Simultaneous Augmentation Mastopexy: An Innovative Anatomical Approach-The Fascioglandular Flap for Improved Lower Pole Support.

Simultaneous breast augmentation and mastopexy is very challenging often considered to be one of the most difficult cosmetic breast surgeries. Although a patient is sometimes better served with 2 separately staged procedures, the demand for single-stage combined augmentation mastopexy is increasing associated with increasing demands for larger implants. Combining these 2 operations presents special problems because of the interplay of opposing forces. To avoid bottoming out, wound dehiscence, and ultimately implant extrusion, it is essential to provide proper coverage and support of the inferior breast pole. The goal of this report is to illustrate the benefit of an inferiorly based fascioglandular flap in providing adequate breast lower pole support in simultaneous breast augmentation mastopexy. 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 .

Is There a Breast Augmentation Outcome Difference Between Subfascial and Subglandular Implant Placement? A Prospective Randomized Double-Blinded Study.

INTRODUCTION: Subfascial breast augmentation is gaining popularity because of no distortion when the pectoral muscle is contracted and minimizing visualization of the edges of the implant. Although some studies have reported a satisfactory outcome with subfascial technique, it still is controversial the influence of the pectoral fascia and outcome compared to the subglandular technique. Therefore, this prospective randomized study aimed to investigate whether there are clinical/radiological differences between subfascial and subglandular pockets following primary breast augmentation. METHODS: Twenty patient candidates for primary breast augmentation were recruited. Each patient was selected for subfascial or subglandular pockets in a randomized fashion. Both patient and surgeon were blinded. Clinical and radiological differences were evaluated through five independent surgeons and MRI (capsule, folds, fluids, base and projection). Median follow-up was 12 months. RESULTS: Breast consistency (p = 0.24), implant pocket (p = 0.52), symmetry (p = 1), contour, and shape (p = 0.09) demonstrated no statistically significant difference after the surgeons' assessments at 3 and 12 months after surgery. MRIs demonstrated a larger implant base in the subfascial group (p = 0.024). No differences were observed in capsule thickness (p = 0.42), folds (p = 0.51), fluids (p = 0.28), or projection (0.20). CONCLUSION: The choice between subfascial and subglandular planes shows no clinical differences and can be selected according to individual professional experience, not evidencing any advantages of one over the other. LEVEL OF EVIDENCE II: 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.

Evaluation of Photographic Variables in Patients with Indication for Facial Rejuvenation.

BACKGROUND: Photography standardization is paramount for appropriate critical analysis of aesthetic surgery outcomes. Therefore, the authors designed a study to evaluate the influence of different variables in photos of patients with indications for undergoing facial rejuvenation. METHODS: This blinded prospective study was conducted by the Section of Plastic Surgery in the Hospital das Clínicas at the Federal University of Paraná. In the study, 29 patients had their photos taken in two separate settings. Photo 1, termed "preoperative" (Pre), was obtained according to the same pattern for all patients. Photo 2, termed "postoperative" (Post), was acquired on the same day using different variables to manipulate the photo outcome. No surgery was actually performed. Both photos (Pre and Post) were sent to five experienced Brazilian plastic surgeons, who provided a score for photo 2 that varied from -10 to +10 compared with photo 1. RESULTS: The photos were examined by 119 plastic surgeons. No significant improvement was observed in most of the groups, except for the group that used a flash for the Post photography (p = 0.035). Almost half of the scores (45.37 %) were above zero. The highest score was found to be ten for two photographs of the makeup group. A score of zero was assigned to 54.62 % of the photos, which means no changes occurred between the Pre and Post photos. CONCLUSION: Inadequate photographic technique can change assessments of photos in a meaningful way. All the factors evaluated had a positive impact, but the only statistically significant variable was the use of a flash in the Post group. LEVEL OF EVIDENCE II: 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 .

Modulation of Photoaging-Induced Cutaneous Elastin: Evaluation of Gene and Protein Expression of Markers Related to Elastogenesis Under Different Photoexposure Conditions.

INTRODUCTION: Photoaging is the process by which ultraviolet rays gradually induce clinical and histological changes in the skin through the production and organization of biological molecules, such as elastin, which is critical to skin strength and elasticity. After exposure to radiation, elastin may undergo alternative mRNA splicing, resulting in modified proteins that contribute to the formation of aging characteristics, such as solar elastosis. The present work aimed to study two different forms of elastin under these conditions: normal elastin and elastin that had been altered in exon 26A. METHODS: These different forms of elastin were characterized for gene expression by quantitative real-time polymerase chain reaction (qPCR) and for protein expression by immunohistochemistry of ex vivo skins (from photoexposed and non-photoexposed areas) and in vitro reconstituted skin. In addition, up- and downstream molecules in the elastin signaling cascade were evaluated. RESULTS: As a result, a significant increase in the gene expression of elastin 26A was observed in both ex vivo photoexposed skin tissues and the in vitro photoexposed reconstituted skins. Additionally, significant increases in the gene expression levels of matrix metalloproteinase-12 (MMP12) and lysyl oxidase (LOX) were observed in the ex vivo skin model. The evaluation of protein expression levels of some photoaging markers on the reconstituted skin revealed increased tropoelastin and fibrillin-1 expression after photoexposure. CONCLUSION: This work contributes to a better understanding of the biological mechanisms involved in photoaging, making it possible to obtain new strategies for the development of dermocosmetic active ingredients to prevent and treat skin aging.

Desmistificando a técnica de deep plane facelift com dissecção anatômica em cadáveres frescos / Demystifying the deep plane facelift technique with anatomical dissection in fresh cadavers

Introdução: Os estudos de anatomia em cadáveres permitiram um melhor entendimento das estruturas da face e, consequentemente, mais segurança ao explorar os planos profundos da região facial. Uma boa técnica deve ser segura, reprodutível e respeitar os pontos anatômicos. O objetivo deste trabalho é desmistificar a técnica de deep plane facelifting por meio da dissecção de cadáveres e exposição das estruturas faciais. Método: A reprodução da técnica de "deep plane facelifting" foi realizada em 14 hemifaces de 7 peças de cadáveres frescos no Instituto de Treinamento de Cadáver em Curitiba no ano de 2021. A técnica cirúrgica foi realizada conforme nossa prática clínica e reproduzida no cadáver. Após o procedimento, as estruturas anatômicas faciais foram dissecadas para correlacionar seu posicionamento junto aos espaços anatômicos da face. Foram avaliados os posicionamentos dos ligamentos da face, vascularização e os ramos do nervo facial. Resultados: Foram identificados os espaços anatômicos relevantes à técnica de deep plane facelifting, como os espaços massetéricos inferior e superior, espaço pré-zigomático, espaço bucal e espaço cervical. Os ramos do nervo facial foram identificados no plano subSMAS e correlacionados com os espaços e planos anatômicos. Conclusão: A técnica de deep plane facelift pode ser reproduzida com segurança desde que sejam respeitados dois parâmetros. O primeiro é a entrada correta nos espaços a fim de respeitar a anatomia. O segundo é o uso de descoladores rombos para dissecção nos planos profundos da face a fim de evitar lesão nervosa dos ramos do nervo facial.

Introduction: Anatomy studies on cadavers have allowed a better understanding of the structures of the face and, consequently, greater safety when exploring the deep planes of the facial region. A good technique must be safe, reproducible, and respect anatomical points. The objective of this work is to demystify the deep plane facelifting technique through the dissection of cadavers and exposure of facial structures. Method: The reproduction of the "deep plane facelifting" technique was performed on 14 hemifaces of 7 pieces of fresh cadavers at the Instituto de Treinamento de Cadáver (Cadaver Training Institute) in Curitiba in 2021. The surgical technique was performed according to our clinical practice and reproduced on the cadaver. After the procedure, the facial anatomical structures were dissected to correlate their positioning with the anatomical spaces of the face. The positioning of the facial ligaments, vascularization, and branches of the facial nerve were evaluated. Results: The anatomical spaces relevant to the deep plane facelifting technique were identified, such as the inferior and superior masseteric spaces, prezygomatic space, buccal space, and cervical space. The facial nerve branches were identified in the sub-SMAS plane and correlated with the anatomical spaces and planes. Conclusion: The deep plane facelift technique can be reproduced safely as long as two parameters are respected. The first is the correct entry into spaces to respect the anatomy. The second is the use of blunt detachers for dissection in the deep planes of the face to avoid nerve damage to the branches of the facial nerve.

Subfascial breast implant: a new procedure.

Breast augmentation techniques using the submuscular and subglandular planes to introduce the implant are well known and widely used procedures. The authors have been using the subfascial dissection plane, a new concept for breast augmentation. From October of 1998 to September of 2001, 263 patients underwent breast augmentation. In all cases, the implants were inserted into the subfascial plane. McGhan 410 anatomic biodimensional, cohesive gel implants (size, 155 to 310 g) were used. There are additional benefits using this technique; these include avoiding implant deformation or distortion (as seen in the retromuscular position), leaving additional soft tissue between the implant and the skin, and minimizing implant edge prominence (inherent to retroglandular placement). These technical details lead to fewer patient complaints. Morbidity is similar to that of other techniques.

A complexidade cicatricial em queimaduras e a possibilidade da terapia com células-tronco derivadas do tecido adiposo: revisão / The complexity of burn healing and the possibility of adipose tissue-derived stem cell therapy: review / La complejidad de la cicatrización de las quemaduras y la posibilidad de la terapia con células madre derivadas del tejido adiposo: revisión

OBJETIVO: Verificar as especificidades do processo cicatricial em queimaduras e identificar se as células-tronco derivadas do tecido adiposo (CTDA) podem se tornar aliadas em sua reparação. MÉTODO: Realizou-se uma revisão da literatura com consultas a Biblioteca Virtual de Saúde, Google Acadêmico, PubMed, Scientific Electronic Library Online, Mendeley catalog of academic literature, artigos e bibliografia especilizada em cicatrização, queimaduras, células-tronco derivadas do tecido adiposo publicados entre 2012 e 2016. RESULTADOS: As queimaduras se diferenciam de outras lesões pela intensidade da inflamação sistêmica e pela sobreposição das fases cicatriciais desorganizando-as. As CTDA são encontradas no estroma vascular do tecido adiposo e podem ser obtidas por lipoaspiração. Estas células podem interferir nas fases cicatriciais pela secreção de citocinas de crescimento, substâncias imunomoduladoras e anti-inflamatórias, assim como pela capacidade de diferenciação celular e homing. CONCLUSÃO: As queimaduras ocorrem na população mundial de forma preocupante, com características de morbidade e mortalidade. Os problemas sistêmicos e locais da reparação tecidual parecem ser atenuados pelas CTDA, sua abundante disponibilidade para o cultivo celular e suas habilidades as apontam como aliadas na recuperação das queimaduras.(AU)

OBJECTIVE: To evaluate the distinctions of the healing process in burns and identify how the adipose-tissue derived stem cells (ATSC) may become allies in this repair process. METHODS: Review of the literature was carried out with consultations at Virtual Health Library, Google Scholar, PubMed, Scientific Electronic Library Online and Mendeley catalog of academic literature and specialized bibliography in healing, burns and ATSC published between 2012 and 2016. RESULTS: Burns differentiate themselves from other lesions by the intensity of systemic inflammation and by the overlapping of the healing wound phases disorganizing them. The ATSC are found in the vascular stroma of adipose tissue and can be obtained by liposuction. These cells can interfere in the healing wound phases by the secretion of growth cytokines, immunomodulatory and anti-inflammatory substances and the ability of cell differentiation and homing. CONCLUSION: Burns occur in the world population in a worrisome way with characteristics of morbimortality. The problems of tissue repair seem to be attenuated by ATSC, their abundant availability for cell culture and their abilities point them as promising allies in healing of burn wound.(AU)

Objetivo: Verificar las especificidades del proceso cicatricial en quemaduras y identificar si las células-tronco derivadas del tejido adiposo (CTDA) pueden tornarse aliadas en su reparación. Método: Se realizó una revisión del literatura con consultas en Biblioteca Virtual de Salud, Google Académico, PubMed, Scientific Electronic Library online online, Mendeley catalog of academic literature, artículos y bibliografía especilizada, quemaduras, CTDA, publicados entre 2012 y 2016. Resultados: Las quemaduras se diferencian de otras lesiones por la intesidad de la inflamación sistémica y por la sobreposición de las fases cicatriciales desorganizándolas. Las CTDA son encontradas en el estroma vascular del tejido adiposo y pueden ser obtenidas por lipoaspiracion. Estas celulas pueden interferir en las fases cicatriciales por secrecion de citoquinas del crecimiento, sustancias inmunomoduladoras, anti inflamatorias y por la capacidad de diferenciacion celular e homing. Conclusión: Las quemaduras ocurren en la población mundial de forma preocupante con caracteristicas de morbimortalidad. Los problemas de la reparacion tecidual parecen ser atenuados por las CTDA, su abundante disponibilidad para el cultivo celular y sus habilidades las apuntan como aliadas en la recuperacion de las quemaduras.(AU)

Síndrome de Proteus: relato de casos / Proteus Syndrome: case reports

INTRODUÇÃO: A síndrome de Proteus é uma doença complexa e rara, classificada nos grupo das hamartoses. Foi primeiramente descrita em dois pacientes, em 1979, por Cohen e Hayden. Existe dificuldade no diagnóstico, sendo comum a confusão com síndromes de Klippel-Trenaunay-Weber, neurofibromatose ou Stuge-Weber. Apresentamos dois casos tratados no Serviço de Cirurgia Plástica e Reparadora da Universidade Federal do Paraná. MÉTODO: Paciente masculino (caso 1), que chegou ao serviço aos 6 anos de idade, tendo como principais apresentações lipomatoses e assimetrias. A segunda paciente (caso 2) deu entrada no serviço com 20 anos de idade e diagnóstico de síndrome de Klippel-Trenaunay-Weber, que posteriormente mostrou se tratar de síndrome de Proteus. CONCLUSÃO: A hipótese etiológica mais aceita para a doença é genética. Acredita-se que exista mosaicismo somático e que a doença seja letal no estado não mosaico. Morte prematura é bastante frequente. Entretanto, a sequela mais comum é a ocorrência de tumores incomuns. O cuidado dos pacientes portadores da síndrome é um desafio devido às suas consequências médicas e psicossociais.

INTRODUCTION: Proteus syndrome is a complex and rare disorder classified as a hamartomatous disease. It was first described in two patients in 1979, by Cohen and Hayden. Proteus syndrome is difficult to diagnose, and is often confused with Klippel-Trenaunay-Weber syndrome, neurofibromatosis, or Sturge-Weber syndrome. In this study we describe two patients who were treated at the Plastic and Reconstructive Surgery Service of the Federal University of Paraná. METHOD: A 6-year-old male patient (case 1) presented to the Service with lipomatosis and asymmetry, as the primary findings. A 20-year-old (case 2) was admitted to the Service with a diagnosis of Klippel-Trenaunay-Weber syndrome, which later was shown to be Proteus syndrome. CONCLUSION: The etiological hypothesis that is most accepted for this disease is genetic. It is believed that somatic mosaicism may occur during pathogenesis, which can be lethal in the mosaic state. Premature death is common. However, the most common sequelae are the occurrence of unusual tumors. The care of patients with this syndrome is a challenge due to medical and psychosocial consequences.

Mastopexy after massive weight loss: extended chest wall-based flap associated with a loop of pectoralis muscle.

Mammaplasty for patients who have experienced massive weight loss involves some concepts that differ from those that apply to mammaplasty for normal patients. Breast anatomic characteristics make this procedure a very challenging situation. The authors present their experience with a new mammaplasty technique using an extended thoracic wall flap associated with a loop of pectoralis. This procedure is a simple and reproducible method for patients with massive weight loss that results in a pleasing breast shape and long-lasting results.

Poland's syndrome: different clinical presentations and surgical reconstructions in 18 cases.

BACKGROUND: The literature reports many variations of Poland's syndrome. This article describes 18 cases of Poland's syndrome in different stages of treatment, with variable clinical presentations and reconstructive techniques. METHODS: This study evaluated 15 females and 3 males, ages 2 to 43 years, for breast deformity, nipple-areolar complex position, pectoralis muscle malformation, thoracic deformities, and the presence of brachysyndactyly. Surgical treatment was performed for 14 patients, individualized for each case. RESULTS: For the women, the hypoplastic breast was treated with a latissimus dorsi muscular flap associated with silicone gel implant in five cases. Two other patients still are receiving tissue expansion for a future muscular and prosthetic reconstruction. Prosthetic implants alone were used on the affected side in four cases. The nipple-areolar complex was reconstructed for two patients. Seven women underwent contralateral breast surgery: reduction mammoplasty in three cases, mastopexy in two cases, and prosthetic implants in two cases. The only man who underwent surgery was treated with endoscopic rotation of the latissimus dorsi muscle flap. CONCLUSIONS: This study demonstrated several breast reconstruction options for patients with Poland's syndrome, reinforcing the importance of an individualized treatment to achieve complete and adequate rehabilitation.

Linfonodo sentinela após mamoplastia de aumento pela via transaxilar: estudo prospectivo controlado por meio de linfocintilografia em 43 pacientes / Sentinel lymph node detection after transaxillary augmentation mammoplasty: a prospective controlled study utilizing lymphoscintigraphy in 43 breasts

OBJETIVO: Verificar se a mamoplastia de aumento pela via transaxilar apresenta potencial de prejudicar a identificação futura do linfonodo sentinela. MATERIAIS E MÉTODOS: Estudo prospectivo controlado em que foram selecionadas 22 pacientes divididas em grupo pós-mamoplastia e grupo controle, totalizando 43 mamas (22 no grupo pós-mamoplastia e 21 no grupo controle) avaliadas por meio de linfocintilografia imediatamente após injeções periareolares de fitato-99mTc. Os testes estatísticos consideraram como diferenças significativas valores de p < 0,05. RESULTADOS: Todas as mamas do grupo pós-mamoplastia apresentaram drenagem linfática para a cadeia axilar, sem diferença com o grupo controle (p = 0,488). A média de linfonodos captantes foi de 1,27 ± 0,46 no grupo pós-mamoplastia e 1,33 ± 0,58 no grupo controle (p = 0,895). A média de tempo para visualização do primeiro linfonodo foi de 3,14 ± 4,42 minutos no grupo pós-mamoplastia e 5,48 ± 5,06 minutos no grupo controle, novamente sem diferença significativa (p = 0,136). CONCLUSÃO: A mamoplastia de aumento pela via transaxilar não acarretou prejuízo na identificação futura do linfonodo sentinela.

OBJECTIVE: To evaluate the potential influence of transaxillary augmentation mammoplasty on future detection of sentinel lymph node. MATERIALS AND METHODS: Prospective controlled study where 22 patients were selected and divided into two groups (post-mammoplasty and control) corresponding to 43 breasts (22 in the post-mammoplasty group and 21 in the control group) evaluated by lymphoscintigraphy immediately after periareolar 99mTc-phytate injections. In the statistical analysis, p values < 0.05 were considered as significant. RESULTS: All the breasts in the post-mammoplasty group presented lymphatic drainage to the axillary chain, with no difference as compared with the control group (p = 0.488). The average number of hot lymph nodes was 1.27 ± 0.46 in the post-mammoplasty group, and 1.33 ± 0.58 in the control group (p = 0.895). The mean time required to visualize the first lymph node was 3.14 ± 4.42 minutes in the post-mammoplasty group, and 5.48 ± 5.06 minutes in the control group (p = 0.136). CONCLUSION: Transaxillary augmentation mammoplasty did not affect the future detection of sentinel lymph node.

A papaína reduz a formação de cápsula fibrosa ao redor de implantes de silicone texturizados em ratos / The papain pocket delivery impairs the capsule fibrous healing around texturedsilicone implants in rats

Objetivo: Estudar o reparo tecidual ao redor dos implantes mamários texturizados sob a açãolocal de papaína (PA). Método: Foram avaliados 36 ratos Wistar, distribuídos aleatoriamenteem dois grupos (n = 18): papaína (PA) e controle (CT). Cada grupo foi distribuído igualmenteem 3 subgrupos (n = 6) e observados nos períodos de 7, 35 e 90 dias pós-operatório. Cadaanimal recebeu um implante texturizado na região dorso-axilar à esquerda (sham - SH), sempapaína, onde se instilou previamente 0,5 mL de solução salina 0,9%; e outro implante tambémtexturizado à direita, onde se instilou 0,5 mL de solução hidrossolúvel contendo papaína. Osanimais do grupo controle (CT) receberam apenas inclusão de um implante texturizado naregião dorso-axilar esquerda com instilação prévia de 0,5 mL de solução salina 0,9%. A análisehistológica, nos 3 subgrupos, foi realizada utilizando-se a coloração de picrosirius red e umsistema analisador de imagens com o programa Image Pro Plus® para verificação da espessurae da densidade de fibras colágenas da cápsula. Resultados: No grupo papaína (PA),observou-se, aos 35 e 90 dias, diminuição significativa da espessura da cápsula fibrosa aoredor do implante, da densidade de fibras colágenas e da quantidade de miofibroblastos emcomparação ao grupo controle (CT). Conclusão: A papaína diminuiu a formação da cápsulafibrosa ao redor dos implantes de silicone texturizado em ratos.

Objective: To study the tissue repair around the textured mammary implants under the action ofpapain (PA). Methods: Thirty-six Wistar rats were evaluated and randomly distributed into twogroups (n = 18): papain (PA) and control (CT). Each group was equally distributed into 3 subgroups(n = 6) and observed on 7th, 35th and 90th pos-operative days. Each animal received a textured implantin the left dorso-axillary region (sham - SH), on were instilled 0.5 mL saline solution 0.9%, andanother textured implant on the right dorso-axillary region (papain - PA), on were instilled 0.5 mLof water-soluble solution of papain. The control group (CT) received only textured implant in theleft dorso-axillary region with prior instillation of 0.5 mL of saline solution 0.9%. The histologicalanalysis of the 3 subgroups was carried out using picrosirius-red stain and an image analyzingsystem using the Image Pro Plus™ program to evaluate the thickness and maturation anddeposition of collagen fibers. Results: At 35th and 90th days, the papain group (PA) presentedreduction on the fibrous capsule thickness around the implant, in the number of collagen fibersand myofibroblasts, comparing to the control group (CT). Conclusion: The papain drug decreasedthe fibrous capsule formation around the textured silicon implants in rats.

Efeitos de contraçäo cutânea e fibroplasia causados pelo laser de CO2 ultrapulsando em pele de ratos / The shrinkage and fibroplasia effects of the ultrapulse CO2, laser on the skin of rats

Em humanos, observa-se no uso do laser e CO2, ultrapulsado que a pele contrai imediatamente após a sua aplicaçäo, aparentemente se mantendo assim após a cicatriza 5äo dos tecidos. Também se observa, fibroplasia mais importante que a apresentada por outras técnicas de rejuvenescimento facial, como peelings e dermoabrasöes. Este estudo avalia a contraçäo cutânea e a deposiçäo de colâgeno após a aplicaçäo de laser de CO2 ultrapulsado em pele dorsal de35 ratos da linhagem Wistar durante 112 dias. No primeiro dia, demonstrou-se por planimetria digital contraçäo tecidual imediata de 49,71 por cento (p<0,0001), mantida até112 dias (p=0,0339). No décimo quarto dia observou-se pela microscopia óptica, uma deposiçäo importante e regular de fibras colágenas na derme superior, denominada zona de fibroplasia, a qual atingiu sua maior espessura no dia 56, com 378, 40 mm; e no dia 112, apresentava 196,76 mm.