Management of calcific myonecrosis using vacuum sealing drainage: A rare case report and 5-year follow-up.

 Calcific myonecrosis (CM), a rare post-traumatic sequel of the lower limb, is characterized by calcified lesions. A diagnosis of CM can be difficult owing to the longtime span from the emergence of the original trauma to the onset of the symptoms of CM. This case report aimed to feature a case of a 55-year-old gentleman who presented with a progressive painful swelling in the anterolateral aspect of the right lower leg with the initial trauma arising 11 years ago. In the conservative treatment, a fluid-filled mass was formed. The histological examination of the biopsy suggested a diagnosis of CM. The patient underwent a complete debridement operation, after which vacuum sealing drainage was used to manage the space left. Three weeks later, direct wound closure was achieved. Five-year follow-ups showed an excellent outcome without recurrence. Complete surgical debridement combined with primary closure is recommended to manage CM. Cite this article as: Wang C, Hao D, Wang S. Management of calcific myonecrosis using vacuum sealing drainage: A rare case report and 5-year follow-up. Acta Orthop Traumatol Turc., 2024;58(2):135-139.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study.

BACKGROUND: The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction. METHODS: We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis. RESULTS: The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases. CONCLUSIONS: Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction. DATA ACCESS STATEMENT: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

[Direct transfistulous ultrasound in minimally invasive surgical treatment of infected pancreatic necrosis]. / Pryamoe chresfistul'noe ul'trazvukovoe issledovanie pri minimal'no invazivnom khirurgicheskom lechenii patsientov s infitsirovannym pankreonekrozom.

OBJECTIVE: To develop a method for direct transfistulous ultrasound in minimally invasive treatment of infected pancreatic necrosis. MATERIAL AND METHODS: There were 148 patients with infected pancreatic necrosis between 2015 and 2019 at the Krasnodar City Clinical Hospital No. 2. Drainage with 28-32 Fr tubes was carried out at the first stage, endoscopic transfistulous sequestrectomy - at the second stage (19 (12.8%) patients). In 84 (56.8%) patients, we applied original diagnostic method (transfistulous ultrasonic assessment of inflammatory focus). RESULTS: There were 3 accesses to omental bursa in 93 (62.8%) patients and 2 in 43 (29.1%) patients. We also performed 2 access to retroperitoneal space in 63 (42.6%) patients and 1 access in 38 (25.8%) cases. Transfistulous ultrasound was used once in 19 (22.6%) patients, twice in 28 (33.3%) and 3 times in 37 (44.1%) patients. Examination was not performed in 18 (12.2%) patients due to the following reasons: migration of drainage catheters - 5, non-rectilinear fistulous tract - 13. No complications were observed. CONCLUSION: Transfistulous ultrasound makes it possible to diagnose pathological changes in the pancreas and parapancreatic tissue at various stages of surgical treatment.

Operative Management and Outcome of Idiopathic Rectal Necrosis in an Octogenarian.

Idiopathic acute rectal necrosis (IARN) is a rare condition due to a robust rectal blood supply. This report describes an 83-year-old man presenting with septic shock due to distal sigmoid and complete rectal necrosis with perforation. He underwent emergent exploratory laparotomy, sigmoid and proximal rectum resection, and end sigmoid colostomy creation with delayed distal rectal evaluation. Bedside proctoscopy revealed pale, viable-appearing distal rectal mucosa on postoperative day 3. The patient had a protracted, complicated hospital stay but required no further operative intervention. Subsequent colostomy reversal was done 8 months postoperatively, and the patient did well and has been discharged with normal gastrointestinal function. Our successful conservative operative management of IARN deviates from previously described management in the literature which is emergent abdominoperineal resection. This conservative surgical strategy appears to have contributed to the patient's positive outcomes, highlighting the importance of considering a similar approach for future IARN cases.

[Descending Necrotizing Mediastinitis with Subclavian Vein Injury due to Cervical Re-debridement: Report of a Case].

A 58-year-old man was admitted to our hospital with fever and neck swelling after dental treatment. He was diagnosed with a cervical abscess and underwent cervical abscess drainage, but 1 week later he developed descending necrotizing mediastinitis and was referred to our department. He underwent mediastinal and pleural drainage, but neck abscess was recured, Re-debridment of the neck abscess resulted in bleeding from right subclavian vein. The bleeding was successfully stopped with TacoSeal after L-shaped sternotomyand dissection of sternocleidomostoid muscle.

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

INTRODUCTION: The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. METHODS: Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. RESULTS: The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. CONCLUSION: The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

[Indocyanine green in delayed esophageal reconstruction after previous extirpation]. / Primenenie indotsianina zelenogo pri otsrochennoi plastike pishchevoda tolstoi kishkoi posle ego ekstirpatsii.

Advanced chemo- and radiotherapy makes it possible to expand the cohort of patients who can undergo surgical treatment for esophageal cancer. Optimization of perioperative approach, diagnosis and modern options for complications reduced early postoperative mortality after esophagectomy. Conduit ischemia with failure of esophageal-gastric or esophageal-intestinal anastomosis is one of the most serious complications. To minimize the risk of anastomotic leakage and graft necrosis in these patients, various methods of intraoperative assessment of graft viability are being investigated. Near-infrared fluorescence imaging with indocyanine green is valuable for real time assessment of graft perfusion. To date, fluorescence imaging is analyzed regarding perfusion of the gastric stalk after esophagectomy. However, there are still few or no data on this method for analysis of colonic conduit perfusion. The absence of plastic material for gastrointestinal reconstruction is the most dangerous moment in case of ischemia and necrosis of colonic graft. We present our first case of delayed retrosternal esophageal repair using intraoperative indocyanine green fluorescence imaging for assessment of conduit perfusion.

Temporary external skin plication: a helpful new technique in gynecomastia surgery.

OBJECTIVE: The aim of this study was to elucidate the external temporary skin plication (ETSP) technique in gynecomastia surgery and evaluate its role in mitigating complications and enhancing cosmetic outcomes. PATIENTS AND METHODS: This study was conducted on patients diagnosed with gynecomastia, explicitly falling under Rohrich Grades IIB and III, with dermal quality being a crucial determinant. Between September 2018 and November 2021, surgical interventions were performed on 96 qualifying patients by the senior author. The operative protocol consisted of ultrasonic and suction-assisted liposuction, supplemented by lateral periareolar piecemeal gland excision. Within the cohort, 42 patients were subjected to the novel ETSP technique. In contrast, the remaining 54 patients underwent standard treatment, serving as the control group for subsequent comparative assessment. RESULTS: One patient required revisions for contour irregularities, while partial nipple necrosis was observed in two patients but healed without surgical intervention. However, saucer-like deformity and total nipple necrosis were not observed in our series. The overall complication rate in our series was 19%, with 9.5% of cases requiring revision. In our control group, the overall complication rate in our series was found to be 22%, with 13% of cases requiring revision. CONCLUSIONS: ETSP provides a homogeneous spread of the excess skin and greatly reduces or eliminates the amount of skin fold formation. ETSP reduces the need for possible skin excision and reduces visible scars and incisions, and it helps improve the results of skin-protective surgeries that are widespread today.

Radiation necrosis after radiation therapy treatment of brain metastases: A computational approach.

Metastasis is the process through which cancer cells break away from a primary tumor, travel through the blood or lymph system, and form new tumors in distant tissues. One of the preferred sites for metastatic dissemination is the brain, affecting more than 20% of all cancer patients. This figure is increasing steadily due to improvements in treatments of primary tumors. Stereotactic radiosurgery (SRS) is one of the main treatment options for patients with a small or moderate number of brain metastases (BMs). A frequent adverse event of SRS is radiation necrosis (RN), an inflammatory condition caused by late normal tissue cell death. A major diagnostic problem is that RNs are difficult to distinguish from BM recurrences, due to their similarities on standard magnetic resonance images (MRIs). However, this distinction is key to choosing the best therapeutic approach since RNs resolve often without further interventions, while relapsing BMs may require open brain surgery. Recent research has shown that RNs have a faster growth dynamics than recurrent BMs, providing a way to differentiate the two entities, but no mechanistic explanation has been provided for those observations. In this study, computational frameworks were developed based on mathematical models of increasing complexity, providing mechanistic explanations for the differential growth dynamics of BMs relapse versus RN events and explaining the observed clinical phenomenology. Simulated tumor relapses were found to have growth exponents substantially smaller than the group in which there was inflammation due to damage induced by SRS to normal brain tissue adjacent to the BMs, thus leading to RN. ROC curves with the synthetic data had an optimal threshold that maximized the sensitivity and specificity values for a growth exponent ß* = 1.05, very close to that observed in patient datasets.

Prediction of clinically significant recurrence after partial nephrectomy. Data from the Cancer Registry of Norway with more than five years of follow-up.

OBJECTIVE: To determine recurrence incidence after partial nephrectomy (PN) for renal cell carcinoma and identify predictors for local recurrence (LR) and metastasis. MATERIAL AND METHODS: We retrospectively evaluated a cohort of 524 patients from the Cancer Registry of Norway, who underwent PN between January 2014 and December 2015 and were followed-up for >6 years. Patient demographics and pathological characteristics were correlated with recurrence and progression-free survival using Kaplan-Meier and Cox regression analyses. RESULTS: Median patient age was 64 years, and the median tumour size was 2.6 cm. A positive surgical margin (PSM) was observed in 11% of the cases, while the LR and metastasis rates were 3.4% and 3.2%, respectively. PSM (hazard ratio [HR], 55.4; 95% confidence interval [CI], 12.55-244.6), tumour number (HR, 45.4; 95% CI, 6.5-316.1) and stage (HR, 33.5; 95% CI, 5.4-205.3) were independent predictors for LR. Undetermined margin status was also a risk factor for LR. Tumour stage (HR, 41.05; 95% CI, 8.52-197.76), tumour necrosis (HR, 1.3; 95% CI, 0.4-4.31) and age (HR, 1.07; 95% CI, 1.01-1.14) were predictors for metastasis. CONCLUSIONS: Both local and distant recurrences after PN were rare, and the pT stage was a common predictor. PSM or indeterminate surgical margin and tumour number were LR predictors, while age at surgery and the presence of tumour necrosis predicted metastasis.

Primary repair with no flaps for lower lip defects (30-80 %) after cancer excision.

Reconstruction of the lip is a necessary procedure when lip tumors are excised. Although many good techniques have been described, they often have disadvantages such as necrosis and extensive suture lines. In our approach, we aim to minimize the suture line and avoid tissue necrosis for medium-sized lip defects (30-80 %). This is a surgical technique report from a single center. After tumor resection, we made a bilateral 15 mm horizontal skin and mucosa incision from the angles of the lip to the lateral sides. The mucosa and skin were dissected from the underlying muscle, and the muscle was cut approximately 15 mm on each side. The lip defect was then closed and sutured in four layers. Finally, the released mucosa was sutured to the corner of the incised skin. We followed the patients for 36 months and found that their speech intelligibility, sensation, mobility, and aesthetic satisfaction were preserved. The scars were also less pronounced compared to flaps, and there were no signs of edema or drooling. In conclusion, our technique offers many advantages for moderate defects of lower lip tumors. By avoiding the use of flaps, we eliminate the complications associated with flap surgery while achieving aesthetically satisfactory results. However, further evaluation by other surgeons is necessary to fully examine the technique's benefits.

Tratamento simultâneo de úlceras de pressão sacral e isquiática com retalho único: apresentação de um caso / Simultaneous treatment of sacral and ischial pressure ulcers with a single flap: case presentation

Úlceras de pressão são alterações da integridade da pele e tecidos subjacentes, causadas por pressão, mais usualmente sobre proeminências ósseas, especialmente em áreas desprovidas de sensibilidade, levando à necrose e ulceração. Dados da literatura internacional estimam que 3 a 14% dos pacientes hospitalizados desenvolvem úlceras de pressão. Descrevemos a correção simultânea de úlceras sacral e isquiática extensas em paciente paraplégico jovem utilizando retalho fasciomiocutâneo de glúteo máximo e de face posterior da coxa.

Pressure ulcers are alterations of the integrity of the skin and underlying tissues, caused by pressure, more commonly on bony prominences, especially in areas devoid of sensitivity, which lead to necrosis and ulceration. Data from the international literature estimate that 3­14% of hospitalized patients develop pressure ulcers. We herein describe the simultaneous correction of extensive sacral and ischial ulcers in a young paraplegic patient, using a gluteus maximus fasciomyocutaneous flap from the posterior aspect of the thigh.

Reconstrução mamária com loja de retalho retropeitoral superior e subcutâneo misto inferior / Breast reconstruction with creation of upper retropectoral and lower mixed subcutaneous cavities and use of flaps

Introdução: Segundo dados do Instituto Nacional de Câncer (INCA) de 2016, estima-se em 57.960 novos casos de câncer de mama no Brasil, o que corresponde a 25% dentre todos os tipos de cânceres no país (excluindo-se os tumores de pele não melanoma). O presente artigo visa apresentar uma forma de abordagem para as reconstruções mamárias imediatas com loja retropeitoral superior e subcutânea mista inferior. Métodos: Os autores descrevem da técnica de reconstrução mamária com retalho do músculo peitoral e pedículo cutâneo inferior, associado à inclusão de implante mamário de silicone. Foi realizada análise retrospectiva de prontuários das pacientes operadas entre os anos 2012 e 2016 no Serviço de Cirurgia Plástica da clínica privada do autor sênior, no Hospital Daher e no Hospital das Forças Armadas. Resultados: Os resultados são satisfatórios, com baixos índices de complicações e com satisfação elevada para os pacientes e os autores. Trinta e seis pacientes foram submetidas à reconstrução mamária com a técnica descrita, com média de idade de 59 anos. As complicações apresentadas foram necrose de complexo areolopapilar, deiscência, seroma, hematoma, liponecrose, deslocamento do implante e trombose venosa profunda. Nenhuma paciente teve necessidade de resgate da reconstrução ou apresentou recidiva da neoplasia mamária durante o período do estudo. Conclusão: Trata-se de técnica que preserva a pele da mama em sua parte inferior, com baixa possibilidade de deiscência ou extrusão do implante nesta região, proporcionando uma dupla proteção deste implante com o músculo peitoral maior nos dois terços superiores e o retalho cutâneo-dermogorduroso no terço inferior, caracterizando um "dual-plane".

Introduction: A total of 57,960 new cases of breast cancer were expected in Brazil in 2016 according to data from the National Cancer Institute, corresponding to 25% of cancers in the country (excluding non-melanoma skin tumors). This study aims at presenting a surgical approach for immediate breast reconstructions with upper retropectoral and lower mixed subcutaneous cavities. Methods: The authors performed breast reconstruction using flaps of the pectoral muscle and inferior cutaneous pedicle associated with insertion of silicone breast implants. The medical records of patients operated between 2012 and 2016 at the Plastic Surgery Service of the senior author's private clinic at Daher Hospital and Armed Forces Hospital were retrospectively analyzed. Results: The results were satisfactory, with low complication rates and high patient and author satisfaction. Thirty-six patients, with a mean age of 59 years, underwent breast reconstruction using the described technique. The complications were nipple-areola complex necrosis, dehiscence, seroma, hematoma, liponecrosis, implant displacement, and deep venous thrombosis. No patient needed salvage surgery or had recurrence of mammary neoplasia during the study period. Conclusion: The present technique preserves the skin located at the lower portion of the breast, with a low risk of dehiscence or extrusion of the implant in this region, providing a double protection of the implant, with the pectoralis major muscle in the upper two thirds and the cutaneous-dermis-fat flap in the lower third, characterizing a "dual-plane" positioning.

Opções de tratamento cirúrgico em lesões cutâneas por extravasamento acidental de drogas: experiência do Hospital das Clínicas da Faculdade de Medicina da USP / Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

RESUMO Objetivo: relatar a experiência da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no tratamento de lesões cutâneas por extravasamento acidental de drogas. Métodos: foram incluídos os pacientes com lesões por extravasamento de drogas num período de 18 meses. Os seguintes parâmetros foram avaliados retrospectivamente: idade, diagnósticos durante internação e comorbidades, níveis séricos de albumina e hemoglobina, local de internação, droga envolvida, segmento anatômico acometido, conduta terapêutica e óbito durante internação. Resultados: foram acompanhados 14 pacientes. A principal droga envolvida foi a noradrenalina (21%). Todos os pacientes foram submetidos a desbridamento da necrose tecidual. Três pacientes foram submetidos a retalhos após preparo do leito com terapia por pressão negativa, com bons resultados. Sete pacientes não tiveram tratamento definitivo de suas lesões por falta de condições clínicas. Conclusão: o tratamento definitivo por meio de retalhos se mostrou adequado para os casos de feridas por extravasamento de drogas em tecido subcutâneo, quando há exposição de estruturas nobres, em pacientes com condições clínicas favoráveis.

ABSTRACT Objective: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs. Methods: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization. Results: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions. Conclusion: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

Como evitar uma retração no meio da cicatriz horizontal e minimizar o risco de necrose nas abdominoplastias clássicas / How to avoid a retraction in the middle of the horizontal scar and minimize the risk of necrosis in the classic abdominoplasty

Introdução: Nas abdominoplastias clássicas, um resultado indesejado após o tracionamento do retalho abdominal é a ocorrência de uma retração suprapúbica, no meio da cicatriz horizontal quando esta coincide com o ponto superior da antiga cicatriz umbilical. Métodos: Foram avaliadas 45 pacientes submetidas à dermolipectomia abdominal associada à lipoaspiração de todo o abdome e flancos, com decorticação de uma área suprapúbica cerca de 5 cm acima da marcação inicial da linha de incisão, com posterior fixação na borda inferior do retalho abdominal. Resultados: Não foram observadas depressões ou necroses na região suprapúbica. Conclusão: Observamos, nos casos operados, que a presença de um coxim dermogorduroso na porção central da linha de sutura nas abdominoplastias clássicas, associada à reconstituição completa dos planos cirúrgicos e fixação deste coxim no retalho abdominal superior, evita a ocorrência de depressões nesta região, evita ocorrência de necroses e melhora a qualidade da cicatriz por redução da tensão de tração sobre os tecidos.

Introduction: In classic abdominoplasty, an undesirable result after abdominal flap traction is the occurrence of a suprapubic retraction in the middle of the horizontal scar when it coincides with the superior point of the old umbilical scar. Methods: Forty-five patients underwent abdominal dermolipectomy associated with liposuction of the entire abdomen and flanks, with decortication of the suprapubic area approximately 5 cm above the initial marking of the incision line, with posterior fixation at the lower border of the abdominal flap. Results: No depressions or necroses were observed in the suprapubic region. Conclusion: We observed that the presence of a dermofat flap in the central portion of the suture line in the classic abdominoplasties associated with the complete reconstruction of the surgical planes and the fixation of this flap in the upper abdominal flap avoids the occurrence of depressions in this region, prevents occurrence of necrosis, and improves the quality of the scar by reducing the tensile stress on the tissues.

Reconstrução de mama com miniabdominoplastia reversa / Breast reconstruction with reverse mini abdominoplasty

Introdução: A mastectomia é muito traumática para a mulher, sendo a reconstrução mamária um procedimento essencial para melhorar o bem-estar psicossocial e a qualidade de vida destas pacientes. A maioria dos cirurgiões plásticos não realiza reconstrução mamária. Sua prática requer um treinamento avançado com longa curva de aprendizado. A reconstrução mamária, utilizando o retalho excedente da abdominoplastia reversa, pode ser uma opção prática e de muita aplicabilidade em pacientes cuidadosamente selecionadas. Métodos: No período de agosto de 2014 a junho de 2016, doze pacientes foram submetidas à reconstrução mamária, com a técnica de miniabdominoplastia reversa. A simetrização foi realizada em seis pacientes que fizeram reconstrução unilateral, sendo um caso reconstruído bilateralmente. Em sete pacientes, os implantes foram colocados em plano supra muscular, e em cinco, em posição sub submuscular. Resultados: Uma paciente apresentou seroma, uma outra teve epiteliólise, um caso de necrose parcial da pele do retalho superficial, todos com evolução favorável. Somente uma paciente teve extrusão do implante. Conclusão: A reconstrução mamária com retalho excedente de miniabdominoplastia reversa associada à colocação de implante demonstrou ser uma boa opção de reconstrução mamária para casos selecionados, com baixa taxa de complicações. Pacientes com flacidez e lipodistrofia no abdome superior são as candidatas ideais para utilização da técnica.

Introduction: Mastectomy is very traumatic for women, and breast reconstruction is an essential procedure to improve their psychosocial well-being and quality of life. Most plastic surgeons do not perform breast reconstruction. This practice requires advanced training with a long learning curve. Breast reconstruction using excess flaps in reverse abdominoplasty can be a practical option and of great applicability in carefully selected patients. Methods: From August 2014 to June 2016, 12 patients underwent breast reconstruction using the reverse mini abdominoplasty technique. Symmetrization was performed in six patients who underwent unilateral reconstruction, with one case reconstructed bilaterally. The implants were placed in the supra-muscular plane and in a submuscular position in seven and five patients, respectively. Results: There was one case each of seroma, epitheliolysis, and partial superficial necrosis of the superficial flap, all with favorable evolution. Only one patient underwent implant extrusion. Conclusion: Breast reconstruction using excess flaps in reverse mini abdominoplasty associated with implant placement is a good option for breast reconstruction in selected patients with a low complication rate. Patients with flaccidity and lipodystrophy in the upper abdomen are the ideal candidates for the use of this technique.

Uso de doble colgajo diep para reconstrucción de extremidad inferior / Double diep flap for lower extremities reconstruction

Introduction: A soft tissue defect considering the extent, location, depth and involved structures can be a complex task, leading to search for unusual reconstructive alternatives. Case report: Puerperal woman, 21 years, previously healthy, admitted for septic shock and skin necrosis of both extremities secondary to purpura fulminans. Escharectomy was performed and the final defect was 27 percent of total body surface, corresponding to necrotic areas of both superior and lower extremities. Is remarkable the presence of musculocutaneous perforating vessels thrombosis and segmental muscular necrosis in legs and interosseous muscles necrosis in hands. In upper extremity coverage was performed with dermoepidermal grafts. To cover peroneal malleolus and feet dorsum, whereas there were no regional or local alternatives, we realize a double DIEP flap. Flap elevation of bilateral DIEP flap was performed simultaneously for two surgical teams. The patient had no complications and was discharged with complete soft tissue coverage.

Introducción: Un defecto de cobertura extenso de extremidades inferiores (EEII), considerando ubicación, profundidad y estructuras involucradas es de una alta complejidad y puede llevar a buscar alternativas reconstructivas poco habituales. Caso Clínico: Paciente de 21 años, puérpera, ingresa por shock séptico y necrosis cutánea extensa de extremidades secundario a un purpura fulminans. Se realiza escarectomía y el defecto resultante es de 27 por ciento de superficie corporal, correspondiendo a zonas necróticas en ambas extremidades, superiores e inferiores. Destaca la presencia de trombosis de vasos perforantes musculocutáneos, necrosis muscular segmentaria en piernas y de musculatura interósea en manos. En extremidades superiores se realizó cobertura con injertos dermoepidérmicos. Para la exposición de ambos maléolos peroneos y dorso de pies, considerando que no existen alternativas locales ni regionales, se decide realizar un colgajo DIEP bilateral; se eleva en un tiempo, con dos equipos quirúrgicos simultáneos. La anastomosis microquirúrgica se realizó a los vasos tibiales de cada extremidad. La evolución postoperatoria fue favorable. La paciente es dada de alta en buenas condiciones generales, extubada, con cobertura cutánea completa.

Influência das complicações pós-operatórias no insucesso da reconstrução de mama imediata com implante de silicone / Influence of postoperative complications on the failure of immediate breast reconstruction with silicone implants

Introdução: A reconstrução da mama imediata pós-mastectomia, com implante de silicone é um método simples, porém, pode evoluir com complicações e remoção do implante. O objetivo do estudo foi analisar as complicações pós-operatórias e buscar relação entre estas e a remoção do implante. Método: No período de 4 anos, foram estudados retrospectivamente 323 casos de reconstrução de mama imediata com implante de silicone após mastectomia total realizados no Institut Gustave-Roussy, França. Resultados: A complicação mais frequente foi a linfocele (34,9%), seguida da necrose cutânea com 22,9%, da infecção com 19,3% e do hematoma, com 13,3% dos casos. A remoção do implante foi mais frequente quando ocorreu algum tipo de complicação cirúrgica e maior quando ocorreu mais de um tipo de complicação. A complicação mais frequente nos casos de remoção do implante foi a infecção (75,0%). O expansor foi o implante que mais teve relação com remoção do implante. O uso de implantes de volume acima de 300 ml teve significativamente mais risco de remoção do implante. Conclusões: 1) A presença de complicação pós-operatória foi fator de risco para a remoção do implante. 2) O risco de remoção foi maior na presença de mais de um tipo de complicação 3) A infecção foi o principal tipo de complicação que se relacionou com a remoção 4) O expansor apresentou maior risco de complicações e de remoção do implante. 5) A utilização de implantes de volume maior do que 300 ml apresentou maior risco de remoção.

Introduction: Immediate breast reconstruction with silicone implants following mastectomy is a simple method, but can develop complications culminating in implant removal. The aim of this study was to analyze postoperative complications and evaluate their correlation with implant removal. Method: In a period of 4 years, 323 cases of immediate breast reconstruction with silicone implants following total mastectomy were retrospectively studied in the Institut Gustave-Roussy, France. Results: The most frequent complication was lymphocele (34.9%), followed by cutaneous necrosis (22.9%), infection (19.3%), and hematoma (13.3%). Implant removal was more frequent when a surgical complication occurred, and even more frequent when there was more than one type of complication. The most frequent complication leading to implant removal was infection (75.0%). The expander was the implant that had the highest correlation with implant removal. The use of implants with a volume greater than 300 ml was associated with a significantly higher risk of implant removal. Conclusions: 1) The presence of postoperative complications was a risk factor for implant removal. 2) The risk of removal was higher when more than one complication was present. 3) Infection was the main type of complication associated with implant removal. 4) The expander presented a higher risk of complications and implant removal. 5) The use of implants with a volume greater than 300 ml had a greater risk of need for removal.