Dermal regeneration matrix in the treatment of acute complex wounds.

INTRODUCTION: Dermal regeneration matrices (DRMs) represent a significant advance in wound treatment, but their use remains limited because of high associated costs. Used correctly, DRMs help improve aesthetic and functional results of skin-grafted areas. OBJECTIVE: This case series reports the use of a DRM of 1-mm and 2-mm thickness in the management of acute complex wounds. MATERIALS AND METHODS: This is a retrospective analysis of a cohort of patients treated between 2015 and 2018. Complex wounds were defined as those with extensive loss of skin and subcutaneous tissue, or as those in critical areas, that required sequential and specialized treatment. Management of acute wounds involved debridement of devitalized tissue, wound bed preparation, DRM implantation, and split-thickness skin grafting (STSG). Negative pressure wound therapy (NPWT) was used in all cases preoperatively, after DRM implantation, and after STSG. Results of integration of DRM and skin grafts were subjectively evaluated. The Vancouver Scar Scale was used to evaluate results 12 months postoperatively. RESULTS: Traumatic injuries were the most common etiology, and the extension of the treated wounds varied between 4 cm × 5 cm to 42 cm × 28 cm, in the greatest dimensions. A 2-mm-thick matrix was used in 14 cases, with skin grafting after 7 to 9 days. In 6 cases, a 1-mm-thick matrix was used, immediately followed by skin grafting. Negative pressure wound therapy was used in all cases. Dermal regeneration matrices and skin graft integration rates of almost 100% were achieved in all cases. No complications occurred. CONCLUSIONS: The results showed use of DRM and NPWT was a good reconstructive option in the management of acute complex wounds that required STSG. With proper patient selection, such treatment is an important tool in the armamentarium of reconstructive procedures.

Lymphocintilographic evaluation of lymphatic circulation in victims of circuferential degloving injuries of the lower limbs.

INTRODUCTION: secondary forms of lymphedema may occur as consequence of tumors, surgeries, radiotherapy, trauma and infections. Degloving injuries are severe and infrequent forms of trauma, with avulsion at the level of muscular fascia, and consequent injury of the lymphatic system. OBJECTIVE: to evaluate the alterations in lymphatic circulation in patients being victims of circumferential degloving injuries in the lower limbs, using lymphoscintigraphic. PATIENTS AND METHODS: retrospective analysis of the cases treated in the period from 2010 to 2016. Segmental, circumferential and unilateral injuries with involvement of the lower limbs were included. Lymphoscintigraphy was performed after a minimum interval of 12 months after the end of treatment. The non-injured lower limb was used as control. The Kleinhans Semiquantitative Index (KSI) was used for the semiquantitative evaluation of the lymphoscintigraphic findings. RESULTS: eighteen patients were evaluated, six of whom were female and 12 were male. The mean age was 28.11 years. The average vertical extension of the circumferential traumatized segment was 29.33cm. The injured area presented variations of 5 to 15% of the body surface, with an average of 8.95%. Lymphoscintigraphy was performed after an average interval of 22.55 months. Alterations were observed on the traumatized limb (TL) in 13 patients. All control limbs (CL) were normal. The mean KSI observed in TL was 8.32, while in CL, the average value was 0.58 (p<0.001). CONCLUSION: patients with circumferential degloving injuries in the lower limbs present compromised lymphatic circulation and high probability to develop lymphedema.

Lymphocintilographic evaluation of lymphatic circulation in victims of circuferential degloving injuries of the lower limbs / Avaliação linfocintilográfica da circulação linfática em pacientes vítimas de desenluvamentos circunferenciais dos membros inferiores

ABSTRACT Introduction: secondary forms of lymphedema may occur as consequence of tumors, surgeries, radiotherapy, trauma and infections. Degloving injuries are severe and infrequent forms of trauma, with avulsion at the level of muscular fascia, and consequent injury of the lymphatic system. Objective: to evaluate the alterations in lymphatic circulation in patients being victims of circumferential degloving injuries in the lower limbs, using lymphoscintigraphic. Patients and Methods: retrospective analysis of the cases treated in the period from 2010 to 2016. Segmental, circumferential and unilateral injuries with involvement of the lower limbs were included. Lymphoscintigraphy was performed after a minimum interval of 12 months after the end of treatment. The non-injured lower limb was used as control. The Kleinhans Semiquantitative Index (KSI) was used for the semiquantitative evaluation of the lymphoscintigraphic findings. Results: eighteen patients were evaluated, six of whom were female and 12 were male. The mean age was 28.11 years. The average vertical extension of the circumferential traumatized segment was 29.33cm. The injured area presented variations of 5 to 15% of the body surface, with an average of 8.95%. Lymphoscintigraphy was performed after an average interval of 22.55 months. Alterations were observed on the traumatized limb (TL) in 13 patients. All control limbs (CL) were normal. The mean KSI observed in TL was 8.32, while in CL, the average value was 0.58 (p<0.001). Conclusion: patients with circumferential degloving injuries in the lower limbs present compromised lymphatic circulation and high probability to develop lymphedema.

RESUMO Introdução: as formas secundárias de linfedema podem ocorrer em consequência de tumores, cirurgias, radioterapia, traumas e infecções. Os desenluvamentos são formas graves e infrequentes de trauma, sendo observada avulsão no plano da fáscia muscular, com consequente lesão do sistema linfático. Objetivo: avaliar as alterações na circulação linfática nos pacientes vítimas de desenluvamentos circunferenciais nos membros inferiores, a partir da análise linfocintilográfica. Pacientes e Métodos: análise retrospectiva dos casos atendidos no período de 2010 a 2016. Foram incluídos os casos com acometimento segmentar, circunferencial e unilateral em membros inferiores. A linfocintilografia foi realizada após um intervalo mínimo de 12 meses do término do tratamento. O membro inferior não traumatizado foi utilizado como controle. Para a avaliação semiquantitativa dos achados linfocintilográficos, utilizou-se o Índice de Kleinhans (ISQTK). Resultados: foram avaliados 18 pacientes, sendo seis do gênero feminino e 12 do masculino. A média de idade foi de 28,11 anos. A extensão vertical do segmento traumatizado circunferencial foi em média de 29,33cm. O segmento traumatizado apresentou variações de 5 a 15% da superfície corporal, com média de 8,95%. A linfocintilografia foi realizada após intervalo médio de 22,55 meses. Foram observadas alterações no exame linfocintilográfico do membro traumatizado (MT) em 13 pacientes. Todos os exames dos membros controle (MC) foram normais. O ISQTK médio observado no MT foi 8,32 (0,3-20,75). No MC o valor médio foi de 0,58 (0,15-0,75). Conclusão: os pacientes com desenluvamentos circunferenciais nos membros inferiores apresentam circulação linfática comprometida e alta probabilidade para o desenvolvimento de linfedema.

Scrotal reconstruction with superomedial fasciocutaneous thigh flap.

OBJECTIVE: to describe the use of a superomedial fasciocutaneous thigh flap for scrotal reconstruction in open areas secondary to the surgical treatment of perineal necrotizing fasciitis (Fournier's gangrene). METHODS: retrospective analysis of cases treated at the Plastic Surgery Service of Santa Casa de Misericórdia, São Paulo, from 2009 to 2015. RESULTS: fifteen patients underwent scrotal reconstruction using the proposed flap. The mean age was 48.9 years (28 to 66). Skin loss estimates in the scrotal region ranged from 60 to 100%. Definitive reconstruction was performed on average 30.6 days (22 to 44) after the initial surgical treatment. The mean surgical time was 76 minutes (65 to 90) to obtain the flaps, bilateral in all cases. Flap size ranged from 10cm to 13cm in the longitudinal direction and 8cm to 10cm in the cross-sectional direction. The complication rate was 26.6% (four cases), related to the occurrence of segmental and partial dehiscence. CONCLUSION: the superomedial fasciocutaneous flap of thigh is a reliable and versatile option for the reconstruction of open areas in the scrotal region, showing adequate esthetic and functional results.

Scrotal reconstruction with superomedial fasciocutaneous thigh flap / Reconstrução escrotal com retalho fasciocutâneo superomedial da coxa

ABSTRACT Objective: to describe the use of a superomedial fasciocutaneous thigh flap for scrotal reconstruction in open areas secondary to the surgical treatment of perineal necrotizing fasciitis (Fournier's gangrene). Methods: retrospective analysis of cases treated at the Plastic Surgery Service of Santa Casa de Misericórdia, São Paulo, from 2009 to 2015. Results: fifteen patients underwent scrotal reconstruction using the proposed flap. The mean age was 48.9 years (28 to 66). Skin loss estimates in the scrotal region ranged from 60 to 100%. Definitive reconstruction was performed on average 30.6 days (22 to 44) after the initial surgical treatment. The mean surgical time was 76 minutes (65 to 90) to obtain the flaps, bilateral in all cases. Flap size ranged from 10cm to 13cm in the longitudinal direction and 8cm to 10cm in the cross-sectional direction. The complication rate was 26.6% (four cases), related to the occurrence of segmental and partial dehiscence. Conclusion: the superomedial fasciocutaneous flap of thigh is a reliable and versatile option for the reconstruction of open areas in the scrotal region, showing adequate esthetic and functional results.

RESUMO Objetivo: descrever a utilização do retalho fasciocutâneo superomedial da coxa para a reconstrução escrotal em áreas cruentas secundárias ao tratamento cirúrgico da fasceíte necrosante do períneo (gangrena de Fournier). Métodos: análise retrospectiva de casos atendidos no Serviço de Cirurgia Plástica da Irmandade da Santa Casa de Misericórdia de São Paulo, no período de 2009 a 2015. Resultados: quinze pacientes foram submetidos à reconstrução escrotal utilizando o retalho proposto. A média de idade foi de 48,9 anos (28 a 66). A estimativa de perda cutânea da região escrotal variou de 60 a 100 %. A reconstrução definitiva foi realizada em média 30,6 dias (22 a 44) após o tratamento cirúrgico inicial. O tempo cirúrgico médio foi de 76 minutos (65 a 90) para a realização dos retalhos, bilaterais em todos os casos. O tamanho dos retalhos variou de 10cm a 13cm no sentido longitudinal por 8cm a 10cm no sentido transverso. O índice de complicações observado foi de 26,6% (quatro casos), referentes à ocorrência de deiscências segmentares e parciais. Conclusão: o retalho fasciocutâneo superomedial da coxa é uma opção confiável e versátil para a reconstrução de áreas cruentas na região escrotal, apresentando resultados estéticos e funcionais adequados.

Retalho fasciocutâneo torácico lateral para reconstrução de defeitos axilares após ressecção de hidradenite supurativa: série de 10 casos / Lateral thoracic fasciocutaneous flap for reconstruction of axillary defects after resection of hidradenitis suppurativa: a series of 10 cases

INTRODUÇÃO: A hidradenite supurativa (HS) é uma inflamação folicular crônica que apresenta quadro clínico variado, desde pequenos nódulos isolados até diversas lesões abscedadas, com formação de fístulas e cicatrizes. A região axilar é uma das áreas mais frequentemente acometidas. O objetivo é analisar uma série de casos acometidos por HS na região axilar, submetidos à exérese cirúrgica ampliada e reconstrução com retalho fasciocutâneo torácico lateral. MÉTODOS: Análise retrospectiva dos prontuários dos pacientes submetidos a tratamento no período entre 2010 e 2012. RESULTADOS: Dez pacientes foram operados, sendo que em dois havia acometimento bilateral, totalizando 12 procedimentos. Foi observado um tempo médio de evolução antes da indicação cirúrgica de 38 meses. O defeito médio observado após a ressecção foi de 10 x 9 cm. O tamanho médio dos retalhos foi de 15 x 10 cm. Em relação às complicações precoces, foram observados dois casos de deiscência (região axilar) e um caso de epiteliólise parcial (segmento distal do retalho). CONCLUSÃO: Observamos que a dissecção deste retalho não é tecnicamente difícil e que não apresenta sequelas funcionais ou estéticas significativas na área doadora, sendo uma opção confiável e versátil para reconstrução de defeitos axilares de maior porte.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic follicular inflammation that presents varied clinical features, from isolated small nodules to several abscessed lesions, with formation of fistulas and scars. The axillary region is one of the most frequently affected areas. The objective is to evaluate a series of patients with HS in the axillary region who underwent extensive surgical excision and reconstruction with a lateral thoracic fasciocutaneous flap. METHODS: A retrospective analysis of the medical records of patients who underwent treatment between 2010 and 2012 was conducted. RESULTS: Ten patients were operated, of whom two had bilateral involvement, totaling 12 procedures. The mean progression time before the surgical indication was 38 months. The mean defect size after the resection was 10 x 9 cm. The mean size of the flaps was 15 x 10 cm. With regard to early complications, two cases of dehiscence (axillary region) and one case of partial epitheliolysis (distal segment of the flap) were observed. CONCLUSION: We observed that dissection of lateral thoracic fasciocutaneous flaps is not technically difficult and does not present significant functional or aesthetic sequelae in the donor area, making it a reliable and versatile option for reconstruction of larger axillary defects.

Degloving injuries of trunk and limbs: comparison of outcomes of early versus delayed assessment by the plastic surgery team.

OBJECTIVE: to analyze cases of degloving of the trunk and limbs, comparing outcomes of early versus delayed assessment by the plastic surgery team. METHODS: we conducted a retrospective analysis of medical charts. Patients comprised two groups: Group I - early assessment, performed within 12 hours post trauma; and Group II - delayed assessment, performed more than 12 hours post trauma. We defined primary grafting as the use of skin from the traumatized skin flap. We excluded cases involving hands, feet or genitalia. RESULTS: there were 47 patients treated with degloving injuries between 2002 and 2010. The mean body surface area affected was 8.2%. Lower limbs were the most frequently affected site (95.7%), whether alone or in association with lesions to other sites. Delayed assessment by the plastic surgery team occurred in 25 cases. Mean hospital stay was 36.1 days for Group I and 57.1 days for Group II (p=0.026). Regarding the number of surgical operations (skin grafts), Group I received a mean of 1.3, while Group II underwent 1.6 (p=0.034). CONCLUSION: based on length of hospital stay and number of operations in trauma patients with degloving of the trunk and limbs, plastic surgery assessment should be carried out early.

Degloving injuries of trunk and limbs: comparison of outcomes of early versus delayed assessment by the plastic surgery team / Desenluvamentos de tronco e membros: comparação dos resultados da avaliação precoce ou tardia pela cirurgia plástica

OBJECTIVE: To analyze cases of degloving of the trunk and limbs, comparing outcomes of early versus delayed assessment by the plastic surgery team. METHODS: We conducted a retrospective analysis of medical charts. Patients comprised two groups: Group I - early assessment, performed within 12 hours post trauma; and Group II - delayed assessment, performed more than 12 hours post trauma. We defined primary grafting as the use of skin from the traumatized skin flap. We excluded cases involving hands, feet or genitalia. RESULTS: There were 47 patients treated with degloving injuries between 2002 and 2010. The mean body surface area affected was 8.2%. Lower limbs were the most frequently affected site (95.7%), whether alone or in association with lesions to other sites. Delayed assessment by the plastic surgery team occurred in 25 cases. Mean hospital stay was 36.1 days for Group I and 57.1 days for Group II (p=0.026). Regarding the number of surgical operations (skin grafts), Group I received a mean of 1.3, while Group II underwent 1.6 (p=0.034). CONCLUSION: Based on length of hospital stay and number of operations in trauma patients with degloving of the trunk and limbs, plastic surgery assessment should be carried out early.

OBJETIVO: Analisar os casos de desenluvamentos de tronco e membros, comparando os resultados da avaliação precoce ou tardia pela equipe de cirurgia plástica. MÉTODOS: Análise retrospectiva de prontuários. Os pacientes foram separados em dois grupos: Avaliação precoce - Grupo I (realizada no intervalo de até 12 horas após o trauma) e Avaliação tardia - Grupo II (realizada mais de 12 horas após o trauma). Definiu-se como enxertia primária aquela realizada com pele proveniente do retalho traumático. Foram excluídos os casos com acometimento de mãos, pés ou genitália. RESULTADOS: Foram atendidos 47 pacientes. A superfície corporal lesada média foi 8,2%. Os membros inferiores foram os locais mais acometidos, em 95,7%, isoladamente ou em associação com lesões em outros locais. A avaliação da Cirurgia Plástica foi solicitada tardiamente em 25 casos. Observou-se tempo médio de internação de 36,1 dias para o grupo I e de 57,1 para o grupo II (p=0,026). Em relação ao número de cirurgias (enxertias de pele), observou-se média de 1,3 no grupo I e 1,6 no grupo II (p=0,034). CONCLUSÃO: Em doentes politraumatizados, vítimas de desenluvamento de tronco e membros, podemos concluir, no que se refere ao tempo de internação e número de operações, que a avaliação da Cirurgia Plástica deve ser precoce.

Lipomas gigantes: série de 14 casos / Giant lipomas: a 14-case series

INTRODUÇÃO: Os lipomas são os tumores mesenquimais benignos mais frequentes na população. Para ser considerado gigante, deve apresentar pelo menos 10 cm em uma de suas dimensões ou pesar ao menos 1.000g. O objetivo do trabalho é analisar uma série de casos de lipomas gigantes atendidos em nosso serviço. MÉTODO: Análise retrospectiva de prontuários e registros anatomopatológicos dos diagnósticos de lipomas submetidos a tratamento cirúrgico no período de janeiro 2003 a janeiro 2010. RESULTADOS: Foram avaliados 14 pacientes, com média de idade de 52,3 anos (33-72) e tempo médio de evolução até o tratamento de 4,4 anos (seis meses - 20 anos); 64% dos casos não apresentavam sintomas. Todos os pacientes foram submetidos à ressecção cirúrgica da neoplasia. O peso médio das peças foi de 3,8 kg (512 g - 22 kg) e o tamanho médio no maior eixo foi de 27,5 cm (15-66 cm). Foram observadas complicações pós-operatórias em 42% dos casos. CONCLUSÃO: Observamos períodos prolongados de evolução até o tratamento, mesmo em casos com lesões de grande volume. A exérese cirúrgica aberta deve ser considerada o tratamento de eleição para estes tumores.

INTRODUCTION: Lipomas are the most common benign mesenchymal tumors worldwide. To be considered giant, they must be at least 10 cm in one of its dimensions or weigh at least 1,000 g. The objective of this study is to analyze a series of cases of giant lipomas seen in our practice. METHOD: We conducted a retrospective analysis of the medical and anatomopathological records of patients diagnosed with lipomas who underwent surgery between January 2003 and January 2010. RESULTS: We evaluated 14 patients with a mean age of 52.3 years (range, 33-72 years) and a mean evolution time until treatment of 4.4 years (range, 6 months to 20 years); 64% of cases presented no symptoms. All patients underwent surgical tumor resection. The average weight of the pieces was 3.8 kg (range, 512 g to 22 kg), while the average length of the longest axis was 27.5 cm (range, 15-66 cm). Postoperative complications were observed in 42% of cases. CONCLUSION: We observed prolonged periods of evolution until treatment, even in cases of large-volume lesions. Open surgical excision should be considered the treatment of choice for these tumors.

Técnicas para retirada de enxertos primários de retalhos traumáticos em áreas de desenluvamento / Techniques for removal of primary grafts from traumatic skin flaps in areas with degloving injuries

No tratamento dos pacientes vítimas de desenluvamento atendidos de maneira correta e precoce, a enxertia primária, com utilização da pele proveniente dos retalhos traumáticos é fundamental. Podem ser utilizados enxertos em ambas as espessuras, parcial ou total, não existindo na literatura uma definição em relação à melhor opção. Esta pele, também, pode ser utilizada de maneira imediata ou após conservação em banco de tecidos. Descrevemos neste artigo as principais técnicas para retirada de enxertos dos retalhos traumáticos.

Primary grafting using skin from traumatic flaps is essential in the correct and early treatment of patients with degloving injuries. Split- or full-thickness grafts can be used; however, the literature does not yet provide any indication of the best option. Moreover, this skin also can also be used immediately or after tissue bank storage. This report describes the main techniques for graft removal from traumatic flaps.

Local complications after industrial liquid silicone injection: case series.

OBJECTIVE: To analyze a case series of patients who underwent injection of industrial liquid silicone in a clandestine manner and by unauthorized persons. METHODS: We conducted a retrospective analysis of medical records of patients treated between September 2003 and December 2010. Data regarding gender, age, location and volume of silicone injected, time between application and clinical manifestations, complications, treatment and outcome were collected. Early manifestations were defined as occurring within 30 days of injection and late manifestations, the ones arising after this period. RESULTS: We treated 12 patients, eight were male, seven transsexuals. The volume injected ranged from 5 ml to 2000 ml, being unknown in three cases. The most often used injected sites were the thighs and buttocks. Eight patients had early manifestations, with inflammation and/or infection. Surgical debridement was necessary in five cases. Three patients with a history of injection in the breast region underwent adenomastectomy. There was one death due to refractory septic shock. CONCLUSION: The use of industrial liquid silicone should be completely contraindicated as a filling material and modification of body contouring, and may have serious complications, even death.

Complicações locais após a injeção de silicone líquido industrial: série de casos / Local complications after industrial liquid silicone injection: case series

OBJETIVO: analisar uma série de casos de pacientes submetidos à injeção de silicone líquido industrial de maneira clandestina e por pessoas não habilitadas. MÉTODOS: análise retrospectiva de prontuários de pacientes atendidos no período de setembro de 2003 a dezembro de 2010. Foram avaliados: sexo, idade, local e volume de silicone injetado, tempo decorrido entre a aplicação e as manifestações clínicas, complicações, tratamento e evolução. Definiu-se como precoce as manifestações ocorridas até 30 dias da injeção e manifestações tardias após este período. RESULTADOS: Foram atendidos 12 pacientes, oito eram do sexo masculino, sendo sete transexuais. O volume injetado variou de 5ml a 2000ml, sendo desconhecido em três casos. Os locais mais frequentemente utilizados para injeção foram a região de coxas e glúteos. Oito casos apresentaram manifestações precoces, com quadros de inflamação e/ou infecção. Foi necessária a realização de desbridamento cirúrgico em cinco casos. Três pacientes com histórico de injeção na região mamária foram submetidas à adenomastectomia. Houve um óbito por quadro de choque séptico refratário. CONCLUSÃO: O uso do silicone líquido industrial deve ser totalmente contraindicado como material de preenchimento e modificação do contorno corporal, podendo apresentar graves complicações e até mesmo óbito.

OBJECTIVE: To analyze a case series of patients who underwent injection of industrial liquid silicone in a clandestine manner and by unauthorized persons. METHODS: We conducted a retrospective analysis of medical records of patients treated between September 2003 and December 2010. Data regarding gender, age, location and volume of silicone injected, time between application and clinical manifestations, complications, treatment and outcome were collected. Early manifestations were defined as occurring within 30 days of injection and late manifestations, the ones arising after this period. RESULTS: We treated 12 patients, eight were male, seven transsexuals. The volume injected ranged from 5ml to 2000ml, being unknown in three cases. The most often used injected sites were the thighs and buttocks. Eight patients had early manifestations, with inflammation and/or infection. Surgical debridement was necessary in five cases. Three patients with a history of injection in the breast region underwent adenomastectomy. There was one death due to refractory septic shock. CONCLUSION: The use of industrial liquid silicone should be completely contraindicated as a filling material and modification of body contouring, and may have serious complications, even death.

Reconstrução tardia da região abdominal inferior e vulvar como tratamento complementar para sequelas pós-correção de extrofia vesical / Delayed reconstruction of the vulvar and lower abdominal regions as a complementary treatment for postsurgical sequelae of bladder exstrophy correction

Patients with malformations of the exstrophy-epispadias complex, including bladder exstrophy, may present for correction of deformities and sequelae in abdominal area, after primary treatment of urogenital malformations, performed early in life and in multiple stages. The secondary correction with aesthetic and functional goals is usually performed after growth and definition of hairy and fat distribution as well as after completion of urological treatment. Psychological aspects should also be considered. We report three female patients, with a history of bladder exstrophy correction in the neonatal period, presenting multiple deformities in the abdominal and vulvar areas, treated at our institution...

Os portadores de malformações do complexo extrofia-epispádia, incluindo a extrofia vesical, podem se apresentar para correções de deformidadese sequelas abdominais após o tratamento primário das malformações urogenitais, realizado nos primeiros anos de vida e em múltiplos estágios. A correção secundária, com objetivos estéticos e funcionais, é normalmente realizada após o crescimento e definição da distribuição pilosae adiposa, bem como após a finalização do tratamento urológico. Os aspectos psicológicos também devem ser considerados. Relatamos uma série de três casos de pacientes do sexo feminino, com antecedente decorreção de extrofia vesical no período neonatal, apresentando múltiplas deformidades na região abdominal e vulvar, submetidas à reconstrução em nosso serviço...

Carcinoma espinocelular como complicação tardia em doença pilonidal sacrococcígea: relato de caso / Squamous cell carcinoma as a late complication of sacrococcygeal pilonidal disease: case report

A malignização é uma ocorrência rara na evolução tardia de cistos pilonidais, tendo sido descrito menos de 70 casos até 2007. Assim como em outras etiologias, a ocorrência de malignidades em feridas crônicas é chamada de úlcera de Marjolin. Normalmente, observa-se a ocorrência de tumores de baixo grau e bem diferenciados, sendo o carcinoma espinocelular o mais frequente. Entretanto trata-se de tumores de comportamento agressivo, com elevado índice de recidivas e metástases linfonodais. Relatamos o caso de um paciente masculino, 41 anos, com cerca de 23 anos de evolução de doença pilonidal sacrococcígea, que evoluiu com malignização para carcinoma espinocelular, submetido a tratamento cirúrgico e radioterápico.

Malignancy occurs ever so rarely on pilonidal cyst late evolution, so much so that less than 70 cases have been described until 2007. As in other etiologies, malignancy in chronic wounds is named Marjolin’s ulcer. Generally, the incidence of low grade and differentiated tumors is most frequently noticeable. Squamous cell carcinoma is the most frequent one. However, these are aggressive tumors, with high rates of recurrence and lymph node metastasis. We report the case of a male patient, 41 years-old, about 23 years of sacroccygeal pilonidal disease evolution, whose has developed malignancy (squamous cell carcinoma), submitted to surgical and radiotherapic treatment.

Desenluvamentos fechados: lesão de Morel-Lavallée: [revisão] / Closed degloving injuries: Morel-Lavallée lesion: [review]

Introdução: Os desenluvamentos fechados, também chamados de lesão de Morel-Lavallée(LML), são lesões incomuns, frequentemente associadas a traumatismos graves. Envolvem forças tangenciais capazes de separar a pele e o tecido subcutâneo da fáscia muscular subjacente. Objetivo: Este trabalho tem como objetivo a revisão de cinco casos de LML atendidosno Serviço de Cirurgia Plástica da Santa Casa de São Paulo. Método: Foram analisados, retrospectivamente, os prontuários de 40 casos de desenluvamentos de tronco e membros atendidos entre 2002 e 2008, dos quais cinco correspondiam a LML e 35 casos a desenluvamentos convencionais ou abertos. Resultados: A superfície corporal desenluvada média foi de 13,2 ± 1,3 %. Os membros inferiores foram locais acometidos em todos os pacientes e, em 2 casos, houve associação com lesões no tronco inferior. Em 3 dos casos, o diagnóstico não foi realizado de maneira precoce, sendo avaliados e tratados após 2 a 17 dias de internação. Em 2 pacientes, foi realizada enxertia primária e em outros 2 casos foi realizado desbridamento inicial e enxertia de pele após granulação. Conclusões: O tratamento de pacientes vítimas de LML requer uma abordagem multidisciplinar e respeito a princípios cirúrgicos básicos, como a correta determinação das áreas viáveis e o restabelecimento da cobertura cutânea. Observa-se que as lesões são agravadas pelos erros e atrasos nas condutas iniciais, com maior morbidade associada e maiores tempos de internação e reabilitação.

Introduction: The closed degloving injuries, also called Morel-Lavallée lesion (MLL), are uncommon and often associated with severe trauma. They involve tangential forces able to separate the skin and subcutaneous tissue from the underlying muscle fascia. Objective: This article aims to describe five cases of MLL treated in the Department of Plastic Surgery, Santa Casa de São Paulo. Methods: Forty cases of trunk and limbs degloving injuries treated between 2002 and 2008 were retrospectively analyzed, being 35 cases of conventional or open deglovings and the remaining 5 of MLL. Results: The average degloved body surface was 13.2 ± 1.3%. The lower limbs were affected sites in all patients and in 2 cases were associated with lesions in the lower trunk. In 3 cases the diagnosis was not made early, being evaluated and treated after 2 to 17 days of hospitalization. In 2 patients the primary graft was used (with the skin of injured area), and in other 2 patients a initial debridement followed by skin grafting after granulation was used. Conclusions: The treatment of patients suffering from MLL requires a multidisciplinary approach and adherence to basic surgical principles, with accurately determination of the viable areas and the restoration of skin coverage. It is observed that the lesions are aggravated by mistakes and delays in the initial steps, associated with increased morbidity and longer hospitalization and rehabilitation times.

Carcinoma das células de merkel: relato de 2 casos / Merkel cell carcinoma: two cases report

Introdução: O carcinoma das células de Merkel (CCM) corresponde a uma forma incomum e agressiva de neoplasia maligna cutânea. Normalmente acomete pacientes acima de 60 anos em áreas cronicamente expostas ao sol. As células de Merkel se localizam na camada basal da epiderme, estão associadas aos mecanorreceptores locais e têm função neuroendócrina pouco compreendida. Integram o sistema neuroendócrino-imuno-cutâneo (N.I.C.S.). Com o uso de novos marcadores imunohistoquímicos, houve aumento no número de casos relatados. No entanto, a baixa incidência desta neoplasia dificulta a realização de estudos com maior nível de evidência científica. O tratamento do CCM envolve cirurgia, radioterapia e quimioterapia, persistindo na literatura discussões a respeito da abordagem mais efetiva. O prognóstico não é bom, sendo observados elevados índices de recidivas locais e metástases, linfonodais e à distância. Objetivo: Este trabalho tem como objetivo o relato de dois casos de CCM tratados em nosso serviço, bem como a revisão da literatura. Relato dos casos: Em ambos os casos, o CCM não foi a suspeita clínica inicial, sendo confirmado após biópsia incisional, que demonstrou neoplasia neuroendócrina. Em relação ao primeiro caso, com lesão na região anterior do tronco, foi realizado tratamento cirúrgico e indicada radioterapia complementar, a qual não foi realizada por óbito do paciente, 4 semanas após a cirurgia, por causas não relacionadas. No segundo caso, de localização pré-auricular, houve perda do seguimento ambulatorial após diagnóstico.

Introduction: Merkel cell carcinoma (MCC) is an uncommon and aggressive cutaneous malignant tumor. It usually occurs in patients above the seventh decade of life, in chronically sun-exposed areas. Merkel cells are located in the basal layer of epidermis, are associated with the local mechanoreceptors, and have neuroendocrine function poorly understood. They integrate the neuroendocrine-imune-cutaneous system (N.I.C.S.). With new imunohistochemistry markers, there was an increase in the number of the cases reported. Nevertheless, the low incidence of this tumor difficult realization of studies with higher scientific level. The treatment of MCC comprehends surgery, radiotherapy and chemotherapy, remaining in the literature discussion about the better treatment. The prognostic isn’t good, being observed high levels of local recidives and metastatic disease, in linfonodes and distant sites. Objective: This paper has the objective of two case reports of MCC treated in our institution, including the literature review. Case reports: In both cases, the MCC wasn’t the first clinical suspect, based on their appearance, being confirmed after incisional biopsy, which demonstraded neuroendocrine tumor. In the first case, the lesion was located in the anterior chest, the surgical treatment has been done and the radiotherapy was indicated; this treatment has not been done because the patient died four weeks after the surgery, for no related causes. In the second, the lesion was in the pre auricular location, the patient did not return to consult after the diagnosis.

Plicatura da base umbilical: proposta técnica para tratar protrusões e evitar estigmas pós-abdominoplastia / Umbilical base plicature: technique proposition for treatment of the bulge aspect

Introdução: A umbilicoplastia (onfaloplastia) corresponde a um tempo fundamental durantea realização das abdominoplastias. Considerações estéticas e importante destaqueno período pós-operatório, tanto pela paciente quanto pelo cirurgião, são atribuídas a estaregião. A protrusão da base umbilical, similar ao aspecto de hérnias, é considerada aspectonão atrativo. Essa situação pode existir no pré-operatório ou evoluir como resultado pósoperatóriodesfavorável. Objetivo: Apresentar uma técnica complementar a ser associadadurante a realização da umbilicoplastia, com a realização da plicatura da base da cicatrizumbilical à aponeurose, objetivando tratar protrusões existentes ou evitar esta indesejávelalteração no pós-operatório. Método: Vinte pacientes do sexo feminino foram submetidasà abdominoplastia convencional com realização da plicatura da base umbilical, durante períodode 12 meses. Em 10 casos, havia protrusão no pré-operatório. Nenhuma das pacientesapresentava hérnia nessa topografia. O acompanhamento pós-operatório variou de 6 a 24meses. Resultados: Foram obtidos bons resultados em todos os casos, com tratamento dadeformidade proposta quando presente, sem recidivas ou sequelas locais. Não houve casosde isquemia local ou deiscência. Nos casos em que não se evidenciava nenhuma deformidadeprévia, não houve alterações no pós-operatório. Conclusão: A plicatura da base umbilical éuma técnica que pode ser utilizada com sucesso para tratamento da protrusão já estabelecida,bem como para evitar que essa situação indesejada possa ocorrer após abdominoplastias.

Introduction: The umbilicoplasty (onfaloplasty) is a main surgical step during abdominoplasty.Esthetic concerns and important reference to this area in the post surgical time are assessed, bythe patient and the surgeon. The bulge aspect of the umbilical base, similar to umbilical hernias,is considered unattractive. This situation could exist in the pre surgical evaluation or it couldbe an unfavorable outcome. Purpose: To present a complementary technique to be associatedduring umbilicoplasty, using the plicature of the umbilical base to aponeurosis, with the objectiveof treat a pre existent bulge of umbilicus or to avoid this undesirable post surgical alteration.Methods: Twenty female patients were submitted to conventional abdominoplasty withumbilical base plicature during a period of 12 months. In 10 cases there were a bulge aspectin pre surgical. None of the patients had umbilical hernia. The follow up has duration of 6 - 24months. Results: There were good results in all cases, with treatment of the deformity when itwas present, with no recidive or sequela. There were no cases of local ischemia or dehiscence.In the cases without previous deformity there weren’t alterations after surgery. Conclusions:The plicature of the umbilical base is a technique that could be used with success in the treatmentof an existent umbilical bulge and to avoid this undesirable situation after abdominoplasty.

Colecistectomia laparoscópica em um paciente com ducto cístico duplo / Laparoscopic cholecystectomy in a patient with duplicated cystic duct

Our objective is to report a case of laparoscopic cholecystectomy in a patient with duplicated cystic duct. A 34 year old male presented with episodic pain in the upper rigth quadrant of the abdomen. Murphy' s sign was not present. Ultrassonography showed gallbladder with multiple calculi and a thickened wall. At laparoscopic cholecystectomy, a duplicated cystic duct was found. Careful dissection and intraoperative cholangiography were performed to rule out common bile duct injury.