algorithms we use these interlocked functions. With these interlocked functions you can perform an atomic operation on a certain variable. So we will look at the details of some other atomic operations. First of all, interlocked exchange. This is another atomic operation. Within this you have passed two parameters. A reference target and a value pass. The previous value of the target will return this function and it will be assigned to a new value. The value of the value will be assigned to it. For example, the value of value is 10 and the target value is 3. So wherever 3 is stored, you have passed its reference pass and you have placed 10 in the value. You have called it this way. When this function returns, this value will return 3 and the value of the value in the target will be 10. The value in the value will be assigned to the target and the previous value of the target will return this function. Similarly, a test set is used. When hardware oriented implementation is done of mutual exclusion or to enforce concurrency, there is a famous algorithm for it which is called a test set algorithm. There is also a test set operation which is available in this operation. Then there is another function. Interlocked exchange add. You pass this as an add-in. You pass the reference pass and you pass the increment. When this function returns, the previous value of the add-in of the add-in reference will return this value. That is, if there is a value of 3 on the reference of add-in, and you have kept the increment 5, then this function will return 3 and the new value of add-in will be 8. That is, the previous value of 3 and the increment you specified will be added to it. Similarly, the new value will return 8. Previously, we had seen that if we want to increment a value by 2 through these interlocked functions, then we cannot call the increment twice. Because if we call it twice, then that operation is not atomic. But with this function, we can also increment 2. We can specify the value of 2, 3 or whatever value you want. We can increment it and it will be operation atomic. Similarly, there is another function. Interlocked Compare Exchange. You have passed these three values. The reference of destination, the value of exchange and the value of a comparant. Now, there is an algorithm below. According to this algorithm, these three things will perform operation. But the way this algorithm is implemented, if you implement it in C or in any programming language, then it will not be atomic operation. The difference is that this operation is atomic. This is a single atomic operation during which no kind of context switching is possible. And this operation will be that the previous value of destination is stored in the temp and returns in the end. That is, the previous value of destination will be returned in the end. And it will be compared with the destination comparant. If the value of comparant and destination is the same, then the value of destination will be assigned to the new value. And the value of exchange will be the new value. For example, the value of destination is 2. The value of reference is 2. The value of comparant is 2. And the value of exchange is 5. The value of destination is 2. And the value of reference is 2. And the value of destination is 2. So, both are equal. The value of exchange is 5. So, this 5 will be assigned to the destination. The value of destination is 5. And the value of previous value will be returned. So, this is the function. There are different algorithms that can enforce mutual exclusion through this operation.


Today's training was a series of live voice events with a possible transfer of patients and picking up patients from a non-standard HLV. This training is imperative to test our individual and collective tasks as a unit and ensure that in a vast array of scenarios we're ready to respond to any medical emergency and provide the best level of patient care we can. We have some really professional soldiers, pilots, medics, and non-ray crew members within our formation and they perform exactly how you would expect them to under duress and in a typical training environment. Night operations bring a whole series of additional stressors on the individual crew and on the medics as well. You have a limited field of view, the visibility gets degraded, you don't really have a good contour of the ground so it's very stressful to fly at night and it's harder to find the point of injury or the AXPs. We operate in the night on a regular basis as medibac units so we must be prepared to handle those situations which is why we train it. This scenario is designed to show that we can work with US ground forces and transport them to foreign hospitals that fall within NATO. So for example we took patients today from our ground units and moved them to a Bulgarian military hospital where they were seen by Bulgarian military personnel. This shows that we're dedicated to our NATO allies and that we can work together on a regular basis.


Live from Las Vegas, it's theCUBE covering IBM Think 2018. Brought to you by IBM. Hello everyone, welcome back to theCUBE's coverage here at IBM Think 2018. We are in Las Vegas, the Mandalay Bay for IBM Think. We're six shows, we're coming into one, it's packed house. The two great guests here, Brian Wallace, who's the CTO of Insurance for DXC Technologies. And we have Bala, VBala, but it goes by Bala, Banking and Capital Market CTO for DXC Technologies. Guys, welcome to theCUBE, thanks for joining us. Thank you. It's our pleasure, yeah, thanks. So, the innovation sandwich I'm calling an IBM strategy. You got in the middle, the meat is data, and the bread is blockchain and AI. Two really fundamental technologies, powered by cloud and variety of other things. Obviously AI is disruptive, we know what that looks like. Blockchain now emerging as a viable infrastructure enabler that's creating token economics, a lot of cool things, certainly in the banking side, seeing a lot of controversy. Blockchain really is driving it. You guys are out in the front lines, you're doing a lot of crowd chats, been following your digital transformation story that you guys have been putting out there. Really, you're on this. So, what's the conversations like that you guys are having with Blockchain and AI share? So, let me begin with a couple of quick points on Blockchain. DXA has done some fantastic work around the world, leveraging both the trust capability that Blockchain brings to bear in financial banking industry use cases like KYC, for instance, institutional KYC in particular, but also in simplification of entire value chains such as lending. And we're doing some very interesting work in lending where not only are we looking at the upfront origination process of lending, but also the downstream securitization, which is where the tokenization of principal and interest payments and those type of things happen. Energy too? Oh yes, absolutely. So, there are a number of these trading type use cases that follow into securitization where we're doing some very interesting work. Well, I'll talk about the globalization because one of the things that we're seeing is in the U.S., a shrinking middle class, but outside the U.S. and the emerging markets, a growing middle class, thanks to mobile technology, thanks to data, thanks to Blockchain, you're seeing countries that, hey, we have that infrastructure, but we don't have the core modern infrastructure, but you throw in a decentralized capability, you've got all these capabilities, and the killer app and all this is money. You're in, that's your vertical. That's your industry. The killer app is money in marketplaces. Your thoughts? I think the beauty of what these technologies are doing is for the first time creating financial inclusion to happen. And the very first case of where financial inclusion is enabled is in payments. So, when we open up the banking system predominantly from a payment perspective, which is what things like Blockchain and others enable, if we succeed in doing that, then for the first time we've enabled, there's two billion people unbanked or under-banked, two billion bringing them into this financial system. A lot of discriminated against too, because they don't have a track record, banks can't handle some of the things that others are now filling the void with crypto and Blockchain. Right, or they can't service them profitably, but for the first time now, you're looking at the economics that Cloud and AI and Blockchain and these technologies bring, not just into banking and capital markets areas, but also into insurance. And I'd love to have my colleague, Brian, talk to the insurance use cases that are enabled as well. Brian, insurance, go. Yeah, so it's a slightly different dynamic. There, it's the, I mean, if you think about the fundamental pattern of Blockchain, it's around eliminating a central or a middleman or a central gatekeeper, if you will. And the entire insurance industry is largely made up of middlemen, right? You've got people with risk at one end and you've got sources of capital at the other end and everybody's playing a role between a broker and a carrier and a reinsurer in sort of facilitating that management and that transfer of risk. So you can extract some efficiencies out of that. So there's a lot of conversations around efficiencies, around automation, but interestingly, it's around the disruptive business model, right? It's the technology is going to mildly interesting, but it's the new business models that Blockchain will enable. I see banking picking up early adoption on Blockchain, but I see maybe lagging a little bit on insurance because, but I definitely see some opportunity there. But short-term, data is driving insurance because I don't have a Tesla, but my friend has a Tesla. The insurance company will know exactly he's rolling through those stop signs. They know everything that he's doing, all the data is there. So AI becomes really the low-hanging fruit for insurance in that industry. Do you agree with that? Comment, reaction? Yeah, and we're just at the beginning, right? Because as you say, data is the asset that we manage. So we have a lot of data in terms of transactional data, the traditional operational data, what we're discovering and what we're really sort of just, just, you know, licking our lips over almost is all of this new unstructured data, you know, whether it's sensor data, behavioral data. And you're right, because the challenge we had around automation and cognitive computing, if you will, we're here at IBM with the Watson Tech, was enough data and the consistency and quality of that data. So we have that now, and we're making tremendous strides around in particular here with the Watson brand and the Watson cognitive. You know, one of the things I wish Dan Hutchison was here, he's not, he's a CTO in charge. You guys have been doing all these crowd chats, our software that we wrote, that's pretty interesting. I've personally enjoyed all the conversations and give a shout out to Dan and you guys for really great conversations. You guys know what you're talking about, it's clear. In the data, you guys are taking an outside-in approach and collaborating, but your topics are on target, right? You're talking about digital transformation, kind of holistically, but then you're starting to dive down into specific use cases. So, Bala, what is the favorite, or the most popular digital disruptive topic that's being discussed within DXC and your clients and in the marketplace? So at the outset within DXC, as digital transformation takes hold with our customers and we aim to be the premier provider of that enablement, what we've realized ourselves is that we provide a lot of services to our clients across many industries, but there are commonalities across what we provide in terms of service delivery. And so it made sense for us to, number one, look at the commonalities and create a platform that is common across industries, across offerings that we bring to the marketplace. That commonality is what we call internally and externally now as Bionics, and it's a platform that we are bringing forward that for the first time ties together what we are talking about both here at this event, but also with our clients, ties together intelligence, orchestration, and automation, which are the fundamental Bionics, and internally we call it platform DXC upon which all of our offerings and services are brought to market. Well, there's disruption going on in your business, so I'm going to talk about for a double down on that for a second. I'm seeing it trend certainly in public sector market where the use cases are well-invent defined. So you're seeing automatic code generation becoming a real part of the delivery process. Now what that's going to do is essentially think of provisioning and configuration management in cloud, if you can apply actual process code that you've done before the commonalities, this is going to change the delivery timeframe. So you're looking at essentially auto provisioning software, not just like configuration management resources, don't worry about saying here's a value chain, here's a blockchain, here's some AI, just configure it like a Lego block, push that could take months to deliver the old way. Your thoughts to that, are you guys on that, you guys see that as something that's going to be an opportunity for you? Some companies I've seen global system integrators being disrupted by this, because they don't have this. New SIs, new system integrators are thinking this way, that's a DevOps mindset. Are you prepared for that? Do you see it coming and what's your answer to that? So we saw that coming about three and a half plus years ago and our shift away from being a pure SI began then.  Rather than a systems integrator. And we began that trend in our journey three plus years ago. And the reason we began that trend is what you pointed out. Today infrastructure is delivered as a code. So not even as a service, but as a code. And so imagine provisioning infrastructure and all the capabilities that ride on it just as code. And that's where this is headed. And if in that model, we become a provider and a provisioner of services rather than just a system. And the cost structure has completely changed because of services. Amazon has proven, and now IBM's following suit with their power platform and other things, that you can actually have the kind of compute but it's a catalog of services. So this is going to change the price competitiveness. So big bids that used to be billions of dollars that you guys can compete. I mean, am I seeing it right? That transition's already, that ship sailed so to speak, right? In terms of the large outsourcing deals, the large, whether it's apps or infrastructure, it's all moving to digital transformation, consumption-based commercial models. And it's really bionics that Bala mentioned a minute ago that is our answer to the threat that you described a minute ago. It's really about automating and digitizing and building intelligence into the entire, if you will, build, deliver, operate value chain of our business. And talk about the multi-vendor, multi-choice, technology choice, as your customers and people in general on this journey of digital transformation, they used to make technology decisions. Now they're making business logic decisions around how to reconfigure their value chains to optimize for new efficiencies and abstract away inefficiencies. Blockchain's a great example, AI's another, automations in the middle, all the cloud. So you have now business logic is the risk. Technology, not so much because infrastructure's code has proven that you could have serverless, you could have all kinds of coolness that can be managed in an agile way. So the business model aspect is key. How are you guys dealing with that? Because I know you're here at the IBM Think Show, their partner. I see you at the Amazon shows. We see you guys everywhere. So you're horizontally scaling by design. Is that what customers want? What's the DX view on this? So our value proposition has always had partners as the key element of what we do. And so if you look at what we do, you can look at it from two perspectives. One, proprietary ways of thinking, proprietary systems are long since gone. And waterfall methodologies. Yes, those are all long since gone. If you're still doing that, note to self. You need to be out of business. Exactly. So we've actually hinged a lot of what we do. Our offerings, our capabilities and so on around openness, open source and so forth. So that's number one. Number two is in this world, it's no longer about just DXC or just IBM or just somebody, one person bringing everything to our clients. It's about how do you engage proactively and build co-innovation and co-services with our partners and bring that to our clients. I mean, IBM just announced a deal with Google. They got TensorFlow in their deal. So you have all kinds of melting pot. Okay, let's talk about blockchain again. Get back to my favorite topic.  You can almost see where this is going. And then you got, on top of that, what's coming is a mass in migration of decentralized application developers. Kind of cloud plus, they know cloud, they know DevOps infrastructure as code, but they're looking at it from a decentralization standpoint, different makeup. And you see ICOs, initial coin offerings. I think that's just an application of inefficiencies around capital markets, but that's, put that aside for a second, but blockchain, cryptocurrency and decentralized applications. How do you guys see that trend? What are you guys doing? Is it you're integrating it in? You mentioned token economics. You're in the banking field, your thoughts on that. Sure. On the blockchain front, as I mentioned to you, there are a number of platforms that are out there. There's the R3 Cordo platform, there's a platform that JPMorgan initiated, that we are leveraging as well. After they poo pooed the coin, but then they're back in the game again. That's right. And then there's a hyperledger fabric as well. So these platforms are going to take their course of evolution, and we are working across all of those platforms. Now, the more interesting thing that you mentioned is people and skills. What we find today in the marketplace with our clients is a dramatic shortage of skills in these areas. And so internally, what we have done at DXC is actually opened our own service delivery to a vast pool of developers that you talked about earlier as being freelance independent folks. We've opened our entire service delivery to them as well. And we look at that global talent pool for our own service delivery. Using community as a way to scale. Yes, and that's exactly what we are doing in our own talent process. It's not just about our people, our employees, but our partners, as well as what exists in the open marketplace. Brian, talk about the insurance area as a way to tease out other trends. Specifically, the question is, what is the biggest things that people know they're walking into? What's the tailwind that they see that's going to give them hope? And then what's the headwinds? What are the blockers? And what should they be aware of? What are some of the marketplace dynamics that translate into other industries? Well, let's start with the obvious blocker is legacy debt, right? So you talked about the risk of all that business knowledge, that domain expertise. That's all today encapsulated in existing what you might call legacy systems, right? So that's the headwind by far. The tailwind is that unlike, say, 15 years ago when we were in the last sort of dot-com boom and it was all about the front office and customer experience, the customer's way ahead of us. So culturally, the customer's challenging industry to catch up. So that's the tailwind in my mind. And the real opportunity is to think about it in terms of a dual agenda. So think about it in terms of progressively, simultaneously building new digital capability whilst ultimately beginning to unbundle and tackle that legacy debt. And I think customers now are starting to see a path forward. We're in the market in both banking and insurance with digital platforms, with industry resource models, API fabrics that can go back in, modernize legacy systems. So there's a real fast time to market time. And it changes your engagement with clients. It's not a one and done. You're sticky through the service layer. It's a journey, but the difference, I think, between DXC and a lot of other people is we are in the market in production with real assets. And you can show how that journey. So it just becomes a conversation around what's your pain point? Where are you starting from? Where do you want to go? And you're bringing the community in to help on the delivery side. Everyone wins. And that community is a combination of three things. That's our own employees, obviously, within the industry and within our offerings that know banking, that know insurance. It's all of the DXC people in the horizontals because we're bringing in everything now. These platforms encapsulate infrastructure, security, service management, analytics, mobility, all of that is built into these platforms. And then it's going out into our partner community and then it's going out into the open community. And we're tapping into all of those. Brian and Bala, thanks for coming on. Two power CTOs here on theCUBE having a CTO conversation around how scale, cloud, AI, blockchain, new technologies enabling new business models at a faster pace of change with a lower cost structure and more time to value. Again, it's all about the value creation. The killer app is money and marketplaces and community. Guys, thanks so much for sharing. I'm John Furrier here at the Think IBM Think 2018 CUBE Studios, more after this short break.