Correction to: Invited Discussion on: Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts.

Aesth Plast Surg.

Invited Discussion on: Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts.

The applicability of acellular dermal matrix (ADM) for breast reconstruction is a consolidated reality, as skin and nipple sparing techniques became standard mastectomy approaches. ADM is a soft connective tissue graft generated via a decellularization process that preserves intact the extracellular skin matrix. ADM not only provides tissue reinforcement, but also better pocket control, and shape without the compressive effects of total sub-muscular coverage. Our preference is using one "Strattice®" ADM in pocket's format to cover the implant's inferior pole, protecting the totality of the implant in its inferior pole by the ADM. This technique besides its versatility is cheaper than other techniques presented. The success of ADM prepectoral breast reconstruction depends on three pillars: careful patient selection, flap perfusion and postoperative management. The challenge in large and/or ptotic breasts under the risk of large badly perfused flaps as well as of nipple, due to the nipple-furcules distance which can be handled with well-selected criteria as mentioned and safe management of nipple ascension as well as the nipple graft. Traditionally, they need to be associated with reducing mammoplasty techniques to achieve the expected aesthetic results in a single stage. Therefore, the plastic surgeon must be prepared for new reconstructive approaches postmastectomy, having the ADM as an excellent option for that.

A técnica de Baroudi-Ferreira reduz o seroma pós-abdominoplastia? / Does the Baroudi-Ferreira technique reduce seroma after abdominoplasty?

Introdução: A cirurgia plástica, em relação à abdominoplastia, evoluiu ao longo dos anos com o aprimoramento de técnicas que inicialmente apresentavam grandes índices de complicações. Porém, mesmo com a evolução das técnicas operatórias, a incidência de seroma pós-operatório se mantém como a complicação precoce mais frequente neste procedimento. O objetivo deste estudo é comparar a ocorrência de seroma em abdominoplastia com e sem a utilização de pontos de adesão. Métodos: Foram avaliadas 20 pacientes submetidas à abdominoplastia sendo distribuídas em dois grupos: Grupo A (abdominoplastia com utilização de pontos de adesão - Técnica de Baroudi-Ferreira) e Grupo B (abdominoplastia sem utilização de pontos de adesão). Resultados: No Grupo A houve seroma em 2 pacientes (20%), sendo significativamente menor (p = 0,05) do que no Grupo B, no qual foi diagnosticado em 7 pacientes (70%). A média de volume observada no Grupo A foi de 26,5 ml enquanto no Grupo B foi de 146,5 ml. O maior volume aspirado em pacientes do Grupo A foi 130 ml observado no 15º dia pós-operatório (DPO), ao passo que no Grupo B foi de 230 ml no 21º DPO. Conclusão: A ocorrência de seroma em abdominoplastia neste estudo foi significativamente menor no grupo em que foi utilizada a Técnica de Baroudi-Ferreira.

Introduction: Abdominoplasty has evolved over the years with improvement of techniques that initially had high complication rates. However, even with the evolution of operative techniques, seroma remains the most frequent early complication of this procedure. This study aims to compare the development of seroma after abdominoplasty with and without the use of quilting sutures. Methods: Twenty patients undergoing abdominoplasty were evaluated and divided into two groups: Group A (abdominoplasty using quilting sutures - Baroudi- Ferreira technique) and Group B (abdominoplasty without the use of quilting sutures). Results: Two patients in Group A (20%) had seroma, which was significantly lower (p = 0.05) than that in Group B, in which seven patients were diagnosed with seroma (70%). The mean volume observed in Group A was 26.5 mL, whereas in Group B, it was 146.5 mL. The highest volume aspirated in Group A was 130 mL, on the 15th postoperative day (POD), whereas in Group B it was 230 mL, on the 21st POD. Conclusion: In this study, the development of seroma in abdominoplasty was significantly lower in the group in which the Baroudi-Ferreira technique was used.

Modified Lipoabdominoplasty: Updating Concepts.

BACKGROUND: Abdominoplasty is a commonly performed aesthetic surgical procedure worldwide, and one of the most frequently performed cosmetic surgical procedures in the United States. Classic abdominoplasty was merged with liposuction in the past decade to create a new technique-lipoabdominoplasty-that was proven to be safe and effective and that improves body contour. The authors have been using lipoabdominoplasty since 2003 with excellent outcomes; however, some details have been added to improve significant shortcomings, including the lack of treatment of the pubic area and flanks, the presence of a high-position scar and, sometimes, a bulging inferior abdomen. METHODS: The authors retrospectively studied 348 patients who underwent lipoabdominoplasty with these related surgical improvements between January of 2010 and February of 2015. Improvements to the original surgical technique included deep liposuction in the lower abdomen, pubic liposuction, and liposuction of the flanks or dorsum with power-assisted liposuction, Scarpa fascia removal in the inferior abdomen, lipoplasty and mons lipolifting, and pubic fixation. RESULTS: Following these key points, superior flap slides to the pubic region by elongation of the vessels and nerves, preserving those structures, avoiding creation of a dead space, and reducing the number of the most common complications. Scarpa fascia removal in the infraumbilical region avoided bulging without increasing the seroma rate. Pubic lifting and its fixation promote rejuvenation of the entire region and avoid elevation of the remnant scar. CONCLUSION: These surgical modifications are safe and avoid common complications related to lipoabdominoplasty, with improved outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Buttock Lifting with Polypropylene Strips.

BACKGROUND: The purpose of this study was to evaluate the results of gluteal suspension with polypropylene strips. PATIENTS AND METHODS: Ninety healthy female patients between the ages of 20 and 50 years (mean, 26 years), who wished to remodel their buttocks from December 2004 to February 2013 were studied retrospectively. All 90 patients were treated with 2 strips of polypropylene on each buttock using the following procedures: 27 (30 %) patients were suspended with polypropylene strips; 63 (70 %) patients were treated with tumescent liposuction in the sacral "V", lower back, supragluteal regions, and flanks to improve buttocks contour (aspirated volume of fat from 350 to 800 cc); 16 (18 %) patients underwent fat grafting in the subcutaneous and intramuscular layers (up to 300 cc in each buttock to increase volume); 5 (6 %) patients received implants to increase volume; and 4 (4.4 %) patients underwent removal and relocation of intramuscular gluteal implants to improve esthetics. RESULTS: Over an 8-year period, 90 female patients underwent gluteal suspension surgeries. Good esthetic results without complications were obtained in 75 of 90 (84 %) cases. Complications occurred in 15 of 90 (16.6 %) patients, including strip removal due to postoperative pain in 1 (1.1 %) patient, and seroma in both subgluteal sulci in 3 (3.3 %) patients. CONCLUSION: The results of this study performed in 90 patients over 8 years showed that the suspension with polypropylene strips performed as a single procedure or in combination with other cosmetic methods helps to enhance and lift ptosed gluteal and paragluteal areas. LEVEL OF EVIDENCE IV: This journal requires that the 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.

Queimaduras elétricas por alta voltagem: cinco anos de análise epidemiológica e tratamento cirúrgico atualizado / High-voltage electrical burns: five-year epidemiological analysis and updated surgical treatment

INTRODUÇÃO: Avaliar cinco anos de análise epidemiológica e tratamento cirúrgico atualizado das queimaduras elétricas por alta voltagem. MÉTODOS: Foi realizado um estudo descritivo, retrospectivo de corte transversal, no Centro de Terapia de Queimados Dr. Oscar Plaisant, do Hospital Federal do Andaraí, Rio de Janeiro, Brasil, no período de janeiro de 2009 a dezembro de 2014. Foi aplicado um formulário nos prontuários dos 38 pacientes incluídos no estudo, a fim de avaliar as variáveis definidas. RESULTADOS: Foram analisados 38 pacientes por queimadura elétrica de alta voltagem, sendo 95% dos casos do sexo masculino, com faixa etária entre 21-42 anos. O local de ocorrência mais frequente foi o trabalho, em 55,3%. A porcentagem de SCQ variou de 1-60%. A parte do corpo mais acometida foi a mão esquerda, em 55,26%. O preparo pré-cirúgico para autoenxertia foi necessário em 34,21%, sendo a média de tempo transcorrido 37,5 dias, o tipo de tratamento cirúrgico foi desbridamento seriado sob anestesia geral em 100%, autoenxertia em 31,6%, amputação em 18,4% e fasciotomia em 5,3% dos pacientes. A taxa de óbito foi de 0%. CONCLUSÕES: O estudo observou que as queimaduras elétricas ocorrem mais frequentemente em adultos jovens no local de trabalho, portanto, é necessário desenvolver políticas de sensibilização para a segurança no local de trabalho. Apesar da gravidade da lesão, pacientes com suporte clínico adequado e avaliação cirúrgica precoce têm mais probabilidade de sobreviver, mesmo com altas taxas de amputação, confirmando a necessidade de mais pesquisas sobre a eletroporação.

INTRODUCTION: Evaluation of a 5-year epidemiological analysis and updated surgical treatment of high-voltage electrical burns. METHODS: A descriptive, retrospective cross-sectional study was conducted in the Center of Burn Treatment Dr. Oscar Plaisant, Federal Hospital of Andaraí, Rio de Janeiro, Brazil, from January 2009 to December 2014. A form was applied to the medical records of 38 patients included in the study in order to assess the defined variables. RESULTS: In total, 38 patients with high-voltage burns were evaluated, 95% of whom were men aged between 21 and 42 years. The most frequent place of occurrence was the workplace in 55.3% of cases. The percentage of burned total body surface area ranged from 1% to 60%. The most affected part of the body was the left hand in 55.26% cases. Presurgical preparation for self-grafting was necessary in 34.21% subjects, and the mean time elapsed was 37.5 days. The type of surgical treatment was serial debridement under general anesthesia in 100% of the patients, self-grafting in 31.6%, amputation in 18.4%, and fasciotomy in 5.3%. The mortality rate was 0%. CONCLUSIONS: The study indicated that electrical burns occur most often in young adults in the workplace; therefore, policies should be developed to raise safety awareness in the workplace. Despite the severity of the injury, patients with adequate clinical support and early surgical evaluation are more likely to survive, even with high rates of amputation, confirming the need for more research on electroporation.

Clinical and radiographic poland syndrome classification: a proposal.

BACKGROUND: Many chest wall deformities have a characteristic radiologic appearance that can be the basis for a definitive diagnosis. Consequently, imaging techniques have fundamental roles in the detection, location, and characterization of these disorders. OBJECTIVE: The authors propose a clinical and radiographic Poland syndrome (CRPS) classification system and possible treatment algorithm for the thoracic manifestations of Poland syndrome (PS) in women, based on both clinical examinations and imaging studies. METHODS: A retrospective study was conducted of 28 female patients evaluated over 17 years in the 28th Infirmary, Plastic and Reconstructive Surgery Division of the Hospital Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, Brazil. After clinical examination, all patients underwent radiographic examination with chest radiographs, conventional computed tomography scans, magnetic resonance imaging and, in some cases, additional imaging studies. All clinical and radiologic variables were compiled in a database and used in the classification system, which included three levels of disease severity. RESULTS: Based on the CRPS classification of the 28 female patients, 10 patients had first-degree PS, 14 patients had second-degree PS, and four patients had third-degree PS. Eighteen patients underwent surgical correction; a total of 39 surgical procedures were performed using the CRPS algorithm. CONCLUSIONS: Identification of the severity of PS using the proposed classification system provided an accurate study of each patient and enabled better planning for the surgical correction of functional and aesthetic deformities.

Breast reconstruction with parenchymal cross after giant lipoma removal.

Lipomas are benign tumors composed of mature fat, usually encapsulated. A literature review showed that the vast majority of lipomas are small, weighing only a few grams, and grow slowly. According to Hawary et al. (Ann Saudi Med 19(2):174-176, 1999) a giant breast lipoma is characterized by a lesion of at least 5 cm in one dimension and weighs more than 500 g. We present a rare case of a giant breast lipoma with slow growth over 22 years that compromised the entire hemithorax through the right iliac fossa. A 49-year-old woman was referred to our plastic surgery unit because of complaints of severe breast asymmetry due to an enormous mass in the right breast. Twenty-two years earlier she had noticed a soft, mobile, nonpulsatile mass in the inferior quadrant of her right breast. She did not look for medical treatment for all those years for fear of it being cancer. Ultrasound suggested a lipomatous lesion. Open mass biopsy revealed lipoma. The patient underwent a whole mass resection, reconstruction with a parenchymal cross flap, and left breast symmetrization with an inverted T technique. An excellent result with a high degree of patient satisfaction was achieved with the procedure. Parenchymal cross flaps seem to be an option in these situations.

Classification for indications of lipoabdominoplasty and its variations.

BACKGROUND: Lipoabdominoplasty, the combination of lipoplasty with classical abdominoplasty, presents new opportunities for the treatment of abdominal lipodystrophy. OBJECTIVE: The author analyzed 211 patients who underwent lipoabdominoplasty from 2000 to 2004. METHODS: After the preoperative physical examination, the patients were classified into 9 different groups according to the indications for the most appropriate technique in each case. Patient groups ranged from those presenting with mild fat panniculus and good quality skin to massive weight loss patients with a high degree of flaccidity. Techniques used in treating the various patient groups included lipoplasty alone, 3 variations of lipominiabdominoplasty, 4 variations of lipoabdominoplasty, and abdominoplasty alone. The surgical principles used in the variations of lipoabdominoplasty included dissection and sculpturing of the subcutaneous deep layer and superficial layer through lipoplasty, selective undermining and plication of the anterior rectus sheath, preservation of the perforator vessels, preservation of Scarpa's fascia and deep fat, skin resection, and umbilical transposition. RESULTS: Two hundred eleven patients were treated between January 2000 and May 2004. Results were good, with high patient satisfaction regardless of variations in technique. There was no loss of sensibility in the suprapubic region in any patients. Among patients who underwent lipoabdominoplasty, there were low complication rates of epidermolysis (1.5%), seroma (1%), hematoma (1%), and necrosis (0.1%). There was no incidence of seroma, necrosis, or hematoma in the lipominiabdominoplasty subgroups I and II; in subgroup III, there was a 2% incidence of necrosis. Seroma was noted in 2% of patients who underwent reverse lipominiabdominoplasty. Similar low complication rates were observed in other groups. CONCLUSIONS: The classification of lipoabdominoplasty indications offers good options for treatment of the abdominal region. Lipoplasty, selective undermining, and maintenance of Scarpa's fascia help reduce surgical trauma that is the main factor affecting hematoma and necrosis rates. The learning curve for these classifications is fast because the described procedures are already familiar to most plastic surgeons.

Síndrome de Parry-Romberg: avaliaçäo pós-operatória imediata: relato de caso / Parry-Romberg syndrom: postsurgical evaluation: case report

A Sindrome de Romberg ou Hemiatrofia Facial Progressiva é uma doença caracterizada por atrofia progressiva do tecido subcutâneo, ossos, músculos e nervos da face. Os autores descrevem um novo caso abordado terapêutica cirúrgica e aspectos clínicos da síndrome

Eficácia do açucar, colagenase e nitrofurazona no tratamento das infecçöes incisionais: estudo experimental em camundongos / The efficacy of sugar, colagenase and nitrofurazone used in infections of the surgical wound: experimental study on mices

O presente estudo objetivou verificar a eficácia de agentes tópicos comumente utilizados no tratamento das infecçöes da ferida operatória e sua possível interferência no processo cicatricial. Foram utilizados 48 camundongos suiços (Mus musculus) em idade adulta, com peso médio de 24 g. Os animais foram divididos em 2 grupos distintos, sendo no primeiro realizado uma iancisäo padronizada no dorso, inoculando-se a seguir uma cepa de Staphylococcus aureus (ATTC 6538), numa concentraçäo de 10.6 colônias por unidade (CPU). Num segundo grupo com igual número de animais foi realizada uma incisäo circular no dorso e implantada no tecido subcutâneo uma esponja de celulose. Os animais foram subdivididos em 4 subgrupos com 6 animais cada, de acordo com o tratamento administrado: soro fisiológico (controle), nitrofurazona, açucar e colagenase. O diâmetro da ferida foi mensurado diariamente. A secreçäo proveniente das feridas foi colhida no pós-operatório imediato, 3º, 7º e 14º dias de tratamento, 3 animais de cada subgrupo foram sacrificados e realizado exame histopatológico da área de lesäo. Nos animais implantados, na mesma ocasiäo foi removida a esponja e feita análise bioquímica. Com os dados obtidos procedeu-se a avaliaçäo estatística. Foi verificada rápida resoluçäo do processo infeccioso sem interferência no processo cicatricial nos grupos tratados com açucar e colagenase (p<0,05). Nossos resultados sugerem a seguinte ordem crescente de erradicaçäo da infecçäo sem interferência com a cicatrizaçäo: açucar, colagenase e nitrofurazona (p<0,05)

Eficácia dos agentes tópicos no tratamento das infecções incisionais: estudo experimental em camundongos / Efficacy of topical agents in the treatment of surgical site infections: an experimental study in mice

O presente estudo objetivou verificar a eficácia de agentes tópicos comumente utilizados no tratamento das infecções da ferida operatória e sua possível interferência no processo cicatricial. Foram utilizados 84 camundongos suiços em idade adulta, com peso médio de 24 g. Os animais foram divididos em dois grupos distintos, sendo no primeirto realizado uma incisão padronizada no dorso, inoculando-se a seguir uma cepa de Staphilococcus aureus (ATCC 6538), numa concentração de 10 colônias por unidade (CPU). Num segundo grupo com igual número de animais foi realizada uma incisão circular no dorso e implantada no tecido subcutâneo uma esponja de celulose...Nossos resultados sugerem a seguinte ordem crescente de erradicação da infeccção sem interferência com a cicatrização: açucar e colagenase, clorexidina, nitrofurazona e por último polivinilpirrolidona-iodado e mercuro-cromo (p,0,05).

Interferência do uso de soluçöes de polivinil-pirrolidona-iodo no processo cicatricial: estudo experimental em camundongos / The interference of the topical solution of polyvinyl-pyrrolidon-iodine (PVPI) on the incidence on the normal wound repair: experimental study mices

Fundamentos: A eficácia da terapêutica antisséptica tópica, para feridas e úlceras cutâneas, associa-se å reduçåo da funçåo fibroblástica e, em geral, do processo cicatricial. O polivinnil-pirrolidona-iodo (PVPI) tem sido reconhecido como uma substância desinfetante por quase meio século, com uma extensa e aplicaçåo no tratamento de infecçöes dermatológicas e cirúrgicas. Objetivos: O propósito deste estudo foi determinar o impacto do uso da soluçåo tópica do PVPI na incidência de infecçåo pós-operatória e no processo normal de cicatrizaçåo. Método: Efetuou-se uma incisåo de 2 cm2 no dorso de 40 camundongos suíços (Mus musculus). Quatro combinaçöes de soluçöes antissépticas foram utilizadas na irrigaçåo pós-operatória das feridas cirurgicas: (a) soluçåo de PVPI a 0,1 por cento, (b) soluçåo de PVPI a 1 por cento e (c) soluçåo de PVPI A 10 POR CENTO. O grupo de controle recebeu irrigaçåo com soluçåo fisiológica (NaCl 0,9 por cento). A área das incisöes cirúrgicas foi medida diaramente. O antibiograma foi efetuado, em todos os grupos, no pós-operatório imediato e após o 3§, 7§, 11§ e 14§ dias. Resultados: A área da ferida cirúrgica do grupo C foi significativamente maior (p<0,05) que nos demais grupos, após o 7§ e 14§ dias de tratamento. O processo cicatricial deu-se de forma mais efetiva no grupo controle. Avaliaçåo histopatológica da borda da incisåo cirúrgica do grupo C demosntrou a presença de um infiltrado inflamatório extenso com reduçåo do número de fibroblastos dérmicos. Conclusöes: Baixas concentraçöes do PVPI e da soluçåo fisiológica podem ser utilizados como agentes antibacterianos tópicos, no tratamento de feridas cirúrgicas e úlceras cutâneas, sem inibir a atividade fibroblástica, essencial para o processo cicatricial. A soluçåo de PVPI a 10 por cento demonstrou ser uma soluçåo desmasiadamente irritante na antissepsia tópica

Paquidermoperiostose / Pachydermoperiostosis

Paquidermoperiostose é uma síndrome caracterizada por baqueteamento dos dedos, neoformaçao perióstea em extremidades de ossos longos, além de espessamento, enrugamento e oleosidade da pele da face e couro cabeludo. Os autores descrevem um novo caso e abordam aspecto históricos, clínicos e histopatológicos da moléstia.