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1.
Plast Reconstr Surg ; 148(2): 334-338, 2021 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-34398085

RESUMO

SUMMARY: Social media have triggered a buccal fat pad excision frenzy. Not surprisingly, there is tremendous appeal of having a slimmer lower face and more defined jawline after undergoing a small intraoral procedure under local anesthesia. Although this procedure is great for social media and seemingly beneficial for jawline aesthetics, the evidence remains limited as to whether or not this is an effective long-term solution. How much the buccal fat pad persists or diminishes as we age is an area of debate. However, the possibility of causing premature aging and midface distortion in the long run is disconcerting.


Assuntos
Tecido Adiposo/cirurgia , Envelhecimento/fisiologia , Bochecha/cirurgia , Ritidoplastia/métodos , Tecido Adiposo/fisiologia , Cadáver , Bochecha/fisiologia , Estética , Humanos , Seleção de Pacientes , Ritidoplastia/efeitos adversos
2.
Med Oral Patol Oral Cir Bucal ; 26(4): e474-e481, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34023838

RESUMO

BACKGROUND: Buccal Fat Pad (BFP) excision has become an aesthetic surgical procedure. Although this procedure is quite common, it is important to bear in mind that the scientific evidence supporting the efficacy of this treatment is scarce and of low quality. The purpose of this systematic review was to analyse all relevant data to assess the efficacy and safety of BFP excision for improving midface aesthetics. MATERIAL AND METHODS: A thorough search of MEDLINE (PubMed), Scopus and Cochrane Library databases was conducted. The PICO approach was used where healthy patients seeking cheek slimming and facial silhouette refining undergo BFP excision and were compared before and after surgery in terms of BFP volume reduction, adverse effects and patient satisfaction. RESULTS: Of the 1,413 references identified, 4 were included in the qualitative synthesis. Only one study reported BFP volume reduction, which was 3.10 mL (95%CI: 2.38 to 3.80; P < 0.001), and the mean volume of the excised tissue was 2.74 ± 0.69 mL (range, 1.8-4.9 mL). 84.6% of the patients stated that their facial contour was much better and the remaining 15.4% noticed that the appearance of their cheeks following BFP excision was better. Seven complications were reported in the 134 cheek refinement procedures. CONCLUSIONS: BFP removal has an initially favorable outcome for facial aesthetics and a low postoperative complication rate, however, there are many procedures being performed with poor quality methodology and there is also a lack of published data on its long-term follow-up results.


Assuntos
Estética Dentária , Procedimentos Cirúrgicos Reconstrutivos , Tecido Adiposo/cirurgia , Bochecha/cirurgia , Humanos , Boca
3.
Ann Plast Surg ; 86(6): 620-626, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34002722

RESUMO

BACKGROUND: The subperiosteum, supraperiosteum, and intrasuborbicularis oculi fat have been used as planes of dissection for orbital fat transposition in transconjunctival lower blepharoplasty. The steep learning curve due to the anatomic complexity in using any of the 3 planes may deter plastic surgeons from performing the procedure. We present the use of clear anatomical midcheek spaces, the premaxillary and prezygomatic spaces, as the plane for orbital fat transposition in transconjunctival lower blepharoplasty. METHODS: We performed a retrospective study of 184 consecutive patients who underwent transconjunctival orbital fat transposition using the midcheek spaces from November 2013 to July 2019. Recorded data included the patient's age, duration of surgery, postoperative complications (chemosis; bleeding; lower eyelid swelling; orbital and/or lower eyelid infection; eye misalignment on primary gaze; binocular diplopia; numbness involving the lower eyelid, cheek, and upper lip; orbicularis oculi paralysis, inferior scleral show, and lower eyelid ectropion), aesthetic result, and patient satisfaction. RESULTS: The mean age is 35.48 ± 6.66 years. Significant aesthetic improvement was achieved not only for herniated orbital fat and prominent lid-cheek junction but also for midcheek depression over an average follow-up of 22.41 ± 16.04 months. The patient satisfaction score (98.91%) was high. No major complications occurred. The mean operating time was 46.74 ± 6.67 minutes. CONCLUSIONS: The natural midcheek spaces could be used as an ideal plane for orbital fat transposition in transconjunctival lower blepharoplasty. By using the midcheek spaces, transconjunctival orbital fat transposition can become a safe and effective technique without the steep learning curve.


Assuntos
Blefaroplastia , Tecido Adiposo/cirurgia , Adulto , Bochecha/cirurgia , Pálpebras/cirurgia , Humanos , Órbita/cirurgia , Estudos Retrospectivos
4.
Plast Surg Nurs ; 41(2): 117-120, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34033639

RESUMO

In this article, we describe reconstruction of a large left-side medial cheek defect in a 78-year-old woman using a cervicofacial rotation advancement flap. To our knowledge, this is the second case of reconstruction of a large traumatic medial cheek defect using an anterior-based subcutaneous cervicofacial rotation advancement flap that has ever been reported. We applied retention sutures at the level of the jawline and zygomatic eminence using 3-0 nonabsorbable sutures between the subcutaneous tissue of the flap and the periosteum. Despite the limitation of having partially injured adjacent tissue available for reconstruction, meticulous dissection together with skilled postoperative nursing care yielded a good aesthetic outcome in this case.


Assuntos
Bochecha/cirurgia , Desenluvamentos Cutâneos/cirurgia , Retalhos Cirúrgicos/cirurgia , Idoso , Desenluvamentos Cutâneos/complicações , Feminino , Humanos , Tela Subcutânea/cirurgia , Tela Subcutânea/transplante , Retalhos Cirúrgicos/irrigação sanguínea
5.
Ital J Dermatol Venerol ; 156(2): 244-247, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33960754

RESUMO

Reconstruction of large defects of the upper cheek defects still remains a challenge for the surgeon, who can apply different techniques. We present a new method involving the use of a dermal regeneration template to achieve an improved, faster healing of pedicled buccal fat flap in a 75-year-old woman affected by melanoma of the upper-middle cheek. The tumor involved soft tissue, zygomatic arch and periocular fact. The choice of the surgical technique consisted first in the creation of a buccal fat pad to restore the important lack of tissue over the underlying bones, and then in the position of a dermal acellular matrix (Integra® Dermal Regeneration Template; Integra LifeSciences Holdings Corporation, Plainsboro, NJ, USA). Three weeks later, once the neodermal formation was finished, a split thickness graft was placed. This is a not yet described association that represents a good surgical option for the restoration of large cheek defects that allows good functional and cosmetic result in older patient when minimal surgical invasion and operative duration are necessary because of a patient's general condition. The postoperative course with this surgical technique was regular and a good functional result was achieved. This technique provides an adequate functional coverage, a restoration of soft tissue lacking and an acceptable cosmetic result without ectropion.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos , Tecido Adiposo/transplante , Idoso , Bochecha/cirurgia , Feminino , Humanos , Retalhos Cirúrgicos , Cicatrização
6.
Microsurgery ; 41(6): 584-593, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33960527

RESUMO

BACKGROUND: Prelamination is a reconstructive technique providing fasciomucosal or composite flaps with low donor-site morbidity. We conducted a systematic review of retrospective studies to assess the application of prelaminated flaps in reconstructive surgery of head and neck cancer patients, and to evaluate the advantages and disadvantages of this technique. METHODS: This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine (www.pubmed.org) and Scopus database (www.scopus.com), running the following search string: "prelamination OR prelaminated AND flap." Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes and complications. RESULTS: A total of 19 articles were selected and reviewed from 128 identified. Seven of 19 articles were case reports, 12 articles were case series. One-hundred-two patients underwent reconstructive treatment by prelamination technique using a wide variety of flaps (92 free, 10 pedicled). The sites of reconstruction were oral cavity (66 floor of the mouth, 3 retromolar trigone, 6 hard palate, 4 cheek, 4 tongue), 8 facial skin (5 of them sited on the nose), 4 oropharyngeal defects, 1 laryngotracheal region. No case of total flap loss was reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 18 patients (17.6%). Primary closure of the donor site was achieved in 97 cases (97%) and 3 (3%) required revision surgery of the donor site. CONCLUSION: Prelamination is an effective and versatile technique, with low donor-site morbidity. Further studies would be needed to investigate the impact on the patient's oncologic outcome. More comparative studies with standard reconstructive techniques are essential to understand when it is worth performing this sophisticated procedure.


Assuntos
Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço , Procedimentos Cirúrgicos Reconstrutivos , Bochecha/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Estudos Retrospectivos , Retalhos Cirúrgicos
8.
Facial Plast Surg Clin North Am ; 29(2): 301-309, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33906762

RESUMO

Festoons represent a combination of fluid accumulation and soft tissue laxity in the superolateral cheek. They remain a difficult entity to treat. The ideal treatment for festoons would possess minimal invasiveness and recovery time, and predictably improve the condition. No nonsurgical treatment currently meets these criteria, and surgical treatments have significant limitations. Fortunately, a variety of treatment options exist that can benefit each patient and be tailored to their specific needs. Knowledge of the underlying anatomy, clinical characteristics, and clinical evaluation will better equip the treating physician to manage festoons.


Assuntos
Blefaroplastia , Ritidoplastia , Bochecha/cirurgia , Pálpebras/cirurgia , Humanos
10.
Ann Plast Surg ; 86(3S Suppl 2): S194-S198, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33651014

RESUMO

INTRODUCTION: Different from Western culture, prominent zygoma and rectangular facial contour are deemed as unaesthetic and masculine in Asians. To achieve an ideal oval facial shape, reduction malarplasty is often performed. METHODS: Twenty-two eligible patients who underwent reduction malarplasty between November 2008 and December 2018 were reviewed. The reduction malarplasty involved repositioning of the osteotomized zygomatic arch and subperiosteal lift via a limited temporal incision. Photographs were collected both preoperatively and postoperatively. Complications and postoperative outcomes were evaluated. RESULTS: Twenty-two patients underwent reduction malarplasty with subperiosteal lift between November 2008 and December 2018. Their mean age was 35 ± 2.30 years. Prominent zygoma and facial contour were significantly improved after surgery. Patients demonstrated satisfaction with outcome (73.77 ± 6.83) and with facial appearance (75.00 ± 5.60). No cheek drooping and major complications were observed during the long-term follow-up. CONCLUSIONS: Prominent zygoma treated with reduction malarplasty with subperiosteal lift via limited temporal incision has a stable and long-lasting effect. This approach can be regarded as a true alternative for facial contour reshaping.


Assuntos
Osteotomia , Procedimentos Cirúrgicos Reconstrutivos , Adulto , Bochecha/cirurgia , Face , Humanos , Zigoma/cirurgia
11.
BMJ Case Rep ; 14(3)2021 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-33727295

RESUMO

A patient presented to our unit with a long history of a discharging skin infection on his left cheek, which came and went. He had been seen by numerous healthcare practitioners including his general practitioner, general dental practitioner and dermatologist, with no resolution. He was eventually diagnosed with an odontogenic cutaneous fistula (OCF), for which he underwent surgical management. The purpose of the study is to describe the diagnosis and surgical management of an OCF, from initial assessment through to postoperative review and discharge. Following surgical management of the OCF and treatment of the source of infection by dental extraction, the patient is no longer experiencing purulent discharge through his left cheek. The extraoral skin site of drainage at his left cheek has resolved completely, with minimal residual scarring. OCF can be managed by a number of different treatment modalities. The treatment of an OCF by surgical excision is presented.


Assuntos
Fístula Cutânea , Dermatopatias , Bochecha/cirurgia , Fístula Cutânea/etiologia , Fístula Cutânea/cirurgia , Odontólogos , Humanos , Masculino , Papel Profissional
12.
Facial Plast Surg ; 37(4): 490-499, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33648012

RESUMO

Acute soft tissue trauma to the head and neck is a common reason for emergency department presentation and should be appropriately evaluated by a facial plastic surgeon. The evaluation of a patient who has suffered facial trauma should always include a comprehensive facial nerve exam and carry a low threshold of suspicion for parotid duct injury when involving the cheek. Injuries to the facial nerve and parotid duct can result in significant long-term functional, cosmetic, and emotional morbidity, particularly when diagnosis is delayed. In the repair of facial nerve transection, neurorrhaphy technique is primarily based on the ability to obtain tension-free anastomosis and outcomes are in large part related to timing of repair. Parotid duct injuries are generally repaired based on the site of ductal injury. In this article, we present a guide to the relevant anatomy of the facial nerve branches and the parotid duct, the important factors guiding treatment decisions alongside their related risks and benefits, as well as the management of complications of facial nerve neurorrhaphy and parotid duct injuries and repair.


Assuntos
Traumatismos Faciais , Traumatismos do Nervo Facial , Anastomose Cirúrgica , Bochecha/cirurgia , Nervo Facial/cirurgia , Traumatismos do Nervo Facial/etiologia , Humanos , Glândula Parótida/cirurgia , Ductos Salivares/cirurgia
13.
Oral Maxillofac Surg Clin North Am ; 33(2): 177-184, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33541783

RESUMO

This article presents an overview of the history of the buccal fat pad flap, its relevant anatomy, and its indications and contraindications. The surgical technique for its harvest is described, as are the postoperative care and possible complications.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos , Tecido Adiposo/transplante , Bochecha/cirurgia , Humanos , Retalhos Cirúrgicos
14.
Facial Plast Surg ; 37(2): 224-232, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33535244

RESUMO

Ruling out cases with strong jawlines, well-developed mid-cheek regions, and good fat presence, if done artistically, fat augmentation strongly assists midface definition and can replenish hollowed regions of the face. This is particularly true for candidates with low bodyfat or smaller skull structures. Hence, fat grafting is a strong adjunct to conventional excisional techniques in facial rejuvenation surgery, regardless of experience, technique, or geographical embedding. While CORE facelift techniques remain the golden standard that define the top level of facelift surgery, fat augmentation has its unique place along the full stretch of an individual surgeon's learning scope, as it will potentially improve results regardless of where one stands.


Assuntos
Ritidoplastia , Tecido Adiposo , Bochecha/cirurgia , Face/cirurgia , Humanos , Rejuvenescimento
16.
Facial Plast Surg ; 37(2): 198-204, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33634449

RESUMO

The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.


Assuntos
Blefaroplastia , Doenças Palpebrais , Bochecha/cirurgia , Pálpebras/cirurgia , Músculos Faciais , Humanos
17.
J Med Case Rep ; 15(1): 64, 2021 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-33563340

RESUMO

BACKGROUND: Pilonidal sinus is commonly seen at the sacrococcygeal region and few other sites, usually located at the midline, at areas where hairs collect or near protuberances or some adjacent rubbing surfaces. Its presence elsewhere is uncommon. We share an interesting case of a recurrent discharging sinus from the cheek bulge of a male which turned out to be a pilonidal sinus containing tuft of hairs on exploration and wide excision. CASE PRESENTATION: A 37 years old hirsute male presents to us with a non-healing discharging sinus at the bulge of the cheek. Exploration after a course of antibiotics showed 2 subcutaneous cavities with tuft of hairs. The area was excised along with a margin, thorough irrigation and curettage was done and the wound was closed primarily; a Z-plasty was incorporated in the central part to break the resultant suture line. Histopathological examination was done to confirm the diagnosis and rule out an off-midline dermoid cyst or an underlying/coexisting malignancy. Post-operative course was uneventful. The patient has been recurrence free for 1.5 years and is satisfied with the nature of the scar. CONCLUSIONS: Pilonidal sinus of the cheek bulge is an extremely rare entity. Complete excision and clinical suspicion are important for cure of this nagging ailment, especially at unexpected areas.


Assuntos
Seio Pilonidal , Adulto , Antibacterianos/uso terapêutico , Bochecha/cirurgia , Humanos , Masculino , Recidiva Local de Neoplasia , Seio Pilonidal/cirurgia , Recidiva , Região Sacrococcígea
18.
J Plast Reconstr Aesthet Surg ; 74(4): 730-739, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33386263

RESUMO

PURPOSE: Cervicofacial flaps represent an excellent option for coverage of cheek defects secondary to oncologic resection, trauma or infection. However, there remains clinical equipoise regarding whether superficial plane or deep plane dissection results in the lowest rates of complications and optimal outcomes. METHODS: A systematic review and meta-analysis of proportions was conducted to assesses outcomes between cheek reconstruction superficial plane or deep plane cervicofacial flaps. Outcome measures included flap necrosis, ectropion, hematoma formation, facial nerve injury, and requirement for further operative or non-operative intervention. RESULTS: Of 881 citations identified for review, 10 met the inclusion criteria. In total, 284 patients received superficial plane flaps while 44 patients received deep plane flaps. Overall, reported rates of complications were low for cervicofacial flaps. The proportion of necrosis, ectropion, and hematoma were 3.05% (95% CI: 0.00-10.71%), 2.03% (95% CI: 0.41-4.42%), and 0.05% (95% CI: 0.00-3.29%), respectively. No cases of permanent facial nerve injury were reported. Sub-group analysis demonstrated comparable rates of complications between superficial and deep plane dissection and no difference was found between groups. Other complications were noted with low incidence. CONCLUSIONS: Currently published literature demonstrates that superficial and deep plane cervicofacial flaps exhibit similar rates of complications, although there is a low level of evidence overall. Overall, the rates of flap necrosis (3.05%), ectropion (2.03%), and hematoma (0.05%) are low. Notably, there were no reported cases of permanent facial nerve injury from either technique.


Assuntos
Bochecha/cirurgia , Neoplasias Faciais/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Retalhos Cirúrgicos/cirurgia , Bochecha/lesões , Dissecação , Humanos , Complicações Pós-Operatórias
19.
Aesthetic Plast Surg ; 45(3): 992-1001, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33452544

RESUMO

INTRODUCTION: A harmonious face is defined in terms of a balanced relationship among all facial tissues. This balance among skin, fat, muscle, and bone is lost with aging as progressive changes occur in their volume, shape, position, and consistency. Aging of the human face generally starts in the third decade of life, mainly in the midface and periorbital areas. Traditional face-lifting surgeries result in minimal improvements in the midface area. Various techniques have been developed using different dissection planes and vectors with different forms of incision, including endoscopic techniques. METHODS: We attempted to combine endoscopic subperiosteal dissection techniques with the percutaneous needle technique, especially in young- to middle-aged patients. We aim to share technical details of our preferred suspension and fixation method for an endoscopic midface lift with the aid of a percutaneous needle and to present the outcomes of this particular technique in 75 patients. RESULTS: Significant rejuvenation of the nasojugal groove was achieved, and patient satisfaction was high. All cases exhibited satisfactory, symmetrical, and stable elevation of the midface. None of the patients required a second surgery. CONCLUSION: Trinity lift allowed for stronger, easier, and faster application of sutures during endoscopic facial surgery without any other mucosal or transcutaneous incisions. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .


Assuntos
Ritidoplastia , Envelhecimento da Pele , Bochecha/cirurgia , Endoscopia , Humanos , Pessoa de Meia-Idade , Rejuvenescimento
20.
Ann Otol Rhinol Laryngol ; 130(9): 1016-1023, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33514267

RESUMO

OBJECTIVES: Advanced cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with poor outcome despite multimodality therapy. Comprehensive risk stratification may pinpoint the most suitable adjuvant treatment. This study aimed to evaluate the outcomes of surgically treated locoregional CSCCHN and to identify prognostic indicators of treatment outcomes. METHODS: We retrospectively analyzed disease variables, pathologic characteristics, and management in association with treatment outcomes of all consecutive advanced CSCCHN patients who underwent surgical resection at Tel Aviv Sourasky Medical Center. RESULTS: From 2008 to 2018, 74 patients met the inclusion criteria. Only perineural invasion (PNI) was significantly associated with worse overall survival (OS) (P = .001). Location within the facial "mask areas" was significantly associated with pathologically negative cervical disease (P = .001). Forty-seven patients underwent adjuvant radiation therapy (RT) which significantly improved OS and disease-free survival versus surgery alone (P = .025 and P = 0.035, respectively). CONCLUSION: PNI was associated with worse OS in surgically treated advanced CSCCHN. Adjuvant RT conferred better outcomes despite high risk features.


Assuntos
Neoplasias Faciais/cirurgia , Linfonodos/patologia , Esvaziamento Cervical , Radioterapia Adjuvante , Couro Cabeludo/cirurgia , Neoplasias Cutâneas/cirurgia , Carcinoma de Células Escamosas de Cabeça e Pescoço/cirurgia , Idoso , Idoso de 80 Anos ou mais , Bochecha/patologia , Bochecha/cirurgia , Quimiorradioterapia Adjuvante , Intervalo Livre de Doença , Neoplasias da Orelha/patologia , Neoplasias da Orelha/cirurgia , Extensão Extranodal/patologia , Neoplasias Palpebrais/patologia , Neoplasias Palpebrais/cirurgia , Neoplasias Faciais/patologia , Feminino , Testa/patologia , Testa/cirurgia , Humanos , Hospedeiro Imunocomprometido , Estimativa de Kaplan-Meier , Neoplasias Labiais/patologia , Neoplasias Labiais/cirurgia , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Gradação de Tumores , Invasividade Neoplásica , Recidiva Local de Neoplasia , Neoplasias Nasais/patologia , Neoplasias Nasais/cirurgia , Procedimentos Cirúrgicos Otorrinolaringológicos , Glândula Parótida , Modelos de Riscos Proporcionais , Procedimentos Cirúrgicos Reconstrutivos , Couro Cabeludo/patologia , Neoplasias Cutâneas/patologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Taxa de Sobrevida , Resultado do Tratamento
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