Comparison of the perceived stigmatization measures between the general population and burn survivors in Brazil.

OBJECTIVES: To compare perceived stigmatization, symptoms of depression and self-esteem of adults from Brazilian general population with Brazilian burns survivors and to verify the possible correlations between these populations. METHOD: The general population and burn survivors administered the adapted Brazilian versions of the Perceived Stigmatization Questionnaire (BR-PSQ-R), Beck Depression Inventory (BDI) and Rosenberg Self-Esteem Scale (RSES). The Student's t-test for independent samples was employed to identify significant differences between the means of the results from the BR-PSQ-R, BDI and RSES instruments, and the Pearson correlation was used to detect correlations between constructs. The significance level was set at 0.05. RESULTS: Participants of this study included: 102 individuals from the general population and 240 burn survivors. The difference between the BR-PSQ-R mean scores of the two groups was not statistically significant (p = 0.077). The mean scores for the BDI (p = 0.001) and RSES (p = 0.001) where found to be lower in the general population, when compared to burn survivors. Moderate correlations were identified between the perceived stigmatization and depression (r = 0.43; p < 0.001) and perceived stigmatization and self-esteem (r = -0.35; p < 0.001). CONCLUSIONS: Participants from the general population and burn survivors exhibit similar levels of perception of stigmatization; the general population presented fewer symptoms of depression and a higher self-esteem when compared to burn survivors.

Does postauricular fascial flap reduce suture complications in otoplasty?

Numerous suture techniques and covering flaps have been described to minimize complications related to sutures in otoplasty. The split postauricular fascial flap is one of such techniques, and it has been used to pad otoplasty suture. The aim of this study was to evaluate complications related to nonabsorbable cartilage sutures in otoplasty, using a variation of the split postauricular fascial flap. In this retrospective case series, we analyzed otoplasty patients in whom simplified split postauricular fascial flap was utilized. A postauricular skin ellipse was de-epithelialized (preserving dermis) and a longitudinally split in half. Flaps were dissected, and they were positioned on the cartilage to promote additional soft tissue coverage to the sutures. The lateral flap covered conchoscaphal sutures while the medial flap covered the conchomastoid sutures. Both the flaps were not sutured to cartilage. Early and late postoperative complications were evaluated. A total of 142 patients were included. Twenty-four (16.9%) patients developed late complications: 13 (9.1%) patients had palpable and visible sutures, nine (6.3%) had suture extrusion and two (1.4%) had hypertrophic scars. In this case series, the simplified split postauricular flap did not prevent or reduce late complications related to suture extrusion in otoplasty. It is possible that suturing the entire length of the flaps may play a role in our results. So, anchoring the flap and possibly tightening it a little may be an important technical step to prevent extrusion of sutures whenever the postauricular flap is used.

Validation of the Perceived Stigmatization Questionnaire for Brazilian adult burn patients.

Currently, there is no questionnaire to assess perceived stigmatization among people with visible differences in Brazil. The Perceived Stigmatization Questionnaire (PSQ), developed in the United States, is a valid instrument to assess the perception of stigmatizing behaviours among burn survivors. The objective of this cross-sectional and multicentre study was to assess the factor structure, reliability and validity of the Brazilian Portuguese version of the PSQ in burn patients. A Brazilian version of the 21-item PSQ was answered by 240 adult burn patients, undergoing rehabilitation in two burns units in Brazil. We tested its construct validity by correlating PSQ scores with depression (Beck Depression Index-BDI) and self-esteem (Rosenberg Self-Esteem Scale-RSE), as well as with two domains of the Revised Burn Specific Health Scale-BSHS-R: affect and body image, and interpersonal relationships. We used Confirmatory Item Factor Analysis (CIFA) to test whether the data fit a measurement model involving a three-factor structure (absence of friendly behaviour; confusing/staring behaviour; and hostile behaviour). We conducted Exploratory Factor Analyses (EFA) of the subscale in a 50% random sample of individuals (training split), treating items as ordinal categorical using unweighted least squares estimation. To assess discriminant validity of the Brazilian version of the PSQ we correlated PSQ scores with known groups (sex, total body surface area burned, and visibility of the scars) and assessed its reliability by means of Cronbach's alpha and using test-retest. Goodness-of-fit indices for confirmatory factor analysis were satisfactory for the PSQ, but not for the hostile behaviour subscale, which was modified to improve fit by eliminating 3 items. Cronbach's alphas for the PSQ refined version (PSQ-R) ranged from 0.65 to 0.88, with test-retest reliability 0.87 for the total score. The PSQ-R scores correlated strongly with depression (0.63; p < 0.001), self-esteem (-0.57; p < 0.001), body image (-0.63; p < 0.001), and interpersonal relationships (-0.55; p < 0.001). PSQ-R total scores were significantly lower for patients with visible scars (effect size = 0.51, p = 0.029). The PSQ-R showed reliability and validity comparable to the original version. However, the cross-cultural structure of the subscale "hostile behaviour" and sensitivity to change of the PSQ should be further evaluated.

Effects of the Metallic Port in Tissue Expanders on Dose Distribution in Postmastectomy Radiotherapy: A Tridimensional Experimental Model of Dosimetry in Breast Reconstruction.

The purpose of this research was to develop an experimental model of dosimetry using a breast phantom and evaluate the effects of the metallic port in tissue expanders on dose distribution in postmastectomy radiotherapy. Dose distribution was assessed using an experimental acrylic dosimetry simulator in the absence and presence of a metallic disc (MD), which is similar to that used in tissue expanders containing a magnetic port, by collecting coronal and sagittal radiochromic films. Dosimetry film analysis did not show any changes in dose distribution, except for a MD shadow in the sagittal film where the dose distribution rate was on average 14% lower than in other areas. This model very closely resembled actual breast reconstruction with a tissue expander containing a magnetic port. Scattering or attenuation of the irradiation dose due to interference of the MD was not evident in areas that could jeopardize the effectiveness of radiation therapy. Therefore, the presence of the MD inside the tissue expander does not likely have an impact on radiotherapy effectiveness during immediate breast reconstruction.

Application of Unilateral Pectoralis Major Muscle Flap in the Treatment of Sternal Wound Dehiscence.

OBJECTIVE: This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of the sternal wound dehiscence. METHODS: A retrospective study including patients who underwent unilateral pectoralis major muscle flap was performed for the treatment of sternotomy dehiscence due to coronary artery bypass, valve replacement, congenital heart disease correction and mediastinitis, between 1997 and 2016. Data from the epidemiological profile of patients, length of hospital stay, postoperative complications and mortality rate were obtained. RESULTS: During this period, 11 patients had their dehiscence of sternotomy treated by unilateral pectoralis major muscle flap. The patients had a mean age of 54.7 years, the mean hospital stay after flap reconstruction was 17.9 days (from 7 to 52 days). In two patients, it was necessary to harvest a flap from the rectus abdominis fascia, in association with the pectoralis major muscle flap, to facilitate the closure of the distal wound. In the postoperative period, seroma discharge from the surgical wound was observed in six patients, five reported intense pain (temporary), three had partial cutaneous dehiscence, and two presented granuloma of the incision. CONCLUSION: The complex wound from sternotomy dehiscences presents itself as a challenge to surgical teams. Treatment should include debridement of necrotic tissue and preferably coverage with well-vascularized tissue. We propose that the unilateral pectoralis major muscle flap is an interesting and low morbidity option for the reconstruction of sternal wound dehiscences, with proper sternum stability and satisfactory functional and aesthetic outcomes.

Gluteal Augmentation With Intramuscular Implants in Patients With Human Immunodeficiency Virus With Lipoatrophy Related to the Use of Antiretroviral Therapy.

INTRODUCTION: Lipodystrophy syndrome associated with highly active antiretroviral therapy (HAART) may lead to low self-esteem and poor compliance with the drug treatment on patients infected with human immunodeficiency virus (HIV), which is a matter of concern for the health system. The aim of this study was to evaluate patients with HIV submitted to gluteal augmentation with intramuscular silicone implants to correct gluteal lipoatrophy related to the use of HAART. METHODS: This is a retrospective evaluation of 10 patients submitted to gluteal augmentation with intramuscular silicone implant for correction of gluteal lipoatrophy related to the use of HAART, operated between 2012 and 2015. Postoperative complications and the degree of patient's satisfaction were analyzed. RESULTS: There were 3 postoperative complications including 1 case of surgical wound dehiscence and 2 cases of seroma. Six months after surgery, 8 patients had an excellent degree of satisfaction, and 2 patients had a good degree of satisfaction related to the procedure. Although this intervention does not offer functional advantages, it improves the body contour, increases patients' self-esteem, and helps them to accept their body image. These advantages can lead to higher compliance with prolonged HAART. CONCLUSIONS: Gluteal augmentation with intramuscular silicone implant can be a viable option to treat patients with HIV with gluteal lipoatrophy related to the use of HAART. The patients were satisfied with the outcomes of the procedure, and there were only minor self-limited postoperative complications.

Negative pressure therapy for the treatment of complex wounds.

The objective of this study is to evaluate the effectiveness of negative pressure therapy (NPT) in the treatment of complex wounds, with emphasis on its mechanisms of action and main therapeutic indications. We searched the Pubmed / Medline database for articles published from 1997 to 2016, and selected the most relevant ones. The mechanisms of action of NPT involveboth physical effects, such as increased perfusion, control of edema and exudate, reduction of wound dimensions and bacterial clearance, and biological ones, such as the stimulation of granulation tissue formation, microdeformations and reduction of Inflammatory response. The main indications of NPT are complex wounds, such as pressure ulcers, traumatic wounds, operative wound dehiscences, burns, necrotizing wounds, venous ulcers, diabetic wounds, skin grafts, open abdomen, prevention of complications in closed incisions and in the association with instillation of solutions in infected wounds.

O objetivo desse estudo é avaliar a eficácia da terapia por pressão negativa (TPN) no tratamento de feridas complexas, com ênfase em seus mecanismos de ação e principais indicações terapêuticas. Foi realizada revisão na base de dados Pubmed / Medline, em artigos publicados de 1997 a 2016, e selecionados os mais relevantes. O mecanismo de ação da TPN envolve efeitos físicos, como o aumento da perfusão, controle do edema e do exsudato, redução das dimensões da ferida e depuração bacteriana, e biológicos, como o estímulo à formação de tecido de granulação, microdeformações e redução da resposta inflamatória local. As principais indicações da TPN são as feridas complexas como úlceras por pressão, feridas traumáticas, deiscências de ferida operatória, queimaduras, feridas necrotizantes, úlceras venosas, feridas diabéticas, os enxertos de pele, o abdome aberto, na prevenção de complicações em incisões fechadas e na associação com instilação de soluções em feridas infectadas.

Revisiting Escharotomy in Patients With Burns in Extremities.

Escharotomy incisions must be made in the inelastic skin eschar that is typical of circumferential third-degree burns. Later, the necrotic tissue must be debrided and substituted with a skin graft. Many reports on this topic have revealed that concepts and techniques vary widely. This study aims to present a critical review of the literature about escharotomy in burns and to highlight a different strategy to perform escharotomy in patients with burned extremities. We conducted a critical review in Pubmed/MEDLINE using the keywords "escharotomy" and "burns." In the present study, we included 22 articles published from 1955 to 2015 (60 years) that contain the aforementioned keywords. With respect to the extremities, most of the publications recommend that medial and lateral longitudinal incisions be performed and that care must be taken to avoid deep structures, particularly nerves. Moreover, the publications mention that escharotomy might result in thick, hypertrophic, retracting, and painful scars. We advocate that incisions performed only on the lateral and medial borders of the extremities are usually unnecessary, and that they contribute to the creation of misconceptions about burns. In addition, these incisions can somehow trigger complications that can be avoided by using the concept of escharotomy in multiple directions, as highlighted in this review.

Evidences of autologous fat grafting for the treatment of keloids and hypertrophic scars.

INTRODUCTION: Since the 1980s, the use of autologous fat grafting has been growing in plastic surgery. Recently, this procedure has come to be used as a treatment for keloids and hypertrophic scars mainly due to the lack of satisfactory results with other techniques. So far, however, it lacks more consistent scientific evidence to recommend its use. The aim of this study was to review the current state of autologous fat grafting for the treatment of keloids and hypertrophic scars, their benefits and scientific evidences in the literature. METHOD: A review in the Pubmed database was performed using the keywords "fat grafting and scar", "fat grafting and keloid scar" and "fat grafting and hypertrophic scar." Inclusion criteria were articles written in English and published in the last 10 years, resulting in 15 studies. RESULTS: These articles indicate that autologous fat grafting carried out at sites with pathological scars leads to a reduction of the fibrosis and pain, an increased range of movement in areas of scar contraction, an increase in their flexibility, resulting in a better quality of scars. CONCLUSION: So far, evidences suggest that autologous fat grafting for the treatment of keloids and hypertrophic scars is associated with a better quality of scars, leading to esthetic and functional benefits. However, this review has limitations and these findings should be treated with reservations, since they mostly came from studies with low levels of evidence.

Bronchial fistula closure with negative pressure wound therapy: a feasible and cost-effective treatment.

Treatment of bronchial fistula (BF) after pulmonary lobectomy is a challenge. Often, patients require long hospital stay, have recurrent empyema and pneumonia, are susceptible to sepsis, often need broad-spectrum antibiotics, as well as various surgical approaches. With the advent and growing evidence of the benefits of negative pressure therapy (NPT), its use in some patients with BF has been reported with encouraging results concerning its feasibility and cost-effectiveness. The aim of this study was to demonstrate the application of NPT as a resource for BF treatment and comparatively analyze the overall cost of treatment. RESUMO O tratamento de fístula brônquica (FB) após lobectomia pulmonar é um desafio. Muitas vezes, o paciente demanda longo tempo de internação, apresenta recidivas de empiema e pneumonia, pode evoluir para sepse, frequentemente necessita de antibioticoterapia de amplo espectro, bem como de várias abordagens cirúrgicas. Com o advento e acúmulo de evidências dos benefícios da terapia por pressão negativa (TPN), seu uso em alguns pacientes com FB tem sido relatado com resultados animadores relativos à sua viabilidade e ao seu custo-efetividade. O objetivo deste estudo foi demonstrar a aplicação de TPN como recurso para tratamento da FB e analisar comparativamente o custo global do seu tratamento.

Diagnosis and Prevalence of Prominent Lobules in Otoplasty: Analysis of 120 Patients with Prominent Ears.

BACKGROUND: The prominence of the ear lobule is considered an anomaly of secondary importance and receives correspondingly less attention in literature. We reviewed a case series of otoplasty patients and analyzed the prevalence of lobule prominence. METHODS: Records of otoplasties between 2007 and 2013 were reviewed. Inclusion criteria were: (1) primary otoplasties; (2) prominence of both ears; and (3) otoplasties conducted by the main author. Patients were divided into two groups: (1) A general group (GG) containing all the patients, and (2) a lobule correction group (LG)-a subgroup of GG containing only the patients who needed lobule correction. RESULTS: From a total of 291 patients, 120 patients were included in GG and 27 patients in LG. There was no statistical difference between groups GG and LG in terms of age and gender. Preoperative diagnosis of lobule prominence was correctly established in 14 patients; 13 patients were diagnosed during surgery. CONCLUSIONS: Lobule prominence should not be underestimated since its diagnosis may be missed in the preoperative period-nearly 50 % in our case. Also its prevalence (22.5 %) is not as infrequent as some may think. Knowledge of lobule correction techniques before surgery is important to avoid less than optimal results in otoplasty. 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.

Satisfaction With Appearance Scale-SWAP: Adaptation and validation for Brazilian burn victims.

AIM: Methodological study that aimed to adapt the Satisfaction with Appearance Scale (SWAP) into Brazilian Portuguese language and to assess the validity, the reliability and the dimensionality of the adapted version in a sample of Brazilian burn victims. METHODS: We carried out the adaptation process according to the international literature. Construct validity was assessed by correlating the adapted version of SWAP scores with depression (Beck Depression Index), self-esteem (Rosenberg Self-Esteem Scale), health-related quality of Life (Short Form Health Survey-36) and health status of burn victims (Burn Specific Health Scale-Revised), and with gender, total body surface area burned, and visibility of the scars. We tested dimensionality using Exploratory Factor Analysis (EFA) and the reliability by means of Cronbach's alpha. RESULTS: Participants were 106 adult burned patients. The correlations between the Brazilian version of the SWAP scores and the correlated construct measures varied from moderate to strong (r=.30-.77). The participants who perceived their burn sequelae was visible reported being more dissatisfied with their body image than the participants who answered that their scars would not be visible (p<.001). Cronbach's alpha for the adapted version was 0.88 and the item-total correlation varied from moderate to strong (r=.35-.73). The EFA resulted in three factors with a total explained variance percentage of 63.2%. CONCLUSION: The Brazilian version of the SWAP was valid and reliable for use with Brazilian burn victims.

Avaliação da qualidade de vida relacionada à saúde no primeiro ano após a queimadura / Assessment of health-related quality of life in the first year after burn / Evaluación de calidad de vida relaciona con la salud en el primer año después de la quemadura

Objetivo: Comparar a percepção de qualidade de vida de vítimas de queimaduras entre o 4º e 6º mês e entre o 9º e 12º mês após a alta hospitalar, de acordo com o sexo, superfície corporal queimada e visibilidade das cicatrizes. Métodos: Estudo longitudinal. Participaram adultos internados em uma unidade de queimados. Foram aplicados formulário de dados sociodemográficos e oMedical Outcomes Study 36-Item Short-Form Survey. Resultados: Houve melhora na percepção da qualidade de vida, destacando-se os domíniosAspecto físico e emocionais. Os homens apresentaram melhores resultados no domínio Dor; e aqueles que classificaram suas cicatrizes como não visíveis nos domínios Estado geral de saúde, Vitalidade, Aspecto social e Emocional entre o 9º e 12º mês. Conclusão: Pacientes relataram pior qualidade de vida em fase precoce e melhora em fase tardia, principalmente no domínio Aspecto físico e emocional entre os homens. As cicatrizes visíveis representaram avaliação negativa na fase tardia.

Objective: To compare the perception of quality of life for burn victims between the 4th and 6th and between the 9th and 12thmonths after hospital discharge, according to gender, body surface burned and visibility of scars. Methods: A longitudinal study.The study participants were adults admitted to a burn unit. A socio-demographic data form and the Medical Outcomes Study36-Item Short-Form Survey were applied. Results: There was an improvement in the perception of quality of life, highlighting thedomains: Role physical and Role emotional. Men showed better results in the domain Bodily pain; and also those who classifiedtheir scars as not visible in the domains: General Health, Vitality, Social Functioning and Role emotional, between the 9th and12th month. Conclusion: Patients reported worse quality of life at an early phase and improvement in a late phase, mainly inthe domains of Role physical and Role emotional, among men. The visible scars represented negative rating in the late phase

Objetivo: Comparar la percepción de calidad de vida de victimas de quemaduras entre el 4º e 6º y entre el 9º y 12º mes despuésdel alta, y sus diferencias según sexo, superficie corporal quemada y visibilidad de la cicatriz. Métodos: Estudio longitudinal.Participaron adultos internados en una Unidad de Quemados. Aplicado formulario de datos sociodemográficos y el MedicalOutcomes Study 36-Item Short-Form-Survey. Resultados: Huvo mejora de la percepción de calidad de vida, destacándoseAspectos físicos y Emocionales. Los hombres presentaron mejores resultados en el dominio Dolor; y los que classificaron suscicatrizes como no visibles en los domínios Estado general de salud, Vitalidad, Aspecto social y Emocional entre el 9º e 12ºmes. Conclusión: Pacientes relataron peor calidad de vida en la fase precoz y mejor en la fase tardía, principalmente en losdomínios Aspecto físico e emocional, entre los hombres. Las cicatrizes visibles representan evaluación negativa en la fase tardía.

Reliability and validity of the body image quality of life inventory: version for Brazilian burn victims.

The aims of this study were to adapt the Body Image Quality of Life Inventory (BIQLI) into Brazilian Portuguese (BP) and to assess the psychometric properties of the adapted version. Construct validity was assessed by correlating the BIQLI-BP scores with the Rosenberg's Self-Esteem Scale, with Burns Specific Health Scale-Revised (BSHS-R), and with gender, total body surface area burned, and visibility of the scars. Participants were 77 adult burn patients. Cronbach's alpha for the adapted version was .90 and moderate linear correlations were found between body image and self-esteem and between BIQLI-BP scores and two domains of the BSHS-R: affect and body image and interpersonal relationships. The BIQLI-BP showed acceptable levels of reliability and validity for Brazilian burn patients.

Effect of acute thermal injury in status of serum vitamins, inflammatory markers, and oxidative stress markers: preliminary data.

The objective of this study was to evaluate the vitamin status, inflammatory markers, and oxidative stress markers in adult patients up to 3 days after thermal injury. This prospective study was conducted with 11 patients 24 to 72 hours after thermal injury (Burn Group), total surface area ranging from 10 to 41%, 34.3 ± 9.3 years, 82% of males, body mass index of 22.3 ± 2.9 kg/m(2). We included 11 healthy adults (Control Group), 36.5 ± 7.6 years, 73% of males, and body mass index of 23.8 ± 2.5 kg/m(2). Laboratory data were measured (plasma total protein, albumin, transferrin, lymphocyte counts, zinc, and iron), as well as serum vitamins (folic acid, vitamin B12, and vitamins A, C, and E), inflammatory stress markers (C-reactive protein, ferritin, and acid α1-glycoprotein) and oxidative stress markers such as glutathione peroxidase (GPx) and thiobarbituric acid reactive substances. The inflammatory stress was characterized by lower levels of total protein (median difference 1.2 g/dL, 95% CI: 0.4-2.1) and albumin (median difference 0.9 g/dL, 95% CI: 0.5-1.5), and higher levels of C-reactive protein (median difference -8.12 mg/dL, 95% CI: -11.62 to 4.61) and α-1 glycoprotein acid (median difference -28.56 mg/dL, 95% CI: -51.57 to -5.07) in burn patients. Decreased serum levels of vitamin A (median difference 1.10 µmol/L, 95% confidence interval [CI]: 0.42-1.66) and vitamin C (median difference 0.82 mg/dL, 95% CI: 0.50-1.04) were also detected. There was no statistical evidence of difference in the serum levels of glutathione peroxidase and thiobarbituric acid reactive substances between burn patients and controls, respectively. Even though there is an inflammatory stress, the obtained data showed that oxidative stress markers are normal 24 to 72 hours after burn injury. The decrease in negative acute phase protein may account for the diminished serum levels of vitamin A, which seems to be related to inflammatory stress. The marked decrease in the serum levels of vitamin C can be justified by augmented cutaneous loss and consumption in the regeneration of vitamin E.

Inflammatory and oxidative stress after surgery for the small area corrections of burn sequelae.

PURPOSE: To compare vitamin levels, inflammatory and oxidative stress markers before and after skin autograft surgery to correct burn scar areas. METHODS: This prospective study was conducted with 8 patients with a median age of 28 years (range, 16 to 40 years) that had burn sequelae and were admitted to a Burn Unit for correction of small burn scar areas [3.3 (1.0-5.0) % of the corporal surface]. The volunteers were evaluated before and 48 hours after excision of scar tissue and skin autograft. Routine laboratory data, along with a food questionnaire and anthropometry were collected in the preoperative period. Serum vitamin A, C, E, B(12) and folic acid levels, inflammatory markers (C-protein reactive, alpha-1-acid glycoprotein, ferritin) and oxidative stress markers (reduced glutathione - GSH and Thiobarbituric Acid Reactive Substances - TBARS) were determined at preoperative and postoperative phases. Data were analyzed with two-sample Wilcoxon test. RESULTS: All volunteers were clinically stable and had adequate nutritional status at admission. After surgery, C-reactive protein serum levels increased [0.4 (0.01-1.0) vs. 2.5 (0.6-4.7) mg/dL, p=0.01] and vitamin A levels decreased [3.4 (2.1-4.2) vs. 2.4 (1.6-4.1) µmol/L, p=0.01]. No changes occurred in other vitamins, ferrritin, alpha-1-acid glycoprotein, GSH and TBARS levels. CONCLUSION: Minimal metabolic changes were produced after skin autograft in small areas of well-nourished patients without active infection or inflammation.