What is the Process for Breast Implant Manufacturing? Inside Eight Breast Implant Factories.

BACKGROUND: With the recent association between breast implants and anaplastic large cell lymphoma, breast implants have become the focus of many warnings. Surgeons and health professionals are not involved in all the processes of the manufacturing and distribution of this product. Not all countries have breast implant factories that are easy for surgeons to visit and better understand the manufacturing process. METHODS: A questionnaire about breast implant manufacturing and distribution was validated in consensus and form. Two plastic surgeons visited eight factories and administered the questionnaire in the presence of a photographer, who documented that the questionnaire was answered in the same way for all visits. Once the visitors finished obtaining the information (questionnaire responses and video recording), this information was validated by a different member of a safety committee in Mexico. For the observations to be considered valid, the information from the questionnaire and the video must be presented. RESULTS: We visited eight factories: three in France (Sebbin, Arion and Eurosilicone), two in Costa Rica (Allergan and Motiva), one in Scotland (Nagor), one in Germany (Polytech) and one in Korea (Bellagel). In four factories (Eurosilicone, Motiva, Nagor and Sebbin), the information on the process for manufacturing an implant was observed and recorded (validated). The quality laboratory was visited, and video recording was performed in six factories (Bellagel, Eurosilicone, Motiva, Nagor, Polytech and Sebbin). CONCLUSION: It was possible to observe and verify that most of the companies that distribute breast implants in Mexico perform their manufacturing processes according to ISO standards. A breast implant registry can help people further understand how BIA-ALCL will behave in the future and allow more tests to better understand this pathology. LEVEL OF EVIDENCE V: 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 .

What is the Evidence of Lymphoma in Patients with Prostheses Other Than Breast Implants?

INTRODUCTION: Medical devices such as hip, knee, breast, vascular prostheses, among others, are very useful in different pathologies. We cannot doubt that their use is a great tool, besides being an advance in medicine; they provide a change in the quality of life of many patients; however, they are not exempt from adverse reactions and events. METHODS: We conduct a systematic review about lymphoma in the presences of prostheses other than breast implants. RESULTS: We selected 21 publications with a total of 24 patients. The largest number of prostheses was related to long bones in a total of 13 prostheses. The most frequent symptoms were: pain (52%), inflammation (24%), visible or palpable mass 20%. The most frequent type of lymphoma was non-Hodgkin B cell lymphoma in 14 cases. DISCUSSION: The presence of microparticles make biological degradation and wear of the implants, with macrophage and lymphocyte activation and the consequent production of proinflammatory cytokines such as tumor necrosis factor α, interleukin-1ß, interleukin-6, and prostaglandin 2 (PGE2). CONCLUSION: Lymphoma is not a common disease in patients with prostheses, and more data are needed to identify risk factors and make proper diagnoses. LEVEL OF EVIDENCE III: 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.

Is Plastic Surgery Combined with Obstetrical Procedures Safe?

In the existing reports on combined procedures of abdominoplasty with Cesarean section or natural delivery, a high incidence of complications and poor aesthetic results are reported. We conducted a survey with the participation of 61 plastic surgeons who performed this procedure in 808 patients, with an average of 13.24 procedures per surgeon. In 783 procedures (96.9% of the cases), the combination was with Cesarean section and 25 procedures (3.13% of cases) were combined with vaginal delivery. The plastic surgery procedures were as follows: 242 abdominoplasty procedures (29.95%), 210 abdominoplasty plus liposuction procedures (25.99%), 18 mini abdominoplasty procedures (2.22%), 121 mini abdominoplasty and liposuction procedures (14.97%), and 217 liposuction procedures (26.85%). The following complications were reported: seroma in 255 cases (31.57%), thrombosis in 212 (26.23%), infection in 170 (21.03%), skin necrosis in 127 (15.71%), and hematoma in 42 (5.19%). There were three deaths due to thrombosis (0.4%). There were redundancy skin abdominal wall defects in 336 (41.66%) cases, unaesthetic scars in 291 (36.11%), abdominal wall defects in 134 (16.58%), unpleasant contours in 22 (2.72%), and rotational folds in 22 (2.72%). Fifty-five (90.16%) surgeons decided to stop delivering babies with these practices. The combination of abdominoplasty with Cesarean section or natural delivery has a high incidence of complications and poor aesthetic results; therefore, we make a strong recommendation to avoid this practice before the patient reaches sixth month postpartum.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 .

Searching for the Best Way to Assess the Risk of Thrombosis in Aesthetic Plastic Surgery; The Role of the Caprini/Pannucci Score.

INTRODUCTION: There is concern regarding the high incidence of thrombosis in plastic surgery patients. For this reason, we wanted to compare the results of the Caprini/Pannucci score in patients with and without a past history of thrombosis admitted for aesthetic plastic surgery. METHODS: This was a case-control study of 152 patients undergoing aesthetic plastic surgery procedures. We formed two groups: Group I had 70 patients who had thrombosis after aesthetic plastic surgery and group II had 82 patients without thrombosis. We studied the considered risk factors for thrombosis. We weighted the factors according to the OR and linear regressions. We then related them to the Caprini/Pannucci score. RESULTS: Patients in group I had a score of 5.68 versus 3.45 in group II (p < 0.001). There was a 9.86% increase in thrombosis for each increased point in the rating. A higher effectiveness of the Caprini score was found in the high-score group; the greatest flaw was in the low-scoring group. The sensitivity was 75.71%, and the specificity was 70.73%. The factors with the greatest impact were the infiltration of fat in the buttocks, degree of obesity and time of surgery. There was an increased risk of thrombosis in patients with gluteal fat injections, varicose veins, obesity and immune disorders as well as those who had previously given birth. CONCLUSION: To increase the effectiveness of the score and to use the score as a basis on which to decide upon prophylactic care, it is necessary to modify the score and add some factors. LEVEL OF EVIDENCE III: 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 .

Macro Fat Embolism After Gluteal Augmentation With Fat: First Survival Case Report.

Gluteal augmentation with fat has become one of the most common cosmetic procedures worldwide. Gluteal augmentation is designed to increase the volume and contour of the gluteal region. Intramuscular lipoinjection has been linked to multiple reports of severe complications, including death due to macro fat embolism (MAFE). The authors present the first reported case of survival and successful recovery after MAFE secondary to gluteal augmentation with fat. A 41-year-old woman, ASA II, was scheduled for augmentation mammaplasty, liposuction, and gluteal augmentation with fat. The patient was operated under general anesthesia with a total intravenous anesthesia technique. A total of 3.5 liters of fat was liposuctioned with no complications. The patient was then positioned in a lateral decubitus position for gluteal augmentation with fat. Right after the last injection, the anesthesiologist noticed a sudden change in capnography followed by hypotension, bradycardia, and hypoxemia. The first reaction in the operating room was to consider that the patient was experiencing a severe episode of fat embolism. She was then resuscitated and transferred to a tertiary facility for intensive care management. To our knowledge, this is the first case report of successful resuscitation in a patient experiencing severe MAFE after gluteal augmentation with fat. We believe that this patient survived the event due to early detection, aggressive management, and proper transfer to an intensive care unit. Level of Evidence: 5.

Is Latin America Ready to Identify Anaplastic Large Cell Lymphoma in Breast Implants Patients? Regional Encounter During the National Plastic Surgery Meeting in Cancun, Mexico.

INTRODUCTION: Anaplastic large cell lymphoma associated with breast implants is receiving increased attention. Most cases have been reported in Europe, North America (USA and Canada), Australia and New Zealand. Fewer cases have been reported in Latin America (including Mexico), Africa and Asia. METHODS: This report was delivered during our national plastic surgery meeting in Cancun in May 2017. Before the meeting, two participants reviewed the literature. The review was performed using the following information sources: PubMed, Embase, Cochrane, Fisterra, Google Scholar and LILACS, with entries from 1980 to August 2015 in several languages (English, Spanish, French and Portuguese). The results were revealed during the meeting to the other participants. The consensus was divided into two parts. The first part included an open-ended question regarding the incidence and prevalence of the problem. The second part included clinical scenarios with different items that were rated by the participants. After this activity, accordance among the responses was evaluated. RESULTS: Seven cases were reported during the meeting (3 from Mexico, 3 from Chile and 1 from Argentina). Fifty percent of the participants reported consulting with guidelines and clinical centers to help with potential cases. Most agreed that further studies must be done in cases of chronic seroma where the capsule plays an important role. DISCUSSION: A current debate exists about the incidence of this problem in Latin America because we did not report the same number of cases as Europe, Australia or North America. More studies are required to determine the differences among reports in Latin America. CONCLUSION: Most representatives agreed that further studies must be done. Concern is increasing, and the problem is known. Other factors involved may be considered, and the problem must not be ignored. NO LEVEL ASSIGNED: 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 .

Morbidity induced by the infiltration of foreign substances into the buttocks: A systematic review.

The infiltration of substances into the buttocks for esthetic purposes can cause local or systemic damage. These infiltrated substances, known as adjuvants, foreign substances, and polymers, often lack sufficient and frequently controversial evidence. To identify the systemic complications associated with substances locally infiltrated in the buttocks for treatment, we conducted a systematic review following the PRISMA criteria. Of 275 publications, 29 met the eligibility criteria: 3 systematic reviews, 6 case series, and 20 case reports. The study comprises 463 cases, mainly women (87%), with an average age of 39.94 years. The average time between infiltrations was 7.65 years. Infiltrated substances included silicone, oils, methyl methacrylate, guaiacol, sodium gadolinium, collagen, paraffin, and other unknown substances. The complications fell into three categories: local, systemic with inflammatory-immune response, and renal damage due to hypercalcemia induced by the granulomatosis caused by the substance. Treatment lacked uniformity, mainly focusing on the main effect. Surgical resection of affected tissue resulted in local and systemic improvement (renal, hypercalcemia, or inflammatory-immune) for most patients. Patients who received comprehensive treatment based on inflammatory-immune control, control of renal involvement, and resection of the tissue area that contained large amounts of the infiltrated substance had a better prognosis than those with diffuse infiltration and delayed treatment.

Face transplant: is it feasible in developing countries?

This article is based on the case of a 28-year-old woman who was involved in a car accident, with diagnosis of polytrauma, loss of left eye, and second- and third-degree burns over the left midface, rendering an exposed area of 8 cm wide and 19 cm length, ranging from glabella to mandible, with skull exposure and loss of left eye.A latissimus dorsi musculocutaneous free flap was transferred into the defect; left eye and nose prosthetics were necessary to restore normal appearance. Excellent results were obtained; reinsertion to patient's normal life and reinstatement of facial appearance were achieved with minimal costs and no postsurgical complications.Analysis of the current situation in developing countries demonstrates that technique and infrastructure do not represent a real challenge to carry on face transplants. However, socioeconomic reality in these societies makes it difficult to establish face transplant as a feasible therapeutic opportunity for the overwhelming majority of patients who are victims of severe facial damage.Therefore, strategies such as latissimus dorsi free flap remains as an excellent therapy to face off our complex facial reconstructive challenges in developing countries such as Mexico.

How to stratify the risk of thrombosis for esthetic plastic surgery? The proposal of a new scale.

Scales to qualify the risk of thrombosis do not include all thrombogenic factors that are generated in esthetic plastic surgery. Methods: We performed a systematic review to assess the risk of thrombosis in plastic surgery. Thrombogenic factors in esthetic surgery were analyzed by a panel of experts. We proposed a scale with 2 versions. In the first version, factors were stratified according to their impact on the possible risk of thrombosis. The second version includes the same factors but in a simplified form. We evaluated the efficacy of the proposed scale by comparing it with the Caprini score; we scored the risk in 124 cases and controls. Results: Using the Caprini score, we found that 81.45% of the patients studied and 62.5% of the cases of thrombosis were observed in the low-risk group. Only 1 case of thrombosis was reported in the high-risk group. Using the stratified version of the scale, we found that the low-risk group comprised 25% of the patients, and there were no cases of thrombosis. The high-risk group included 14.51% of patients; 10 presented thrombosis (62.5%). The proposed scale was very effective in detecting both low-risk and high-risk patients undergoing esthetic surgery procedures.

[Systemic steroids use in second degree burn using an animal model]. / Esteroides sistémicos en quemaduras de segundo grado. Uso en un modelo animal.

BACKGROUND: the use of steroids is recognized in septic shock. There are reports of their use in burns. It is also known their negative effect in wound healing. OBJECTIVE: to know the effect of steroids in burn healing. METHODS: two groups of ten rats (wistar) were exposed to metallic cylinder at 95°C for 15 seconds on the back. At the moment of the burn one group received hydrocortisone dose 5 mg/kg. The other group didn't received medication. The scar was removed at the fifth day and the burn injury was covered with queratinocyte culture. The rats were sacrificed at 14th day. The presence of infection and the percentage of new epithelium, fibrosis, inflammatory process, presence of fibroblast and vascular proliferation were evaluated. We compared both groups using χ(2) test. RESULTS: there are no difference between groups in fibrosis, inflammatory process, or fibroblast presence. But there is a difference in vascular proliferation against the first group (steroid group). There were no signs of infection and all of them were epithelized at the 14th day. CONCLUSIONS: the use of steroids in burns only showed difference in vascular proliferation.

[Clinical research X. Usefulness of an organic mesh in the repair of abdominal defects]. / Reparación del defecto herniario. Empleo de malla de material orgánico.

OBJECTIVE: to measure the compliance, security and usefulness of organic mesh (bovine pericardium) in the repair of abdominal defect in an animal model. METHODS: Wistar rats (weight 300 to 500 g), were anesthetized and an abdominal defect of 1 cm in each animal was performed. Animals were divided according to the repair material used: bovine pericardium mesh (n = 6) and polipropilene mesh (n = 6). Animals were sacrificed on day 28 after the surgery. Presence of infection, necrosis and adherences (macroscopic and microscopic) were compared. Tensile force was also measured in both groups. RESULTS: inflammation, necrosis and adherences were similar in both groups. The prolene mesh (mean rupture force 66.5 joules) was stronger than bovine pericardium (mean rupture force 47.4 joules) p = 0.002, however, had also more adherences. CONCLUSIONS: there is no difference between inflammation, necrosis and adherences. But the polipropilene mesh was stronger than the bovine pericardium mesh. This finding could have relevance in the clinical practice (hernia recurrence).

Patient Blood Management Strategies to Avoid Transfusions in Body Contouring Operations: Controlled Clinical Trial.

BACKGROUND: Anemia is a frequent process of morbidity and mortality in body contouring procedures. In aesthetic surgery, there are no standardized processes to minimize bleeding during surgery. For this reason, a study was designed to implement patient blood management strategies to reduce bleeding and transfusions in patients undergoing body contouring operations. METHODS: From January of 2017 to May of 2018, a prospective cohort-type observational study was conducted, including two groups of patients undergoing single or combined body contouring procedures. The first group did not receive patient blood management strategies, whereas the second group did receive these strategies. These measures consisted of preoperative strategies to ensure the patient had optimal hemoglobin and hematocrit levels and supportive intraoperative measures to minimize blood loss. The results were validated with different statistical tests according to the variables studied. RESULTS: A total of 409 patients were included in the study and were divided into two groups. The anthropometric and hemoglobin variables were similar in both groups. The 207 patients for whom patient blood management strategies were implemented lost an average of 1.2 g/dl less hemoglobin at 72 hours than the 202 patients for whom patient blood management strategies were not implemented (p ≤ 0.0001). CONCLUSIONS: Patient blood management strategies, such as increasing hemoglobin before surgery, and strategies to minimize blood loss during surgery, proved to be effective at reducing bleeding in patients undergoing body contouring surgery, also decreasing the need to perform postoperative blood transfusions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Where Does the Transplanted Fat is Located in the Gluteal Region? Research Letter.

INTRODUCTION: Liposuction is one of the most popular plastic surgery procedures. As in any surgery, there are risks and complications, especially when combined with fat injection. Case reports of fat embolism have been reported. A possible explanation is the puncture and tearing of gluteal vessels during the procedure, especially when a deep injection is planned. OBJECTIVE: To identify the places where fat can be located after injection during a fat graft in the gluteus. METHODS: An experimental study was done in which colorant was injected in four directions using four different quadrants of the gluteus. We Injected 10 cc six times following clock hands until 60 cc were injected, and the cutaneous flap and the muscles were then elevated. Our main purpose was to describe where the colorant went and if it was in contact with the vessels (superior and inferior gluteal vessels). In total, four gluteus muscles were injected and dissected. RESULTS: Injection in the lower lateral quadrant was mainly into the muscle, and colorant was observed in the hypogastric vessels. The injection in the upper quadrants stayed mainly in the subcutaneous tissue. CONCLUSIONS: During surgery, it is important to identify the location of the perforators and to avoid a deep injection, especially from the lower lateral quadrant to the superior medial quadrant (Q4 to Q1), as the probability of puncturing and injecting fat into the main vessels from this direction is higher.

Understanding Fatal Fat Embolism in Gluteal Lipoinjection: A Review of the Medical Records and Autopsy Reports of 16 Patients.

BACKGROUND: Deaths secondary to gluteal lipoinjection are relatively recent events of major importance. However, little is known in relation to their behavior and clinical evolution. Therefore, an analysis was performed of case records from clinical cases that encountered this problem, correlating the results with the findings during autopsies. METHODS: An analysis was performed of records from patients who died secondary to gluteal lipoinjection. Patient-specific data, surgical procedure, clinical picture, evolution, and outcome were analyzed. The findings of the autopsies and the involvement of other organs were also analyzed and correlated. RESULTS: From 2000 to 2009, 16 files were obtained that fulfilled the indicated requirements. There were no statistically significant differences in the general characteristics of the patients, such as age, body mass index, or volume lipoinjected or liposuctioned. The clinical pictures were similar in all cases, and the autopsy findings showed the presence of microembolism in all cases and macroembolism in the most severe cases. CONCLUSIONS: The most significant parameter of severity in patients who undergo gluteal lipoinjection is the presence of fat in macroscopic form in the circulation. The volumes of liposuctioned or lipoinjected fat have little influence. Hypoxemia, hypotension, and bradycardia are the characteristic clinical features. Although there is no specific treatment, immediate aggressive vital support to attempt to stabilize the patient is crucial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

How to Improve Speaking Skills in Plastic Surgery Training? Survey in Residents Participants in Pecha Kucha Contest.

BACKGROUND: Little is known about educational games in Plastic Surgery training. Pecha kucha game has proved to be helpful tool to improve communicative skills. This study survey in resident participants in Pecha Kucha contest assessed how to improve speaking skills in plastic surgery training. METHODS: In the second edition of Pecha Kucha contest of the Mexican Society of Plastic Surgery, a survey was conducted with the residents to know the utility of this educational game. RESULTS: Twenty-six residents participated in the survey. Most of them from the Universidad Nacional Autonoma de México. Most of the residents considered it to be a good tool in order to improve communication skills and helpful for their future practice. The amount of time to present an idea was considered enough to express an idea. The most common proportion between words and images was 20-80% in the presentation. CONCLUSION: Pecha Kucha helped to improve communication skills during residents' training. We encourage other plastic surgery societies to incorporate educational games in their national and international meetings.

Microscopic and Macroscopic Fat Embolism: Solving the Puzzle with Case Reports.

BACKGROUND: The frequency of fat embolism mortality after liposuction has increased. As the only dependable evidence for this problem is that available in the medical literature, a study of clinical case reports is warranted. METHODS: The authors reviewed the medical literature by searching for case reports of fat embolism after liposuction in humans who manifested either of the variants of the condition: microscopic fat embolism or macroscopic fat embolism. The authors performed a literature search of the PubMed and PubMed Central databases from the first case of fat embolism syndrome associated with liposuction reported until March of 2017; keywords Fat Embolism (Fat Embolism Syndrome), Liposuction, and Case (((fat embolism) AND liposuction) AND case) were used. A detailed analysis of the data contained in the clinical case reports was conducted. RESULTS: In total, 39 and 98 articles were found in PubMed and PubMed Central, respectively, using the keywords (((Fat + Embolism) + AND + Liposuction) + AND + Case). After analysis, only 15 reports corresponded to cases of macroscopic or microscopic fat embolism after liposuction, and the basic statistics of the two proposed variants were examined. CONCLUSIONS: This work provides relevant information regarding very important characteristics of microscopic and macroscopic fat embolism. Despite the diagnostic difficulty, clinical diagnosis remains the gold standard for identifying microscopic and macroscopic fat embolism. The establishment of a rapid and timely diagnosis is of great help for appropriate treatment.

Prevention of Fat Embolism in Fat Injection for Gluteal Augmentation, Anatomic Study in Fresh Cadavers.

INTRODUCTION: Liposuction is a popular surgical procedure. As in any surgery, there are risks and complications, especially when combined with fat injection. Case reports of fat embolism have described a possible explanation as the puncture and tear of gluteal vessels during the procedure, especially when a deep injection is planned. METHODS: A total of 10 dissections were performed in five fresh cadavers. Each buttocks was divided into four quadrants. We focused on the location where the gluteal vessels enter the muscle and the diameter of the vessels. Colorant at two different angles was injected (30° and 45°). We evaluated the relation of the colorant with the main vessels. RESULTS: We found two perforators per quadrant. The thickness of the gluteal muscle was 2.84 ± 1.54 cm. The area under the muscle where the superior gluteal vessels traverse the muscle was located 6.4 ± 1.54 cm from the intergluteal crease and 5.8 ± 1.13 cm from the superior border of the muscle. The inferior gluteal vessels were located 8.3 ± 1.39 cm from the intergluteal crease and 10 ± 2.24 cm from the superior border of the muscle. When we compared the fat injected at a 30° angle, the colorant stayed in the muscle. Using a 45° angle, the colorant was in contact with the superior gluteal artery and the sciatic nerve. No puncture or tear was observed in the vessels or the nerve. CONCLUSIONS: The location where the vessels come in contact with the muscle, which can be considered for fat injection, were located in quadrants 1 and 3. A 30° angle allows for an injection into the muscle without passing into deeper structures, unlike a 45° injection angle.

Breast Implant and Anaplastic Large Cell Lymphoma Meta-Analysis.

Recent studies have shown a relationship between lymphoma and breast implants. We performed a meta-analysis about this problem. We found 80 cases, 50 of which were reported in the United States (62.5%). The average age was 52 years. The average time between breast implant surgery and lymphoma was 11 years. Forty-one percent of the breast implants were silicone, 42.19% were saline and 15.8% were unknown. The coverage of the breast implants was texturized in 21.3% and unknown in 78%. The most common brands were McGhan and Mentor. In 72.6% of the cases, the brand was unknown. The clinical findings were seroma (67.33%), nodes (13.8%), mass (22.1%), other (11.7%) and unknown (32%). The most common surgical treatment was capsulectomy and breast implant removal. In 97% of the cases, ALK was negative and 3% were positive. The most common marker was CD30. The most common chemotherapy regimen was CHOP. Three patients died. Two of the patients had extracapsular extension of the disease and breast cancer history. Lymphoma related with the breast implant was a different type of lymphoma, and in most cases, it was less aggressive. The disease was confined to the capsule. Few patients developed aggressive disease, were extracapsular and showed bad prognosis.

Chronic Wounds in Burn Injury: A Case Report on Importance of Biofilms.

According to the National Institutes of Health and the Center for Disease and Prevention, it is estimated that 65 to 80 percent of the human infectious are caused by biofilms. Antibiotics and drainage of purulent discharge are the main treatment measures. But in chronic infections sometimes these findings are not easy to recognize. Biofilm is an extracellular polymeric conglomeration generally composed of extracellular DNA, proteins, and polysaccharides, which help bacteria to survive into the host. The following case is the example of chronic wound in burn patient, where biofilm gets involved and special attention is given to the relationship biofilm-chronic wound injury in a burn patient.