The role of the perioperative prone position in the low recurrence of pressure injuries in the pelvic region.

OBJECTIVE: A pressure injury (PI) is a localised area of damage to the skin and/or underlying soft tissue as a result of a sustained mechanical loading. There are three key aetiological mechanisms to PI formation-direct cell deformation, inflammatory oedema and ischaemic damage-which are typically activated sequentially to drive a spiral of injury. This article discusses the role of the perioperative prone position as a rational approach to reducing the recurrence of pelvic PI after reconstructive surgery. METHOD: Patients with deep PI in the pelvic region, who were operated on from 2011 to 2019, were retrospectively evaluated. The protocol of care included training in the prone position, followed by maintenance of the prone position for 4-6 weeks postoperatively. The reconstruction was performed with fasciocutaneous and myocutaneous local or regional flaps. RESULTS: The study evaluated a total of 26 patients. The rate of recurrence of PIs was 15.4% (4/26) in the mean follow-up of 54 months. Regarding postoperative complications, four cases of partial dehiscence of the suture occurred. CONCLUSION: This perioperative protocol of maintaining a prone position seems to be safe for the patient, and it can be used to prevent or reduce the recurrence of deep PIs on the pelvic region after reconstructive surgery.

Sensory testing in patients with hemodialysis-associated carpal tunnel syndrome submitted to surgical decompression.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common compression neuropathy of the upper limb. Close to 5% of patients with chronic renal failure who need hemodialysis present CTS. Clinical history and physical examination remain the most adequate tools for diagnosis, and there is still controversy regarding the most reliable test to complement it. Evaluation of sensory thresholds using Pressure-Specified Sensory Device (PSSD) has become an important instrumental test. METHOD: This study aimed to determine the values of pressure sensory thresholds using the PSSD before and after treatment of CTS in a special group of patients who underwent chronic hemodialysis. The PSSD incorporates a pressure transducer linked to a computer capable of measuring the cutaneous pressure thresholds referred by the patient. Two groups were compared as follows: group 1, patients with hemodialysis-related CTS; and group 2, CTS in non-hemodialysis patients. The following measurements were assessed: static one point, moving one point, static two points, and moving two points. RESULTS: There was improvement (lower thresholds) in the postoperative measurements in all parameters assessed in group 1, and improvements in all parameters except the moving one point test in group 2. CONCLUSIONS: Nerve decompression, as expected, can be considered a good treatment of CTS even in more severe cases as in those patients under hemodialysis. The PSSD tests were reliable to confirm the diagnosis and thus to indicate the decompression. It is even more beneficial to provide a comparison between preoperative and postoperative data and different causes of CTS.

Lymph fasciocutaneous lateral thoracic artery flap: anatomical study and clinical use.

BACKGROUND: The lateral thoracic flap was first studied in the mid-1970s but its use has been limited because of pedicle anatomical variations. However, after the development of lymph node transfer surgery, the axilla/upper lateral thorax presented as a promising donor area. Through a detailed anatomical study, the lateral thoracic flap was evaluated regarding its vascularization and composition. Later, it was used for pedicle and free flap reconstructions. METHODS: A total of 40 flaps were dissected in fresh cadavers and the characteristics of the lateral thoracic pedicle and its relationship to the upper lateral thoracic axillary lymph nodes (LTLN) were analyzed. We performed six pedicle flap reconstructions around the shoulder area and a free lymph node transfer for lower limb lymphedema. RESULTS: In the cadaveric dissections, the lateral thoracic pedicle branched off the axillary vessels and was found to be a primary level I axillary lymph node irrigator before reaching the skin. The cutaneous portion of the artery was present in 87.5% of the dissections. Arterial caliber was an average of 1.3 and venous, 2.6 mm. Five to seven lymph nodes were isolated with each pedicle and a lymph fasciocutaneous flap could be designed. In seven clinical cases, all of the flaps survived. Functioning lymph nodes were visualized on lymphoscintigraphy after their transfer to the ankle. Donor area had an inconspicuous evolution. CONCLUSION: Lateral thoracic flap is a feasible flap with low donor area morbidity in a concealed region that can be harvested with upper LTLN for transplantation.

Clinical outcomes following nipple-areola-sparing mastectomy with immediate implant-based breast reconstruction: a 12-year experience with an analysis of patient and breast-related factors for complications.

Nipple-sparing mastectomy (NSM) is increasingly offered to women for therapeutic and prophylactic indications. Although, clinical series have been described, there are few studies describing risk factors for complications. The objective of this study is to evaluate the incidence of complications in a series of consecutive patients submitted to NSM and differences between clinical risk factors, breast volume, and different incision types. In a cohort-designed study, 158 reconstructed patients (invasive/in situ cancer and high risk for cancer) were stratified into groups based on different types of incision used (hemi-periareolar, double-circle periareolar, and Wise-pattern). They were matched for age, body mass index, associated clinical diseases, smoking, and weight of specimen. Also included were patients treated with adjuvant chemotherapy and postoperative radiotherapy. Mean follow-up was 65.6 months. In 106 (67 %) patients, NSM was performed for breast cancer treatment and in 52 (32.9 %) for cancer prophylaxis. Thirty-nine (24.6 %) patients were submitted to hemi-periareolar technique, 67 (42.4 %) to double-circle periareolar incision, and 52 (33 %) to Wise-pattern incision. The reconstruction was performed with tissue expander and implant-expander. Local recurrence rate was 3.7 % and the incidence of distant metastases was 1.8 %. Obese patients and higher weight of specimen had a higher risk for complications. After adjusting risk factors (BMI, weight of specimen), the complications were higher for patients submitted to hemi-periareolar and Wise-pattern incisions. This follow-up survey demonstrates that NSM facilitates optimal breast reconstruction by preserving the majority of the breast skin. Selected patients can have safe outcomes and therefore this may be a feasible option for breast cancer management. Success depends on coordinated planning with the oncologic surgeon and careful preoperative and intraoperative management. Surgical risk factors include incision type, obesity, and weight of breast specimen.

Alternative surgical treatment of paralytic lagophthalmos using autogenic cartilage grafts and canthopexy.

PURPOSE: This study aims to analyze the use of autogenic auricular cartilage grafts as weight for the upper eyelid in conjunction with lateral canthopexy for patients with mild paralytic lagophthalmos. This procedure was also accompanied by elevation of the lower eyelid using the cartilage graft for moderate cases. METHODS: We conducted a retrospective study including case series of 30 patients with paralytic lagophthalmos from 1997 to 2010. For mild cases, cartilage from the auricular scapha was placed in pretarsal space of the upper eyelid and cartilage from the concha was inserted in preaponeurotic space and then sutured to the levator aponeurosis in conjunction with lateral canthopexy. For moderate cases, lower eyelid was also elevated by suturing cartilage graft to tarsum and resting it by the inferior orbital rim. RESULTS: All patients had some degree of keratopathy before the intervention. After treatment, they presented with evident clinical improvement, reduction of eye symptoms, and resolution of keratopathy. During the mean postoperative follow-up of 37.3 months, none of the patients presented with cartilage graft exposition, reabsorption, visibility, infection, or warping. Complete eye closure was achieved in 24 (80%) patients, whereas the remaining 6 (20%) patients had residual asymptomatic lagophthalmos. CONCLUSIONS: The intervention using autogenic auricular cartilage grafts explained in this study was only effective for the treatment of mild and moderate cases of paralytic lagophthalmos. This outpatient surgery is associated with low morbidity and achievement of functional and aesthetic improvement.

Prefabricated bone flap: an experimental study comparing deep-frozen and lyophilized-demineralized allogenic bones and tissue expression of transforming growth factor ß.

BACKGROUND: Extensive bone defects are still a challenge for reconstructive surgery. Allogenic bones can be an alternative with no donor area morbidity and unlimited amount of tissue. Better results can be achieved after allogenic bone preparation and adding a vascular supply, which can be done along with flap prefabrication. The purpose of this study was to evaluate demineralized/lyophilized and deep-frozen allogenic bones used for flap prefabrication and the tissue expression of transforming growth factor ß (TGF-ß) in these bone fragments. METHODS: Fifty-six Wistar rat bone diaphyses were prepared and distributed in 4 groups: demineralized/lyophilized (experimental group 1 and control group 2) and deep freezing (experimental group 3 and control group 4). Two bone segments (one of each group) were implanted in rats to prefabricate flaps using superficial epigastric vessels (experimental groups) or only transferred as grafts (control groups). These fragments remained in their respective inguinal regions until the death that occurred at 2, 4, and 6 weeks after the operation. Semiquantitative histologic (tetracycline marking, cortical resorption, number of giant cells, and vascularization) and histomorphometrical quantitative (osteoid thickness, cortical thickness, and fibrosis thickness) analyses were performed. Transforming growth factor ß immunohistochemistry staining was also performed. RESULTS: Group 1 fragments presented an osteoid matrix on their external surface in all periods. Cartilage formation and mineralization areas were also noticed. These findings were not observed in group 3 fragments. Group 1 had more mineralization and double tetracycline marks, which were almost not seen in group 3. Cortical resorption and the number of giant cells were greater in group 3 in all periods. Vascularization and fibrosis thickness were similar in both experimental groups. Group 1 had more intense TGF-ß staining within 2 weeks of study. Nevertheless, from 4 weeks onward, group 3 presented statistically significant stronger staining. CONCLUSIONS: Although there are some differences between the preparation methods of allogenic bone, it is possible to prefabricate flaps with demineralized/lyophilized and deep-frozen bones.

Monsplasty for women after massive weight loss.

BACKGROUND: Ptosis with excess skin in the pubic area is a very common deformity in patients after massive weight loss. This deformity requires adequate surgical treatment whether combined with abdominoplasty or not. The enlarged pubogenital area may lead to psychosocial distress and impaired quality of life. METHODS: A series of 23 women with a mean age of 39.5 years who previously underwent bariatric surgeries and later presented with pubogenital ptosis underwent monsplasty. The preoperative surgical markings and the surgical technique presented are easily reproducible. In this prospective study, the surgical outcomes were assessed by questionnaires applied to the patients, who scored the following parameters: movement dynamics, aesthetic appearance, sexual performance, improved hygiene, and use of clothing items. RESULTS: Four of the parameters assessed (movement dynamics, aesthetic appearance, hygiene, and use of clothing items) showed clear improvement, with scores ranging from good to very good. A small percentage of the patients (13%) reported fair improvement in sexual performance. CONCLUSION: The findings showed monsplasty to be a simple and reproducible technique with favorable outcomes and low morbidity rates. 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 the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Evaluation of aesthetic abdominal surgery using a new clinical scale.

BACKGROUND: Evaluation of outcomes after aesthetic surgery still is a challenge in plastic surgery. The evaluation frequently is based on subjective criteria. This study used a new clinical grading scale to evaluate aesthetic results for plastic surgeries to the abdomen. The method scores each of the following five parameters: volume of subcutaneous tissue, contour, excess of skin, aspect of the navel, and quality of the scar on the abdominal wall. The scale options are 0 (poor), 1 (fair), and 2 (good), and the total rate can range from 0 to 10. METHODS: The study included 40 women ages 18-53 years. Of these 40 women, 20 underwent traditional abdominoplasty, and 20 had liposuction alone. Preoperatively and at least 1 year later, photographic results were analyzed and scored by three independent plastic surgeons. RESULTS: In the abdominoplasty group, the average grade rose from 2.9±0.4 to 6.8±0.4 postoperatively. In the liposuction group, the average grade was 5.3±0.5 preoperatively and 7.7±0.4 postoperatively. In both groups, the average postoperative grade was significantly higher than the preoperative grade. The mean scores for groups A and L were significantly different, demonstrating that the scale was sensitive in identifying different anatomic abnormalities in the abdomen. CONCLUSIONS: The rating scale used for the aesthetic evaluation of the abdomen was effective in the analysis of two different procedures: conventional abdominoplasty and liposuction. Abdominoplasty provided the greater gain according to a comparison of the pre- and postoperative scores.

Outcome analysis of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammaplasty techniques.

BACKGROUND: Bilateral mammaplasty or mastopexy is frequently used for oncoplastic objectives. However, little information has been available regarding outcome following immediate and delayed reconstruction. METHOD: Patients were divided into Group I (immediate reconstruction) and Group II (delayed reconstruction). Retrospective review was performed to compare complications, length of hospital stay, revision surgeries, and satisfaction. The associations between the complications with potential risk factors (timing, age, body mass index, smoking, and comorbid medical conditions) were analyzed. RESULTS: There were a total of 144 patients with a mean follow-up of 47 months. Of the 106 patients in Group I, complications occurred in 24 (22.6%), skin necrosis was observed in 7.5%, fat necrosis in 5.6%, and 6.6% patients developed local recurrence. Mean period of hospitalization was 1.89 days. Of the 38 patients of the Group II, complications occurred in 12 (31.5%), skin necrosis was observed in 7 (18.4%), fat necrosis in 4 (10.5%), and 5.2% patients developed local recurrence. Mean period of hospitalization was 1.35 days. Increased length of hospital stay greater than 1 day (P < 0.001) and the number of revision surgeries (P = 0.043) were associated with the timing of the reconstruction. In univariate analysis, no difference between groups was found with respect to complication incidence (P = 0.275); however, after adjusting for other risk factors, the probability of complications tend to be higher for Group II (OR = 2.65; 95% confidence interval = 1.01-7.00; P = 0.049). CONCLUSIONS: On the basis of the results of our study, the probability of complications tends to be higher for delayed reconstructions, and it is demonstrated that obesity and smoking are risk factors for complications. Ultimately, these data may facilitate the provision of individualized risk information for shared medical decision-making.

Analysis of the strength of the abdominal fascia in different sutures used in abdominoplasties.

BACKGROUND: Protrusion of the abdominal wall secondary to abdominoplasty may occur in patients with weakness of the aponeurotic structures. The anterior layer of the rectus abdominis muscle consists of fibers that are transverse rather than vertical. Based on this anatomical feature, vertical sutures are suggested for the correction of diastasis recti, since they include a greater amount of fascial fibers and thus would be more resistant to tensile strength than horizontal ones. METHODS: The anterior layers of the rectus abdominis muscles of 15 fresh cadavers were dissected. Two vertical lines were marked on each side of the linea alba, corresponding to the site where plication is usually performed in abdominoplasties. Three abdominal levels were evaluated: the supraumbilical, umbilical, and infraumbilical levels. A simple suture was placed in the vertical direction in one group and in the horizontal direction in the other group, at each of the three levels previously described. These sutures were connected to a dynamometer, which was pulled medially toward the linea alba until rupture of the aponeurosis occurred. RESULTS: The mean strength required to rupture the aponeurotic structures in which the vertical sutures had been placed was greater than for the horizontal ones (p < 0.0001). CONCLUSION: The vertical suture of the rectus abdominis sheaths was stronger than the horizontal suture because of the more transversal arrangement of its aponeurotic fibers. Thus, routine use of the vertical suture in plications of the aponeurosis of the rectus abdominis muscles is suggested.

Clinical trial comparing 3 different wound dressings for the management of partial-thickness skin graft donor sites.

PURPOSE: A review of the literature reveals a lack of consensus regarding local management of skin graft donor sites. This study was undertaken to determine the effects of 3 different dressings on healing of donor sites and patient discomfort related to donor sites. DESIGN: This study is a comparison cohort study. SUBJECTS AND SETTING: We recruited 34 burn patients scheduled for partial-thickness skin grafts; their mean age was 36 ± 18 years (mean ± SD, range 20 to 54 years), and 63% were male. All subjects were managed at Burn Unity Care, located in Sao Paulo, Brazil. MATERIALS AND METHODS: Subjects were randomly allocated to 1 of 3 groups: (1) a study group (group A) whose donor sites were dressed with a bovine collagen calcium-alginate dressing covered with transparent polyurethane film; (2) a second intervention group (group B), whose donor sites were dressed only with transparent polyurethane film dressing; and (3) a control group whose donor sites were dressed with rayon soaked in 0.9% saline (group C). Two independent observers assessed donor site wounds for epithelialization, scabbing, quantity and characteristics of exudate, and complications. Pain was measured using the visual analog scale, the brief pain inventory, and Index of Pain Management. RESULTS: Subjects managed with the bovine collagen calcium-alginate dressing covered with transparent polyurethane film (group A) achieved the greatest epithelialization (6.3 vs 8.2 for thin film dressing only P < .02 and 6.3 vs 11.7 days for control group P < .01). Patients managed with the bovine collagen calcium-alginate dressing covered with transparent polyurethane film also reported less pain that subjects allocated to the control (group C) or thin film only group (group B), (P < .05). Ninety percent of subjects allocated to the calcium alginate covered with thin film dressing reported mild pain intensity on the Visual Analog Scale, 85% of did not report pain localized to the donor site on the brief pain inventory, and scores on the Index of Pain Management ranged from 23 to 11. CONCLUSION: Study findings suggest that use of a collagen calcium-alginate dressing with a transparent film covering reduces the time for complete epithelialization and may reduce pain related to skin graft donor sites.

Facial reanimation with masseteric nerve: babysitter or permanent procedure? Preliminary results.

The authors are presenting a series of 10 cases of complete unilateral facial paralysis submitted to (I) end-to-end microsurgical coaptation of the masseteric branch of the trigeminal nerve and distal branches of the paralyzed facial nerve, and (II) cross-face sural nerve graft. The ages of the patients ranged from 5 to 63 years (mean: 44.1 years), and 8 (80%) of the patients were females. The duration of paralysis was no longer than 18 months (mean: 9.7 months). Follow-up varied from 6 to 18 months (mean: 12.6 months). Initial voluntary facial movements were observed between 3 and 6 months postoperatively (mean: 4.3 months). All patients were able to produce the appearance of a smile when asked to clench their teeth. Comparing the definition of the nasolabial fold and the degree of movement of the modiolus on both sides of the face, the voluntary smile was considered symmetrical in 8 cases. Recovery of the capacity to blink spontaneously was not observed. However, 8 patients were able to reduce or suspend the application of artificial tears. The authors suggest consideration of masseteric-facial nerve coaptation, whether temporary (baby-sitter) or permanent, as the principal alternative for reconstruction of facial paralysis due to irreversible nerve lesion with less than 18 months of duration.

Facial palsy after blunt trauma and without facial bone fracture.

A 14-year-old patient had a low-energy facial blunt trauma that evolved to right facial paralysis caused by parotid hematoma with parotid salivary gland lesion. Computed tomography and angiography demonstrated intraparotid collection without pseudoaneurysm and without radiologic signs of fracture in the face. The patient was treated with serial punctures for hematoma deflation, resolving with regression and complete remission of facial paralysis, with no late sequela. The authors discuss the relationship between facial nerve traumatic injuries associated or not with the presence of facial fractures, emphasizing the importance of early recognition and appropriate treatment of such cases.

Mammaplasty with inferior pedicle flap after massive weight loss.

BACKGROUND: After massive weight loss, one of the stigmas that afflict women is the remaining deformity of the breasts which become flaccid and ptotic, with an absent or flat upper pole. The authors propose the use of a well-established mammaplasty technique to fill the upper pole, reshape the breast cone, and correct ptosis with nipple-areola complex (NAC) repositioning. METHODS: A total of 16 patients were analyzed; all underwent gastroplasty between 18 and 24 months prior to mammaplasty. The mean age was 41.6 years (range = 26-62) and the mean BMI previous to the mammaplasty was 29.2 kg/m(2) (range = 24.9-38.9). The technique included a dermo-lipo glandular flap pedicled on the inframammary fold (IMF) together with a superior flap containing the NAC. RESULTS: All patients who underwent surgery were satisfied with the outcomes since a more aesthetic breast shape was achieved, with projection of the upper pole and correction of ptosis. Adverse events included dehiscence at the junction point of the flaps in the inframammary fold, which resolved with secondary-intention wound healing in three patients; partial necrosis of the areola in one patient; epidermolysis in one of the NACs in one patient; and infection in one of the breasts in one patient, which resolved with proper antibiotic therapy. CONCLUSION: When compared to the current mammaplasty techniques performed in formerly obese patients, this is a good surgical option because it uses tissues adjacent to the breast itself and does not require silicone prosthesis for breast augmentation. The patients reported increased self-esteem and improvement in their quality of life.

Which end is up? Terminology for terminolateral (end-to-side) nerve repair: a review.

By convention, we "come from" and "go to." A flap has a donor site and goes to a recipient site. A transplant comes from a donor and goes to a recipient. Neural regeneration proceeds from proximal to distal. It seems most appropriate then for a nerve repair description to follow this logical order. Therefore an "end-to-side" repair would mean that the donor nerve, the nerve that is providing the axons with which to neurotize the recipient nerve, should be the nerve named first. An end-to-side repair would therefore require that the nerve whose end is sutured into the side of the recipient nerve be the nerve that is bringing the proximal axons to regenerate distally, for whatever that purpose may be, sensory or motor. A side-to-end repair would therefore require that the nerve whose side is sutured to the end of the recipient nerve be the nerve that is bringing the proximal axons to regenerate distally, for whatever that purpose may be, sensory or motor. The full descriptive phrase must include whether the intent is to reinnervate a skin target and is, therefore, a sensory repair, or to reinnervate a motor target. The names of both the donor and the recipient nerves must be specified. Illustrations of these logical possibilities are shown in this review of the modern history of "end-to-side" or "side-to-end" nerve coaptations.

Aesthetic quality of the nipple-areola complex in breast reconstruction with a new local graft technique.

BACKGROUND: Reconstruction of the nipple-areola complex (NAC) is the last stage of breast reconstruction and represents the search for symmetry in regard to the contralateral breast. The objective of this study was to present an areola reconstruction technique with local skin graft to improve the texture and aspect of the reconstructed areola, searching for a natural look. METHODS: This technique was performed on 122 patients who in the period from January 2000 to December 2005 were submitted to nipple and areola reconstruction. Once the position of the new nipple was determined, markings were made for the reconstruction of the areola. Then the external limit of the new areola was incised and the skin was centripetally deepidermized up to 85% of its diameter. After this procedure the detached skin was repositioned in its bed as a graft and sutured with 4.0 mononylon thread. Incisions with an 11-blade scalpel were then made in V and C forms associated with the detachment of this skin of the receptor area along the local graft so that at the end of the healing process they would determine alterations in the areolar texture mimicking the texture of a normal areola. All patients underwent tattooing 3 months after reconstruction of the NAC taking into account the different shades of the contralateral areola and nipple colors. RESULTS: The use of a local skin graft associated with C and V incisions allowed alteration in the texture of the reconstructed areola. The use of different ink shades for tattooing helped to give a tridimensional aspect to this areola. These factors determined a good aesthetic result in these patients. CONCLUSION: This areola reconstruction using a local skin graft allows change in the areola texture and a tridimensional aspect similar to that of a normal areola without the inconvenience of grafting from a distance.

Botulinum toxin injection in long-standing facial paralysis patients: improvement of facial symmetry observed up to 6 months.

BACKGROUND: Despite modern reanimation surgical techniques, facial paralysis presents with functional and aesthetic deficits. We evaluated facial symmetry after treating with botulinum toxin the healthy side of the face of 25 patients with long-standing facial paralysis who had previously been treated by surgical methods, with 6 months follow-up. METHODS: Evaluation consisted of a clinical score, the two subscales of the Facial Disability Index, and surface electromyography. The mean botulinum toxin dose was 38 +/- 5 U (range = 15-69 U). RESULTS: The clinical score showed significant reduction of asymmetry of 48.4% at 1 month and 16.8% after 6 months. The initial result was a consequence of reduced motion on the treated side combined with better motion on the paralyzed side. At 6 months, the treated side returned to basal scores. The residual effect seen in symmetry was due to an increase (18%) of motion in the paralyzed side. There was a significant decrease in the action potential of muscles on the nonparalyzed side 1 month post injection but completely reverted after 6 months. The Physical Function Index increased, but not significantly. The Social/Well-Being Function Index showed a significant increase at 6 months compared to pretreatment. CONCLUSION: The proposed treatment improved facial symmetry for up to 6 months. Even after the end of the clinical effect of the drug, the paralyzed side's clinical score was 18% higher than pretreatment, with an increased quality of life.

Lacrimal gland prolapse: management during aesthetic blepharoplasty: review of the literature and case reports.

Prolapse of the lacrimal gland is an acquired clinical condition caused mainly by relaxation of the local suspending ligaments. Before an aesthetic blepharoplasty, there should be a preoperative clinical suspicion of lacrimal gland pathology for patients with bulging lateral thirds of the upper eyelids. It should be borne in mind that inadvertent removal of the lacrimal gland can lead to important alterations in ocular lubrication. This report describes two clinical cases of patients with lacrimal gland prolapse associated with dermatochalasis and their treatment.

[Cutaneous sensibility threshold in the feet of diabetic patients with pressure specified sensory device: an assessment of the neuropathy]. / Limiar de sensibilidade cutânea dos pés em pacientes diabéticos através do pressure specified sensory device: uma avaliação da neuropatia.

OBJECTIVES: Neuropathy is a severe progressive loss of protective sensation in the feet, increasing patient vulnerability to mechanical trauma and consequently more prone to development of chronic wounds, major distortion of the foot bone architecture and to eventual limb amputation. Prophylaxis should be enforced to avoid foot ulceration and for this purpose, evaluation of the degree of loss of sensation on the skin is essential. The PSSD (Pressure Specified Sensory Device) was developed to quantify the threshold of pressure applied to the skin that the patient might recognize as positive. Pressure of one or two points is tested both statically and with movement, thus assessing the function of fast and slow response nerve fibers. METHODS: 33 diabetic patients, type II, with no previous history of wounds on the lower extremity were studied. The tests used were, one point static, one point moving and two points, static and moving on the cutaneous territory of the fibular nerve and posterior tibial nerve (two territories - medial plantar and calcaneous nerves). RESULTS: Altered values were observed for the static and dynamic tests over the three nerve territories studied. Differences were statically significant (p < 0.05). This numeric quantification of the threshold of pressure supports the evaluation of the status of the fiber/receptor structures as well as the functional deficit subsequent to diabetic neuropathy.

[Body contour surgery in the massive weight loss patient: three year-experience in a secondary public hospital]. / Cirurgia do contorno corporal no paciente após perda ponderal maciça: experiência de três anos em hospital público secundário.

OBJECTIVE: To present the clinical-surgical three year-experience related to body contour surgery in the massive weight loss patient, performed by the Plastic Surgery team of the Sapopemba State Hospital. METHODS: Retrospective study performed at the Sapopemba State Hospital, linked to the 'Hospital das Clínicas' of the University of São Paulo School of Medicine, from July 2005 to July 2008. A total of 98 patients was operated, whose morbid obesity had been treated by bariatric surgery, after success of the technique, or weight loss by non-surgical method. Exclusion criteria were smoking, gestational intent and weight instability. Stable weight for at least 6 months after satisfactory weight loss was required from patients. RESULTS: Of the 98 operated patients, 97% were female, with mean age of 40.5 years and the weight loss method was the surgery in 88% of cases. From 177 plastic surgeries performed, 46% were abdominoplasty, followed by mammaplasty (15%), thigh suspension (13%) and brachioplasty (12%). Mean hospital stay was of two days and the main diagnosed complications were: seroma (28%), minor necrosis/dehiscences (18%), major necrosis/dehiscences (4%), hematomas (4%), superficial thrombophlebitis from the saphena vein (2%) and deep venous thrombosis (1%). CONCLUSION: An increasing demand for surgeries to improve body contour after massive weight loss has been detected. Plastic surgeons must know the clinical peculiarities and higher risk of complications of these patients, control their expectations, analyze results and engage in a continued investigation to improve surgical techniques.