Surgical outcome of modified Karydakis flap and modified Limberg flab in the management of sacroccygeal pilonidal disease: a comparative study

Introduction: Sacrococcygeal pilonidal disease (SPD) is a chronic suppurative condition of the sacrococcygeal region causing chronic sinus tract or cyst. It is an acquired complex disease more common in young adult males, causing considerable morbidity and long periods of interruption in work or education. From simple conservative techniques to complex flap reconstruction, many debatable treatment options are offered; however clear dynamics toward the widespread use of minimally invasive methods and off-midline flap reconstruction are suggested in all guidelines, which recommend the Karydakis and Limberg flap modification. The plethora of literature compares procedures for identification of a single best treatment approach, which has proven to be difficult. The surgical outcome of both techniques is compared in the present study. Objective: To compare the surgical outcomes of the modified Karydakis flap (MKF) versus the modified Limberg flap (MLF) in SPD. Materials and Methods: The present study was conducted at the general surgery department on SPD patients who were ≥18 years old. A total of 67 participants were included after obtaining the informed consent, with group A comprising 33 patients undergoing the MLF procedure and group B comprising 34 patients undergoing the MKF procedure. Results: The mean patient age was 28.85 (range, 18-44) years old. For the MKF and MLF methods, the average operating duration was 32.5 (range, 25-40) and 54.5 (range, 45-65) minutes, respectively. The MKF approach was found to significantly improve pain score, mean sitting painless time, return to normal activity, wound healing time, and patient satisfaction. Conclusion: Comparative outcomes were seen between both MKF and MLF; however, our findings show that MKF is a more favourable method than MLF with superior outcomes. (AU)

Reanimação estática do lábio inferior na paralisia facial como complicação de preenchimento / Static lower lip reanimation as a filler complication of facial paralysis

Procedimentos de rejuvenescimento facial substitutos da cirurgia tradicional tornaram-se cada vez mais populares para promover uma aparência jovial com procedimentos minimamente invasivos, como toxina botulínica injetável, preenchimento de tecidos moles e peelings químicos. No entanto, complicações podem ocorrer mesmo na presença de um injetor habilidoso e experiente. Apresentamos o caso de uma paciente submetida a reanimação labial estática usando retalho dermoadiposo para lesão do nervo facial direito após remoção de nódulos como complicação de preenchimento. A "abordagem modificada de bull horn" foi realizada para elevação do lábio superior em torno das asas nasais e columela e ao longo do sulco nasolabial direito. O retalho foi desepitelizado e obtido. Usando a ponta aberta de uma pequena cânula de lipoaspiração, a porção distal do retalho foi encapsulada e fixada diretamente em C-loop e foram utilizados pontos U, transfixando o retalho para o periósteo do arco zigomático. Nos três anos de seguimento não foram observadas complicações significativas e a paciente não relatou nenhuma limitação funcional ou insatisfação com o aspecto das cicatrizes no sulco nasolabial e ao redor das asas nasais e da columela.

Facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular to promote a youthful appearance with minimally invasive procedures such as injectable botulinum toxin, soft-tissue fillers, and chemical peels. Nevertheless, complications can occur even with an astute and experienced injector. Here we present the case of a patient who underwent static lip reanimation using a dermoadiposal flap for right facial nerve damage following nodule removal as a filler complication. A "modified bulls horn approach" to the upper lip lift was performed around the nasal wings and columella and along the right nasolabial fold. The flap was de-epithelized and harvested. Using the open tip of a small liposuction cannula, the distal portion of the flap was tunneled and fixed directly in a C-loop fashion using U stitches, transfixing the flap to the periosteum of the zygomatic arch. At 3 years follow-up, no significant complications were observed, and the patient reported no functional limitations or dissatisfaction with the scars in the nasolabial fold or around the nasal wings and columella.

Tratamento para queloides: revisão de literatura / Treatment of keloids: a literature review

Introdução: Queloides surgem de resposta excessiva à lesão da derme, resultando em proliferação de fibroblastos, produção exagerada de colágeno e comprometimento da pele sadia adjacente. O diagnóstico é clínico e muitos métodos conservadores e cirúrgicos já foram utilizados para tratamento. Porém, dados da eficácia desses tratamentos são limitados e não há consenso na literatura quanto a melhor técnica a ser empregada, permanecendo uma lacuna que necessita ser preenchida, a fim de que seus usos sejam indicados com maior confiabilidade, em um modelo de medicina baseada em evidências. Métodos: Revisão não sistemática da literatura sobre "queloides" nas bases de dados PubMed, Scielo, MEDLINE, UptoDate e livros-texto das áreas de Dermatologia e Cirurgia Dermatológica. Revisão de Literatura: Foram enumeradas e abordadas as principais informações sobre técnicas cirúrgicas e adjuvantes empregadas para essas lesões, que são: excisão, injeções intralesionais, crioterapia, laserterapia, revestimento com gel de silicone, radioterapia e pressoterapia. Torna-se relevante o levantamento dessas informações, tendo em vista que, além de poder causar dor, prurido e restrição de movimento, o principal motivo da procura de assistência médica para queloide é devido ao aspecto cosmético/estético, e as taxas de reincidência e falha terapêutica ainda são altas, sendo necessário conscientizar o paciente sobre o procedimento e seus efeitos. Conclusão: São muitos os tratamentos disponíveis para o queloide, sejam cirúrgicos ou não, todavia não há consenso sobre uma abordagem universalmente aceita. São necessários mais estudos, com a finalidade de definir a melhor conduta e atingir melhores resultados, visto a qualidade mediana das evidências apresentadas nos estudos.

Introduction: Keloids are characterized by an abnormal response to dermal trauma, resulting in fibroblast proliferation, excessive collagen production, and impairment of adjacent healthy tissue. The diagnosis is clinical, and many conservative and surgical methods can be used as treatments. However, data on the efficacy of these treatments are limited, and there is no consensus regarding the best treatment option. This gap needs to be filled by developing comprehensive evidence-based therapies. Methods: A non-systematic literature review of keloid scars was carried out using PubMed, Scielo, MEDLINE, UptoDate, and dermatology and dermatological surgery textbooks. Literature review: The search retrieved relevant information on surgical and adjuvant therapies used for keloids, including excision, intralesional injections, cryotherapy, laser therapy, silicone gel sheeting, radiation therapy, and pressure therapy. These data are crucial because, in addition to complaints of pain, itching, and restriction of movement, the main reason for seeking treatment for keloids is for cosmetic and aesthetic improvement, and the rates of recurrence and treatment failure are high, emphasizing the importance of creating awareness regarding the available procedures and their effectiveness. Conclusion: Many surgical and adjuvant therapies for keloids are available. Nonetheless, there is no consensus on a universally accepted treatment. Therefore, additional high-quality studies are needed to identify the most effective therapeutic approaches to achieve better results.

Seguridad, eficacia y tolerabilidad de un novedoso apósito de gel de silicona para uso posoperatorio en cirugía dermatológica / Safety, efficacy and tolerability of a novel silicone gel dressing for postoperative use in dermatological surgery

Durante muchos años, el gel de silicona ha tenido un rol primario en el tratamiento y la prevención de cicatrices anómalas en forma de cicatrices hipertróficas y queloides luego de la epitelización. Los autores publican los hallazgos preliminares sobre el uso de un novedoso apósito de gel de silicona grado médico que forma una película y que fue aprobado para ser usado en heridas abiertas y en lesiones de la piel como único tratamiento y en combinación con otros tratamientos previos a la reepitelización. Un estudio observacional de 105 pacientes analizó la efectividad del gel de silicona en la estimulación de la epitelización acelerada, la reducción de la respuesta inflamatoria y la prevención de la formación de cicatrices. El estudio se realizó en una variedad de intervenciones quirúrgicas dermatológicas. Las observaciones de los autores confirmaron el rol de la silicona en la aceleración de la cicatrización de heridas, la prevención de la formación de cicatrices y la utilidad de este nuevo apósito de silicona que forma una película cuando se lo combina con otras modalidades de tratamiento. (SKINmed. 2012; 10:S1- S7).

For many years, silicone gel has played a primary role in the treatment of prevention of abnormal scars in the form of after epithelialization. The authors publish the pre-elimination findings use of a novel medical grade silicone gel dressing that form a film that was approved for use in open wounds and in skin as the only treatment and in combination with other treatments prior to re-epithelialization. An observational study of 105 patients analyzed the effectiveness of silicone gel in the stimulation of accelerated epithelialization, reducing the inflammatory response and preventing the formation of scars. The study was conducted on a variety of dermatological surgeries. The authors' observations confirmed the role of silicone in acceleration of wound healing, prevention of the formation of the usefulness of this new silicone dressing that forms a film it is combined with other forms of treatment.

Padronização da técnica cirúrgica de fenolização de matriz ungueal para onicocriptose / Standardization of the nail matrix phenolization surgical technique for treating onychocryptosis

A onicocriptose é afecção bastante comum em adolescentes e adultos jovens. Muitos tratamentos já foram descritos, conservadores e clínicos. Descrevemos a padronização da técnica de cirurgia de onicocriptose com fenol 88% realizada desde 2009 no ambulatório de dermatologia ligado a um serviço universitário.

Onychocryptosis is a common condition in adolescents and young adults. Many conservative and clinical treatments have already been described. The authors of the present paper describe the standardization of the onychocryptosis surgical technique using 88% phenol, which is performed at a university hospital's dermatology outpatient clinic since 2009.

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.

Complicaciones y manejo de procedimientos dermatoestéticos: una actualización para el dermatólogo / Complications associated with cutaneous aesthetic procedures: an update for the dermatologist

En las últimas décadas se han desarrollado nuevas técnicas e indicaciones de los procedimientos estéticos mínimamente invasivos, presentando cada vez mejores resultados con un alto nivel de seguridad, sin embargo, estos no se encuentran exentos de complicaciones, las que pueden ser transitorias o permanentes. El conocimiento, abordaje, tratamiento y prevención de las distintas complicaciones son esenciales para los dermatólogos y cirujanos plásticos. Los procedimientos más utilizados son: administración de rellenos, peeling químicos, láser, luz pulsada intensa y ultrasonido de alta frecuencia. La siguiente revisión tiene como objetivo reconocer las principales complicaciones de estos procedimientos y su manejo.

In recent decades, new techniques and indications of minimally invasive aesthetic procedures have been developed, presenting increasingly better results with a high level of safety, however these are not exempt from complications, which may be transient or permanent. The knowledge, approach, treatment and prevention of the different complications are essential for the dermatologist and plastic surgeons. The most used procedures are the administration of fillers, chemical peels, lasers, intense pulsed light and high frequency ultrasound. The following review aims to recognize the main complications of these procedures and their management.

Upper Body Lift: serie de casos en un hospital clínico universitario entre los años 2013-2016: descripción de la técnica quirúrgica / Upper Body Lift: cases series from a clinical hospital between years 2013-2016, and description of the surgical technique

Introducción: En pacientes obesos la pérdida masiva de peso presenta efectos beneficiosos para la salud, sin embargo, suelen cursar con un excedente cutáneo que genera problemas físicos, afectando la calidad de vida. En casos severos las técnicas convencionales de contorno corporal, no permiten dar solución a grandes alteraciones, siendo necesario utilizar procedimientos más extensos. El Upper Body Lift es una técnica que ofrece un manejo integral del tronco superior. Objetivos: Describir una serie de casos de pacientes sometidos a Upper Body Lift y presentar la técnica quirúrgica. Material y Método: Serie de casos prospectiva entre enero del 2013 y junio de 2016, en un hospital clínico universitario. Se excluyó a pacientes con información incompleta u operados en otro centro. Se utilizó estadística descriptiva. Resultados: 8 pacientes manejados mediante Upper Body Lift, con edad 39,75 ± 9,37 años, 6 (75%) mujeres. Con pérdida de peso de 36,75 ± 9,11 Kg, alcanzando un IMC de 25,97 ± 2,35 Kg/m2. En hombres la región pectoral se manejó con liposucción y posterior injerto de pezón, en mujeres se realizó mastopexia sin implantes en 5 (83,33%). No se observó complicación mayor y en 4 casos (50%) se presentó complicación menor durante posoperatorio. Discusión: Esta serie presenta resultados similares a lo descrito por otros autores. Conclusiones: El Upper Body Lift es un procedimiento que ofrece un manejo integral y con buenos resultados, en pacientes con gran excedente cutáneo en tronco superior.

Introduction: Obese patients gets beneficial health effects with the massive weight loss, however they develop excessive redundant skin and become physical problems affecting their quality of life. In severe cases, the conventional body contouring techniques are not able to solve this large alterations, being necessary to use more extensive procedures. The Upper Body Lift is a technique that offers integral management of the upper trunk. Objectives: To describe a case series of patients submitted to Upper Body Lift and present the surgical technique. Materials and Methods: Prospective case series of patients with Upper Body Lift between January 2013 and June 2016 in a clinical hospital. Patients with incomplete information or operated in another center were excluded. Descriptive statistics was used. Results: 8 patients were included, age 39.75 ± 9.37 years, 6 (75%) women. Prior to the contouring surgery they lose 36.75 ± 9.11 kg, reaching a BMI of 25.97 ± 2.35 kg/m2. In men the chest region was managed with liposuction and subsequent nipple graft, in women mastopexy without implants was performed in 5. No major complications was observed, 4 had minor complications during the postoperative period. Discussion: This series presents similar results to those described by other authors. Conclusions: The Upper Body Lift offers comprehensive and successful management in patients with large upper body disturbance.

Colgajo de Limberg: variantes y aplicaciones / Limberg´s fl aps: variants and applications

La piel es asiento frecuente de injurias en especial traumáticas o neoplásicas, surgiendo la necesidad de la reconstrucción de la brecha quirúrgica. Existen múltiples opciones de reconstrucción y su uso dependerá del tamaño del defecto quirúrgico a reparar y de la experiencia y preferencia del cirujano tratante. Presentaremos al colgajo romboidal de Limberg y sus variantes como una técnica reconstructiva de gran utilidad para cubrir defectos cutáneos en cara y otras partes del cuerpo respetando la función y estética de la región.

The skin is a frequent seat of injuries especially traumatic or neoplastic, arising the need for reconstruction of the surgical gap. There are multiple reconstruction options and their use will depend on the size of the surgical defect to be repaired and on the experience and preference of the treating surgeon. We will present the rhombus Limberg fl ap and its variants as a reconstructive technique of great utility to cover skin defects in the face and other parts of the body respecting the function and aesthetics of the region.

Giant congenital melanocytic nevi: 40 years of experience with the serial excision technique

Abstract: Although giant congenital melanocytic nevus is a rare lesion, it causes significant deformity and carries a risk of malignant degeneration. Different surgical techniques for the lesion removal are described, including serial resection, resection with skin grafting, and resection and coverage with expanded skin flap (skin expanders). The aim of this study is to report the author's 40 years of experience with cases requiring at least 4 serial excisions to complete the treatment. Serial resection is an effective, safe, and simple technique that requires a lot of patience. Treatment often results in a single linear scar, requires no donor sites, nor large flaps. It is not subject to potencial complications of expanders and avoid aesthetic deformities depending on the location.

Total earlobe reconstruction with a superiorly based preauricular flap

Abstract: An 86-year-old woman was referred for treatment of a lentigo maligna melanoma on the left earlobe, confirmed by cutaneous biopsy. The resulting surgical defect involved the earlobe's full thickness. The authors outline a simple method for reconstructing the entire lobe in one stage, without grafts, whilst offering a pleasant appearance. Earlobe deformity may be congenital or, more often, acquired due to trauma, burns or surgery. Ear lobules are an important reference point for facial symmetry and they serve decorative purposes like wearing earrings. Losing them represents an obvious aesthetic abnormality. Several methods developed to reconstruct this deformity have presented various advantages and disadvantages.

Remote limb ischemic post-conditioning attenuates ischemia-reperfusion injury in rat skin flapby limiting oxidative stress

PURPOSE: To investigate the effect of remote ischemic post-conditioning (RIPoC) against ischemia-reperfusion (I/R) injury on flaps of rats. METHODS: Sprague-Dawley rats were randomized into the Sham, Control, RIPoC1 and RIPoC2 groups. All the animals were submitted to a 5×4 cm superficial inferior epigastric artery flap. Eight hours of flap ischemia was induced and two protocols of limb RIPoC were applied. Tissue MDA level and SOD activity in 24-h reperfusion were assessed. Flap survival was assessed 7 days postoperatively. RESULTS: Compared to the Control group, the RIPoC1 group showed statistically decreased MDA level at 6-, 12-, and 24-h reperfusion (P = 0.01, P < 0.01 and P < 0.01, respectively), and statistically increased SOD activity at 12- and 24-h reperfusion (P < 0.05 and P < 0.01, respectively). Flap survival rate on the 7th day was significantly higher in the RIPoC1 group than the control group (47.9 ± 6.4 vs . 29.4 ± 7.1 %, P < 0.01). CONCLUSION: Three cycles of 5-min Limb remote ischemic post-conditioning rather than a single cycle of 15-min limb RIPoC has protective effect on flaps against ischemia-reperfusion injury by attenuating oxidative stress.

Lower lip reconstruction with nasolabial flap - going back to basics

Squamous cell carcinoma of the lower lip is frequent, and radical excision sometimes leads to complex defects. Many lip repair techniques are aggressive requiring general anesthesia and a prolonged post-operative period. The nasolabial flap, while a common flap for the repair of other facial defects, is an under-recognized option for the reconstruction of the lower lip. We describe the use of nasolabial flap for the repair of a large defect of the lower lip in a ninety year-old male, with good functional results and acceptable cosmetic outcome. We believe the nasolabial flap is a good alternative for intermediate-to-large lower lip defects in patients with impaired general condition.

Surgical treatment of basal cell carcinoma: an algorithm based on the literature

Abstract Although basal cell carcinoma can be effectively managed through surgical excision, the most suitable surgical margins have not yet been fully determined. Furthermore, micrographic surgery is not readily available in many places around the world. A review of the literature regarding the surgical treatment of basal cell carcinoma was conducted in order to develop an algorithm for the surgical treatment of basal cell carcinoma that could help the choice of surgical technique and safety margins, considering the major factors that affect cure rates. Through this review, it was found that surgical margins of 4mm seem to be suitable for small, primary, well-defined basal cell carcinomas, although some good results can be achieved with smaller margins and the use of margin control surgical techniques. For treatment of high-risk and recurrent tumors, margins of 5-6 mm or margin control of the surgical excision is required. Previous treatment, histological subtype, site and size of the lesion should be considered in surgical planning because these factors have been proven to affect cure rates. Thus, considering these factors, the algorithm can be a useful tool, especially for places where micrographic surgery is not widely available.

O to Z flaps in facial reconstructions

Local flaps are the standard procedure to reconstruct facial defects. As it occurs in any surgical procedure, the incision should be planned so that scars are located in the minimum skin tension lines. We report two cases of O to Z flaps in the supra and infraciliary regions. One of them is a hatchet flap.

Posttraumatic eyebrow reconstruction with hair-bearing temporoparietal fascia flap / Reconstrução de sobrancelha após trauma com retalho de fáscia temporoparietal associado à ilha de pele de couro cabeludo

The temporoparietal fascia flap has been extensively used in craniofacial reconstructions. However, its use for eyebrow reconstruction has been sporadically reported. We describe a successfully repaired hair-bearing temporoparietal fascia flap after traumatic avulsion of eyebrow. Temporoparietal fascia flap is a versatile tool and should be considered as a therapeutic option by all plastic surgeons.

O retalho de fáscia temporoparietal tem sido usado em inúmeras reconstruções craniofaciais. No entanto, sua utilização para a reconstrução de sobrancelha tem sido relatada esporadicamente. Descreve-se aqui o reparo com retalho de fáscia temporoparietal associado à ilha para a reconstrução de sobrancelha, após avulsão traumática, realizado com sucesso. O retalho de fáscia temporoparietal é uma ferramenta versátil e deveria ser considerada no arsenal terapêutico de todos os cirurgiões plásticos.

Contoured technique for lentigo maligna

The surgical approach to lentigo maligna is a challenge to dermatologists, given the difficulty of clinical delimitation of borders. We report here a case of a 69-year-old female patient presenting with brownish macules on her face, since 10 years ago, with histopathological diagnosis of lentigo maligna. The surgical management employed was excision of visible borders with the contoured technique and immediate submission of these borders for histopathological analysis before complete excision of the tumor. This technique is a variant of staged excision, with lower rates of recurrence and acceptable aesthetic results.

Reconstrucción axilar mediante colgajos en secuelas de quemadura / Axillary reconstruction through flaps in sequels burn

Las secuelas de quemadura en la región axilar son complejas y tienen relación directa con su anatomía. La reparación va a depender del defecto, desde contracturas leves que comprometan uno de los pilares a contracturas complejas donde la articulación está comprometida en bloque con la pared torácica. En este trabajo presentamos nuestra experiencia mediante la utilización de colgajos en todos los casos, presentando una diversidad de técnicas, desde zetaplastias, colgajos cutáneos, fasciocutáneos y musculocutáneos, tanto en secuelas axilares agudas como crónicas, con excelentes resultados estéticos y funcionales

The sequelae of burn in the axillary region are complex and are directly related to their anatomy. The repair will depend on the defect, from mild contractions that commit one of the pillars to complex joint contractures which is committed to block the chest wall. We present our experience using fl aps in all cases, presenting a variety of techniques, from Z-plasties, skin fl aps, musculocutaneous and fasciocutaneous both acute and chronic sequelae axillary, with excellent aesthetic and functional results

Angiogenic effects of cryosurgery with liquid nitrogen on the normal skin of rats, through morphometric study

BACKGROUND: Cryosurgery is an efficient therapeutic technique used to treat benign and malignant cutaneous diseases. The primary active mechanism of cryosurgery is related to vascular effects on treated tissue. After a cryosurgical procedure, exuberant granulation tissue is formed at the injection site, probably as a result of angiogenic stimulation of the cryogen and inflammatory response, particularly in endothelial cells. OBJECTIVE: To evaluate the angiogenic effects of freezing, as part of the phenomenon of healing rat skin subjected to previous injury. METHODS: Two incisions were made in each of the twenty rats, which were divided randomly into two groups of ten. After 3 days, cryosurgery with liquid nitrogen was performed in one of incisions. The rats' samples were then collected, cut and stained to conduct histopathological examination, to assess the local angiogenesis in differing moments and situations. RESULTS: It was possible to demonstrate that cryosurgery, in spite of promoting cell death and accentuated local inflammation soon after its application, induces quicker cell proliferation in the affected tissue and maintenance of this rate in a second phase, than in tissue healing without this procedure. CONCLUSIONS: These findings, together with the knowledge that there is a direct relationship between mononuclear cells and neovascularization (the development of a rich system of new vessels in injury caused by cold), suggest that cryosurgery possesses angiogenic stimulus, even though complete healing takes longer to occur. The significance level for statistical tests was 5% (p<0,05). .