RESUMO
Úlceras de pressão são alterações da integridade da pele e tecidos subjacentes, causadas por pressão, mais usualmente sobre proeminências ósseas, especialmente em áreas desprovidas de sensibilidade, levando à necrose e ulceração. Dados da literatura internacional estimam que 3 a 14% dos pacientes hospitalizados desenvolvem úlceras de pressão. Descrevemos a correção simultânea de úlceras sacral e isquiática extensas em paciente paraplégico jovem utilizando retalho fasciomiocutâneo de glúteo máximo e de face posterior da coxa.
Pressure ulcers are alterations of the integrity of the skin and underlying tissues, caused by pressure, more commonly on bony prominences, especially in areas devoid of sensitivity, which lead to necrosis and ulceration. Data from the international literature estimate that 314% of hospitalized patients develop pressure ulcers. We herein describe the simultaneous correction of extensive sacral and ischial ulcers in a young paraplegic patient, using a gluteus maximus fasciomyocutaneous flap from the posterior aspect of the thigh.
Assuntos
Humanos , Masculino , Adulto , Paraplegia/cirurgia , Paraplegia/complicações , Úlcera por Pressão/cirurgia , Úlcera por Pressão/complicações , Retalho Miocutâneo/cirurgia , Retalho Miocutâneo/efeitos adversos , Necrose/cirurgia , Fatores de Risco , Espasticidade MuscularRESUMO
Los defectos de pared abdominal son un desafío para los cirujanos plásticos. El sarcoma de partes blandas es muy recidivante y hay que hacer amplias exéresis con margen oncológico y como consecuencia quedan amplias zonas por reconstruir. El colgajo transverso de recto abdominal es una opción reconstructiva de esta región con buenos resultados estéticos y funcionales. El objetivo del trabajo es mostrar los resultados de la reconstrucción inmediata de la pared abdominal luego de una amplia exéresis oncológica. Se presenta una paciente femenina, mestiza, de 60 años, con diagnóstico de sarcoma de partes blandas, que abarcaba todo el hemiabdomen ínfero izquierdo hasta límites del reborde costal izquierdo, comprometía aponeurosis, el músculo recto izquierdo, y pequeña parte del peritoneo que se reparó. Se decidió una amplia exéresis y se planificó la reconstrucción con un colgajo miocutáneo transverso de recto del abdomen. Se utilizaron mallas de polipropileno. Se logró la reconstrucción inmediata del defecto oncológico con buenos resultados estéticos y funcionales(AU)
Abdominal wall defects are a challenge for plastic surgeons. Soft-tissue sarcoma is very recurrent and it is necessary to make extensive exeresis with oncological margin and, as a result, there are large areas to be reconstructed. The transverse rectus abdominis flap is a reconstructive option for this region and with good aesthetic and functional results. The objective of the work is to show the results of the immediate reconstruction of the abdominal wall after an extensive oncological exeresis. We present the case of a female patient, mestiza, aged 60 years, with a diagnosis of soft-tissue sarcoma, which encompassed all the left inferior hemiabdomen to the left costal margin limits, compromised the aponeurosis, the left rectus muscle, and a small part of the peritoneum that was repaired. A wide exeresis was decided and the reconstruction was planned with a transverse rectus abdominis myocutaneous flap. Polypropylene meshes were used. The immediate reconstruction of the oncological defect was achieved with good aesthetic and functional results(AU)
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Neoplasias de Tecidos Moles/diagnóstico , Telas Cirúrgicas/estatística & dados numéricos , Parede Abdominal/cirurgia , Retalho Miocutâneo/efeitos adversosRESUMO
INTRODUÇÃO: As sequelas de mastectomia se apresentam de formas variadas exigindo, do cirurgião, experiência e criatividade para obter o melhor resultado na reconstrução de uma nova mama. Dentre as dificuldades para que este objetivo seja alcançado, está o desafio de um melhor preenchimento do polo superior da mama. O objetivo deste trabalho é apresentar uma opção terapêutica alternativa para correção do polo superior dentre as técnicas já existentes com este propósito. MÉTODO: A técnica cirúrgica utilizou o retalho de músculo grande dorsal com extensão gordurosa para preenchimento do polo superior da neomama durante sua reconstrução. A técnica descrita foi utilizada em 8 pacientes durante a reconstrução mamária tardia, com idades variando entre 39 e 70 anos. O tamanho desta extensão gordurosa variou entre 4,0 × 10,0 e 7,0 × 13,0 cm. O componente gorduroso do retalho foi avaliado após 3 meses através de ressonância magnética. RESULTADOS: Foram usados implantes mamários que variavam entre 270 e 435 ml. O acompanhamento pós operatório variou entre 3 meses a 1 ano. Ocorreram 2 casos de epidermólise (28%) na junção do retalho cutâneo com a área receptora. Não houve perda ou sofrimento do retalho. Os resultados demonstram clinicamente ou visualmente que a correção da depressão do polo superior da neomama foi alcançada adequadamente, bem como a viabilidade do retalho gorduroso, observada nos exames de imagem (ressonância magnética). CONCLUSÃO: A técnica proposta é uma alternativa adequada para o tratamento da maioria dos casos de reconstrução mamária em que se busca o preenchimento da depressão existente no polo superior da mama.
INTRODUCTION: The sequelae of mastectomy presents in numerous ways, requiring the experience and creativity of the surgeon to achieve the best result in the reconstruction of a new breast. One of the difficulties in achieving this objective is the challenge of adequately filling the upper pole of the breast. The objective of this work was to present an alternative therapeutic option for correction of the upper pole of the neobreast. METHODS: In our surgical technique, a latissimus dorsi muscle flap with fat extension is used for filling the upper pole of the neobreast during its reconstruction. The described technique was used in 8 patients during late breast reconstruction. The patients' ages ranged from 39 and 70 years. The size of the fat extension ranged from 4.0 × 10.0 cm to 7.0 × 13.0 cm. The fat component of the flap was evaluated after 3 months by using magnetic resonance imaging (MRI). RESULTS: Breast implants that varied in volume between 270 and 435 mL were used. The follow-up period after surgery ranged from 3 months to 1 year. Two patients had epidermolysis (28%) at the junction of the cutaneous flap and the receiver area. No graft loss or other complications occurred. Our results demonstrate clinically or visually that correction of the depression in the upper pole of the neobreast was satisfactorily achieved. The viability of the fat flap, as observed on MRI, was adequate. CONCLUSION: The proposed technique is a suitable alternative method for filling the depression in the upper pole of the neobreast in most cases of breast reconstruction.
Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , História do Século XXI , Radioterapia , Mama , Tecido Adiposo , Mamoplastia , Implantes de Mama , Procedimentos de Cirurgia Plástica , Géis de Silicone , Glândulas Mamárias Humanas , Gorduras , Músculos Superficiais do Dorso , Retalho Miocutâneo , Radioterapia/efeitos adversos , Radioterapia/métodos , Mama/cirurgia , Tecido Adiposo/cirurgia , Mamoplastia/efeitos adversos , Mamoplastia/métodos , Implantes de Mama/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Géis de Silicone/uso terapêutico , Géis de Silicone/farmacologia , Estudo de Avaliação , Glândulas Mamárias Humanas/cirurgia , Gorduras/uso terapêutico , Músculos Superficiais do Dorso/cirurgia , Retalho Miocutâneo/cirurgia , Retalho Miocutâneo/efeitos adversosRESUMO
BACKGROUND: The functional impact of obesity on abdominal wall strength after abdominally based autologous reconstruction is unknown. The purpose of this study was to determine if obesity alters the postoperative abdominal wall strength profile after autologous reconstruction. METHODS: We prospectively examined abdominal wall strength and function following autologous breast reconstruction between 2005 and 2010. Enrolled patients completed functional testing [upper abdominal strength (UA), lower abdominal strength (LA), and functional independence measure (FIM)] and psychometric testing utilizing the short form 36 (SF36). Data were obtained at preoperative, early (<90d), and late (90-365d) follow-up visits. Obese patients were compared with non-obese patients in both unilateral and bilateral reconstructions. RESULTS: Overall, 167 patients were enrolled, with obesity noted in 34% of patients. Obese Unilateral reconstruction patients had lower preoperative UA strength (4.7 vs.4.2, P=0.05) and FIM (6.7 vs. 6.9, P=0.008) scores compared with non-obese patients. These scores significantly worsened in all patients from preoperative to early follow-up, yet scores did not differ at late follow-up between obesity cohorts. Obese bilateral reconstruction patients had similar preoperative functional scores; however, UA strength scores at early (2.5 vs. 3.2, P=0.008) and late (3.6 vs. 4.3, P=0.005) follow-up were significantly lower compared with non-obese patients. No differences in subjective health were noted in follow-up for unilateral or bilateral reconstructions. CONCLUSION: Obesity significantly impacts the abdominal function profile of autologous breast reconstruction patients; however, subjective physical and mental health differences are less notable. This is especially true for obese patients who undergo bilateral reconstructions. In these patients, a careful balance between optimizing flap perfusion, limiting donor site morbidity, and enabling functional recovery should be considered.
Assuntos
Parede Abdominal/fisiopatologia , Mamoplastia , Força Muscular/fisiologia , Retalho Miocutâneo , Obesidade/fisiopatologia , Parede Abdominal/cirurgia , Adulto , Autoenxertos , Feminino , Indicadores Básicos de Saúde , Humanos , Mamoplastia/efeitos adversos , Mamoplastia/métodos , Retalho Miocutâneo/efeitos adversos , Estudos ProspectivosRESUMO
BACKGROUND: Free tissue transfer from an abdominal donor site has become a popular method for postmastectomy breast reconstruction. The detrimental effects of adjuvant chemotherapy on healing and the resulting clinical impact on patient outcome remains somewhat unclear for abdominal bulges and hernias resulting after free tissue transfer from the abdominal donor site. METHODS: An institutional review board-approved retrospective review of 155 free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps performed for breast reconstruction was undertaken to evaluate the effect of adjuvant chemotherapy on abdominal donor-site morbidity. The primary outcome studied was the development of hernias and bulges. Statistical analysis was performed using univariate and multivariate classification and regression tree (CART) analysis. RESULTS: Of the 155 patients, 51 underwent bilateral MS-TRAM flaps and 104 underwent unilateral MS-TRAM flap reconstruction. Thirty-nine patients underwent adjuvant chemotherapy. A statistically significant association was seen between chemotherapy treatment and the incidence of hernias alone (P < 0.05; odds ratio, 6.42; 95% confidence interval, 0.88-73.58). Multivariable CART analyses corroborated these findings and revealed that presence of diabetes mellitus (DM), bilaterality, and receiving chemotherapy treatment were related to increased incidence of hernias (P = 0.011, 0.005, and 0.017, respectively) after controlling for clinical variables such as smoking status, chronic obstructive pulmonary disease, and type of closure. Univariate analyses also revealed a statistically significant association between bilaterality in conjunction with chemotherapy treatment and the incidence of hernias alone (P = 0.0002; odds ratio, 37.56; 95% confidence interval, 4.56-476.35). This highly significant finding is further augmented by multivariable CART analyses, which found that patients who were bilateral and underwent chemotherapy treatment or those with DM were significantly more likely to develop hernias (P < 0.001 and P = 0.016, respectively). CONCLUSIONS: To date, our study is the single largest series of abdominal donor-site complications in patients receiving chemotherapy and free MS-TRAM breast reconstruction. We have demonstrated an increase in the incidence of abdominal donor-site complications, specifically abdominal bulges and hernias, in patients undergoing chemotherapy for advanced stages of breast cancer. This increased complication rate is most pronounced in patients requiring chemotherapy who undergo bilateral reconstruction, and is also a significant risk for patients receiving chemotherapy who have preexisting DM.
Assuntos
Parede Abdominal , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/cirurgia , Mamoplastia , Retalho Miocutâneo , Sítio Doador de Transplante , Adulto , Antineoplásicos , Quimioterapia Adjuvante , Feminino , Hérnia Abdominal , Humanos , Microcirurgia , Análise Multivariada , Retalho Miocutâneo/efeitos adversos , Estudos Retrospectivos , Fatores de RiscoRESUMO
Los grandes defectos torácicos requieren generalmente procedimientos complejos para su reparación; en la mayoría de los casos es necesaria la combinación de tejidos autólogos y materiales aloplásticos, por lo que constituye un desafío para el cirujano plástico. En nuestra institución los que se presentan suelen ser secundarios a exéresis tumoral, bien de origen primario o secundario. Se dispone de varias opciones reconstructivas para cubrir los amplios defectos resultantes de las amplias escisiones y poder aportar colgajos vascularizados, amplios y voluminosos. A pesar de no disponer en nuestro medio de técnicas avanzadas para el soporte rígido, hemos podido dar cobertura a todos los defectos y se ha garantizado una adecuada estabilidad de la pared torácica. Presentamos cuatro casos tratados por grandes defectos del tórax. Se tuvo como objetivo mostrar la forma en que se realizó la reconstrucción inmediata con la combinación de colgajos miocutáneos y material aloplástico(AU)
Reconstruction of large defects of the chest wall frequently requires the use of complex techniques that combines autologous tissues and alloplastic materials, which poses a real challenge for the cosmetic surgeon. Those chest defects that are seen in our institution are secondary to tumor excision, either of primary or of secondary origin. Many reconstructive options are necessary to cover large defects as a result of wide resection of tumors and to supply the defect with large, bulky and well vascularized flaps. Although advanced techniques for rigid support are not available in our conditions, it has been possible to cover all defects and to assure adequate stability of the chest wall. Four cases of large chest defects were presented in this paper. The objective was to show how the immediate reconstruction was carried out by combining autologous flaps and alloplastic materials(AU)