Gustavo Coelho

Computer Simulation of Breast Reduction Surgery

BackgroundPlastic surgery of the breast, particularly breast reduction, is considered difficult. It can become a challenge for a less experienced surgeon to understand exactly what to do when facing a particular type of breast and how to avoid unsatisfactory results.MethodsThe goal of this study was to create a computer model of the breast that provides a basis for the simulation of breast surgery, particularly breast reduction. The reconstruction of elastic parameters is based on observations of the breast with the patient in different positions.ResultsIt is shown that several measurements with the patient in different positions allow one to choose the parameters of the model and determine the elastic coefficients of the breast and the skin. The geometry of the breast before and after surgery is simulated. A qualitative study of the incision parameters’ influence on the final geometry of the breast is presented.ConclusionThe developed methodology and software allow one to estimate the form of the breast after the surgery by knowing its form before surgery and taking into consideration the parameters of incision applied by the surgeon at the time of surgery. The described approach can be used for the qualitative and quantitative study of breast reduction surgery with a satisfactory result.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Microsurgical reconstruction of maxillectomy defects: experience of 24 cases

IntroductionThe defect complexity and reconstructive options make the maxillary reconstruction a controversial theme and in a constant debate. The maxilla is a fundamental aesthetic and functional structure of the face. Microsurgical vascularized flaps replaced the usage of prosthetic material and pedicled flaps as a “gold standard” for the reconstruction of complex defects following maxillectomy.MethodsThe authors report their experience of 24 maxillectomies with immediate microsurgical reconstruction, performed by the senior author (H.C.) between 1998 and 2011. They evaluate and classify the defects and the reconstructive options according to the classification system as proposed by Cordeiro and Santamaria in 2000, by a patient questionnaire and post-operative surgeon follow-up for the functional (diet, speech, and vision) and aesthetic end results.ResultsThere were no flap failures. The main etiology was squamous cell carcinoma and the most used flap was rectus abdominis free flap. Classes I and II were responsible for the cases in which the reconstructive algorithm was not followed. Most patients responded as having a normal diet, a nearly normal speech and unaffected vision. In a score of 1 to 5, the mean score in esthetic given by the patient was 3.62, while the mean score given by the surgeons was 4.13.ConclusionsMicrosurgical reconstruction of maxillectomy defects with free flaps is the best reconstructive option, being the osteomyocutaneous flaps as the gold standard. Although with limited rehabilitation, good functional and aesthetic results are to be expected with myocutaneous flaps. The existence of an algorithm facilitates the classification and systematization of maxillary reconstruction. However, due to defect complexity and large number of reconstructive options, a perfect solution does not exist. The individual assessment of the patient and the defect always provides the best method for the reconstructive planning, mainly when choosing free flaps.Level of Evidence: Level IV, therapeutic study.

Breast ligaments: an anatomical study

BackgroundAlthough the anatomy of the breast, and in particular the ligamentous system, has been widely studied for decades, there is still some controversy regarding some specific anatomical structures. The aims of this study were the ligamentous anatomy of the female breast through cadaveric dissection and to establish relationships with anthropometric and physiological data.MethodsAt the National Institute of Legal Medicine, we developed a protocol of cadaveric dissection in order to study the ligamentous anatomy of the breast. We performed the dissection of seven female cadavers (14 breasts).ResultsIn each analyzed breast, the Cooper ligaments, suspensory ligament of the axilla, horizontal septum, and the inframammary ligament were recognized. We performed a statistical comparison between height and other parameters, including humeral length, distance between the suprasternal notch and the nipple, and suspensory ligament length.ConclusionsThis study allowed a greater understanding about the precise location of the different mammary ligaments using anatomical landmarks, including bony structures, and it confirmed that the inframammary ligament is present and related to the inframammary fold. This structure has been consistently identified in a constant anatomic position, and it is more frequently found at the level of the fifth rib.Level of Evidence: Not ratable.

Lower limb reconstruction with bone free flaps: experience of 25 cases

Bone structure is fundamental for the function of the lower limbs—orthostatism and locomotion. Before the technical evolution observed in the last two decades, many extremities that are saved now were amputated in the past. Lower limb bone defects are generally associated with complex traumatic lesions and constitute a permanent reconstructive challenge. The management of this kind of defect requires a multidisciplinary approach involving plastic and orthopedic surgeons. The bone free flaps are a very important and technically exacting tool for lower limb bone reconstruction. We present and analyze our experience in 25 traumatic cases where we used 17 fibula free flaps and 2 iliac crest free flaps for tibia and talus reconstruction; 5 fibula free flaps for femur reconstruction; and 1 antebrachial radial osteocutaneous free flap for first metatarsal reconstruction. We registered 88% of success (three flap necroses—12%) with good bone integration and good functional recovery. Lower limb bone reconstruction is a long and tortuous stair whose success depends not only on the multidisciplinary surgical team but also on the patients cooperation and determination

Dual-Sided Polytetrafluoroethylene mesh in Immediate Prosthetic Breast Reconstruction following Treatment of Severe Fibrocystic Mastopathy

Breast reconstruction is well established, with various options, and every effort should be employed in order to recreate a natural breast symmetry while preserving safety and quality of life for patients. In recent years, immediate breast reconstruction, using either prostheses or autogenous tissue, has gained wider acceptance. Whenever possible, immediate breast reconstruction should be recommended, allowing that the reconstruction is made at the time of mastectomy under the same anesthesia. This technical evolution allows better preservation of the skin and pectoral muscles, reducing the feeling of mutilation and emphasizing the indication of immediate reconstruction. In this work, the authors present a clinical case of breast reconstruction of a 35-year-old patient with severe fibrocystic mastopathy, who has been submitted to subcutaneous mastectomy and immediate breast reconstruction with breast implants using a dual-sided polytetrafluoroethylene mesh, in the lower pole of the breast, highlighting the importance and success of this type of material, being a good option in cases of breast reconstruction when there is an inadequate coverage of the implants by the pectoralis muscle.Level of Evidence: Level V, therapeutic study.

Revascularization of the hand by intra-arterial injection of heparin

A BSS patient, 20 years old, male, presented at the E.R. after an accident at work with traumatic slough of the left hand (crushing injury by hydraulic splitter of firewood). During physical examination, the patient presented hemodynamic stability with injury of the palmar region of the left hand with signs of devascularization of the second and third fingers. The X-ray showed fracture of the proximal phalanx of the first, second and third fingers. Two hours and 30 min after entering the E.R. and about 3 h and 30 min after the traumatic injury, the patient was taken into surgery. Reduction and fixation with K-wires of the fractures were performed. No tendon vascular and nerve injuries of the left hand were found (Fig. 1); however, intra-arterial thrombi could be seen in the common palmar digital artery (3 mm) and palmar digital arteries of the second (2 mm) and third (2 mm) fingers without apparent transmural injury of the vascular wall (Fig. 2). Five thousand units of Heparin was injected into the radial artery showed clear improvement of vascularization with perfusion of the second and third fingers of the left hand after about 5 min (Fig. 3). Papaverine was also applied topically on this vessel as a vasodilator therapy. The patient was hospitalized for 8 days with a continuous iv perfusion of neodextril (Dextran), showing good perfusion and no signs of ischemia (Fig. 4).

Adenoid cystic carcinoma of head and neck: apropos of a case

Adenoid cystic carcinoma (ACC) is a rare malignant neoplasm, arising from glandular tissues, found mainly in the head and neck. Generally, it presents insidiously but can behave aggressively making its course unpredictable. Surgery and adjuvant radiotherapy continue to be the cornerstone for its treatment. ACC remains extremely difficult to treat. The authors report a case of a 37-year-old woman with bloody rhinorrhea for 6 months. She was diagnosed with a left nasal cavity lesion that was biopsied, and the anatomopathological result showed ACC. The patient was submitted to a left extended maxillectomy, microsurgical reconstruction and radiotherapy.