Invited Discussion on: Global Prevalence and Preferences of Progressive Tension Suture Usage in Abdominoplasties.

The effectiveness of using quilting/progressive tension sutures in reducing seroma formation after abdominoplasties is well established in the literature, eliminating the use of drains regardless of the simultaneous performance of liposuction. However, despite being widely studied and advocated, the quilting/progressive tension sutures technique is still not widespread, and most surgeons still insist on the use of drains. The author provides a brief literature review on this subject and comments on the work carried out by Wen et al., analyzing divergences between literature data and those presented by Wen et al., and trying to identify the causes of low adherence to the evaluated technique.

Invited Discussion on: The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction.

One in eight women will have a lifetime diagnosis of confirmed breast cancer, and one in three of these women will undergo a mastectomy. About half of women undergoing mastectomies will opt for some type of breast reconstruction. Breast cancer itself and breast reconstruction bring physical changes that are accompanied by psychological changes of varying degrees. The decision process about cancer treatment and whether or not to perform breast reconstruction brings suffering. In the case of choosing to perform the reconstruction, deciding when to perform it and which surgical technique to choose from among several available is quite complex, and may result in regret. The author provides a brief literature review on this subject and comments on the work carried out by Cai and Momeni, comparing data and results.Level of Evidence V 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.

Invited Discussion on: Management of Expander and Implant Associated Infections in Breast Reconstruction.

The author presents an objective review on "Management of Expander and Implant Associated Infections in Breast Reconstruction," discussing different points related to this subject, such as infection definition, identification of risk factors, related microorganisms, surgical techniques, preventive measures, antibiotic prophylaxis and therapy. Flaws in methodologies are identified and points of discrepancy in data and treatment results from previously published studies are pointed out, with discussion of possible causes for these inconsistencies. LEVEL OF EVIDENCE V: 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.

Invited Discussion on: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and the Textured Implant Crisis.

The author discusses some important points about breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and adds new and updated information about the disease (ALCL). LEVEL OF EVIDENCE V: 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.

Super giant squamous cell carcinomas.

Squamous cell carcinomas (SCCs) larger than 2 cm in diameter are associated with a greater risk for disfigurement, local recurrence, and metastasis. Giant SCCs are rare. They may develop near aesthetically and functionally important structures and infiltrate them. Treatment may be difficult with the need for large tissue resections and complex surgical reconstruction, with important repercussions on the quality of life of patients. We report 2 cases of super giant SCCs with long-standing evolution that were successfully treated with surgical excision and followed for 24 months posttreatment without signs of local recurrence and/or metastasis.

Increased intraoperative bleeding in patients undergoing abdominoplasty after gastroplasty is not due to coagulopathy.

BACKGROUND: Abdominoplasties carried out in patients previously underwent gastroplasty present high rates of complications, including increased bleeding in the intra- and postoperative periods. METHODS: This study evaluated bleeding, coagulation parameters (coagulogram, dosage of fibrinogen, FII, FV, FVII, FVIII, FIX, FX, and FXII), and thromboelastography in two groups of women who underwent abdominoplasties: a group with a history of gastroplasty by the Fobi-Capella technique (group I) and the other group without a history of obesity (group II). Analyses were performed before, during, and after each surgical procedure. Vitamins K and C were also dosed. Bleeding was measured by counting and weighing compresses at the end of each surgery, and the withdrawn surgical specimens were weighed. RESULTS: Statistically, group I patients had more bleeding than group II in all evaluated operative periods (p = 0.007). There was no significant change in the coagulogram or decrease in coagulation factors that could be associated with increased bleeding in any of the analyzed groups. Thromboelastography, which provides a comprehensive analysis of thrombin generation and of hemostasis in real time, did not differ between groups. Vitamin K was significantly increased in group I patients (p = 0.019). The weight of the surgical specimens removed was significantly higher in group I (p = 0.007) and there was correlation of the weight with the degree of bleeding. CONCLUSIONS: The results of this study demonstrate an increase of bleeding during the intraoperative period of abdominoplasty in patients with a history of gastroplasty that it is not due to changes in hemostasis. 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 .

Double-mesh technique for correction of abdominal hernia following mammary reconstruction carried out with bipedicled TRAM flap and the primary closing of the donor area by using a single polypropylene mesh.

BACKGROUND: Mammary reconstruction by using the transverse myocutaneous flap of the abdominal straight muscle (TRAM) is still an option well accepted in many parts of the world. However, bipedicled TRAM flaps are associated with greater morbidity of the abdominal donor area. The aim of this study was to describe an efficient technique for correcting the delayed defects of the abdominal wall following mammary reconstruction carried out with bipedicled TRAM flaps by using two polypropylene prostheses overlapped in different anatomical planes. METHODS: At Hospital Estadual Sumaré at Universidade Estadual de Campinas, 18 women who underwent unilateral mammary reconstruction with bipedicled TRAM flaps and immediate fixation of two rectangular flaps of polypropylene mesh on the donor area were assessed. Later on, three patients (16.7%) presented with deformity of the anterolateral abdominal wall in the donor area. Each of these herniations was corrected by fixing two polypropylene meshes in different anatomical planes: the first mesh, which was bigger and preperitoneal, was fixed from the costal borders until the pubis; the second mesh was fixed from the external oblique muscle to the contralateral external oblique muscle, remaking the median line. RESULTS: All patients were followed up for at least 18 months, without any signs of relapse, abdominal asymmetry, or chronic pain and with satisfactory functional results. CONCLUSION: The correction of delayed deformities of the abdominal wall after mammary reconstruction with bipedicled TRAM flaps using double mesh was carried out in an effective and secure way, providing an interesting surgical option for mastologists and plastic and general surgeons.

An unusual adverse event of botulinum toxin injection in the lower face.

BACKGROUND: In the lower third of the face, botulinum toxin A is used to obtain a more harmonious contour. The anatomical complexity of the face requires a more precise application of botulinum toxin. AIM: Describe the treatment of an unexpected effect after botulinum toxin A application in the lower third of the face. PATIENT/METHODS: A 51-year-old female patient presented to our clinic for application of botulin toxin aiming to improve facial wrinkles and contour. 50 U of botulinum toxin type A were applied to the upper third and 20 U to the lower third of the face. The patient returned after 10 days with a smile asymmetry and an excessive and unconscious lowering on the right side of the lower lip while laughing. So, 3 U of botulinum toxin were applied to the center of the depressor labii inferioris muscle on the right side. RESULTS: The patient returned with a satisfactory correction of the smile asymmetry. CONCLUSION: Although treatments with botulinum toxin A are considered safe, unexpected results can occur. In our case, it probably occurred due to medial injection or diffusion of botulinum toxin A into depressor anguli oris muscle on the left side that may lead to paralysis of the left depressor labii inferioris muscle and downward hyperfunction of the unaffected right lower lip. The correction was made with a new injection of botulinum toxin A in the depressor labii inferioris hyperactive muscle at the right side.

Pinna synthetic mold for otoplasty techniques application.

INTRODUCTION: The ear deformity Tanzer type V, also known as prominent ears, is the most common genetic defect of the pinna. The surgery designed for its correction is known as otoplasty. This esthetic surgery can be performed using different techniques, which requires great skill of its operator. OBJECTIVE: The purpose of this work is the development of a new tool for otoplasty techniques training, aimed on the possibility to minimize errors during the otoplasty. METHODS: Synthetic molds of the external ear from patients with Tanzer type V deformity were made, using silicone material and rayon. RESULTS: The main procedures of otoplasty could be performed in the molds made of silicone and rayon with a good esthetic result. CONCLUSION: The elaborated molds had identical size and shape of a human ear and could be positioned in the same shape of the patient ears. Thus, the synthetic molds were presented as promising simulation tools for the training and surgical enhancement of otoplasty, especially for doctors beginners.

Model for human skin reconstructed in vitro composed of associated dermis and epidermis.

CONTEXT AND OBJECTIVE: The technique of obtaining human skin with dermis and epidermis reconstructed from cells isolated from patients can enable autologous skin grafting on patients with few donor sites. It also enables in vitro trials on chemicals and drugs. The objective of this work was to demonstrate a method for obtaining human skin composed of associated dermis and epidermis, reconstructed in vitro. DESIGN AND SETTING: Experimental laboratory study, in the Skin Cell Culture Laboratory of Faculdade de Ciências Médicas, Universidade Estadual de Campinas. METHODS: Cells from human fibroblast cultures are injected into bovine collagen type I matrix and kept immersed in specific culturing medium for fibroblasts. This enables human dermis reconstruction in vitro. On this, by culturing human keratinocytes and melanocytes, differentiated epidermis is formed, leading to the creation of human skin composed of associated dermis and epidermis, reconstructed in vitro. RESULTS: We showed that human skin composed of associated dermis and epidermis can be successfully reconstructed in vitro. It is histologically formed in the same way as human skin in vivo. Collagen tissue can be identified in the dermis, with cells and extracellular matrix organized in parallel to multilayer epidermis. CONCLUSIONS: It is possible to obtain completely differentiated human skin composed of associated dermis and epidermis, reconstructed in vitro, from injection of human fibroblasts into bovine collagen type I matrix and culturing of human keratinocytes and melanocytes on this matrix.

Model of human epidermis reconstructed in vitro with keratinocytes and melanocytes on dead de-epidermized human dermis.

CONTEXT: Recent progress in the field of epithelial culture techniques has allowed the development of culture systems in which the reconstructed epidermis presents characteristics of morphological differentiation similar to those seen in vivo. Human epidermis reconstructed in vitro may be used as the best alternative for the in vitro testing of the toxicology and efficiency of products for topical use, as well as in the treatment of skin burns and chronic skin ulcers. OBJECTIVE: To demonstrate a method for obtaining human epidermis reconstructed in vitro, using keratinocytes and melanocytes cultivated on dead de-epidermized human dermis. TYPE OF STUDY: Experimental/laboratory. SETTING: Skin Cell Culture Laboratory of the Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil. PROCEDURE: Human keratinocytes and melanocytes cultured in vitro were grown on a biological matrix (dead de-epidermized human dermis) and the system was kept at an air-liquid interface, in a suitable culturing medium, until a stratified human epidermis was formed, maintaining the histological characteristics of the epidermis in vivo. RESULTS: It was histologically demonstrated that it is possible to reproduce a differentiated epidermis through keratinocytes and melanocytes cultured on dead de-epidermized human dermis, thus obtaining a correctly positioned human epidermis reconstructed in vitro with functional keratinocytes and melanocytes that is similar to in vivo epidermis. CONCLUSIONS: It is possible to obtain a completely differentiated human epidermis reconstructed in vitro from keratinocyte and melanocyte cultures on a dead de-epidermized human dermis.

Low-fidelity bench models for basic surgical skills training during undergraduate medical education.

It is remarkable the reduction in the number of medical students choosing general surgery as a career. In this context, new possibilities in the field of surgical education should be developed to combat this lack of interest. In this study, a program of surgical training based on learning with models of low-fidelity bench is designed as a complementary alternative to the various methodologies in the teaching of basic surgical skills during medical education, and to develop personal interests in career choice.

Pinna synthetic mold for otoplasty techniques application / Molde sintético auricular para aplicação de técnicas de otoplastia

Abstract Introduction The ear deformity Tanzer type V, also known as prominent ears, is the most common genetic defect of the pinna. The surgery designed for its correction is known as otoplasty. This esthetic surgery can be performed using different techniques, which requires great skill of its operator. Objective The purpose of this work is the development of a new tool for otoplasty techniques training, aimed on the possibility to minimize errors during the otoplasty. Methods Synthetic molds of the external ear from patients with Tanzer type V deformity were made, using silicone material and rayon. Results The main procedures of otoplasty could be performed in the molds made of silicone and rayon with a good esthetic result. Conclusion The elaborated molds had identical size and shape of a human ear and could be positioned in the same shape of the patient ears. Thus, the synthetic molds were presented as promising simulation tools for the training and surgical enhancement of otoplasty, especially for doctors beginners.

Resumo Introdução A deformidade da orelha tipo V de Tanzer, também conhecida como orelhas proeminentes, é o defeito genético mais comum da aurícula. A cirurgia criada para sua correção é conhecida como otoplastia. Essa cirurgia estética pode ser feita com diferentes técnicas, o que requer grande habilidade de seu operador. Objetivo O objetivo desse trabalho é o desenvolvimento de uma nova ferramenta para o treinamento de técnicas de otoplastia, com o objetivo de minimizar erros durante a otoplastia. Método Foram feitos moldes sintéticos da orelha externa de pacientes com deformidade tipo V de Tanzer com material de silicone e rayon. Resultados Os principais procedimentos de otoplastia foram feitos nos moldes de silicone e rayon com um bom resultado estético. Conclusão Os moldes elaborados tinham tamanho e forma idênticos aos de uma orelha humana e puderam ser posicionados no mesmo formato das orelhas dos pacientes. Assim, os moldes sintéticos foram apresentados como ferramentas de simulação promissoras para o treinamento e aperfeiçoamento cirúrgico da otoplastia, especialmente para médicos iniciantes.

An unusual presentation of giant pilomatrixoma in an adult patient.

BACKGROUND: Pilomatrixoma (OMIM ID #132600) is a benign cutaneous tumor originating from the pilosebaceous follicle and characterized by the presence of subcutaneous nodules of up to 3.0 cm in diameter, usually on the head, neck and upper extremities. It is most common in the first two decades of life and after the age of 60. MAIN OBSERVATIONS: An adult female patient was evaluated, presenting a solid tumoral lesion with erythematous surface and purplish tone, with approximately 7.5 x 5.0 cm in size, in the interscapulovertebral region. It was thought to be an epidermoid cyst, sarcoma, calcified hemangioma, giant dermatofibroma, or nodular basal cell carcinoma. The resection of the lesion was carried out and, at the histological examination, specific details were observed that led to the diagnosis of pilomatrixoma. CONCLUSION: Pilomatrixoma should be suspected in the differential diagnosis of giant adnexal tumors.

Giant hemangioma presenting as a scalp mass leading to a craniofacial deformity.

Hemangioma is the most common vascular tumor during childhood. However, cases of giant hemangiomas determining deformities in the craniofacial region are not reported frequently. Craniofacial giant hemangiomas are challenging for surgeons since they cause aesthetic and/or functional problems and may be associated with important complications such as ulcerations, infections and bleedings. The present report is aimed at describing a rare case of craniofacial asymmetry in a 30-year-old patient, secondary to an extensive mass whose growth deformed the scalp in the frontal-parietal-temporal region. The lesion was completely surgically removed with good aesthetic results, and the anatomopathological examination revealed that it was a cavernous hemangioma.

Organic bench model to complement the teaching and learning on basic surgical skills.

PURPOSE: To propose an organic bench model made with fruits/vegetables as an alternative to complement the arsenal of simulators used in the teaching and learning of basic surgical skills during medical graduation and education. METHODS: They were described the training strategies, through the use of fruits (or vegetables) to the learning of different techniques of incision, sutures, biopsies and basic principles of reconstruction. The preparation of bench model, the processes of skill acquisition, feedback and evaluation were also delineated. RESULTS: A proposal for teaching based on an organic model with training delivered in multiple sessions, with increasing levels of difficulty, and with feedback and evaluation during all the process was structured. CONCLUSION: The organic model, being simple, versatile, portable, reproducible, readily available, and having low cost, is another option to complement the existing simulators for teaching and learning of basic surgical skills.

Avaliação do ensino e aprendizagem de noções básicas de tratamento de queimados entre alunos do curso de medicina / Assessment of teaching and learning burn treatment basics among medical students

Introdução: Agravo de grande importância biopsicossocial, queimadura é um tema crucial na formação médica, uma vez que recém-formados se deparam com pacientes que sofreram queimaduras nos mais variados cenários profissionais. Métodos: Este estudo avaliou o ensino e a aprendizagem do tema queimaduras em alunos do curso de Medicina de uma faculdade pública do Estado de São Paulo; foi aplicado um questionário específico para avaliar o conhecimento sobre o atendimento inicial ao paciente queimado na primeira série (grupo 1 - 54 estudantes), e na sexta série (grupo 2 - 60 estudantes). Resultados: Observou-se, no grupo 1, grande desconhecimento sobre o tema, com média geral de desconhecimento ("erros") de 70,98% e de acertos de 29,02%; no grupo 2, essas taxas foram de 36,66 % e 63,34 %, respectivamente. Somente 63,34% dos alunos do sexto ano conseguiriam conduzir adequadamente o tratamento de um paciente queimado e, consequentemente, oferecer a este paciente um melhor prognóstico. Conclusões: Os dados são preocupantes, uma vez que não se verificou conhecimento nem preparo adequados dos formandos para atendimento de pacientes queimados, e que queimaduras são situações de emergência que exigem intervenção médica rápida, adequada e eficiente, a fim de reduzir a morbimortalidade das vítimas.

Introduction: Burns, an injury of high biopsychosocial importance, are a crucial issue in medical training, and newly graduated students face burn patients in a variety of professional settings. Methods: This study assessed the teaching and learning of burns among medical students at a public facility in the State of São Paulo; a specific questionnaire was applied to evaluate first year (Group 1: 54 students) and sixth year (Group 2: 60 students) medical students' knowledge about the initial care of burn patients. Results: In Group 1, there was a substantial lack of knowledge about the subject, with a general average incorrect answer rate ("errors") of 70.98% and a correct answer rate of 29.02%; in Group 2, these rates were 36.66% and 63.34%, respectively. Only 63.34% of the sixth-year students would be able to adequately conduct the treatment of a burn patient, gauged by their ability to offer a patient a better prognosis. Conclusions: The data are disturbing, since adequate knowledge and preparation of the trainees for the care of burn patients has not been verified, and burns are emergency situations that require prompt, adequate, and efficient medical intervention to reduce patients' morbidity and mortality.

Ectopic thyroid presenting as a submandibular mass.

Although extremely rare, the presence of ectopic thyroid tissue in the submandibular region should be considered in the differential diagnosis of tissue masses in the cervical region. Diagnosis is confirmed by fine-needle aspiration biopsy and exclusion of malignancy should be confirmed by histopathologic analysis of the lesion. In general, surgery is the treatment of choice. A rare case of ectopic thyroid in the right submandibular region is reported; it was diagnosed after total thyroidectomy and successfully treated through surgery.

Diagnostic accuracy of frozen section tests for surgical diseases.

OBJECTIVE: To evaluate the accuracy of frozen section tests at different anatomical sites performed in an academic department of pathology. METHODS: We conducted a retrospective study from a computerized database of all frozen section tests. These diagnoses were compared to definite paraffin, used as controls. The tests were divided into three groups: inconclusive, consistent and inconsistent, the latter being subdivided into false positives and false negatives. The main indications for examinations and anatomical sites involved with diagnostic disagreements were also analyzed. RESULTS: Four hundred and thirty-three specimens were frozen tested, and the main indication was diagnostic (75.75%). In 404 tests (93.30%) diagnoses of biopsies in paraffin and frozen section were consistent. In 20 cases (4.62%) the results of frozen section biopsy were inconclusive and in 9 (2.08%) they were false negative. There were no false positive results. The most commonly assessed organ was the thyroid (25.64%). In the overall analysis, the body region most related with inconclusive diagnoses was the thyroid (seven cases) and in relation to specific sites it was the lungs/pleura/mediastinum (13.33%). Skin was the organ that showed more discordant diagnoses between frozen biopsies and paraffin. CONCLUSION: The global accuracy of frozen section was 93.30%; for specific anatomical sites, diagnostic accuracy ranged from 86.67% to 100%.