Novas tecnologias e inovações em cirurgia mamária / New technologies and innovations in breast surgery

Introdução: A cirurgia de mama, especialmente as associadas aos implantes de silicone, teve uma crescente popularização, tornando-se a cirurgia plástica mais realizada no mundo. Junto com esta proliferação, observa-se um aumento da preocupação com a segurança dos implantes mamários de silicone, pelas intercorrências relacionadas. Objetivo: Revisar métodos existentes para minimizar as complicações relacionadas com implante mamário de silicone, bem como as tecnologias existentes e tendências tecnológicas para implantes mamários de silicone. Métodos: Foi realizada revisão de artigos científicos relacionados com novas tecnologias e tendências para redução das complicações relacionadas com implantes mamários de silicone, bem como as patentes e fabricantes de implante de silicone mamário. Resultados: Identificamos inicialmente 78 referências, sendo reduzido para 40 para publicação, todos com linhas de pesquisas que buscam melhores resultados e redução das complicações relacionadas com implantes de silicone, seja esta cirurgia com objetivo estético ou reconstrutivo. Conclusão: A busca por um implante mamário que reduza as possíveis e frequentes complicações, principalmente a formação do biofilme, processos infecciosos e resposta imune, é o foco da maioria das pesquisas encontradas. Com o mesmo objetivo, porém surgindo mais recentemente como alternativas, existem as pesquisas para o uso de matriz dérmica acelular e a lipoenxertia, com boas expectativas.

Introduction: Breast surgery with silicone implants is gaining popularity and has become the most performed plastic surgery worldwide. However, there is increasing concern about the safety of silicone breast implants due to associated complications. Objective: To review existing technologies, technological trends, and existing methods to minimize complications related to silicone breast implants. Methods: We conducted a literature review of articles describing new technologies and trends to reduce complications related to silicone breast implants, along with information on patents and manufacturers of silicone breast implants. Results: We initially identified 78 articles, out of which 40 were shortlisted for publication . All articles had a common aim of obtaining better results and reducing complications related to silicone implants, either in aesthetic or reconstructive surgeries. Conclusion: The search for a breast implant that reduces possible and frequent complications, especially biofilm formation, infectious processes, and abnormal immune response, was the focus of most articles studied. Acellular dermal matrix and fat grafting have been reported in the literature as promising alternatives.

Punctal and canalicular plugs: Indications, efficacy and safety.

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

Cavernous Hemangioma Between the Elastomer and Fibrous Capsule of a Breast Implant.

Hemangiomas are described in many locations, but breast hemangioma (BH) is rare, accounting for only 0.4% of all breast tumors. These tumors are difficult to diagnose preoperatively using conventional imaging modalities because they lack pathognomonic characteristics. Mammographic and sonographic appearances of BH were described in just a few case reports, and breast implant-related hemangiomas are even rarer. We report a case of the tumor arising in an atypical location-between the elastomer and fibrous capsule of a breast implant.Level of Evidence V 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 .

In Vitro Cytotoxicity of Maxillofacial Silicone Elastomers: Effect of Nano-particles.

PURPOSE: Silicone elastomers are generally used for maxillofacial extraoral prostheses. The purpose of this in vitro study was to evaluate the cytotoxicity of different kinds of nanoparticles added to two types of maxillofacial elastomers. MATERIALS AND METHODS: A-2000 and A-2006 silicone elastomers were used. The silicone specimens were divided into eight groups according to the presence of additional nanoparticles (n = 18). The following represents the groups in the study: Group A: A-2000 silicone (control group); Group B: A-2006 silicone (control group); Group C: A-2000 silicone and the addition of titanium dioxide (TiO2 ); Group D: A-2006 silicone and the addition of TiO2 ; Group E: A-2000 silicone and the addition of fumed silica; Group F: A-2006 silicone and the addition of fumed silica; Group G: A-2000 silicone and the addition of silaned silica; Group H: A-2006 silicone and the addition of silaned silica. A paired sample t-test was used to analyze the cytotoxicity of each group after 24, 48, and 72 hours. RESULTS: Based on the results of the 24-hour analysis, the biocompatibility values of the (A-2006) fumed silica group were higher than those of the control groups. There was no statistically significant difference in A-2006 and A-2000 groups. The cytotoxicity values of the control groups and TiO2 (A-2000 silicone) elastomer groups increased at all test times; however, the cytotoxicity values of the TiO2 (A-2006), fumed silica (A-2006), silaned silica (A-2006), fumed silica (A-2000), and silaned silica (A-2000) groups increased significantly only from 24 to 48 hours. CONCLUSION: Nanoparticles of TiO2 , fumed silica, and silaned silica added to a commercial silicone-based elastomer used for fabrication of maxillofacial prostheses are nontoxic.

[ASIA syndrome: breast implant and Still's disease]. / Síndrome ASIA: Prótesis mamarias y enfermedad de Still.

Connective tissue diseases associated with silicone breast implants have been widely discussed. In the last decade, siliconosis has been included in the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) next to Gulf War syndrome, macrophage myofascitis and postvaccination phenomena. The ASIA syndrome may appear as lupus, rheumatoid arthritis, or more rarely, as adult Still's disease. We discuss the case of a patient with prolonged fever and clinical criteria for ASIA and Still's disease. The prostheses were resected and pathology showed absence of breast implant associated anaplastic lymphoma ALK (-). Physicians should be alert to these new entities linked to silicone breast implants.

Síndrome ASIA: prótesis mamarias y enfermedad de Still / ASIA syndrome: breast implant and Still's disease

Las enfermedades del tejido conectivo vinculadas a implantes mamarios de siliconas han sido tema de discusión. En la última década, la siliconosis ha sido incluida dentro del síndrome autoinmune/inflamatorio inducido por adyuvante (ASIA) junto al síndrome de la guerra del Golfo, síndrome de miofascitis macrofágica y fenómenos post vacunales. El ASIA puede manifestarse como lupus, artritis reumatoidea, o más raramente como enfermedad de Still del adulto. Presentamos el caso de una paciente con fiebre prolongada y criterios clínicos compatibles con ASIA y enfermedad de Still. Se resecaron las prótesis y la anatomía patológica descartó linfoma anaplásico ALK (-) vinculado a prótesis. Los médicos debemos estar alertas ante la aparición de estas nuevas entidades asociadas a los implantes mamarios de siliconas.

Connective tissue diseases associated with silicone breast implants have been widely discussed. In the last decade, siliconosis has been included in the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) next to Gulf War syndrome, macrophage myofascitis and postvaccination phenomena. The ASIA syndrome may appear as lupus, rheumatoid arthritis, or more rarely, as adult Still's disease. We discuss the case of a patient with prolonged fever and clinical criteria for ASIA and Still's disease. The prostheses were resected and pathology showed absence of breast implant associated anaplastic lymphoma ALK (-). Physicians should be alert to these new entities linked to silicone breast implants.

Gluteoplastia Técnica Intramuscular (XYZ) / Gluteoplasty using the Intramuscular (XYZ) Method

INTRODUÇÃO: No conceito de beleza corporal, a forma e o tamanho das nádegas são fundamentais, provocando uma crescente busca não só de mulheres, como também de homens, pela cirurgia de gluteoplastia. O objetivo deste trabalho é apresentar a experiência do autor em gluteoplastia com a técnica intramuscular (XYZ). MÉTODO: No período de 2010 a 2015 foram operados 29 pacientes com idades entre 22 e 64 anos (média 43 anos), sendo 26 mulheres (89,66%) e três homens (10,34%). Foram usados implantes redondos ou ovais, com volumes entre 240 e 420 ml (média de 330 ml), dependendo da melhor indicação para cada caso. RESULTADOS: Foram obtidos bons resultados sob o aspecto de aumento de volume e harmonia da região glútea, com alto índice de satisfação dos pacientes. CONCLUSÕES: Na casuística do estudo a técnica intramuscular (XYZ) se mostrou segura, tanto nas cirurgias primárias como nas cirurgias secundárias, para tratar casos de assimetria e/ou implantes visíveis. Com a pré- determinação dos pontos fixos XYZ, o procedimento torna-se seguro e reprodutível.

INTRODUCTION: The shape and size of the buttocks are essential to the notion of bodily beauty. This has resulted in a growing interest in gluteoplasty among both women and men. The aim of the present study was to present the author's experience with gluteoplasty using the intramuscular XYZ method. METHOD: Between 2010 and 2015, 29 patients aged 22 to 64 years (average, 43 years) underwent gluteoplasty; of these 26 were women (89.66%) and 3 were men (10.34%). Round or oval implants were used, with volumes of 240 to 420 ml (average, 330 ml), depending on the individual case. RESULTS: Good results were obtained in terms of volume increase and harmony of the gluteal region, with a high degree of patient satisfaction. CONCLUSIONS: The intramuscular XYZ method was safe, both for primary and secondary surgery, to treat cases of asymmetry and/or visible implants. Predetermining the XYZ reference points makes this procedure safe and reproducible.

Vitamin D deficiency as a risk factor for the development of autoantibodies in patients with ASIA and silicone breast implants: a cohort study and review of the literature.

The development of autoimmunity and/or autoimmune diseases is multifactorial. Vitamin D is one of the factors that might play a role. We postulated that both the presence of adjuvants and insufficient levels of vitamin D may result in the development of autoimmunity in patients with autoimmune/inflammatory syndrome induced by adjuvants (ASIA) in relation to silicone implant incompatibility. We measured vitamin D levels in 135 patients with ASIA in relation to silicone implant incompatibility and related findings to the presence of autoantibodies that are commonly used to diagnose systemic autoimmune diseases. Furthermore, we systematically reviewed the literature regarding vitamin D deficiency as a risk factor for the development of autoantibodies. Vitamin D measurements were available for analysis in 131 of 135 patients with ASIA in relation to SIIS. Twenty-three patients (18%) tested positive for autoantibodies, from which 18 patients (78%) had either a vitamin D deficiency or insufficiency (median vitamin D level 60.5 mmol/L), whereas five patients (22%) had sufficient vitamin D levels. The risk to develop autoantibodies was significantly increased in vitamin D deficient and/or insufficient patients [RR 3.14; 95% CI, 1.24-7.95; p = 0.009]. Reviewed literature suggested an association between vitamin D levels and the presence and/or titer levels of autoantibodies in different autoimmune diseases. From our current study and from our review of the literature, we conclude that vitamin D deficiency is related to the presence of autoantibodies. Whether vitamin D supplementation results in a decrease of autoimmunity needs to be studied prospectively.

Granuloma after sling surgery: an attempt to answer the 'why' and 'what to do next'.

PURPOSE: To review cases of granuloma formation after sling surgery with a view to find out possible aetiological factors and propose a further plan of management MATERIALS AND METHODS: A retrospective analysis of 120 eyes of 108 patients who underwent frontalis sling surgery with silicone rod from Jan 2008 to Dec 2015 was conducted. All patients with severe ptosis and poor levator function who underwent frontalis sling surgery with silicone rod were included in the study irrespective of the cause of ptosis and method of passing the sling. A complete ophthalmic and ptosis examination was done. In all the cases, the prolene suture was tied over the sleeve to tighten it and it was buried along with the silicone rod in forehead pocket. All the cases with granuloma formation were first subjected to a microbiological examination including culture and sensitivity to antibiotics. All the patients were given a trial of antibiotics. RESULTS: We encountered 10 cases of granuloma in 120 eyes of 108 patients operated during this period. The duration between time of surgery and presentation varied from 2 weeks to 4 months. The microbiological examination revealed positive culture in 5 cases. None of the cases responded to the course of antibiotics given for 10 days. The histopathological examination done in 5 cases (2 of them culture positive and 3 of them culture negative) revealed granulomatous inflammation of non-specific type. The sling was explanted in all cases which resulted in prompt resolution of granuloma in 7-10 days. CONCLUSIONS: The granuloma is primarily due to exposure of the sling itself or the sleeve enveloping the sling or the suture tied around the sleeve thereby. They do not respond to antibiotics but respond very well to explantation. These patients can be taken up for re-sling surgery after a waiting period of 3 months.

Calcitriol mediated hypercalcaemia with silicone granulomas due to cosmetic injection.

We present a case of a 41-year-old woman with medical history significant for urolithiasis presenting to our hospital for psychiatric evaluation due to worsening depression and suicidal ideations for the past 2 weeks. Initial laboratory results show hypercalcaemia of 13.5 mg/mL that led to consulting internal medicine. On further questioning, the patient admitted to cosmetic silicone injections in her buttocks which were causing calcium deposition under her skin, leading to disfigurement of the sacrum and lumbar regions. She underwent further evaluation with CT and laboratory testing, which effectively ruled out malignancy and primary hyperparathyroidism. The hypercalcaemia was diagnosed as non-PTH-dependent with high levels of 1,25-dihydroxyvitamin D and low PTH. She eventually underwent tissue biopsy confirming the presence of silicone granulomas responsible for the calcitriol-mediated hypercalcaemia. This case reminds one to keep a broad differential especially in patients with hypercalcaemia in which malignancy and primary hyperparathyroidism have been ruled out.

Estudo da eficiência bactericida do biocida policloreto de dialildimetilamônio em materiais usados para confecção de próteses orais e faciais / Study of the bactericidal efficiency of the biocide poly(diallyldimethylammonium chloride) used in materials for the manufacture of oral and facial prostheses

As próteses faciais e intraorais tem um importante papel na devolução da estética e de algumas funções para os pacientes. Por meio da restauração da imagem corporal é possível reintegrá-lo a sociedade, resgatando assim a identidade do indivíduo. A boa condição dessas próteses é primordial para que estas possam exercer suas funções adequadamente e manter o local, onde estão inseridas, livre de infecções e inflamações. Portanto, a não formação de colônias e biofilmes bacterianos em materiais eleitos para confecção dessas próteses, trarão benefícios aos pacientes reabilitados. Visando isso, a presente dissertação verificou a capacidade de inclusão e a eficiência bactericida do biocida policloreto de dialildimetilamônio (PDADMAC) em resina acrílica autopolimerizável (RAAQ) e termopolimerizável (RAAT), e silicone de uso médico. Os resultados mostraram que o biocida PDADMAC quando dissolvido no tetrahidrofurano apresentou boa incorporação tanto nas resinas acrílicas, quimicamente ativas e termo ativas, quanto no silicone de uso médico e que apenas os corpos de prova que receberam 2 mililitros do PDADMAC em massa polimérica tiveram uma resposta bactericida eficaz.

The facial and intraoral prosthesis has an important role in the aesthetics and return of some functions to patients. Through restoration of the body image can reistante to can society , thus recovering the individual's identity . The good condition of these prostheses is essential so they can perform their function properly and maintain the the area where the prostheses are inserted free of infection and inflammation. Therefore, no formation of bacteria colonies and biofilms in the chosen materials for making these prostheses , will bring benefits to patients rehabilitated. The present work evaluated the capability of inclusion and the bactericidal efficiency of the biocide poly(diallyldimethylammonium chloride) ( pDADMAC ) of acrylic resin autopolymmerized ( RAAQ ) and thermal polymerized ( RAAT ) , and silicone medical use. The results showed that the biocide pDADMAC when dissolved in tetrahydrofuran presented a good incorporation in both acrylic resins and in the medical grade silicone and that only the samples that received 2 ml of pDADMAC in polymer had an effective bactericidal response.

Posterior capsule opacity in Retinitis Pigmentosa according to different biomaterials of intraocular lenses: Our clinical experience.

BACKGROUND AND AIM: Complicated Cataract is frequently associated with Retinitis Pigmentosa (RP). This retinopathy is a great cause of visual impairment, and cataract surgery may resolve partially the situation and restore sight. Unfortunately, in this case there is a very high incidence of Posterior Capsule Opacity (PCO) ranging in several studies a percentage of 100% at six months. Our goal was to evaluate whether the high incidence of PCO is associated to specific type of Intraocular Lens (IOL) biomaterials. MATERIALS AND METHODS: This observational retrospective study deals with 75 eyes of 43 patients affected with RP who underwent to cataract surgery with posterior chamber IOL implants (40% ECCE and 60% Phaco). Selected biomaterials were: 30 Poly (methyl methacrylate) (PMMA), 11 silicone, 34 acrylic. Observations were performed with retro-illumination camera and when recorded capsular fibrosis a PCO YAG laser capsulotomy was made. The patients were controlled at 3-6-12 months after the initial surgical treatment. RESULTS: At three months of follow up, 80% of patients with PMMA, 81.8% silicone implants underwent to YAG capsulotomy while only 44% of acrylic type. At six months of follow-up 83.3% of patients with PMMA and 81.8% silicone implants underwent to YAG capsulotomy while only 49.88% of acrylic type. At 12 months of follow up 89.9% of patients with PMMA and 90.95 silicone implants underwent to YAG capsulotomy while only 52.82% of acrylic type. CONCLUSIONS: We could not be able to differentiate incidence between different brand type of lens in PMMA. For Acrylic lens instead we noted an incidence of PCO of 41.38% with hydrophobic material and 60.0% of hydrophilic material. In conclusion to avoid massive PCO in RP, our experience is statistically significant, in fact the protective action of smooth material hydrophobic lens avoids the epithelial growth and fibrosis towards the center of visual axis.

Elastomeric and soft conducting microwires for implantable neural interfaces.

Current designs for microelectrodes used for interfacing with the nervous system elicit a characteristic inflammatory response that leads to scar tissue encapsulation, electrical insulation of the electrode from the tissue and ultimately failure. Traditionally, relatively stiff materials like tungsten and silicon are employed which have mechanical properties several orders of magnitude different from neural tissue. This mechanical mismatch is thought to be a major cause of chronic inflammation and degeneration around the device. In an effort to minimize the disparity between neural interface devices and the brain, novel soft electrodes consisting of elastomers and intrinsically conducting polymers were fabricated. The physical, mechanical and electrochemical properties of these materials were extensively characterized to identify the formulations with the optimal combination of parameters including Young's modulus, elongation at break, ultimate tensile strength, conductivity, impedance and surface charge injection. Our final electrode has a Young's modulus of 974 kPa which is five orders of magnitude lower than tungsten and significantly lower than other polymer-based neural electrode materials. In vitro cell culture experiments demonstrated the favorable interaction between these soft materials and neurons, astrocytes and microglia, with higher neuronal attachment and a two-fold reduction in inflammatory microglia attachment on soft devices compared to stiff controls. Surface immobilization of neuronal adhesion proteins on these microwires further improved the cellular response. Finally, in vivo electrophysiology demonstrated the functionality of the elastomeric electrodes in recording single unit activity in the rodent visual cortex. The results presented provide initial evidence in support of the use of soft materials in neural interface applications.

Overnight corneal swelling with high and low powered silicone hydrogel lenses.

PURPOSE: To compare central corneal swelling after eight hours of sleep in eyes wearing four different silicone hydrogel lenses with three different powers. METHODS: Twenty-nine neophyte subjects wore lotrafilcon A (Dk, 140), balafilcon A (Dk, 91), galyfilcon A (Dk, 60) and senofilcon A (Dk, 103) lenses in powers -3.00, -10.00 and +6.00 D on separate nights, in random order, and on one eye only. The contra-lateral eye (no lens) served as the control. Central corneal thickness was measured using a digital optical pachometer before lens insertion and immediately after lens removal on waking. RESULTS: For the +6.00 D and -10.00 D, lotrafilcon A induced the least swelling and galyfilcon A the most. The +6.00 D power, averaged across lens materials, induced significantly greater central swelling than the -10.00 and -3.00 D (Re-ANOVA, p<0.001), (7.7±2.9% vs. 6.8±2.8% and 6.5±2.5% respectively) but there was no difference between -10.00 and -3.00 D. Averaged for power, lotrafilcon A induced the least (6.2±2.8%) and galyfilcon A the most (7.6±3.0%) swelling at the center (Re-ANOVA, p<0.001). Central corneal swelling with +6.00 D was significantly greater than -10.00 D lens power despite similar levels of average lens transmissibility of these two lens powers. CONCLUSIONS: The differences in corneal swelling of the lens wearing eyes are consistent with the differences in oxygen transmission of the silicone hydrogel lenses. In silicone hydrogel lenses central corneal swelling is mainly driven by central lens oxygen transmissibility.