Mamoplastia secundária com ressecção em monobloco e neoposicionamento do implante no espaço retropeitoral parcial / Secondary mammaplasty with monobloc resection and implant repositioning in the partial retropectoral pocket

Introdução: As cirurgias de aumento de mamas com implantes de silicone estão entre os procedimentos de cirurgia plástica mais realizados. O objetivo desse estudo é avaliar os casos de pacientes com prótese de silicone, submetidas à mamoplastia secundária, apresentando uma alternativa de abordagem com ressecção em monobloco do tecido mamário, cápsula fibrosa e prótese de silicone; e o neoposicionamento do implante em loja retromuscular peitoral parcial. Métodos: Foram analisados 24 casos de mamoplastia secundária com neoposicionamento da prótese, apresentando os motivos da indicação da cirurgia e o detalhamento da abordagem cirúrgica para maior facilidade na execução do procedimento e a obtenção de resultados mais satisfatórios. Resultados: Todos os casos operados apresentavam alterações no exame físico das mamas, como: ptose mamária contratura capsular, posicionamento inadequado dos implantes e assimetrias mamárias. Nos casos estudados, as próteses com revestimento de poliuretano e sua completa adesão à cápsula fibrosa permitiram a ressecção mais prática, mesmo com variáveis graus de contratura capsular. As cápsulas fibrosas que envolviam implantes texturizados tinham características mais finas e a instabilidade das próteses, pela presença de seroma residual ou pelo excessivo tamanho da loja da prótese, desencadearam maior dificuldade na ressecção. Conclusão: A realização de mamoplastia secundária com troca de prótese, empregando a ressecção em monobloco e neoposicionamento do implante no espaço retromuscular peitoral parcial com suturas do músculo ao tecido mamário, oferece uma alternativa para otimizar o procedimento, maior estabilidade do músculo até completa cicatrização e a formação de nova cápsula fibrosa.

Introduction: Breast augmentation with silicone implants is one of the most common plastic surgery procedures. The objective of this study was to evaluate patients with previous silicone implantations undergoing secondary mammaplasty, presenting an alternative approach with en block resection of breast tissue, fibrous capsule, and silicone implant, followed by implant repositioning in the partial retropectoral pocket. Methods: This study included 24 cases of secondary mammaplasty with implant repositioning. It presents the indications for surgery and details the surgical approach for easier procedures and more satisfactory results. Results: All the included cases presented breast changes on physical examination, such as breast ptosis, capsular contracture, improper implant position, and breast asymmetry. In the studied cases, the use of polyurethane-coated implants and their complete adherence to the fibrous capsule resulted in a more practical resection even with varying degrees of capsular contracture. Fibrous capsules of textured implants were thinner, and implant instability due to the presence of residual seroma or pockets bigger than necessary resulted in more difficult resection. Conclusion: Secondary mammaplasty with en bloc resection, along with implant replacement and repositioning in the partial retropectoral pocket with sutures involving muscle and breast tissue is an alternative to optimize the procedure, providing greater muscle stability until complete healing and new fibrous capsule formation.

Effect of breast reconstruction modality on the development of postmastectomy shoulder morbidity.

BACKGROUND: The aim of this study was to evaluate the impact of breast reconstruction modality on the incidence of shoulder morbidity. METHODS: Breast cancer patients who underwent immediate reconstructions using three modalities, namely, tissue expander-implant, latissimus dorsi (LD) pedicled flap, and deep inferior epigastric artery perforator (DIEP) flap, from 2008 to 2013 were examined. The cumulative incidence of shoulder morbidity was compared among the reconstruction modalities, and risk factor analysis was performed using multivariable analysis. RESULTS: A total of 430 reconstructions (223 expander-implant, 44 LD flap, and 163 DIEP flap) in 420 patients were analyzed in this study. Shoulder morbidity developed in 95 patients (22.1%) and was most common in the LD group (43.2%) followed by the expander-implant (23.8%) and the DIEP (14.1%) groups over a mean follow-up of 52 (range: 24-120) months. The multivariable analysis showed that the expander-implant (odds ratio (OR) 2.15, p = 0.010) and the LD flap (OR 6.27, p < 0001) were significant risk factors for shoulder morbidity, compared to the DIEP flap. Old age (p = 0.041), presence of tumor-positive lymph nodes (p = 0.014), and receiving neoadjuvant chemotherapy (p = 0.002) were independent risk factors for the development of shoulder morbidity. Early rehabilitation within 2 postoperative-months reduced the risk of sustained shoulder morbidity. CONCLUSION: The choice of reconstruction modality might affect the development of postmastectomy shoulder morbidity. Understanding the risk factors for shoulder morbidity would help to improve the informed consent process and assist surgeons in the early diagnosis and initiation of rehabilitation therapy to prevent chronic shoulder dysfunction after breast reconstruction.

Reconstrução mamária em decúbito único lateral com retalho miocutâneo do músculo grande dorsal e implante de silicone: sistematização e série de casos / Breast reconstruction with latissimus dorsi myocutaneous flap and silicone implant in the single lateral decubitus position: systematization and case series

Introdução: O câncer de mama é afecção de grande relevância para a saúde pública, sendo que seu tratamento cirúrgico e a reconstrução mamária evoluíram bastante ao longo do tempo. A utilização do retalho miocutâneo do grande dorsal (RMGD) com implante mamário de silicone apresenta-se como um verdadeiro cavalo de batalha ao cirurgião plástico em função de sua confiabilidade anatômica e segurança. Realizar esta cirurgia em decúbito único lateral torna o procedimento mais breve e mantém os resultados da técnica convencional. O objetivo do estudo é apresentar a sistematização desta cirurgia em uma série de casos. Método: Estudo retrospectivo realizado por análise de prontuários e documentação fotográfica de 29 pacientes operadas pelo autor e submetidas à reconstrução mamária com RMGD e implante de silicone em decúbito único lateral. Resultados: Houve um caso de extrusão do implante de silicone por seroma e infecção no sítio receptor (3,5%). Uma paciente cursou com seroma no dorso (3,5%). Um caso de necrose parcial da ilha de pele do retalho (3,5%) e dois casos de sofrimento do envelope cutâneo da mastectomia (7,0%). Uma paciente necessitou retirada do implante de silicone por extensa recidiva local (3,5%). Um caso de contratura capsular Baker III após radioterapia adjuvante (3,5%). Quatro pacientes tiveram suas cicatrizes revisadas (14%). Três pacientes tiveram limitação de movimentos (10,5%). Os resultados mostraram-se compatíveis com os apresentados para a técnica convencional na literatura vigente. Conclusão: A sistematização desta técnica dispensa mudança de decúbito e torna o procedimento mais breve, mantendo sua segurança e confiabilidade.

Introduction: Breast cancer is an important public health condition, and its surgical treatment and the subsequent breast reconstruction has evolved significantly over time. The use of the latissimus dorsi myocutaneous flap (LDMF) with silicone breast implants is a mainstay of plastic surgeons due to the anatomical reliability and safety. Performing this surgery in the single lateral decubitus position makes the procedure shorter and maintains the results of the conventional technique. The objective of this study was to present a systematization of this surgery from a series of cases. Method: Retrospective study using medical records and photographic documentation of 29 patients operated on by the author and submitted to breast reconstruction with a LDMF and silicone implant in a lateral decubitus position. Results: Silicone implant extrusion due to seroma and infection at the receptor site was noted in one patient (3.5%). One patient had a seroma on the back (3.5%); there was one patient with partial necrosis of the skin island of the flap (3.5%), and two patients with mastectomy skin envelope (7.0%). One patient required removal of the silicone implant due to extensive local recurrence (3.5%) while another patient showed Baker III capsular contracture after adjuvant radiotherapy (3.5%). Four patients had scar review (14%), and three patients showed limitation of movement (10.5%). The results were comparable to those reported for the conventional technique. Conclusion: The systematization of this technique requires no change of the decubitus position and makes the procedure shorter, while maintaining safety and reliability.

Fibromatose agressiva (tumor desmoide) associada ao implante mamário: revisão da literatura e apresentação de três novos casos / Aggressive fibromatosis (desmoid tumor) associated with breast implant: literature review and presentation of three new cases

INTRODUÇÃO: As fibromatoses consistem na proliferação de tecido fibroso, na forma de faixas ou nódulos, associadas às fáscias e aponeuroses. Sua variedade agressiva, denominada previamente tumor desmoide, se comporta de forma semelhante a uma neoplasia maligna, com destruição local de tecidos, sem, entretanto, originar metástases. MÉTODOS: Fez-se revisão da literatura de1979 a janeiro de 2017. Dados de três pacientes, operados entre maio de 2010 e agosto de 2015, foram revistos, com proservação até março de 2017. Observaram-se idade, características do implante, via de introdução do mesmo, tempo decorrido entre o implante e o aparecimento da fibromatose, tratamento cirúrgico instituído, acompanhamento clínico e resultados. RESULTADOS: Foram encontrados 24 trabalhos na literatura disponível, versando sobre fibromatose agressiva da parede torácica associada ao implante mamário de silicone, nos quais foram relatados 34 casos. São apresentados três casos de fibromatose agressiva associados ao implante mamário de silicone. Os casos foram tratados com sucesso por ressecção alargada da parede torácica, incluindo pele, musculatura, costelas, fáscia endotorácica e pleura parietal. A reconstrução foi bem-sucedida, realizada com tela aloplástica (Prolene & reg;) recoberta por retalho muscular em dois casos e retalho cutâneo local em um caso. CONCLUSÃO: A associação de fibromatose agressiva e implante mamário é rara. O tratamento deve consistir em cirurgia alargada, removendo-se o implante e toda a área da cápsula adjacente, em conjunto com parte da mama, costelas subjacentes, musculatura intercostal, fáscia endotorácica e pleura parietal. A reconstrução deve ser feita com tela aloplástica associada a retalho muscular ou retalho tegumentar local.

INTRODUCTION: Fibromatoses consists of the proliferation of fibrous tissue, in the form of bands or nodules, associated with fasciae and aponeuroses. The aggressive variety, previously denominated desmoid tumor, behaves similarly to malignant neoplasm, with local destruction of tissues, without, however, producing metastases. METHODS: A literature review was carried out from 1979 to January 2017. Data from three patients, operated between May 2010 and August 2015, were reviewed. Age, implant characteristics, route of introduction, time elapsed between implantation and fibromatosis, surgical treatment, clinical follow-up and results were observed. RESULTS: Twenty-four papers were found in the literature reporting aggressive fibromatosis of the chest wall associated with silicone breast implant. In these studies, 34 cases were reported. Three new cases of aggressive fibromatosis associated with silicone breast implant are now presented. These cases were successfully treated by extensive resection of the chest wall, including skin, musculature, ribs, endothoracic fascia, and parietal pleura. The reconstruction was successful, performed with alloplastic mesh (Prolene & reg;) covered by muscular flap in two cases and local skin flap in one case. CONCLUSION: The association of aggressive fibromatosis and breast implant is rare. The treatment should consist of extensive surgery, removing the breast implant and the entire area of the capsule around it, part of breast, together with the underlying ribs, intercostal muscles, endothoracic fascia and parietal pleura. The reconstruction should be made with an alloplastic mesh, covered by muscular flaps or local skin flap.

Mamoplastia/mastopexia com implante: técnica Lockpocket / Mammoplasty/mastopexy using implants: the Lockpocket technique

Introdução: A mamoplastia foi o procedimento em cirurgia plástica mais realizado no Brasil, ficando em segundo lugar no mundo, logo atrás dos Estados Unidos. Existem diversas técnicas para correção de ptose das mamas associado a aumento do volume com implantes mamários. O objetivo é descrever uma variação técnica de mamoplastia com prótese, isolando o implante em um bolsão fechado de tecido fascioglandular (Lockpocket). Métodos: Realizado um estudo prospectivo entre junho de 2013 e junho de 2016 totalizando 43 pacientes que foram submetidos à mamoplastia de aumento com prótese de silicone, isolado do meio externo por um bolsão fechado de tecido fascioglandular, e ressecção de tecido dermoglandular excedente para correção de ptose mamária, sendo realizada análise estatística. Resultados: Das 43 pacientes, a maioria (22 pacientes) apresentaram ptose grau II, segundo a classificação de Regnault. Os volumes de tecido glandular retirado e volume das prótese introduzidos foram semelhantes, sendo observado um total de sete complicações: deiscência parcial (n = 4), assimetria discreta (n = 2) e ptose residual em um caso. Conclusão: A mamoplastia de aumento com correção de ptose mamária - técnica Lockpocket - é uma boa opção, permitindo a escolha prévia do volume do implante utilizado, isolando-o em uma loja totalmente fechada de tecido fascioglandular, e exérese exata de tecido mamário.

Introduction: Mammoplasty is the most commonly performed plastic surgery procedure in Brazil, which is second only to the United States in terms of the number of mammoplasties performed. Several techniques based on increasing volume using breast implants are used to correct breast ptosis. We aimed to describe a technical variation of implant mammoplasty: isolation of the implant in a closed pocket of fascioglandular tissue (Lockpocket). Methods: This prospective study was carried out between June 2013 and June 2016. Forty-three patients underwent (1) augmentation mammoplasty using a silicone implant that was isolated from the external environment by a closed pocket of fascioglandular tissue, and (2) resection of excess dermoglandular tissue to correct mammary ptosis. Were subsequently analyzed statistically. Results: Of the 43 patients, the majority (22 patients) presented grade II ptosis according to the Regnault classification. The volume of glandular tissue removed was similar to the volume of the prosthesis introduced. A total of seven complications were observed: partial dehiscence (n = 4), discrete asymmetry (n = 2), and residual ptosis (n = 1). Conclusion: Augmentation mammoplasty with correction of mammary ptosis (the Lockpocket technique) is a good option because it allows the surgeon to choose in advance the volume of the implant to be used. The method also isolates the implant in a totally closed plane of fascioglandular tissue, and involves the precise removal of breast tissue.

Mycobacteriosis in patients with breast implants: a case review from the Ivo Pitanguy Institute / Micobacteriose em implantes mamários: revisão da casuística do Instituto Ivo Pitanguy

INTRODUCTION: Reports of infections caused by rapidly growing mycobacteria during plastic surgery have increased in recent years despite improvements in techniques of asepsis/antisepsis and antibiotic prophylaxis. Infections occurring after the insertion of breast implants are a cause of patient morbidity and a significant problem for the surgeon. METHODS: Breast implant surgery cases complicated by mycobacterial infections at the Infirmary ward 38th of the Santa Casa da Misericórdia, Rio de Janeiro were retrospectively reviewed. A description of the current guidelines for the prevention and treatment of mycobacteriosis is included. Laboratory confirmed and clinically suspected cases were included in this study. RESULTS: Of 483 augmentation mammaplasty cases, 3 patients developed mycobacterial infections in the last 3 years. In 2 patients, there was a suspicion of infection that was not confirmed by laboratory data. CONCLUSIONS: Prophylaxis is fundamental for reducing the incidence of mycobacteriosis during plastic surgery procedures. However, the identification, diagnosis, and treatment of mycobacterial diseases are important to minimize the morbidity of this type of infection.

INTRODUÇÃO: Nos últimos anos, foram crescentes os registros de infecções por micobactéria de crescimento rápido em cirurgia plástica, mesmo com a melhoria dos métodos de assepsia/ antissepsia e da antibioticoprofilaxia. A infecção após inclusão de implantes mamários causa grande morbidade às pacientes e transtorno ao cirurgião. MÉTODO: Estudo retrospectivo dos casos de infecção por micobactéria de crescimento rápido da 38ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro, após inclusão de implantes mamários, em que são apresentadas propostas de prevenção e tratamento da micobacteriose. Foram incluídos os casos confirmados laboratorialmente e os clinicamente suspeitos. RESULTADOS: Até o presente momento foram confirmados 3 casos de infecção por micobactéria, num total de 483 mamaplastia de aumento no decorrer de 3 anos. Em 2 pacientes, houve suspeita de infecção, porém sem confirmação laboratorial. CONCLUSÕES: A profilaxia é o pilar fundamental para a redução do impacto da micobacteriose em procedimentos de cirurgia plástica. Entretanto, saber identificar, diagnosticar e tratar corretamente a micobacteriose é de suma importância para minimizar a morbidade da paciente.

Fisioterapia en la reconstrucción mamaria posmastectomía: a propósito de un caso / Physical therapy in postmastectomy mammary reconstruction: with regard to a case

La reconstrucción mamaria posmastectomía, se considera actualmente parte integral del tratamiento multidisciplinario del carcinoma de mama, pues contribuye a restaurar de una forma objetiva, la imagen corporal de la paciente y revierte las secuelas psicológicas negativas, ocasionadas por la mastectomía. Las técnicas reconstructivas de la mama consisten en la aplicación de una serie de técnicas quirúrgicas con posibilidades de aplicación selectiva o adyuvantes, en función de las necesidades y posibilidades de la paciente. En este trabajo se destaca las modalidades de intervención del fisioterapeuta, en las distintas etapas del proceso quirúrgico, como miembro del equipo multidisciplinar de la Asociación de Mujeres Andaluzas Mastectomizadas (AMAMA). Así mismo, se establece una valoración de los resultados mediante el Cuestionario de Calidad de Vida para Cáncer de Mama

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A two-year prospective analysis of trunk function in TRAM breast reconstructions.

BACKGROUND: Functional outcomes in breast reconstruction are important quality measures and aid in patients' decision-making process. To address the concerns of abdominal wall morbidity with transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions, the authors prospectively evaluated the long-term effects of postmastectomy breast reconstruction on trunk function using objective clinical measures. METHODS: Using a multicenter prospective cohort design, they recruited women undergoing first-time immediate or delayed breast reconstructions from 12 centers and 23 plastic surgeons. Trunk functional data, objectively measured with Cybex machines, for patients with an expander/implant, pedicle TRAM, and free TRAM reconstructions were evaluated preoperatively and at postoperative years 1 and 2 in 183 patients. The effects of procedure type, timing, and laterality on trunk peak torque and range of motion were analyzed using linear regression. RESULTS: At 2 years postoperatively, procedure type, timing, and laterality did not significantly affect the range of motion for trunk flexion and extension. Peak torque for trunk flexion at year 2 was significantly decreased in patients with TRAM compared with expander/implant reconstructions (p < 0.05), with a 6 to 19 percent decrease in flexion peak torque. However, no significant difference in flexion peak torque was found between patients with free and pedicle TRAM reconstructions. CONCLUSIONS: The authors found that (1) breast cancer patients with TRAM reconstructions had a less than 20 percent long-term deficit in trunk flexion peak torque and (2) there was no significant difference in trunk function between patients receiving pedicle and free TRAM reconstructions.

Reconstruction of breast using a laser lithographic model: a case report.

A three-dimensional laser scanner enables the measurement of surface data from objects with no contact, both quickly and in three dimensions. A 40-year-old woman with a right breast cancer had undergone a simple mastectomy. The surface of the chest was then measured with the non-contact three-dimensional laser scanner. Using the mirror image of data obtained by the same system, a mask-like model of the breast was made using laser lithography technology. This model was used for reconstruction of the breast after mastectomy. It was effective in determining the position and form of the breast which was to be repaired.