Endoscopic Delayed Breast Reconstruction With Expanders and Implants via the Axillary Incision Made for Sentinel Lymph Node Biopsy or Lymphadenectomy.

BACKGROUND: Classic techniques of delayed prosthetic breast reconstruction use the mastectomy scar as an access route. As a result, the filling of the expander must be postponed until the wounds have healed. This creates an asymmetry between the breasts with the volume changes caused by the filling of the expander, which may occur over several weeks and cause considerable discomfort. METHODS: Delayed breast reconstruction was performed via the axillary incision made for sentinel lymph node biopsy or lymphadenectomy with endoscopic assistance and detachment of the pectoralis major muscle. The filling of the expander and symmetrization with the contralateral breast was performed in the first stage.The expander was replaced with the definitive prosthesis 3 months later, after endoscopic capsulotomy. Fat grafting was performed to create a lipobed around the implant and to improve tissue quality. RESULTS: Sixty-two patients underwent surgery. Mean follow-up was 19 months. There were no major complications in the reconstructed breast. One case of hematoma in a contralateral breast reduction and an oil cystic mass secondary to fat grafting were recorded. In all cases, the filling of the expander with the definitive volume was possible during the first stage. CONCLUSIONS: Endoscopic delayed breast reconstruction with insertion of implants through the axillary incision for sentinel node biopsy or lymphadenectomy is safe and feasible. It achieves complete intraoperative expansion, symmetry between the volumes of the breasts during the first stage, and avoids problems with the scar and the risk of extrusion, as the scar is placed remotely in the axilla.

Reparación de fístula traqueoesofágica recurrente con colgajo gastro-omental libre en un paciente irradiado / Recurrent tracheoesophageal fistula repair with gastro-omental free flap in an irradiated patient

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Breast Cleavage Remodeling with Fat Grafting: A Safe Way to Optimize Symmetry and to Reduce Intermammary Distance.

BACKGROUND: In their descriptions of the ideal breast, most studies have focused primarily on the dimensions, shape, and proportions. The distance between the breasts has only very rarely been considered. The intermammary distance and the medial symmetry between the breasts are important parts of the outcome of surgery and have a strong bearing on patient satisfaction. However, the control surgeons have over these factors is only relative, and depends heavily on the underlying anatomical characteristics of the patients. METHODS: Eighty-six patients undergoing breast augmentation, breast reduction, or mastopexy and breast reconstruction with separated or asymmetric breasts underwent fat grafting in the medial quadrants. Intermammary distances were measured before fat grafting and 12 months later. Complications were also recorded. RESULTS: This technique obtained a statistically significant reduction in the mean intermammary distance (p < 0.0001) from 3 ± 0.6 cm (range, 1.6 to 5 cm) to 1.7 ± 0.4 cm (range, 1 to 2.8 cm) at 12-month follow-up. There were no major complications: one capsular contracture in a breast reconstruction requiring capsulotomy and an oil cyst requiring aspiration were reported. CONCLUSION: The authors' technique allows safe remodeling of the medial cleavage of the breast, reducing the intermammary distance and optimizing the symmetry between the breasts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abdominoplasty with Customized Transverse Musculoaponeurotic Plications.

BACKGROUND: The standard abdominoplasty technique uses a wide, vertically oriented plication of the rectus sheath to narrow the waistline. However, this plication is not always enough to achieve good cosmetic and functional results. This is also the case with other plication techniques. To strengthen the abdominal wall at the points of greatest weakness in each particular patient, the authors have developed a personal technique consisting of customized transverse plications at the points of maximum protrusion in the musculoaponeurotic layer, in addition to the classic vertical plication. METHODS: Ninety-eight women were divided randomly into two groups: the control group (group A) comprised 44 patients (44.9 percent) who underwent classic vertical plication; the experimental group (group B) comprised 54 patients (55.1 percent) in whom vertical plication was associated with one or more customized horizontal plications. Results were rated on a scale of 0 to 10 by external observers and the patients. Complications and recurrences were recorded. RESULTS: In group A, the mean global rating scores were 8.5 of 10 for external raters and 8.3 of 10 for patients. In group B, they were 9.5 of 10 and 9.8 of 10, respectively. In group B, there were no recurrences of prominences, whereas three were recorded in group A. Five cases of seroma were registered in each group and resolved by closed suction. CONCLUSION: In some cases, vertical plication with customized transverse plications produces results that are aesthetically superior to those of the classic approach, achieves long-lasting effects, and does not increase the rate of recurrences or the risk of complications.

Expanded Flaps in Surgical Treatment of Pressure Sores: Our Experience for 25 Years.

BACKGROUND: Because the ischial region is the main weight-bearing area in sitting, it is one of the areas most frequently affected by pressure ulcers in paraplegic patients resuming the sitting position during the subacute and chronic stages. The techniques described to date have not been able to reduce the high rates of recurrence and flap dehiscence. Other groups have described successful tissue expansion in the treatment of pressure ulcers, but to date, the long-term results of the procedure have not been reported. METHODS: The long-term follow-up of 138 reconstructions of the ischial region in patients with pressure ulcers types III to IV treated with posterior thigh expanded rotation flaps is reported. RESULTS: All patients achieved complete resolution, with adequate coverage of deeper layers, although 15.94% presented minor complications. None of these complications impeded full repair of the lesion. The 28 lesions that recurred were all reconstructed with the re-expansion of the same flap. There were no cases of flap dehiscence. CONCLUSIONS: The use of tissue expanders to treat ischial pressure ulcers, especially in patients with long life expectancy, offers important advantages over other approaches. The procedure provides abundant, high-quality tissue and may be repeated many times without creating new scars. With the use of tissue expanders, other reconstructive options can be reserved for the future.

Platelet-rich plasma mixed-fat grafting: a reasonable prosurvival strategy for fat grafts?

BACKGROUND: One of the most interesting developments in practical applications of fat grafting in recent years is the use of prosurvival strategies to improve maintenance of volume. Platelet-rich plasma (PRP) plays a decisive role in the repair and regeneration of different tissues via the activation and secretion of a great variety of growth factors and other cytokines stored in the alpha-granules of the platelets. This review aimed to assess the efficacy of PRP mixed-fat grafting as a prosurvival strategy for fat grafts. METHODS: Online searches of the Cochrane Library and MEDLINE until January 2014 were conducted. The review included studies with at least one clinical end point in which the effect of PRP on the absorption and viability of the fat graft could be assessed. RESULTS: The review comprised 6 preclinical studies with a control group and 9 clinical studies of humans. It also included comparative studies performed with other prosurvival strategies for fat grafts, such as combination with the stromal vascular fraction and second-generation PRP, also called "platelet-rich fibrin." The results indicate that PRP may have a dose-dependent positive effect on fat grafts and suggest low complication rates. CONCLUSIONS: The development of new growth factor delivery systems or cell therapies to enrich fat grafts is an area that merits further research.

Transplant of an autologous platelet gel prosthesis to fill defects after tumor excision.

BACKGROUND: Tumor excision causes disfigurement in the breast. We present our technique for filling the defect with activated platelet gel, thus avoiding the deformity. METHODS: Between 2006 and 2011, 23 patients (age range, 45-72 years) underwent tumorectomy for breast cancer. After estimating and extracting the volume of blood required, we centrifuged the blood at 1800 rpm for 8 minutes. Later, the middle and lower thirds of the plasma) were separated and activated with CaCl2 at a ratio of 1/20, forming a gel, which was used to fill the tumorectomy cavity. RESULTS: Imaging tests (ultrasound, mammography, and magnetic resonance imaging) performed 12 months after surgery revealed scar tissue in the area where the autoprosthesis had been inserted. Magnetic resonance imaging showed no retraction or deformity in the skin silhouette. Histology study after 1 year demonstrated that the platelet gel had been replaced by fibrous scar tissue with dense collagen and the presence of small capillary vessels. Patients recorded high rates of satisfaction. CONCLUSIONS: This technique maintains the shape and volume of the breast, avoiding deformities and retractions of the nipple areola complex by filling the defect with an autoprosthesis. After 12 months, the autoprosthesis had been replaced by fibrous tissue and dense collagen. Postoperative control was good, and the effectiveness of adjuvant radiotherapy or chemotherapy was not altered. No cases of tumor relapse were recorded. On palpation, consistency and softness were similar to that of breast tissue. The aesthetic results were highly satisfactory.

Treatment of grade 3 tuberous breasts with Puckett's technique (modified) and fat grafting to correct the constricting ring.

BACKGROUND: Augmentation of tuberous breasts classified as grade 3 is a challenge to surgeons. The authors describe their technique for correcting grade 3 tuberous breasts with a book-shaped opening of the breast, insertion of an anatomic prosthesis, and fat grafting. METHODS: The authors' technique for correcting grade 3 tuberous breasts consists of reducing the areolar diameter and performing a book-shaped opening of the breast, applying a modified version of Puckett's technique. The modification consists of opening each breast, remodeling the glandular flap on each side to make them symmetric, inserting the same size subglandular anatomic prosthesis, and covering the prosthesis with the glandular flaps held in place by transcutaneous fixation stitches. After 6 months, fat grafting of the remaining constricting ring and the cleavage is performed. RESULTS: The study enrolled 28 patients with asymmetric bilateral tuberous breasts ages 18 to 39 years. At 12 months, using a questionnaire to rate their results, 68% of the patients were "very satisfied," 25% were "satisfied," and 7% were "not satisfied." The medical team's ratings at 12 months were "excellent" for 82% of the cases and "good" for 18% of the cases. CONCLUSION: For patients with grade 3 tuberous breasts, the authors perform aesthetic breast enlargement by reducing the size of the areola, making a book-shaped opening in the breast, and carrying out fat grafting to correct the cleavage and the remaining constricting ring. The patients and the medical team both expressed high levels of satisfaction with the results.

Fat grafting in postmastectomy breast reconstruction with expanders and prostheses in patients who have received radiotherapy: formation of new subcutaneous tissue.

BACKGROUND: In secondary mammary reconstruction in irradiated patients, the use of expanders and prostheses is controversial, given that radiotherapy increases tissue fibrosis and capsular contracture. The authors assessed the usefulness of tissue expansion, prostheses, and fat grafting in patients who had received radiotherapy. METHODS: The authors conducted a study of 65 mastectomized patients (age range, 34 to 62 years) who had received radiotherapy with a 6-MeV electron accelerator. In the first operation, they inserted the Natrelle 133-MV expander (Allergan, Inc., Irvine, Calif.) endoscopically under the pectoralis major at the end of the mastectomy scar and performed total immediate expansion. The authors injected a mean quantity of 150 +/- 25 cc of fat in the upper quadrants between the skin and the muscle and also inside the muscle. After 3 months, they removed the expander through the same incision, inserted the McGhan Style 410 cohesive silicone prosthesis, and injected a mean 150 +/- 30 cc of fat in the lower quadrants. In the third stage, the nipple-areola complex was reconstructed. RESULTS: Mean follow-up was 1 year, with controls after 1 week, 1 month, 3 months, and 12 months. No complications were recorded with the fat injections. Patients' mean satisfaction rating was 4 on a scale of 1 (low) to 5 (high), and the capsular contracture was never above 1 on the Baker classification. CONCLUSION: In mastectomized patients who received radiotherapy, fat grafting in addition to traditional tissue expander and implant breast reconstruction achieves better reconstructive outcomes with the creation of new subcutaneous tissue, accompanied by improved skin quality of the reconstructed breast without capsular contracture.