Evaluation of Chlorhexidine Concentration on the Skin After Preoperative Surgical Site Preparation in Breast Surgery-A Randomized Controlled Trial.

BACKGROUND: Although there is a rationale supporting that preoperative showering with 2% or 4% chlorhexidine gluconate (CHG) would decrease skin bacterial colonization, there is no consensus that this practice reduces the risk of surgical site infection (SSI). OBJECTIVES: Analyze the skin concentration of CHG after preoperative showering associated with the traditional skin preparation with CHG 4% for breast surgery. METHODS: Randomized controlled trial that included 45 patients, all candidates for augmentation mammaplasty, allocated into three groups (A: no preoperative showering; B: one preoperative showering; C: two preoperative showering with CHG 4%) in a 1:1:1 ratio. Skin swabs collection was performed right before the surgical incision. The samples were, then, sent to spectrophotometry in order to determine the skin concentration of CHG at the beginning of surgery. RESULTS: The age ranged from 18 to 61 years, with a mean of 37 years old. Group C had the lowest median concentration (0.057) followed by group B (0.060) and group A (0.072), however, with no statistical significance. The areola was the place with the lowest median concentration level (0.045), followed by the axilla (0.061) and the inframammary fold (IMF) (0.069). Still, when comparing the distribution of the sites, a statistically significant difference was found only between the axilla and the areola (p = 0.022). CONCLUSION: Preoperative showering with CHG 4% did not increase the concentration of this agent on the skin surface right before the surgical incision. 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 .

Simultaneous Cranioplasty and External Ventricular Drain Implantation in Patients with Hydrocephalus: Case Series and Literature Review

Introduction The increase in intracranial pressure (ICP) is a neurological complication resulting from numerous pathologies that affect the brain and its compartments. Therefore, decompressive craniectomy (DC) is an alternative adopted to reduce ICP in emergencies, especially in cases refractory to clinical therapies, in favor of patient survival. However, DC is associated with several complications, including hydrocephalus (HC). The present study presents the results of an unusual intervention to this complication: the implantation of an external ventricular drain (EVD) in the intraoperative period of cranioplasty (CP). Methods Patients of both genders who presented with HC and externalization of the brain through the cranial vault after decompressive hemicraniectomy and underwent EVD implantation, to allow the CP procedure, in the same surgical procedure, were included. Results Five patients underwent DC due to a refractory increase in ICP, due to automobile accidents, firearm projectiles, falls from stairs, and ischemic strokes. All evolved with HC. There was no uniform time interval between DC and CP. The cerebrospinal fluid (CSF) was drained according to the need for correction of cerebral herniation in each patient, before undergoing cranioplasty. All patients progressed well, without neurological deficits in the immediate postoperative period. Conclusion There are still several uncertainties about the management of HC resulting from DC. In this context, other CP strategies simultaneous to the drainage of CSF, not necessarily related to ventriculoperitoneal shunt (VPS), should be considered and evaluated more deeply, in view of the verification of efficacy in procedures of this scope, such as the EVD addressed in this study.

Reconstrução de mandíbula com retalho livre de fíbula: série de casos / Mandibular reconstruction with fibula free flap: case series

Introdução: A reconstrução da mandíbula é um procedimento complexo, que visa a correção das deformidades do terço inferior da face e reabilitação funcional, incluindo mastigação e competência oral. O retalho livre de fíbula é a primeira escolha para a reconstrução de falhas segmentares da mandíbula e tecido mole adjacentes. Métodos: Foi realizado um estudo clínico retrospectivo, no período de janeiro de 2005 a julho de 2017, analisando os prontuários dos pacientes submetidos a reconstruções microcirúrgicas após a ressecção de neoplasias em cabeça e pescoço, operados pelo serviço de cirurgia plástica do Hospital das Clínicas da Universidade Federal de Pernambuco (HC-UFPE). Resultados: Seis pacientes foram incluídos no estudo, sendo três do sexo masculino (50%), a idade variou de 12 a 48 anos, com média de 24 anos. Em 83% dos casos foram realizadas reconstruções com retalhos livres de fíbula osteomiocutâneos (em um dos casos não houve necessidade de confeccionar ilha de pele junto ao retalho). Observou-se uma cobertura eficaz dos extensos defeitos estudados, apresentando em todos os casos bons resultados quanto ao aspecto funcional e estético. Em 83% dos casos reconstrução imediata foi realizada. A prototipagem da fíbula e da área receptora foi realizada em dois casos. Conclusão: Retalhos livres de fíbula constituem uma ótima alternativa para reconstrução em cabeça e pescoço. Nossa experiência inicial e a literatura mostram resultados satisfatórios, restaurando parcialmente forma e função das áreas acometidos.

Introduction: Mandibular reconstruction is a complex procedure aimed at correcting defects of the lower third of the face and achieving functional rehabilitation, including chewing and oral competence. Fibula free flap is the first choice for the reconstruction of segment defects of the adjacent mandible and soft tissue. Methods: A retrospective clinical study was conducted from January 2005 to July 2017, analyzing the medical records of patients undergoing microsurgical reconstructions after resection of head and neck neoplasms at the plastic surgery service of the Clinical Hospital of the Federal University of Pernambuco (HC-UFPE). Results: This study included six patients, of which three were men (50%), aged between 12 and 48 years and with a mean age of 24 years. In 83% of the cases, reconstructions were performed with osteomyocutaneous fibula free flaps (in one case, there was no need for skin island flap). We observed an adequate coverage of the large defects analyzed, with good functional and aesthetic appearance in all cases. Immediate reconstruction was performed in 83% of cases. The fibula and receptive area were prototyped in two cases. Conclusion: Fibula free flaps are a great alternative for head and neck reconstruction. Our initial experience and literature show satisfactory results, partially restoring the shape and function of the affected areas.

Functional and aesthetic evaluation after cranial reconstruction with polymethyl methacrylate prostheses using low-cost 3D printing templates in patients with cranial defects secondary to decompressive craniectomies: A prospective study.

BACKGROUND: Cranial reconstruction surgery is a procedure used as an attempt to reestablish the cranial bone anatomy. This study evaluates the symptomatic and aesthetic improvement of patients with cranial defects secondary to decompressive craniectomies after cranial reconstruction with customized polymethyl methacrylate (PMMA) prostheses. Secondly, we aim to divide our experience in the production of these prostheses with a low-cost method. METHODS: A prospective study was carried out with patients submitted to cranioplasty at the Hospital da Restauração between 2014 and 2017. A total of 63 cranioplasties were performed using customized PMMA prosthesis produced by 3D impression molds. All patients underwent a functional and aesthetic evaluation questionnaire in the preoperative period and in the sixth postoperative month. RESULTS: Sixty-three patients underwent cranioplasty with a mean age of 33 years, ranging from 13 to 58 years, 55 males and 8 females. The mean area of the defect was 147 cm2. The mean postoperative follow-up of the patients was 21 months, ranging from 6 to 33 months. Fifty-five patients attended the 6-month postoperative consultation. All patients presented symptomatic improvement after reconstruction of the skull. The infection rate was 3.2%, 4.8% of extrusion, 1.6% of prosthesis fracture, 7.9% of extradural hematoma, 17.4% of reoperation, 5% of wound dehiscence, and 4.8% of removal of the prosthesis. CONCLUSION: Cranioplasty, with a customized PMMA prosthesis, improved the symptoms and aesthetic appearance of all operated patients. The use of prototypes to customize cranial prostheses facilitated the operative technique and allowed the recovery of a cranial contour very close to normal.

Adhesion sutures for seroma reduction in cranial reconstructions with polymethyl methacrylate prosthesis in patients undergoing decompressive craniectomy: A clinical trial.

BACKGROUND: Cranial reconstruction with polymethyl methacrylate (PMMA) prosthesis is used for calvarial defects secondary to decompressive craniectomies. Seroma is one of the most frequent complications of this procedure and can lead to the dehiscence, extrusion, infection, and loss of the prosthesis. The objective of the study is to analyze the effectiveness of the tacking sutures between the prosthesis and the scalp flap in reducing the seroma. METHODS: This is a prospective study with 63 patients submitted to cranioplasty between 2014 and 2017 for defects resulting from decompressive craniectomies. All patients were followed up postoperatively for at least 3 months and the diagnosis of seroma was made clinically. In the first 22 patients, the conventional technique was applied and, in the following 41, the technique with tacking sutures was used. The incidence of seroma was collected for both groups. RESULTS: The overall incidence of seroma was 65.1%. Compared to the conventional technique, the use of tacking sutures was associated with a statistically significant reduction in the incidence of seroma from 90.9% to 51.2% (P = 0.002). CONCLUSION: The use of the tacking sutures in cranioplasties with PMMA prosthesis reduced the incidence of seroma postoperatively.

Neo-onfaloplastia com enxerto cutâneo / Neoomphaloplasty with cutaneous graft

Introdução: A cicatriz umbilical é decorrente da queda do coto umbilical, que ocorre alguns dias após o nascimento. Sua presença, formato e localização na parede abdominal fornecem ao indivíduo uma conotação estética e sensual. Métodos: Estudo primário, prospectivo, de intervenção. A casuística foi de conveniência, no período de fevereiro de 2006 a junho de 2016, incluindo pacientes de ambos os gêneros, alocados do ambulatório do Hospital das Clínicas da Universidade Federal de Pernambuco (HC-UFPE) e clínica privada. Os critérios de inclusão foram pacientes com indicação de abdominoplastia e que apresentavam um comprometimento da irrigação da pele da região umbilical e periumbilical devido a defeitos herniários da região. O estudo seguiu os critérios de Helsinki e os pacientes assinaram o Termo de Consentimento Livre e Esclarecido. Resultados: Foram operados 28 pacientes, sendo observada uma boa integração da pele enxertada, resultando em uma cicatriz umbilical de aparência natural e sem complicações. Conclusões: A neo-onfaloplastia com enxerto cutâneo é de fácil execução e que, a longo prazo, tem demonstrado um bom resultado estético, principalmente nos retalhos abdominais espessos, demonstrando ser mais uma opção técnica na realização de neo-onfaloplastias.

Introduction: The umbilical scar is due to the fall of the umbilical stump that occurs a few days after birth. Its presence, shape, and location on the abdominal wall provide the individual with an aesthetic and sensual connotation. Methods: A primary prospective interventional study. The sample was of convenience, from February 2006 to June 2016, and included patients of both sexes attending the outpatient clinic of the Hospital das Clínicas of the Federal University of Pernambuco (HC-UFPE), a private clinic . The inclusion criteria were patients with abdominoplasty indications presenting with compromised circulation to the skin of the umbilical and periumbilical region caused by hernia defects in this area. The study followed the criteria of Helsinki and the patients signed an Informed Consent Form. Results: Twenty-eight patients underwent surgery and good integration of the grafted skin was observed. This resulted in an umbilical scar with a natural appearance and without complications. Conclusions: Neoomphaloplasty with a cutaneous graft is easy to perform and, in the long term, has shown to provide good aesthetic results, especially in thick abdominal flaps, thus proving to be an additional technical option for neoomphaloplasty procedures.

Uso do sistema VAC no tratamento da fascite necrosante da parede abdominal / Vacuum assisted closure sistem in the treatment of necrotizing fasciitis of abdominal wall

O paciente cirúrgico portador de abdome aberto é de difícil manuseio devido as perdas de água e eletrólitos, a difícil reposição volêmica, o grande número de curativos diários e o risco de infecção. A utilização do sistema VAC permite medir rigorosamente as perdas por um período de 48 horas, que pode ser renovado, facilita a reposição volêmica, diminue o risco de contaminação e de infecção e cria um ambiente úmido que facilita o processo de cicatrização. Quando comparado o custo com processos tradicionais além da vantagem verificada com o sistema VAC. Ocorre também uma redução do risco e do período de permanência hospitalar. Os autores relatam o tratamento de um paciente do no HC-UFPE que documenta essas vantagens.

The patient with peritoneostomy is difficult to manege due to the losses of water and alectrolytes, the difficult volemic replacement, the great number of daily dressings and the risk of infection. The use of system VAC allows the acurate measurement of the losses for a period of 48 hours, that can be renewed, facilitates the volemic replacement, decreases the infection and contamination risk and creates a humid environment that helps the healing process. When compared with traditional processes beyond the advantage verified with system VAC, the costs are lower. A reduction of the risk and the period of hospital stay also occurs. The authors present a case carried out in the HC-UFPE that registers these advantages.

Avaliação de pacientes esquistossomóticos quanto ao conteúdo mineral ósseo, nível de magnésio corporal total e atividade da enzima lecitina: colesterol acetiltransferase em pós-esplenectomizados com auto-implante esplênico / Evaluation of bone mineral density, total magnesium level and activity of a lecithin enzyme, acetyl-cholesterol transferase of post-splenectomy schistosomal patients with splenic autograft

Nos portadores jovens de esquistossomose cirúrgica existe déficit do conteúdo mineral ósseo (BMD), ocasionando retardo no desenvolvimento estato-ponderal que melhora com os tratamentos clínico e cirúrgico. Contudo, alguns pacientes permanecem com déficit do BMD. Foi objetivo geral do presente trabalho estudar o papel do magnésio no metabolismo ósseo nos pacientes esquistossomóticos; foram avaliados os níveis séricos e urinários de magnésio, antes e após dose de saturação desse cátion, para verificação de possível déficit do mesmo nesses pacientes, além da possível associação dos níveis séricos e urinários de magnésio com os níveis da enzima lecitina colesterol acetiltransferase (LCAT). Foram incluídos 18 portadores de esquistossomose na forma hepatoesplênica, com idade variando entre 13 e 24 anos, média de 18,6 ± 2,9; 11 eram do sexo masculino e sete do feminino. Todos haviam-se submetido a tratamento cirúrgico, que consistiu de: esplenectomia, ligadura da veia gástrica esquerda e auto-implante de tecido esplênico, no epíploo maior. Esses pacientes foram tratados clínica e cirurgicamente no Serviço de Cirurgia Geral da Criança do Hospital das Clínicas da UFPE, no período de 1990 a 2001. Foi avaliado o BMD, antes e após tratamento clínico, com dose única de oxamniquine, e o tratamento cirúrgico. O BMD foi medido nas vértebras lombares (L2-L4), usando um densitômetro modelo LUNAR DPX-L®. Quatorze pacientes apresentaram BMD deficiente. O magnésio sérico e o urinário foram medidos antes e 24 horas após a infusão de dose de saturação desse íon (6mg/ kg de MgSO4). A deficiência de magnésio foi considerada quando a reabsorção desse íon era maior do que 40 por cento. Quatro pacientes (22,2 por cento) apresentaram depleção do magnésio. Não houve correlação entre os níveis de reabsorção de magnésio e os níveis de LCAT. Observou-se melhora no BMD no pós-operatório (p = 0,052), entretanto, sem alcançar significância estatística. Essa melhora esteve associada ao aumento, no pós-operatório, da LCAT. Embora o papel do magnésio no metabolismo ósseo, nos pacientes esquistossomóticos, não seja definitivo, os dados dão suporte ao conceito de que esse cátion deva ser considerado na correção do déficit de BMD desses pacientes.