Transplant of an autologous platelet gel prosthesis to fill defects after tumor excision.

BACKGROUND: Tumor excision causes disfigurement in the breast. We present our technique for filling the defect with activated platelet gel, thus avoiding the deformity. METHODS: Between 2006 and 2011, 23 patients (age range, 45-72 years) underwent tumorectomy for breast cancer. After estimating and extracting the volume of blood required, we centrifuged the blood at 1800 rpm for 8 minutes. Later, the middle and lower thirds of the plasma) were separated and activated with CaCl2 at a ratio of 1/20, forming a gel, which was used to fill the tumorectomy cavity. RESULTS: Imaging tests (ultrasound, mammography, and magnetic resonance imaging) performed 12 months after surgery revealed scar tissue in the area where the autoprosthesis had been inserted. Magnetic resonance imaging showed no retraction or deformity in the skin silhouette. Histology study after 1 year demonstrated that the platelet gel had been replaced by fibrous scar tissue with dense collagen and the presence of small capillary vessels. Patients recorded high rates of satisfaction. CONCLUSIONS: This technique maintains the shape and volume of the breast, avoiding deformities and retractions of the nipple areola complex by filling the defect with an autoprosthesis. After 12 months, the autoprosthesis had been replaced by fibrous tissue and dense collagen. Postoperative control was good, and the effectiveness of adjuvant radiotherapy or chemotherapy was not altered. No cases of tumor relapse were recorded. On palpation, consistency and softness were similar to that of breast tissue. The aesthetic results were highly satisfactory.

Endoscopic reconstruction of partial mastectomy defects using latissimus dorsi muscle flap without causing scars on the back.

BACKGROUND: Results obtained with breast-conserving therapy are not always satisfactory. Reconstruction with a pure latissimus dorsi muscle flap is a useful option. The techniques described for endoscopic dissection of the flap create several scars on the back. As a result, they do not improve on the open approach, which causes a horizontal scar at the level of the bra strap. The authors' technique avoids all scars on the back using a single incision in the highest folds of the axilla, which also is used for the sentinel node biopsy or lymphadectomy and quadrantectomy. METHODS: The study was performed with 23 patients. The tumor was extracted via a clockwise downward periareolar incision and via another incision in a fold of the axilla. Through this axillary incision, the sentinel lymph node biopsy or lymphadectomy was performed, and the external part of the latissimus dorsi muscle was harvested endoscopically for the reconstruction. RESULTS: Both the medical team and the patients reported high satisfaction with the aesthetic and functional results due to the preservation of the breast shape and the absence of any scarring on the back. CONCLUSION: Endoscopy-assisted techniques make either three small scars on the back or one long scar, with the muscle sectioned distally, or a vertical incision in the midaxillary line, which may form a hypertrophic or keloid scar. The authors' approach avoids the creation of these scars on the back because the endoscopy and the distal sectioning of the muscle flap are performed through the single axillary incision.

Endoscopically assisted aesthetic augmentation of tuberous breasts and fat grafting to correct the double bubble.

BACKGROUND: Treatment of tuberous breasts types 1 and 2 must deal with the problem of the pseudo-double bubble in the primitive inframammary fold and also must release the constrictive ring. Two techniques currently are used to overcome these problems, but neither is entirely satisfactory. The first technique, in which the approach is via the primitive inframammary fold, leaves significant scarring when the lower poles expand. The second technique, in which the approach is periareolar, considerably reduces the area's sensitivity. This report presents a new endoscopically assisted technique with an axillary approach designed to solve these problems. METHODS: Between 2005 and 2010, 68 patients (ages 18-42 years) underwent surgery. The intervention was bilateral in 57 and unilateral in 11 of these patients. All cases involved tuberous breasts types 1 and 2 (Grolleau's classification). The augmentation involves a transaxillary subfascial endoscopic approach, opening of the fascia at the primitive inframammary fold, and releasing of the constricting ring to enable the breast to expand, followed by implantation of an anatomic prosthesis to add volume to the lower quadrants. If the pseudo-double bubble appears, fat grafting is applied during the same surgical procedure. RESULTS: The results were reported to be highly satisfactory both by the patients and by the independent medical team. For six patients (8.82 %), fat grafting had to be repeated in the double bubble. No major complications were reported. CONCLUSION: The endoscopically assisted subfascial breast augmentation technique obtains highly satisfactory results in tuberous breasts types 1 and 2 (Grolleau's classification). The single scar is concealed in the axillary fold. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Breast reconstruction with fat grafting alone.

We describe our technique for breast reconstruction using fat grafting alone in patients with flaccid, elastic skin, via multiple injections of fat tissue. The technique involves following 3 stages: puckering stitches, to remodel the mass each time fat grafting is performed; cone formation-pexia, the creation and lifting of a cone with the tissue from the area; and neoformation of the inframammary fold, in which the cone is anchored in the pectoralis major and the fold at the level of the sixth rib. Using fat grafting and these 3 maneuvers, we obtain satisfactory breast reconstruction.

Periorbital rejuvenation to improve the negative vector with blepharoplasty and fat grafting in the malar area.

PURPOSE: Periorbital rejuvenation is not achieved by upper and lower blepharoplasty alone; the presence of malar atrophy and the excessive length of the lower eyelid may change the face's oval shape, with the progressive formation of the negative vector. We describe our technique combining blepharoplasty and malar fat grafting to reverse the negative vector. METHODS: After thorough anamnesis, we perform the blepharoplasty and canthopexy if necessary. In the upper blepharoplasty, we do not extirpate muscle, and in the lower blepharoplasty, we extirpate the fat pads via the transconjunctival route. In the case of excess skin, we prefer to perform skin pinching without resecting muscle, followed by a canthopexy. We then perform malar fat grafting by using fat obtained with low to moderate-pressure aspiration and centrifugation, injected with criss-cross tunnels in the malar region with a volume of 7 to 12 cm3 of fat on each side. RESULTS: Between 2006 and 2010, we operated on 142 female patients (age range, 45-74 years). The follow-up period was 2 years. In patients with "good fat quality" (n = 129), the results at 24 months were "excellent" in 93.79% of cases, "good" in 3.8%, and "fair" in 2.32%. The medical team's ratings were "excellent" in 97.6% of cases and "good" in 2.3%. In patients with "poor fat quality" (n = 13) at 12 months, a high percentage of the injected fat had been reabsorbed. The application of high-density hyaluronic acid was recommended (16). CONCLUSION: Periorbital rejuvenation is a part of integral facial rejuvenation and is achieved only if, in addition to the blepharoplasty, the negative vector is also corrected. With the technique of malar fat grafting, we achieve very good remodeling of the oval face shape, correct the negative vector, and shorten the height of the eyelid; the preadipocytes improve the tissue quality, especially in the skin.

Mucosal perforators from the facial artery.

The cutaneous perforators of the facial artery have been well described, but to our knowledge the oral mucosal perforators have not. We studied 10 facial arteries from 10 hemifaces in 5 cadavers. The arteries were injected with latex, and we studied all perforators that extended from the facial artery and headed directly to the oral mucosa. The diameter and length of the facial artery and its mucosal perforators were measured and compared. We found 52 oral mucosal perforators in the 10 facial arteries injected with latex. Their mean (SD) diameter was 0.5 (0.2) mm and the mean (SD) number/facial artery was 5.2 (1.1). Their mean (SD) length was 16.4 (5.3) mm. Most of those to the cheek were localised between the branching-off points of the inferior and superior labial arteries. The facial artery has perforators to the oral mucosa of the cheek, most of them between the points at which the labial arteries emerge.

Cutaneous perforators of the fourth dorsal interosseous space: anatomic study.

PURPOSE: Many investigators have studied the vascular anatomy of the dorsal metacarpal arteries but little attention has been paid to the exact distribution of the cutaneous perforators of the dorsum of the hand. We present an anatomic study of the cutaneous perforators within the fourth dorsal interosseous space, which was supposed to have the most inconsistent vascular anatomy. METHODS: Twenty hands were dissected after black latex injection. A skin paddle was outlined along the fourth dorsal metacarpal space. Suprafascial dissection was performed, preserving any vessel piercing the fascia and reaching the skin. Each perforator was traced back to its origin. The location and origin of each perforator was recorded by digital pictures and measured from a reference point. RESULTS: In 17 of the cases (85%) at least 1 perforator was identified within the fourth space piercing the dorsal interosseous muscle fascia and reaching the skin. In 10 hands, a perforator branching off the proximal communicating branch was identified, located a mean distance of 11 mm from the carpometacarpal joint line. CONCLUSIONS: A dissectable perforator was found consistently (17 of 20; 85%) in the proximal third of the fourth dorsal interosseous space branching off the proximal communicating branch. Few perforators branch off the middle third of the dorsal metacarpal artery. The perforator described herein shows the connection between the superficial and deep vascular systems of the ring and small metacarpal spaces, and establishes the anatomic basis for reconstructive flaps.

The anatomic basis of the fourth dorsal metacarpal flap: a cadaveric dissection.

PURPOSE: To study the vascularization of the fourth dorsal intermetacarpal space and to determine the contribution of the dorsal metacarpal artery and the interosseous muscle fascia to flap viability. The fourth dorsal intermetacarpal space is considered to be less reliable as a donor site because of previously reported vascular variations. METHODS: We performed 15 cadaver dissections. The vascular tree was injected with black latex through the radial and ulnar arteries at the forearm. The skin paddle was designed within the fourth intermetacarpal space. The proximal border was placed at the wrist joint line. The distal border was located 1 cm proximal to the head of the fourth and fifth metacarpal. The width of the skin paddle was based on whether the donor site could be closed directly. A zigzag incision was performed from the distal end of the skin paddle to the volar edge of the interdigital web. The borders of the skin paddle were outlined down to the fascia of the dorsal interosseous muscle. Once the fourth dorsal metacarpal artery was identified each vascular connection was dissected and recorded. RESULTS: The fourth dorsal metacarpal artery was identified in all specimens under the dorsal interosseous muscle fascia. The distal recurrent branch consistently entered the base of the flap superficial to the extensor digitorum communis tendon of the small finger and the dorsal interosseous muscle fascia. Cutaneous perforators branching off the dorsal metacarpal artery were not found consistently. CONCLUSIONS: Reliable flaps can be raised from the fourth dorsal intermetacarpal space based solely on the distal recurrent branch, excluding the dorsal metacarpal artery and interosseous muscle fascia.

Intense pulsed light for hairy grafts and flaps.

BACKGROUND: Intense pulsed light (IPL) is an effective and safe method of hair removal. OBJECTIVE: To evaluate the clinical response of hairy grafts and flaps of different anatomic areas to an IPL source. METHODS: Four patients (three men, one woman; 17-72 years old) with hairy skin grafts (n = 2) or flaps (n = 2) were included. Donor skin areas included the forehead (n = 1), supraclavicular (n = 1), abdomen (n = 1), and groin (n = 1). Excisional surgery was performed because of basal cell carcinoma (BCC) of the nasal wall (n = 1), squamous cell carcinoma (SCC) of the forehead (n = 1), congenital nevus of the malar region (n = 1), and breast carcinoma (n = 1). The treatment was IPL with the following parameters: wavelength 695-755 nm, pulse width 3.8-4.5 msec, delay 20-30 msec, spot size 10 mm x 45 mm, fluence 38-42 J/cm2, and an interval of 4 weeks. A total of one to six treatment sessions were administered. RESULTS: A progressive decrease in terminal hair and delayed hair growth rate (more than 8 months) were observed in all the patients. Improvement of skin coarseness, pigmentation, and erythema was also observed in the graft and its periphery in one patient. Persistent erythema (more than 48 hours) was the only side effect, observed in one patient. CONCLUSION: IPL is an effective method to depilate hairy grafts and flaps.

XXXI Congreso Nacional de la Sociedad Española de Senología y Patología Mamaria / No disponible

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