Rita Valença-Filipe

Dissection Technique for Abdominoplasty: A Prospective Study on Scalpel versus Diathermocoagulation (Coagulation Mode)

Background: The purpose of this study was to evaluate the effect of the dissection technique on outcomes and complications after a full abdominoplasty, comparing 2 different techniques used to raise the abdominal flap: the steel scalpel and the diathermocoagulation device on coagulation mode. Methods: A prospective study was performed at a single center from January 2009 to December 2011 of patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, abdominoplasty performed with steel scalpel/knife; and group B, abdominoplasty performed with diathermocoagulation on coagulation mode. Several variables were determined: general characteristics, time until drain removal, daily and total volume of drain output, length of hospital stay, operative time, readmission, reoperation, emergency department visits, and local and systemic complications. Results: A total of 119 full abdominoplasties were performed in women (group A, 39 patients; group B, 80 patients). There were no statistically significant differences between groups with respect to general characteristics, except for body mass index, comorbidities, and weight of the surgical specimen; there were no differences for operative time, systemic complications, hematoma, and necrosis incidence. The scalpel group had a highly significant reduction of 54.56% on total drain output, and a 2.65 day reduction on time to drain removal and no reported cases of seroma or healing problems (difference of 81.25% and 90.00%, respectively, between the 2 groups). Conclusions: Performing abdominal dissection with scalpel had a beneficial effect on patient recovery, as it reduced time requested for drain removal, total drain output, and incidence of seroma and wound healing problems.

Pyoderma gangrenosum after breast reduction: A rare complication

Pyoderma gangrenosum (PG) is a chronic, recurrent and often destructive, inflammatory disease that belongs to the spectrum of neutrophilic dermatoses. The incidence is low, making recognition difficult, one report estimates it to be three cases per million per year in the United States. Diagnostic criteria include the presence of a rapidly progressive, painfull necrolytic ulcer with an irregular, violaceous and undermined border and exclusion of other causes for cutaneous ulceration and at least one of the following: history suggestive of pathergy or clinical finding of cribiform scarring; systemic diseases associated with PG; histophatologic findings (sterile dermal neutrophilia, mixed inflammation, lymphocitic vasculitis); treatment response (rapid response to systemic steroid treatment). The criteria cannot be used in isolation, but when used together, they support a diagnosis of PG. 3 In asmany as 70% of cases, PG is associated with a variety of diseases, with inflammatory bowel disease, rheumatoid arthritis, hematologic disease, and malignancy being the most frequent. Workup for PG should begin with a thorough history and physical that focuses on the risk factors and associated disorders. Wound culture for bacteria, acid-fast bacillus, and fungus can rule out an infection. Full-thickness biopsy should be performed peripherally in the erythematous halo, often showing a lymphocytic or neutrophilic vasculitis; although histopathologic findings in PG are nonspecific, its main value lies in the exclusion of other diseases. PG can occurs after any surgical procedure and its recognition is often delayed, leading to significant morbidity, including prolonged therapy, numerous hospitalizations, persistence of severely painful ulcerations, psychological trauma and extensive scarring with

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure

When an auricular defect is caused by high‐energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year‐old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A “printed” ear made of silicone, based on the patients CT‐scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.

FACIAL ALLOTRANSPLANTATION PROCUREMENT USING A TRANSPAROTID APPROACH: A NEW ANATOMICAL MODEL

Full face transplantation is a complex procedure and a detailed plan is needed. Coaptation of motor nerve branches at more distal sites instead of the level of the main trunk is highly desirable, but may be difficult to find, are thin, fragile and have limited length for safe and tension‐free coaptation. In addition, nerve grafts may be necessary. In this study, the technical feasibility of facial allotransplantation procurement using a transparotid approach was investigated.

ALT chimeric flap associated to a dura mater biomatrix substitute for severe desfigurative mandible osteoradionecrosis and deficient bone consolidation after a free fibula flap

Although radiotherapy can increase cure rates after head and neck cancer it often comes with secondary effects, one of the worst of which is osteoradionecrosis. Obliterative endarteritis, hyperaemia, hyalinisation, cellular loss, hypovascularisation, thrombosis, and fibrosis are common histological findings. Bone cells are damaged as a result of acute inflammation, free radicals, and the chronic activation of fibroblasts. 1 In extreme cases, even free transfer may be not enough for adequate reconstruction, and alternative plans should be considered. The persistence of poor coverage in an extensively irradiated area, and an inadequate barrier around the bone, were identified as the two main problems that prevented adequate healing of bone in a 41-year-old woman with severe osteoradionecrosis and deficient bony consolidation after a fibular free flap. Despite the flap being viable with patent microvasular anastomoses and normal radiological bone density, there was no effective consolidation (Fig. 1), and subsequently the mandibular reconstruction plate extruded and a persistent orocutaneous fistula developed (Fig. 2).

Giant atypical lipoma of the thigh.

Lipomas are the most common soft tissue tumors and constitute 16% of all mesenchymal neoplasms. Giant lipomas should be differentiated from liposarcomas, which are usually closely related to the tumor’s dimensions. It is difficult to differentiate low-grade liposarcomas from benign lipomas based solely on imaging findings. Final diagnosis rests on histopathologic evaluation to assess mitotic activity, cellular atypia, necrosis, and invasion. Herein we describe a case of a 4500-g giant lipoma of the thigh. This case is of particular interest because of the functional limitation and lymphedema of the lower limb caused by compression of the femoral vessels and nerve.

The Ultrasound-Guided Fat Transplantation

To the Editor: Fat transplantation is currently a widely-used procedure in plastic and reconstructive surgery. Despite the guidelines and technical principles are well known, it remains a “blind” method with unpredictable and sometimes inconsistent results. On sonograms, the fat in normal breast parenchyma is hypoechoic, fibrous tissue is echogenic, and glandular tissue is intermediate in echogenicity, and give that, theoretically once injected fat will not offer great contrast with the surrounding tissues. We have investigated the feasibility of ultrasound-assisted fat transplantation and high-quality breast sonograms were obtained using 7.5 to 10 MHz linear transducers, imaging the infiltrated area within the transducer focal zone. This technique was used in 2 patients with different clinical situations:

Severe traumatic facial injury: avatars and thermographic damage evaluation.

935e survival is not standardized and cannot be a useful measure of success. Third, large-volume autologous fat transfer is about volume increase; this is the most pertinent clinical outcome. However, increasing by 100 ml a 100-ml mastectomy defect or AA recipient breast doubles the original recipient volume (100 percent augmentation) and is a much more formidable achievement than increasing by the same 100 ml a 2000-ml buttock recipient (5 percent augmentation). Therefore, absolute volume increases cannot be used as a measure of surgical prowess or quality of injected fat. Fourth, assuming all the augmented volume is live fat, the most striking achievement in autologous fat transfer is by how much a defined recipient volume can further increase in volume. This percentage augmentation is the real clinical challenge and is the most relevant measurement of proficiency in autologous fat transfer. The best-documented report on autologous fat transfer breast augmentation without preexpansion by Spear and Pittman had a 40 percent augmentation.8 A meta analysis of published autologous fat transfer breast augmentation, including reports of stem cell supplementation, had a 35 percent augmentation.9 By meticulously grafting droplets of fat as a fine mist that maximizes the graft-to-recipient interface, it seems possible to enlarge a recipient site by 35 to 40 percent. In contrast, reports of Brava (Brava, LLC, Miami, Fla.) plus autologous fat transfer breast augmentation showed an 80 percent9 and, as we got better, a 90 percent augmentation.10 Temporary expansion of the recipient to double or even triple its size before autologous fat transfer has proven to be the best way of increasing the effective augmentation ratio (Figs. 1 and 2). Despite all the available technology, just doubling the size of a recipient site with healthy fat remains a formidable clinical challenge. The most popular yardstick of prowess in autologous fat transfer, percentage graft survival, is mostly an indication of how much the surgeon has overgrafted or undergrafted a recipient site. It says nothing about the effective augmentation and has little clinical relevance. We plead with future generations of authors to replace their reports of percentage graft survival with the much more clinically relevant percentage augmentation of a specific recipient site. DOI: 10.1097/PRS.0000000000001191

Full face allotransplantation procurement with en block facial nerve dissection as a way to increase neurotization possibilities for targeted reinnervation

Facial transplantation is an original work for each patient, because facial anatomies are unique, depending on the extent of the initial injury and previous reconstructive procedures. Reorganization after face transplantation occurs through neuromuscular pathways and sensory and proprioceptive feedback. Successful coaptation of as many major sensory and motor nerves is the key to optimize functional outcomes. The identification of healthy nerves for neurotization in the recipient is crucial for successful nerve regeneration within the allograft. However, due to the severity of the initial injury and resultant scar formation, a lack of healthy nerve stumps is a commonly encountered problem. Recently, nerve transfers were described as an option that could theoretically be used in face transplantation, either as a primary nerve reconstruction when there are no available healthy nerves or as a secondary procedure for enhancement of functional outcomes. Inclusion of the parotid gland and limiting facial nerve coaptation to the level of the main trunk adds complexity, poor aesthetic outcomes with fullness to the cheeks, less targeted postoperative reinnervation, and synkinesias. Coaptation of motor nerve branches at more distal sites (as close as possible of effector muscles) is highly desirable, allowing faster reinnervation; however, distal branches may be difficult to find, are thin, fragile and have limited length for safe, tension-free coaptation. In addition, nerve grafts may be necessary. We have investigated the technical feasibility of facial allotransplantation procurement using a transparotid approach in a cadaveric study.The extratemporal course of the facial nerve (main trunk, temporofacial/cervicofacial divisions, and individual facial branches) was elevated en bloc as part of the allograft. The nerves were dissected out from the parotid completely and left as loose attachments to the allograft specimen. Lengthening of all branches (up to 20 mm) was attained just by dissection and mobilization of the parotid gland. Full face transplantation with en bloc facial nerve dissection was technically feasible and follows principles of targeted nerve reinnervation. It allows to select the level of facial nerve section to the temporofacial and cervicofacial divisions or final branches, avoiding section at the level of the main trunk, reducing the likelihood of occurrence of synkinesias. This technique implies an anterograde dissection from the trunk, which may be easier to perform in some circumstances than a retrograde dissection after finding the distal thin and fragile branches, medial to the parotid gland. It gives various neurotization possibilities (Fig. 1): direct division to division or branch to branch neurorrhaphy; crossdivision neurotization; division to proximal branches coaptation; or division to distal branches with interpositional grafts (e.g., thoracodorsal, great auricular). It also excludes the parotid gland from the allograft (reduces bulk). To reduce time constraints, an elective surgery 3 months before the transplantation as performed by Cavadas et al. to identify and tag the recipient nerves, may be useful. The transparotideal approach can be a possibility only when indicated in each particular situation, depending on *Correspondence to: Ricardo Horta, M.D., Avenida Men eres, no 234, Bloco 2, 4 Frente Esquerdo, 4450-189, Matosinhos SulPorto, Portugal. E-mail: ricardojmhorta@gmail.com Received 12 March 2014; Accepted 26 March 2014 Published online 7 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22259

Multi-staged flap reconstruction for complex radiation thoracic ulcer.

INTRODUCTION Chest wall reconstruction due to previous radiation therapy can be challenging and complex, requiring a multidisciplinary approach. PRESENTATION OF CASE The authors present the case of a 84-year-old woman with a right chest wall radionecrosis ulcer, that was submitted to an ablative surgery resulting in a full-thickness defect of 224 cm2, firstly reconstructed with a pedicled omental flap. Due to partial flap necrosis, other debridements and chest wall multi-staged flap reconstruction were performed. DISCUSSION This case highlights that the reconstructive choice should be individualized and dependent on patient and local factors. The authors advise that surgical team should work closely and be well versed in chest wall reconstruction with a variety of pedicled flaps, when a complication occurs. CONCLUSION A multi-staged flap reconstruction could be a salvage procedure for the coverage of complex, great and complicated chest wall defects due to previous radiation therapy.