Histological and Quantitative Appraisal of the Intradermal and Subcutaneous Distribution of the Hyaluronic Acid Injected into the Nasolabial Fold.

BACKGROUND: Histological analysis of hyaluronic acid (HA) applied in the nasolabial fold (NLF) studied gel distribution into the dermis and subcutaneous fat, correlating density of NLF tissues, with cohesivity, concentration and degradation of HA. METHOD: Ten patients received two injection points on each NLF. They were intradermal near the nasal ala and subcutaneous near the oral commissure. Injection points received 0.1 ml of 24 mg/ml HA cross-linked by BDDE 2.0 ppm through a bolus technique injection without retrograde backflow. Biopsies were taken 72 h and 9 months after application to histological analysis. RESULTS: Dermis density fragmented the gel into small nodules, spreading it into the reticular dermis. Seventy-two hours after application, average diameter of the small nodules was 0.30 mm and at month nine 0.05 mm. Softness of the subcutaneous fat and high concentration of HA created a single and compact nodule. Seventy-two hours after application, average of nodule diameters was 1.05 mm and at month nine 0.49 mm. HA biodegradation occurred on the external surface of the gel. The single nodule offered small contact surface to enzymes, slowing gel degradation. The sum average of the diameters of the small nodules offered a large contact surface to enzymes, accelerating gel degradation. CONCLUSION: Permanence of the HA into the tissues depended on the relationship between the gel distribution and its degradation. Due to the small contact surface of the single nodule to enzymes, permanence of the HA into the subcutaneous fat was more extended than into the dermis. 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 .

Histological and Clinical Appraisal of Distribution and Long Acting New Hyaluronic Acid into the Subcutaneous Fat of the Forehead to Improve Horizontal Lines.

BACKGROUND: A new hyaluronic acid (HA) was appraised to improve forehead horizontal lines (FHL). Histological analysis correlated the gel distribution with clinical findings and also with wrinkle depth, 48 h and 12 months after HA application. METHODS: The new filler composed by 24 mg/ml of HA cross-linked with BDDE 2.0 ppm was injected into the subcutaneous fat, just beneath the dermis, through a retrograde backflow injection technique applied in sequence. Biopsies were taken with a 3.0-mm-diameter skin punch before HA application, 48 h and 12 months after HA application for histological evaluation. RESULTS: Subcutaneous application created a compact cylindrical filament as pattern of gel distribution, which acted as strut raising the FHL to the level of the surrounding tissues. Diameter average of the filament 48 h after HA application was 1.18 mm and at month twelve 0.34 mm. The residual amount of the gel at month twelve ensured the long acting of the HA into the subcutaneous fat. FHL depth of 251.83 µm before HA application and 190.20 µm after 12 months indicated that the residual amount of gel at month twelve still projected FHL. CONCLUSION: High cohesivity of HA and low density of forehead subcutaneous fat caused the gel to take the form of a compact cylindrical filament. The small amount of gel still presenting into the subcutaneous fat 12 months after application validated the long acting of the HA. Evidence-based analysis showed that this new filler might be considered a safe alternative for improvement in the FHL. 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 .

Effectiveness and Long-Acting of the Hyaluronic Acid Injected into the Nasolabial Fold Measured Through Magnetic Resonance Imaging.

BACKGROUND: MRI analyzed quantitatively the HA injected into the NLF subcutaneous fat to correlate the gel diffusion and degradation with the morphological changes of the NLF appearance for twelve months. Measurements of the gel diffusion and degradation were taken by MRI as parameters to assess the clinical efficacy and long-acting of the HA in NLF rejuvenation. METHOD: HA was applied into the superficial compartment of the subcutaneous fat of twenty NLFs. Each NLF received three injection points, from the nasal ala toward the oral commissure, 1.0-1.5 cm distant from each other, according to the NLF length. A bolus injection technique without retrograde backflow applied per injection point 0.15-0.20 ml of HA for moderate. NLF and 0.20-0.25 ml for severe NLF. Patients were evaluated through MRI and clinically twenty-four hours, one month and twelve months after the HA application. RESULTS: MRI, in T2-weighted, displayed the gel as a dense, spindle-shaped nodule as pattern of the gel diffusion, measuring its largest longitudinal and transverse axes. Twenty-four hours after HA application the longitudinal axis measured 1.79 cm, after one month 2.33 cm and at month twelve 0.91 cm. The transverse axis measured 0.92 cm at 24 hours, 1.13 cm after one month and 0.47 cm at month twelve. CONCLUSION: Despite reduction in size and denseness of the spindle-shaped nodule, the small amount of gel presenting into the subcutaneous fat after twelve months of the application evidenced the HA efficacy and long-acting in NLF rejuvenation. 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 .

Quantitative Appraisal Through MRI of Breast Tissue Thickness and Implant Projection After Breast Augmentation with High- and Extra-High-Profile Round Implants.

BACKGROUND: Changes in breast tissue thickness and in implant projection 5 years after augmentation with high- and extra-high-profile round implants were measured through MRI with a DICOM standard viewer. METHODS: Twenty-four females with small-volume breast asymmetry without hypertrophy or ptosis underwent subfascial breast augmentation for cosmetic purposes, by using micro-textured soft cohesive silicone gel-filled round implants, from a single manufacturer. MRI measured the linear antero-posterior dimension of breast tissue thickness and projection of the implants. Statistical analysis of data was performed by Pearson correlation coefficient, line graph, and scatter diagram. RESULTS: The "r" of Pearson for right and left breasts indicated a significant correlation between the breast tissue thickness before and 5 years after augmentation. Closeness of the lines displayed in the line graph indicated strong linear positive correlation between the breast tissue thicknesses. The "r" values for projection of right and left implants indicated a significant correlation between the projection standardized by the manufacturer and that encountered 5 years after augmentation with high- and extra-high-profile round implants. A scatter diagram of data indicated a strong positive correlation between implant projection standardized by the manufacturer and that encountered 5 years after augmentation, on both breasts. CONCLUSION: Soft cohesive silicone gel-filled high- and extra-high-profile round implants supported breast tissue compressing without significant loss of the implant projection. Despite the consistency of the soft cohesive silicone gel, the implant softness and flexibility were preserved, resulting in low-pressure gradient over the mammary parenchyma without significant changes of the breast tissue thickness. EBM LEVEL 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.

Mastopexy Autoaugmentation by Using Vertical and Triangular Flaps of Mammary Parenchyma Through a Vertical Ice Cream Cone-Shaped Approach.

BACKGROUND: Mastopexy autoaugmentation by using an extended vertical flap and two transverse triangular flaps of mammary parenchyma was performed through an adjustable vertical ice cream cone-shaped approach. METHOD: A vertical rectangular flap with the length of the inferior pole and thickness of the mammary parenchyma was supported at the inframammary fold. Dissection of the vertical flap was extended underneath the areola until the projection of its upper limit, adding 4-5 cm to the length of the vertical flap. A triangular flap supported on its lower half with 4-6 cm long and thickness of the vertical pillar was dissected on both vertical pillars. Patients were followed up for 2 years. RESULTS: The vertical rectangular flap filled the upper pole and central breast. The triangular flaps apart from filling the lower pole increased the mammary cone projection. The medial rotation advancement of the triangular flaps created a transverse support girdle at the lower pole, maintaining the vertical flap into position. In addition, fixation of the vertical flap along its entire length avoided long-term down-displacement of the breast. A keel resection of mammary parenchyma was performed in the larger breast in mild or moderate asymmetries. CONCLUSION: Mastopexy autoaugmentation through an adjustable vertical approach using vertical and triangular flaps of mammary parenchyma filled the upper pole and central breast and reshape the lower pole, recovering the breast contour. It provided long-term stabilization of the mammary cone without a breast implant or fat transfer. 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 .

High- and Extra-High-Profile Round Implants in Breast Augmentation: Guidelines to Prevent Rippling and Implant Edge Visibility.

BACKGROUND: Rippling and implant edge visibility after breast augmentation depends on several factors. Among the most relevant are breast soft tissue thickness, particularly the retroareolar mammary parenchyma, and implant profile. They were correlates to prevent these occurrences. METHODS: Thirty patients underwent breast augmentation through subfascial dissection involving the pectoralis, serratus, external oblique, and rectus abdominis fascias. The thickness of the retroareolar mammary parenchyma distributed patients into two groups. Group I: patients with thickness equal to or greater than 4.0 cm received high-profile 85% fill round implants. Group II: patients with thickness up to 3.9 cm received extra-high-profile 100% fill round implants. MRI was performed preoperatively and 5 years after augmentation to evaluate breast tissue changes and implant contouring. RESULTS: Seventeen patients with high-profile implants and thirteen patients with extra-high-profile implants had noticeable improvement of the breasts without the occurrence of rippling or implant edge visibility. A natural appearance of the breast, increased mammary cone, balanced upper and lower pole contouring was maintained at 5 years postoperatively. MRI performed 5 years after breast augmentation validated patient clinical outcomes not evidencing implant deformities, or soft tissue thinning, parenchymal atrophy or chest wall deformities. CONCLUSIONS: The adequate correlation between retroareolar mammary parenchyma thickness with high-profile 85% fill and extra-high-profile 100% fill textured round implants was of utmost importance in preventing rippling and implant edge visibility. The wide fascial support, width of the implant smaller than the breast diameter, and soft cohesive gel-filled implants were co-adjuvant factors in preventing rippling and implant edge visibility. 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 .

Muscle Insertion and Strength of the Muscle Contraction as Guidelines to Enhance Duration of the Botulinum Toxin Effect in the Upper Face.

BACKGROUND: In this series of patients the cutaneous insertion and strength of voluntary contraction of the muscles in the upper third of the face were used as guidelines for botulinum toxin application named "BTA Codes." METHOD: Anatomical dissection of fresh cadavers identified the shape and cutaneous insertions of the muscles in the upper third of the face. Patient voluntary contraction of the muscles in the upper third of the face created different patterns of skin lines classified by the 4-grade Facial Wrinkle Scale. For botulinum toxin application injections points followed the muscle cutaneous insertion and dose the 4-grade Facial Wrinkle Scale. RESULTS: Injection points ranged from 3 to 23 points per patient, average of 9.4 points. Dose per point varied from 2.5 to 7.5 U, ranging from 12.5 to 72.5 U per patient, average of 33.82 U. Skin lines resulting from the voluntary contraction of the muscle prior to toxin application were stated as baseline 1. The absence of skin lines and muscle activity on day fifteen after toxin application defined baseline 2. Skin lines resulting from the recovered voluntary contraction of the muscle after toxin application like those of baseline 1 established baseline 3. The botulinum toxin effect was the time elapsed between baselines 2 and 3, ranging from 171 to 204 days, average of 183.72 days, greater than the 3 or 4 months reported in the literature. CONCLUSION: "BTA Codes" is a set of rules to apply botulinum toxin supported by muscle anatomy and degree of voluntary contraction to enhance the duration of its effect. 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 .

Anatomy of Forehead, Glabellar, Nasal and Orbital Muscles, and Their Correlation with Distinctive Patterns of Skin Lines on the Upper Third of the Face: Reviewing Concepts.

BACKGROUND: The purpose of this study is to establish a relationship between the skin lines on the upper third of the face in cadavers, which represent the muscle activity in life and the skin lines achieved by voluntary contraction of the forehead, glabellar, and orbital muscles in patients. METHODS: Anatomical dissection of fresh cadavers was performed in 20 fresh cadavers, 11 females and 9 males, with ages ranging from 53 to 77 years. Subcutaneous dissection identified the muscle shape and the continuity of the fibers of the eyebrow elevator and depress muscles. Subgaleal dissection identified the cutaneous insertions of the muscles. They were correlated with skin lines on the upper third of the face of the cadavers that represent the muscle activity in life. Voluntary contraction was performed by 20 voluntary patients, 13 females and 7 males, with ages ranging from 35 to 62 years. Distinct patterns of skin lines on the forehead, glabellar and orbital areas, and eyebrow displacement were identified. RESULTS: The frontalis exhibited four anatomical shapes with four different patterns of horizontal parallel lines on the forehead skin. The corrugator supercilii showed three shapes of muscles creating six patterns of vertical glabellar lines, three symmetrical and three asymmetrical. The orbicularis oculi and procerus had single patterns. The skin lines exhibited in voluntary contraction of the upper third of the face in patients showed the same patterns of the skin lines achieved in cadavers. CONCLUSIONS: Skin lines in cadavers, which are the expression of the muscle activity in life, were similar to those achieved in the voluntary contraction of patients, allowing us to assert that the muscle patterns of patients were similar to those identified in cadavers. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Z-plasty: a comparative study between theoretical and practical elongation / Zetaplastia: estudo comparativo entre o alongamento teórico versus prático

Introduction: The study of the final elongation values produced by 45º, 60º, 75º, and 90º-angle z-plasties performed on the skin of the lower abdomen of fresh cadavers were compared with the theoretical mathematical data published in the literature. Methods: Four z-plasties with 2-cm main and secondary branches each, and with 45º, 60º, 75º, and 90º angles were performed on the skin of the lower abdomen in 11 fresh cadavers to evaluate the final elongation produced. Results: The mean elongation at their respective angles was lower than that found in the literature, with a p value of <0.01. Conclusion: The elongation values obtained from the present study showed a significant difference from the published values.

Introdução: O estudo do alongamento final produzido por zetaplastias com ângulos de 45, 60, 75 e 90 graus na pele do abdome inferior de cadáveres frescos foi comparado com os dados matemáticos teóricos apresentados pela literatura. Métodos: Foram realizadas quatro zetaplastias com ramos principais e secundários de 2 cm cada um deles e ângulos de 45, 60, 75 e 90 graus na pele do abdome inferior de 11 cadáveres frescos para avaliar o alongamento final produzido. Resultados: A média dos alongamentos para os respectivos ângulos foi inferior ao encontrado na literatura, com valor de p < 0,01. Conclusão: Existiu diferença significativa entre os valores da literatura e os encontrados no presente estudo.

A superior vertical dermal pedicle for the nipple-areola: an alternative for severe breast hypertrophy and ptosis.

BACKGROUND: Nipple-areola nourishment and sensation have been the main concern in reduction mammaplasty for severe breast hypertrophy and ptosis. Free grafting for the nipple-areola can cause flatness and loss of sensation. These complications can be improved by pedicle techniques for the nipple-areola, no matter the pedicle orientation. The aesthetic outcomes and complications are similar for the inferior and superior pedicle techniques. The pedicle length has been crucial to nipple-areola viability and sensation. METHODS: Using a keyhole pattern, a vertical flap with a superior pedicle was outlined for nipple-areola transposition. The mammary tissue under the flap was removed, creating a vertical dermal flap 7-14 cm long, and the superior pedicle was located on the new site of the areola marked by the pattern. Sensation was evaluated monthly by subjective contact testing of the four quadrants of the nipple-areola. RESULTS: The Pearson product-moment correlation coefficient was used to correlate the return of sensation with the length of the dermal flap and the amount of breast tissue removed. Sensation was achieved for the four quadrants 6 months after the breast reduction for all the patients of this series. Recovery of sensation was significantly greater for the superior quadrants than for the inferior quadrants in the first 3 months. CONCLUSIONS: The vertical dermal flap with the superior pedicle preserves nipple-areola nourishment and sensation. It is an alternative option for pedicle techniques in surgical correction of severe breast hypertrophy and ptosis.

Carboinsuflação em úlceras crônicas dos membros inferiores / Carbon insufflations in chronic ulcers of the lower limbs

A infusão controlada do CO2 recupera o tecido de granulação em úlceras crônicaspor insuficiência venosa dos membros inferiores, facilitando a integração do enxerto autólogo de pele. Método: Foram avaliadas ulcerações com evolução média de 12,5 meses. A infusão controlada do CO2 foi aplicada a 0,5 cm. da borda da ferida, com a agulha voltada para o tecido de granulação. As puncturas foram realizadas a cada 2,5 cm. As sessões foram repetidas com intervalos de 72 horas. Biopsias foram realizadas no tecido de granulação antes e após a infusão do CO2. Resultados: Observou-se aumento numérico de capilares, macrófagos e fibroblastos no tecido de granulação após a infusão controlada do CO2. O aumento médio do diâmetro das arteríolas pré-capilares foi de 3,4 vezes. Conclusão: A infusão controlada do CO2 estimulou a fibrogênese e promoveu uma resposta vasomotora e celular na ferida, facilitando o fechamento espontâneo das úlceras de membros inferiores ou tornando-as aptas a receber o enxerto autólogo de pele.

CO2 infusion-controlled restores granulation tissue in chronic venous caused by venous insufficiency of the lower limbs, becoming ready to receive autologous skin grafting. Methods: Mean time of ulceration was 12.5 months. CO2 infusion-controlled was applied 0.5 cm. from the wound edge. Punctures were done 2.5 cm. distant from each other along the border of the wound with the needle pointed toward the granulation tissue. Biopsies were taken from the granulation tissue before and after CO2 application. The sessions were performed at intervals of 72 hours. Results: Notice able increase of capillaries, macrophages and fibroblasts were founded into the granulation tissue after CO2 infusion controlled. Diameter of pre-capillary arterioles increased 3.4 times after CO2 infusion controlled. Conclusion: CO2 infusion-controlled restores the blood flow in chronic wound of the lower limbs, promoting its spontaneous closure or improving granulation tissue ready to receive autologous skin grafting.

How texture-inducing contraction vectors affect the fibrous capsule shrinkage around breasts implants?

BACKGROUND: Breast augmentation was performed on nine female volunteer patients to determine the influence of three textured surfaces on fibrous capsule formation. The high degree of surface texture reduced the capsular fibrous tissue formation. METHODS: Patients were distributed according to the degree of texture created by the open-pore diameter and depth of the surface texture. Macroscopic and histological examinations were performed to evaluate the implant texture and fibrous capsule interface. Magnetic resonance imaging established a mutual correlation with breast firmness achieved by the Baker grade. RESULTS: The parallelogram law was applied to linear vectors arising from the same initial point into the concavities or undulations on the textured surface to achieve the resultant contraction vector. They were identical to resultant vectors created on the fibrous capsule except in the inverted direction. The adhesive effect or mirror-image tissue response to the implant texture on the fibrous capsule noticeably reduced capsular contracture but only with macrotextured implants. Increased capsular contracture resulted from implants showing micro- and medium surface texture with no significant difference between them. CONCLUSION: Biocell™ implants created resultant vectors on the capsular interface of small and similar lengths with divergent directions creating natural breast firmness. Biodegradation of Polyurethane™ foam disrupted the texture from creating resultant vectors of long and different lengths and in variable directions, increasing breast firmness from 12 months. Siltex™ implants created few and very long resultant vectors perpendicular to the fibrous capsule that developed fibrous capsule contraction after 9 months. We conclude that implants with macrotextured surfaces significantly reduced the risk of fibrous capsular contraction.

Retalhos cutâneos de avanço de ambas hemifaces para reconstrução do nariz após múltiplos carcinomas basocelulares no dorso nasal / Bilateral facial cutaneous flaps for nose reconstruction after multiples basal cell

Os autores relatam caso de múltiplos carcinomas basocelulares no dorso nasal, tratados comcrioterapia, cirurgia e uso tópico de 5-fluoracil. Os múltiplos tumores não foram recidivas detumores anteriores, mas decorrentes da qualidade da pele do dorso nasal. Isto ficou evidentena biopsia após a ressecção cirúrgica, demonstrando ausência de comprometimento nasmargens da ressecção. A ulceração por uso prolongado do 5-fluoracil ocorreu pela ação doquimioterápico sob o tecido normal. A retirada da pele do dorso até a base da pirâmide nasalfoi realizada para evitar novos tumores sobre a mesma. A reconstrução por dois retalhoscutâneos de hemiface permitiu a reparação do nariz, sem comprometer o contorno facial.

The authors report a case of multiples basal cell carcinoma (BCC) over the dorsum treatedwith criotherapy, surgery and 5-fluoracil. They were not recurrence of former tumors occurringdue to the poor skin quality. It was clearly showed through the biopsy exhibitingno BCC at the margin of resection. The wound caused by excessive use of 5-fluoracil wasdue to chemotherapy action over the normal skin. Removal of the skin from the dorsumto the base of the nose was performed to avoid new BCC. Reconstruction using cutaneousflaps on both sides of the face restored the nose and facial contour.

Elevação da temperatura cutânea após a infusão controlada de dióxido de carbono / Increase of the skin temperature after infusion-controlled carbon dioxide

Introdução: A infusão controlada do dióxido de carbono eleva a temperatura cutânea no local da aplicação. O aumento da temperatura ocorre em razão da resposta inflamatória local, com dilatação dos vasos da microcirculação cutânea. Método: A temperatura da pele foi avaliada em 10 pacientes, 7 mulheres e 3 homens, apresentando flacidez cutânea com aumento da gordura subjacente na face medial do braço e parede abdominal anterior. Os valores da temperatura foram obtidos, antes e após a infusão controlada do dióxido de carbono, usando um termômetro digital. Resultados: Após a infusão controlada do dióxido de carbono houve aumento médio da temperatura cutânea de 3,48°C, no local da aplicação. Conclusão: A vasodilatação da microcirculação cutânea acompanhada pelo aumento do fluxo sanguíneo periférico, após a infusão controlada do dióxido de carbono, provocou um aumento da temperatura no local da aplicação.

Introduction: Carbon dioxide infusion-controlled increases the skin temperature. It occurs through a local inflammatory reaction leading dilatation of the cutaneous microcirculation. Methods: Ten patients, 7 females and 3 males, exhibiting skin flaccidity with increase of the subjacent fat, were submitted to carbon dioxide infusion-controlled on the medial portion of the arms and anterior abdominal wall. Measurement of the skin temperature was performed before and after the infusion using a digital thermometer. Results: The mean elevation of the skin temperature after carbon dioxide infusion was 3.48°C. Conclusion: Infusion-controlled carbon dioxide stimulated dilation of the cutaneous micro circulation improving the blood flow with increase of the local temperature.

Endoscopic correction of eyebrow asymmetry in associated forehead soft-tissue injuries.

Supported by anatomical principles, a subgaleal endoscopically assisted selective myotomy of the forehead and glabellar muscles was used to achieve eyebrow symmetry in patients with unilateral facial nerve palsy and associated forehead soft-tissue injuries. Selective myotomy equalizes the agonist-antagonist muscle relationship on both sides of the forehead, thereby allowing the untouched muscle to exert its activity without opponent restriction. Selective myotomy allows for the management of the muscles' group action as well as individual manipulation of each muscle in accordance with its participation in the eyebrow deformity.

Mammaplasty combining vertical and transverse approaches through a vertical incision.

An adjustable vertical marking is described for vertical mammaplasty in mild and moderate hypertrophy or ptosis of the breast. A vertical rectangular flap with the pedicle supported at the inframammary fold provides fullness for the upper or the lower pole of the breast. It is fixed over the pectoralis aponeurosis along the upper pole to the base of the pedicle. Length, width, and thickness of the vertical rectangular flap change regarding the extent of breast ptosis and hypertrophy. Two transverse triangular flaps, dissected in the lower pole of the breast, are supported on the inferior half of the vertical pillars at the incision margins. The criss-crossing of the triangular flaps creates a transverse support sling, avoiding the downward displacement of the breast. The vertical flap is applied in conjunction with the triangular flap to attempt to achieve projection and support for the breast with long-term stabilization of the mammary cone. Resection of mammary tissue is performed transversely just above the pedicle of the vertical flap.

Selective myotomy in forehead endoscopy.

Endoscopic forehead surgery in a subgaleal plane allows selective manipulation of the forehead and glabellar muscles in accordance with their influence in forehead and brow deformity. Myotomy begins by interrupting the blend of the fibers of the elevator and depressor muscles, thereby exposing the bone fixation and cutaneous insertions of the depressor muscles. Myotomy of the depressor group is performed by section of the muscle fibers as close as possible to their bone fixation, with release of the cutaneous insertions at the brow level. The involuntary frontalis contraction free from the active opposition of the depressor muscles and free from the restriction of the inelastic structure of the periosteum stabilizes the brow elevation and gives a natural, long-term result. No fixation methods are used to hold the forehead flap in position. Transverse section of the frontalis muscle is performed to restore brow symmetry or excessive lift of the brow.

Lower blepharoplasty through a biplanar flap / Retalho biplanar para blefaroplastia inferior

A byplanar flap, composed by cutaneous and muscular flaps with common musculocutaneous pedicle, is proposed to an adequate of the cutaneous and muscle excess in lower bepharoplasty. The byplanar flap allows to resect different quantities of the skin and muscle, in accordance to the palpebral deformity. It provides anappropriate vascular support, either for the cutaneous and for the muscular flap, through its common pedicle. The byplanar flap in association with the lateralcanthopexy promotes the recovery of the lower eyelid muscular sling with the lateral canthus and lower eyelid support. The resection and fixation of the muscular portion of the byplanar flap elevate the skin and muscle flaps together, providing the adequate correction of the excess of both tissues, decreasing the occurrence of scleral show or ectropion.

Concordância diagnóstica e definiçäo das margens de ressecçäo entre a biópsia de congelaçäo e a parafina para tumores de pele / Diagnostic accuracy and definition of marginal compromise in malignant skin tumors. A comparison between frozen and paraffin sections

O presente estudo avaliou a concordância diagnóstica, bem como a definiçäo das margens de ressecçäo, através de exame anatomopatológico pelos métodos de congelaçäo e inclusäo em parafina para tumores de pele com diagnóstico clínico de carcinoma basocelular (CBC) e carcinoma espinocelular (CEC). Foram realizadas biópsias excisionais cujas margens de ressecçäo estenderam-se 5 mm além dos limites clínicos apresentados pelos tumores. Os resultados obtidos mostraram a eficiência do método de congelaçäo para definir as margens de ressecçäo para os dois tipos de tumores analisados. A concordância diagnóstica entre os métodos pela congelaçäo e pela parafina ocorreu em 99 das 104 biópsias excisionais realizadas (95 por cento). Houve apenas um diagnóstico falso-positivo e quatro diagnósticos falso-negativos

Ritidoplastia frontal incisäo coronal versus videoendoscopia / Forehead rhytidoplasty coronal incision versus videoendoscopy

As dificuldades para se obter adequada ressecçäo da pele e a extensäo da cicatriz quando é utilizada a incisäo coronal têm sido a principal restriçäo ao emprego desta técnica, apesar de seus bons resultados. A videoendoscopia, por sua vez, permite a manipulaçäo natural da musculatura das regiöes frantal e globelar, possibilitando um "lift" anatômico frontal e dos supercílios sem necessidade de ressecçäo. Entretanto, a videoendoscopia é um procedimento de introduçäo recente, exigindo observaçöes mais detalhadas antes de ser incorporada à rotina terapêutica das alteraçöes da regiäo fronto-globelar