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Silicone implants have gone through adaptations to improve esthetic outcomes. With the progress of technology, including gel rheology, different properties have been introduced. Ergonomic style implants (ESI) feature enhanced rheological properties and provide a shaped contour with a round base. This study investigated outcomes for ESI in breast augmentation concerning lower pole stretching (LPS) and implant stability and describes an algorithm to assist in decision-making. A total of 148 patients (296 breasts) underwent breast augmentation with ESI; this procedure was indicated in patients with good skin quality and <6 cm between the nipple–areola complex and the inframammary fold. The mean patient age was 29.6 years (range: 19–39), and 93 patients (62.8%) underwent primary breast augmentation with demi/full projection (average volume of 245 cc [175–375 cc]). Axillary incision and subfascial pocket were indicated in 115 (77.7%) and 72 (48%) cases, respectively. Average LPS values were 32.2% (24.91 mm) and 10.86% (9.42 mm) at up to 10 days and 10 days to 12 months postprocedure, respectively. Patients were followed for a mean of 29.9 ± 26.4 months (range: 6–66). Complication rates per breast and per patient were 5% and 10%, respectively, and included subcutaneous banding in the axilla (1.6%), implant displacement (1.2%), and wound dehiscence (0.8%). No cases of infection, seroma, or rippling complications were observed. The present decision-making algorithm summarizes the process involved in breast augmentation using ESI and is intended to help standardize decisions. With correct planning, long-lasting outcomes can be achieved due to favorable interactions between ESI and the patient's tissues. [ABSTRACT FROM AUTHOR]

Background and purpose: Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material. Materials and methods: retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. clinical and treatment variables were correlated with early and late complications. Results: 251 patients were included; mean age was 49.7 (25 to 78) years. reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% cI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% cI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). arterial hypertension (OR = 4.78; 95% cI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% cI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% cI: 1.26-9.99, p = 0.016) were related to late complications. Conclusions: The overall rate of complications was low in this population. radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. already well-known clinical risk factors for complications after breast reconstruction were identified. [ABSTRACT FROM AUTHOR]

Some deep-water offshore fields produce oil with high gas/oil ratios and ultra-high %CO 2 (>60%mol) with the onus of processing low-grade gas simultaneously handling huge CO 2 dispatch goals. Thus, processing solutions are needed to make feasible such high-capacity gas rigs hundreds of kilometers offshore. Feasibility relies on the choices for CO 2 capture and adjustment of water and hydrocarbon dew-points of such high flow rate gas. This problem was approached adopting supersonic separators for dew-point adjustments and for CO 2 capture on a floating-hub processing 50 MMsm ³/d of CO 2 ultra-rich gas, reinjecting 96% of treated CO 2 -rich gas for enhanced oil recovery, while reserving 4% as fuel-gas after CO 2 abatement to 20%mol for power production. Process alternatives were assessed in terms of power demand and profitability comparing supersonic separator with membrane-permeation for CO 2 removal. Results show that 1st supersonic separator for dew-point adjustments of raw gas recycling condensate to the oil-gas-water separator and 2nd supersonic separator for CO 2 removal avoiding CO 2 freeze-out, give optimum net present value and minimum CO 2 emissions. On one hand, these facts are consequences of less compressor investment as 2nd supersonic separator ejects pressurized CO 2 condensate requiring 5% less compression power for enhanced oil recovery relatively to the power required by the low-pressure CO 2 -rich permeate from the membrane-permeation alternative. On the other hand, the best net value of supersonic separator alternative also reflects its highest revenues derived from recycling condensate from 1st supersonic separator entailing 18% higher oil production. Image 1 • Offshore gas-hub for high-scale processing of 68% CO 2 natural gas is investigated. • Two serial supersonic separator units are the best economic option for gas-hub. • 1st supersonic separator unit adjusts water and hydrocarbon dew-points ejecting C3+. • 2nd supersonic separator unit removes CO 2 without freeze-out ejecting liquid CO 2. • 2nd supersonic separator economically outperforms membranes for limited CO 2 capture. [ABSTRACT FROM AUTHOR]

Purpose/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 CTV 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, CTV NT:210.1 cc and CTV MISS:13.57 cc. Only 50.6% (125) of the patients presented the CTV Boost completely inside the CTV Quadrant and in 47.3% (117), partially inside. Among patients with any CTV MISS, 80.3% (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 CTV 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. [ABSTRACT FROM AUTHOR]

In offshore natural gas (NG) production, hydrate formation is a big concern that can impact the production and even stop NG flow. In this context, the injection of Thermodynamic Hydrate Inhibitors (THIs) in wellheads is widely employed in order to avoid these undesirable problems on subsea flowlines to gas processing rigs. However, in the main three-phase high-pressure separator in the gas rig, THI losses for gas phase are significant, particularly when the adopted THI is volatile like methanol and ethanol. This work discloses a new supersonic separator (SS) THI recovery process – SS-THI-Recovery – that treats the gas effluent from three-phase high-pressure separator achieving four simultaneous results: (i) gas water dew-point adjustment (WDPA); (ii) gas hydrocarbon dew-point adjustment (HCDPA); (iii) production of C3+ (propane and heavier) liquids as LPG; and (iv) recovery of almost all THI which would be lost in the gas otherwise. The proposition employs a supersonic separator (SS) battery followed by an anti-hydrates separator (LTX), a liquid-liquid THI extraction step and auxiliary THI distillation. SS-THI-Recovery was evaluated with HYSYS 8.8 simulator using methanol, ethanol and monoethylene glycol (MEG) as THIs. Supposing that the THI in the gas phase would be totally lost along with the exported gas otherwise, with SS-THI-Recovery the losses of methanol, ethanol and MEG were reduced by 91.9%, 79.3% and 99.2%, respectively, and such recovery factors could be further improved by increasing water flow rate in liquid-liquid THI extraction. Such high THI recovery entails reduction of THI costs with make-up, storage and transportation. Additionally, SS-THI-Recovery process is simple, with low footprint, and of easy implementation even for non-volatile THIs like MEG. Furthermore, the produced NG is ready for commercialization, dismissing additional treatment steps, not counting the commercial value of LPG. Therefore, new SS-THI-Recovery process configures an innovative and profitable alternative for gas treatment and THI recovery on gas processing offshore platforms. [ABSTRACT FROM AUTHOR]

The supersonic separator (SS) was investigated for treating humid natural gas with 44%mol CO 2 in offshore rigs and compared to the conventional Water Dew Point Adjustment (WDPA) via TEG Absorption, Hydrocarbon Dew Point Adjustment (HCDPA) via Joule-Thomson Expansion (JTE) and CO 2 removal via Membrane Permeation (MP). SS was tested as a single-step operation for WDPA + HCDPA. To simulate SS and MP, two Unit Operation Extensions (UOE) were developed for simulator HYSYS 8.8 (AspenTech). MP-UOE uses an empirical approach calibrated with operation data, whereas SS-UOE is entirely funded on thermodynamics, not demanding calibration. MP-UOE and SS-UOE use the thermodynamic infrastructure of HYSYS: property packages and several proved multiphase flash algorithms. MP-UOE and SS-UOE performed accordingly the expected characteristics of the respective operations and were critical to accomplish this analysis as SS and MP are not available in simulators. In terms of final gas quality (WDP ≤ -45 o C @ 1.01 bar , HCDP ≤ 0 o C @ 45 bar , %CO 2 ≤ 15%mol ) the best process configuration was found to be a hybrid one: SS WDPA + HDPA and MP CO 2 removal, with low footprint and low power demand (- 6.9% ) relative to conventional 3-step way. If used for CO 2 removal, SS could abate CO 2 from 44% to 21.85%mol . Albeit less effective than MP, SS CO 2 removal is a noticeable option that produces fuel gas for power generation with %CO 2 ≈ 20% as required by new turbo-shafts. Moreover, CO 2 is withdrawn from SS as a pumpable liquid allowing a cut of 44% in the power demanded for CO 2 separation and injection as EOR agent. [ABSTRACT FROM AUTHOR]

Introduction Chest desmoid tumors (CDT) are rare lesions characterized by fibroblastic proliferation from the connective tissue. Although CDT have been studied previously, no cases following subfascial transaxillary breast augmentation (TBA) have been described. Presentation of case The authors describe a case of CDT in a 28-year-old woman one year after TBA, which presented as a painful and progressive mass in the lower-inner right breast quadrant. MRI showed a soft-tissue tumor (6 × 3 × 4 cm) that affected the region of the right anterior costal margin, without signs of structural costal invasion. Patient was treated surgically, exposing the right costal-sternal region through an inframammary approach and resecting the CDT. The remaining capsular flap was mobilized into the defect and a form-stable silicone implant was utilized to cover the chest wall defect and achieve an adequate breast contour. The patient is currently in 5th year after chest reconstruction, with satisfactory results. Neither the tumor or the symptoms recurred. Discussion CDT is an uncommon evolution following TBA. Although it is a rare disease, thoracic and plastic surgeons must be alert to avoid misdiagnosis. Defect reconstruction is necessary, mobilizing the capsular flaps and replacing the implants in order to obtain a satisfactory outcome. Conclusion Knowledge of this rare post-operative evolution is crucial, and early surgical intervention is warranted in order to avoid more aggressive treatment. This case report provides general knowledge of CDT, and may be used as guidance for early diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Gas hydrate formation is an issue in natural gas production. In offshore deepwater scenarios the situation is aggravated by the inaccessibility, salinity, low temperatures and high pressures. Monoethylene glycol (MEG) injection in well-heads is one of the used technologies for flow assurance in gas flowlines. Rich MEG is processed in MEG Recovery Units (MRU) to be recovered as Lean MEG returned to well-heads. In offshore rigs, besides determining energy requirements, the assessment of energy degradation is also important, which can be done by Exergy Analysis. In this work, an exergy formulation is developed and three technologies of offshore MRUs are assessed. Since exergy is a property that depends on the definition of a reference environment reservoir (RER), Exergy Analysis is performed via two RER approaches, both presenting consistent results. Approach #1 prescribes the usual standard atmosphere, with the addend that it is saturated by equilibrium with an infinite body of liquid water and MEG is in chemical equilibrium with air species. Since MEG is spontaneously oxidable, this entails very high exergy flows for MRU streams with MEG. As MEG is practically conserved, high exergy efficiencies result for all MRUs hindering their discrimination. Approach #2 prescribes also the standard atmosphere in equilibrium with liquid water containing MEG at infinite dilution, but not in chemical equilibrium with air. The MEG condition in MRU streams is now more akin with the MEG state in this RER, resulting that MEG streams have lower magnitude of exergy flow, leading to realistic exergy efficiencies that allow MRU discrimination. The underlying reason is that the input exergy flows now have magnitude comparable with exergy losses. [ABSTRACT FROM AUTHOR]

Summary Background 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. [ABSTRACT FROM AUTHOR]

Abstract: INTRODUCTION: Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors. PRESENTATION OF CASE: The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted. DISCUSSION: Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair. CONCLUSION: The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications. [Copyright &y& Elsevier]

Summary: Background: Breast sarcoma during pregnancy is an extremely rare event and represents a complex problem because of a more advanced stage at presentation. Method: This report presents the first case of a 24-year-old woman with a gestational age of 20 weeks with a fast growing tumour in her left breast (29 × 19 × 15 cm) and infiltrating the skin/pectoralis muscles. Radical mastectomy was performed with a gestational age of 22 weeks and a different design was planned for the latissimus dorsi musculocutaneous flap (LDMF) with primary closure in the V–Y pattern. Result: Satisfactory chest wall coverage and contour were achieved. Final histopathological findings allowed a diagnosis of undifferentiated sarcoma. With a gestational age of 37 weeks, a healthy infant was delivered by means of a caesarean section. The patient is currently in the second postoperative year and no recurrence has been observed. Conclusion: Management of a large breast sarcoma in a pregnant patient presents unique challenges in consideration of the potential risks to the foetus and the possible maternal benefit. The results of this study demonstrate that the VY-LDMF is a reliable technique and should be considered in cases of immediate large thoracic wound reconstruction. [Copyright &y& Elsevier]

Abstract: Introduction: Although the use of local flaps in conservative breast surgery (CBS) reconstruction is a reliable technique, little information has been available regarding outcome following the use of perforator flaps. The purpose of this study is to analyze the feasibility, surgical planning and outcome following CBS reconstruction with intercostal artery perforator (ICAP) flap. Patients/methods: Thirteen patients underwent CBS reconstructions with an ICAP flap. These flaps were raised from adjacent tissue located on the lateral and thoracic region and based on perforators originating from the costal and muscular segment of the intercostal vessels. The technique was indicated in patients with small/moderate volume breasts. Results: Mean time of follow-up was 32 months. Flap complications were evaluated and information on patient satisfaction were collected. 61.5 percent had tumors located in the lower-outer quadrants and 69.2 percent had tumors measuring 2 cm or less (T1). Complications occurred in 3 patients (23%), including wound dehiscence in 2 patients and fat necrosis in one. All cases were treated by conservative approach with a good result. No flap loss or wound infection were reported. 90 percent were either satisfied or very satisfied with their result. Conclusion: The ICAP flap is a reliable technique for immediate CBS reconstruction. The technique is advantageous because it does not require the use of muscle transfer, with minimum donor site morbidity. Success depends on patient selection, coordinated planning with the oncological surgeon and careful intra-operative management. [Copyright &y& Elsevier]

Abstract: Although the biodimensional anatomical expander-implant system (BEIS) is a reliable technique, little information has been available regarding outcome following nipple-areola sparing mastectomy (NSM). To perform the resection of glandular tissue, while improving the surgical access and maintaining the nipple-areola vascularization we have developed a new approach for NSM based on the double concentric periareolar incision (DCPI). The purpose of this study is to analyze the feasibility, surgical planning and its outcome following NSM. 18 patients underwent NSM reconstructions. Mean time of follow-up was 29 months. The technique was indicated in patients with small/moderate volume breasts. Flap complications were evaluated and information on aesthetic results and patient satisfaction were collected. 83.3% had tumors measuring 2cm or less (T1) and 72.1% were stage 0 and I. All patients presented peripherally tumors located (at least 5cm from the nipple). Skin complications occurred in 11.1%. One patient (5.5%) presented small skin necrosis and a wound dehiscence was observed in one patient (5.5%). The aesthetic result was good/very good in 94.4 percent and the majority of patients were very satisfied/satisfied. No local recurrences were observed. All complications except one were treated by a conservative approach. DCPI–BEIS is a simple and reliable technique for NSM reconstruction. The success depends on patient selection, coordinated planning with the oncologic surgeon and careful intra-operative and post-operative management. [Copyright &y& Elsevier]

Abstract: The efficacy of breast-conserving surgery for the local control of early breast cancer has been repeatedly evidenced. Although immediate reconstruction following breast-conserving surgery has been described, little information is available regarding surgical management in reoperative settings due to positive margins. We studied the influence of intraoperatively assessed and postoperatively controlled surgical margin status on the type of breast-conserving surgery and report our results regarding complications in a reoperative breast reconstruction scenario. All patients were seen by a multidisciplinary team who recommended breast-conserving surgery. According to the breast volume, ptosis and tumor size/location, the patients were also evaluated by a plastic surgeon, who recommended reconstruction with the appropriate technique. Intraoperative assessment of surgical margins was determined by histological examination of frozen sections. The mean follow-up time was 48months. Two hundred and eighteen patients (88.5%) underwent breast-conserving surgery and immediate reconstruction. Twelve (5.5%) patients had a positive tumor margin after review of the permanent section. All patients underwent re-exploration. In 1.3%, a second reconstructive technique was indicated and in 2.2% a skin-sparing mastectomy with total reconstruction was performed. Our findings support the important role of the intraoperative assessment of surgical margins and its interference in the selection of reconstruction techniques and negative margins; however, it will not guarantee complete excision of the tumor. Success depends on coordinated planning with the oncologic surgeon and careful intraoperative management. [Copyright &y& Elsevier]

Summary: The objective of this study is to describe the surgical planning of the inferior dermoglandular pedicle (IDP) technique and its outcome following partial mastectomy reconstruction. A total of 26 patients with breast cancer underwent immediate IDP reconstruction. IDP was indicated to reconstruct superior/central breast defects. Postoperative complications were evaluated and information on esthetic result and satisfaction were collected. About 57.6 percent had tumors measuring 2cm or less (T1). Immediate complications occurred in 34.2 percent with skin necrosis in 11.4 and dehiscence in 7.6 percent. Late complications were observed in 11.4 percent. The cosmetic result was considered to be good or very good in 88.4 percent and the majority of patients were satisfied. All complications were treated by conservative approach. IDP is a reliable technique and should be given consideration in cases of superior/central quadrant reconstruction. The success of the procedure depends on patient selection and careful intra-operative management. [Copyright &y& Elsevier]

Abstract: Oncoplastic Breast Surgery (OPBS) is becoming an integral part of breast cancer management, but few surgeons have received formal training in these techniques. An International Symposium has recently debated the key issues which impact on training and specialisation in OPBS, as well as patient access to these procedures. The Symposium concluded that increasing the availability of OPBS is a major challenge, which demands much closer collaboration and cooperation between breast and plastic surgeons, backed up by new training schemes, new curricula and new guidelines. [Copyright &y& Elsevier]