ISSN 1983-5175
Revista Brasileira de Cirurgia Plástica | Brazilian Journal of Plastic Surgery | Volume 35 • Number 3 • July/September 2020
Volume 37, Número 2 - Abr/Maio/Jun - 2015 - ISSN 0101-2800
Rev. Bras. Cir. Plást. Volume 35 - Number 3 - July/September 2020
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ISSN Online: 2177-1235 ISSN Impresso: 1983-5175
SOCIEDADE BRASILEIRA DE CIRURGIA PLÁSTICA
REVISTA BRASILEIRA DE CIRURGIA PLÁSTICA BRAZILIAN JOURNAL OF PLASTIC SURGERY Jul/Aug/Sep - 2020 - Volume 35, Issue 3 EDITOR-IN-CHIEF Dov Charles Goldenberg - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP Brazil.
CO-EDITORS Antonio Roberto Bozola - Hospital de Base de São José do Rio Preto, São José do Rio Preto, SP Brazil. Hugo Alberto Nakamoto - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Rolf Gemperli - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
ASSOCIATE EDITORS Fr a n c i s c o C l a r o d e O l i v e i r a J u n i o r – Universidade Estadual de Campinas, Campinas, SP, Brazil. José Horácio Costa Aboudib Junior – Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. Kátia Torres Batista – Rede Sarah de Hospitais do Aparelho Locomotor de Brasília, DF, Brazil. Marcelo Sacramento Cunha – Faculdade de Medicina da Universidade Federal da Bahia, Salvador, BA, Brazil. Marcus Vinícius Martins Collares – Faculdade de Medicina Universidade Federal do Rio Grande do Sul - Porto Alegre, RS, Brazil. Miguel Sabino Neto - Universidade Federal de São Paulo, São Paulo, SP, Brazil.
NATIONAL EDITORIAL BOARD Anne Karoline Groth - Hospital Erasto Gaertner – Curitiba, PR, Brazil. Carlos Alberto Komatsu - Clínica Komatsu, São Paulo, SP, Brazil. Carlos Eduardo Guimarães Leão - Fundação Hospitalar do Estado de Minas Gerais - Belo Horizonte, MG, Brazil. Carlos Lacerda de Andrade Almeida - Hospital Agamenon Magalhães do Estado de Pernambuco - Recife, PE, Brazil. Cristina Pires Camargo - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil. Daniel Francisco Mello – Santa Casa de Misericórdia de São Paulo, SP, Brazil. Dimas André Milcheski - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil. Diogo Franco Vieira de Oliveira - Hospital Universitário Clementino Franco Filho da Universidade Federal do Rio de Janeiro - Rio de Janeiro, RJ, Brazil.
Douglas Jorge - Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo SP, Brazil. Eduardo Montag - Hospital das Clínicas da Faculdade Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Fabiel Spani Vendramin – Universidade Federal do Pará – Belém, PA, Brazil. Fábio de Freitas Busnardo - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil. Fábio Xerfan Nahas - Universidade Federal de São Paulo, São Paulo, SP, Brazil. Fausto Viterbo de Oliveira Neto - Universidade Estadual Paulista Júlio de Mesquita Filho, UNESP - Botucatu, SP, Brazil. Fernando Gomes de Andrade - Universidade Federal de Alagoas - Maceió, AL, Brazil. Fernando Serra Guimarães - Universidade Federal do Rio de Janeiro - Rio de Janeiro, RJ, Brazil. Henri Friedhofer - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Humberto Campos - Escola Bahiana de Medicina e Saúde Pública - Salvador, BA, Brazil. Joel Veiga Filho, Hospital Universitário De Pouso Alegre, MG, Brazil. José Carlos Daher - Centro de Estudos do Hospital Daher Lago Sul - Brasília, DF, Brazil. Juarez Moraes Avelar – Clinica Avelar – São Paulo, SP, Brazil. Luiz Carlos Ishida - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Luis Henrique Ishida - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Lydia Masako Ferreira - Universidade Federal de São Paulo - São Paulo, SP, Brazil. Marco Tulio Junqueira Amarante - Santa Casa de Misericórdia de Poços de Caldas - Poços de Caldas, MG, Brazil. Max Domingues Pereira - Universidade Federal de São Paulo - São Paulo, SP, Brazil. Miguel Sabino Neto - Universidade Federal de São Paulo - São Paulo, SP, Brazil. Nelson Sarto Piccolo - Pronto Socorro Para Queimaduras - Goiânia, GO, Brazil. Paulo Roberto de Albuquerque Leal - Instituto Nacional de Câncer - Rio de Janeiro, RJ, Brazil. Renato da Silva Freitas - Universidade Federal do Paraná, Curitiba, PR, Brazil. Rodrigo d’Eça Neves - Universidade Federal de Santa Catarina - Florianópolis, SC, Brazil. Rodrigo Itocazo Rocha - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Rui Manuel Rodrigues Pereira - Instituto Materno Infantil De Pernambuco – IMIP, PE, Brazil.
Salustiano Gomes de Pinho Pessoa - Universidade Federal do Ceará - Fortaleza, CE, Brazil. Sérgio da Cunha Falcão - Universidade Federal da Paraíba - João Pessoa, PB, Brazil. Sérgio da Fonseca Lessa - Santa Casa da Misericórdia do Rio de Janeiro, RJ, Brazil. Vera Lúcia Nocchi Cardim - Hospital da Beneficência Portuguesa de São Paulo - São Paulo, SP, Brazil. Wandir Antonio Schiozer - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil. Wilson Cintra Junior - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
INTERNATIONAL EDITORIAL BOARD Fernando Molina - Hospital General Dr. Manuel Gea González - Mexico City, Mexico. Jesse A. Taylor - University of Pennsylvania Philadelphia, Pennsylvania, USA. John Persing - Yale University - New Heaven, New York, USA. Joseph G. McCarthy - New York University - New York, New York, USA. Juan Martin Chavanne Nougues - Austral University Hospital - Buenos Aires, Argentina. Keneth Salyer - World Cranofacial Foundation Dallas, Texas, USA. Paolo Persichetti - University of Rome - Rome, Italy. Riccardo Mazzola - European Association of Plastic Surgeons - Rome, Italy. Richard Hooper - Burn and Plastic Surgery Clinic - Seattle, Washington, USA. Rogério Izar Neves - Institute Pennsylvania State University - Hershey, Pennsylvania, USA. Scott P. Bartlett - Children’s Hospital of Philadelphia - Philadelphia, Pennsylvania, USA. Steven Wall - Oxford, The Manor Hospital Oxford, Inglaterra. Thomas Biggs - International Society of Aesthetic Plastic Surgery - Houston, Texas, USA.
EDITORIAL OFFICE Ednéia Pereira de Souza E-mail: rbcp@cirurgiaplastica.org.br João Egídio de Alvarenga Junior E-mail: joaoegidio@cirurgiaplastica.org.br
PATRON Ricardo Baroudi (in memoriam) * 1932 † 2018
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REVISTA BRASILEIRA DE CIRURGIA PLÁSTICA BRAZILIAN JOURNAL OF PLASTIC SURGERY
INSTRUCTIONS TO AUTHORS The Brazilian Journal of Plastic Surgery is the official publication of the Brazilian Society of Plastic Surgery (BSPS). It is a quarterly journal, and has been regularly published since 1986. The Brazilian Journal of Plastic Surgery is indexed in the Latin American and Caribbean Health Sciences Literature (LILACS) database. The aim of the Brazilian Journal of Plastic Surgery is to record scientific developments in Reconstructive and Aesthetic Plastic Surgery, to promote research, and to support and inform professionals in this specialty, as well as to report new investigations, surgical experiments, and other original contributions. Manuscripts submitted for publication in the Brazilian Journal of Plastic Surgery must cover topics related to plastic surgery and related areas. The journal publishes the following types of articles: Editorials, Original Articles, Review Articles, Case Reports, Ideas and Innovations, Special Articles, and Letters to the Editor. The content of Brazilian Journal of Plastic Surgery is licensed by Creative Commons (CC BY) International attribution 4.0 (https://creativecommons.org/licenses/by/4.0/) Articles for advertising or commercial purposes will not be accepted. The authors are responsible for the content and information in their manuscripts. The Brazilian Journal of Plastic Surgery strongly condemns plagiarism and self-plagiarism; such manuscripts will be immediately excluded from the evaluation process. HOW TO CONTACT THE JOURNAL Revista Brasileira de Cirurgia Plástica Rua Funchal, 129, 2º andar - Vila Olímpia São Paulo - SP - Brazil - Zip Code 04551-060 Tel: 55 11 3044-0000 - Fax: 55 11 3846-8813 E-mail: rbcp@cirurgiaplastica.org.br Site: www.rbcp.org.br TYPES OF ARTICLES Editorial - These are generally articles published in each issue of the Brazilian Journal of Plastic Surgery, selected for their importance to the scientific community. These are written either by the Editorial Board or by renowned specialists in their subject areas. The Editorial Board may consider publishing editorials that are spontaneously submitted. Original Article - This category includes controlled and randomized trials and observational studies, as well as basic investigations using animal experimentation. Original articles
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must contain the following sections: Introduction, Objective, Methods, Results, Discussion, Conclusion, References, Summary, and Abstract. The length of the text should not exceed 3,000 words, excluding tables, references, summary, and abstract. The number of references should not exceed 30, and the number of figures or figure parts should be limited to 20. There should be no more than 4 tables. Review Article - These are critical and organized evaluations of the literature related to a specific subject of clinical importance. Review articles should be limited to 3,000 words, excluding references and tables, and a maximum of 6 figures or figure parts. References should have been recently published, preferably in the last 5 years. The maximum number allowed is 40. Case Report - These are descriptions of unique patients or situations, especially rare diseases, and innovative methods of diagnosis or treatment. The text consists of: an Introduction, which positions the reader in relation to the importance of the topic and introduces the objectives behind the presentation(s) of the case(s) in question; the Case Report itself; and a Discussion, in which relevant aspects are examined and compared to the literature. The number of words should be at most 1,000, excluding references and tables. The maximum number of references is 10. The recommended limit of figures or figure parts is 8. The body of the article should include the Introduction, Case Report, Discussion, and References. Ideas and Innovation - These are brief items describing original concepts, not exceeding 1,000 words, 10 references, and 8 figures or figure parts. The body of the article should include the Introduction, Methods, Results, Discussion, Conclusion, and References. Letter to the Editor - In principle, these should comment on, discuss, or criticize articles published in the Brazilian Journal of Plastic Surgery. However, these can also relate to other topics of general interest. A maximum of 250 words is recommended and up to 5 references may be included. Whenever appropriate and feasible, the response from the authors of the article under discussion will be published along with the letter. Special Article - These are articles not classified in the categories described above, which the Editorial Board considers particularly relevant to the specialty. The review criteria for these articles are unique, as they do not have a word limit or restrictions on the number of references.
EDITORIAL POLICY Peer Review Prior to publication, all articles submitted to the Brazilian Journal of Plastic Surgery undergo a review and arbitration process, in order to ensure quality and appropriateness in the selection of articles to be published. Initially, articles are evaluated by the office secretary, to determine whether they comply with publication standards and are complete. All manuscripts are then submitted to peer review by at least three reviewers, who are selected from among the members of the Editorial Board. Article acceptance is based on originality, significance, and scientific contribution. The reviewers fill out a form that provides a rigorous appraisal of all items of an article. At the end, the reviewers make general comments about the work and express their opinion as to whether it should be published or revised according to recommendations. Based on this information, the editor makes a final decision. In case of discrepancies between the reviewers, an additional opinion may be requested for a better assessment. When reviewers suggest modifications, these are then forwarded to the corresponding author, and a revised manuscript is subsequently sent to reviewers to determine whether suggestions/requirements were met. In exceptional cases, when required by the subject of the manuscript, the Editor can request the opinion of a professional who is not part of the Editorial Board, for an evaluation. This entire process is carried out through the submission and management system for online publication (GNPapers). The evaluation is double-blinded, ensuring anonymity throughout the process. The decision on the acceptance of the article for publication will occur, whenever possible, within 3 months from the date of its receipt. The dates for receiving and approving the manuscript for publication are reported in the article published, in order to respect the priority interests of the authors. The Brazilian Journal of Plastic Surgery asks its reviewers to follow the Committee on Publication Ethics (COPE) Ethical Guidelines for Peer Reviewers, available at: http://publicationethics.org/files/Ethical_guidelines_for_peer_ reviewers_0.pdf Language Articles should be submitted in either Portuguese or English. Authors must follow current spelling conventions, use straightforward and accurate terminology, and avoid the informality of colloquialisms. When the manuscripts received are not written in English or the Editorial Board deems appropriate, the Journal will provide a translation free of charge to the author(s). If an English version already exists, it should be submitted to streamline the publication process. In the printed version of the Journal, the articles are published in Portuguese. On the website, all articles are published in Portuguese and English, both in HTML and PDF formats. Research on Humans and Animals Research projects on human beings must comply with the Declaration of Helsinki (https://www.wma.net/what-we-do/ medical-ethics/declaration-of-helsinki/), Resolution 466/2012 (http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf), Resolution 510/2016 (http://conselho.saude.gov.br/resolucoes/2016/
Reso510.pdf) of the Conselho Nacional de Saúde and Circular Letter nº 166/2018- CONEP/SECNS/MS (http://conselho. saude.gov.br/images/comissoes/conep/documentos/CARTAS/ CartaCircular166.pdf). All research involving human beings must be submitted to the appreciation of a Research Ethics Committee (CEP) and the publication of the article is linked to the approval of the study by this Research Ethics Committee. Animal investigations must be carried out in accordance with rules applicable to such procedures, as specified in the Basel Declaration (www.basel-declaration.org) and the Guide for the Care and Use of Laboratory Animals (Institute of Laboratory Animal Resources, National Academy of Sciences, Washington, D.C., USA). The Editorial Board of the Journal may decline articles that do not strictly comply with ethical principles of research, whether involving humans or animals. The authors should accurately identify all drugs and chemicals used, providing the names of active ingredients, dosages, and routes of administration. They should also avoid using commercial or proprietary names. Policy for the registration of clinical trials The Brazilian Journal of Plastic Surgery supports the clinical trial registration policies of the World Health Organization (WHO) and International Committee of Medical Journal Editors (ICMJE), recognizing the importance of these initiatives for the international registration and dissemination of information on open access clinical trials. Thus, clinical trials are only acceptable if duly registered before the start of data collection on www. clinicaltrials.gov or an equivalent international repository. The identification number should be recorded at the end of the abstract. Within this context, the Brazilian Journal of Plastic Surgery adopts the definition of a clinical trial recommended by the WHO, summarized as follows: “any research that prospectively designates humans for one or more interventions aimed at assessing their effects on health-related outcomes. Interventions include drugs, cells and other biological products, surgical procedures, radiological, devices, behavioral therapies, changes in care processes, preventive care, etc”. Authorship Criteria We suggest that authorship criteria for articles be adopted according to the recommendations of the ICMJE. Thus, only those individuals who have contributed directly to the intellectual content of the work should be listed as authors. The authors should meet all the following criteria, in order to have public responsibility for the work content: 1. Having conceived and planned the activities that led to the final work, or interpreted the results of these activities, or both; 2. Having written the work or revised successive versions and taken part in the review process; 3. Having approved the final version. Individuals who do not meet the aforementioned requirements or whose participation consists of purely technical or general support may be mentioned in the Acknowledgments section.
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HOW TO PREPARE THE MANUSCRIPT The Journal adheres to the Vancouver Requirements - Uniform Requirements for Manuscripts Submitted to Biomedical Journals, as organized by the ICMJE - “Vancouver Group”, available at www.icmje.org. Compliance with the instructions is mandatory for the study to be considered for review. Identification The manuscript should include the title of the work, written in a concise and descriptive manner, in Portuguese and English, the full names of the authors and their respective titles, as well as the institution where the study was carried out. These should be followed by the name of the corresponding author, along with the author’s address, telephone, and e-mail. If the work was presented at a conference, the name of the event, place, and date of the presentation should be mentioned. Potential conflicts of interest and funding sources should be stated. The maximum number of authors permitted for an article is 8, and the contribution of each author must be specified. Authors are considered those who have: contributed substantially to the design and planning, and/or analysis and interpretation of the data; contributed significantly to the draft or critical review of the content; and participated in the approval of the final version of the manuscript. Summary or Abstract (only for original articles, special articles, review articles, and case reports). The abstract of an original article should be structured, with an Introduction, Methods, Results, and Conclusions. The abstract should be written in order to allow understanding of the study without reading the entire text. Similarly, the Abstract must accurately reflect the Summary, and should follow the same structure: Introduction, Methods, Results, and Conclusions. Review articles and Case Reports should also include a Summary and Abstract, but a structured format as above is not required. Neither the Summary nor the Abstract may exceed 250 words. At least 5 keywords should be listed, with a maximum of 10, identifying the subject of the work. The descriptors should be based on the Health Sciences Descriptors (DeCS) published by Bireme, a translation of the Medical Subject Headings (MeSH) of the National Library of Medicine, available at: http://www.decs.bvs.br Text Articles should be divided in accordance with the category to which they belong. References should be cited numerically in order of appearance in the text, using superscript numerals. Introduction - This section should discuss the purpose of the article and the rationale for the study. It must establish the theoretical premise that led the authors to investigate the topic. The Introduction should explain why the topic should be studied, clarifying flaws or inconsistencies in the literature and/ or difficulties in clinical practice that make the work interesting to the specialist. Objective - This section must describe the purpose of the work clearly and objectively in one paragraph. Methods - This section should clearly describe the basis for selection of observation and experimental elements, such as patients, laboratory animals, and controls. Where appropriate,
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inclusion and exclusion criteria should be described. This section should provide sufficient detail to allow reproduction and use in other works. Methods that have already been published, but about which little is generally known, must be accompanied by a bibliographical reference; new techniques should be described in detail. Similarly, the time and place of study, statistical methods, and any computer programs should be described. The authors should state in this section that the study was approved by the Ethics Committee of the institution where the work was carried out, providing the registration number in the text. Results - Tables and illustrations should be presented in a logical sequence in the text. The information in tables or figures should not be repeated in the text. Discussion - In this section, the author is expected to demonstrate personal knowledge and critical thinking in relation to the work, by comparing the results obtained with those in the literature. Comments should be related to the scope, position, and correlation of the study with respect to other literature and should include limitations and future prospects. Conclusions - These should be concise and address only the proposed objectives. Acknowledgments - If desired, these should be presented at the end of the text, mentioning the names of participants who contributed intellectually or technically in any phase of the work, but did not meet the requirements for authorship. Any funding agency that supported the research that resulted in the published article should also be mentioned. References References should be cited when actually consulted, in Arabic superscript numerals and numbered in the order of citation in the text. All authors up to 6 should be cited; if the authors exceed 6, the first 6 should be cited, followed by et al. The presentation should be based on the “Vancouver Style” format and the titles of the journals should be abbreviated according to the style presented in the List of Journals Indexed in Index Medicus, of the National Library of Medicine. The following are some examples of the main types of bibliographic references; other examples can be consulted at the website of the National Library of Medicine (http://www.nlm.nih.gov/bsd/ uniform_ requirements.html). Journal Article Quintas RC, Coutinho AL. Risk factors for the commitment of surgical margins in basal cell carcinomas resections. Rev Bras Cir Plást. 2008;23(2):116-9. Book Chapter D’Assumpção EA. Problems and solutions in rhytidoplasty. In: Melega JM, Baroudi R, eds. Plastic surgery fundamentals and art: cosmetic surgery. Rio de Janeiro: Medsi; 2003. p. 147-65. Book Saldanha O. Lipoabdominoplasty. Rio de Janeiro: Di Livros; 2004.
Thesis Freitas RS. Jaw bone elongation using internal device: quantitative analysis of results [Doctoral thesis]. São Paulo: University of São Paulo, School of Medicine; 2003. 97p. Events Carreirão S. Reduction mammoplasty. In: XXXVI Brazilian Conference of Plastic Surgery; 2001 Nov 11-16; Rio de Janeiro, Brazil. Tables The numbering of tables should be sequential, using Arabic numerals, in the order in which they are cited in the text. All tables (maximum of 4) should have a title and header for columns and should be cited in the text. The table footer should include the legend for abbreviations and statistical tests used. The tables should be presented only as necessary for the effective understanding of the work, and should not repeat information already mentioned in the text.
Figures All figures (graphs, photographs, illustrations) should be numbered sequentially, in Arabic numerals, following their order of citation. The figures must be accompanied by their respective legends, but these should not be included within the image. Abbreviations used in the figures must be spelled out in the legends. The number of figures must not exceed 20 (twenty) for original articles, and each image attached to the study is considered a figure; for example, Figure 1 (A, B, C, D), will correspond to 4 of the 20 allowed figures. Photos of patients should have a uniform background, especially when color is used, and without showing any foreign objects, e.g., doorknobs, lamps, etc. The field photographed should be strictly of the area of interest. In pictures of the face, use resources to prevent patient identification; however, if identification is possible, the author should enclose an individual authorization. The resolution must follow the instructions below:
Recommended Format
Color
Minimum Resolution Mode
Line art
Image consisting of lines and text that does not contain shading or shaded areas
tif, png, jpg
1-bit monochrome or RGB
300 dpi
Medium shade
Continuous photo shade that does not contain text
tif, png, jpg
RGB or grayscale
300 dpi
Combination
Containing halftone image plus text or line-art elements
tif, png, jpg
RGB or grayscale
300 dpi
Type of Image
Description
Example
• Line example taken from: Di Lamartine J, Cintra Junior R, Daher JC, Cammarota MC, Galdino J, Pedroso DB, et al. Reconstrução do complexo areolopapilar com double opposing flap. Rev Bras Cir Plást. 2013;28(2):233-40. • Shade example taken from: Alves JC, Fonseca RP, Silva Filho AF, Andrade Filho JS, Araujo IC, Almeida AC, et al. Ressecção alargada no tratamento do dermatofibrossarcoma protuberante. Rev Bras Cir Plást. 2014;29(3):395-403. • Combination example taken from: Alves JC, Fonseca RP, Silva Filho AF, Andrade Filho JS, Araujo IC, Almeida AC, et al Ressecção alargada no tratamento do dermatofibrossarcoma protuberante. Rev Bras Cir Plást. 2014;29(3):395-403.
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HOW TO SUBMIT A MANUSCRIPT Manuscripts must be submitted electronically at www.rbcp. org.br. Authors must register before submitting the work, following the guidelines that appear on the website. Texts, figures, and tables should be inserted in the respective fields in the electronic submission system.
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DECLARATIONS AND DOCUMENTS In accordance with the guidelines of the ICMJE, certain documents and statements from the author(s) are requested for evaluation of a manuscript: • A cover letter to the Editor-in-chief, containing information about the findings and the most important conclusions of the manuscript, explaining its relevance to the scientific community. The cover letter should also state that the manuscript has not been previously published and has not been submitted for publication in another journal; • Declaration of potential author conflicts of interest (document generated in the system for submission of manuscripts, prior to the completion of the submission process) - Conflicts of interest include employment, sponsorship, any individual or institute funding, public
or private, with interest in the content of the material submitted. If the article is accepted, this information will be published in the final version; Approval of the study by the Ethics Committee of the institution in which the work was carried out, enclosing the protocol number and name of the Research Ethics Committee to which the project was submitted; Transfer of copyrights (document generated in the system for the submission of manuscripts, prior to the completion of the submission process). All published manuscripts become the permanent property of the Brazilian Journal of Plastic Surgery and cannot be reproduced without the written consent of the publisher. The copyright grants exclusive and unlimited rights to reproduce and distribute works accepted in any form of publication (printed, electronic media, or any other form). The Brazilian Journal of Plastic Surgery has an open access home page. ARTICLES ACCEPTED FOR PUBLICATION
Once accepted for publication, a sample of the article for publishing (PDF format) will be sent to the corresponding author for evaluation and final approval.
CHECKLISTS Prior to the submission of a manuscript, the authors should use the checklist corresponding to the category of the article: • CONSORT (CONsolidated Standards of Reporting Trials) checklist and flowchart for controlled and randomized tests, available at http://www.consort-statement.org/ • STARD (Standards for Reporting of Diagnostic Accuracy) checklist and flowchart for studies of diagnostic accuracy, available at: http://www.stard-statement.org/
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PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist and flowchart for systematic reviews, available at: http://www.prismastatement.org/ STROBE checklist for observational studies in epidemiology, available at: http://www.strobe-statement.org/index. php?id=strobe-home
Dov Charles Goldenberg Editor-In-Chief Antonio Roberto Bozola Hugo Alberto Nakamoto Rolf Gemperli Co-editors
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SOCIEDADE BRASILEIRA DE CIRURGIA PLÁSTICA BRAZILIAN SOCIETY OF PLASTIC SURGERY Board of Directors President Dênis Calazans Loma First Vice President Pedro Bins Ely Second Vice President Pedro Pita General Secretary Leandro da Silva Pereira Adjunct Secretary Kátia Torres Batista General Treasurer Antônio Carlos Vieira Adjunct Treasurer Eduardo Montag
Address Rua Funchal, 129 - 2º andar - 04551-060 - São Paulo - SP, Brazil Telefone: 55 11 3044-0000 - Fax: 55 11 3846-8813 rbcp@cirurgiaplastica.org.br / www.rbcp.org.br Desktop Publishing and Editorial Consulting: GN1 Sistemas e Publicações Ltda. Fone: (19) 3633-1624 Site: www.gn1.com.br E-mail: comercial@gn1.com.br
Revista Brasileira de Cirurgia Plástica / Sociedade Brasileira de Cirurgia Plástica. — v.1, (jun. 1986)—.— São Paulo: Fundo Educacional da SBCP, 1986. v.l: il
Trimestral ISSN Online 2177-1235 ISSN Impresso 1983-5175
1. Cirurgia Plástica - Publicações periódicas. I. Sociedade Brasileira de Cirurgia Plástica
CDU 616-089.844 CDD 617.95005
Revista Brasileira de Cirurgia Plástica (Brazilian Journal of Plastic Surgery) Is indexed in LILACS - Latin-American and Caribbean Literature on Health Scienses
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Jul/Aug/Sep - 2020 - Volume 35, Issue 3
EDITORIAL / EDITORIAL RBCP Master Class and the new Resident Ambassador RBCP Master Class e os novos residentes Embaixadores Dov Goldenberg .................................................................................................................................................................260
ORIGINAL ARTICLES / ARTIGOS ORIGINAIS Breast region measurements: direct or indirect anthropometry? Medidas da região mamária: antropometria direta ou indireta? Paulo Rogério Quieregatto do Espirito Santo; Aline Fernanda Perez Machado; Soraia Ferrara; Andrea do Amaral Quieregatto do Espirito Santo; Fabianne Furtado; Richard Eloin Liebano; Miguel Sabino Neto; Lydia Masako Ferreira ........................................................................................................................................................................261-268 Treatment of breast ptosis by placing subfascial silicone implants followed by inverted “T” mastopexy Tratamento da ptose mamária através da colocação de implantes de silicone subfascial seguidos de mastopexia em “T” invertido Lincoln Graça Neto ....................................................................................................................................................269-275 Surgical treatment for breast ptosis with silicone prosthesis: evaluation of surgical results and patient satisfaction Tratamento cirúrgico de ptose mamária com inclusão de prótese de silicone: avaliação de resultados cirúrgicos e satisfação de pacientes Giselly de Fátima Mendes Pascoal; Jorge luiz abel; Geraldo Scozzafave ........................................................276-282 Facelift light, rhytidoplasty for the treatment of the face and neck lower third with reduced scarring and adhesion points Facelift light, ritidoplastia para tratamento do terço inferior da face e pescoço com cicatriz reduzida e pontos de adesão Isaac Rocha Furtado; Nicodemus de Oliveira Silva ..............................................................................................283-287 Reconstruction of eyelid zones II and III: case series Reconstrução das zonas II e III palpebrais: série de casos Délcio Aparecido Durso; Sérgio Domingos Bocardo ...........................................................................................288-293 A new concept in neck aging: “cervicofacial waist” Um novo conceito em envelhecimento de pescoço: “cintura cervicofacial” Ticiano Cesar Teixeira Cló; Walter Ferraz Flavio Junior; Felipe Xavier Cló; Guilherme do Valle Castro Ribeiro .......................................................................................................................................................................................294-303
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Low-cost synthetic model for skin flap training Modelo sintético e de baixo custo para treinamento de retalho cutâneo Arthur Antunes Coimbra Pinheiro Pacífico; Aline Santos Correia; Bárbara Matos de Carvalho Borges; Mateus Bonfim Costa; Mateus Pinheiro Fernandes Feitosa Arrais; Samy Lima Carneiro; Thiago Maciel Valente; Nelson Gurgel Simas de Oliveira ..........................................................................................................................................304-308 Evaluation of the use of tissue expander in a university service Avaliação do uso de expansor de tecido em um serviço universitário Kethelyn Keroline Telinski Rodrigues; Maria Cecilia Closs Ono; Jean Raitz Novais; Isabella Correa de Oliveira; Heloize Callegari Menegazzo; Renato da Silva Freitas ........................................................................................309-315 Epidemiological profile of patients with skin cancer treated at the Regional Hospital of Asa Norte/DF Brazil Perfil epidemiológico de pacientes portadores de câncer de pele atendidos no Hospital Regional da Asa Norte/DF - Brasil Altino Vieira de Rezende Filho Neto; Heloiza Gutierrez Yamamoto; Jefferson Lessa Soares de Macedo; Cristiano Gonçalves Fleury Curado; José Luiz de Oliveira Neto; Marcos Antônio Peixoto de Carvalho; Ocimar Barbosa Trindade; Ivam Pereira Mendes Neto ....................................................................................................................316-321 Trend in hospitalization for burns in Santa Catarina in the Single Health System, Brazil, in the period 2008-2018 Tendência de internação hospitalar por queimadura em Santa Catarina no Sistema Único de Saúde, Brasil, no período entre 2008 e 2018 Felipe Oliveira Duarte; Stefany Goudzenko Hernandez; Marcos Oliveira Machado; Jorge Bins Ely ..........322-328
IDEAS AND INNOVATIONS / IDEIAS E INOVAÇÕES Chassaignac bursa flap: protection and support in reduction mammoplasties with implant Retalho bolsa de Chassaignac: proteção e sustentação nas mamoplastias redutoras com implante Cesar Kelly Villafuerte Velez; Luana Kelly Marques Villafuerte; Paloma Restrepo Villafuerte ..................329-333
REVIEW ARTICLE / ARTIGO DE REVISÃO Lymph node transplantation in the management of post-mastectomy lymphedema: a systematic review with meta-analysis Transplante linfonodal no manejo do linfedema pós-mastectomia: revisão sistemática com metanálise Rafael Vilela Eiras Ribeiro; Lucio Henrique Romão dos Santos-Júnior; Irene Daher Barra ....................334-339 Breast asymmetry: literature review and a new proposal for clinical classification Assimetria mamária: revisão da literatura e nova proposta de classificação clínica Gladstone Eustáquio de Lima Faria; Dov Charles Goldenberg; Ricardo Frota Boggio ................................. 340-345 Festoons, edema, and malar bags: is there a consensus on aesthetic treatment? Festoons, edema e bolsas malares: existe consenso no tratamento estético? Caroline Silva Costa de Almeida; Kyldery Wendell Moura Cavalcante; Rafael Ximenes Bandeira de Morais; André Luiz Belém Negromonte dos Santos; Eduarda Augusta de Lucena Caldas; Marcel Fernando Miranda Batista Lima; Igor Chaves Gomes Luna; Rafael Anlicoara ................................................................................346-352
CASE REPORTS / RELATOS DE CASO Reconstructive surgery in the context of Covid-19: complications in the treatment of an inguinal complex wound Cirurgia reparadora no contexto da Covid-19: complicações evolutivas no tratamento de ferida complexa inguinal Vinícius Gomes da Silveira; Pedro Soler Coltro; Henrique Ovidio Coraspe Gonçalves; Diogo Hummel Hohl; Gabriel Maziero Alves Silva; Jayme Adriano Farina-Junior ..............................................................................353-357 ix
Severe complication by irregular use of industrial silicone in a transsexual patient: a case report Complicação grave do uso irregular de silicone industrial em paciente transexual: relato de caso Monique Mendes; Gustavo Gomes Ribeiro Monteiro; Emilly freire Barbosa Bastos; Dimas André Milcheski; Araldo Ayres Monteiro Junior; Rolf Gemperli ......................................................................................................358-362 Columellar reconstruction with chondrocutaneous graft after injury caused by CPAP Reconstrução de columela com enxerto condrocutâneo após lesão causada por CPAP Giovanna Calil Vicente Franco de Souza; Claudio Messias Moraes; Marcos Antônio Teixeira do Amaral Filho; Sara Ferreira Faro; Daniel de Cazeto Lopes; Ricardo Portella Perrone ............................................................363-367 Piezoelectric preservative rhinoplasty: an alternative approach for treating bifid nose in Tessier No. 0 facial cleft Rinoplastia preservadora piezoelétrica: uma abordagem alternativa para tratamento de nariz bífido em fissura facial nº 0 de Tessier Luiz Carlos Ishida; Rodolfo Costa Lobato; Bruno Ferreira Luitgards; Marcelo José Monteiro Carvas; Juan Felippe Guimarães Urcioli Mosquera de Rodriguez; Rolf Gemperli ................................................................ 368-372 Nasal reconstruction with paramedian frontal flap after cancer resection Reconstrução nasal com retalho frontal paramediano após ressecção oncológica Carlos Miguel Pereira; Eduardo Pinheiro Venturelli Júnior; Rodrigo Silva Rocha; Paolla Ribeiro Gonçalves; Fabio Neves Silva; Sérgio Domingos Bocardo ...................................................................................................... 373-377
SPECIAL ARTICLE / ARTIGO ESPECIAL Speed in surgery: 10 quick tips to increase confidence and manual training on the young plastic surgeon Velocidade em cirurgia: 10 dicas rápidas para elevar a confiança e o adestramento manual do jovem cirurgião plástico Gibran Busatto Chedid; Paula Girelli; Carlos Oscar Uebel .................................................................................378-383
LETTER TO THE EDITOR / CARTA AO EDITOR Social media and scientific knowledge Redes sociais e conhecimento científico Murilo Sgarbi Secanho; Marcelo Hanato Santos; Matheus de Carvalho Sales Peres; Balduino Ferreira de Menezes Neto; Aristides Augusto Palhares; Fausto Viterbo de Oliveira Neto; Dov Goldenberg .................384-385 Investigation of ethical and scientific irregularities contained in the article published by the Revista Brasileira de Cirurgia Plástica Investigação de irregularidades éticas e científicas contidas no artigo veiculado pela Revista Brasileira de Cirurgia Plástica Nelson Albino Neto; Kleber Tetsuo Kurimori; Dimas André Milcheski ........................................................... 386-387
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Editorial RBCP Master Class and the new Resident Ambassador RBCP Master Class e os novos residentes Embaixadores The presence of young minds is the guarantee of the perpetuation of our journal. We are experiencing a moment of profound change in the means of interpersonal interactivity and in the ways of disseminating knowledge. A need that has become mandatory has brought electronic media an even greater importance as a tool for interpersonal interaction. To this end, an important initiative from our National President Dr. DĂŞnis Calazans Loma, allowed the creation of a group of Residents- called RBCP Ambassadors - with national representation, to assist and encourage the dissemination and interactivity in relation to the studies published in RBCP . With the support of DECOM, our Communications Department (Director Dr. Marcela Cammarota) created an exclusive channel for discussing articles published in our journal, in the form of online debates called Master Class, where the participation of experienced residents and coordinators generate a scientific debate on the main published articles. Every two weeks, articles published and available online on our website will be discussed, highlighting their strengths, bringing the topic up to date and generating a critical analysis of the article, as to its form, methodology, results and level of evidence. The advantages of this initiative are multiple, for teaching plastic surgery, for critical learning of the analysis of a scientific paper and, finally, for the dissemination of studies to our associates and medical colleagues, allowing an additional stimulus for authors to publish in our journal . Once again, the RBCP Editorial Board seeks new frontiers to be crossed, with the objective of promoting ethical and qualified scientific dissemination. Dov Goldenberg Editor-in-Chief RBCP
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Original Article Breast region measurements: direct or indirect anthropometry? Medidas da região mamária: antropometria direta ou indireta? PAULO ROGÉRIO QUIEREGATTO DO ESPIRITO SANTO 1* ALINE FERNANDA PEREZ MACHADO 1 SORAIA FERRARA 1 ANDREA DO AMARAL QUIEREGATTO DO ESPIRITO SANTO 1 FABIANNE FURTADO 1 RICHARD ELOIN LIEBANO 1 MIGUEL SABINO NETO 1 LYDIA MASAKO FERREIRA 1
Institution: Federal University of São Paulo, São Paulo, SP, Brazil. Article received: March 29, 2020. Article accepted: June 4, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0048
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ABSTRACT
Introduction: Accurate female breast measurements are difficult due to the topography, volume, and projections present there. Therefore, this study aimed to compare breast region measurements obtained by direct (tape measurement) and indirect (computer-based photogrammetry) anthropometry. Methods: This is a transversal study. Forty women were evaluated, aged 18-60 years, body mass index of <29.2kg/m² that had 12 anatomical marks on the breast region and arms. These points’ union formed 7 linear segments and 1 angle for each hemibody, and 1 segment common to both hemibodies. The photographs obtained in a standardized way were measured using computer-based photogrammetry with Image ToolTM software. The same segments were also measured by direct anthropometry, using a tape measure. The Shapiro-Wilk test was used to assess whether each variable was normally distributed. The Pearson correlation test was applied to evaluate the correlation between different methods: the direct (tape measurement) and indirect (photogrammetry by Image ToolTM) anthropometry. The significance level adopted for statistical tests was 5% (p<0,05). Results: Significant differences were found in the comparisons between the tape measurement and computer-based photogrammetry for all segments analyzed (p>0.05). Conclusion: There is a correlation between the breast measurements obtained by direct (tape measurement) and indirect (photogrammetry by Image ToolTM software) anthropometry, especially the papilla measures. Keywords: Breast; Anthropometry; Photogrammetry; Mammaplasty; Women; Surgery, Plastic.
Federal University of São Paulo, São Paulo, SP, Brazil.
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RESUMO
Introdução: As medidas precisas dos seios femininos são difíceis de obter devido à topografia, volume e projeções presentes. Portanto, este estudo teve como objetivo comparar medidas da região mamária obtidas por antropometria direta (fita métrica) e indireta (fotogrametria computadorizada). Métodos: Este é um estudo transversal. Foram avaliadas 40 mulheres, com idades entre 18 e 60 anos, índice de massa corporal <29,2 kg / m², que tinham 12 marcas anatômicas na região das mamas e braços. A união desses pontos formou 7 segmentos lineares e 1 ângulo para cada hemicorpo, e 1 segmento comum a ambos os hemicorpos. As fotografias obtidas de forma padronizada foram mensuradas por fotogrametria computadorizada com o software Image Tool®. Os mesmos segmentos também foram medidos por antropometria direta, com fita métrica. O teste de Shapiro-Wilk foi usado para avaliar se cada variável tinha uma distribuição normal. O teste de correlação de Pearson foi aplicado para avaliar a correlação entre os diferentes métodos: antropometria direta (medição com fita) e indireta (fotogrametria por Image Tool®). O nível de significância adotado para os testes estatísticos foi de 5% (p <0,05). Resultados: Diferenças significativas foram encontradas nas comparações entre a fita métrica e a fotogrametria computadorizada para todos os segmentos analisados (p> 0,05). Conclusão: Existe correlação entre as medidas dos seios da face obtidas pela antropometria direta (medição com fita métrica) e indireta (fotogrametria pelo software Image Tool®), principalmente nas medidas da papila. Descritores: Mama; Antropometria; Fotogrametria; Mamoplastia; Mulheres; Cirurgia Plástica
INTRODUCTION
OBJECTIVE
Accurate measurements of female breasts are challenging due to the topography, volume, and projections present there1. Therefore, linear breast reference parameters were created to directly analyze the size, shape and positioning1-5. In clinical practice, breast measurements are done by direct anthropometry, usually using tape measure or compass. However, these measures may be altered due to respiratory oscillations or slight body positioning changes in body positioning 6 . Despite the limitations of direct breast anthropometric measurements, they have been the most widely used method for expressing and comparing mammaplasty results, both in scientific publications and in events (conferences, symposia, forums, etc.). Given the need for a method that would overcome direct anthropometry limitations, some authors have proposed photogrammetry7-9. However, in the literature, the existing studies comparing photogrammetry and direct anthropometry are not specific for the breast region.
This study compares breast region measurements obtained by direct (tape measurement) and indirect (computer-based photogrammetry, Image Tool TM software) anthropometry.
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METHODS The study was approved and conducted by the Research Ethics Committee of the Universidade Federal de São Paulo (UNIFESP) (1054/10). Written informed consent was obtained from all volunteers before their inclusion in the study. Forty female volunteers, aged 18 to 60, body mass index (BMI) of <29.9kg/m², were included in the study, between June and December 2018. They were recruited from the Plastic Surgery Division Outpatient Service at UNIFESP. Each side of the thorax was separately analyzed, with a total of 80 hemibodies. Women who underwent a mastectomy, with a history of any type of conservative breast surgery, congenital or acquired chest deformities and severe breast ptosis in which 262
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the nipples cross a transverse line at the limit of the umbilicus were not included in the study. Each volunteer was instructed to place their feet on predetermined marks on the floor with a 3 cm distance between their medial margins and remain in anatomical position, with the head in the Frankfurt position during measurements. The distance between the most posterior point of the volunteer’s feet and the photography background was 70cm. Self-adhesive labels with 0.6 cm diameter were used to mark the anatomical landmarks used in each hemibody. These landmarks in counterclockwise were: the center of the mammary papilla (PAP), the midpoint of the base of the xiphoid process (Xi), jugular notch center (IJ), half the distance between the jugular notch center and the acromion (xCl), lateral border of the acromion (Ac), the most cranial point of the fold in the anterior axillary line (Ax) and the anterior projection of the lateral epicondyle (EpL) (Figure 1).
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papilla to half the distance between the jugular notch center and the acromion (segment xCl-PAP), the center of the mammary papilla to the lateral border of the acromion (segment Ac-PAP), the center of the mammary papilla to most cranial point of the fold in the anterior axillary line (segment Ax-PAP), lateral border of the acromion to the anterior projection of the lateral epicondyle (segment Ac-EpL), half the distance between the acromion and the lateral epicondyle to the lateral epicondyle (Ac-yUm). The confluence of the segments (IJ-Xi) and (IJ-PAP) formed the  angle (Figure 2).
Figure 2. Distance of the anatomical landmarks and anthropometric points. Ac: Lateral border of the acromion; xCl: Half the distance between the jugular notch center and the acromion; IJ: Jugular notch center; Ax: The most cranial point of the fold in the anterior axillary; Â: Angle; yUm: Halfway point between the acromial end and the projection of the lateral epicondyle; PAP: Center of the mammary papilla; Xi: Midpoint of the base of the xiphoid process; EpL: Line and the anterior projection of the lateral epicondyle.
Figure 1. Demarcation of the anatomical landmarks and anthropometric points. Ac: Lateral border of the acromion; xCl: Half the distance between the jugular notch center and the acromion; IJ: Jugular notch center; Ax: The most cranial point of the fold in the anterior axillary; yUm: Halfway point between the acromial end and the projection of the lateral epicondyle; PAP: Center of the mammary papilla; Xi: Midpoint of the base of the xiphoid process; EpL: Line and the anterior projection of the lateral epicondyle.
From these points, 8 line segments and 1 angle per hemibody were formed. Only the segment passing through the anterior median line, from the center of the jugular notch to the base of the xiphoid process (segment IJ-Xi), was common to both hemibodies. The other 7 segments were formed bilaterally: center of the mammary papilla to the anterior median line, passing through the base of the xiphoid process (segment PAPXi), center of the mammary papilla to jugular notch center (segment IJ-PAP), the center of the mammary 263
We used a SonyTM DSC-W120 digital camera, with the distance from the lens to the voluntary determined by the framework, without zooming, on a tripod with bubble level. All photographs were standardized with 7.0 megapixels and JPEG format. Two spotlights were positioned at the height of 1.50m from the floor and at a distance of 1.60m from the photography background, convergently directed, each one angled at 45º to the blue photography background (Figure 3). The breast region’s photographic framing was delimited superiorly by a transverse line at the gnathion (Gn) and inferiorly by a transverse line at the bottom of the navel. A ruler with a millimeter scale 0-10cm long was attached to the volunteer’s right mesogastric region to proceed to the Image ToolTM 3.0 software calibration. A centimeter-scale was chosen for digital photogrammetry. Rev. Bras. Cir. Plást. 2020;35(3):261-268
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weight of 63.4 (±5.4), height of 1.57 (±0.1) and BMI of 25.7 (±2.2). The prevalence of white race was 65%, black 2.5%, and others 32.5%. Table 1 shows the clinical characteristics of all volunteers. Table 1. Clinical characteristics for all volunteers. Mean ± SD Age (years)
29.1 ± 10.3
Weight (kg)
63.4 ± 5.4
Height (m)
1.57 ± 0.1
BMI (kg/m²)
25.7 ± 2.2
Race (%) White
65%
Black
2.5%
Others
32.5%
SD: standard deviation; BMI: Body mass index.
Figure 3. Photographic standardization and systematization.
Direct anthropometry was performed with a tape measure with a scale in millimeters. The tape measure was placed in the label’s center and directed to the label’s center on the opposite side of the selected segment. For measuring the α angle, a dotted line was drawn using a dermographic pen and a metallic ruler, crossing over the segment IJ-Xi and another one over the segment IJ-Pa. Then, a 180° clear plastic protractor was placed in the center of the label of the jugular notch (IJ), and the measure corresponding to the angle was obtained. The same evaluator collected all indirect (photography and software) and direct anthropometry data. Statistical analysis Data will be analyzed using GraphPad Prism 6.0 for Windows. Variables were tested for normal distribution by the Shapiro-Wilk test. Data are presented as mean and SD. The Pearson correlation test was applied to evaluate the correlation between the direct (tape measurement) and indirect (photogrammetry by Image ToolTM software) anthropometry, considering weak correlation (0.20 to 0.39), moderate correlation (0.40 to 0.69), a strong correlation (0.70 to 0.89) and very strong correlation (0.9 to 1). A significance level of 5% (p<0.05) was adopted to interpret the data.
RESULTS The study included 80 breasts of 40 female volunteers with a mean age of 29.1 (±10.3) years old, Rev. Bras. Cir. Plást. 2020;35(3):261-268
The means of segments obtained using the tape measure (direct anthropometry measurements) and photogrammetry by Image ToolTM software (indirect anthropometric measurements) were 16.35 (±1.14) and 12.90 (±1.69) of IJ-Xi, 11.16 (±1.07) and 10.98 (±1.30) of PAP-Xi, 22.08 (±3.08) and 18.24 (±2.65) of IJ-PAP, 21.46 (±3.54) and 15.66 (±2.82) of xCl-PAP, 22.00 (±3.45) and 14.29 (±2.82) of Ac-PAP, 14.44 (±3.28) and 8.57 (±2.52) of Ax-PAP, 29.12 (±1.58) and 24.53 (±1.91) of Ac-EpL, 14.49 (±0.95) and 12.30 (±1.00) of Ac-yUm, and 29.90 (±2.91) and 37.82 (±4.60) of  angle. The measurements of all segments obtained using the tape measure (direct anthropometry measurements) showed significant differences when compared with photogrammetry by Image ToolTM software (indirect anthropometric measurements) (Table 2). There was a moderate positive and statistically significant correlation between the measures:  angle (r=0.46; p<0.0001), Ac-yUm (r=0.64; p<0.0001), IJ-Xi (r=0.64; p<0.0001) and Ac-EpL (r=0.66; p<0.0001) (Table 2 and Figure 4); strong positive and statistically significant correlation between the measures: Ac-PAP (r=0.79; p<0.0001), Ax-PAP (r=0.79; p<0.0001), xCl-PAP (r=0.83; p<0.0001) and IJ-PAP (r=0.86; p<0.0001) (Table 2 and Figure 5); and very strong positive and statistically significant correlation between the measure: PAP-Xi (r=0.91; p<0.0001) (Table 2 and Figure 6).
DISCUSSION Breasts are considered a symbol of femininity, sensuality, and motherhood; therefore, they play a fundamental role in women’s physical and mental health10. In 1955, Penn2 collected measurements from 150 women; only 20 considered having symmetrical and aesthetically perfect breasts. This way, an attempt 264
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Table 2. Mean, Standard deviation (SD), Pearson correlation (r), Confidence interval (CI) and p value of measurements obtained with tape measure and photogrammetry by Image ToolTM. Tape measure
Photogrammetry
Mean ± SD
Mean ± SD
IJ-Xi
16.35 ± 1.14
PAP-Xi
Segments
r
CI
p value
12.90 ± 1.69
0.64
0.50 to 0.76
< 0.0001
11.16 ± 1.07
10.98 ± 1.30
0.91
0.86 to 0.94
< 0.0001
IJ-PAP
22.08 ± 3.08
18.24 ± 2.65
0.86
0.78 to 0.90
< 0.0001
xCl-PAP
21.46 ± 3.54
15.66 ± 2.82
0.83
0.75 to 0.88
< 0.0001
Ac-PAP
22.00 ± 3.45
14.29 ± 2.82
0.79
0.69 to 0.86
< 0.0001
Ax-PAP
14.44 ± 3.28
8.57 ± 2.52
0.79
0.70 to 0.86
< 0.0001
Ac-EpL
29.12 ± 1.58
24.53 ± 1.91
0.66
0.52 to 0.77
< 0.0001
Ac-yUm
14.49 ± 0.95
12.30 ± 1.00
0.64
0.49 to 0.75
< 0.0001
 angle
29.90 ± 2.91
37.82 ± 4.60
0.46
0.27 to 0.62
< 0.0001
SD: Standard deviation; r: Pearson correlation; CI: Confidence interval; IJ-Xi: Segment from the jugular notch center to the base of the xiphoid process; PAPXi: Center of the mammary papilla to anterior median line, passing through the base of the xiphoid process; IJ-PAP: Center of the mammary papilla to jugular notch center; xCl-PAP: Center of the mammary papilla to half the distance between the jugular notch center and the acromion; Ac-PAP: Center of the mammary papilla to lateral border of the acromion; Ax-PAP: Center of the mammary papilla to most cranial point of the fold in the anterior axillary line; Ac-EpL: Lateral border of the acromion to anterior projection of the lateral epicondyle; Ac-yUm: Half the distance between the acromion and the lateral epicondyle to the lateral epicondyle; Â angle: Confluence of the segments (IJ-Xi) and (IJ-PAP).
Figure 4. Moderate correlation between photogrammetry and tape measure.
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Figure 5. Strong correlation between photogrammetry and tape measure.
Figure 6. Very strong correlation between photogrammetry and tape measure.
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was made to set a normal standard for breast measures. Since then, several authors have developed protocols for direct breast anthropometric measurements1-5. When used the same anthropometric points for direct measurement of the breast region, using different measuring instruments (compass and metric tape), there may be differences in the measures found6. Nechala et al., in 19998, have compared direct anthropometry with photogrammetry for face measurements and concluded that there was no consensus on determining the best measurement method. Given the lack of consensus of photogrammetry in different body areas, this study aimed to investigate the differences between measurements obtained by direct (tape measurement) and indirect (digital photogrammetry) anthropometry of the breast region, a subject of significant importance in plastic surgery. The standardization of positions, relative measurements, and photographic angles and markers on the anthropometric points and/or anatomical landmarks bring reliability and reproducibility to a scientific 266
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study11-15. The systematization and standardization of photographic framing, distance, and height of the camera and reflectors so as patient positioning are needed procedures for sequenced evaluations, for example, for pre- and postoperative comparisons, thereby allowing validating the comparison of techniques and results, preserving the scientific rigor13. An alternative method is an indirect anthropometry using computer-based photogrammetry, which performs the measurement of photographs with graphic software aid and does not require the patient’s physical presence for data collection8,9. This method allows centesimal precision, reducing errors, besides enabling measurements over time. Thus, it is possible to compare pre- and postoperative differences quantitatively. The average time spent with data collection for each volunteer, from the beginning to the end of the measurement interview was 34 minutes, 10 minutes spent only for measurements with a tape measure. Four volunteers reported discomfort while performing the measurements. This event did not allow a tacit recommendation of scientific rigor concerning the need of 2 intra-evaluator measurements to verify the accuracy or the degree of reproducibility of the method used. The determining factor for the use of the labels was the fact that they minimize discomfort and pain as felt when marking with pen the center of the mammary papilla. Christie et al., in 200516, used this same tactic, reporting that the use of self-adhesive labels at the time of the photography sessions lessened the discomfort of demarcating anthropometric points besides reducing the chances of errors. According to Westreich, in 1997 1, the most challenging measurements were the segment from the axilla to the center of the mammary papilla, and the segment of the mammary fold’s lateral point since markings made on soft tissue are too much variable to be included in studies of breast measurements. These markings can vary from woman to woman and change even with the patient’s slight movements, and may, therefore, be inaccurate, which was also highlighted in the study by Smith et al. (1986)4. Until now, the breasts are measured by digital photography. However, the studies are not clear, and standardization should be made for the breast measurement. The literature used direct anthropometry,1,4,6,7 or the studies evaluated mastectomy and voluminous breast17,18. The Pearson correlation test demonstrated that measures that are directly related to the breast presented a strong or very strong correlation. However, measurements related to the arm and chest showed a moderate correlation. Therefore, for measurements related to the breast, especially the papilla, the use of tape measure and digital photography 267
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performed by Image ToolTM could be an option in the evaluation of breasts in women. Thus, the discomfort reported by volunteers could be minimized because digital photography is faster than a tape measure. Although clinical photographs have been taken in 5 different positions - anteroposterior (AP), right and left profiles and right and left oblique, according to literature guidelines1,14,15 - in this study, given the fact that all points determined for evaluation could also be evaluated in frontal position, only the AP position was standardized. How was demonstrated by Quieregatto et al., in 2015 19, our results demonstrate that the association between direct and indirect anthropometry could not be indiscriminately used. The present study demonstrates two forms to evaluate the healthy breast. We are looking for the best way to suggest breast evaluation. Other studies are necessary to compare different breast measurement software.
CONCLUSION There was a correlation between direct (tape measurement) and indirect (photogrammetry by Image ToolTM software) anthropometry in the segments that directly involve the breast, especially the papilla. However, although there is a correlation between the measurements, they are statistically different when obtained by direct and indirect anthropometry
COLLABORATIONS PRQES
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Resources, Software, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
AFPM
Analysis and/or data interpretation, Conception and design study, Data Curation, Investigation, Methodology, Software, Writing - Review & Editing
SF
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Realization of operations and/or trials, Supervision, Writing - Original Draft Preparation, Writing - Review & Editing
AAQES
Data Curation, Formal Analysis, Investigation, Software, Visualization Rev. Bras. Cir. Plást. 2020;35(3):261-268
Breast region measurements
FF
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Formal Analysis, Project Administration, Resources, Software, Supervision, Writing - Review & Editing
REL
Analysis and/or data interpretation, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Methodology, Supervision, Validation, Writing - Review & Editing
MSN
Analysis and/or data interpretation, Conceptualization, Final manuscript approval, Investigation, Methodology, Supervision, Visualization, Writing Original Draft Preparation
LMF
Analysis and/or data interpretation, Conceptualization, Final manuscript approval, Investigation, Supervision, Writing - Review & Editing
REFERENCES 1. Westreich M. Anthropomorphic breast measurement: protocol and results in 50 women with aesthetically perfect breasts and clinical application. Plast Reconstr Surg. 1997 Aug;100(2):468-79. 2. Penn J. Breast reduction. Br J Plast Surg. 1955 Jan;7(4):357-71. 3. Brown TP, Ringrose C, Hyland RE, Cole AA, Brotherston TM. A method of assessing female breast morphometry and its clinical application. Br J Plast Surg. 1999 Jul;52(5):355 - 9. 4. Smith Junior DJ, Palin Junior WE, Katch VL, Bennett JE. Breast volume and anthropomorphic measurements: normal values. Plast Reconstr Surg. 1986 Sep;78(3):331-5. 5. Odo LM, Guimarães PA, Lemos ALA, Pozzobon AV, Sabino Neto M, Ferreira LM. Avaliação do tratamento cirúrgico da assimetria mamária por meio de medidas lineares. Arq Catarin Med. 2009;38(Suppl 1):43-5.
*Corresponding author:
6. Quieregatto PR, Hochman B, Ferrara SF, Furtado F, Liebano RE, Sabino Neto M, et al. Anthropometry of the breast region: how to measure?. Aesthetic Plast Surg. 2014 Mar;38(2):344-9. 7. Ward CM. An analysis, from photographs, of the results of four approaches to elongating the columella after repair of bilateral cleft lip. Plast Reconstr Surg. 1979 Jul;64(1):68-75. 8. Nechala P, Mahoney J, Farkas LG. Digital two-dimensional photogrammetry: a comparison of three techniques of obtaining digital photographs. Plast Reconstr Surg. 1999 Jun;103(7):1819-25. 9. Hochman B, Castilho HT, Ferreira LM. Padronização fotográfica e morfométrica na fotogrametria computadorizada do nariz. Acta Cir Bras. 2002 Jul/Aug;17(4):258-66. 10. Pozzobon AV, Sabino Neto M, Veiga DF, Abla LE, Pereira JB, Biasi TL, et al. Magnetic resonance images and linear measurements in the surgical treatment of breast asymmetry. Aesthetic Plast Surg. 2009 Mar;33(2):196-203. 11. Farkas LG, Bryson W, Tech B, Klotz J. Is photogrammetry of the face reliable?. Plast Reconstr Surg. 1980 Sep;66(3):346-55. 12. McCausland TM. A method of standardization of photographic viewpoints for clinical photography. J Audiov Media Med. 1980 Jul;3(3):109-11. 13. Rodrigues OR, Geraldelli S, Minamoto H, Schmidt Junior AF. A fotografia em ciências biológicas: uso no ensino e na documentação científica. Acta Cir Bras. 1995;10(4):173-82. 14. Gherardini G, Matarasso A, Serure AS, Toledo LS, DiBernardo BE. Standardization in photography for body contour surgery and suction-assisted lipectomy. Plast Reconstr Surg. 1997 Jul;100(1):227-37. 15. Hochman B, Nahas FX, Ferreira LM. Fotografia aplicada na pesquisa clínico-cirúrgica. Acta Cir Bras. 2005;20(Suppl 2):19-25. 16. Christie D, Sharpley C, Curtis T. Improving the accuracy of a photographic assessment system for breast cosmesis. Clin Oncol (R Coll Radiol). 2005 Feb;17(1):27-31. 17. Reddy JP, Lei X, Huang SC, Nicklaus KM, Fingeret MC, Shaitelman SF, et al. Quantitative assessment of breast cosmetic outcome after whole-breast irradiation. Int J Radiat Oncol Biol Phys. 2017 Apr;97(5):894-902. 18. Nicoletti G, Scevola S, Faga A. Is breast reduction a functional or a cosmetic operation? Proposal of an objective discriminating criterion. J Plast Reconstr Aesthet Surg. 2009 Dec;62(12):1644-6. 19. Quieregatto PR, Hochman B, Furtado F, Ferrara SF, Machado AFP, Sabino Neto M, et al. Photographs for anthropometric measurements of the breast region. Are there limitations?. Acta Cir Bras. 2015 Jul;30(7):509-16.
Paulo Rogério Quieregatto do Espirito Santo Rua Napoleão de Barros, 715, 4º andar, Vila Clementino, São Paulo, SP, Brazil. Zip Code: 04023-002 E-mail: contato@pauloquieregatto.com.br
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Original Article Treatment of breast ptosis by placing subfascial silicone implants followed by inverted “T” mastopexy Tratamento da ptose mamária através da colocação de implantes de silicone subfascial seguidos de mastopexia em “T” invertido LINCOLN GRAÇA NETO 1*
Institution: Private Clinic, Curitiba, PR, Brazil. Article received: May 13, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0049
1
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ABSTRACT
Introduction: The treatment of breast ptosis using mastopexy associated with the placement of silicone prosthesis in a single surgical procedure is a challenge for surgeons. There are several techniques described in the literature. This study aims to describe the placement of silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, totally separating it from the rest of the breast parenchyma in the treatment of patients with breast ptosis. Moreover, analyze the aesthetic results of operated patients. Methods: During the period from September 2017 to February 2019, 64 mastopexies with an inverted “T” scar were performed associated with silicone breast implants placed in the subfascial plane, bilaterally, textured high-profile round prostheses whose volumes ranged from 180ml to 380ml, in patients with breast ptosis. Results: The average age was 34 years, ranging from 19 to 55 years. The postoperative follow-up time was 1 to 18 months. The main complications were: 3 cases (4.6%) of residual skin flaccidity in the 8-month follow-up; two cases (3.1%) of unsightly scars; one case (1.5%) of partial areola necrosis. There was no case of infection or seroma. Conclusion: The technique of placing silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, totally separating it from the rest of the breast parenchyma, was effective in the treatment of patients with breast ptosis. Keywords: Breast; Prosthesis implant; Plastic surgery; Aesthetics; Atrophy.
Faculdade Evangélica de Medicina, Department of Surgery, Curitiba, PR, Brazil.
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Treatment of breast ptosis by placing silicone implants
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RESUMO
Introdução: O tratamento da ptose mamária utilizando a mastopexia associada à inclusão de prótese de silicone em tempo cirúrgico único é um desafio para os cirurgiões. Existem várias técnicas descritas na literatura. O objetivo deste estudo é descrever a colocação de implantes mamários de silicone em plano subfascial, seguido de ampla dissecção anterior da fáscia do músculo peitoral maior separando-a totalmente do restante do parênquima mamário no tratamento de pacientes com ptose mamária; e analisar os resultados estéticos dos pacientes operados. Métodos: Durante o período de setembro de 2017 a fevereiro de 2019 foram realizadas 64 mastopexias com cicatriz em “T” invertido associadas à inclusão de implantes mamários de silicone em plano subfascial, bilateralmente, próteses redondas texturizadas de perfil alto cujos volumes variaram de 180ml a 380ml, em pacientes com ptose mamária. Resultados: A média de idade foi de 34 anos, sendo que variou de 19 a 55 anos. O tempo se seguimento pós-operatório foi de 1 a 18 meses. As principais complicações foram: 3 casos (4,6%) de flacidez residual de pele no seguimento de 8 meses; dois casos (3,1%) de cicatrizes inestéticas; um caso (1,5%) de necrose parcial de aréola. Não houve nenhum caso de infecção ou seroma. Conclusão: A técnica de colocação de implantes mamários de silicone em plano subfascial, seguido de ampla dissecção anterior da fáscia do músculo peitoral maior separando-a totalmente do restante do parênquima mamário foi efetiva no tratamento de pacientes com ptose mamária. Descritores: Mama; Implante de prótese; Cirurgia plástica; Estética; Atrofia.
INTRODUCTION Breast ptosis is characterized by laxity and excess skin on the breasts, which can be associated, in most cases, with atrophy of the breast content or volume. The leading causes of breast ptosis are age, gravity, breastfeeding, and weight loss. The surgery that corrects or treats breast ptosis is mastopexy. It aims to restore the breast’s shape1. When thinking about restoring the breast’s shape, this means not only repositioning them or bringing them to the “ideal” position. It also means remodeling it in its size and consistency, making it firmer. Still, in that same opportunity, an item that should not be overlooked is the nipple-areolar complex (NAC)2. The NAC must be located at the apex of the mammary “cone”. It must be repositioned and adequate in its size so that it is proportional to the size of the “new” breast, making it more harmonious and youthful. In other words, aspects that should be valued in mastopexy as a whole for the surgery’s success are breast location, shape, size, consistency, and NAC position. Rev. Bras. Cir. Plást. 2020;35(3):269-275
The evaluation or quantification of breast ptosis in categories or types was initially carried out by the Frenchman Regnault in 19763. He proposed its classification taking into account the NAC position concerning the inframammary fold (IMF). Ptosis could be true (grade I, II, and III), partial ptosis, and pseudoptosis. Most mastopexy techniques are derived from breast reduction techniques. In 1957, Arié4 described his mammoplasty technique, which was modified by Pitanguy, in 19605, adding the marking of point “A” (also called Pitanguy point). Silveira Neto, in 19766, described the super medial dermal flap with perforating vessels from the internal mammary artery. In situations or cases where there is a significant breast volume loss, either by multiple pregnancies and consequent breastfeeding, or weight loss (in the case of morbidly obese ex-obese), silicone breast implants can be used. The first description in the literature was made by Gonzales-Ulloa, in 19607. Since then, many variants have been suggested, whether submuscular8,9,10 or subglandular11,12. 270
Graça Neto L.
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In 1999 13 and 2003 14 , Graf et al. made the first description of the subfascial plan for breast augmentation surgery. Over these almost 20 years, the technique became popular15-18 and found its place as a good alternative for breast cosmetic and restorative surgery19,20. It is safe and is widely spread in our country 21 . A recent study of breast fasciae (superficial and deep) 22 demonstrated the richness of details surrounding this organ anatomy and thus confirmed what had already been described in other regions of the human body; the concept of a bilaminar fascia system. These membranes join laterally and at the peripheries of anatomical structures, forming areas of adhesion. In these areas, there are vessels, nerves, and lymphatics. They are connected superior and inferior through thin ligaments.
implant. The subfascial pocket extended to the second intercostal space. Hemostasis of bleeding vessels was performed, irrigation of the prosthesis pocket with a solution of 100ml of SS with 1g of cefazolin and 80mg of gentamicin, using 50ml of the solution on each side (right and left), placement of a Mentor HP textured silicone implant and finally, closing or synthesis of the subfascial pocket with 3.0 monofilament thread in separate points (Figures 1 and 2).
OBJECTIVE The objective of this study is to describe the placement of silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, totally separating it from the rest of the breast parenchyma in the treatment of patients with breast ptosis. Moreover, analyze the aesthetic results of operated patients.
METHODS
Figure 1. Inverted “T” marking.
During the period from September 2017 to February 2019, 64 mastopexies with an inverted “T” scar (as described by Pitanguy) were performed, associated with silicone breast implants placed in the subfascial plane, bilaterally, textured high-profile round prostheses whose volumes ranged from 180ml to 380ml in patients with breast ptosis. All patients came from a private clinic, operated by the same surgeon, under thoracic epidural anesthesia, following a thromboembolism prevention protocol, using prophylactic antibiotics, and using a 4.8 suction drain, as well as hospitalization for 24 hours. Operative technique The patient was operated on in the supine position, with a back tilt at 30o, abduction of the upper limbs at 90o, infiltration of saline solution (SS) with adrenaline in the proportion of 1: 250,000 in the marks previously performed in standing (orthostatic position).
Figure 2. Placement of the silicone implant (prosthesis).
1. Placement of the silicone implant
2. Mastopexy
The surgery was started with skin and subcutaneous cell tissue (SSCT) incision in the inframammary fold (IMF), subfascial dissection to accommodate the previously chosen silicone breast
Then, the mastopexy itself started, with an incision in skin and SSCT over the marks made with methylene blue up to the pectoralis major muscle fascia, removing the breast tissue at the lower breast pole.
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Treatment of breast ptosis by placing silicone implants
When the aponeurosis is found, it is avoided to incise or damage it, keeping it intact, and then it is broadly dissected superiorly and laterally, freeing all breast tissue from the fascia, but keeping it adhered in its periphery to the pectoralis major muscle. Periareolar de-epithelialization (Schwartzmann maneuver) is then carried out between Pitanguy’s “ABC” points (Figures 3, 4, 5, 6, 7, and 8), followed by the NAC’s rise (Figure 9) through the Silveira Neto maneuver6 (medial dermal pedicle). The next step is the removal of the excess tissue, followed by approximation of the medial and lateral columns with nylon 3.0 thread in separate points, “assembling” the breast (Figures 10 and 11), placing a suction drain, subdermal suture with thread monofilament 4.0 in separate stitches and intradermal suture with 5.0 monofilament thread (Figure 12).
Figure 5. Complete dissection of the fascia.
Figure 3. Schwartzmann’s maneuver. Figure 6. Closer view where fascia is observed.
Figure 4. Resection of tissue in the lower pole of the breast accessing to the fascia of the pectoralis major muscle.
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Figure 7. Breast tissue tractioned superiorly.
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Figure 8. Lateral view.
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Figure 12. Suture performed on the vertical and horizontal scars.
RESULTS
Figure 9. Silveira Neto6 maneuver.
The average age of the 64 patients included in this study was 34 years, ranging from 19 to 55 years. Forty patients had grade 2 ptosis from the Regnault Classification, and twenty-four had grade 3 ptosis. The postoperative follow-up time was from 1 to 18 months, with 41 patients having a follow-up longer than six months (Figures 13 and 14) and 23 with fewer than six months.
Figure 10. “Assembly” of the breast by approaching the lateral and medial pillars.
Figure 13. 1-year postoperative period, prosthesis with 180ml volume.
Figure 11. Positioning of the NAC in the breast “cone”.
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The main complications were: 3 cases (4.6%) of residual skin flaccidity after eight months; two cases (3.1%) of unsightly scars (one hyperchromic and one hypertrophic); one case (1.5%) of partial NAC necrosis Rev. Bras. Cir. Plást. 2020;35(3):269-275
Treatment of breast ptosis by placing silicone implants
Figure 14. A. Postoperative 6 months, prosthesis with a volume of 380ml.
followed by partial suture dehiscence (Table 1). No case of infection or seroma. The patient who presented necrosis of 75% of NAC was one of the cases of grade 3 ptosis and smoker. Table 1. Postoperative complications. N
%
Skin sagging
3
4.6
Unsightly scars
2
3.1
NAC necrosis
1
1.5
NAC: Nipple-areolar Complex.
DISCUSSION The option for mastopexy alone without introducing a silicone breast implant often does not bring total aesthetic satisfaction to the patient and the surgeon23. There are complaints in the late postoperative period of lower upper breast pole projection and breast consistency loss. In search of more effective results, surgeons opted for mastopexy with a single-time prosthesis7. The advantages would be many: better shape, projection, symmetry, adequate positioning of the NAC, and, if necessary, increased volume23. The main benefit of locating the implant in the retroglandular plane is that it is less painful in the immediate postoperative period than the retromuscular plane. It allows for a more uniform distribution of the breast parenchyma on the silicone implant, leaving the breast more harmonious. The disadvantages would be the insufficient coverage of the implant, leaving the prosthesis more exposed, and the chance of flaccidity and pseudoptosis in the late postoperative period. With that in mind, some surgeons use the retromuscular plane8,9, which in addition to being more painful, brings the risk in the late postoperative period of glandular ptosis on the muscle and the implant, determining the aspect of “waterfall” (waterfall deformity). Rev. Bras. Cir. Plást. 2020;35(3):269-275
The use of the fascia of the pectoralis major muscle as an option to cover the implant and its advantages over both retromuscular and retroglandular techniques became popular due to Graf et al. ‘s description in 199913 and 200314. This plan was chosen based on this premise for the location and positioning of silicone implants in this study. Some other aspects differentiate this study, and they are: the implant placement is the first important step of the surgery, and the access route is through the IMF; there is an extensive dissection of the fascia, on its anterior face completely separating it from the rest of the breast. So, what are the intentions of these tactics? When opting for this silicone implantation initially, the idea is to avoid the exposure for an extended period, as it is a fast and safe procedure, bringing less risk of contamination. Some authors implant the silicone at the time of breast assembly23, exposing the prosthesis to the external environment for much longer. The access route through the IMF has lower capsular contracture rates than the areolar route18, probably due to implant contamination by bacteria from the mammary ducts normal flora; the areolar approach is the option of other authors12. The wide disconnection of the fascia anterior face, isolating the prosthesis/fascia (CPF) “set” from the rest of the breast (parenchyma), be it glandular and/or fatty, allows technical ease to assemble the breast, approaching the pillars and performing the maneuvers6 needed to reposition the NAC, for example. The breast parenchyma distribution over the CPF is done homogeneously, without exposure of the silicone (previously implanted in the subfascial plane) and, with practicality and range of movements, as there is a disconnection between the parenchyma and the deep fixation tissues (fascia) of the breast. It should be noted, however, that the fascia obviously remains attached to the pectoralis major muscle throughout its periphery, except for the 3 to 4 cm where it was incised to place the silicone, so it is on the periphery of anatomical structures that adhesion zones are formed, where are vessels, nerves and lymphatics; and they interconnect superior and inferior through thin ligaments22. Concerning complications, the values were similar to those in the literature21,23. However, this study is concise compared to others23. The fact that there was no case of capsular contracture is perhaps not due to the subfascial technique itself, but due to the short period (18 months), especially in cases that were operated on less than six months ago. The complications observed here (one case of partial necrosis of the NAC, unsightly scars, and pseudoptosis) refer to the immediate and recent postoperative period. It should be noted that the case of NAC necrosis was in a smoking patient. The 274
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study’s continuity is necessary to obtain more practical and real data in relation, for example, to the capsular contracture index, through a more extensive sample, and, mainly, a longer time for analysis and comparison with the literature. Like other authors13-17, some details could be observed concerning the subfascial plane. They are implant stability, peripheral protection of the silicone prosthesis making its edges less visible and less palpable, little bleeding during dissection, little pain postoperative, less postoperative edema, as there is the preservation of the lymphatics, as described13,14,22 and, consequently, easy recovery and faster return to daily activities.
CONCLUSION The study demonstrated that the technique of placing silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, completely separating it from the rest of the breast parenchyma, was effective in the treatment of patients with breast ptosis.
ACKNOWLEGMENTS Special acknowlegments to Mr. Egídio for his collaboration during the reviews.
COLLABORATION LGN
Project Administration
REFERENCES 1. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg. 1990 Jun;85(6):961-6. 2. Castro CC, Coelho RF, Cintra HP. The value of non-prefixed markung in reduction mammoplasty. Aesthet Plast Surg. 1984;8(4):237-41. 3. Regnault PCI. Reduction mammplasty by B technique. In: Goldwyn RM, ed. Plastic and Reconstrutive Surgery of the Breast. Boston: Little Brown; 1976. p. 269-83. 4. Arié G. Una nueva técnica de mastoplastia. Rev Latinoam Cir Plast. 1957;3(1):23-31. 5. Pitanguy, I. Breast hypetrophy. In: Wallace AB, ed. Transactions of the International Society of Plastic Surgeons, Second Congress. Edinburgh: E. & S. Livingstone; 1960. p. 509.
*Corresponding author:
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6. Silveira Neto E. Mastoplastia redutora setorial com pedículo areolar interno. In: Anais do XIII Congresso Brasileiro de Cirurgia Plástica e I Congresso Brasileiro de Cirurgia Estética; Abr 1976; Porto Alegre, RS, Brasil. Porto Alegre (RS): SBCP; 1976. 7. Gonzales-Ulloa M. Correction of hypotrophy of the breast by means of exogenous material. Plast Reconstr Surg. 1960 Jan;25:15-26. 8. Daniel MJB. Inclusão de prótese de mama em duplo espaço. Rev Bras Cir Plást. 2005;20(2):82-7. 9. Chiquetti A, Silva ABD. Tratamento das ptoses mamárias com implantes submusculares e pontos de fixação do tecido mamário ao muscular: aspectos técnicos e avaliação de resultado. Rev Bras Cir Plást. 2018;33(3):317-23. 10. Khan UD. Muscle-spliting, subglandular, and partial submuscular augmentation mamoplasties: a 12-year retrospective analysis of 2026 primary cases. Aesthet Plast Surg. 2013;37(2):290-302. 11. Daher JC, Amaral JDLG, Pedroso DB, Cintra Junior R, Borgatto MS. Mastopexia associada a implante de silicone submuscular ou subglandular: sistematização das escolhas e dificuldades. Rev Bras Cir Plást. 2012 Abr/Jun;27(2):294-300. 12. Carramaschi FR, Tanaka MP. Mastopexia associada à inclusão de prótese mamária. Rev Bras Cir Plást. 2003;18(1):26-36. 13. Graf RM, Bernardes A, Auersvald A, Damasio RCC. Subfascial endoscopic transaxillary augmentation mammaplasty. Rev Bras Cir Plást. 1999;14(2):45-54. 14. Graf RM, Bernardes A, Rippel R, Araujo LR, Damasio RC, Auersvald A. Subfascial breast implant: a new procedure. Plast Reconstr Surg. 2003;111(2):904-8. 15. Hunstad JP, Webb LS. Subfascial breast augmentation: a comprehensive experience. Aesthetic Plast Surg. 2010 Jun;34(3):365-73. 16. Tijerina VN, Saenz RA, Garcia-Guerrero J. Experience of 1000 cases on subfascial breast augmentation. Aesthetic Plast Surg. 2010 Fev;34(1):16-22. 17. Goes JCS, Munhoz AM, Gemperli R. The subfascial approach to primary and secondary breast augmentation with autologus grafting form-stable implants. Clin Plast Surg. 2015 Out;42(4):551-64. 18. Benito-Ruiz J, Manzano ML, Salvador-Miranda L. Five-year outcomes of breast augmentation with form stables implants: periareolar vs transaxillary. Aesthetic Surg J. 2017 Jan;37(1):46-56. 19. Jinde L, Jianliang S, Xiaoping C, Xiaoyan T, Jiaqing L, Qun M, et al. Anatomy and clinical significance os pectoral fascia. Plast Recontr Surg. 2006 Dez;118(7):1557-60. 20. Egeberg A, Sorensen JA. The impact of breast implant location on the risk of capsular contraction. Ann Plast Surg. 2016 Ago;77(2):255-9. 21. Abramo AC, Scartozzoni M, Lucena TW, Sgarbi RG. High- and extra- high-profile round implants in breast augmentation: guidelines to prevent rippling and implant edge visibility. Aesthetic Plast Surg. 2018 Nov;43(2):305-12. 22. Rehnke RD, Groening RM, Van Buskirk ER, Clarke JM. Anatomy of the superficial fascia system of the breast: a comprehensive theory of breast fascial anatomy. Plast Reconstr Surg. 2018 Nov;142(5):1135-44. 23. Wada A, Millan LS, Galafrio ST, Gemperli R, Ferreira MC. Tratamento da ptose mamária e hipomastia utilizando a técnica de mamoplastia com pedículo súpero medial e implante mamário. Rev Bras Cir Plást. 2012;27(4):576-83.
Lincoln Graça Neto Rua Ângelo Sampaio, 2029, Batel,Curitiba, PR, Brazil. Zip Code: 80420-160 E-mail: lgracaneto@hotmail.com
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Original Article Surgical treatment for breast ptosis with silicone prosthesis: evaluation of surgical results and patient satisfaction Tratamento cirúrgico de ptose mamária com inclusão de prótese de silicone: avaliação de resultados cirúrgicos e satisfação de pacientes GISELLY DE FÁTIMA MENDES PASCOAL 1* JORGE LUIZ ABEL 2 GERALDO SCOZZAFAVE 3
Institution: Heliópolis Hospital, Sacomã, São Paulo, SP, Brazil. Article received: July 8, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0050
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ABSTRACT
Introduction: The correction of breast ptosis associated with skin flaccidity is done through mastopexy with the inclusion of an implant. This work’s objective was to evaluate the surgical results and the satisfaction of patients who underwent breast ptosis surgery with silicone prosthesis placement. Methods: We selected 22 patients who underwent mastopexy with implant placement, from February to September 2016, at the Plastic Surgery Service of Hospital Heliópolis. Interviews were conducted applying to the patients a questionnaire to verify the degree of satisfaction and changes in the daily routine after surgery. The surgical results evaluation was carried out by three surgeons, who attributed scores to different items. Results: 100% of the interviewees feel satisfied with the surgery, and all reported an improvement in their self-esteem. In the evaluation of surgeries performed with surgeons, about 91% of the results are between regular and good. Conclusion: The degree of patient’s satisfaction who underwent mastopexy with insertion was excellent. There was a favorable impact on the quality of life and well-being of the patients evaluated, with the post-surgical result being classified as regular or good. Keywords: Plastic surgery; Breast implants; Mammoplasty; Self-image; Silicone gels
Federal University of Pará, Belém, PA, Brazil. Plastic Surgery Clinic Dr. Wilson Cintra, Jardim Paulista, São Paulo, SP, Brazil. 3 Heliópolis Hospital, Sacomã, São Paulo, SP, Brazil. 1 2
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RESUMO
Introdução: A correção da ptose mamária associada à flacidez de pele é corrigida através da mastopexia com inclusão de implante. O objetivo deste trabalho foi avaliar os resultados cirúrgicos e a satisfação de pacientes submetidas à cirurgia de ptose mamária com inclusão de prótese de silicone. Métodos: Foram selecionadas 22 pacientes submetidas à mastopexia com inclusão de implante, no período de fevereiro a setembro de 2016, no Serviço de Cirurgia Plástica do Hospital Heliópolis. Foi realizada entrevista com as pacientes, por meio de aplicação de questionário, com a finalidade de verificar o grau de satisfação e as alterações no cotidiano diário após a cirurgia. A avaliação dos resultados cirúrgicos foi realizada mediante avaliação de três cirurgiões, do qual atribuíram notas a diferentes itens. Resultados: 100% das entrevistadas se sentem satisfeita com a cirurgia e todas relataram a melhora da autoestima delas. Na avaliação das cirurgias realizada com os cirurgiões, cerca de 91% dos resultados estão entre regular e bom. Conclusão: O grau de satisfação das pacientes submetidas à mastopexia com inserção foi excelente e houve impacto favorável na qualidade de vida e bem-estar das pacientes avaliadas, sendo que o resultado pós-cirúrgico se enquadra como regular ou bom. Descritores: Cirurgia plástica; Implantes de mama; Mamoplastia; Autoimagem; Géis de silicone.
INTRODUCTION
OBJECTIVE
Breast ptosis is characterized by breasts fall, decreased volume, sagging skin, or both. It is an alteration resulting from the inadequate relationship between the breast skin and its content1. It can be defined in varying degrees, according to the relationship between the nipple and the inframammary fold2. Mastopexy is plastic surgery that treats breast ptosis, aiming to improve the breast’s shape through tiny scars, the anatomical repositioning of the breasts and the nipple-areola complex, avoiding lesions or neurovascular changes3. The correction of breast ptosis is done with an increase in breast volume through silicone implants or removal of excess skin and lifting (mastopexy), or the association between them. Mastopexy associated with silicone implants is considered a more complex procedure than mastopexies without implants, due to the variable results, relapses, and related complications4. The correction of breast ptosis associated with skin flaccidity is still a topic of discussion and controversy. The critical analysis of aesthetic results and patient and team satisfaction is not well established in the literature5. On the other hand, patients have become increasingly critical about the result of breast surgery, as they expect a natural, lasting shape and minimal scarring6.
This study’s objective was to evaluate the surgical results and the satisfaction of patients who underwent mastopexy with an implant, from February to September 2016, at the Plastic Surgery Service of Hospital Heliópolis.
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METHODS We selected all patients who underwent mastopexy with breast implant operated by the same resident doctor from the last year of plastic surgery, from February to September 2016, at the Plastic Surgery Service of Hospital Heliópolis. Twenty-two patients were counted and followed from the preoperative outpatient interview until the 6th postoperative month when they were discharged. All patients were initially screened at the outpatient clinic, being subjected to a directed medical interview with clarification about the surgery, expectations, and possible complications. Further laboratory tests were requested, including complete blood count, complete biochemistry, serology for HIV (human immunodeficiency virus) and hepatitis, beta HCG (human chorionic gonadotropin), and liver function as well as chest X-ray, electrocardiogram and cardiological consultation. 277
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After this screening, the patients were photographed, then the surgical planning, length of stay, complications, and the size and shape of the prosthesis were discussed. Inclusion factors: female gender, aged between 18 and 70 years, not having undergone previous plastic surgery in another service, stable weight with BMI (body mass index) up to 28, and presenting a deficient breast volume that justified the placement of the prosthesis. Exclusion factors: being a smoker, having uncontrolled comorbidities, history of previous surgical complications, refusing to sign a free and informed consent form for the study, having laboratory alterations, or high risk that contraindicate the surgery, and emotionally unstable patients or who do not understand the procedure surgical. Two questionnaires were carried out for the present study. The first questionnaire included data regarding age, prosthesis shape, profile, implant volume, surgical reintervention, intraoperative complications, postoperative complications, the distance between the wishbone and point A, the scar shape ( periareolar, inverted T, areola and vertical), mammary pocket plane (subglandular, subfascial and submuscular), capsular contracture (Baker scale), degree of previous ptosis and pregnancy. The analysis followed the principles of resolution 466/2012 of the National Health Council, which deals with the ethical and legal aspects of research involving human beings in Brazil. The second questionnaire included an interview directed at the satisfaction with the surgery and if it interfered with the patients’ social, sexual life, and body care. Evaluation of surgical results A critical and qualitative analysis of the 22 patients’ surgical results was carried out. Three
different plastic surgeons from the Plastic Surgery Service of Hospital Heliópolis with experience in performing mastopexy with a prosthesis compared the pre- and postoperative photographs. For this, a questionnaire with five items (Chart 1) was used as described in Cintra Júnior et al. in 20167. After data collection, a results descriptive evaluation was performed.
RESULTS In the protocol for evaluating the surgical results obtained through the application of the questionnaires, the following data were recorded: age ranging from 26 to 69 years; weight from 49 to 77kg; prosthesis shape: 100% round; profile: 54.54% high, 31.81% super high and 13.63% moderate; implant volume: 240 to 350ml; reintervention: 13.63% of cases; and intraoperative complication: 0%. Regarding patients who presented complications in the postoperative period, it was observed that 14 patients had some type of complication or more than one type (Table 1). It was found that three patients needed surgical reintervention, one of the cases was due to asymmetry and scarring, another to perform the resuture and the third to perform hematoma drainage. Regarding the shape of the scar, 31.81% of the patients had a periareolar shape, 45.45% an inverted T shape (Figure 1), and 22.72% a vertical periareolar shape. In the breast pocket plane, 63.63% were subglandular, 31.81% subfascial, and 4.5% submuscular. Capsular contracture was seen in only one patient, with four on the Baker scale. Type 1 ptosis was observed in 40.90% of patients, type 2 in 50.0%, and type 3 in 9.0%. Regarding the number of pregnancies, 45.45% of the patients had two pregnancies, 40.90% had one pregnancy, and 13.63% had no pregnancy.
Chart 1. Description of the items evaluated and the scores given in the questionnaire answered by the three plastic surgeons about the patients who underwent a mastopexy. Scores Breast form Breast volume Symmetry between breasts Posicionamento NAC* Quality and extent of scars
0 – Bad
1 – Regular
2 - Good
Inadequate
Regular
Adequate
Inadequate and disharmonious
Adequate and disharmonious Inadequate and disharmonious
Adequate and harmonic
Very different
Little different
Equal or very similar
Away from the breast cone apex
Near the breast cone apex
Exactly at the breast cone apex
Slightly enlarged and well-positioned
Thin, clear and well-positioned
Alargadas Hypertrophic or very extensive
*NAC: Nipple areola complex. Source: Cintra Júnior et al., In 20167.
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Surgical treatment for breast ptosis: results and satisfaction Table 1. Patients who underwent mastopexy with a breast implant and presented postoperative complications (n = 14). Number of cases
Complications
4
Enlargement
1
Enlargement + dehiscence
1
Enlargement + dehiscence + asymmetry
3
Asymmetry
4
Hypertrophic scar
2
Dark scar
1
Hematoma
1
Inflammation
2
Serous secretion
1
Necrosis
1
Infection
1
Keloid
A
B
C
D
Figure 1. A and C. Anterior view before surgery; B and D. Postoperative, with the arrow indicating the inverted T-shaped scar.
When questioning patientsâ&#x20AC;&#x2122; satisfaction with the surgery, it was found that most patients were satisfied with the change after surgery (Table 2). When the patients were asked what they liked most about the result of the breast surgery, most of them (50%) reported that they liked everything (Figure 2) and the others said they liked the volume, the shape, the correction of the ptosis and the removal of excess skin. On the other hand, when asked about what they liked least about the result of the surgery, 50% answered that nothing, that is, they liked everything, 33.3% did not like the scar (Figure 3) and a smaller percentage even mentioned the points and pain as an answer to this question. Rev. Bras. Cir. PlĂĄst. 2020;35(3):276-282
It is possible to observe in Figure 3D that the left breast had an abnormal scar, around the areola and vertically, and it was also one of the patients that presented asymmetry, as can also be seen in Figure 4. This patient was one of the three patients that needed surgical reintervention for correction. Regarding the evaluation carried out by the three surgeons, it is possible to observe the divergence of the results among them. However, it is noteworthy that the majority of patients fit the postsurgical result, in regular or good in the different items evaluated (Table 3), and only 8,8% of the results were considered bad.
DISCUSSION Female breasts are essential symbols of femininity, sexuality, and motherhood. Thus, they are extremely related to female psychosexual wellbeing8. Therefore, in the last few years, the number of breast surgeries performed has increased a lot. However, this increase has, consequently, also a more significant number of complications9,10. In this study, a considerable number of patients were observed who presented some type of complication in the postoperative period, but the complications presented were of lesser intensity. The objectives of breast surgeries are focused on a good evaluation of the final aesthetic result and a postoperative free of complications. For the patient, it is a satisfactory result from both an aesthetic and functional point of view, improving her quality of life in several aspects11. In the present study, half of the patients had their inverted T-type scars. According to Neligan, in 201512, the various surgical approaches to mastopexy are divided based on the scarâ&#x20AC;&#x2122;s pattern. There are four basic scar patterns for mastopexy techniques: periareolar, vertical, J or L, and inverted T. Regarding the breast pocket plane, 75% of patients had the subglandular plane. According to Spear et al., in 20041, in daily surgical practice, inserting a silicone implant, particularly in the subglandular plane, seems simple. However, the indications for the best tissue plane to use for implant coverage and association with mastopexy can become challenging, eventually requiring secondary procedures1. Among the existing mastopexy techniques, Neligan, in 201512, states that the periareolar technique is the most suitable for patients with mild to moderate breast ptosis, which would be the case for more than 83% of the patients evaluated in this study. In this technique, firmer parenchyma is preferable to more 279
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Table 2. Answers to questions related to patient satisfaction concerning surgery (n = 22). Question
Yes
No
7
15
Did you regret having the surgery?
0
22
Did surgery influence social life?
15
7
Did the surgery influence the affective life?
16
8
Do your breasts interfere with professional life?
Did surgery influence sex life?
16
8
Are you satisfied with the result of breast surgery?
22
0
Was the result of the surgery close to what you heard from the plastic surgeon?
22
0
Is the result close to what you expected?
22
0
Did the surgery change your life? How?
22
0
Did breast surgery affect body care?
16
8
Self-esteem Are you satisfied with your breasts?
21
Partly
Has your body improved?
22
0
Are you satisfied with your body?
21
1
Do you believe that breast surgery has anything to do with satisfaction with your body?
21
1
A
B
Figure 2. Patient who was completely satisfied with the surgery. A. Before surgery; B. Postoperative.
Figure 4. Patient who was dissatisfied with the scar in the postoperative period and needed reintervention.
A
B
C
D
Figure 3. Patients who were not satisfied with the scar. A and C. Before surgery; B and D. Postoperative with arrows indicating the scars.
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flaccid tissues. The incisions for this technique range from an upper half moon to a full circle of removed skin. Mild ptosis was defined as presenting the nipple 1 cm from the inframammary fold and being above the breast’s lower pole. In moderate ptosis, the nipple is 1-3 cm below the inframammary fold but is still above the breast’s lower pole. In severe ptosis, the nipple is more than 3 cm below the inframammary fold and is located below the lower breast contour. In pseudoptosis, the nipple is above the inframammary fold, but most of the breast tissue is below and gives the appearance of ptosis2.
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Surgical treatment for breast ptosis: results and satisfaction Table 3. Results of the evaluation of the plastic surgeon for the different items evaluated by patients undergoing mastopexy (n = 22). Evaluated items
Score 0
Score 1
Score 2
Surgeon 1 Form
1
5
16
Volume
1
3
18
Symmetry
2
9
11
NAC*
3
7
12
Scar
3
10
9
Form
1
15
6
Volume
1
7
14
Symmetry
1
8
13
NAC
2
15
5
Scar
2
10
10
Surgeon 2
Surgeon 3 Form
2
10
10
Volume
0
11
11
Symmetry
1
12
9
NAC
3
10
9
Scar Total (%)
6
7
8
29 (8,8)
139 (42,2)
161 (48,9)
*NAC: Nipple-areola complex.
Regarding the questioning about the patients’ satisfaction with the surgery, Ozgür et al., in 199813, affirm that psychology should be an integral part of plastic surgery since many patients showed relief from psychological and social problems after the surgical procedures. All patients reported that they did not regret having the surgery and said that the surgery result was within the expected expectations; only one was partially satisfied because she would like it to get bigger. According to Neligan, 201512, most patients come to the consultation with some notion of what to expect from the surgery. These predetermined ideas come from internet research and image observation and conversations with other people who have undergone mastopexy. All patients evaluated stated that their selfesteem improved after the surgery. In this sense, several studies have already been carried out, highlighting the improvement in self-esteem11,14. According to Santos et al., in 201915, in a study with patients who underwent breast surgery, most were dissatisfied with the body in the pre-surgical period and pointed out the breast as the most significant discomfort, and the desire to raise self-esteem showed as the primary motivation among the evaluated group. Finally, the authors report that the level of post-surgical satisfaction among patients was Rev. Bras. Cir. Plást. 2020;35(3):276-282
high, with surgery interfering in professional, personal, and sexual aspects. When asked about what they liked least about the surgery, about 33% of patients reported that they did not like the scar. In 201512, Neligan stated that although scars are an inherent part of any surgical procedure, their final quality cannot be predicted. According to Sanfelice and André, in 200716, the breasts have very varied shapes, and therefore they must have specific approaches for each type in particular and, consequently, they can present different results in the face of surgery due to this variation. Among the characteristics mainly cited by patients they liked the most, are the increase in volume and the reduction of sagging. Mansur and Bozola, in 200917, claim that most patients who seek breast plastic surgery, want larger breasts and correction of flaccidity. Regarding the difference between surgeons in the results obtained, the significant variability and subjectivity in the evaluation of the items analyzed are perceived, which was also reported in a study carried out by Cintra Júnior et al., in 20167. However, these same authors affirm that the weak agreement between the scores awarded by the evaluators do not invalidate the results obtained. However, it is noteworthy that surgeons considered 91.1% of surgeries to be regular or good, demonstrating that even surgeons considered surgeries with satisfactory results.
CONCLUSION The degree of satisfaction of patients who underwent mastopexy with insertion was excellent, and there was a favorable impact on the quality of life and well-being of the patients evaluated. In the evaluation of plastic surgeons, the postsurgical results of mastopexy with insertion of the evaluated patients, the majority, 90%, of the items were considered to be fair or good.
COLLABORATION GFMP
Analysis and/or data interpretation, Conception and design study, Data Curation, Final manuscript approval, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Writing - Original Draft Preparation, Writing - Review & Editing
JLA
Writing - Review & Editing
GS
Writing - Original Draft Preparation 281
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REFERENCES 1. Spear SL, Pelletiere CV, Menon N. One-stage augmentation combined with mastopexy: aesthetic results and patient satisfaction. Aesthetic Plast Surg. 2004 Nov;28(5):259-67. DOI: https://doi.org/10.1007/s00266-004-0032-6 2. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg. 1976 Abr;3(2):193-203. 3. Rohrich RJ, Gosman AA, Brown AS, Reisch J. Mastopexy preferences: a survey of board-certified plastic surgeons. Plastic Reconstr Surg. 2006 Dez;118(7):1631-8. DOI: https://doi. org/10.1097/01.prs.0000248397.83578.aa 4. Spear SL, Low M, Ducic I. Revision augmentation mastopexy: indications, operations, and outcomes. Ann Plast Surg. 2003 Dez;51(6):540-6. DOI: https://doi.org/10.1097/01.sap.0000096450.04443.be 5. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006 Mai;56(5):481-6. DOI: https://doi.org/10.1097/01.sap.0000208935.28789.2d 6. Daher JC, Amaral JDLG, Pedroso DB, Cintra Júnior R, Borgatto MS. Mastopexy associated with submuscular or subglandular silicone implants: indications and complications. Rev Bras Cir Plást. 2012 Jun;27(2):294-300. DOI: http://dx.doi.org/10.1590/ S1983-51752012000200021 7. Cintra Júnior W, Modolin MLA, Rocha RI, Gemperli R. Augmentation mastopexy after bariatric surgery: evaluation of patient satisfaction and surgical results. Rev Col Bras Cir. 2016 Jun;43(3):160-4. DOI: https://doi.org/10.1590/0100-69912016003005 8. Pitanguy I, Bretano J, Ramalho MC, Porto MJ. Implante de silicone gel com revestimento de poliuretano. Rev Bras Cir Plást. 1990;80(2):119-30.
*Corresponding author:
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9. Grewal NS, Fisher J. Why do patients seek revisionary breast surgery?. Aesthet Surg J. 2013 Fev;33(2):237-44. DOI: https://doi. org/10.1177/1090820X12472693 10. Hanwright PJ, Hirsch EM, Seth AK, Chow G, Smetona J, McNichols C, et al. A multi-institutional perspective of complications rates for elective non-reconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010. Aesthet Surg J. 2013 Mar;33(2):378-86. DOI: https://doi.org/10.1177/1090820X13478819 11. Freire M, Sabino Neto M, Garcia EB, Quaresma MR, Ferreira LM. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg. 2007 abr;119(4):1149-56. DOI: https://doi.org/10.1097/01.prs.0000254358.55104.9f 12. Neligan PC. Cirurgia plástica. 3ª ed. Rio de Janeiro: Elsevier; 2015. v. 5. 13. Ozgür F, Tuncali D, Güler GK. Life satisfaction, self-esteem, and body image: a psychosocial evaluation of aesthetic and reconstructive surgery candidates. Aesthetic Plast Surg. 1998 Nov/Dez;22(6):412-9. 14. Silva MMA, Resende VCL, Veiga DF, Brito MJ, Sabino Neto M, Ferreira LM. Impacto da mamoplastia redutora na sexualidade feminina. Rev Bras Cir Plást. 2013;28(Supl 1):1-103. 15. Santos GR, Araújo DC, Vasconcelos C, Chagas RA, Lopes GG, Setton L, et al. Impacto da mamoplastia estética na autoestima de mulheres de uma capital nordestina. Rev Bras Cir Plást. 2019;34(1):58-64. 16. Sanfelice AF. Mammary plastic arts planning: new classification of mammary shapes. ACM Arq Catarin Med. 2007 Jun;36(Supl 1):55-8. 17. Mansur JRB, Bozola AR. Mastopexy and breast augmentation with protection and inferior support of the prosthesis with inferior pedicle flap. Rev Bras Cir Plást. 2009;24(3):304-9.
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Original Article Facelift light, rhytidoplasty for the treatment of the face and neck lower third with reduced scarring and adhesion points Facelift light, ritidoplastia para tratamento do terço inferior da face e pescoço com cicatriz reduzida e pontos de adesão ISAAC ROCHA FURTADO 1* NICODEMUS DE OLIVEIRA SILVA 2
Institution: Monte Klinikum Hospital, Fortaleza, CE, Brazil. Article received: June 10, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0051
1 2
283
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ABSTRACT
Introduction: Facelift light represents a technique standardization to treat face and neck lower third, with lesser scars, SMAS plication in all patients, and adhesion points to reduce bruises. Moderate detachment allows the patient to return to their activities faster. Methods: Surgery is performed after prior periauricular marking of all patients of the area to be detached and the skin’s design to be removed. Anesthesia is local with sedation, and without the need for haircuts. Flap detachment, SMAS plication, adhesion points in the anterior and posterior flaps are performed, in addition to the internal suture by layers and liposuction of the subment when necessary. The dressing is compressive without using drains. Results: One hundred and eighty-five patients underwent rhytidoplasty using this technique since 2014. Their age varied between 31 and 84 years, with an average of 55 years. Lymphatic drainage is performed after seven days, and after two weeks, a considerable reduction in edema has been observed. Conclusion: Facelift light is a useful technique, simple to perform with reduced scarring and few complications, favoring the early return of patients to their activities. Keywords: Rhytidoplasty; Plastic surgery; Abnormalities of the skin; Suture techniques; Face.
Isaac Furtado Clinic, Fortaleza, CE, Brazil. Hospital Geral de Fortaleza, Fortaleza, CE, Brazil.
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Facelift light, rhytidoplasty for the treatment of the face and neck lower third
■
RESUMO
Introdução: O facelift light apresenta uma padronização da técnica com o objetivo de tratar o terço inferior da face e o pescoço, com menores cicatrizes, plicatura do SMAS em todos os pacientes e utilização de pontos de adesão para redução de hematomas. O descolamento moderado permite um retorno mais rápido do paciente às suas atividades. Métodos: A cirurgia é feita após uma marcação prévia periauricular de todos pacientes, com a área a ser descolada e o desenho da pele a ser retirada. A anestesia é local e sedação, sem a necessidade de cortes no cabelo. É feito o descolamento dos retalhos, plicatura do SMAS, pontos de adesão nos retalhos anterior e posterior, além da sutura interna por planos e lipoaspiração do submento quando necessária. O curativo é compressivo sem a utilização de drenos. Resultados: Foram submetidos à ritidoplastia por essa técnica 185 pacientes a partir de 2014. Com a idade variando entre 31 e 84 anos, sendo a média de 55 anos. É feita drenagem linfática a partir de sete dias e com duas semanas observou-se uma redução considerável do edema. Conclusão: O facelift light é uma técnica eficaz, de simples execução, cicatrizes reduzidas e com poucas complicações, favorecendo o retorno precoce dos pacientes às suas atividades. Descritores: Ritidoplastia; Cirurgia plástica; Anormalidades da pele; Técnicas de sutura; Face.
INTRODUCTION Non-surgical aesthetic procedures, such as botulinum toxin and fillers, are increasingly delaying the indication for facial lifting, especially in the frontotemporal region1. In this context, we observed a lack of publications that contemplate the mini facelift technique with a reduced scar standardization as part of the therapeutic arsenal for the face middle and lower thirds treatment. Thus, we used the facelift light technique standardization, which consists in moderate detachment, demarcated in the preoperative period, as well as its execution with specific points for the detachment, associated with the plication of the superficial aponeurotic system (SMAS) and the points of adhesion (Figures 1, 2, 3 and 4). Standardized preoperative marking makes this technique reproducible and with less learning curve, but without compromising the results. The SMAS plication proved to be essential for the best treatment and lasting traction, associated with a reduction in skin tension, with less risk of flap necrosis and a better quality of the scar.
OBJECTIVE Evaluate the results of the facelift light as a standardized and reproducible technique, the moderate SMAS detachment and plication, with natural results, associated with lower rates of complications and early return to activities. Rev. Bras. Cir. Plást. 2020;35(3):283-287
Figure 1. Standardized marking of the detachment area, showing the incision site. Arrows indicate the area to be detached, 4-6 cm from the lobe.
METHODS Two hundred eighty-four patients who underwent rhytidoplasty using the facelift light technique were operated on from 2014 to 2020, 39 were men. Patients aged between 31 and 84 years (with a mean of 56 years). All patients were operated on and observed by the same surgeon and author of this study 284
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(2014 - 24, 2015 - 35, 2016 - 33, 2017 - 42, 2018 - 51, 2019 - 80, 2020 - 19). Surgical technique
Figure 2. Red line represents the skin mark to be removed, with the drawing of the tragus flap. Lilac line represents the post-tragal and periauricular incision.
Figure 3. SMAS plication points, with traction direction. The suture order starting at the angle of the mandible.
With the patient in an orthostatic position, the preoperative marking of the region of the incision is made, of the region to be released and of the possible skin to be removed (Figures 1 and 2). Taking the location of the ear lobe insertion as the center of the circumference, we make a circle that varies from 4 to 6 centimeters, according to the existing alterations in the mandible branch (“jowl” or “bulldog”) and the platysmal bands of the neck. In the submental region, liposuction is already scheduled, if necessary. All patients were operated on a hospital operating room under local anesthesia associated with sedation. Local infiltration was performed with lidocaine solution (40 ml), saline solution (120 ml), and an adrenaline ampoule. The incision is made only in the glabrous area, so there is no need to cut hair. The incision starts at the rib capillary region (around 1.5 cm), breaking at an angle of 90 degrees in the pre-auricular region, descending retrotragal, and outlining the ear from its posterior region to its upper portion (Figure 2). Subcutaneous detachment is done initially with the scalpel and then with scissors in the demarcated area. The second step is the plication of the superficial muscle-aponeurotic system (SMAS), made with colorless nylon 4.0 (Figure 3). Starting the suture through the mandible branch, then in the anterior region, and finally in the posterior region, leaving the entire surface smooth and without sagging. The next step is the adhesion suture of the entire flap, made with monocryl 4.0, pulling gently without marking the skin too much (Figure 4). The adhesion points follow the same order as the SMAS, starting with the mandible branch. After the excess skin is removed, adjusting with the drawing made previously, there may be the need to remove a little more or less. The skin is sutured with monocryl 4.0 and, finally, with a continuous intradermal suture performed with monocryl 5.0; there is no need for drains. The last step is liposuction of the subment, made by a small median incision in the subment. And the compressive dressing with gauze around the ear, padded gauze, and the elastic band. The dressing is renewed 24 hours after discharge (Figure 5).
RESULTS
Figure 4. Adhesion points. Stitches with monocryl 4.0 (in white) and colorless mononylon 4.0 (in blue).
285
Partial results are seen in the first few weeks, especially after lymphatic drainage. After a month, edema is no longer observed. In the long term, the Rev. Bras. Cir. Plást. 2020;35(3):283-287
Facelift light, rhytidoplasty for the treatment of the face and neck lower third
DISCUSSION
Figure 5. Marking, detachment, adhesion points, excess skin, suture and dressing.
surgery can be redone around 5 to 7 years, and since it does not change the hair implant, it can be done several times over the years without leaving stigmas, as seen in one year postoperative (Figures 6 and 7). The complications were much less, where the rare hematomas were restricted to small regions drained by 7-day transcutaneous puncture (12 cases). The main complaint is the persistence in elderly and postbariatric patients of some skin in the central cervical region.
Figure 6. Postoperative period of 2 months and 1 year.
Figure 7. Postoperative with detail in the retroauricular region.
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Facial rejuvenation must encompass several complementary forms of treatment and act effectively in all facial regions. The rising cosmiatric arsenal, with fillers added to the botulinum toxin, puts into question the broad coronal lifting, especially in younger patients. In older individuals, understanding the interaction between these complex anatomical changes is essential when choosing a surgical strategy, which can vary from periorbital treatment, through conservative frontal lifting, to radical liftings in this region2. Facelift light is approached in this study as an alternative for the face middle and lower thirds treatment, with a standardized, reproducible mark; with a reduced scar, moderate detachment, plication of the SMAS and points of adhesion; as well as with natural results, few complications and early return of patients to daily activities. Standardized preoperative marking facilitates the technique reproducibility with more accessible and safer learning compared to classic rhytidoplasty or aggressive detachments3. Since the most aggressive and profound approaches, or large detachments, bring an even higher risk of other complications, such as injuries to facial nerve branches and flaps suffering 4. Several authors report that they have reduced the detachmentsâ&#x20AC;&#x2122; amplitude and realized that results are equally good and very similar to those obtained with the broader and more generalized detachments used before. These are now reserved for cases of great skin flaccidity and for those who need large cervical degreasing associated with platysma plication5,6. Another essential point of rhytidoplasty is the treatment of the superficial musculoaponeurotic system (SMAS) 5,7, as it has become essential during the performance of the facial lifting, since it determines the elevation and traction of the tissue planes, with longterm effects8. These techniques can be used, ranging from mobilization, plication, and repositioning, to subaponeurotic resections. In this context, the facelift light is performed with the standardized plication of the SMAS, without detachment and deep resections, to reduce the risk of injury to the subaponeurotic structures. The use of adhesion points applied in the pre and behind-the-ear regions reduced to zero the incidence of large bruises requiring urgent surgical drainage9,10, making the use of drains unnecessary with the use of this technique. Thus, the rejuvenation surgery of the face middle and lower thirds has been evolving to perform less invasive and less aggressive techniques, in 286
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order to reduce complications and provide an earlier return to the usual activities of patients8-12; without, however, compromising the occurrence of natural and satisfactory results to patients.
CONCLUSION The facelift light technique was considered satisfactory due to the quality of the results obtained in this series, the low rate of complications, and the early return of patients to their activities.
COLLABORATIONS IRF
Analysis and/or data interpretation, Conception and design study, Writing Original Draft Preparation
NOS
Writing - Review & Editing
REFERÊNCIAS 1. Menezes MVA, A bla LEF, Dutra LB, Junqueira AE, Ferreira LM. Modified minilifting results: prospective study. Rev Bras Cir Plást. 2010;25(2):285-90. 2. Tabatabai N, Spinelli HM. Limited incision nonendoscopic brow lift. Plast Reconstr Surg. 2007;119(5):1563-70.
*Corresponding author:
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3. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plastic Reconstr Surg. 2005 Dez;116(7):197385;discussion:1986-7. 4. Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in aesthetic plastic surgery. Plast Reconstr Surg. 2006 Mai;117(6):1809-27. 5. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976 Jul;58(1):80-8. 6. Saldanha OR, Azevedo SFD, Saldanha Filho OR, Saldanha CB, Chaves LO. Ritidoplastia com descolamento composto. Rev Bras Cir Plást. 2010;25(1):135-40. 7. Pitanguy I, Degand M, Ceravolo MP, Bos H. Considerações sobre nossa experiência com dissecção e plicatura do SMAS em meloplastia. Rev Bras Cir Plást. 1981;71(1):57-72. 8. Maloney BP, Schiebelhoffer J. Minimal-incision endoscopic facelift. Arch Facial Plast Surg. 2000;2(4):274-8. 9. Destro MWB, Destro C, Baroudi R. Adhesion stitches in rhytidoplasty: a comparative study. Rev Bras Cir Plást. 2013;28(1):55-8. 10. Cló TXT, Ferraz Junior WFF, Leão CEG, Cló FX, Mourão LM, Leão LR. Perioperative systematization for the prevention of hematomas following face-lift procedures: a personal approach bases on 1,138 surgical cases. Rev Bras Cir Plást. 2019 Jan/Mar;34(1):2-9. 11. Aboudib JH, Pontes R, Amaral PB, Castro CC. Debate sobre ritidoplastias: “radicais ou econômicas?”. Rev Bras Cir Plást. 2005;20(4):253-5. 12. Zani R, Fadul Junior R, Rocha MAD, Santos RA, Alves MCA, Ferreira LM. Facial nerve in rhytidoplasty: anatomic study of its trajectory in the overlying skin and the most common sites of injury. Ann Plast Surg. 2003 Set;51(3):236-42.
Isaac Rocha Furtado Avenida Dom Luís, 1233, Sala 606, Fortaleza, CE, Brazil. Zip Code: 60160.230 E-mail: dr.isaacfurtado@gmail.com
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Original Article Reconstruction of eyelid zones II and III: case series Reconstrução das zonas II e III palpebrais: série de casos DÉLCIO APARECIDO DURSO 1* SÉRGIO DOMINGOS BOCARDO 1
Institution: Hospital Federal de Ipanema, Rio de Janeiro, RJ, Brazil. Article received: July 8, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0052
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Introduction: The eyelids represent anatomical structures of high complexity, requiring the plastic surgeon’s technical skills and experience to their reconstruction. Defects in these areas happen mainly after tumor resection, with the lower eyelids being a frequent site of lesions of this nature. The options for reconstruction vary according to some criteria, including the size of the resulting defect, location, and depth. The result of the reconstruction is mainly aimed at restoring the proper functioning of this delicate structure. Methods: This work presents a series of seven cases of patients of different complexity, attended, and treated by the Plastic Surgery Service of the Federal Hospital of Ipanema. We show the versatility of local flaps to restore the proper anatomy and function of the lower eyelid. We also try to highlight different types of tumor pathologies that occur in this region. Results: No patient evolved with ectropion or anatomical distortion, ultimately obtaining a good cosmetic and functional result. Discussion: The medial region of the eyelids represents a significant challenge for its reconstruction since, in this topography, there are delicate structures such as the lacrimal canaliculus and the medial canthal ligament. Several local flaps can be used depending on the extent and depth of the defect generated after trauma or tumor excision. Having mastery over the periorbital anatomy and surgical options is essential for successful treatment. Keywords: Carcinoma, Basal cell; Eyelid neoplasms; Surgical flaps; Face; Anatomy.
Hospital Federal de Ipanema, Department of Plastic Surgery, Rio de Janeiro, RJ, Brazil.
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RESUMO
Introdução: As pálpebras representam estruturas anatômicas de grande complexidade, exigindo habilidades técnicas e experiência por parte do cirurgião plástico para a sua reconstrução. Defeitos nessas áreas são produzidos, principalmente, após ressecção tumoral, sendo as pálpebras inferiores sede frequente de lesões dessa natureza. As opções para reconstrução variam de acordo com alguns critérios, entre eles: tamanho do defeito resultante, localização e profundidade. O resultado da reconstrução visa sobretudo reestabelecer o funcionamento adequando dessa nobre estrutura. Métodos: Este trabalho apresenta uma série de sete casos, de diferentes complexidades, de pacientes atendidos e tratados pelo Serviço de Cirurgia Plástica do Hospital Federal de Ipanema. Mostramos a versatilidade dos retalhos locais para restaurar a anatomia e função adequadas da pálpebra inferior, bem como ressaltar diferentes tipos de patologias tumorais incidentes nessa região. Resultados: Nenhum paciente evoluiu com ectrópio ou distorção da anatomia, obtendo ao final bom resultado cosmético e funcional. Discussão: A região medial das pálpebras representa uma área de grande desafio para reconstrução, uma vez que nessa topografa se localizam estruturas nobres, como o canalículo lacrimal e o ligamento cantal medial. A depender da extensão e profundidade do defeito gerado, após trauma ou exérese tumoral, vários são os retalhos locais que podem ser utilizados. Ter domínio sobre a anatomia periorbital e das opções cirúrgicas é fundamental para o sucesso no tratamento. Descritores: Carcinoma basocelular; Neoplasias palpebrais; Retalhos cirúrgicos; Face; Anatomia.
INTRODUCTION Detailed knowledge of the eyelids and ocular region anatomy (Figure 1) helps the surgeon select the best surgical technique capable of restoring eye function and perfecting the aesthetic result. The eyelid is divided into an anterior and posterior lamella. The anterior lamella is composed of skin and orbicularis muscle. The posterior lamella is composed of the conjunctiva, tarsus, and eyelid retractor muscles. The orbital septum can be considered a median lamella and is not usually reconstructed. The ocular conjunctiva on the surface of the globe is continuous with the conjunctiva that lines the eyelids’ inner surface; this relationship needs to be maintained or restored during reconstruction to preserve eyelid function1,2. The periorbital zones can be didactically divided, as shown in Figure 2, and are numbered from I to V. Surgical excision of skin tumors is one of the most frequent causes of eyelid defects. Basal cell carcinoma (BCC) is the most frequent tumor in this location, corresponding to about 90% of cases, with a predominance of lesions in the lower eyelid1. Squamous Rev. Bras. Cir. Plást. 2020;35(3):288-293
Figure 1. Palpebral anatomy. Division of the eyelid structures into anterior, middle and posterior lamellae (Source: Atlas of Aesthetic Eyelid and Periocular Surgery, 20043).
cell carcinoma, sebaceous carcinoma, and melanoma are less prevalent histological types 2. The defects resulting from the excision of cutaneous eyelid tumors require detailed knowledge of the periorbital region’s 289
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Case 1 Skin graft: 86-year-old patient, whose lesion affected the skin, reaching zone III, resection was performed with preservation of the middle and posterior lamella structures. Skin grafting was performed, obtaining ipsilateral anterior preauricular skin and repairing the defect (Figure 3).
Figure 2. Eyelid zones. Representative illustration of the division of the periorbital region into zones numbered from I to V.
anatomy and the most appropriate surgical approaches for the success of reconstruction.
OBJECTIVE The objective of the work is to apply different forms of reconstruction of eyelid defects located specifically in zone II and III or that corresponding to the lower eyelid and the medial angle, respectively.
METHODS Serie of seven patients between 69 and 90 years old with a surgical wound on the lower eyelid, after removal of malignant tumors, with defects ranging from approximately 30% to 80% of horizontal extension (Table 1). Patients underwent local anesthesia with or without sedation or general anesthesia. After complete excision of the tumor located in the lower eyelid, surgical reconstruction was performed, according to the extent and depth, using neighborhood flaps or skin grafting. In none of the cases, tarsal reconstruction with cartilage graft was not performed, which is usual in lower eyelid surgeries with extensive involvement of this anatomical structure (Figure 2). Different flaps were drawn and made, and a more superficial defect was repaired with a skin graft from the preauricular area.
Figure 3. Patient underwent full-thickness pre-auricular skin grafting after excision of BCC in zone II.
More superficial defects can be repaired with skin grafts, constitute donor areas: retroauricular and preauricular skin in some cases of the upper eyelid, as they have similarities with the eyelid skin1,4. Case 2 Paramedian frontal flap: patient presented a recurrent lesion in the right eye (RE) medial canthus with ten months of evolution. Resection and intraoperative freezing were performed. The generated defect had depth up to the orbit periosteal region. The patient had several scar areas in the nasal and glabellar dorsal region; the paramedian and contralateral frontal flap was selected for reconstruction (Figure 4). Cases 3 and 4 Imre flap: two male patients were selected, the first of them with a large lesion, with partial blockage of the visual axis. He underwent resection with intraoperative freezing. The pathology revealed to be
Table 1. Materials and methods. Patient Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7
Sex M F F F M M F
Age 90 69 76 73 81 76 86
Tumor Sebaceous carcinoma Basal cell carcinoma Basal cell carcinoma Basal cell carcinoma Basal cell carcinoma Basal cell carcinoma Basal cell carcinoma
Location Zone III Zone III Zone III Zone III Zone II and III Zone III Zone II and III
Surgical Technique Imre flap Paramedian frontal flap Glabellar flap Esser flap Esser flap Imre flap Skin graft
M: Male; F: Female.
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Case 5 Glabellar flap: 76-year-old patient with an ulcerated lesion in the transition region from the medial palpebral canthus to the nasal dorsum. It was performed a glabellar flap (Figure 7).
Figure 4. Paramedian frontal flap: patient presented with a recurrent lesion in the medial corner of the RE, with 10 months of evolution.
sebaceous carcinoma. The second case was a 76 years old male, with histopathological diagnosis of BCC (Figures 5 and 6). Figure 7. Transposed glabellar flap to restore anatomy of the left medial canthus.
Cases 6 and 7 Esser flap: A 73-year-old woman and an 81-yearold man were operated on, both diagnosed with BCC (Figures 8 and 9).
Figure 5. Imre flap, reconstruction of a major defect in the left medial canthus, with excellent functional and cosmetic results.
Figure 8. Esser flap after wide detachment is rotated to correct defects in zone II and III.
RESULTS
Figure 6. Imre flap: surgical sequence.
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Seven patients aged between 69 and 90 years were operated on, four females and three males, six with a BCC diagnosis, and one with a sebaceous tumor. All operated cases were located in periorbital zones II and/or III, in the medial canthus of the unilateral lower eyelid. All of them evolved with 291
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Figure 9. Case 7. Esser flap with good final scar positioning.
useful function without retraction or distortion of the anatomy and preservation of the lacrimal pathways’ drainage.
DISCUSSION In superficial lesions, a free skin graft is used, which is preferably obtained from the retroauricular region. The skin to be grafted, after cleaning the subcutaneous cell tissue, is sutured in the recipient bed, and a Brow dressing is made. Five days after the dressing is done, the tie-over is removed4. In deep lesions where the bone part is exposed after resection, the glabella VY flap is used, which is practical and simple; two incisions forming an inverted V in the glabella region are made, then the flap is detached and slid to the place where the lesion was resected and sutured1,5. In cases where the ends of the eyelids are included in the resection, the frontomedial flap is used. In these cases, the surgery will be performed in two stages - the frontomedial flap is initially transposed; after 3 to 4 weeks, the second time is done: the pedicle is resected, the rest being taken to its original bed. Then the area is degreased, and the ends of the eyelids are remade5,6. The frontal flap is safe, with little morbidity in the donor area, and is an essential option for eyelid reconstructions. The need for a posterior surgical procedure for resectioning the pedicle and the excess volume of flap fat tissue is one of the main disadvantages of this procedure. The patient presented an adequate postoperative evolution without complications7,8. When the defect is greater than 50% of the lower eyelid, and this same defect has a circular shape, the Imre sliding flap should be considered. The incision 292
is parallel to the lower palpebral margin, extending to the inner canthus and descending to the nasolabial fold. This flap must be well taken off throughout the genian region to avoid ectropion9. The use of the Imre flap provided good aesthetic and functional result, similar to other flaps commonly used for that kind of reconstructions, such as Mustardé, Esser, and the glabellar flap for the medial canthus. As an advantage, we believe that this method ensures a better positioning of the final scar in the natural grooves of the face9. The simple or bilobed glabellar flap is characterized by its transposition of skin from the glabellar region to the medial eye canthus. It is essential to incorporate the vascular pedicle of this flap into the supratrochlear artery. The result may not reproduce the concavity typical of the medial eye canthus. It is important to note that hair in the glabellar region represents a disadvantage in using this flap since it can provide hair growth in an area of glabrous skin, such as the inner eye canthus1,6. The Esser flap is used to repair significant defects in the lower eyelid. Its incision begins in the lateral canthus, extends upwards, and descends to the preauricular region (Figures 8 and 9). The entire flap is dissected in the genian and preauricular region through a plane immediately above the musculoaponeurotic system, and, finally, it is rotated and advanced to cover the defect1,5,7.
CONCLUSION Eyelid reconstruction requires not only precise anatomical knowledge, but also the most varied surgical techniques to obtain a functional and aesthetically satisfactory result and, thus, minimize postoperative complications.
COLLABORATIONS DAD
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Visualization, Writing Original Draft Preparation, Writing - Review & Editing
SDB
Project Administration, Validation
REFERENCES 1. Mélega JM. Cirurgia Plástica - os princípios e a atualidade I. Rio de Janeiro: Guanabara Koogan; 2004. 2. Baker SR. Retalhos locais em reconstrução facial. 2º ed. Rio de Janeiro: DiLivros; 2009.
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Reconstruction of eyelid zones II and III: case series 3. Spinelli HM, Lewis AB, Elahi E. Atlas of aesthetic eyelid & periocular surgery. New York: W. B. Saunders; 2004. 4. Galimberti G, Ferrario D, Casabona GR, Molinari L. Utilidade dos retalhos de avanço e rotação para fechamento de defeitos cutâneos na região malar. Surg Cosmet Dermatol. 2013;5(1):769. 5. Sasson EM, Codner MA. Eyelid reconstruction. Operat Tech Plast Reconstr Surg. 1999;6(4):250-64. 7. Lima EA. Enxertia de tecido palpebral na reconstrução de tumores cutâneos. Surg Cosmet Dermatol. 2010;2(4):333-5.
*Corresponding author:
6. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg, 1993;91(6):1017-24;discussion: 1025-6. 8. Kakizaki H, Madge SN, Mannor G, Selva D, Malhotra R. Oculoplastic surgery for lower eyelid reconstruction after periocular cutaneous carcinoma. Int Ophthalmol Clin. 2009;49(4):143-55. 9. Metzger JT. Joseph Imre, Jr., and the Imre flap. Plast Reconstr Surg Transplant Bull. 1959 Mai;23(5):501-9.
Délcio Aparecido Durso Rua Antônio Parreiras 126, Apart. 803, Ipanema, Rio de Janeiro, RJ, Brazil. Zip Code: 22411-020 E-mail: delciodurso@gmail.com
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Original Article A new concept in neck aging: “cervicofacial waist” Um novo conceito em envelhecimento de pescoço: “cintura cervicofacial”
TICIANO CESAR TEIXEIRA CLÓ 1* WALTER FERRAZ FLAVIO JUNIOR 1 FELIPE XAVIER CLÓ 2 GUILHERME DO VALLE CASTRO RIBEIRO 2
Institution: Cló & Ribeiro Plastic Surgery, Belo Horizonte, MG, Brazil. Article received: November 10, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0053
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Introduction: The aging of the lower third of the face stimulates the definition deletion of the mandibular border and the cervicofacial angle, besides the appearance of platysmal bands in the anterior neck region. Patients have high expectations that the facelift will significantly resolve such effects. To achieve these results, we have developed an approach to defining what we call the cervicofacial waist. Methods: The author proposes a new surgical facelift approach that has been performed on 444 consecutive patients since 2015, which involves an aggressive plication of the SMAS-platysma plus lateral traction, also by plication, of the platysma medial bands. Results: Despite the difficulty in comparing results with different techniques, we perceive a significant improvement in our results with the new surgical technique, without increasing the complication rates. Discussion: We are looking for new techniques because the cervical region’s traditional treatments seem flawed and based on ill-founded concepts. These involve the medial plication of the platysma bands by a submental approach, bringing them closer together and impairing the cranial elevation of the SMAS-platysma. Thus, we started to directly perform lateral plications on the bands through the lateral access of the face detachment, making a cervicofacial waist. Conclusion: The sum of the effects of the plication of the SMAS with the lateral plication of the platysma medial band makes the cervicofacial definition clearer with important optimization of the desired aesthetic effects. Keywords: Rhytidoplasty; Neck; Aging; Superficial musculoaponeurotic system; Lipectomy.
Cló & Ribeiro Plastic Surgery, Belo Horizonte, MG, Brazil. Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
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Introdução: O envelhecimento do terço inferior da face promove o apagamento da definição da borda mandibular e do ângulo cervicofacial, além do surgimento das bandas platismais na região anterior do pescoço. Os pacientes têm grande expectativa de que o facelift resolva de maneira significativa tais efeitos. Para alcançar estes resultados, desenvolvemos uma abordagem cuja finalidade é a definição marcante do que chamamos de cintura cervicofacial. Métodos: O autor propõe uma nova abordagem cirúrgica de facelift já realizada em 444 pacientes consecutivos, desde 2015, que envolve uma plicatura agressiva do SMAS-platisma somada a uma tração lateral, também por plicatura, das bandas mediais do platisma. Resultados: Apesar da dificuldade em comparar resultados com diferentes técnicas, percebemos claramente uma melhora significativa nos nossos resultados com a nova técnica cirúrgica, sem aumento dos índices de complicações. Discussão: Buscamos novas técnicas pelo fato de que os tratamentos clássicos da região cervical nos parecem falhos e baseados em conceitos mal fundamentados. Estes envolvem a plicatura medial das bandas platismais por abordagem submentoniana, aproximando-as e prejudicando a elevação cranial do SMAS-platisma. Assim, passamos a realizar plicaturas laterais diretamente sobre as bandas através do acesso lateral do descolamento da face, com confecção de uma cintura cervicofacial. Conclusão: A soma dos efeitos da plicatura do SMAS com a plicatura lateral da banda medial do platisma torna a definição cervicofacial mais nítida com otimização importante dos efeitos estéticos desejados. Descritores: Ritidoplastia; Pescoço; Envelhecimento; Sistema musculoaponeurótico superficial; Lipectomia.
INTRODUCTION In the early days of plastic surgery, the various attempts to treat wrinkles were based on the idea that wide tissue detachments associated with skin strips resections with the skin’s traction would generate faces with a rejuvenated aspect. However, what these techniques were able to achieve were ephemeral results and poor quality scars1-7. From the SMAS treatment concepts, there was a vast evolution in facelift techniques, with the achievement of more lasting and more natural results1-4,6-9. The superficial and deep facial tissues are continuously subject to environmental factors such as sun and pollution, the muscle relaxation process, and gravity action, which, together, aggravate the face aging process10. As gravity result, aging of the face lower third causes the definition of the mandibular edge and cervicofacial angle to be erased, besides the appearance of platysmal bands in the anterior region of the neck, because of the fall of the SMASplatysma1,7,10 (Figure 1). Rev. Bras. Cir. Plást. 2020;35(3):294-303
Figure 1. Aging of the lower third of the face with the erasure of the cervicofacial angle.
Ellenbogen and Karlin created, in 19808, criteria to define success in a cervical rejuvenation process: a very evident mandibular line, presence of subhioid depression, thyroid protuberance, defined border of the sternocleidomastoid muscle and a cervicomentual 295
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angle of 105 to 120 degrees8. Although still current and very accurate, the most important thing is to try to bring the contours of the lower third of the face closer to those that the patient had when she was younger. Those who undergo facelift have high expectations of reaching a well-marked and youthful cervical and mandibular line, often considering them essential aspects in the aesthetic success of the surgery1,4,7,8. To achieve these results more predictably and efficiently, we have developed an approach that clearly defines what we call “cervicofacial waist.”
OBJECTIVE The objective of the present work is to describe and demonstrate the efficiency increase in the cervicofacial angle definition during the facelift through a cervical strapping technique based on the platysmal band’s lateral plication.
METHODS The technique of platysmal bands lateral plication with the cervicofacial waist definition was performed by the author in all subsequent cases from its conception in January 2015 until February 2019. This technique was performed in 444 consecutive facelifts (there were no criteria for not inclusion or exclusion). The patients’ age ranged from 37 to 79 years, with a mean age of 58.6. Four hundred thirty-three women and 11 men underwent the procedure. All surgeries were performed in a hospital with general anesthesia, and the patients were discharged the morning after surgery. All followed the same protocols for preoperative assessment, prevention of thromboembolism, and bruising. All the cases analyzed were conducted at the plastic surgery clinic Cló & Ribeiro, in Belo Horizonte, Brazil, from January 2015 to February 2019. The analysis of the medical records occurred between August and November 2019. The elaboration of the article followed the Helsinki principles.
Figure 2. Schematic figure of preoperative marking.
Description of the surgical technique - cervicofacial waist During the facelift, we prolonged the detachment of the skin flap in the inframandibular region in the form of a narrow tunnel to the ipsilateral medial platysmal band, previously marked with the patient seated (Figures 2 and 3). A lipectomy is performed on the platysma surface to make it appear in the platysmal band area to be treated, using scissors or aspirating with a Pontes cannula1. 296
Figure 3. Preoperative marking photo.
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Next, we perform the lateral plication of each band through a single “U” or “X” suture with a double pass and 2-0 nylon thread. The first pass of the suture contours the edge of the platysmal band in the cervicofacial angle region, and the second passes laterally about 3 centimeters from the first. When the knot is tied, the platysma band is significantly lateralized, and the cervicofacial angle begins to be well defined. Likewise, central flaccidity in the anterior region of the neck is attenuated (Figure 4).
Figure 6. Surgical photo of the internal aspect of the waist. Figure 4. Schematic drawing of the platysmal band lateral plication showing the beginning of the definition of the cervicofacial waist.
Then we started plicating the SMAS-platysma with two 2-0 nylon sutures. One pre-auricular, just above the angle of the mandible, and another infraauricular just below, both close to the earlobe. The traction is done in a cephalic direction with a clear suspension effect. In this region, we do the most significant traction of the SMAS plication, reaching 3 to 4 centimeters in width. This great superior traction over the mandible’s angle enhances the effect of the previous lateral plication of the platysma medial band. Thus, it defines the mandible edge, as it deepens the inframandibular region, giving the desired effect of defining the waist from the entire cervicofacial angle (Figure 5).
Figure 5. Cervicofacial waist after plication of the SMAS-platysma and lateral bands.
After these two main sutures in the region of the mandible angle, we finish the plication of the SMAS on the face and neck (Figures 6 and 7 - perioperative photos of the waist definition - internal and external aspect). Rev. Bras. Cir. Plást. 2020;35(3):294-303
Figure 7. Surgical photo of the external aspect of the waist.
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RESULTS It is tough to compare results obtained with the various facelift techniques 4,11 objectively. The characteristics of each face and the number of aging changes in each face are very varied. Those with higher degrees of sagging and falling may have an excellent result when considering the case’s difficulty but may have a worse degree of the final definition of the mandibular edge or cervicofacial angle than others that had less severe sagging and falling. Besides, even though the surgeon can assess the final result of a case as excellent, taking into account objective criteria, the degree of demand and expectation of the patient may lead her to consider the same final result to be only reasonable. It is good to remember that the patient often compares her final result with that of other patients instead of comparing it with her preoperative appearance. Therefore, we opted for the methodology that we explain below to compare several results obtained by the author before and after using this technique. One of the team’s plastic surgeons, who does not participate or perform facelifts, evaluated preand postoperative photographs of 100 patients who underwent face surgery by the author, 50 cases were operated before using the technique (before 2015) and 50 already with its use (from 2015). All postoperative photos of the author are taken 5 to 7 months after surgery, and it is important to remember that some patients do not take them. Therefore, in each of the groups, all included cases were consecutive, as long as they had postoperative photos. The examiner was blinded as to the technique used in each patient and evaluated the degree of improvement in each case concerning three parameters: mandibular definition, cervicofacial angle, and platysmal bands. The final result was classified as weak, good, very good, or excellent (Figures 10 to 17). Through this analysis, we obtained the results shown in Tables 1 and 2. Thus, we see a significant increase in results considered excellent and a significant decrease in results considered only good or even weak (Figure 8). There was no increase in the main complications of the facelift in the evaluated period. The beginning of this technique coincides with the period in which the author started to dedicate himself exclusively to facial plastic surgeries, having concomitantly adopted a strict hematoma prevention protocol, the main complication of facelifts12-16. It can be observed a significant drop in the incidence of hematomas despite the progressive increase in the number of cases operated in the same period, which went from 52 in 2012 to 112 cases in 2018 (Figure 9). 298
Figure 8. Example of a result case considered weak by the evaluator.
Figure 9. Example of a result case considered weak by the evaluator.
DISCUSSION Our discontent with the treatment and definition of these areas has always been significant. The traditional treatments that involve the medial approximation of the platysmal bands by a submentonian approach seemed flawed and based on ill-founded concepts. As they age, suffering from gravity, the platysmas, and their medial bands move away from Rev. Bras. Cir. Plást. 2020;35(3):294-303
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Figure 10. Example of a result case considered good by the evaluator.
Figure 12. An example of a result case considered very good by the evaluator.
Figure 11. Example of a result case considered good by the evaluator.
Figure 13. An example of a result case considered very good by the evaluator
the cervicofacial angle in a caudal direction. Thus, face aging favors the definition deletion of the mandibular edge and the cervicofacial angle, as well as the appearance of platysma bands in the neck’s anterior region because of the fall of SMAS-Platysma1-7,10,17. Despite these bands not moving away from each other in a lateral direction, many authors continue to propose their aggressive medial approach through plication through submental access7,9,10,18,19,20.
McKinney et al., In 199617, proposed a classification to define the aging degree of the face lower third (Table 3)17,1 and Feldman, in 199020, developed a medial plication technique that influenced several plastic surgeons around the world entitled by him as “Corset.” In such a technique, he proposes a double suture of rigorous approximation of the medial edges with progressive tightening and overlapping of the medial muscle edge, similar to a corset, without drying out or cutting the platysma muscle18-20
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Figure 14. Example of a result case considered excellent by the evaluator.
Excellent
21
Very good
22
Good
5
Weak
2
Figure 16. Analysis of results before and after the author’s lateral plication technique.
Figure 17. Incidence of hematomas in the author’s facelifts.
Table 3. Classification of platysmal bands by McKinney et al., in 199617. Grade
Characteristics
I
Barely visible platysmal bands.
II
Moderately visible platysmal bands.
III
Very visible platysmal bands.
IV
Very visible platysmal bands with excessive skin flaccidity.
Figure 15. Example of a result case considered excellent by the evaluator.
Table 1. Analysis of results of the old technique. Old technique (with plication of the S MAS-platysma without lateral plication of the platysmal bands) Excellent
11
Very good
21
Good
12
Weak
6
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Rohrich et al., in 20115 and 20164, and other authors, use concepts similar to those of Feldman, however they associate with this treatment several types of sections of the medial edges of the platysma7,9,10,18-22. Despite the good results achieved by surgeons who use such concepts and techniques, we understand that such an approximation of the medial bands will act in a counterproductive manner in the elevation of the SMAS-platysma in the cranial direction. In Rev. Bras. Cir. Plást. 2020;35(3):294-303
Neck aging: “cervicofacial waist”
our opinion, although this maneuver causes the definition of the cervicofacial angle, it prevents the proper elevation of the pre-auricular SMAS-platysmas (Figure 18).
Thus, as of January 2015, we began to use a new technique for treating platysmal bands and accentuated the definition of the anterior neck. We started to perform lateral plications directly on the bands through the lateral access of the face detachment. The submental is approached whenever necessary, either for liposuction or for the treatment of subplatysmal fat. When necessary, the medial bands can receive only an approach suture in the region of the largest bulging in the subment. When used, this single suture is made close to the submental incision and far from the cervicofacial angle. What we propose, in addition to promoting an effective treatment of platysmal bands, surprised us by significantly enhancing the effect of our suspension with aggressive plication of the SMAS-platysma. A high definition of the mandibular edges and the cervicofacial angle is created in the anterior neck, and to this effect, we call the cervicofacial waist (Figure 19).
Figure 18. Aggressive medial plication lowering the SMAS.
For many years, we have performed plicatures on facelifts that promote aggressive suspensions of the pre- and infra-auricular SMAS-platysmas, especially in the region of the mandibular angles, where, often, the width of the plications reaches 4 cm on each side. When we performed submentonian medial plications of the platysmal bands, we never achieved such significant lateral elevations of the SMAS. Even though we have frequently been able to perform these large elevations in recent years, in a significant number of cases, we have encountered still unsatisfactory results concerning the definition of the cervicofacial angle in the anterior neck. In many cases, we note that in addition to the elevations of the pre- and infra-auricular SMAS, some type of lateral traction would be needed that would act more directly on the anterior neck10,23. It was clear that tractions performed at a distance from the anterior cervical midline often did not have the efficiency that a maneuver performed directly over the bands would have. Like Pelle-Ceravolo et al. (2016)10, we also believe that the conventional traction of the lateral edge of the platysmas, far from their medial bands, has a limited effect on them. To optimize the results, we must perform lateral traction as close as possible to the area where we want the highest definition, that is, directly over the medial bands. Also, the sum of these tractions promotes a significant decrease in the neck diameter in the region of the cervicofacial angle (cervicofacial waist). Rev. Bras. Cir. Plást. 2020;35(3):294-303
Figure 19. Making the cervicofacial waist.
Differently than Pelle-Ceravolo et al., in 201610, our support of the cervicofacial angle in the anterior neck is made by adding the effects of the “X” suture directly over the platysmal band and the plication in the cephalic sense of the SMAS of the region of the mandibular angle. Pelle-Ceravolo et al. (2016)10, fix the traction of the edge of the platysma bands at a distance in the mastoid region, leaving long strands that cross the region below the mandible angle. As the surgery is performed with the face turned to the opposite side, these long threads that join the traction bands to the 301
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mastoid region certainly lose tension when the patient rectifies the face, reducing its traction effect. As we do, the effect of the plication performed on the medial platysmal band enhances the effect of SMAS cephalic plication on the entire flaccidity of the anterior neck.
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CONCLUSION The sum of the effects of the SMAS plication and the lateral plication of the platysma’s medial band makes the cervicofacial definition clearer and creates the effect of defining the waist of the neck just below the angles and branches of the mandible. Besides, it made the platysmal bands and submandibular glands imperceptible in the vast majority of cases through traction and increased platysma tension. The technique benefit becomes evident when we observe, in addition to the comparative study results, its use by the author in more than 400 consecutive cases since the first time in 2015.
COLLABORATIONS TCTC
Analysis and/or data interpretation, Conception and design study, Data Curation, Final manuscript approval, Methodology, Project Administration, Realization of operations and/or trials, Supervision, Writing - Review & Editing
WFFJ
Conception and design study, Final manuscript approval, Realization of operations and/or trials, Writing - Original Draft Preparation, Writing - Review & Editing
FXC
Data Curation, Final manuscript approval, Writing - Original Draft Preparation, Writing - Review & Editing
GVCR
Analysis and/or data interpretation, Investigation
REFERENCES
Figure 20. Pre and postoperative (7 months) using the described technique.
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1. Pontes R. O universo da ritidoplastia. Rio de Janeiro: Revinter; 2011. 2. Pitanguy I, Radwanski HN, Amorim NFG. Treatment of the aging face using the “round-lifting” technique. Aesthet Surg J. 1999;26:216. 3. Castro CC. Ritidoplastia: arte e ciência. Rio de Janeiro: DiLivros; 2007. 4. Rohrich RJ, Narasimhan K. Long-term results in face lifting: observational results and evolution of technique. Plast Reconstr Surg. 2016 Jul;138(1):97-108. 5. Rohrich RJ, Ghavami A, Mojallal A. The five-step lower blepharoplasty: Blending the eyelid-cheek junction. Plast Reconstr Surg. 2011 Set;128(3):775-83. 6. Cló TCT, Flávio WF, Leão CEG, Cló FX, Lacerda LM, Leão LR. Sistematização perioperatória para prevenção de hematomas em face-lifts: abordagem pessoal após 1138 casos operados. Rev Bras Cir Plást. 2019;34(1):2-9. 7. Warren RJ, Neligan P. Cirurgia plástica estética. 3ª ed. Rio de Janeiro: Elsevier; 2015. v. 2. 8. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976 Jul;58(1):80-8. 9. Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: integrating anatomy with clinical practice to optimize results. Plast Reconstr Surg. 2013 Ago;132(2):339-50.
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Neck aging: “cervicofacial waist” 10. Pelle-Ceravolo M, Angelini M, Silvi E. Complete platysma transection in neck rejuvenation: a critical appraisal. Plast Reconstr Surg. 2016 Out;138(4):781-91. 11. Castro CC, Aboudib JHC, Giaquinto MGC, Moreira MBL. Avaliação sobre resultados tardios em ritidoplastia. Rev Bras Cir Plást. 2005;20(2):124-6. 12. Cló TCT, Flávio WF, Cló FX. Necrose extensa em face pósritidoplastia: relato de caso. Rev Bras Cir Plást. 2019;34:90-3. 13. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacution following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg. 2005 Dez;116(7):1973-85. 14. Pitanguy I, Ramos H, Garcia LC. Filosofia, técnica e complicações das ritidectomias através da observação e análise de 2600 casos pessoais consecutivos. Rev Bras Cir. 1972;62:277-86. 15. Weissman O, Farber N, Remer E, Tessone A, Trivizki O, Bank J, et al. Post-facelift flap necrosis treatment using charged polystyrene microspheres. Can J Plast Surg. 2013 Spring;21(1):45-7. 16. Mustoe TA, Park E. Evidence-based medicine: face lift. Plast Reconstr Surg. 2014 Mai;133(5):1206-13.
*Corresponding author:
17. McKinney P. The management of platysma bands. Plast Reconstr Surg. 1996;98(6):999-1006. 18. Righesso R, Chem EM, Netto R, Martins ALM, Sartori N. Ritidoplastia videoassistida do terço inferior da face: corset videoendoscópico. Rev Bras Cir Plást. 2014;29(3):328-36. 19. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg. 2014 Dez;134(6):1173-83. 20. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990 Mar;85(3):333-43. 21. Narasimhan K, Ramanadham S, O’Reilly E, Rohrich RJ. Secondary neck lift and the importance of midline platysmaplasty: review of 101 cases. Plast Reconstr Surg. 2016 Abr;137(4):667-75. 22. Pita PCC, Azevedo SFD, Cabral PO, Melo SRPP. Lifting cervical gravitacional. Rev Bras Cir Plást. 2010;25(2):291-6. 23. Gonzalez R. The LOOP – lateral overlapping plication of the platysma: an effective neck lift without submental incision. Clin Plast Surg. 2014;41:65-72.
Ticiano Cesar Teixeira Cló Rua República Argentina, 507, Bairro Sion, Belo Horizonte, MG, Brazil. Zip Code: 30315-490 E-mail: ticianoclo@gmail.com
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Original Article Low-cost synthetic model for skin flap training Modelo sintético e de baixo custo para treinamento de retalho cutâneo
ARTHUR ANTUNES COIMBRA PINHEIRO PACÍFICO 1* ALINE SANTOS CORREIA 1 BÁRBARA MATOS DE CARVALHO BORGES 1 MATEUS BONFIM COSTA 1 MATEUS PINHEIRO FERNANDES FEITOSA ARRAIS 1 SAMY LIMA CARNEIRO 1 THIAGO MACIEL VALENTE 1 NELSON GURGEL SIMAS DE OLIVEIRA 1
Institution: University of Fortaleza UNIFOR, Fortaleza, CE, Brazil. Article received: August 8, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0054
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Introduction: The search for learning surgical techniques within the operating room is linked to difficulties, such as reducing teaching time by surgeons and ethical problems. Models have already been developed to facilitate the practice of surgical techniques, however, with high cost, difficult access, and ethical and moral complications. The present work aims to present a synthetic model, unpublished and practical for the training of skin flap techniques, formulated to be easy to reproduce and low cost, allowing its feasibility. Methods: In the model, fabric, sponge for car washing, latex elastic, fine-tipped brush, scalpel, and surgical suture instruments were used. The fabric is fixed by the elastic on the surface of the sponge, simulating skin and subcutaneous. The flap to be made on the surface of the fabric is then drawn. Results: The model created was satisfactory, since it improves the handling of surgical instruments and the learning of the proposed flap technique, besides having demonstrated good elasticity and tensile strength. In medical schools, there is a lack of approach to essential topics in plastic surgery. The importance of low-cost and easy-to-execute models, such as the above, is emphasized to facilitate the learning of students interested in the subject, seeking to fulfill the educational function without breaking ethical principles. Conclusion: The proposed model is an excellent form of training because it presents logistical and instructive benefits, facilitating learning, without causing harm to animals. Keywords: Simulation; Training; Medical education; Surgical flaps; Reconstructive surgical procedures.
University of Fortaleza UNIFOR, Fortaleza, CE, Brazil.
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RESUMO
Introdução: A busca pela aprendizagem de técnicas cirúrgicas dentro da sala de operação está vinculada a dificuldades, como a redução do tempo de ensino pelos cirurgiões e problemas éticos. Já foram elaborados modelos para facilitar a prática de técnicas cirúrgicas, contudo de custo elevado, difícil acesso e com complicações éticas e morais. O presente trabalho tem como objetivo apresentar um modelo sintético, inédito e prático para o treinamento das técnicas de retalho cutâneo, formulado para ser de fácil reprodução e de baixo custo, permitindo sua exequibilidade. Métodos: No modelo foi utilizado malha, esponja para lavagem de carro, elástico de látex, pincel de ponta fina, bisturi e instrumentos cirúrgicos de sutura. A malha é fixada pelo elástico sobre a superfície da esponja, simulando pele e subcutâneo. Desenha-se, então, o retalho a ser feito na superfície do tecido. Resultados: O modelo criado mostrou-se satisfatório, visto que aprimora o manuseio de instrumentos cirúrgicos e o aprendizado da técnica de retalho proposta, além de ter demonstrado boa elasticidade e resistência a tração. Nas faculdades de medicina percebe-se uma carência na abordagem de temas importantes da cirurgia plástica. Ressalta-se a importância de modelos de baixo custo e de fácil execução, como o supracitado, para facilitar a aprendizagem de estudantes interessados no assunto, buscando cumprir a função educacional sem romper princípios éticos. Conclusão: O modelo proposto é uma excelente forma de treinamento por apresentar benefícios logísticos e instrutivos, facilitando a aprendizagem, sem causar prejuízo aos animais. Descritores: Simulação; Capacitação; Educação médica; Retalhos cirúrgicos; Procedimentos cirúrgicos reconstrutivos.
INTRODUCTION The surgical flap consists of a tissue mobilized from one part of the body to another with a vascular peduncle and can be kept intact or sectioned, to perform vascular anastomosis and maintain the blood supply of that tissue. These can be classified according to the composition of the tissue found in it (cutaneous, musculocutaneous, fasciocutaneous, osteocutaneous and sensory), and according to the movement of the skin towards the receptor area (advance, rotation, transposition, and interpolation)1,2. They are a choice to reconstruct a defect on vital structures, tissues devoid of a perivascular membrane, or implants. To improve their surgical skills, medical students seek to expand their theoretical knowledge through observation and practice in operating rooms3,4. However, this learning vehicle has become a restricted alternative due to the increased demand to surgeons for greater effectiveness, seeking to reduce surgical time and, consequently, the time available for teaching; in addition to ethical conflicts that may arise Rev. Bras. Cir. Plást. 2020;35(3):304-308
by allowing the student to practice them in the patient, because of the concept of non-maleficence3. Given these difficulties, practical models were elaborated to allow their use outside the operating room and resemble human tissue. According to the material used for its manufacture and its purpose, these are classified as high, intermediate, and low fidelity. However, many of these have high costs, difficult access, and ethical complications, making them unfeasible for practice5,6. Thus, low-cost and synthetic models for the training of surgical techniques, such as the skin flap, are a relevant tool and can present positive results regarding the facilitation of the teaching and learning process of a complex theme, such as surgery. Allowing not only a more effective fixation of theoretical content but improving practical skills so that ethical principles are preserved.
OBJECTIVE The present work aims to present a synthetic model that is unpublished and practical for the training of skin flap techniques. 305
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METHODS Its construction is made from the following components (Figure 1): 1) 24cm2 of mesh fabric (96% polyester, 4% elastane); 2) car wash sponge (11x13x6cm); 3) latex rubber bands; 4) fine-tipped permanent brush; 5) scalpel (handle # 3, blade # 15); 6) 3-0 nylon threads; 7) surgical suture instruments (needle holder, mousetooth forceps and scissors).
After assembly, the fine-tipped brush is used to draw on the fabric’s surface the type of flap to be made. Finally, the model can already be used to train the various techniques described using the appropriate surgical instruments (Figure 2D). Thus, the model mentioned above was made with a maximum cost of 10 reais and simulates this procedure’s technique. It is worth mentioning that the fabric is the only component that cannot be reused after use, and that needs replacement. The model was made at the University of Fortaleza (UNIFOR) by the university’s academic league of plastic surgery in January 2019. Moreover, the study mentioned above did not specify the involvement of humans and animals, so there was no need for approval by the Ethics Committee to prepare the skin flap model, which is obtained through synthetic materials. The model was used in extracurricular activities elaborated by the academic league of plastic surgery of the university; the activities took place in a 4-hour shift under the supervision of academic members of the academic league who had teaching guidance.
RESULTS
Figure 1. Demonstration of the material needed to construct the model.
The assembly consists of covering one of the sponge surfaces with fabric to simulate the skin and the subcutaneous sponge. Besides, in order to have the fabric fixed on the sponge, latex elastics are used for this fixation, remaining immobile and slightly stretched (Figures 2A, 2B, and 2C).
A
The model was used in the event of the academic surgical leagues of a Private University of Fortaleza/ CE, in which students from various school periods, approximately 50 students, had contact with the proposed model (Figure 3).
B Figure 3. Practice of performing the skin flap using the proposed model.
C
D
Figure 2. Demonstration of the model construction steps. A. Sponge block, rubber bands and mesh fabric; B. Positioning the fabric on the sponge; C. Fixing the fabric to the sponge with the latex elastic; D. Model duly ready and with the flap markings to be made.
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The model presented satisfactory results in the simulation of the skin flap technique. The fabric, although limited in the simulation of human skin consistency, demonstrated good elasticity and tensile strength, allowing the improvement of surgical instrumentation manipulation and knowledge of principles and practice of procedure. Besides, it Rev. Bras. Cir. Plást. 2020;35(3):304-308
Synthetic model for skin flap training
allowed the development of skills also by the instructor students, such as interpersonal communication. It is added that the presence of students more experienced and trained by the teacher, contributed to the elaboration of a less hostile environment for learning, facilitating the clarification of doubts in a simple and accessible language.
DISCUSSION During the medical career, most surgical practices are restricted to the hours destined to general surgery and are often insufficient for academics interested in the surgical field. Regarding plastic surgery, there is a lack of treatment for essential themes in this area, such as the cutaneous flap7. Microsurgery is a n a rea of pa ra moun t importance in the plastic surgeon curriculum. Many models that allow the practice of this flap have already been developed and tested, demonstrating efficacy in the development of skills in microsurgery. According to the systematic review of non-biological models by Abi-Rafeh et al., in 20198, simulation models should play an even more significant role in developing a microsurgery training curriculum. The model developed in this article was planned for the technique of cutaneous flap; unfortunately, it does not meet the specificities and characteristics of a model that allows the practice of free flap. The model described was presented to a plastic surgeon, a professor of medicine at the University of Fortaleza. The professor evaluated the simulator and admitted the possibility of applying this model to teaching the procedure since the designs and geometries of some flaps are relatively complex to understand. Moreover, due to its high relevance, being one of the pillars of skin surgery, it is essential to the academic interested in the specialty, the knowledge of its execution through training in practical models of low cost and easy maintenance9, since, for better learning, the training repeated several times, with a low-cost material, is something that proves indispensable.
The model also allows the execution of rotation, transposition, interpolation, and simple advancement flaps, as shown in Figure 4, and can be used to train various types of flaps.
The model proposed by Denadai et al., In 20125, made from chicken skin, proved to be a complementary alternative to the arsenal of existing simulation models due to its similarity, in texture and consistency, to human tissue 10. However, when it comes to its continuous use in teaching programs, the animal model can be expensive, since it needs a collection and storage service so that it does not bring biological risk to the students of the institutions. Besides, its preparation is time-consuming and delicate, since it is necessary to Rev. Bras. Cir. Plรกst. 2020;35(3):304-308
A
B
C
Figure 4. Demonstration of the flap techniques performed on the model. A. Markings of the Limberg flaps, Z-plasty, bilobed, triangular and simple advancement; B. Incisions and removal of injuries; C. Suture and completion of flap techniques.
defrost the parts in advance, a process that, when not done well, can leave the material hardened, causing the loss of needle threads during training and further increasing it cost. The use of animal material also presents several ethical and bureaucratic complications, since besides being questionable, they conflict with modern concepts of animal welfare. With this, the current diversity and complexity of surgical medical knowledge require a new direction in teaching through innovative means, seeking to fulfill the educational function without harming the animals. The proposed model, which is based on the use of synthetic fabric overlapping a layer of sponge for car wash, proved to be entirely objective regarding the execution of the technique, as the chosen fabric has good resistance to suture, reducing the probability of dehiscence, doing the practice aimed at improving the skin flap technique viable and safe. Besides, the model is easy to prepare and store, as it does not need to be conserved, and its assembly is simple, practical, and fast. The proposed model is easy to perform and assembled to facilitate the understanding of the skin flap technique. 307
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CONCLUSION t is believed that the use of this synthetic model becomes relevant in the training of medical students and residents in plastic surgery, because it allows the practice of this medical skill, with minimal ethical conflicts and without the need to train in animals or the patient himself. Besides, the surgical simulation of the cutaneous flap, using the proposed synthetic model, is a suggestion for the exercise of this technique because it presents logistical and instructive benefits, such as the use of low-cost materials, easy storage, and preparation. However, further studies on the effectiveness of training with synthetic models for undergraduate medical students are needed, with the elaboration of questionnaires evaluating students’ perception and instructors’ perception.
COLLABORATIONS AACPP
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Resources, Software, Supervision, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
ASC
Data Curation, Methodology, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
BMCB
Analysis and/or data interpretation, Conceptualization, Funding Acquisition, Supervision, Visualization, Writing Original Draft Preparation, Writing Review & Editing
MBC
Supervision, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
*Corresponding author:
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MPFFA
Supervision, Visualization, Writing Original Draft Preparation, Writing Review & Editing
SLC
Supervision, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
TMV
Supervision, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
NGSO
Supervision, Validation, Visualization
REFERENCES 1. Galimberti G, Ferrario D, Casabona GR, Molinari L. Usefulness of rotation and advancement flap for the closure of skin defects in the malar region. Surg Cosmet Dermatol. 2013;5(1):769. 2. Townsend Junior CM, Beauchamp RD, Evers B, Mattox K. Sabiston Tratado de cirurgia: a base biológica da prática cirúrgica moderna. 19ª edição. Rio de Janeiro: Elsevier; 2015. 3. Anastakis DJ, Regehr G, Reznick RK, Cusimano M, Murnaghan J, Brown M, et al. Assessment of technical skills transfer from the bench training model to the human model. Am J Surg. 1999 Fev;177(2):167-70. 4. Purim KSM, Santos LDS, Murara GT, Maluf EMCP, Fernandes JW, Skinovsky J. Avaliação de treinamento cirúrgico na graduação de medicina. Rev Col Bras Cir. 2013;40(2):152-6. 5. Denadai R, Saad-Hossne R, Oshiiwa M, Bastos EM. Training on synthetic ethylene-vinyl acetate bench model allows novice medical students to acquire suture skills. Acta Cir Bras. 2012 Mar;27(3):271-8. 6. Hammoud MM, Nuthalapaty FS, Goepfert AR, Casey PM, Emmons S, Espey EL, et al. To the point: medical education review of the role of simulators in surgical training. Am J Obstetr Gynecol. 2008 Out;199(4):338-43. 7. Khatib M, Soukup B, Boughton O, Amin K, Davis CR, Evans DM. Plastic surgery undergraduate training. How a single local event can inspire and educate medical students. Ann Plast Surg. 2014;1-5. 8. Abi-Rafeh J, Zammit D, Jaberi MM, Al-Halabi B, Thibaudeau S. Nonbiological microsurgery simulators in plastic surgery training: a systematic review. Plast Reconstr Surg. 2019 Sep;144(3):496e507e. 9. Friedlich M, Wood T, Regehr G, Hurst C, Shamji F. Structured assessment of minor surgical skills (SAMSS) for clinical clerks. Acad Med. 2002 Out;77(10 Supl 1):S39-S41. 10. Denadai R, Saad-Hossne R, Souto L. Simulation-based cutaneous surgical-skill training on a chicken-skin bench model in a medical undergraduate program. Indian J Dermatol. 2013 Mai;58(3):200-7.
Arthur Antunes Coimbra Pinheiro Pacífico Rua Mariana Furtado Leite, 1250, Apart. 1201, Bairro Eng, Luciano Cavalcante, Fortaleza, CE, Brazil. Zip Code: 60811-030 E-mail: arthurh.pacifico@gmail.com
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Original Article Evaluation of the use of tissue expander in a university service Avaliação do uso de expansor de tecido em um serviço universitário KETHELYN KEROLINE TELINSKI RODRIGUES 1 MARIA CECILIA CLOSS ONO 1 JEAN RAITZ NOVAIS 1 ISABELLA CORREA DE OLIVEIRA 1 HELOIZE CALLEGARI MENEGAZZO 1 RENATO DA SILVA FREITAS 1*
Institution: Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil. Article received: March 3, 2020. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0055
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ABSTRACT
Introduction: Tissue expansion is an important reconstruction method to solve defects such as burns and giant nevi or breast reconstruction. This article aims to report the experience of the Plastic Surgery Service of the Hospital de Clínicas of the Federal University of Paraná (UFPR) with the use of expanders. Methods: This is a retrospective, descriptive, and analytical study of patients who underwent tissue expansion for reconstructive surgery at the Hospital de Clínicas da UFPR, from January 2010 to December 2016. Results: 61 patients and 80 surgeries were analyzed, including re-expansion procedures. Age ranged from 2 to 73 years (mean 31). The majority of patients were female (83.6%), aged over 40 years, undergoing breast reconstruction treatment after radical mastectomy (36%). The complications observed in these patients were: signs of infection (14.7%), suture dehiscence (3.2%), seroma (3.2%), defect in the expander (3.2%), exposure of the expander (3, 2%), necrosis (1.6%) and signs of hypoperfusion (1.6%). Patients undergoing breast reconstruction had the highest number of complications (40.1%). Reexpansion was necessary for 37.7% of patients. Conclusion: The skin expansion technique is indicated for several pathologies’ treatment. The tissue expansion procedure has high complication rates. Knowing the patient’s profile, the main types of complications, and the factors associated with these complications can help prevent them. Keywords: Devices for tissue expansion; Tissue expansion; Mammoplasty; Pigmented nevus; Burns.
Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil.
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RESUMO
Introdução: Expansão tecidual é um método de reconstrução importante para a cobertura de defeitos como queimaduras e nevos gigantes ou na reconstrução mamária. Esse artigo tem como objetivo relatar a experiência do Serviço de Cirurgia Plástica do Hospital de Clínicas da Universidade Federal do Paraná (UFPR) com o uso de expansores. Métodos: Esse é um estudo retrospectivo, descritivo e analítico dos pacientes que foram submetidos à expansão tecidual para cirurgia reconstrutora no Hospital de Clínicas da UFPR, entre o período de janeiro de 2010 a dezembro de 2016. Resultados: Foram analisados 61 pacientes e 80 cirurgias, incluindo os procedimentos de reexpansão. A idade variou entre 2 a 73 anos (média 31). A grande maioria dos pacientes pertenceu ao sexo feminino (83,6%), na faixa etária acima de 40 anos, sendo submetidos ao tratamento para reconstrução mamária após mastectomia radical (36%). As complicações observadas nesses pacientes foram: sinais de infecção (14,7%), deiscência da sutura (3,2%), seroma (3,2%), defeito no expansor (3,2%), exposição do expansor (3,2%), necrose (1,6%) e sinais de hipoperfusão (1,6%). Pacientes submetidos à reconstrução mamária tiveram o maior número de complicações (40,1%). A reexpansão foi necessária em 37,7% dos pacientes. Conclusão: A técnica de expansão de pele é indicada para o tratamento de diversas patologias. O procedimento de expansão tecidual apresenta taxas de complicações altas e o conhecimento do perfil do paciente, dos principais tipos de complicações e dos fatores associados a essas complicações podem auxiliar na sua prevenção. Descritores: Dispositivos para expansão de tecidos; Expansão de tecido; Mamoplastia; Nevo Pigmentado; Queimaduras.
INTRODUCTION Tissue expansion is the technique that allows the reconstruction of defects by the gradual distension of a flexible skin area, preparing it for use in solving any defect such as breast reconstruction, burns, and giant nevi1. This reconstructive method has advantages such as the use of tissues of color and texture similar to the defect, less damage to the donor area, and aesthetic improvement. In burns, tissue expansion is indicated when the wounds have completely healed, and the resulting scars need to be treated. Patients with burn sequelae may have limited tissue availability for flaps. Specific areas such as the scalp benefit from tissue expansion by allowing the treatment of sequelae with similar tissue2 (Figure 1), as well as the head and neck region. The expansion can be done in tissues surrounding the wound, or donor areas of free flaps in situations that nearby regions are not available3. Giant congenital nevus can be defined as an ectopic concentration of melanocytes of neuroectodermal origin with a diameter greater than 20 cm and affecting about 1 in every 20,000 live births4. Rev. Bras. Cir. Plást. 2020;35(3):309-315
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B
Figure 1. Patient with an area of alopecia on the scalp due to the burn submitted to treatment with tissue expander. A. Preoperative period; B. Final result after three-stage treatment with round type expanders.
Besides the aesthetic implications, patients with this type of anomaly need to deal with 5 to 12% associated risk of malignancy. Therefore, prophylactic excision is recommended4. The use of tissue expanders is frequent in this treatments5. The number of procedures involving skin expanders for breast reconstruction has also been 310
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increasing. Statistics from the American Society of Plastic Surgeons, in 20166, show that approximately 90% of breast reconstructions with prostheses are performed in two stages, the first of which is tissue expansion (Figure 2). The use of expanders may also be required in breast agenesis. In Poland’s syndrome, there is a partial or total absence of the pectoralis major, pectoralis minor, serratus and breast muscles, and the nipple-areola complex; therefore, expansion is one of the techniques used in its treatment7
the Hospital de Clínicas da UFPR (approval number: 68550217.4.0000.0096). Medical records of patients who underwent expansion between January 2010 and December 2016 were analyzed. All patients who underwent surgery for tissue expansion during this period were included. Exclusion criteria included the abandonment of treatment and the death of the patient during this period. The data obtained were age, gender, pathology indicative of the procedure, type of expander, insertion site, evolution, and complications. From the data obtained, a descriptive statistical analysis was carried out, emphasizing the relationship between the complications found and parameters, such as the cause of treatment, the format of the expander, and the insertion site.
RESULTS
A
B
C
D
Figure 2. Patient undergoing treatment for left breast for ductal carcinoma in situ. Late breast reconstruction was performed with a large dorsal flap and a round, smooth expander with a remote valve. After six months, and after the expansion was completed, she was replaced with an expander for prosthesis and symmetrization with a zigzag periareolar augmentation mammoplasty. A. Preoperative period; B. Result after placing the expander; C. Result after replacing the expander with the prosthesis; D. Final result.
OBJECTIVE This article has as main objective to report the experience of the plastic surgery service at the Hospital de Clínicas of the Federal University of Paraná (UFPR) with the use of expanders, emphasizing the complications found, their possible causes and management.
METHODS This is a retrospective, descriptive, and analytical study of patients who underwent tissue expansion for reconstructive surgery at Hospital de Clínicas da UFPR. This study was submitted and approved by the Ethics and Research Committee of 311
Sixty-one patients and 80 surgeries, including reexpansion procedures, were analyzed. The majority of patients were female (83.6%). The age at the first surgical stage of the patients analyzed was between 2 and 73 years (mean 31), with the majority in the age group above 40 years (41%), followed by young people between 11 and 20 years (27.9%). The main indication for surgery was breast reconstruction after mastectomy (36%), followed by a burn scar correction (31.1%) and giant nevi correction (14.7%). Other causes include post-trauma scar correction (6.6%), vascular malformation correction (4.9%), breast agenesis due to Poland’s syndrome (3.3%), microtia (1.6%), and resection of dermofibrosarcoma (1.6%). Concerning the complications most seen in the procedures performed, signs of infection (14.7%) stand out. Other complications observed were: suture dehiscence (3.2%), seroma (3.2%), expander defect (3.2%), expander exposure (3.2%), necrosis (1.6%) and signs of hypoperfusion (1.6%). Patients undergoing breast reconstruction had the highest number of complications. Considering the 22 patients who received treatment, four presented, in the first stage, infectious signs in the breast where the expander was placed, and another four presented the following complications each: exposure of the expander, dehiscence of the suture, seroma and signs of hypoperfusion. In five cases, it was necessary to remove the expander. Patients suffering from seroma, and exposure only needed to relocate the expanders. One of the patients died due to cancer complications. Among patients undergoing expansion to correct burns, two showed signs of infection after surgery. Two others presented complications due to suture dehiscence and one due to defect in the expander. They Rev. Bras. Cir. Plást. 2020;35(3):309-315
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all required the removal of the expander. Forty percent of the complications in patients with burn sequelae were in the lower limbs. The other correlations between the cause of treatment and the percentage of complications are shown in Table 1. The chest region was associated with a higher number of complications than other parts of the body: 11 of the 28 patients who underwent the procedure in this region had some type of complication. The other correlations between the anatomical region submitted to expansion and complications are shown in Table 2. Regarding age, the greatest number of complications occurred in patients over 40 years of age. In this group, 36% had some type of complication (Table 3). Reexpansion was necessary for 37.7% of patients. Of the 19 surgeries performed on these patients for reexpansion, two had complications. One of the patients who underwent breast reconstruction showed signs of infection, while the second surgery of a patient with a giant nevus had the expander’s exposure. The majority of patients started the expansion during the intraoperative period (95%), and the time of
evolution varied from 0 to 168 months, with an average of 58.9 months. Table 4 shows the number of complications concerning the year.
DISCUSSION In the mid-1950s, Neumann was the first surgeon to use an expander implant through a latex balloon to enlarge the periauricular region after an ear trauma8. Since then, skin expanders have been used for the most diverse procedures. In terms of shape, an expander follows three patterns: round, rectangular, and semi-lunar (croissant). The rectangular is known for allowing additional tissue expansion, thus increasing the options for flap design. The valve can be integrated into the expander or attached via a silicone tube. The content of the expanders available on the market is almost always a saline solution. Another option found is filling with carbon dioxide, recently approved by the “US - Food and Drug Administration (FDA)” 9.
Table 1. Indications for expansion surgery and number of complications *. Etiology
Number of patients
% Total
Number of complications
% Complications
Breast reconstruction
22
36
9
40.1
Burn sequel
19
31.1
5
26.3
Giant Nevus
9
14.7
3
33.3
Post-trauma scar sequel
4
6.6
1
25.0
Vascular malformation
3
4.9
1
33.3
Poland syndrome
2
3.3
1
50.0
Dermatofibrosarcoma resection
1
1.6
1
100.0
Microtia
1
1.6
0
0
* If the same patient performed more than one surgery, the number of complications was counted in all procedures.
Table 2. Anatomical region submitted to expansion and number of complications *. Anatomical region
Number of patients
% Total number of patients
Number of complications
%
Chest
28
45.9
11
39.3
Lower limbs
9
14.8
3
33.3
Scalp
9
14.8
2
22.2
Face
8
13.1
2
25.0
Back
7
11.5
1
14.3
Abdomen
2
3.3
0
0
Upper limbs
1
1.6
0
0
Neck
1
1.6
1
100.0
Complications
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Table 3. Distribution of patients by age and number of complications. Age (years)
Number % Number of % of of patients Total complications Complications
0-10
9
14.8
3
33.3
11-20
17
27.9
5
29.4
21-30
6
9.8
0
0
31-40
4
6.6
1
25.0
>40
25
41.0
9
36.0
Table 4. Distribution of cases concerning the year and the number of complications *. Year of surgery
Number of surgeries
Number of complications
% of complications
2010
8
3
37.5
2011
11
2
18.2
2012
17
4
17.6
2013
17
4
23.5
2014
14
3
21.4
2015
7
2
28.6
2016
6
3
33.3
Total
80
21
In the Plastic Surgery Service of Hospital de ClĂnicas da UFPR, the three types of expanders are used, the round one being recommended in breast reconstructions and the croissant and rectangular types most used in other types of surgery, such as treating burn sequelae, for example. The contents of these expanders have always been a saline solution. A critical point to be defined in the preoperative period is the expansion design. Attention should be paid to the donor site as infections, trauma, and unstable scarring can lead to implant failure or extrusion. The incision site must also be chosen with caution. For example, if the goal is to remove an injury, it is appropriate to position the incision at the edges of the injury. The majority of expansions begin during the intraoperative period, when a volume is placed making a slight compression to avoid the hematoma formation, since in most cases - except for breast reconstruction - a vacuum suction drain is not used. Although there are many citations in the literature to start the expansion in one to three weeks after the expander is inserted, in our service, the scar is expected to mature more, and tissue expansion begins
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in about four weeks. If there are no complications, weekly expansion is performed, until the required volume is reached. The use of state-of-the-art or osmotic expanders with self-inflating expansion may eliminate the need for repeated injections, reducing the number of infections and other complications10. However, there are still no such devices commercially available in our market11. The profile of patients, the number of surgeries, and the number of complications have changed in our department in recent decades if we compare it with a study by Freitas et al., from 2011. In the period from January 2005 to December 2009, most of these patients were in their second decade of life and underwent expansion due to burning sequelae. In the present study, we found a prevalence of women over the fourth decade of life undergoing breast reconstruction treatment after radical mastectomy, with the old profile of patients in the second position. This change in profile is consistent with the worldwide increase in the number of breast reconstruction procedures with prostheses performed in two stages, the first of which is tissue expansion6. In proportion to the number of surgeries performed in the last decades 12 , the number of complications has decreased. In patients undergoing radical mastectomy for cancer treatment, a significant challenge is a need for post-surgical radiation. Radiation leads to fibrosis, which compromises the quality of the skin and subcutaneous tissue, resulting in higher incidences of complications and possibly impairing the final aesthetic result13. These complications may conduct to the need of the radiotherapy treatment interruption, thus compromising the final result. In other situations, it may be necessary to deflate the expander to allow adequate access to the chest wall and internal mammary lymph nodes. In burns, the most common complications are infection, exposure, and expander malfunction. According to Bozkurt et al., N 200814, the highest number of complications in these patients occurs in the head region, and when using larger expansion volumes (400 and 800ml). However, the results obtained in this research are in line with LoGiudice and Gosain (2003)15, with more significant complications in the lower limbs, possibly due to less rich vascularization and the amount of tissue available region. The highest incidence of complications with the age group is found in patients over 40 years old and those between 11 to 20 years old, coinciding with the age groups with the highest prevalence in patients after radical mastectomy and burn sequelae.
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It is essential to know the types of complications, frequency, and associated factors to minimize them. Besides, the choice of the best expander option and the correct surgery technique and expansion are essential for a good result. The future of the skin expansion technique is auspicious. The increase in the number of studies observed in the last decades on expansion, not only of skin but also of nerves, bones, and other parts of the body, can be of great value to surgeons in the future16.
CONCLUSION The skin expansion technique is indicated for several pathologies’ treatment. Besides, the patient profile treated at the Hospital de Clínicas da UFPR has changed in the last decades. Since 2010, there has been an increase in the number of patients who underwent treatment for breast reconstruction, exceeding the number of patients due to burning sequelae who underwent the same procedure. Most of the complications observed in these patients were infections related to the insertion of expanders in the chest region to perform the breast reconstruction procedure.
COLLABORATIONS KKTR
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Software, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
MCCO
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Resources, Supervision, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
JRN
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Writing - Original Draft Preparation, Writing - Review & Editing
Rev. Bras. Cir. Plást. 2020;35(3):309-315
IO
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Methodology, Writing Original Draft Preparation, Writing - Review & Editing
HCM
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Software, Writing - Original Draft Preparation, Writing Review & Editing
RSF
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Data Curation, Final manuscript approval, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Realization of operations and/or trials, Resources, Supervision, Validation, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
REFERENCES 1. Di Mascio D, Castagnetti F, Mazzeo F, Caleffi E, Dominici C. Overexpansion technique in burn scar management. Burns. 2006 Jun;32(4):490-8. 2. Tavares Filho JM, Belerique M, Franco D, Porchat CA, Franco T. Tissue expansion in burn sequelae repair. Burns. 2007 Abr;33(2):246-51. 3. Barret JP. ABC of burns: burns reconstruction. BMJ. 2004;329(7460):274-6. 4. Paschoal FM. Nevo melanocítico congênito. An Bras Dermatol. 2002 Nov/Dez;77(6):649-58. 5. Viana ACL, Gontijo B, Bittencourt FV. Giant congenital melanocytic nevus. An Bras Dermatol. 2013 Nov/Dez;88(6):86378. 6. American Society of Plastic Surgeons (ASPS). Plastic surgery statistics [Internet]. Arlington Heights, IL: ASPS; 2016; [acesso em 2017 Abr 01]. Disponível em: https://www.plasticsurgery.org/ news/plastic-surgery-statistics?sub=2016+Plastic+Surgery+St atistics 7. Araujo MP, Araujo AJ. Sindrome de Moebiüs-Poland: relato de caso. Rev Med. 1999;78(3):371-7. 8. Ashley KL, Bruce SB. Tissue expansion. In: Thorne CH, ed. Grabb and Smith’s Plastic Surgery. Philadelphia, PA: Lippincott Wilians Wilkins; 2013. p. 512-40. 9. Ascherman JA, Zeidler K, Morrison KA, Appel JZ, Berkowitz RL, Castle J, et al. Carbon dioxide–based versus saline tissue expansion for breast reconstruction: results of the XPAND prospective, randomized clinical trial. Plast Reconstr Surg. 2016 Dez;138(6):1161-70. 10. Chummun S, Addison P, Stewart KJ. The osmotic tissue expander: a 5-year experience. J Plast Reconstr Aesthet Surg. 2010 Dez;63(12):2128-32. 11. Pitanguy I, Radwanski HN, Amorim NFG, Lintz JE, Moraes Neto AEM. The use of tissue expanders in burn sequelae. Acta Med Misericordia. 2000;2(3):59-64. 12. Freitas RS, Oliveira e Cruz GA, Scomação I, Nasser IJG, Colpo PG. Tissue expansion at Hospital de Clínicas-UFPR: our experience. Rev Bras Cir Plást. 2011 Set;26(3):407-10.
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13. Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Winefield HR. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg. 2005 Nov;75(11):940-7. 14. Bozkurt A, Groger A, O’Dey D, Vogeler F, Piatkowski A, Fuchs PCH, et al. Retrospective analysis of tissue expansion in reconstructive burn surgery: evaluation of complication rates. Burns. 2008;34(8):1113-8.
*Corresponding author:
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15. LoGiudice J, Gosain AK. Pediatric tissue expansion: indications and complications. J Craniofac Surg. 2003 Nov;14(6):866-72. 16. Wood RJ, Adson MH, Van Breek AL, Peltier GL, Zubkoff MM, Bubrick MP. Controlled expansion of peripheral nerves: comparison of nerve grafting and nerve expansion/repair for canine sciatic nerve defects. J Trauma. 1991 Mai;31(5):686-90.
Kethelyn Keroline Telinski Rodrigues Avenida Presidente Getúlio Vargas ,1811, Apart. 41 , Rebouças, Curitiba, PR, Brazil. Zip Code: 80240-040 E-mail: kety.rodrigues@gmail.com
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Original Article Epidemiological profile of patients with skin cancer treated at the Regional Hospital of Asa Norte/DF - Brazil Perfil epidemiológico de pacientes portadores de câncer de pele atendidos no Hospital Regional da Asa Norte/DF - Brasil ALTINO VIEIRA DE REZENDE FILHO NETO 1* HELOIZA GUTIERREZ YAMAMOTO 1 JEFFERSON LESSA SOARES DE MACEDO 1 CRISTIANO GONÇALVES FLEURY CURADO 1 JOSÉ LUIZ DE OLIVEIRA NETO 1 MARCOS ANTÔNIO PEIXOTO DE CARVALHO 1 OCIMAR BARBOSA TRINDADE 1 IVAM PEREIRA MENDES NETO 1
Institution: Hospital Regional da Asa Norte, Plastic Surgery Unit, Brasília, DF, Brazil. Article received: September 22, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0056
1
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■
ABSTRACT
Introduction: Skin cancer is the most common neoplasm in the Brazilian population, corresponding to 30% of all malignant tumors registered in the country. Non-melanoma malignant tumors are the type of cancer with the highest incidence and prevalence in Brazil. Basal cell carcinoma (BCC) is the most common, accounting for between 70% and 75% of cases. Squamous cell carcinoma (SCC) accounts for 20% of cases. The objective is to determine the epidemiological profile, the types and subtypes found in the histopathological results, the surgical conduct and its effectiveness in patients with a suspected malignant skin lesion. Methods: A retrospective descriptive study, based on the analysis of electronic medical records for resection of skin lesions suspected of malignancy, carried out by the Plastic Surgery team at the Regional Hospital of Asa Norte, Brasília/DF, from January 2012 to December 2016. Results: 533 patients were submitted to surgery, being female (51.6%), with a mean age of 68.97 years and 84% diagnosed with basal cell carcinoma with solid subtype. The compromised margins reached 11% of the sample. The most prevalent reconstructions were primary closure and local flaps. Conclusion: The epidemiological profile of patients treated with lesions suspected of skin cancer showed prevalence in women over 60 years with a history of sun exposure. The face was the most affected site, the nose being the most common topography. BCC is the most common type, and the circumscribed solid subtype was the most prevalent. The most used type of reconstruction was primary closure and local flap. Keywords: Basal cell carcinoma; Skin cancer; Margin compromise; Excision margins; Surgical flaps; Plastic surgery.
Hospital Regional da Asa Norte, Plastic Surgery Unit, Brasília, DF, Brazil.
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■
RESUMO
Introdução: O câncer de pele é a neoplasia mais comum na população brasileira, correspondendo a 30% de todos os tumores malignos registrados no país. Os tumores malignos não melanoma são o tipo de câncer de maior incidência e prevalência no Brasil. O carcinoma basocelular (CBC) é o mais comum, correspondendo entre 70% e 75% dos casos. O carcinoma epidermóide (CEC) responde por 20% dos casos. O objetivo é determinar o perfil epidemiológico, os tipos e subtipos encontrados nos resultados de histopatológico, a conduta cirúrgica e sua eficácia, dos pacientes com suspeita de lesão maligna de pele. Métodos: Estudo retrospectivo descritivo, baseado na análise de prontuário eletrônico de ressecção de lesões de pele suspeitas de maligna, pela equipe da Cirurgia Plástica do Hospital Regional da Asa Norte, Brasília/DF, no período de janeiro de 2012 a dezembro de 2016. Resultados: Foram submetidos à cirurgia 533 pacientes, sendo sexo feminino (51,6%), com média de idade de 68,97 anos e 84% com diagnóstico de carcinoma basocelular com subtipo sólido. As margens comprometidas atingiram 11% da amostra. As reconstruções mais prevalentes foram fechamento primário e retalhos locais. Conclusão: O perfil epidemiológico dos pacientes atendidos com lesões suspeitas de câncer de pele demonstrou prevalência em mulheres e acima de 60 anos, com história de exposição solar. A face foi o local mais acometido, sendo o nariz a topografia mais comum. O CBC é tipo mais comum e o subtipo sólido circunscrito foi o mais prevalente. O tipo de reconstrução mais utilizado foi o fechamento primário e o retalho local. Descritores: Carcinoma basocelular; Câncer de pele; Comprometimento de margem; Margens de excisão; Retalhos cirúrgicos; Cirurgia plástica.
INTRODUCTION Skin cancer is the most common neoplasm in the Brazilian population, corresponding to 30% of all malignant tumors registered in the country. Among skin tumors, the non-melanoma type has the highest incidence and lowest mortality¹. Skin cancer has a growing incidence, according to the National Cancer Institute (INCA), an official body of the Ministry of Health. National rates are 60 cases/100,000 inhabitants, with basal cell carcinoma (BCC) being the most common type, corresponding to 70-75% of cases. The most common subtype is nodular 1,2,3. The second most common type of malignant skin tumor is squamous cell carcinoma (SCC), with 15 to 20% of cases. Mortality due to BCC and SCC is low, as they rarely metastasize. However, they are locally aggressive and recurrent4. Melanoma represents only 3% of malignant neoplasms; nevertheless, it is the most aggressive and metastatic. It was estimated 6260 new cases for the year 20181-4, with 2,920 men and 3,340 women. Rev. Bras. Cir. Plást. 2020;35(3):316-321
This study’s objectives were to verify the epidemiological profile, types, and surgical management of patients with suspected skin malignancy at the Plastic Surgery Unit of Hospital Regional da Asa Norte, Brasília / DF.
METHODS This is a descriptive retrospective study, based on the analysis of electronic medical records (TRAKcare) of patients undergoing surgical treatment for resection of a suspected lesion of skin malignancy, by the Plastic Surgery team at the Regional Hospital of Asa Norte, Brasília / DF, from January 2012 to December 2016. A database was created in the Excel program, including all patients who underwent resection of a lesion in the team’s operating room. Inclusion criteria 1. Patients undergoing resection of lesions with clinical characteristics of malignancy; 317
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2. Patients operated by the Plastic Surgery Unit team; 3. Minimum outpatient follow-up of at least six months after the operation; 4. Patients who needed hospitalization for a procedure in the operating room with sedation associated with local anesthesia or general anesthesia for resectioning skin lesions (exeresis, incisional biopsies, excisional biopsies, and enlarged compromised margin). 5. Anatomopathological result checked in a later consultation. Exclusion criteria 1. Incomplete data in the medical record; 2. Patients undergoing the surgical procedure who did not come for postoperative follow-up; 3. Cases of low complexity that were operated in the small surgery outpatient clinic of Plastic Surgery at Hospital Regional da Asa Norte, with no need for sedation or general anesthesia and a minimum stay of 6 hours.
www.rbcp.org.br Table 1. Distribution by location of suspicious lesions in the head and neck region. Head and neck regions
n. (%)
Scalp
23 (2%)
Cervical region
47 (5%)
Face
957 (93%)
Total
1027 (100%)
Face location 1/3 upper face 153 (16%)
1/3 midface 669 (70%)
1/3 lower face 135 (14%)
n. (%) Front
80 (8%)
Temporal
73 (7%)
Julgar, Malar, zygomatic, buccinator
124 (13%)
Periorbital
143 (15%)
Nose
281 (29%)
Ear
121 (13%)
Nasogenian
29 (3%)
Mandible and chin
44 (5%)
Tongue and palate
4 (0,5%)
Lip
58 (6%)
Ethical aspects This research project was approved by the CEP of the Health Department of the Federal District under the number of the CAAE: 15090018.6.0000.5553, exempt from the Informed Consent Form (ICF).
RESULTS Five hundred thirty-three patients who underwent resection of a suspected lesion in the period met the selection criteria. Regarding gender, 273 were females (51.6%) and 260 males (48.4%), with a mean age of 68 years (range, 1 to 102 years) and 1,484 injuries (mean of 2.78 injuries/patient) were resected. As for the location, 69% of resections were in the head and neck, followed by the upper limb (15%), trunk (13%), and only 2% lesions in the lower limb. Considering the lesions located in the head and neck region, 975 (93%) were on the face, 47 (5%) on the scalp and 23 (2%) on the cervical region. Regarding the lesions located on the face, these preferentially affected the middle third of the face. The nose was the location with the highest number of resections, followed by the periorbital region (Table 1 and Figure 1). The results of the histopathological analysis identified that 188 (13%) resected lesions were benign, 377 (25%) pre-malignant (actinic keratosis), and 318
Figure 1. Distribution of suspicious lesions by region of the face.
919 (62%) malignant. Among the malignant lesions, basal cell carcinoma 760 (84%) stood out, followed by squamous cell carcinoma 129 (14%). When the types of lesions were distributed by age, patients with BCC and pre-malignant lesions (keratoses) were a homogeneous group of older age, and basal squamous cell carcinoma showed greater age heterogeneity. On the other hand, younger patients were more frequent in other types of injuries (Figure 2). The main subtypes identified for basal cell carcinoma were nodular in 520 cases (68%), superficial in 155 (20%), and sclerodermiform in 68 (9%). As for the margin compromised, 12% were compromised. Regarding SCCs, 50% of the moderately differentiated SCC types were identified, followed by 33% well-differentiated SCC, 13% in situ SCC, and only 3% poorly differentiated SCC. Compromised margins were observed in less than 10%. Rev. Bras. Cir. Plรกst. 2020;35(3):316-321
Epidemiological profile of patients with skin cancer Table 2. Subtypes of melanoma. Melanoma
Figure 2. Box plot of the distribution of types of lesions by age. BCC: Basal Cell Carcinoma; SCC: Squamous Cell Carcinoma.
Only five cases of sarcoma were identified, one example of Marjolin’s ulcer and one case of cancer metastasis from another organ to the skin – a clear cell renal cell carcinoma (Figure 3).
Figure 3. Metastasis of clear cell renal tumor from the kidney to skin.
Eight cases of malignant melanoma were found, and there was no margin compromise in the histopathological result (Table 2). The enlargement of the compromised margin was performed in 100 cases (11%), of which three had compromised margins again, being referred to the oncology service for complementary radiotherapy. Regarding the surgical procedures for reconstruction of the defect created to the detriment of resection of the lesion, the majority (77%) needed only primary closure, 135 (9%) underwent skin graft, the majority being total skin (93%) of which the main donor area was the supraclavicular region and 188 (12%) flaps. Among the flaps consecrated for reconstruction, 47 flaps were medium-frontal/Indian, 40 nasogenian, 14 Limberg, and 12 retroauricular. The mid-frontal flap was used to reconstruct the nose, the inner canthus of the eye, and lower eyelid. Microsurgical flaps were performed in three Rev. Bras. Cir. Plást. 2020;35(3):316-321
n.8
In situ
1
Lentigo maligna
1
Acral lentiginous melanoma
2
Superficial spreading malignant
1
Malignant
1
Nodular malignant
2
reconstructions. Only six cases were submitted to closure by the second intention. Through the perceptual map, it was verified that the grafts, in general, were more indicated when there was a result of histopathology of SCC, the flaps were more indicated in BCC and the primary closure in cases of BCC, actinic keratosis and benign lesions (Figure 4).
Figure 4. Perceptual map correlating the most prevalent histopathological and surgical procedures. BCC: Basal Cell Carcinoma; SCC: Squamous Cell Carcinoma
DISCUSSION In the literature, we found a higher frequency of malignant skin neoplasia in men, but some studies show higher frequencies in women over 40 years of age. In our study, the average age was 68 years, affecting women more and being rare in children and blacks. Those with previous skin diseases and light skin sensitive to sunlight (Fitzpatrick phototype I and II), burn scars, chronic ulcers, arsenic exposure, ionizing radiation, xeroderma pigmentosum, HPV infection and Gorlin and Bazex syndromes have risk factors that may be related to the appearance of BCC and SCC1-4. The head and neck regions are the most affected by sun exposure and the chronic action of ultraviolet B rays (UVB), especially in tropical countries like Brazil1-4. 319
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The most common skin cancer is BCC, which accounts for 70-80% of cases. Its most common subtype is nodular and the least aggressive. For 2018, 165,580 new cases were estimated, with 85,170 men, 80,410 women and 1,769 deaths. The second most frequent is SCC. Melanoma is rarer, representing only 3% of malignant neoplasms. It is noteworthy that it is the most aggressive due to its high possibility of metastasis; data from this study reveal similarity with the literature1-7. Early diagnosis is essential to avoid significant deformities resulting from the tumor and reduce the need for aggressive treatment methods. The suggestive diagnosis is clinical and dermatoscopy can help. The definition of the histological type is made employing incisional or excisional biopsy for lesions above 1.0 cm8,9. Treatments are the surgical procedure of tumor removal with a safety margin or the aid of freezing the piece in the intraoperative period or Mohs micrographic surgery, resulting in high efficacy with low recurrence10-11. Curettage, electrocoagulation, liquid nitrogen cryosurgery, and 5% imiquimod and topical 5-fluoracil may be options for superficial BCC less than 1.0 cm8. In patients without clinical conditions for surgical resection with extensive tumors, radiation therapy may be an alternative. The margin recommended by the literature in the BCC is between 3-4 mm for circumscribed lesions, as in the nodular form, with a size smaller than 2 cm, and between 5-6 mm for tumors with poorly defined margins, such as superficial and infiltrative ones, or with size larger than 2cm. While for SCC, margins are generally 4mm for the well-differentiated and 6mm for the undifferentiated. In SCC with metastases and aggressive tumors with lymph node metastases, lymphadenectomy and complementary radiotherapy should be performed1-10. We identified 11% of margin compromise in specimens, similarly reported by Su et al., in 20179. The index of margins compromised in the literature varies between 4% to 18%; its conduct is controversial in the literature10. In melanoma, excisional biopsy is recommended as an initial approach. An incisional biopsy is acceptable for extensive lesions and/or in places where the entire lesion’s extraction causes a functional or aesthetic defect. The enlargement of the margins of the primary lesion in melanoma varies according to the depth of invasion in millimeters (Breslow Index - Table 3)11-18. Sentinel lymph node biopsy is indicated if there 320
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are no clinical signs of lymph node involvement and one of the following factors: Breslow> 1mm; between 0.8mm and 1mm if mitotic index ≥ 1 / mm2, presence of ulceration or angiolymphatic invasion; and Breslow underestimated by a deep positive margin (Table 3)11-18. Table 3. Expansion of margins in melanoma, according to AJCC, 8th edition16. Tumor thickness (mm)
Margins (cm)
Melanoma in situ
0,5 a 1cm
Breslow ≤ 1mm
1cm
Breslow de 1,1 to 2mm
1 to 2cm
Breslow > 2mm
2cm
Although there are established conducts for the treatment of skin cancer, there is no absolute consensus for all situations according to histological type, size, depth or location of the lesion, and aspects such as age, clinical conditions of the patient, aesthetic result, number lesions and whether the tumor is primary or recurrent.
CONCLUSION In the treatment of skin cancer, multidisciplinary participation, and the plastic surgeon working with oncological principles are essential, performing tumor excision and reconstruction of the affected area to maintain function and restore aesthetics. Our study showed a prevalence of females with a mean age of 68 years. The face is the most affected site, the nose being the most common topography. The circumscribed solid basal cell carcinoma was the most frequent subtype, and the most used type of reconstruction was primary closure. Such data corroborate the leading risk factor for non-melanoma skin cancer: chronic sun exposure.
COLLABORATIONS AVRFN
Analysis and/or data interpretation, Realization of operations and/or trials
HGY
Data Curation
JLM
Analysis and/or data interpretation, Writing - Review & Editing
CGF
Realization of operations and/or trials
JLON
Realization of operations and/or trials
MAPC
Realization of operations and/or trials
OBT
Realization of operations and/or trials
IPMN
Realization of operations and/or trials Rev. Bras. Cir. Plást. 2020;35(3):316-321
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REFERENCES 1. Barreiro G, Zanella FA, Rosa KGD, Calvett R, Senandes LS, Vizzotto MD, et al. O impacto de ações assistenciais na percepção da qualidade do Sistema Único de Saúde (SUS), Brasil: um estudo transversal. Rev Bras Cir Plást. 2016;31(2):242-5. 2. Instituto Nacional do Câncer (INCA). Estimativa 2012: incidência do câncer no Brasil [Internet]. Rio de Janeiro (RJ): INCA; 2012; [acesso em 2019 Jun 01]. Disponível em: http://www.inca.gov.br 3. Bariani RL, Nahas FX, Barbosa MVJ, Farah AB, Ferreira LM. Basal cell carcinoma: an updated epidemiological and therapeutically profile of an urban population. Acta Cir Bras. 2006 Mar/Abr;21(2):66-73. 4. Veríssimo P, Barbosa MVJ. Tratamento cirúrgico dos tumores de pele nasal em idosos. Rev Bras Cir Plást. 2009;24(2l):219-33. 5. Nasser N. Epidemiologia dos carcinomas basocelulares em Blumenau, SC, Brasil, de 1980 a 1999. An Bras Dermatol. 2005;80(4):363-8. 6. Carvalho MP, Oliveira Filho RS, Gomes HC, Veiga DF, Juliano Y, Ferreira LM. Auto-estima em pacientes com carcinomas de pele. Rev Col Bras Cir. 2007;34(6):361-6. 7. Maia M, Proença NG, Moraes JC. Risk factors for basal cell carcinoma: a case-control study. Rev Saúde Pública. 1995 Fev;29(1):27-37. 8. Chinem VP, Miot HA. Epidemiology of basal cell carcinoma. An Bras Dermatol. 2011;86(2):292-305. 9. Su SY, Giorlando F, Ek EW, Dieu T. Incomplete excision of basal cell carcinoma: a prospective trial. Plast Reconstr Surg. 2007 Out;120(5):1240-8. 10. Gregorio TCR, Sbalchiero JC, Leal PRA. Acompanhamento a longo prazo de carcinomas basocelulares com margens comprometidas. Rev Soc Bras Cir Plást. 2005;20(1):8-11.
*Corresponding author:
11. Eliezri YD, Cohen PR. Cancer recurrence following Mohs micrographic surgery: a mechanism of tumor persistence. Plast Reconstr Surg. 1992 Jul;90(1):121-5. 12. Holmikvist K, Rogers G, Dahl P. A. Incidence of residual basal cell carcinoma in patients who appear free after biopsy. J Am Acad Dermatol. 2002;41(4):600-5. 13. Quintas RCS, Coutinho ALF. Fatores de risco para o comprometimento de margens cirúrgicas nas ressecções de carcinomas basocelular. Rev Bras Cir Plást. 2008;23(2):116-9. 14. Duz GL, Chagas JF, Faria JCM. Pesquisa de linfonodo sentinela em pacientes com melanoma cutâneo: correlação clínica e cintilográfica. Rev Bras Cir Plást. 2007;22(2):76-80. 15. Hayes AJ, Maynard L, Coombes G, Newton-Bishop J, Timmons M, Cook M, et al. Wide versus narrow excision margins for high-risk, primary cutaneous melanomas: long-term followup of survival in a randomized trial. Lancet Oncol. 2016 Fev;17(2):184-92. 16. Gershenwald JE, Scolyer RA, Hess KR, Sondak VK, Ling GV, Ross MI, et al. Melanoma of the skin. In: Amin MB, Edge SB, Greene FL, eds. AJCC Cancer Staging Manual. 8th ed. New York: Springer International Publishing; 2017. p. 563-85. 17. Gershenwald JE, Scoyler RA, Hess KR et al. American Joint Committee on Cancer (AJCC) on Cancer Staging Manual [Internet]. 8th Edition, 2016; [acesso em 2019 Ago 10]. Disponível em: http//www.cancerstaging.org 18. Gomes MWS, Galvão M, Moreira M, Caiado B, Cheldid R, Graziosi G. Perfil das reconstruções microcirúrgicas no INCA: análise retrospectiva de 46 casos. Rev Bras Cir Plást. 2012;27(3):35.
Altino Vieira de Rezende Filho Neto SMAS Trecho 1, Lote C, Bloco J, Apart. 703, Park Sul Guara, Brasília, DF, Brazil. Zip Code: 71218-010 E-mail: altinofn@hotmail.com
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Original Article Trend in hospitalization for burns in Santa Catarina in the Single Health System, Brazil, in the period 2008-2018 Tendência de internação hospitalar por queimadura em Santa Catarina no Sistema Único de Saúde, Brasil, no período entre 2008 e 2018 FELIPE OLIVEIRA DUARTE 1* STEFANY GOUDZENKO HERNANDEZ 2 MARCOS OLIVEIRA MACHADO 2 JORGE BINS ELY 3
Institution: Universidade do Sul de Santa Catarina, Palhoça, SC, Brazil. Article received: February 29, 2020. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0057
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ABSTRACT
Introduction: Burns are defined as important lesions to the skin or organic tissue caused by electricity, chemical, radioactive agents, friction or friction, exposure, or contact with extreme heat or cold. Methods: Ecological study of time series, with data obtained in the state of Santa Catarina, using the Hospital Information System of the Unified Health System database, from 2008 to 2018. For each year of the studied period, the hospitalization rates for burns were calculated, grossly and specifically, according to the dependent variables of interest: age group and sex. It was used the simple linear regression method for the analysis of temporal trends and standardized morbidity coefficients. Results: There were 9,158 hospitalizations in the studied period. At the beginning of the period, the hospital admission rate was 12.06/100,000 inhabitants, ending the period with an increase to 17.07/100,000 inhabitants. In males, the rate started with 14.52/100,000, ending the historical series with 22.51/100,000 inhabitants. For women, the initial rate was 9.52/100,000 and, at the end of the period, increased to 11.72/100,000. The age group most affected in both sexes was 0 to 4 years. Conclusion: There was an increase in the general hospitalization rate. The male sex presented higher rates in the period, but both sexes tended to increase. The age group from 0 to 4 years old stood out as the most affected in the state of Santa Catarina. Keywords: Burns; Hospitalization; Epidemiology; Morbidity; Surgery, Plastic.
University Hospital, Florianópolis, SC, Brazil. Universidade do Sul de Santa Catarina, Palhoça, SC, Brazil. 3 Federal University of Santa Catarina, Florianópolis, SC, Brazil. 1 2
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RESUMO
Introdução: Queimaduras são definidas como importantes lesões da pele ou tecido orgânico, causadas por eletricidade, agentes químicos, radioativos, atrito ou fricção, exposição ou contato com calor ou frio extremo. Métodos: Estudo ecológico de séries temporais, com dados obtidos no estado de Santa Catarina, utilizando o banco de dados do Sistema de Informações Hospitalares do Sistema Único de Saúde, no período de 2008 a 2018. Para cada ano do período estudado, foram calculadas as taxas de internação por queimadura, bruta e específicas, de acordo com as variáveis dependentes de interesse: faixa etária e sexo. Para análise das tendências temporais, foram utilizados os coeficientes de morbidade padronizados e o método de regressão linear simples. Resultados: Ocorreram 9.158 internações no período estudado. A taxa de internação hospitalar no início do período, foi de 12,06/100.000 habitantes; finalizando o período com aumento para 17,07/100.000 habitantes. No sexo masculino, a taxa iniciou com 14,52/100.000, finalizando a série histórica com 22,51/100.000 habitantes. Já no sexo feminino, a taxa inicial foi de 9,52/100.000 e, ao final do período, aumentou para 11,72/100.000. A faixa etária mais acometida em ambos os sexos foi a de 0 a 4 anos. Conclusão: Houve aumento na taxa de internação geral. O sexo masculino apresentou taxas superiores no período, mas ambos os sexos tenderam ao aumento. Destacou-se a faixa etária dos 0 a 4 anos como a mais acometida no estado de Santa Catarina. Descritores: Queimaduras; Hospitalização; Epidemiologia; Morbidade; Cirurgia plástica.
INTRODUCTION Burns are defined as important lesions to the skin or organic tissue caused by electricity, chemical, radioactive agents, friction or friction, exposure or contact with extreme heat or cold. They can be classified, in terms of depth, as first-degree, when the lesions reach only the epidermal layer; second-degree, when there is the involvement of the epidermis and the superficial or deep dermis layer; and, third-degree, when there are lesions of all the skin appendages1. Factors associated with burn injuries are considered: low income, urban area, home environment, and the handling of hot liquids2. Among children, the age of one to three years is more prevalent in accidents associated with neuropsychomotor development and greater freedom of movement3. In elderly patients, in addition to injuries that occur in the kitchen, they also happen in the bathroom, related to excessively hot bath4. Several complications can occur in burn patients, including infection of the lesion, pneumonia, acute renal failure, shock, and sepsis5. Among the hospitalized patients, 35.8% develop skin infections and 24.4% respiratory infections, with the elderly being the most affected6. Rev. Bras. Cir. Plást. 2020;35(3):322-328
Treatment of burn victims is costly for the state and the patient. The average stay of major burns in a hospital environment is 41.5 days, with the body surface burned directly related to gravity, causing a great economic and emotional impact7. The final average cost of this type of patient can reach R$ 26,386.22, including grafts, debridement, and time spent in the Single Health System (SUS in Portuguese)8. Patients face many challenges after hospital discharge, such as social stigmas due to the injury, which reduces the possibility of the patient returning to his economic potential. Another difficulty is that the mobility of the affected area, as the surface of the burned area can cause mobility difficulties in the affected region with permanent sequelae9. Currently, there is a trend in the world to decrease the incidence of burn cases, the degree of mortality, the duration of hospital stays, and the severity10. In Brazil, the epidemiological profile of the adult patient who suffers burns is predominantly male, with an average age of 25 to 26 years, injured by flammable products in their own home. The majority of incidents occur in the upper extremities, and most are either first degree only or first and second degree combined. Second- and third-degree scald burns predominate on children, mainly on the trunk and upper limbs11. 323
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This study’s general objective is to analyze the time trend for hospitalization due to burns in Santa Catarina from 2008 to 2018. The specific objectives are: to identify the general rate of hospitalization due to burns and to evaluate the tendency of the time series according to sex and range age by sex.
affiliated with SUS sent data on admissions made through the Hospitalization Authorization (AIH) to municipal and state managers. The data were exported in Comma Separated Values (CVC) format and saved in an Excel spreadsheet. Population demographic information was taken from the Instituto Brasileiro de Geografia e Estatística (IBGE) website, using the 2000 and 2010 censuses, and its inter-census estimates. The study’s dependent variables referred to the rates according to male and female sex and age group (0-4 years, 5-9 years, 10-19 years, 20-39 years, 40-59 years, 60 years or more) by gender. The independent variable was the year 2008 to 2018 For each year of the studied period, the hospitalization rates for burns, grossly and specifically, were calculated according to the dependent variables of interest: age group and sex, calculated for every 100,000 inhabitants using the total number of hospitalizations, divided by the general population of the period (general, by sex and age group by sex). Standardized morbidity coefficients and the simple linear regression method were used with the Statistical Package for the Social Sciences (SPSS) version 18.0 to analyze the temporal trends in burn morbidity. In this method, the standardized hospitalization rates were considered as dependent variables, and the years of the study calendar as independent variables, thus obtaining the model estimated according to the formula Y = b0 + bI X, where y = standardized coefficient, b0 = average coefficient for the period, Bi = average annual increase and X = year. The results were presented in rates, r = correlation coefficient, b = slope, and p-value. P <0.05 was considered statistically significant.
METHODS
RESULTS
An ecological time-series study was carried out using data obtained in the state of Santa Catarina in the public domain database of the Hospital Information System of the Unified Health System (SIH-SUS)16. The study population was extracted from SIHSUS hospital admissions data for burns in the state of Santa Catarina, which occurred from 2008 to 2018. Data inclusion was performed considering the International Classification of Disease ICD-10 in the case of burns and corrosion: T20 to T32. Hospitalization data with ignored sex or age were excluded. During the study period, the estimated population of burns was 4,480,073, according to SIH-SUS17. Data collection was performed based on information in the public domain database on the DATASUS website, from the SUS Hospital Information System (SIH-SUS), available at http://tabnet.datasus. gov.br/cgi/tabcgi.exe?sih/cnv/niuf.def. Hospital units
In the period analyzed (2008-2018), there were 9,158 hospitalizations for burns registered in public hospitals in Santa Catarina. The trend in the general rate of hospitalization for burns is shown in Figure 1. The rate of hospitalization in 2008, at the beginning of the period, was 12.06 hospitalizations per 100,000 inhabitants, ending the period (2018), with the rate increasing to 17.07 hospitalizations per 100,000 inhabitants. When stratifying the hospitalization rate by sex, it was noticed that in males, it is higher (Figure 2). The male hospitalization rate started at 14.52, ending the historical series with 22.51/100,000 inhabitants. In females, the initial rate was 9.52 hospitalizations per 100,000 inhabitants and, at the end of the period, increased to 11.72 per 100,000 inhabitants. There were more variations in the trend in males in the period, with a significant increase from 2013.
In the south of Brazil, there have been small variations in the rates of hospitalization of burns in recent years (13.11 to 14.6/100,000 inhabitants), being higher in males and the 0-19 age group (Favassa et al., in 201712). The state of Paraná stands out in the region, which has higher rates compared to other states12. In Santa Catarina (SC), from 2006 to 2012, there was a significant decrease in the rate (from 15 to 10/100,000 inhabitants). The group most affected in the state is one to four years of age, with the hospitalization rate inversely proportional to age13. The accomplishment of a higher number of national scientific, technical studies on the epidemiology of burns is necessary and desired14. The provision of new data, even public knowledge, but through research, is essential for the responsible agencies to develop effective prevention methods, based on the studied local population15. Therefore, this study’s objective was to analyze the time series of hospitalization rates for burns in the state of SC, according to sex and age group, in order to provide peculiar and relevant information for the design of public policies. The purpose is to promote and protect collective health concerning burns that are a significant cause of morbidity and mortality in the Brazilian population.
OBJECTIVE
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The rate of hospitalization for burns in males by age group is shown in Figure 4. During the entire period, there is an increase in the age group from 0 to 4 years, from 44.75 (100,000 inhabitants) to 115.37 (100,000 inhabitants).
Figure 1. Time trend of the general rate of hospitalization for burns in the state of Santa Catarina between 2008 and 2018.
Figure 4. Time trend of the hospitalization rate for burns in the state of Santa Catarina between 2008 and 2018, according to the male gender by age group.
Figure 2. Time trend of the hospitalization rate for burns in the state of Santa Catarina between 2008 and 2018, according to sex.
Figures 3 and 4 show the trend of the time series according to the age group by sex. In Figure 3, which shows the time trend for hospitalization due to burns in females, it can be seen that the most affected group is 0-4 years old, with rates of 28, 86 at the beginning of the period, and 69.40 per 100,000 at the end of the historical series. Besides, there is an increase in the rate in the age group of 5 to 9 years in 2016 from 11.44 to 26.01 per 100,000 inhabitants.
Figure 3. Time trend of the hospitalization rate for burns in the state of Santa Catarina between 2008 and 2018, according to the female gender by age group.
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Table 1 shows the annual percentage change, coefficient of determination (R2), the average annual change (β), the p-value, and the trend stratified by sex and age group. There was a 29.34% increase in the overall burn rate over the study period (2008 to 2018). Concerning sex, there is a significant upward trend for both men and women, with an annual percentage change of 35.49% and 17.91%, respectively. When analyzed by age group, there was a tendency to increase in ages between 0-4, 5-9, and over 60 years old in females. In males, there was a tendency to increase in ages between 0-4, 10-19, and over 60 years
DISCUSSION In the world, burns represent a significant cause of morbidity and mortality and can lead to considerable economic and social impact7. These injuries are in fourth place as the most prevalent type of trauma in the world, after traffic accidents, falls, and interpersonal violence and they represent one of the biggest problems in global public health due to the impact represented by the severity of their injuries18. The data obtained in the present study demonstrated a time trend of increase in the number of hospitalizations due to burns in the state of Santa Catarina in the studied period (2008-2018). However, a similar study in the same state between 1998 and 2012 showed a decrease in the number of cases13. The morbidity rate in 1998 was close to 16 hospitalizations per 100,000 inhabitants, decreasing in 2012 to less than 14 hospitalizations/100,000 and remaining 325
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Table 1. Temporal trend in hospitalization due to burns in the state of Santa Catarina between 2008 and 2018, according to sex and age group by sex Annual Percentage Variation (%)
R2
Average Annual Variation (ฮฒ)
p-value
Trend
29.34
0.735
0.499
0.001
Increase
General hospitalization rate Hospitalization rate by sex Female
17.91
0.44
0.248
0.026
Increase
Male
35.49
0.794
0.756
0
Increase
0-4 years
58.41
0.902
4.112
0
Increase
5-9 years
71.22
0.447
1.201
0.024
Increase
10-19 years
28.12
0.089
0.103
0.373
Stable
20-39 years
-97.71
0.346
-0.416
0.057
Stable
40-59 years
-39.15
0.042
-0.072
0.546
Stable
More than 60 years
55.53
0.785
0.542
0
Increase
0-4 years
61.21
0.858
6.788
0
Increase
5-9 years
70.38
0.311
1.795
0.074
Stable
10-19 years
50.54
0.372
0.498
0.046
Increase
20-39 years
-15.64
0.007
-0.042
0.802
Stable
Hospitalization rate by age group Female
Male
40-59 years
1.01
0.093
0.202
0.362
Stable
More than 60 years
42.5
0.526
0.737
0.012
Increase
constant14. Another study carried out in the southern region of Brazil, between 2008 and 2016, found that the hospitalization rate for burns at the beginning of the period was 13.11 per 100,000 inhabitants, ending in 2016 with 14.60/100,000 inhabitants and remaining constant14. When we analyzed these results, it was noticed that both are in a temporal agreement since the hospitalization rates increased sharply from the year 2015. In Brazil in the period from 2000 to 2014 the general hospitalization rate was 14.56 per 100,000 inhabitants and, when comparing hospitalization rates in Brazil by states, this longitudinal study found that the state of Goiรกs had the highest overall hospitalization rate due to burns, reaching 28.8 per 100,000 inhabitants, a number significantly higher than that observed in the southern states of Brazil19. This difference found was not explained by the author of the work. It is relevant to note that this type of epidemiological, ecological study does not often present enough information to justify individual issues. As for the sex of victims of burn hospitalization in Brazil, the present study observed an increase in both sexes, and the highest rate of victims hospitalized for burns was male patients. These data agree with results obtained in other international studies, where 326
countries such as Finland and Germany also have a predominance of male hospitalizations20,21. Even compared with other studies in the national territory, it was observed that there is a predominance of males8,11. The triggering factor for the predominance of the male profile in hospitalization rates, although not explicitly demonstrated, may be associated with the way men relate to the work they do because epidemiologically, men are occupants of professions with greater danger and that require more significant physical effort and would subject them to more risk of accidents. The high hiring of male professionals in chemical and oil industries in activities that require the handling of mechanical and welding equipment, and professions that require contact with flammable fuels, would be responsible for the increase in these rates. As for the female sex, burn accidents would be most associated with domestic accidents, domestic violence, and self-harm, as in suicide attempts22. The group that includes individuals from 0 to 4 years old stood out as the most affected age group in both sexes. This finding agrees with other countries such as Portugal, which presented a rate of 54.6 per 100,000 inhabitants in the same age group, where scalding in the home environment was characterized as a significant cause of burn 23. Because they are Rev. Bras. Cir. Plรกst. 2020;35(3):322-328
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still without the cognitive integrity of discerning risk situations, younger children are more exposed to accidents, intrinsically related to their parents’ knowledge about preventing burns, and first aid24. Children, aged between 5 and 9 years old, tended to increase hospitalizations in women and stability in men. The possible accomplishment of housework can explain this predominance as an assistant in the kitchen, the most commonplace of accidents in schoolchildren and preschoolers3. In the 10-19 age group, there was an increase in the trend in males and stability in females. There was a scarcity of studies in the literature covering adolescents. Serra et al., in 201225, carried out a study with hospitalizations for burns between 12 and 18 years old, in the period from 2007 to 2011, and the authors found that 33.33% of hospitalizations were caused by alcohol and the most prevalent age was 17 years. This fact can be justified by the ambivalence of interacting with the external world in a freer way, without apparently having to assume the responsibilities of adult life25. Besides, the male gender in this age group starts to consume alcohol and drugs, leading to higher suicide attempts and burn accidents. Concerning the age group of adults, in this study between 20-59 years, there was a tendency towards stability. The elderly, contained in the age group above 60 years, showed an increase in both sexes during the period, suggesting a relationship with the increase in longevity in recent years. This increase in hospitalizations can be explained by changes inherent to age, such as decreased sensory and cognitive functions, predisposing a deficit in the preventing accidents and increasing the possibility of thermal trauma. In the literature that male domestic accidents are the most prevalent, this age group is related to worse clinical evolution, weak recovery, and a higher number of days of hospitalization and hospital cost4,26,27. A recent study performed in the country showed that health professionals have unsatisfactory knowledge with the first assistance to the burned individual28, which can cause a higher number of complications and a more significant number of hospitalizations due to negligence in the first care. Besides, the state of Santa Catarina has a high level of notification concerning the rest of Brazil and a higher number of notifications in recent years. All scientific studies are subject to bias and limitations. As limitations in this study, the fact that the data source was exclusively the DATASUS database, thus excluding data from hospitalizations of private patients or financed by health insurance, for this reason, there may be underreporting of hospitalizations due to external causes29. In addition to the limitations, Rev. Bras. Cir. Plást. 2020;35(3):322-328
the possibility that hospitals that are not accredited as being of high complexity can use codes other than burns when issuing hospitalization to raise more resources for care, decreasing the numbers in this study data. Despite this, DATASUS is still considered a good source by WHO. It should be noted that more regionalized studies are needed to observe better the factors associated with burns.
CONCLUSION During the period studied, there were 9,158 hospitalizations due to burns, corresponding to the rate of 14.52 hospitalizations per 100,000 inhabitants at the beginning of the period and 22.51 hospitalizations per 100,000 inhabitants at the end of the historical series. When analyzing the general hospitalization rate, there is an increase of 29.34% in the period. Both rates of hospitalization due to burns tended to increase, with males being the highest throughout the study. When observing the different age groups, the group that includes individuals from 0 to 4 years old stands out as the most affected in the state of Santa Catarina.
COLLABORATIONS FOD
C o n c e p t i o n a n d d e s i g n s t u d y, Conceptualization, Final manuscript a p p r o v a l , M e t h o d o l o g y, P r o j e c t Administration, Supervision, Visualization, Writing - Original Draft Preparation, Writing - Review & Editing
SGH
Analysis and/or data interpretation, Conception and design study, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing - Original Draft Preparation
MOM
Analysis and/or data interpretation, Conception and design study, Final manuscript approval, Formal Analysis, Methodology, Project Administration, Supervision, Writing - Review & Editing
JBE
Analysis and/or data interpretation, Conceptualization, Data Curation, Investigation, Methodology, Supervision
REFERENCES 1. Piccolo NS, Serra MCVF, Leonardi DF, Lima Júnior EM, Novaes FN, Correa MD, et al. Projeto e Diretrizes. Queimaduras: diagnóstico e tratamento inicial. São Paulo (SP): Associação Médica Brasileira (AMB)/Conselho Federal de Medicina (CFM); 2008. 2. Queiroz PR, Lima KC, Alcântara IC. Prevalência e fatores associados a queimaduras de terceiro grau no município de Natal, RN. Rev Bras Queimaduras. 2013;12(3):169-76.
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3. Meschial WC, Sales CF, Oliveira MLF. Fatores de risco e medidas de prevenção das queimaduras infantis: revisão integrativa da literatura. Rev Bras Queimaduras. 2014;15(4):267-73. 4. Silva RV, Rita CMS, Novaes MRCG. Fatores de risco e métodos de prevenção de queimaduras em idosos. Rev Bras Cir Plást. 2015;30(3):461-7. 5. Nestor A, Turra K. Perfil epidemiológico dos pacientes internados vítimas de queimaduras por agentes inflamáveis. Rev Bras Queimaduras. 2014;13(1):44-50. 6. Strassle PD, Williams FN, Weber DJ, Sickbert-Bennett EE, Lachiewicz AM, Napravnik S, et al. Risk factors for healthcareassociated infections in adult burn patients. Infect Control Hosp Epidemiol. 2017 Dez;38(12):1441-8. 7. Adorno Filho ET, Almeida KG, Reis GC, Costa GR, Kracik AS, Tuluche LHF, et al. Análise dos custos de pacientes internados na Santa Casa Misericórdia de Campo Grande, tratados com e sem auxílio de oxigenoterapia hiperbárica. Rer Bras Cir Plást. 2014;29(4):562-6. 8. Pereira Júnior S, Ely JB, Sakae TM, Nolla A, Mendes FD. Estudo de pacientes vítimas de queimaduras internados no Hospital Nossa Senhora Da Conceição em Tubarão – SC. Arq Catarin Med. 2007;36(2):22-7. 9. Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, et al. Burn wound healing and treatment: review and advancements. Crit Care. 2015 Jun;19(1):243. 10. Smolle C, Cambiaso-Daniel J, Forbes AA, Wurzer P, Hundeshagen G, Branski LK. Recent trends in burn epidemiology worldwide: a systematic review. Burns. 2017;43(2):249-57. 11. Cruz BF, Cordovil PBL, Batista KNM. Perfil epidemiológico de pacientes que sofreram queimaduras no Brasil: revisão de literatura. Rev Bras Queimaduras. 2012;11(4):246-50. 12. Favassa MT, Vietta GG, Nazário NO. Tendência temporal de internação por queimadura no Sul do Brasil. Rev Bras Queimaduras. 2017 Set/Dez;16(3):163-8. 13. Gervasi LC, Tibola J, Scheneider IJC. Tendência de morbidade hospitalar por queimaduras em Santa Catarina. Rev Bras Queimaduras. 2014;13(1):31-7. 14. Gragnani A, Ferreira LM. Pesquisa em queimadura. Rev Bras Queimaduras. 2009;8(3):91-6. 15. Gimenes GA, Alferes FCBA, Dorsa PP, Barros ACP, Gonella HA. Estudo epidemiológico de pacientes internados no Centro de Tratamento de Queimados do Conjunto Hospitalar de Sorocaba. Rev Bras Queimaduras. 2009;8(1):14-7. 16. Ministério da Saúde (BR). Departamento de Informática do SUS (DATASUS). SIHSUS [Internet]. Brasília (DF): DATASUS; 2008; [acesso em 2018 Set 17]. Disponível em: http://datasus.saude.gov. br/sistemas-eaplicativos/hospitalares/sihsus
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17. Ministério da Saúde (BR). Departamento de Informática do SUS (DATASUS). Tecnologia da Informação a serviço do SUS. TABNET (Informações em Saúde) - SIHSUS [Internet]. Brasília (DF): DATASUS; 2016; [acesso em 2018 Set 17]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/ cnv/niuf.def 18. Hernández CMC, Núnez VP, Suárez FAP, Banqueris RF, Gil SRL, Machado AAB. Mortalidade por queimaduras em pacientes hospitalizados em Manzanillo-Cuba em 2015-2017. Rev Bras Queimaduras. 2018;17(2):76-80. 19. Santos JV, Souza J, Amarante J, Freitas A. Burden of burns in Brazil from 2000 to 2014: a Nationwide Hospital-Based Study. World J Surg. 2017 Ago;41(8):2006-12. 20. Tanttula K, Haikonen K, Vuola J. Hospitalized burns in Finland: 36305 casos from 1980- 2010. Burns. 2018 Mai;44(3):651-7. 21. Theodorou P, Xu W, Weinand C, Perbix W, Maegele M, Lefering R, et al. Incidence and treatment of burns: a twenty-year experience from a single center in Germany. Burns. 2013;39 49-54. 22. Lacerda LA, Carneiro AC, Oliveira AF Gragnani A, Ferreira LM. Estudo epidemiológico da Unidade de Tratamento de Queimaduras da Universidade Federal de São Paulo. Rev Bras Queimaduras. 2010;9(3):82-8. 23. Santos JV, Viana V, Oliveira A, Ramalho A, Sousa-Teixeira J, Duke J, et al. Hospitalisations with burns in children younger than five years in Portugal, 2011-2015. Burns. 2019 Ago;45(5):1223-30. 24. Cox SG, Burahee A, Albertyn R, Makahabane J, Rode H. Parent knowledge on pediatric burn prevention related to the home environment. Burns. 2016 Dez;42(8):1854-60. 25. Serra MC, Queiroz ME, Silva VP, Bufada M, Araújo N, Macieira L, et al. Perfil das queimaduras em adolescentes. Rev Bras Queimaduras. 2012;11(1):20-2. 26. Abu-Sittah GS, Chahine FM, Janom H. Manegement of burns in the elderly. Ann Burns Fire Disasters. 2016 Dez;29(4):249-5. 27. Giuli AE, Itakussu EY, Valenciano PJ, Fujisawa DS, Trelha CS. Caracterização de idosos vítimas de queimaduras internados em um centro de tratamento de queimados. Rev Bras Queimaduras. 2015;14(4):253-6. 28. Pan R, Silva MTR, Fidelis TLN, Vilela LS, Silveira-Monteiro CA, Nascimento LC. Conhecimento de profissionais de saúde acerca do atendimento inicial intra-hospitalar ao paciente vítima de queimaduras. Rev Gaúcha Enferm. 2018 Set;39:2017-79. 29. Tomimatsu MFAI, Andrade SM, Soares DA, Mathias TAF, Sapata MPM, Soares DFPP, et al. Qualidade da informação sobre causas externas no Sistema de Informações Hospitalares. Rev Saúde Pública. 2009;43(3):413-20.
Felipe Oliveira Duarte Avenida Professor Othon Gama D’Eça 900, Centro, Florianópolis, Santa Catarina, Brazil. Zip Code: 88015-240 E-mail: duarte.cirurgiaplastica@gmail.com
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Ideas and Innovations Chassaignac bursa flap: protection and support in reduction mammoplasties with implant Retalho bolsa de Chassaignac: proteção e sustentação nas mamoplastias redutoras com implante CESAR KELLY VILLAFUERTE VELEZ 1* LUANA KELLY MARQUES VILLAFUERTE 2 PALOMA RESTREPO VILLAFUERTE 3
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ABSTRACT
Introduction: Macromastias with fatty substitution, great flaccidity, and severe ptosis, constitute a specific group of difficult treatment, many without long-term results. The authors present the technique called Chassaignac bursa flap, indicated for selected cases. Methods: When applied to 41 patients (2013-2019), the tactic allowed the creation of two independent spaces, one for the removal of the mammary parenchyma and the other isolated, pre-muscular, a flap composed by pedicles semicircular, superior, medial and lateral, dome-shaped, which protect the implant in the Chassaignac retromammary area. Results: The patients evolved without complications, with the maintenance of the upper pole, a symmetrical harmonic redistribution of the breasts, without recurrent ptosis. Conclusion: The bag flap proved feasible, allowing for safety during the operation and a lasting implant support. Keywords: Mammoplasty; Open reduction; Breast implant; Hypertrophy; Surgical flaps.
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Institution: Hospital Municipal da Mulher, Feira de Santana, BA, Brazil. Article received: June 5, 2020. Article accepted: August 8, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0058
RESUMO
Introdução: As macromastias com substituição gordurosa, grande flacidez e ptose severa, constituem um grupo específico de difícil tratamento, muitos deles sem resultados perduráveis a longo prazo. Os autores apresentam a técnica denominada retalho bolsa de Chassaignac, indicada para casos selecionados. Métodos: Aplicada em 41 pacientes (2013-2019), a tática permite a criação de 2 espaços independentes, um para a retirada do parênquima mamário e outro isolado, pré-muscular, que consiste em um retalho composto, de pedículo semicircular, superior, medial e lateral, em forma de cúpula, que protege o implante na área retromamária de Chassaignac. Resultados: As pacientes evoluíram sem complicações, com manutenção do polo superior, uma redistribuição harmônica simétrica das mamas, sem ptoses recidivantes. Conclusão: O retalho em bolsa se mostrou factível, permitindo segurança no transoperatório e sustentação perdurável do implante. Descritores: Mamoplastia; Redução aberta; Implante mamário; Hipertrofia; Retalhos cirúrgicos.
Hospital Municipal da Mulher, Department of Plastic Surgery, Feira de Santana, BA, Brazil. University of Salvador, Faculty of Medicine, Salvador, BA, Brazil. 3 Universidad Abierta Interamericana, Faculty of Medicine, Rosario, Santa Fe, Argentina. 1 2
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INTRODUCTION After the publication of Sánchez et al., in 20081, about reduction mammoplasty with a silicone implant, a large contingent of patients began to request it. Some specialists incorporated it into their surgical arsenal, for cases specially selected within the universe of hypertrophies breast cancer. On the other hand, most publications that combine mammoplasties and implants have focused on treating hypomastias and breast ptosis. This one is a topic in which many authors have described techniques, with different tactics, for locating and protecting the implant, as Soares et al. , in 20112, in a double plane; Sánchez et al., 20081, Mansur and Bozola, in 20093, with an inferior pedicle; Gomes, in 20084, with an upper pedicle; Graf et al., in 20035, with a subfascial implant, among others; however, there are few publications regarding combined treatment in macromastias. The challenges and difficulties of this surgery are similar to the ptosis treatment and begin in the intraoperative period. In most suprapeptorial techniques, a single surgical space is shared by implantation, parenchyma removal and ascending flaps of the areolomamilar complex (AMC) , which increases the frequency of immediate complications, such as hematoma, infection, dehiscence or extrusion and late complications, such as asymmetries and ptosis due to sliding of the implant (bottoming out) or due to tissue fall (waterfall). The retromuscular techniques provide support for the prosthesis; however, in the late evolution, they can also present the animation deformity and the double bubble7, expected consequences for structures of different embryological origins. Following the anatomical description of the retromammary space, the posterior breast capsule, and the Giraldes suspensory ligament7,8, we idealized the possibility of surgical construction of a flap composed as a lipo-connective-glandular dome, with a semicircular pedicle (upper, medial and lateral), to protect the loose retromammary areolar space, isolating the implant site from the rest of the surgical procedures. The tactic aims to protect the prosthesis during surgery, to reduce risks in the postoperative period and to provide long-lasting support to the implant and the neo-breast itself, due to the scar adherence in the supradome cleavage plane, avoiding recurrent ptosis, erasure of the upper pole and asymmetries; anatomical aspects illustrated are shown in Figure 1, and we called it the Chassaignac or Kangaroo (CBF) bag flap.
OBJECTIVE The authors describe the surgical preparation of a bag flap, with the breast base tissues, in a preRev. Bras. Cir. Plást. 2020;35(3):329-333
A
B
Figure 1. Sagittal drawings: A. Posterior and ligament anatomy of the breast; B. Kangaroo bag flap: a. Chassaignac Bursa; b. Giraldes capsule; c. Cooper’s ligaments; d. Inframammary groove; e. Ribs; f. Pre-pectoral fascia; g. Musculature; h. Breast resection area; i. Implant in the Chassaignac bag space, cbf., af .: AMC flap. AMC: Areolomamilar Complex
muscular and pre-fascial way, in the dome form, which protects the implant in the Chassaignac space, isolating and supporting it in reduction mammoplasties. It is applied in specifically selected cases.
METHODS In the period from 2013 to 2019, 41 patients underwent reduction mammoplasty and CBF. They were between 18 and 65 years old, 100% primary, 90% under epidural anesthesia, 10% general, and all were hospitalized for 24 hours. They were followed-up between 6 months to 1 year. The analysis of patient satisfaction was performed every 6 months, in a simple questionnaire form, with three objective questions: very satisfied, satisfied, and not very satisfied. Clinical analyzes and conclusions were carried out, recorded in periodic reviews, with physical examination and photographs, evaluated by a doctor and nurse. The proposed study is authorized by the Institutional Committee of Hospital da Mulher (0072020) and followed the principles of the Declaration of Helsinki. The authors have no conflicts of interest. Selection Breast hypertrophies with great liposubstitution, extreme flaccidity, severe ptosis, or total absence of the upper pole. Round implants, cohesive silicone, high profile, textured, microtextured, or polyurethane, with low volume (175 to 225cc), are used. Marking Patient in an orthostatic position, in the following areas (Figure 2): 330
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Figure 2. Marking: A. Pitanguy; B. Implant area; C. Bilateral marking.
1. At the implantation site, cutaneous demarcation of the detachment area, with the help of a circular plate 12 cm in diameter, placed 2 cm from the sternal midline and 1 cm above the breast crease; 2. In the area of breast resection, using the Pitanguy technique; 3. In the areas of liposuction, lateral, and preaxillary, if necessary (S/N). Surgical technique It is infiltrated subcutaneously under demarcation with Villafuerte-Vélez et al. (2017) 9: 250cc saline, one adrenaline ampoule, one dexamethasone acetate ampoule (8mgs). Incision of the epidermal design and lateral and axillary liposuction (S/N). Decortication of the periareolar triangle and the lower medial triangle; in this and slightly above the inframammary fold, a 5cm incision was made for retromammary access, detaching the Chassaignac space, in the previously demarcated extension. A wet compress is introduced into the pocket, continuing with breast resection, initiated by the suprafascial side. In the medial area, a protective dome of the implant pocket is advanced, constituted by the posterior mammary capsule, free in its upper and internal area. The retroareolar and upper tissue are dried out in block and keel. It is also possible to remove all breast tissue, from upper to lower, preserving and sculpting the protective bag extended by the compress. Then, the superomedial pedicle flap, for areolar transposition, the retromammary compress is removed, and the silicone implant is inserted (Figure 3), closing the entrance via with 3-0 nylon. Finally, the breast is assembled with pillar sutures (S/N), subcutaneous tissue and AMC repositioning; 2-0, 3-0, 4-0, 5-0 mononylon yarns, and 4-0 polyglycolic acid are used. The surgical sequence is shown in Figure 4. The drain is placed through the side incision (nasogastric tube 16), the dressing with neomycin ointment, compresses, and surgical bra. The drain is removed and discharged after 24 hours, weekly review for one month, followed by monthly.
RESULTS Of the 41 patients (2013-2019), we obtained: 1 case of small medial skin dehiscence (2.43%); 1 case 331
Figure 3. Kangaroo bag flap, implant in the Chassaignac space, prepectoral.
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D
E
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Figure 4. Surgical sequence: A. Decortication, detachment of the retromammary area of the implant; B. Kangaroo bag; C. Excision of the parenchyma; D. Placed implant and suture; E. AMC transposition flap; F. Neo-breast finished.
of hypertrophic scarring (2.43%); 2 cases of mild asymmetry of the AMC (4.87%); no case of hematoma, necrosis, infection, extrusion or contracture; 1 case of mild unilateral ptosis (2.43%); and there was no complaint of paresthesia. The aesthetic result obtained an excellent degree of satisfaction in 97.56% of the cases, and the average breast removal was 1.640g (Figures 5, 6, and 7).
DISCUSSION The paradox of removing large breast volumes and, simultaneously, placing implants, has its specific application in challenging pathologies, since, for them, the medium- and long-term results, with other techniques, could be susceptible to complications and dissatisfaction1. After continuous clinical observation of the breast position in the profile view, we conclude that the mammary base and its inframammary fold are always in constant position; the groove is fixed, at the level of the 7th rib and acts as a pivot, it does Rev. Bras. Cir. Plást. 2020;35(3):329-333
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Figure 5. Pre and postoperative 1 year. CBF, 180cc textured round implant, removal of 1,194g.
Figure 7. Pre and postoperative 1 year. CBF, 205cc polyurethane round implant, 1.546g removed.
Figure 8. Key point: inferior groove and breast base, always constant in the different degrees of hypertrophy (footprint).
Figure 6. Pre and postoperative 1 year. CBF, 200cc textured round implant, removal of 1,772g.
not descend, even in large hypertrophies or ptosis, allowing the breast base to tilt, but without overpassing the breast adhesion (Figure 8), an anatomical fact that is also noticeable in breasts with lower thoracic implantation, which we believe to be of great value in the proposed surgical resource. The publication by Sampaio et al., in 201310, rescues us the importance of retromammary anatomy, Rev. Bras. Cir. Plรกst. 2020;35(3):329-333
proposing basilar removal (Giraldes breast capsule) and Chassaignac bursa, for greater adherence in breast reconstructions with a submuscular prosthesis. However, the authors of this article propose a new approach, taking advantage of these anatomical structures to make a pre-muscular pouch that protects the implant and functions as a barrier and support capsule, preventing inferior or lateral slips. This principle is similar to that published by Faria et al., in 201711, in the Lockpocket technique for mammoplasty/ mastopexy with subfascial implants, an excellent proposal in ptosis with smaller hypertrophies, but limited in large hypertrophies, where the pectoral fascia is atrophic, a clinical observation made after more than a decade of the gigantomastia treatment program12. Besides, the velcro healing effect of the remaining breast tissues is added, in the dissection plane above the kangaroo bag, allowing its firm and adherent redistribution, also avoiding recurrent breast ptosis. The use of silicone presented here is not for increasing but recommended to maintain the upper pole when smaller volumes of prostheses are indicated, fulfilling the main objective of the breast reduction. 332
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CONCLUSION The basis of the Chassaignac bursa flap (CBF) has its anatomical key in the construction of a pedicled dome structure, as a protective barrier, which offers security during the operation and support of the implant and the neo-breast in the long term, being practiced in cases selected, which combine the reduction mammoplasty and the implant.
COLLABORATIONS CKVV
Writing - Original Draft Preparation
LKMV
Writing - Review & Editing
PRV
Writing - Review & Editing
REFERENCES 1. Sanchéz J, Carvalho AC, Erazo P. Mastopexia com prótese: técnica em “D” espelhado. Rev Bras Cir Plást. 2008;23(3):200-6. 2. Soares AB, Franco FF, Rosim ET, Renó BA, Hachmann JOPA, Guidi MC, et al. Mastopexia com uso de implantes associados a retalho de músculo peitoral maior: técnica utilizada na Disciplina de Cirurgia Plástica da Unicamp. Rev Bras Cir Plást. 2011 Dez;26(4):659-63. DOI: http://dx.doi.org/10.1590/S198351752011000400021 3. Mansur JRB, Bozola AR. Mastopexia e aumento das mamas com proteção e suporte inferior da prótese com retalho de pedículo inferior. Rev Bras Cir Plást. 2009;24(3):304-9.
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4. Gomes RS. Mastopexia com retalho de pedículo superior e implante de silicone. Rev Bras Cir Plást. 2008;23(4):241-7. 5. Graf RM, Bernardes A, Rippel R, Araujo LR, Damasio RC, Auersvald A. Subfascial breast implant: a new procedure. Plast Reconstr Surg. 2003 Fev;111(2):904-8. DOI: http://dx.doi. org/10.1097/01.PRS.0000041601.59651.15 6. Khavanin N, Jordan SW, Rambachan A, Kim JY. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg. 2014 Nov;134(5):922-31. DOI: http://dx.doi.org/10.1097/ PRS.0000000000000582 7. Bono JEP. Mamoplastia ligamentar. Rev Bras Cir Plást. 2008;23(3):192-9. 8. Procópio LD, Silva DDP, Rosique R. Implante submuscular em duplo bolso para mastopexias de aumento. Rev Bras Cir Plást. 2019;34(2):187-95. 9. Villafuerte-Vélez CK, Castro-Cabrera AC, Restrepo-Villafuerte C. Corticoterapia profiláctica transquirúrgica de la hiperplasia cicatricial. Estudio clínico-estadístico prospectivo. Cir Plást Iberolatinoam [Internet]. 2017 Mar; [citado 2020 Abr 25]; 43(1):339. Disponível em: http://scielo.isciii.es/scielo.php?script=sci_ arttext&pid=S0376-78922017000100005&Ing=es 10. Sampaio MM, Fraga M, Ferreira AP, Barros AC. Structured mammaplasty: a new approach for obtaining breast symmetry. Plast Reconstr Surg. 2013 Fev;131(2):300e-2e. DOI: http://dx.doi. org/10.1097/PRS.0b013e318278d7d9 11. Faria CADC, Moura LG, Almeida CM, Galdino MCA, Santos GC, Pedroso DB, et al. Mammoplasty/mastopexy using implants: the Lockpocket technique. Rev Bras Cir Plást. 2017 Jan;32(2):218-24. 12. Villafuerte-Vélez CK. PROTG-Programa social de tratamiento de la gigantomastia, Bahía-Brasil. Cir Plást Iberolatinoam [Internet]. 2018 Set; [citado 2020 Abr 25]; 44(3):341-6. Disponível em: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S037678922018000300020&lng=es
Cesar Kelly Villafuerte Velez Avenida João Durval, 3665, Multiplace 305, Feira de Santana, BA, Brazil. Zip Code: 44051-900 E-mail: kelly@gd.com.br
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Review Article Lymph node transplantation in the management of post-mastectomy lymphedema: a systematic review with meta-analysis Transplante linfonodal no manejo do linfedema pós-mastectomia: revisão sistemática com metanálise RAFAEL VILELA EIRAS RIBEIRO 1,2* LUCIO HENRIQUE ROMÃO DOS SANTOS-JÚNIOR 3 IRENE DAHER BARRA 1,4
Institution: Private Clinic, Juiz de Fora, MG, Brazil. Article received: September 30, 2019. Article accepted: December 16, 2019. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0059
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ABSTRACT
This study aimed to analyze, through a systematic literature review with meta-analysis, the success rates of the use of autologous lymph node transplantation for the management of upper limb lymphedema in mastectomized patients, regarding the reduction of excessive volume in the affected limb. The most relevant studies originally published and indexed in any language until August 2019 were analyzed, in the US National Library of Medicine, Cochrane Central Register of Controlled Trials, Web of Science, and Scientific Electronic Library Online databases. The sample consisted of 10 publications that met the established inclusion and exclusion criteria, including 194 patients with 50.0 years average age, being followed up for 31.7 months average. Most patients had the right upper limb affected by lymphedema (58.1%), with symptoms that started more than a year before lymph node transplant surgery (86.4%). Only four patients (2.6%) did not undergo lymphadenectomy during the treatment of breast cancer. Lymph node transplantation provided an average reduction of 52.18% in the excessive volume presented by patients in the limb due to lymphedema. Most of the patients surveyed had a volume reduction higher than 50%. It is concluded that autologous lymph node transplantation is a good option for the management of lymphedema related to breast cancer, providing a considerable reduction in the excessive volume of the affected limb. Keywords: Mastectomy; Autologous transplantation; Lymph nodes; Lymphedema related to breast cancer; Meta-analysis
Sociedade Brasileira de Cirurgia Plástica, São Paulo, SP, Brazil. Private Clinic, Juiz de Fora, MG, Brazil. 3 Faculty of Medicine of ABC, São Paulo, SP, Brazil. 4 Hospital Souza Aguiar, Rio de Janeiro, RJ, Brazil. 1 2
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RESUMO
Este estudo teve o objetivo de analisar, por meio de uma revisão sistemática da literatura com metanálise, os índices de sucesso do uso do transplante autólogo de linfonodos para o manejo do linfedema de membros superiores em pacientes mastectomizadas, quanto à redução do volume excessivo no membro acometido. Foram analisados os mais relevantes estudos publicados originalmente em qualquer idioma até agosto de 2019, indexados às bases de dados US National Library of Medicine, Cochrane Central Register of Controlled Trials, Web of Science e Scientific Electronic Library Online. A amostra foi composta por 10 publicações que se adequaram aos critérios de inclusão e exclusão estabelecidos, incluindo 194 pacientes, as quais apresentaram idade média de 50,0 anos, sendo acompanhadas por, em média, 31,7 meses. A maioria das pacientes apresentou o membro superior direito acometido pelo linfedema (58,1%), iniciando os sintomas há mais de um ano prévio à cirurgia de transplante de linfonodos (86,4%). Apenas quatro pacientes (2,6%) não foram submetidas à linfadenectomia durante o tratamento do câncer de mama. O transplante de linfonodos foi capaz de prover uma redução média de 52,18% no volume excessivo apresentado pelas pacientes no membro em decorrência do linfedema, sendo que, a maior parte das pacientes pesquisadas apresentaram redução de volume maior do que 50%. Conclui-se que o transplante autólogo de linfonodos se apresenta como uma boa opção para o manejo do linfedema relacionado ao câncer de mama, proporcionando considerável redução no volume excessivo do membro acometido. Descritores: Mastectomia; Transplante autólogo; Linfonodos; Linfedema relacionado a câncer de mama; Metanálise.
INTRODUCTION Breast cancer is one of the leading public health problems in Brazil1, and, very often, it requires the surgical procedure as one of the methods for its treatment2. However, one of the most frequent complications in the postoperative period of breast cancer is lymphedema, a chronic condition caused by the accumulation of fluid rich in proteins in the interstitial space3-6, whose development can occur immediately after surgery, in rare cases, or years after the treatment6-10. The main risk factors for the development of lymphedema after mastectomy are lymphadenectomy and/or axillary radiation therapy, obesity, and invasive procedures performed on the limb homolateral to breast cancer11,12. Scientific evidence has shown that mastectomy performance associated with immediate breast reconstruction can be a safe and effective method to reduce the risk of developing lymphedema13. However, the occurrence of lymphedema related to breast cancer is still a reality in the routine medical clinic13-25. To solve this occurrence, the technique of Rev. Bras. Cir. Plást. 2020;35(3):334-339
autologous transplantation of vascularized lymph nodes has been used, aiming to restore the function of the lymphatic system and interrupt the vicious cycle that causes its destruction and the progression of lymphedema14-19,21,23-26. However, the literature is still scarce about research that shows the success rates of using this technique in patients who developed lymphedema after mastectomy.
OBJECTIVE This study aimed to analyze, through a systematic literature review with meta-analysis, the success rates of the use of autologous lymph node transplantation for the management of upper limb lymphedema in mastectomized patients, regarding the reduction of excessive volume in the limb affected.
METHODS A methodology based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)22 was used for systematic reviews. The most 335
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relevant studies originally published and indexed in any language until August 2019 were analyzed in the US National Library of Medicine (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scientific Electronic Library Online databases ( SciELO). To select quality scientific evidence studies, publications were sought for meta-analysis and randomized controlled trials (RCT) in humans without restriction on publication year. The following keywords were used, in different combinations: “lymph node transfer”, “lymph node transplantation”, “lymph node graft”, “lymphedema”, “mastectomy”, “breast cancer surgery”, “postmastectomy” and “cancer.” The inclusion and exclusion criteria were applied, according to Chart 1. Chart 1. Inclusion and exclusion criteria for publications. Inclusion criteria • RCT Design
• Meta-analysis • Case series
Sample
• Human
Intervention
• Autologous lymph node transplantation in mastectomized patients who developed lymphedema
Publication period
• Not specified
Language
• Not defined
Exclusion criteria
Design
• Methodology poorly explained and/or incomprehensible • Case report • Literature review
Publication form
RESULTS Searches in different databases resulted in 2,490 publications, which were reduced to 57 after the first stage of analysis (title and summary), 26 after the second stage (removal of duplicates) and, finally, 10 publications after the third stage (analysis of the full content of the articles), which fit the established inclusion and exclusion criteria. Regarding the ten studies included in this meta-analysis sample, eight are specifically related to the results of autologous lymph node transplantation for the management of post-mastectomy upper limb lymphedema14,15,19-21,23-26, while one compared these findings with the findings of patients undergoing only physical therapy17. The publications included in this sample included 194 patients, who had 50.0 years average age, being followed up for 31.7 months average (Table 1). As shown in Table 2, most patients presented the right upper limb affected by lymphedema (58.1%), beginning the symptoms more than a year before the lymph node transplantation surgery (86.4%). Only four patients (2.6%) did not undergo lymphadenectomy during the treatment of breast cancer.
• Only abstract
RCT: Randomized Controlled Trials.
At first, the selection of publications was made by analyzing the title, and summary of studies obtained as search results (step 1), followed by the elimination of duplicate results obtained in the different databases searched (step 2). Subsequently, the full version of the publications was read, and the inclusion and exclusion criteria were applied (step 3), aiming to establish the final selection of publications to be included in this research sample, according to the method used in Ribeiro’s study in 201913. In the publications that were part of the sample of this study, data were collected regarding sample size, mean age and patient follow-up, limb affected by lymphedema, previous period of presentation of symptoms, whether or not lymphadenectomy was performed during cancer treatment, in addition to the reduced volume percentage in the limbs affected by 336
lymphedema. Studies like the one by Gharb et al., in 201118, were excluded because, despite having a similar objective to this research, the percentages of reduction in circumference, perimeter, or volume in the limb affected by lymphedema in patients were not defined. The collected data were submitted to a metaanalysis to formulate the results of this research, using the SPSS for Windows 15 software (IBM SPSS Software, New York, USA)
Table 1. General characteristics of the sample. Study Becker et al.26 Becker et al.
14
Lin et al.20
Sample (n)
Average age (years)
Average followup (months)
24
58.7
99
6
60.5
21
13
50.7
56.3
Saaristo et al.25
9
50
6
Cheng et al.15
10
53.3
39.1
10
54.6
6
Nicoli et al.24 Dionyssiou et al.
18
47.7
18
Gratzon et al.19
50
12
-
17
Liu et al.
30
60
22.1
Montag et al.23
24
52.8
18
Total
194
-
-
-
50.0
31.7
21
Average
Legend: n = number; - = data not specified in the publication.
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In general, lymph node transplantation was able to provide an average reduction of 52.18% in the excessive volume presented by patients in the limb as a result of lymphedema; in fact, most of the patients surveyed had a volume reduction higher than 50% (Table 3).
DISCUSSION One of the factors that have motivated new research involving women undergoing breast cancer treatment is the occurrence of lymphedema in patients who undergo mastectomy 4-6,11,27,28, not yet being established all the etiological factors for such occurrence. Anyway, it is recognized that axillary lymph node dissection is a risk factor for the development of lymphedema after mastectomy6,11-13,29, regardless of the surgical technique (simple mastectomy associated with axillary lymph node dissection or modified
radical mastectomy) 29. In this study, it was found that the majority of patients included in the sample underwent lymphadenectomy (97.4%), which may have contributed to the development of upper limb lymphedema after treatment for breast cancer. Therefore, even though many experts have sought risk and preventive factors, the occurrence of lymphedema after a mastectomy is still a reality in clinical practice13-21,23-26, causing a loss in patients’ quality of life who develop it. Thus, lymph node transplantation has been used as one of the forms of treatment, improving lymphatic drainage from an affected limb in patients with damaged lymph nodes or hypoplastic lymphatic vessels16. Therefore, this study aimed to identify the rates of excessive volume reduction caused by lymphedema in the upper limbs of mastectomized patients submitted to autologous lymph node transplantation.
Table 2. Characteristics related to lymphedema presented by the patients. Affected limb
Study
Symptoms
Lymphadenectomy
Right
Left
≤ 1 year
> 1 year
Yes
No
6
18
24
0
6
0
9
11
2
Becker et al.
14
10
Becker et al.14
3
3
Lin et al.20
9
4
4
Saaristo et al.
-
-
2
7
9
0
Cheng et al.15
-
-
0
10
-
-
Nicoli et al.24
-
-
-
-
-
-
26
25
Dionyssiou et al.
17
Gratzon et al.19 Liu et al.21 Montag et al.
23
Total %
-
-
-
-
-
-
27
23
-
-
48
2
-
-
0
30
30
0 0
15
9
3
21
24
68
49
15
95
152
4
58.1%
41.9%
13.6%
86.4%
97.4%
2.6%
Legend: ≤ = less than or equal to; > = greater than; % = percentage; - = data not specified in the publication.
Table 3. General characteristics of patients undergoing mastectomy associated with immediate reconstruction. Reduction of abnormal limb volume
Study
Total
> 50%
≤ 50%
No reduction
Average (%)
Becker et al.
10
6
6
2
-
Becker et al.14
2
3
0
1
-
Lin et al.20
0
9
3
1
50.55
Saaristo et al.25
0
3
4
2
-
26
Cheng et al.
0
4
6
0
40.4
Nicoli et al.24
-
-
-
-
91.5
Dionyssiou et al.17
0
13
5
0
57
15
Gratzon et al.
-
-
-
-
58.68
Liu et al.21
0
15
6
9
47.06
Montag et al.23
-
-
-
-
20.1
19
Total %
12
53
30
15
-
10.9%
48.2%
27.3%
13.6%
52.18
Legend: ≤ = less than or equal to; > = greater than; % = percentage; - = data not specified in the publication.
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It is recognized that the association of mastectomy with immediate breast reconstruction can prevent the occurrence of post-mastectomy lymphedema13,27,30,31. In this context, a study was found that evaluated the performance of lymph node transplantation simultaneously with breast reconstruction, concluding that this is a useful technique. It caused lymphatic recovery in 83.3% of the patients, without the need for additional posterior surgery, since the procedure had been performed in an associated manner25. Ly m p h n o d e t r a n s p l a n t a t i o n h a s b e e n emphasized as a considerably effective method, especially when analyzing a study that compares patients who are treated only with physiotherapy and medications (reaching rates of 18% reduction in the volume of the affected limb), with patients undergoing the surgical procedure, of lymph node transplantation, which presented around 57%17. In general, the findings of this study corroborate the referred research, since it showed that the average percentage of reduction in volume was 52.18% and that most patients had more than half of the excessive circumference reduced after the transplant lymph node. Such findings encourage the indication of the technique since this represents a considerable reduction in the arms discrepancy presented by women with lymphedema and relief in the physical, social, and psychological symptoms of these patients. It is important to note that, in the case of autologous transplants, lymph node donor sites may be compromised in the event of inadequate collection procedures, which could further aggravate patients’ situations for whom solutions are sought. In the study by Demiri et al., in 201816, 1.6% (n = 3/189) of the patients developed lymphedema in the lymphatic flap’s lower limb donor. In the study by Viitanen et al., in 201232, although none of the patients developed lymphedema at the donor site, the first post-surgical lymphoscintigrams indicated the need to reduce surgical trauma during the collection of the lymphatic flap. Thus, the importance of a detailed study about each case is mentioned here so that the decision making about the procedures to be adopted is duly based, in particular, on scientific evidence. It is essential to mention that the technical and scientific evolution makes lymph node transplantation promising, especially when considering its association with other techniques. As an example, it is mentioned that the research presented the highest average percentage of excessive volume reduction in the limb affected by lymphedema in this study by Nicoli et al., in 201524 (91.5%), in which lymph node transplantation was associated with laser liposuction, enhancing the results and causing a more satisfactory immediate prognosis. 338
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Finally, the need to conduct further research with the focus on the success rates of lymph node transplants for the management of lymphedema related to breast cancer is emphasized, especially with standardized methodologies and testing the associations with methods and technologies that can favor the results and improve the patients’ quality of life.
CONCLUSION Considering the systematic review and metaanalysis carried out, it is concluded that autologous lymph node transplantation is a good option for the management of lymphedema related to breast cancer, providing a considerable reduction (52.18%) in the excessive volume of the affected limb.
COLLABORATIONS RVER
Analysis and/or data interpretation, Conception and design study, Data Curation, Final manuscript approval, Methodology, Realization of operations and/ or trials, Supervision, Writing - Original Draft Preparation
LHRSJ
Conception and design study, Writing Review & Editing
IDB
Final manuscript approval, Supervision
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Lymph node transplantation in the management of post-mastectomy lymphedema 9. Miller CL, Colwell AS, Horick N, Skolny MN, Jammallo LS, O’Toole JA, et al. Immediate implant reconstruction is associated with a reduced risk of lymphedema compared to mastectomy alone: a prospective cohort study. Ann Surg. 2016 Feb;263(2):399-405. 10. Pandey RA, Shrestha S. Prevalence of arm lymphedema among patients with breast cancer surgery. JCMS Nepal. 2016;12(3):111-7. 11. Bevilacqua JL, Kattan MW, Changhong Y, Koifman S, Mattos IE, Koifman RJ, et al. Nomograms for predicting the risk of arm lymphedema after axillary dissection in breast cancer. Ann Surg Oncol. 2012 Ago;19(8):2580-9. 12. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013 Mai;14(6):500-15. 13. Ribeiro RVE. Prevalência de linfedema após mastectomia em portadoras de câncer de mama: uma revisão sistemática acerca da influência da reconstrução imediata. Rev Bras Cir Plást. 2019;34(1):113-9. 14. Becker C, Pham DN, Assouad J, Badia A, Foucault C, Riquet M. Postmastectomy neuropathic pain: results of microsurgical lymph nodes transplantation. Breast. 2008 Abr;17(5):472-6. 15. Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013 Jun;131(6):1286-98. 16. Demiri E, Dionyssiou D, Tsimponis A, Goula OC, Miotalothridis P, Pavlidis L, et al. Donor-site lymphedema following lymph node transfer for breast cancer-related lymphedema: a systematic review of the literature. Lymphat Res Biol. 2018 Fev;16(1):2-8. 17. Dionyssiou D, Demiri E, Tsimponis A, Sarafis A, Mpalaris V, Tatsidou G, et al. A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer. Breast Cancer Res Treat. 2016 Fev;156(1):73-9. 18. Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu ES, Chung KP, Chen HC. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg. 2011 Dez;67(6):589-93. 19. Gratzon A, Schultz J, Secrest K, Lee K, Feiner J, Klein RD. Clinical and psychosocial outcomes of vascularized lymph node transfer for the treatment of upper extremity lymphedema after breast cancer therapy. Ann Surg Oncol. 2017 Jun;24(6):1475-81. 20. Lin CH, Ali R, Chen SC, Wallace C, Chang YC, Chen HC, t al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009 Abr;123(4):1265-75.
*Corresponding author:
21. Liu HL, Pang SY, Lee CC, Wong MM, Chung HP, Chan YW. Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: clinical results, lymphoscintigraphy findings, and proposed mechanism. J Plast Reconstr Aesthet Surg. 2018 Jul;71(7):1033-40. 22. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009 Jul;6(7):e1000097. 23. Montag E, Okada AY, Arruda EGP, Fonseca AS, Bromley M, Munhoz AM, et al. Influence of vascularized lymph node transfer (VLNT) flap positioning on the response to breast cancer-related lymphedema treatment. Rev Col Bras Cir. 2019 Mai;46(2):e2156. 24. Nicoli F, Constantinides J, Ciudad P, Sapountzis S, Kiranantawat K, Lazzeri D, et al. Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema. Lasers Med Sci. 2015 Mar;30(4):1377-85. 25. Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Ann Surg. 2012 Mar;255(3):468-73. 26. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long- term results following microsurgical lymph node transplantation. Ann Surg. 2006 Abr;243(3):313-5. 27. Avraham T, Daluvoy SV, Riedel ER, Cordeiro PG, Van Zee KJ, Mehrara BJ. Tissue expander breast reconstruction is not associated with an increased risk of lymphedema. Ann Surg Oncol. 2010;17(11):2926-32. 28. Crosby MA, Card A, Liu J, Lindstrom WA, Chang DW. Immediate breast reconstruction and lymphedema incidence. Plast Reconstr Surg. 2012 Mai;129(5):789e-95e. 29. Park JH, Lee WH, Chung HS. Incidence and risk factors of breast cancer lymphoedema. J Clin Nurs. 2008 Jun;17(11):1450-9. 30. Card A, Crosby MA, Liu J, Lindstrom WA, Lucci A, Chang DW. Reduced incidence of breast cancer-related lymphedema following mastectomy and breast reconstruction versus mastectomy alone. Plast Reconstr Surg. 2012 Dez;130(6):1169-78. 31. Lee KT, Mun GH, Lim SY, Pyon JK, Oh KS, Bang SI. The impact of immediate breast reconstruction on post-mastectomy lymphedema in patients undergoing modified radical mastectomy. Breast. 2013;22(1):53-7. 32. Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM. Donor-site lymphatic function after microvascular lymph node transfer. Plast Reconstr Surg. 2012;130(6):1246-53.
Rafael Vilela Eiras Ribeiro Avenida Itamar Franco, 4001/718 Leste, Centro Empresarial Monte Sinai, Bairro Dom Bosco, Juiz de Fora, MG, Brazil. Zip Code: 36033-318 E-mail: vilelaeiras@hotmail.com
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Review Article Breast asymmetry: literature review and a new proposal for clinical classification Assimetria mamária: revisão da literatura e nova proposta de classificação clínica GLADSTONE EUSTÁQUIO DE LIMA FARIA 1* DOV CHARLES GOLDENBERG 2 RICARDO FROTA BOGGIO 3
Institution: Private Clinic, São Paulo, SP, Brazil. Article received: July 24, 2019. Article accepted: February 29, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0060
■
ABSTRACT
Breast asymmetry is a prevalent diagnosis that has several surgical modalities for its treatment. The correct diagnosis, taking into account the existing classification systems, is imperative for achieving the best results. The leading and most accepted proposals for the classification and treatment of breast asymmetries were raised through the literature review. These available classifications date from the 60s and 70s and need to be updated to the current clinical context. A more simplified and reproducible classification was proposed after a comprehensive literature review, considering the most frequent asymmetries in aesthetic plastic surgery offices, with their respective treatment guides. Five groups were created: 1 - hypotrophic breasts with volume asymmetry; 2 - hypotrophy with volume and contour asymmetry; 3 normotrophic, ptotic breasts and with no desire to increase the volume; 4 - normotrophic, ptotic breasts and with a desire to increase the final volume; 5 - asymmetric and hypertrophic breasts. Based on the clinical findings, a treatment algorithm was created for each subtype of asymmetry, including in this arsenal, breast implants of different volumes, mastopexies, reduction mammoplasty, and fat grafting. It is important to emphasize that breast asymmetry is the rule and not the exception, therefore, it is a reason for patient dissatisfaction and a challenge for the plastic surgeon. Keywords: Breast; Silicone elastomers; Breast implant; Mammoplasty; Classification.
Private Clinic, São Paulo, SP, Brazil. Hospital das Clínicas, Faculty of Medicine, University of São Paulo, SP Brazil. 3 Instituto Boggio, São Paulo, SP, Brazil. 1 2
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RESUMO
A assimetria mamária é um diagnóstico prevalente com diversas modalidades cirúrgicas para seu tratamento. O correto diagnóstico, levando-se em conta os sistemas de classificação existentes é imperativo para que os melhores resultados sejam alcançados. Através de revisão da literatura foram levantadas as principais e mais aceitas propostas de classificação e tratamento das assimetrias mamárias. Estas classificações disponíveis datam da década de 60 e 70 e carecem de atualização para o contexto clínico atual. Após ampla revisão da literatura foi proposta uma classificação mais simplificada e reprodutível, levando-se em conta as assimetrias mais frequentes nos consultórios de cirurgia plástica estética, com seus respectivos guias de tratamento. Cinco grupos foram criados: 1 - mamas hipotróficas com assimetria de volume; 2 - hipotrofia com assimetria de volume e contorno; 3 - mamas normotróficas, ptóticas e sem desejo de aumento do volume; 4 - mamas normotróficas, ptóticas e com desejo de aumento do volume final; 5 - mamas assimétricas e hipertróficas. Baseado nos achados clínicos, foi criado um algoritmo de tratamento para cada subtipo de assimetria, incluindo neste arsenal, próteses mamárias de volumes diferentes, mastopexias, mamoplastia redutoras, além da lipoenxertia. Importante ressaltar que a assimetria mamária é a regra e não a exceção, entretanto, é motivo de insatisfação das pacientes e um desafio para o cirurgião plástico. Descritores: Mama; Elastômeros de silicone; Implante mamário; Mamoplastia; Classificação.
INTRODUCTION In addition to their role in the physiology of lactation, breasts are related to femininity, sensuality, and self-esteem. Variations in normality, shape, volume, or position affect women psychologically and are an essential cause of demand in plastic surgery offices1. The recognition of the importance of breast asymmetry dates from 1968 when the author describes the surgical treatment modalities2. The interest in creating a classification was growing and, in 1976, Elsahy2, proposed a morphological classification of breast asymmetries, in order to facilitate preoperative planning. Later, in 19843, Vandenbussche subdivided them as to their etiology into four types (1 - congenital, 2 - primary, 3 - secondary, and 4 - tertiary), concluding that type 2 asymmetry was the most frequent2. In 2006, another group analyzed 177 patients with breast asymmetries to propose a classification and its treatment4. These works contributed to the understanding of breast asymmetries and their treatment, but a more simplified and reproducible update to clinical practice, added to the new therapeutic modalities available, is a medical need that has not yet been met. Rev. Bras. Cir. Plást. 2020;35(3):339-345
Gross anomalies, such as Poland’s syndrome, are widely discussed, but there is an evident need to detail Vandenbussche’s type 23, not only for its incidence but also because it is the subtype that most refer to the aesthetic character of these abnormalities. Another critical milestone to be considered was the consecration of fat grafting within the therapeutic arsenal of breast surgeries, which had its condemnation phase, but is now widely accepted, both in reconstructive and aesthetic surgeries5.
OBJECTIVE The present work proposes a practical and simplified classification of breast asymmetries with the highest incidence in plastic surgery offices, and with a more accurate diagnosis, it proposes to guide surgical treatment.
METHODS The textual search was carried out on PubMed with the terms “breast” and “asymmetry” and articles that had the proposal to classify breast asymmetries were considered eligible. Also included were articles 341
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dealing with the subject of asymmetry even though it did not propose a classification. After confronting the information collected about classification and treatment, an attempt was made to make the classification more simplified and reproducible at the clinical practice, taking into account, in this new classification, the patientâ&#x20AC;&#x2122;s possible interest in the final volume of the breasts and the incorporation of fat grafting, as a therapeutic arsenal. Chest asymmetries, as described in the Vandenbussche classification, in 19843, despite its high relevance and limitations for better results in correcting breast asymmetries, were not included in the new classification proposal, since plastics surgeons do not address most of them.
are included in types 3 and 4, they have breast ptosis and have been subdivided into those who wish to maintain volume (type 3) and those with a desire for volumetric increase (type 4). And finally, asymmetric hypertrophic breasts in type 5.
Type 1
Hypotrophic breasts with volume asymmetry
Type 2
Hypotrophic breasts with volume and contour asymmetry
Type 3
Normotrophic breasts, with ptosis, with no desire for volumetric increase
Type 4
Normotrophic breasts, with ptosis, and desire for volumetric increase
Type 5
Hypertrophic asymmetric breasts
RESULTS In Chart 1, we see the principal authors with their respective classification proposals. Chart 1. Classifications available for mammary asymmetry. 1 - Unilateral aplasia; 2- Unilateral hypoplasia; 3- Hypertrophy;
Hueston (1968) (review)
1
4- Destruction of the nipple-areolar complex (NAC); 5- Mastectomy. 1- Unilateral hypertrophy; 2- Unilateral hypotrophy;
Elsahy (1976)
3- Hypo and hypertrophy.
2
4- Bilateral hypertrophy; 5- Bilateral hypotrophy.
Figure 1. Proposed simplified classification for breast asymmetries.
1- Congenital; Vandenbussche (1984) (150 patients)
3
2- Primary; 3- Secondary; 4- Tertiary. 1- Bilateral hypertrophy (n = 30);
After the classification described in Figure 1 and based on the treatments recommended by the medical literature, the surgical planning protocol was created and used for the therapeutic decision, as shown in Figure 2.
2- Hypertrophy, normotrophy (n = 15); Araco et al. (2006)4 (177 patients)
3- Hypertrophy with amastia or hypoplasia (n = 10); 4- Amastia or hypoplasia, normal contralateral (n = 5); 1- Bilateral hypoplasia (n = 81);
Type 1
Type 2
Type 3
Type 4
Type 5
Different prostheses
Different prostheses + fat grafting
Simple mastopexy
Mastopexy with identical prostheses
Reduction mammoplasty
Figure 2. Surgical planning protocol to correct breast asymmetries.
2- Unilateral ptosis (n = 36).
In the classification proposed in this work (Figure 1), the first group presents hypotrophic breasts with volume asymmetry (type 1), the second group presents volume and shape asymmetry in hypotrophic breasts (type 2). Normotrophic breasts 342
In type 1, the breasts are hypotrophic and have a similar contour. The simple prostheses placement of different volumes is enough. Particular attention should be given when measuring breast volume and estimating which difference in volume and/or profile to use. Most of the time, the experience of the surgeon Rev. Bras. Cir. PlĂĄst. 2020;35(3):339-345
Breast asymmetry
associated or not with the use of molds is sufficient. Techniques that use Archimedes’ law to measure volume turn out to be of difficult clinical applicability6 and three-dimensional scanning software is still poorly accessible to most surgeons. In type 2, simply placing different implants is not enough. Some areas of the breast, after the placement of the prostheses, deserve a thorough analysis with the stretcher in an elevated headboard position and the areas for fat grafting demarcated. In this situation, we may have a volumetric deficit in any of the breast poles or in the entire breast. The fat preparation technique ranges from simple decanting7 to the Coleman technique (1995)8 and the fat infiltration performed with 1.8mm cannulas in the subcutaneous and intramammary plane4,8 In type 3, the patient has ptosis and is satisfied with the volume of the breasts and/or does not want the use of implants. In this case, simple mastopexy is performed, using the surgeon’s experience technique, drying the mammary parenchyma of the largest breast sufficiently for volumetric symmetrization9,10. Type 4 also presents ptosis and differs from type 3 only by the patient’s desire to increase the final volume, and, for this reason, breast implants are used during a mastopexy. Priority is given to identical implants, and symmetrization is done by manipulating the breast parenchyma. In this group, refinements with fat grafting can also be of great value. In type 5, there is asymmetry with evident breast hypertrophy, and, in this case, there is an indication of symmetrization through reduction mammoplasty with recognized techniques10,11 such as Pitanguy, in 196712 and Silveira Neto, in 197613.
RESULTS In Figure 3A, there is a type 1 breast asymmetry, whose treatment was performed with a Mentor 300ml breast prosthesis (subfascial plane) on the right and 275ml on the left, both with a high profile. In Figure 3B, we have an asymmetry of volume and contour, configuring type 2. On the left, the surgical mark and the liposuction area in the underarm region are shown. In this case, the prostheses (subfascial plane) used were quite different: textured Silimed 230ml high model on the right and 305ml extra high on the left, in addition to global fat grafting on the left and medial pole on the right. In detail, the surgical marking and liposuction area. Figure 3C shows another example of type 2 asymmetry, but asymmetry predominated in contour and mammary fold. In this case, it was decided to keep the same prosthesis textured, 330ml extra high Silimed (subfascial plane), mammary fold lowering, and fat grafting of the lower poles of both breasts. Rev. Bras. Cir. Plást. 2020;35(3):339-345
Figure 3. Clinical cases of breast asymmetry with their classification and surgical treatment.
In Figure 3D, there is a case of type 3 asymmetry, where there is breast ptosis and the patient’s desire to keep the breast volume smaller. Mastopexy performed using the Pigossi technique, resulting scar in inverted T. In another case of type 4 asymmetry (Figure 3E), the patient has ptosis but wishes to increase the breast volume. It was indicated mastopexy with prosthesis and 343
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marking proposed by Pitanguy 196712, using a 200ml prosthesis in the subglandular plane. Finally, a case of type 5 breast asymmetry (Figure 3F), in which there is evident breast hypertrophy with dense and ptotic breasts. We opted for the reduction mammaplasty technique with superomedial pedicle, a technique by Silveira Neto (1976)13.
DISCUSSION As it is a frequent pathology and of unique importance in women’s self-esteem and well-being, breast asymmetry is a reason for the high demand in plastic surgery offices. The analysis of this pathology begins with adequate clinical evaluation of the patient, in all its aspects such as volume, contour, consistency, and presence of ptosis. The creation of classification systems facilitates the language between specialists, and the protocols guide the forms of treatment. Obviously, each patient is unique and must be assessed individually, since breast asymmetry is considered the rule and not the exception. Several morphometric studies have attempted to establish fixed points for better breast evaluation. However, they presented limitations both in vivo and through photographs, as they were linear measures14. Despite these limitations, several of these parameters have been used since its publication in 1986, as the distance between the sternal furcula and the nipple, and the distance between the nipple and the mammary fold15. Perfect breast symmetry, even according to morphometry studies, is practically nonexistent in the pre- or postoperative period, but it is a reality and not a distortion of the patient’s self-image, therefore deserving its due respect. Brown et al., In 199916, demonstrated that the finding of asymmetry is more frequently reported in patients looking for reduction mammoplasty compared to patients looking for breast augmentation. Classifications favor more accurate diagnoses and, when associated with treatment protocols, minimize the chances of errors due to inappropriate conduct. An example of this is the high incidence of postoperative breast asymmetry demonstrated in a retrospective study after breast augmentation surgery, concluding that preoperative systematizations are essential to minimize conduct errors17. Stark’s work in 1991 18 demonstrates how classifications translate a universal language among surgeons. Its preoperative analysis was based on the classifications of Elsahy (1976)2 and Vandenbussche (1984)3, and the study aimed to propose an objective assessment of asymmetric breasts in the postoperative period using standardized measures18. The classification of Vandenbussche (1984)3 takes into account only the etiology of asymmetry (congenital, primary, secondary 344
or tertiary), which is of great value for reconstructive surgery, but somewhat limited for aesthetic cases since the vast majority would fit in the congenital and primary etiologies. The classification of Elsahy (1976)2, on the contrary, assesses in detail the breast asymmetries from a clinical and morphological point of view, subdividing them into five main groups. Its limitation is the analysis complexity, with multiple possible associations involving breast trophism and not evaluating the patient’s desire regarding the change in her breast volume. In 2006, Araco et al. noted the evident need for a new classification and, based on their sample of 177 patients, subdivided the asymmetries into six categories and proposed the respective treatment for each one. At work, however, there is no mention of fat grafting in its treatment algorithm as a valuable adjuvant therapy and does not mention the current and relevant desire of the patient regarding the final breast volume considered normotrophic4. Emphasizing the need for such classifications for better understanding, clinical analysis, and communication among professionals, Roxo et al., in 200919, proposed a classification and treatment of mammoplasty; however, this classification is limited to patients after massive weight loss. A standardized language undoubtedly facilitates the discussion of cases and the exchange of experiences, guiding the conduct of the less experienced and making the dialogue with the patient in the preoperative medical consultation clearer.
CONCLUSION The extensive review of the literature allowed the creation of a simpler and reproducible classification of breast asymmetries. It was added to the treatment protocols already established in this work, fat grafting as an adjunct in the treatment of asymmetries. The patient’s desire regarding the final volume of her breasts was also included.
COLLABORATION GELF
Conception and design study, Data Curation, Final manuscript approval, Methodology, Project Administration, Writing - Original Draft Preparation
DCG
Review & Editing
RFB
Review & Editing
REFERENCES 1. Hueston JT. Surgical correction of breast asymmetry. Aust NZJ Surg. 1968 Nov;38(2):112116. 2. Elsahy NI. Correction of asymmetries of the breast. Plast Reconstr Surg. 1976 Jun;57(6):700-3.
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Breast asymmetry 3. Vandenbussche F. Asymmetries of the breast: a classification system. Aesthetic Plast Surg. 1984;8(1):27-36. 4. Araco A, Gravante G, Araco F, Gentile P, Castrí F, Delogu D, et al. Breast asymmetries: a brief review and our experience. Aesthetic Plast Surg. 2006 Mai/Jun;30(3):309-19. 5. Illouz YG, Sterodimas A. Autologous fat transplantation to the breast: a personal technique with 25 years of experience. Aesthetic Plast Surg. 2009 Set;33(5):706-15. 6. Stark B, Olivari N. Breast asymmetry: an objective analysis of postoperative results. Eur J Plast Surg. 1991;14:173-6. 7. Tezel E, Numanoglu A. Practical do-it-yourself device for accurate volume measurement of breast. Plast Reconstr Surg. 2000 Mar;105(3):1019-23. 8. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg. 1995 Set/Oct;19(5):421-5. 9. Sakai RL, Tavares LC, Soares RA, Oliveira IN, Komatsu CA, Faiwichow L. Mastoplastia de aumento em mamas assimétricas: implantes de silicone + lipoenxertia. Rev Bras Cir Plást. 2013;28(3 Supl 1):1-103. 10. Pigossi N, Andrade A, Calange H. Mamaplastia estética e funcional - experiência de 25 anos. Arq Catar Med. 1994;23:19-22. 11. Ariè G. Nova técnica em mamoplastia. Rev Lat Amer Cir Plást. 1975;3:28. 12. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg.1967;20(1):78-85.
*Corresponding author:
13. Silveira Neto E. Mastoplastia redutora setorial com pedículo areolar interno. In: Anais do XIII Congresso Brasileiro de Cirurgia Plástica e I Congresso Brasileiro de Cirurgia Estética; Abr 1976, Porto Alegre, RS, Brasil. Porto Alegre (RS): SBCP; 1976. 14. Quieregatto PR, Hochman B, Furtado F, Ferrara SF, Machado SF, Sabino Neto M. Photographs for anthropometric measurements of the breast region. Are there limitations?. Acta Cir Bras. 2015;30(7):509-16. 15. Smith Junior DJ, Palin Junior WE, Katch VL, Bennet JE. Breast volume and anthropomorphic measurements: normal values. Plast Reconstr Surg. 1986 Set;78(3):331-5. 16. Brown TP, Ringrose C, Hyland RE, Cole AA, Brotherston TM. A method of assessing female breast morphometry and its clinical application. Br J Plast Surg. 1999 Jul;52(5):355-9. 17. Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patientes. Plast Reconstr Surg. 2003 Apr;111(4):15139;discussion:1520-3. 18. Stark B, Olivari N. Breast asymmetry: an objective analysis of postoperative results. Eur J Plast Surg. 1991;14(4):173-6. 19. Roxo CDP, Rodrigues EW, Roxo ACW, Aguiar EBP. Classificação e abordagem de mamas pós-grandes perdas ponderais. Rev Bras Cir Plást. 2009 Jul/Set;24(3):310-4.
Gladstone Eustáquio de Lima Faria Rua Alves Guimarães, 462, Sala 31, São Paulo, SP, Brazil. Zip Code: 05410-000 E-mail: gladstonefaria@hotmail.com
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Review Article Festoons, edema, and malar bags: is there a consensus on aesthetic treatment? Festoons, edema e bolsas malares: existe consenso no tratamento estético? CAROLINE SILVA COSTA DE ALMEIDA 1* KYLDERY WENDELL MOURA CAVALCANTE 1 RAFAEL XIMENES BANDEIRA DE MORAIS 2 ANDRÉ LUIZ BELÉM NEGROMONTE DOS SANTOS 2 EDUARDA AUGUSTA DE LUCENA CALDAS 3 MARCEL FERNANDO MIRANDA BATISTA LIMA 1 IGOR CHAVES GOMES LUNA 1 RAFAEL ANLICOARA 1
Institution: Hospital das Clínicas, Department of Plastic Surgery, Federal University of Pernambuco, Recife, PE, Brazil. Article received: September 18, 2019. Article accepted: February 22, 2020. Conflicts of interest: none.
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ABSTRACT
Introduction: Periorbital changes are some of the first detectable signs of aging. The most outstanding currently, refers to the rejuvenation of this region, involving the treatment from the eyebrows to the transition orbital-malar, where are festoons, edemas, and malar bags. However, this management is complex, involving several approaches: invasive or noninvasive techniques. Thus, this review aims to describe the scientific evidence of the most current techniques used in the treatment of festoons, edema, and malar bags and to evaluate the complications related to each modality. Methods: The research was carried out in three databases, PubMed, Cochrane, and LILACS - using the descriptors “bolsa malar,” “malar mounds,” “festoons” and “malar bags” in the period from 2014 to 2019, in English and Portuguese. Results: We selected 13 articles; most of the studies were retrospective reviews (76.9%), seven dealt with noninvasive techniques, three about invasive, and three on the association of techniques. Regarding the procedures described, the noninvasive ones were represented by the use of Kinesio tape, tetracycline injection, doxycycline and hyaluronic acid, and the use of microneedling with radiofrequency. The invasive ones were represented by microaspiration, myocutaneous flap, subperiosteal lift of the middle face, and direct excision. Conclusion: There are numerous techniques for treating festoon and malar bags, but it is up to the plastic surgeon to know its advantages and disadvantages to decide the most appropriate in each situation. Thus, there is no consensus, but it is vital to diagnose correctly to indicate the best treatment. Keywords: Conservative treatment; Plastic surgery; Minimally invasive surgical procedures; Edema; Blepharoplasty; Eyelid diseases.
DOI: 10.5935/2177-1235.2020RBCP0061
Hospital das Clínicas, Department of Plastic Surgery, Federal University of Pernambuco, Recife, PE, Brazil. University of Pernambuco, Recife, PE, Brazil. 3 Federal University of Pernambuco, Recife, PE, Brazil. 1 2
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RESUMO
Introdução: As alterações periorbitais são alguns dos primeiros sinais detectáveis do envelhecimento. O destaque, atualmente, refere-se ao rejuvenescimento dessa região, envolvendo o tratamento desde as sobrancelhas até a transição órbito-malar, onde se encontram festoons, edemas e bolsas malares. Entretanto, este manejo é complexo, envolvendo várias abordagens: técnicas invasivas ou não invasivas. Assim, esta revisão objetiva descrever as evidências científicas relacionadas às técnicas mais atuais utilizadas no tratamento de festoons, edemas e bolsas malares e avaliar as complicações relacionadas à cada modalidade. Métodos: A pesquisa foi realizada em três bases de dados - PubMed, Cochrane e LILACS - utilizando os descritores “bolsa malar”, “malar mounds”, “festoons” e “malar bags” no período de 2014 a 2019, na língua inglesa e portuguesa. Resultados: Foram selecionados 13 artigos, a maioria dos estudos eram revisões retrospectivas (76,9%), sete versavam sobre técnicas não invasivas, 3 sobre invasivas e 3 sobre associação das técnicas. Em relação aos procedimentos descritos, os não invasivos foram representados pelo uso de Kinesio tape, injeção de tetraciclina, doxiciclina e de ácido hialurônico, e o uso de microagulhamento com radiofrequência. Já os invasivos foram representados por microaspiração, retalho miocutâneo, lift subperiosteal da face média e excisão direta. Conclusão: Existem inúmeras técnicas para tratamento de festoon e bolsas malares, mas cabe ao cirurgião plástico conhecer suas vantagens e desvantagens para decidir a mais adequada em cada situação. Assim, não há consenso, mas é vital diagnosticar corretamente para indicar o melhor tratamento. Descritores: Tratamento conservador; Cirurgia plástica; Procedimentos cirúrgicos minimamente invasivos; Edema; Blefaroplastia; Doenças palpebrais.
INTRODUCTION Aesthetic interventions in the face have been increasingly sought after by patients in the context of plastic surgery, improving the facial contour, and returning the harmony and beauty of the face without losing naturalness1. Data from the American Society for Aesthetic Plastic Surgery (ASAPS) 2017 and the Sociedade Brasileira de Cirurgia Plástica (SBCP) 2016 show that in recent years approximately two hundred thousand surgical procedures have been performed such as blepharoplasty and facelift and more than one million noninvasive procedures on the face as the application of botulinum toxin and hyaluronic acid1,2. The periorbital region’s rejuvenation has gained prominence in recent years and ranges from the treatment of the eyebrow area to the transition orbitalmalar, where the festoons, edema, and malar bags are found. Periorbital changes are one of the earliest detectable signs of aging, but this region is still very Rev. Bras. Cir. Plást. 2020;35(3):346-352
neglected because it manifests pathologies that exhibit complex resolutions. Besides, the region has a variable terminology that hinders diagnosis and treatment. However, more relevant than knowing nomenclature is to know the region’s anatomy, remembering the three main structures involved in the degeneration that occurs with aging: the orbicularis muscle, the orbital-malar ligament and the cutaneous zygomatic ligament (Figure 1). The malar edema is a fluid accumulation on the malar eminence, the malar bag is represented by chronic edema of permanent soft parts and the festoons are an accumulation of cascading skin3. In this way, anatomical knowledge and current changes in behavior in the face of festoons, edema and malar bags can help in better management. Thus, surgical treatments associated with new invasive and noninvasive treatments lead to the best proposed aesthetic result, respecting the clinical condition and the will of each patient, with the plastic surgeon’s joint decision. 347
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RESULTS The original research yielded 58 records, of which 23 duplicates were removed, leaving 35 articles for the first phase of screening (Figure 2). After title review and summary to determine relevance on the treatment of festoons, edema, and malar bag, 13 were eligible for full-text revision and listed in Chart 1. Most studies were retrospective reviews (76%), three prospective interventionists (23%), and only one systematic review. The types of techniques employed varied among invasive options (46.15%) and noninvasive (53.85%), being represented by the use of Kinesio tape, local injection of antimicrobial, injection of hyaluronic acid, microneedling with radiofrequency, microaspiration, myocutaneous flap, subperiosteal lift of the middle face and direct excision. The findings were as follows:
Figure 1. Anatomy of the periorbital region.
Thus, this study aims to conduct a systematic literature review on the current types of treatments for festoon, edema, and malar bags correction, dealing with invasive and noninvasive techniques. The objective is also to state the main advantages and disadvantages of each technique, besides proposing a modernized treatment algorithm, since there are few studies on the subject.
METHODS This is a literature review limited to Pubmed database, Cochrane, and LILACS in English and Portuguese between 2014 and 2019, using the following descriptors: “bolsa malar,” “malar mounds,” festoons” and “malar bags. “ Exclusion criteria were: publications without full access, repeated by overlapping the keywords-key, not directly related to the theme, before 2014 and languages other than Portuguese or English. Two independent reviewers conducted the initial research of articles and subsequent selection. All research information was tabulated in a spreadsheet for statistical data analysis. This review is supplemented with photos of patients to illustrate some types of treatment, but they are not identified, and their personal information is also not present. Thus, this work does not require approval in the Research Ethics Committee, although the principles of the Helsinki Declaration of 2013 were followed.
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Figure 2. Organization chart of the articles search.
Noninvasive treatment Noninvasive procedures are more conservative and non-surgical interventions, with variable results, used as primary therapy for mild or moderate malar edema with more restriction of outcome in the treatment of bags and festoons. Although not isolated, the first choice for the most advanced conditions, noninvasive procedures, represent adjunct benefits to surgical therapies. Kinesio Tape Only one study described the use of Kinesio tape. The tape was indicated to minimize festoon,
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Festoons, edema and malar bags Chart 1. Articles of interest with the main variables. Authors
Year
Technique
Indication Malar bag and festoons
Kpodzo et al.
2014
Invasive/noninvasive
Hilton et al.8
2014
Noninvasive
Malar edema
Stevens et al.14
2014
Invasive
Malar bag and festoons
Endara et al.12
2015
Invasive
Festoons
Farrapeira16
2015
Invasive
Festoons
Perry et al.6
2015
Noninvasive
Festoons
Iverson and Patel10
2017
Noninvasive
Malar edema
Costin5
2018
Noninvasive
Festoons
Asaadi13
2018
Invasive and noninvasive
Festoons Malar bag
3
Braz et al.
2018
Noninvasive
Jeon and Geronemus11
2018
Noninvasive
Festoons
Godfrey et al.7
2019
Noninvasive
Edema and festoons
Newberry et al.15
2019
Invasive/noninvasive
Edema, bag and festoons
9
through on-site application in an ascending vector, with noticeable improvement after three months, but with limited result in the more advanced festoons4.
erythema and edema. The procedure can be repeated in 1-2 months if necessary10. Invasive treatment
Tetracycline and doxycycline injection Two studies focused on the use of antimicrobials in periorbital rejuvenation. In one of them, the application of tetracycline 2% between the orbicularis muscle and deep fascia showed improvement in the contour to correct the festoons 5. Doxycycline was used in the concentration of 10mg/ml in order to correct festoons and malar edema6. Complications such as ischemia, necrosis, nerve paralysis, persistent pain, or edema were not identified5. However, the application of these antimicrobials presents limited results, requiring more extensive and more detailed studies to determine the safety and efficiency of this treatment.
The invasive treatment of malar and festoon bags can range from the myocutaneous flap to the direct excision of excess skin. The choice of a given type of surgical procedure depends on the correct diagnosis, the patient’s age, and the pathologies’ associations, among other variables. Microsuction Two articles focused on using this technique to treat patients with edema and malar bag. Superficial liposuction is performed to the orbicularis muscle in the subcutaneous plane. The care required is to avoid skin perforations and irregularities in the facial contour11.
Hyaluronic acid injection
Myocutaneous flap - orbicular muscle skin
In four of the thirteen articles included, there was a description of fillers’ use to treat of edema and malar bag. Most studies agree that moderate to severe cases of malar bags or festoons are not adequately treated with filling, the best therapy being the surgical approach7-9.
The most performed surgical modality in the studies (38.46%) is indicated for patients with malar bag and mild to moderate festoons11-13. A subciliary incision is performed, myocutaneous flap dissection to the orbital edge and removal of excess skin (Figures 3 and 4)11. Among the complications observed in the studies, we can have ectropion in up to 4% of cases and hematoma in 3%.
Microneedling with radiofrequency The use of radiofrequency microneedling devices for the treatment of malar and festoon bag was found in two articles, because they provide energy, similar to microwaves, to induce thermal lesions in adipose and dermal tissue, sparing the epidermis and improving the contour of the periorbital region. Studies generally report mild and temporary side effects such as Rev. Bras. Cir. Plást. 2020;35(3):346-352
Middle face subperiosteal lift In two studies, the indication of this technique was described for patients with festoons. Three routes can perform this: temporal, transpalpebral, or endoscopic assisted video. All techniques aim to make the resuspension 349
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Direct excision - in canoe As discussed in three articles, such a procedure is also indicated for patients presenting severe festoons. The incision is made in the festoon’s demarcated area in the form of a canoe or ellipse, and excess skin is removed. As the scar is evident, it is better indicated in older adults. Lagophthalmos and ectropion are the main complication3,15.
DISCUSSION
Figure 3. Muscle-skin flap, subciliary incision.
A
Since 1978, when Furnas first described “festoons”, the terms used to describe edema or excess tissue immediately below the infraorbital border within the pre-zygomatic space are variable. As all three anomalies (edema, malar bag, and festoon) cause lumps, we propose the following definitions to describe this broad anatomical problem: malar edema is an accumulation of fluid on the malar eminence that often varies in severity and can worsen after salty meals or in the morning. The malar bag is chronic edema of soft tissues in the pre-zygomatic space, which contains fat or orbicularis muscle due to descent or hypertrophy, and may be congenital. On the other hand, festoons are loose-skin cascade nets and orbicularis muscle below the infra-orbital edge (Figure 5), may also contain herniated or ptotic fat and accumulate edema. They are often found in older adults and represent a progression of the entities described above16.
B
Figure 4. Myocutaneous flap technique: A. Preoperative marking; B. Representing orbicularis muscle (white arrow) and lower orbital edge (blue arrow).
of the orbital-malar ligament and suspension of the soft tissue. The difference is that in the first technique, the access is made by the temporal region, in the second by the lower eyelid, and in the third, an incision is made in the temporal region and the oral mucosa. The disadvantage of the video-assisted technique is the fact that it presents a longer learning curve, longer surgical time, besides attending with approximately 25% of oral wound dehiscence. On the other hand, the transpalpebral route may present hematoma more frequently and the temporal access route3,14. 350
A
B
Figure 5. A. Representation of malar bag; B. Malar festoon.
The treatment of festoons, edema, and the malar bag is complex, involves diverse pathophysiology and inconsistency of terminology. The choice of an erratic approach will leave patients dissatisfied and with poor aesthetic results. Thus, treatment should be individualized, based on size, content (edema, fat, skin, and muscle), patient preference, and knowledge of the plastic surgeon. The choice of only non-surgical Rev. Bras. Cir. Plást. 2020;35(3):346-352
Festoons, edema and malar bags
procedures should be made cautiously, as it presents limited results if poorly indicated. Kinesio tape was used in the treatment of festoons, but its mechanism of action is based on the improvement of lymphatic drainage, being better applied in malar edema or after surgeries as an adjuvant to minimize postoperative edema and ecchymosis4. Similarly, radiofrequency microneedling without association with other techniques would not be the best choice for the treatment of festoons, because despite causing a potential reduction of fat and decreased sagging skin in the lower eyelid, it is not enough to bring the best outcome to the patient10. On the other hand, the use of antimicrobials, according to Perry et al., in 20155, seems to produce activity similar to growth factor, stimulating the proliferation of fibroblasts, as well as collagen production and fibrin deposition. Thus, tetracycline 2% or doxycycline 10mg/ml between the orbicularis muscle and deep fascia can improve the repair of the periorbital surface, however, with a poor result in the correction of festoons and severe malar bag because it already contains excess skin5,6. The use of hyaluronic acid is controversial because, at the same time, it can mask an irregular contour in the periorbital region can also aggravate malar edema in some cases, especially if hydrophilic, with possible involvement of lymphatic drainage8. Besides, periorbital fat atrophy and malar bone resorption contribute to the loss of the lower periorbital areaâ&#x20AC;&#x2122;s structural support. It is believed that medial and lateral resorption of SOOF(suborbicularis oculi fat) and the regeneration of ligaments and orbicularis leads to loosening the ceiling of the pre-zygomatic space, contributing to the pathogenesis of periorbital aging3,14. Thus, surgical techniques aim to restore the region by acting more anatomically with more predictable and lasting results. The choice of a specific technique over another depends on existing skin excess, patient age, and especially the surgeonâ&#x20AC;&#x2122;s proximity to the surgical procedure. Microaspiration in the periorbital region acts in such a way as to prevent the malar bag progression to the festoons, besides leading to a local fibrosis and face contour improvement3. The myocutaneous flap, subperiosteal lift, and direct excision rejuvenate the periorbital region by acting on the ligament, muscle regeneration, and excess skin. However, the complications inherent to surgical techniques are more feared and more challenging to treat when compared to less invasive techniques. Thus, an algorithm is brought in an attempt to minimize doubts, facilitate the interpretation and choice of treatment in the face of a case of periorbital rejuvenation (Figure 6). It is noteworthy that despite the numerous invasive and noninvasive techniques, a single approach is not revolutionary. Thus, most often, Rev. Bras. Cir. PlĂĄst. 2020;35(3):346-352
repetitive treatments and a combination of techniques are necessary, leading to an increase in the cost and postoperative recovery time14. Furthermore, studies on the subject are deficient, mainly in Portuguese (found only one in this review), because these are studies at grade IV and V levels, limiting critical analysis and highlighting the need for higher quality studies.
Figure 6. Algorithm for edema, bag and malar festoon treatment.
CONCLUSION There are numerous techniques for treating festoon and malar bags, but it is up to the plastic surgeon to know its advantages and disadvantages to decide the most appropriate for each type of patient. Therefore, there is no consensus, but it is essential to diagnose correctly and remember that the association of techniques may be the best treatment.
COLLABORATIONS CSCA
Analysis and/or data interpretation, Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Writing - Original Draft Preparation, Writing - Review & Editing
KWMC
Data Curation, Writing - Original Draft Preparation
RXBM
Analysis and/or data interpretation, Conception and design study, Data Curation, Formal Analysis, Writing - Original Draft Preparation, Writing - Review & Editing
ALBNS
Analysis and/or data interpretation, Data Curation, Formal Analysis, Investigation, Methodology, Writing - Original Draft Preparation, Writing - Review & Editing
EALC
Writing - Original Draft Preparation, Writing - Review & Editing 351
Almeida CSC et al.
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MFMBL
Data Curation, Methodology, Writing Original Draft Preparation
ICGL
Project Administration, Supervision, Visualization, Writing - Review & Editing
RA
Supervision, Visualization
REFERENCES 1. International Society of Aesthetic Plastic Surgery (ISAPS). ISAPS International survey on aesthetic/cosmetic procedures performed in 2017 [Internet]. New York: ISAPS; 2017; [acesso em 2019 Jun 20]. Disponível em: https://www.isaps.org/wp- content/ uploads/2019/03/ISAPS_2017_International_Study_Cosmetic_ Procedure s_NEW.pdf 2. Sociedade Brasileira de Cirurgia Plástica (SBCP). Censo 2016. Situação da Cirurgia Plástica no Brasil [Internet]. São Paulo (SP): SBCP; 2017; [acesso em 2019 Jun 18]. Disponível em: http://www2. cirurgiaplastica.org.br/wp- content/uploads/2017/12/CENSO-2017.pdf 3. Kpodzo DS, Nahai F, McCord CD. Malar mounds and festoons: review of current management. Aesthet Surg J. 2014 Fev;34(2):235-48. 4. Furnas DW. Festoons of orbicularis muscle as a cause of baggy eyelids. Plast Reconstr Surg. 1978;61(4):540-6. 5. Costin BR. Kinesio tape for treatment of lower eyelid festoons. Ophthalmic Plast Reconstr Surg. 2018 Nov/Dez;34(6):602. 6. Perry JD, Mehta VJ, Costin BR. Intralesional tetracycline injection for treatment of lower eyelid festoons: a preliminary report. Ophthalmic Plast Reconstr Surg. 2015 Jan/Fev;31(1):50-2.
*Corresponding author:
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7. Godfrey KJ, Kally P, Dunbar KE, Campbell A, Callahan AB, Lo C, et al. Doxycycline injection for sclerotherapy of lower eyelid festoons and malar edema: preliminary results. Ophthalmic Plast Reconstr Surg. 2019 Set/Out;35(4):474-7. 8. Hilton S, Schrumpf H, Buhren BA, Bölke E, Gerber PA. Hyaluronidase injection for the treatment of eyelid edema: a retrospective analysis of 20 patients. Eur J Med Res. 2014 Mai;19:30. 9. Braz AV, Black JM, Pirmez R, Minokadeh A, Jones DH. Treatment of malar mounds with hyaluronic acid fillers: an anatomical approach. Dermatol Surg. 2018 Nov;(44 Suppl 1):S56-S60. 10. Iverson SM, Patel RM. Dermal filler-associated malar edema: treatment of a persistent adverse effect. Orbit. 2017 Dez;36(6):473-5. 11. Jeon H, Geronemus RG. Successful noninvasive treatment of festoons. Plast Reconstr Surg. 2018;141(6):977e-8e. 12. Endara M, Oh C, Davison SP, Baker SB. The management of festoons. Clin Plast Surg. 2015;42(1):87-94. 13. Asaadi M. Etiology and treatment of congenital festoons. Aesthetic Plast Surg. 2018 Ago;42(4):1024-32. 14. Stevens HPJD, Willemsen JCN, Durani P, Rasteiro D, Omoruyi OJ. Triple-layer midface lifting: long-term follow-up of an effective approach to aesthetic surgery of the lower eyelid and the midface. Aesthetic Plast Surg. 2014 Ago;38(4):632-40. 15. Newberry CI, McCrary H, Thomas JR, Cerrati EW. Updated management of malar edema, mounds, and festoons: a systematic review. Aesthet Surg J. 2019;40(3):246-58. 16. Farrapeira AB. Tratamento da bolsa malar e festoons. Rev Bras Cir Plást. 2014;29(4):486-9.
Caroline Silva Costa de Almeida Rua Barão de Itamaracá 78, Espinheiro, Recife, PE, Brazil. Zip Code: 52020-070 E-mail: carol_costaalmeida@hotmail.com
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Case Report Reconstructive surgery in the context of Covid-19: complications in the treatment of an inguinal complex wound Cirurgia reparadora no contexto da Covid-19: complicações evolutivas no tratamento de ferida complexa inguinal VINÍCIUS GOMES DA SILVEIRA 1 PEDRO SOLER COLTRO 1* HENRIQUE OVIDIO CORASPE GONÇALVES 1 DIOGO HUMMEL HOHL 1 GABRIEL MAZIERO ALVES SILVA 1 JAYME ADRIANO FARINA-JUNIOR 1
Institution: Plastic Surgery Division – Faculty of Medicine of Ribeirão Preto of USP, Ribeirão Preto, SP, Brazil. Article received: April 21, 2020. Article accepted: April 30, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0044
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ABSTRACT
Introduction: At the end of 2019, the world saw the emergence of a new respiratory syndrome called Covid-19, caused by a new type of coronavirus, Sars-CoV-2. Classified as a pandemic, it has caused impacts of considerable magnitude. Case Report: A 57-year-old man developed a right inguinal wound after surgical exploration for infection of a prosthesis used in a femur-popliteal bypass. The Plastic Surgery team opted for treatment with surgical debridement associated with negative pressure therapy to prepare the wound bed. In the postoperative period, he had severe acute respiratory syndrome and suspected Covid-19, requiring intubation and intensive care. A sample for RT-PCR of Sars-CoV-2 was collected, and the medications chloroquine and azithromycin were associated with the treatment. Despite intensive treatment, the patient died. The result of the RT-PCR test for the new coronavirus was positive, being released two days after death. Discussion: The analysis of this report allows us to suppose that the patient probably contracted the new coronavirus at the hospital, as he was hospitalized for 35 days before the evolution of respiratory failure. This fact, together with its unfavorable evolution, corroborates the orientation of minimizing hospitalizations and surgical procedures as much as possible to promote more safety for the patient and the health team. Conclusion: Inpatients are susceptible to infection with the new coronavirus and can set up a group at higher risk since many of them are already weakened. Keywords: SARS virus; Plastic surgery; Coronavirus; Wounds and injuries; Debridement.
University of São Paulo, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, SP, Brazil.
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Reconstructive surgery in the context of Covid-19
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RESUMO
Introdução: No final de 2019, o mundo viu surgir uma nova síndrome respiratória denominada Covid-19, causada por um novo tipo de coronavírus, o Sars-CoV-2. Classificada como uma pandemia, ela tem causado impactos de magnitude ainda imensuráveis. Relato de caso: Homem de 57 anos desenvolveu ferida inguinal direita, após exploração cirúrgica por infecção de prótese usada em bypass femoro-poplíteo. A equipe de cirurgia plástica optou pelo tratamento com desbridamento cirúrgico, associado com terapia por pressão negativa para preparo do leito da ferida. No pós-operatório, apresentou síndrome respiratória aguda grave e suspeita de Covid-19, com necessidade de intubação e de cuidados intensivos. Foi colhido amostra para RT-PCR do Sars-CoV-2 e associado ao tratamento as medicações cloroquina e azitromicina. Apesar do tratamento intensivo, o paciente foi a óbito. O resultado do exame RT-PCR para o novo coronavírus foi positivo, sendo liberado dois dias após a morte. Discussão: A análise deste relato permite supor que o paciente provavelmente contraiu o novo coronavírus dentro do próprio hospital, pois o mesmo encontrava-se internado pelo período dos 35 dias anteriores à evolução para insuficiência respiratória. Esse fato, juntamente com sua evolução desfavorável, corrobora a orientação de minimizar ao máximo as internações e os procedimentos cirúrgicos a fim de promover maior segurança ao paciente e à equipe de saúde. Conclusão: Pacientes internados estão susceptíveis à infecção pelo novo coronavírus e podem configurar grupo de maior de risco, uma vez que muitos deles já se encontram debilitados. Descritores: Vírus da SARS; Cirurgia plástica; Coronavírus; Ferimentos e lesões; Desbridamento.
INTRODUCTION In late 2019, the world saw a new respiratory syndrome called Covid-19 appear, caused by a new type of coronavirus, Sars-CoV-2. In March 2020, the World Health Organization classified this new disease as a pandemic, which has caused impacts of immeasurable magnitude1. In recent months, there has been a notable scientific production that sought to understand better the pathophysiology of this new disease, the origin and genetic sequencing of SARS-CoV-2, characteristics of its dissemination, pathogenesis, means of diagnosis, support protocols and treatment of patients2. This pandemic revealed that the world was not prepared for a crisis of such proportions. The scarcity of necessary supplies (personal protective equipment, mechanical ventilators), sanitary structure (availability of beds, especially those for intensive care), and trained human resources (doctors, nursing staff, physiotherapy, etc.) is a frequent finding in coping with Covid-193. Much more than just being a health crisis, the pandemic exposes Plastic Surgery to a new challenge: how to deal with patients who need surgical treatment in the context of facing this new virus? Rev. Bras. Cir. Plást. 2020;35(3):353-357
The speed of dissemination of the new coronavirus was higher than that of precautionary measures and preparation of health workers. Numerous simultaneous efforts have been made, such as social distance, travel restrictions, suspension of non-priority ambulatory care, interruption of elective surgeries, and maintenance of urgent / emergency surgeries or oncological cases, in addition to encouraging the use of personal protective equipment (PPE) and team training. Despite this, there has been an intra-hospital Sars-CoV-2 spread. There was also the admission of patients infected with coronavirus, not only in Brazil but also in the world1. The importance of viral dissemination by asymptomatic patients, companions, and health professionals is well known. It is estimated that about 80% of transmissions come from this group4. Following the guidelines of national and international health authorities, there was a recommendation to suspend elective surgeries and non-priority consultations in the office, in addition to adhering to social distance. Such measures, in addition to reducing patients’ exposure to the risk of infection, also increase the availability of nursing beds and intensive care to cope with the crisis. 354
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In this article, we report the case of a patient with a complex inguinal wound treated by the Plastic Surgery team at Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo (HCFMRPUSP). The patient evolved with acute respiratory failure, requiring intensive care. The diagnostic confirmation of Covid-19 was performed “post mortem” after a positive RT-PCR test for the new coronavirus.
CASE REPORT A 57-year-old man with peripheral arterial obstructive disease, in the postoperative period of the right femur-popliteal bypass with a prosthesis, was hospitalized on 02/29/2020 due to infection of the prosthesis and antibiotic therapy was started intravenously. As a surgical history, he underwent left infrapatellar amputation in 2015, three femur-popliteal bypasses on the right (2015, 2017, 2018), and the reapproach of that bypass on 02/13/2020 with a finding of a thickened PTFE prosthesis, with signs of infection. On 03/05/2020, the Vascular Surgery team performed right inguinal surgical exploration with findings of local infection, followed by surgical debridement, resulting in an inguinal wound. On the following day, the patient developed acute arterial obstruction of the right lower limb (RLL), being treated utilizing catheterized thromboembolectomy, followed by the return of the pulse in the affected limb. However, there was a progressive worsening of tissue perfusion, and on 03/13/2020, right suprapatellar amputation was performed. The Plastic Surgery team, which was already in a contingency and relocation regime with the minimum possible individual exposure due to the pandemic, was called in to assess the right inguinal wound on 03/31/2020. Upon examination, we identified a complex 10 x 8 cm wound, with the presence of sloughs and areas with granulation tissue, with no signs of infection and absence of exposure of large vessels (Figure 1). We opted for treatment with surgical debridement associated with negative pressure therapy (NPT) to prepare the wound bed5-6 (Figure 2). After three days, the patient developed a febrile peak, tachycardia, and tachypnea, progressing to severe acute respiratory syndrome (SARS) and the need for intensive care. After transfer to the intensive care unit (ICU), orotracheal intubation was performed, and the patient was in respiratory and contact isolation, according to the HCFMRP-USP protocol during the Covid-19 pandemic. Chest X-ray performed on the bed showed an infiltrate bilateral interstitial (Figura 3). According to the SAPS 3 system, the calculation of the probability of death upon admission to the ICU was 90.98%7. 355
Figure 1. Wound in the right inguinal region with sloughs and areas with granulation tissue.
Figure 2. Application of negative pressure therapy on the wound.
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Reconstructive surgery in the context of Covid-19
Figure 3. Image of the chest radiograph taken in the bed showing bilateral interstitial infiltrate.
A sample for RT-PCR of Sars-CoV-2 was collected due to SARS suspicion by coronavirus. Medications chloroquine and azithromycin were associated with the treatment, according to the HCFMRP-USP protocol. On 04/04/2020, after maintaining a febrile plateau refractory to pharmacological measures, the patient developed hypotension and the need for vasoactive drugs, maintaining protective ventilation. Despite intensive treatment and pharmacological measures, the patient maintained hemodynamic instability with a rising vasoactive drug, being diagnosed with refractory septic shock. At the same time, he worsened renal function with the indication for renal replacement therapy, but without hemodynamic conditions for hemodialysis. The evolution of the clinical picture was unfavorable, with cardiac arrest in pulseless electrical activity. Non-resuscitation was chosen due to the refractoriness of the measures instituted, and he was then declared dead on 04/05/2020. The result of the RTPCR test for the new coronavirus was positive, being released two days after death. Medical record review data reveal that this patient shared the wardroom with another patient who also developed SARS on 02/04/2020, also in need of intensive care and orotracheal intubation. This patient was also diagnosed with infection by the new coronavirus confirmed by RT-PCR.
DISCUSSION The new scenario presented by the coronavirus pandemic has led to a series of social restrictions and changes in hospital routines1. The rediscussion and continued elaboration of patient and health team safety protocols are necessary since about 80% of those Rev. Bras. Cir. Plรกst. 2020;35(3):353-357
infected with Sars-CoV-2 can be asymptomatic, being, therefore, a relevant source of transmission4. The analysis of this report allows us to suppose that the patient probably contracted the new coronavirus within the hospital, as he was hospitalized for 35 days before the evolution to respiratory failure. This fact, together with its unfavorable evolution, corroborates the orientation to minimize hospitalizations and surgical procedures as much as possible to promote more excellent safety for the patient and the health team1. Besides, the situation reinforces the need to use PPE and reinforce hygiene measures8. Another essential factor to be considered would be the relocation of assistant teams and resident doctors to reduce exposure and chance of infection by the medical team9. Until the writing of this article, no member of our team manifested a picture suggestive of contamination by the new coronavirus.
CONCLUSION As reported in this case, hospitalized patients are susceptible to infection with the new coronavirus and may be at a higher risk group, since many of them are already weakened. Plastic surgery is also included in this context since it performs treatment of patients with complex wounds that may have multiple comorbidities, and that may require hospitalizations for prolonged periods. We emphasize the need to protect patients and professionals with the use of PPE to minimize the risk of contamination with the new coronavirus that causes the Covid-19 pandemic.
COLLABORATIONS VGS
Analysis and/or data interpretation, conception and design study, conceptualization, data curation, final manuscript approval, writing - original draft preparation.
PSC
Analysis and/or data interpretation, conception and design study, conceptualization, final manuscript approval, supervision, writing original draft preparation, writing - review & editing.
HOCG
Analysis and/or data interpretation, data curation, final manuscript approval.
DHH
Analysis and/or data interpretation, data curation, final manuscript approval.
GMAS
Analysis and/or data interpretation, data curation, final manuscript approval.
JAFJ
Analysis and/or data interpretation, conception and design study, final manuscript approval, project administration, supervision, writing - original draft preparation, writing - review & editing. 356
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REFERENCES 1. COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg. 2020 Apr 15; [Epub ahead of print]. DOI: https://doi.org/10.1002/bjs.11646 2. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020 Mar;323(14):1341-2. DOI: https://doi.org/10.1001/jama.2020.3151 3. Ranney ML, Griffeth V, Jha AK. Critical supply shortages - the need for ventilators and personal protective equipment during the Covid-19 pandemic. N Engl J Med. 2020 Mar 25; [Epub ahead of print]. DOI: https://doi.org/10.1056/NEJMp2006141 4. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020 Mar 16; [Epub ahead of print]. DOI: https://doi.org/10.1126/science.abb3221 5. Coltro PS, Ferreira MC, Batista BP, Nakamoto HA, Milcheski DA, Tuma Júnior P. Role of plastic surgery on the treatment complex wounds. Rev Col Bras Cir. 2011 Nov/Dec;38(6):381-6.
*Corresponding author:
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6. Lima RVKS, Coltro PS, Farina Júnior JA. Negative pressure therapy for the treatment of complex wounds. Rev Col Bras Cir. 2017 Jan/Feb;44(1):81-93. DOI: https://doi.org/10.1590/010069912017001001 7. Silva Junior JM, Malbouisson LMS, Nuevo HL, Barbosa LGT, Marubayashi LY, Teixeira IC, et al. Aplicabilidade do escore fisiológico agudo simplificado (SAPS 3) em hospitais brasileiros. Rev Bras Anestesiol. 2010;60(1):20-31. DOI: https://doi.org/10.1590/ S0034-70942010000100003 8. Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M. Medical masks vs N95 respirators for preventing COVID-19 in health care workers: a systematic review and meta-analysis of randomized trials. Influenza Other Respir Viruses. 2020 Apr 4; [Epub ahead of print]. DOI: https://doi.org/10.1111/irv.12745 9. Nassar AH, Zern NK, McIntyre LK, Lynge D, Smith CA, Petersen RP, et al. Emergency restructuring of a general surgery residency program during the coronavirus disease 2019 pandemic: the University of Washington experience. JAMA Surg. 2020 Apr 6; [Epub ahead of print]. DOI: https://doi.org/10.1001/jamasurg.2020.1219
Pedro Soler Coltro Av. Bandeirantes 3900, Câmpus Universitário, Monte Alegre, Ribeirão Preto, SP, Brazil. Zip Code: 14048-900 E-mail: psc@usp.br
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Case Report Severe complication by irregular use of industrial silicone in a transsexual patient: a case report Complicação grave do uso irregular de silicone industrial em paciente transexual: relato de caso MONIQUE MENDES1 GUSTAVO GOMES RIBEIRO MONTEIRO 1* EMILLY FREIRE BARBOSA BASTOS 1 DIMAS ANDRÉ MILCHESKI 1 ARALDO AYRES MONTEIRO JUNIOR 1 ROLF GEMPERLI 1
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ABSTRACT
The use of industrial liquid silicone as a material for aesthetic modification of body contour is a practice that has been carried out clandestine for about 60 years. Currently, most reports come from countries in Asia and South America, and the victims are mainly women and transsexuals. Due to the large number of cases with complications, the use of industrial silicone for aesthetic purposes has never been approved. However, it continues to be applied alone or associated with other products, determining severe local and systemic complications. We report a case of death of a transsexual patient after injecting industrial silicone in the thighs and buttocks. Keywords: Silicones; Death; Allografts; Necrosis; Transgender people; Body contour.
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Institution: Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil. Article received: April 14, 2019. Article accepted: June 12, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0062
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O uso do silicone líquido industrial como material para modificação estética no contorno corporal é uma prática realizada de forma clandestina há cerca de 60 anos. Atualmente, a maioria dos relatos provém de países da Ásia e América do Sul e as vítimas são principalmente mulheres e transexuais. Devido ao grande número de casos com complicações, o uso do silicone industrial para fins estéticos nunca foi aprovado. Entretanto, continua a ser aplicado isoladamente ou associado a outros produtos, determinando graves complicações locais e sistêmicas. Relata-se um caso de óbito de paciente transexual após injeção de silicone industrial em coxas e glúteos. Descritores: Silicones; Morte; Aloenxertos; Necrose; Pessoas transgênero; Contorno corporal.
Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.
Rev. Bras. Cir. Plást. 2020;35(3):358-362
Complication by use of industrial silicone
INTRODUCTION The clandestine injection of industrial liquid silicone to modify body contour became popular around 70 years ago when industrial-grade silicone was developed during World War II for military purposes1-3. Since the publication of Andrews et al., in 19894, showing for the first time the local and systemic complications of liquid silicone in humans, this type of material has had its use contraindicated by the Food and Drug Administration (FDA) and the former Medicines Division (DIMED) in Brazil4,5. Currently, the majority of victims are women and transsexuals from countries in Asia and South America. Due to the lack of resources for plastic surgery, they end up using unqualified professionals1-3. Despite the prohibitions, the use of industrial silicone for aesthetic purposes continues to be done alone or in association with other products, leading to severe and potentially fatal complications1,6.
OBJECTIVE To report a case of death after injection of industrial silicone in the buttocks and thighs in a transsexual patient.
the second debridement, it was replaced by a simple dressing with 1% silver sulfadiazine and cerium nitrate. Cultures guided antibiotic therapy.
Figure 1. Computed tomography of the pelvis and lower limbs showing diffuse local densification with liquid laminae, more accentuated in the lumbar, sacral, gluteal regions, and roots of the thighs.
A
CASE REPORT In this study, we report a healthy transsexual female patient, 24 years old, presenting an injection of 3000ml of industrial liquid silicone in the buttocks and anterolateral thighs. This procedure was performed in a home environment by a non-qualified professional. After five days, she started showing signs of inflammation and epidermolysis at the infiltration site, being submitted to superficial debridement at a medical service near her residence. Due to a worsening of her general condition, she then sought the emergency room at the Hospital das Clínicas of the University of São Paulo. Upon admission, she already had extensive necrosis in the glutes and lateral region of the hip associated with signs of septic shock, requiring orotracheal intubation and the use of vasoactive drugs. Imaging exams showed diffuse densification with liquid laminae pervaded, more pronounced in the lumbar, sacral, buttocks, and thigh roots (Figure 1). The patient underwent six sequential surgical procedures for extensive debridement of devitalized tissues, with identification of purulent collections and viscous substance, compatible with silicone (Figures 2, 3, and 4). Initially, negative pressure therapy was used. After
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B
C
Figure 2. Evolution of the wound after serial debridement; Right lateral; A. 6 days of evolution; B. After first debridement; C. After second debridement, with extension of the area of necrosis to the dorsal region and lateral and anterior aspect of the thighs.
With a condition of acute renal failure attributed to sepsis and the use of nephrotoxic drugs, the patient remained in the ICU. On the thirty-second day of hospitalization, because of an apparent local and systemic control of the infection, partial allogeneic skin grafting was performed, in mesh (3: 1), on the raw areas to reduce the degree of spoliation (Figure 5).
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A
defined the cause of death as a septic shock with pulmonary and skin focus.
DISCUSSION
B
Figure 3. Evolution of the wound after serial debridement; A. After the fourth debridement, exposure of the bilateral maximum gluteal muscle, B. After the fifth debridement, using a dressing with 1% silver sulfadiazine + cerium nitrate.
A
B
Figure 4. Evolution of the wound after serial debridement; A. After the fourth debridement, with extension to the lateral and anterior aspect of the thighs, B. After the fifth debridement, using a dressing with 1% silver sulfadiazine + cerium nitrate.
A
A
B
Figure 5. Evolution of the wound after serial debridement and allogeneic skin grafting; A. After sixth debridement and grafting of homogeneous skin in 3: 1 mesh; B. Dressing opening, five days after grafting, with the integration of approximately 60% of the grafted skin.
However, five days after the grafting, the patient presented a new clinical worsening with hemodynamic instability, evolving to death. The necropsy report 360
Polydimethylsiloxane (silicone) is a compound formed by the conjugation of silicon with oxygen and methane. In its manufacture, it is inherently contaminated with impurities, heavy metals, and volatile polymers. Besides, when it hardens, it ends up releasing acetic acid, which may be responsible for the initial tissue damage after the injection. This combination of factors contributes to the severe complications frequently observed6. In addition to its isolated use, silicone is also intentionally associated with other agents to increase inflammation and fibroplasia at injection sites, preventing its migration by gravitational action. Sakuraiâ&#x20AC;&#x2122;s formula is a well-known example of its association with olive oil. Other sclerosing agents used are croton oil, snake venom, and peanut oil7. Winer et al. created the term siliconoma., in 19642, to describe the foreign body reaction similar to those already described after the injection of oil and paraffin. These substances promote an equivalent type of anatomopathological tissue reaction, called sclerosing lipogranulomatosis1,5,8,9. In an attempt to eliminate, through the phagocytic activity of tissue macrophages and circulating blood cells, the silicone can be transported by the lymphatic route to organs at a distance, leading to embolism. Besides, its intravascular injection can also result in immediate embolism4,10,11. Due to the illegal nature of the practice, there are few reports of acute reactions in this context. These patients are reluctant to seek medical attention, except in life-threatening circumstances. The most severe systemic manifestations include pulmonary, neurological, cardiac, hepatic, gastrointestinal involvement and sepsis12. From a local point of view, complications range from skin color and consistency changes to an intense inflammatory process with nodules, ulceration, necrosis, abscesses, and fistulas. Scarring retractions and deformities are also observed. The latency period for these sequelae appearance is variable, reaching up to 30 years. Therefore, identifying and punishing those responsible is often difficult5,10. According to the literature, the complete elimination of silicone deposits is not feasible, since liquid silicone diffuses through deep tissues, forming islands of fibrosis among healthy tissues. Thus, its eradication would culminate in very extensive resections leading to even more severe sequelae3,5,9. Rev. Bras. Cir. PlĂĄst. 2020;35(3):358-362
Complication by use of industrial silicone
The debridement of devitalized tissues and early irrigation can minimize the damage caused by the initial silicone hardening reaction and dilute contaminants. In addition to surgical intervention, the use of antimicrobial dressings, intravenous antibiotics, and systemic steroids is also recommended5,9. Allogeneic skin grafting, as a biological dressing, is an option until the wound bed is appropriately prepared to receive autografts or other definitive coverage. Local or regional flaps should be used to rebuild areas with exposure to deep structures. Despite reports of adjuvant therapies such as hyperbaric oxygen, intralesional corticosteroids, and topical immunomodulators, there are not yet enough studies validating their effectiveness. Liposuction does not seem to be effective in removing tissues impregnated with fibrous oil. The intense local fibrosis alone makes aspiration with cannulas difficult and increases the risk of injury to adjacent structures3,5. The National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária, Anvisa) prohibits the use of industrial-grade liquid silicone in cosmetic procedures, and its application is considered a crime against public health provided for in the Penal Code. For aesthetic purposes, polydimethylsiloxane (silicone) is the raw material for many prostheses and implants and must be handled by qualified people and in a hospital environment13. The exclusive use of the medical product containing silicone oil authorized by Anvisa is for the treatment of diseases of the retina to promote intraocular tamponade 9,14 . Therefore, its use is restricted to the doctor specialized in ophthalmology and is prohibited for facial fillings or body contour treatment15.
CONCLUSION The injection of industrial liquid silicone for aesthetic purposes to alter body contour is strongly contraindicated and is considered a crime against public health provided for in the Penal Code. Its misuse produces serious complications, challenging to treat and potentially fatal, as described in this case report.
COLLABORATIONS MM
Analysis and/or data interpretation, Conceptualization, Data Curation, Final manuscript approval, Methodology, Visualization, Writing - Original Draft Preparation
Rev. Bras. Cir. Plást. 2020;35(3):358-362
GGRM
Analysis and/or data interpretation, Conception and design study, Data Curation, Final manuscript approval, Formal Analysis, Methodology, Project Administration, Writing - Original Draft Preparation, Writing - Review & Editing
EfBB
Conception and design study, Data Curation, Final manuscript approval, Formal Analysis, Methodology, Writing Original Draft Preparation
DAM
Analysis and/or data interpretation, Conception and design study, Final manuscript approval, Formal Analysis, Methodology, Supervision, Validation, Writing - Original Draft Preparation
AAMJ
Final manuscript approval, Supervision, Validation, Writing - Review & Editing
RG
Analysis and/or data interpretation, Supervision, Writing - Review & Editing
REFERENCES 1. Behar TA, Anderson EE, Barwick WJ, Mohler JL. Sclerosing lipogranulomatosis: a case report of scrotal injection of automobile transmission fluid and literature review of subcutaneous injection of oils. Plast Reconstr Surg. 1993 Fev;91(2):352-61. 2. Winer LH, Sternberg TH, Lehman R, Ashley FL. Tissue reactions to injected silicone liquids. A report of three cases. Arch Dermatol. 1964 Dez;90:588-93. 3. Hage JJ, Kanhai RC, Oen AL, van Diest PJ, Karim RB. The devastating outcome of massive subcutaneous injection of highly viscous fluids in male-to-female transsexuals. Plast Reconstr Surg. 2001 Mar;107(3):734-41. 4. Andrews JM, Haddad CM, Ramos RR, Martins DMFS, Ferreira LM. Morbidade e mortalidade após injeção de silicone líquido em seres humanos. A Folha Médica. 1989 Ago;99(2). 5. Freitas RJ, Cammarosano MA, Rossi RHP, Bozola AR. Injeção ilícita de silicone líquido: revisão de literatura a propósito de dois casos de necrose de mamas. Rev Bras Cir Plást. 2008;23(1):53-7. 6. Chasan PE. The history of injectable silicone fluids for s o f t- t i s s u e a u g m e n t a t i o n . P l a s t R e c o n s t r S u r g. 2007;120(7):2034-40;discussion:2041-3. 7. Balkin SW. DPM injectable silicone and the foot: a 41-year clinical and histologic history. Dermatol Surg. 2005;31:1557. 8. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006 Set;118(3 Suppl):77S-84S. 9. Rohrich RJ, Potter JK. Liquid injectable silicone: is there a role as a cosmetic soft-tissue filler?. Plast Reconstr Surg. 2004 Abr;113(4):1239-41. 10. Gemperli R, Alonso N, Lodovici O, Pigossi N. Estudo clínico das reações sistêmicas e locais ao uso indevido do silicone líquido e/ ou óleo mineral. Rev Hosp Fac Med S Paulo. 1984;39(4):158-62. 11. Schmid A, Tzur A, Leshko L, Krieger BP. Silicone embolism syndrome: a case report, review of the literature, and comparison with fat embolism syndrome. Chest. 2005 Jun;127(6):2276-81. 12. Bartsich S, Wu JK. Silicone embolism syndrome: a sequela of clandestine liquid silicone injections. A case report and review of the literature. J Plast Reconstr Aesthet Surg. 2010;63(1):e1-3.
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13. Agência Nacional de Vigilância Sanitária (ANVISA). Portal ANVISA [Internet]. Brasília (DF): ANVISA; 2020; [acesso em 2020 Mar 10]. Disponível em: http://portal.anvisa.gov.br/ 14. Siqueira RC, Gil ADC, Jorge R. Cirurgia de descolamento de retina com injeção de óleo de silicone no sistema de vitrectomia transconjuntival sem sutura de 23-gauge. Arq Bras Oftalmol. 2007;70(6):905-9.
*Corresponding author:
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15. Agência Nacional de Vigilância Sanitária (ANVISA). Consultas [Internet]. Brasília (DF): ANVISA; 2020; [acesso em 2020 Fev 10]. Disponível em: https://consultas.anvisa.gov.br/#/ saude/253510028760211/
Gustavo Gomes Ribeiro Monteiro Rua Enéas de Carvalho Aguiar 255, Ribeirão Preto, SP, Brazil. Zip Code: 14020-130 E-mail: monteiroggr@hotmail.com
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Case Report Columellar reconstruction with chondrocutaneous graft after injury caused by CPAP Reconstrução de columela com enxerto condrocutâneo após lesão causada por CPAP GIOVANNA CALIL VICENTE FRANCO DE SOUZA 1* CLAUDIO MESSIAS MORAES 1 MARCOS ANTÔNIO TEIXEIRA DO AMARAL FILHO 1 SARA FERREIRA FARO 1 DANIEL DE CAZETO LOPES 1 RICARDO PORTELLA PERRONE 1
Institution: Guilherme Álvaro Hospital, Santos, SP, Brazil. Article received: April 29, 2019. Article accepted: July 8, 2019. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0063
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ABSTRACT
Introduction: Continuous positive pressure in the nasal airways (CPAP) is a non-invasive form of ventilation used in premature newborns in intensive care units. However, it can affect the nose of these patients, even evolving with ischemia and columellar necrosis. Several techniques are described to reconstruct the columella, such as skin grafts, composite grafts, local flaps, and free flaps, but the atrial chondrocutaneous graft has stood out. This study aims to describe a case of columella necrosis using CPAP with reconstruction using posterior atrial chondrocutaneous grafting. Case Report: A brown, female patient, with a history of prematurity and prolonged use of CPAP when she was born due to hyaline membrane syndrome, developed columella necrosis. The patient underwent posterior auricular chondrocutaneous grafting to reconstruct the columella. She presented a satisfactory surgical result, evolving with 100% graft vitality. Discussion: Columellar necrosis associated with the use of CPAP can be aesthetically and functionally debilitating, and represents a reconstructive challenge. The options for obtaining acceptable results are limited. However, the use of ear grafts is technically straightforward, uses structurally similar donor tissues, does not cause additional scarring on the nose, is performed in a surgical period, and generally has an excellent result. Posterior auricular composite grafting for columellar reconstruction proved safe, with satisfactory aesthetic and functional results and minimal morbidity in the donor area. Keywords: Acquired nasal deformities; Necrosis; Continuous positive airway pressure; Reconstructive surgical procedures; Autografts
Irmandade da Santa Casa da Misericórdia de Santos, Plastic Surgery and Burning Service, Santos, SP, Brazil.
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Columella reconstruction with chondrocutaneous graft
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Introdução: A pressão positiva contínua nas vias aéreas nasais (CPAP) é uma forma não invasiva de ventilação utilizada em recém-nascidos prematuros em unidades de terapia intensiva. Porém, ela pode acometer o nariz destes pacientes, evoluindo até mesmo com isquemia e necrose columelar. Diversas técnicas são descritas para reconstruir a columela, como enxertos de pele, enxertos compostos, retalhos locais e retalhos livres; mas o enxerto composto condrocutâneo auricular tem se destacado. O objetivo deste trabalho é descrever um caso de necrose de columela por uso de CPAP com reconstrução utilizando enxertia condrocutânea auricular posterior. Relato do Caso: Paciente do sexo feminino, parda, com história de prematuridade e uso prolongado de CPAP quando recém-nascida devido à síndrome da membrana hialina, evoluiu com necrose de columela. Foi submetida à enxertia composta condrocutânea auricular posterior para reconstrução da columela. A paciente apresentou resultado cirúrgico satisfatório, evoluindo com 100% de vitalidade do enxerto. Discussão: A necrose columelar associada ao uso do CPAP pode ser estética e funcionalmente debilitante, e representa um desafio reconstrutivo. As opções para obter resultados aceitáveis são limitadas, porém o uso de enxertos de orelha é tecnicamente simples, utiliza tecidos doadores estruturalmente semelhantes, não provoca cicatrizes adicionais no nariz, é realizado em um tempo cirúrgico e geralmente tem um resultado muito bom. A enxertia composta auricular posterior para reconstrução columelar se mostrou segura, com resultado estético e funcional satisfatório e mínima morbidade da área doadora. Descritores: Deformidades adquiridas nasais; Necrose; Pressão positiva contínua nas vias aéreas; Procedimentos cirúrgicos reconstrutivos; Autoenxertos.
INTRODUCTION Continuous positive airway pressure (CPAP) is a non-invasive form of ventilation used as a method of respiratory support in premature newborns in intensive care units as an alternative to endotracheal intubation and tracheostomy 1-6. However, due to immaturity, the nose of these patients can be easily affected 6 . Nasal injury is a relatively common consequence secondary to CPAP, with an incidence of around 13.2% to 50% 1,5, and can vary from edema and erythema to columellar laceration and necrosis3,5. Less than 1% of these patients develop irreversible ischemia and necrosis, resulting in a spectrum of nasal disfigurement2. Patients with functional and/or aesthetic impairment of columella after using CPAP may need intervention2. For columellar reconstruction, size, symmetry, color matching, skin texture, condition of the surrounding tissue, and donor area must be considered7. Several techniques have been described, and they include skin grafts, composite grafts, Rev. Bras. Cir. Plást. 2020;35(3):363-367
local flaps, and free flaps 7. Among these various procedures, the auricular chondrocutaneous graft is one of the most advantageous methods, as it allows the reconstruction of the structural cartilage together with the skin, in a single surgical time, in addition to the ear being considerably similar in shape, curve, color and texture to the columela1,7. The objective of this study is to report a case of an atrial chondrocutaneous graft for columellar reconstruction after necrosis using CPAP.
CASE REPORT Female patient, 4 years old, brown, with a history of prematurity (gestational age 31 weeks and 4 days) and fetal distress due to placental abruption, developed hyaline membrane syndrome, requiring mechanical ventilation for 16 days and continuous positive pressure in the nasal airways for another 8 days. As a result of using CPAP, he presented a columella lesion with local necrosis. On physical examination, a patient with no columella, with a consequent drop in the tip of the 364
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nose (Figure 1). For reconstruction, the posterior atrial chondrocutaneous graft was chosen.
Figure 3. Surgical marking.
Figure 1. Preoperative.
Patient in the supine position under general anesthesia. Surgical demarcation 1 (Figure 2) was performed on the columellar defect, with transversal lines at the upper and lower edges, joined by a median vertical line, and the donor area in the posterior region of the left ear with an ellipse (Figure 3). Incision over the ear tag, followed by removal of a composite graft containing skin, subcutaneous tissue, and cartilage. An incision was made over the nasal marking, making two lateral flaps. Graft positioning, with cartilage fitting at the base of the columella, followed by suturing it to the flaps (Figures 4 and 5). Compressive dressing made with gauze.
Figure 4. Posterior auricular chondrocutaneous grafting.
Figure 2. Scheme of surgical marking.
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The patient did not have any complications and was discharged from the hospital on the 1st postoperative day. The surgical wound showed no signs of complication, with a good appearance. The patient returned for outpatient follow-up and the graft was 100% vital (Figure 6). She will remain in follow-up until adolescence, to assess the need for re-approach for aesthetic refinement. Rev. Bras. Cir. Plรกst. 2020;35(3):363-367
Columella reconstruction with chondrocutaneous graft
Figure 5. Immediate postoperative.
for obtaining acceptable functional and cosmetic results are limited in the reconstruction of this delicate subunit, but the use of composite grafts is consistent with many fundamentals of plastic surgery8. Nasal reconstruction requires the management of several layers simultaneously in a three-dimensional shape7,8. The practice has shown advances since in 19859, surgeons Burget and Menick, proposed the principle of subunits of the nose10. Nasal columella has traditionally been a subunit that is difficult to repair due to its unique contours, limited availability of adjacent skin, and tenuous vascularization10. The simplicity and elegance of using compound ear grafts to repair such defects were already recognized in 18968. The procedure is technically straightforward, uses structurally similar donor tissues, does not cause additional scarring on the nose, performs in a surgical procedure, and usually has a very satisfactory result8. Posterior auricular composite grafting for columella reconstruction proved safe and had little technical difficulty in repairing the described lesion. The aesthetic and functional result was satisfactory, with minimal morbidity in the donor area.
COLLABORATIONS GCVFS
Conception and design study, Writing - Original Draft Preparation, Writing Review & Editing
CMM
Conception and design study, Writing - Original Draft Preparation, Writing Review & Editing
MATAF
Conception and design study, Writing Review & Editing
SFF
Conception and design study, Writing Review & Editing
DCL
Methodology, Supervision
RPP
Final manuscript approval, Supervision
REFERENCES Figure 6. Late postoperative.
DISCUSSION Although nursing initiatives have sought to reduce the incidence, nasal injury remains a common problem in preterm newborns who receive noninvasive respiratory support, especially in preterm infants born less than 30 weeks of gestation 2,3,5,6. Columellar necrosis associated with CPAP use can be aesthetically and functionally debilitating and represents a reconstructive challenge2. The options Rev. Bras. Cir. Plást. 2020;35(3):363-367
1. Chang CS, Swanson JW, Wilson A, Low DW, Bartlett SP. Columellar reconstruction following nasal continuous positive airway pressure injury. Plast Reconstr Surg. 2018 Jan;141(1):99e102e. 2. Chao JW, Raveendran JA, Sauerhammer TM, Rogers GF, Oh AK, Boyajian M. Columellar reconstruction after nasal continuous positive airway pressure associated necrosis. J Craniofac Surg. 2017 Jun;28(4):928-30. 3. Günlemez A, Isken T, Gökalp AS, Türker G, Arisoy EA. Effect of silicon gel sheeting in nasal injury associated with nasal CPAP in preterm infants. Indian Pediatr. 2010 Mar;47(3):265-7. 4. Yong SC, Chen SJ, Boo NY. Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: a randomised control study. Arch Dis Child Fetal Neonatal Ed. 2005 Nov;90(6):F480-3.
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5. Li Y, Sepulveda A, Buchanan EP. Late presenting nasal deformities after nasal continuous positive airway pressure injury: 33-year experience. J Plast Reconstr Aesthet Surg. 2015 Mar;68(3):339-43. 6. Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving noninvasive respiratory support: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018 Jan;103(1):F29-35. 7. Son D, Kwak M, Yun S, Yeo H, Kim J, Han K. Large auricular chondrocutaneous composite graft for nasal alar and columellar reconstruction. Arch Plast Surg. 2012 Jul;39(4):323-8.
*Corresponding author:
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8. Teltzrow T, Arens A, Schwipper V. One-stage reconstruction of nasal defects: evaluation of the use of modified auricular composite grafts. Facial Plast Surg. 2011 Jun;27(3):243-8. 9. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985 Ago;76(2):239-47. 10. Sherris DA, Fuerstenberg J, Danahey D, Hilger PA. Reconstruction of the nasal columella. Arch Facial Plast Surg. 2002 Jan/ Mar;4(1):42-6.
Giovanna Calil Vicente Franco de Souza Rua Alferes Ângelo Sampaio, 967, Apart. 801, Bairro Água Verde, Curitiba, PR, Brazil. Zip Code: 80250-120 E-mail: giovannacvfsouza@hotmail.com
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Case Report Piezoelectric preservative rhinoplasty: an alternative approach for treating bifid nose in Tessier No. 0 facial cleft Rinoplastia preservadora piezoelétrica: uma abordagem alternativa para tratamento de nariz bífido em fissura facial nº 0 de Tessier LUIZ CARLOS ISHIDA 1 RODOLFO COSTA LOBATO 1* BRUNO FERREIRA LUITGARDS 1 MARCELO JOSÉ MONTEIRO CARVAS 1 JUAN FELIPPE GUIMARÃES URCIOLI MOSQUERA DE RODRIGUEZ 1 ROLF GEMPERLI 1
Institution: Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, São Paulo, SP, Brazil. Article received: May 13, 2019. Article accepted: June 22, 2019. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0064
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The bifid nose management in Tessier nº 0 facial cleft is controversial due to its characteristics, such as a wide bone vault, low dorsal height, excessive skin, soft tissues volume, and distant upper and lower lateral cartilages. Conservative rhinoplasty techniques, using piezoelectric instruments, can be a good option for the bifid nose treatment, as they preserve the roof and upper lateral cartilages and perform a more accurate osteotomy. We report the treatment of bifid nose in a 13-year-old boy with facial cleft No. 0, to whom was performed conservative rhinoplasty with the aid of piezoelectric material. Given the excess of skin and soft tissues, a completely external transcutaneous approach was chosen. For osteotomies, lateral fractures under direct piezo-assisted vision were performed to have better control of the bone vault narrowing. The upper lateral cartilages and the internal nasal valves were preserved and brought back to the midline with horizontal “U” sutures to obtain a projection of the cartilaginous vault. A large segment of skin and soft tissue was excised after narrowing the nasal vault. A year of follow-up shows a narrow bone pyramid, better projection, and tip definition, but persisting with a vertically short nose. Conservative rhinoplasty techniques, assisted by piezoelectrics, may be an option for bifid nose treatment, requiring long-term follow-up and a study with more cases. Keywords: Nose; Nasal diseases; Rhinoplasty; Piezosurgery; Plastic surgery.
Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, São Paulo, SP, Brazil.
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Piezoelectric preservative rhinoplasty
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O manejo do nariz bífido na fissura facial de Tessier nº 0 é controverso devido às suas características, como uma ampla abóbada óssea, baixa altura dorsal, excesso de pele, volume de partes moles e cartilagens laterais superiores e inferiores distantes. Técnicas conservadoras de rinoplastia, utilizando instrumentos piezelétricos, podem ser uma boa opção para o tratamento do nariz bífido, pois preservam o teto e as cartilagens laterais superiores e realizam uma osteotomia mais precisa. Relatamos o tratamento de nariz bífido em um menino de 13 anos com fissura facial nº 0, no qual foi realizada a rinoplastia conservadora com auxílio de material piezoelétrico. Dado o excesso de pele e tecidos moles, optou-se por uma abordagem transcutânea completamente externa. Para osteotomias, fraturas laterais sob visão direta assistida por piezo foram realizadas para ter um melhor controle do estreitamento da abóbada óssea. As cartilagens laterais superiores e as válvulas nasais internas foram preservadas e reaproximadas à linha média com suturas em “U” horizontais, a fim de obter projeção da abóbada cartilaginosa. Um grande segmento de pele e tecidos moles foi extirpado após estreitamento da abóbada nasal. Um ano de acompanhamento mostra uma pirâmide óssea estreita, melhor projeção e definição de ponta, mas persistindo com um nariz verticalmente curto. Técnicas conservadoras de rinoplastia, assistidas por piezoelétricas, podem ser uma opção para o tratamento do nariz bífido, exigindo um acompanhamento a longo prazo e um estudo com mais casos. Descritores: Nariz; Doenças nasais; Rinoplastia; Piezocirurgia; Cirurgia plástica.
INTRODUCTION Facial cleft 0, described by Tessier, in 19761, can present with several alterations, including bifid nose, characterized by a wide and low nasal dorsum and bifid tip, which occur due to anatomical changes such as nasal bones and lateralized maxillary processes, horizontal upper lateral cartilages (ULC) and flat and hypoplastic wing cartilages, with malformed and asymmetric nostrils2. Surgical correction of the bifid nose is usually performed with chisel osteotomies and structured rhinoplasty, using cartilaginous septal grafts to correct cartilaginous anomalies3,4. Recent studies have shown that piezoelectric devices provide greater control in nasal osteotomies5,6. Some studies also emphasize the advantages of preservative rhinoplasty, such as avoiding an open roof, middle third collapse, and internal valve insufficiency 7,8. This article reports the treatment of bifid nose in a patient with Tessier No. 0 facial cleft by preservative and piezo-assisted rhinoplasty.
institution complaining about the dorsum and the nasal tip. In addition to the aesthetic complaint, the patient had psychological disorders due to social isolation and school bullying (Figure 1).
CASE REPORT A thirteen-year-old boy with a bifid nose was referred to the plastic surgery department of our Rev. Bras. Cir. Plást. 2020;35(3):368-372
Figure 1. A-F. Male patient, 13 years old, with bifid nose: frontal, base, lateral and 45º.
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After computed tomography, he showed a bifid nasal tip, alar and ULC lateralized, and distant nasal bones, defining the diagnosis of facial cleft No. 0, with no frontal dysplasia findings (Figure 2).
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Figure 2. A. 3D soft tissue reconstruction in computed tomography; B-E. 3D bone reconstruction - frontal, left 45º, basal and right 45º.
Despite being bifid, the nasal bones had a central spike that continued with the anomalous soft parts of the middle third. Both structures were resected: soft parts with a blade and bone part with piezoelectric, providing adequate exposure of the nasal bones and upper lateral cartilages. The nasal bones were medialized through lateral and medial osteotomies, performed with a piezoelectric osteotome, to minimize damage to the structures. The septal cartilage and ULC were preserved, without opening the cartilaginous roof, preserving the individual units of the internal nasal valve described by Saban, in 20187 and Ishida et al., In 19998. After detachment of zone K (separating the bone pyramid from cartilaginous), horizontal “U” sutures were performed, approaching the ULC that was horizontal and apart, narrowing the nose and raising the height of the nasal dorsum (Figure 4).
He underwent surgical correction with access through a diamond-shaped incision on the nasal dorsum, removing the non-elastic skin from the same area and extending the incision to the columella. An excess of abnormal soft tissues was identified in the middle third of the nose, occupying an area above the septum (bifid) and between the ULC, making them horizontal and distant. Although the alar cartilages were lateralized, their domes were normoplastic and well defined (Figure 3).
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Figure 3. A. Nasal dorsum skin to be resected; B. Medium wide third; C. Demarcation of excess soft tissue; D. Piezo-assisted resection of anomalous bone in the midline; E. Bone and soft tissue being resected; F. Horizontal and distant alar cartilages.
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Figure 4. A. Lateral osteotomy using a piezoelectric instrument; B. “U” points medializing the upper lateral cartilages; C. Soft tissue closure; D. Excess dry skin.
The treatment of the nasal tip was performed with interdomal points and between the medial crosses, and the primary closure of the surgical wound was performed in two planes, bringing together the soft parts preserved during the opening. Standard postoperative care was performed, and the result after one year was satisfactory for the patient (Figure 5). Rev. Bras. Cir. Plást. 2020;35(3):368-372
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Figure 5. Front, base, side and 45º views: A-D. Preoperative; EH. Postoperative.
DISCUSSION The bifid nose is part of the spectrum of midline facial malformations (Tessier No. 0-14) and may occur in isolation or associated with deformities of the lips, palate, and forehead9. In this case, we present a 13-year-old patient with Tessier No. 0 facial cleft who had an isolated bifid nose, whose treatment initially proposed was orthognathic surgery and later rhinoplasty, but this was not accepted by the patient and family, who only wanted rhinoplasty. It was tactically opted for external access through a diamond-shaped incision in the nasal dorsum, allowing broad access, dissection and visualization of redundant structures, resection of bone, and anomalous soft parts in the midline, as well as the use of piezoelectric instrumentation for osteotomies controlled. The literature varies concerning the appropriate age and access to treat isolated bifid noses. According to Saied and El-Sherbiny, in 20114, access in these cases varies according to the degree of the deformity; in cases with a small separation of the domus, transcolumellar marginal access may be sufficient for adequate correction10. On the other hand, cases with greater separation of the tip and cartilaginous back require better visualization and resection of excess skin and soft tissues, with the incision on the nasal dorsum being the access of choice2,3,4,9. We opted for access through the back as the patient had excess skin and, in our view, would not contract sufficiently after surgery if it were not resected. Despite the unpredictability of healing, especially in patients with black skin, other studies have shown similar maneuvers with good evolution2,3. Regarding the tip, the alar cartilages were not fragile or hypoplastic, allowing treatment with interdomal sutures. On the other hand, the ULC was released from the K zone and medialized, without opening the cartilaginous roof, avoiding the violation of the elements of the internal nasal valve7,8. In 20187 and Ishida et al., in 19998, Saban point out the advantages of preservative rhinoplasty, such as Rev. Bras. Cir. Plást. 2020;35(3):368-372
preservation of ULC and prevention of open roof and collapse of the middle third, which could occur in bifid noses after classical rhinoplasty3,4,9. Regarding bone treatment, Ortiz-Monasterio et al., in 198710, demonstrated that osteotomies should be routine in cases of bifid nose, regardless of age. In this case, piezoelectric instrumentation was used for more controlled osteotomies and resection of the bony dorsum to tune the upper nasal third. This technique allows osteotomies with less ecchymosis and postoperative morbidity and more precise control of the height of the osteotomy with less bone comminution5,6. A limitation of the case is the persistence of nasal shortening. In order to lengthen this type of nose, in our opinion, it would be necessary to use extended spacer grafts attached to a columellar strut, in addition to dorsal grafts, but we chose not to violate the septal cartilage to collect them at this time. This could be done in a surgical review, but the patient is satisfied with the height of the back achieved and does not admit further interventions. Conservative and piezoelectric-assisted rhinoplasty is an alternative approach for treating the bifid nose and has not yet been described in the literature. Long-term follow-up and more cases are needed to prove its efficiency in treating bifid nose. * All photos were authorized by the minor’s father, who signed the Free and Informed Consent Term and the photos’ publication term.
COLLABORATIONS LCI
Analysis and/or data interpretation, Conception and design study, Final manuscript approval, Writing - Original Draft Preparation
RCL
Conceptualization, Investigation, Realization of operations and/or trials, Writing - Original Draft Preparation, Writing - Review & Editing
BFL
Data Curation, Final manuscript approval, Investigation, Realization of operations and/or trials, Writing - Review & Editing
MJMC
Conceptualization, Realization of operations and/or trials, Supervision, Writing - Review & Editing
JFGUMR Conceptualization, Final manuscript approval, Investigation, Methodology, Writing - Original Draft Preparation RG
Conception and design study, Conceptualization, Supervision, Visualization, Writing - Review & Editing 371
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REFERENCES 1. Tessier P. Anatomical classification of facial, crânio-facial and látero-facial clefts. J Maxillofac Surg. 1976 Jun;4(2):69-92. 2. Kolker AR, Sailon AM, Meara JG, Holmes AD. Midline cleft lip and bifid nose deformity: description, classification, and treatment. J Craniofac Surg. 2015 Nov;26(8):2304-8. 3. Ozturk S, Zor F, Isik S. Surgical correction of severe bifid nose. J Cleft Lip Palate Craniofac Anomal. 2014;1(2):115-8. 4. Saied S, El-Sherbiny A. Algorithm for aesthetic reconstruction of the bifid nose in tessier number 0 cleft. J Plast Reconstr Surg. 2011 Jul;35(2):187-90. 5. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J. 2016 Jan;36(1):21-34.
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6. Ilhan AE, Cengiz B, Eser BC. Double-blind comparison of ultrasonic and conventional osteotomy in terms of early postoperative edema and study design and patient selection. Aesthet Surg J. 2016 Abr;36(4):390-401. 7. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018 Feb;38(2):117-31. 8. Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC. Treatment of the nasal hump with preservation of the cartilaginous framework. Plast Reconstr Surg. 1999 Mai;103(6):172933;discussion:1734-5. 9. Miller PJ, Grinberg D, Wang TD. Midline cleft: treatment of bifid nose. Arch Facial Plast Surg. 1999 Jul/Set;1(3):200-3. 10. Ortiz-Monasterio F, Fuente del Campo A, Dimopulos A. Nasal clefts. Ann Plast Surg. 1987 Mai;18(5):377-97.
Rodolfo Costa Lobato Rua Doutor Melo Alves, 55, Cj 23, Cerqueira Cesar, São Paulo, SP, Brazil. Zip Code: 01417-010 E-mail: rodolfolobato49@yahoo.com.br
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Case Report Nasal reconstruction with paramedian frontal flap after cancer resection Reconstrução nasal com retalho frontal paramediano após ressecção oncológica CARLOS MIGUEL PEREIRA 1* EDUARDO PINHEIRO VENTURELLI JÚNIOR 1 RODRIGO SILVA ROCHA 1 PAOLLA RIBEIRO GONÇALVES 1 FABIO NEVES SILVA 1 SÉRGIO DOMINGOS BOCARDO 1
Institution: Hospital Federal de Ipanema, Plastic Surgery, Rio de Janeiro, RJ, Brazil. Article received: May 31, 2019. Article accepted: July 8, 2019. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0065
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Introduction: Basal cell carcinoma is the most frequent type of tumoral lesion of the skin, often affecting the nasal region. The resulting defects require the use of nasal reconstruction techniques. The first plastic surgery described is the nasal reconstruction, according to the Indian method. Over the centuries, it has been the object of several modifications by the biggest names in the specialty, culminating in the paramedian frontal flap. Case Report: A 62-year-old male patient went to the Plastic Surgery Service of the Federal Hospital of Ipanema, presenting an ulcerated, scaly lesion, occupying the entire lateral region of the nose with three years of evolution, suggesting at physical examination malignant skin tumor. It was performed cutaneous lesion excision and immediate reconstruction with a paramedian frontal flap and further refinement surgery. Conclusion: Due to its vascularization by the supratrochlear artery and texture similar to the nasal tissue, the paramedian frontal flap is the gold standard for the correction of significant nasal defects. Keywords: Nasal neoplasms; Reconstruction; Acquired nasal deformities; Reconstructive surgical procedures; Surgical flaps; Case reports.
Hospital Federal de Ipanema, Plastic Surgery, Rio de Janeiro, RJ, Brazil.
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Nasal reconstruction after cancer resection
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Introdução: O carcinoma basocelular é o tipo mais frequente de lesão tumoral de pele acometendo frequentemente a região nasal. Os defeitos resultantes exigem o emprego de técnicas de reconstrução nasal. A primeira cirurgia plástica descrita é a reconstrução nasal segundo o método indiano. Ao longo dos séculos sofreu diversas modificações pelos maiores nomes da especialidade, culminando no retalho frontal paramediano. Relato do Caso: Paciente do sexo masculino, 62 anos, apresentou-se no serviço de Cirurgia Plástica do Hospital Federal de Ipanema com lesão ulcerada, descamativa, ocupando toda a região lateral do nariz com três anos de evolução, sugestiva ao exame físico de tumor maligno de pele. Foi realizada exérese da lesão cutânea e imediata reconstrução com retalho frontal paramediano e posterior cirurgia de refinamento. Conclusão: Devido à sua vascularização pela artéria supratroclear e textura semelhante ao tecido nasal, o retalho frontal paramediano constitui-se como o gold standard para a correção de grandes defeitos nasais. Descritores: Neoplasias nasais; Reconstrução; Deformidades adquiridas nasais; Procedimentos cirúrgicos reconstrutivos; Retalhos cirúrgicos; Relatos de casos.
INTRODUCTION
CASE REPORT
The first description of nasal reconstruction was made around 700 B.C in the treatise of Ayurveda medicine called Sushruta Samhita. Although performed since ancient times, the Indian method was only published in the 18th century in the Madras Gazette of Bombay1. In 1597, Tagliacozzi published a series of works in which he described the reconstruction of the nose using forearm flaps; this became known as the Italian method2. During the 19th century, Blasius, Dieffenbach, and Petrali expanded the internal coating method in addition to the external one2. Gillies, Converse, Kazanjian, and Millard perfected the method throughout the 20th century, with new flap designs and restoring methods of nasal support. Kazanjian consecrated the median frontal flap in the United States in the 20th century first half3. In the 80’ and 90’, Burget and Menick3,4, with their principles of nasal aesthetic subunits and the analysis of facial vascularization, established the paramedian frontal flap as the preferred method for nasal reconstruction. The work’s objective is to illustrate a case of nasal cutaneous tumor exeresis and its immediate reconstruction with a paramedian frontal flap, demonstrating its importance in nasal reconstruction surgery.
62-year-old male patient with a history of ischemic stroke 40 years ago with sequelae of monoparesis of the right upper limb, with no smoking or drinking habits. He presented an ulcerated, scaly lesion, occupying the entire left lateral region of the nose with three years of evolution, suggesting a malignant skin tumor (Figures 1 and 2).
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Figure 1. Preoperative in frontal view.
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The flap was rotated, positioned over the defect, refined and sutured to the edges with 5-0 nylon thread. The donor region was sutured in regions eligible for coaptation. An elastic suture was applied in the remainder, leaving the resulting central defect to heal by second intention (Figures 4 and 5).
Figure 2. Preoperative in oblique view.
Under general anesthesia and after due asepsis, the tumor lesion to be excised was marked with a 4 mm safety margin and infiltrated with an anesthetic solution of 1% lidocaine + adrenaline 1: 200,000. The tumoral lesion was extensively resected, and the piece sent for the intraoperative freezing examination which revealed to be a superficial basal cell carcinoma with free limits. Then, the paramedian frontal flap was marked according to the Gillies 3 drawing “up and down” (Figure 3). Resulting defect dimensions were considered and were respected the flap limits described by Menick in 20023: approximately 2 cm lateral to the midline near the eyebrow head and with a pedicle width of approximately 1, 5 cm in the vertical direction. The flap was detached distal-proximally, dissecting initially in the subcutaneous plane and more proximally in the juxtaperiosteal plane.
Figure 4. Transoperative showing the elastic suture of the donor area.
Figure 5. Immediate postoperative showing the obtained nasal reconstruction.
Figure 3. Transoperative showing the nasal defect and the flap design.
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Four weeks later, the flap pedicle’s transection was performed with the repositioning of the eyebrow head. Finally, the flap was refined with degreasing and rotation of the left nasal wing. Rev. Bras. Cir. Plást. 2020;35(3):373-377
Nasal reconstruction after cancer resection
After three months of post-surgery, the patient was clinically well, without functional complaints, although he had highlighted a disturbance regarding the aesthetic result, the donor area was practically healed. We then opted for nasal refinement surgery, which was performed in the sixth postoperative month. In the subsequent follow-up, at 9 months postoperatively, the patient was satisfied with the functional and aesthetic result (Figures 6 and 7).
Figure 7. 9-month postoperative period showing the result obtained.
Figure 6. 9-month postoperative period with demonstration of the result obtained.
DISCUSSION Basal cell carcinoma is the most common malignant skin tumor in our daily practice. In the present case, it was a superficial defect, although large (greater than 1.5 cm)5, reaching four of the aesthetic subunits of the nose: lateral wall, wing, back, and nasal tip. The principle of aesthetic subunits described by Menick, in 20104, advocates that if the subunit is affected in more than 50% of its area, it must be removed entirely, which is particularly useful in the subunits of the lower third of the nose because its curved and prominent lines could result in more apparent scarring. Rev. Bras. Cir. Plást. 2020;35(3):373-377
In the present case, this principle was not strictly followed, taking into account the already considerable dimensions of the initial defect and the respect for the surgical safety margin. Although several techniques can be used, the paramedian frontal flap is particularly safe, reliable, and reproducible. Its vascularization through the supratrochlear artery makes the frontal region skin the most similar in color and texture to that of the nose6,7. The flap’s design can be presented in different forms, from oblique to a “gull” format by Millard5, passing through the “up and down” by Gillies3. The paramedian frontal flap vascularization is mainly done by the supratrochlear vessels. These pass over the orbital margin externally to the periosteum, follow vertically upwards within the frontalis muscle, and assume a subdermal position next to the capillary line5. The pedicle is usually sectioned four weeks after the first surgery, configuring the surgery in two stages, being this one the most traditional7. In 2010, Menick 4 advocated surgery in three stages, with an intermediate phase of “debulking,” especially indicated in smoking patients, with previous scars or full-thickness defects. The donor area, with a significant defect, was approached with an elastic suture according to Nigri, in 20118, the remainder being left to heal by second intention, which was not a problem8. As expected in two-stage surgery, refinement surgery was necessary. In this case, flap degreasing and nasal wing rotation were performed. The patient was 376
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satisfied with the aesthetic and functional result, and the refinement process was not continued.
FNS
Writing - Review & Editing
SDB
Supervision
CONCLUSION
REFERENCES
The paramedian frontal flap allows the transfer of tissue to the nasal region efficiently and safely with little morbidity in the donor area, allowing a malleable and similar coverage to the nasal tissue with excellent viability.
1. Cintra HPL, Bouchama A, Holanda T, Jaimovich CA, Pitanguy I. Uso do retalho médio-frontal na reconstrução do nariz. Rev Bras Cir Plást. 2013;28(2):212-7. 2. Baker SR. Principles of nasal reconstruction. Maryland, US: Mosby; 2002. 3. Menick FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002 Mai;109(6):1839-55;discussion:1856-61. 4. Menick FJ. Nasal reconstruction. Plast Reconstr Surg. 2010 Abr;125(4):138e-50e. 5. Quintas RCS, Araújo GP, Medeiros Junior JHGM, Quintas LFFM, Kitamura MAP, Cavalcanti ELF, et al. Reconstrução nasal complexa: opções cirúrgicas numa série de casos. Rev Bras Cir Plást. 2013;28(2):218-22. 6. Costa MJM. Versatilidade do retalho médio-frontal nas reconstruções faciais. Rev Bras Cir Plást. 2016;31(4):474-80. 7. Menick FJ. Nasal reconstruction: forehead flap. Plast Reconstr Surg. 2004;113(6):100e-11e. 8. Santos ELN, Oliveira RA. Tratamento de ferida com uso de sutura elástica. Rev Bras Cir Plást. 2014;29(4):587-8.
COLLABORATIONS CMP
Analysis and/or data interpretation, Conception and design study, Data Curation, Writing - Original Draft Preparation
EPVJ
Software
RSR
Data Curation
PRG
Analysis and/or data interpretation
*Corresponding author:
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Carlos Miguel Pereira Rua Gomes Carneiro, 155, Apart. 1201, 22071-110, Ipanema, RJ, Brazil. Zip Code: 22071-110 E-mail: carlosmppereira@hotmail.com
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Special Article Speed in surgery: 10 quick tips to increase confidence and manual training on the young plastic surgeon Velocidade em cirurgia: 10 dicas rápidas para elevar a confiança e o adestramento manual do jovem cirurgião plástico GIBRAN BUSATTO CHEDID 1* PAULA GIRELLI 2 CARLOS OSCAR UEBEL 1,3
■
ABSTRACT
The purpose of this article is to show 10 quick tips that aim to aid in the development of confidence, improvement of manual skill, and surgical planning in the daily training routine of the young plastic surgeon; skills capable of reducing overall surgical time without compromising the meticulousness of the movements performed. Keywords: Teaching hospitals; Plastic surgery; General surgery; Motor dexterity; Learning curve.
■ Institution: Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil. Article received: April 1, 2019. Article accepted: July 15, 2020. Conflicts of interest: none.
DOI: 10.5935/2177-1235.2020RBCP0066
RESUMO
O presente artigo tem como objetivo demonstrar 10 dicas rápidas que tem como alvo o auxílio no desenvolvimento de confiança, de melhora da habilidade manual e de planejamento cirúrgico na rotina diária de treinamento do jovem cirurgião plástico; habilidades capazes de promover redução do tempo cirúrgico global, sem comprometer a meticulosidade dos movimentos realizados. Descritores: Hospitais de ensino; Cirurgia plástica; Cirurgia geral; Destreza motora; Curva de aprendizado.
Sociedade Brasileira de Cirurgia Plástica, Porto Alegre, RS, Brazil. Ernesto Dornelles Hospital, Residency in General Surgery, Porto Alegre, RS, Brazil. 3 São Lucas Hospital, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil. 1 2
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INTRODUCTION Learning and developing surgical skills is an active process that requires commitment and effort. We can identify three main stages of this learning process. The first stage consists of a cognitive phase that involves receptive learning techniques that include reading and also listening and watching specific tasks. The second stage of learning consists of an integrative guided process that allows the cognitive techniques learned to be incorporated into a structure that qualify the beginning surgeon to perform the steps of a surgical procedure. However, still, without the presence of fluidity obtained only with the continuous practice and experience that characterizes the third and last stage. In this autonomous phase, the surgeon gains confidence and self-direction of decisions without supervision from a more experienced surgeon. In the 1890s, William Stewart Halsted became the first chief surgeon in the Johns Hopkins Hospital surgery teaching program in the United States, and thus the embryo of what would be the medical residency program was created. Over the years and the development of medical specialties such as plastic surgery, since the dawn of medicine, surgeons around the world have learned from the master-apprentice model by following the observation, action, repetition, and teaching of the acquired technical acts. The development of an excellent manual technique is essential for the safety of the surgical procedure that must be performed smoothly and in a linear manner. The brief operative time considerably reduces the patient’s exposure to surgical trauma. This lesser exposure to movements imposed by the surgeon, generates a less inflammatory response to surgical trauma, with less stress hormones release, less risk of thromboembolic and infectious complications, less time of exposure to anesthetics, and, therefore, less overall risk of intra and postoperative complications. Let us see the words of the exponent of world plastic surgery Sir Harold Gillies, who already had the principle and taught his disciples the following maxim: “speed in surgery consists of not doing the same thing twice”. In order for us to accomplish this feat of following the steps of surgery linearly and synchronously, we first of all need to be prepared both at the level of surgical planning and at the technical level, so that we can thus avoid the need for repairs to our movements intraoperative, generating a surgical procedure driven by fluidity, synchrony, and safety1,2,3. OBJECTIVE The present work aims to show 10 quick tips to aid in the development of confidence, improvement of Rev. Bras. Cir. Plást. 2020;35(3):378-383
manual skill and surgical planning in the daily training routine of the young plastic surgeon, producing an improvement in the overall operative time without compromising the meticulousness of the movements performed.
METHODS Tip number 1 - Planning the surgery: the “airplane pilot” mode We recommend that the day before the surgery, step-by-step written planning to be used at the time of the operation is carried out. A preoperative checklist realization, with all the steps to perform during the surgery, is a great way that serves as a guide during the surgery performed. When performing the manual description of the surgery to be made, all steps to be completed must be carefully memorized, repeating the checklist and reading it carefully so that it is unnecessary to check during the procedure, verifying it only in cases of need. We compare the realization of the surgery planning at this moment, to which the pilot of aviation preparing for an intercontinental trip carries out. He prepares his travel plan, records it in the logbook, and foresees all the steps and directions to be used in the trip and checks all materials, items, and devices to be used. Therefore, avoid maneuvers and unplanned situations, anticipating and reviewing until the complete memorization of the step by step of the surgery in question. Tip number 2 - Preoperative marking: writing the map of the mine With a thorough preoperative marking, the novice surgeon avoids the temptation to modify the surgical plan previously established to carry out the surgery. We recommend that the marking be done in a quiet environment, without haste, before anesthetic induction, in an appropriate room (office), with the patient in a comfortable position and informed of the need for such drawings. The drawings must be accurate, following the patient’s natural relief. We use here, colored pens for different anatomical divisions, which will help guide us when making the incisions. Marking the patient before entering the operating room avoids the use of time in the operating room, speeds up the work of the anesthesiologist and nursing professionals, and avoids unnecessary movements because planning changes. At that time, the plastic surgeon must have all the patience and thoroughness in the execution of the drawings, meticulously made, 379
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so that at the moment of the surgery, he only needs to follow the paths indicated by the previously planned and drawn lines. Always remembering this principle: surgery begins in the office. Tip number 3 - Holding the scalpel: supported violin bow technique Once the preoperative planning and marking are completed, we proceed to the start of our actual surgical work. The correct handle of the scalpel can be important to perform an effective and precise dieresis, obeying anatomical plans, avoiding accidents and unwanted movements. We recommend the position we call the supported violin bow, where the surgeon wields the scalpel handle between the first, second and third fingers, using the fifth finger extended to form an angle of support with the incised surface, using it as a guide for stabilization and depth of movement. (Figure 1). The support of the tip of the fifth finger on the adjacent skin promotes, in large incisions, when necessary, the precise shape, ensuring the blade in a position perpendicular to the tissue to be incised, avoiding deepening of the dieresis zone.
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precision in the movements performed. In cases where the wrists cannot be supported on the table, such as during the cauterization of a deep area or in the making of the pocket for breast implant prosthesis, we can use our own anterior superior iliac spines as support. By supporting the elbows on the flanks, on top of the anterior superior iliac spines, the plastic surgeon acquires a support base to perform the precise movement, imitating the support of the wrists on the operating table in cases of positional impossibility. Tip number 5 - Finger extension: the anatomical forceps The anatomical forceps are widely used in plastic surgery in practically all procedures performed under the body surface. Correct gripping of the forceps between the fingers can save time and offer a comfortable working position, avoiding unnecessary tissue handling and trauma in unwanted areas. We recommend that the anatomical forceps be used between the first and second fingers, making use of the third finger to support the dissected tissue, generating a slight protrusion of the tissue, carried out with the internal rotation of the wrist and exposure of the tissue fibers to dissected, thus maintaining a better approach and a 90-degree dieresis angle concerning tissue fibers (Figure 2).
Figure 1. The scalpel handle is held between the first, second and third fingers, using the fifth finger extended to form a support angle with the incised surface. A useful guide for stabilization and depth of movement.
Tip number 4 - Fine-tuning: Avoiding tremors with the supported wrist technique To proceed with precise movements, especially in delicate areas such as the face that have essential anatomical structures, we need to work with maximum precision in our movements. Here we recommend using the supported wrist technique. By supporting the wrists on the operating table or even gently on the patient’s body areas adjacent to the incision, we can avoid small tremors resulting from the surgeon’s muscle stress. Widely used during surgeries using microscopes, this simple technique offers excellent 380
Figure 2. Forceps held between the first and second fingers, using the third finger to support the dissected tissue, generating a gentle protrusion of the tissue, performed with the internal rotation of the wrist.
Tip number 6 - Suturing: flat needle holder technique Holding the needle holder impaled with the upper ring touching the hand’s thenar eminence and with the fourth finger resting on the lower ring, we can perform the movement of opening, gripping, and closing the rack more quickly and accurately. A small medial movement is performed with the region of the thenar and lateral eminence with the fourth finger, generating friction of the needle holder’s upper ring at Rev. Bras. Cir. Plást. 2020;35(3):378-383
Speed in surgery: 10 quick tips
the thenar eminence and thus opening it with a short and precise movement under the flat hand. When performing the suture, we used the needle holder’s angled removal, already positioning the needle for the subsequent movement. This technique is widely used in performing large plications as in abdominal surgeries that require large amounts of stitches to be performed. Here, when inserting the needle at the end of the tissue to be sutured, the surgeon first performs an internal rotation movement with the wrist passing 3/4 of the needle area between the tissue (Figure 3). Once this movement was carried out, the surgeon now performs an external rotation of the wrist, attaches the needle end to the tip of the needle holder again, removing it from the tissue and thus with a 180-degree rotation movement of the needle holder, leaning on his first and second fingers, reestablish the position for the next movement. Thus, the needle - needle holder complex is already prepared, not requiring the needle’s manual repositioning at the tip of the needle holder.
with the second finger under one of its rods, for better positioning of the cut and performing opposite traction movements of the blades, with the help of the first and third fingers of the left hand positioned on the rings of the instrument. The first finger makes traction in the upper direction, and the third finger performs the movement in the lower opposite direction, generating the shearing movement and producing the cutting of the proposed tissue (Figure 4).
Figure 4. Opposite forces generating the shear cut.
Tip number 8 - Observe, realize, and teach: learning to learn
Figure 3. Needle holder impaled with the upper ring touching the thenar eminence of the hand and the fourth finger resting on the lower ring. A small medial movement is performed with the region of the thenar and lateral eminence with the fourth finger, generating friction of the upper ring of the needle holder in the thenar eminence and opening it.
Tip number 7 - Using your left hand: understanding the scissors shear The training of both hands to perform surgical movements is extremely important for an optimal operative time. The use of surgical scissors with the left hand is necessary in cases where we do not have proper spatial positioning on the tissues to be dissected or threads to be cut with the right hand. The surgeon can make a precise cut with the surgical scissors positioned in his left hand. We start with an understanding of how scissors produce their cut. The scissors have two blades that, once articulated, perform the tissues’ dieresis using the principle of the action of mechanical shearing forces, applied under lever motion. Thus, in cases where it is necessary to use surgical scissors on the surgeon’s left hand, it is recommended to support it Rev. Bras. Cir. Plást. 2020;35(3):378-383
The observation of more experienced surgeons is of the paramount value for the development of the mastery of the apprentice surgeon. By carefully observing the movements of a senior surgeon, we try to pay attention to the small details of his movements’ fluidity and the stages of the surgery in which he gives greater or lesser speed to his maneuvers. We recommend observing the most significant number of different surgeons and different surgeries. After observing and memorizing the steps and maneuvers, we then try to repeat them in our daily surgical practice, respecting each professional’s surgical style and personality. The learning pyramid shows that 20% of what we memorize and retain comes from audiovisual media, 75% of what we practice, and 90% of what we can teach. We, therefore, recommend that you learn to teach in order to learn 3,4. Tip number 9 - Identifying errors with the mirror effect One of the most significant benefits that we can have in our journey to surgical mastery is the knowledge of the art of recognizing our own mistakes. The early identification of defects and manias must be carried out, and such mode must be set aside. The advent of portable video cameras is of great value so 381
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that the young surgeon can closely observe his way of operating. Maintaining the habit of videotaping the surgical procedures helps to improve the surgical style, which must always be precise and gentle with the tissues handled. Tip number 10 – Keeping the focus: respecting the patient’s integrity The moment of the surgery requires total and absolute concentration from the plastic surgeon. Small distractions can be catastrophic during the manipulation of delicate structures that can easily generate irreparable sequelae, both physically and psychically, and with unsatisfactory results for the patient and the surgeon. We must have the habit of demanding maximum silence and concentration inside the operating room, avoiding distractions with music and side conversations that should be left for leisure hours. Even small, seemingly tiny distractions can ultimately increase the time of surgery, the risk of unplanned untimely movements and the risk of serious injuries, such as nerve injuries, so difficult to repair. The surgical procedure must be seen as a moment of total respect and dedication to the patient who gives us permission and confidence to exercise our work on his valuable and unique body. For this solid relationship of trust to be honored, the surgeon must remain in absolute concentration during his medical act, maintaining serenity, calm, and active posture in the face of surgical movements. RESULTS With the use of the ten tips, the novice plastic surgeon has the opportunity to obtain a possible improvement in his surgical time, reducing the time of exposure of the patient to operative trauma, avoiding the most adverse situations and seeking the benefit and maintenance of his patient’s health, without losing the meticulousness in performing a plastic surgery procedure. Countless factors are of relevance when it comes to surgical competence and ability. Elements such as knowledge, communication, decision-making ability, and psychological characteristics are factors that can be compared and analyzed, however, measuring the skill and technical competence of the young surgeon who begins his training in plastic surgery is always difficult to perform. In order for there to be an adequate and stimulating level of learning for the young plastic surgeon, the supportive relationship between colleagues in the medical residency programs must be emphasized and the strengthening of the bonds between the teaching staff and the students5. Different teaching methods must be encouraged so 382
that the beginning surgeon has a wide range of ways of absorbing the daily technical practice of our specialty. DISCUSSION Technical learning is closely linked to an initial cognitive phase in which instruction for the task occurs with a demonstration by the instructor (teacher/ preceptor), which must be based on trust and respect and followed by the acquisition of knowledge. Subsequently, an associative phase takes place, in which the repeated practice of the task associated with the instructor’s “feedback” to eliminate the possible errors of the practiced task, consequently generates the acquisition of the sought skill. At the end of these two initial stages, the plastic surgeon in training is faced to an autonomous phase where the self-sustained performance of tasks occurs, practically without the need for corrections and developing the habit of teaching6,7. CONCLUSION The way we learn is decisive in the development of how we will teach, so the attention to learning and teaching techniques guided by close professional ties must be continuous, daily, and continually evolving, encouraging repetition, study, observation, and technical-scientific production8,9,10. We can use our quick tips that, combined with the daily practice routine, bring one more proposal regarding the teaching and learning method, emphasizing the development of the habit of observation, action, and teaching. It offers the novice plastic surgeon an effective method of technical improvement, based on meticulous planning and active posture so that during the operation there is a low rate of surgical trauma, an increase in confidence in performing tasks and, especially, the path to our final destination: the safety of our patients.
COLLABORATIONS GBC
Conception and design study, Validation, Writing - Review & Editing
PG
Conceptualization, Final manuscript approval, Validation, Writing - Review & Editing
COU
Project Administration, Supervision REFERENCES
1. Bamji A. Sir Harold Gillies: surgical pioneer. Trauma. 2006;8(3):143-56. 2. Gillies SH, Millard DR. The principles and art of plastic surgery. London: Butterworth & Co.; 1957. 3. Kotsis SV, Chung KC. Application of the see one, do one, teach one concept in surgical training. Plast Reconstr Surg. 2013 Mai;131(5):1194-201.
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Speed in surgery: 10 quick tips 4. Khan MS, Bann SD, Darzi AW, Butler PEM. Assessing surgical skill using bench station models. Plast Reconstr Surg. 2007;120(3):793-800. 5. Rohrich RJ, Weber RA. Are teachers born or do they develop over time?. Plast Reconstr Surg. 2012 Mai;129(5):1209-11. 6. Grunwald T, Krummel T, Sherman R. Advanced technologies in plastic surgery: how new innovations can improve our training and practice. Plast Reconstr Surg. 2004 Nov;114(6):1556-67. 7. Kopta JA. The development of motor skills in orthopaedic education. Clin Orthop Relat Res. 1971 Mar/Abr;75:80-5.
*Corresponding author:
8. Collins A, Brown JS, Newman SE. Cognitive apprenticeship: teaching the crafts of reading, writing, and mathematics. In: Resnick LB, ed. Knowing, learning, and instruction: essays in honor of Robert Glaser. Hillsdale, NJ: Lawrence Erlbaum Associates; 1989. p. 453-94. 9. Clark CI, Snooks S. Objectives of basic surgical training. Br J Hosp Med. 1993 Out;50(8):477-9. 10. Baldwin PJ, Paisley AM, Brown SP. Consultant surgeonsâ&#x20AC;&#x2122; opinion of the skills required of basic surgical trainees. Br J Surg. 1999 Ago;86(8):1078-82.
Gibran Busatto Chedid Rua Mostardeiro, 157, Sala 606, Porto Alegre, RS, Brazil. Zip Code: 90430-001 E-mail: gichedid@hotmail.com
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Letter to the Editor Social media and scientific knowledge Redes sociais e conhecimento científico MURILO SGARBI SECANHO 1* MARCELO HANATO SANTOS 1 MATHEUS DE CARVALHO SALES PERES 1 BALDUINO FERREIRA DE MENEZES NETO 1 ARISTIDES AUGUSTO PALHARES 1 FAUSTO VITERBO DE OLIVEIRA NETO 1
Dear editor, Social networks have become information tools with pulsating content, with the ability to disseminate knowledge interactively and practically. In plastic surgery, it is not different. American and European journals adopt Twitter, Facebook, and Instagram to disseminate their publications among specialist doctors, residents, and lay public1. Journal clubs, classes, case discussions, podcasts are held on these platforms, encouraging the participation of readers2. The exchange of knowledge brings everyone together and creates a stimulating environment, especially for residents, encouraging the reading of articles in these publications and dissemination to patients. Evidence also points to the role of social networks in increasing the journal’s impact factor, not only in plastic surgery but also in other specialties3. Given the benefits demonstrated in the literature, for greater dissemination of articles from the Revista Brasileira de Cirurgia Plástica (RBCP), as well as creating new knowledge platforms and encouraging participation among readers, we suggest the creation of official RBCP profiles on social networks.
REFERENCES Institution: Universidade Estadual de São Paulo, Faculty of Medicine of Botucatu, Botucatu, SP, Brazil. Article received: March 10, 2020. Article accepted: July 15, 2020. Conflicts of interest: none.
*Corresponding author:
1
1. Branford OA, Kamali P, Rohrich RJ, Song DH, Mallucci P, Liu DZ, et al. #PlasticSurgery. Plast Reconstr Surg. 2016;138(6):1354-65. 2. Asyyed Z, McGuire C, Samargandi O, Al-Youha S, Williams JG. The use of Twitter by plastic surgery journals. Plast Reconstr Surg. 2019 Mai;143(5):1092e-8e. 3. O’Kelly F, Nason GJ, Manecksha RP, Cascio S, Quinn FJ, Leonard M, et al. The effect of social media (#SoMe) on journal impact factor and parental awareness in paediatric urology. J Pediatr Urol. 2017 Out;13(5):513.e1-e7. DOI: http://dx.doi.org/10.1016/j. jpurol.2017.03.027
Murilo Sgarbi Secanho Avenida Professor Montenegro s/n, Botucatu, SP, Brazil. Zip Code: 18618-687 E-mail: murilo_sgs@hotmail.com
Universidade Estadual de São Paulo, Faculty of Medicine of Botucatu, Department of Surgery and Orthopedics, Botucatu, SP, Brazil.
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Response DOV GOLDENBERG 1
Dear reader, We appreciate the letter and consider its subject to be pertinent. The Revista Brasileira de Cirurgia Plástica (RBCP), as well as the Sociedade Brasileira de Cirurgia Plástica (SBCP), invest in continuous efforts to disseminate scientific content. In particular, the articles published in the RBCP, have been published on its own website and SBCP’s corporate media. Our current objective is to increase the penetration of scientific information, permeating, as suggested, the most comprehensive social networks with news and discussions about the scientific articles published in our Journal.
1
Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil.
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Letter to the Editor Investigation of ethical and scientific irregularities contained in the article published by the Revista Brasileira de Cirurgia Plástica Investigação de irregularidades éticas e científicas contidas no artigo veiculado pela Revista Brasileira de Cirurgia Plástica NELSON ALBINO NETO1*
Institution: EFCAN Advogados, Jurídico São Paulo - SP - Brazil Article received: July 15, 2019. Article accepted: Septembe 22, 2020.
*Corresponding author:
1
With due respect to the authors’ professional background, we think that the article distances itself from the ethical and scientific precepts that it should respect. Initially, it should be noted that the article was not submitted to the Research Ethics Committee, in a notorious affront to Resolution No. 466/12 and Circular Letter No. 166/2018, of the National Health Council. Furthermore, the report presents inconsistencies that denote the authors’ apparent intention to crucify the use of polymethylmethacrylate (PMMA) in cosmetic procedures. In this sense, the statement that PMMA was the causative agent of adverse effects stands out, without there being any evidence for it. The authors did not seek anatomopathological evidence that PMMA was used in the reported procedure. Therefore, it does not seem ethical or scientific to mention PMMA in the article’s title without at least evidence of its use in the investigated procedure. Finally, given the circumstances in which the procedure was performed, the possibility of using an inappropriate product cannot be excluded. Therefore, the mention of PMMA in the title and content of the article, without any evidence that the product was, in fact, the agent causing the adverse effects, does not respect the basic rule of a scientific article, that the conclusion must correspond to the objective of the work. For these reasons, sure that the article does not conform to the ethical and scientific standards that it must respect, we ask the editor for the appropriate measures.
Nelson Albino Neto Rua Joaquim Floriano, n. 72, 6º andar, São Paulo, SP, Brazil. Zip Code: 04534-000 E-mail: nalbino@efcan.com.br
EFCAN Advogados, Jurídico, São Paulo, SP, Brazil.
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Response KLEBER TETSUO KURIMORI 1 DIMAS ANDRÉ MILCHESKI 1
1
Letter in response to the letter to the editor entitled “Investigation of ethical and scientific irregularities contained in the article published by the Revista Brasileira de Cirurgia Plástica.” The authors of the article “Severe complication of the irregular use of PMMA: case report and the current Brazilian situation” are available to clarify any doubts not addressed in the text of the published article; also, they reinforce their commitment to medical ethics and research ethics. Following the Revista Brasileira de Cirurgia Plástica (RBCP) recommendations and guidelines, we affirm that we fulfill all ethical requirements for the publication of the case report. Such requirements can be accessed through the electronic address: http://rbcp.org.br/instructions-for-authors. It is worth mentioning that it is not required by the RBCP to submit articles such as “case report” to the Research Ethics Committee, but rather an Informed Consent Form signed by the patient. It is also noteworthy that when collecting the signature of the said consent form, the patient was of legal age and fully aware and agreed with the case report’s disclosure. The term was correctly presented and following legal criteria. We refute the intention to crucify the use of PMMA, since we report precisely its use in an irregular and improper way and its consequences. There is no declared position of the authors regarding its use in aesthetic procedures, but verification and publications made by regulatory entities (ANVISA) and medical entities (CRM, CFM, SBCP, and SBD). These can be reviewed in the bibliographic references of the article. We affirm that six attempts were made to identify exogenous material with an anatomopathological examination in the various tissue samples obtained from each debridement surgery. However, such identification was not possible due to the intense necrosis identified, as it is reported in this transcript of the article: suppuration and necrosis of the dermis (Figure 3) and subcutaneous cellular tissue with nodular formations containing pus and exogenous material, as well as signs of bilateral gluteus maximus fasciitis. “ We agree with the statement that the possibility of using an inappropriate product cannot be excluded. This observation is in the discussion of the article: “In the case described, it can be said that both the quality of the product and the technique used are questionable. In this case, the combination of actions not recommended led to the case’s complication and dramatic evolution. “ Finally, we conclude that in the Brazilian context, and with the Federal Council of Medicine (CFM) alert since 2006 about “fanciful and exaggerated disclosure” and mutilating and fatal cases reported in the national media and Brazilian medical articles in recent years, the use of the term “irregular use of PMMA” in the title of the article is appropriate since the patient sought gluteal augmentation through PMMA in a non-specialized center and with an unqualified professional. We affirm that the search for PMMA in non-specialized centers contributes to the significant number of complications due to questionable antisepsis, application of an unskilled technique, and doubtful product quality. We appreciate the opportunity for such clarifications and make ourselves available for any questions.
Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil.
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Counterreply Regarding the authors’ response, some considerations must be presented. The article prepared by the authors brings an unfounded reference to PMMA as the causative agent of the adverse effects reported in the case. At the same time, in the response presented to the Letter to the Editor, they state that “6 attempts were made to identify exogenous material with anatomopathological exam in the different samples of tissue obtained in each debridement surgery. However, such identification was not possible due to the intense necrosis identified”, that is, it was not verified that the patient used PMMA. This is an unfounded reference since the authors did not bring evidence that the procedure was performed with PMMA, and, as the authors themselves state, there is no anatomopathological confirmation of the causative agent, only imaging tests, visual inspection, and palpation, which are not suitable for this purpose. Furthermore, given the narrated circumstances that the procedure was performed in a beauty salon by a non-medical professional, the possibility of using industrial silicone in the procedure cannot be excluded, a hypothesis not addressed by the authors in their article. Then, it is not ethical, nor scientific, quote the PMMA in the title and the article’s content, without any evidence that the product was, in fact, the agent that caused the adverse effects. Evidently, the article’s publication resulted in a negative link with PMMA, damaging the entire distribution chain and all the trained professionals -including thousands of plastic surgeons- who make correct use of the product, which is duly registered with ANVISA and other regulatory authorities. Thus, we understand that the response prepared by the authors must be more emphatic concerning the questions posed, promoting a true retraction to all those who were and continue to be harmed by the publication of an article prepared with flagrant ethical and scientific deviations. We remain at your disposal.
RBCP Editor’s Note
Conep’s guidelines on the approval of the Research Ethics Committee for “case report” articles appeared before the article was submitted on 10/18/2018, a period close to the moment when the Revista Brasileira de Cirurgia Plástica (RBCP) adopted the recommendations of Circular Letter 166/2018 - CONEP / SECNS / MS. The articles published by the RBCP are, without a doubt, scientific, and their function is to expand, contribute and discuss experiences and discoveries in the field of plastic surgery, without any interest in promoting or criticizing for commercial purposes. Dov Goldenberg Editor-in-Chief RBCP
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Rev. Bras. Cir. Plรกst. 2020;35(3)
SOCIEDADE BRASILEIRA DE CIRURGIA PLÁSTICA BRAZILIAN SOCIETY OF PLASTIC SURGERY