Does the Use of Intraoperative Breast Sizers Increase Complication Rates in Primary Breast Augmentation? A Retrospective Analysis of 416 Consecutive Cases in a Single Institution.

Background. Is the use of intraoperative breast sizers beneficial for plastic surgeons or do they result in higher complication rates? Methods. This is a retrospective study of 416 consecutive cases of primary breast augmentation with silicone implants at the Plastic Surgery Service of Professor Ivo Pitanguy at the 38th Infirmary Santa Casa Misericórdia Hospital, Rio De Janeiro, from January 2011 to March 2014. 212 cases (51%) were carried out with use of intraoperative breast sizers with 204 cases (49%) without the use of implant sizers. This study compares the outcome of cases that employed the use of intraoperative implant sizers versus those that did not in terms of infection, hematoma/seroma formation, and capsular contracture. Results. Of 416 primary breast augmentation cases, there were 5 cases of infection (1.2%), 4 cases of seroma (1%), 3 cases of hematoma (0.7%), and 7 cases of capsular contracture (Baker's Grade III/IV)(1.7%). Total complication rate limited to infection, seroma, hematoma, and capsular contracture was 1.15% (95% CI 0.96-1.93%). There was a significant difference in the scores for breast sizers (M = 4.3, SD = 1.4) and no breast sizers (M = 2.3, SD = 0.87) conditions, t(8) = 2.79, p = 0.018. The use of implant sizers was correlated with a higher complication rate. Conclusion. Good results could be obtained without the use of breast sizers in primary breast augmentation with use of a biodimensional tissue based planning system while eliminating risks of infection and reducing intraoperative time. Notwithstanding, in a residency program breast sizers can be an excellent training tool to shorten the learning curve in the novice surgeon.

Leiomioma cutâneo piloeretor: relato de caso e análise de possibilidades terapêuticas / Cutaneous pilar leiomyoma: case report and analysis of therapeutic possibilities

Introdução: O leiomioma cutâneo piloeretor (LCP) é um tumor benigno de pele, de incidência rara, proveniente do músculo eretor do pelo. Sua apresentação clínica mais frequente é o aparecimento de nódulos isolados ou em grande número. Em geral, são dolorosos, sensíveis ao frio, toque, pressão e à emoção. Vários agentes farmacológicos têm sido utilizados com algum sucesso para redução da dor e do desconforto local. Entretanto, em casos nos quais os sintomas dolorosos são intensos ou causam restrição social, a cirurgia torna-se uma abordagem alternativa a ser considerada. Neste artigo relatamos o caso de um paciente do sexo masculino, portador de múltiplos leiomiomas cutâneos na parede torácica anterior à esquerda e no abdome, bem como a terapêutica utilizada para seu caso. Métodos: O tratamento compreendeu a ressecção cirúrgica total da lesão, com fechamento da ferida com o uso de enxerto de pele parcial, retirado da região anterolateral da coxa direita. Resultados: A reconstrução imediata do defeito resultante, com enxerto de pele parcial, assegurou a cicatrização sem intercorrências. Após o tratamento, houve completa remissão do quadro doloroso, o que permitiu completa reintegração social do paciente, tendo sido alcançado ainda resultado estético aceitável. Conclusão: O LCP constitui patologia de difícil tratamento, embora tenha várias possibilidades terapêuticas. A ressecção cirúrgica completa de múltiplos leiomiomas cutâneos pode impedir a recorrência da doença, embora alguma recidiva local seja relatada na literatura.

Introduction: Cutaneous pilar leiomyoma (CPL) is a rare benign skin tumor arising from arrector pili muscles. Its most common clinical manifestation is the appearance of nodules that may either be isolated or clustered. In general, these tumors are painful and sensitive to cold, touch, pressure, and emotional stimuli. Several pharmacological agents have been used with some success to reduce local pain and discomfort. However, in cases with intensely painful symptoms or that cause social constraints to the patient, surgery becomes an alternative approach. Here, we report the case of a male patient with multiple cutaneous leiomyomas in the left anterior chest wall and abdomen, and the therapeutic approaches used for this case. Methods: The treatment included a complete surgical resection of the tumor and wound closure with partial skin graft taken from the anterolateral region of the right thigh. Results: The immediate reconstruction of the resulting defect with a partial skin graft ensured healing without complications. After the treatment, complete remission of the pain symptoms occurred, in addition to an acceptable aesthetic outcome, which allowed the full social reintegration of the patient. Conclusion: CPL is a disease that is difficult to treat; however, several therapeutic approaches can be used. The complete surgical resection of multiple cutaneous leiomyomas can prevent the recurrence of the disease, although some local recurrences have been reported in the literature.

Protocolo de prevenção de tromboembolismo venoso em cirurgia plástica: resultados em 2759 pacientes no Instituto Ivo Pitanguy / Venous thromboemboembolism prevention protocol in plastic surgery: results in 2759 patients at the Ivo Pitanguy Institute

Introdução: A embolia pulmonar é a causa de morte mais previsível em pacientes hospitalizados, sendo isso ainda mais prevalente em pacientes cirúrgicos. 200.000 novos casos ocorrem anualmente, com início súbito e geralmente levando à morte nas primeiras 2 horas. Prevenir é, portanto, mais efetivo que tratar a doença estabelecida. Esse estudo objetiva demonstrar a importância e segurança do protocolo de prevenção do tromboembolismo venoso. Métodos: Conduzimos um estudo retrospectivo no período de maio de 2009 a maio de 2011, quando 2759 pacientes foram submetidos à cirurgia plástica no Instituto Ivo Pitanguy. Todos os pacientes foram submetidos ao protocolo de prevenção e avaliados quanto aos fatores de risco para tromboembolismo venoso. A soma desses fatores gerou um escore que determinou a conduta profilática a ser adotada. Resultados: Houve três casos de tromboembolismo venoso (0,1%), sendo 1 de TEP e 2 de TVP. A quimioprofilaxia com enoxaparina administrada aos 3 pacientes de acordo com o protocolo de prevenção. Nossas taxas permaneceram abaixo das encontradas na literatura, com diferença estatisticamente significativa nos numero total de casos (p < 0,0001). Houve 34 casos de hematoma (1,2%), sendo 55,9% em pacientes submetidos à quimioprofilaxia e 44,1% em pacientes que usaram apenas o dispositivo de compressão pneumática intermitente apenas. As taxas totais de hematoma também permaneceram abaixo das encontradas na literatura, também com diferença estatisticamente significativa (p < 0,001). Conclusão: O protocolo de prevenção do tromboembolismo venoso do Instituto Ivo Pitanguy se provou seguro e importante na prevenção dos casos de TEV, com taxas de hematoma abaixo do descrito na literatura.

Introduction: Pulmonary embolism is the most predictable cause of death in hospitalized patients, even more in surgical patients. 200.000 new cases occur annually, with sudden onset and generally leading to death in the first 2 hours. Preventing is most effective than treating stablished disease. This study aims to show the importance and safety of the venous thromboembolism prevention protocol. Methods: We conducted a retrospective study in the period between May 2009 and May 2011 at The Ivo Pitanguy Institute, where 2759 patients underwent plastic surgery (aesthetic and reconstructive). All patients were assessed for predisposing and exposing risk factors for venous thromboembolism and the sum of those factors generated a score determining the prophylactic procedure to be adopted according to the protocol. Results: There were three cases of venous thromboembolism (0.1%): one case of pulmonary embolism and two cases of deep venous thrombosis. Chemoprophylaxis with heparin was administered in the three patients according to the venous thromboembolism prevention protocol. Our rates remained below those found in the literature, with a statistically significant difference in total cases (p < 0.0001). There were 34 cases of hematoma (1.2%): 55.9% in patients submitted to pharmacological prophylaxis with heparin and 44,1% in patients who used sequential compression devices only. The total rates of hematoma also remained below those found in the literature with a statistically significant difference (p < 0,001). Conclusion: The venous thromboembolism prevention protocol of the Ivo Pitanguy Institute proved to be important and safe, preventing the occurrence of venous thromboembolism cases with low rates of hematoma.

Sequela de injeção de silicone em lábio inferior: correção cirúrgica pela técnica do biquíni modificada / Sequelae of inferior lip silicone injection: surgical correction using the modified "bikini" technique

Pacientes portadores de sequelas devido a injeções de substâncias inabsorvíveis tem se tornado cada vez mais frequentes. O silicone injetável ou polidimetilsiloxano fluido é um polímero manufaturado que contém silicone elementar. As complicações consequentes ao uso desta substância podem ser precoces ou tardias. Apresentamos um relato de caso onde uma deformidade por injeção de silicone em lábios foi tratada cirurgicamente usando a técnica do biquíni modificada obtendo um bom resultado funcional e estético.

Increasing numbers of patients have sequelae due to the injection of non-absorbable substances. Injectable silicone or polydimethylsiloxane fluid is a manufactured polymer containing elemental silicon. The complications associated with the use of this substance can present early or late. Here we present a case report in which a deformity due to a silicone injection in the lips was surgically treated using the modified "bikini" technique that produced a functionally and aesthetically favorable result.

Long-term ultrasonographic evaluation of midline aponeurotic plication during abdominoplasty.

BACKGROUND: The purpose of this study was to evaluate the efficiency of the plication of the anterior rectus sheath during abdominoplasty and the anatomical characteristics of patients with recurrence. METHODS: Thirty-eight patients were selected. Patients had undergone abdominoplasty between 1 and 5 years previously. Patients were divided into two groups: group A, 18 patients who had undergone surgery 5 years previously; and group B, 20 patients who had undergone surgery 1 year before. All patients were submitted to a complete physical examination by the plastic surgeon to evaluate the abdominal wall. In addition, an ultrasound examination was performed by the same radiologist in all patients to evaluate rectus diastasis recurrence at two levels: in the supraumbilical region and in the infraumbilical region. The insertion of the recti muscles in the costal margin was also assessed. Groups were compared using Fisher's exact test and the t test. Groups were similar regarding age, body mass index, number of smokers, physical activity, and number of pregnancies. RESULTS: There was no recurrence of diastasis in any cases of the group with a follow-up of more than 5 years, whereas in the 1-year follow-up group there were two cases of recurrence of the diastasis. Only one of the patients who had recurrence of rectus diastasis had a clinical complaint. CONCLUSIONS: Recurrence of rectus diastasis is not directly related to the length of the follow-up. It may occur within the first year after abdominoplasty. Recurrence of diastasis diagnosed by ultrasound is not related to a clinical complaint. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Uso do retalho médio-frontal na reconstrução do nariz / Use of mid-forehead flap in nasal reconstruction

INTRODUÇÃO: Seiscentos anos antes de Cristo, foi descrito o retalho médio-frontal pelo indiano Sushruta Samhita. Até hoje, esse retalho, chamado ''retalho indiano", é usado na reconstrução do nariz. O objetivo deste trabalho foi analisar os resultados da 38ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro, Serviço do Professor Ivo Pitanguy, na reconstrução nasal com emprego de retalho médio-frontal. MÉTODO: Foi realizado estudo retrospectivo com 10 casos operados no serviço referido para reconstrução nasal com retalho indiano, no período de 21 anos (1991 a 2012). RESULTADOS: O número de subunidades nasais atingidas variou de 4 a 9, com média de 6,5 subunidades. Em 70% dos pacientes foi realizada expansão prévia do retalho médio-frontal e em 90% foram utilizados enxertos cartilaginosos e/ou ósseos. Cinco pacientes apresentaram distorções pós-operatórias, que foram corrigidas por outras cirurgias. Nenhum caso de infecção pós-operatória, de necrose do retalho ou de extrusão de enxertos foi registrado. CONCLUSÕES: Este trabalho permitiu demonstrar que o retalho médio-frontal tem ainda importante papel na reconstrução nasal de grandes defeitos, com resultados satisfatórios, atribuídos a sua segurança vascular, à quantidade de pele que se obtém, e à semelhança de cor, textura e espessura cutâneas.

BACKGROUND: Six hundred years before Christ, the mid-forehead flap was described by the Indian Sushruta Samhita. Until today, this flap called ''Indian flap", has a major role in the reconstruction of the nose. The aim of this work was to analyze the results of the 38th Infirmary of the Santa Casa da Misericórdia of Rio de Janeiro, Professor Ivo Pitanguy's Service, in nasal reconstruction with the mid-forehead flap. METHODS: We did a retrospective study of 10 cases operated in the service for nasal reconstruction with Indian flap, during a 21 year period (1991-2012). RESULTS: The number of nasal sub-units affected varied from 4 to 9, with an average of 6.5 subunits. In 70% of the patients, was performed a previous expansion of the mid-forehead flap and in 90% were used cartilage grafts and/or bones. Five patients had postoperative distortions, that were corrected with other surgeries. No cases of infection, necrosis of the flap or graft extrusion were recorded. CONCLUSIONS: This study allowed to demonstrate that the mid-forehead flap still have an important role in nasal reconstruction of major defects, showing satisfactory results due to its vascular safety, the amount of skin which is obtained, likeness of color, texture and skin thickness.

Protocolo de prevenção de tromboembolismo venoso no Instituto Ivo Pitanguy: eficácia e segurança em 1351 pacientes / Protocol for the prevention of venous thromboembolism at the Ivo Pitanguy Institute: efficacy and safety in 1351 patients

INTRODUÇÃO: Eventos tromboembólicos causam grande preocupação, em decorrência das altas taxas de morbidade e mortalidade existentes e da possibilidade de apresentação clínica com sintomas escassos e, muitas vezes, inespecíficos. A prevenção é a maneira mais eficaz de lidar com esse tipo de evento, que, uma vez estabelecido, pode levar rapidamente à morte. MÉTODO: Foi realizado estudo retrospectivo, no período entre maio de 2009 e maio de 2010, com pacientes submetidos a cirurgia plástica no Instituto Ivo Pitanguy. Todos os pacientes foram submetidos ao protocolo de prevenção de tromboembolismo venoso, após serem avaliados quanto aos fatores predisponentes e de risco. A soma desses fatores gerou uma pontuação, que determinou a profilaxia a ser adotada. RESULTADOS: Foram avaliados 1.351 pacientes durante o período de um ano. Não houve incidência de tromboembolismo venoso. Foram observados 16 casos de hematoma, 9 (56,25%) deles ocorreram após profilaxia com heparina e 7 (43,75%) sem o uso de quimioprofilaxia. CONCLUSÕES: O protocolo para prevenção de tromboembolismo venoso no Instituto Ivo Pitanguy foi eficaz, sem ocorrência de eventos tromboembólicos e com incidência de hematomas abaixo da encontrada na literatura médica.

INTRODUCTION: Thromboembolic events are a serious concern due to the high rates of morbidity and mortality as well as the possibility of existing disease presenting with scarce and often nonspecific symptoms. Prevention is the most effective management method for this kind of event, which can quickly lead to death once it occurs. METHODS: A retrospective study was conducted between May 2009 and May 2010 on patients undergoing plastic surgery at the Ivo Pitanguy Institute. All patients underwent the protocol for the prevention of venous thromboembolism after being assessed for risk factors. These factors were summed to generate a score, which determined the prophylaxis to be implemented. RESULTS: During one year, 1351 patients were assessed. There was no incidence of venous thromboembolism. There were 16 cases of hematoma, 9 (56.25%) of which occurred after heparin prophylaxis and 7 (43.75%) of which occurred without the use of prophylaxis. CONCLUSIONS: The protocol for the prevention of venous thromboembolism at the Ivo Pitanguy Institute was effective, with no occurrence of VTE cases and the incidence of hematomas remained below that found in the medical literature.

Avaliação do posicionamento do complexo aréolo-papilar na evolução pós-operatória da cirurgia de mamoplastia de aumento / Evaluation of nipple-areola complex position after breast augmentation surgery

Patients submitted to augmentation mammoplasty are often concerned about the possibility of sagging breasts. Although plastic surgeons usually respond that this is unlikely, this is not supported by the literature. This study aimed to precisely understand the changes in nipple aréola complex position after breast implantation, especially phenomena of "tendency to ptosis" and "bottoming out." Methods: Medicai and photographic records were selected from among patients operated on at the Ivo Pitanguy Institute - 38th Infirmary of the Santa Casa de Misericordia of Rio de Janeiro from January 2009 to December 2010 and analyzed, and a literature review was performed. Results: Among 20 breasts in 10 patients, bottoming out was observed in 9 breasts in 6 patients, including 5 moderate and 4 mild. There was tendency to ptosis in 9 breasts in 5 patients, including 3 mild and 6 moderate. Only one breast did not present changes in the nipple-areola complex. Conclusion: Bottoming out and tendency to ptosis occur frequently after breast augmentation and require further to ptosis occur frequently after breast augmentation and require further study...

A mastoplastia de aumento, muito comumente, gera na paciente indagações acerca da possibilidade de queda das mamas. A resposta do cirurgião plástico é geralmente afirmativa, porém, este não encontra respaldo na literatura. Neste trabalho, objetivamos justamente entender a variação de posição do complexo aréolo-papilar pós-inclusão de implantes mamários observando, principalmente, os fenômenos de "tendência à ptose" e "bottoming out". Métodos: Seleção de prontuários dentre as pacientes operadas no Instituto Ivo Pitanguy - Enfermaria 38 da Santa Casa de Misericórdia do Rio de Janeiro de jan/2009 a dez/201O, com base em critérios de inclusão e exclusão, utilizando-se para esta pesquisa de revisão dos prontuários, registro fotográfico e revisão da literatura. Resultados: Dentre as 20 mamas (10 pacientes) analisadas observamos "bottoming out" em nove mamas (seis pacientes), das quais cinco de graus moderados e quatro leves. Houve "tendência à ptose" em nove mamas (cinco pacientes) sendo três leves e seis moderadas. Conclusão: Os fenômenos bottomlng out" e tendência à ptose" são uma realidade que precisa ser amplamente estudada para melhor esclarecimento das pacientes...

Facial rejuvenation surgery: a retrospective study of 8788 cases.

BACKGROUND: Surgical rejuvenation of the aging face is common in aesthetic surgery, and many surgical techniques have been described for accomplishing it. The keys to consistent results are the surgeon's judgment and ability to individualize a treatment plan according to the patient's needs. To obtain natural-appearing results, the surgeon must consider the morphological characteristics of the aging face. OBJECTIVES: The authors describe their approach for "round" facelift technique and strategies for avoiding complications. METHODS: This retrospective study included 8788 consecutive patients who underwent facelift procedures in a single clinic between 1958 and 2010. All cases involved the round-lifting technique. RESULTS: Patients in this series ranged in age from 28 to 84 years. The percentage of male patients increased in later years (6.3% in 1970-1974 vs 18.6% in 1986-2010), and there was a trend toward increasing age after 1979 (17.7% of patients aged 60 years or older vs 8.3% before 1980). Submental liposuction was the most common facelift procedure performed (92.2% of patients, 1990-2010). Up to 97% of the cases treated after 1999 underwent repositioning of the malar fat pad. The overall complication rate was 4.5%, with the most frequent complications being hematoma (3%) and cutaneous slough or necrosis (1%). CONCLUSIONS: Repositioning the vector connecting the tragus with the Darwin tubercle provides more natural correction of aging tissues than do other techniques. The authors' intent was to keep the structures in their natural location, as they had been prior to aging. Superficial musculo-aponeurotic system (SMAS) plication, malar fat pad repositioning, and correct traction of facial tissues showed satisfactory results. This technique is less aggressive than undermining of the SMAS and deep-plane techniques. LEVEL OF EVIDENCE: 4.

Incisão transareolopapilar para mamoplastia de aumento: experiência dos últimos 10 anos do Instituto Ivo Pitanguy / Transareolopapilar incision for breast augmentation: 10-year experience at the Ivo Pitanguy Institute

INTRODUÇÃO: Várias vias de acesso foram criadas para a inclusão de implantes na cirurgia de aumento das mamas. Em 1966, Pitanguy descreveu a via de acesso transareolopapilar. O objetivo do presente estudo é avaliar as mamoplastias de aumento realizadas no Instituto Ivo Pitanguy (Rio de Janeiro, RJ, Brasil), nas quais se utilizou a incisão transareolopapilar, nos últimos 10 anos. MÉTODO: Realizado estudo retrospectivo, analisando-se os seguintes parâmetros: tamanho dos implantes, indicação da incisão transareolopapilar e complicações pós-operatórias, como alterações cicatriciais. RESULTADOS: Foram incluídas no estudo 53 pacientes, com média de idade de 33,54 anos e tempo médio de seguimento de 11,6 meses. A maioria (60,4 por cento) dos implantes possuía menos de 200 ml. Doze pacientes foram submetidas a reintervenções pelas seguintes razões: nódulo mamário (1 caso), infecção (1 caso), contratura capsular (1 caso), e insatisfação com a forma das mamas (4 casos), com o volume (4 casos) e com a cicatriz unilateral (1 caso). Dezesseis (30,2 por cento) pacientes desenvolveram alguma complicação menor no pós-operatório e 13 (24,5 por cento) apresentaram alguma alteração cicatricial no pós-operatório: hipocromia (18,9 por cento), hipertrofia unilateral (1,9 por cento), retração cicatricial unilateral (1,9 por cento), e aréola bífida (1,9 por cento). Vinte (37,7 por cento) pacientes realizaram seguimento pós-operatório superior a um ano e relataram satisfação com a cicatriz. CONCLUSÕES: A incisão transareolopapilar permite a inclusão de implantes de tamanho pequeno a moderado, com baixo índice de complicações pós-operatórias e cicatriciais, desde que seguida a correta técnica cirúrgica.

BACKGROUND: There are numerous access routes for inserting implants during breast augmentation surgery. In 1966, Pitanguy described the transareolopapilar route. The aim of this study was to assess the use of transareolopapilar incision during breast augmentation surgery at the Ivo Pitanguy Institute (Rio de Janeiro, RJ, Brazil), over the past 10 years. METHODS: Retrospective analyses of the size of the implants used, indications for transareolopapilar incision, postoperative complications, and postoperative scarring were performed. RESULTS: Fifty-three patients with a mean age of 33.54 years were included, and the mean follow-up period was 11.6 months. Most (60.4 percent) of the implants were <200 ml. Twelve patients required a second operation due to a breast lump (1 case); infection (1 case); capsular contracture (1 case); and dissatisfaction with breast shape (4 cases), volume (4 cases), and unilateral scarring (1 case). Sixteen (30.2 percent) patients developed some form of minor postoperative complication; 13 (24.5 percent) had one or more scarring issues, including hypochromia (18.9 percent), hypertrophy (1.9 percent), scar retraction (1.9 percent), and areola bifida (1.9 percent). Twenty (37.7 percent) patients underwent postoperative follow-up for more than one year and were satisfied with the postoperative scar. CONCLUSIONS: The transareolopapilar incision facilitates the insertion of small-to-moderate size implants with a low rate of postoperative complications and a low incidence of scarring, provided the correct surgical technique is used.

Minimal-scar handlift: a new surgical approach.

BACKGROUND: Removal of excess skin from the aging hand can cause scarring in one of the body's most visible areas, which is highly undesirable for patients. A minimal-scar approach to tightening this skin, in conjunction with the rejuvenating effects of minimally-invasive procedures, is therefore needed. OBJECTIVES: The authors describe a new technique for limiting scar size and visibility by locating the incision in a unique position on the ulnar side of the dorsum of the hand. METHODS: Eleven patients were treated with the authors' method between March and September 2009. Both hands were treated for each patient, but these procedures occurred separately, at an interval of two to four months. The surgical approach included skin flap advancement and rotation, and the procedure took place under local anesthesia and sedation. The resultant scar was S-shaped. Changes in postoperative stress ratio were visualized. RESULTS: Patients reported being highly satisfied with this procedure with regard to scar size, quality, and location. No major complications were observed, such as infection, flap necrosis, and nerve damage. All minor complications were treated conservatively. Patients with Fitzpatrick skin types I-III profited from less scar visibility in their outcomes. All patients experienced quick recovery with minimal downtime, independent of skin type. CONCLUSIONS: The minimal-scar handlift technique is an effective surgical approach to rejuvenating the hand and can be implemented concurrently with minimally-invasive techniques for volume restoration. The complication rate is low, and patient/surgeon satisfaction with outcomes is high.

Botulinum toxin dosage template for frontal wrinkle effacement.

BACKGROUND: There is no consensus in the literature about the ideal technique for precisely placing botulinum toxin in the frontal facial regions for the most natural posttreatment appearance. OBJECTIVES: The authors describe a safe and effective dosage template for botulinum toxin injection (a "dose disc," which makes it possible to estimate the approximate area to which the action of the toxin dose will reach, thereby guiding the positioning of the injection in a very practical way) for frontal wrinkle effacement, preserving residual movement whenever possible. METHODS: Fifty adult patients who presented to the authors' private clinic between January 2009 and May 2010 with aesthetic concerns about cutaneous expression wrinkles in the frontal region of their faces were selected for this study. Patients were sequentially divided into two groups: Group 1 included the first 15 patients, who underwent injections in the frontal region on the first visit and glabellar injections 15 days later; Group 2 included the subsequent 35 patients, who underwent frontal and glabellar treatment simultaneously. All pretreatment markings in both groups were made with the authors' "dose disc, which allows for overlap of the "halos" of effect. RESULTS: In the 50 patients included in the study, 317 injections were performed with the dose disc. Two treatment failures occurred (etiology unknown), and five patients presented with failure due to irregular technical positioning of the discs. The latter patients were treated at the beginning of the study and exhibited residual wrinkles. Only one case of complete toxin inactivity was observed. All patients with treatment failures underwent successful correction with additional injections. There was no evidence of palpebral ptosis, eyebrow ptosis, or any other serious diffusion or positioning side effects. CONCLUSIONS: A fixed dose disc template can be a useful tool for botulinum toxin injections in the frontal region of the face. Future studies assessing other disc models for different doses and different injection methods are needed, with the goal of establishing a longer duration of the effect and devising similar templates for other facial areas.

Inclusion of calf implants for the correction of lower limb amyotrophy / Inclusão de implantes de panturrilha na correção das amiotrofias dos membros inferiores

BACKGROUND: Lower limb amyotrophy is a serious deformity that is often disabling and causes esthetic problems such as asymmetries and changes in the shape and contour of the legs. The present study evaluated the use of silicone implants for the correction of lower limb amyotrophy. METHODS: Women who underwent surgical correction of lower limb amyotrophy with silicone implants between 2002 and 2009 at the Plastic Surgery Service of Instituto Ivo Pitanguy at the 38th Nursing Service of Santa Casa da Misericórdia, Rio de Janeiro and at their associated services were retrospectively reviewed. RESULTS: Five cases were studied and the results were retrospectively assessed. Follow-up ranged from 3 months to 2 years after surgery until the last postoperative visit. In 4 of 5 patients, the desired result was obtained after a single surgical procedure, and no patient developed capsular contracture, compartment syndrome, circulatory disorders, neurological disorders, or infections. CONCLUSIONS: Calf augmentation in patients with lower limb amyotrophy did not correct the associated functional deficit, but resulted in a high level of satisfaction with regard to the esthetic improvement of the limb, thus improving the quality of life of these patients.

INTRODUÇÃO: As amiotrofias dos membros inferiores são deformidades por vezes incapacitantes, mas que trazem aos pacientes problemas estéticos, como assimetrias e alterações da forma e contorno das pernas. Este estudo teve como objetivo avaliar a aplicabilidade do uso de implantes de silicone para correção de amiotrofias de membros inferiores. MÉTODO: Estudo retrospectivo de pacientes, todas do sexo feminino, submetidas a correção cirúrgica de amiotrofia de pernas com a utilização de implantes de silicone, entre 2002 e 2009, no Serviço de Cirurgia Plástica do Instituto Ivo Pitanguy, na 38ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro e em serviços associados. RESULTADOS: Foram analisados 5 casos. A maioria dos resultados foi avaliada de maneira retrospectiva. O tempo de acompanhamento variou de 3 meses a 2 anos, desde a cirurgia até a última consulta pós-operatória. Do total de pacientes, 4 apresentaram resultado desejado em apenas um procedimento cirúrgico e nenhuma paciente apresentou contratura capsular, síndrome compartimental, alterações circulatórias, alterações neurológicas ou infecção. CONCLUSÕES: O aumento das panturrilhas em pacientes portadoras de amiotrofias de membros inferiores não proporcionou modificações no tocante ao deficit funcional prévio. Todavia, essas pacientes, geralmente bastante castigadas pela doença de base, apresentam índice de satisfação muito elevado com a melhoria estética do membro, otimizando, dessa forma, a qualidade de vida dessas pacientes.

Mycobacteriosis in patients with breast implants: a case review from the Ivo Pitanguy Institute / Micobacteriose em implantes mamários: revisão da casuística do Instituto Ivo Pitanguy

INTRODUCTION: Reports of infections caused by rapidly growing mycobacteria during plastic surgery have increased in recent years despite improvements in techniques of asepsis/antisepsis and antibiotic prophylaxis. Infections occurring after the insertion of breast implants are a cause of patient morbidity and a significant problem for the surgeon. METHODS: Breast implant surgery cases complicated by mycobacterial infections at the Infirmary ward 38th of the Santa Casa da Misericórdia, Rio de Janeiro were retrospectively reviewed. A description of the current guidelines for the prevention and treatment of mycobacteriosis is included. Laboratory confirmed and clinically suspected cases were included in this study. RESULTS: Of 483 augmentation mammaplasty cases, 3 patients developed mycobacterial infections in the last 3 years. In 2 patients, there was a suspicion of infection that was not confirmed by laboratory data. CONCLUSIONS: Prophylaxis is fundamental for reducing the incidence of mycobacteriosis during plastic surgery procedures. However, the identification, diagnosis, and treatment of mycobacterial diseases are important to minimize the morbidity of this type of infection.

INTRODUÇÃO: Nos últimos anos, foram crescentes os registros de infecções por micobactéria de crescimento rápido em cirurgia plástica, mesmo com a melhoria dos métodos de assepsia/ antissepsia e da antibioticoprofilaxia. A infecção após inclusão de implantes mamários causa grande morbidade às pacientes e transtorno ao cirurgião. MÉTODO: Estudo retrospectivo dos casos de infecção por micobactéria de crescimento rápido da 38ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro, após inclusão de implantes mamários, em que são apresentadas propostas de prevenção e tratamento da micobacteriose. Foram incluídos os casos confirmados laboratorialmente e os clinicamente suspeitos. RESULTADOS: Até o presente momento foram confirmados 3 casos de infecção por micobactéria, num total de 483 mamaplastia de aumento no decorrer de 3 anos. Em 2 pacientes, houve suspeita de infecção, porém sem confirmação laboratorial. CONCLUSÕES: A profilaxia é o pilar fundamental para a redução do impacto da micobacteriose em procedimentos de cirurgia plástica. Entretanto, saber identificar, diagnosticar e tratar corretamente a micobacteriose é de suma importância para minimizar a morbidade da paciente.

Assessment of vertical scar migration after classical abdominoplasty followed by lower abdominal flap fixation / Avaliação da migração vertical da cicatriz pós-abdominoplastia clássica com fixação do retalho abdominal inferior

BACKGROUND: In plastic surgery, the postoperative scar is a frequent concern. It is very important for the surgeon to understand the natural evolution of the scar. The abdominoplasty scar has a natural tendency to move upwards over time. In this study, the extent of natural vertical scar migration after abdominoplasty was calculated and the effect of fixing the lower abdominal flap to prevent this rise was assessed. METHODS: This prospective and randomized study was conducted at the 38th Nursing service of Santa Casa de Misericórdia do Rio de Janeiro, during 2010, and included 20 female patients with an indication for abdominoplasty. The patients were randomly divided into two groups, A and B. Classical abdominoplasty was performed in group A patients, according to the technique recommended by Prof. Ivo Pitanguy. Patients in group B also underwent lower abdominal flap fixation by suturing of Scarpa's fascia and the rectus abdominis muscle aponeurosis. At both two weeks and six months after surgery, the distance of vertical scar movement was measured in 16 patients after application of exclusion criteria. The average vertical migration and the mean difference between the groups were calculated. RESULTS: The average difference between the groups in vertical migration throughout the scar was 0.4 cm, with a mean overall migration of 1.06 cm and 0.68 cm in groups A (control group) and B (cases with fixation), respectively. CONCLUSIONS: The scar formed after abdominoplasty undergoes vertical migration over time; this migration is decreased when the lower abdominal flap is fixed. The surgeon should be aware of scar migration for better planning of the incision location.

INTRODUÇÃO: Na cirurgia plástica, uma constante preocupação é a cicatriz pós-operatória. É muito importante para o cirurgião conhecer a evolução natural da cicatriz. A cicatriz de abdominoplastia tem a tendência natural de subir com o passar do tempo. Neste estudo, calculou-se a migração vertical natural da cicatriz pós-abdominoplastia, avaliando o efeito da fixação do retalho abdominal inferior na prevenção dessa ascensão. MÉTODO: Estudo prospectivo e randomizado, realizado na 38ª Enfermaria da Santa Casa de Misericórdia do Rio de Janeiro durante o ano de 2010, incluindo 20 pacientes do sexo feminino com indicação de abdominoplastia, divididas em dois grupos, A e B, aleatoriamente. Nas pacientes do grupo A, foi realizada abdominoplastia clássica, segundo técnica preconizada pelo Prof. Ivo Pitanguy, e no grupo B foi incluída a fixação do retalho abdominal inferior por meio de sutura interessando a fáscia de Scarpa e a aponeurose do músculo reto abdominal. Duas semanas e seis meses após a cirurgia, foi medida a distância vertical em 16 pacientes, após aplicação dos critérios de exclusão, calculando-se a média de migração vertical e a diferença média entre os dois grupos. RESULTADOS: A diferença média de migração vertical ao longo de toda a cicatriz foi de 0,4 cm, sendo a média geral de migração nos grupo A (controle) e B (casos com fixação) de 1,06 cm e 0,68 cm, respectivamente. CONCLUSÕES: A cicatriz pós-abdominoplastia sofre migração vertical ao longo do tempo, sendo menor quando o retalho inferior é fixado. O cirurgião deve estar ciente da migração sofrida pela cicatriz para melhor planejamento da posição de sua incisão.

Island technique for prominent ears: an update of the Ivo Pitanguy clinic experience.

BACKGROUND: Prominent ears are a relatively common and instantly-recognizable condition. Numerous studies have reported psychological distress, emotional trauma, and behavioral problems associated with this deformity in childhood. The multitude of approaches clearly indicates the lack of a definitive technique to correct this issue in all patients. OBJECTIVES: The authors describe the "island technique," originated by the senior author (IP), which involves dissecting a cartilaginous island to reconstruct the antihelix and the triangular fossa and correct the conchascaphal angle. METHODS: The authors retrospectively reviewed the charts of all patients (n = 111) who underwent otoplasty with the island technique at the senior author's private clinic between July 1990 and July 2008. Patients who underwent treatment with a modified island technique or any other approach were excluded. Charts were examined for patient history and demographics, etiology, concurrent procedures, and complications. RESULTS: Eighty patients were female (72%); 31 were male (28%). The average age was 28.2 years (range, five to 65). The most common etiology was a combination of overdeveloped concha and an underdeveloped antihelical fold (n = 76, 69%). Other facial aesthetic procedures were simultaneously performed in 54 patients (49%). Early complications occurred in two patients (1.8%), including hematoma and wound dehiscence. Late complications were observed in 12 patients (10.8%). All complications were addressed without consequence to the surgical outcome. No recurrence was observed. CONCLUSIONS: The island technique is an effective, simple, and reliable surgical option to correct prominent ears. Its greatest advantages are the absence of recurrence and the minimal incidence of complications.

Mutirões de cirurgia plástica do Instituto Ivo Pitanguy: Fernando de Noronha / Plastic surgery task force of Ivo Pitanguy Institute: Fernando de Noronha

Fernando de Noronha é um arquipélago formado por 21 ilhas, ocupando uma área de 26 km2. Na área da Saúde, o arquipélago possui o Hospital São Lucas, um Posto de Saúde vinculado ao Programa de Saúde da Família e um SAMU. A I Semana da Cirurgia Plástica do Instituto Ivo Pitanguy em Fernando de Noronha representou a expansão do trabalho feito na 38ª Enfermaria da Santa Casa da Misericórdia para lugares carentes da especialidade. A II Semana foi a continuidade natural deste projeto. O objetivo foi oferecer à população atendimento em cirurgia plástica com consultas, cirurgias e palestra, com o foco na prevenção, diagnóstico e tratamento do câncer de pele, visto que a população local apresenta grande risco para esta doença. A equipe da primeira Missão contou com a participação de dois instrutores e seis residentes do Instituto Ivo Pitanguy, além de uma dermatologista convidada. Já na segunda Missão, houve a participação de um instrutor do Hospital Oswaldo Cruz (SUS-PE). Todos os casos foram documentados e fotografados. Somando-se a primeira e a segunda Missão, foram realizados 280 atendimentos, sendo 93 consultas sem indicação de tratamento cirúrgico e 187 pacientes operados. Do ponto de vista de Saúde Pública, a I e a II Semana da Cirurgia Plástica do Instituto Ivo Pitanguy representaram uma economia significativa para o Estado de Pernambuco. Além disso, este projeto trouxe uma inestimável experiência de vida a todos aqueles que formaram estas equipes. A possibilidade de ajudar à população com as nossas habilidades e conhecimentos só nos orgulha e enaltece ainda mais a tradição de nossa escola.

Fernando de Noronha is an archipelago formed by 21 islands and has an area of 26 square km2. The main island contains the public hospital São Lucas, a Health Care Center and a SAMU (Mobile Emergency Care Service). The I Week of Plastic Surgery of the Ivo Pitanguy Institute expanded the work performed at the 38th Infirmary of the Holy House of Rio de Janeiro to areas with lack of Plastic Surgery Services. The second mission was the natural continuation of the project. The objective of the project was to offer specialized care in Plastic Surgery with consultation, surgeries, and an educative class, focused in the prevention, diagnostic and treatment of skin cancer to the population, due to its susceptibility to the disease. The first team had two instructors, six residents of the Ivo Pitanguy Institute and a dermatologist. The second mission had an instructor from other service (Oswaldo Cruz Hospital), from the State of Pernambuco. All cases were logged and photographed. The two missions performed 280 consultations, being 93 without the need of surgery and 187 surgeries. The Missions enabled a significant economy to the State of Pernambuco. Beyond it, the missions brought a great life experience for those who performed then. The possibility to help people with our skills and knowledge make us very proud and ennoble the tradition of our school.

Tratamento cirúrgico do nevo melanocítico gigante / Surgical treatment of giant melanocytic nevi

O nevo melanocítico congênito está presente em aproximadamente 1% dos recém nascidos. As lesões classificadas como pequenas e médias são relativamente comuns, e possuem risco de degeneração maligna baixo. Por outro lado, as lesões chamadas de gigantes são raras e possuem maior risco de malignização. Neste trabalho é relatada a experiência do autor, no tratamento cirúrgico dos nevos melanocíticos gigantes.

Congenital melanocytic nevi are present in approximately 1% of newborns. The lesions classified as small and medium are relatively common, and have low risk of malignant degeneration, however, lesions called giants are rare and have a higher risk of malignancy. This work describes the author’s experience in the surgical treatment of giant pigmented nevi.