Microneedling in the Treatment of Post-burn Hypertrophic Scars.

INTRODUCTION: Post-burn hypertrophic scars are an important cause of physical discomfort, limitation of movements, psychological disorders, low self-esteem and reduced quality of life. Treatment for this condition is complex and involves several options. Microneedling, also known as minimally invasive percutaneous collagen induction, is an affordable minimally invasive option that can be combined with other treatments, including ablative ones. OBJECTIVE: The goal of this study was to present our microneedling approach for the treatment of hypertrophic scars after burns. METHOD: A prospective study of 15 patients with post-burn hypertrophic scars was conducted between October 2016 and June 2022. All patients were treated with microneedling and drug delivery of triamcinolone. Scars were evaluated using Vancouver Scar Scale (VSS), Burn Scar Assessment Scale (BSAS) and angle measurement for amplitude of movement evaluation of joints. RESULTS: A significant improvement in the VSS score was obtained after microneedling (8.8 ± 0.44 to 4.1 ± 0.98; p = 0.012), especially in the acute group (less than 1 year after burns): 9.3 ± 0.49 to 3.5 ± 1.36; p = 0.041. There was a significant and progressive improvement of the scars throughout the treatment sessions in all criteria evaluated and in the ranges of joint movement (p = 0.012). CONCLUSION: Our microneedling protocol promoted a significant improvement of post-burn scars, especially in acute hypertrophic scars, and in the amplitude of joint motion. Sequential treatments provided progressive improvement. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of Post-Facelift Facial Paralysis With Botulinum Toxin Type A.

BACKGROUND: Facial nerve injury after facelift is rare; hence, its treatment is poorly established. Botulinum toxin type A (BTXA) can be employed to resolve the asymmetry. To our knowledge, there is no protocol in the literature about the best timing for this treatment, injection sites, or recommended dose. OBJECTIVES: The authors sought to propose a protocol to guide the management of asymmetries post-facelift. METHODS: Fifteen patients with post-rhytidectomy facial palsies were treated in the non-paralyzed side with BTXA. After analysis of the smile deviation vectors, it is possible to identify the muscles that should be treated. The dose varied from 1 to 2 volume-unit per point. Patients were examined after 15 days for outcomes evaluation and touch-up if needed. Patients were re-treated after 5 to 6 months in case of asymmetry recurrence. RESULTS: Symmetry was achieved in all cases. Six patients had definitive nerve lesions and required treatment every 6 months after the first session. Five patients had lesions affecting the upper third of the face; 4 of them were definitive nerve lesions. Two of the 4 patients who were treated less than 2 weeks after surgery recovered early from the post-facelift paralysis and developed reversed asymmetry due to the BTXA. In 7 patients, the post-facelift asymmetry was due to neuropraxis: the recovery from the nerve injury and BTXA treatment occurred symmetrically on both sides of the face in the following months after 1 single session. CONCLUSIONS: Asymmetries post-facelift were successfully managed with the proposed protocol. The best time for injection was 2 to 4 weeks after surgery.

Disinfection of 3D-printed protective face shield during COVID-19 pandemic.

This study assessed the disinfection using 70% ethanol; H2O2-quaternary ammonium salt mixture; 0.1% sodium hypochlorite and autoclaving of four 3D-printed face shields with different designs, visor materials; and visor thickness (0.5-0.75 mm). We also investigated their clinical suitability by applying a questionnaire to health workers (HW) who used them. Each type of disinfection was done 40 times on each type of mask without physical damage. In contrast, autoclaving led to appreciable damage.

Contralateral Botulinum Toxin Improved Functional Recovery after Tibial Nerve Repair in Rats.

BACKGROUND: There is clinical and experimental evidence that botulinum toxin applied to the healthy side of patients with facial paralysis positively affects functional recovery of the paralyzed side. The authors created an experimental model to study the effects of botulinum toxin injection in the gastrocnemius muscle contralateral to the side of tibial nerve lesion/repair in rats. METHODS: Fifty rats were allocated into five groups: group I, control; group II, tibial nerve section; group III, tibial nerve section and immediate neurorrhaphy; group IV, tibial nerve section, immediate neurorrhaphy, and botulinum toxin injected into the contralateral gastrocnemius muscle; and group V, botulinum toxin injected into the gastrocnemius muscle and no surgery. Assessment tools included a walking track, electromyography, gastrocnemius muscle weight measurement, and histologic analysis of the nerve. RESULTS: Paralysis in group V was transient, with function returning to normal at 8 weeks. At 12 weeks, group V had lower latency levels. At week 12, group IV showed higher functional outcomes and amplitude levels than group III, and lower muscle atrophy on the side injected with botulinum toxin compared with group V. CONCLUSION: Transient paralysis of the contralateral gastrocnemius muscle by botulinum toxin type A improved functional recovery in rats that underwent section and repair of the tibial nerve.

Fractional Carbon Dioxide Laser in Patients with Skin Phototypes III to VI and Facial Burn Sequelae: 1-Year Follow-Up.

BACKGROUND: Fractional carbon dioxide laser treatment in postburn scars is safe and effective, but high rates of hypochromia (35 percent) have been described in patients with skin phototypes V and VI after 2 months. The authors evaluated the efficacy and safety of fractional carbon dioxide laser treatment of burn scars in skin phototypes III to VI after 1 year, focusing on the incidence of hypochromia. METHODS: A case series of 20 patients had skin phototypes III to VI with facial burn sequelae. They underwent three sessions of fractional laser. Laser fluence was increased in patients with no hypochromia and reepithelialization time of less than 15 days. Scars were evaluated after 2 months and 1 year by a five-item scale: color, hydration, surface irregularities, volume, and distensibility. RESULTS: The mean time for reepithelialization was 13.3 days (range, 2 to 40 days). The average final score of the scale increased from 4.4 before treatment to 7.33 after 1 year for physicians, and from 5.35 to 7.5 for patients. There was also an increase in the subjective score, which patients used to assess their skin. Two months after treatment, 60 percent of patients presented with punctate hypochromia. After 1 year, only 15 percent of patients still had mild hypochromia; all of them had skin phototypes V and VI. Nevertheless, they were satisfied with overall bleaching of the skin. CONCLUSIONS: Fractional carbon dioxide laser improved skin quality. Late punctate hypopigmentation should be considered a possible complication in patients with skin phototypes V and VI. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Extracellular matrix remodeling derangement in ex-obese patients.

A known consequence of the large weight loss after bariatric surgery is the appearance of large skinfolds, particularly in the abdomen region of the patients. The balance between the synthesis of extracellular matrix (ECM) components and their proteolysis, mainly by fibrinolytic systems and matrix metalloproteases (MMPs), may be disturbed in these patients. The causes underlying the deregulation of ECM remodeling that occurs in these patients are not, however, clear. We investigated molecular mechanisms responsible for this dysfunction of ECM remodeling process, comparing it to normal skin. Collagen types, MMP2 and MMP9 expression and activity, interleukins 1ß (IL1ß) and 6 (IL6), and transcription coactivator PGC-1ß expression were analyzed in 16 patients. Ex-obese patients presented increased expression of collagen types III and IV mRNA, increased expression of MMP2, decreased expression and activity of MMP9, and increased expression of PGC-1ß in the skin. Inflammation markers IL1ß and IL6 mRNA were not different. We have demonstrated that obese patients with extensive weight loss after bariatric surgery have increased expression of PGC-1ß in the skin, which can result in a decreased expression and activity of MMP9 and increased collagen types III and IV deposition. These molecular changes may contribute for the formation of saggy skinfolds observed in these patients and impair wound healing.

Tibial and fibular nerves evaluation using intraoperative electromyography in rats.

PURPOSE: To evaluate a new model of intraoperative electromyographic (EMG) assessment of the tibial and fibular nerves, and its respectives motor units in rats. METHODS: Eight Wistar rats underwent intraoperative EMG on both hind limbs at two different moments: week 0 and week 12. Supramaximal electrical stimulation applied on sciatic nerve, and compound muscle action potential recorded on the gastrocnemius muscle (GM) and the extensor digitorum longus muscle (EDLM) through electrodes at specifics points. Motor function assessment was performaced through Walking Track Test. RESULTS: Exposing the muscles and nerves for examination did not alter tibial (p=0.918) or fibular (p=0.877) function between the evaluation moments. Electromyography of the GM, innervated by the tibial nerve, revealed similar amplitude (p=0.069) and latency (p=0.256) at week 0 and at 12 weeks, creating a standard of normality. Meanwhile, electromyography of the EDLM, innervated by the fibular nerve, showed significant differences between the amplitudes (p=0.003) and latencies (p=0.021) at the two different moments of observation. CONCLUSION: Intraoperative electromyography determined and quantified gastrocnemius muscle motor unit integrity, innervated by tibial nerve. Although this study was not useful to, objectively, assess extensor digitorum longus muscle motor unit, innervated by fibular nerve.

Tibial and fibular nerves evaluation using intraoperative electromyography in rats

ABSTRACT PURPOSE: To evaluate a new model of intraoperative electromyographic (EMG) assessment of the tibial and fibular nerves, and its respectives motor units in rats. METHODS: Eight Wistar rats underwent intraoperative EMG on both hind limbs at two different moments: week 0 and week 12. Supramaximal electrical stimulation applied on sciatic nerve, and compound muscle action potential recorded on the gastrocnemius muscle (GM) and the extensor digitorum longus muscle (EDLM) through electrodes at specifics points. Motor function assessment was performaced through Walking Track Test. RESULTS: Exposing the muscles and nerves for examination did not alter tibial (p=0.918) or fibular (p=0.877) function between the evaluation moments. Electromyography of the GM, innervated by the tibial nerve, revealed similar amplitude (p=0.069) and latency (p=0.256) at week 0 and at 12 weeks, creating a standard of normality. Meanwhile, electromyography of the EDLM, innervated by the fibular nerve, showed significant differences between the amplitudes (p=0.003) and latencies (p=0.021) at the two different moments of observation. CONCLUSION: Intraoperative electromyography determined and quantified gastrocnemius muscle motor unit integrity, innervated by tibial nerve. Although this study was not useful to, objectively, assess extensor digitorum longus muscle motor unit, innervated by fibular nerve.

Epidemiologic Overview of Synkinesis in 353 Patients with Longstanding Facial Paralysis under Treatment with Botulinum Toxin for 11 Years.

BACKGROUND: Patients with longstanding facial paralysis often exhibit synkinesis. Few reports describe the prevalence and factors related to the development of synkinesis after facial paralysis. Botulinum toxin type A injection is an important adjunct treatment for facial paralysis-induced asymmetry and synkinesis. The authors assessed the clinical and epidemiologic characteristics of patients with sequelae of facial paralysis treated with botulinum toxin type A injections to evaluate the prevalence of synkinesis and related factors. METHODS: A total of 353 patients (age, 4 to 84 years; 245 female patients) with longstanding facial paralysis underwent 2312 botulinum toxin type A injections during an 11-year follow-up. Doses used over the years, previous treatments (electrical stimulation, operations), and how they correlated to postparalysis and postreanimation synkinesis were analyzed. RESULTS: There was a significant association between cause and surgery. Most patients with facial paralysis caused by a congenital defect, trauma, or a tumor underwent reanimation. There were no sex- or synkinesis-related differences in the doses used, but the doses were higher in the reanimation group than in the no-surgery group. Synkinesis was found in 196 patients; 148 (41.9 percent) presented with postparalysis synkinesis (oro-ocular, oculo-oral) and 58 (16.4 percent) presented with postreanimation synkinesis. Ten patients presented with both types. CONCLUSIONS: This study determined the high prevalence (55.5 percent) of synkinesis in patients with longstanding facial paralysis. Postparalysis synkinesis was positively associated with infectious and idiopathic causes, electrical stimulation, facial nerve decompression, and no requirement for surgery. Postreanimation synkinesis was present in 28.2 percent of reanimated patients and was significantly associated with microsurgical flaps, transfacial nerve grafting, masseteric-facial anastomosis, and temporalis muscle transfers.

Comparison of the efficacy of onabotulinumtoxinA and abobotulinumtoxinA at the 1: 3 conversion ratio for the treatment of asymmetry after long-term facial paralysis.

BACKGROUND: Botulinum toxin A injection into the nonparalyzed side is used to treat asymmetry resulting from facial palsy. OnabotulinumtoxinA and abobotulinumtoxinA units are not equivalent. The authors compared the conversion ratio of 1:3 in patients with facial palsy. METHODS: Fifty-five patients (age, 16 to 67 years; 43 women) with longstanding facial palsy were randomly treated with either onabotulinumtoxinA (n = 25) or abobotulinumtoxinA (n = 30) injections into the nonparalyzed side. Adverse effects, facial symmetry, subjective satisfaction, and Facial Disability Index were assessed after 1 and 6 months. RESULTS: The incidence of adverse effects was higher with abobotulinumtoxinA (93.3 percent versus 64.0 percent; p = 0.007). Clinical scores of the nonparalyzed side decreased after 1 month and increased again at 6 months, with no between-group differences. Scores of the paralyzed side were lower in the onabotulinumtoxinA group before treatment, but similar in both groups thereafter. The paralyzed side scores increased after 1 month, and at 6 months were still higher than the pretreatment scores in both groups. Subjective assessment improved at all time points compared with pretreatment scores and differed between the two groups only at 1 month, when the abobotulinumtoxinA group was a bit too paralyzed. The physical function and social/well-being function subscales of the Facial Disability Index did not differ between the two groups. CONCLUSIONS: Both toxins efficiently reduced asymmetry in patients with facial palsy. Adverse effects were higher with abobotulinumtoxinA at an equivalence ratio of 1:3. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Protocolo de aplicação bilateral de toxina botulínica tipo A para evitar assimetria no tratamento de espasmo hemifacial / Protocol for bilateral application of botulinum toxin type A to avoid asymmetry during treatment of hemifacial spasms

Introdução: O espasmo hemifacial (EHF) caracteriza-se por movimento tônico-clônico involuntário da musculatura de uma hemiface. O tratamento tem sido realizado com aplicação de toxina botulínica (TxB). A aplicação unilateral classicamente descrita resulta em assimetria semelhante à paralisia facial. O objetivo desse trabalho foi normatizar o tratamento do EHF bilateralmente com TxB, a fim de prevenir a ocorrência de assimetria facial iatrogênica. Método: Foram analisadas 66 aplicações em 15 pacientes, seguindo o protocolo do serviço para paralisia facial, acrescentado de pontos pré-tarsais no lado com EHF. Foi feita dose complementar na reavaliação após 15 dias nos pacientes que apresentavam algum grau residual de espasmo ou assimetria, buscando-se a dose necessária para alcançar controle satisfatório do espasmo sem causar assimetria facial. Resultados: A dose média total foi 20,2 U do lado não acometido e 28,4 U do lado acometido, totalizando 48,6 U por aplicação. Houve diferença significante entre as hemifaces na dose para os músculos zigomático, orbicular da boca e orbicular dos olhos. Conclusões: A técnica proposta de aplicação bilateral de TxB controlou adequadamente o EHF e evitou assimetria iatrogênica. Como regra geral, a aplicação deve ser feita na proporção de 1:1,5 U no orbicular dos olhos (porção lateral) e 1:2 U no orbicular da boca. Nos demais músculos, a dose nos dois lados deve ser a mesma, realizando-se dose de reforço em 15 dias caso permaneça algum grau de espasmo. O único local com pontos exclusivos do lado acometido é a região pré-tarsal do músculo orbicular do olho.

Introduction: Hemifacial spasm (HFS) is characterized by the involuntary tonic-clonic movement of the muscles of the hemiface. It is usually treated with botulinum toxin (BTX). The classically described unilateral application of BTX results in an asymmetry similar to facial paralysis. The aim of this study was to standardize the treatment of HFS by applying BTX bilaterally to prevent the occurrence of iatrogenic facial asymmetry. Methods: The outcomes of 66 applications in 15 patients were analyzed according to the protocol of the facial paralysis service, to which pretarsal sites were added on the HFS side. On reassessment 15 days later, a complementary dose was administered to patients who exhibited some residual degree of spasm or asymmetry with the aim of determining the dose required to achieve satisfactory spasm control without causing facial asymmetry. Results: The total mean dose was 20.2 U at the contralateral side and 28.4 U at the spasm side (a total dose of 48.6 U per application). There was a significant difference between the doses applied to the zygomaticus, orbicularis oris, and orbicular oculi muscles on each hemiface . Conclusions: The proposed bilateral BTX application technique was effective in controlling HFS and prevented iatrogenic asymmetry. In general, application should be performed at a ratio of 1:1.5 U in the orbicularis oculi (lateral portion) and 1:2 U in the orbicularis oris. In the remaining muscles, the same dose should be administered on both sides and an additional dose can be applied 15 days later if some degree of spasm is present. The pretarsal region of the orbicularis oculi muscle is the only area for which BTX application on the healthy side is unnecessary.

Pseudoxanthoma Elasticum Treatment with Fractional CO2 Laser.

SUMMARY: Pseudoxanthoma elasticum (PE) is a rare genetic disease characterized by calcification and fragmentation of elastic fibers of the skin, retina, and cardiovascular system. We report a case of PE in which fractional carbon dioxide laser treatment was successfully used to achieve improvement of the cervical skin with 2-year follow-up, in a patient with Fitzpatrick skin type IV. After the fifth session, the patient presented with a local herpes infection. The postlaser reaction of the PE skin was similar to that of the normal skin, in terms of the duration of redness, pain, swelling, and duration of crusting. The overall cosmetic result was satisfactory, with improvement in skin texture, irregularity, volume, and distensibility. The herpetic infection reinforces the value of antiviral prophylaxis during laser treatment of extrafacial areas.

Fatores preditivos de complicações em procedimentos da cirurgia plástica - sugestão de escore de segurança / Predictive factors for complications in plastic surgery procedures ­ suggested safety scores

Introdução: O objetivo deste estudo foi analisar, em nosso meio, a associação entre a ocorrência de complicações em procedimentos de cirurgia plástica e os fatores de risco presentes nessa população, e apresentar uma Escala de Segurança para planejamento do ato cirúrgico em Cirurgia Plástica. Métodos: Estudo do tipo caso- -controle, com pacientes submetidos à cirurgia plástica no período de 2010-2011, em vários centros de cirurgia plástica e que apresentaram algum tipo de complicação pós-operatória. Os controles foram pacientes submetidos a procedimentos semelhantes de cirurgia plástica no mesmo período, e que não tiveram complicações. Foi realizada análise descritiva por meio de frequências absoluta e relativa e medidas de tendência central (média e mediana) e dispersão (desvio padrão e valores mínimo e máximo). A análise da associação foi realizada pelo Teste da Associação pelo x2 e modelos de regressão logística univariada e múltipla. Em todas as análises foi considerado estatisticamente significativo quando p<0,05. Resultados: Foram analisados 168 pacientes, sendo 75 casos com complicações (Grupo I, 44,64%) e 93 controles (Grupo II). Houve associação estatisticamente significativa entre a presença de complicação com duas variáveis, ter realizado procedimento associado (p=0,049), e o tempo de cirurgia maior que 240 minutos (p=0,049). Conclusão: A literatura demonstra aspectos multifatoriais de risco nos procedimentos da cirurgia plástica. A seleção adequada do paciente, o planejamento pré-operatório e os cuidados profiláticos no trans e pós-operatório têm contribuído para diminuição de incidência de complicações graves. Os principais fatores de risco relacionados a complicações no pós-operatório foram tempo cirúrgico maior que 4 horas e associação cirúrgica.

Introduction: This study analyzed the association between plastic surgery complications and risk factors in the study population, and presents a safety scale for planning plastic surgery procedures. Methods: A case-control study was performed, including patients who underwent procedures at various plastic surgery centers from 2010­2011 and who had some type of postoperative complication. The control group consisted of patients who underwent similar procedures during the same period without complications. Descriptive analysis was performed using absolute and relative frequency and measures of central tendency (mean and median) and dispersion (standard deviation and minimum and maximum value). Associations were analyzed using the chi-squared test of association and univariate and multiple logistic models. In all analyses, statistical significance was defined as p-values <0.05. Results: A total of 168 patients were analyzed: 75 cases with complications (Group I, 44.64%) and 93 controls (Group II). There was a statistically significant association between the presence of a complication and two variables: undergoing an associated procedure (p = 0.049) and surgery duration greater than 240 minutes (p = 0.049). Conclusion: The literature shows multifactorial risks for plastic surgery procedures. Proper patient selection, preoperative planning, and intra- and postoperative prophylactic care have contributed to decreased incidence of serious complications. The main risk factors associated with postsurgical complications were surgery durations longer than 4 hours and associated procedures.

Mastoplastia redutora associada a implante de silicone: quando indico? / Reduction mastoplasty with silicone implants: When is it indicated?

Introdução: Insatisfação dos pacientes com resultado de mamoplastia redutora pode ser identificado em alguns casos, especialmente quando apresentam ptose acompanhada de flacidez excessive, estrias, e ainda, componente mamário mais gorduroso que glandular. Nesses tipos de pacientes, é muito difícil conseguir bons resultados por longo período. Implantes mamários de pequeno volume, podem ser colocados no mesmo tempo da mamoplastia redutora com o objetivo de se obter melhor forma, contorno e projeção das mamas, com maior satisfação a longo prazo. Método: No período de 1997 a 2012, duzentos e sessenta e quatro pacientes com idade entre 27e 55 anos (idade média de 38), foram submetidas à mamoplastia redutora com imediata colocação de implante mamário. Resultados: Foram obtidos resultados satisfatórios, com adequado preenchimento do pólo superior, mamas firmes e reduzida estatística de ptose pós-operatória. Foram identificados dois casos de carcinoma in sito, como achados no anátomo-patológico. Conclusão: Mastoplastia redutora associada a implantes de silicone é um procedimento seguro para casos selecionados.

INTRODUCTION: Patient dissatisfaction with reduction mammoplasty outcomes can occur, especially in cases of ptosis accompanied by excessive flaccidity, striations, and a higher fat than glandular content. In such cases, achieving long-lasting results is very difficult. Small-volume breast implants can be placed during the reduction mammoplasty with the purpose of obtaining better breast shape, contour, and projection as well as greater long-term satisfaction. METHOD: Between 1997 and 2012, 264 patients aged 27-55 years (mean, 38) underwent reduction mammoplasty with immediate placement of breast implants. RESULTS: Satisfactory results were obtained, with adequate filling of the upper pole, increased breast firmness, and statistical reduction in postoperative ptosis. Two cases of carcinoma in situ were identified in the pathological exam. CONCLUSION: Reduction mastoplasty associated with silicone implants is safe for selected cases.