Comparison of Outcomes in Immediate Implant-Based Breast Reconstruction: Acellular Dermal Matrix versus Inferior Dermal Flap.

Background Implant-based breast reconstruction has evolved tremendously in the last decades, mainly due to the development of new products and techniques that make the procedure safer and more reliable. The purpose of this study was to compare the outcomes in immediate one-stage breast reconstruction between acellular dermal matrix (ADM) and inferior dermal flap (IDF). Methods We conducted a retrospective comparative study of patients submitted to immediate breast reconstructions with an anatomical implant and ADM or IDF in a single center between 2016 and 2018. Outcomes evaluated included major complications, early complications, reinterventions, readmissions, and reconstruction failure. Simple descriptive statistics and univariate analysis were performed. Results A total of 118 breast reconstructions (85 patients) were included in the analysis. Patients in the IDF group had a higher body mass index (median = 27.0) than patients in the ADM group (median = 24). There were no statistically significant differences among both groups regarding immediate major complication, early complications, readmissions, and reinterventions. Conclusion There are no significant differences in complications between the ADM and IDF approach to immediate implant breast reconstruction. In patients with higher body mass index and large, ptotic breasts, we recommend an immediate implant reconstruction with IDF.

Impact of Body Mass Index, Age and Tobacco Use on the Outcomes of Immediate Breast Reconstruction with Implants and Acellular Dermal Matrix.

Background This study aimed to analyze the effect of body mass index (BMI), age, and tobacco use on alloplastic breast reconstruction. Methods We conducted a retrospective study of patients who submitted to immediate breast reconstructions with an anatomical implant and acellular dermal matrix in a single center between 2016 and 2018. Outcomes evaluated included immediate complications, early complications, reinterventions, readmissions, and reconstruction failure. Patients were divided into two groups concerning each potential risk factor (BMI < or ≥25; age < or ≥ 50 years; and smokers vs nonsmokers). Simple descriptive statistics and univariate analysis were performed. Results A total of 101 breast reconstructions (73 patients) were included in the analysis. The mean BMI was 24, and the mean age was 44.5 years old. Smokers accounted for 14 breast reconstructions (13.9%). The rate of early infections, mastectomy flap necrosis, and implant removal was significantly higher in overweight patients. The total volume of breast drainage was higher in the age ≥ 50 years group. Smoking did not alter the outcomes. Conclusions A BMI ≥ 25 is a risk factor for early infections and reconstructive failure. Age ≥ 50 years is associated with a higher volume of breast drainage but does not seem to impact the success of the reconstruction. Smoking does not appear to affect the outcomes significantly in this type of reconstruction. Surgeons should consider delaying the reconstruction or using autologous tissue when patients are overweight.

Giant chondrosarcoma of the chest wall: a rare surgical challenge.

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning-sparing key reconstructive options without compromising the tumor resection-allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Bilateral Lower Limb Salvage after Fourth-degree Burns: Subscapular Axis Free and Chimeric Flaps Effectiveness in Complex Reconstruction.

Microsurgery is usually required for reconstruction of complex lower limb defects, preserving otherwise unsalvageable injuries. Fourth-degree burns are severe traumatic injuries. A case of bilateral lower limb salvage through a resourceful use of subscapular axis free and chimeric flaps for acute burn reconstruction of extensive lower leg injuries is reported. A 48-year-old man sustained a 40% surface area flame burn, circumferential and full-thickness at the lower limbs. Debridement of fourth-degree burns of the anterior lower legs resulted in bone exposure of the left and right tibias, right medial malleolus, and Achilles tendon. A latissimus dorsi (LD) flap plus a chimeric subscapular axis free flap with 3 components (LD, serratus anterior (SA), and parascapular) were designed for reconstruction. LD insetting for left tibia coverage with anastomoses to anterior tibial vessels was performed. Right side flap insetting provided tibia coverage with LD; medial malleolus with SA; and Achilles tendon with parascapular flap. An anatomical variation required anastomoses to proximal (chimeric LD + SA) and distal (parascapular) ends of posterior tibial vessels because of an independent origin of the pedicles. At 10-months follow-up after intensive rehabilitation, the patient showed proper functional outcomes at daily-life and work activities with autonomous walking using a single crutch. This case highlights the importance of microsurgery and chimeric flaps for limb salvage in extreme situations. The authors review and discuss the surgical options, emphasizing specific considerations of microsurgical reconstruction in burn patients.

Warping Characteristics of Rib Allograft Cartilage.

When septal cartilage is lacking, commercially available costal cartilage allograft can be used. Such allografts have "off-the-shelf" accessibility, are available in multiple sizes, are aseptically processed to meet sterility, and are screened to minimize infectious risks. The purpose of this study was to evaluate the effect of donor age, storage temperature, and orientation of a bilayered construct on the degree of warping of a commercialized fresh frozen costal cartilage allograft in vitro over time. A total of 140 fresh frozen costal cartilage cadaveric specimens were separated into three donor age groups. These were allocated into three harvesting subgroups: group a, single pieces (cephalocaudal segments); group b, two laminated pieces of the same rib sutured together in anatomical position (laminated group); and group c, two pieces from the same rib reversed onto each other and sutured together (oppositional group). Photographs were examined and analyzed to determine the degree of cartilaginous warping. Decreased rates of warping were seen in commercially available, aseptically processed costal cartilage allografts procured from older cadavers. Warping was also decreased when oppositional suturing techniques were used as a way to address those intrinsic cartilage forces.

Abdominoplasty and Patient Safety: The Impact of Body Mass Index and Bariatric Surgery on Complications Profile.

BACKGROUND: Abdominoplasty is a frequent aesthetic surgical procedure. Despite its popularity, patient safety requires further attention because of an important risk of complications. Obesity and bariatric surgery are potential risk factors. This study evaluated the impact of body mass index (BMI) and bariatric surgery on complications profile. METHODS: A retrospective review of patients undergoing abdominoplasty over a 5-year period was conducted. Patient demographics, comorbidities, BMI, bariatric surgery, complications (minor and major) and drainage outcomes were evaluated. Univariate and multivariate logistic regression analyses were performed for risk assessment. RESULTS: The 191 study patients showed an overall complication rate of 32.5%, comprising minor (27.7%) and major complications (7.9%). Seroma was the most common complication (20.9%). Mean BMI was 27.1 kg/m2. Obesity was present in 14.1%, and bariatric surgery in 53.4%. Obese patients had significant higher rates of overall complications (74.1%, p < 0.001), minor complications (66.7%, p < 0.001), seroma (51.9%, p < 0.001) and drainage outputs (p < 0.001). Bariatric patients showed an increased time (p = 0.003) and volume of drainage (p < 0.001), without significant differences in complications. Obesity and preoperative BMI were the only independent risk factors for overall complications (OR 8.3; and OR 1.3; p < 0.001), minor complications (OR 7.4; and OR 1.3; p < 0.001) and seroma (OR 4.5; and OR 1.2; p = 0.002). Diabetes was an independent risk for major complications (OR 4.6; p = 0.047). CONCLUSION: Obesity has negatively impacted the profile and risk of complications, whereas bariatric surgery independently did not. Our study provides an accurate understanding of abdominoplasty complications, allowing better risk stratification, candidate selection refinement, morbidity reduction, fair patient counseling and overall improvement in patient safety. EBM LEVEL III: 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 .

Evidence-based Nasal Analysis for Rhinoplasty: The 10-7-5 Method.

Rhinoplasty is one of the top 5 aesthetic surgical procedures performed in plastic surgery. A methodical evaluation based on solid and up-to-date scientific evidence in different key areas of nasal and facial analysis is presented, the 10-7-5 method. This represents the most important preoperative step for a successful rhinoplasty. The 10-7-5 method for nasal analysis is a useful instrument that provides the rhinoplasty surgeon a deep comprehension of nasal anatomy. Understanding the nasal structures' main relationships and consequences of each surgical maneuver on nasal framework assists on establishing the appropriate surgical goals for each patient, both in primary and secondary rhinoplasty cases. This systematic analysis of patient's frontal, lateral, and basal nasal views provides a background to identify changes to ideal aesthetic proportions and how to surgically restore them while maintaining gender and ethnic congruency.

Índices de predição de mortalidade na unidade de queimados. Estudo comparativo / Mortality prediction models in the burn unit. Comparative study

INTRODUÇÃO E OBJECTIVO: Os índices de prognóstico em queimados determinam a mortalidade previsível da população, que permanece uma importante medida de avaliação dos cuidados prestados. O estudo visa comparar diferentes índices de predição de mortalidade numa unidade de queimados (UQ) e identificar potenciais aplicabilidades. MATERIAL E MÉTODOS: Estudo retrospetivo dos doentes internados na UQ entre 2016 e 2018 (n = 409). Avaliação da mortalidade e comparação das especificidades entre sobreviventes e falecidos, através de dados demográficos e clínicos na admissão. Avaliação de quatro índices (Abbreviated Burn Severity Index (ABSI), modelo de Ryan, Belgian Outcome in Burn Injury (BOBI) e revised-Baux) na determinação da mortalidade prevista versus observada, e análise da discriminação e ajuste dos modelos (curvas ROC e area under the curve, AUC; testes de Hosmer-Lemeshow). RESULTADOS: A média de idades dos doentes foi de 59.1 anos, sendo 56.5% homens, com superfície corporal queimada total (SCQT) média de 12%, queimaduras de terceiro grau presentes em 67% e lesão inalatória em 11.5%. A mortalidade global observada foi de 6.4% (n = 26). Os doentes falecidos eram significativamente mais velhos (71.7 vs. 58.3 anos; p < 0.001), apresentavam maior SCQT (23.2 vs. 11.2%; p < 0.001) e mais queimaduras de terceiro grau (92.3 vs. 65.3%; p = 0.005), sem diferenças significativas no género ou lesão inalatória. Os índices de mortalidade apresentaram ajuste e discriminação adequados. Todos os índices evidenciaram valores-p > 0.05 no teste de Hosmer-Lemeshow. O revised- Baux e o ABSI apresentaram um bom poder de discriminação (AUC 0.84 ± 0.04 e 0.81 ± 0.04, respectivamente), o BOBI moderado/bom (0.79 ± 0.04) e o Ryan moderado (0.73 ± 0.05). CONCLUSÕES: Os quatro índices de mortalidade revelaram um desempenho preditivo adequado, com o revised-Baux apresentando a melhor precisão na previsão da mortalidade. A sua utilização nas UQ constitui uma ferramenta preciosa na estratificação do risco, controlo da qualidade dos cuidados, comparação de novas estratégias terapêuticas e investigação científica

BACKGROUND AND OBJECTIVE: Prognostic scoring models in burn patients predict mortality risk in burn-injured populations. Mortality remains a main outcome measure for burn care. The study aims to compare different mortality prediction models in the burn unit (BU) and identify their potential applications. METHODS: Retrospective study of 409 burn patients admitted in the BU between 2016 and 2018, including mortality assessment and comparative analysis of survivors and deceased patients' characteristics based on admission demographic data and clinical criteria. Evaluation of four models (Abbreviated Burn Severity Index (ABSI), Ryan model, Belgian Outcome in Burn Injury (BOBI) and revised-Baux) on assessment of predicted mortality versus observed, and analysis of models' discriminative power and goodness-of-fit (ROC curves and area under the curve - AUC; and Hosmer-Lemeshow tests). RESULTS: Patients mean age was 59.1 years and mean total burned surface area (TBSA) was 12%; 56.5% were male; third degree burns were present in 67% and inhalation injury in 11.5%. Overall observed mortality rate was 6.4% (n = 26). Deceased patients were significantly older (71.7 vs. 58.3 years; p < 0.001), presented a larger TBSA (23.2 vs. 11.2%; p < 0.001) and higher frequency of third degree burns (92.3 vs. 65.3%; p = 0.005), with no significant difference on patient gender and inhalation injury. Mortality prediction models presented adequate goodness-of-fit and discrimination. All models showed p-values > 0.05 in Hosmer-Lemeshow test assessment. Revised-Baux and ABSI showed good discriminative power (AUC 0.84 ± 0.04 and 0.81 ± 0.04, respectively), BOBI discrimi¬nation was moderate / good (0.79 ± 0.04) and moderate with Ryan (0.73 ± 0.05). CONCLUSIONS: The four mortality indices revealed appropriate predictive performance, with revised-Baux presenting as the most accurate model for prediction of mortality. Their use in the BU represents a valuable tool for risk stratification, quality control of burn care, appraisal of new therapeutic strategies and scientific research purposes

Giant chondrosarcoma of the chest wall: a rare surgical challenge

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning—sparing key reconstructive options without compromising the tumor resection—allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Perineal reconstruction using an inferior gluteal artery perforator flap after abdominoperineal resection.

The abdominoperineal resection is a surgical procedure which implies the removal of rectum, anal canal and the creation of a terminal colostomy. The most frequent complications of this type of surgery are haemorrhage, surgical wound complications, persistent perineal sinus and perineal hernia. Intraoperative haemorrhage or contamination and neoadjuvant radiotherapy are risk factors for the development of perineal complications. Perineal wound infection, with subsequent healing delay, has multifactorial aetiology and its incidence can reach up to 66% according to literature. The prevention of these complications requires adequate surgical technique to avoid or minimise the known risk factors. The treatment of a perineal wound complication depends on the clinical and radiographic findings. When there is no wound resolution in 6 months, it is considered a persistent sinus and treatment will probably require a flap. Several options of surgical treatment are available however, there are no randomised studies to determine which one is the best.