Comparison of Outcomes in Immediate Implant-Based Breast Reconstruction: Acellular Dermal Matrix versus Inferior Dermal Flap.

Background Implant-based breast reconstruction has evolved tremendously in the last decades, mainly due to the development of new products and techniques that make the procedure safer and more reliable. The purpose of this study was to compare the outcomes in immediate one-stage breast reconstruction between acellular dermal matrix (ADM) and inferior dermal flap (IDF). Methods We conducted a retrospective comparative study of patients submitted to immediate breast reconstructions with an anatomical implant and ADM or IDF in a single center between 2016 and 2018. Outcomes evaluated included major complications, early complications, reinterventions, readmissions, and reconstruction failure. Simple descriptive statistics and univariate analysis were performed. Results A total of 118 breast reconstructions (85 patients) were included in the analysis. Patients in the IDF group had a higher body mass index (median = 27.0) than patients in the ADM group (median = 24). There were no statistically significant differences among both groups regarding immediate major complication, early complications, readmissions, and reinterventions. Conclusion There are no significant differences in complications between the ADM and IDF approach to immediate implant breast reconstruction. In patients with higher body mass index and large, ptotic breasts, we recommend an immediate implant reconstruction with IDF.

Impact of Body Mass Index, Age and Tobacco Use on the Outcomes of Immediate Breast Reconstruction with Implants and Acellular Dermal Matrix.

Background This study aimed to analyze the effect of body mass index (BMI), age, and tobacco use on alloplastic breast reconstruction. Methods We conducted a retrospective study of patients who submitted to immediate breast reconstructions with an anatomical implant and acellular dermal matrix in a single center between 2016 and 2018. Outcomes evaluated included immediate complications, early complications, reinterventions, readmissions, and reconstruction failure. Patients were divided into two groups concerning each potential risk factor (BMI < or ≥25; age < or ≥ 50 years; and smokers vs nonsmokers). Simple descriptive statistics and univariate analysis were performed. Results A total of 101 breast reconstructions (73 patients) were included in the analysis. The mean BMI was 24, and the mean age was 44.5 years old. Smokers accounted for 14 breast reconstructions (13.9%). The rate of early infections, mastectomy flap necrosis, and implant removal was significantly higher in overweight patients. The total volume of breast drainage was higher in the age ≥ 50 years group. Smoking did not alter the outcomes. Conclusions A BMI ≥ 25 is a risk factor for early infections and reconstructive failure. Age ≥ 50 years is associated with a higher volume of breast drainage but does not seem to impact the success of the reconstruction. Smoking does not appear to affect the outcomes significantly in this type of reconstruction. Surgeons should consider delaying the reconstruction or using autologous tissue when patients are overweight.

Giant chondrosarcoma of the chest wall: a rare surgical challenge.

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning-sparing key reconstructive options without compromising the tumor resection-allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Giant chondrosarcoma of the chest wall: a rare surgical challenge

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning—sparing key reconstructive options without compromising the tumor resection—allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

The use of forearm free fillet flap in traumatic upper extremity amputations.

BACKGROUND: Complete traumatic upper extremity avulsions are an infrequent but devastating injury. These injuries are usually the result of massive blunt trauma to the upper limb. Intact issue from amputated or nonsalvageable limbs may be transferred for reconstruction of complex defects resulting from trauma when the indications for replantation are not met. This strategy allows preservation of stump length or coverage of exposed joints, and provides free flap harvest for reconstruction without additional donor-site morbidity. METHODS: A retrospective review at São João Hospital was performed on seven patients who had undergone immediate reconstruction with forearm free fillet flaps between 1992 and 2007. RESULTS: There were six men and one woman, with patient age ranging from 17 to 74 years (mean, 41 years). Amputation sites were at the humeral neck (n = 1), at the humeral shaft (n = 5), and below the elbow (n = 1). The area of the forearm free fillet flap skin paddle was 352.14 +/- 145.48 cm (mean +/- SD). The two major complications were the flap loss and the patient death on postoperative day 3 in other case. The postoperative course in the remaining five cases was uneventful with good healing of the wounds. Minor complications included two small residual defects treated by split-thickness skin grafting and one wound infection requiring drainage and revision. CONCLUSIONS: The forearm free fillet flap harvested from the amputated limb provides reliable and robust tissue for reconstruction of large defects of the residual limb without additional donor-site morbidity. Microsurgical free fillet flap transfer to amputation sites is valuable for achieving wound closure, improving stump durability, and maximizing function via preservation of length.

Repair of a full-thickness abdominal wall defect with an innervated latissimus dorsi free flap.

A 38-year-old man developed an infection that led to necrosis of the abdominal wall after perforation of a gastric ulcer. A split-thickness skin graft over the abdominal viscera was used to achieve temporary primary closure. After full systemic and local stabilisation, it was reconstructed with a free innervated latissimus dorsi myocutaneous flap.

Retrospective study of 1251 maxillofacial fractures in children and adolescents.

BACKGROUND: Fractures of the facial skeleton are relatively uncommon in children and adolescents, and only a few reports review a significant number of patients. The authors performed a retrospective study to analyze the different characteristics of such fractures in the pediatric population of Portugal. METHODS: The authors reviewed the clinical records of a series of 912 patients 18 years of age or younger with facial fractures treated by the Departments of Plastic, Reconstructive, and Aesthetic Surgery and of Maxillofacial Surgery, São João Hospital, in Porto, Portugal, between the years 1993 and 2002. The following parameters were evaluated: age; sex; cause of accident; hour, day, and month of hospital admission; location and type of fractures; presence and location of associated injuries; treatment methods; length of in-hospital stay; and complications. RESULTS: A total of 1251 fractures were treated. The ratio of boys to girls was 3.1:1. Patients between 16 and 18 years old were the major group (47.8 percent). Motor vehicle accident was the most common cause of injury (53.3 percent of patients). Mandibular fracture was the most common type of fracture (48.8 percent). Associated injuries occurred in 558 patients (64.5 percent). CONCLUSIONS: Pediatric facial fractures are usually associated with severe trauma. The number of fractures caused by automobile accidents has decreased (p < 0.05). The incidence of this type of fracture is high in Portugal.

Osteofasciocutaneous flap based on the dorsal ulnar artery. A new option for reconstruction of composite hand defects.

Since the initial description of the dorsal ulnar artery fasciocutaneous flap by Becker and Gilbert in 1988 many modifications have been introduced to allow more versatility to the flap. The authors describe the dissection technique of an osteofasciocutaneous flap based on the dorsal ulnar artery and present a clinical case where this flap has been used to reconstruct a bone defect of the fifth metacarpal. Up to one third of the outer cortex of a long bone is supplied by the periosteal arterioles. This permits the inclusion of a small amount of ulnar cortical bone in the dorsal ulnar flap to reconstruct compound defects of the hand. The essential precaution is not to disrupt the continuity formed by the posterior border of the ulna, the periosteum, bony attachments of the flexor carpi ulnaris and extensor carpi ulnaris muscles, fascia and the skin. This flap allows the transposition of optimal soft tissue coverage to the hand with vascularised bone preserving the main arteries to the hand.

A new retroauricular flap for facial reconstruction.

A retroauricular reverse flow flap based on the anastomosis of the frontal branch of the temporal superficial artery with the corresponding vessel of the opposite side as well as with the ipsilateral supraorbital and supratrochlear arteries, was used in two clinical cases for forehead and facial reconstructions. The arc of rotation associated with the length of the pedicle allows its transfer, in a one-stage procedure, to cover small to medium defects of any part of the forehead, face and parts of the scalp. The procedure is safe, simple and causes minimum donor site morbidity.

Tuberous breast: a surgical challenge.

Since the presentation of the tuberous breast deformity by Rees and Aston in 1976, many surgical procedures have been developed, but the correction of such a deformity still remains a surgical challenge. The authors report the last cases treated in the Department of Plastic and Reconstructive Surgery of São João Hospital-Porto and discuss about the ideal procedure which should be used according to the type of deformity. They emphasize the periareolar approach and the good results obtained by the Liacyr Ribeiro technique.