Eufemiano Cardoso

Tissue-engineered breast reconstruction with Brava-assisted fat grafting: a 7-year, 488-patient, multicenter experience.

Background: The ability of autologous fat transfer to reconstruct an entire breast is not established. The authors harnessed the regenerative capabilities of external expansion and autologous fat transfer to completely reconstruct breasts. Methods: The authors performed 1877 Brava plus autologous fat transfer procedures on 616 breasts in 488 women to reconstruct 99 lumpectomies, 87 immediate breast reconstructions, and 430 delayed total breast reconstructions. After 2 to 4 weeks of Brava expansion, which increased volume by 100 to 300 percent, the authors diffusely grafted the breasts with 100 to 400 ml (225 ml average) of 15 g–sedimented, manually harvested lipoaspirate. The procedure was repeated every 8 to 14 weeks until completion. The authors compared costs of this reconstruction with established deep inferior epigastric artery perforator/transverse rectus abdominis musculocutaneous flaps and implant procedures. Results: Follow-up ranged from 6 months to 7 years (mean, 2.5 years), with 0.5 percent locoregional recurrence. Four hundred twenty-seven women completed the reconstruction, whereas 12.5 percent dropped out (2.5 percent medical, 10 percent personal reasons). Completion required 2.7 procedures for nonirradiated and 4.8 procedures for irradiated mastectomies. Patients recovered soft, natural appearing breasts with nearly normal sensation. Complications included five pneumothoraces and 20 ulcerative infections. Radiographically recognized benign palpable masses were observed in 12 percent of nonirradiated and 37 percent of irradiated breasts. The cost of Brava plus autologous fat transfer is 47 percent and 66 percent that of current reconstruction alternatives. Conclusion: Brava plus autologous fat transfer is a minimally invasive, incisionless, safe, economic, and effective alternative for breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Megavolume autologous fat transfer: part II. Practice and techniques.

The authors describe the techniques that use the principles of fat grafting to allow them to successfully graft megavolumes (250-ml range) of autologous fat into breasts. The Brava external volume expansion device preoperatively increases the volume and vascularity of the recipient site. Low-pressure liposuction and minimal centrifugation are used to gently extract and purify the adipose tissue with minimal trauma. Even and diffuse reinjection of the fat increases graft-to-recipient interface and reduces interstitial fluid pressure. Postoperative Brava use protects the graft and acts as a three-dimensional immobilizing splint. By adhering to these techniques, we have been able to graft megavolumes of fat into the breasts of over 1000 patients and obtain substantial long-term volume retention.

Aesthetic applications of Brava-assisted megavolume fat grafting to the breasts: a 9-year, 476-patient, multicenter experience.

Background: Autologous fat grafting to the breasts was banned in 1987 because of unpredictable graft retention and cyst formation that could not be differentiated from cancer. Surgical and radiologic advances induced a lifting of the ban in 2009. Small- to moderate-volume autologous fat grafting to the breast has become common. The authors present their aesthetic applications of megavolume autologous fat grafting to the breast. Methods: Autologous fat grafting with Brava preexpansion was performed on 294 patients for aesthetic augmentation, 45 patients for congenital deformity correction, 43 patients for iatrogenic deformity correction, and six patients for implant-to-fat conversion. Autologous fat grafting for implant-to-fat conversion was performed on 88 patients without Brava. A case example is presented for each indication. The baseline, perioperative, grafted, and postoperative volumes were recorded. Results: Follow-up ranges from 6 months to 9 years (mean, 3.5 years). The mean volume grafted was 346 ml per breast, and the mean postoperative augmentation measured at least 6 months postoperatively was 266 ml per breast. No patients required open biopsy or were diagnosed with cancer. There was one pneumothorax, requiring a temporary chest tube, with no further complication. Conclusion: Large-volume autologous fat grafting after Brava use or implant removal is a safe and effective alternative for breast augmentation and deformity correction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Percutaneous aponeurotomy and lipofilling: a regenerative alternative to flap reconstruction?

Background: The application of a new approach is presented, percutaneous aponeurotomy and lipofilling, which is a minimally invasive, incisionless alternative to traditional flap reconstructions. Methods: The restrictive subdermal cicatrix and/or endogenous aponeurosis is punctured, producing staggered nicks. Expansion of the restriction reconstructs the defect and creates a vascularized scaffold with micro-openings that are seeded with lipografts. Wide subcutaneous cuts that lead to macrocavities and subsequent graft failure are avoided. Postoperatively, a splint to hold open the neomatrix/graft construct in its expansive state is applied until the grafts mature. Thirty-one patients underwent one to three operations (average, two) for defects that normally require flap tissue transfer: wounds where primary closure was not possible (n = 9), contour defects of the trunk and breast requiring large-volume fat grafts (n = 8), burn contractures (n = 5), radiation scars (n = 6), and congenital constriction bands (n = 3). Results: The regenerated tissue was similar in texture and consistency to the surrounding tissues. Wider meshed areas had greater tissue gain (range, 20 to 30 percent). There were no significant wound-healing issues, scars, or donor-site morbidities. Advancement tension was relieved without flap undermining or decreased perfusion. Conclusions: Realizing that, whether scar or endogenous fascia, the subdermal aponeurosis limits tissue stretch and/or its three-dimensional expansion, a minimally invasive procedure that expands this cicatrix into a matrix ideally suited for fat micrografts was developed. Grafting this scaffold applies tissue-engineering principles to generate the needed tissue and represents a regenerative alternative to reconstructive flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Facial clefts in Saudi Arabia: an epidemiologic analysis in 179 patients.

&NA; One hundred and seventy‐nine consecutive cases of facial clefts that were treated at the King Khalid University Hospital, in Riyadh, Saudi Arabia, were analyzed for an epidemiologic study. Isolated cleft lip was present in 38 percent, cleft of lip and palate in 37.4 percent, and cleft of the posterior palate in only 22.4 percent. There was a male preponderance in all types. In cases of cleft lip with or without cleft palate, the more commonly affected side was the left, followed by bilateral cases. Associated malformations were present in 13.4 percent. A positive family history was found in 26.8 percent of cases. A significant number of patients (7.8 percent) were first seen at more than 10 years of age. The incidence of facial clefts at this hospital was 0.3 per 1000 live births, computed over a period of 6 years. This incidence is significantly lower than that reported from European and Far Eastern countries.

Mentolabial sulcus: a histologic study

This study deals with the structure of the lower lip in the region of the mentolabial sulcus with particular emphasis on the morphologic factors responsible for producing and maintaining the sulcus. The results of this study provide information about the anatomic framework as it pertains to reconstructive and aesthetic procedures on the lower face deformed by injuries.

Postburn deformity of lip-chin complex: a method to restore the mentolabial sulcus

An extensive postburn deformity of the lower lip presents a difficult reconstructive problem. Efforts to reconstruct the resultant defect by conventional methods were found unsatisfactory. In a deformed lower lip, restoration of the contour of the lip with a well-defined mentolabial sulcus should be the aim of any reconstructive effort to bring aesthetic balance to the face. We describe a simple and effective method of restoring the function and form of the lip-chin complex.

Mutilating meat mincer injuries of the hand

A total of 25 cases of acute injuries caused by a meat mincer are presented. Of these, 20 were children. The pattern of injury and the extent of damage to individual digits of the hand are defined. Due to the mutilating nature of the injury, attempts at replantation or revascularization failed in all but two of the ischaemic digits. Emphasis must be placed on the safety and prevention of these dreadful accidents.

A recessively inherited non-lethal form of popliteal pterygium syndrome

Two siblings, a 10-year-old boy and a 6-month-old girl, born in a Palestinian family, with manifestations of popliteal pterygium syndrome are presented. This rare form of syndrome is usually assumed to be autosomal dominant. Parental consanguinity and lack of phenotype manifestation in the ancestry of the present family favoured an interpretation of determination by an autosomal recessive trait.

Four years' experience of limb replantation in Saudi Arabia: a clinical review

This is a review of 70 patients with traumatic limb and digit amputations treated at King Khalid University Hospital, Riyadh in Saudi Arabia from April 1984 to April 1988. Out of 70 cases 34 were not suitable for replantation. In the remaining 36 patients replantation or revascularization was attempted on 46 units. The data are discussed and compared with other published series. Our net survival rate was 67.4 per cent. The survival rate improved from 62.8 per cent in the first 2 years to 81.8 per cent in the subsequent 2 years. The average hospital stay (34 days) was much longer than that reported from developed countries. The increased emergency workload due to a high incidence of referral of unsuitable cases and the longer hospital stay should be taken into account while establishing a replant service in a developing country. Eighteen cases were followed up for more than 1 year; of these, 61 per cent had good (grade I or grade II) functional recovery. The survival rate and functional recovery improved with increased experience and this is a strong argument in favour of centralizing the replant services.