Marcus Castro Ferreira

Critical analysis of reduction mammaplasty techniques in combination with conservative breast surgery for early breast cancer treatment.

Background: Although reduction mammaplasty is a well-described technique for aesthetic purposes, there are few previous reports regarding its application and clinical outcome following conservative breast surgery reconstruction. The purpose of this study was to analyze the feasibility of the technique and its outcome following conservative breast surgery. Methods: Oncologic data and information on age, body mass index, smoking history, and comorbid conditions were collected. Reconstructed and opposite breast complications were evaluated. Reduction mammaplasty was indicated to reconstruct moderate breast defects in patients with enough remaining breast tissue. Mean follow-up was 22 months. Results: Seventy-four patients underwent immediate reduction mammaplasty following breast-conserving surgery. In 55.4 percent of patients, tumors measured 2 cm or less (T1) and in 47.2 percent they were located in the upper outer quadrants. Breast complications occurred in 13 patients (17.6 percent), with skin necrosis in six (8.1 percent), infection in two (2.7 percent), partial areola necrosis in two (2.7 percent), dehiscence in two, and total areola necrosis in one (1.35 percent). Late complications represented by skin lesions and fat necrosis were observed in five patients (6.8 percent). Obese patients and smokers had a significantly higher rate of reconstructed breast complications compared with the normal/overweight patients (p = 0.002) and nonsmokers (p = 0.043). No significant association between complications and age, hypertension, diabetes, axillary lymph node dissection, or chemotherapy was found. Conclusions: Reduction mammaplasty is a consistent technique for reconstruction following breast-conserving surgery. Complications are more often observed in the reconstructed breast, and obese patients and smokers are higher risk patients.

Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction.

Background: Aesthetic surgery of female genitalia is an uncommon procedure, and of the techniques available, labia minora reduction can achieve excellent results. Recently, more conservative labia minora reduction techniques have been developed, because the simple isolated strategy of straight amputation does not ensure a favorable outcome. This study was designed to review a series of labia minora reductions using inferior wedge resection and superior pedicle flap reconstruction. Methods: Twenty-one patients underwent inferior wedge resection and superior pedicle flap reconstruction. The mean follow-up was 46 months. Aesthetic results and postoperative outcomes were collected retrospectively and evaluated. Results: Twenty patients (95.2 percent) underwent bilateral procedures, and 90.4 percent of patients had a congenital labia minora hypertrophy. Five complications occurred in 21 patients (23.8 percent). Wound-healing problems were observed more frequently. The cosmetic result was considered to be good or very good in 85.7 percent of patients, and 95.2 percent were very satisfied with the procedure. All complications except one were observed immediately after the procedure. Conclusions: The results of this study demonstrate that inferior wedge resection and superior pedicle flap reconstruction is a simple and consistent technique and deserves a place among the main procedures available. The complications observed were not unexpected and did not extend hospital stay or interfere with the normal postoperative period. The success of the procedure depends on patient selection, careful preoperative planning, and adequate intraoperative management.

Outcome analysis of breast-conservation surgery and immediate latissimus dorsi flap reconstruction in patients with T1 to T2 breast cancer

Background: The latissimus dorsi myocutaneous flap is frequently used for total breast reconstruction; however, few reports have been available regarding clinical outcome following conservative breast surgery. The aim of this study was to perform a retrospective review on 48 patients undergoing immediate latissimus dorsi myocutaneous flap surgery following conservative breast surgery between 1999 and 2004. Methods: Information on age, body mass index, smoking history, comorbid medical conditions, and oncologic status was collected. Reconstructed breast and donor-site complications were evaluated. Results: Mean follow-up was 16 months. In 56.2 percent of patients, tumors measured 2 cm or less (T1) and in 47.9 percent were located in the upper outer quadrants. Flap complications occurred in seven and donor-site complications occurred in 12 of 48 patients. Dorsal seroma (20.8 percent), dorsal dehiscence (6.2 percent), and partial flap loss (6.2 percent) were the most common complications. Surgical intervention with skin suture was necessary in two cases of dorsal wound dehiscence. Partial flap losses were limited and were treated by a conservative approach. A significant as-sociation (p =0.035) was detected between dorsal seroma and obesity (body mass index ≥ 30 kg/m2) and was associated with a 5.2-fold increase in the odds of developing this complication. No significant association between complications and age, smoking history, hypertension, diabetes, axillary lymph node dissection, or chemotherapy was found. Conclusions: On the basis of our observations, the latissimus dorsi myocutaneous flap is a consistent technique for reconstruction following conservative breast surgery. Donor-site complications are more often observed in those who are obese; they are higher risk patients.

Complications after Polymethylmethacrylate Injections : Report of 32 Cases

Background: During the past 15 years, polymethylmethacrylate has been used as a synthetic permanent filler for soft-tissue augmentation. Methods: This article reports 32 cases of complications seen at Hospital das Clínicas, Faculty of Medicine, University of São Paulo, for procedures performed elsewhere. Results: The average age of the patients was 43.6 years (range, 22 to 70 years). Twenty-five patients were women. Sixteen injection procedures were performed by certified plastic surgeons, nine by dermatologists, two by urologists, and one by a nonphysician. Complications were classified into five groups according to main presentation as follows: tissue necrosis (five cases), an acute complication that can be related to technical mistakes but that can also be dependent on patient factors or caused by local infection; granuloma (10 cases), which usually presents as a subacute complication 6 to 12 months after the procedure; chronic inflammatory reactions (10 cases), which usually occur years later and can be related to a triggering event, such as another operation or infection in the area that was injected (these reactions are immunogenic in origin and may have cyclic periods of activation and remission); chronic inflammatory reaction in the lips (six cases), which may be present with severe symptoms, especially with lymphedema, because of mobility of the lip; and infections (one case), which are rare but possible complications after filling procedures. Conclusions: Polymethylmethacrylate filler complications, despite being rare, are often permanent and difficult or even impossible to treat. Safety guidelines should be observed when considering use of polymethylmethacrylate for augmentation.

TISSUE EXPANDER COMPLICATIONS IN PLASTIC SURGERY. A 10-YEAR EXPERIENCE

INTRODUCTION Tissue expanders have been of great value in plastic surgery. Tissue expansion was developed for a specific indication; however, within a very short time, the concept of tissue expansion found wide applicability. From 1990 to 1999, 315 expanders in 164 patients were utilized. A retrospective analysis of complications and prognostic factors for complications were done. METHODS The indications for tissue expansion were burns (50%), trauma (32%), and sequelae of previous surgery (8.8%). The expanders were inserted most frequently in the scalp, trunk and neck. RESULTS There were 22.2% of complications and the most common were expander exposure (50%), infection (24%) and bad function of the expander (12.8%). The present study revealed an increased rate of minor complications in the group of 0 to 10 years of age and an increased rate of major complications for face and neck expansions compared to trunk expansion. There were no increased complication rates for the other age and anatomic site groups, previous expansion, concomitant expansion and type of expander used. CONCLUSIONS The outcomes from tissue expansion procedures done in our hospital are similar to those reported in the literature. Tissue expansion is a good and safe technique.

Nerve sources for facial reanimation with muscle transplant in patients with unilateral facial palsy: clinical analysis of 3 techniques.

Ninety-one patients with long-standing unilateral facial palsy and submitted to reanimation of the face with muscle transplant were divided into 3 nonrandomized groups: group I: 2-stage facial reanimation, cross face followed by gracilis muscle transplant, 58 patients; group II: 1-stage reanimation with latissimus dorsi muscle transplant, 11 patients (a branch of the facial nerve on the nonparalyzed side of the face was used as the nerve source for reanimation in groups I and II); group III: 1-stage reanimation with gracilis muscle transplant and neural coaptation of the respective nerve and the ipsilateral masseteric branch of the trigeminal nerve, 22 patients. No microvascular complications were observed. The average interval between surgery and initial muscle contractions was 11.1 months, 7.2 months, and 3.7 months in group I, group II, and group III, respectively. The quality (intensity and shape) of the smile, voluntary or involuntary, obtained on the reanimated side in relation to the unaffected side was considered good or excellent in 53.4%, 54.5%, and 86.3% of the patients in groups I, II, and III, respectively. In group I, the average age of the patients with excellent or good results (19.8 + 10.5 years) was significantly lower than that of the patients with fair or poor results or absence of movement (36.5 + 13.3 years). The smile was considered emotional or involuntary in 34% of the patients in group I and 45% in group II. Most of the patients in each group were only able to produce “voluntary smiles”. Crossed synkinesis with lip puckering was observed in 48% of the patients in group I and 90% in group II. The results obtained with 1-stage facial reanimation with masseteric nerve were more uniform and predictable than those obtained with the other techniques evaluated in this study.

Sensibility of the breast after reduction mammaplasty.

Changes in breast sensibility after reduction mammaplasty remain a controversial subject and most previous studies report only qualitative results. There is more accurate measuring of the sensibility of the skin with the Pressure-Specified Sensory Device (PSSD), which measures the pressure perception of the skin in grams per square millimeter. The evaluation of breast sensibility before and after reduction mammaplasty using the upper medial pedicle technique was undertaken in 25 patients. The PSSD was used to measure one dynamic point threshold in nine points of the breast during the preoperative period and 6 months after surgery. After surgery all patients had decreased sensation in all points studied, and this was significant. There are few reports of breast sensibility after mammaplasty using the PSSD, and the discrepancy in results reported using other methods of evaluation could be related to precision in evaluation.

Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting

Free flaps based on perforator vessels, and in particular the deep inferior epigastric perforator (DIEP) flap, are currently being applied in abdominal reconstruction. However, one of the main disadvantages is the operative complexity. Through anatomical study and clinical experience with the DIEP flap in breast reconstruction, the intramuscular path of the perforator vessels was comparatively studied, to establish the main anatomical parameters that favor procedure planning. Thirty DIEP flaps from 15 fresh cadavers were used. The number, location, and intramuscular course of the perforator vessels were determined. In addition, an initial clinical study was performed in 31 patients using 35 DIEP flaps in breast reconstruction. The number, location, and the intramuscular course of the perforators were assessed. In the cadaver study, 191 perforator vessels were detected (6.4 vessels per flap). Thirty-four percent were located in the lateral row, and the rectilinear course was observed in 79.2 percent of these vessels. In the medial row, only 18.2 percent of the perforator vessels presented this configuration (p = 0.001). Thirty-one patients underwent DIEP flap breast reconstruction, with 26 immediate and four bilateral reconstructions. In 22 of 35 flaps (62.9 percent), two perforators were used. In 25 flaps (71.4 percent), the lateral row perforators with a rectilinear course were observed. Mean operative time was 7 hours and 37 minutes. Two total flap losses and two partial necroses were observed. The majority of the lateral row perforators presented a rectilinear intramuscular course, which was shorter than that of the medial row perforators. This anatomical characteristic favors dissection with reduced operative time and vascular lesion morbidity, resulting in an important anatomical parameter for DIEP flap harvesting.

Abdominal wall closure after selective aponeurotic incision and undermining.

The tension required to pull the anterior and the posterior rectus sheaths toward the midline was studied in 20 fresh cadavers at two levels: 3 cm above and 2 cm below the umbilicus. The quotient of the force used to mobilize the aponeurotic site to the midline and its resulting displacement was called the traction index. These indices were compared in three situations: (1) prior to any aponeurotic undermining, (2) after the incision of the anterior rectus sheath and the undermining of the rectus muscle from its posterior sheath, and (3) after additionally releasing and undermining the external oblique muscle. A significant decrease in aponeurotic resistance was observed after each dissection. The anterior sheath showed higher resistance to traction compared with the posterior sheath on both levels. No statistical difference was noted in the comparison of the values of the aponeurosis above and below the umbilicus. These results suggest that these procedures are effective in assisting in the closure of abdominal wall defects because these maneuvers decrease substantially the tension required for advancement of the aponeurotic edges.

Surgical treatment of lymphedema of the penis and scrotum

PURPOSE Lymphedema of the penis and scrotum, regardless of its etiology, is determined by reduced lymphatic flow with subsequent enlargement of the penis and scrotum. The clinical course of this condition is characterized by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse, and voiding in the standing position. The purpose of the present study is to present the experience and results of the treatment of lymphedema of the penis and scrotum by removing affected tissues and correcting the penoscrotal region. MATERIALS AND METHODS Seventeen patients with lymphedema of the penis and scrotum were treated with a modified Charles procedure, which consists of the excision of the affected skin followed by scrotoplasty and midline suture simulating the scrotal raphe. The penis is covered with a split-thickness skin graft by means of a zigzag suture on its ventral surface. RESULTS Regression of symptoms and improvement of previous clinical conditions were verified in the follow-up which ranged from 6 months to 6 years. One patient who had undergone lymphadenectomy with radiation therapy due to penile cancer had recurrent scrotum lymphedema. CONCLUSIONS The modified Charles procedure for the treatment of penoscrotal lymphedema is easily reproducible and allows better local hygiene, easier ambulation, voiding in the standing position, resuming sexual intercourse, and finally, better cosmetic results in the affected area with remarkable improvement in quality of life.