Abordaje medial modificado para dislocación codo crónico: un abordaje quirúrgico novedoso con buen resultado funcional / Modified medial approach for chronic elbow dislocation: a novel surgical approach with good functional outcome

Background : Chronic elbow dislocation is defined as untreated elbow dislocation for longer than 2 weeks. Goal of treatment is stable reduction of elbow joint and facilitation of early elbow motion for optimal end result. Known operative methods is the Kocher posterolateral approach.which can accumulate hematome, and longer time needed to identify Ulnar nerve. Therefore, we would like to introduce the new modified medial elbow joint incision approach. Methodology: This study utilized a cross-sectional review of patients with surgical treatment of simple chronic elbow dislocation. Questionnaires were taken using Oxford Elbow Score, Mayo Elbow Performance Index, and Disability of Arm, Shoulder, and Hand Questionnaire to assess current elbow status Result : Utilizing Oxford elbow score, the analytic group score value ranged from 21-46, while control group's score value were 37-42 (P-value <0.0001). Mayo Elbow Performance Index score, from the analytic group, scored ranges from 45 - 82. the control group, a mean value of 85 were scored (P-value <0.0001), the DASH score revealed total mean value of 8.3 in the analytic group, compared to score 6 in the control group (P-value = 0.0468 ). The range of motion is increased in total flexion and extension from both groups(P-value <0.0001) Conclusion: Modified medial elbow approach provides faster method of identifying ulnar nerve, requires less skin flap for closure and less space for blood accumulation. Modified medial elbow approach provides good functional outcome with no complications related to ulnar nerve reported in this study.

Sistematização perioperatória para prevenção de hematomas em face-lifts: abordagem pessoal após 1. 138 casos operados / Perioperative systematization for the prevention of hematomas following face-lift procedures: a personal approach based on 1, 138 surgical cases

Introdução: O hematoma, complicação mais frequente do face-lift, pode exigir reabordagem cirúrgica e atrasar a recuperação do paciente. Na literatura, sua incidência varia entre 0,2 e 8%, sendo fundamentais novos estudos para padronização das medidas de prevenção. O objetivo é apresentar uma proposta de sistematização perioperatória que previna eficientemente a formação de hematomas em ritidoplastias. Métodos: Foram analisados 594 prontuários de pacientes operados pelo autor entre os anos de 2011 a 2018 a fim de se comparar as incidências de hematomas anteriores e posteriores à sistematização implementada no ano de 2015. Resultados: De julho de 2011 a dezembro de 2014, antes da adoção da sistematização, houve uma incidência de hematomas de 3,43% em 233 casos. Após sua adoção, houve uma queda para 1,66% em 361 casos realizados. Os últimos 177 casos consecutivos não apresentaram a complicação. Conclusão: Observamos redução expressiva da incidência de hematomas pós-ritidoplastias após o uso da padronização proposta. Nenhuma das medidas adotadas seria eficiente isoladamente, sendo o conjunto essencial na prevenção desta grave complicação.

Introduction: Hematoma, the most frequent complication of face-lift procedures, may require a second surgical approach, which delays patient recovery. In the literature, its incidence ranges from 0.2% to 8%, and further studies are essential to standardize preventive measures. The objective is to present a proposal of perioperative systematization for effectively prevention of hematoma formation after rhytidectomies. Methods: We analyzed the medical records of 594 patients who underwent operation by the author between 2011 and 2018 to compare the incidence of hematomas before and after the systematization implemented in 2015. Results: From July 2011 to December 2014, before the adoption of the systematization, the incidence of hematomas was 3.43% in 233 cases. After its adoption, the incidence decreased to 1.66% in 361 cases. The last 177 consecutive cases did not have this complication. Conclusion: We observed a significant reduction in the incidence of hematomas following rhytidectomy after the use of the proposed standardization. None of the measures would be effective alone; thus, their combined adoption is essential in preventing this serious complication.

Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: meta-analysis / Efetividade da associação da anestesia regional à anestesia geral na redução da mortalidade em revascularização miocárdica: metanálise

ABSTRACT BACKGROUND AND OBJECTIVES: Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta-analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction. METHODS: Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables. RESULTS: 17 original articles analyzed. Meta-analysis of mortality (RD = -0.01, 95% CI = -0.03 to 0.01), CVA (RR = 0.79, 95% CI = 0.32-1.95), MI (RR = 0.96, 95% CI = 0.52-1.79) and LHS (MD = -1.94, 95% CI = -3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR = 0.68, 95% CI = 0.50-0.93). ICUS was lower in NA (MD = -2.09, 95% CI = -2.92 to -1.26). CONCLUSION: There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.

RESUMO INTRODUÇÃO E OBJETIVOS: A anestesia neuroaxial (AN) vem sendo utilizada em associação com a anestesia geral (AG) para revascularização miocárdica, entretanto a anticoagulação durante a cirurgia torna questionável a viabilidade dos benefícios mediante o risco de hematoma de espaço peridural. O objetivo deste estudo foi executar metanálises analisando a efetividade da AN associada à AG comparada à AG isolada para a cirurgia de revascularização miocárdica relativa à redução da mortalidade. MÉTODOS: Foram analisados mortalidade, arritmias, acidente vascular cerebral (AVC), infarto miocárdico (IM), tempo de internação hospitalar (TIH), tempo de internação em unidade de terapia intensiva (TUTI), reoperações, transfusão sanguínea (TS), qualidade de vida, grau de satisfação e disfunção cognitiva pós-opertória. A diferença média (DM) ponderada foi estimada para as variáveis contínuas e risco relativo (RR) e a diferença de risco (DR) para variáveis categóricas. RESULTADOS: Analisados 17 artigos originais. Metanálise da mortalidade (DR = -0,01; IC 95% = -0,03 a 0,01), AVC (RR = 0,79; IC 95% = 0,32 a 1,95), IM (RR = 0,96; IC 95% = 0,52 a 1,79) e TIH (DM = -1,94; IC 95% = -3,99 a 0,12) não demonstraram significância estatística. Arritmia foi menos frequente com AN (RR = 0,68; IC 95% = 0,50 a 0,93). O TUTI foi menor no com AN (DM = -2,09; IC 95% = -2,92 a -1,26). CONCLUSÃO: Não se observaram diferenças estatisticamente significantes quanto a mortalidade. A combinação de AN e AG mostrou menor incidência de arritmias e menor TUTI.

Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: meta-analysis.

BACKGROUND AND OBJECTIVES: Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta-analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction. METHODS: Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables. RESULTS: 17 original articles analyzed. Meta-analysis of mortality (RD=-0.01, 95% CI=-0.03 to 0.01), CVA (RR=0.79, 95% CI=0.32-1.95), MI (RR=0.96, 95% CI=0.52-1.79) and LHS (MD=-1.94, 95% CI=-3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR=0.68, 95% CI=0.50-0.93). ICUS was lower in NA (MD=-2.09, 95% CI=-2.92 to -1.26). CONCLUSION: There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.

[Safety of reducing the recovery time after percutaneous and laparoscopic liver biopsy]. / Seguridad de la reducción del tiempo de reposo posbiopsia hepática percutánea y por vía laparoscópica.

BACKGROUND: Liver biopsy is the main diagnostic tool for the study of the liver, and as such, its inherent complications have been minimised as much as possible over the years, through the modification of several factors regarding its procedure, including post-biopsy recovery time. The aim of this study was to evaluate the safety in the reduction of post-liver biopsy recovery time. MATERIAL AND METHODS: A non-blinded, randomised clinical trial was conducted in the "Hermanos Ameijeiras" Hospital from November 2011 to October 2012, on 128 patients in order to assess safety when reducing post-biopsy recovery times. The patients were randomised into 2 groups. Group A was allowed a 6-hour recovery time, while Group B was allowed a 2-hour recovery time after liver biopsy. Complications were fully recorded. The Chi squared test of homogeneity and Student t test was used as appropriate, in the statistical analysis, a significance level of 0.05 was set. RESULTS: The main biopsy indication was elevated plasma transaminases. Pain in the puncture site was the most recurrent complication (67.2%), and the most serious complication was subcapsular liver haematoma in two cases (1.6%). There were no differences regarding the liver biopsy technique that could have caused complications in any group. CONCLUSIONS: There were no significant differences between 2 hours and 6 hours post-liver biopsy recovery time in terms of complications, so it is considered that after two hours the patient is incorporated more quickly into their activities, and the institution spends less material and human resources.

Venous thromboembolism prophylaxis in the massive weight loss patient: relative risk of bleeding.

BACKGROUND: Measures that can reduce the incidence of venous thromboembolism (VTE) are of great clinical importance. In addition to the use of sequential compression devices (SCDs), chemoprophylaxis with low-molecular-weight heparin (LMWH) has been recommended by the American College of Chest Physicians for major general surgery procedures. There remains inconclusive evidence to support guidelines for the plastic surgery population, and some surgeons hesitate to use anticoagulation due to concerns about bleeding in broad planes of dissection. The purpose of this study was to evaluate the risk of postoperative complications secondary to chemical thromboprophylaxis in massive weight loss patients. METHODS: Five hundred forty-six surgical cases were enrolled in an institutional review board-approved prospective clinical database in the 2 years before and after routine LMWH use was initiated. Inclusion required weight loss of greater than 50 lb. Group 1 had SCDs only (n = 334), whereas group 2 had SCDs and LMWH 6 hours postoperatively (n = 212). Risk of VTE was calculated and complications of LMWH administration were analyzed. RESULTS: The overall risk of deep venous thrombosis and pulmonary embolism was 0.18%. There was no statistical difference between the groups (P > 0.05). Overall risk of hematoma was 5.4%, in concordance with the literature. There was no difference in hematoma risk between the groups (4.6% before and 6.6% after LMWH; P = 0.3). The transfusion rate was 8.5% before use of LMWH (group 1) and 7.6% after (group 2; P = 0.7). CONCLUSIONS: Strategies to reduce VTE rates remain important in all areas of plastic surgery. We have demonstrated no increased risk of transfusion or hematoma and a low overall incidence of VTE after implementing a chemoprophylaxis regimen. Postoperative LMWH can provide an excellent balance between VTE prophylaxis and the risk of bleeding complications.

Atenolol prevents the formation of expansive hematoma after rhytidoplasty.

OBJECTIVE: To evaluate the perioperative use of atenolol in reducing the incidence of hematoma after rhytidoplasty. METHODS: Between January 2007 and February 2013, 80 patients were randomized into two groups: Group A (n = 26) received perioperative atenolol in order to maintain heart rate (PR) around 60 per minute; Group B (n = 54) did not receive atenolol. Both groups underwent the same anesthetic and surgical technique. We monitored blood pressure (BP), HR, hematoma formation and the need for drainage. Patients were followed-up until the 90th postoperative day. The variables were compared between the groups using the ANOVA test. Continuous variables were presented as mean ± standard deviation and the differences were compared with the Student's t test. Values of p d" 0.05 were considered significant. RESULTS: In group A the mean BP (110-70 mm Hg ± 7.07) and HR (64 / min ± 5) were lower (p d" 0.05) than in group B (135-90 mm Hg ± 10.6) and (76 / min ± 7.5), respectively. There were four cases of expansive hematoma in group B, all requiring reoperation for drainage, and none in group A (p d" 0,001). CONCLUSION: The perioperative use of atenolol caused a decrease in blood pressure and heart rate and decreased the incidence of expanding hematoma after rhytidectomy.

Atenolol prevents the formation of expansive hematoma after rhytidoplasty / O atenolol previne a formação de hematoma expansivo após ritidoplastia

Objective: To evaluate the perioperative use of atenolol in reducing the incidence of hematoma after rhytidoplasty. Methods: Between January 2007 and February 2013, 80 patients were randomized into two groups: Group A (n = 26) received perioperative atenolol in order to maintain heart rate (PR) around 60 per minute; Group B (n = 54) did not receive atenolol. Both groups underwent the same anesthetic and surgical technique. We monitored blood pressure (BP), HR, hematoma formation and the need for drainage. Patients were followed-up until the 90th postoperative day. The variables were compared between the groups using the ANOVA test. Continuous variables were presented as mean ± standard deviation and the differences were compared with the Student's t test. Values of p d" 0.05 were considered significant. Results: In group A the mean BP (110-70mmHg ± 7.07) and HR (64 / min ± 5) were lower (p d" 0.05) than in group B (135-90mmHg ± 10.6) and (76 / min ± 7.5), respectively. There were four cases of expansive hematoma in group B, all requiring reoperation for drainage, and none in group A (p d" 0,001). Conclusion: The perioperative use of atenolol caused a decrease in blood pressure and heart rate and decreased the incidence of expanding hematoma after rhytidectomy. .

Objetivo: avaliar o uso perioperatório do atenolol na redução da incidência de hematoma pós-ritidoplastia. Métodos: entre janeiro de 2007 e fevereiro de 2013 foram randomizados 80 pacientes em dois grupos: Grupo A (n=26) recebeu atenolol perioperatório com objetivo de manter frequência de pulso (FP) ± 60 por minuto, Grupo B (n=54) não recebeu atenolol. Ambos os grupos foram submetidos à mesma técnica anestésico-cirúrgica. A pressão arterial (PA) e FP, formação de hematoma e a necessidade de drenagem foram monitorizados. Houve seguimento até o 90º dia de pós-operatório. As variáveis foram analisadas entre os dois grupos utilizando-se o teste de ANOVA. As variáveis contínuas foram apresentadas como média (± Desvio-padrão) e as diferenças foram comparadas utilizando-se o t de Student. Foram considerados significantes os valores p<0,05. Resultados: as médias no grupo A de PA (110-70mmHg ± 7,07) e FP (64 /min ± 5) foram menores (p<0,05) em relação ao grupo B (135-90mmHg ± 10,6) e (76/min ± 7,5), respectivamente. Houve quatro casos de hematoma expansivo no grupo B, todos com necessidade de reoperação para a sua drenagem e nenhum no grupo A (p<0,001). Conclusão: o uso do atenolol perioperatório promoveu a redução de pressão arterial e frequência de pulso e diminuiu a incidência de hematoma expansivo pós-ritidoplastia. .

Ritidoplastia videoassistida do terço inferior da face: corset videoendoscópico / Endoscopically assisted rhytidoplasty of the lower third of the face: the videoendoscopic corset

INTRODUÇÃO: Após um período em que a controvérsia em cirurgias faciais teve como foco a abordagem ao SMAS, atualmente se persegue a melhora do contorno cervical. Descolamentos maiores, como os praticados pelo acesso submentoniano, podem aprimorar os resultados, entretanto acarretam aumento das complicações, sobretudo de hematomas, desencorajando seu emprego. No intuito de minimizar estes riscos, propõe-se o uso adjuvante do videoendoscópio durante a realização de cervicoplastias, segundo a Técnica de Feldman. As adaptações necessárias para a realização do procedimento são detalhadas. MÉTODO: Estudo retrospectivo de 16 pacientes submetidos a procedimento cirúrgico nos últimos 12 meses, sequencialmente, de acordo com a técnica apresentada. Os resultados foram graduados pelo autor principal (RR) e por três cirurgiões plásticos independentes (EC, RN, AM), sem que estes conhecessem detalhes da técnica empregada. Os fotogramas pré e pós-operatórios de seis meses foram avaliados e pontuados conforme os parâmetros definidos por Ellenbogen & Karlin, gerando notas 'de 0 a 10', que foram aplicadas à Grade de Labbé. RESULTADOS: A média geral do grupo foi 8,29, escore ótimo, segundo a Escala de Labbé. Em dez casos (62,5%), atingiu-se resultado ótimo (8-10 pontos); cinco casos (31,25%), bom (6-7 pontos), e apenas um caso (6,25%), escore abaixo de 6 pontos, classificado como mediano. Não houve ocorrência de hematomas, aderências cutâneas ou recidiva das bandas platismais. CONCLUSÃO: A técnica apresentada parece propiciar resultados adequados, sem aumento das complicações. Adicionalmente, possibilita uma cicatriz submentoniana de menor extensão, além da visualização magnificada e direta de todas as estruturas abordadas, por todos os membros da equipe.

INTRODUCTION: In contemporary facial surgery, the focus of controversy has shifted from superficial muscular aponeurotic system approaches, to methods by which to improve the neck contour. Larger detachments, such as those resulting from the use of submental access, can provide better outcomes. However, the associated potential for increased complication rates, particularly hematomas, discourages the practice of such detachments. In order to minimize these risks, we propose the use of videoendoscopic assistance during cervicoplasty procedures, such as Feldman's method. The adjustments required to carry out this procedure are described in this study. METHOD: This retrospective study included 16 patients, who were sequentially submitted to a surgical procedure in the preceding 12 months, using the technique described above. The results were scored by the main author (RR) and 3 independent plastics surgeons (EC, RN, AM), who were unaware of the details of the technique used. Preoperative and 6-month postoperative photographs were evaluated and scored according to the parameters defined by Ellenbogen and Karlin, with values ranging from 0-10 subsequently applied to the grading system of Labbé. RESULTS: The group average postoperative score was 8.29, the optimal grade according to the scale of Labbé. An optimal outcome (8-10 points) was reached in 10 cases (62.5%); a good outcome (6-7 points) was reached in 5 cases (31.25%); a score below 6, rated as average, occurred in only one case (6.25%). There was no occurrence of hematomas, skin adhesions or recurrent platysmal bands. CONCLUSION: The proposed technique appears to provide satisfactory results without increasing the rate of complications. Moreover, use of the technique was associated with less extended submental scar, in addition to improving the direct view of the structures manipulated for all members of the surgical team.

Assessment of the outcomes associated with periprocedural anticoagulation management in children with acute lymphoblastic leukemia.

OBJECTIVE: To report the outcomes of an institutional protocol for periprocedural anticoagulant (AC) management in children with acute lymphoblastic leukemia (ALL). STUDY DESIGN: Children being treated for ALL who received full-dose (therapeutic) anticoagulation before undergoing at least 1 lumbar puncture (LP) were included in this retrospective cohort study. The main outcome was the risk of traumatic LP; exploratory analysis included the risks of symptomatic spinal hematoma and progression/recurrence of the thrombotic event. Analyses were conducted using logistic regression analysis with a generalized estimating equation approach. RESULTS: Twenty-two children with ALL receiving an AC underwent a total of 396 LPs. Although traumatic LP was associated with full-dose AC therapy in univariable analysis, a multiple logistic regression model controlling for other risk factors for traumatic LP showed that AC therapy was not significantly associated with the risk of traumatic LP when the ACs were held as per the institutional protocol. No patient developed symptomatic spinal hematoma. Exploratory analysis revealed that AC dose, a likely marker of thrombus burden, was significantly associated with progression/recurrence of the thrombotic event in univariable analysis. CONCLUSION: In our cohort, recent AC therapy was not statistically associated with an increased risk of bleeding after LP when following a specific protocol for periprocedural AC management. The risk associated with the progression/recurrence of thromboembolic events requires further evaluation.

Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients.

BACKGROUND: Hematoma is the most common postoperative complication of rhytidoplasty, resulting in higher morbidity and longer recovery. Quilting suture for closure of the undermined area in abdominoplasty avoids the occurrence of seroma. Based on this principle and with the objective of reducing the number of patients with hematomas in rhytidoplasty, a similar surgical tactic was developed in which a hemostatic net is created with a running transfixing suture of 5-0 nylon encompassing the skin and the superficial musculoaponeurotic system-platysma. METHODS: The study enrolled 525 consecutive patients who underwent rhytidoplasty between July 2009 and February 2013. The first 120 patients (group A) were evaluated retrospectively and considered control subjects. The remaining 405 patients (group B) had application of the described tactic, with data collected prospectively. The occurrence of hematoma, ischemia, and necrosis was observed during the first 72 h after surgery. RESULTS: Control group A included 17 patients with hematoma (14.2 %) during the first 72 h, whereas no patient in group B experienced such a complication (p < 0.001). The surgical tactic did not significantly increase the occurrence of ischemia. This complication was experienced by 11 patients in group A (9.2 %) and 26 patients in group B (6.4 %) (p = 0.408). The tactic also did not change the incidence of necrosis, which was present in three group A patients (2.5 %) and six group B patients (1.5 %) (p = 0.723). CONCLUSION: The hemostatic net is an efficient and safe method for preventing early hematomas in rhytidoplasties. LEVEL OF EVIDENCE III 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 .

Pontos de adesão nas ritidoplastias: estudo comparativo / Adhesion stitches in rhytidoplasty: a comparative study

INTRODUÇÃO: Os hematomas constituem uma das complicações mais frequentes no pós-operatório imediato de ritidoplastias. O objetivo deste estudo é avaliar a eficácia do emprego de pontos de adesão na prevenção de hematomas em ritidoplastias. MÉTODO: Foram avaliados, retrospectivamente, 2 grupos constituídos por 88 pacientes submetidos a ritidoplastia. Os pacientes do grupo 1 não receberam pontos de adesão, que foram aplicados em todos os pacientes do grupo 2. RESULTADOS: No grupo 1, foram observados 5 (5,7%) hematomas extensos, que foram tratados cirurgicamente, e 12 (13,6%) hematomas de pequeno porte, solucionados com punção local. No grupo 2, não foi verificado nenhum hematoma que necessitasse limpeza cirúrgica. Foram observados 5 (5,68%) casos com pequenas coleções hemáticas, solucionados com punção local, e 4 (4,54%) seromas. CONCLUSÕES: Durante ritidoplastias, a aplicação de 12 a 15 pontos de adesão nas áreas dissecadas, bilateralmente, proporcionou melhor recuperação no período pós-operatório, com ausência de hematomas que exigissem limpeza cirúrgica.

BACKGROUND: Hematomas are one of the most frequent complications in the immediate postoperative period following rhytidoplasty. In the present study, we aimed to assess the efficacy of using adhesion stitches to prevent the development of hematomas following rhytidoplasty. METHODS: We performed a retrospective assessment of 2 groups of 88 patients who underwent rhytidoplasty. Adhesion stitches were applied to all patients in group 2, but not to those in group 1. RESULTS: Five patients (5.7%) in group 1 developed massive hematomas that were treated surgically and 12 patients (13.6%) developed small hematomas that were resolved by local puncture. The patients in group 2 did not develop any hematoma that required surgical evacuation. Five patients (5.68%) developed small hematomas that were resolved by local puncture and 4 patients (4.54%) developed seromas. CONCLUSIONS: During rhytidoplasty, the bilateral application of 12-15 adhesion stitches in the dissected areas prevented the development of hematomas that required surgical evacuation, thus improving postoperative recovery.

Complications in blepharoplasty: how to avoid and manage them.

UNLABELLED: Complications in blepharoplasty are uncommon and, when they occur, they are usually mild and transient, such as hematomas and chemosis. However, sometimes they can be severe, such as blindness, or they might require surgical correction, such as ectropion. OBJECTIVE: To evaluate the results and complications of transcutaneous blepharoplasty performed in the same procedure, discussing how to treat and how to avoid them. METHODS: A retrospective study of 200 medical records of consecutive patients that underwent transcutaneous blepharoplasty from January 2007 to January 2009. The variables analyzed were age, gender, complications, clinical outcome, patient satisfaction, and photographic documentation. RESULTS: The incidence of complications was 9.5% (19 patients). The complications were 1 hematoma, 12 cases of chemosis and 13 patients who underwent canthoplasty, 6 patients with malposition of the lower eyelid (5 retractions and 1 ectropion). Medical treatment was performed in 12 patients and revision surgery in 7 cases of all the patients who had complications. CONCLUSIONS: We demonstrated that blepharoplasty is a procedure with a high satisfaction and a low complication rate, and it is an excellent surgical procedure, when properly indicated.

Complications in blepharoplasty: how to avoid and manage them / Complicações em blefaroplastia: como evitá-las e corrigi-las

Complications in blepharoplasty are uncommon and, when they occur, they are usually mild and transient, such as hematomas and chemosis. However, sometimes they can be severe, such as blindness, or they might require surgical correction, such as ectropion. OBJECTIVE: To evaluate the results and complications of transcutaneous blepharoplasty performed in the same procedure, discussing how to treat and how to avoid them. METHODS: A retrospective study of 200 medical records of consecutive patients that underwent transcutaneous blepharoplasty from January 2007 to January 2009. The variables analyzed were age, gender, complications, clinical outcome, patient satisfaction, and photographic documentation. RESULTS: The incidence of complications was 9.5 percent (19 patients). The complications were 1 hematoma, 12 cases of chemosis and 13 patients who underwent canthoplasty, 6 patients with malposition of the lower eyelid (5 retractions and 1 ectropion). Medical treatment was performed in 12 patients and revision surgery in 7 cases of all the patients who had complications. CONCLUSIONS: We demonstrated that blepharoplasty is a procedure with a high satisfaction and a low complication rate, and it is an excellent surgical procedure, when properly indicated.

As complicações em blefaroplastia não são comuns e quando ocorrem são geralmente discretas e transitórias, como hematoma e quemose. Entretanto, algumas vezes podem ser definitivas, como cegueira, ou necessitarem de novas abordagens cirúrgicas para correção, como ectrópio. OBJETIVO: Avaliar resultados e complicações das blefaroplastias transcutâneas realizadas em um mesmo serviço, demonstrando como tratá-las e evitá-las. CASUÍSTICA E MÉTODO: Estudo retrospectivo de 200 prontuários de pacientes consecutivos submetidos à blefaroplastia transcutânea entre o período de janeiro de 2007 a janeiro de 2009 em um mesmo serviço. As variáveis analisadas foram: idade, sexo, complicações, evolução clínica, grau de satisfação e documentação fotográfica. RESULTADOS: A incidência de complicações foi de 9,5 por cento (19 pacientes). As complicações encontradas foram: 1 hematoma, 12 casos de quemose, sendo que esta ocorreu em 61,5 por cento dos 13 pacientes que realizaram cantoplastia, 6 pacientes com mau posicionamento de pálpebra inferior, sendo que, destes, 5 correspondem à retração e 1 ao ectrópio. Foi realizado tratamento clínico com acompanhamento ambulatorial em 12 pacientes e cirurgia revisional em 7 casos do total de pacientes com complicações. CONCLUSÕES: Demonstrou-se que a blefaroplastia é uma cirurgia com alta taxa de satisfação e baixo número de complicações, sendo um excelente procedimento cirúrgico, quando corretamente indicada.

Neuraxial hematoma after epidural anesthesia. Is it possible to prevent or detect it? Report of two cases.

BACKGROUND AND OBJECTIVES: Spinal hematomas are rare and they affect the central nervous system. They can cause permanent neurologic sequelae and death if they are not treated properly. Early diagnosis and treatment are fundamental for a good neurologic prognostic. The objective of this report was to emphasize for anesthesiologists the importance of early diagnosis and treatment of spinal hematomas, besides improving their prevention. CASE REPORTS: Case 1: The patient underwent epidural lumbar anesthesia for femoropopliteal revascularization. He was being treated with acetylsalicylic acid, clopidogrel, and enoxaparin, which were discontinued before the surgery. The patient developed paraplegia in the immediate postoperative period. Neurosurgical decompression was performed after the diagnosis, but without recovery in the long run. Case 2: The patient underwent epidural lumbar anesthesia for right knee osteotomy, without intercurrences. The patient remained without neurological complaints until approximately 48 hours after the surgery when he developed urinary retention, pain in the right lower limb, paresthesias, and difficulty moving both feet. The MRI showed an epidural lumbar hematoma, and the patient underwent immediate surgical decompression. He showed complete neurological recovery after 10 months of rehabilitation. CONCLUSIONS: The clinical cases presented here showed different outcomes, indicating the importance of early diagnosis and treatment for a good evolution. Diagnosis by MRI with early decompression shortly after the development of the first clinical manifestations remains the standard treatment. Identification of patients at risk for neuraxial bleeding and change in anesthetic technique, as well as the establishment of postoperative neurologic evaluation protocols in patients undergoing neuraxial anesthesia can contribute for prevention of severe neurologic sequelae.

Hematoma neuroaxial após bloqueio peridural: é possível prevenir ou detectar?: relato de dois casos / Neuraxial hematoma after epidural anesthesia: is it possible to prevent or detect it?: report of two cases

JUSTIFICATIVA E OBJETIVOS: Os hematomas espinais são raros e acometem o sistema nervoso central. Podem causar sequelas neurológicas permanentes e morte se não tratados adequadamente. O diagnóstico e tratamento precoces são fundamentais para o bom prognóstico neurológico. O objetivo deste trabalho foi despertar no anestesiologista maior sensibilidade para o diagnóstico e o tratamento precoces dos hematomas espinais, além de aperfeiçoar sua prevenção. RELATO DOS CASOS: Caso 1: Paciente submetido à anestesia peridural lombar para a realização de revascularização fêmuro-poplítea. Estava em uso de ácido acetilsalicílico, clopidogrel e enoxaparina, medicamentos suspensos antes da operação. O paciente evoluiu com paraplegia no pós-operatório imediato. Realizou-se descompressão neurocirúrgica após o diagnóstico, porém sem recuperação do quadro em longo prazo. Caso 2: Paciente submetido à anestesia peridural lombar para osteotomia em joelho direito, sem intercorrências. O paciente permaneceu sem queixas neurológicas até aproximadamente 48 horas, quando iniciou quadro de retenção urinária, dor em membro inferior direito, parestesias e dificuldade de movimentação dos pés. Foi feita ressonância nuclear magnética, a qual evidenciou hematoma peridural lombar, sendo realizada a descompressão cirúrgica imediata. Após 10 meses de reabilitação, houve recuperação neurológica completa. CONCLUSÕES: Os casos clínicos apresentados mostraram desfechos diferentes, destacando a importância do diagnóstico e do tratamento precoces para a boa evolução do quadro clínico. O diagnóstico pela ressonância nuclear magnética, com a descompressão precoce logo após as primeiras manifestações clínicas, permanece como tratamento padrão. A identificação dos pacientes de risco para sangramentos neuroaxiais, a mudança de técnica anestésica, assim como o estabelecimento de protocolos de avaliação neurológica pós-operatória nos pacientes submetidos aos bloqueios de neuroeixo...

BACKGROUND AND OBJECTIVES: Spinal hematomas are rare and they affect the central nervous system. They can cause permanent neurologic sequelae and death if they are not treated properly. Early diagnosis and treatment are fundamental for a good neurologic prognostic. The objective of this report was to emphasize for anesthesiologists the importance of early diagnosis and treatment of spinal hematomas, besides improving their prevention. CASE REPORTS: Case 1: The patient underwent epidural lumbar anesthesia for femoropopliteal revascularization. He was being treated with acetylsalicylic acid, clopidogrel, and enoxaparin, which were discontinued before the surgery. The patient developed paraplegia in the immediate postoperative period. Neurosurgical decompression was performed after the diagnosis, but without recovery in the long run. Case 2: The patient underwent epidural lumbar anesthesia for right knee osteotomy, without intercurrences. The patient remained without neurological complaints until approximately 48 hours after the surgery when he developed urinary retention, pain in the right lower limb, paresthesias, and difficulty moving both feet. The MRI showed an epidural lumbar hematoma, and the patient underwent immediate surgical decompression. He showed complete neurological recovery after 10 months of rehabilitation. CONCLUSIONS: The clinical cases presented here showed different outcomes, indicating the importance of early diagnosis and treatment for a good evolution. Diagnosis by MRI with early decompression shortly after the development of the first clinical manifestations remains the standard treatment. Identification of patients at risk for neuraxial bleeding and change in anesthetic technique, as well as the establishment of postoperative neurologic evaluation protocols in patients undergoing neuraxial anesthesia can contribute for prevention of severe neurologic sequelae.

JUSTIFICATIVA Y OBJETIVOS: Los hematomas espinales son raros y acometen el sistema nervioso central. Pueden causar secuelas neurológicas permanentes e incluso la muerte si no se tratan adecuadamente. El diagnóstico y el tratamiento precoces son elementos fundamentales para el buen pronóstico neurológico. El objetivo de este trabajo fue despertar en el anestesiólogo una mayor sensibilidad hacia el diagnóstico y el tratamiento precoces de los hematomas espinales, además de perfeccionar su prevención. RELATO DE LOS CASOS: Caso 1: Paciente que fue sometido a la anestesia epidural lumbar para la realización de la revascularización femoro-poplítea. Estaba usando ácido acetilsalicílico, clopidogrel y enoxaparina, medicamentos que fueron suspendidos antes de la operación. El paciente evolucionó con paraplejia en el postoperatorio inmediato. Se realizó la descompresión neuro-quirúrgica posterior al diagnóstico, pero sin la recuperación del cuadro a largo plazo. Caso 2: Paciente que fue sometido a la anestesia epidural lumbar para la osteotomía en la rodilla derecha, sin intercurrencias. El paciente no presentó quejas neurológicas durante aproximadamente 48 horas, cuando inició el cuadro de retención urinaria, dolor en el miembro inferior derecho, parestesias y dificultad para mover los pies. Se realizó la resonancia nuclear magnética, que arrojó hematoma epidural lumbar, siendo realizada la descompresión quirúrgica inmediata. Después de 10 meses de rehabilitación, se verificó una recuperación neurológica completa. CONCLUSIONES: Los casos clínicos presentados aquí, arrojaron diferentes desenlaces, destacando la importancia del diagnóstico y del tratamiento precoces para una buena evolución del cuadro clínico. El diagnóstico por la resonancia nuclear magnética, con la rápida descompresión inmediatamente después de las primeras manifestaciones clínicas, permanece como un tratamiento estándar. La identificación de los pacientes de riesgo para sangramientos neuroaxiales...

Bridge-therapy with enoxaparin in the preoperative period of endarterectomy.

Cervical clot is one of the complications of endarterectomy. This risk may be higher in patients using aspirin or clopidogrel. On the other hand, stroke may occur if the medication is interrupted before surgery. We carried out a prospective study of 124 endarterectomies in 119 patients in which aspirin or clopidogrel was stopped and a bridge-therapy with enoxaparin was administered preoperatively. There was no case of stroke during the period of the bridge-therapy. One patient developed cervical clot (0.8%) in the fifth postoperative day. Mortality rate in this series was 0.8%. There was no complication directly related to the use of enoxaparin. Bridge-therapy with low molecular weight heparin is a safe strategy for patients elected for endarterectomy.

Bridge-therapy with enoxaparin in the preoperative period of endarterectomy / Terapia-ponte com enoxaparina no período pré-operatório da endarterectomia

Cervical clot is one of the complications of endarterectomy. This risk may be higher in patients using aspirin or clopidogrel. On the other hand, stroke may occur if the medication is interrupted before surgery. We carried out a prospective study of 124 endarterectomies in 119 patients in which aspirin or clopidogrel was stopped and a bridge-therapy with enoxaparin was administered preoperatively. There was no case of stroke during the period of the bridge-therapy. One patient developed cervical clot (0.8 percent) in the fifth postoperative day. Mortality rate in this series was 0.8 percent. There was no complication directly related to the use of enoxaparin. Bridge-therapy with low molecular weight heparin is a safe strategy for patients elected for endarterectomy.

Hematoma cervical é uma das complicações graves de endarterectomia. O risco dessa complicação pode ser maior em pacientes em uso de antiagregante plaquetário. Por outro lado, a suspensão de antiagregante plaquetário no período pré-operatório de endarterectomia eleva o risco de acidente vascular cerebral (AVC). Realizamos estudo prospectivo de 119 pacientes submetidos a endarterectomia (124 procedimentos), nos quais foi suspenso antiagregante plaquetário (aspirina ou clopidogrel) e foi administrada terapia-ponte com enoxaparina subcutânea no período pré-operatório. Nessa série, não houve ocorrência de AVC no período pré-operatório. Um paciente (0,8 por cento) desenvolveu hematoma cervical no quinto dia pós-operatório. A mortalidade nessa série foi de 0,8 por cento. Não houve nenhuma complicação atribuída diretamente ao uso de enoxaparina. A terapia-ponte com heparina de baixo peso molecular demonstrou ser estratégia segura no preparo de pacientes para endarterectomia.