ALEXANDRE SIQUEIRA FRANCO FONSECA
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- Optimizing Outcomes in Free Flap Breast Reconstruction in the Community Hospital Setting: A Stepwise Approach to DIEP/SIEA Flap Procedures with Banking a Hemiabdominal Flap(2017) OKADA, Alberto; PEREIRA, Diego Daniel; MONTAG, Eduardo; PORTOCARRERO, Marcelo; FELICIO, Carlos; ARRUDA, Eduardo Gustavo; FONSECA, Alexandre; GEMPERLI, Rolf; MUNHOZ, Alexandre MendoncaBackground Free flap breast reconstruction is a conventional procedure in many countries; however, microvascular compromise remains a devastating outcome. Given the morbidity of total necrosis, optimizing free flap salvage stands out as an important area for research, especially among surgeons to overcome the learning curve period and in resource constrained scenario such as community hospitals. To ensure free deep inferior epigastric perforator (DIEP)/superficial inferior epigastric artery (SIEA) flap breast reconstruction, the authors present a technique involving raising a hemiabdominal flap as a free flap, and banking the remaining flap to be utilized if needed in a subsequent procedure. Methods A retrospective review was performed on all free flap breast reconstructions. In this period, 84 patients (mean age: 50.18 years) were included. Results In this study, 65.5% patients underwent immediate reconstruction, and 51.2% received DIEP reconstruction; 9.52% patients were returned to the operating room, and salvage reconstruction using the banked flap was performed in all patients. No differences were observed regarding early complications and age, body mass index, American Society of Anesthesiologists status, diabetes, smoking history, chemotherapy, radiotherapy, and type of flap used ( p >0.05). Hypertension was significantly associated with early complications ( p <0.05). Donor-site complications were associated with RT ( p <0.05). Conclusion The banked flap is a reliable method for ensuring DIEP/SIEA flap survival and should be considered in higher risk reconstructions and community hospitals. We believe that the present technique can be a good addition to the arsenal of plastic surgeons dealing with free flap breast reconstructions in selected patients.
- Validation of Videoconference With Smartphones in Telemedicine Facial Trauma Care: Analysis of Concordance to On-Site Evaluation(2016) FONSECA, Alexandre Siqueira Franco; GOLDENBERG, Dov Charles; STOCCHERO, Guilherme Flosi; LUIZ, Arthur Vicentini Costa; GEMPERLI, RolfBackground The continental size of some countries and heterogeneous hospital network prevents patients who live in remote areas from getting adequate initial assessment of facial trauma. The authors present an alternative model for trauma assessment by videoconference via smartphones and analyze the concordance between telemedicine and face-to-face management. Methods Fifty patients with either a confirmed or suspected diagnosis of facial trauma were independently evaluated by 2 teams of physicians: Face-to-face and telemedicine-based. The face-to-face team attended patients at bedside (physical examination and computed tomography scan analysis). The telemedicine team consisted of a general surgery resident on duty in the emergency room and a plastic surgeon researcher remotely communicating via smartphones. Both teams answered a questionnaire, which contained data concerning patient's epidemiology, physical examination, computed tomography (CT) scan findings, and treatment option to be followed. Data were analyzed and compared regarding the similarity of answers. Results The sample studied was consistent with the literature, showing a predominance of young males. Traffic accidents and personal violence were the main causes of trauma. The concurrency of answers for physical examination findings was considered substantial ( = 0.720). For CT scan findings, it was almost perfect ( = 0.899); for defining the treatment option, it was almost perfect ( = 0.891). High concurrency of face CT scan findings was observed after we calculated the positive predictive value (89.9%), negative predictive value (99.3%), sensitivity (94.2%), specificity (98.8%), and accuracy (98.3%). Conclusions The proposed model to facial assessment trauma by videoconference via smartphones is feasible, showing high concordance level with face-to-face assessment.
- What a difference a clip makes! Analysis of boost volume definition in radiation therapy for conservative breast surgery(2018) FREITAS, Thiago Brasileiro de; LIMA, Kennya Medeiros Lopes de Barros; CARVALHO, Heloisa de Andrade; MARQUES, Patricia de Azevedo; MATTOS, Fabio Teixeira Belfort; FONSECA, Alexandre Siqueira Franco; MUNHOZ, Alexandre Mendonca; FILASSI, Jose Roberto; STUART, Silvia R.; MARTA, Gustavo NaderPurpose/objective(s): To evaluate the role of surgical clips placement in the definition of boost treatment volume. Materials/methods: Clinical Target Volumes (CTV) were defined as: CTV Breast, CTV Quadrant (based on physical exam and pre-surgical images), CTV Boost, defined by clip plus margin (1 cm for 2 or more clips and 2 cm for 1 clip only) plus radiological changes, CTV NT (normal tissue), defined by CTV Quadrant minus CTV Boost and CTV MISS (CTV that would be outside the treatment volume), defined by cry Boost minus CTV Quadrant. Results: A total of 247 patients were included. Upper lateral quadrant was the most common clinical location (47.3%). The median number of clips used was three. The mean volumes were: CTV Breast:982.52 cc, CTV Boost:36.59 cc, CTV Quadrant:285.07 cc, Cry NT:210.1 cc and CTV MISS:13.57 cc. Only 50.6% (125) of the patients presented the CTV Boost completely inside the Cry Quadrant and in 473% (117), partially inside. Among patients with any CFV MISS, 803% (98) had 10% or more of CTV Boost outside the treatment volume. Regarding CTV MISS, there were no statistically significant differences between the groups with 1 clip versus 2 or more clips, nor between patients with or without reconstructive surgery. In average, the CTV Boost was 87% smaller than the CFV Quadrant. The whole quadrant irradiation would lead to unnecessary irradiation of 26% of normal breast tissue. Conclusion: Surgical bed clipping is up most important in the definition of the boost volume irradiation to ensure precision minimizing geographical miss and optimizing surrounding normal tissue sparing.
- Avaliação do índice de infecção de implantes mamários utilizados na reconstrução de mama do Instituto do Câncer do Estado de São Paulo(2014) ALMEIDA, PATRÍCIA NORONHA DE; ARRUDA, EDUARDO GUSTAVO PIRES DE; OKADA, ALBERTO; MONTAG, EDUARDO; FERREIRA, MARCUS CASTRO; BUSNARDO, FÁBIO FREITAS; FONSECA, ALEXANDRE SIQUEIRAABSTRACT Introduction: Placement of breast implants is the most commonly used form of breast reconstruction. Despite its advantages, infection of the implant, either in the tissue expander or mammary prosthesis, can be a significant problem, including the need to remove it. The objective of this work is to evaluate the infection rate of breast implants used for breast reconstruction in patients submitted to surgery at the Cancer Institute of the State of São Paulo (ICESP), as well as its correlation with clinical, oncological, and surgical factors. Patients and methods: This is a retrospective study on 120 patients submitted to breast reconstruction with breast implants at the ICESP from February 2009 to March 2010. Results: The infection rate (24.3%) was statistically related to immediate reconstruction (88.9%), diabetes mellitus (25%), body mass index >30 (52.8%), systemic arterial hypertension (52.8%), and skin injury due to mastectomy (27.8%). Of the infected implants, 44% were removed, most of which were expanders placed during immediate reconstruction. Conclusions: Breast reconstruction with implants is the safest and most effective form of treatment. However, consideration should be given to patients who are prone to the development of infection, in order to optimize its prevention and attempt to perform its treatment at an early stage.
- Influence of vitamin D status on hospital length of stay and prognosis in hospitalized patients with moderate to severe COVID-19: a multicenter prospective cohort study(2021) REIS, Bruna Z.; FERNANDES, Alan L.; SALES, Lucas P.; SANTOS, Mayara D.; SANTOS, Caroline C. Dos; PINTO, Ana J.; GOESSLER, Karla F.; FRANCO, Andre S.; DURAN, Camila S. C.; SILVA, Carla B. R.; MACEDO, Marina B.; DALMOLIN, Henrique H. H.; BAGGIO, Janaina; BALBI, Guilherme G. M.; ANTONANGELO, Leila; CAPARBO, Valeria F.; GUALANO, Bruno; MURAI, Igor H.; PEREIRA, Rosa M. R.Background: Vitamin D acts as a mediator in the immune system regulating antiviral mechanisms and inflammatory processes. Vitamin D insufficiency has been suggested as a potential risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, although its impact on the prognosis of hospitalized patients with coronavirus disease 2019 (COVID-19) remains unclear. Objective: This multicenter prospective cohort study was designed to investigate whether serum 25-hydroxyvitamin D [25(OH)D] concentration is associated with hospital length of stay and prognosis in hospitalized patients with COVID-19. Methods: Patients with moderate to severe COVID-19 (n = 220) were recruited from 2 hospitals in Sao Paulo, Brazil. Serum 25(OH)D concentrations were categorized as follows: <10 ng/mL, 10 to <20 ng/mL, 20 to <30 ng/mL, and >= 30 ng/mL, and <10 ng/mL and >= 10 ng/mL. The primary outcome was hospital length of stay and the secondary outcomes were the rate of patients who required invasive mechanical ventilation and mortality. Results: There were no significant differences in hospital length of stay when the 4 25(OH)D categories were compared (P = 0.120). Patients exhibiting 25(OH)D<10 ng/mL showed a trend (P = 0.057) for longer hospital length of stay compared with those with 25(OH)D >= 10 ng/mL [9.0 d (95% CI: 6.4, 11.6 d) vs. 7.0 d (95% CI: 6.6, 7.4 d)]. The multivariable Cox proportional hazard models showed no significant associations between 25(OH)D and primary or secondary outcomes. Conclusions: Among hospitalized patients with moderate to severe COVID-19, those with severe 25(OH)D deficiency (<10 ng/mL) exhibited a trend for longer hospital length of stay compared with patients with higher 25(OH)D concentrations. This association was not significant in the multivariable Cox regression model. Prospective studies should test whether correcting severe 25(OH)D deficiency could improve the prognosis of patients with COVID-19.
- Influência do posicionamento do retalho linfonodal vascularizado na resposta ao tratamento cirúrgico do linfedema secundário ao câncer de mama.(2019) MONTAG, Eduardo; OKADA, Alberto Yoshikazu; ARRUDA, Eduardo Gustavo Pires; FONSECA, Alexandre Siqueira; BROMLEY, Miluska; MUNHOZ, Alexandre Mendonça; BUSNARDO, Fábio Freitas; GEMPERLI, RolfABSTRACT Objective: to evaluate the initial therapeutic experience of transplantation of vascularized lymph nodes in patients with lymphedema of the upper limbs secondary to the treatment of breast cancer, and to verify if the positioning of the transplant influences the surgical result. Methods: we conducted a prospective, comparative test of two therapeutic modalities, with 24 patients with lymphedema of the upper limb after breast cancer treatment, classified as grades 2 and 3, according to the International Lymphedema Society. The two types of procedures performed were: 1) total breast reconstruction with - deep inferior epigastric perforator (DIEP) flap associated with lymph node flap, in patients with no previous breast reconstruction or loss of previous reconstruction (axillary positioning); 2) isolated inguinal lymph node flap performed in patients with completed breast reconstruction or without the desire to perform the breast reconstruction (wrist positioning). Results: the reduction percentage of the affected limb volume was 20.1% (p=0.0370). The number of infectious episodes (cellulites) also decreased significantly, from 41% in the preoperative period to 12.5% in the postoperative one (p=0.004). There were no differences between the proximal and distal groups. Conclusion: the transplantation of lymph nodes positively affected the postoperative evolution of patients with lymphedema secondary to breast cancer. We observed no differences in relation to flap positioning.
- Influence of advanced age on postoperative outcomes and total loss following breast reconstruction: a critical assessment of 560 cases(2018) MATSUMOTO, WALTER KOITI; MUNHOZ, ALEXANDRE MENDONÇA; OKADA, ALBERTO; MONTAG, EDUARDO; ARRUDA, EDUARDO GUSTAVO; FONSECA, ALEXANDRE; FERRARI, ORLANDO; BRASIL, JOSÉ AUGUSTO; PRETTI, LIA; FILASSI, JOSÉ ROBERTO; GEMPERLI, ROLFABSTRACT Objective: to evaluate the role of age in the risk of postoperative complications in patients submitted to unilateral breast reconstruction after mastectomy, with emphasis on total reconstruction loss. Methods: we conducted a retrospective study of patients submitted to breast reconstruction, whose variables included: oncological and reconstruction data, postoperative complications, including loss of reconstruction and complications of surgical wound. We divided the patients into two groups, according to the classification of the Brazilian National Elderly Policy and the Statute of the Elderly: young (age <60 years) and elderly (60 years or more). We also grouped them according to the World Health Organization classification: young people (age <44 years), middle age (45-59 years); elderly (age 60-89 years) and extreme advanced age (90 years or older). We applied the surgical risk classification of the American Society of Anesthesiologists to investigate the role of the preoperative physical state as a possible predictor of complications. Results: of the 560 patients operated on, 94 (16.8%) were 60 years of age or older. We observed a local complication rate of 49.8%, the majority being self-limited. The incidences of necrosis, infection and dehiscence were 15.5%, 10.9% and 9.3%, respectively. Patients older than 60 years presented a chance of complication 1.606 times greater than the younger ones. Forty-five (8%) patients had loss of the reconstruction; there was no statistically significant difference in the mean age of the patients who presented this result or not (p=0.321). Conclusion: in selected patients, breast reconstruction can be considered safe; most documented complications were limited and could be treated conservatively.
- The use of contralateral free extended latissimus dorsi myocutaneous flap for a tertiary failed breast reconstruction: Is it still an option?(2016) MUNHOZ, Alexandre Mendonca; MONTAG, Eduardo; ARRUDA, Eduardo Gustavo; OKADA, Alberto; FONSECA, Alexandre; FILASSI, Jose Roberto; GEMPERLI, RolfBackground: Unsuccessful breast reconstruction management represents a complex challenge for the plastic surgeon. Although these events rarely occur, many patients are not suitable candidates for conventional flaps, because of either previous donor-site surgery or lack of sufficient tissue. Methods: In this study, a contralateral free latissimus dorsi musculocutaneous flap (CL-LDMF) was planned for correction of major lesions in the anterior chest wall. Twelve patients underwent secondary/tertiary breast reconstruction with CL-LDMF with a customized shape (horizontal, oblique, or ""fleur-de-lis"") depending on the amount of tissue necessary. The technique was indicated in patients with large thoracic defects who lacked a donor site and had undergone previous unsuccessful pedicled LDMF. Results: The mean follow-up time was 42.5 months (range: 18-72 months). Five local complications occurred in four of the 12 patients. Dorsal dehiscence was observed in one, local wound infection in one, small partial CL-LDMF necrosis in one, and dorsal seroma in one patient. All cases of complications were limited and treated with a conservative approach except for one implant extrusion 4 months after reconstruction. No total flap loss was reported. All patients achieved a satisfactory thoracic and breast reconstruction. Conclusion: The results of this study demonstrate that free CL-LDMF is a reliable technique and should be considered in selected cases of tertiary reconstructions. The majority of complications were immediate, minor, and comparable to other reconstructive techniques. We believe that in selected patients, especially those who do not have available donor-site areas, free CL-LDMF is advantageous and should be part of the armamentarium of all plastic surgeons who deal with tertiary breast reconstructions.