Gilvani Azor de Oliveira e Cruz

Lipoabdominoplasty: Liposuction with Reduced Undermining and Traditional Abdominal Skin Flap Resection

Abdominoplasty surgery has spread universally, as both an aesthetic and a reconstructive procedure, and new techniques are appearing with the goal of minimizing ischemic complications of the flap and bettering body contour. The purpose of this article is to demonstrate that an abdominoplasty technique with limited undermining and preservation of the flap perforator vessels makes it possible to reduce the complication rate attributable to flap necrosis and seroma in abdominoplasty. Doppler flowmetry color study of the abdominal wall was performed before the surgical procedure and on postoperative day 15 after lipoabdominoplasty for a series of 20 patients to evaluate the blood supply of the abdominal wall. This study confirmed the preservation of perforator arteries in the periumbilicus area and right upper quadrant after abdominoplasty with liposuction and reduced undermining.

Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases

BackgroundThe literature reports many variations of Poland’s syndrome. This article describes 18 cases of Poland’s syndrome in different stages of treatment, with variable clinical presentations and reconstructive techniques.MethodsThis study evaluated 15 females and 3 males, ages 2 to 43 years, for breast deformity, nipple–areolar complex position, pectoralis muscle malformation, thoracic deformities, and the presence of brachysyndactyly. Surgical treatment was performed for 14 patients, individualized for each case.ResultsFor the women, the hypoplastic breast was treated with a latissimus dorsi muscular flap associated with silicone gel implant in five cases. Two other patients still are receiving tissue expansion for a future muscular and prosthetic reconstruction. Prosthetic implants alone were used on the affected side in four cases. The nipple–areolar complex was reconstructed for two patients. Seven women underwent contralateral breast surgery: reduction mammoplasty in three cases, mastopexy in two cases, and prosthetic implants in two cases. The only man who underwent surgery was treated with endoscopic rotation of the latissimus dorsi muscle flap.ConclusionsThis study demonstrated several breast reconstruction options for patients with Poland’s syndrome, reinforcing the importance of an individualized treatment to achieve complete and adequate rehabilitation.

Mastopexy After Massive Weight Loss: Extended Chest Wall–Based Flap Associated with a Loop of Pectoralis Muscle

Mammaplasty for patients who have experienced massive weight loss involves some concepts that differ from those that apply to mammaplasty for normal patients. Breast anatomic characteristics make this procedure a very challenging situation. The authors present their experience with a new mammaplasty technique using an extended thoracic wall flap associated with a loop of pectoralis. This procedure is a simple and reproducible method for patients with massive weight loss that results in a pleasing breast shape and long-lasting results.

Evaluation of molar teeth and buds in patients submitted to mandible distraction: long-term results.

Background: Despite all benefits offered by mandible distraction, complications and long-term consequences need to be evaluated to define its safety and morbidity. Forty mandible distractions were studied. Panoramic mandible radiographs obtained preoperatively, during distraction, and during the postoperative period were reviewed, with the intention of evaluating development and complications of molar buds and teeth in the distraction area. Methods: The mean patient age was 8.1 years. Twenty-five patients had craniofacial microsomia (one associated with a no. 10 facial cleft), five had temporomandibular joint ankylosis, two had familiar cases of auriculocondylar syndrome, one had a Tessier no. 30 facial cleft, and one had Treacher Collins syndrome. The severity of mandible hypoplasia was Pruzansky grade I in four cases, grade IIA in eight cases, grade IIB in 16 cases, and grade III in one case. Mean radiographic follow-up was 44.8 months. Results: Molar buds located in the distraction area erupted without any deformity or displacement in 18 sides (45 percent). Fourteen cases presented distalization of a dental bud to a superior position in the mandibular ramus (four migrated back to the original position). Six molar buds presented perforations, four had shape deformities (two caused by dental fracture), and two had dental root injuries followed by root absorption lately. One case developed a dentigerous cyst. Conclusions: Almost half of the patients did not have any molar bud or tooth alterations after mandible distraction, and more than 20 percent presented only bud distalization. Therefore, preventive bud enucleation or tooth extraction should be avoided before mandible distraction.

Implications of Transaxillary Breast Augmentation: Lifetime Probability for the Development of Breast Cancer and Sentinel Node Mapping Interference

The article entitled ‘‘Implications of Transaxillary Breast Augmentation: Lifetime Probability for the Development of Breast Cancer and Sentinel Node Mapping Interference’’ by Arturo Prado and Patricio Leniz, from Division of Plastic Surgery, School of Medicine, Clinical Hospital, JJ Aguirre University of Chile is an updated article and deserves some consideration. Currently, transaxillary breast augmentation is being performed worldwide. Among main incisions, transaxillary access has gained popularity because of good aesthetic results and the possibility of minimizing scar visibility [3,4,6,12,14]. As we know, women currently have an average risk of 13.2% (often expressed as 1 in 8) for receiving a diagnosis of breast cancer at some time in their lives [10]. From an epidemiologic point of view, as this population ages, breast cancer among women with previously augmented breasts can be expected to increase. Conservative oncologic surgery is a current tendency for the treatment of early breast cancers, and pathologic analysis of axillary lymph nodes is the single most important predictor of long-term survival [2,5,11,13]. As mastologists perform sentinel node staging for adequate treatment of breast cancer, they are very concerned about any previous surgery involving the axilla. To date, little literature is available on the interference of transaxillary breast implants in future sentinel lymph node detection. Munhoz et al. [9], in a preliminary study, performed lymphoscintigraphy preand postoperatively on a transaxillary breast augmentation patient. They did not observe alterations in sentinel node localization, and thus concluded that sentinel node assessment in the setting of prior breast implant augmentation through the transaxillary approach is feasible. Authors of the discussed paper explained very well the importance of an untouched sentinel node for preservation of axillary drainage and prevention of breast cancer spread through ways other than the axilla. However, their study with a limited number of cadavers did not elucidate how sentinel node damage could be avoided during the introduction of a high cohesive gel implant through an axillary approach. The authors simply laid the implant over the axilla and measured the prosthesis diameter movement during implant insertion into the pocket. An important unexplored aspect of the study was observation of lymphatic vessels after implant insertion. The authors observed lymphatic vessels without this maneuver, after simply laying the implant over the axillary area. The mammary gland and its skin envelope have a common origin and share the same lymphatic drainage pathways. On the basis of this, the breast is essentially a single unit with a specialized lymphatic system that presents preferential drainage through selected channels to a designated (sentinel) lymph node in the lower axilla [1]. Periareolar blue dye injection is a good and simple method for identifying axillary lymphatic structures. Some authors compare it with peritumoral radiocolloid injection used to identify the lymphatic metastasis route [1,7,8]. As we know, transaxillary breast augmentation can damage lymphatic vessels during subcutaneous tunnel dissection for introduction of the implant into the breast pocket. Thus, some landmarks need to be defined so damage to lymphatic structures can be Correspondence to R. M. Graf, M.D., Ph.D.; email: ruthgraf@bsi.com.br Aesth. Plast. Surg. 31:322 324, 2007 DOI: 10.1007/s00266-006-0204-7

Tessier no. 4 facial cleft: evolution of surgical treatment in a large series of patients.

Background: Tessier no. 4 facial cleft is a rare, complex, and challenging craniofacial malformation. The present article aims to describe different clinical features evidenced in 21 cases of this malformation, discussing a 20-year experience with and evolution of its surgical treatment. Methods: Some demographic data, clinical features, and reconstructive results were evaluated retrospectively. These patients have been evaluated and treated in three specialized Brazilian craniofacial centers. Nineteen were already operated on, with a mean follow-up of 3.5 years (range, 1 to 20 years). Results: Sex distribution showed a male prevalence (2:1). The average age of initial treatment was 5.4 years. Four cases were affected on the right side of the face, seven on the left, and 10 bilaterally. Six patients had other rare associated facial clefts, including nos. 5 (three patients), 7, 9, and 10. Cleft upper lip was evidenced in all patients, and maxillary hypoplasia was present in five and maxilla cleft in eight. Lower eyelid coloboma was seen in almost every case (19 patients); 10 of these had medial canthus dystopia. Four patients had amniotic bands in the limbs. Surgical repair was individualized to each patient. Surgical experience gained with these patients allowed the authors to develop some technical modifications, which have improved aesthetic results, camouflaging scars into natural folds and anatomical units, without compromising functional outcomes. Conclusions: The great majority of Tessier no. 4 facial clefts can be appropriately treated using local flaps. Classic techniques are extremely useful, but long-term results could be improved if the technical modifications described were adopted.

Tissue expansion at Hospital de Clinicas-UFPR: our experience

BACKGROUND: The shortage of tissue for large defect reconstruction is a challenge for the plastic surgeon. Tissue expansion emerged in this context, and in the last 30 years has become one of the most widely used modalities in reconstructive surgery. Tissue expansion is a very versatile technique that can be performed in patients of all ages for the correction of different pathologies. The most common indications are burn sequelae and giant congenital nevus. The present study describes the indications and use of tissue expanders at the Hospital de Clinicas of Universidade Federal do Parana. METHODS: Patients who underwent tissue expansion for reconstructive surgery between January 2005 and December 2009 were retrospectively reviewed. RESULTS: A total of 24 patients (70.8% female and 29.2% male) were analyzed. Ages ranged from 3 to 46 years old (average, 17.1 years). The most common indication for tissue expansion was the treatment of burn sequelae (62.5%), mainly in the head and neck. Alopecia was the second most prevalent indication (29.2%), followed by scar retraction in the neck (20.8%). Other indications were giant congenital melanocytic nevus (16.7%), Polands syndrome (8.3%), abdominal scar (8.3%), and amastia (4.2%). Complications developed in 11 patients, and the highest incidence of complications, reported in 8 (72.7%) patients, was among those with burn sequelae as the primary pathology. The complications were infection, rupture, extrusion, wound dehiscence, and displacement of the expander. CONCLUSIONS: Tissue expansion is indicated for the treatment of several diseases among which burn sequelae is one of the most common indications.

Combination micrografting and tattooing in the reconstruction of eyebrows of patients with craniofacial clefts.

The absence of an eyebrow, either partial or total, has been observed in patients with craniofacial clefts, such as the Tessier 9 to 13 cleft. Several techniques have been used to improve the appearance of the region, such as island scalp flaps and scalp strip grafting, with limited or marginally satisfactory aesthetic results. The authors report 2 patients with craniofacial clefts in whom a novel technique combining 2 separate surgical approaches, micrografting and tattooing, was used. The use of micrografting with single or double hair units, properly angulated, produces natural-looking and satisfactory results with a minimum of morbidity. Excellent volume and appearance of the eyebrow may be achieved in a single session using this technique. Tattooing performed subsequently over the microimplanted hairs provides the illusion of greater density to the eyebrow, resulting in an appearance closer to normal.

Avaliação da integração de enxerto de pele com a utilização do 2-octilcianoacrilato: estudo experimental em ratos

A fixacao dos enxertos de pele total atraves da sutura demanda tempo cirurgico relativamente longo. O surgimento de adesivos teciduais tem se apresentado com varias aplicacoes clinicas, constituindo alternativa a sutura convencional. O objetivo deste estudo e avaliar a eficacia do adesivo 2-octilcianoacrilato, quando comparado a sutura simples, na fixacao de enxertos de pele total, analisando-se a integracao do enxerto. Foram retirados enxertos de pele total de 1 cm2, bilateralmente, do dorso de nove ratos machos, com peso medio de 150 gramas. A pele retirada para a enxertia foi recolocada sobre o defeito, a fixacao foi realizada atraves de sutura continua com fio monofilamentar de nailon 4-0 no lado esquerdo e adesivo de 2-octilcianoacrilato no lado direito. Os aspectos clinico e histologico da integracao do enxerto foram analisados no 7o e 14o dia de pos operatorio. Utilizou-se o software Sens-a-Ray para comparacao de resultados. Evidenciamos maior integracao do enxerto de pele total no lado do adesivo de 2-octilcianoacrilato (80%) em comparacao ao lado da sutura continua (44%), sendo que houve perda total do enxerto do lado da cola de 2-octilcianoacrilato em 11,1% do casos comparado a 33,3% da sutura continua. O tempo medio da fixacao do enxerto no grupo da cola de 2-octilcianoacrilato foi de 23 segundos, contra 4 minutos da sutura convencional. Foi demonstrado uma maior integracao e um menor tempo de fixacao do enxerto no grupo do adesivo 2- octilcianoacrilato.

The surgical repair of half-nose

Absence of half-nose is an extremely rare congenital malformation, which has a devastating impact on the patient and the family. A review of indexed English-language literature found 91 cases of half-nose, including 50 patients with proboscis lateralis. Pathogenesis is not clear, and the reported cases have sporadically occurred. Many aspects must be considered when reconstructing a congenital half-nose, such as timing of surgery, type of tissue to be used and the need to reconstruct nasal airway. The aim of this article is to present personal experience in seven cases of half-nose reconstruction, in order to review the literature regarding to this rare entity, highlighting aspects of incidence, pathogenesis and surgical treatment. Nasal reconstruction was performed at ages of 5-7 years to minimise psychological trauma. Forehead skin demonstrated to be an excellent donor site to re-surface the nose. For the inner lining, contralateral cutaneous nasal flap was our preference. Concerning the nasal framework reconstruction, alar contour was restored using a cartilage graft from the lower portion of ear tragus and concha.