Response to sirolimus in capillary lymphatic venous malformations and associated syndromes: Impact on symptomatology, quality of life, and radiographic response.

BACKGROUND: Capillary lymphatic venous malformations (CLVM) and associated syndromes, including Klippel-Trenaunay syndrome (KTS) and congenital lipomatous overgrowth, vascular malformation, epidermal nevi, skeletal, and spinal syndrome (CLOVES), are underrecognized disorders associated with high morbidity from chronic pain, recurrent infections, bleeding, and clotting complications. The rarity of these disorders and heterogeneity of clinical presentations make large-scale randomized clinical drug trials challenging. Identification of PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha [gene]) mutations in CLVM has made targeted medications, such as sirolimus, attractive treatment options. The aim of this study was to investigate the safety and efficacy of sirolimus therapy in CLVM. PROCEDURE: A combined prospective and retrospective cohort of pediatric and young adult patients with CLVM treated with sirolimus was evaluated for disease response, including symptom improvement, quality of life (QOL), and radiologic response. Sirolimus dosing regimens and toxicities were also assessed. RESULTS: Twenty-nine patients with CLVM, including KTS and CLOVES, were included. Ninety-three percent of patients reported improved QOL, and 86% had improvement in at least one symptom. Most significantly, improvement was noted in 100% of patients with bleeding and 89% with thrombotic complications with corresponding decreases in mean D-dimer (p = .008) and increases in mean fibrinogen (p = .016). No patients had progressive disease on sirolimus. Most common side effects included neutropenia, lymphopenia, infection, and aphthous ulcers/stomatitis. No toxicities were life-threatening, and none required long-term discontinuation of sirolimus. CONCLUSION: Sirolimus appears to be effective at reducing complications and improving QOL in patients with CLVM and associated syndromes. In this patient cohort, sirolimus was well tolerated and resulted in few treatment-related toxicities.

Congenital Midline Cervical Cleft and Thyroglossal Duct Fibrous Cord-Like, is There a Mixed Presentation?

INTRODUCTION: Congenital midline cervical cleft is a rare condition and is frequently misdiagnosed as thyroglossal duct cyst. Otherwise, the combination of congenital midline cervical cleft and thyroglossal duct fibrosis in the same patient is as rare as important to be registered with the intention to inform and offer specific managements details for the literature. CASE PRESENTATION: Eight-year-old boy with simultaneous congenital midline cervical cleft and a thyroglossal duct fibrosis. The anatomic, clinical, radiologic, and pathologic characteristics of the congenital midline cervical cleft are described as well as surgical technique for removal and repair with Z-plasty. CONCLUSION: Congenital midline cervical cleft is a rare condition and when diagnosed must be surgically treated as early as possible. Its differential diagnosis is a clinical challenge.

Comparing Results of Syndactyly Operated Children Younger and Older Than 1 Year.

INTRODUCTION: Syndactyly has a cosmetic, functional, and psychosocial impact, and surgical treatment is indicated in most cases. This study aimed to retrospectively identify whether patients undergoing surgical release of syndactyly younger than 1 year presented different results compared with those operated older than 1 year. METHODS: Patients were assessed through photographic records by 3 independent specialist surgeons for the quality of scar, presence of web creep, rotational, flexion-extension, and lateral flexion deformities using the Withey score. RESULTS: Thirty-four patients were included in the study, totaling 51 commissures operated. The score was higher in the group operated younger than 1 year (5.83 ± 2.39) compared with the group older than 1 year (3.94 ± 1.93), being statistically significant, with a P value of 0.011. CONCLUSIONS: Children with syndactyly operated younger than 1 year have worse postoperative outcomes measured by the Withey score than those operated older than 1 year.

Re: Brazilian Consensus Recommendation on the Use of Polymethylmethacrylate Filler in Facial and Corporal Aesthetics by Túlio Armanini Blanco Souza, Letícia Marques Colomé, Eduardo André Bender, Gottfriede Lemperle Aesthethic Plastic Surgery 2018; 42(5): 1244-51.

The self-titled study Brazilian Consensus Recommendation cannot be considered a consensus and more specifically cannot be considered a Brazilian consensus. The study does not represent the point-of-view of members of the Brazilian Society of Plastic Surgery. The content of this paper is plenty of contradictory and questionable affirmations. Method is flaw and does not inform any consistent data. Results and discussion are in the same section, making unclear what is result and what is pure speculation. This report is not a consensus nor reflects the opinion of plastic surgeons represented by the Brazilian Society of Plastic Surgery (SBCP). Moreover, SBCP does not approve the use of PMMA as a filler for esthetical purposes in healthy patients.Level of Evidence V 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 www.springer.com/00266 .

Successful Treatment of a Complex Vascular Malformation With Sirolimus and Surgical Resection.

Management of complex vascular malformation represents a challenge as it may include a wide variety of options such as embolization, laser therapy, sclerotherapy, and surgical resection but may lead to significant morbidity and is associated with high recurrence rates. In extreme and/or recurrent cases, successful use of sirolimus has been described. We report a case of large unresectable complex venous malformation treated with oral sirolimus for 24 months. Therapy was well tolerated. Patient had substantial improvement in symptoms and shrinkage of the lesion. The Medical Therapy made excision of the malformation possible and patient had a successful surgical procedure. This report provides further evidence that sirolimus should be considered as part of the armamentarium in the management of these rare conditions.

Validation of Videoconference With Smartphones in Telemedicine Facial Trauma Care: Analysis of Concordance to On-Site Evaluation.

BACKGROUND: The continental size of some countries and heterogeneous hospital network prevents patients who live in remote areas from getting adequate initial assessment of facial trauma. The authors present an alternative model for trauma assessment by videoconference via smartphones and analyze the concordance between telemedicine and face-to-face management. METHODS: Fifty patients with either a confirmed or suspected diagnosis of facial trauma were independently evaluated by 2 teams of physicians: Face-to-face and telemedicine-based. The face-to-face team attended patients at bedside (physical examination and computed tomography scan analysis). The telemedicine team consisted of a general surgery resident on duty in the emergency room and a plastic surgeon researcher remotely communicating via smartphones. Both teams answered a questionnaire, which contained data concerning patient's epidemiology, physical examination, computed tomography (CT) scan findings, and treatment option to be followed. Data were analyzed and compared regarding the similarity of answers. RESULTS: The sample studied was consistent with the literature, showing a predominance of young males. Traffic accidents and personal violence were the main causes of trauma. The concurrency of answers for physical examination findings was considered substantial (κ = 0.720). For CT scan findings, it was almost perfect (κ = 0.899); for defining the treatment option, it was almost perfect (κ = 0.891). High concurrency of face CT scan findings was observed after we calculated the positive predictive value (89.9%), negative predictive value (99.3%), sensitivity (94.2%), specificity (98.8%), and accuracy (98.3%). CONCLUSIONS: The proposed model to facial assessment trauma by videoconference via smartphones is feasible, showing high concordance level with face-to-face assessment.

Robotic and Plastic Surgery: actuality and prospects for the near future, a scoping review.

OBJECTIVE: This work aims to review the existing use of robotics in plastic surgery. METHODS: A meticulous selection process identified 22 articles relevant to this scoping review. RESULTS: The literature on the use of robotics in plastic surgery is sparse. Nonetheless, this review highlights emerging benefits in microsurgery, breast reconstruction, and transoral surgery. CONCLUSION: This scoping review identifies critical articles reporting the emerging use of robotics in plastic surgery. While the scientific medical community has yet to extensively document its use, the available evidence suggests a promising future for robotics in this field.

Surgical Treatment of Vascular Anomalies.

Recommendation for the surgical approach to vascular anomalies is rapidly evolving. From an isolated approach, surgery is best seen nowadays as an adjunctive tool in multidisciplinary management. Several studies focusing on targeted therapy based on genetic findings were published, and their use in clinical practice is on the way.

Stroke Due to Orthognathic Surgery: Case Report of a Rare Complication.

Le Fort I osteotomy is a frequent surgical procedure used in orthognathic surgeries to treat severe malocclusions and is associated with relatively rare surgical complications. Here, the authors report a case of thrombotic ischemic stroke as a result of this procedure, a complication still not described in the literature. A 19-year-old man with class II malocclusion and retrognathia underwent orthognathic surgery for aesthetic purposes. The surgery included a Le Fort I maxillary osteotomy with vertical impaction, bilateral sagittal split ramus osteotomy for mandibular advancement, and genioplasty. Postoperatively, the patient developed left eye blindness, headache, somnolence, aphasia, and right hemiplegia. Medical imaging showed the Le Fort I line of fracture extending from the maxillary osteotomy to the left optic canal and to the left carotid canal, with osseous fragments impinging the petrous segment of the internal carotid artery, left carotid artery occlusion and associated to an ischemic stroke at the left middle cerebral artery territory. Treatment required decompressive craniectomy and later focused on clinical stabilization, infection management, orthognathic care, neurorehabilitation, and cranioplasty. The hemiplegia and aphasia partially recovered during 12 months, and final dental occlusion was appropriate. Our report demonstrates that an unfavorable Le Fort I fracture trajectory can lead to ischemic stroke and severe neurological deficits.

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.

Management of arteriovenous malformation of the ear: A protocol for resection and reconstruction.

OBJECTIVE: Arteriovenous malformations (AVM) of the ear show unique features. Progressive growth or inadequate management of AVMs may lead to bleeding, infection, cartilage exposure, and ultimately loss of structure. Total ear amputation is an alternative; however, due to the structural complexity of the ear, reconstruction is technically challenging. This study presents a treatment algorithm based on a clinical series, with treatment options including resection and immediate and late reconstruction. METHODS: Between 2004 and 2018, 12 patients with auricular AVMs were treated with AVM resection and ear reconstruction at our hospital. Among these 12 patients, seven were women, and patients' ages ranged between 4 and 34 years. Parameters considered before resection and reconstruction were compromised ear extension (partial, total, or extra-auricular involvement), thickness (cutaneous and cartilaginous), symptoms (bleeding, infection, ulceration, and/or cartilage exposure), and preoperative embolization. Total resection of AVMs was planned as the first step in all cases, followed by primary closure. AVM resection was categorized into a partial or total procedure, resulting in partial or total ear defects. Reconstruction was categorized as immediate or delayed. RESULTS: Preoperative embolization was performed in 10 patients. AVMs were totally removed, resulting in seven total ear amputations. In six of these patients, total ear reconstruction was performed 6 months later, and all patients were recurrence-free. Only one patient did not undergo ear reconstruction. Regrowth was not observed in any reconstructed ear. CONCLUSION: Treatment of ear AVMs requires a planned approach to achieve favorable clinical outcomes and for concomitant safe and definitive reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1322-1326, 2020.

Trismus and oral health conditions during diagnosis of malignant oral neoplasms.

INTRODUCTION: Trismus has been considered a late complication of cancer treatment. It can occur prior to treatment, mainly caused by tumor invasion or muscle spasms induced by the presence of the tumor. OBJECTIVE: In this study, we evaluated the incidence of trismus and its effect on oral health in patients with malignant neoplasms of the oral cavity before performing the cancer treatment. METHODS: This review was carried out via interviews, visual clinical inspection and objective measurement of maximal mouth opening in 35 consecutive patients. Trismus was defined as a maximal mouth opening <35mm. RESULTS: Trismus was observed in 15 patients, with a total incidence of 42%. A high rate of tooth loss was recorded, and trismus association with tooth loss was statistically verified using the Chi-square and Fisher's exact tests, the t-student test and Mann-Whitney non-parametric test. All tests were performed at p<0.05. CONCLUSION: Edentulous patients are eight times more likely to have trismus compared to patients that are partially and fully dentate. Trismus was demonstrated to be correlated with tooth loss; however other oral health conditions were not shown to be a modifying factor.

The impact of COVID-19 on the plastic surgery activity in a high-complexity university hospital in Brazil: the importance of reconstructive plastic surgery during the pandemic.

BACKGROUND: The Hospital das Clínicas - University of Sao Paulo Medical School (HCFMUSP) is the largest university hospital complex in Brazil. HCFMUSP has been converted into a reference center for coronavirus disease 2019. The Division of Plastic Surgery postponed non-essential surgeries and outpatient consultations, accomplishing new guidelines (ANG) of national and international organizations. Even with these challenges arising from the pandemic, alternatives were considered to maintain institutional characteristics. This study aims to analyze this new scenario and the impact on patients' assistance and Plastic Surgery residents training. METHODS: Total number of surgeries, type of procedures, and outpatient consultations in 2020, before (pre-ANG) and after (post-ANG) ANG, were compared with the same period in 2019 (2019-pre and 2020-post). RESULTS: A marked reduction in the total number of surgeries and outpatient consultations was observed in the post-ANG period. In the post-ANG period, 267 operations were performed (26.7 ± 20.3/week), while in the 2019-post period, 1036 surgeries were performed (103.6 ± 9.7/week) (p = 0.0002). Similarly, 1571 consultations were conducted in the post-ANG period (157.1 ± 93.6/week), while in the 2019-post period, 3907 were performed (390.7 ± 43.1/week) (p = 0.0003). However, in the post-ANG period, an increase in the proportion of reconstructive compared with aesthetic surgery was observed. The maintenance of highly complex procedures such as microsurgical transplants was also identified. CONCLUSIONS: The predominant profile of reconstructive surgeries at the Division of Plastic Surgery allowed the continuity of procedures at all technical complexity levels, patient care maintenance, and Plastic Surgery residents training.Level of evidence: not ratable.

Surgical treatment of myelomeningocele carried out at 'time zero' immediately after birth.

BACKGROUND/AIMS: To present a protocol of immediate surgical repair of myelomeningocele (MMC) after birth ('time zero') and compare this surgical outcome with the surgery performed after the newborn's admission to the nursery before the operation. METHODS: Data from the medical files of 31 patients with MMC that underwent surgery after birth and after admission at the nursery (group I) were compared with a group of 23 patients with MMC admitted and prospectively followed, who underwent surgery immediately after birth--'at time zero' (group II). RESULTS: The preoperative rupture of the MMC occurred more frequently in group I (67 vs. 39%, p < 0.05). The need for ventriculoperitoneal shunt was 84% in group I and 65% in group II and 4 of them were performed during the same anesthetic time as the immediate MMC repair, with no statistically significant difference. Group I had a higher incidence of small dehiscences when compared to group II (29 vs. 13%, p < 0.05); however, there was no statistically significant difference regarding infections. After 1 year of follow-up, 61% of group I showed neurodevelopmental delay, whereas only 35% of group II showed it. CONCLUSIONS: The surgical intervention carried out immediately after the birth showed benefits regarding a lower incidence of preoperative rupture of the MMC, postoperative dehiscences and lower incidence of neurodevelopmental delay 1 year after birth.

Robotic and Plastic Surgery: actuality and prospects for the near future, a scoping review

ABSTRACT Objective This work aims to review the existing use of robotics in plastic surgery. Methods A meticulous selection process identified 22 articles relevant to this scoping review. Results The literature on the use of robotics in plastic surgery is sparse. Nonetheless, this review highlights emerging benefits in microsurgery, breast reconstruction, and transoral surgery. Conclusion This scoping review identifies critical articles reporting the emerging use of robotics in plastic surgery. While the scientific medical community has yet to extensively document its use, the available evidence suggests a promising future for robotics in this field.

The role of micro-anchor devices in medial canthopexy.

Telecanthus, the lateral displacement of the medial canthus, can be a congenital deformity or can occur after facial trauma or tumor resection. Treatment of telecanthus remains a challenge for plastic surgeons. For proper correction, it is necessary to shift the medial canthus medially, fixing its tendon to the bone. The ideal technique would allow easy, safe, and stable fixation of the tendon, permit a unilateral approach with minimal incisions, and be cost-effective. The purpose of this study was to evaluate the feasibility and results (immediate and long-term) of medial telecanthus repair using ipsilateral titanium microanchor fixation. Nine patients, 7 with unilateral telecanthus and 2 with bilateral telecanthus, underwent ipsilateral canthopexy involving a microanchor device. Anthropometric measurements of the orbital regions were taken before, immediately after, and at 1 year after surgery. Data for the affected sides were compared with those for the unaffected sides, and the evolution of those values was assessed throughout the 1-year follow-up period. For all patients, the final values were lower than those initially obtained. At 1 year after surgery, the intercanthal distance was reduced to age-adjusted normal values in all cases. On the operated side, stable improvement was observed in terms of the distance from the medial canthus to the midline, although some degree of recurrence was noted in most of the patients. The use of a microanchor system for medial canthopexy can be considered an easily performed and effective option for treating canthal dystopia, especially when an ipsilateral approach is preferred.

Blindness as a complication of monobloc frontofacial advancement with distraction.

The monobloc frontofacial osteotomy provides aesthetic and functional improvement in the treatment of various craniofacial deformities. This procedure, through highly complex, has had some significant associated complication, such as cerebrospinal fluid leakage, hematoma, infection, and bone resorption. Distraction has been successfully used to gradually elongate bone and soft tissue. This method seems to provide improved results over conventional surgery, with less morbidity. We present a case of a patient with Apert syndrome who underwent monobloc advancement using the Rigid External Device (RED) device and who developed a transient bilateral amaurosis on the fourth postoperative day before distraction. A second procedure was performed to push back the frontal bandeau, maintaining the device in position. The blindness was resolved with this procedure as well as treatment with systemic steroids. The distraction was started thereafter, and the desired improvement was acquired. To our knowledge, this is the first case of transient bilateral amaurosis in a patient undergoing monobloc distraction.

POSTOPERATIVE RETROSPECTIVE ANALYSIS OF THE TREATMENT OF DUPLICATED THUMB.

OBJECTIVE: To evaluate postoperative epidemiological and functional factors in patients operated to treat duplicate thumb. METHODS: This retrospective case series evaluated 20 patients (23 thumbs) treated from January 2012 to December 2016 at our service. Epidemiological and clinical factors were studied, including Tada score. RESULTS: Of the 34 children who were treated surgically, only 20 appeared for the functional evaluation and were included in the study. Of the operated cases, 60% were Wassel type 4. All evaluated cases had good functional results (Tada score ≥5, mean score: 6.65). The most frequently used surgical technique was resection of the radial thumb with reconstruction of the radial collateral ligament (47.8% of cases). CONCLUSION: Surgical correction of duplicated thumb yields good results, as long as attention is paid to abnormalities in bones, ligaments, and tendons. Level of Evidence IV; Case series.

OBJETIVO: Avaliar os fatores epidemiológicos e funcionais pós operatórios dos pacientes operados por duplicação de polegar. MÉTODOS: Essa é uma série retrospectiva de casos em que foram avaliados 20 pacientes (23 polegares), operados entre janeiro de 2012 e dezembro de 2016, no Hospital Menino Jesus/ SP. Foram estudados fatores epidemiológicos e clínicos, dentre os quais o score funcional de Tada. RESULTADOS: Das 34 crianças operadas, apenas 20 compareceram para avaliação funcional. Dos casos operados, 60% eram Wassel tipo 4. Todos os casos avaliados obtiveram resultado funcional bom (Tada maior ou igual a 5), com score médio de 6,65. A técnica cirúrgica mais utilizada foi a ressecção do polegar radial com reconstrução do ligamento colateral radial, presente em 47,8% das vezes. CONCLUSÃO: A correção cirúrgica da duplicação de polegar cursa com bons resultados, desde que se atente para as anormalidades osteoligamentares e tendíneas. Nível de Evidência IV; Série de casos.

Seating position, seat belt wearing, and the consequences in facial fractures in car occupants.

INTRODUCTION: Trauma caused by traffic accidents is among the main etiologies involved in the occurrence of facial fractures throughout the world. However, the trauma mechanisms involved are different according to the location where the study was performed, due to different conditions of development, legislation, and culture. A retrospective study was done between February 2001 and July 2006, with the purpose of determining the epidemiology and the mechanisms involved in the occurrence of facial fractures among car occupants in the metropolitan area of São Paulo. METHODS: Data were collected from 297 patients admitted with facial fractures to the emergency room of the Hospital das Clínicas, São Paulo University Medical School. Within this period, 151 individuals had been involved in traffic accidents, among which 56 (37.08%) were inside passenger cars. These were grouped based on the seating position that they were occupying at the time of the accident and the wearing of seat belts. Data concerning the number and location of fracture lines were obtained from the different groups, and a fracture/patient index (F/P I) was calculated to compare and make reference to the impact energy among these groups, for subsequent analysis and discussion. RESULTS: 323 fracture lines occurred among 56 patients who were car occupants. By applying the F/P I, we obtained higher values in the group of rear-seat passengers who were not wearing seat belts (7.23 fractures per patient), followed by the group of drivers not wearing seat belts (6.33 fractures per patient), the group of front-seat passengers not wearing seat belts (5.58 fractures per patient), the group of drivers wearing seat belts (5.54 fractures per patient) and, finally, the group of front-seat passengers wearing seat belts (4.00 fractures per patient). None of the rear-seat passengers was wearing seat belts. CONCLUSION: The data collected indicate that the driver position shows a high incidence of facial fractures, not being effectively protected by the seat belt, although the wearing of seat belts seems to have a protective role against the occurrence of facial fractures in front-seat passengers. It was not possible to evaluate the wearing of seat belts among rear-seat passengers, even though the high incidence of fractures in this group showed its high susceptibility to the occurrence of facial fractures, which highlights the need of taking protective measures against this situation.

Impacto socioeconômico da pandemia da COVID-19 entre cirurgiões plásticos do Brasil / Socioeconomic impact of the COVID-19 pandemic among plastic surgeons in Brazil

Introdução: Devido à crise sanitária mundial provocada pela disseminação da COVID-19, muitos serviços de saúde interromperam a realização de procedimentos cirúrgicos não urgentes. No cenário da Cirurgia Plástica, no qual a maioria das cirurgias são eletivas, estimam-se consequências socioeconômicas a estes especialistas. O objetivo deste estudo é dimensionar este impacto. Métodos: Os efeitos da pandemia dentro da prática clínica dos cirurgiões plásticos brasileiros foi investigada por meio de um questionário on-line, endereçado aos associados da Sociedade Brasileira de Cirurgia Plástica. Resultados: A pesquisa foi aplicada a 645 cirurgiões. A maioria dos entrevistados relatou restrições operacionais à realização de procedimentos e redução da renda, sobretudo nas regiões severamente afetadas pela pandemia. Cirurgiões plásticos com mais de 10 anos de formação foram os mais prejudicados. Elevada taxa de contaminação, sobrecarga mental, diminuição na prática de atividades físicas e uso de medicações psiquiátricas também foram relatados. Conclusão: A pandemia da COVID-19 trouxe mudanças no cenário pessoal e profissional do cirurgião plástico brasileiro. Devido à importante redução no volume de trabalho, houve impacto financeiro nos especialistas de todas as regiões do país, além de reflexos na saúde física e mental. Adaptações foram necessárias para manutenção dos atendimentos, além de exploração de novas áreas de atuação para suprir a baixa demanda de cirurgias estéticas durante a crise.

Introduction: Global sanitary crisis caused by the spread of COVID-19 induced many health services to stop performing non-urgent surgical procedures. In the scenario of plastic surgery, where most procedures are elective, socioeconomic consequences are estimated for these specialists. The objective of this study is to measure this impact. Methods: Effects of the pandemic within the clinical practice of Brazilian plastic surgeons were investigated through an online questionnaire addressed to members of the Sociedade Brasileira de Cirurgia Plástica. Results: A survey was applied to 645 surgeons. Most respondents reported operation restrictions on procedures and income reduction, especially in regions severely affected by the pandemic. Plastic surgeons with more than 10 years of experience were the most affected. High contamination rates, mental overload, decreased physical activity, and psychiatric medications have also been reported. Conclusion: COVID-19 pandemic brought changes to the personal and professional life of the Brazilian plastic surgeon. Due to the significant reduction in the workload, there were financial impacts on specialists from all country regions, besides physical and mental health issues. Adaptations were mandatory to maintain services and explore new areas of activity to supply the low demand for cosmetic surgery during the crisis.