Use of flow cytometry and cytology to differentiate breast implant-associated anaplastic large cell lymphoma from reactive seromas in Brazilian patients.

INTRODUCTION: The combination of cytology and multiparametric flow cytometry (MFC) may be useful in the diagnosis of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and may be a practical way to differentiate lymphoma from benign and reactive seromas. Although the Brazilian breast implant market is the second largest in the world, with several manufacturers and the almost exclusive use of textured implants, the occurrence of BIA-ALCL in Brazil is underreported. METHODS: One hundred seventeen sequential collections of suspicious periprosthetic fluid (PF) from 105 Brazilian patients registered between March/2018 and March/2021 were evaluated by routine cytomorphology and flow cytometry. The combination of CD30, HLA-DR, and CD25 was used together with T and B lymphocyte and monocyte evaluation. The PF samples were divided into positive, acute reactive (neutrophilic exudate), or chronic reactive (macrophage or lymphocyte rich), and unavailable samples. RESULTS: Nine BIA-ALCL positive cases (7.7%) were identified, with typical morphology and increased FSC/SSC dispersion, bright expression of CD30, CD25 and HLA-DR, and absence or weakness of T-cell antigens (CD3, CD8, CD4, CD5, and CD7). Reactive samples were acute (n = 18, 15.4%) and chronic (n = 70, 59.8%). Twenty samples were excluded. The mean age of BIA-ALCL patients was 50 years (31-57 years) and 35 years in reactive patients (20-69 years). CONCLUSION: Use of MFC with a comprehensive antibody panel consisting of CD30 in conjunction with CD25 and HLA-DR can discriminate anaplastic cells of BIA-ALCL from lymphoid or neutrophilic reactive cells and should be considered in the initial evaluation of seroma.

A Picture of Breast Reconstruction in a Public Oncology Hospital in Latin America: A Ten-Year Experience.

OBJECTIVE: Breast cancer is the most frequent malignant tumor among women worldwide, with the sole exception of non-melanoma skin cancer. Currently, one of the most common treatments in Brazil is modified radical mastectomy, which, although effective, leads to both physical and psychological complications. In this context, breast reconstruction seeks to restore the functional and psychosocial health of women. This study aims to investigate the characteristics of breast reconstructions after mastectomy by comparing immediate and delayed reconstructions. MATERIALS AND METHODS: This is a retrospective observational study, which was performed by analyzing the electronic medical records of the Erasto Gaertner Hospital in Curitiba, Brazil, from between January 2007 and December 2017. RESULTS: After applying exclusion criteria, we analyzed a total of 268 medical records from January 2010 to December 2017. The most frequent histological type was invasive ductal carcinoma. Patients treated after 2014 had a higher number of immediate reconstructions, and the most commonly used method was alloplastic reconstruction using expanders (66.5%). There was no significant difference in the frequency of immediate or late complications between patients who opted for immediate or delayed reconstructions. The most common immediate complication was surgical wound dehiscence, and the use of neoadjuvant chemotherapy was not associated with a higher rate of complications in immediate reconstructions. CONCLUSION: The current preference is for immediate reconstructions with breast tissue expanders in combination with chemotherapy, which follows a trend in Brazil and worldwide that has been identified in the literature. Finally, the growth in immediate reconstructions with no associated increase in complications demonstrates the effectiveness of this practice.

Linfoma anaplásico de células grandes associado a implante mamários: um desafio diagnóstico / Breast implant-associated anaplastic large cell lymphoma: a diagnostic challenge

O linfoma anaplásico de células grandes associado a implante mamário (BIA-ALCL ) é uma entidade provisória com características morfológicas e imunofenotípicas indistinguíveis do linfoma anaplásico de células grandes (ALCL) ALK negativo. Ao contrário do ALCL, o BIA-ALCL surge principalmente em associação ao implante mamário. A confirmação diagnóstica do BIA-ALCL pode ser difícil e a associação de características morfológicas e patológicas com citometria de fluxo e imuno-histoquímica pode auxiliar no diagnóstico. O objetivo deste relatório é descrever um caso de BIA-ALCL no qual a análise citológica e imunofenotipológica utilizando citometria de fluxo sugeriu a presença de grandes células positivas para CD30 no líquido de derrame.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a provisional entity with morphological and immunophenotypic characteristics indistinguishable from ALKnegative anaplastic large cell lymphoma (ALCL). Unlike ALCL, BIA-ALCL arises mainly in association with breast implantation. Diagnostic confirmation of BIA-ALCL can be difficult and associating morphological and pathological hallmarks with flow cytometry and immunohistochemistry can assist in the diagnosis. The objective of this report is to describe a case of BIA-ALCL in which cytological and immunophenotypological analysis using flow cytometry suggested the presence of large CD30-positive cells in the effusion fluid.

Thoracic Wall Reconstruction: Surgical Planning in Extended Malignant Resections.

INTRODUCTION: The reconstruction of defects in thoracic wall remains a challenge for plastic surgeons. Advances in surgical treatment of illnesses of thoracic wall have been fostering the treatment of lesions within more advanced levels. Consequently, larger and more complex defects are generated, demanding soft tissue covering and framework repair. OBJECTIVE: The aim of this study was to report the experience in chest wall reconstruction and demographics of a tertiary cancer center. METHODS: All patients submitted to thoracic wall reconstruction by the plastic surgery department from January 2012 to May 2018 in a tertiary cancer center were evaluated. RESULTS: Thirty-two patients have undergone thoracic wall reconstruction. The majority of patients in our series were submitted to surgical treatment of locally advanced breast cancer (84.3%). The most common defect location was the right anterolateral region (65.6%). The latissimus dorsi musculocutaneous flap was the most used in thoracic wall reconstructions. Three cases of thoracectomy with rib resection were reconstructed with methylmethacrylate and polypropylene surgical mesh associated with musculocutaneous flap. Four patients presented major complications, and 12 patients (37.5%) presented minor complications. There were no deaths related to procedures or instability of thoracic wall. Twenty-two patients presented progression of the disease, and 16 died due to the primary pathology. CONCLUSIONS: Extended resection of the chest wall is associated in most cases with advanced disease, especially advanced breast cancer. Despite poor prognosis associated to locally advanced disease, it is imperative to perform chest wall reconstruction and allow the patient to continue adjuvant therapy (radiotherapy or chemotherapy) and improve quality of life.

Reconstruction options for locally advanced breast cancer cases and their impact on the quality of life

Introduction: Radical surgical procedures are indicated for part of the patients with locally advanced breast cancer (LABC). The improvement in the use of myocutaneous flaps allowed surgeons to perform extensive resections, a procedure that can be traumatic for women, leading to several biopsychosocial complications in a shortened survival. Objectives: This study aimed at understanding the effects of surgical treatment on the quality of survival of patients with guarded and unchanging prognosis. Methodology: The project was designed in two stages: review of medical records with a sample of 27 cases and face-to-face interviews with the administration of questionnaires in a sample of five cases among the remaining patients who underwent LABC surgery at Hospital Erasto Gaertner in Curitiba (PR). Results: On average, the answers obtained with the World Health Organization Quality of Life (WHOQOL-BREF) instrument were "regular" for physical, psychological, and environmental domains and "good" for the social relations domain. In the 12-item short-form survey (SF-12), the means were 45,125 points for the mental component and 40,875 points for the physical one. These values show the impact of advanced disease, hygienic surgery, and chest reconstruction on the quality of life of the patients, reflecting the biopsychosocial damage caused by LABC. Conclusion: The data reveal that LABC treatment is aggressive, but in patients with survival, the surgical treatment associated with chest reconstruction had surprisingly positive results in relation to quality of life.

Prehabilitation: how to prepare our patients for elective major abdominal surgeries? / Pré-habilitação: como preparar nossos pacientes para cirurgias abdominais eletivas de maior porte?

Surgical approach is the main form of treatment for several diseases of the abdominal cavity. However, surgical procedure itself is a stressor that may lead to adverse effects unrelated to the treatment goal. Prehabilitation has emerged as a multifactorial preoperative health conditioning program, which promotes improvement in functional capacity and postoperative evolution. The present study reviews literature using MEDLINE, Ovid, Google Scholar, and Cochrane databases in order to determine the concept of prehabilitation program and the indications and means of patient selection for it, as well as to suggest ways to implement this program in cases of major abdominal surgeries.

Várias doenças da cavidade abdominal têm, na abordagem cirúrgica, sua principal forma de tratamento. Entretanto, o próprio procedimento cirúrgico é um agente estressor que pode promover efeitos adversos não relacionados com o objetivo do tratamento. A pré-habilitação emergiu como um programa multifatorial de condicionamento de saúde pré-operatório, que promove melhora na capacidade funcional e na evolução pós-operatória. O presente estudo faz uma revisão da literatura usando os bancos de dado MEDLINE, Ovid, Google Scholar e Cochrane para determinar o conceito, as indicações, os meios de seleção dos pacientes, e para sugerir as formas de implementação do programa de pré-habilitação em cirurgias abdominais de grande porte.

Inframammary fold subcutaneous cushion assessment using MRI (magnetic resonance imaging).

BACKGROUND: The inframammary fold (IMF) is one of the most important elements in the determination of the aesthetic of the female breast. During mastectomies, it is important to preserve the subcutaneous portion nearby the IMF, attempting that, this preservation will greatly facilitate reconstruction allowing more satisfying aesthetic results. The aim of the present study is to evaluate the thickness of the subcutaneous IMF cushion using magnetic resonance imaging (MRI) acquisition images. METHODS: We have gauged the right breast IMF subcutaneous cushion from patients (all the cases without previous surgery in this topography) who were submitted to MRI in a diagnosis radiology center, between January and February of 2017. MRI images were analyzed in T1 fat saturated sequences. The assessment of the fold cushion was realized in the projection of axial measurements in sagittal plane. RESULTS: Among the 50 evaluated patients, the median measure of breast base was 9.91 cm. The median measure of the subcutaneous IMF cushion assessment in the sagittal projection of the breast base meridian was 2.40 cm (varying from 1.34 to 4.05 cm, with percentile 5% of 1.51 cm and percentile 95% of 3.55 cm). CONCLUSIONS: Other studies indicate the negligible amount of breast tissue and the low incidence of neoplasia in this topography, the preservation of the IMF seems feasible. The measurements of the IMF thickness, evaluated by MRI in this study, provide reference values for maintaining a desirable inframammary crease.

Safety check list in outpatient surgery teaching. / Checklist de segurança no ensino de cirurgia ambulatorial.

This article proposes the use of a safe surgical checklist in the teaching of the discipline of Ambulatory Surgery during medical graduation. It discusses its benefits and potential implementation and adherence difficulties. It underscores the importance of developing a patient safety culture and active learning methodologies to train students for greater commitment and accountability with the quality of care provided to the community in the academic outpatient clinic of the school hospital.

Este artigo propõe a utilização de um checklist de cirurgia segura no ensino da disciplina de Cirurgia Ambulatorial durante a graduação em Medicina. Discorre sobre seus benefícios e potenciais dificuldades de implantação e adesão. Ressalta a importância do desenvolvimento da cultura de segurança do paciente e das metodologias ativas de aprendizagem para treinar os estudantes para maior compromisso e responsabilidade com a qualidade da assistência prestada à comunidade no ambulatório acadêmico do hospital escola.

Pré-habilitação: como preparar nossos pacientes para cirurgias abdominais eletivas de maior porte? / Prehabilitation: how to prepare our patients for elective major abdominal surgeries?

RESUMO Várias doenças da cavidade abdominal têm, na abordagem cirúrgica, sua principal forma de tratamento. Entretanto, o próprio procedimento cirúrgico é um agente estressor que pode promover efeitos adversos não relacionados com o objetivo do tratamento. A pré-habilitação emergiu como um programa multifatorial de condicionamento de saúde pré-operatório, que promove melhora na capacidade funcional e na evolução pós-operatória. O presente estudo faz uma revisão da literatura usando os bancos de dado MEDLINE, Ovid, Google Scholar e Cochrane para determinar o conceito, as indicações, os meios de seleção dos pacientes, e para sugerir as formas de implementação do programa de pré-habilitação em cirurgias abdominais de grande porte.

ABSTRACT Surgical approach is the main form of treatment for several diseases of the abdominal cavity. However, surgical procedure itself is a stressor that may lead to adverse effects unrelated to the treatment goal. Prehabilitation has emerged as a multifactorial preoperative health conditioning program, which promotes improvement in functional capacity and postoperative evolution. The present study reviews literature using MEDLINE, Ovid, Google Scholar, and Cochrane databases in order to determine the concept of prehabilitation program and the indications and means of patient selection for it, as well as to suggest ways to implement this program in cases of major abdominal surgeries.

Checklist de segurança no ensino de cirurgia ambulatorial / Safety check list in outpatient surgery teaching

RESUMO Este artigo propõe a utilização de um checklist de cirurgia segura no ensino da disciplina de Cirurgia Ambulatorial durante a graduação em Medicina. Discorre sobre seus benefícios e potenciais dificuldades de implantação e adesão. Ressalta a importância do desenvolvimento da cultura de segurança do paciente e das metodologias ativas de aprendizagem para treinar os estudantes para maior compromisso e responsabilidade com a qualidade da assistência prestada à comunidade no ambulatório acadêmico do hospital escola.

ABSTRACT This article proposes the use of a safe surgical checklist in the teaching of the discipline of Ambulatory Surgery during medical graduation. It discusses its benefits and potential implementation and adherence difficulties. It underscores the importance of developing a patient safety culture and active learning methodologies to train students for greater commitment and accountability with the quality of care provided to the community in the academic outpatient clinic of the school hospital.

Evaluation of complications and flap losses in mandibular reconstruction with microvascularized fibula flap.

The mandibular defects caused by mandibulectomies can involve esthetic and functional sequelae in patients. The fibula presents positive aspects and can be used as an option for mandibular reconstruction after tumor resections or extensive traumas. Furthermore, this retrospective study of the patients who have passed through a mandibular reconstruction with a microvascular fibular flap over the last 17 years describes the experience of the Oral and Maxillofacial SurgeryService at the ErastoGaertner Hospital, Curitiba/PR. The use of this flap type has a complication rate of 32.3%, which includes the fixation material exposure, flap resorptions, fistulas, pathological fractures, tumor recurrence, infections, seromas, and thrombocytopenia. Most of them are associated with patients who have received radiotherapy and/or chemotherapy. These data suggest a high frequency of complications when a reconstruction plate fixation is used. Minor complications are usual and they should not be overlooked because they can lead to devastating consequences.

Ossificação do pedículo vascular de um retalho livre de fíbula: relato de caso / Ossification of vascular pedicle in fibula free flap: a case report

Introdução: Várias são as vantagens da utilização de retalhos fibulares para as reconstruções de defeitos craniomaxilofaciais, incluindo a baixa morbidade da área doadora, boa qualidade óssea possibilitando a realização de implantes osteointegrados quando indicados, além da possibilidade de inclusão de uma ilha de pele quando indicado. Durante a dissecção do retalho, próximo à região do pedículo vascular, normalmente inclui-se um cuff muscular e uma faixa de periósteo. O potencial osteogênico do periósteo transplantado tem sido objeto de estudo. Relato de caso: paciente de 15 anos, submetido à reconstrução microcirúrgica com um retalho fibular para um defeito mandibular pós-ressecção de um sarcoma ósseo. Evoluiu com aumento de volume, de consistência óssea na região cervical próximo à cervicotomia realizada para anastomose vascular. Exames de imagem mostravam características ósseas da massa. Foi então submetido à nova cervicotomia e exploração da massa, sendo observada uma formação de tecido ósseo no local da anastomose vascular. Exame anatomopatológico da peça mostrava formação de tecido ósseo adjacente ao retalho periostal. Discussão: Durante a dissecção do retalho fibular, a osteotomia é realizada a alguns centímetros da articulação do joelho, isto a fim de facilitar a dissecção do pedículo vascular na região do oco poplíteo. O pedículo vascular fica então envolto por uma cuff muscular e por uma tira de periósteo. Este mantém sua capacidade osteogênica, que pode ser ativada de acordo com o estímulo do local. A ossificação do periósteo do pedículo vascular de retalhos livres de fíbula permanece um evento raro, porém relatado por centros diferentes.

Introduction: The use of fibula flaps for the reconstruction of craniomaxillofacial defects has many advantages, including the low morbidity of the donor area, good bone quality for use of osseointegrated implants, and the possibility to include a skin island, when indicated. During the dissection of the flap, a muscle "cuff" and a periosteal strip are usually included near the region of the vascular pedicle. The osteogenic potential of the transplanted periosteum has been the object of studies. Case report: A 15-year-old male patient underwent microsurgical reconstruction using a fibula flap for a mandibular defect caused by the resection of a bone sarcoma. He developed increased volume and bone consistency in the cervical region next to the area where a cervicotomy was performed for vascular anastomosis. Imaging examinations showed the characteristics of the bone mass. He then underwent a new cervicotomy and mass exploratory surgery because bone tissue formation was observed at the site of vascular anastomosis. Anatomopathological examination of the specimen showed bone tissue formation next to the periosteal flap. Discussion: During fibula flap dissection, osteotomy is performed a few centimeters from the knee joint to facilitate the dissection of the vascular pedicle in the region of the popliteal fossa. Then, the vascular pedicle is surrounded by a muscle cuff and periosteal strip. This maintains its osteogenic capacity, which can be activated according to the stimulus of the area. Although periosteal ossification of the vascular pedicle in fibula free flaps is a rare event, it has been reported in different centers.

An alternative experimental model for training in microsurgery.

OBJECTIVE: to describe a new model of training in microsurgery with pig spleen after splenectomy performed by undergraduate students of the Discipline of Operative Technique of the UFPR Medical School. METHODS: after the completion of splenectomy we performed dissection of the vascular pedicle, distal and proximal to the ligation performed for removal of the spleen. After complete dissection of the splenic artery and vein with microscope, clamps were placed and the vessels were cut. We then made the anastomosis of the vessels with 9.0 nylon. RESULT: the microsurgical training with a well-defined routine, qualified supervision and using low cost experimental materials proved to be effective in the practice of initial microvascular surgery. CONCLUSION: the use of pig spleen, which would be discarded after splenectomy, is an excellent model for microsurgical training, since besides having the consistency and sensitivity of a real model, it saves the sacrifice of a new animal model in the initial learning phase of this technique.

A versatilidade do retalho anterolateral da coxa em reconstruções oncológicas: série de casos do serviço de cirurgia plástica reconstrutora e microcirurgia do hospital Erasto Gaertner / Versatility of the anterolateral thigh flap in oncology reconstructions: case reports of the reconstructive plastic surgery and microsurgery procedures in Erasto Gaertner Hospital

Introdução: Retalho anterolateral da coxa (ALT) foi descrito em 1984, baseado nos vasos perfurantes da artéria circunflexa femoral lateral. Trata-se de um retalho cutâneo, localizado no terço médio da coxa anterior, e lateral aos músculos reto femoral e vasto lateral. A baixa morbidade, relacionada à área doadora, e a possibilidade de utiliza-lo com diversas dimensões o tornam um retalho muito versátil. Objetivo: Apresentar sua versatilidade no serviço de Cirurgia Plástica Reconstrutora e Microcirurgia, do Hospital Erasto Gaertner, através do relato de três casos. Casos: Foram descritos dois casos com utilização do retalho ALT para reconstrução de cabeça e pescoço, e um caso com reconstrução do hemitórax direito.

Introduction: The anterolateral thigh (ALT) flap first described in 1984 is based on perforator vessels of the lateral femoral circumflex artery. It is a cutaneous flap located in the middle third of the anterior thigh and lateral to the rectus femoris and vastus lateralis. The low morbidity related to the donor site and its usefulness for different dimensions make it a versatile flap. Objective: This study aimed to present the versatility of the ALT flap in plastic and reconstructive surgeries at the Erasto Gaertner Hospital through a report of three cases. Cases: We describe three cases in which the ALT flap was used for the head and neck, and right hemithorax reconstructions.

An alternative experimental model for training in microsurgery / Modelo experimental alternativo para treinamento em microcirurgia

OBJECTIVE: to describe a new model of training in microsurgery with pig spleen after splenectomy performed by undergraduate students of the Discipline of Operative Technique of the UFPR Medical School. METHODS: after the completion of splenectomy we performed dissection of the vascular pedicle, distal and proximal to the ligation performed for removal of the spleen. After complete dissection of the splenic artery and vein with microscope, clamps were placed and the vessels were cut. We then made the anastomosis of the vessels with 9.0 nylon. RESULT: the microsurgical training with a well-defined routine, qualified supervision and using low cost experimental materials proved to be effective in the practice of initial microvascular surgery. CONCLUSION: the use of pig spleen, which would be discarded after splenectomy, is an excellent model for microsurgical training, since besides having the consistency and sensitivity of a real model, it saves the sacrifice of a new animal model in the initial learning phase of this technique. .

OBJETIVO: descrever um novo modelo de treinamento em microcirurgia com baço de suínos após esplenectomia realizada pelos alunos de graduação da disciplina de técnica operatória do curso de medicina da UFPR. MÉTODOS: após a realização da esplenectomia realizamos dissecção do pedículo vascular distal e proximal a ligadura realizada para a retirada do baço. Após a dissecção completa da artéria e veia esplênica ,com microscópio, são colocados os clampes e o vaso é seccionado. É então realizada a anastomose dos vasos com mononylon 9,0. RESULTADO: o treinamento microcirúrgico, com uma rotina bem definida, supervisão qualificada e utilizando materiais experimentais de baixo custo, mostrou-se efetivo na prática de cirurgia microvascular inicial. CONCLUSÃO: a utilização do baço suíno, que seria desprezado após esplenectomia, é um excelente modelo para treinamento microcirúrgico, pois além de ter a consistência e delicadeza de um modelo real poupa o sacrifício de um novo modelo animal, na fase inicial de aprendizado desta técnica. .

Escolha do vaso receptor em reconstrução de mama microcirúrgica / Recipoient vessel options in microsurgical breast reconstruction

INTRODUÇÃO: A transferência microvascular de tecido autógeno se tornou o padrão de referência para a reconstrução da mama. Como em qualquer reconstrução com tecido livre, a escolha do vaso receptor é fundamental para o planejamento adequado na reconstrução mamária. O objetivo do presente estudo é determinar quais dentre os vasos receptores disponíveis (a artéria mamária interna e seus vasos perfurantes ou os vasos circunflexos escapulares) são mais adequados para a reconstrução microvascular da mama. MÉTODO: Foi realizada análise retrospectiva de 117 pacientes consecutivas submetidas a reconstrução da mama microvascular, entre janeiro de 2005 e dezembro de 2007. Foi estabelecido um algoritmo que pode ser aplicado para a seleção do vaso receptor com base em alguns parâmetros, como dissecção axilar, tempo da reconstrução (imediata ou tardia) e presença de radioterapia pré-operatória. Foram avaliadas as complicações relacionadas ao retalho, a taxa de conversão e os resultados clínicos. RESULTADOS: A artéria mamária interna e seus vasos perfurantes e os vasos circunflexos escapulares são adequados para a reconstrução da mama, com taxas semelhantes de complicações e de viabilidade. Observou-se, também, maior risco de perda do retalho com o uso do retalho da artéria epigástrica inferior superficial em comparação ao retalho da artéria epigástrica inferior profunda ou retalho musculocutâneo abdominal transverso de músculo reto do abdome com preservação do músculo. CONCLUSÕES: A reconstrução mamária microcirúrgica é um método seguro e confiável, com alta viabilidade do retalho e baixas taxas de complicação.

BACKGROUND: Microvascular transfer of autogenous tissue have become the gold standard for breast reconstruction. As in any free tissue reconstruction, recipient vessel choice is fundamental for adequate planning in breast reconstruction. The purpose of the present study is to determine which of the available recipient vessels (the internal mammary artery and its perforators vessels or circumflex scapular vessels) are adequate for microvascular breast reconstruction. METHODS: A retrospective analysis of 117 consecutive patients who underwent microvascular breast reconstruction between January 2005 and December 2007 was performed. An algorithm that could be applied to the selection of the recipient vessel based in the axillary node dissection, immediate or late reconstruction, preoperative radiotherapy was established. Flap related complications, conversion rate and clinical outcomes were analised. RESULTS: The internal mammary perforator, the internal mammary and the circumflex scapular are adequate recipient vessels for breast reconstruction, with similar rates of complications and viability. We also observed a lower flap viability rate when using superficial inferior epigastric artery flap comparing to deep inferior epigastric artery perfurator and transverse rectus abdominis musculocutaneous with muscle preservation flaps. CONCLUSIONS: Microsurgical breast reconstruction is a safe and reliable method, with high flap viability and low complications.

Reconstrução oromandibular complexa com dois retalhos microcirúrgicos / Double free flap for oromandibular reconstruction

Introdução: O tratamento cirúrgico de tumores localmente avançados de cabeça e pescoçodeixa como sequelas defeitos extensos e complexos. Retalhos microcirúrgicos são a primeiraopção para reconstrução. Objetivo: Determinar a segurança e o impacto na sobrevida empacientes submetidos a dois retalhos microcirúrgicos. Método: Vinte e três pacientes foramsubmetidos a reconstrução oromandibular entre 2006 e 2007 e divididos em 2 grupos, de acordocom o número de retalhos. Idade, sexo, tabagismo, desnutrição, tipo histológico, radioterapia,recidiva, complicações e sobrevida foram avaliados. Resultados: Dezessete pacientes foramsubmetidos a retalho microcirúrgico único (grupo I) e seis pacientes, a dois retalhos microcirúrgicossimultâneos (grupo II). Carcinoma epidermóide foi o tumor mais comum (83,3%grupo II versus 47,1% grupo I). No grupo I, o retalho mais utilizado foi o retalho de fíbula em8 (47,1%) casos. No grupo II, os retalhos mais utilizados foram fíbula + ântero-lateral da coxaem 4 casos. Recidivas ocorreram em 3 pacientes do grupo I e 1 paciente do grupo II (17,6%versus 16,7%; p = 0,928). Tempo médio de sobrevida livre de doença foi de 11,8 + 6,8, nogrupo I, versus 10,8 + 8,4, no grupo II (p = 0,77). Houve três perdas totais do retalho (90,3%sobrevida do retalho), sendo uma perda de retalho fibular no grupo II e perda de um retalhofibular e ântero-lateral da coxa no grupo II, com sobrevida no grupo II de 86,4%. Conclusão:Acreditamos que o uso de dois retalhos microcirúrgicos é seguro, com sobrevida do retalhosemelhante ao grupo que realizou apenas um retalho microcirúrgico.

Introduction: Ablative surgery for locally advanced head and neck tumors can lead to devastatingsequels. Free flaps are the gold standard in reconstruction. Aim: To determine safetyand survival impact in patients submitted to double free flaps procedures. Method: Twentythree patients were submitted do oromandibular reconstruction between 2006 and 2007. forcomparison purposes they were divided in two groups: group I – single free flap, and groupII – double free flap. Data such as age, sex, smoking history, malnutrition, histological type,radiotherapy, recurrence, complications and survival were collected. Results: seventeenpatients were distributed in group I and 6 patients in group II. squamous cell carcinoma wasthe most common histological type (83.3% group II versus 47.1% group I). Fibular free flapwas the most used flap in group I (8 cases – 47.1%). The most common flap combination ingroup II was fibular free flap+anterolateral thigh flap in 4 cases. Recurrence was observed inthree patients from group I and one patient from group II (17.6% versus 16.7%; p = 0.928).mean survival time free from disease was 11.8 months + 6.8 in group I versus 10.8 + 8,4 ingroup II (p = 0.77). There were three total flap loss (90.3% flap survival), one fibular flap fromgroup I and one fibular and one anterolateral thigh flap in group II. Flap survival in group IIwas 86.4%. Conclusion: We believe that double free flap reconstruction in head and neck issafe, reliable and has similar flap survival as single free flap procedures.

Influence of preoperative feeding on the healing of colonic anastomoses in malnourished rats.

BACKGROUND: Malnutrition influences healing of gastrointestinal anastomoses. The authors hypothesize that colonic anastomotic healing is decreased by malnutrition and might be improved by preoperative feeding. METHODS: Eighty adult male Wistar rats were divided into 4 groups: (1) control rats 1 (C1), fed regular chow ad libitum for 21 days; (2) malnourished pair-fed rats (M), fed 50% of the food ingested by the control rats for 21 days; (3) preoperative nutrition rats (PRE), fed 50% of the average of the controls for 21 days and then fed preoperative nutrition with regular chow ad libitum for 1 week before the operation; and (4) control rats 2 (C2), fed regular chow ad libitum for 28 days. On days 21 (C1 and M) and 28 (PRE and C2), rats underwent 2 colonic transections and, subsequently, 2 end-to-end anastomoses. Rats were killed on postoperative day 5. The anastomoses were resected for tensile strength and histological analysis. RESULTS: PRE rats showed increased maximal tensile strength vs the M group (0.09+/-0.01 vs 0.15+/-0.01; P<.05) and similar values of maximal tensile strength as the controls (0.15+/-0.01 vs 0.15+/-0.02; P=.91). Collagen type I was higher in controls vs the PRE group (6.13+/-0.39 vs 4.90+/-1.53; P<.05); nevertheless, the PRE group showed higher collagen type I than M rats (4.90+/-0.36 vs 3.83+/-0.35; P<.05). CONCLUSIONS: Preoperative feeding for 7 days increases the maximal tensile strength, as well as the percentage area of mature collagen, approaching similar values as the control group.

Facial rejuvenation with SMASectomy and FAME using vertical vectors.

The quest for better results in the midface after a face lift has led to the repositioning of a structure called the malar fat pad. Finger-assisted malar elevation (FAME) consists of detaching the malar fat pad from the underlying SMAS, which allows for the elevation of this structure. Two hundred five patients (189 females and 16 males) from January 2002 to August 2007 underwent a facial rejuvenation procedure comprising short-scar rhytidoplasty, SMASectomy, and FAME, with or without a simultaneous endobrow, blepharoplasty, and lipofilling. The midface fixation technique consisted of a stitch from the malar fat pad and SMAS flap to the periosteum at the zygomatic arch which was performed in every case. Elevation of the midface and improvement of the nasolabial fold and the mandible contour were obtained in all cases. Facial aging should be evaluated as a global process instead of a segmented one. Aging occurs in every structure of the face in different ways, depending on the vector of descent, thereby treatment must be individualized. We have observed improvement of the midface when using the FAME procedure in a rhytidoplasty with SMASectomy with deep fixation.