Jesus Benito-Ruiz

Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps

Soft tissue heel defects reconstruction represents a challenge for plastic surgeons because of the poor availability of regional tissue to perform the reconstruction. We divide the heel on the anterior or weight-bearing heel and the posterior or non–weight-bearing heel. Our preferences are the fasciocutaneous instep flap for anterior heel defects and the reverse sural flap for posterior heel defects. We have performed 11 reconstructions of the heel. The complications were total necrosis of 1 instep flap in a previously irradiated patient and 1 case of partial tip necrosis in a reverse sural flap. Functional recovery has been very satisfactory for both procedures. Regional island flaps are for us the first therapeutic option because the skin is similar to the lost one and less time consuming than a free-flap reconstruction.

Assessing the Long-Term Viability of Facial Fat Grafts: An Objective Measure Using Computed Tomography

BACKGROUND Autologous fat transplantation for soft tissue augmentation is a commonly used technique without a universally accepted approach. The literature includes a variety of reports describing varying degrees of success or failure. OBJECTIVE To evaluate the behavior of facial fat grafts in humans with the use of an objective measuring tool. METHODS A prospective randomized study, comparing patients pre- and postoperatively, was designed to evaluate the long-term viability of fat grafting. Participants were 18 men and 8 women between 34 and 59 years of age (mean, 45.07 yrs; standard deviation, 6.54 yrs). A total of 52 hemifaces in 26 patients diagnosed with HIV and demonstrating facial lipoatrophy were treated with fat transplantation using Colemans technique. HIV-positive patients were chosen as study participants because their nearly total lack of subcutaneous fat diminishes the bias in the evaluation of fat volume. Fat graft viability was evaluated by measuring the volume of adipose tissue evolution via computed tomography scan before fat grafting, at the second month after fat grafting, and 1 year after fat grafting. Descriptive statistical analysis was performed. RESULTS The mean volume on the right and left cheeks before fat grafting was 1.57 cc. The mean volume 2 months after the procedure was 2.93 cc with a statistically significant mean increase of 1.36 cc (P < .001) between baseline and the second month after the procedure. The mean volume after 12 months was 3.29 cc (P < .001), with a mean increase compared with the baseline of 1.72 cc, and of 0.36 cc between months 2 and 12. The statistically significant posttreatment improvement (P < .001) was maintained until month 12 of the follow-up period. CONCLUSIONS Using objective measurement, this study demonstrates that with one fat grafting procedure a durable result can be achieved, persisting for a minimum of 12 months without any trend towards reabsorption.

Assessment of a Suction-Assisted Cartilage Shaver Plus Liposuction for the Treatment of Gynecomastia

BACKGROUND The development of feminized breasts in men may cause significant emotional distress and embarrassment, particularly in young men and adolescents. Numerous techniques have been described for the correction of gynecomastia, many of which include the removal of fat and glandular tissue. OBJECTIVE The authors assess the utility of combining vibroliposuction with the use of a power-assisted arthroscopic-endoscopic cartilage shaver to correct gynecomastia and suggest a treatment algorithm for patients with gynecomastia. METHODS Forty consecutive patients with a median age of 32 years (range 19-57 years) and with varying degrees of gynecomastia underwent a combined approach that included vibroliposuction (power-assisted tumescent liposuction) for the removal of fatty tissue, followed by the removal of fibrous tissue with the use of a power-assisted cartilage shaver. Follow-up periods ranged in duration from six to 18 months. RESULTS All patients had satisfactory results. However, expansive hematomas requiring surgical drainage developed in three patients. Other complications included one case of insufficient resection requiring reoperation and three cases of hyperpigmentation and skin irregularities in patients with grade I gynecomastia. CONCLUSIONS Combination treatment using vibroliposuction and a power-assisted arthroscopic-endoscopic cartilage shaver is an effective treatment for gynecomastia, but the technique has a learning curve. This procedure is most appropriate for patients with grades II and III gynecomastia, or as a first-stage treatment for patients with grade IV gynecomastia.

Transaxillary subfascial breast augmentation.

The authors view is that transaxillary subfascial breast augmentation provides consistent, satisfactory results with ease of dissection. Compared with submuscular placement, this technique involves less risk of hematoma, less pain, and faster recovery, and injury to the intercostobrachial nerve is less likely. Also, there is no change of implant shape with muscle contracture. (Aesthetic Surg J 2003;23:480-483).

Hip and Buttock Implants to Enhance the Feminine Contour for Patients with HIV

The antiretroviral therapy for patients with human immunodeficiency virus (HIV) causes lipodystrophy, or a change in the distribution of body. Treatment for the facial changes is well addressed and covered in the recent literature, but female patients also report changes in their buttocks and lower limbs. There is no treatment for the lower limb deformity, but plastic surgeons can do something for the buttock. The authors propose a classification for the deformities of these patients and a new solution to improve the contour of this area and to reduce the social impact of deformity on women with HIV. This consists of placing two silicone implants, in the buttock and on the hip, to give a rounder appearance. The authors think that hip implants may be indicated also for gender reassignment surgery and for women with masculine features.

Waterproof Camera Case for Intraoperative Photographs

Accurate photographic documentation has become essential in reconstructive and cosmetic surgery for both clinical and scientific purposes. Intraoperative photographs are important not only for record purposes, but also for teaching, publications, and presentations. Communication using images proves to be the superior way to persuade audiences. This article presents a simple and easy method for taking intraoperative photographs that uses a presterilized waterproof camera case. This method allows the user to take very good quality pictures with the photographic angle matching the surgeon’s view, minimal interruption of the operative procedure, and minimal risk of contaminating the operative field.

Endoscopic breast reconstruction with intraoperative complete tissue expansion and partial detachment of the pectoralis muscle

We present the surgical technique for mammary reconstruction using tissue expander with endoscopic approach, associated to partial detachment of the pectoralis muscle at the fourth rib and complete or nearly complete intraoperative expansion. Tissue expansion for breast reconstruction is a well-honored technique that provides satisfying esthetic outcomes, with minimal morbidity for the patient. Nevertheless, this technique has some potential problems: (1) wound dehiscence with extrusion of the expander; (2) the patient discomfort during the expansion process (weekly visits for the refill of the expander); (3) the poor definition of the lower pole of the breast and cranial migration of the expander with excessive roundness of the upper pole. By using intraoperative tissue expansion, these drawbacks can be avoided. We report herein our experience with this technique in 53 consecutive patients (56 breasts) undergoing a secondary breast reconstruction since December 2001.

Nipple Shields in Transaxillary Breast Augmentation

Background Infection after breast augmentation occurs in 1.1% to 2.5% of patients. Bacterial contamination of the implants could explain some complications of breast implant surgery, including infection, capsular contracture and even anaplastic large cell lymphoma. Because of the evidence of bacterial spread from the nipple, nipple shields have been proposed as a routine maneuver to avoid contamination of the implants. Objective To determine if nipple shields are useful in transaxillary breast augmentation. Methods A culture was obtained from the dressing (nipple shield) in 26 patients with transaxillary incision, and follow-up lasted for 18 months. A retrospective study of patients undergoing breast augmentation between 2008 and 2012 was conducted as well to know our rate of infections. A total of 753 patients between the ages of 18 and 62 years, with a mean age of 34 years, were identified. Of these 753 patients, most underwent surgery using a transaxillary incision (72.5%). The most common placement plane was subfascial (59.2%), and in most cases, an anatomical prosthesis (78%) was used. Results No cases of infection or capsular contracture were observed in the study group. However, 13.5% of the breasts had positive cultures of swabs taken under the nipple shields. Staphylococcus epidermidis and Enterococcus faecalis were isolated from the nipple culture. Within the retrospective study, we detected 2 cases of acute infection (0.26%) and 5 cases of late infection (0.66%). The acute infections were caused by Staphylococcus aureus. In the late infections, Pseudomonas aeruginosa was isolated in 3 cases, and S. aureus was isolated in 1 case. Conclusions Nipple shields did not make any difference for outcomes when using the transaxillary method. Acute infections seem to occur more frequently via the areola route. Late infections seem to have a hematogenous component because an infectious background was present in all cases.

Columella reconstruction using a free flap from the first web space of the foot.

Nasal columella defects can result in significant cosmetic and functional deformities. If a local flap transfer cannot be performed, columella reconstruction becomes a significant challenge for the surgeon. The columella of a healthy 30-year-old woman whose nose was scarred and contracted because of cocaine abuse, was successfully reconstructed by transferring a microvascular free flap from the first web space of the foot. The reconstructed columella had a satisfactory contour and a good texture, although there was slight, albeit unproblematic, color mismatching.

Multislice Computed Tomography Angiography of the Fourth Dorsal Interosseous Space in Cadavers

PURPOSE To study computed tomography angiography (CTA) findings and compare anatomic correlation of the 4th dorsal metacarpal spaces and to determine the role of this technique for anatomic studies and flap design. METHODS Hands from 17 cadavers were injected with a radiopaque mixture. The specimens were imaged using 16-detector-row computed tomography. Each image was analyzed by a radiologist, a plastic surgeon, and an anatomist. The following data were recorded: the presence of the 4th dorsal metacarpal artery, proximal and distal communicating branches and distal recurrent branch, and the number of cutaneous perforators. Afterwards, a meticulous dissection was carried out. A correlation between the radiologic findings and the gross anatomy was established. RESULTS In all specimens, the 4th dorsal metacarpal artery and distal recurrent branch were identified. In 15 cases, at least 1 perforator was identified within the 4th space. In 2 cases, no perforator was identified. In all cases, the radiologic findings correlated with the anatomic findings in the dissection. CONCLUSIONS Multislice CTA provides good-quality information about the vascular anatomy of the dorsal aspect of the hand, including perforator vessels less than 0.5 mm in diameter. Multislice CTA allows for observation of the axis, trajectory, and branching pattern of the blood vessels and, most importantly, demonstrates the anatomic relationships among blood vessels, bones, and soft tissue.