Preoperative clinical management of patients who are candidates for facial transplantation / Manejo clínico pré-operatório de pacientes candidatos ao transplante facial

Introduction: Face transplantation has gained recognition, changing the clinicalsurgical scenario for restoring complex facial defects, as it attributes functional and aesthetic recovery to patients who have suffered serious accidents. At the time of writing this article, in official publications, 43 patients had already undergone facial transplantation worldwide. Face transplantation has numerous pieces of evidence that can irrefutably provide improvements to the patient. For this, preoperative care for the patient must be carefully established so that there is good surgical performance. Case Report: Male patient, 46 years old, reports that, at the age of 6, he had burns due to exposure to gasoline, with 72% of his body surface burned, showing sequelae of burns and surgical reconstructions on the face, with redundant and ptotic skin flap on the left cheek, absence of upper and lower lip and exposure of lower teeth. Conclusion: It is important to publicize this innovative procedure in different medical specialties and preoperative care through a thorough investigation, which attributes better surgical effectiveness, allowing the rescue of their facial identity, once stigmatized.

Introdução: O transplante de face adquiriu reconhecimento, alterando o panorama clínico-cirúrgico para a restauração de defeitos faciais complexos, visto que atribui recuperação funcional e estética a pacientes que sofreram acidentes graves. Até o momento da redação deste artigo, em publicações oficiais, 43 pacientes já haviam realizado o transplante facial em todo mundo. O transplante de face possui inúmeras evidências que podem fornecer melhorias ao paciente de forma irrefutável. Para isso, cuidados pré-operatórios ao paciente devem ser cuidadosamente estabelecidos para que haja um bom desempenho cirúrgico. Relato de Caso: Paciente sexo masculino, 46 anos, relata que, aos 6 anos de idade, teve queimadura por exposição à gasolina, com 72% de superfície corporal queimada, apresentando sequelas de queimaduras e reconstruções cirúrgicas na face, com retalho cutâneo redundante e ptótico em bochecha esquerda, ausência de lábio superior e inferior e exposição dos dentes inferiores. Conclusão: Ressalta-se a importância da divulgação desse procedimento inovador em diferentes especialidades médicas e dos cuidados pré-operatórios através de uma investigação minuciosa, que atribuem uma melhor eficácia cirúrgica, possibilitando o resgate de sua identidade facial, uma vez estigmatizada.

Volumetric Comparison Between CT Scans and Smartphone-Based Photogrammetry in Patients Undergoing Chin Augmentation With Autologous Fat Graft.

BACKGROUND: The most accurate methods for assessing fat grafted volume, such as computed tomography (CT) scan and magnetic resonance imaging, use 3-dimensional (3D) evaluation of the recipient area. Currently, other measurement techniques such as photogrammetry (compilation of photos) are employed. OBJECTIVES: The aim of the present study was to compare 3D images obtained by CT scan with those obtained by photogrammetry in patients undergoing autogenous fat grafting to the chin. METHODS: A prospective longitudinal study was undertaken to assess patients undergoing autologous fat grafting to the chin, capturing preoperative and postoperative (6 months) images with CT scan and photogrammetry. Captured images were submitted to 3D reconstruction with Blender image software. RESULTS: A total of 40 patients were submitted to surgery. Seventy-five percent were female. Median age and BMI were 26.5 years and 23.6 kg/m2, respectively. Median volume of fat grafted was 10 mL (interquartile range 8-12.25 mL). Results showed that the median preoperative volume measured by CT scan was larger than the photogrammetry measurement (12.48 mL vs 12.01 mL, respectively, P < .001). Likewise, a larger volume was measured by CT scan than by photogrammetry (15.54 mL vs 14.94 mL respectively, P < .001) 6 months postoperatively. However, there was no difference between CT scan and photogrammetry measurements of the change in volume from preoperatively to postoperatively (P = .89). CONCLUSIONS: There was no agreement between fat graft volume measurements obtained by 3D photogrammetry and CT scan techniques with regard to absolute values of fat graft volume measurements, however no difference was found between the 2 methods when comparing preoperative with postoperative fat graft volume variation.

Tradução, adaptação e validação linguística do FACE-Q Câncer de Cabeça e Pescoço para o português do Brasil / FACE-Q Head and Neck Cancer Questionnaire for Brazilian Portuguese: Translation, Cross-Cultural Adaptation, and Linguistic Validation

Introdução: As neoplasias de cabeça e pescoço costumam afetar funções fundamentais, como engolir, falar, comer e se socializar. A avaliação do seu tratamento deve, portanto, levar em consideração a opinião do médico e a perspectiva do paciente. Essa dificuldade em avaliar o sucesso do tratamento levou ao desenvolvimento do FACE-Q - Módulo de Câncer de Cabeça e Pescoço, um questionário de resultados relatados pelo paciente que mede a aparência, função facial, qualidade de vida e experiência de cuidado para neoplasias de cabeça e pescoço. O objetivo é a tradução, adaptação cultural e validação linguística do questionário FACE- Q Câncer de Cabeça e Pescoço para o português brasileiro. Métodos: A tradução, adaptação cultural e validação linguística do questionário completo ocorreram em quatro etapas, usando as diretrizes oficiais da Organização Mundial da Saúde e da Sociedade Internacional de Farmacoeconomia e Pesquisa de Resultados. Resultados: Uma versão em português brasileiro semântica, idiomática e conceitualmente equivalente foi obtida por meio de uma tradução validada linguisticamente do módulo FACE-Q Head and Neck Cancer em inglês. Conclusão: A versão em português brasileiro apresenta uma versão com equivalente ao instrumento original em inglês, que pode ser utilizada como avaliação crítica de resultados relatados pelo paciente.

Introduction: Head and neck neoplasms often affect fundamental functions, such as swallowing, speech, eating, and socializing. Evaluating their treatment should consider the physician's opinion and the patient's perspective. This difficulty in assessing the success of treatment led to the development of the FACE-Q Head and Neck Cancer Module, a questionnaire of patient-reported outcomes that measure the appearance, facial function, quality of life, and experience of care to head and neck neoplasms. The objective is to translation, cultural adaptation, and linguistic validation of the FACE-Q Head and Neck Cancer questionnaire for Brazilian Portuguese. Methods: The translation, cultural adaptation, and linguistic validation of the full questionnaire took place in four stages, using official guidelines from the World Health Organization and the International Society of Pharmacoeconomics and Outcomes Research. Results: A semantic, idiomatic, and conceptually equivalent Brazilian Portuguese version was achieved through a linguistically validated translation of the English FACE-Q Head and Neck Cancer module. Conclusion: The Brazilian Portuguese version presents a version equivalent to the original English instrument, which can be used as a critical patient-reported outcome assessment.

Complications using tissue expanders in burn sequelae treatment at a reference university hospital: a retrospective study.

BACKGROUND: tissue expanders have high relevance in plastic surgery and among indications it is worth mentioning their use in the treatment of burn reconstruction. Although it shows good results, its use requires special care because some complications can interrupt the reconstruction process. The objective of this study was to report the experience of the Clinics Hospital (University of Sao Paulo) with the use of tissue expanders to treat burn sequelae, establishing the incidence of complications, and identifying risk factors for their occurrence. METHODS: a retrospective, observational, and analytical study, evaluating the use of expanders in burns sequelae treatment from 2009 to 2018. RESULTS: 245 expanders were placed in 84 patients, 215 were female, with a mean age of 19.96 years, being 40% in the trunk and 20% in the scalp, with a predominance of rectangular shape in 76.7% of cases. Complications were classified as major and minor.Complications occurred in 17.95% of cases, and extrusion and infection were the most common. There was a higher incidence of complications in expanders used in the upper and lower limbs as well as in those who did not undergo concomitant expansion (p <0.05), with an even higher chance of major complications in patients submitted to additional expansion. From 2009 to 2018, we observed a decrease in the incidence of complications. CONCLUSION: the complication rate (17.95%) is similar to other studies of the literature, there was a higher rate of complication with expanders placed in the limbs and a higher rate of major complications when additional expansion was done.

Reconstrução após ressecção bipalpebral com preservação do globo ocular: desafio estético e funcional / Reconstruction after bipalpebral resection with preservation of the eyeball: aesthetic and functional challenge

Introdução: A reconstrução palpebral pode ser realizada por fechamento primário, enxerto de diferentes lamelas e retalhos locais e/ou regionais, únicos ou combinados. Essa reconstrução se torna mais complexa quando a pálpebra superior e a inferior são ressecadas em espessura total e o globo ocular é preservado. O objetivo é relatar as técnicas utilizadas para reconstrução periorbital em casos de ressecção bipalpebral (superior e inferior) com preservação do globo ocular pelo Grupo de Cirurgia Órbitopalpebral da Divisão de Cirurgia Plástica e Queimaduras do HCFMUSP. Métodos: Foram revistos todos os casos que se encaixaram nos critérios de inclusão no período de 2000 a 2019, sendo descritos dados epidemiológicos, cirúrgicos e de seguimento pós-operatório. Resultados: Apenas dois casos foram submetidos à exérese total do tecido periorbital e permaneceram passíveis de preservação do globo ocular. Ambos foram reconstruídos com retalhos frontais com oclusão total do globo ocular no primeiro momento, seguido pela liberação em etapas, mantendo o globo viável após a finalização da reconstrução. Discussão: São escassos os relatos semelhantes na literatura e, nestes casos, os resultados cirúrgicos se mostraram funcionalmente aceitáveis, mas com limitações estéticas importantes. Conclusão: Sugerimos uma nova opção para a reconstrução total da pálpebra superior e inferior (com um único retalho pedicular, desprovido de enxerto conjuntivo e em múltiplos estágios) que fornece proteção e conservação do globo ocular durante as diferentes etapas da cirurgia. Os resultados foram funcionalmente favoráveis, considerando a gravidade dos casos.

Introduction: Eyelid reconstruction can be performed by primary closure, a graft of different lamellae, and local and/or regional flaps, single or combined. This reconstruction becomes more complex when the upper and lower eyelids are resected to total thickness, and the eyeball is preserved. The objective is to report the techniques used for periorbital reconstruction in bipalpebral resection cases (upper and lower) with preservation of the eyeball by the Group of Orthopalpebral Surgery of the Division of Plastic Surgery and Burns of HCFMUSP. Methods: All cases that met the inclusion criteria from 2000 to 2019 were reviewed, and epidemiological, surgical, and postoperative follow-up data were described. Results: Only two cases were submitted to total exeresis of the periorbital tissue and remained susceptible to eyeball preservation. Both were reconstructed with frontal flaps with complete occlusion of the eyeball at the first moment, followed by the release in stages, keeping the globe viable after reconstruction completion. Discussion: Similar reports are scarce in the literature, and, in these cases, surgical results were functionally acceptable but with significant aesthetic limitations. Conclusion: We suggest a new option for total reconstruction of the upper and lower eyelid (with a single pedicular flap, devoid of connective graft and in multiple stages) that protects and conserves the eyeball during the various stages of surgery. The results were functionally favorable, considering the severity of the cases.

Complications using tissue expanders in burn sequelae treatment at a reference university hospital: a retrospective study / Complicações com o uso de expansores teciduais para tratamento de sequela de queimaduras em um hospital universitário de referência: estudo retrospectivo

ABSTRACT Background: tissue expanders have high relevance in plastic surgery and among indications it is worth mentioning their use in the treatment of burn reconstruction. Although it shows good results, its use requires special care because some complications can interrupt the reconstruction process. The objective of this study was to report the experience of the Clinics Hospital (University of Sao Paulo) with the use of tissue expanders to treat burn sequelae, establishing the incidence of complications, and identifying risk factors for their occurrence. Methods: a retrospective, observational, and analytical study, evaluating the use of expanders in burns sequelae treatment from 2009 to 2018. Results: 245 expanders were placed in 84 patients, 215 were female, with a mean age of 19.96 years, being 40% in the trunk and 20% in the scalp, with a predominance of rectangular shape in 76.7% of cases. Complications were classified as major and minor.Complications occurred in 17.95% of cases, and extrusion and infection were the most common. There was a higher incidence of complications in expanders used in the upper and lower limbs as well as in those who did not undergo concomitant expansion (p <0.05), with an even higher chance of major complications in patients submitted to additional expansion. From 2009 to 2018, we observed a decrease in the incidence of complications. Conclusion: the complication rate (17.95%) is similar to other studies of the literature, there was a higher rate of complication with expanders placed in the limbs and a higher rate of major complications when additional expansion was done.

RESUMO Introdução: os expansores teciduais são de importante relevância na cirurgia plástica, e dentre suas indicações destaca-se seu uso no tratamento de sequelas de queimaduras. Ainda que apresente bons resultados, seu uso requer cuidados especiais pois a incidência de complicações não é desprezível. Objetivo: relatar a experiência do Hospital das Clínicas da FMUSP com a utilização de expansores teciduais para tratamento de sequelas de queimaduras, estabelecendo a incidência de complicações e identificando possíveis fatores de risco para ocorrência das mesmas. Método: estudo retrospectivo, observacional e analítico, avaliando o uso de expansores no tratamento de sequelas de queimaduras no período de 2009 a 2018 no Hospital das Clínicas da FMUSP. Resultados: no período de análise estabelecido, foram colocados 245 expansores, sendo 215 em pacientes do sexo feminino, com idade média de 19,96 anos, sendo 40% em tronco e 20% em couro cabeludo, predominando uso do retangular em 76,7% dos casos. As complicações foram divididas em maiores e menores. As complicações ocorreram em 17,95% dos casos, sendo extrusão e infecção as de maior incidência. Houve maior incidência de complicação em expansores utilizados nos membros superiores e inferiores bem como naqueles que não realizaram expansão concomitante (p<0,05), havendo ainda maior chance de complicações absolutas nos pacientes submetidos à expansão adicional. Observou-se também diminuição no número de complicações entre 2009 e 2018. Conclusão: a taxa de complicação (17,95%) é semelhante a da literatura, observando-se maior taxa de complicação nos expansores colocados em membros e maior taxa de complicações absolutas quando realizada expansão adicional.

Rinoplastia preservadora piezoelétrica: uma abordagem alternativa para tratamento de nariz bífido em fissura facial nº 0 de Tessier / Piezoelectric preservative rhinoplasty: an alternative approach for treating bifid nose in Tessier No. 0 facial cleft

O manejo do nariz bífido na fissura facial de Tessier nº 0 é controverso devido às suas características, como uma ampla abóbada óssea, baixa altura dorsal, excesso de pele, volume de partes moles e cartilagens laterais superiores e inferiores distantes. Técnicas conservadoras de rinoplastia, utilizando instrumentos piezelétricos, podem ser uma boa opção para o tratamento do nariz bífido, pois preservam o teto e as cartilagens laterais superiores e realizam uma osteotomia mais precisa. Relatamos o tratamento de nariz bífido em um menino de 13 anos com fissura facial nº 0, no qual foi realizada a rinoplastia conservadora com auxílio de material piezoelétrico. Dado o excesso de pele e tecidos moles, optou-se por uma abordagem transcutânea completamente externa. Para osteotomias, fraturas laterais sob visão direta assistida por piezo foram realizadas para ter um melhor controle do estreitamento da abóbada óssea. As cartilagens laterais superiores e as válvulas nasais internas foram preservadas e reaproximadas à linha média com suturas em "U" horizontais, a fim de obter projeção da abóbada cartilaginosa. Um grande segmento de pele e tecidos moles foi extirpado após estreitamento da abóbada nasal. Um ano de acompanhamento mostra uma pirâmide óssea estreita, melhor projeção e definição de ponta, mas persistindo com um nariz verticalmente curto. Técnicas conservadoras de rinoplastia, assistidas por piezoelétricas, podem ser uma opção para o tratamento do nariz bífido, exigindo um acompanhamento a longo prazo e um estudo com mais casos.

The bifid nose management in Tessier nº 0 facial cleft is controversial due to its characteristics, such as a wide bone vault, low dorsal height, excessive skin, soft tissues volume, and distant upper and lower lateral cartilages. Conservative rhinoplasty techniques, using piezoelectric instruments, can be a good option for the bifid nose treatment, as they preserve the roof and upper lateral cartilages and perform a more accurate osteotomy. We report the treatment of bifid nose in a 13-year-old boy with facial cleft No. 0, to whom was performed conservative rhinoplasty with the aid of piezoelectric material. Given the excess of skin and soft tissues, a completely external transcutaneous approach was chosen. For osteotomies, lateral fractures under direct piezo-assisted vision were performed to have better control of the bone vault narrowing. The upper lateral cartilages and the internal nasal valves were preserved and brought back to the midline with horizontal "U" sutures to obtain a projection of the cartilaginous vault. A large segment of skin and soft tissue was excised after narrowing the nasal vault. A year of follow-up shows a narrow bone pyramid, better projection, and tip definition, but persisting with a vertically short nose. Conservative rhinoplasty techniques, assisted by piezoelectrics, may be an option for bifid nose treatment, requiring long-term follow-up and a study with more cases.

The impact of COVID-19 on the plastic surgery activity in a high-complexity university hospital in Brazil: the importance of reconstructive plastic surgery during the pandemic.

BACKGROUND: The Hospital das Clínicas - University of Sao Paulo Medical School (HCFMUSP) is the largest university hospital complex in Brazil. HCFMUSP has been converted into a reference center for coronavirus disease 2019. The Division of Plastic Surgery postponed non-essential surgeries and outpatient consultations, accomplishing new guidelines (ANG) of national and international organizations. Even with these challenges arising from the pandemic, alternatives were considered to maintain institutional characteristics. This study aims to analyze this new scenario and the impact on patients' assistance and Plastic Surgery residents training. METHODS: Total number of surgeries, type of procedures, and outpatient consultations in 2020, before (pre-ANG) and after (post-ANG) ANG, were compared with the same period in 2019 (2019-pre and 2020-post). RESULTS: A marked reduction in the total number of surgeries and outpatient consultations was observed in the post-ANG period. In the post-ANG period, 267 operations were performed (26.7 ± 20.3/week), while in the 2019-post period, 1036 surgeries were performed (103.6 ± 9.7/week) (p = 0.0002). Similarly, 1571 consultations were conducted in the post-ANG period (157.1 ± 93.6/week), while in the 2019-post period, 3907 were performed (390.7 ± 43.1/week) (p = 0.0003). However, in the post-ANG period, an increase in the proportion of reconstructive compared with aesthetic surgery was observed. The maintenance of highly complex procedures such as microsurgical transplants was also identified. CONCLUSIONS: The predominant profile of reconstructive surgeries at the Division of Plastic Surgery allowed the continuity of procedures at all technical complexity levels, patient care maintenance, and Plastic Surgery residents training.Level of evidence: not ratable.

Tratamento cirúrgico de hemangioma infantil nasal e labial na fase involuída: relato de caso / Surgical treatment of infantile nasal and labial hemangioma in the involuted phase: a case report

Hemangioma infantil (HI) é o tumor vascular mais comum e a neoplasia benigna mais frequente da infância, com maior incidência no sexo feminino e na população branca. Quase 60% dos casos ocorrem em cabeça e pescoço, sendo o tratamento ativo durante a fase proliferativa mais frequentemente indicado, em decorrência dos possíveis problemas funcionais e do potencial desfigurante. Relatamos um caso de paciente com hemangioma infantil involuído de ponta nasal e lábio superior, tratado de forma expectante durante a infância, submetida à correção da deformidade residual com técnicas de rinoplastia, associado à zetaplastia e lipoenxertia do lábio superior com bom resultado e satisfação do paciente.

Infantile hemangioma (IH) is the most common vascular tumor and the most frequent benign neoplasm in childhood, with the highest incidence in females and the white population. Almost 60% of cases occur in the head and neck, and active treatment during the proliferative phase is the most frequently indicated, due to possible functional problems and disfiguring potential. We report a case of a patient with involute infantile hemangioma of the nasal tip and upper lip, treated expectantly during childhood, submitted to residual deformity correction with rhinoplasty techniques, associated with zetaplasty and upper lip grafting with good results and patient satisfaction.

Xantogranuloma juvenil gigante: acometimento palpebral difuso e simultâneo / Giant Juvenile Xanthogranuloma: diffuse and simultaneous palpebral involvement

O xantogranuloma juvenil (XGJ) é um tumor benigno e o mais comum do grupo das doenças histiocitárias proliferativas nãoLangerhans. Lesões; 2cm são consideradas XGJ gigantes, com relatos de lesões de até 18cm. Lesões oculopalpebrais podem necessitar de tratamento cirúrgico para controle de sintomas. Esse trabalho relata o caso de um menino de 8 anos que teve as 4 pálpebras acometidas por XGJ gigantes, além do terço médio. Ele foi submetido a 3 ressecções, sendo uma bastante profunda, necessitando enxerto de pele de espessura total diretamente sobre o músculo levantador da pálpebra superior. Posteriormente, 3 procedimentos de lipoenxertia foram realizados, atingindo resultado funcional e estético adequado, sem recorrência lesional.

Juvenile xanthogranuloma (JXG) is the most common benign tumor of the group of non-Langerhans histiocytic proliferative diseases. Lesions >2 cm are considered giant JXG, with reports of lesions of up to 18 cm. Oculopalpebral lesions may require surgical treatment to control symptoms. This study reports a case of an 8-year-old boy who had four eyelids and the middle third of the face affected by giant JXG. He underwent three resections, one of which was of great depth that required a full-thickness skin graft directly on the levator palpebrae superioris muscle. Subsequently, four fat-grafting procedures were performed and adequate functional and

Retalho interósseo posterior reverso do antebraço para o tratamento cirúrgico do trauma elétrico da mão: relato de caso / Reverse posterior interosseous flap of the forearm for the surgical treatment of electric hand trauma: Case report

Introdução: Lesões que acometem as mãos com importante perda cutânea frequentemente requerem retalhos para cobertura precoce, visto que permitem melhor reabilitação. Dentre as opções, o retalho interósseo posterior reverso do antebraço é o mais utilizado para defeitos no dorso da mão e punho, com baixas taxas de complicações. Normalmente, esse retalho não é utilizado para a reconstrução de defeitos em região palmar, já que geralmente não alcança esse local. Relato de caso: Apresentamos o caso de um paciente com queimadura elétrica de terceiro grau, em palma da mão direita, cuja reconstrução foi realizada com o uso do retalho interósseo posterior reverso do antebraço, após debridamentos conservadores, no 14o dia após a queimadura. O paciente apresentou boa evolução pós-operatória, sem complicações ou sequelas funcionais a longo prazo. Conclusão: O retalho interósseo posterior reverso do antebraço permite cobertura adequada de lesões em palma da mão, preservando sua funcionalidade.

Introduction: Lesions affecting the hands with significant skin loss often require flaps for early coverage, as these permit faster healing. Among the various options, the reverse posterior interosseous flap of the forearm is most commonly used for defects involving the back of the hand and wrist due to low complication rates. Normally, this flap is not used for the reconstruction of defects in the palmar region since its distal reach is insufficient. Case report: We present the case of a male patient with third-degree electrical burns on his right palm, whose reconstruction was performed on the 14th day postinjury using the reverse posterior interosseous flap of the forearm after conservative debridement. The patient presented good postoperative evolution, without long-term complications or functional sequelae. Conclusion: The reverse posterior interosseous flap of the forearm permits adequate coverage of palm injuries, preserving its functionality.

Translation, Cross-Cultural Adaptation and Linguistic Validation of the FACE-Q Questionnaire for Brazilian Portuguese.

BACKGROUND: Patient-reported outcomes measurement instruments (PRO) are a good way to measure results after aesthetic procedures. FACE-Q is a systematized and standardized PRO tool and was not available in Portuguese. METHODS: This cross-sectional study included four stages: translation of FACE-Q, backtranslation, testing in patients who underwent facial aesthetic procedures and review of the questionnaires between September and December, 2018. Guidelines merging WHO and ISPOR's rules were followed. RESULTS: Translation was conducted by two translators, resulting in two versions, translation A and translation B, which were reconciled to generate the first Portuguese version. Reconciliation showed inconsistencies between TA and TB in 63% (n = 222) of the 353 questions, which were solved by maintaining TA in 25% of cases (n = 87), TB in 27% and a new version in 11% (n = 40) of the questions. Backtranslation showed written differences with the original FACE-Q in 64 (22.7%) of the 353 question, but only one case of semantic difference, which was corrected resulting in production of the second Portuguese version. Seven patients with a mean age of 35.8 years were interviewed to assess the difficulty in understanding the questionnaires. Four patients had no or minor difficulties understanding the questionnaire, and the other three had difficulties and suggested changes that led to a third Portuguese version. The third version was reviewed for grammar and spelling resulting in the final Portuguese version. CONCLUSION: A Brazilian Portuguese version of the FACE-Q questionnaire was obtained maintaining equivalency with the source instrument. This will allow cross-cultural research and comparison of results between different studies. 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 .

Surgical treatment of a penoscrotal massive localized lymphedema: Case report.

INTRODUCTION: Massive localized lymphedema is an aggressive type of lymphedema that causes great functional impairment for the patient, depriving from one's basic life activities. The treatment of this type of lesion is eminently surgical, requiring ablative surgery (complete surgical resection of the lesion), but the possible techniques not always provide a good functional result. PRESENTATION OF CASE: We reported a case of a penoscrotal massive lymphedema treated by our Body Contour Group/Plastic surgery department of our institute. We performed the resection of the giant penoscrotal lesion, used a posterior scrotal flap for defect's reconstruction and a split-thickness skin graft for penis' body reconstruction, closed with Z-plasty. DISCUSSION: Contrary to what the literature says, we prefer to use the split-thickness skin graft to reconstruct the penis' body in these cases, against local flaps. According to our experience with some similar cases, this technique provides a better functional result once it allows the penis to a better expansion during erection. The key maneuver to avoid contracture of the graft and retraction of the penis is to perform a broken line suture (Z-plasty) in the topography of the median raphe. CONCLUSION: In cases of penoscrotal massive lymphedema, the treatment's option with better results is the surgical one. The use of a scrotal flap associated with split-thickness skin graft for penis provides good aesthetic and functional outcomes.

Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo. / Opções de tratamento cirúrgico em lesões cutâneas por extravasamento acidental de drogas: experiência do Hospital das Clínicas da Faculdade de Medicina da USP.

OBJECTIVE: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs. METHODS: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization. RESULTS: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions. CONCLUSION: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

OBJETIVO: relatar a experiência da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no tratamento de lesões cutâneas por extravasamento acidental de drogas. MÉTODOS: foram incluídos os pacientes com lesões por extravasamento de drogas num período de 18 meses. Os seguintes parâmetros foram avaliados retrospectivamente: idade, diagnósticos durante internação e comorbidades, níveis séricos de albumina e hemoglobina, local de internação, droga envolvida, segmento anatômico acometido, conduta terapêutica e óbito durante internação. RESULTADOS: foram acompanhados 14 pacientes. A principal droga envolvida foi a noradrenalina (21%). Todos os pacientes foram submetidos a desbridamento da necrose tecidual. Três pacientes foram submetidos a retalhos após preparo do leito com terapia por pressão negativa, com bons resultados. Sete pacientes não tiveram tratamento definitivo de suas lesões por falta de condições clínicas. CONCLUSÃO: o tratamento definitivo por meio de retalhos se mostrou adequado para os casos de feridas por extravasamento de drogas em tecido subcutâneo, quando há exposição de estruturas nobres, em pacientes com condições clínicas favoráveis.

Opções de tratamento cirúrgico em lesões cutâneas por extravasamento acidental de drogas: experiência do Hospital das Clínicas da Faculdade de Medicina da USP / Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

RESUMO Objetivo: relatar a experiência da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no tratamento de lesões cutâneas por extravasamento acidental de drogas. Métodos: foram incluídos os pacientes com lesões por extravasamento de drogas num período de 18 meses. Os seguintes parâmetros foram avaliados retrospectivamente: idade, diagnósticos durante internação e comorbidades, níveis séricos de albumina e hemoglobina, local de internação, droga envolvida, segmento anatômico acometido, conduta terapêutica e óbito durante internação. Resultados: foram acompanhados 14 pacientes. A principal droga envolvida foi a noradrenalina (21%). Todos os pacientes foram submetidos a desbridamento da necrose tecidual. Três pacientes foram submetidos a retalhos após preparo do leito com terapia por pressão negativa, com bons resultados. Sete pacientes não tiveram tratamento definitivo de suas lesões por falta de condições clínicas. Conclusão: o tratamento definitivo por meio de retalhos se mostrou adequado para os casos de feridas por extravasamento de drogas em tecido subcutâneo, quando há exposição de estruturas nobres, em pacientes com condições clínicas favoráveis.

ABSTRACT Objective: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs. Methods: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization. Results: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions. Conclusion: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

Immunohistochemistry of the uterine cervix of rats bearing the Walker 256 tumor treated with copaiba balsam.

PURPOSE: To investigate the immunohistochemistry of the uterine cervix of 20 Wistar rats (Rattus norvegicus) bearing the Walker 256 tumor, treated with copaiba oil (Copaifera officinalis). METHODS: The animals were grouped into four subgroups, with five rats each: the GCT and GCopT received distilled water and topically copaiba, respectively, while the GCG and GCopG received distilled water and copaiba by gavage, respectively. The substances were administered for nine days. On the 12th day, after euthanasia, the tumor pieces were sent to the identification of T CD4+, T CD8+ and Natural Killer cells. RESULTS: It was found that the pattern of expression for specific markers of phenotypes of cells involved in tumor immune response was similar in all groups, regardless the administration way of copaiba oil (topical or gavage). CONCLUSION: Copaiba balsam, administered either topically or by gavage, did not alter the pattern of tumor immune response in rats bearing Walker 256 Tumor.

Immunohistochemistry of the uterine cervix of rats bearing the Walker 256 tumor treated with copaiba balsam

PURPOSE: To investigate the immunohistochemistry of the uterine cervix of 20 Wistar rats (Rattus norvegicus) bearing the Walker 256 tumor, treated with copaiba oil (Copaifera officinalis). METHODS: The animals were grouped into four subgroups, with five rats each: the GCT and GCopT received distilled water and topically copaiba, respectively, while the GCG and GCopG received distilled water and copaiba by gavage, respectively. The substances were administered for nine days. On the 12th day, after euthanasia, the tumor pieces were sent to the identification of T CD4+, T CD8+ and Natural Killer cells. RESULTS: It was found that the pattern of expression for specific markers of phenotypes of cells involved in tumor immune response was similar in all groups, regardless the administration way of copaiba oil (topical or gavage). CONCLUSION: Copaiba balsam, administered either topically or by gavage, did not alter the pattern of tumor immune response in rats bearing Walker 256 Tumor.

Retalho supraclavicular para tratamento de queimadura cervical: relato de caso / Supraclavicular flap for cervical burn treatment: case report

Objetivo: Descrever o caso de um paciente com queimaduras de 2º grau profundo em região cervical tratado com retalho supraclavicular após perda de enxertia de pele. Relato de Caso: Foi realizada revisão completa da história hospitalar do paciente para descrever o mecanismo de queimadura, os exames realizados e os tratamentos efetuados, bem como a evolução do mesmo após cada procedimento cirúrgico. Apresentado o caso de um jovem com queimaduras de 2º grau profundo em região cervical, cujo tratamento com enxertos de pele não foi bem sucedido, optando-se pelo tratamento com retalhos de pele obtidos da região supraclavicular bilateralmente. Conclusão: Concluiu-se que, no caso apresentado, o retalho de pele apresentou-se como melhor opção ao enxerto, uma que vez o paciente apresentava dificuldade em manter o repouso do local, com movimentos que facilitavam a perda dos enxertos.

Purpose: To describe the case of a patient with deep 2nd degree burn on the cervical region treated with supraclavicular flap after grafts losses. Case Report: We reviewed the complete hospital history of this patient to describe the mechanism of burn, the examinations and treatments performed as well as the evolution of the same after each surgical procedure. We present a case of a young man with deep 2nd degree burn on the cervical region whose treatment with skin grafting was not successful, opting for the treatment with skin flaps obtained from the supraclavicular region bilaterally. Conclusion: It was concluded that in the presented case, the skin flap was presented as the best graft option, once that the patient had difficulty in keeping the rest of the site, with movements that facilitated the loss of grafts.

Estudo morfológico do efeito subagudo de altas doses do óleo de copaíba em ratos / Morphological study of the subacute effect of high doses of copaíba oil on rat's

Objetivo: estudo morfológico sobre efeito subagudo de altas doses do óleo de copaíba em rins,estômago e fígado de ratos. Método: estudo experimental, utilizando 16 ratos (Rattus norvegicusalbinus), da linhagem Wistar, machos, distribuídos em dois grupos de oito ratos cada. Cada animalrecebeu, via gavagem, a determinada dose de óleo de copaíba - Copaifera officinalis - ou água destilada,durante 14 dias, conforme: Grupo copaíba (GCop): 6,0 ml/kg de copaíba e Grupo Água (GA): 6,0 ml/kgde água destilada. Após o 14o dia, os ratos foram submetidos à anestesia inalatória e posteriorlaparotomia longitudinal mediana xifopúbica para retirada de seus rins, estômago e fígado. Resultados:o estômago dos animais do grupo GCop, foi o órgão que mais sofreu alterações, desenvolvendoortoceratose compacta em sua mucosa e infiltrado inflamatório misto em mucosa e submucosa associadoà vasocongestão; nos rins observou-se vasocongestão glomerular difusa; já o fígado não apresentoualteração microscópica alguma. Conclusão: Conclui-se que o uso subagudo de copaíba em altas dosesprovoca um processo inflamatório no estômago e faz com que haja espessamento da mucosa gástrica,além de levar a uma vasocongestão glomerular renal e não alterar a microscopia hepática.

Objective: to evaluate morphologically the subacute effect of high doses of copaiba oil in rat?skidneys, stomach and liver. Method: 16 Wistar male rats (Rattus norvegicus albinus) were used,distributed in two groups of eight rats each. Each group received, by way of gavage, a quantity of theadopted substance, during 14 days, according to the following division: Copaiba Group (CopG): 6.0ml/kg of copaiba oil and Water group ? Standard group ? (SG): 6.0 ml/kg of distilled water. After the14th day, the rats were submitted to inhalatory anesthesia followed by a longitudinal midlinelaparotomy, which aimed to take out the rat?s kidneys, stomach and liver and send them tomicroscopical analyze. Results: Rat?s stomachs were the organs which suffered most of thealterations, showing compact orthokeratosis, mucosal and submucosal polimorfonuclear andmononuclear infiltrate and submucosal vascular congestion; in the kidneys were observed extenseglomerular vascular congestion; and the livers didn?t show any microscopic alterations. Conclusions:It was concluded that the subacute use of copaiba oil in high doses promotes relevant pathologicalalterations on rat?s kidneys and stomach, but does not alter microscopically the hepatic structure.

Efeito subagudo de altas doses do óleo de copaíba nos níveis de enzimas hepáticas em soro de ratos / The subacute effect of high doses of copaiba oil in the levels of hepatic enxymes in serum of rats.

Analisar o efeito subagudo de altas doses do óleo de copaíba em aminotransferases (AST - aspartato aminotransferase e ALT - alanina aminotransferase), fosfatase alcalina e gamaglutamiltransferase (gama GT), em ratos . Método: estudo experimental, no Laborarório deCirurgia Experimental UEPA. Utilizados 15 ratos (Rattus norvegicus albinus), da linhagem Wistar,machos, distribuídos em três grupos de cinco ratos cada. Cada animal recebeu, via gavagem, adeterminada dose de óleo de copaíba - Copaifera officinalis - ou água destilada, durante 14 dias,conforme: Grupo copaíba 6 (GCop6), 6,0 ml/kg de copaíba; Grupo copaíba 7,2 (GCop7), 7,2 ml/kgde copaíba; e Grupo Água (GC, 6,0 ml/kg de água destilada. Após o 14o dia, foram retiradasamostras de sangue dos animais em que foram ensaiadas as enzimas hepáticas. Resultados: noGCop7, todos os animais morreram devido a alta dose de copaíba, que provocou ulceração eperfuração da parede gástrica. Dentre os outros dois grupos, os níveis séricos de AST e ALTmantiveram-se estáveis e normais, enquanto que os níveis de fosfatase alcalina e gama GTestavam, estatisticamente, elevados no Gcop6 em relação à normalidade. Conclusão: o usosubagudo de copaíba em altas doses não altera os níveis séricos de AST e ALT; no entanto, essamesma dosagem leva ao aumento no soro da fosfatase alcalina e da gama GT.

To evaluate the subacute effect of high doses of copaiba oil in the aminotransferases(ASAT - aspartate Aminotransferase and ALAT - alanine Aminotransferase), alkaline phosphataseand gamma-glutamyl-transferase (gamma GT). Method: 15 Wistar male rats (Rattus norvegicusalbinus) were used, distributed in three groups of five rats each. Each group received, by way ofgavage, a quantity of the adopted substance, during 14 days, according to the following division:Copaiba 6 Group (Cop6G): 6.0 ml/kg of copaiba oil; Copaiba 7.2 Group (Cop7G): 7.2 ml/kg ofcopaiba oil; and Water group ? Standard group ? (SG): 6.0 ml/kg of distilled water. Results: afterthe 14th day, blood samples were collected from the animals, in which hepatic enzymes wereassayed. In the Cop7G, all the animals died due to the high doses of copaiba oil, which caused anulceration and perforation on gastric and colonic walls. Between the other two groups, the serumlevels of ASAT and ALAT remained stable and normal. However, the serum levels of alkalinephosphatase and gamma GT were statistically elevated in the Cop6G regarding normality.Conclusions: it was concluded that the subacute use of copaiba oil in high doses does not alter theserum levels of ASAT and ALAT. However, this same quantity of copaiba oil increased thealkaline phosphatase and the gamma GT serum levels