Thoracic Wall Reconstruction: Surgical Planning in Extended Malignant Resections.

INTRODUCTION: The reconstruction of defects in thoracic wall remains a challenge for plastic surgeons. Advances in surgical treatment of illnesses of thoracic wall have been fostering the treatment of lesions within more advanced levels. Consequently, larger and more complex defects are generated, demanding soft tissue covering and framework repair. OBJECTIVE: The aim of this study was to report the experience in chest wall reconstruction and demographics of a tertiary cancer center. METHODS: All patients submitted to thoracic wall reconstruction by the plastic surgery department from January 2012 to May 2018 in a tertiary cancer center were evaluated. RESULTS: Thirty-two patients have undergone thoracic wall reconstruction. The majority of patients in our series were submitted to surgical treatment of locally advanced breast cancer (84.3%). The most common defect location was the right anterolateral region (65.6%). The latissimus dorsi musculocutaneous flap was the most used in thoracic wall reconstructions. Three cases of thoracectomy with rib resection were reconstructed with methylmethacrylate and polypropylene surgical mesh associated with musculocutaneous flap. Four patients presented major complications, and 12 patients (37.5%) presented minor complications. There were no deaths related to procedures or instability of thoracic wall. Twenty-two patients presented progression of the disease, and 16 died due to the primary pathology. CONCLUSIONS: Extended resection of the chest wall is associated in most cases with advanced disease, especially advanced breast cancer. Despite poor prognosis associated to locally advanced disease, it is imperative to perform chest wall reconstruction and allow the patient to continue adjuvant therapy (radiotherapy or chemotherapy) and improve quality of life.

Reconstruction options for locally advanced breast cancer cases and their impact on the quality of life

Introduction: Radical surgical procedures are indicated for part of the patients with locally advanced breast cancer (LABC). The improvement in the use of myocutaneous flaps allowed surgeons to perform extensive resections, a procedure that can be traumatic for women, leading to several biopsychosocial complications in a shortened survival. Objectives: This study aimed at understanding the effects of surgical treatment on the quality of survival of patients with guarded and unchanging prognosis. Methodology: The project was designed in two stages: review of medical records with a sample of 27 cases and face-to-face interviews with the administration of questionnaires in a sample of five cases among the remaining patients who underwent LABC surgery at Hospital Erasto Gaertner in Curitiba (PR). Results: On average, the answers obtained with the World Health Organization Quality of Life (WHOQOL-BREF) instrument were "regular" for physical, psychological, and environmental domains and "good" for the social relations domain. In the 12-item short-form survey (SF-12), the means were 45,125 points for the mental component and 40,875 points for the physical one. These values show the impact of advanced disease, hygienic surgery, and chest reconstruction on the quality of life of the patients, reflecting the biopsychosocial damage caused by LABC. Conclusion: The data reveal that LABC treatment is aggressive, but in patients with survival, the surgical treatment associated with chest reconstruction had surprisingly positive results in relation to quality of life.

Breast Auto-augmentation (Mastopexy and Lipofilling): An Option for Quitting Breast Implants.

BACKGROUND: Breast augmentation with implants is one of the most commonly performed plastic surgical procedures, but has potential complications-asymmetry, implant displacement, rippling and wrinkling, capsular contracture, late seromas, and benign and malignant tumors-and potential financial costs. The auto-augmentation procedure, with mastopexy and lipofilling, is a second option to offer to patients who do not desire to continue with breast implants in secondary procedures. OBJECTIVE: This study aimed to present a series of patients who intended to quit having breast implants, and they went to an auto-augmentation procedure, with mastopexy and lipofilling. METHOD: The study included patients who underwent a mastopexy plus lipofilling following breast implant removal. The indications for the surgical procedure were: desire of not having breast implants anymore and smaller breasts, capsular contracture, and implant rupture. The surgical procedure is detailed. Fat grafting and mastopexy are done immediately at the time of explantation. RESULTS: A total of 26 patients (mean age 59.1 years) underwent mastopexy plus lipofilling following breast implant removal. The mean follow-up was 18 months. The mean amount of lipofilling was 258 cc. No major complications were observed, no infection, dehiscence, hematoma, or seroma. One patient had an oil cyst which was handled with resection. CONCLUSION: The auto-augmentation procedure after implant removal with local flaps and lipofilling is the better option for patients in whom breast implants are not an option anymore. Complication and reoperation rates are low and patient satisfaction is good. LEVEL OF EVIDENCE IV: This 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 .

Retalho anterolateral da coxa reverso: uma opção de reconstrução para os membros inferiores / Reverse anterolateral thigh flap: a reconstruction option for the lower limbs

Introdução: A reconstrução cutânea e de tecidos moles na região ao redor do joelho é frequentemente desafiadora para o cirurgião plástico e tem como objetivo fornecer uma boa função articular do joelho com aparência estética aceitável. O planejamento cirúrgico requer considerar a técnica mais simples que leve ao fechamento da ferida, com mínima morbidade na área doadora. Há poucos relatos do uso do retalho anterolateral (ALT) reverso na literatura, em se tratando de defeitos na fossa poplítea, joelho e porção proximal da perna. O objetivo é descrever uma serie de casos de pacientes submetidos à reconstrução de ferida em fossa poplítea, joelho e terço superior da perna com retalho ALT reverso. Métodos: Quatro pacientes, dos quais 3 eram reconstruções de fossa poplítea e 1 reconstrução de joelho e terço proximal da perna. Todos submetidos à ressecção ampla da ferida/ tumor, dissecção do retalho ALT reverso, e transposição para o defeito. Resultados: Follow-up de 2 a 18 meses, evidenciando-se morbidade mínima para área doadora, com cobertura total do defeito e ótimo resultado funcional do membro afetado, com bom resultado estético. Apenas em um dos casos evidenciou-se sofrimento e necrose parcial (15%) do retalho devido a hematoma e compressão do pedículo, nos demais não foi evidenciado sofrimento dos retalhos, deiscência, seroma ou infecção. Conclusão: O retalho ALT da coxa reverso mostrou-se uma opção viável, apresentando bom resultado funcional e estético para a reconstrução cutânea e de tecidos moles na região de fossa poplítea, joelho e terço superior da perna.

Introduction: Cutaneous and soft tissue reconstruction in the region around the knee is often challenging for the plastic surgeon and aimed at providing good knee joint function with acceptable aesthetic appearance. Surgical planning requires considering the simplest technique that leads to wound closure, with minimal morbidity in the donor area. The literature has reported only few cases of the use of the reverse anterolateral (ALT) flap for defects in the popliteal fossa, knee, and leg proximal portion. The objective is to describe a series of cases of patients who underwent reconstruction with a reverse ALT flap for wounds in the popliteal fossa, knee, and upper third of the leg. Methods: Among four patients, three received popliteal fossa reconstructions and one received knee and leg proximal third reconstructions. All the patients underwent wound/tumor extensive resection, dissection of the reverse ALT flap, and transposition to the defect. Results: During follow-up for 2 to 18 months, minimal morbidity was observed in the donor area, with a total coverage of the defect, optimal functional result of the affected limb, and good aesthetic result. Only one case had a partial necrosis (15%) of the flap due to hematoma and pedicle compression. In the other patients, no evidence of flap failure, dehiscence, seroma, or infection were found. Conclusion: The reverse ALT flap was a viable option, presenting good functional and aesthetic results for cutaneous and soft tissue reconstructions in the popliteal fossa, knee, and upper third of the leg.

Effect of cilostazol in experimental model of degloving injuries in rat limbs.

PURPOSE: To evaluate the effect of the cilostazol on the evolution of partially avulsed flaps, using experimental model of cutaneous degloving in rat limbs. METHODS: A controlled and randomized experimental study was carried out in which the blood flow and the percentage of flap necrosis were evaluated. We compared the study group, which received cilostazol, and the control group, which received enteral saline solution in the postoperative period. The blood flow in the flap was evaluated through Laser Doppler flowmetry, and a planimetry using the IMAGE J® software was employed for the calculation of the area of necrosis. RESULTS: Enteral administration of cilostazol was associated with a higher mean blood flow in all regions of the flap, with a statistically significant difference in the proximal and middle regions (p<0.001) and a lower percentage of necrotic area in the flap (p<0.001). CONCLUSION: Postoperative enteral administration of cilostazol increased blood flow and decreased the total area of necrosis of avulsed cutaneous flaps of rat limbs.

Effect of cilostazol in experimental model of degloving injuries in rat limbs

Abstract Purpose: To evaluate the effect of the cilostazol on the evolution of partially avulsed flaps, using experimental model of cutaneous degloving in rat limbs. Methods: A controlled and randomized experimental study was carried out in which the blood flow and the percentage of flap necrosis were evaluated. We compared the study group, which received cilostazol, and the control group, which received enteral saline solution in the postoperative period. The blood flow in the flap was evaluated through Laser Doppler flowmetry, and a planimetry using the IMAGE J® software was employed for the calculation of the area of necrosis. Results: Enteral administration of cilostazol was associated with a higher mean blood flow in all regions of the flap, with a statistically significant difference in the proximal and middle regions (p<0.001) and a lower percentage of necrotic area in the flap (p<0.001). Conclusion: Postoperative enteral administration of cilostazol increased blood flow and decreased the total area of necrosis of avulsed cutaneous flaps of rat limbs.

Incisão periareolar em zigue-zague para tratamento de ginecomastias / Periareolar zigzag incision as treatment for gynecomastia

Introdução: Ginecomastia é a hipertrofia e hiperplasia benigna da mama masculina. Representa a condição benigna mais frequente da mama masculina. O objetivo é avaliar os resultados estéticos, e satisfação dos pacientes submetidos a uma nova abordagem para o tratamento da ginecomastia, com incisão periareolar em zigue-zague. Métodos: Apresentamos uma casuística de 13 casos de ginecomastia tratados com a técnica periareolar em zigue-zague. Resultados: Todos os pacientes ficaram satisfeitos com a cicatriz camuflada na transição, naturalmente irregular, da pele periareolar com o complexo aréolo mamilar. Não houve complicações na série descrita. Conclusão: A abordagem descrita é uma excelente alternativa para o tratamento das ginecomatias. Proporciona um resultado estético satisfatório, é de fácil execução e tem a vantagem de não deixar estigmas na mama masculina operada.

Introduction: Gynecomastia is a benign hypertrophy and hyperplasia of the male mammary gland, and is considered the most frequent benign condition of the male breast. The objective is to evaluate aesthetic results and satisfaction of patients undergoing a new approach using a periareolar zigzag incision for the treatment of gynecomastia. Methods: We present 13 cases of male gynecomastia treated with a periareolar zigzag incision technique. Results: All patients were satisfied with the scar hidden in the transitional, naturally irregular periareolar skin of the nipple-areolar complex. No complications were observed in this patient series. Conclusion: This approach is an excellent, easy-to-perform surgical alternative for the treatment of gynecomastia, providing a satisfactory cosmetic result without the presence of a stigmatizing scar.

Influence of the Pectoralis Major Muscle Sling in Chest Wall-Based Flap Suspension After Vertical Mammaplasty: Ten-Year Follow-Up.

BACKGROUND: The pectoralis muscle sling has proven to be a suitable alternative technique for long-term results in breast parenchyma suspension. Although the pectoralis muscle sling has been subjectively observed to reduce the bottoming-out effect with a bipedicled muscle flap (muscular loop), there has not been a study to objectively or numerically prove it. OBJECTIVES: This study aimed to radiologically evaluate the influence of a pectoralis muscle sling in supporting the chest wall-based flap after a vertical breast-reduction technique. METHODS: Twenty-one female patients underwent a vertical breast reduction with the chest wall-based flap and were randomly divided into two subgroups. Ten patients were in subgroup (S), which consisted of patients with a muscle sling. Eleven patients without the muscle sling technique were assigned as a control group (C). Periodic radiological examinations were performed at 1, 3, 6, and 12 months and then at 10 years postoperatively to analyze the breast flap and any migration with respect to three titanium clips placed intraoperatively on the chest wall parenchyma flap. RESULTS: Patients in subgroup S had a significantly higher difference in migration of the chest wall-based flaps between the first day and 10 years postoperatively when compared with patients in subgroup C (P < .001), as shown by the distances measured between titanium clip locations. CONCLUSIONS: After 10 years of follow-up, there were changes in chest wall-based flap bottoming-out in patients in whom a pectoralis major muscle sling was utilized compared with those patients without it. Thus, a pectoralis major muscle sling seems to provide greater and longer-lasting support to the flap position on the patient's chest. LEVEL OF EVIDENCE: 2 Therapeutic.