Reconstrucción mamaria con TRAM bipediculado. Variantes utilizadas y resultados obtenidos / Breast reconstruction with bipedicled TRAM. Variants used and results obtained

La reconstrucción mamaria utilizando el colgajo TRAM (transverse rectus abdominis muscle) bipediculado es un procedimiento poco frecuente aunque en ciertas ocasiones es de gran utilidad. Las indicaciones principales están descriptas para los casos que se requieren volúmenes de tejidos de mayor cantidad que la reconstrucción mamaria convencional, antecedentes de irradiación de grandes zonas de la pared del tórax y, en ciertas ocasiones, en reconstrucciones mamarias autólogas bilaterales. La presente publicación revisa el uso de 12 colgajos TRAM bipediculados en nuestra institución, las variantes que hemos usado y los resultados obtenidos. También se detallan elementos anatómicos de interés técnico con el objeto de reducir las complicaciones.

Breast reconstruction using the bipedicle TRAM (transverse rectus abdominis muscle) flap is a rare procedure, although it is sometimes very useful. The main indications are described for cases that require larger tissue volumes than conventional breast reconstruction, a history of irradiation of large areas of the chest wall, and on certain occasions, in bilateral autologous breast reconstructions. This publication reviews the use of 12 bipedicle TRAM flaps in our institution, the variants that we have used, and the results obtained. Anatomical elements of technical interest are also detailed to reduce complications.

Reconstrucción mamaria inmediata prepectoral / Immediate prepectoral breast reconstruction

Introducción. La reconstrucción mamaria inmediata con implantes prepectorales permite realizar la mastectomía oncológica con un resultado estético en un solo tiempo quirúrgico y con menor morbilidad del área dadora. Las indicaciones son precisas, en directa relación con las condiciones de la mastectomía. Material y métodos. Se presentan 83 pacientes en el período comprendido entre febrero de 2020 a febrero de 2022 con mastectomías uni- y bilaterales, con conservación del complejo areola-pezón los cuales fueron injertados en 7 casos. La incisión en surco submamario se realizó en 60 casos, radiada externa en 8 casos, vertical en 8 casos y 7 casos con patrón de reducción en el Instituto Oncológico Alexander Fleming. Los criterios de exclusión que utilizamos son tumores mamarios a menos de 1 cm del complejo areola pezón y tumores localmente avanzados. Resultados. En total se realizaron 98 mastectomías, de las cuales 86 fueron terapéuticas y 12 profilácticas por mutaciones genéticas. La extracción de ganglios se realizó por una incisión axilar, excepto en el patrón de reducción donde se realizó a través de la incisión de la mastectomía. En 42 pacientes se utilizaron implantes anatómicos y en 56 casos redondos texturizados. El seguimiento de las pacientes fue a 25 meses. Conclusión. La reconstrucción mamaria prepectoral lleva a la reconstrucción de la mama en el mismo espacio con una baja morbilidad y resultado natural. Las indicaciones para esta técnica deben ser muy precisas para lograr obtener los resultados deseados. En nuestra experiencia, la reconstrucción mamaria inmediata con implante directo es una técnica segura y reproducible, con excelentes resultados en pacientes en las que está debidamente indicada la técnica, con una baja tasa de complicaciones y disminución en el tiempo de tratamiento y de recuperación.

Introduction. Immediate breast reconstruction with pre pectoral implants allows to perform oncologic mastectomy with an aesthetic result in a single surgical time and with less morbidity of the donor area. The indications are precise and directly related to the conditions of the mastectomy. Material and methods. We present 83 patients in the period from February 2020 to February 2022 with uni and bilateral mastectomies, with preservation of the nipple-areola complex which was grafted in 7 cases. The incision in the submammary sulcus was performed in 60 cases, external radiated in 8 cases, vertical in 8 cases and 7 with reduction pattern at the Alexander Fleming Oncological Institute. The exclusion criteria we used are breast tumors less than 1 cm from the nipple areola complex and locally advanced tumors. Results. A total of 98 mastectomies were performed, of which 86 were therapeutic and 12 prophylactic for genetic mutations. Node removal was performed through an axillary incision, except in the reduction pattern where it was performed through the mastectomy incision. Anatomical implants were used in 42 patients and textured round implants in 56 cases. The follow-up of the patients was 25 months. Conclusion. Pre pectoral breast reconstruction leads to reconstruction of the breast in the same space with low morbidity and natural results. The indications for this technique must be very precise to achieve the desired results. In our experience, immediate breast reconstruction with direct implant is a safe and reproductible technique, with excellent results in patients in whom the technique is properly indicated, with a low rate of complications and decrease in treatment and recovery time.

Percepções e expectativas de homens trans acerca dos relacionamentos afetivo-sexuais pós-transição / Trans men's perceptions and expectations of post-transition affective-sexual relationships / Percepciones y expectativas de los hombres trans sobre las relaciones afectivo-sexuales después de la transición

As identidades transmasculinas ganharam visibilidade social e acadêmica no Brasil a partir de 2010, contudo, as questões subjetivas dos homens trans ainda são pouco debatidas, em particular temas associados aos relacionamentos afetivos na experiência desses sujeitos. Este estudo qualitativo tem por objetivo identificar as percepções e expectativas dos homens trans acerca dos relacionamentos afetivo-sexuais no cenário pós-transição de gênero. Participaram da pesquisa 15 homens transexuais hormonizados, com idades entre 20 e 41 anos. A coleta de dados foi realizada por meio de entrevista semiestruturada nas modalidades presencial e on-line. Empregou-se análise temática reflexiva, que resultou em dois temas analíticos. Os resultados apontam que os homens trans, ao contrário de suas expectativas iniciais, percebem que tiveram menos oportunidades de relacionamentos afetivo-sexuais depois de sua transição de gênero. Os participantes atribuem essa dificuldade especialmente ao fato de não terem se submetido à cirurgia de redesignação sexual. O desconforto é acentuado por sua materialidade corpórea divergente da cisnormatividade, sistema regulador que associa pessoas pertencentes ao gênero masculino à presença de um pênis. Outra fonte de desconforto é o repúdio social, que alimenta a abjeção, exotização e fetichização dos corpos transmasculinos. Também são descritas as especificidades do relacionamento dos homens trans com mulheres cisgênero, heterossexuais e lésbicas. Os resultados evidenciam que a fixação persistente no genital, como referente e signo determinante do gênero e da sexualidade, modula e regula a busca e o encontro de parceira(o) íntima(o).(AU)

Transmasculine identities have gained social and academic visibility in Brazil since 2010, but subjective issues, especially those associated with affective relationships, are still little discussed. This qualitative study sought to identify trans men's perceptions and expectations regarding post-transition affective-sexual relationships. A total of 15 transsexual men undergoing hormone therapy, aged between 20 and 41 years, participated in the research. Data were collected by means of in-person and online semi-structured interviews and analysed using reflexive thematic analysis, which resulted in two analytical themes. Results show that trans men, differently from their initial expectations, perceive fewer opportunities for affective-sexual relationships after their gender transition. The participants attribute this difficulty, especially, to the fact that they have not undergone sexual reassignment surgery. Discomfort isaccentuated by their bodily materiality diverging from cisnormativity, the regulatory system that associates people belonging to the male gender with the presence of a penis. Another source of discomfort is the social repudiation, which reinforces the abjection, exoticization, and fetishization of transmasculine bodies. The specifics of trans men's relationships with cisgender, heterosexual, and lesbian women are also described. The results show that the persistent fixation on the genital, as a referent and determinant sign of gender and sexuality, modulates and regulates the search for and encounter of intimate partners.(AU)

Las identidades transmasculinas han ganado visibilidad social y académica en Brasil desde 2010, sin embargo, las cuestiones subjetivas de los hombres trans son aún poco discutidas, en particular las cuestiones asociadas a las relaciones afectivas en la experiencia de estos sujetos. Este estudio cualitativo tiene como objetivo identificar las percepciones y expectativas de los hombres trans sobre las relaciones afectivo-sexuales después de la transición de género. Participaron en la investigación 15 hombres transexuales hormonados, de edades comprendidas entre los 20 y los 41 años. La recopilación de datos se realizó mediante una entrevista semiestructurada en las modalidades presencial y en línea. Se realizó un análisis temático reflexivo, que dio como resultado dos temas analíticos. Los resultados muestran que los hombres trans, al contrario de sus expectativas iniciales, perciben que han tenido menos oportunidades de relaciones afectivo-sexuales después de su transición de género. Los participantes atribuyen esta dificultad especialmente al hecho de no haberse sometido a cirugía de reasignación sexual. La incomodidad se acentúa por su materialidad corpórea divergente de la cisnormatividad, un sistema normativo según el cual las personas pertenecientes al género masculino deben tener pene. Otra fuente de malestar es el repudio social, que alimenta la abyección, la exotización y la fetichización de los cuerpos transmasculinos. También se describen las especificidades de las relaciones de los hombres trans con las mujeres heterosexuales, cisgénero y lesbianas. Los resultados muestran que la persistente fijación en los genitales, como referente y signo determinante del género y la sexualidad, modula y regula la búsqueda y el encuentro de parejas íntimas.(AU)

Feasibility study of immediate breast reconstruction with fusion fascia combined with implants / 中华肿瘤杂志

Objective: To investigate the oncologic and surgical safety of the fused fascia method for immediate breast reconstruction with implants. Methods: The clinical data of 343 patients with immediate breast reconstruction with implants in Tianjin Medical University Cancer Hospital from 2014-2017 were retrospectively analyzed to compare the 5-year local recurrence-free survival, 5-year disease-free survival and 5-year overall survival of patients with breast reconstruction by fusion fascia and other methods, and to analyze the complication incidences of implant removal between different implant groups. Results: Of the 343 patients with breast reconstruction, 95 were in the fused fascia group (fascia group) and 248 were in the non-fascia group (25 in the bovine pericardial patch group and 223 in the muscle flap group). At a median follow-up of 49 months, the differences in 5-year local recurrence-free survival (90.1% and 94.9%, respectively), 5-year disease-free survival (89.2% and 87.6%, respectively), and 5-year overall survival (95.2% and 95.1%, respectively) between patients in the fascial and non-fascial groups were not statistically significant (P>0.05). The complication incidence of implant removal was 24.0% (6/25) in the patch group and 2.1% (2/95) and 2.2% (5/223) in the fascia and muscle flap groups, respectively. Conclusion: Immediate breast reconstruction with fused fascial combined with implant is safe and feasible, less invasive than muscle flaps, more economical and with fewer complications than patches.

Quality of breast reconstruction service at a university hospital as assessed by the patients

Purpose: To evaluate the quality of breast reconstruction service at a university hospital, as assessed by the patients. Methods: This cross-sectional study enrolled adult women who underwent immediate or delayed breast reconstruction by any technique performed at a university hospital between 1 and 24 months before the assessment. The Brazilian version of the Health Service Quality Scale (HSQS) was self-applied to the participants. The HSQS produces percentage scores, which are expressed in values ranging from 0 to 10 for each domain of the scale, and into an overall percentage quality score. The management team was asked to establish a minimum satisfactory score for the breast reconstruction service. Results: Ninety patients were included. The management team considered 8.00 the minimum satisfactory score for the service. The overall percentage score was 93.3%. Only one domain, 'Support,' had an average score lower than that considered satisfactory (7.22 ± 3.0); while the others had higher scores. The domain that scored highest was 'Qualification' (9.94 ± 0.3), followed by 'Result' (9.86 ± 0.4). There was a positive correlation between 'type of oncologic surgery' and 'intentions of loyalty to the service' (ρ = 0.272; p = 0.009) and a negative correlation between 'education' and 'quality of the environment' (ρ = ­0.218; p = 0.039). The higher the patient's level of education, the higher the score attributed to 'relationship' (ρ = 0.261; p = 0.013) and the lower the score of 'aesthetics and functionality' (ρ = ­0.237; p = 0.024). Conclusion: The quality of the breast reconstruction service was considered satisfactory, but there is a demand for structural improvements, better interpersonal relationships, and a stronger support network for patients.

Uso de injertos capsulares autólogos periprotésicos en mamoplastías estéticas / Used of peri prosthetics autologous capsular graft in aesthetic mammoplasty

INTRODUCCIÓN Y OBJETIVO: presentamos nuestra experiencia con el uso de injertos de capsulas autólogas peri protésicas en pacientes que evolucionaron con ptósis mamaria importante, que tenían implantes siliconados envejecidos implantados en plano subglandular y que además presentaban contractura capsular unilateral Baker III o IV y donde fue necesario cambiar de plano de implantación a sub muscular prolongando la cobertura protésica de musculo pectoral con capsulas autólogas a manera de injer-to simple para cubrir totalmente al implante siliconado, obtenidas de la mama sana contra lateral tipo I a II de Baker, seguido de la mamoplastia de elevación. El objetivo del trabajo es utilizar y reaprovechar tejidos autólogos sanos a cero costos. MATERIAL Y MÉTODO: registramos 12 pacientes operadas, de quienes se obtuvo un segmento de capsulas peri protési-cas autólogas resecadas en bloque de la mama sana contra lateral incluyendo el implante en su interior a través de disección digital simple o con electrobisturí, de prótesis implantadas en plano sub glandular. No se reglo el tamaño de la capsula en únicos moldes, sino se utilizó el tamaño requerido para la cobertura del implante, las cuales fueron injertadas uniendo el segmento medial y el distal del músculo pectoral, cubriendo y protegiendo el nuevo implante que fue implantado en plano submuscular. Posteriormente se ejecutó la mamoplastia de elevación. RESULTADOS: de las 12 pacientes, 1 evoluciono con shock anafiláctico por automedicación de una quinolona fluorada y presento edema generalizado, seroma moderado al 5to día de post operación lo que generó una revisión quirúrgica de urgencia, observando necrosis del injerto capsular motivo por el que fueron movidas. Y una paciente presento un aumento significativo y proyección del polo inferior mayor de la mama en relación con su homóloga seguramente porque se injerto un segmento mayor tamaño de capsula y no quedo a tensión suficiente en esa región, pero no se presentó ninguna reacción local inflamatoria excepto una forma asimétrica de esa mama. El resto es decir las otras 10 pacientes evolucionaron satisfactoriamente. CONCLUSIÓN: el uso de capsulas peri protésicas autólogas, son una alternativa técnica para tener en cuenta en mamoplastias de elevación cuando se opta por cambio de plano de implantación de las prótesis, cuando no se cuentan con matrices acelulares de alto costo, siendo un tejido con alta probabilidad de integración a cero costos y cuando es necesario cubrir al implante.

INTRODUCTION AND OBJECTIVE: we present our experience of using periprosthetic autologous capsule grafts in patients who evolved with significant breast ptosis, had aged silicone implants placed in the sub glandular plane, had unilateral capsular contracture Baker III or IV and had the need to change the plane of implantation to sub muscle plane to prolong the prosthetic coverage with autologous grafted capsules obtained from the healthy contralateral breast Baker type I to II, followed by lifting mammoplasty. The objective of this project is to use and take advantage of healthy autologous tissues at no cost. MATERIALS AND METHODS: we registered 12 operated patients from whom we resected, from the healthy contralateral breast, segments of autologous periprosthetic capsules, including the implant inside through simple digital dissection or with an electro scalpel of the prostheses located in the sub-glandular plane. The size of the capsule was not regulated in single mold, instead the required size to cover the implant was used and was grafted joining the medial and distal segment of the pectoral muscle, wrapping and protecting the new implant located at the submuscular plane. Subsequently, mammoplasty elevation was performed. RESULTS: of the 12 patients, 1 evolved, on the 5th day of surgery, with an anaphylactic shock due to self medication with a fluorinated quinolone tablet presenting a generalized edema, intense seroma, leading to an emergency surgical review and observing necrosis on the capsular graft, which had to be removed. Another patient presented a significant increase and projection of the lower pole of the breast in relation to its counterpart, surely because a larger segment of the capsule was grafted and was not tensioned enough in that region. No local inflammatory reaction was observed except for an asymmetric shape of that breast. The ten remaining patients evolved satisfactorily. CONCLUSIONS: the use of autologous periprosthetic capsules is an alternative technique to be considered for mammoplasty elevation when deciding to change the prostheses implantation plane, since it is a tissue with a high probability of integration at no cost, especially when high cost acellular matrices are not available and when it is necessary to cover the new implant.

Aesthetic assessment of breast reconstruction in the eyes of plastic surgeons versus nonplastic physicians

SUMMARY OBJECTIVE: The aim of this study was to evaluate the perception of the aesthetic result of breast reconstruction surgery from the perspective of plastic surgeons compared with physicians who are not specialists in plastic surgery. METHODS: Twenty patients who underwent breast reconstruction after mastectomy had their aesthetic results evaluated by 16 plastic surgeons and 16 nonplastic physicians, yielding a total of 620 ratings (320 ratings from plastic surgeons and 320 ratings from other specialists). For all analyses, the level of rejection adopted for the null hypothesis was 5% (p-value <0.05). RESULTS: Significant differences were observed between the two groups. On average, medical professionals who specialized in plastic surgery always obtained higher scores than other physicians. However, no significant differences were found in the assessment of the aesthetic outcome of breast reconstruction according to the sex of the rating medical professional for any of the assessments considered in this study. A strong positive linear correlation between the time since training in the medical specialty of plastic surgery (r=0.750, p=0.001) and the mean aesthetic outcome score was observed in this study. CONCLUSION: Plastic surgeons assessed the aesthetic results of breast reconstruction more positively than nonplastic physicians.

Clinical effects of free latissimus dorsi myocutaneous flap combined with artificial dermis and split-thickness skin graft in the treatment of degloving injury in lower extremity / 中华烧伤杂志

Objective: To observe the clinical effects of free latissimus dorsi myocutaneous flap combined with artificial dermis and split-thickness skin graft in the treatment of degloving injury in lower limbs. Methods: A retrospective observational study was conducted. From December 2017 to December 2020, 8 patients with large skin and soft tissue defect caused by degloving injury in lower extremity were admitted to Ningbo No.6 Hospital, including 5 males and 3 females, aged from 39 to 75 years, with wound area of 25 cm×12 cm-61 cm×34 cm. The free latissimus dorsi myocutaneous flap with latissimus dorsi muscle in the width of 12-15 cm and flap area of 20 cm×8 cm-32 cm×8 cm was used to repair the skin and soft tissue defect of bone/tendon exposure site or functional area. The other defect was repaired with bilayer artificial dermis, and the flap donor site was sutured directly. After the artificial dermis was completely vascularized, the split-thickness skin graft from thigh was excised and extended at a ratio of 1∶2 to 1∶4 and then transplanted to repair the residual wound, and the donor site of skin graft was treated by dressing change. The survival of latissimus dorsi myocutaneous flap, artificial dermis, and split-thickness skin graft after operation was observed, the interval time between artificial dermis transplantation and split-thickness skin graft transplantation was recorded, and the healing of donor site was observed. The appearance and function of operative area were followed up. At the last outpatient follow-up, the sensory recovery of flap was evaluated by British Medical Research Council evaluation criteria, the flap function was evaluated by the comprehensive evaluation standard of flap in Operative Hand Surgery, the scar of lower limb skin graft area and thigh skin donor area was evaluated by Vancouver scar scale, and the patient's satisfaction with the curative effects was asked. Results: The latissimus dorsi myocutaneous flap survived in 6 patients, while the distal tip of latissimus dorsi myocutaneous flap was partially necrotic in 2 patient and was repaired by skin grafting after resection at split-thickness skin grafting. The artificial dermis survived in all 8 patients after transplantation. The split-thickness skin graft survived in 7 patients, while partial necrosis of the split-thickness skin graft occurred in one patient and was repaired by skin grafting again. The interval time between artificial dermis transplantation and split-thickness skin graft transplantation was 15-26 (20±5) d. The donor site of latissimus dorsi myocutaneous flap healed with linear scar after operation, and the thigh skin graft donor site healed with scar after operation. The patients were followed up for 6-18 (12.5±2.3) months. The color and elasticity of the flap were similar to those of the surrounding skin tissue, and the lower limb joint activity returned to normal. There was no increase in linear scar at the back donor site or obvious hypertrophic scar at the thigh donor site. At the last outpatient follow-up, the sensation of the flap recovered to grade S2 or S3; 3 cases were excellent, 4 cases were good, and 1 case was fair in flap function; the Vancouver scar scale score of lower limb skin graft area was 4-7 (5.2±0.9), and the Vancouver scar scale score of thigh skin donor area was 1-5 (3.4±0.8). The patients were fairly satisfied with the curative effects. Conclusions: In repairing the large skin and soft tissue defect from degloving injury in lower extremity, to cover the exposed bone/tendon or functional area with latissimus dorsi myocutaneous flap and the residual wound with artificial dermis and extended split-thickness skin graft is accompanied by harvest of small autologous flap and skin graft, good recovery effect of functional area after surgery, and good quality of healing in skin grafted area.

Factors influencing decisions on contralateral symmetrisation procedure among patients with breast cancer

INTRODUCTION@#Oncoplastic breast-conserving surgery (OBCS) can cause breast asymmetry. Although contralateral breast surgery to achieve symmetry was offered to these patients, the uptake of symmetrisation was variable. We aimed to determine the factors that deter patients with breast cancer undergoing OBCS from opting for symmetrisation.@*METHODS@#All patients with breast cancer who underwent OBCS of displacement type with no symmetrisation were prospectively surveyed to explore the social, economic, psychological and physical reasons against symmetrisation.@*RESULTS@#A total of 28 patients participated in a survey administered at a mean 21.6 (range 2-47) months after OBCS. A combination of factors, such as worry and desire to treat breast cancer first (67.9%), not being overly concerned about breast cosmesis (57.1%) and fear of pain from additional operation (28.6%), deterred patients from immediate symmetrisation. Worry and desire to treat breast cancer first was the most important single factor for 50% of the patients. Reasons for no delayed symmetrisation included not being overly concerned about breast cosmesis (70.4%), fear of breast cancer recurrence (48.1%) and being happy with current breast cosmesis (33.3%), with the former two reasons equally cited as the single most important deterrent by 30% of patients each.@*CONCLUSION@#A combination of factors may deter patients from symmetrisation. The most significant factors deterring OBCS among patients were worry and desire to treat breast cancer first for immediate symmetrisation, and not being overly concerned about breast cosmesis and fear of breast cancer recurrence for delayed symmetrisation. Reassuring these patients may increase their uptake of symmetrisation, thereby improving patient cosmesis and satisfaction.

Incision selection for nipple-sparing mastectomy with implant-based breast reconstruction / 中华外科杂志

Objective: To examine the outcome of different incision selection for nipple-sparing mastectomy (NSM) with implant-based breast reconstruction (IBBR). Methods: Ninety-Two cases accepted NSM and IBBR from totally 1 002 cases of breast cancer admitted to Beijing Tongren Hospital Affiliated to Capital Medical University from June 2013 to December 2020 were analyzed retrospectively. All the patients were female, aging (42.0±7.5) years (range: 27 to 64 years). There were 12 patients at stage 0, 47 patients at stage Ⅰ, 17 patients at stage Ⅱ, and 16 patients at stage Ⅲ. The patients were divided in three groups by the incision: peri-areolar group (n=23), inframammary group (n=33) and lateral group (n=36). The age, tumor size, lymph node status, hormone receptor, operation method and postoperative complications were followed-up of three groups and compared by one-way ANOVA, χ2 test or Fisher's exact test and expansion to comparied. Results: There was no significant difference in operation time ((180.7±54.0) minutes vs. (176.9±48.1) minutes vs. (194.6±37.5) minutes, F=1.401, P=0.252), postoperative drainage volume ((497.5±226.0) ml vs. (495.4±182.5) ml vs. (519.8±172.0) ml, F=0.167, P=0.846) and drainage time ((8.8±3.8) days vs. (8.0±2.5) days vs. (8.3±2.9) days, F=0.542, P=0.583) among the peri-areolar, inframammary, and lateral groups. The cumulative postoperative complications were relatively higher in the peri-areola group (26.1%(6/23) vs. 0 vs.8.3%(3/36), χ²=9.675, P=0.004). All female patients were followed up for (49.0±25.6) months(range: 12 to 112 months). Breast cancer related death rate was 2.2% (2/92), local recurrence was 1.1% (1/92), regional recurrence was 4.3% (4/92), distant metastasis was 6.5% (6/92), and the disease-free survival rate was 88.0% (81/92). Conclusion: The surgical effects of the peri-areolar, inframammary and lateral incisions for NSM and IBBR are approximate, the total complication rate of the peri-areolar incision is slightly higher.

Application of acellular bovine pericardium patch in implant based immediate breast reconstruction / 中华外科杂志

Objective: To examine the clinical effect of acellular bovine pericardium patch in implant based immediate breast reconstruction. Methods: The clinicopathological information of 141 breast cancer patients, who admitted to Department of Breast Reconstruction and Oncoplastic Surgery, Tianjin Medical University Cancer Hospital, underwent immediate mammoplasty with implants combined with acellular bovine pericardium patches were analyzed from June 2016 to October 2019. All patients were female, with the age of (38.8±8.5) years (range: 13 to 60 years). The body mass index was (21.9±2.5) kg/m2 (range: 16.0 to 32.3 kg/m2). There were 39 cases of duct carcinoma in situ, 46 cases of stage Ⅰ, 40 cases of stage Ⅱ and 16 cases of stage Ⅲ. All patients received nipple-areola-sparing mastectomy or skin-sparing mastectomy with sentinel lymph node biopsy or axillary lymph node dissection, and prosthesis implantation with sub-pectoralis combined with breast patch. The correlation of clinicopathological characters and complications was assessed by t test, χ2 test, Fisher's exact probability method and Logistic regression. Pre-and post-operative aesthetic, quality of life scores were recorded. Results: The operation time (M(IQR)) was 3.6(1.5) hours (range: 3.0 to 6.5 hours). The early postoperative complication rate was 22.0% (31/141), prosthesis removal was the main postoperative complication, accounting for 64.5% (20/31) of the total complications, of which 15 cases occurred in the first 30 patients. The follow-up time was 28(8) months (range: 20 to 53 months), The most frequent long-term complications were capsular contracture and implant displacement, with the incidence of 11.2% (14/125) and 10.4% (13/125), respectively. Multivariate analysis showed that prosthesis volume ≥300 ml (OR=8.173, 95%CI: 1.302 to 51.315, P=0.021) and peri-areolar incision (OR=7.809, 95%CI: 2.162 to 28.211, P<0.01) were independent relative factors for the occurrence of short-term postoperative local complications. After 2 years of operation, the score of breast appearance satisfaction was 71.7±15.5, postoperative effect satisfaction was 90.4±9.5, psychological satisfaction was 90.7±17.1, sexual satisfaction was 70.1±25.1. The immediate postoperative satisfaction rate at discharge was 95.4% (134/141), and 17.6% (22/125) of patients had the intention to received revision surgery. Conclusions: Prosthesis volume ≥300 ml and peri-areolar incision were independent realtive factors for short-term local complications after bovine pericardium patch combined with prosthesis implantation in the immediate breast reconstruction. After completing the learning curve, the postoperative complications of the procedure could be decreased.

Linguistic validation and psychometric testing of the Filipino version of the Breast-Q Reconstruction Module

Background@#The introduction of new therapeutic options and advances in the field of breast surgery has put the importance of patient satisfaction and quality of life at par with long-term survival. These essential parameters help physicians and patients decide on the appropriate approach when managing both malignant and benign breast conditions. They have also been used to measure the outcome and success of breast surgery, whether cosmetic or reconstructive, using patients’ perspectives. To date, there is no available questionnaire that is translated, culturally adapted, and validated among Filipino patients to specifically assess their quality of life (QOL) and satisfaction after breast reconstructive surgery.@*Objective@#This study aims to translate a previously validated, internationally accepted, patient-reported outcome (PRO) instrument, the Breast-Q Reconstruction Module, and validate its use among Filipino patients. @*Methods@#This is a tool validation study of a Filipino translation of the Breast-Q Reconstruction Module for the preoperative and postoperative settings. Forward and backward translations were done for the two questionnaires and were finalized after assessment of accuracy and feasibility by language professionals and bilingual patients. We recruited patients referred to the Division of Plastic Surgery of a tertiary government hospital for breast reconstruction to answer the final questionnaires, with 15 re-taking each questionnaire after two weeks. Psychometric properties of the questionnaires, including internal consistency, construct validity, test-retest reliability, and acceptability, were then evaluated. @*Results@#We included 30 patients in this validation study. The internal consistencies of the translated Preoperative and Postoperative Breast-Q Reconstruction Module had high Cronbach’s α coefficients (range: 0.92–0.98 and 0.97–1.00, respectively). Internal consistency was also supported by high mean item-total correlations in all dimensions. The two questionnaires had good test-retest reliability as supported by high intraclass correlation (range for Preoperative: 0.995–1.000 and for Postoperative: 0.95–1.00). Construct validity was supported by inter-scale correlations with low to moderate Spearman’s coefficients (range for Preoperative: 0.22–0.34 and for Postoperative: 0.11–0.27). The sexual well-being dimension had the lowest inter-scale Spearman’s coefficient in both questionnaires and is the only dimension with low acceptability. @*Conclusion@#The translated Preoperative and Postoperative Breast-Q Reconstruction Module has high internal consistency, test-retest reliability, acceptability, and low to moderate construct validity among Filipino patients after breast reconstruction surgery. However, the “Satisfaction with the Nipple Reconstruction” subscale is pending since there were no qualified respondents in the sample population. In considering how their relatively conservative culture influences the way Filipino patients tend to view the importance of sexual satisfaction as it relates to their medical management, the sexual well-being domain is suggested to be interpreted separately when assessing the patient’s overall satisfaction with breast reconstruction procedure.

Surgical management of nipple areola complex in central breast cancer / 中华肿瘤杂志

Objective: To explore the surgical strategy of nipple areola complex (NAC) management in central breast cancer. Methods: A retrospective analysis was conducted on 164 cases of central breast cancer who underwent surgery treatment from December 2017 to December 2020 in the Breast Center of Beijing Tongren Hospital, Capital Medical University. Prior to the surgery, the tumor-nipple distance (TND) and the maximum diameter of the tumor were measured by magnetic resonance imaging (MRI). The presence of nipple invagination, nipple discharge, and nipple ulceration (including nipple Paget's disease) were recorded accordingly. NAC was preserved in patients with TND≥0.5 cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative intraoperative frozen pathological margin. All patients with signs of NAC involvement, TND<0.5 cm or positive NAC basal resection margin confirmed by intraoperative frozen pathology underwent NAC removal. χ(2) test or Fisher exact test was used to analyze the influencing factors. Results: Of the 164 cases of central breast cancer, 73 cases underwent breast-conserving surgery, 43 cases underwent nipple-areola complex sparing mastectomy (NSM), 34 cases underwent total mastectomy, and the remaining 14 cases underwent skin sparing mastectomy (SSM). Among the 58 cases of NAC resection (including 34 cases of total mastectomy, 14 cases of SSM, and 10 cases of breast-conserving surgery), 25 cases were confirmed tumor involving NAC (total mastectomy in 12 cases, SSM in 9 cases, and breast-conserving surgery in 4 cases). The related factors of NAC involvement included TND (P=0.040) and nipple invagination (P=0.031). There were no correlations between tumor size (P=0.519), lymph node metastasis (P=0.847), bloody nipple discharge (P=0.742) and NAC involvement. During the follow-up period of 12 to 48 months, there was 1 case of local recurrence and 3 cases of distant metastasis. Conclusions: For central breast cancer, data suggest that patients with TND≥0.5cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative NAC margin in intraoperative frozen pathology should be treated with NAC preservation surgery, whereas for those with TND<0.5 cm or accompanied by signs of NAC invasion, NAC should be removed. In addition, nipple reconstruction can be selected to further improve the postoperative appearance of patients with central breast cancer.

Mamoplastia de reducción oncoplástica en paciente con cancer de seno y macromastia: reporte de caso / Oncoplastic reduction mammoplasty in patients with breast cancer and macromasty: review of the literature and case report

Resumen El cáncer de mama es la patología maligna más frecuente en la población femenina, su tratamiento ha evolucionado progresivamente en dirección a la conservación del seno a través del desarrollo de la cirugía Oncoplástica de seno, que consiste en manejo conservador con mastectomía parcial y reconstrucción inmediata. Las pacientes que presentan de manera concomitante cáncer de seno y macromastia, representan un reto mayor en el tratamiento debido a la dificultad de generar simetría con el seno contralateral y que además presentan sintomatología específica relacionada con la macromastia que disminuye su calidad de vida. El objetivo de este artículo es reportar el caso de una paciente que se maneja de manera exitosa y simultánea el cáncer de seno y macromastia, mediante cirugía oncoplástica de seno derecho y en el mismo tiempo quirúrgico, mamoplastia de reducción bilateral, obteniendo adecuado control oncológico y mejoría significativa en su calidad de vida medida por cuestionario BREAST-Q. MÉD.UIS.2021;34(3): 93-101.

Summary Breast cancer is the most frequent malignant pathology in the female population. Its treatment has progressively evolved in the direction of breast conservation through the development of oncoplastic breast surgery, which consists of conservative management with partial mastectomy and immediate reconstruction. Patients who present breast cancer concomitantly with macromastia, represent a greater challenge in treatment due to the difficulty of generating symmetry with the contralateral breast; they also present specific symptoms related to macromastia that diminishes their quality of life. The objective of this article, is to report the case of a patient with breast cancer and macromastia, who is successfully and simultaneously managed with oncoplastic surgery of the right breast and bilateral reduction mammoplasty, obtaining adequate oncological control and significant improvement in her quality of life measured by BREAST-Q questionnaire. MÉD.UIS.2021;34(3): 93-101.

Reconstrucción mamaria diferida con expansor-implante y matriz dérmica autóloga. Una alternativa terapéutica aplicable en tejidos no irradiados. / Delayed breast reconstruction with expander-implant and autologous dermal matrix. An alternative applicable therapeutic in non irradiated tissues.

INTRODUCCIÓN Y OBJETIVO: la reconstrucción mamaria diferida o post mastectomía tiene una importancia trascendental en la vida de la mujer así también como parte del tratamiento integral y multidisciplinario del cáncer mamario, ya que tamaña agresión impacta en la autoestima y funcionalidad social en aquellas mujeres que por algún motivo no fueron sometidas a reconstrucción inmediata. El objetivo es describir a través de la técnica expansor-implante, matriz dérmica autóloga, injerto de grasa y reconstrucción del complejo areola pezón con tejidos autólogos, los resultados alcanzados en pacientes mastectomizadas y reconstruidas de manera diferida. MATERIAL Y MÉTODO: es un estudio retrospectivo, longitudinal, observacional y descriptivo de una serie pequeña de 5 pacientes privadas mastectomizadas no irradiadas que no fueron sometidas por algún motivo a reconstrucción inmediata en otros centros médicos y que acudieron al consultorio privado derivadas por médicos cirujanos mastólogos-oncólogos para ser sometidas en forma diferida a reconstrucción con expansor implante en una secuencia técnica de 3 tiempos quirúrgicos en un periodo comprendido entre abril del 2015 y octubre del 2020. RESULTADOS: la reconstrucción diferida habitualmente la realizamos con expansor-implante y optamos por la utilización de colgajos autólogos siempre cuando se hubiera irradiado la mama enferma. En 4 de 5 pacientes realizamos la reconstrucción del complejo areola pezón (CAP), 3 pacientes fueron de reconstrucción unilateral y 2 de bilateral, en 2 mujeres ocupamos prótesis de doble lumen tipo anatómicos y en 3 mujeres expansor con puerto a distancia, utilizando en 2 pacientes, prótesis de forma redonda y en un implante expansor anatómico. Presentamos un caso de deflación del implante a los 3 años post reconstrucción no reportamos casos de necrosis grasa, ni cuadros infecciosos, no presentamos casos de contractura capsular y reportamos un solo caso de seroma tardío de origen traumático en una paciente de reconstrucción unilateral a los 7 meses post implante. CONCLUSIÓN: la técnica reconstructiva diferida de expansor-implante, matriz dérmica autóloga, y tejidos propios para la reconstrucción del CAP, representan una buena opción terapéutica de baja morbilidad en pacientes que no han sido sometidas a irradiación post mastectomía. Creemos que a nivel nacional aún faltan políticas en salud y conductas que beneficien a las mujeres con cáncer mamario en el camino largo del tratamiento integral de la enfermedad hasta la reconstrucción mamaria y su re inserción con funcionalidad social, laboral y emocional, para unificar criterios y protocolos entre servicios públicos, privados, ministerio de salud, secretarias regionales de salud y sociedades científicas de Mastologia y Cirugía Plástica apoyando a los pocos equipos en reconstrucción mamaria , optimizando protocolos médicos que beneficien a las pacientes enfermos.

INTRODUCTION AND OBJECTIVE: delayed breast reconstruction or post mastectomy has a transcendental importance in women ́s life as well as part of the comprehensive and multidisciplinary treatment of breast cancer. Such aggression impacts on self-esteem and social functionality in women who for some reason were not undergoing immediate reconstruction. The objective is to describe the results achieved in mastectomized patients, through the expander-implant technique, autologous dermal matrix, fat graft and reconstruction of the nipple areola complex (NAC) with autologous tissues MATERIAL AND METHOD: it is a retrospective, longitudinal, observational and descriptive study of a small group of 5 non-irradiated mastectomized private patients who were not subjected to an immediate reconstruction at other medical centers. They came to the private practice referred by other mastologists-oncologists medical surgeons to be submitted to a delayed breast reconstruction with expander prosthesis in a 3 surgical times technique between April 2015 and October 2018. RESULTS: the delayed breast reconstruction is usually performed with expander prosthesis and for those injured breasts that had been irradiated, we use autologous flaps. In 4 out of 5 patients we performed the reconstruction of the NAC, 3 were submitted to unilateral reconstruction and 2 were bilateral, 2 women had anatomical double lumen prosthesis, 3 had expander implant with remote port at which 2 were round and one anatomical. We presented only one case of deflation 3 years later after reconstruction. We didn ́t report cases of fat necrosis nor infectious symptoms. We didn ́t have any case of capsular contracture but only a single case of late seroma after 7 months' post implant in a patient with unilateral reconstruction due to a traumatic incident. CONCLUSION: the delayed breast reconstructive technique with expander-implant, uses of autologous dermal matrix or own tissues for reconstructing the NAC, represents a good therapeutic option of low morbidity to patients who have not undergone post-mastectomy irradiation. We briefly believe that at a National level there is a lack of health policies and therapeutic behaviors that could benefit women with breast cancer on this long path from a complete treatment of this disease to breast reconstruction and its social, labor and emotional reintegration, to unify criteria and protocols between public services, private services, ministry of health, regional secretaries of health and scientific societies such as Mastology and Plastic Surgery to support the few teams in breast reconstruction and optimize medical protocols to benefits the sick patient.

Lipoinyección mamaria con fines estéticos: resultados a largo plazo con una sesión / Breast lipoinjection for aesthetic purposes: long-term results with one session

Resumen Antecedentes: La cirugía de aumento mamario con lipoinjerto se ha incrementado debido a que evita usar prótesis. Es utilizado para aumentos moderados con fines estéticos, no retarda el diagnóstico de cáncer ni aumenta el riesgo de sufrirlo. Objetivo: Revisar nuestra experiencia en aumento mamario estético con lipoinjerto, en una sesión y con seguimiento superior a un año. Materiales y Método: Se diseñó una cohorte prospectiva de mujeres. Se excluyeron aquellas con alteraciones congénitas, mesenquimopatías y fumadoras. La lipoinyección se efectuó con principios de Coleman. Para la medición del volumen mamario preoperatorio se utilizó la aplicación Breast-V. Volumen de aumento, tasa de retención y tasa de aumento fueron calculados. Resultados: 73 pacientes fueron lipoinjertadas, 35 superaron seguimiento a un año. Volumen mamario inicial fue 219,5 ± 44,1 cc. Volumen de aumento fue 99,9 ± 29,8 cc, tasa de retención grasa injertada 41,4%, tasa de aumento del volumen mamario 48,1%. 41 pacientes presentaron imágenes posoperatorias: quistes 15 pacientes (36,6%); necrosis grasa 2 pacientes (4,9%); macrocalcificaciones 8 pacientes (19,5%); microcalcificaciones 1 paciente (2,5%), cuya biopsia fue negativa para malignidad. Discusión: El lipoinjerto mamario es un procedimiento seguro, con resultados adecuados cuando se realiza en una sesión y por el mismo cirujano, siguiendo principios de Coleman. El aumento porcentual es el índice más significativo para evaluar su éxito. Conclusiones: Lipoinyección mamaria en una sesión es una técnica segura que logra aumento moderado del volumen mamario. Es útil para aumentos moderados o corrección de asimetrías leves. No hay evidencia de que interfiera con el diagnóstico precoz del cáncer de mama.

Background: Lipograft breast augmentation has increased due to avoidance of prosthetics. It is used for moderate increases for aesthetic purposes, it does not delay the diagnosis of cancer or increase the risk of suffering it. Aim: To review our experience in cosmetic breast augmentation with lipograft, in one session and with a follow-up of more than one year. Materials and Method: A prospective cohort of women was designed. Those with congenital alterations, mesenchymopathies and smokers were excluded. Lipoinjection was carried out with Coleman's principies. The Breast-V application was used to measure preoperative breast volume. Volume of increase, retention rate and rate of increase were calculated. Results: 73 patients were lipografted, 35 had a one-year follow-up. Initial breast volume was 219.5 ± 44.1 cc. Volume increase was 99.9 ± 29.8 cc, grafted fat retention rate 41.4%, breast volume increase rate 48.1%. 41 patients presented postoperative images: cysts 15 patients (36.6%); fat necrosis 2 patients (4.9%); macrocalcifiations 8 patients (19.5%); microcalcifiations 1 patient (2.5%), whose biopsy was negative for malignancy. Discussion: The mammary lipograft is a safe procedure, with adequate results when performed in one session and by the same surgeon, following Coleman principles. The percentage increase is the most significant index to evalúate your success. Conclusions: Breast lipoinjection in one session is a safe technique that achieves a moderate increase in breast volume. It is useful for moderate magnification or correction of slight asymmetries. There is no evidence that it interferes with the early diagnosis of breast cancer.

Mastoplastia de reducción con la técnica de pedículo inferior en pacientes con hipertrofia mamaria / Reduction mastoplasty by means of the inferior pedicle technique in patients with mammary hypertrophy

Introducción: La mastoplastia de reducción mediante la técnica de pedículo inferior es una de las intervenciones quirúrgicas estéticas más empleadas para corregir la hipertrofia mamaria. Objetivo: Caracterizar a las pacientes con hipertrofia mamaria, a quienes se les practicó mastoplastia de reducción con la técnica de pedículo inferior. Métodos: Se realizó un estudio descriptivo, observacional, transversal y retrospectivo de 185 pacientes entre 10 y 59 años de edad, con diagnóstico de hipertrofia mamaria, atendidas en el Servicio de Cirugía Plástica y Caumatología del Hospital General Docente Octavio de la Concepción y de la Pedraja del municipio de Baracoa, a las cuales se les practicó mastoplastia de reducción por técnica de pedículo inferior, desde enero de 2004 hasta diciembre 2020. Resultados: En la serie predominaron las féminas entre 30-39 años de edad (42,8 %), los resultados estéticos evaluados de buenos (90,3 %), las complicaciones escasas (20,0 %), con primacía de la necrosis de la piel en el punto inferior de unión de los colgajos (7,0 %) y las pacientes satisfechas con el proceder (93,5 %). El tejido glandular resecado varió entre menos de 300 g y más de 1 200, según el grado de hipertrofia. Conclusiones: La técnica de reducción mamaria a pedículo inferior es versátil, segura y aplicable a todo tipo de hipertrofia, con una tasa de complicaciones baja; asimismo ofrece resultados estéticos favorables y alto grado de satisfacción.

Introduction: The reduction mastoplasty by means of the inferior pedicle technique is one of the most used cosmetic surgical interventions to correct mammary hypertrophy. Objective: To characterize the patients with mammary hypertrophy to whom reduction mastoplasty was practiced with the inferior pedicle technique. Methods: A descriptive, observational, cross-sectional and retrospective study of 185 patients between 10 and 59 years, with diagnosis of mammary hypertrophy was carried out. They were assisted in the Plastic Surgery and Caumatology Service of Octavio de la Concepción y de la Pedraja Teaching General Hospital from the municipality of Baracoa, to whom reduction mastoplasty by inferior pedicle technique was practiced, from January, 2004 to December, 2020. Results: In the series there was a prevalence of the females between 30-39 years (42.8 %), the cosmetic results with good evaluation (90.3 %), few complications (20.0 %), with primacy of the skin necrosis in the inferior space of the flap union (7.0 %) and the patients satisfied with the procedure (93.5 %). The dried up glandular tissue varied in less than 300 grams and more than 1 200, according to the degree of hypertrophy. Conclusions: The mammary reduction technique to inferior pedicle is versatile, safe and applicable to all types of hypertrophy, with a low rate of complications; also it offers favorable cosmetic results and high degree of satisfaction.

Exposed Implant after Immediate Breast Reconstruction - Presentation and Analysis of a Clinical Management Protocol / Exposição de prótese após reconstrução imediata da mama: apresentação e análise de protocolo clínico

Abstract Objective Infection and exposure of the implant are some of the most common and concerning complications after implant-based breast reconstruction. Currently, there is no consensus on the management of these complications. The aim of the present study was to review our cases and to present a clinical protocol. Methods We conducted a retrospective review of consecutive patients submitted to implant-based breast reconstruction between 2014 and 2016. All patients were managed according to a specific and structured protocol. Results Implant exposure occurred in 33 out of 277 (11.9%) implant-based reconstructions. Among these, two patients had history of radiotherapy and had their implant removed; Delayed reconstruction with a myocutaneous flap was performed in both cases. Signs of severe local infection were observed in 12 patients, and another 5 presented with extensive tissue necrosis, and they were all submitted to implant removal; of them, 8 underwent reconstruction with a tissue expander, and 2, with a myocutaneous flap. The remaining 14 patients had no signs of severe infection, previous irradiation or extensive tissue necrosis, and were submitted to primary suture as an attempt to salvage the implant. Of these, 8 cases (57.1%) managed to keep the Conclusion Our clinical protocol is based on three key points: history of radiotherapy, severe infection, and extensive tissue necrosis. It is a practical and potentially-reproducible method of managing one of the most common complications of implant-based breast reconstruction.

Resumo Objectivo Infecção e exposição da prótese são algumas das complicações mais comuns e preocupantes após reconstrução da mama com implantes. Atualmente, ainda não há consenso quanto ao manejo destas complicações. O objetivo deste estudo foi o de revisar os casos da nossa instituição e apresentar um protocolo clínico. Métodos Realizou-se uma revisão retrospectiva de todos os casos consecutivos submetidos a reconstrução mamária imediata com prótese entre 2014 e 2016. Todos os casos foram conduzidos de acordo com um protocolo específico e estruturado. Resultados A exposição do implante ocorreu em 33 de 227 reconstruções (11,9%). Dentre estas, duas pacientes tinham histórico de radioterapia, e foram submetidas a remoção da prótese e posterior reconstrução com retalho miocutâneo. Sinais de infecção local grave foram observados em 12 pacientes, e, em 5, necrose extensa de tecido, e todas foram submetidas a remoção dos implantes; destas, 8 foram recons truídas com expansor, e 2, com retalho miocutâneo. As 14 pacientes remanecentes não haviam sido submetidas previamente à radioterapia, não tinham sinais de infecção, nem necrose extensa; portanto, foram submetidas a sutura primária em uma tentativa de salvar a prótese. Dessas, 8 pacientes (57,1%) conseguiram manter os implantes originais. Conclusão Nosso protocolo clínico é baseado em três pontos principais: histórico de radioterapia, infecção grave, e necrose extensa de tecido. Ele constitui um método prático e potencialmente reprodutível de manejo de uma das complicações mais comuns da reconstrução mamária com implantes.