Injection of freshly collected adipose tissue for the treatment complex cryptoglandular anal fistula: case report

Introduction: Perianal fistula is a common colorectal disease which is caused mainly by cryptoglandular disease. Although most cases are treated successfully by surgery, management of complex perianal fistulas (CPAF) remains a challenge with limited results in recurrence and sometimes associated with fecal incontinence. The CPAF treatment with autologous adipose-derived mesenchymal stem cells (ASCs) had become a research hotspot. The technique started to be used in the treatment of Crohn's disease (CD) fistulas, where the studies showed safe and goods result from the procedure. Cultured ASCs have been used but this approach requires the preceding collection of adipose tissue, time for isolation of ASCs and subsequent in vitro expansion, need for laboratory facilities, and expertise in cell culturing. These factors have been getting over by using the commercially available alternative, allogenic ASCs. Treatment with allogeneic ASCs has shown good results in patients with CD fistulas, however with the disadvantage of being expensive. Objective: To show that the injection with freshly collected adipose tissue is an alternative to treatment with autologous or allogenic ASCs with several advantages. Methods: In this case report, we show our first experience in the treatment of CPAF with the application of collected adipose tissue in a tertiary referral hospital from Belo Horizonte, Brazil. Results The patient had a good postoperative recuperation with a complete fistula healing after 8 months without adverse effects. Conclusion: Injection with freshly collected adipose tissue is a promising and apparently safe sphincter-sparing technique in the treatment of CPAF. (AU)

Retalho de Bernard-Burow unilateral com "cutback" de mucosa jugal para tratamento de tumor de lábio inferior: relato de caso / Bernard-Burow flap unilateral with cheek mucosa "cutback" for treatment of lower lip tumor: a case report

O câncer de lábio corresponde a 25-30% de todos os cânceres de boca, sendo mais frequente o de lábio inferior. O carcinoma de células escamosas (CCE) é o subtipo mais incidente, estando o tabagismo como um dos principais fatores de risco. O relato demonstra técnica simples e efetiva para tratamento cirúrgico de CCE no lábio inferior de paciente tabagista. A realização de retalho unilateral de Bernard-Burow, mesmo em defeito maior que 50% do diâmetro inicial do lábio, mostrou-se factível. A adição de "cutback" na mucosa e dissecção parcimoniosa por planos pode ter propiciado uma boa evolução estética e funcional, já que determinou alívio na tensão sobre as suturas. A menor complexidade de execução desta reconstrução, se comparada a outras técnicas, pode garantir uma boa alternativa na tentativa de diminuir a morbidade pós-operatória neste tipo de cirurgia.

Lip cancer corresponds to 25-30% of all oral cancers, with the lower lip being more frequent. Squamous cell carcinoma (SCC) is the most common subtype, with smoking as one of the main risk factors. The report demonstrates a simple and effective technique for SCC's surgical treatment on a smoking patient's lower lip. Even in a defect larger than 50% of the initial lip diameter, the unilateral Bernard-Burow flap proved feasible. The addition of "cutback" in the mucosa and parsimonious dissection by planes may have provided a good aesthetic and functional evolution since it determined tension relief on the sutures. The less complex execution of this reconstruction, compared to other techniques, can guarantee a good alternative to decrease postoperative morbidity in this type of surgery.

Fat grafting associated with negative pressure wound therapy.

PURPOSE: To describe a case report of FG associated with NPWT in the treatment of complex wound on the distal third of the lower limb with bone exposure. CASE REPORT: A 59-year-old patient with chronic left tibial osteomyelitis since childhood underwent extensive debridement of the distal tibial diaphysis (40% of bone thickness per 10 cm extension) and placement of bioactive glass S53P4. Distal necrosis occurred in the fasciocutaneous flap used as the primary bone coverage. After flap debridement, the case was resolved with FG, directly on the exposed bone and biomaterial, associated with NPWT. Three weeks after the first FG session over bony tissue, 100% granulation was achieved with NPWT. The closure was completed with thin laminated skin graft over the granulated wound area. DISCUSSION: The association of FG and NPWT is not known in the clinical practice. Except for the only one experimental study described by Kao et al.4, the theme was not addressed in the medical literature before. In this clinical case, the result obtained regarding the granulation tissue formation drew attention and prevented the use of more complex flaps such as the microsurgical ones. Accelerated granulation tissue formation was observed, filling an extensive and deep bone defect, even with infected bone and biomaterial. Low morbidity and no complications were observed with the use of FG associated with NPWT. When the grafted fat was compacted with the NPWT, it seemed to behave as a true autologous biological matrix with large amount of cells. To date, scientific studies on fat grafting have focused on the cellular aspect (adipocytes and mesenchymal cells), growth factors and fat differentiation in different tissues. The property of aspirated adipose tissue as a biological matrix seemed to be revealed by the application of NPWT in association with FG. This new roll for the aspirated fat tissue may represent a new research field in plastic surgery.

Fat grafting associated with negative pressure wound therapy

Abstract Purpose: To describe a case report of FG associated with NPWT in the treatment of complex wound on the distal third of the lower limb with bone exposure. Case Report: A 59-year-old patient with chronic left tibial osteomyelitis since childhood underwent extensive debridement of the distal tibial diaphysis (40% of bone thickness per 10 cm extension) and placement of bioactive glass S53P4. Distal necrosis occurred in the fasciocutaneous flap used as the primary bone coverage. After flap debridement, the case was resolved with FG, directly on the exposed bone and biomaterial, associated with NPWT. Three weeks after the first FG session over bony tissue, 100% granulation was achieved with NPWT. The closure was completed with thin laminated skin graft over the granulated wound area. Discussion: The association of FG and NPWT is not known in the clinical practice. Except for the only one experimental study described by Kao et al.4, the theme was not addressed in the medical literature before. In this clinical case, the result obtained regarding the granulation tissue formation drew attention and prevented the use of more complex flaps such as the microsurgical ones. Accelerated granulation tissue formation was observed, filling an extensive and deep bone defect, even with infected bone and biomaterial. Low morbidity and no complications were observed with the use of FG associated with NPWT. When the grafted fat was compacted with the NPWT, it seemed to behave as a true autologous biological matrix with large amount of cells. To date, scientific studies on fat grafting have focused on the cellular aspect (adipocytes and mesenchymal cells), growth factors and fat differentiation in different tissues. The property of aspirated adipose tissue as a biological matrix seemed to be revealed by the application of NPWT in association with FG. This new roll for the aspirated fat tissue may represent a new research field in plastic surgery.

Tratamento de fratura de assoalho orbital com cartilagem conchal / Treatment of orbital floor fracture with conchal cartilage

Introdução: A reconstrução dos defeitos no assoalho orbital após fraturas constitui um desafio ao cirurgião plástico, pois além da expectativa estética e reconstrutora do paciente, cabe o tratamento de possíveis complicações funcionais, como diplopia e parestesias faciais. O objetivo é demonstrar uma série de casos utilizando cartilagem auricular conchal para reposição volumétrica orbital e estrutural do assoalho. Métodos: Foram avaliados 24 pacientes, operados pelo autor deste trabalho no período de 2013 a 2016, por motivo de fraturas de assoalho orbital pura (blow-out) ou impura (conjugadas a lesões de margem orbital, como zigoma e maxila). A técnica de estruturação do assoalho utilizou enxerto cartilaginoso autólogo conchal em todos os casos. Os pacientes foram catalogados quanto à presença de queixas pré-operatórias, como parestesia e diplopia, e sintomas, como enoftalmia, assim como resultados pós-operatórios. Resultados: A presença de lesões concomitantes como fratura de complexo zigomático e fratura maxilar pode influenciar no sucesso da reconstrução, assim como as fraturas com maior área de descontinuidade no assoalho orbital. Poucos pacientes apresentaram queixas pós-operatórias e somente dois casos (9,2%) necessitaram de nova abordagem cirúrgica. Conclusão: A cartilagem conchal auricular autóloga é um material adequado à reconstrução de defeitos no assoalho orbital pós-fratura, apresentando como vantagens a fácil obtenção, baixa morbidade, cicatriz inconspícua, excelente adaptação ao formato do assoalho da órbita e consequente reposição volumétrica.

Introduction: The reconstruction of defects in the orbital floor after fractures poses a challenge to the plastic surgeon because besides the patient's aesthetic and reconstructive expectations, possible functional complications such as diplopia and facial paresthesia must be treated. This study aimed at reporting a series of cases in which conchal auricular cartilage was used for volumetric orbital and structural replacement of the floor. Methods: Twenty-four patients, with surgery performed by the author, between 2013 and 2016, for pure (blow-out) or impure (conjugated to orbital margin injuries, such as zygoma and maxilla) orbital floor fractures, were evaluated. The repair technique involved autologous conchal cartilage graft in all cases. Patients were classified for the presence of preoperative complaints, including paresthesia and diplopia, and symptoms such as enophthalmia, as well as postoperative outcomes. Results: The existence of concomitant lesions, such as zygomatic complex and maxillary fracture, as well as fractures with greater discontinuity in the orbital floor, may influence the success of reconstruction. Few patients exhibited postoperative complaints and only two (9.2%) required a new surgical approach. Conclusion: Autologous conchal auricular cartilage is a suitable material for reconstruction of defects in the post-fracture orbital floor, possessing various advantages, including ease of attainment, low morbidity, inconspicuous scar, and excellent adaptation to the shape of the orbital floor and consequent volumetric replacement.

Mamoplastia: retalho fascioadenocutaneo areolado / Mammoplasty: fascioadenocutaneous areolar flap

INTRODUÇÃO: Várias são as técnicas descritas para mamoplastia. Contudo nenhuma contempla a ressecção mamaria com a preservação areolar por meio de um pedículo obliquo múltiplo que envolve o sistema neurovascular superior medial e o sistema neurovascular inferior lateral; alem de preservar na glândula remanescente a unidade areolo-glandular original. Esta técnica mostra se, em tese, ideal para o tratamento da gigantomastia juvenil em nulipara, que ainda pode se beneficiar de uma mama mais funcional e preservada na sua inervação primaria e na sua capacidade de amamentação. Este retalho também pode usufruir de grande segurança contra isquemia em função de um largo pedículo vascular. OBJETIVO: Descrever a técnica de mamoplastia e relatar a serie inicial de casos operados nesta sistematização. MÉTODO: Em 40 mamas operadas descreve se a técnica do retalho fascioadenocutaneo areolado com mensuração da quantidade ressecada, sensibilidade pré- e pós- operatório e complicações. RESULTADOS: Todos os casos tiveram evolução satisfatória, sem necrose e com sensibilidade do complexo areolopapilar (CAP) preservada em mais de 70% das mamas operadas. CONCLUSÃO: O retalho fascioadenocutaneo areolado inervado mostrou-se seguro, funcional e versátil.

INTRODUCTION: Several mammoplasty techniques have been described. However, none involves breast resection with preservation of the areola through an oblique multiple pedicle that involves the medial superior neurovascular system and the lateroinferior neurovascular system, or preserves the original areola-glandular unit in the remaining gland. This technique is, in theory, ideal for the treatment of juvenile gigantomastia in nulliparous women who can still benefit from a more functional breast with its primary innervation and the patient's ability to breast-feed preserved. This flap can also present higher safety against ischemia owing to a broad vascular pedicle. OBJECTIVE: To describe this mammoplasty technique and report the initial series of operated cases. METHOD: The fascioadenocutaneous areolar flap technique is described in 40 operated breasts, including the quantity of the resected tissue, pre- and postsurgery sensitivity, and complications encountered. RESULTS: All cases had a satisfactory evolution, without necrosis and with preserved sensitivity of the nipple-areola complex in >70% of the breasts operated. CONCLUSION: The innervated fascioadenocutaneous areolar flap was safe, functional, and versatile.

Rinoplastias secundárias nas seqüelas de traumas / Secondary rhinoplasty on trauma sequelae

Relatar a experiência do serviço no tratamento das seqüelas das fraturas nasais, discutindo as indicações das diversas vias de acesso, as áreas doadoras de enxertos ósseos e cartilaginosos, os métodos de fixação e o reconhecimento dos enxertos. Método: Durante os últimos 10 anos, foram realizadas cerca de 320 rinoplastias para tratamento de seqüelas de fraturas do nariza. Foram utilizadas as vias intranasal, exorrinoplastias, "degloving" do terço médio da face e via coronal. Foram aplicados enxertos ósseos em quase 60% dos casos, sendo esses enxertos ósseo retirados da taboa externa do crânio, do septo nasal ou da crista ilíaca e, muitas vezes, fixados por miniplacas e parafusos, alguns deles revestidos de fáscia temporal, principalmente nas rinoplastias coronais. Enxertos cartilaginosos também foram largamente aplicados e as áreas doadoras foram o próprio septo ou conchas auriculares. Resultados: Foram observados resultados estético-funcionais satisfatórios na quase totalidade dos pacientes e as poucas complicações foram absorções de enxertos (1%), desvio da ponta nasal (3%), exposição do enxerto através da pele (1%), insuficiência das válvulas nasais (3%), perfuração do septo nasal (1%), irregularidades perceptíveis do dorso do nariz (3%) e sinéquias (1%).