Reconstrução de couro cabeludo com retalho livre de músculo grande dorsal após escalpelamento por mordida de cachorro / Scalp reconstruction with large dorsal muscle-free flap after dog bite scalping

RESUMO Introdução: O escalpelamento é caracterizado pelo trauma em região do couro cabeludo, que pode ser classificado como parcial ou total. O trauma por escalpelamento é extremamente mutilante e estigmatizante, principalmente quando expõe o osso sem periósteo, que pode levar a quadro de osteomielite crônica e erosão de tábua externa. Quando há lesões extensas de couro cabeludo acima de 200cm² e com lesão de periósteo é necessária grande quantidade de tecido com retalho microcirúrgico, que não está disponível em todos os centros. O objetivo deste trabalho é relatar caso de paciente de 69 anos, feminina, que sofreu trauma por avulsão total de couro cabeludo de grande extensão de 550cm² com exposição de calota craniana sem periósteo e inviabilização total do escalpe após mordida de cachorro. Devido à inviabilização total do escalpe avulsionado, optou-se pelo transplante de retalho livre de músculo grande dorsal com anastomose microvascular do pedículo toracodorsal com os vasos temporais superficiais. O retalho evoluiu com boa perfusão e na área cruenta foi realizado enxertia parcial. Métodos: Análise retrospectiva de prontuário da paciente em questão. O presente trabalho segue os padrões de declaração de Helsinque e aprovação do comitê de ética e pesquisa. Conclusão: O retalho livre de músculo grande dorsal mostrou-se eficaz neste caso de reconstrução de lesão extensa do couro cabeludo (550cm²) com lesão parcial de periósteo devido ao escalpelamento. O retalho recuperou a forma do crânio e a função de proteção da calota craniana.

ABSTRACT Introduction: Scalping is characterized by trauma in the scalp region, which can be classified as partial or total. Scalping trauma is extremely mutilating and stigmatizing, especially when exposing the bone without periosteum, leading to chronic osteomyelitis and external table erosion. When there are extensive scalp lesions above 200cm², and with periosteum, the lesion is required a large amount of tissue with microsurgical flap, which is not available in all centers. This work aims to report a case of a 69-year-old female patient who suffered trauma due to total avulsion of a big scalp of 550cm² with exposure of a skull cap without periosteum and total unviability of the scalp after a dog bite. Due to the total unviability of the avulsed scalp, we opted to transplant a large dorsal muscle free flap with microvascular anastomosis of the thoracodorsal pedicle with the superficial temporal vessels. The flap evolved with good perfusion, and partial grafting was performed in the bloody area. Methods: Retrospective analysis of the medical records of the patient in question. This paper follows the Declaration of Helsinki's standards and the approval of the Ethics and Research Committee. Conclusion: The free flap of the large dorsal muscle proved effective in this case of reconstruction of the scalp's extensive lesion (550cm²) with partial periosteum lesion due to scalping. The flap recovered the shape of the skull and the protective function of the skull cap.

Reconstrução de couro cabeludo com retalho expandido / Scalp reconstruction with expanded flap

Introdução: A presença de defeitos extensos em couro cabeludo apresenta-se como um grande desafio reconstrutor para o cirurgião plástico. Estes defeitos têm vasta etiologia como: traumática, queimaduras térmicas ou elétricas, ressecções tumorais benignas e malignas ou congênitas, sequelas de tratamentos radioterápicos e infecções. Destacando-se lesões como o escalpelamento e queimaduras (térmicas ou elétricas), geram repercussões significativas como a perda de tecido grave, osteomielite crônica ou sequelas menores como uma alopecia cicatricial. O objetivo deste trabalho é relatar um caso de reconstrução de couro cabeludo em fase tardia com expansor tecidual e posterior retalho de avanço, devido à alopecia cicatricial, em paciente feminina de 11 anos vítima de escaldamento por água quente em região frontotemporal direita. Métodos: Foi realizada análise retrospectiva de prontuário da paciente em questão. O presente trabalho segue os padrões do comitê de ética de Helsinque. Conclusão: A técnica de expansão tecidual de couro cabeludo por estágios e posterior confecção de retalho de avanço de escalpo demonstrou ser eficaz de restaurar a estrutura pilosa e linha da implantação capilar da paciente com mínima distorção local, restituindo a forma e a estética do couro cabeludo da paciente.

Introduction: The presence of extensive scalp defects is a major reconstructive challenge for the plastic surgeon. These defects have a vast etiology, such as traumatic, thermal or electrical burns, benign and malignant or congenital tumor resections, radiotherapy treatments sequelae, and infections. Noting that injuries such as scalping and burns (thermal or electrical), generate significant repercussions such as severe tissue loss, chronic osteomyelitis or minor sequelae such as scar alopecia. This study aims to report a case of late scalp reconstruction with a tissue expander and posterior advancement flap, due to cicatricial alopecia, in an 11-year-old female, victim of scalding by hot water in the right frontotemporal region. Methods: It was performed a retrospective analysis of the patient's medical record. The present work follows the standards of the Helsinki ethics committee. Conclusion: The scalp tissue expansion technique by stages and subsequent scalp advancement flap performing proved to be effective in restoring the patient's hair structure and hairline with minimal local distortion, restoring the scalp's shape and aesthetics of the patient.

Tratamento a laser para estrias de distensão: revisão bibliográfica / Laser treatment for stretch marks: a literature review

Estrias de distensão são cicatrizes na derme que constrangem os pacientes e oferecem desafios ao tratamento clínico. Resultam do rápido estiramento da pele, frequentemente presente em adolescentes, gestantes, obesos e indivíduos com rápida mudança de peso. Apresentam-se inicialmente como placas eritematosas e edemaciadas (estrias rubras) e, conforme amadurecem, tornam-se esbranquiçadas e atróficas (estrias albas), devido à degradação e reorganização de fibras de elastina e de colágeno. Atualmente, lasers representam modalidade terapêutica não invasiva emergente, que já demonstrou sucesso na redução da vascularização excessiva das estrias rubras, e no estímulo à produção de colágeno e elastina nas albas. Foi realizada revisão da literatura no PubMed referente ao tratamento de estrias atróficas com laser de janeiro de 2000 até dezembro de 2016. Os autores encontraram 28 artigos que se enquadraram nos critérios de inclusão. Existem poucos estudos clínicos randomizados avaliando a eficácia ao longo prazo e a segurança de aparelhos à base de energia. Baseado em casos clínicos e revisões sistemáticas, ambos os lasers - ablativo e não ablativo - fracionados demonstraram melhora modesta do aspecto das estrias distensas. Há tendência a sugestão do laser não ablativo fracionado de 1.540 nanômetro como sendo opção de primeira escolha para tratamento das estrias distensas. Porém, estudos futuros devem focar em desenhos de pesquisa com duração mais longa, medidas objetivas e padronizadas da avaliação dos resultados como biópsias e estudos moleculares, que demonstrem aumento nas fibras elásticas e fibras de colágeno, que correlacionem com a melhora do aspecto clínico das estrias após aplicação de lasers com parâmetros sistematizados.

Stretch marks are scars on the dermis that cause patients to be self-conscious and that pose challenges in clinical treatment. They result from rapid stretching of the skin and often observed in adolescents, pregnant women, obese individuals, and people experiencing rapid change in weight. They initially appear as erythematous and edematous plaques (red striae), and as they mature, they become whitish and atrophic (striae alba) due to the degradation and reorganization of elastin and collagen fibers. Currently, laser treatment is an emerging noninvasive therapeutic modality that is successful in reducing the excessive vascularization of red striae and in stimulating the production of collagen and elastin in the alba. In the present literature review, PubMed was searched for articles on the treatment of atrophic striations with laser that were published from January 2000 to December 2016. The authors have found 28 articles that met the inclusion criteria. Only few randomized clinical trials have evaluated the long-term efficacy and safety of energybased treatments. Based on clinical cases and systematic reviews, both ablative and non-ablative fractional lasers caused moderate improvement in the appearance of distending striae. The 1540-nm non-ablative fractional laser is more likely to be considered the first-line treatment for stretch marks. However, future studies should focus on research with longer duration, studies with objective and standardized measures for the evaluation of results, such as biopsy results, and molecular studies showing an increase in elastic and collagen fibers that correlate to the improvement in the clinical appearance of the striae after using lasers with systematized parameters.

Contralateral Botulinum Toxin Improved Functional Recovery after Tibial Nerve Repair in Rats.

BACKGROUND: There is clinical and experimental evidence that botulinum toxin applied to the healthy side of patients with facial paralysis positively affects functional recovery of the paralyzed side. The authors created an experimental model to study the effects of botulinum toxin injection in the gastrocnemius muscle contralateral to the side of tibial nerve lesion/repair in rats. METHODS: Fifty rats were allocated into five groups: group I, control; group II, tibial nerve section; group III, tibial nerve section and immediate neurorrhaphy; group IV, tibial nerve section, immediate neurorrhaphy, and botulinum toxin injected into the contralateral gastrocnemius muscle; and group V, botulinum toxin injected into the gastrocnemius muscle and no surgery. Assessment tools included a walking track, electromyography, gastrocnemius muscle weight measurement, and histologic analysis of the nerve. RESULTS: Paralysis in group V was transient, with function returning to normal at 8 weeks. At 12 weeks, group V had lower latency levels. At week 12, group IV showed higher functional outcomes and amplitude levels than group III, and lower muscle atrophy on the side injected with botulinum toxin compared with group V. CONCLUSION: Transient paralysis of the contralateral gastrocnemius muscle by botulinum toxin type A improved functional recovery in rats that underwent section and repair of the tibial nerve.

Tibial and fibular nerves evaluation using intraoperative electromyography in rats.

PURPOSE: To evaluate a new model of intraoperative electromyographic (EMG) assessment of the tibial and fibular nerves, and its respectives motor units in rats. METHODS: Eight Wistar rats underwent intraoperative EMG on both hind limbs at two different moments: week 0 and week 12. Supramaximal electrical stimulation applied on sciatic nerve, and compound muscle action potential recorded on the gastrocnemius muscle (GM) and the extensor digitorum longus muscle (EDLM) through electrodes at specifics points. Motor function assessment was performaced through Walking Track Test. RESULTS: Exposing the muscles and nerves for examination did not alter tibial (p=0.918) or fibular (p=0.877) function between the evaluation moments. Electromyography of the GM, innervated by the tibial nerve, revealed similar amplitude (p=0.069) and latency (p=0.256) at week 0 and at 12 weeks, creating a standard of normality. Meanwhile, electromyography of the EDLM, innervated by the fibular nerve, showed significant differences between the amplitudes (p=0.003) and latencies (p=0.021) at the two different moments of observation. CONCLUSION: Intraoperative electromyography determined and quantified gastrocnemius muscle motor unit integrity, innervated by tibial nerve. Although this study was not useful to, objectively, assess extensor digitorum longus muscle motor unit, innervated by fibular nerve.

Tibial and fibular nerves evaluation using intraoperative electromyography in rats

ABSTRACT PURPOSE: To evaluate a new model of intraoperative electromyographic (EMG) assessment of the tibial and fibular nerves, and its respectives motor units in rats. METHODS: Eight Wistar rats underwent intraoperative EMG on both hind limbs at two different moments: week 0 and week 12. Supramaximal electrical stimulation applied on sciatic nerve, and compound muscle action potential recorded on the gastrocnemius muscle (GM) and the extensor digitorum longus muscle (EDLM) through electrodes at specifics points. Motor function assessment was performaced through Walking Track Test. RESULTS: Exposing the muscles and nerves for examination did not alter tibial (p=0.918) or fibular (p=0.877) function between the evaluation moments. Electromyography of the GM, innervated by the tibial nerve, revealed similar amplitude (p=0.069) and latency (p=0.256) at week 0 and at 12 weeks, creating a standard of normality. Meanwhile, electromyography of the EDLM, innervated by the fibular nerve, showed significant differences between the amplitudes (p=0.003) and latencies (p=0.021) at the two different moments of observation. CONCLUSION: Intraoperative electromyography determined and quantified gastrocnemius muscle motor unit integrity, innervated by tibial nerve. Although this study was not useful to, objectively, assess extensor digitorum longus muscle motor unit, innervated by fibular nerve.

Comparisons of the results of peripheral nerve defect repair with fibrin conduit and autologous nerve graft: An experimental study in rats.

INTRODUCTION: The standard treatment for nerve defects is nerve autograft. There is no conduit available that provides the same regenerative capacity of nerve autograft. This study evaluated the histological and functional recovery of nerve defects treated with fibrin conduit in comparison to the nerve autograft, in a rat model. METHOD: A sciatic nerve injury model (10-mm defect) was performed in 20 Wistar rats, nerve defect was reconstructed using a fibrin conduit (n = 10). A nerve autograft was used as control (n = 10). The walking behavior was measured by footprint analysis at 4, 8, and 12 weeks and sciatic function index was determined. After 12 weeks, histological analysis was performed to evaluate the regenerated nerve and measured axonal density. The triceps surae muscle weight was also evaluated. RESULTS: The fibrin conduit group showed less improvement in walking behavior compared to nerve autograft (-53 ± 2 vs. -36 ± 2; P < 0.001 at 12 weeks). The fibrin conduit group presented axonal density of 40.0 axons/10.995µm2 and the nerve autograft group had 67.2 axons/10.995µm2 (P < 0.001). The triceps surae muscle weight ratio of the fibrin conduit group was 41 ± 3% versus 71 ± 4% of the nerve autograft group (P < 0.001). CONCLUSION: The fibrin conduit could be used for nerve reconstruction following peripheral nerve injury in the rat model. However, the functional recovery in the fibrin conduit repair group was worse than that in nerve autograft group and the nerve repair with the fibrin conduit has less myelinated fibers when compared to the repair with nerve autograft.

Microsurgical head and neck reconstruction: retrospective analysis of 30 free flaps / Reconstrução microcirúrgica em cabeça e pescoço: análise retrospectiva de 30 retalhos livres

Introduction: Reconstructive head and neck surgery is a challenge for the plastic surgeon and requires a large technical arsenal, in which microsurgery plays an essential role. The objective to retrospectively analyze microsurgical head and neck reconstruction performed at the Pontifical Catholic University of Campinas over a period of 2 years. Methods: The medical charts of patients who underwent microsurgical reconstruction after head and neck surgery between June 2014 and October 2016 were reviewed to determine which flap was used, the length of the vascular pedicle, recipient vessels, microvascular anastomoses, surgical time, length of hospital stay, complications, and success rate. Results: Thirty microsurgical reconstructions were performed using 3 types of flaps: anterolateral thigh (n = 15), antebrachial radial (n = 8), and fibula (n = 7). Recipient vessels: facial artery (70%) and facial vein (50%), as 92.4% of microvascular anastomoses were end-to-end. The average operative time was 10.1 hours. The average length of hospital stay was 10.7 days. Two flaps were lost due to arterial thrombosis, resulting in a success rate of 93.3%. Conclusions: The microsurgical reconstructions were effective for the repair of complex defects as well as to partially restore the shape and function of the affected tissues. Complications were observed in less than 50% of the cases, although these presented with significant morbidity. The success rate was similar to that reported by major centers of reconstructive microsurgery. The learning curve is long, although it tends to improve with staff training and the acquisition of experience over time.

Introdução: Cirurgia reconstrutiva em cabeça e pescoço representa desafio ao cirurgião plástico e requer amplo arsenal técnico, no qual a microcirurgia figura papel essencial. O objetivo é analisar retrospectivamente as reconstruções microcirúrgicas em cabeça e pescoço realizadas na Pontifícia Universidade Católica de Campinas no período de dois anos. Métodos: Pacientes submetidos à reconstrução microcirúrgica após cirurgia de cabeça e pescoço, entre junho de 2014 e outubro de 2016, tiveram seus prontuários revisados para avaliação do retalho utilizado, comprimento do pedículo vascular, vasos receptores, anastomoses microvasculares, duração da cirurgia, tempo de internação, complicações e índice de sucesso. Resultados: Foram realizadas 30 reconstruções microcirúrgicas com três tipos de retalhos: anterolateral da coxa (n = 15), antebraquial radial (n = 8) e fíbula (n = 7). Vasos receptores: artéria facial (70%) e veia facial (50%), sendo que 92,4% das anastomoses microvasculares foram término-terminais. As cirurgias duraram, em média, 10,1 horas. O tempo médio de internação hospitalar foi de 10,7 dias. Houve perda de dois retalhos por trombose arterial, levando à taxa de sucesso de 93,3%. Conclusões: As reconstruções microcirúrgicas analisadas foram eficazes na reparação dos defeitos complexos, restaurando parcialmente forma e função dos tecidos acometidos. Foram observadas complicações em menos da metade dos casos, porém com morbidade elevada. O índice de sucesso foi semelhante ao de grandes centros de microcirurgia reconstrutiva. A curva de aprendizado é longa, mas tende a melhorar com o treinamento da equipe e aquisição de experiência ao longo do tempo.