Use of flaps in inguinal lymphadenectomy in metastatic penile cancer.

PURPOSE: Reviewing surgical procedures using fasciocutaneous and myocutaneous flaps for inguinal reconstruction after lymphadenectomy in metastatic penile cancer. MATERIAL AND METHODS: We reviewed the current literature of the Pubmed database according to PRISMA guidelines. The search terms used were "advanced penile cancer", "groin reconstruction", and "inguinal reconstruction", both alone and in combination. The bibliographic references used in the selected articles were also analyzed to include recent articles into our research. RESULTS: A total of 54 studies were included in this review. About one third of penile cancers are diagnosed with locally advanced disease, often presenting with large lymph node involvement. Defects in the inguinal region resulting from the treatment of metastatic penile cancer are challenging for the surgeon and cause high patient morbidity, rendering primary closure unfeasible. Several fasciocutaneous and myocutaneous flaps of the abdomen and thigh can be used for the reconstruction of the inguinal region, transferring tissue to the affected area, and enabling tensionless closure. CONCLUSIONS: The reconstruction of defects in the inguinal region with the aid of flaps allows for faster postoperative recovery and reduces the risk of complications. Thus, the patient will be able to undergo potential necessary adjuvant treatments sooner.

Relation Between Post-Augmentation Parenchymal Atrophy and Local Tissue Pressure.

BACKGROUND: Breast parenchyma interacts dynamically with an inserted implant, which may lead to local atrophy and sensory involvement, changes in vascular tissue and lactation, and volume reduction over time. The inversely proportional relationship between pressure and volume cannot be stated with certainty; that is, the larger implants having more local pressure would lead to compression, thus leading to atrophy of parenchyma more intensely compared with smaller implants. The objective of this study was to assess and list breast parenchyma volume changes with different pressure levels due to silicone implants of several sizes. OBJECTIVES: The authors sought to list the pressure exerted by silicone implants and the atrophy caused in the breast tissue. METHODS: Thirty-six women were placed in 3 groups (n = 12) and subjected to augmentation mammoplasty in the subglandular plane. The measurement of pressure in millimeters of mercury was conducted with help of molds with the same base and projection of implants introduced posteriorly. MRI was conducted in all participants in the preoperative period and at 6 and 12 months after surgery. RESULTS: Twelve months after breast implant insertion, the groups had a significant glandular volume reduction (mean, 12.97% in the right breast and 12.42% in the left breast). There was a statistically significant difference in the proportions of volume reduction and the pressure levels measured. CONCLUSIONS: A reduction in breast volume was verified. This reduction was also related to the level of pressure exerted on the implant.

Lower Body Lift After Bariatric Surgery: 323 Consecutive Cases Over 10-Year Experience.

BACKGROUND: Lower body lift is a widespread procedure for massive weight loss patients aimed to improve the contour of the lower trunk, gluteal region and proximal lower extremity. The data about complications are confusing, and there is a lack of uniform studies for massive weight loss patients. A simple formula to carry out a reliable procedure in a short time with a low complication rate should be advocated. METHODS: This retrospective study analyzed data of 323 patients undergoing lower body lift after bariatric surgery over a 10-year period. Selection criteria, careful preoperative marking, reliable intra- and postoperative care and a few surgical tips are discussed. All the complications (both major and minor) and the aesthetic satisfaction were evaluated. Risk factors assessed were patient age, tobacco consumption, current BMI, operative time and combined surgery. RESULTS: The overall complication rate was 42%. We recorded a lower rate of major complications and skin dehiscence; no infection and no skin necrosis were observed. The most frequent complication was seroma (35%). A complication development was straight related to age (p = 0.0177) and tobacco use (p = 0.0336). Patients' satisfaction about overall aesthetic was high. CONCLUSIONS: We present our case load and describe an easy recipe to perform a safe surgery without undermining and liposuction in short operative times. The reasonable overall complication rate and the surprisingly lower rate of dehiscence and skin necrosis combined with a pleasant aesthetic result make the lower body lift an easy and safe procedure, when applied to the appropriate patient population. 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.

Reconstruction of the Nose: Management of Nasal Cutaneous Defects According to Aesthetic Subunit and Defect Size. A Review.

The nose represents the most common site for the presentation of cutaneous cancer, especially in sun-exposed areas: ala, dorsum, and tip. Even the smallest loss of substance can create aesthetic and psychosocial concerns for patients; therefore, surgeons who perform nasal reconstruction should be strictly confident with the pertinent surgical anatomy in order to tailor the procedure to the patient's condition and needs. Radical tumor excision and satisfactory aesthetic and functional results are primary targets. Restoring the original shape is the goal of any reconstruction: appropriate reshaping of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures are paramount features. Multiple options exist to re-establish functional and aesthetic integrity after surgical oncology; nevertheless, the management of nasal defects can be often challenging, and the gold standard is yet to be found. The current goal is to highlight some of the more common techniques used to reconstruct cutaneous defects of the nose with a specific focus on decision making based on the aesthetic subunit and defect size. The authors attempt to share common pitfalls and offer practical suggestions that they have found helpful in their clinical experience.

Endocrine-Metabolic Response in Patients Undergoing Multiple Body Contouring Surgeries After Massive Weight Loss.

BACKGROUND: The endocrine-metabolic response to trauma is directly related to its magnitude, but little is known about the adverse effects of combined surgical procedures on morbidity. OBJECTIVES: The authors sought to evaluate risk factors by measuring the endocrine-metabolic response in patients who underwent multiple body-contouring surgeries after massive weight loss. METHODS: This prospective, randomized, interventional study included 46 massive weight loss patients who experienced a weight loss >30% of their body mass index (BMI) and were referred for body contouring surgery. Patients were randomly allocated to the control group (n = 10) or intervention group (n = 36), which in turn was divided into 3 subgroups (n = 12, each) according to BMI, surgical time, and scar length values. Blood samples were collected from all patients at different time points to assess biological stress markers. RESULTS: Levels of IL-6 in patients in the higher ranges of BMI and operating time and with more extensive scar length were significantly higher in the immediate postoperative period compared with baseline. Concentrations of noradrenaline were significantly higher 24 hours after surgery compared with baseline only in patients in the higher range of operating time. A higher level of IL-6 at 72 hours after surgery compared with baseline was associated with more extensive scar length. Levels of other biological stress markers did not significantly differ. CONCLUSIONS: The combination of surgical procedures did not significantly affect the concentrations of most biological stress markers. The variable of operating time most influenced increase in plasma concentrations of stress markers.

Functional and Volumetric Analysis of the Pectoralis Major Muscle After Submuscular Breast Augmentation.

BACKGROUND: Dual plane breast augmentation is a technical variation of the submuscular plane described as a technique that reduces contour deformities due to contraction of the pectoralis major muscle and lower risk of double-bubble deformity associated with breast ptosis. Despite improvement in the aesthetic aspect, there is still no consensus whether this technique affects the function of the pectoralis major muscle. OBJECTIVES: The aim of this study was to correlate functional with volumetric changes associated with dissection of the muscle origin in submuscular breast augmentation. METHODS: Thirty women who desired to undergo breast augmentation were selected prospectively and randomly allocated to 2 groups: 10 patients in the control group and 20 patients in the interventional group, who underwent submuscular breast augmentation. Magnetic resonance imaging and volumetric software were used to assess muscle volume and isokinetic dynamometry was used to assess function of the pectoralis major muscle. Preoperative measurements were compared with those at 3, 6, and 12 months after surgery. RESULTS: Magnetic resonance imaging revealed significant decrease in muscle volume at 6 and 12 months follow-up. The isokinetic test conducted during adduction showed a significant difference in muscle strength between groups from baseline to the 12-month follow-up, and between the 3- and 12-month follow-up. No significant differences in muscle strength during abduction were observed from baseline to the 3-, 6-, and 12-month follow-up. CONCLUSIONS: Submuscular breast augmentation reduced muscle strength during adduction 12 months after surgery, but without a significant correlation with volumetric muscle loss.

Utility of video-assisted endoscopy in transaxillary breast augmentation.

BACKGROUND: Breast augmentation through incisions in the axillae is an option for patients who wish to avoid scars on the breasts. The axillary approach also preserves the mammary parenchyma and lactiferous ducts. The utility of video-assisted endoscopy during this procedure as a means to improve safety and aesthetic outcomes remains debatable. OBJECTIVES: The authors compared outcomes of transaxillary breast augmentation with and without video-assisted endoscopy. METHODS: Thirty-four women who underwent transaxillary breast augmentation with or without video-assisted endoscopy were evaluated in a prospective, randomized study. Patients received high-profile silicone implants in the subglandular plane and were monitored for an average of 25 months. Operating time, complication rates, postoperative pain, patient satisfaction, and aesthetic parameters were evaluated. RESULTS: Operative time were significantly longer for patients who underwent transaxillary breast augmentation with video-assisted endoscopy compared with patients who underwent nonendoscopic surgery. CONCLUSIONS: Video-assisted endoscopy increased operating time but did not improve the safety of transaxillary breast augmentation or yield better aesthetic outcomes. LEVEL OF EVIDENCE: 3 Therapeutic.

Evaluation of the effects of silicone implants on the breast parenchyma.

BACKGROUND: Despite being the cosmetic procedure most performed worldwide, there are still few objective measurements of postoperative volumetric analysis of breast augmentation available in the literature. OBJECTIVE: The aim of this study was to evaluate volumetric changes in the breast parenchyma after the placement of silicone implants in the subglandular plane. METHODS: Thirty-four women were randomly allocated to the intervention group (n = 24), who underwent breast augmentation in the subglandular plane, or to the control group (n = 10), who received no intervention. Volumetric magnetic resonance imaging was performed at inclusion, and after 6 and 12 months in all participants. The non-parametric Friedman's test was used for statistical analysis. RESULTS: There was a significant reduction in glandular volume (mean, 22%) at 12 months postoperatively in patients who underwent breast augmentation. CONCLUSIONS: Breast augmentation caused reduction in the volume of the breast parenchyma. LEVEL OF EVIDENCE: 3 Therapeutic.

Analysis of the use of isotretinoin as an adjuvant in rhinoplasty.

BACKGROUND: Isotretinoin has been used in the treatment of acne for decades through the reduction of sebaceous secretion. There are reports in the literature that isotretinoin may be associated with decreased skin thickness, especially in patients with thick nasal skin for whom rhinoplasty can be more challenging. The objective of this study was to quantify, through ultrasonography, the effect of the use of oral isotretinoin in patients undergoing rhinoplasty, pre- and postoperatively. METHODS: Twenty-four patients participated in this randomized, single-blind controlled pilot clinical trial. The intervention group used oral isotretinoin (20 mg/day) for 2 months before rhinoplasty and for 4 months after. Both groups underwent rhinoplasty in the same plastic surgery department and were submitted to high-frequency (22 MHz) ultrasound evaluation of the epidermis and dermis on the nasal dorsum, nasal tip, and left nose wing at the beginning of the study and 6 months after rhinoplasty, with the aim of assessing changes in skin thickness. RESULTS: Six months after rhinoplasty, a statistically significant reduction was observed in the thickness of the epidermis and dermis of the nasal dorsum and left nose wing, as well as of the epidermis of the nasal tip, but only in the intervention group. The results of the satisfaction questionnaire were better after rhinoplasty in both groups, with no statistical difference between them regarding the specific questions; however, the intervention group had significantly higher satisfaction scores than the control group. CONCLUSIONS: Isotretinoin was effective in reducing the thickness of the skin covering the nose of the evaluated sites.

Helix Thigh Lift. A Novel Approach to Severe Deformities in Massive Weight Loss Patients.

BACKGROUND: After massive weight loss, the severe gynoid body contour deformities are not always faceable with optimal results. The thigh is one of the most demanding area to address; therefore, the approach should be virtually individualized. The authors describe the helix thigh lift: A novel technique that combines vertical with horizontal axis of pull. The goal of this ultimate customization is to dramatically impact physical functioning and esthetics of this patient population. METHODS: Thigh lift patients from 2016 to 2019 were assessed retrospectively; fourteen patients were selected for helix thigh lift procedure. Preoperative markings, surgical technique and outcomes were described. The mean follow-up time was 14.8 ± 3.2 months. A questionnaire was administered to evaluate the results. RESULTS: Fourteen female patients (mean age, 42 ± 4.8 years) underwent helix thigh lift after massive weight loss. The overall complication rate was 36 percent. They were all minor complications and were treated in an outpatient setting. Seroma formation was the most frequent, at 29 percent. No skin necrosis was reported. Complication development was straight related to the age of the patient (p = 0.0455). The patients were very satisfied with the overall outcome. CONCLUSIONS: Helix thigh lift effectively addresses the severe gynoid body contour deformities. The high satisfaction and the reasonable complication rate suggest that this is a safe and effective technique. The age of the patient was significantly associated to complication development. A dramatic improvement of ease in performing activities of daily living along with reduction of the skin problems leads to significant improvement of the quality of life.

Evaluation of the effects of transaxillary breast augmentation on sentinel lymph node integrity.

BACKGROUND: The transaxillary approach for breast augmentation has gained popularity because of the absence of scarring on the breast. However, the effects of this procedure on breast cancer detection and treatment (which rely heavily on the results of axillary status studies) remain under debate. Specifically, sentinel lymph node biopsy is not indicated for patients who have undergone axillary surgery, due to controversy about the interference of the axillary approach with evaluation of the axillary drainage. OBJECTIVES: The authors evaluate changes in axillary lymphatic drainage in patients who underwent transaxillary breast augmentation. METHODS: Twenty-seven patients who presented to Rio de Janeiro State University for breast augmentation were selected for this study. All patients underwent preoperative mammary lymphoscintigraphy, a subsequent transaxillary breast augmentation, and postoperative lymphoscintigraphy at 21 days and six months after the procedure. The postoperative imaging results examining the axillary lymphatic chain and the first axillary lymph node were analyzed and compared to the preoperative images. RESULTS: One of the 27 patients (4.5%) demonstrated a lower rate of lymphatic drainage at 21 days postoperatively compared to preoperative values, but the flow rate had recovered by her six-month follow-up visit. All other patients showed no changes between the preoperative and postoperative images at either time point. The sentinel lymph node remained visible in all patients at all time points, and all breasts showed drainage primarily to the axillary lymphatic chain. Two patients experienced hematoma and one patient experienced late infection at four months postoperatively. The sentinel lymph node was still evident in both axillae. CONCLUSIONS: The data showed preservation of lymphatic drainage and visible sentinel lymph nodes even after transaxillary breast augmentation. Therefore, the authors believe that this procedure does not alter the integrity of mammary drainage for properly selected patients. These data provide surgeons with a less invasive treatment option for patients with early breast cancer, even when they have undergone prior breast augmentation through a transaxillary approach.

Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction.

OBJECTIVES: to assess the degree of patient satisfaction after undergoing breast augmentation and compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume. METHODS: a prospective study was carried out at University Hospital Pedro Ernesto of State University of Rio de Janeiro, in 94 women from Rio de Janeiro, aged 18 to 49 years, submitted to breast augmentation mammaplasty with breast implant due to hypomastia. All implants were textured, with a round base and high projection and were introduced into the retroglandular space through an inframammary access. The patients were divided into three groups: Control, Silicone and MamaSize®, with 44, 25 and 25 patients, respectively. Satisfaction questionnaires were applied in the pre and postoperative periods by the same evaluator, through the visual analogue scale, in which '0' meant very unsatisfied and '100' very satisfied for the four variables: shape, size, symmetry and consistency. The degree of satisfaction with the surgical scar was also assessed in the postoperative period. RESULTS: when the preoperative and postoperative satisfaction levels were compared, there was a difference in all variables for the three groups, with statistical significance. However, when the postoperative data were compared with each other, there was no significant difference. The degree of satisfaction with the surgical scar was high. CONCLUSION: the augmentation mammaplasty with breast implant had a high index of satisfaction among patients. However, there was no difference in the degree of satisfaction in the postoperative period between the three methodologies of breast volume measurement.

The Impact of Labiaplasty on Sexuality.

BACKGROUND: Labiaplasty is one of the aesthetic procedures that has shown the greatest increase in the number of operations in recent years, although the absolute number of these procedures is still very low. Labia minora hypertrophy causes not only functional discomfort and sexual difficulties, but also embarrassment and aesthetic concern. The aim of this study was to assess the impact of labiaplasty on the patient's quality of life, self-esteem, and sexual function. METHODS: Twenty-four consecutive sexually active patients, who expressed the desire to undergo labiaplasty, were divided into two groups of 12 patients each: the intervention group that underwent labiaplasty immediately after responding the first questionnaires, and the control group that received no intervention during the study period. All patients were assessed for health-related quality of life, self-esteem, and sexual function using the Brazilian Portuguese versions of the Medical Outcomes Study 36-Item Short Form Health Survey, the Brazilian version of the Rosenberg Self-Esteem scale, and the Female Sexual Function Questionnaire, respectively. The questionnaires were administered at inclusion and at 3 and 6 months later in both groups. Comparisons within and between groups were performed. Statistical analysis was performed at a significance level of p < 0.05. RESULTS: No significant differences in Rosenberg Self-Esteem scale or Medical Outcomes Study 36-Item Short Form Health Survey score were found in either group during the study period. However, a significant improvement was found in the Female Sexual Function Questionnaire total score in the pain and enjoyment domains. CONCLUSION: Labiaplasty had a positive impact on sexual functioning of the study population.

Use of flaps in inguinal lymphadenectomy in metastatic penile cancer

ABSTRACT Purpose: Reviewing surgical procedures using fasciocutaneous and myocutaneous flaps for inguinal reconstruction after lymphadenectomy in metastatic penile cancer. Material and Methods: We reviewed the current literature of the Pubmed database according to PRISMA guidelines. The search terms used were "advanced penile cancer", "groin reconstruction", and "inguinal reconstruction", both alone and in combination. The bibliographic references used in the selected articles were also analyzed to include recent articles into our research. Results: A total of 54 studies were included in this review. About one third of penile cancers are diagnosed with locally advanced disease, often presenting with large lymph node involvement. Defects in the inguinal region resulting from the treatment of metastatic penile cancer are challenging for the surgeon and cause high patient morbidity, rendering primary closure unfeasible. Several fasciocutaneous and myocutaneous flaps of the abdomen and thigh can be used for the reconstruction of the inguinal region, transferring tissue to the affected area, and enabling tensionless closure. Conclusions: The reconstruction of defects in the inguinal region with the aid of flaps allows for faster postoperative recovery and reduces the risk of complications. Thus, the patient will be able to undergo potential necessary adjuvant treatments sooner.

Volumetric Evaluation of the Mammary Gland and Pectoralis Major Muscle following Subglandular and Submuscular Breast Augmentation.

BACKGROUND: Besides being a procedure with high level of patient satisfaction, one of the main causes for reoperation after breast augmentation is related to contour deformities and changes in breast volume. Few objective data are available on postoperative volumetric analysis following breast augmentation. The aim of this study was to evaluate volume changes in the breast parenchyma and pectoralis major muscle after breast augmentation with the placement of silicone implants in the subglandular and submuscular planes. METHODS: Fifty-eight women were randomly allocated either to the subglandular group (n = 24) or submuscular group (n = 24) and underwent breast augmentation in the subglandular or submuscular plane, respectively, or to a control group (n = 10) and received no intervention. Volumetric magnetic resonance imaging was performed at inclusion in all participants and either after 6 and 12 months in the control group or at 6 and 12 months after surgery in the intervention groups. RESULTS: Twelve months after breast augmentation, only the subglandular group had a significant reduction in glandular volume (mean, 22.8 percent), while patients in the submuscular group were the only ones showing significant reduction in muscle volume (mean, 49.80 percent). CONCLUSIONS: Atrophy of the breast parenchyma occurred after subglandular breast augmentation, but not following submuscular breast augmentation. In contrast, submuscular breast augmentation caused atrophy of the pectoralis major muscle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction / Comparação entre diferentes métodos de escolha de volume de implantes mamários e o grau de satisfação pós-operatório

ABSTRACT Objectives: to assess the degree of patient satisfaction after undergoing breast augmentation and compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume. Methods: a prospective study was carried out at University Hospital Pedro Ernesto of State University of Rio de Janeiro, in 94 women from Rio de Janeiro, aged 18 to 49 years, submitted to breast augmentation mammaplasty with breast implant due to hypomastia. All implants were textured, with a round base and high projection and were introduced into the retroglandular space through an inframammary access. The patients were divided into three groups: Control, Silicone and MamaSize®, with 44, 25 and 25 patients, respectively. Satisfaction questionnaires were applied in the pre and postoperative periods by the same evaluator, through the visual analogue scale, in which '0' meant very unsatisfied and '100' very satisfied for the four variables: shape, size, symmetry and consistency. The degree of satisfaction with the surgical scar was also assessed in the postoperative period. Results: when the preoperative and postoperative satisfaction levels were compared, there was a difference in all variables for the three groups, with statistical significance. However, when the postoperative data were compared with each other, there was no significant difference. The degree of satisfaction with the surgical scar was high. Conclusion: the augmentation mammaplasty with breast implant had a high index of satisfaction among patients. However, there was no difference in the degree of satisfaction in the postoperative period between the three methodologies of breast volume measurement.

RESUMO Objetivos: avaliar o grau de satisfação de pacientes submetidas à mamoplastia de aumento e comparar três métodos diferentes, fáceis, baratos e universais, de escolha pré-operatória de volume de implante mamário. Métodos: estudo prospectivo, realizado no Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro, em 94 mulheres naturais do Rio de Janeiro, com idades entre 18 e 49 anos, e submetidas à cirurgia de mamoplastia de aumento com implante, por hipomastia. Todos os implantes eram texturizados, com base redonda e projeção alta e foram introduzidos na loja retroglandular, por via inframamária. As pacientes foram divididas em três grupos: Controle, Silicone e MamaSize®, com 44, 25 e 25 pacientes, respectivamente. Foram realizados questionários de satisfação nos períodos pré e pós-operatórios pelo mesmo avaliador, através de escala analógico-visual, em que 0 significava muito insatisfeita e 100 significava muito satisfeita para as quatro variáveis: forma, tamanho, simetria e consistência. No período pós-operatório avaliou-se também o grau de satisfação com a cicatriz cirúrgica. Resultado: quando comparados os graus de satisfação do pré-operatório com os do pós-operatório, houve diferença em todas as variáveis dos três grupos, com significância estatística. Entretanto, quando comparados os dados dos pós-operatórios entre si, não houve diferença significativa. O grau de satisfação com a cicatriz cirúrgica foi elevado. Conclusão: a mamoplastia de aumento com implante teve um grande índice de satisfação entre as pacientes. No entanto, não houve diferença no grau de satisfação no período pós-operatório entre as três metodologias de mensuração de volume mamário.