Marisa Marques

Long-term follow-up of breast capsule contracture rates in cosmetic and reconstructive cases.

Background: Silicone gel breast implants are associated with long-term adverse events, including capsular contracture, with reported incidence rates as high as 50 percent. However, it is not clear how long the follow-up period should be and whether there is any association with estrogen or menopausal status. In addition, the placement of Baker grade II subjects in the majority of reports has been in data sets of controls instead of capsular contracture. Methods: A retrospective medical study (1998 to 2004) was performed in women (n = 157) who received textured silicone breast implants for aesthetic or reconstructive procedures at the Hospital of S. João (Portugal). Medical data were collected that included the following: patient demographics, history, lifestyle factors, surgical procedures, and postoperative complications. Statistical analyses included Pearson chi-square testing, logistic regression modeling, and chi-squared automatic interaction detection (CHAID) methods. Results: The reconstructive cohort had a great incidence of capsular contracture compared with the cosmetic cohort. If one considered no capsular contracture versus capsular contracture, the follow-up period should be longer than 42 months. However, if considering no capsular contracture and grade II subjects versus grade III or IV subjects, a longer follow-up period of 64 months was determined. There was no association between capsular contracture and menopause/estrogen status. Conclusions: Increased frequencies of capsular contracture were recorded in breast reconstruction that were not attributable to estrogen or menopausal status. On the basis of these results, the authors propose a follow-up period longer than 42 months and the inclusion of Baker grade II subjects.

Effects of coagulase-negative staphylococci and fibrin on breast capsule formation in a rabbit model.

BACKGROUND The etiology and ideal clinical treatment of capsular contracture (CC) remain unresolved. Bacteria, especially coagulase-negative staphylococci, have been previously shown to accelerate the onset of CC. The role of fibrin in capsule formation has also been controversial. OBJECTIVE The authors investigate whether fibrin and coagulase-negative staphylococci (CoNS) modulate the histological, microbiological, and clinical outcomes of breast implant capsule formation in a rabbit model and evaluate contamination during the surgical procedure. METHODS Thirty-one New Zealand white female rabbits were each implanted with one tissue expander and two breast implants. The rabbits received (1) untreated implants and expanders (control; n = 10), (2) two implants sprayed with 2 mL of fibrin and one expander sprayed with 0.5 mL of fibrin (fibrin; n = 11), or (3) two implants inoculated with 100 µL of a CoNS suspension (10(8)CFU/mL-0.5 density on the McFarland scale) and one expander inoculated with a CoNS suspension of 2.5 × 10(7) CFU/mL (CoNS; n = 10). Pressure/volume curves and histological and microbiological evaluations were performed. Operating room air samples and contact skin samples were collected for microbiological evaluation. The rabbits were euthanized at four weeks. RESULTS In the fibrin group, significantly decreased intracapsular pressures, thinner capsules, loose/dense (<25%) connective tissue, and negative/mild angiogenesis were observed. In the CoNS group, increased capsular thicknesses and polymorph-type inflammatory cells were the most common findings. Similar bacteria in capsules, implants, and skin were cultured from all the study groups. One Baker grade IV contracture was observed in an implant infected with Micrococcus spp. CONCLUSIONS Fibrin was associated with reduced capsule formation in this preclinical animal model, which makes fibrin an attractive potential therapeutic agent in women undergoing breast augmentation procedures. Clinical strategies for preventing bacterial contamination during surgery are crucial, as low pathogenic agents may promote CC.

Animal Model of Implant Capsular Contracture: Effects of Chitosan

BACKGROUND The mechanism(s) responsible for breast capsular contracture (CC) remain unknown, but inflammatory pathways play a role. Various molecules have been attached to implant shells in the hope of modifying or preventing CC. The intrinsic antibacterial and antifungal activities of chitosan and related oligochitosan molecules lend themselves well to the study of the infectious hypothesis; chitosans ability to bind to growth factors, its hemostatic action, and its ability to activate macrophages, cause cytokine stimulation, and increase the production of transforming growth factor (TGF)-β1 allow study of the hypertrophic scar hypothesis. OBJECTIVE The authors perform a comprehensive evaluation, in a rabbit model, of the relationship between CC and histological, microbiological, and immunological characteristics in the presence of a chitooligosaccharide (COS) mixture and a low molecular weight chitosan (LMWC). METHODS Eleven adult New Zealand rabbits were each implanted with three silicone implants: a control implant, one impregnated with COS, and one impregnated with LMWC. At four-week sacrifice, microdialysates were obtained in the capsule-implant interfaces for tumor necrosis factor alpha (TNF-α) and interleukin-8 (IL-8) level assessment. Histological and microbiological analyses were performed. RESULTS Baker grade III/IV contractures were observed in the LMWC group, with thick capsules, dense connective tissue, and decreased IL-8 levels (p < .05) compared to control and COS groups. Capsule tissue bacterial types and microdialysate TNF-α levels were similar among all groups. CONCLUSIONS Chitosan-associated silicone implantation in a rabbit model resulted in Baker grade III/IV CC. This preclinical study may provide a model to test various mechanistic hypotheses of breast capsule formation and subsequent CC.

Effects of Fibrin, Thrombin, and Blood on Breast Capsule Formation in a Preclinical Model

BACKGROUND The root cause of capsular contracture (CC) associated with breast implants is unknown. Recent evidence points to the possible role of fibrin and bacteria in CC formation. OBJECTIVES The authors sought to determine whether fibrin, thrombin, and blood modulated the histological and microbiological outcomes of breast implant capsule formation in a rabbit model. METHODS The authors carried out a case-control study to assess the influence of fibrin, thrombin, and blood on capsule wound healing in a rabbit model. Eighteen New Zealand white rabbits received four tissue expanders. One expander acted as a control, whereas the other expander pockets received one of the following: fibrin glue, rabbit blood, or thrombin sealant. Intracapsular pressure/volume curves were compared among the groups, and histological and microbiological evaluations were performed (capsules, tissue expanders, rabbit skin, and air). The rabbits were euthanized at two or four weeks. RESULTS At four weeks, the fibrin and thrombin expanders demonstrated significantly decreased intracapsular pressure compared to the control group. In the control and fibrin groups, mixed inflammation correlated with decreased intracapsular pressure, whereas mononuclear inflammation correlated with increased intracapsular pressure. The predominant isolate in the capsules, tissue expanders, and rabbit skin was coagulase-negative staphylococci. For fibrin and thrombin, both cultures that showed an organism other than staphylococci and cultures that were negative were associated with decreased intracapsular pressure, whereas cultures positive for staphylococci were associated with increased intracapsular pressure. CONCLUSIONS Fibrin application during breast implantation may reduce rates of CC, but the presence of staphylococci is associated with increased capsule pressure even in the presence of fibrin, so care should be taken to avoid bacterial contamination.

Gangrena de Fournier: de urgencia urológica hasta el departamento de cirugía plástica

Resumen La gangrena de Fournier (GF) es una enfermedad infecciosa rara y potencialmente fatal, caracterizada por fascitis necrotica del perine y la pared abdominal junto con el escroto y el pene en los varones y la vulva en las mujeres. La perdida de piel puede ser muy incapacitante y de dificil resolucion. El tratamiento de esta entidad debe ser agresivo. Se han usado varias tecnicas para reconstruir la perdida de tejidos: injertos cutaneos, transposicion de los testiculos y del cordon para una bolsa subcutanea en el muslo, colgajo pediculado musculocutaneo, fasciocutaneo o varios otros tipos de colgajo pediculados miocutaneos. El pediculo cutaneo superomedial del muslo es un pediculo arterial probable y demostro ser un metodo eficaz en la reconstruccion de grandes defectos escrotales.

Fournier's gangrene: from urological emergency to plastic surgery

Fourniers gangrene (FG) is a rare and potentially fatal infectious disease characterised by necrotic fasciitis of the perineum and abdominal wall in addition to the scrotum and penis in men and the vulva in women. Skin loss can be very damaging and difficult to repair. This condition must be treated aggressively. Several techniques are used to reconstruct lost tissue: skin grafts, transposition of the testicles and spermatic cords to a subcutaneous pocket in the upper thigh, scrotal musculocutaneous flaps, fasciocutaneous flaps and several other types of pediculated myocutaneous flaps are all employed. The supero-medial thigh skin flap is a likely arterial flap and has been shown to be an effective method for reconstructing large scrotal defects.

Neurosensible reconstruction of the thumb in an emergency situation: review of 107 cases.

Coverage of a soft tissue defect of the thumb that cannot be replanted or without bone shortening is difficult to achieve, but it is essential to preserve key-pinch and to restore a sensible and painless pulp. We reviewed retrospectively 107 cases of thumb reconstruction in an emergency situation using the following flaps: Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler. The choice of the flap was determined by the extension and location of the injury; Foucher flap (56 cases) was the most used one, and it proved to be the best choice as shown by the results. Nevertheless, Tezcan flap also proved to be a good alternative.

Six years of follow-up after bilateral hand replantation.

Replantation is the gold standard surgical treatment of amputations of the upper limb; however, this demanding procedure is not always preformed in bilateral limb amputation. The objective of this study was to analyze, six years after surgery, the sensorimotor recovery of both replanted hands. A 21-year-old patient with bilateral hand amputation was benefited from limb replantation. Surgery included debridement of the amputated hands and recipients stumps, bone fixation, arterial and venous anastomoses, nerve sutures, tendon sutures and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Sensory and motor evaluation was performed 6 years after replantation. At 6 years, the patient presented a good/satisfactory recovery of range of motion and strength, better at right hand. The patient was able to perform right thumb opposition. Static two-point discrimination was 20mm, sensitivity to pain and thermal stimuli and ability to sweat were present on both hands. Reinnervation was confirmed by electromyography. Functional recovery was higher at the right hand when compared to the left hand. He was highly satisfied with the result of surgery for right hand and fairly satisfied with the result for left hand. He was able to return to a secretary work 16 months after the accident. A proper functional result can be accomplished with bilateral hand replantation.

The ''PIP Problem'': Clinical and Histologic Characteristics

Implants from Poly Implant Prothése (PIP), the French manufacturer, showed increased risk of implant rupture and silicone leakage through the shell. Concerns also exist about the potential irritant behavior of silicone gel filler in these implants. This report presents the clinical, histologic, and microbiologic characteristics of a capsule and a siliconoma from a patient with a ruptured PIP implant. A 41-year-old woman submitted to breast augmentation in 2005 with PIP silicone gel implants presented with a recent history of progressive asymmetric breast enlargement and an enlarged lymph node on her right axilla. No capsular contracture was observed. A breast ultrasonography showed intra- and extracapsular ruptures of the right implant. The woman underwent explantation. Histologic analysis of the breast capsules showed a thin capsule with a chronic, mild inflammatory response. Microbiologic analysis showed no bacterial agent. The irritant behavior of the PIP silicone gel previously described was not able to produce capsular contracture or an exuberant inflammatory reaction. Studies to evaluate the potential risks of the silicone gel and to define the hazards for women implanted with those prostheses are urgently needed.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 www.springer.com/00266.

Mandibular distraction in a tracheostomized patient with Pierre-Robin sequence

The triad of glossoptosis, micrognathia, and cleft palate characterizes the Pierre Robin sequence (PRS). Complications can be severe and the clinical manifestations are very heterogeneous, but airway obstruction is almost present and may be life threatening. To avoid tracheostomy or allow for early decannulation in severely affected children, external or biorebsorbable internal distraction devices can be applied to repair mandibular deficiences. We report a case of a children submitted to bilateral mandibular distraction with external nonresorbable devices. After optimal lengthening of mandibles, laringotracheoplasty was performed to close the tracheostomy with improvement of respiratory pattern and quality of life this child. Biorebsorbable internal distraction devices offers some advantages, but complications include device failure to support resistance. Distraction osteogenesis has become a safe, less‐invasive procedure with a negligible risk of infection making it effective to substitute tracheostomy as first choice in treatment of patients with Pierre Robin Sequence and life threatening airway obstruction.