Francisco Parada

Recent developments in the ability to predict and modify breast cancer risk

The identification of women at higher risk for breast cancer is a matter of public health and anyone who participates in any treatment modality of this condition (this includes the plastic surgeon) should be aware of the tools and predictive models of breast cancer. Screening for breast cancer in the community, and probably during the daily plastic surgery consultation, until recently, was limited to decisions about when to initiate a mammography study. New developments that predict and modify breast cancer risk must be clearly understood by our specialty through identification of women at higher risk for breast cancer and be familiar with the current issues related to screening and risk-reduction measures. In this review, we discuss current knowledge regarding the recent data of breast cancer risk, screening strategies for high-risk women and medical and surgical approaches to reduce breast cancer risk. Patients with breast cancer belong to one of three groups: a. Sporadic breast cancer (75%)--patients without family history or those who have a breast biopsy with proliferative changes. b. Genetic mutation breast cancer (5%)--women who have a genetic predisposition, and most of these are attributable to mutations in the breast cancer susceptibility gene 1 (BRCA1) and breast cancer susceptibility gene 2 (BRCA2). c. Cluster family breast cancer (20%)--seen in women with a relevant history of breast cancer in the family and breast biopsy with proliferative breast changes with no association with mutations.Those at high risk for breast cancer should investigate the family history with genetic testing consideration, clinical history, including prior breast biopsies and evaluation of mammographic density. Tools for breast cancer risk assessment include the Gail and Claus model, genetic screening,BRCAPRO and others that are evaluated in this review.

Tumores gastrointestinales estromales (GIST): Experiencia del Servicio de Cirugía del Hospital Clínico de la Universidad de Chile entre 1999 y 2005

BACKGROUND Gastrointestinal stromal tumors (GIST) are the most common mesenchymatous tumors of the digestive tract. The pathological diagnosis is based on microscopy and immunohistochemistiy. AIM To review the experience of our surgical unit in patients with GIST MATERIAL AND METHODS: Review of medical records of 15 patients (aged 66+/-13 years, 11 women), with a pathological diagnosis of GIST, treated between 1999 and 2005. RESULTS The main presenting symptoms were melena in 40%, hematemesis in 20%, abdominal pain in 60% and anemia in 13%. In only one patient, the tumor appeared as an incidentaloma. All patients underwent upper gastrointestinal endoscopy A CAT scan was done in 87%, a barium swallow in 60% and a digestive endosonography in 20%. Thirteen tumors were located in the stomach and two in the small bowel. Mean tumor diameter was 5.3+/-1.7 cm. Surgical management was a tumor resection in 40%, a partial gastrectomy in 27%, a total gastrectomy in 20% and an intestinal excision in the rest. Mean hospital stay was 6.9+/-4.2 days. No postoperative complications were recorded. CONCLUSIONS The main clinical presentation of GIST in this retrospective series was an upper gastrointestinal bleeding. Surgical treatment was devoid of complications.

Perioperative thromboelastography analysis during suction-assisted lipectomy: a prospective cohort study

OBJECTIVE The purpose of this study was to prospectively investigate coagulation during suction-assisted lipoplasty (SAL) and to compare it to other plastic surgery where no SAL was used, with the aid of a computerised thromboelastograph coagulation analyser (TEG). METHODS A prospective cohort study enrolled 50 pure SAL patients and 50 patients presenting for other aesthetic plastic surgery operations, without the need of liposuction. TEG evaluates in real time the competency of the blood clot in samples that are studied under a low shear environment resembling venous flow. Six thromboelastographic measurements were performed in each patient: one preoperative, two intraoperative at the middle and end of the surgery and three postoperative at 60, 90 minutes and 24 hours. All the patients also had standard pre- and postoperative coagulation studies. RESULTS R (time of clot to form) and K (time or speed the clot takes to be firm) were shorter in the SAL group vs control (P<0.001). Angle (growth and stranding process of fibrin) and MA (dynamic properties of the platelets and the final strength and elasticity of the fibrin clot) were greater in SAL vs control (P<0.001). None of the cases had pre- or postoperative coagulation study abnormalities. CONCLUSIONS TEG analysis demonstrates that SAL patients have decreased initial clotting time, decreased time to full clot formation, increased pro-coagulability state, and increased clot rigidity. The clot lysis time was not different between the studied groups.

Effects of Abdominoplasty on Intra-Abdominal Pressure and Pulmonary Function

BACKGROUND Abdominal wall weakness is a consequence of rectus abdominis diastasis and flaccidity of the myofascial component. A degree of plicature of the rectus abdominis generates an increase of intra-abdominal pressure (IAP), which may result in an increase of intrathoracic pressure, thus affecting thoracic hemodynamics and leading to inadequate ventilation. OBJECTIVES To assess changes generated by plicature of the rectus abdominis on IAP and pulmonary function in patients undergoing abdominoplasty. METHODS A total of 10 female patients with abdominal ptosis were included. Chronic smokers and patients with respiratory co-morbidities were excluded. The IAP was measured using a modified Krons trans-bladder technique. Pulmonary function was assessed by pulmonary compliance (P-Comp) and was calculated with parameters provided by the mechanical ventilator. Both were calculated before and after plicature. RESULTS The mean values for IAP before and after plicature were 6.6 and 9.3 mmHg respectively. Before plicature, the mean P-Comp value was 38.97 mL/cm of water, and after it was 36.54 mL/cm. Both differences were statistically significant. CONCLUSIONS Based on the results obtained, it is possible to conclude that plicature of the rectus abdominis generates significant physiological changes, such as an increase in IAP and a decrease of P-Comp, which do not have a clinically relevant impact on healthy individuals. Measuring IAP with the modified technique and the assessment of pulmonary function using P-Comp are both reliable and provide a more accurate correlation with such physiologic changes. LEVEL OF EVIDENCE 3: Therapeutic.

Leadership in Plastic Surgery Today

This article was developed after the authors heard young plastic surgeons of their unit ask what attribute makes people want to follow a leader. What people most seek to find in a leader has been constant over time and shared in different countries, genders, and age groups. These qualities include honesty, a forward-looking perspective, inspiration, and competence (Kouzes and Posner, Clin Lab Manage Rev 8:340, 1994). However, the residents and fellows thought differently and told the authors how “they” wanted to be seen when they became leaders. They wanted to viewed as shifting engines pulling forward teams of plastic surgery as hard as possible, leaving space for followers to develop and grow. They also wanted to be seen as having impeccable behavior related to the assumption of obligations, and finally as having the “most” informal authority possible, an authority that is not negotiable because it is given by peers to the leader due to personal qualities and actions. Obtaining formal authority at a very young age is fine, but if a surgeon’s associates have not given him or her informal authority, the surgeon is only the “boss” and not the leader of the group. Informal authority is constructed over a time line and given by others to the leader because of what he or she has in values and personal attitudes and because of what the leader has done and can go on doing with sustained credibility and competency. Therefore, it is the authors’ opinion that the exercise of leadership in plastic surgery is supported by informal authority and that the leader of leaders will be the one who has the most of this attribute that never is given formally.