Facial reanimation with masseteric nerve: babysitter or permanent procedure? Preliminary results.

The authors are presenting a series of 10 cases of complete unilateral facial paralysis submitted to (I) end-to-end microsurgical coaptation of the masseteric branch of the trigeminal nerve and distal branches of the paralyzed facial nerve, and (II) cross-face sural nerve graft. The ages of the patients ranged from 5 to 63 years (mean: 44.1 years), and 8 (80%) of the patients were females. The duration of paralysis was no longer than 18 months (mean: 9.7 months). Follow-up varied from 6 to 18 months (mean: 12.6 months). Initial voluntary facial movements were observed between 3 and 6 months postoperatively (mean: 4.3 months). All patients were able to produce the appearance of a smile when asked to clench their teeth. Comparing the definition of the nasolabial fold and the degree of movement of the modiolus on both sides of the face, the voluntary smile was considered symmetrical in 8 cases. Recovery of the capacity to blink spontaneously was not observed. However, 8 patients were able to reduce or suspend the application of artificial tears. The authors suggest consideration of masseteric-facial nerve coaptation, whether temporary (baby-sitter) or permanent, as the principal alternative for reconstruction of facial paralysis due to irreversible nerve lesion with less than 18 months of duration.

Estudo comparativo da fixação dos transplantes musculares na reanimação facial unilateral com ou sem o uso do tendão palmar longo / Comparative study of muscle transplants insertion technique for unilateral facial reanimation with and without the palmaris longus tendon

Vinte e seis pacientes com paralisia facial unilateral de longa duração foram submetidos à reanimação facial em único estágio com transplante do músculo grácil inervado pelo ramo massetérico do nervo trigêmeo. Foram divididos em 2 grupos não-randomizados de acordo com a técnica de fixação: Grupo I (19 pacientes), fixação do músculo com uso do tendão palmar longo inserido no músculo orbicular nos lábios superior e inferior do lado não paralisado (além da linha média); Grupo II (7 pacientes), fixação do retalho apenas com pontos separados no músculo orbicular dos lábios superior e inferior no lado paralisado. A avaliação qualitativa demonstrou melhores resultados no Grupo I (94,1% vs 66,6%). Na comparação do posicionamento do arco de cúpido em repouso, no pré e pós-operatório, observamos melhora estatisticamente significante (p<0,05) em ambos os grupos. Durante o sorriso, entretanto, houve melhora significativamente maior na centralização do arco de cúpido nos pacientes submetidos à fixação com tendão palmar longo (Grupo I).

Twenty-six patients with unilateral long-stading facial palsy underwent 1-stage reanimation with free gracilis muscle transplant innervated by the masseteric branch of the trigeminal nerve. They were divided into 2 nonrandomized groups according to insertion technique: group I (19 patients), palmaris longus tendon graft placed between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side; group II (7 patients), interrupted suture between the free flap and the orbicularis oris of the upper and lower lip on the paralyzed side. Qualitative evaluation of the smile demonstrated better results in patients from group I (94,1% vs 66,6%). Comparing the position of the Cupid's bow at rest, pre- and postoperatively in each patient, we observed significant improvement of facial symmetry in both groups. During smile, however, there was significantly higher rate of centralization of the Cupid`s bow in patients submitted to reanimation with the use of the palmaris longus tendon (group I).

[Body contour surgery in the massive weight loss patient: three year-experience in a secondary public hospital]. / Cirurgia do contorno corporal no paciente após perda ponderal maciça: experiência de três anos em hospital público secundário.

OBJECTIVE: To present the clinical-surgical three year-experience related to body contour surgery in the massive weight loss patient, performed by the Plastic Surgery team of the Sapopemba State Hospital. METHODS: Retrospective study performed at the Sapopemba State Hospital, linked to the 'Hospital das Clínicas' of the University of São Paulo School of Medicine, from July 2005 to July 2008. A total of 98 patients was operated, whose morbid obesity had been treated by bariatric surgery, after success of the technique, or weight loss by non-surgical method. Exclusion criteria were smoking, gestational intent and weight instability. Stable weight for at least 6 months after satisfactory weight loss was required from patients. RESULTS: Of the 98 operated patients, 97% were female, with mean age of 40.5 years and the weight loss method was the surgery in 88% of cases. From 177 plastic surgeries performed, 46% were abdominoplasty, followed by mammaplasty (15%), thigh suspension (13%) and brachioplasty (12%). Mean hospital stay was of two days and the main diagnosed complications were: seroma (28%), minor necrosis/dehiscences (18%), major necrosis/dehiscences (4%), hematomas (4%), superficial thrombophlebitis from the saphena vein (2%) and deep venous thrombosis (1%). CONCLUSION: An increasing demand for surgeries to improve body contour after massive weight loss has been detected. Plastic surgeons must know the clinical peculiarities and higher risk of complications of these patients, control their expectations, analyze results and engage in a continued investigation to improve surgical techniques.

Cirurgia do contorno corporal no paciente após perda ponderal maciça: experiência de três anos em hospital público secundário / Body contour surgery in the massive weight loss patient: three year-experience in a secondary public hospital

OBJETIVO: Apresentar a experiência clínico-cirúrgica de três anos relacionada às cirurgias de contorno corporal no paciente após perda ponderal maciça, realizadas pela equipe de Cirurgia Plástica do Hospital Estadual de Sapopemba. MÉTODOS: Estudo retrospectivo realizado no Hospital Estadual de Sapopemba, vinculado ao Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de julho de 2005 a julho de 2008. Foram operados 98 pacientes submetidos a tratamento de obesidade mórbida por meio de gastroplastia redutora, com sucesso para a técnica, ou emagrecimento por método não-cirúrgico. Os critérios de exclusão foram tabagismo, intenção gestacional e instabilidade ponderal, exigindo-se peso estável por pelo menos seis meses após atingido a perda ponderal satisfatória. RESULTADOS: Dos 98 pacientes operados, 97 por cento eram do sexo feminino, com idade média de 40,5 anos e o método de emagrecimento foi cirúrgico em 88 por cento deles. Das 177 cirurgias plásticas realizadas, 46 por cento foram abdominoplastias, seguidas por mastoplastias (15 por cento), suspensões de coxa (13 por cento) e braquioplastias (12 por cento). O período médio de internação foi dois dias e as principais complicações diagnosticadas foram: seroma (28 por cento), necroses/deiscências de pequeno porte (18 por cento), necroses/ deiscências de grande porte (4 por cento), hematomas (4 por cento), tromboflebite superficial de veia safena (2 por cento) e trombose venosa profunda (1 por cento). CONCLUSÃO: O desejo de cirurgias para melhora do contorno corporal após perda ponderal maciça constitui demanda crescente. Cabe ao cirurgião plástico conhecer as peculiaridades clínicas e os riscos maiores de complicações desses pacientes, ponderar suas expectativas, analisar os resultados e manter a busca constante pelo aperfeiçoamento das técnicas cirúrgicas.

OBJECTIVE: To present the clinical-surgical three year-experience related to body contour surgery in the massive weight loss patient, performed by the Plastic Surgery team of the Sapopemba State Hospital. METHODS: Retrospective study performed at the Sapopemba State Hospital, linked to the "Hospital das Clínicas" of the University of São Paulo School of Medicine, from July 2005 to July 2008. A total of 98 patients was operated, whose morbid obesity had been treated by bariatric surgery, after success of the technique, or weight loss by non-surgical method. Exclusion criteria were smoking, gestational intent and weight instability. Stable weight for at least 6 months after satisfactory weight loss was required from patients. RESULTS: Of the 98 operated patients, 97 percent were female, with mean age of 40.5 years and the weight loss method was the surgery in 88 percent of cases. From 177 plastic surgeries performed, 46 percent were abdominoplasty, followed by mammaplasty (15 percent), thigh suspension (13 percent) and brachioplasty (12 percent). Mean hospital stay was of two days and the main diagnosed complications were: seroma (28 percent), minor necrosis/dehiscences (18 percent), major necrosis/dehiscences (4 percent), hematomas (4 percent), superficial thrombophlebitis from the saphena vein (2 percent) and deep venous thrombosis (1 percent). CONCLUSION: An increasing demand for surgeries to improve body contour after massive weight loss has been detected. Plastic surgeons must know the clinical peculiarities and higher risk of complications of these patients, control their expectations, analyze results and engage in a continued investigation to improve surgical techniques.

The versatility of the free lateral arm flap in head and neck soft tissue reconstruction: clinical experience of 210 cases.

A study of the authors' experience with 210 free lateral arm flaps used to repair head and neck oncological defects over an 8-year period. Patients' ages ranged from 4 to 83 years (average: 49.7 years). One hundred and forty-one were male and 66 female. Three patients received two consecutive flaps each. They were used to reconstruct: the tongue, 53 cases; retromolar trigone, 42 cases; soft/hard palate, 34 cases; skin/facial contour, 19 cases; hypopharynx, 17 cases; buccal mucosa, 12 cases; lips, five cases. Flap cutaneous dimensions ranged from 4 x 2 cm to 17 x 8 cm. Flap was composed of: skin and fascia, 18 cases; sensate (neurovascular) skin, six cases; subcutaneous fat tissue, five cases; skin and vascularised nerve graft, three cases, skin and partial triceps muscle, three cases. Nerve coaptations were performed for all lip reconstructions. All flaps survived except for nine (success rate: 95.2%). Severe postoperative clinical complications preceded flap failure and death in two cases. All but six donor sites were closed primarily. Complications related to the donor site were: paresthesia of the forearm, 210 cases; dog ear, 16 cases; hypertropic scar, 14 cases; weakness, nine cases; haematoma, five cases; seroma, three cases; dehiscence, one case. Radial nerve injury was not observed in this series. The lateral arm flap can be considered safe and versatile for most soft tissue head and neck microsurgical reconstructions. The possibility of sensory recovery through neural anastomoses and low donor site morbidity enhances its efficiency.

Intraneural hematoma with extrinsic compression: experimental study in rats and therapeutic options.

Intraneural hematoma can result in the median nerve in the carpal tunnel after trauma or coagulation disorders. The decision for expectant management or decompressive surgical techniques is still controversial. Fifty male Wistar rats were divided into five groups. The sciatic nerve was wrapped around with a silastic device in four groups. In group A, the sciatic nerve was just wrapped by the silastic tube. In group B, an intraneural injection of autologous blood was added. In group C, after the hematoma creation, the silastic device was removed and a longitudinal epineurotomy was performed. In group D, the silastic device was removed after the hematoma, but the nerve was not opened. In group E (sham-operated), the sciatic nerve was exposed without hematoma or compression. Nerve function recovery was assessed periodically over 61 days using the Bain-Mackinnon-Hunter Sciatic Function Index (SFI). Group A (extrinsic compression) presented initial SFI of -26.29 +/- 2.89, with return to baseline values on the fifth postoperative day. Group B (hematoma and extrinsic compression) exhibited the poorest function (SFI of -85.23 +/- 3.51) after surgery and recovery in 23 days. Group C (liberation of silastic and hematoma drainage through epineurotomy) and group D (only removal of the silastic tube) presented similar initial SFI values of -32.78 +/- 7.45 and -45.13 +/- 6.84, respectively. In both the groups, the SFI values returned to baseline level on fifth postoperative day. The statistical analysis of SFI identified a significant difference (P < .0001) between the expectant management (group B) and the descompressive surgery approach (groups C and D) by 1st to 19th postoperative day. The number of degenerative fibers and density of degenerative fibers were statistically significantly longer in group B when compared with the other groups. There was no statistical difference between the other groups when these parameters were analyzed. Thus, immediate decompressive procedures of the intraneural hematoma provide a faster functional recovery and reduce the damage to the axon fibers.

Reconstrução microcirúrgica de deformidades cervicais pós queimadura com o retalho anterolateral da coxa / Microsurgical reconstruction of post burn neck deformities with free anterolateral thogh flap

Deformidades cervicais pós queimadura apresentam problemas funcionais e estéticos que desafiam Cirurgiões Plásticos. Quando essas deformidades envolvem pequenas áreas nós podemos realizar z-plastias, retalhos locais e enxertos cutâneos, mas em áreas ex- tensas nós temos que considerar os retalhos microcirúrgicos. O retalho ânterolateral da coxa tem sido utilizado em casos severos de contratura cervical, com bons resultados estéticos e funcionais.

Introduction: post burn neck contractures present with function alanda esthetic problems thatare achallenge for Plastic Surgeons. When theses deformities involve small areas we can perform Z-plasties, local flaps and skin graft, but in extensive areas we have to consider free flaps transfer. Free anterolateral thigh flap has been used in severe cases of neck contractures, with good aesthetic and functional results. Materials and Methods: 8 patients with extensive anterior neck contractures underwent free flap reconstruction with anterolateral thigh flap. There were 3 women and 5 men with mean age of 24,4 years (range 10 to 51). All cases resulted from flame burns. We have included in these series, patients that underwent to another procedure before, functional deficit (limited extension and rotation) and aesthetic consideration. After 60 days of surgery, 7 patients have been submitted to deffating procedure (liposuction) of the flap. Results: in all patients, release of contractures was excellent. All flaps survived well. One case presented with marginal necrosis of 3 x 1 cm of the flap, and another case with a marginal necrosis of burned area (receptor site).

Hematoma intraneural experimental em ratos: avaliação da recuperação funcional e histomorfometria neural / Experimental intraneural hematoma model in rats: evaluation of functional recovery and neural histomorphometry

A formação do hematoma intraneural com comprometimento de nervos periféricos pode ocorrer após trauma ou coagulopatias. O tratamento expectante ou abordagem cirúrgica descompressiva ainda não estão definidos. Foram estudados 40 ratos da raça Wistar divididos em 4 grupos. No grupo A realizou-se injeção intraneural de 0,2 ml de sangue autógeno no nervo ciático direito. No grupo B, após produção do hematoma, fez-se descompressão imediata com epineurotomia longitudinal. No grupo D realizamos liberação imediata do hematoma com neurólise interfascicular. No grupo C (CONTROLE) apenas realizou-se a exposição do nervo ciático sem formação de hematoma. A avaliação da função nervosa foi feita com o índice de Função Ciática de Bain-Mackinnon-Hunter (IFC). O grupo A apresentou IFC inicial de -28,43, com recuperação funcional no 5° dia. A drenagem imediata desse hematoma através de uma epineurotomia longitudinal (B) determinou retorno da função ciática normal desde o 1° dia (IFC= -14,42). Tratando o hematoma através da neurólise interfascicular observamos um IFC inicial de -23,69 e retorno da função ciática normal no 3° dia. Os parâmetros histomorfométricos apontaram melhora dos parâmetros de isquemia após os 2 tipos de intervenção cirúrgica aplicadas neste estudo. Não houve diferença entre os tipos de intervenções aplicadas.

Emergence of intraneural hematoma with involvement of peripheral nerves can occur after trauma or coagulation disorders. The decision for expectant management or decompressive surgical techniques is still controversial. Forty male Wistar rats were divided into 4 groups. In group A, an intraneural injection of autologous blood was provided at the right sciatic nerve. In group B, after the hematoma creation, a longitudinal epineurotomy was performed. In the group C (sham-operated), the sciatic nerve was exposed without hematoma. In group D. immediately after the hematoma creation, an interfascicular neurolysis was performed. Nerve function recovery was assessed using the Bain-Mackinnon-Hunter Sciatic Function Index (SFI). At the end of the study, the animals were sacrificed and a specimen of the sciatic nerve at compression midpoint was removed for morphometric analysis. Group A displayed an initial SFI of -28.43, with full functional recovery on the fifth day. Immediate drainage of the hematoma by longitudinal epineurotomy (group B) promoted recovery of normal sciatic function on the first day (SFI -14.42). Addressing the hematoma via interfascicular neurolysis resulted in an initial SFI of -23.69 and recovery of normal sciatic function on the third day. The morphometric variables indicated an improvement of ischemic parameters following both types of surgical intervention.

Recuperacao da funcao nervosa apos hematoma intraneural: estudo experimental comparativo em ratos submetidos a neurolise interna imediata / Backup of the nervous function after intraneural hematoma: comparative experimental study in rats submitted to the immediate internal neurolisis

O trauma de nervos perifericos constitui uma situacao comum, porem com apresentacao clinica extremamente variavel. Quando associado a grandes contusoes, em particular no trauma fechado de membros, pode levar a alteracoes sensitivas e motoras no territorio do nervo comprometido sem que haja necessariamente seccao nervosa. A opcao pela conduta expectante ou pela abordagem cirurgica descompressiva frente a essa situacao e muito pouco estudada. Diante disso, desenvolveu-se um...