A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.
Nipple-sparing mastectomy (NSM) is increasingly offered to women for therapeutic and prophylactic indications. Although, clinical series have been described, there are few studies describing risk factors for complications. The objective of this study is to evaluate the incidence of complications in a series of consecutive patients submitted to NSM and differences between clinical risk factors, breast volume, and different incision types. In a cohort-designed study, 158 reconstructed patients (invasive/in situ cancer and high risk for cancer) were stratified into groups based on different types of incision used (hemi-periareolar, double-circle periareolar, and Wise-pattern). They were matched for age, body mass index, associated clinical diseases, smoking, and weight of specimen. Also included were patients treated with adjuvant chemotherapy and postoperative radiotherapy. Mean follow-up was 65.6 months. In 106 (67 %) patients, NSM was performed for breast cancer treatment and in 52 (32.9 %) for cancer prophylaxis. Thirty-nine (24.6 %) patients were submitted to hemi-periareolar technique, 67 (42.4 %) to double-circle periareolar incision, and 52 (33 %) to Wise-pattern incision. The reconstruction was performed with tissue expander and implant-expander. Local recurrence rate was 3.7 % and the incidence of distant metastases was 1.8 %. Obese patients and higher weight of specimen had a higher risk for complications. After adjusting risk factors (BMI, weight of specimen), the complications were higher for patients submitted to hemi-periareolar and Wise-pattern incisions. This follow-up survey demonstrates that NSM facilitates optimal breast reconstruction by preserving the majority of the breast skin. Selected patients can have safe outcomes and therefore this may be a feasible option for breast cancer management. Success depends on coordinated planning with the oncologic surgeon and careful preoperative and intraoperative management. Surgical risk factors include incision type, obesity, and weight of breast specimen.
Reduction mammaplasty is a consistent technique for reconstruction following breast-conserving surgery. Complications are more often observed in the reconstructed breast, and obese patients and smokers are higher risk patients.
The TBA procedure without endoscopic assistance is a simple and reliable technique for breast augmentation. Most of the complications in this study were minor and predictable. They did not interfere with the aesthetic outcome nor the normal postoperative recovery. With TBA, success depends on patient selection as well as careful intra- and postoperative management.
Free flaps based on perforator vessels, and in particular the deep inferior epigastric perforator (DIEP) flap, are currently being applied in abdominal reconstruction. However, one of the main disadvantages is the operative complexity. Through anatomical study and clinical experience with the DIEP flap in breast reconstruction, the intramuscular path of the perforator vessels was comparatively studied, to establish the main anatomical parameters that favor procedure planning. Thirty DIEP flaps from 15 fresh cadavers were used. The number, location, and intramuscular course of the perforator vessels were determined. In addition, an initial clinical study was performed in 31 patients using 35 DIEP flaps in breast reconstruction. The number, location, and the intramuscular course of the perforators were assessed. In the cadaver study, 191 perforator vessels were detected (6.4 vessels per flap). Thirty-four percent were located in the lateral row, and the rectilinear course was observed in 79.2 percent of these vessels. In the medial row, only 18.2 percent of the perforator vessels presented this configuration (p = 0.001). Thirty-one patients underwent DIEP flap breast reconstruction, with 26 immediate and four bilateral reconstructions. In 22 of 35 flaps (62.9 percent), two perforators were used. In 25 flaps (71.4 percent), the lateral row perforators with a rectilinear course were observed. Mean operative time was 7 hours and 37 minutes. Two total flap losses and two partial necroses were observed. The majority of the lateral row perforators presented a rectilinear intramuscular course, which was shorter than that of the medial row perforators. This anatomical characteristic favors dissection with reduced operative time and vascular lesion morbidity, resulting in an important anatomical parameter for DIEP flap harvesting.
The V-Y latissimus dorsi musculocutaneous flap is a reliable technique for immediate locally advanced breast cancer reconstruction. The technique is advantageous because the V-Y design allows primary closure of the chest wound and donor defect. Success depends on patient selection, coordinated planning with the breast cancer surgeon, and careful intraoperative management.
The aim of this study was to determine the presence of species of the genus Eimeria species in naturally infected bovines in Southern Bahia, Northeast Brazil. The study population comprised 117 Zebu crossbred cattle that belonged to 10 dairy herds with extensive or semi-extensive production systems. The modified Gordon and Whitlock technique was used to determine positive samples and number of oocysts per gram of feces. Statistical analyses were performed using the chi-square test with Yates correction and a 95% confidence interval. Thirty-nine cattle (33.33%) were positive, and ten different species were identified in infected animals: E. bovis (24.79%); E. canadensis (8.55%); E. zuernii (6.83%); E. ellipsoidalis (5.99%); E. cylindrica (3.42%); E. auburnensis (3.42%); E. brasiliensis (2.56%); E. bukidnonensis (1.71%); E. alabamensis (0.85%), and E. subspherica (0.85%). Higher parasitism was observed in animals up to one year of age (p = 0.005), but no animal presented clinical signs of the disease. As the presence of clinical eimeriosis was not evidenced and all animals were Zebu crossbred cattle from extensive or semi-extensive production systems, further studies should be conducted to investigate the effects of these factors on disease development.Keywords: Coccidian, dairy cattle, age group, frequency. ResumoO objetivo deste estudo foi determinar a presença de espécies do gênero Eimeria em bovinos naturalmente infectados, na região Sudeste da Bahia, Nordeste do Brasil. A população do estudo incluiu 117 bovinos mestiços de raças Zebuínas que pertenciam a 10 fazendas leiteiras com sistemas de produção extensivo ou semiextensivo. A técnica de Gordon e Whitlock modificada foi utilizada para determinar as amostras positivas e o número de oocistos por grama de fezes. A análise estatística foi realizada utilizando o teste do qui-quadrado com correção de Yates e intervalo de confiança de 95%. Trinta e nove animais (33,33%) foram positivos, e dez diferentes espécies foram identificadas nos animais infectados: E. bovis (24,79%), E. canadensis (8,55%), E. zuernii (6,83%), E. ellipsoidalis (5,99% ), E. cylindrica (3,42%), E. auburnensis (3,42%), E. brasiliensis (2,56%), E. bukidnonensis (1,71%), E. alabamensis (0,85%) e E. subspherica (0,85%). Maior parasitismo foi observado em animais com até um ano de idade (p = 0,005), mas nenhum animal apresentou sinais clínicos que fossem compatíveis com a parasitose. Como não foi observado presença de eimeriose clínica e como todos os animais eram mestiços zebuínos e pertencentes ao sistema de criação extensivo ou semiextensivo, novos estudos devem ser conduzidos para comprovar a influência desses fatores no surgimento da doença.Palavras-chave: Coccídio, gado leiteiro, faixa etária, frequência.
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