Tratamiento quirúrgico del síndrome subacromial mediante la técnica de Neer. Estudio casuístico / Surgical treatment of the subacromial syndrome using Neer's technique. Case study

RESUMEN Introducción: el síndrome subacromial es una afección caracterizada por el pinzamiento tendinoso intraarticular por osteofitos o estrechamiento del espacio. Objetivos: evaluar la técnica de Neer en el tratamiento de pacientes con síndrome subacromial y los factores y actividades que favorecen esta afección. Materiales y métodos: se realizó un estudio observacional, descriptivo, prospectivo a pacientes con síndrome subacromial tratados con acromioplastia por la técnica de Neer. El universo lo conformaron 66 pacientes mayores de 20 años, que presentaron síndrome subacromial con síntomas por más de seis meses, y que fueron tratados con la técnica de Neer. Resultados: el sexo más afectado fue el femenino, con 65,2 %. Predominó el grupo etario de 41 a 50 años. El dolor en etapa prequirúrgica fue de moderado a severo en un 77,2 %, y nulo o leve después de la operación. La función en etapa prequirúrgica estuvo afectada de moderada a severa en un 68,1 %, y nula o leve después del tratamiento quirúrgico. La flexión anterior activa estuvo por debajo de 90º en un 83,1 % antes de ser operados, y por encima de 90º en un 80,3 % en el posquirúrgico. La fuerza muscular era mala o regular en etapa prequirúrgica en un 77,2 %, resultando ser excelente o buena después de la operación. Conclusiones: una vez aplicada la técnica de Neer, el dolor fue leve o nulo en la mayoría del universo, la función del hombro fue buena, la flexión anterior adecuada, y buena la fuerza muscular. Se recomienda emplear esta técnica quirúrgica en esta afección (AU).

ABSTRACT Introduction: subacromial syndrome is a condition characterized by intra-articular tendinous impingement by osteophytes or narrowing of space. Objective: to evaluate Neer's technique in the treatment of patients with subacromial syndrome and the factors and activities favoring this condition. Materials end methods: an observational, descriptive, prospective study was performed in patients with subacromial syndrome treated with acromioplasty using Neer's technique. The universe was formed by 66 patients aged over 20 years, who presented subacromial syndrome with symptoms for more than 6 months, and were treated with Neer's technique. Results: the most affected sex was the female one, with 65.2 %. The age group aged 41 to 50 years predominated. In pre-surgical stage, pain ranged from moderate to severe in 77.2 %, and from null to mild after surgery. Preoperative function was moderate to severe in 68.1 % and null or mild after surgical treatment. The previous active flexion was below 90° in 83.1 % before being operated, and above 90° in 80.3 % after surgery. Muscle strength was poor or regular in pre-surgical stage in 77.2 %, being excellent or good after surgery. Conclusions: once Neer's technique was applied, the pain was mild or null in most of the universe, the shoulder function was good, the anterior flexion adequate, and the muscle strength good (AU).

Reconstrução mamária com loja de retalho retropeitoral superior e subcutâneo misto inferior / Breast reconstruction with creation of upper retropectoral and lower mixed subcutaneous cavities and use of flaps

Introdução: Segundo dados do Instituto Nacional de Câncer (INCA) de 2016, estima-se em 57.960 novos casos de câncer de mama no Brasil, o que corresponde a 25% dentre todos os tipos de cânceres no país (excluindo-se os tumores de pele não melanoma). O presente artigo visa apresentar uma forma de abordagem para as reconstruções mamárias imediatas com loja retropeitoral superior e subcutânea mista inferior. Métodos: Os autores descrevem da técnica de reconstrução mamária com retalho do músculo peitoral e pedículo cutâneo inferior, associado à inclusão de implante mamário de silicone. Foi realizada análise retrospectiva de prontuários das pacientes operadas entre os anos 2012 e 2016 no Serviço de Cirurgia Plástica da clínica privada do autor sênior, no Hospital Daher e no Hospital das Forças Armadas. Resultados: Os resultados são satisfatórios, com baixos índices de complicações e com satisfação elevada para os pacientes e os autores. Trinta e seis pacientes foram submetidas à reconstrução mamária com a técnica descrita, com média de idade de 59 anos. As complicações apresentadas foram necrose de complexo areolopapilar, deiscência, seroma, hematoma, liponecrose, deslocamento do implante e trombose venosa profunda. Nenhuma paciente teve necessidade de resgate da reconstrução ou apresentou recidiva da neoplasia mamária durante o período do estudo. Conclusão: Trata-se de técnica que preserva a pele da mama em sua parte inferior, com baixa possibilidade de deiscência ou extrusão do implante nesta região, proporcionando uma dupla proteção deste implante com o músculo peitoral maior nos dois terços superiores e o retalho cutâneo-dermogorduroso no terço inferior, caracterizando um "dual-plane".

Introduction: A total of 57,960 new cases of breast cancer were expected in Brazil in 2016 according to data from the National Cancer Institute, corresponding to 25% of cancers in the country (excluding non-melanoma skin tumors). This study aims at presenting a surgical approach for immediate breast reconstructions with upper retropectoral and lower mixed subcutaneous cavities. Methods: The authors performed breast reconstruction using flaps of the pectoral muscle and inferior cutaneous pedicle associated with insertion of silicone breast implants. The medical records of patients operated between 2012 and 2016 at the Plastic Surgery Service of the senior author's private clinic at Daher Hospital and Armed Forces Hospital were retrospectively analyzed. Results: The results were satisfactory, with low complication rates and high patient and author satisfaction. Thirty-six patients, with a mean age of 59 years, underwent breast reconstruction using the described technique. The complications were nipple-areola complex necrosis, dehiscence, seroma, hematoma, liponecrosis, implant displacement, and deep venous thrombosis. No patient needed salvage surgery or had recurrence of mammary neoplasia during the study period. Conclusion: The present technique preserves the skin located at the lower portion of the breast, with a low risk of dehiscence or extrusion of the implant in this region, providing a double protection of the implant, with the pectoralis major muscle in the upper two thirds and the cutaneous-dermis-fat flap in the lower third, characterizing a "dual-plane" positioning.

An evidence-based approach to assessing surgical versus clinical diagnosis of symptomatic endometriosis.

Challenges intrinsic to the accurate diagnosis of endometriosis contribute to an extended delay between the onset of symptoms and clinical confirmation. Intraoperative visualization, preferably with histologic verification, is considered by many professional organizations to be the gold standard by which endometriosis is diagnosed. Clinical diagnosis of symptomatic endometriosis via patient history, physical examination, and noninvasive tests, though more easily executed, is generally viewed as less accurate than surgical diagnosis. Technological advances and increased understanding of the pathophysiology of endometriosis warrant continuing reevaluation of the standard method for diagnosing symptomatic disease. A review of the published literature was therefore performed with the goal of comparing the accuracy of clinical diagnostic measures with that of surgical diagnosis. The current body of evidence suggests that clinical diagnosis of symptomatic endometriosis is more reliable than previously recognized and that surgical diagnosis has limitations that could be underappreciated. Regardless of the methodology used, women with suspected symptomatic endometriosis would be well served by a diagnostic paradigm that is reliable, conveys minimal risk of under- or over-diagnosis, lessens the time from symptom development to diagnosis, and guides the appropriate use of medical and surgical management strategies.

Can basal cell carcinoma lateral border be determined by fluorescence diagnosis?: Verification by Mohs micrographic surgery.

BACKGROUND: The preferential accumulation of 5-aminolaevulinic acid (ALA)-induced protoporphyrin IX (PpIX) in neoplastic cells supports its potential use in the photodetection of epithelial tumours through porphyrin fluorescence. OBJECTIVE: To assess the validity of fluorescence diagnosis (FD) as an efficient pre-surgical in vivo imaging tool for defining the lateral boundaries of various types of basal cell carcinomas (BCCs). METHODS: The BCC tumour area was determined for 27 patients using FD digitalized imaging system, where the accumulation of PpIX in tumour tissue in relation to normal tissue was measured. Subsequently, BCCs were excised according to the complete area defined by FD using Mohs micrographic surgery (MMS). RESULTS: Of the 27 BCCs, the FD margin of the lesion coincided with the histopathological picture in 12 BCCs (44.44%). The mean value of accumulation factor (AF) was 2.7. Although 17 pigmented BCCs showed attenuated or absent fluorescence in the center, fluorescence at their periphery was used as a guide for excision, and statistically, the pigmentation of the BCCs showed no effect on the results of the FD efficacy (p=1.0). CONCLUSION: Fluorescence diagnosis of BCC may be beneficial as a guide to the safety margin needed before MMS. The safety margin is decided according to the FD tumour diameter in relation to the clinical tumour diameter.

Surgical skills of specialty trainees in emergency gynaecological laparoscopic procedures: a national UK survey.

A web-based survey was e-mailed to all specialty trainees ST Years 3-7 (n = 773) to assess their competence in emergency laparoscopic procedures. The trainees were asked about their competence level in a diagnostic laparoscopy; a salpingectomy; a salpingotomy; and an oophorectomy/cystectomy for adnexal torsion. Subsequently, they were asked how they would manage a tubal ectopic pregnancy with contralateral tubal disease. We received 202 responses (26%) and of these: 79% of trainees can perform a diagnostic laparoscopy independently; 32% can perform a salpingectomy and 12% can perform a salpingotomy independently; 14% can manage an adnexal torsion without supervision.

Comparación de resultados quirúrgicos: un mínimo control, por favor / Comparison of surgical results: minimum standardization, please

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La investigación traslacional en cirugía / Translational research in surgery

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La gestión en la práctica diaria. Réplica / Management in daily practice. In reply

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Use of bleomycin sulfate in treatment of keloidal scars

Keloidal scars may be clinically and/or surgically treated; however, drugs or surgical procedures do not prevent or cure the scars. The author used intralesional injections of bleomycin as a new treatment. The histopathological examination performed before and after infiltrations demonstrates the beneficial effect ofbleomycin, confirmed by the clinical progression of the lesions. The study was carried out with 15 patients treated at the Plastic Surgery Service of Clementino Fraga Filho Teaching Hospital - Universidade Federal do Rio de Janeiro, from February 1998 to March 2000.

Multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography in patients with mitral valve prolapse, flail, and endocarditis: diagnostic accuracy in the identification of mitral regurgitant defects by correlation with surgical findings.

Multiplane transesophageal echocardiography is a useful tool to study mitral regurgitation. We evaluated the diagnostic accuracy of multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography. We used 4 midesophageal and 2 transgastric views in 313 patients with degenerative lesions, endocarditic lesions, or both to identify regurgitant defects, comparing transesophageal echocardiography results with surgical findings. The overall diagnostic accuracy using individual scallops was 97.2% (P <.00001) with a sensitivity of 96.6% and a specificity of 97.6%. Considering the single sections of the mitral valve, an accuracy of 98%, 97.1%, and 98%, was found, respectively, for the lateral, middle, and medial third of the anterior leaflet. For the posterior leaflet, the accuracy was 98% for the lateral scallop, 98.4% for the middle, and 96.1% for the medial. This strategy provides good accuracy in diagnosing both simple and challenging mitral-valve lesions and its widespread use should be recommended.

Concepts on mammaplasties and mastopexies

Many techniques have been described for reduction mammaplasty and mastopexy.The techniques for reduction mammaplasty and mastopexy combine the resection of skin and breast tissue. The assessment of excess skin and quantity of tissue to be removed is a key element in mammaplasties. The format of the skin differs from patient to patient, depending on the quality of the skin and its relation with the glandular tissue. The principles described in this paper have been used in more than 4,000 patients. Long-term course has shown satisfactory results. Scars are a problem that seems to concern surgeons more than patients themselves. It is concluded that patients who undergo mammaplasty are aware that there will be a scar after the surgery. However, how the scar looks is more important than how long it is.

Ultrasound-Assisted Liposuction: 348 cases analysed

The authors report their experience in using ultrasound-assited liposuction in 348 patients in the period between October 1998 and July 2001. The application of ultrasound brought additional benefits to results, such as improved skin accomodation and the treatment of difficult cases, such as, gynecomasty, dorsum and secondary liposuction. The technique was perfomed in three stages- super-wet infiltration (1.35-1), followed by ultrasound-assisted liposuction and conventional liposuction. The equipment used was a Lisonix 2000generator at the setting of 5, that is, 50 (per cent) of the device's power, which proved to be the setting that causes the least secondary effects, such as tissue fibrosis and seroma. This study also considers the history of ultrasound-assisted liposuction and focuses on the physical aspects of ultrasound, with a review of the literature on the use of the ultrasound technique.

The open palm technique in severe Dupuytren's contracture

This paper aims to study the author's experience with the open palm technique originally described by McCash for the treatment of serve Dupuytren's contractures. All patients presented hand ulnar border (ring and little fingers) impairment and belonged to stages III to IV of the classification proposed by Tubiana. In a period of 6 years, 35 patients were submitted to regional fasciectomy. On average, 18 days were necessary (extremes of 15 and 25) to complete scar healing. We obtained an average articular residual deficit of 25 to the ring finger and 30 to the little finger at the proximal interphalangeal articulation level.

Laserlipólise: lipoaspiraçäo com Nd-YAG laser

The authors report their experience with laserlipolysis, a surgical procedure that uses a Nd-YAG type laser with a 1064nm wavalenght to treat localized adiposity, as an isolated or associated method to other traditional procedures. The physical principles of laser action on the adipocyte, anesthetic details, application techinique, cases, advantages, limitations, disadvantages, complications and long-term results are analysed. Moreover, the principle of action of laserlipolysis - photo-hyperthermia - on fat and adjacent tissue is demonstrated and analysed by histological studies.

Serious microstomia resulting from burn by caustic soda: case report / Microstomia grave decorrente de queimadura por soda cáustica: relato de caso

This study reports the case of patient with serious microstomia resulting from burn by caustic soda. It describes a technique for oral commissuroplasty used to treat this important tissue deformity. It also includes a literature review of the topic.

Disfunçäo da articulaçäo temporomandibular (ATM)

The authors report the treatment of TMJ dysfunction in 656 consecutive patients, using simple relative TMJ rest, with immediate cures in more than 80 (per cent) of the patients. The anatomophysiology of the TMJ and mainly the pain mechanism are discussed. The authors studied the occurrence of TMJ dysfuntion without pain in the population and observed that treatments is not necessary in 35 (per cent) of the cases. More severe cases require surgery 4 (per cent). The major steps of surgical treatment and final results are described.

Incidence of hematoma and seroma in abdominoplasty with and without the use of drains / Incidência de hematoma e seroma em abdominoplastia com e sem o uso de drenos

Based on the experience with 69 patients submitted to abdominoplasty, the authors compare the use of capillary tubes, suction drains and not using drains in the postoperative period as to the effectiveness in preventing hematomas and seromas under the abdominal flap. They also study the association of these fluid collections with known risk factors. They describe the indications and surgical technique employed in their cases and compare results obtained with data available in literature.

Lower blepharoplasty through a biplanar flap / Retalho biplanar para blefaroplastia inferior

A byplanar flap, composed by cutaneous and muscular flaps with common musculocutaneous pedicle, is proposed to an adequate of the cutaneous and muscle excess in lower bepharoplasty. The byplanar flap allows to resect different quantities of the skin and muscle, in accordance to the palpebral deformity. It provides anappropriate vascular support, either for the cutaneous and for the muscular flap, through its common pedicle. The byplanar flap in association with the lateralcanthopexy promotes the recovery of the lower eyelid muscular sling with the lateral canthus and lower eyelid support. The resection and fixation of the muscular portion of the byplanar flap elevate the skin and muscle flaps together, providing the adequate correction of the excess of both tissues, decreasing the occurrence of scleral show or ectropion.

Pharyngoesophageal reconstruction: using microsurgical jejunum and pectoralis major flaps / Reconstrução faringoesofágica: utilização do retalho peitoral maior e jejuno microcirúrgico

Pharyngoesophageal reconstruction is one of the majorchallenges of neck surgery. Many treatment options have been described. All of them involve procedures of greater or lesser technical complexity and high ratesof complications and mortality. The present study describes the techniques performed at the Service of Plastic Surgery of the PUC-RS São Lucas Hospital in 10 reconstructions: myocutaneous pectoralis major flap and microsurgical jejunal flap. Indications, complications, advantages and disadvantages of each method are discussed.