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ISSN-e 1984-8773

Volume 17 O Number 4 O October - December 2025

CASE REPORT

COLLISION TUMOR OF MELANOMA AND BASAL CELL CARCINOMA: CASE REPORT WITH EXUBERANT DERMOSCOPY SCIENTIFIC SUPPORT

CASE REPORT Q Vermilionectomy: report of two cases comparing classical excision and W-plasty Q

Facial rosacea outside the nasal region: case report and surgical approach

REVIEW ARTICLE Q Current evidence on the pathophysiological mechanisms of skin laxity: a narrative review Q

www.surgicalcosmetic.org.br

Phenol peels: indications, complications and patient management, a literature review

ORIGINAL ARTICLE Q Prevalence of cellulite in Brazilian women: a cross-sectional study

Online ISSN: 1984-8773 Surg Cosmet Dermatol. 2025;v.17: n.4 oct-dec. p.367-74.

Oﬃcial publication of the Brazilian Society of Dermatology

www.surgicalcosmetic.org.br

PUBLISHED Q UARTERLY CHIEF EDITOR Hamilton Ometto Stolf State University of Campinas (Unicamp), Campinas (SP), Brazil.

CO-EDITORS Bogdana Victoria Kadunc Municipal Civil Servant Hospital, São Paulo (SP), Brazil. Célia Luiza Petersen Vitello Kalil Federal University of the Southern Border, Passo Fundo (RS), Brazil. Vitor Costa Fabris UNIARP School of Medicine, Caçador (SC), Brazil. Center for Studies in Aesthetic Dermatology, Caçador (SC), Brazil.

Surg Cosmet Dermatol. | Rio de Janeiro | v. 17 | n. 4 | oct-dec. 2025 | p. 367-464.

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Sociedade Brasileira de Dermatologia Afiliada à Associação Médica Brasileira

www.sbd.org.br

Surgical & Cosmetic Dermatology SURGICAL & COSMETIC DERMATOLOGY Publicação Oficial da Sociedade Brasileira de Dermatologia Official Publication of Brazilian Society of Dermatology Publicação Trimestral (Quarterly Edition) ISSN-e 1984-8773 O October - December 2025 O Volume 17 O Número 4

Executive Board | 2025-2026

Areas editors

President: Carlos Baptista Barcaui | RJ

Cosmetic Dermatology Doris Hexsel Brazilian Center for Studies in Dermatology, Porto Alegre (RS), Brazil.

Editors Editor-in-chief: Hamilton Ometto Stolf State University of Campinas (Unicamp), Campinas (SP), Brazil. São Paulo State University, São Paulo (SP), Brazil.

Reconstructive Dermatologic Surgery Lauro Lourival Lopes Filho Federal University of Piauí,Teresina (PI), Brazil.

Carolina Malavassi Murari University of Santo Amaro, São Paulo (SP), Brazil.

Healing and wounds Gisele Viana de Oliveira Minas Gerais State Civil Servants’ Pension Institute, Belo Horizonte (MG), Brazil.

Laser and Technology Celia Kalil Santa Casa de Misericordia Hospital in Porto Alegre, Porto Alegre (RS), Brazil.

Luciana Patrícia Fernandes Abbade Botucatu Medical School of the São Paulo State University – Unesp, São Paulo (SP), Brazil.

Luciana Cirillo Maluf Azevedo ABC Medical School, Santo André (SP), Brazil. Nail surgery Nilton Di Chiacchio Municipal Civil Servant Hospital, São Paulo (SP), Brazil. Tricologia Carolina Fechine School of Medicine of the University of São Paulo, São Paulo (SP), Brazil. Luciana Pontes Ruston Clinic, São Paulo (SP), Brazil. Micrographic Surgery Felipe Cerci Mackenzie Evangelical University Hospital, Curitiba (PR), Brazil.

Coeditors: Bogdana Victoria Kadunc Municipal Civil Servant Hospital, São Paulo (SP), Brazil. Célia Luiza Petersen Vitello Kalil Federal University of the Southern Border, Passo Fundo (RS), Brazil. Vitor Costa Fabris UNIARP School of Medicine, Caçador (SC), Brazil. Center for Studies in Aesthetic Dermatology, Caçador (SC), Brazil.

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Cosmetic Dermatologic Surgery Carlos Gustavo Wambier Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America. Diagnostic Imaging Paula Tavares Colpas 3RQWLřFDO &DWKROLF 8QLYHUVLW\ RI &DPSLQDV &DPSLQDV (SP), Brazil.

Surg Cosmet Dermatol. 2025;v.17: n.4 oct-dec. p.367-74.

Surgical & Cosmetic Dermatology National editorial board Alcidarta dos Reis Gadelha School of Medicine of the Amazonas State University, Manaus (AM), Brazil. Ana Paula Gomes Meski Clinical Hospital of the School of Medicine of the University of São Paulo, São Paulo (SP), Brazil.

Luciana Cirillo Maluf Azevedo ABC Medical School, Santo André (SP), Brazil. Luciana Patrícia Fernandes Abbade Botucatu Medical School of the São Paulo State University – Unesp, São Paulo (SP), Brazil.

Ana Cláudia Cavalcante Espósito Federal University of São Paulo, Department of Dermatology and Radiotherapy, Botucatu (SP), Brazil.

Luciana Takata Pontes Ruston Clinic, São Paulo (SP), Brazil. Luis Antonio Torezan University of São Paulo – USP, São Paulo (SP), Brazil.

André Luiz Simião 3RQWLřFDO &DWKROLF 8QLYHUVLW\ RI &DPSLQDV &DPSLQDV (SP), Brazil.

Luiz Fernando F. Kopke Federal University of Santa Catarina – UFSC, Florianópolis (SC), Brazil.

Carlos Baptista Barcaui Rio de Janeiro State University, Pedro Ernesto University Hospital, Rio de Janeiro (RJ), Brazil.

Maria Fernanda Gavazzoni Santa Casa de Misericordia Hospital in Rio de Janeiro, Rio de Janeiro (RJ), Brazil.

Carlos Gustavo Wambier Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America.

Monica Manela Azulay Federal University of Rio de Janeiro, Rio de Janeiro (RJ), Brazil.

Carolina Oliveira Costa Fechine School of Medicine of the University of São Paulo, São Paulo (SP), Brazil.

Nilton Di Chiacchio Municipal Civil Servant Hospital, São Paulo (SP), Brazil.

Carolina Malavassi Murari University of Santo Amaro, São Paulo (SP), Brazil.

Paula Tavares Colpas 3RQWLřFDO &DWKROLF 8QLYHUVLW\ RI &DPSLQDV &DPSLQDV (SP), Brazil.

Emerson Vasconcelos de Andrade Lima Santa Casa de Misericordia Hospital in Recife, Recife (PE), Brazil.

Samira Yarak Federal University of São Paulo, São Paulo (SP), Brazil.

Érica de Oliveira Monteiro Federal University of São Paulo – UNIFESP, São Paulo (SP), Brazil. Érico Pampado Di Santis University of Taubaté – UNITAU,Taubaté (SP), Brazil.

International Board of Reviewers

Fabiane Mulinari Brenner Clinical Hospital, Federal University of Paraná, Department of Dermatology, Curitiba (PR), Brazil.

Jerry Brewer University of South Carolina, Colúmbia (SC), Estados Unidos da América.

Felipe Bochnia Cerci Mackenzie Evangelical University Hospital, Curitiba (PR), Brazil. Flávia Alvim Sant’anna Addor MEDCIN Group, Clinical Research, Osasco (SP), Brazil. Francisco M. Paschoal ABC Medical School, São Paulo (SP), Brazil. Gisele Viana de Oliveira Minas Gerais State Civil Servants’ Pension Institute, Belo Horizonte (MG), Brazil. Izelda Carvalho Costa University of Brasilia - UnB, Brasília (DF), Brazil. José Roberto Pereira Pegas Padre Bento Hospital Complex in Guarulhos, Guarulhos (SP), Brazil. Lauro Lourival Lopes Filho Federal University of Piauí,Teresina (PI), Brazil. Luciana Archetti Conrado Integra Dermatologia Clinic, São Paulo (SP), Brazil.

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A/C SURGICAL & COSMETIC DERMATOLOGY

PUBLISHED QUARTERLY 7ƦƤƩƯƪƤƢƭ 7ƦƢƮ Nazareno Nogueira de Souza

Av. Rio Branco, 39 18º andar Cep: 20.090-003 Rio de Janeiro-RJ, Brazil. Phone: 55 (21) 2253-6747 E-mail: surgical@sbd.org.br website: www.surgicalcosmetic.org.br

/ƪƣƳƢƳƪƢƯ Vanessa Mafra

Surgical & Cosmetic Dermatology LV DQ RǤFLDO SXEOLFDWLRQ RI WKH %UD]LOLDQ 6RFLHW\ of Dermatology (SBD) in partnership with the Brazilian Society of DermatoloJLFDO 6XUJHU\ 7KH WHFKQLFDO DQG VFLHQWLǦF FRQWHQW SUHVHQWHG LQ WKLV SXEOLFDWLRQ is co-owned by the Brazilian Society of Dermatology. Published by: Brazilian Society of Dermatology.

The advertisements published in this issue are the sole responsibility of the advertisers, just as the concepts expressed in signed articles are the sole responsiELOLW\ RI WKHLU DXWKRUV DQG GR QRW QHFHVVDULO\ UHǧHFW WKH RSLQLRQ RI WKH 6%' All rights reserved and protected by law 9.610 of 02/19/98. No part of this publication may be reproduced without prior written authorization from the Brazilian Society of Dermatology, regardless of the means employed: electronic, mechanical, photographic, recording or any other. Material for distribution to the medical profession. The magazine is in the Legal Deposit, at the National Library, in accordance with Decree No. 1.825, of December 20, 1907. Licença Creative Commons

INDEXED Q

Sumários. org (www.sumarios.org/)

DOAJ (https://doaj.org/)

Latindex (www.latindex.org)

Lilacs (https://bases.bireme.br/)

SCOPUS (http://www.scopus.com/home.url)

Periódica (http://periodica.unam.mx)

Redalyc (http://www.redalyc.org)

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Surg Cosmet Dermatol. 2025;v.17: n.4 oct-dec. p.367-74.

SURGICAL & COSMETIC DERMATOLOGY / INSTRUCTIONS TO AUTHORS GUIDE FOR AUTHORS Surgical & Cosmetic Dermatology is an interdisciplinary open-access journal dedicated to publishing research on all aspects of Dermatologic Surgery. It also welcomes articles in Cutaneous Oncology, Cosmetic Surgery and Dermatology, Laser, and other Therapy Technologies. Please see Editorial Policies to: General information Language Open access Authorship Peer-review policy Copyright and licensing Ethical guidelines and research integrity PREPRINT We accept the submission of articles deposited in preprints repositories. Authors can share their preprint anywhere at any time. If a preprint is accepted for publication, we encourage authors to link it to their formal publication through their Digital 2EMHFW ,GHQWLǦHU '2, Authors can update their preprints on bioRxiv (https:// www.biorxiv.org/), medRxiv (https://www.medrxiv.org/) or others with their accepted manuscript. DISCLAIMER Statements and opinions expressed in the articles and communications published on Surgical & Cosmetic Dermatology are those of the author(s) and not necessarily those of the Editor(s), Publisher, or Society. SUBMISSION GUIDELINES Proper preparation of the manuscript makes the review DQG SXEOLFDWLRQ SURFHVVHV PRUH HǤFLHQW 7KXV ZH UHFRPPHQG VRPH SUHFDXWLRQV WKDW FDQ VLJQLǦFDQWO\ IDFLOLWDWH WKH SUHSDUDWLRQ of papers. Articles must be unpublished and written in the author’s original language (Portuguese or English): the editorial team will provide the necessary versions. The font must be Times New Roman or Arial, 12 points. The study's title must be concise, informed in Portuguese and English, containing up to 150 characters without spaces, accompanied by a short title. Abstracts in Portuguese and English must follow the appropriate format for the type of article. 4. Authors must inform full name, abbreviations, and their LQVWLWXWLRQDO DǤOLDWLRQV IROORZHG E\ FLW\ VWDWH DQG FRXQWU\ /LQNV WR LQVWLWXWLRQV PXVW EH OLVWHG LQ KLHUDUFKLFDO RUGHU H J ǦUVW WKH

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Department, second the University). The inclusion of miniFXUULFXOXPV LV QRW DOORZHG :KHQ DQ DXWKRU LV DǤOLDWHG ZLWK PRUH WKDQ RQH LQVWLWXWLRQ HDFK PXVW EH LGHQWLǦHG VHSDUDWHO\ :KHQ WZR RU PRUH DXWKRUV DUH DǤOLDWHG ZLWK WKH VDPH LQVWLWXWLRQ LW VKRXOG EH LGHQWLǦHG RQO\ RQFH $XWKRUV EHORQJLQJ WR 3ULYDWH &OLQLFV must cite them as an institution. It is mandatory to mention the 25&,' QXPEHU XVHG WR LGHQWLI\ UHVHDUFKHUV IRU WKH ǦUVW DQG ODVW authors. The author must assume at least one responsibility in the elaboration of the study and must inform the contribution of each one in the submission. One of the authors must be designated as the corresponding author, providing an email address. Authors must also mention the place where the work was conducted. $XWKRUV PXVW FOHDUO\ VWDWH DQ\ FRQǧLFWV RI LQWHUHVW DQG ǦQDQFLDO VXSSRUW The keywords must be cited in Portuguese and English, totaling 3 to 10 per language, and they must be included in all types of articles. We recommend that the keywords are obtained from DeCS (Health Science Descriptors) or MeSH (Medical Subject Headings), which can be accessed on the internet. The limit number of words for texts must follow the type of article and calculated excluding references and abstracts in Portuguese and English. Extensive and repetitive introductory information should be avoided, giving preference to the most recent, not yet published. Avoid repeating the same information in the abstract, introduction, and discussion. Weights and measurements must be expressed in the decimal metric system and temperatures in degrees centigrade. Drugs must be mentioned by their generic names, followed by the dose and dosage used, avoiding commercial terms or brands. Descriptions of any equipment, instruments, tests, and reagents must contain the name of the manufacturer and the place of manufacture. According to the ICMJE, only those who actively participated in the study can be designated as authors, thus assuming public responsibility for its content. Authorship credits must be based solely on substantial contributions to: discussion and planning of the topic and protocol, analysis or interpretation of data; writing of the article or its review; UHVSRQVLELOLW\ IRU ǦQDO DSSURYDO IRU SXEOLFDWLRQ Other minor contributions such as literature suggestions, data collection and analysis, funding obtaining, technical assistance in conducting routines, patients referral, routine test interpretation, and head of service or department that are not involved in the study do not constitute criteria for authorship. They can be recognized separately in the “Acknowledgments” session, according to the authors’ decision.

ARTICLE TYPES A Surgical & Cosmetic Dermatology publishes the following article types: REVIEW ARTICLES 5HYLHZ DUWLFOHV GHHSHQ VSHFLǦF WKHPHV LQ WKH DUHDV RI interest of S&CD, algorithms, compilations, statistics, consensus, and guidelines.These papers have a free format; however, they must contain an unstructured abstract of up to 100 words and conclusions RU ǦQDO FRQVLGHUDWLRQV /LPLW WH[W XS WR ZRUGV LOOXVWUDWLRQV and 60 references. Systematic review articles or meta-analyses must follow relevant guidelines (http://cochrane.org.br). ORIGINAL ARTICLE Original articles report original investigative research in Dermatological Surgery, Cutaneous Oncology, Imaging Diagnosis, Dermatology Technology, and Cosmetic Dermatology. Examples: experimental studies, clinical studies, comparisons and descriptions of techniques, or evaluation methods.The text should contain up to 4000 words, 10 illustrations, and 35 references and follow the IMRDC format (Introduction and objective, Methods, Results, Discussion, Conclusion). Abstract: The abstract must contain up to 250 words and be structured, comprising: Introduction, Objective, Methods, Results, and Conclusions. It is not allowed to state that results or other data will be presented or discussed. Introduction: State the reasons that motivated the study, describing the current state of knowledge on the subject. Use the last paragraph to specify the central question or objective of the research and the primary hypothesis tested, if any. Methods: Explain how the study was conducted: Study type: describe its design specifying the temporal direction (retrospective or prospective), the type of randomization, if any (pairing, drawing, sequencing, etc.), if the study was blind, comparative, placebo-controlled, etc. Location: indicate where the study was conducted (private or public institution), mentioning the research’s approval by the Research Ethics Committee, the selection procedures, the inclusion and exclusion criteria, and the initial number of patients. Procedures: describe the main characteristics of the interventions performed, detailing the technique and considering that the investigation study should be reproducible. Methodology: Description of the methods used to evaluate the results. Statistical analysis: Inclusion of descriptive and/or comparative statistical analysis describing the sample planning (representative of the universe to be studied), analysis and statistical WHVWV DQG SUHVHQWLQJ WKH DGRSWHG VLJQLǦFDQFH OHYHOV :H HQFRXUDJH using unusual statistical analyses, but a more detailed description should be made in this case.

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Results: Report the main results that point estimates and measures of dispersion should accompany (e.g., mean and standard HUURU RU LQWHUYDO HVWLPDWHV H J FRQǦGHQFH LQWHUYDOV DV ZHOO DV the descriptive levels of the tests statistics used (e.g., “p-value”). Findings must also be interpreted from a clinical point of view. Discussion: Emphasize the new and essential results found by the study, which will be part of the conclusion. Also, report observations from other relevant studies, mentioning the OLPLWDWLRQV RI WKH ǦQGLQJV DQG LPSOLFDWLRQV IRU IXWXUH UHVHDUFK Conclusions: Clearly and concisely answer the proposed objectives of the study. The same emphasis must be given to studies with positive or negative results. DIAGNOSTIC IMAGING Diagnostic Imaging addresses topics or clinical cases where imaging exams (dermoscopy, confocal microscopy, ultrasound, and other methods) are essential for diagnosis or treatment. It must contain unstructured abstract of up to 100 words, text up to 1200 words, 6 illustrations, and 5 references. HOW I DO IT? How do I do it? describes new techniques or details of procedures. It must contain unstructured abstract of up to 100 words, an introduction with a literature review, methods, results, discussion, and conclusion. Limit: 1200 words, 8 illustrations, and 30 references. CASE REPORT Case report is the description of cases or series of relevant cases in the areas of interest of S&CD, depicting treatments, complications, etc. It must contain unstructured abstract of up to 100 words, an introduction with a literature review, methods, results, discussion, and conclusion, whenever pertinent. Limit: text up to 1200 words, 8 illustrations and 30 references. LETTERS TO THE EDITOR Letters to the editor are objective, brief, and constructive comments on previously published studies or research. The text should be up to 600 words, with a maximum of 5 references. ETHICS COMMITTEE 7KH DXWKRUL]DWLRQ FHUWLǦFDWH E\ DQ (WKLFV &RPPLWWHH LV only required for the Original Articles of prospective research. REFERENCES Bibliographic references must be listed on the last pages of the article and numbered according to the citation in the text (in sequential numerical order), following the Vancouver style, as indicated by the International Committee of Medical Journal (GLWRUV ,&0-( 5HIHUHQFHV FLWHG LQ WDEOH DQG ǦJXUH OHJHQGV PXVW

Surg Cosmet Dermatol. 2025;v.17: n.4 oct-dec. p.367-74. keep the sequence with the citations in the text. If a document KDV VL[ RU PRUH DXWKRUV SURYLGH WKH QDPH RI WKH ǦUVW VL[ DXWKRUV followed by "et al". Below are examples of the most common types of references taken from ICMJE: Journal articles: Hallal AH, Amortegui JD, Jeroukhimov IM, Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. J Am Coll Surg. 2005;200(6):869-75. Book chapter: Reppert SM. Circadian rhythms: basic aspects and pediatric implications. In: Styne DM, Brook CGD, editors. Current concepts in pediatric endocrinology. New York: Elsevier; 1987. p .91-125. Website and online content: With author: Fugh-Berman A. Pharmed OUT [Internet]. Washington: Georgetown University, Department of Physiology and Biophysics; c2006 [cited 2007 Mar 23]. Available from: http:// www.pharmedout.org/. When the author is an organization: International Union of Biochemistry and Molecular Biology. Recommendations on Biochemical & Organic Nomenclature, Symbols & Terminology etc. [Internet]. London: University of London, Queen Mary, Department of Chemistry; [updated 2006 Jul 24; cited 2007 Feb 22]. Available from: http://www.chem.qmul.ac.uk/iubmb/. Previous presentation at events: Bruhat M, Silva Carvalho JL, Campo R, Fradique A, Dequesne J, Setubal A, editors. Proceedings of the 10th Congress of the European Society for Gynaecological Endoscopy; 2001 Nov 22-24; Lisbon, Portugal. Bologna (Italy): Monduzzi Editore, International Proceedings Division; c2001. 474 p. FIGURES Figures, charts, and tables must be cited in sequential numerical order in the text in Arabic numerals (example: Figure 3, Chart 7), and the Editor is responsible for suppressing the redundant ones. Figure and charts legends and table titles and footnotes must accurately describe their content in short sentences, EXW VXǤFLHQW IRU XQGHUVWDQGLQJ HYHQ LI WKH DUWLFOH LV QRW IXOO\ UHDG They must be uploaded in the system in the step corresponding WR LOOXVWUDWLRQV DYRLGLQJ XVLQJ WKH ǦHOG IRU WKH WH[W VR WKH ZRUGV ZLWKLQ WKH ǦJXUHV DUH QRW FRXQWHG Figures must have a minimum resolution of 300 DPI, minimum width of 1,200 pixels with proportional height, and JPG or TIF formats. The photographs must be in focus, allowing the visualization of the details. Arrows or lines can be used to highlight areas of interest.The legends of histological images must VSHFLI\ VWDLQLQJ DQG PDJQLǦFDWLRQ ,I D ǦJXUH KDV EHHQ SUHYLRXVO\ published, its source should be cited and included in the references.

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The copyright holder's permission for its reproduction must be sent to the journal. The use of pictures that identify patients’ faces requires a written authorization (see the document Consent of Publishing Patient Photographs on the journal’s website). Regarding videos, it is necessary to insert subtitles containing information such as the title of the manuscript, authorship, institution, and other relevant comments. When using patient images, their identity must be preserved; otherwise, written permission for disclosure must be attached. Charts must be prepared in Microsoft Excel. Tables do not need to be described in the text because their objective is to supplement it and not augment it. The units used to express the results (m, g, g/100, mL, etc.) should appear at the top of each FROXPQ 3DWLHQWV PXVW EH LGHQWLǦHG E\ QXPEHUV RU OHWWHUV DQG never by names, initials, or hospital registration numbers. COVER LETTER The cover letter must include the following information: An explanation of why your manuscript is suitable for publishing in Surgical & Cosmetic Dermatology. &RQǦUPDWLRQ WKDW WKH PDQXVFULSW V FRQWHQW LV RULJLQDO DQG has not been published nor is being considered for publication elsewhere. If the manuscript is being submitted for a particular special LVVXH LWV VSHFLǦF QDPH PXVW EH PHQWLRQHG LQ WKH FRYHU OHWWHU If the article reports the results of a health intervention in human participants, Surgical & Cosmetic Dermatology strongly recommends its record in an appropriate registry. The registration number and date must be indicated in this letter. AUTHORS’ DECLARATIONS 7KH IROORZLQJ ǦQDO VWDWHPHQWV PXVW EH LQFOXGHG LQ WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 7KHVH GHFODUDWLRQV DUH H[SHFWHG to be submitted along with the cover letter since Surgical & Cosmetic Dermatology adopts a double-blind peer review. ‘Acknowledgments’ – list of people who contributed to the article (and does not meet the criteria for authorship), including contributors who provided professional writing services or materials. ‘Availability of data and materials’ – availability statements contain information on where data supporting the results reported in the article can be found, such as hyperlinks to publicly archived datasets. Example sentences are: ‘All data generated or analyzed during this study are included in this article’; ‘The datasets generated and/or analyzed during the current study are available in the [NAME] repository’, ‘The datasets generated during and/ or analyzed during the current study are available from the corresponding author on reasonable request’ or ‘Not applicable’ if no new data were created or analyzed in the study. ‘Financial support’ - all sources of funding of the study

should be disclosed; it is necessary to indicate grants that authors have received in support of the research. Ý&RQǧLFW RI LQWHUHVWÞ Û DOO ǦQDQFLDO DQG QRQ ǦQDQFLDO competing interests must be declared in this section. If the authors do not have any competing interests, it is necessary to state ‘The DXWKRUV GHFODUH WKDW WKH\ KDYH QR FRQǧLFW RI LQWHUHVWÞ ‘Authors’ contributions’ – Each author is expected to have made substantial contributions to the manuscript, which should EH VSHFLǦHG LQ WKLV VHFWLRQ 3OHDVH XVH LQLWLDOV WR UHIHU WR HDFK authors’ contribution. For example: ‘AB, CD, and EF conceived this research and designed experiments. GH participated in the design and interpretation of the data. IJ performed experiments and analysis. KL and MN wrote the paper and participated in the UHYLVLRQV RI LW $OO DXWKRUV UHDG DQG DSSURYHG WKH ǦQDO PDQXVFULSWÞ 7KH PD[LPXP DFFHSWDEOH OLPLW RI DXWKRUV LV ǦYH WKHUH will only be an exception for more complex works (ex. Original $UWLFOH 5HYLHZ XSRQ MXVWLǦFDWLRQ DQG DSSURYDO E\ WKH HGLWRUV ‘Ethics approval/Ethics approval and consent to participate’: manuscripts reporting studies involving human participants or human data must include a statement on ethics approval and consent and include the name of the ethics committee that approved the study and the committee’s reference number. Studies involving animals must include a statement on ethics approval. If the manuscript does not report on or involve the use of any animal or human data, it is necessary to state ‘Not applicable’. ‘Consent for publication’if the manuscript contains any individual's personal data in any form, consent for publication must be obtained from that person, or in the case of children, their parent or legal guardian. All presentations of case reports must have consent for publication.

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SUBMISSION Manuscripts should be submitted through our online submission system (https://www.gnpapers.com.br/scd/default. asp?lang=en). The submitting author is responsible for the manuscript during the submission and peer-review process. They must ensure that all eligible co-authors have been included in the author list and have all read and approved the submitted manuscript. 7KH IROORZLQJ ǦOHV DUH UHTXLUHG WR VXEPLW D PDQXVFULSW 7KH PDLQ PDQXVFULSW ǦOH ZKLFK PXVW QRW LQFOXGH WKH QDPHV RI DXWKRUV RU FR DXWKRUV DQ DQRQ\PRXV ǦOH VLQFH WKH journal uses double-blind peer review). References and smaller WDEOHV VKRXOG EH LQFOXGHG LQ WKLV ǦOH A title page, which must contain the names of all DXWKRUV DQG FR DXWKRUV WKHLU DǤOLDWLRQV HPDLOV DQG DOO DXWKRUVÞ declarations. A cover letter. )LJXUH řOHV $Q\ DGGLWLRQDO ǦOHV DV VXSSOHPHQWDO PDWHULDO WR WKH manuscript. $OO GRFXPHQWV VXFK DV &RS\ULJKW &RQǧLFW RI ,QWHUHVW DQG Consent for Publishing Photographs are available on the journal’s website and in the online submission system. These documents must be signed by all participating authors and attached to the system when submitting the manuscript. Consent for Publishing Patient Photographs is only necessary when the patient’s IDFH LV IXOO\ LGHQWLǦHG 7KH HGLWRUV ZLOO RQO\ UHTXHVW WKH 3DSHU Participation document if necessary.

Surg Cosmet Dermatol. 2025;v.17: n.4 oct-out. p.375-6.

Table of contents Official publication of the Brazilian Society of Dermatology OCTOBER - DECEMBER 2025 O Volume 17 O Number 4 ISSN:1984-5510 Online ISSN: 1984-8773

REVIEW ARTICLE Current evidence on the pathophysiological mechanisms of skin laxity: a narrative review

377

Doris Hexsel, Lilia Maria Lima de Oliveira, Indira Valente Bezerra, Ana Carolina Krum dos Santos, Camile Hexsel, Fabio Saito,Vitor Costa Fabris

Phenol peels: indications, complications and patient management, a literature review

384

Gabriela Roncada Haddad, Ana Carolina Salomão Gerolamo, Nicole Dias Sbrissa, José Ferreira de Oliveira Neto, Isabela Novello, Ricardo Henrique Marcelino

ORIGINAL ARTICLE Mapping scientific contributions in surgical and cosmetic dermatology (2009-2024): Authors, institutions, and countries - Part I

389

Helena Cargnelutti Grimaldi, Sandro da Silva Camargo

Effectiveness of 1% Centella asiatica ointment in women with melasma: A study on the Melasma Area and Severity Index (MASI) and patient satisfaction scores

397

Cintyadewi Wignjosoesastro, Diah Adriani Malik, Puguh Riyanto

Prevalence of cellulite in Brazilian women: a cross-sectional study

403

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LETTER TO THE EDITOR From a surgical standpoint - A comment on: “Bilateral temporal triangle alopecia mimicking male pattern alopecia in an adult female: a case report and review of the literature

410

Hudson Dutra Rezende, Renata Almeida Chaebub Rodrigues, Ana Lígia Scotti Alérico, Ingrid Palloma Vieira de Melo, Sandra Lopes Mattos e Dinato

HOW DO I DO? Non-surgical management of ectropion using hyaluronic acid gel with cannula injection

413

Ana Paula Dornelles Manzoni, Fabiane Kumagai Lorenzini, Taisa de Boni Gauer, Bruna Bonamigo Thomé, Renan Rangel Bonamigo

Theoretical description of a local anesthesia protocol with non-pharmacological strategies for dermatological procedures in children João Paulo Turri Brufatto, Marina Gagheggi Maciel, Adriana Salath Schikiera Martinelli, Giovanna Silva Barbosa, Thiago Jesse Kucarz, /XL] 5REHUWR 'DO %HP 3LUHV -¼QLRU 5HQDWD )HUUHLUD 0DJDOK¥HV $QGU«D )HUQDQGHV (OR\ GD &RVWD )UDQ©D 7KDLV +HOHQD %XǡR (OLVD 1XQHV 6HFDPLOOL

375

416

Table of contents

CASE REPORT Localized tenosynovial giant cell tumor of the left index finger – a case report

422

Sunil Kumar Gupta

Lipofilling in a patient with Parry-Romberg syndrome: from diagnosis to treatment

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Nivin Mazen Said, Denise Lima Sousa, Airton Kenji Motizuki, Emanuella Rosyane Duarte Cerqueira, Franklin Sousa Rocha

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ISSN-e 1984-8773 APOIO CIENTÍFICO:

www.surgicalcosmetic.org.br/

Current evidence on the pathophysiological mechanisms of skin laxity: a narrative review ² ƪ ǣ narrativa

Review Article Authors: Doris Hexsel 1 Lilia Maria Lima de Oliveira 2 Indira Valente Bezerra 1 Ana Carolina Krum dos Santos 1 Camile Hexsel 1,3,4 Fabio Saito 5 Vitor Costa Fabris 6 1

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Hexsel Dermatologic Clinic, Dermatology and Research de partments, Porto Alegre (RS), Brazil Harvard T.H Chan School of Public Health, Principles and Practice of Clinical Research (PPCR) - Post-graduate Program, Boston (MA), United States Madison Medical Affiliates, Mohs Surgery, Waukesha (WI), United States Medical College of Wisconsin, Department of Dermatology, Milwaukee (WI), United States Brazilian Society of Plastic Surgery, Board Certified Plastic Surgeon, São Paulo (SP), Brazil Hexsel Dermatologic Clinic, Research Department, Porto Alegre (RS), Brazil

Correspondence: Doris Hexsel E-mail: doris@hexsel.com.br / pesquisa@hexsel.com.br

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Funding: None. Conﬂict of interest: Dr. Doris Hexsel serves as speaker and consultant for Galderma. Dr. Fabio Saito is an Associate Director for Customer Educataion & Training - Brazil and LATAM at Galderma. No other authors report conflicts of interest. Submitted on: 03/18/2025 Final decision: 08/26/2025

How to cite this article: Hexsel D, Oliveira LML, Bezerra IV, Santos ACK, Hexsel C, Saito F, Fabris VC. Current evidence on the pathophysiological mechanisms of skin laxity: a narrative review. Surg Cosmet Dermatol. 2025;17:e20250453.

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383

ISSN-e 1984-8773 APOIO CIENTÍFICO:

www.surgicalcosmetic.org.br/

Phenol peels: indications, complications and patient management, a literature review Peeling de fenol: indicações, complicações e manejo do paciente, uma revisão da literatura

Review Article Authors: Gabriela Roncada Haddad 1 Ana Carolina Salomão Gerolamo 2 Nicole Dias Sbrissa 2 José Ferreira de Oliveira Neto 3 Isabela Novello 3 Ricardo Henrique Marcelino 3 1

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170486 ABSTRACT Phenol peels are a deep chemical exfoliation technique used for decades for facial rejuvenation, acne VFDUV DQG K\SHUSLJPHQWDWLRQ 7KH %DNHU *RUGRQ IRUPXOD LV WKH PRVW FRPPRQO\ XVHG SURYLGLQJ HǡHFWLYH UHVXOWV EXW ZLWK VLJQLǦFDQW ULVNV 7KH SURFHGXUH UHTXLUHV DQHVWKHVLD DQG VWULFW SRVWRSHUDWLYH FDUH GXH WR possible complications such as hyperpigmentation, hypopigmentation, infections, scarring, and systemic toxicity, especially cardiotoxicity.This descriptive and exploratory literature review, based on articles from WR KLJKOLJKWV WKH PHWKRGÞV HǡHFWLYHQHVV EXW HPSKDVL]HV WKH QHHG IRU IXUWKHU VWXGLHV RQ LWV long-term safety and on proper patient management. Keywords: 3KHQRO &KHPH[IROLDWLRQ 'UXJ 5HODWHG 6LGH (ǡHFWV DQG $GYHUVH 5HDFWLRQV

RESUMO O peeling de fenol é uma técnica de esfoliação química profunda usada há décadas para rejuvenescimento facial, cicatri]HV GH DFQH H KLSHUSLJPHQWD©·HV $ IµUPXOD GH %DNHU *RUGRQ « D PDLV XWLOL]DGD SURSRUFLRQDQGR UHVXOWDGRV HřFD]HV PDV FRP ULVFRV VLJQLřFDWLYRV 2 SURFHGLPHQWR H[LJH DQHVWHVLD H FXLGDGRV ULJRURVRV QR SµV RSHUDWµULR GHYLGR D SRVV¯YHLV FRPSOLFD©·HV FRPR KLSHUSLJPHQWD©¥R KLSRFURPLD LQIHF©·HV FLFDWUL]HV H WR[LFLGDGH VLVW¬PLFD SULQFLSDOPHQWH FDUG¯DFD (VWD UHYLV¥R GH OLWHUDWXUD GHVFULWLYD H H[SORUDWµULD EDVHDGD HP DUWLJRV GH D GHVWDFD D HřF£FLD GR P«WRGR PDV UHIRU©D D QHFHVVLGDGH GH PDLV HVWXGRV VREUH VXD VHJXUDQ©D D ORQJR SUD]R H VREUH R PDQHMR DGHTXDGR GRV SDFLHQWHV Palavras-chave: )HQRO $EUDV¥R 4X¯PLFD (IHLWRV &RODWHUDLV H 5HD©·HV $GYHUVDV 5HODFLRQDGRV D 0HGLFDPHQWRV

Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Department of Infectiology, Dermatology, Diagnostic Imaging and Radiotherapy, Botucatu (SP), Brazil Centro Universitário Municipal de Franca, School of Medicine, Franca (SP), Brazil Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Botucatu School of Medicine, Botucatu (SP), Brazil

Correspondence: Gabriela Roncada Haddad E-mail: doris@hexsel.com.br / pesquisa@hexsel.com.br

Funding: None Conﬂict of interest: None Submitted on: 06/23/2025 Final decision: 10/15/2025

How to cite this article: Haddad GR, Gerolamo ACS, Sbrissa ND, Oliveira Neto JF, Marcelino RH, Novello I. Phenol peels: indications, complications and patient management, a literature review. Surg Cosmet Dermatol. 2025;17:e20250486.

384

Haddad GR, Gerolamo ACS, Sbrissa ND, Oliveira Neto JF, Marcelino RH, Novello I.

,Q -XQH %UD]LOÞV 1DWLRQDO +HDOWK 6XUYHLOODQFH $JHQF\ $QYLVD LVVXHG 5HVROXWLRQ QR IRUELGGLQJ the importation, manufacturing, compounding, marketing, advertising, and use of phenol-based products in health or aesthetic procedures.6,7 Since then, phenol peels have been banned in Bra]LO GHVSLWH UHSRUWV RQ LWV VDIHW\ DQG HǡHFWLYHQHVV Therefore, the aim of this study is to conduct a literature UHYLHZ RQ WKH LPSRUWDQFH VDIHW\ DQG HǡHFWLYHQHVV RI SKHQRO EDVHG SHHOV DQG WKHLU ULVNV DQG EHQHǦWV IRU SDWLHQWV ,Q DGGLWLRQ it provides information on current techniques, indications and contraindications for their use in treatment plans, and possible complications associated with their management. METHODS This study is a descriptive and exploratory literature review conducted through searches in Google Scholar and PubMed databases. In Google Scholar, the search strategy used the 'H&6 GHVFULSWRUV à$EUDV¥R 4X¯PLFDá $1' )HQRO $1' 5HMXYHQHVFLPHQWR ,Q 3XE0HG WKH &KHPH[IROLDWLRQ $1' 3KHQRO $1' 5HMXYHQDWLRQ 0H6+ GHVFULSWRUV ZHUH XVHG Full-text articles published between 2000 and 2025, in Portuguese or English, were included. Studies without published and available full text, those conducted on animal models, or WKRVH DGGUHVVLQJ GLǡHUHQW WHFKQLTXHV DQG SURFHGXUHV DV ZHOO DV duplicate articles, were excluded. RESULTS AND DISCUSSION The initial search yielded a total of 47 results, 24 from Google Scholar and 23 from PubMed. Of these, 14 articles were LQFOXGHG 7ZHQW\ ǦYH VWXGLHV ZHUH H[FOXGHG EDVHG RQ WKHLU WLWOHV and 8 based on the abstract or full text (Figure 2).

INTRODUCTION Chemical peels consist of the application of a chemical agent to the skin, which causes controlled destruction of the epidermis and part of the dermis by chemical exfoliation, followed by the promotion of cellular regeneration, ie, re-epitheOLDOL]DWLRQ 1,2 3HHOV DUH FDWHJRUL]HG DFFRUGLQJ WR GHSWK DV VXSHUǦFLDO medium, or deep. The deeper the procedure, the more apparent LWV HǡHFWV EXW DOVR WKH JUHDWHU WKH ULVNV DQG WKH GLVFRPIRUW 6XSHUǦFLDO SHHOV DFW RQO\ RQ WKH HSLGHUPLV PHGLXP SHHOV DFW RQ the epidermis and papillary dermis, and deep peels penetrate to the reticular dermis. Phenol peels are an example of deep peels.3 Phenol, or carbolic acid (C6H5OH) (Figure 1), is a chemical agent that promotes facial rejuvenation. In addition, it cauVHV FRDJXODWLRQ RI VNLQ SURWHLQV KDV DQ DQHVWKHWLF HǡHFW RQ QHUYH HQGLQJV SURGXFHV EDFWHULRVWDWLF HǡHFWV ZKHQ XVHG LQ FRQFHQWUDtions of up to 1%, and is bactericidal in higher concentrations. Phenol-based peels were developed after the First World War. In England, scholars already used phenol to treat blemishes and scars, but the technique did not develop further. In the V QHZ DGYDQFHV XVKHUHG LQ WKH HUD RI SHHOV XVLQJ PRGLǦHG phenol solutions (with the addition of croton oil, septisol, and water) and histological evaluations of their results, allowing for FRPSDULVRQV EHWZHHQ WKH HǡHFWV RI SKHQRO DQG WKRVH RI RWKHU peel subtypes.3 In 1962, Baker and Gordon discovered the current formula used in phenol peels, in which the substance is diluted in concentrations ranging from 45% to 55%.4,5 Its use requires thorough history taking and physical examinations as well as laboratory tests, since phenol is highly toxic and is absorbed systemically through the skin barrier. Phenol can cause local edema and erythema and has possible cardiac WDFK\FDUGLD YHQWULFXODU H[WUDV\VWROHV DWULDO DQG YHQWULFXODU Ǧbrillation, and electromechanical dissociation), renal, and hepatic VLGH HǡHFWV DQG PD\ FDXVH FHQWUDO QHUYRXV V\VWHP GHSUHVVLRQ 4,5

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Screening

Articles excluded after title and abstract screening (n = 20) Articles in other languages (n = 3) Articles excluded with full text unavailable (n = 3)

Inclusion

Full-text articles assessed for eligibility (n = 16)

1 undergraduate thesis and 1 letter to the editor excluded Articles included in the qualitative synthesis (n = 14)

ĎČĚėĊ 1: Structural formula of phenola

ĎČĚėĊ ͖ǣ Flowchart of study selection for literature review

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Formulation and application The Baker-Gordon formula, still the most widely used in phenol peels, contains components that enhance the activity of phenol on the skin, such as croton oil and liquid soap (Figure 3). ,Q WKHLU DEVHQFH FHOOXODU UHJHQHUDWLRQ WHQGV WR EH OHVV HǡHFWLYH 4 &URWRQ RLO LQFUHDVHV ORFDO YDVFXODUL]DWLRQ HQKDQFLQJ WKH keratocoagulative action of phenol and promoting deeper cutaQHRXV LQǦOWUDWLRQ 8 Because it is highly toxic to the skin, it can cause edema and local erythema. Liquid soap, in turn, acts as a tensoactive agent, primarily responsible for reducing the lipid VXUIDFH WHQVLRQ RI WKH VNLQ SURPRWLQJ HPXOVLǦFDWLRQ DQG H[IRliation and facilitating permeability.4 It is important to remove the lipid barrier and local hair before the procedure to ensure uniform penetration and miniPL]H GLVFRPIRUW GXULQJ WKH SURFHGXUH 7KH IDFH VKRXOG EH GLvided into sections, and the application begin with the largest DUHD XVLQJ FRWWRQ RU JDX]H 7R DYRLG LQFUHDVLQJ WR[LFLW\ YLJRURXV rubbing movements should be avoided. Contact time varies between 10 and 15 minutes per area.4,9 Studies show that phenol absorption through the skin can vary according to the pressure applied, the degree of friction, and exposure time. Fractionated application, with intervals between treated areas, is recommended to reduce systemic absorption and increase safety. Furthermore, phenol penetration is directly related to the composition of the formula, with croton RLO DQG OLTXLG VRDS EHLQJ HVVHQWLDO WR RSWLPL]H GHUPDO GLǡXVLRQ and enhance clinical response.

Phenol may also be used to treat scarring, particularly acne scars,12,16 and promotes skin-lightening. It also appears to be HǡHFWLYH LQ DGGUHVVLQJ PDOLJQDQW DQG SUHPDOLJQDQW OHVLRQV VXFK as actinic keratoses.11,14,15,16 7KH HǤFDF\ RI SKHQRO ZDV GHPRQVWUDWHG LQ D FOLQLFDO study assessing the punctuated application of 88% phenol to WUHDW SKRWRDJLQJ ZKLFK VKRZHG VLJQLǦFDQW LPSURYHPHQW LQ VNLQ TXDOLW\ DQG KLVWRORJLFDO UHRUJDQL]DWLRQ RI FROODJHQ ǦEHUV 10 $ UHcent review highlighted that, even with the advent of modern techniques such as lasers and botulinum toxin, phenol remains a method of choice for static periorbital and perioral rhytides, producing superior results in certain cases15,18 (Figure 4).

Indications Despite the development of new technologies in aesthetic dermatology, phenol peels remain relevant due to their relatiYH VLPSOLFLW\ DQG KLJK HǤFDF\ DQG DUH WKH PRVW FRPPRQO\ XVHG agents for deep chemical peels.10,11,12,13 The Baker formula, whether applied using a punctuated technique or to the entire face, is primarily indicated for the treatment of severe facial aging asVRFLDWHG ZLWK VXQ H[SRVXUH FKDUDFWHUL]HG E\ GHHS UK\WLGHV 4,11,12 Studies report positive outcomes with the use of 88% phenol peels for rejuvenation of the perioral and periorbital regions.14,15

Component

Quantity

Phenol (88% phenol + 12% water)

3ml

Regular/distilled water

2ml

Liquid soap (hexachlorophene) 0.025%

8 drops

Croton oil

3 drops

ĎČĚėĊ ͘ǣ Progression of patient undergoing phenol peel. A and B - before peel; C - 3 days after peel; D - 6 days after peel; and E and F - 2 years after procedure. Source: Personal archive

ĎČĚėĊ ͗ǣ Baker-Gordon formula

386

Haddad GR, Gerolamo ACS, Sbrissa ND, Oliveira Neto JF, Marcelino RH, Novello I.

Patient management Due to its action on the intermediate reticular dermis, phenol peels are highly painful procedures and must be accompanied by appropriate anesthesia and analgesia.11 Some studies report the use of hypnotic agents for conscious sedation.17 $QDOJHVLFV PD\ EH prescribed for pain control following the procedure.4 Because it is a deep peel, phenol application leads to the formation of thick crusts, so post-peel care may require the use RI YDVHOLQH EDVHG PRLVWXUL]HUV RU WRSLFDO DQWLELRWLFV 4,11 Pruritus LV D FRPPRQ VLGH HǡHFW DQG FDQ EH DOOHYLDWHG ZLWK ORZ SRWHQF\ corticosteroids and cold compresses.11 $IWHU WKH SURFHGXUH DQ RFFOXVLYH PDVN JHQHUDOO\ PDGH of adhesive tape or vaseline ointment, is applied and removed after 48 hours.4 )ROORZ XS DSSRLQWPHQWV LQ WKH ǦUVW GD\V DQG throughout the postoperative period are essential. Epidermal regeneration begins around 48 hours after the procedure, but full recovery may take up to 3 months.11,17 Despite extensive clinical practice, there is still no stanGDUGL]DWLRQ UHJDUGLQJ DQDOJHVLD 'L 6DQWLV HW DO REVHUYHG WKDW LQWHQVH SDLQ GXULQJ WKH ǦUVW KRXUV DIWHU WKH SHHO UHPDLQV D challenge, with pain control largely relying on the practitioner’s experience rather than on an established protocol.17 Continuous monitoring in an appropriate clinical setting is also crucial given the risk of cardiovascular adverse events, even in patients with no comorbidities.20 Complications Post-phenol peel complications are rare, particularly when performed by professionals familiar with the formula and application technique.18 Due to disruption of the skin barrier, there is a risk of secondary bacterial infection or herpetic eruption.4,9 Permanent deeper scarring may occur, especially in regions such as the lips, eyelids, and jawline.8,10 Therefore, it is important to assess the patient’s history of keloids prior to the procedure to anticipate potential unsightly scarring.9,17 Other possible comSOLFDWLRQV LQFOXGH SRVW LQǧDPPDWRU\ K\SHUSLJPHQWDWLRQ DUHDV

of depigmentation, and prolonged erythema.4,13,14,21 Small white cysts known as milia may also appear due to rapid re-epitheliaOL]DWLRQ 4 Regarding systemic toxicity, cardiac, hepatic, and renal toxicities are of particular concern.11,19 $ VWXG\ DVVHVVLQJ DGYHUVH HǡHFWV DVVRFLDWHG ZLWK LPSURSHU SKHQRO XVH KLJKOLJKWHG WKH importance of cardiotoxicity.19 In another retrospective study, phenol did not impair renal or hepatic function but was associated with arrhythmias in susceptible individuals, regardless of concentration or technique used.20 Even pre-screened and adequately hydrated patients may develop transient cardiac arrhythmias.9 .DGXQF DQG 9DQWL HPSKDVL]H WKH QHHG IRU FRQWLQXRXV ECG monitoring during the procedure,20 particularly in individuals with subclinical cardiovascular risk. Therefore, in addition to prior patient assessments with clinical and laboratory tests, it LV DGYLVDEOH WR VSDFH RXW SKHQRO SHHO DSSOLFDWLRQV DFURVV GLǡHUHQW areas and ensure continuous intravenous hydration to facilitate proper metabolite elimination.4,11,19 Finally, the relationship between phenol and carcinogenesis remains unclear. One hypothesis suggests that certain formulations may have carcinogenic potential.9 CONCLUSION $OWKRXJK WKH SURFHGXUH KDV JDLQHG YLVLELOLW\ LQ UHFHQW years, there are still few studies on phenol peels, and particularly few clinical studies. It is an aggressive approach with VLJQLǦFDQW UHSRUWHG EHQHǦWV PDLQO\ LQ FRPEDWLQJ VNLQ DJLQJ DQG FDQ EH SHUIRUPHG VDIHO\ DQG HǡHFWLYHO\ E\ NQRZOHGJHDEle physicians. Given the potential for systemic complications, such as cardiotoxicity and arrhythmias, and ongoing regulaWRU\ GHEDWHV WKH GHYHORSPHQW RI VWDQGDUGL]HG VDIHW\ SURWRFROV proper monitoring, and careful patient screening are essential. 1HYHUWKHOHVV SKHQRO SHHOV UHPDLQ D UHOHYDQW DQG HǡHFWLYH WKHrapeutic alternative and deserve re-evaluation in light of more UREXVW VFLHQWLǦF HYLGHQFH O

387

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REFERENCES: 1. Oremović LBZSM. Chemical peelings--when and why? Acta Clin Croat. 2010:545-8. 2. Khunger N, Task Force IADVL. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74(Suppl):5-12. 3. Brody HJ, Monheit GD, Resnik SS, Alt TH. A history of chemical peeling. Dermatol Surg. 2000;26(5):405- 9. 4. Velasco MVR, Okubo FR, Ribeiro ME. Rejuvenescimento da pele por peeling químico: enfoque no peeling de fenol. An Bras Dermatol. 2004;79(1):91-9. 5. Odo MEY, Chichierchio AL. Práticas em cosmiatria e medicina estética: procedimentos cirúrgicos de pequeno porte. São Paulo: Tecnopress; 1998. 6. Agência Nacional de Vigilância Sanitária. Anvisa proíbe venda e uso de produtos à base de fenol em procedimentos de saúde em geral ou estéticos [Internet]. 2024. Available from: https:// www.gov.br/anvisa/pt-br/assuntos/noticias- anvisa/2024/anvisa-proibe-venda-e-uso-de-produtos-a-base-de-fenol-em- procedimentos-de-saude-em-geral-ou-esteticos 7. Agência Nacional de Vigilância Sanitária. Uso de fenol continua proibido para fins estéticos e outros não autorizados [Internet]. 2024. Available from: https://www.gov.br/anvisa/pt-br/assuntos/noticias-anvisa/2024/uso-de-fenol- continua-proibido-para-fins-esteticos-e-outros-nao-autorizados. 8. Hetter GP. An Examination of the Phenol-Croton Oil Peel: Part IV. Face Peel Results with Different Concentrations of Phenol and Croton Oil. Plast Reconstr Surg. 2000;105(3):1061–83. 9. Starkman SJ, Mangat DS. Chemical Peel (Deep, Medium, Light). Facial Plast Surg Clin North Am. 2020;28(1):45–57.

10.

11. 12. 13.

14.

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16. 17.

18. 19.

20.

Mendonça MCC, Segheto NN, Aarestrup FM, Aarestrup BJV. Punctuated 88% phenol peeling for the treatment of facial photoaging: a clinical and histopathological study. Dermatol Surg. 2018;44(2):241–7. Marta V, Maria T, Chisaki C, Benemond PH. Peelings químicos: revisão e aplicação prática. Surg Cosmet Dermatol. 2025;5(1):58–68. Fabbrocini G, Padova M, Tosti A. Chemical Peels: what s new and what isn t new but still works well. Facial Plast Surg. 2009;25(5):329–36. Atiyeh B, Oneisi A, Fadi Ghieh. Medium-depth trichloroacetic acid and deep phenol–croton oil chemical peeling for facial rejuvenation: an update. J Craniofac Surg [Internet]. 2021;32(8):e745–50. Costa IMC, Peres AS, Costa MC, Figueira RBFC. Is there still a place for deep chemical peels in the treatment of perioral wrinkles? J Cosmet Dermatol. 2020;19(10):2634–6. Antelo DAP, Vasconcellos JB, Orofino-Costa R. Estudo comparativo da aplicação regional de peeling de fenol e toxina botulínica: ainda um tratamento acessível e eficiente para rugas periorais e periorbitárias. Surg Cosmet Dermatology. 2020;12(3). Fulton JE, Porumb S. Chemical Peels. American Journal of Clinical Dermatol. 2004;5(3):179–87. Di P, Lopes B, Vieira R, Mandelbaum SH. Peeling profundo de fenol: como controlar a dor durante a aplicação e até 12 horas após? Surg Cosmet Dermatol. 2014;6(1):11–4. Bagatin E, Hassun K, Talarico S. Revisão sistemática sobre peelings químicos. Surg Cosmet Dermatol. 2009;1(1):37–46. Oliveira CN, Bisson GB, Ferreira Jr O. Adverse effects associated with the irresponsible use of phenol peeling: literature review. Oral Surg, Oral Med, Oral Pathol Oral Radiol. 2025;139(2):161–5. Kadunc BV, Vanti AA. Avaliação da toxicidade sistêmica do fenol em peelings faciais. Surg Cosmet Dermatol. 2009;1(1):10–4.

AUTHOR’S CONTRIBUTION: Gabriela Roncada Haddad 0000-0002-7516-9586 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Ana Carolina Salomão Gerolamo 0009-0001-4831-5728 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH manuscript. Nicole Dias Sbrissa 0009-0009-5425-3584 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH manuscript. José Ferreira de Oliveira Neto 0009-0000-8721-2732 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLcipation in the conduct of the study, Critical review of the literature, Critical revision of the manuscript. Ricardo Henrique Marcelino 0009-0003-4759-781X $XWKRUÞV FRQWULEXWLRQ $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Isabela Novello 0000-0002-2496-4475 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLcipation in the conduct of the study, Critical review of the literature, Critical revision of the manuscript.

388

ISSN-e 1984-8773 APOIO CIENTÍFICO:

www.surgicalcosmetic.org.br/

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Original Article Authors: Helena Cargnelutti Grimaldi1 Sandro da Silva Camargo2 1 2

Private Practice, Bagé (RS), Brazil Universidade Federal do Pampa (Unipampa), Applied Computing, Bagé (RS), Brazil

DOI: KWWS ZZZ G[ GRL RUJ VFG ABSTRACT Introduction: The journal Surgical & Cosmetic Dermatology (SCD), founded in 2009, has played a FHQWUDO UROH LQ GLVVHPLQDWLQJ VFLHQWLǦF DGYDQFHV LQ GHUPDWRORJLF VXUJHU\ FRVPHWLF GHUPDWRORJ\ DQG UHODWHG FOLQLFDO SUDFWLFHV LQ %UD]LO DQG /DWLQ $PHULFD +RZHYHU VWXGLHV HYDOXDWLQJ LWV VFLHQWLǦF RXWSXW IURP D ELEOLRPHWULF DQG VFLHQWLǦF QHWZRUN SHUVSHFWLYH UHPDLQ VFDUFH Objective: 7R PDS WKH SULQFLSDO DXWKRUV LQVWLWXWLRQV DQG WRSLFV FRYHUHG E\ WKH MRXUQDO DV ZHOO DV LWV SDWWHUQV RI VFLHQWLǦF FROODERUDWLRQ Methods: 2YHU VWXGLHV SXEOLVKHG VLQFH WKH LQFHSWLRQ RI 6&' ZHUH DQDO\]HG XVLQJ GDWD H[WUDFWHG IURP LWV GLJLWDO DUFKLYH %LEOLRPHWULF LQGLFDWRUV DQG FR DXWKRUVKLS QHWZRUNV ZHUH SURFHVVHG ZLWK VSHFLǦF GDWD DQDO\VLV DQG YLVXDOL]DWLRQ WRROV Results: 7KH UHVXOWV LGHQWLǦHG WKH PRVW SURGXFWLYH DQG LQǧXHQWLDO DXWKRUV DQG KLJKOLJKWHG FRQVROLGDWHG institutional and international collaborations. Conclusions: 7KH ǦQGLQJV GHPRQVWUDWH WKH HYROXWLRQ RI WKH MRXUQDOÞV VFLHQWLǦF VFRSH DQG LWV UHOHYDQFH DV DQ RSHQ DFFHVV SODWIRUP IRU GLVVHPLQDWLQJ GHUPDWRORJLFDO NQRZOHGJH 7KLV LQIRUPDWLRQ PD\ VHUYH DV D YDOXDEOH UHVRXUFH IRU UHVHDUFKHUV HGLWRUV DQG LQVWLWXWLRQV LQWHUHVWHG LQ WKH HGLWRULDO KLVWRU\ DQG GLUHFWLRQ of SCD. Keywords: Bibliometrics; Dermatological Surgical Procedures; Cosmetic Techniques; Collaboration Indicator

Correspondence: Sandro da Silva Camargo E-mail: sandrocamargo@unipampa.edu.br

Funding: None Conﬂict of interest: None

RESUMO Introdução: A revista Surgical & Cosmetic Dermatology (SCD), fundada em 2009, tem desempenhado papel FHQWUDO QD GLYXOJD©¥R GH DYDQ©RV FLHQW¯řFRV HP FLUXUJLD GHUPDWROµJLFD FRVPLDWULD H SU£WLFDV FO¯QLFDV DřQV QR %UDVLO H América Latina. No entanto, ainda são escassos os estudos que avaliam sua produção sob uma perspectiva bibliométrica H GH UHGHV FLHQW¯řFDV Objetivo: Mapear os principais autores, instituições e países envolvidos com a SCD, bem como suas dinâmicas de FRODERUD©¥R FLHQW¯řFD Metodologia: Foram analisados os mais de 1.000 estudos publicados desde a criação da revista, a partir de dados extraídos de seu arquivo eletrônico. Indicadores bibliométricos e redes de coautoria foram processados com ferramentas HVSHF¯řFDV GH DQ£OLVH H YLVXDOL]D©¥R Resultados: 2V UHVXOWDGRV LGHQWLřFDUDP RV DXWRUHV PDLV SURGXWLYRV H LQŚXHQWHV DO«P GH GHVWDFDU FRODERUD©·HV LQVWLtucionais e internacionais consolidadas. Conclusões: 2V DFKDGRV GHPRQVWUDP D HYROX©¥R GR HVFRSR FLHQW¯řFR GD UHYLVWD H VXD UHOHY¤QFLD FRPR YH¯FXOR GH GLIXV¥R GR FRQKHFLPHQWR GHUPDWROµJLFR HP DFHVVR DEHUWR 7DLV LQIRUPD©·HV SRGHP VXEVLGLDU SHVTXLVDGRUHV HGLWRUHV H LQVWLWXL©·HV LQWHUHVVDGDV QD KLVWµULD H QRV UXPRV HGLWRULDLV GD 6&' Palavras-chave: %LEOLRPHWULD 3URFHGLPHQWRV FLU¼UJLFRV GHUPDWROµJLFRV 7«FQLFDV &RVP«WLFDV ,QGLFDGRU GH Colaboração

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Submitted on: 07/07/2025 Final decision: 08/04/2025

How to cite this article: Grimaldi HC, Camargo SS. Mapping scientific contributions in surgical and cosmetic dermatology (2009-2024): Authors, institutions, and countries - Part I. Surg Cosmet Dermatol. 2025;17:e20250492.

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ǣ 1. Kadunc B. Surgical & Cosmetic Dermatology and Scientific Communication. Surg Cosmet Dermatol. 2018;10(3):187. 2. Kanmounye US, Sebopelo LA, Keke C, Zolo Y, Senyuy WP, Endalle G, et al. Mapping global neurosurgery research collaboratives: a social network analysis of the 50 most cited global neurosurgery articles. Neurosurg Open. 2021;2(2):okab006. 3. Furukawa HS, Cruz ACL, Brandão GSNB, Bagatin E. Cienciometria: uma ferramenta para inserção da Dermatologia brasileira na produção científica mundial. Surg Cosmet Dermatol. 2022;14:e20220148. 4. Musbahi A, Rao CB, Immanuel A. World J Surg. 2022;46(6):1314-24. 5. Song M, Liu Q, Guo H, Wang Z, Zhang H. Global trends and hotspots in robotic surgery over the past decade: a bibliometric and visualized analysis. J Robot Surg. 2024;19(1):33. 6. Cheng WM, Lee CH. International collaboration in Taiwan Emergency Department Publications: a social network analysis. J Acute Med. 2024;14(3):108-15. 7. Grimaldi HC, Camargo SS. Anais Brasileiros de Dermatologia: who wrote this century-old history? An Bras Dermatol. 2025;100(3):527-38. 8. DeVito NJ, Richards GC, Inglesby P. How we learnt to stop worrying and love web scraping. Nature. 2020;585(7826):621–2. 9. Hauge TC, Katz GE, Davis GP, Jaquess KJ, Reinhard MJ, Costanzo ME, et al. A novel application of Levenshtein distance for assessment of high-level motor planning underlying performance during learning of complex motor sequences. J Mot Learn Dev. 2020;8(1):67–86.

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AUTHOR’S CONTRIBUTION: Helena Cargnelutti Grimaldi $XWKRUÞV FRQWULEXWLRQ $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLHZ RI WKH literature. Sandro da Silva Camargo $XWKRUÞV FRQWULEXWLRQ $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH manuscript, Acquisition, analysis and interpretation of data.

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Original Article Authors: Cintyadewi Wignjosoesastro1 Diah Adriani Malik1 Puguh Riyanto1 1

Diponegoro University/National Diponegoro Hospital Medical Center, Dermatovenereology, Semarang (JAWA TENGAH), Indonesia

'2, KWWS ZZZ G[ GRL RUJ VFG Introduction: Melasma is a chronic dermatosis characterized by irregular hyperpigmented patches. Objectives: 7R HYDOXDWH WKH HǡHFWLYHQHVV RI WRSLFDO &HQWHOOD DVLDWLFD &$ LQ WUHDWLQJ PHODVPD XVLQJ WKH 0HODVPD $UHD DQG 6HYHULW\ ,QGH[ 0$6, 6FRUH DQG SDWLHQW VDWLVIDFWLRQ Methods: 7KLV VLQJOH EOLQG UDQGRPL]HG FOLQLFDO WULDO 5&7 FRPSDUHG &$ RLQWPHQW ZLWK K\GURTXLQRQH FUHDP IRU ZHHNV DORQJVLGH GDLO\ VXQVFUHHQ XVH 0$6, VFRUH DQG SDWLHQW VDWLVIDFWLRQ ZHUH PHDVXUHG EHIRUH DQG DIWHU WUHDWPHQW ZLWK DGYHUVH HǡHFWV PRQLWRUHG WKURXJKRXW Results: 7KH &$ JURXS KDG D JUHDWHU GHFUHDVH LQ 0$6, VFRUHV EXW WKH GLǡHUHQFH EHWZHHQ JURXSV ZDV QRW VWDWLVWLFDOO\ VLJQLǦFDQW 3DWLHQW VDWLVIDFWLRQ ZDV VLPLODU EHWZHHQ WKH WZR JURXSV ZLWK D VOLJKWO\ ORZHU LPSURYHPHQW LQ WKH &$ JURXS Conclusion: %RWK &$ DQG K\GURTXLQRQH VLJQLǦFDQWO\ UHGXFHG 0$6, VFRUHV DIWHU ZHHNV ZLWK QR VLJQLǦFDQW GLǡHUHQFH LQ HǡHFWLYHQHVV RU SDWLHQW VDWLVIDFWLRQ &$ PD\ EH FRQVLGHUHG D YLDEOH DOWHUQDWLYH IRU SDWLHQWV VHHNLQJ FRPSDUDEOH WKHUDSHXWLF RXWFRPHV ZLWK D ORZHU ULVN RI LUULWDWLRQ Keywords: 6NLQ &UHDP 0HODQRVLV 3DWLHQW 6DWLVIDFWLRQ

RESUMO Introdução: O melasma é uma dermatose crônica caracterizada por manchas hiperpigmentadas irregulares. Objetivos: $YDOLDU D HřF£FLD GD &HQWHOOD DVLDWLFD &$ WµSLFD QR WUDWDPHQWR GR PHODVPD XWLOL]DQGR R 0HODVPD $UHD DQG 6HYHULW\ ,QGH[ 0$6, H D VDWLVID©¥R GR SDFLHQWH Métodos: (VWH HQVDLR FO¯QLFR UDQGRPL]DGR (&5 VLPSOHV FHJR FRPSDURX D SRPDGD GH &$ D FRP R FUHPH GH KLGURTXLQRQD D SRU VHPDQDV DFRPSDQKDGR GR XVR GL£ULR GH SURWHWRU VRODU 2 HVFRUH 0$6, H D VDWLVID©¥R GR SDFLHQWH IRUDP PHGLGRV DQWHV H GHSRLV GR WUDWDPHQWR FRP RV HIHLWRV DGYHUVRV PRQLWRUDGRV GXUDQWH WRGR R WUDWDPHQWR Resultados: 2 JUXSR &$ DSUHVHQWRX PDLRU UHGX©¥R GR HVFRUH 0$6, PDV D GLIHUHQ©D Q¥R IRL HVWDWLVWLFDPHQWH VLJ QLřFDWLYD 2V Q¯YHLV GH VDWLVID©¥R GR SDFLHQWH IRUDP VHPHOKDQWHV HQWUH RV GRLV JUXSRV FRP XPD PHOKRUD OLJHLUDPHQWH PHQRU QR JUXSR &$ Conclusão: 7DQWR D &$ TXDQWR D KLGURTXLQRQD UHGX]LUDP VLJQLřFDWLYDPHQWH RV HVFRUHV 0$6, DSµV VHPDQDV VHP GLIHUHQ©D VLJQLřFDWLYD QD HřF£FLD RX QD VDWLVID©¥R GR SDFLHQWH $ &$ SRGH VHU FRQVLGHUDGD XPD DOWHUQDWLYD YL£YHO SDUD SDFLHQWHV TXH EXVFDP UHVXOWDGRV WHUDS¬XWLFRV FRPSDU£YHLV FRP PHQRU ULVFR GH LUULWD©¥R Palavras-chave: &UHPH SDUD D 3HOH 0HODQRVH 6DWLVID©¥R GR 3DFLHQWH

397

Correspondence: Cintyadewi Wignjosoesastro E-mail: dewi.dvjuli21@gmail.com

Funding: None Conﬂict of interest: None Submitted on: 09/25/2025 Final decision: 10/15/2025

How to cite this article: Wignjosoesastro C, Malik CA, Riyanto P. Effectiveness of 1% Centella asiatica ointment in women with melasma: A study on the Melasma Area and Severity Index (MASI) and patient scores. Surg Cosmet Dermatol. 2025;17:e20250517.

Wignjosoesastro C, Malik CA, Riyanto P

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ǣ 1. Liu W, Chen Q, Xia Y. New Mechanistic insights of melasma. Clin Cosmet Investig Dermatol. 2023;16:429–42. 2. Mahajan VK, Patil A, Blicharz L, Kassir M, Konnikov N, Gold MH, et al. Medical therapies for melasma. Vol. 21, Journal of Cosmetic Dermatology. John Wiley and Sons Inc; 2022. p. 3707–28. 3. Åström M, Thet Lwin ZM, Teni FS, Burström K, Berg J. Use of the visual analogue scale for health state valuation: a scoping review. Quality of Life Research [Internet]. 2023;32(10):2719–29. Available from: https:// doi.org/10.1007/s11136-023-03411-3. 4. Hussain A, Shahbaz U, Shaheen E, Ghias A, Khalid A, Aman S. Comparison of effectiveness and safety of topical 30% metformin versus 4% hydroquinone in the treatment of epidermal melasma. Journal of Pakistan Association of Dermatologists. 2024;34(1):73–9. 5. Viorizka PBB, Setyaningrum T, Qurnianingsih E, Damayanti. The profile and triggering factors of melasma patients: a retrospective study. Berkala Ilmu Kesehatan Kulit dan Kelamin. 2023;35(2):142–7. 6. Seetan K, Shatanawi M, Ali A, Khamees A, Alsheikh A, Alawneh A, et al. Disease characteristics, determinants, and perception of use of sunscreen and sun-protective behaviors among patients of color with melasma: a cross- sectional study. Photodermatol Photoimmunol Photomed. 2022;38(5):495-500.

9. 10. 11.

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Bylka W, Znajdek-Awizeń P, Studzińska-Sroka E, Brzezińska M. Centella asiatica in cosmetology. V. 30. Postepy Dermatologii i Alergologii. 2013. p. 46–9. Kwon KJ, Bae S, Kim K, An IS, Ahn KJ, An S, et al. Asiaticoside, a component of Centella asiatica, inhibits melanogenesis in B16F10 mouse melanoma. Mol Med Rep. 2014;10(1):503–7. Fernenda L, Ramadhani AP, Syukri Y. Aktivitas pegagan (Centella asiatica) pada dermatologi. Jurnal Sains Farmasi & Klinis. 2023;9(3):237. Calapai G. Assessment report on Centella asiatica (L.) Urban, herba. European Medicine Agency. 2012;44:4. González-Molina V, Martí-Pineda A, González N. Topical treatments for melasma and their mechanism of action. J Clin Aesthet Dermatol [Internet].2022;15(5):19–28. Hydroquinone. Schwartz C, Jan A, Zito PM. . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. AboAlsoud ES, Eldahshan RM, AbouKhodair Mohammed H, Elsaie ML. Safety and efficacy of topical metformin 30% cream versus triple combination cream (Kligman’s formula) in treating melasma: a randomized controlled study. J Cosmet Dermatol. 2022;21(6):2508–15.

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ISSN-e 1984-8773 APOIO CIENTÍFICO:

www.surgicalcosmetic.org.br/

Prevalence of cellulite in Brazilian women: a cross-sectional study Prevalência de celulite nas mulheres brasileiras: um estudo transversal

Original Article Authors: Doris Hexsel1 Ana Carolina Krum dos Santos1 Nathalia Hoffman Guarda Aguzzoli1 Vitor Costa Fabris1 1

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170489 ABSTRACT Introduction: Cellulite is a highly prevalent condition among women. However, its prevalence is not currently based in high-quality population studies. Objectives: To estimate the prevalence of cellulite among Brazilian women. Methods: Cross-sectional study with 385 participants and a convenience sampling.The survey was based on the Hexsel & Hexsel cellulite evaluation scale and shared by SBD members. Results: The study included 614 women, primarily between 20 and 29 years-old (32.8%). The prevalence of cellulite was 92.5%. In women between 12 and 19 years-old, the prevalence reached 72%; above 70 years-old, it was 100%. Among women reporting cellulite, 82.7% reported depressed lesions and GHVFULEHG HOHYDWHG OHVLRQV 7KHUH ZDV D VLJQLǦFDQW DVVRFLDWLRQ EHWZHHQ ERG\ ZHLJKW DQG SUHVHQFH of cellulite. Conclusions: Cellulite has an estimated prevalence rate of 92.5% in the Brazilian population; it is less prevalent among adolescents (72%) and reaches scores close to 100% among women over 70 years-old. It is most prevalent among overweight and obese women. Keywords: Cellulite; Prevalence; Cross-Sectional Studies

RESUMO Introdução: Embora a celulite seja uma condição altamente prevalente entre as mulheres, as estimativas de sua prevalência não são baseadas em estudos populacionais de alta qualidade. Objetivo: Estimar a prevalência da celulite entre mulheres brasileiras. Métodos: Estudo transversal com tamanho amostral calculado de 385 participantes e amostragem por conveniência. O questionário foi baseado na escala para avaliação celulite de Hexsel & Hexsel e foi divulgado por membros da SBD. Resultados: Participaram da pesquisa 614 mulheres, principalmente entre 20 e 29 anos (32,8%). A prevalência de celulite foi de 92,5%. Entre mulheres de 12 a 19 anos de idade, foi de 72%; entre as acima de 70 anos, de 100%. Das mulheres que referiram ter celulite, 82,7% relataram a presença de lesões deprimidas e 19,4% relataram lesões HOHYDGDV +RXYH DVVRFLD©¥R VLJQLřFDWLYD HQWUH R SHVR FRUSRUDO H D SUHVHQ©D GH FHOXOLWH Conclusões: A prevalência estimada da celulite na população brasileira é de 92,5%, sendo menor entre adolescentes (72%) e atingindo valores próximos a 100% em mulheres acima de 70 anos. É mais prevalente em mulheres com sobrepeso e obesas. Palavras-chave: Celulite; Prevalência; Estudos Transversais

403

Clínica Hexsel de Dermatologia, Research, Porto Alegre (RS), Brazil

Correspondence: Doris Hexsel E-mail: doris@hexsel.com.br

Funding: None Conﬂict of interest: None Submitted on: 06/30/2025 Final decision: 10/23/2025 Ethical approval: This study protocol was approved by the Hospital Moinhos de Vento Research Ethics Committee on 02/27/2023, under registration number CAAE 65633122.3.0000.5330. Participants signed the Informed Consent Form or Informed Assent Form, and their participation was anonymous. Acknowledgments We would like to thank all study participants and dermatologists who shared it, with special mention to Dr. Ilner Souza, who publicized the survey in Brazil's North.

How to cite this article: Hexsel D, Santos ACK, Aguzzoli NHG, Fabris VC. Prevalence of cellulite in Brazilian women: a cross-sectional study. Surg Cosmet Dermatol. 2025;17:e20250489.

Hexsel D, Santos ACK, Aguzzoli NHG, Fabris VC

INTRODUCTION Cellulite is a highly prevalent condition in the female population, characterized by irregularities on the skin surface, and it DǡHFWV SULPDULO\ WKH WKLJKV DQG EXWWRFNV ,WV W\SLFDO FOLQLFDO SUHsentation consists of depressed and elevated skin lesions, especially in areas with a higher percentage of body fat and greater laxity. Although it is highly prevalent among women, with some authors HVWLPDWLQJ UDWHV RI WR ZRUOGZLGH WKHVH ǦJXUHV DUH QRW EDsed on observational studies conducted at national or global levels.1,2 6SHFLǦFDOO\ LQ %UD]LO RQH UHJLRQDO VWXG\ DVVHVVHG WKH SUHvalence of cellulite among female adolescents in the state of São Paulo,3 but there are still no representative data on the prevalence of this condition among Brazilian women as a whole. Given this gap in statistical knowledge regarding such a highly prevalent condition, this study intended to estimate the prevalence of cellulite among Brazilian women aged 12 years and older. METHODS This is a cross-sectional study with a convenience sample, and the inclusion criteria were Brazilian women, literate, aged 12 years or older. Data collection was conducted through an online survey on the Google Forms platform, completed anonymously either by the participant directly or by her legal guardian, after signing the Informed Consent Form (or the Informed Assent Form for participants aged 12 to 18). The instrument was based on the validated Hexsel & Hexsel cellulite scale.4 The survey asked participants about their age, self-declared ethnicity, region of residence, place of residence (urban or rural), income range, weight, height, presence of cellulite in any body area, and the appearance of their lesions. All information was self-assessed. The survey was distributed and publicized via the Internet. The survey link was shared by the researchers to their contact networks and, in each region of the country, sent to dermatologists through members of the Regional Chapters of the Brazilian Society of Dermatology. The survey was shared WKURXJK GLǡHUHQW UHJLRQDO JURXSV DV D VWUDWHJ\ WR PLWLJDWH WKH selection bias inherent to the study design and thereby ensure better representativeness of the Brazilian population. The data were collected from 04/14/2023 to 03/05/2025.5 The project was approved by the Hospital Moinhos de Vento de Porto Alegre Research Ethics Committee before its execution, and the researchers followed the principles of the Declaration of Helsinki and Good Clinical Practice. The sample VL]H ZDV FDOFXODWHG EDVHG RQ WKH SURǦOH RI WKH %UD]LOLDQ IHPDOH population according to 2019 data from the Brazilian Institute of Geography and Statistics (IBGE).5 The Brazilian population SURǦOH ZDV FRQVLGHUHG DFFRUGLQJ WR DJH UHJLRQ LQFRPH SODFH RI residence, and color or race, with a tolerance interval of 5% for each category. This resulted in a minimum sample size of 385 participants for the primary objective of the study (analysis of cellulite prevalence).

For the statistical analysis of categorical variables (Tables 1 and 2), the chi-square test was used to evaluate the association between each variable (age, income, and race/ethnicity) and the presence or absence of cellulite.When conducting the chi-square test, if the association Tables and expected count Tables did not meet the prerequisite of expected frequencies equal to or JUHDWHU WKDQ )LVKHUÞV H[DFW WHVW ZDV DSSOLHG 7KH VLJQLǦFDQFH level for all tests was set at _ &UDP«UÞV 9 FRHǤFLHQW 9 was also calculated to assess the degree of association in Tables ODUJHU WKDQ ,Q VWDWLVWLFDOO\ VLJQLǦFDQW DVVRFLDWLRQV WKH DGjusted standardized residual, also known as the Z-residual, was calculated as a post-hoc interpretation method. Residual difIHUHQFHV ZHUH FRQVLGHUHG VLJQLǦFDQW ZKHQ JUHDWHU WKDQ RU ORZHU WKDQ FRQǦUPDWLRQ RI WKH QXOO K\SRWKHVLV ! = ! ZLWK WKH = YDOXH FRUUHVSRQGLQJ WR D VLJQLǦFDQFH OHYHO of alpha equal to 5% (_ < 0.05). The independent-samples t-test was used in the analysis RI QXPHULFDO YDULDEOHV 7DEOH WR DVVHVV GLǡHUHQFHV LQ ERG\ mass, height, or BMI given the presence or absence of celluliWH ,Q WKHVH FDVHV &RKHQÞV G HǡHFW VL]H ZDV FDOFXODWHG DQG FODVVLǦHG DV QHJOLJLEOH 1 VPDOO 6 Û PHGLXP 0 Û RU ODUJH / DERYH 6,7 7KH VLJQLǦFDQFH OHYHO adopted for all analyses was set at _ < 0.05.The statistical procedures followed the recommendations of Field (2013)8 and were performed using IBM SPSS Statistics, version 23.0. The sample size was not based on the objectives of the analyses presented in Tables 2 and 3 and, therefore, the data should be interpreted with caution and as exploratory in nature. RESULTS In total, 614 women participated in the study. Participants aged 18 years or older accounted for 98.7% of respondents, whereas adolescents between 12 and 17 years represented only 1.1%. The age group with the highest representation in the sample was 20 to 29 years (32.8%). Of the total, 608 (99.1%) lived in urban areas. The sample included participants from all regions of Brazil: 29 (4.7%) from the Central-West, 41 (6.7%) IURP WKH 1RUWK IURP WKH 1RUWKHDVW from the Southeast, and 211 (34.3%) from the South. Complete demographic data are shown in Table 1. Tables 3 and 4 show the relationship between the presence of cellulite and self-reported ethnicity, income, weight, height, and BMI. Table 5 presents reSRUWV IURP SDUWLFLSDQWV ZKR FODVVLǦHG WKH DSSHDUDQFH RI WKHLU cellulite as “other appearance.” The vast majority of participants (92.5%) reported having cellulite. Of these, 82.7% reported depressed lesions, and 19.4%, elevated lesions. A little more than half (50.3%) reported DQ àRUDQJH SHHOá DSSHDUDQFH :KHQ VWUDWLǦHG E\ UHJLRQ RI SDUWLFLSDQWV IURP WKH 1RUWK DQG &HQWHU :HVW UHSRUWHG KDYLQJ cellulite, as did 93% in the South and Southeast and 88% in the 1RUWKHDVW

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Question

How old are you?

What is your ethnicity?

In what region of Brazil do you live? Do you live in an urban or rural area? What is your income level?

ĆćđĊ ͕: Survey given to participants Answer options ( ) 12 to 19 ( ) 20 to 29 ( ) 30 to 39 ( ) 40 to 49 ( ) 50 to 59 ( ) 60 to 69 ( ) 70 to 79 ( ) 80 or older ( ) White ( ) Asian ( ) Mixed ( ) Black 1RUWK 1RUWKHDVW 6RXWKHDVW 6RXWK ( ) Central-West ( ) Urban ( ) Rural ( ) Up to 2 Brazilian minimum monthly salaries ( ) 2 to 5 Brazilian minimum monthly salaries ( ) More than 5 Brazilian minimum monthly salaries

What is your weight in kilograms? Example answer: 70.2 kg What is your height in centimeters? Example answer: 162 cm

Open-ended question Open-ended question ( ) Yes 1R ( ) Depressed (“holes”) ( ) Elevated ("lumps") ( ) Other appearance ( ) I don't have cellulite

Do you have cellulite?

If yes, your lesions are (mark all that apply): ,I \RX PDUNHG àRWKHU DSSHDUDQFH á SOHDVH EULHǧ\ GHVFULEH what your cellulite looks like. If you did not mark “other appearance,” please leave the answer blank.

Open-ended question

Your cellulite lesions look like:

( ) Orange peel ( ) Cottage cheese ( ) Quilt ( ) I don't have cellulite ( ) Other appearance

,I \RX PDUNHG àRWKHU DSSHDUDQFH á SOHDVH EULHǧ\ GHVFULEH ZKDW your cellulite looks like. If you did not mark “other appearance,” please leave the answer blank.

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DISCUSSION This study estimated the prevalence of cellulite across GLǡHUHQW DJH JURXSV LQ WKH %UD]LOLDQ IHPDOH SRSXODWLRQ 7KH ǦQGLQJ WKDW FHOOXOLWH LV OHVV SUHYDOHQW DPRQJ \RXQJHU ZRPHQ (12 to 19 years) is consistent with expectations, given what is known about the pathophysiological mechanisms involved in

405

the development of cellulite.9-11 Interestingly, the self-reported prevalence in this age group was similar to that found in the study by Soares et al.,3 which estimated the prevalence of cellulite in adolescents through clinical evaluation conducted by trained professionals. This indicates that self-diagnosis of cellu-

Hexsel D, Santos ACK, Aguzzoli NHG, Fabris VC

ĆćđĊ ͖: Descriptive results and chi-square inferences for association between age and cellulite outcomes Has other lesion Has depressed Has elevated Has other lesion Has cellulite types lesions lesions types Age range (n) n (%) n (%) n (%) n (%) n (%) 12 to 19 years (43) 20 to 29 years (203) 30 to 39 years (157) 40 to 49 years (120) 50 to 59 years (50) 60 to 69 years (33) 70 to 79 years (8)

31 ? 186 149 118 B 45 31 8

(72%)* (92%) (95%) (98%)* (90%) (94%) (100%)

p (r²(f); df;V): 0.00 (26.4; 6; 0.24)

27 171 138 106 38 22 5

(63%) (84%) (88%) (88%) (76%) (67%) (63%)

5 35 38 23 8 9 2

(12%) (17%) (24%) (19%) (16%) (9%) (2%) **

2 9 13 16 10 8 1

(5%) (4%) (8%) (13%) (20%) (24%) (13%) **

3 28 37 24 9 6 0

(7%) (14%) (24%) (20%) (18%) (18%) (0%) **

p: Fisher’s exact test. rt GI FKL VTXDUH IRU HDFK WHVW IRU D JLYHQ QXPEHU RI GHJUHHV RI IUHHGRP 9 &UDP«UÞV 9 IRU WDEOHV ODUJHU WKDQ VLJQLǦFDQW DVVRFLDWLRQ S < 0.05); B Count higher than expected count, adjusted residual (Z) greater than 1.96. ? Count lower than expected count, adjusted residual (Z) less than -1.96. ** Statistical tests not performed.

ĆćđĊ ͗: Descriptive results and chi-square inferences for association between income, ethnicity, and presence of cellulite Has cellulite Has cellulite Region of the country (n) Self-reported ethnicity (n) n (%) n (%) Up to 2 Brazilian minimum 11 (100%) monthly salaries (135) Asian (11) 122 (90%) 433 (93%) 2 to 5 Brazilian minimum White (467) 148 (93%) monthly salaries (160) 26 (87%) Black (30) 298 (93%) ( ) More than 5 Brazilian Mixed (106) 98 (92%) minimum monthly salaries (319) p (r²; df;V): 0.54 (1,3; 2; 0.05)

p(f) (r²(f); df;V): 0.56 (2; 3; 0.06)

p: chi-square test; p(f): Fisher’s exact test when the prerequisite of expected count greater than 5 was not met. r²(df): chi-square found in each test for a given number of degrees of freedom;V: Cramér’s V for tables larger than 2×2.

lite is reasonably accurate even when performed by younger patients. The prevalence of 100% in the population aged 70 to 79 years was also expected, since skin laxity is an aggravating factor for cellulite that worsens with aging, showing that the pathophysiological mechanisms responsible for the onset of cellulite tend to add up and intensify with advancing age.9-11 The study also found increased prevalence of cellulite in the 40 to

DJH JURXS 7KLV ǦQGLQJ PD\ EH D VWDWLVWLFDO ǧXFWXDWLRQ LQ WKH analysis (type I error, false positive) and/or be the result of the fact that assessments were self-reported. Participants in this age group may be more perceptive than others regarding changes in how their body looks. 1R VWDWLVWLFDOO\ VLJQLǦFDQW GLǡHUHQFHV ZHUH REVHUYHG LQ WKH SUHYDOHQFH RI FHOOXOLWH DPRQJ SDWLHQWV RI GLǡHUHQW HWKQLFLWLHV or household income levels, underlining the universality of this

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ĆćđĊ ͘: Descriptive results and independent-samples t-test inferences for comparison of body weight, height, ơ Has cellulite Yes No M (SD) M (SD) Body mass (kg) 66.82 (13.44) 57.00 (10.01) p 0.08* (T; d ES) / 163.59 (7.25) 163.21 (5.42) Height (cm) p 0.11 (T; d ES) 1 BMI (kg/m²) 25.03 (5.55) 21.39 (3.60) p 0.14 (T; d ES) / %0, ERG\ PDVV LQGH[ 0 PHDQ 6' VWDQGDUG GHYLDWLRQ S VLJQLǦFDQFH FDOFXODWHG IRU HDFK WHVW W LQGHSHQGHQW VDPSOHV W WHVW G &RKHQÞV G HǡHFW VL]H (6 HǡHFW VL]H FODVVLǦHG DV QHJOLJLEOH 1 VPDOO 6 Û PHGLXP 0 Û RU ODUJH / DERYH VLJQLǦFDQW DVVRFLDWLRQ S

ĆćđĊ ͙: Self-reported appearance of cellulite and description of other types of cellulite presented by participants who marked “other appearance.” Appearance of cellulite Occurrences Orange peel 310 Quilt 130 Cottage cheese 110 Other types Occurrences Ripples / irregularities 21 Visible only when pressed 9 Skin laxity / excess skin 4 Minimally visible / imperceptible 3 Holes / craters 3 /XPSV 1 Darkening of the area 1 Wounds 1 Fibrosis 1 Surface lines 1 /LSHGHPD 1 Frank lipodystrophy 1 Cannot describe 1 Fat nodules 1 Frizzy skin 1 /DFHG 1 Pleated skin 1

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Hexsel D, Santos ACK, Aguzzoli NHG, Fabris VC

condition among Brazilian women.Traditionally, Caucasian ethnicity has been considered a risk factor for developing cellulite,12,13 but the data from this study do not support that hypothesis. Because Brazil is a highly mixed-race country, it is possible WKDW HWKQLF LQǧXHQFHV RQ WKH GHYHORSPHQW RI FHOOXOLWH SOD\ D VPDOOHU UROH DPRQJ %UD]LOLDQV ZLWK WKHLU HǡHFW RYHUZKHOPHG E\ factors such as overweight and age. Many studies cite estimates of 80% to 90% prevalence for cellulite in the general female population,13,14 but the data that originated these estimates lack statistical grounding in prevalence studies with broad population coverage. Several articles mention these estimates without citing primary sources. The data from this study indicate an even higher overall prevalence of cellulite among Brazilian women, at 92.5%. In this study, individuals with cellulite also had higher ERG\ ZHLJKW EXW QR VLJQLǦFDQW GLǡHUHQFHV ZHUH IRXQG LQ WHUPV of height or BMI compared with women without cellulite. A higher prevalence of cellulite among women with greater body weight was expected, given that the thickness of the subcutaQHRXV DGLSRVH WLVVXH LQǧXHQFHV KRZ WKH VNLQ VXUIDFH ORRNV 9,10 The mean BMI of participants with cellulite was 25.03, compaUHG ZLWK IRU SDUWLFLSDQWV ZLWKRXW FHOOXOLWH 7KLV GLǡHUHQFH ZDV QRW VLJQLǦFDQW OLNHO\ GXH WR WKH VWXG\ÞV ORZ VWDWLVWLFDO SRZHU since this was a secondary analysis variable that was not included in the sample size calculation. Regarding statistical analyses of secondary data, subgroup analyses were not performed based on the type of cellulite lesion reported by participants (for example, depressed versus elevated lesions). Given the large number of analyses that would have been required (more than 60) and the considerable sample size of this study (614), there would have been a prohibitively high probability of type I errors (false positives), which would have made a reliable interpretation of the results impossible. Thus, the data were reported quantitatively and descriptively in Table 1, VWUDWLǦHG E\ DJH JURXS ,Q WKH VSHFLǦF FDVH RI FHOOXOLWH SUHYDlence by region, statistical tests were not performed because the

participants’ region of residence is only a confounding factor, LQGLUHFWO\ UHODWHG WR GHWHUPLQDQWV WKDW FRXOG DFWXDOO\ LQǧXHQFH the development of the condition, such as ethnicity, income, and weight.13 This study has limitations. The main one is the use of a convenience sampling rather than a randomized sample, which increases the risk of selection bias, partially mitigated by the inclusion of a large number of participants. Other biases inherent to the study methodology include the exclusive participation of literate women with Internet access, which reduces participation among socially vulnerable women, and the fact that cellulite was self-assessed. In addition, although all women could participate in the survey once they received the recruitment link, it is likely that women with cellulite were more inclined to respond, possibly leading this study to overestimate the prevalence of the condition. Even though the distribution of participants in this study GRHV QRW UHǧHFW WKH %UD]LOLDQ SRSXODWLRQ LQ WHUPV RI LQFRPH DJH group, ethnicity, and state population, the sample included 467 Caucasian women of various income levels, aged 20 to 59 years, a number large enough to ensure internal validity for data analysis in this population subgroup. Self-assessment is also not a major limitation, since, as previously discussed, even young women seem able to diagnose the presence of cellulite with a reasonable degree of accuracy. Thus, even under a conservative interpretation, the data reported in this study have external validity for the subgroup of Caucasian women aged 20 to 59 years. CONCLUSIONS Prevalence of cellulite is extremely high among Brazilian women, with an estimated rate of 92.5%. It is less common during adolescence (72%) and may reach values close to 100% in older age groups, above 70 years. It is more prevalent among women with higher body weight, and in the Brazilian population, self-declared ethnicity does not appear to be a risk or protective factor for the development of cellulite. O

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REFERENCES: 1. Luebberding S, Krueger N, Sadick NS. Cellulite: an evidence-based review. Am J Clin Dermatol. 2015;16(4):243-56. 2. Nürnberger F, Müller G. So-called cellulite: an invented disease. J Dermatol Surg Oncol 1978;4(3):221–9. 3. Soares JLM, Rocha VA, Sanudo A, Miot HA, Bagatin E. Prevalence and factors associated with gynoid lipodystrophy in Brazilian adolescent girls: a cross-sectional study. Int J Dermatol. 2022;61(7):861-6. 4. Hexsel DM, Dal’Forno T, Hexsel CM. A validated photonumeric cellulite severity scale. J Eur Acad Dermatol Venereol. 2009;23(5):523-8. 5. IBGE. Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento. Pesquisa Nacional por Amostra de Domicílios Contínua; 2019. Disponível em https://www.ibge.gov.br/. 6. Bakeman R. Recommended effect size statistics for repeated measures designs. Behav Res Methods. 2005;37(3):379-84. 7. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale: Erlbaum; 1988. 8. Field A. Discovering statistics using IBM SPSS statistics. Sage; 2013.

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11.

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Hexsel DM, Abreu M, Rodrigues TC. Side-by-side comparison of areas with and without cellulite depressions using magnetic resonance imaging. Dermatol Surg. 2009; 35(10):1471–7. Hexsel DM, Siega C, Schilling-Souza J. A comparative study of the anatomy of adipose tissue in areas with and without raised lesions of cellulite using magnetic resonance imaging. Dermatol Surg. 2013;39(12):1877-86. Tokarska K, Tokarski S, Woźniacka A, Sysa-Jędrzejowska A, Bogaczewicz J. Cellulite: a cosmetic or systemic issue? Contemporary views on the etiopathogenesis of cellulite. Postepy Dermatol Alergol. 2018;35(5):442-6. Arora G, Patil A, Hooshanginezhad Z, Fritz K, Salavastru C, Kassir M. Cellulite: presentation and management. J Cosmet Dermatol. 2022;21(4):1393-1401. Gabriel A, Chan V, Caldarella M, Wayne T, O'Rorke E. Cellulite: current understanding and treatment. Aesthet Surg J Open Forum. 2023;21:5:ojad050. Friedmann DP, Vick GL, Mishra V. Cellulite: a review with a focus on subcision. Clin Cosmet Investig Dermatol. 2017;10:17-23.

AUTHOR’S CONTRIBUTION: Doris Hexsel 0000-0002-0615-9026 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Ana Carolina Krum dos Santos 0000-0001-9863-1836 Conception and design of the study, Preparation and writing of the manuscript, Acquisition, analysis and interpretation of data, Critical review of the literature, Critical revision of the manuscript. 1DWKDOLD +RŔPDQ *XDUGD $JX]]ROL 0000-0001-6472-0910 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ Critical review of the literature, Critical revision of the manuscript. Vitor Costa Fabris 0000-0002-3540-2769 $XWKRUÞV FRQWULEXWLRQ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH conduct of the study, Critical review of the literature, Critical revision of the manuscript.

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From a surgical standpoint - A comment on: “Bilateral temporal triangle alopecia mimicking male pattern alopecia in an adult female: a case report and review of the literature” Perspectiva cirúrgica - Um comentário sobre: “Alopecia triangular temporal bilateral simulando alopecia androgenética de padrão masculino em mulher adulta: relato de caso e revisão da literatura”

Letter to the Editor Authors: Hudson Dutra Rezende1 Renata Almeida Chaebub Rodrigues1 Ana Lígia Scotti Alérico1 Ingrid Palloma Vieira de Melo1 Sandra Lopes Mattos e Dinato1 1

Centro Universitário Lusíada (UNILUS), Dermatology, Santos (SP), Brazil

DOI: KWWS ZZZ G[ GRL RUJ VFG

ABSTRACT Temporal triangular alopecia (TTA) is a rare condition frequently mistaken for androgenetic alopecia or other hair disorders. We comment on the recent case reported by Lucca et al., emphasizing the imporWDQFH RI KLVWRSDWKRORJLFDO FRQǦUPDWLRQ LQ VXVSHFWHG FDVHV WR DYRLG PLVGLDJQRVLV DQG XQQHFHVVDU\ WUHDWPHQWV $OWKRXJK YDOXDEOH WULFKRVFRS\ PD\ QRW UHOLDEO\ GLVWLQJXLVK 77$ IURP FRQGLWLRQV VXFK DV DORSHFLD DUHDWD WULFKRWLOORPDQLD RU IURQWDO ǦEURVLQJ DORSHFLD LQ DGYDQFHG VWDJHV 6XUJLFDO FRUUHFWLRQ UHPDLQV WKH WUHDWPHQW RI FKRLFH IRU FRQǦUPHG 77$ EXW FDXWLRQ LV ZDUUDQWHG ZKHQ FRQVLGHULQJ KDLU WUDQVSODQWDWLRQ in other forms of alopecia, as outcomes and safety may be compromised in the absence of diagnostic certainty. Keywords: $ORSHFLD 7UDQVSODQWDWLRQ 3DWKRORJ\ &OLQLFDO 6XUJHU\ 3ODVWLF

RESUMO A alopecia triangular temporal (ATT) é uma condição rara, frequentemente confundida com alopecia androgenética ou RXWURV GLVW¼UELRV FDSLODUHV &RPHQWDPRV R UHFHQWH UHODWR GH FDVR GH /XFFD HW DO GHVWDFDQGR D LPSRUW¤QFLD GD FRQřUPDção histopatológica nos casos suspeitos para evitar diagnósticos equivocados e tratamentos desnecessários. Embora seja XPD IHUUDPHQWD ¼WLO D WULFRVFRSLD SRGH Q¥R GLIHUHQFLDU GH IRUPD FRQř£YHO D $77 GH FRQGL©·HV FRPR DORSHFLD DUHDWD WULFRWLORPDQLD RX DORSHFLD IURQWDO řEURVDQWH HP HVW£JLRV DYDQ©DGRV $ FRUUH©¥R FLU¼UJLFD SHUPDQHFH R WUDWDPHQWR GH HVFROKD SDUD $77 FRQřUPDGD PDV R WUDQVSODQWH FDSLODU GHYH VHU LQGLFDGR FRP FDXWHOD HP RXWUDV IRUPDV GH DORSHFLD para garantir a segurança e resultados adequados. Palavras-chave: Alopecia;Transplante; Patologia Clínica; Cirurgia Plástica

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Correspondence: Hudson Dutra Rezende E-mail: contato@hudsondutra.com.br / hudsondutra@live.com

Funding: None Conﬂict of interest: None Submitted on: 07/28/2025 Final decision: 09/03/2025

How to cite this article: Rezende HD, Rodrigues RAC, Alérico ALS, Melo IPV, Dinato SLM. From a surgical standpoint - A comment on: “Bilateral temporal triangle alopecia mimicking male pattern alopecia in an adult female: a case report and review of the literature.” Surg Cosmet Dermatol. 2025;17:e20250502.

Rezende HD, Rodrigues RAC, Alérico ALS, Melo IPV, Dinato SLM.

To the Editor :H UHDG ZLWK JUHDW LQWHUHVW WKH FDVH UHSRUW E\ /XFFD HW al. describing bilateral temporal triangular alopecia (TTA) in an DGXOW ZRPDQ D UDUH FRQGLWLRQ WKDW LV IUHTXHQWO\ PLVWDNHQ IRU androgenetic alopecia or other causes of hair loss. Their report underscores the diagnostic challenges posed by this entity and KLJKOLJKWV WKH LPSRUWDQFH RI D WKRURXJK HYDOXDWLRQ :H ZRXOG OLNH WR H[SDQG WKH GLVFXVVLRQ E\ HPSKDVL]LQJ WKH QHHG IRU KLVWRSDWKRORJLFDO FRQǦUPDWLRQ in suspected cases and careful consideration of the role of hair WUDQVSODQWDWLRQ LQ WUXH 77$ FRPSDUHG ZLWK LWV GLǡHUHQWLDO GLDJQRVHV :KLOH WULFKRVFRS\ LV XQGRXEWHGO\ D YDOXDEOH GLDJQRVWLF WRRO LWV OLPLWDWLRQV PXVW EH DFNQRZOHGJHG ,W UHOLHV RQ SK\VLFLDQ H[SHUWLVH DQG VHYHUDO IRUPV RI DORSHFLD SDUWLFXODUO\ LQ FKURQLF RU DGYDQFHG VWDJHV PD\ SUHVHQW ZLWK LQFRQVSLFXRXV RU YHU\ VXEWOH WULFKRVFRSLF ǦQGLQJV 7KLV FDQ PDNH LW GLǤFXOW WR GLVWLQJXLVK TTA from other conditions such as late-stage alopecia areata XQLORFXODULV DQG WULFKRWLOORPDQLD ZKLFK KDYH GLǡHUHQW WKHUDSHXWLF DSSURDFKHV DQG SURJQRVHV 'HOD\LQJ KLVWRORJLFDO FRQǦUPDWLRQ PD\ OHDG WR XQQHFHVVDU\ RU HYHQ KDUPIXO LQWHUYHQWLRQV in such cases. The case reported by the authors illustrates the potential FRQVHTXHQFHV RI WKHVH GLDJQRVWLF SLWIDOOV $ SDWLHQW ZLWK DORSHFLD DUHDWD LQYROYLQJ WKH IURQWDO KDLUOLQH ZRXOG PRVW OLNHO\ XQGHUJR intralesional corticosteroid injections in an area that is highly inQHUYDWHG SDLQIXO DQG FRVPHWLFDOO\ VHQVLWLYH PDNLQJ WKH LQKHUHQW ULVN RI FXWDQHRXV DWURSK\ SDUWLFXODUO\ FRQFHUQLQJ 3DWLHQWV ZLWK SDWFK\ IURQWDO ǦEURVLQJ DORSHFLD ))$ ZRXOG OLNHO\ XQGHUJR V\VWHPLF WKHUDSLHV VXFK DV K\GUR[\FKORURTXLQH RU GR[\F\FOLQH ZKLFK KDYH WKHLU RZQ DGYHUVH HǡHFWV $ PLVGLDJQRVLV RI WULFKRWLOORPDQLD PD\ H[SRVH SDWLHQWV WR XQZDUUDQWHG SV\FKRWKHUDSHXWLF RU SKDUPDFRORJLFDO LQWHUYHQWLRQV LQFOXGLQJ DQWLSV\FKRWLFV (YHQ D PLVGLDJQRVLV RI DQGURJHQHWLF DORSHFLD ZRXOG OLNHO\ H[-

SRVH WKH SDWLHQW WR FKURQLF XVH RI WRSLFDO DQG RU RUDO PLQR[LGLO DQG _ UHGXFWDVH LQKLELWRUV DV FRXOG KDYH RFFXUUHG LQ WKH FDVH reported by Lucca et al. Although surgical correction remains the treatment of FKRLFH IRU FRQǦUPHG 77$ the role of hair transplantation in RWKHU IRUPV RI DORSHFLD VKRXOG EH DSSURDFKHG ZLWK FDXWLRQ 3URFHHGLQJ ZLWK WUDQVSODQWDWLRQ ZLWKRXW GLDJQRVWLF FHUWDLQW\ PD\ compromise both clinical outcomes and patient safety. ,Q DORSHFLD DUHDWD IRU H[DPSOH VXUJLFDO DSSURDFKHV RQ FKURQLF OHVLRQV HYHQ DIWHU SURORQJHG GLVHDVH VWDELOLW\ KDYH SURYHQ ULVN\ &LYDV HW DO UHSRUWHG WKH FDVH RI D \HDU ROG PDQ XQGHUJRLQJ H\HEURZ KDLU WUDQVSODQWDWLRQ IRU WKHUDS\ UHVLVWDQW DORSHFLD DUHDWD ZKR H[SHULHQFHG GLVHDVH UHDFWLYDWLRQ DQG FRPSOHWH JUDIW ORVV DIWHU \HDUV 6LPLODUO\ DV HPSKDVL]HG E\ 5REHUW 7UXH LQ KLV UHFRPPHQGDWLRQV IRU VXUJLFDO FDQGLGDF\ SDWLHQWV ZLWK DFWLYH trichotillomania are not suitable candidates for hair restoration SURFHGXUHV DV FRPSXOVLYH KDLU SXOOLQJ FDQ GHVWUR\ ERWK QDWLYH and transplanted follicles, resulting in unsatisfactory outcomes and unnecessary costs. Lastly, although surgical treatment has EHHQ WULHG IRU ))$ WKLV DSSURDFK UHPDLQV FDXWLRXV DV JUDIW VXUYLYDO UDWHV DUH JHQHUDOO\ ORZHU WKDQ LQ XQDǡHFWHG LQGLYLGXDOV DQG results tend to be more limited. %H\RQG WKH ULVN RI XQQHFHVVDU\ FOLQLFDO LQWHUYHQWLRQV DQG WKHLU SRWHQWLDO DGYHUVH HǡHFWV LW VKRXOG EH VWUHVVHG WKDW ZKLOH FRQJHQLWDO WULDQJXODU DORSHFLD LV PRVW HǡHFWLYHO\ WUHDWHG ZLWK KDLU WUDQVSODQWDWLRQ GLDJQRVLV FRQǦUPDWLRQ WKURXJK KLVWRSDWKRORJ\ UHPDLQV HVVHQWLDO 0LVGLDJQRVLV LQYROYLQJ RWKHU GLǡHUHQWLDO FRQGLWLRQV H[SRVHV SDWLHQWV WR LQHǡHFWLYH RU ULVN\ WUHDWPHQWV DQG PD\ DOVR OHDG WR LUUHYHUVLEOH DHVWKHWLF DQG SV\FKRORJLFDO GLVWUHVV %\ UHLQIRUFLQJ WKH GLDJQRVWLF YDOXH RI ELRSV\ DQG FODULI\LQJ WKH UROH RI VXUJLFDO LQWHUYHQWLRQV ZH DLP WR SURPRWH VDIHU DQG PRUH HǡHFWLYH PDQDJHPHQW RI SDWLHQWV ZLWK 77$ DQG RWKHU XQFRPmon forms of alopecia. O

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REFERENCES: 1. Katoulis AC, Liakou AI, Bozi E, Alevizou A, Rigopoulos D. Temporal triangular alopecia: clinical, trichoscopic, and histopathological features. Skin App Dis. 2019;5(4):230–5. 2. Lucca MB, Ferreira LO, Boff AL, Vettorato R. Alopecia triangular temporal bilateral simulando alopecia androgenética de padrão masculino em mulher adulta: relato de caso e revisão da literatura. Surg Cosmet Dermatol. 2025;17:e20250380. 3. Bang CY, Byun JW, Kang MJ, Yang BH, Song HJ, Shin J, et al. Successful treatment of temporal triangular alopecia with topical minoxidil. Ann Dermatol. 2013;25(3):387–8.

Civas E, Aksoy B, Ozer F, Eski M. Long-term result of hair transplantation for therapy- resistant alopecia areata of eyebrows. Indian J Dermatol Venereol Leprol. 2017;83(5):618–9. True RH. Is every patient of hair loss a candidate for hair transplant? Deciding surgical candidacy in pattern hair loss. Indian J Plast Surg. 2021;54(4):435–40.

AUTHOR’S CONTRIBUTION: Hudson Dutra Rezende ; $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Renata Almeida Chaebub Rodrigues 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Ana Lígia Scotti Alérico $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH Ingrid Palloma Vieira de Melo ; $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH Sandra Lopes Mattos e Dinato $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH

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Non-surgical management of ectropion using hyaluronic acid gel with cannula injection Manejo não cirúrgico de ectrópio pela aplicação de ácido hialurônico com cânula

How do I do it? Authors: Ana Paula Dornelles Manzoni 1 Fabiane Kumagai Lorenzini1 Taisa de Boni Gauer1 Bruna Bonamigo Thomé1 Renan Rangel Bonamigo1 1

Universidade Federal de Ciências da Saúde (UFCSPA), Dermatology Service, Porto Alegre (RS), Brazil

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170470

ABSTRACT The treatment of eyelid ectropion remains challenging. Surgical approaches are more widely used, but techniques using hyaluronic acid have shown increasing promise. This article describes a novel technique for hyaluronic acid injection through a cannula to correct severe cicatricial ectropion secondary to lamellar ichthyosis. Despite the need for further studies, the procedure proved to be safe and easily reproducible. Keywords: Ectropion; Hyaluronic Acid; Cannula

RESUMO 2 WUDWDPHQWR GR HFWUµSLR SDOSHEUDO FRQWLQXD D VHU XP GHVDřR $V DERUGDJHQV FLU¼UJLFDV DLQGD V¥R PDLV XWLOL]DGDV PDV DV W«FQLFDV FRP £FLGR KLDOXU¶QLFR W¬P VH PRVWUDGR FDGD YH] PDLV SURPLVVRUDV (VWH DUWLJR GHVFUHYH XPD W«FQLFD LQ«GLWD GH LQMH©¥R GH £FLGR KLDOXU¶QLFR DWUDY«V GH XPD F¤QXOD SDUD FRUUH©¥R GH HFWUµSLR FLFDWULFLDO VHYHUR VHFXQG£ULR ¢ LFWLRVH ODPHODU $SHVDU GH QHFHVVLWDU PDLV HVWXGRV R SURFHGLPHQWR PRVWURX VH VHJXUR H IDFLOPHQWH UHSURGXW¯YHO Palavras-chave: (FWUµSLR FLGR +LDOXU¶QLFR &¤QXOD

Correspondence: Ana Paula Dornelles Manzoni E-mail: apmanzoni@gmail.com / anamanzoni@icloud.com

Funding: None Conﬂict of interest: None Submitted on: 05/12/2025 Final decision: 08/26/2025

How to cite this article: Manzoni APD, Lorenzini FK, Gauer TB, Thomé BB, Bonamigo RR. Non-surgical management of ectropion using hyaluronic acid gel with cannula injection. Surg Cosmet Dermatol. 2025;17:e20250470.

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Manzoni APD, Lorenzini FK, Gauer TB, Thomé BB, Bonamigo RR.

INTRODUCTION Ectropion is an eyelid malposition with exposure of the RFXODU VXUIDFH ,W SULPDULO\ DǡHFWV WKH ORZHU H\HOLG DQG FDQ OHDG to several ocular complications.1 ,Q FLFDWULFLDO HFWURSLRQ &( contracture of the skin and subcutaneous tissue shortens the anterior lamella, resulting in eyelid eversion.2,3 When left untreated, ectropion may cause permanent corneal damage and potentially lead to blindness.4,5 Currently, in addition to surgical correction, there has been a trend toward minimally invasive approaches, VXFK DV WKH XVH RI K\DOXURQLF DFLG +$ ǦOOHUV The present case describes a patient with lamellar ichthyoVLV DQG ELODWHUDO HFWURSLRQ ZLWK RQH H\H DOUHDG\ DǡHFWHG E\ VHcondary corneal ulcer and amaurosis.6 In an attempt to improve the ectropion and prevent progression to complete blindness, HA was injected using a cannula.This novel technique has never been described in the literature before.

CASE PRESENTATION A 67-year-old woman had lamellar ichthyosis, bilateral ectropion, a left ocular prosthesis, and severely impaired vision in the right eye due to conjunctival and corneal exposure. The goal was to use HA for tissue expansion to elevate the inferior tarsal border and facilitate eyelid closure, thereby minimizing ocular sequelae. For safety and to ensure a more homogeneous distribution of the acid, a cannula was preferred over a needle. The procedure consisted of introducing a 22G rigid cannula into the plane between the skin and orbicularis oculi muscle, followed by retrograde injection of 1 mL of medium G SULPH +$ ǦOOHU PJ P/ LQWR WKH DQWHULRU ODPHOOD DORQJ WKH ORZHU H\HOLG )LJXUH 7KH FDQQXOD DGYDQFHG HDVLO\ ZLWKLQ WKH supramuscular plane, causing minimal discomfort, and no bleeding or ecchymosis was observed. Immediate expansion of the

ĎČĚėĊ ͕ǣ A - Ectropion correction technique using hyaluronic acid with a cannula. Demonstration of the cannula entry point and trajectory in the correction of ectropion. B - Eyelid volumization with hyaluronic acid. Hyaluronic acid acting as tissue expander to reduce ectropion

ĎČĚėĊ ͖ A - Patient with lamellar ichthyosis and bilateral ectropion. Blindness in the left eye and severely impaired vision in the right eye due to conjunctival and corneal exposure. B - Immediate expansion of the lower eyelid after hyaluronic acid injection. Evident overcorrection with bluish ơ ǡ sponse for tissue expansion 414

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lower eyelid was evident, characterized as overcorrection with a EOXLVK GLVFRORUDWLRQ FDXVHG E\ WKH 7\QGDOO HǡHFWÜDQ H[SHFWHG DQG GHVLUDEOH UHVSRQVH IRU DFKLHYLQJ WLVVXH H[SDQVLRQ )LJXUH The primary goal of this procedure is not simply aesthetic improvement, but rather to prevent the progression of corneal ulcers secondary to ectropion. Therefore, intentional overcorrection is part of the therapeutic strategy. The patient has undergone annual HA injections using a cannula for 5 years, with no recurrence of corneal ulcers during follow-up. DISCUSSION Surgical correction remains the most common treatment for CE; however, HA injection techniques have proven to be a viable alternative, capable of expanding the anterior lamellar region, stimulating neocollagenesis, and improving eyelid apposi-

ǣ 1. Mitchell DA, Lyons AB, Moy RL. Correction of cicatricial and involutional lower eyelid ectropion with hyaluronic acid. JAAD Case Rep. 2018;4:628-30. 2. Worley B, Huang JW, Macdonald J. Approach to treatment of cicatricial ectropion: a systematic review and meta-analysis comparing surgical and minimally invasive options. Arch Dermatol Res. 2020;312:165-72. 3. Enghelberg M, Michaelos L, Lonescu C, Stingu T, Georgescu D. Volumizing hyaluronic acid filler as a temporary tissue expander in lower eyelid cicatricial ectropion. Pan-Am J Ophthalmol. 2017;16:52–4.

tion.1 Moreover, HA injection is minimally invasive and has a low complication risk.2 Patient satisfaction with aesthetic outcomes is similar to that of surgical correction.2,3 Potential complications of HA injection include hePDWRPD HGHPD XQHYHQ ǦOOHU GLVWULEXWLRQ RYHUFRUUHFWLRQ DQG vascular occlusion.4 The use of a 22G cannula reduces the risk of arterial and venous ischemia, particularly relevant given the YDVFXODU DQDWRP\ RI WKH ORZHU H\HOLGÜD UHJLRQ DW LQFUHDVHG ULVN for ischemic complications.4 Cannulas require a single entry point, decreasing the likelihood of hematoma, ecchymosis, and discomfort. The use of a cannula to correct CE with HA injections KDV SURYHQ WR EH D VDIH VLPSOH DQG HǡHFWLYH WHFKQLTXH 1HYHUtheless, further prospective comparative studies are required to validate its widespread application. O

Bravo BSF, Totti J, Gelpi BEA, Bianco de Souza S, Bravo LG. Use of hyaluronic acid fillers to correct scleral show: a review of technique. J Clin Aesthet Dermatol. 2018;11:38-40. Veloso LK, Ferreira G, Marques JP, Meneghim RLF, Galindo AF, Padovani CR, Schellini SA. Short-term qualitative and quantitative analyses of preseptal injection of hyaluronic acid on the treatment of acquired lower eyelid cicatricial ectropion. Arq Bras Oftalmol. 2023;87(5):e20220245. Byrd LB, Gurnani B, Martin N. Corneal Ulcer. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.

AUTHOR’S CONTRIBUTION: Ana Paula Dornelles Manzoni 0000-0001-6184-4440 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Fabiane Kumagai Lorenzini 0000-0001-6365-8705 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Taisa de Boni Gauer 0000-0002-7815-6107 Conception and design of the study. Bruna Bonamigo Thomé Conception and design of the study.

0000-0002-3445-9480

Renan Rangel Bonamigo Critical review of the literature.

0000-0003-4792-8466

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Theoretical description of a local anesthesia protocol with non-pharmacological strategies for dermatological procedures in children Descrição teórica de protocolo de anestesia local com estratégias não farmacológicas para procedimentos dermatológicos em crianças

How do I do it? Authors: João Paulo Turri Brufatto1 Marina Gagheggi Maciel1 Adriana Salath Schikiera Martinelli1 Giovanna Silva Barbosa1 Thiago Jesse Kucarz1 Luiz Roberto Dal Bem Pires Júnior1 Renata Ferreira Magalhães1 Thais Helena Buffo1 Andréa Fernandes Eloy da Costa França1 Elisa Nunes Secamilli1 1

Universidade Estadual de Campinas (UNICAMP), Clinical Medicine Department, Dermatology, Campinas (SP), Brazil

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170478

ABSTRACT Pain and anxiety management during pediatric dermatological procedures is a crucial aspect of medical care. Skin biopsies can cause stress and discomfort in children, negatively impacting the relationship between health care providers, patients, and caregivers. This study describes a local anesthesia protocol based on non-pharmacological techniques, consisting of prior explanation, parental support, visual distraction, and the use of cold or vibration before pharmacological anesthesia. Implementing this protocol may UHGXFH SDLQ DQG DQ[LHW\ SHUFHSWLRQ ZKLOH RǡHULQJ D ORZ FRVW ORZ WHFK DQG VDIH FDUH RSWLRQ Keywords: Dermatology; Pediatric Anesthesia; Biopsy; Pain

RESUMO O manejo da dor e da ansiedade em procedimentos dermatológicos pediátricos é um tema muito importante na PHGLFLQD $ ELµSVLD GH SHOH SRGH JHUDU HVWUHVVH H GHVFRQIRUWR HP FULDQ©DV H SUHMXGLFDU R Y¯QFXOR GRV SURřVVLRQDLV GH saúde com os pacientes e seus cuidadores. Este estudo descreve um protocolo de anestesia local baseado em técnicas não farmacológicas, composto de explicação prévia, apoio parental, distração visual e uso de gelo ou vibração antes da anestesia farmacológica. A aplicação do protocolo pode reduzir a percepção de dor e ansiedade, além de promover um cuidado seguro, de baixo custo e baixa densidade tecnológica. Palavras-chave: Dermatologia; Anestesia Pediátrica; Biópsia; Dor

Correspondence: João Paulo Turri Brufatto E-mail: jp.brufatto@gmail.com

Funding: None Conﬂict of interest: None Submitted on: 05/28/2025 Final decision: 09/11/2025

How to cite this article: Brufatto JPT, Maciel MG, Martinelli ASS, Barbosa GS, Kucarz TJ, Pires Júnior LRDB, Magalhães RF, França AFEC, Buffo TH, Secamilli EN. Theoretical description of a local anesthesia protocol with non-pharmacological strategies for dermatological procedures in children. Surg Cosmet Dermatol. 2025; 17:e20250478.

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INTRODUCTION Pain and anxiety are fundamental aspects of the medical experience in the pediatric population, directly impacting treatment adherence, longitudinality of care, and the quality of care provided.1 Attention to these factors is critical to ensure a safer and more humanized environment,1 especially in invasive procedures such as skin biopsies.2 3DLQ LV GHǦQHG DV DQ XQSOHDVDQW VHQVRU\ DQG HPRWLRQDO experience associated with actual or potential physical harm.3 7KLV SHUFHSWLRQ RI SDLQ PD\ EH LQWHQVLǦHG E\ SV\FKRVRFLDO IDFtors such as anxiety, fear of the unknown, and a sense of vulnerability.4 Dermatological procedures, such as skin biopsies, often trigger an uncontrolled anxiety response, making it essential to DGRSW HǡHFWLYH VWUDWHJLHV WR UHGXFH VXǡHULQJ IRU ERWK FKLOGUHQ and their caregivers during medical procedures.5,6 Child mental health is a relevant factor to be considered, as it may compromise how the procedure is experienced and neJDWLYHO\ LQǧXHQFH ORQJLWXGLQDOLW\ RI FDUH ZLWKLQ WKH KHDOWK V\Vtem.7,8 Children who undergo painful procedures without adequate emotional support may develop fears and trauma related to medical visits, impairing adherence to necessary treatments.7,8 In addition, poorly managed pain may result in neurophysiological changes over time, increasing sensitivity to pain in future HYHQWV DQG DǡHFWLQJ WKH FKLOGÞV SHUFHSWLRQ RI KHDOWK FDUH 7,8 Therefore, strategies that aim at minimizing pain and anxiety are critical to promoting more humanized care and improving the child’s experience of caring for their own health.9 A multidisciplinary approach to pediatric pain management is a frequent subject in the literature, combining play-based interventions and nonpharmacological techniques.5,6,9 However, the development of structured protocols remains uncommon in WKH VFLHQWLǦF OLWHUDWXUH 7KH GHYHORSPHQW RI JXLGHOLQHV IRU SHdiatric dermatological procedures may represent an important contribution to improved clinical and emotional outcomes in children undergoing invasive procedures such as skin biopsies, DQG PD\ DOVR IRVWHU IXUWKHU UHVHDUFK LQ WKLV ǦHOG Several studies indicate that the combination of local anesthesia with nonpharmacological methods, together with GLVWUDFWLRQ WHFKQLTXHV DQG HPRWLRQDO VXSSRUW FDQ VLJQLǦFDQWO\ reduce pain and discomfort in children undergoing invasive procedures. The present study aimed to describe a local anesthesia protocol based on nonpharmacological therapies, using sensory distraction strategies and emotional support for skin biopsy procedures in children. The goal is to reduce pain perception, minimize anxiety, and improve cooperation among pediatric patients, thereby providing a more humanized experience. METHODS A narrative literature review was conducted using the PubMed, Scopus, and SciELO databases. Articles published within the last 5 years were selected using the following English descriptors (MeSH terms): “pediatric OR children OR child OR neonatal,” “pain management,” and “non-pharmacology

anesthesia.” Inclusion criteria comprised clinical studies, systematic reviews, and meta-analyses addressing strategies for the management of pain and anxiety in children undergoing surgical procedures. Studies involving exclusively adult samples or addressing only pharmacological anesthesia without integration of non-pharmacological strategies were excluded. Figure 1 summarizes the results of the literature search. Based on the data collected, a structured protocol for local anesthesia in children undergoing skin biopsies was developed, incorporating psychological and sensory approaches. RESULTS 7KH SURWRFRO FRPSULVHV IRXU VWDJHV 7KH ǦUVW VWDJH FRQsists of providing clear, age-appropriate explanations about the procedure, addressing both the child and their caregivers.9,10,11 The guidance should be presented in a playful and accessible manner, using resources such as stories, dolls, drawings, or illustrated books, with the aim of demystifying the experience and reducing procedure-related anxiety. 9,10,11 The second stage involves encouraging parental support, allowing the caregiver to remain by the child’s side during the procedure and promoting physical and verbal contact as a strategy to enhance the sense of emotional security.12,13 The third stage involves the use of visual and auditory distraction strategies, such as electronic devices to watch videos or listen to stories, helping to shift their focus away from the procedure and consequently reduce stress.9,14,15 Finally, the fourth stage refers to the application of sensory modulation measures, including prior use of ice or vibratory devices at the biopsy site, with the goal of minimizing the perception of pain DVVRFLDWHG ZLWK LQǦOWUDWLRQ RI WKH ORFDO DQHVWKHWLF 16,17 The protocol is summarized in Figure 2. Figure 3 illustrates the tools used in our hospital for the application of ice in (A) and vibration in (B). DISCUSSION The implementation of play-based strategies has been widely studied and recommended for pediatric patients in inWHQVLYH FDUH DQG RQFRORJ\ VHWWLQJV DV HǡHFWLYH PHWKRGV WR DOOHviate childhood anxiety and improve treatment adherence.18,19,20 The use of these strategies allows children greater control over their experience, promotes an understanding of pain beyond its exclusively physical dimension, reduces fear, and provides a more welcoming environment.19 Emotional support, including verbal encouragement and physical contact from parents, is essential for helping children feel safe.21 Studies show that parental presence and physical contact can lower cortisol levels, thereby decreasing the physiological stress response.21 In addition, prior preparation and clear, age-appropriate explanations of the procedure to both parents and patients can help reduce uncertainty about procedures, promoting a calmer experience for children.22,13

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Included

Evaluation

MeSH terms: “pediatric OR children OR child OR neonatal,” “pain management,” “non-pharmacology anesthesia.” Records from PubMed, Scopus, and SciELO* (n = 88)

Records removed after evaluation: Duplicate articles removed (n = 6)

Articles screened (n = 82)

Excluded based on title or abstract (n = 62)*

Articles selected for full-text review (n = 20)

Articles excluded due to lack of access to content (n = 0)

Articles meeting eligibility criteria (n = 20)

Articles excluded for not addressing the study topic (n = 11)**

Studies included in the review (n = 9)

* Adult studies and pharmacological anesthesia studies were excluded. ** Pain management strategies for procedures in the pediatric population were considered eligible. ĎČĚėĊ ͕ǣ The image illustrates the narrative review process of the study

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ĎČĚėĊ ͕ǣ The image illustrates the narrative review process of the study

B ĎČĚėĊ ͗ǣ A - Frozen test tube applied directly to the skin. B - Vibratory device applied directly to the skin Many health care centers worldwide face challenges in performing procedures under general anesthesia in children due to the lack of anesthetic infrastructure, intravenous sedatives, or trained specialists.23 This limitation can represent a major obstacle to the investigation of serious dermatological conditions, such as genodermatoses or autoimmune diseases, which require histopathological examination for accurate diagnosis.24,25 The SURWRFRO GHVFULEHG LQ WKLV VWXG\ RǡHUV D VLPSOH DFFHVVLEOH DQG low-cost solution to facilitate dermatological diagnoses, enabling centers without high-complexity hospital infrastructure to advance the evaluation of complex cases.

In addition, the approach proposed in this study may contribute to improved family adherence to treatment, as a properly conducted procedure can strengthen the bond with the health care team and lower the resistance from both the child and their caregivers to medical care.13,25 This has a direct impact on the longitudinality of care, promoting more comprehensive clinical follow-up and potentially reducing the need for unnecessary interventions in the future.1,9 The combination of non-pharmacological techniques in pediatric pain management may also help build a more positive relationship between children and health care professionals.20 Children who experience a careful and humanized approach tend to develop greater trust in the medical team, which facilitates long-term care and promotes a more holistic approach to the health of patients and their caregivers across primary, secondary, and tertiary health care settings.27,28,29,30 CONCLUSION The combination of local ice or vibration with distracWLRQ VWUDWHJLHV DQG HPRWLRQDO VXSSRUW LV DQ HǡHFWLYH DOWHUQDWLYH for minimizing pain and anxiety in children undergoing skin biopsies. The protocol proposed in this study can be implemenWHG LQ JHQHUDO GHUPDWRORJ\ VHUYLFHV RǡHULQJ DQ HYLGHQFH EDVHG approach to pediatric pain management. Future studies are neeGHG WR HYDOXDWH LWV HǡHFWLYHQHVV XVLQJ REMHFWLYH PHDVXUHV RI SHdiatric pain and comfort, as well as parameters such as duration and body surface area of ice application, thereby contributing to advances in pediatric dermatological care. O

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ǣ 1. Brito TRPD, Resck ZMR, Moreira DDS, Marques SM. As práticas lúdicas no cotidiano do cuidar em enfermagem pediátrica. Esc Anna Nery. 2009;13(4):802–8. 2. Arantes MGDA, Siqueira ALF, Pizzol AF, Sanna IP. Tratamento cirúrgico da síndrome de Klippel-Trenaunay em crianças: abordagens dermatológicas e cirurgia vascular. Rev Ibero-Am Humanid Ciênc Educ. 2024;10(10):633–44. 3. Forget P, Kahtan H, Jordan A. Personalized pain assessment: What does ‘acceptable pain’ mean to you? Eur J Pain. 2023;27(9):1139-43. 4. Fein JA, Zempsky WT, Cravero JP. Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130:e1391. 5. Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: an update. Pediatrics. 2016;137(2):e20154271. 6. Witti N, Coynor S, Edwards C, Bradshaw H. A guide to pain assessment and management in the neonate. Curr Emerg Hosp Med Rep. 2016;4:1–10. 7. Valeri BO, Holsti L, Linhares MB. Neonatal pain and developmental outcomes in children born preterm: a systematic review. Clin J Pain. 2015;31(4):355–62. 8. Mathias EG, Pai MS, Kumar V, Narayanakurup D, Kulkarni M, Guddattu V. Nonpharmacological interventions for managing postoperative pain and anxiety in children: a randomized controlled trial. Clin Exp Pediatr. 2024. 9. Reducing Children's Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial Holly Cordray. Otolaryngol Head Neck Surg. 2022;167(2):366-74. 10. Berman L, Lingras K, Lin J, Berger JN, Hofflander M, Anderson L. Clinician perception of care at the end of life in a quaternary neonatal intensive care unit. Front Pediatr. 2023;11:1197360. 11. Freire RJB, Poeta L, Lôbo TERSB, Lôbo FB, Galvão MFG, Silva LDA. Estratégias para reduzir a ansiedade pré-operatória em pacientes pediátricos. Rev Contemp. 2024;4(3):e3425. 12. Scott MG, Smiley PA, Ahn A, Lazarus MF, Borelli JL, Doan SN. A mother's touch: preschool-aged children are regulated by positive maternal touch. Dev Psychobiol. 2022;64(1):e22272. 13. Peres T, Oliveira R, Publitz MR, Alves SC, Garcia MC, Soares LR. Estratégias de intervenção e tratamento para crianças e adolescentes com transtorno opositor-desafiador: uma revisão bibliográfica. RECIMA21. 2024;5(7):e575408. 14. Oliveira ER, Campos RO. Benefícios dos recursos lúdicos aplicados na psicologia hospitalar: revisão de literatura [Internet]. 2022 [citado 2024 dez 15]. Disponível em: https://zenodo.org/record/7347426 15. Tonetto LM, da Rosa VM, Brust-Renck P, Denham M, da Rosa PM, Zimring C. Playful strategies to foster the well-being of pediatric cancer patients in the Brazilian Unified Health System: a design thinking approach. BMC Health Serv Res. 2021;21:1-10.

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Santos LGB. O uso da vibração associada à baixa temperatura no gerenciamento da dor durante punção venosa em crianças com cardiopatia congênita hospitalizadas [dissertação]. UERJ; 2024 [citado 2024 nov 2]. Disponível em: https://uerj.br. Varshini I, Vinay C, Uloopi KS, RojaRamya KS, Chandrasekhar R, Penmatsa C. Effectiveness of pre cooling the injection site, laser biostimulation, and topical local anesthetic gel in reduction of local anesthesia injection pain in children. Int J Clin Pediatr Dent. 2021;14(1):81 3. Demir Imamoglu Z, Aytekin Ozdemir A. The effect of a cognitive behavioural intervention package on peripheral venous cannulation pain, fear and anxiety in paediatric patients: randomised controlled trial. J Pediatr Nurs. 2024;72:e126–33. Desalu I, Sarpong P, Osazuwa MO, Ndikontar Kwinji R, Faponle AF, Suleiman MK. Global pediatric anesthesia – Anglophone West Africa perspective. Paediatr Anaesth. 2024;34(1):74–84. Aşkın Ö, Engin B, Gencebay G, Tüzün Y. A multistep approach to the diagnosis of rare genodermatoses. Clin Dermatol. 2020;38(6):722–8. Peła Z, Gałecka M, Murgrabia A, Kondratowicz A, Gałecki P. Depressive disorder and dermatological autoimmune diseases. J Clin Med. 2024;13(1):123. The cortisol response in parents staying with a sick child at hospital. Nurs Open. 2020;7(3):1012–8. Chen J, Deng K, Yu D, Fan C, Liu L, Gu H. Recent developments in the non- pharmacological management of children's behavior based on distraction techniques: A concise review. Healthcare (Basel). 2024;12(2):156. Espinosa Fernández MG, González-Pacheco N, Sánchez-Redondo MD, Cernada M, Martín A, Pérez-Muñuzuri A, et al. Sedoanalgesia in neonatal units. An Pediatr (Engl Ed). 2021;94(1):e1–8. McNair M, Campbell-Yeo C, Johnston C, Taddio A. Non-pharmacologic management of pain during needle puncture procedures in infants: current research evidence and practical considerations: an update. Clin Perinatol. 2019;46(4):709–73. Sabeti F, Mohammadpour M, Pouraboli B, Tahmasebi M, Hasanpour M. Health care providers' experiences of the non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care units. J Pediatr Nurs. 2021;61:e52–8. DeCosta P, Skinner TC, Grabowski D. The role of trust in the care of young children with type 1 diabetes. Children (Basel). 2021;8(5):351. Waite-Jones JM, Swallow V, Madill A. From 'neurotic' to 'managing' mother: the 'medical career' experienced by mothers of a child diagnosed with juvenile idiopathic arthritis. Br J Health Psychol. 2020;25(1):170–88. Cordray H, Patel C, Prickett KK. Reducing Children's Preoperative Fear with an Educational Pop-up Book: a Randomized Controlled Trial Holly Cordray. Otolaryngol Head Neck Surg. 2022;167(2):366-74. Javed H, Oyibo SO, Alfuraih AM. Variability, validity and operator reliability of three ultrasound systems for measuring tissue stiffness: a phantom study. Cureus. 2022;14(11):e31731.

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AUTHOR’S CONTRIBUTION: João Paulo Turri Brufatto 0000-0001-9752-377X 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Marina Gagheggi Maciel 0000-0001-6077-4209 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLcipation in the conduct of the study. Adriana Salath Schikiera Martinelli 0000-0001-6723-9188 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Giovanna Silva Barbosa 0000-0001-7217-2862 Critical review of the literature, Critical revision of the manuscript. Thiago Jesse Kucarz Critical review of the literature.

0009-0000-7339-3026

Luiz Roberto Dal Bem Pires Júnior 0009-0001-6728-420X Preparation and writing of the manuscript, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied. Renata Ferreira Magalhães 0000-0001-9170-932X $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ Andréa Fernandes Eloy da Costa França 0000-0003-1657-4570 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 7KDLV +HOHQD %XŔR 0000-0002-6833-7596 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ Elisa Nunes Secamilli 0000-0001-9036-4200 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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Localized tenosynovial giant cell tumor of the Ƥ Ȃ Tumor de células gigantes tenossinovial localizado no dedo indicador esquerdo – relato de caso

Case report Authors: Sunil Kumar Gupta 1 1

All India Institute of Medical Sciences Gorakhpur India, Department of Dermatology & Venereology, Gorakhpur (UP), India

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170440 ABSTRACT Tenosynovial giant cell tumors (TGCTs) are rare, benign neoplasms of the tendon sheaths, usually affecting the hands. In this case report, a 52-year-old female presented with a painless enlarging mass on WKH OHIW LQGH[ ǦQJHU +LVWRSDWKRORJLFDO H[DPLQDWLRQ UHYHDOHG D QRGXODU OHVLRQ ZLWK IRDP\ KLVWLRF\WHV multinucleated giant cells, and lymphocytes. Surgical excision led to full recovery with no recurrence. 7KLV FDVH HPSKDVL]HV WKH LPSRUWDQFH RI FRQVLGHULQJ 7*&7V LQ GLǡHUHQWLDO GLDJQRVLV RI ǦQJHU PDVVHV DQG KLJKOLJKWV VXUJLFDO H[FLVLRQ DV DQ HǡHFWLYH WUHDWPHQW Keywords: 6RIW 7LVVXH 1HRSODVPV *LDQW &HOO 7XPRUV +DQG 6XUJLFDO 3URFHGXUHV

RESUMO Tumores de células gigantes tenossinoviais (TCGTs) são neoplasias raras e benignas das bainhas tendíneas que normalmente acometem as mãos. Neste relato de caso, uma paciente de 52 anos apresentava uma massa indolor e de crescimento progressivo no dedo indicador esquerdo. O exame histopatológico revelou uma lesão nodular com histiócitos espumosos, células gigantes multinucleadas e linfócitos. A excisão cirúrgica resultou em recuperação completa, sem recorrência. Este caso enfatiza a importância de considerar os TCGTs no diagnóstico diferencial de massas digitais e GHVWDFD D H[FLV¥R FLU¼UJLFD FRPR XP WUDWDPHQWR HřFD] Palavras-chave: Neoplasias de Tecidos Moles;Tumores de Células Gigantes; Mãos; Procedimentos Cirúrgicos

Correspondence: Sunil Kumar Gupta E-mail: dr.sunil_30@yahoo.co.in

Funding: None Conﬂict of interest: None Submitted on: 02/15/2025 Final decision: 05/04/2025

How to cite this article: Gupta SK. Localized tenosynovial giant cell tumor of the left index finger – a case report. Surg Cosmet Dermatol. 2025;17:e20250440.

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Gupta SK.

INTRODUCTION Tenosynovial giant cell tumors (TGCTs) are rare, locally aggressive but typically benign neoplasms of the joints, bursae, and tendon sheaths.1,2 7*&7V FDQ DǡHFW DOO DJH JURXSV EXW DUH PRUH common in younger individuals and in females. They primarily SUHVHQW ZLWK SDLQ VZHOOLQJ DQG VWLǡQHVV $FFRUGLQJ WR WKH :RUOG +HDOWK 2UJDQL]DWLRQ UHFODVVLǦFDWLRQ WKH WHUP àORFDOL]HG TGCT” includes giant cell tumors of the tendon sheath and QRGXODU WHQRV\QRYLWLV ZKHUHDV àGLǡXVH 7*&7á LQFOXGHV GLǡXVH-type giant cell tumors and pigmented villonodular synovitis.1,2 CASE REPORT $ \HDU ROG ZRPDQ SUHVHQWHG WR WKH 'HUPDWRORJ\ RXWSDWLHQW VHUYLFH ZLWK GLVFRPIRUW LQ KHU OHIW LQGH[ ǦQJHU DQG DQ enlarging mass for 3 years. On physical examination, there was a tender nodule 2 × 2 cm on size at the volar aspect of the left LQGH[ ǦQJHU LQYROYLQJ WKH GLVWDO SKDODQ[ )LJXUH 7KH QRGXOH ZDV LOO GHǦQHG IURP WKH VXUURXQGLQJ WLVVXH DQG QRW DVVRFLDWHG with paresthesia. Movement of the distal interphalangeal joint was mildly restricted. The patient had no history of smoking or DOFRKRO DEXVH )DPLO\ KLVWRU\ ZDV DOVR QRW UHOHYDQW ; UD\ LPDJLQJ VKRZHG D VRIW WLVVXH PDVV ZLWKRXW ERQH HURVLRQ )LJXUH $IWHU GLVFXVVLQJ WUHDWPHQW RSWLRQV ZLWK WKH SDWLHQW VXUJLFDO H[FLVLRQ ZDV SODQQHG $ OLQHDU LQFLVLRQ ZDV PDGH RYHU WKH PDVV XQGHU OLGRFDLQH LQǦOWUDWLRQ 7KH WXPRU ZDV FOHDUO\ H[SRVHG RQ WKH YRODU DVSHFW RI WKH OHIW LQGH[ ǦQJHU XS WR WKH GLVWDO SKDODQ[ DQG FRPSOHWHO\ H[FLVHG )LJXUH 3ULPDU\ FORVXUH RI WKH VXUJLFDO ZRXQG ZDV SHUIRUPHG +LVWRSDWKRORJLFDO H[DPLQDtion of the excised tumor revealed a nodular lesion consisting of an admixture of foamy histiocytes, ovoid mononuclear cells, PXOWLQXFOHDWH JLDQW FHOOV DQG O\PSKRF\WHV LQ D ǦEURWLF VWURPD Numerous vessels of varying calibers were present. Scattered hemosiderin deposition was noted. Mitotic activity was readily REVHUYHG )LJXUH 3RVWRSHUDWLYH IROORZ XS ZDV SHUIRUPHG RQH PRQWK DIWHU the procedure. The patient made a full recovery without movePHQW UHVWULFWLRQ RU VXEVWDQWLDO VZHOOLQJ )LJXUH )OH[LRQ DW WKH GLVWDO LQWHUSKDODQJHDO MRLQW RI WKH OHIW LQGH[ ǦQJHU ZDV QRUPDO No clinical or radiologic signs of recurrence were observed at follow-up 3 months after the excision.

Figure 1: Tender 2 × 2 cm nodule on the volar aspect of the Ƥ

DISCUSSION TGCTs are the second most common soft tissue tumor of the hand after ganglion cysts, with an incidence of 1.8 per million individuals per year and a prevalence of 8%-19% in hand joints.3 7*&7V SULPDULO\ DǡHFW LQGLYLGXDOV DJHG WR \HDUV DQG DUH PRUH IUHTXHQW LQ IHPDOHV 0 ) 1,4 7KH :+2 FODVVLǦFDWLRQ GLYLGHV 7*&7V LQWR ORFDOL]HG 7*&7 / 7*&7 DQG GLǡXVH 7*&7 ' 7*&7 / 7*&7 LV characterized as a well-circumscribed nodular lesion, most freTXHQWO\ DǡHFWLQJ VPDOO MRLQWV ' 7*&7V SUHVHQW DV DQ LQǦOWUDWLYH and aggressive variant associated with a high rate of recurrence and joint destruction.4

7*&7V DUH GULYHQ E\ D WUDQVORFDWLRQ RI WKH &6) JHQH on chromosome 1p13, leading to overexpression of colony-stiPXODWLQJ IDFWRU &6) ZKLFK SURPRWHV QHRSODVWLF SUROLIHUDWLRQ DQG UHFUXLWPHQW RI LQǧDPPDWRU\ PRQRF\WHV YLD &6) 5 activation.5 This process results in the accumulation of histiocyte-like cells, giant cells, hemosiderin-laden macrophages, and V\QRYLDO ǦEURVLV 5 *HQRPLF VWXGLHV KDYH LGHQWLǦHG DGGLWLRQDO mutations contributing to TGCT pathogenesis, including the &6) &2/ $ IXVLRQ JHQH LPSOLFDWHG LQ WXPRU SURJUHVVLRQ DQG 67$7 DOWHUDWLRQV SRWHQWLDOO\ PRGXODWLQJ WXPRU JURZWK and immune evasion.

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ĎČĚėĊ ͖ǣ X-ray showing a softtissue mass without bone erosion

ĎČĚėĊ ͗ǣ The tumor was clearly exposed on the volar aspect of the Ƥ phalanx and completely excised

0DJQHWLF UHVRQDQFH LPDJLQJ 05, UHPDLQV WKH JROG standard for diagnosing TGCT. L-TGCT appears as a well GHǦQHG OREXODWHG PDVV ZKHUHDV ' 7*&7 VKRZV LQǦOWUDWLYH GLǡXVH JURZWK ZLWK KHPRVLGHULQ GHSRVLWLRQ OHDGLQJ WR EORRming artifacts on gradient-echo sequences.8 Emerging imaging

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Gupta SK.

ĎČĚėĊ ͘ǣ Histopathological examination (H&E stain) of the excised tumor revealed a nodular lesion consisting of an admixture of foamy histiocytes, ovoid mononuclear cells, ǡ Ƥ stroma

ĎČĚėĊ ͙ǣ Post-operative follow-up after one month

+LVWRORJLFDOO\ 7*&7V FRQVLVW RI PRQRQXFOHDU KLVWLRF\WH OLNH FHOOV H[SUHVVLQJ &6) &' DQG &' PXOWLQXFOHDted giant cells; hemosiderin-laden macrophages; and foamy maFURSKDJHV DORQJ ZLWK FKURQLF LQǧDPPDWRU\ LQǦOWUDWHV 2,3 +LJK mitotic activity and focal necrosis are observed in aggressive or recurrent cases. 5HFHQW DGYDQFHV LQ ELRPDUNHU UHVHDUFK VXJJHVW WKDW VROXEOH &6) OHYHOV LQ SODVPD PD\ VHUYH DV D GLDJQRVWLF DQG SURJnostic marker, correlating with tumor burden and response to &6) 5 LQKLELWRUV 9 6XUJLFDO H[FLVLRQ UHPDLQV WKH ǦUVW OLQH WUHDWPHQW IRU L-TGCT, with a 9% recurrence rate, whereas D-TGCT has a recurrence rate of up to 23% due to incomplete resection and LQǦOWUDWLYH JURZWK 10 5HFHQW VWXGLHV VXSSRUW DUWKURVFRSLF V\QRYHFWRP\ IRU LQtra-articular L-TGCT, as it reduces the risk of recurrence. Open resection for D-TGCT often requires multiple interventions. Given the high recurrence rate and surgical morbidity associated with D-TGCT, recent therapeutic advances have

IRFXVHG RQ WDUJHWLQJ WKH &6) &6) 5 SDWKZD\ 3H[LGDUWLQLE 3/; D W\URVLQH NLQDVH LQKLELWRU 7., WKDW VHOHFWLYHO\ LQKLELWV &6) 5 ZDV DSSURYHG E\ WKH 8 6 )'$ LQ IRU unresectable TGCT .11 Emactuzumab, a monoclonal antibody WDUJHWLQJ &6) 5 KDV VKRZQ SURPLVLQJ UHVXOWV DQG IHZHU KHSDWLF DGYHUVH HǡHFWV FRPSDUHG ZLWK SH[LGDUWLQLE 10 Vimseltinib, a QH[W JHQHUDWLRQ &6) 5 LQKLELWRU FXUUHQWO\ LQ 3KDVH WULDOV KDV GHPRQVWUDWHG KLJKHU HǤFDF\ DQG LPSURYHG VDIHW\ SURǦOHV 12 CONCLUSION This case underscores the importance of early diagnosis and complete surgical excision in L-TGCTs while recognizing the therapeutic challenges posed by D-TGCTs due to its inǦOWUDWLYH QDWXUH DQG KLJK UHFXUUHQFH UDWHV 7KH DGYHQW RI &6) 5 LQKLELWRUV LPPXQH FKHFNSRLQW EORFNDGH DQG JHQH WKHUDS\ RǡHUV QHZ KRSH IRU WKH PDQDJHPHQW RI DGYDQFHG 7*&7V highlighting the need for a multidisciplinary approach that integrates surgery, targeted treatment, and personalized strategies. O

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ǣ 1. de Saint Aubain Somerhausen N, van de Rijn M. Tenosynovial giant cell tumour, localized type. In: Fletcher CDM, Bridge JA, Hogendoorn P, Mertens F. WHO Classification of Tumours of Soft Tissue and Bone, ed 4; Lyon, France: International Agency for Research on Cancer (IARC); 2013. P. 100-1. 2. Staals EL, Ferrari S, Donati DM, Palmerini E. Diffuse-type tenosynovial giant cell tumour: current treatment concepts and future perspectives. Eur J Cancer 2016;63:34-40. 3. Mastboom MJL, Verspoor FGM, Verschoor AJ, Uittenbogaard D, Nemeth B, Mastboom WJB, et al. Higher incidence rates than previously known in tenosynovial giant cell tumors. Acta Orthop. 2017;88(6):688-94. 4. Somerhausen ND, van de Rijn M. Tenosynovial giant cell tumor. In: WHO classification of tumors editorial board, editor. 5th World Health Organization classification of tumors of soft tissue and bone. 5. West RB, Rubin BP, Miller MA, Subramanian S, Kaygusuz G, Montgomery K, et al. A landscape effect in tenosynovial giant-cell tumor from activation of CSF1 expression by a translocation in a minority of tumor cells. Proceedings of the National Academy of Sciences. 2006;17;103(3):690-5. 6. Tap WD, Gelderblom H, Palmerini E, Desai J, Bauer S, Blay JY, et al. Pexidartinib versus placebo for advanced tenosynovial giant cell tumour (ENLIVEN): a randomised phase 3 trial. The Lancet. 2019;394(10197):478-87.

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Ricketts TD, Prieto-Dominguez N, Gowda PS, Ubil E. Mechanisms of macrophage plasticity in the tumor environment: manipulating activation state to improve outcomes. Frontiers in immunology. 2021;12:642285. Murphey MD, Rhee JH, Lewis RB, Fanburg-Smith JC, Flemming DJ, Walker EA. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics. 2008;28(5):1493-518. Cassier PA, Italiano A, Gomez-Roca C, Le Tourneau C, Toulmonde M, D'Angelo SP, et al. Long-term clinical activity, safety and patient-reported quality of life for emactuzumab- treated patients with diffuse-type tenosynovial giant-cell tumour. Eur J Cancer. 2020;141:162-70. Siegel M, Bode L, Südkamp N, Kühle J, Zwingmann J, Schmal H, et al. Treatment, recurrence rates and follow-up of Tenosynovial Giant Cell Tumor (TGCT) of the foot and ankle-A systematic review and meta-analysis. PLoS One. 2021;16(12):e0260795. Tap WD, Singh AS, Anthony SP, Sterba M, Zhang C, Healey JH, et al. Results from phase I extension study assessing pexidartinib treatment in six cohorts with solid tumors including TGCT, and abnormal CSF1 transcripts in TGCT. Clin Cancer Res. 2022;28(2):298-307. Blay JY, Gelderblom H, Rutkowski P, Wagner A, van de Sande M, Gonzalez AF, et al. 1509P Efficacy and safety of vimseltinib in tenosynovial giant cell tumour (TGCT): Phase II expansion. Ann Oncol. 2022;33:S1236-7.

AUTHOR’S CONTRIBUTION: Sunil Kumar Gupta 0000-0001-9033-4394 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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ISSN-e 1984-8773 APOIO CIENTÍFICO:

www.surgicalcosmetic.org.br/

Ƥ Ǧ ǣ Lipoenxertia em paciente com síndrome de Parry-Romberg: do diagnóstico ao tratamento

Case report Authors: Nivin Mazen Said1 Denise Lima Sousa1 Airton Kenji Motizuki2 Emanuella Rosyane Duarte Cerqueira1 Franklin Sousa Rocha1 1

DOI: KWWS ZZZ G[ GRL RUJ VFG Parry-Romberg syndrome is a rare condition characterized by progressive unilateral facial atrophy, involving the skin, muscles, fat, and bones. Treatment aims to restore facial symmetry, with autologous fat JUDIWLQJ DQ HǡHFWLYH RSWLRQ 7KLV UHSRUW GHVFULEHV WKH FDVH RI D \HDU ROG ZRPDQ ZKR XQGHUZHQW WKUHH sessions of Coleman-type fat grafting using autologous abdominal fat.The procedure improved facial aesthetics and quality of life, with high patient satisfaction. Despite partial and unpredictable resorption of fat over the course of follow-up, this technique remains a viable alternative for correcting facial deformities. Keywords: Transplantation, autologous; Facial Hemiatrophy; Abdominal Fat

RESUMO $ V¯QGURPH GH 3DUU\ 5RPEHUJ « XPD FRQGL©¥R UDUD FDUDFWHUL]DGD SRU DWURřD SURJUHVVLYD XQLODWHUDO GD IDFH HQYROYHQGR SHOH P¼VFXORV JRUGXUD H RVVRV 2 WUDWDPHQWR YLVD UHVWDXUDU D VLPHWULD IDFLDO VHQGR D OLSRHQ[HUWLD DXWµORJD XPD RS©¥R HřFD] 5HODWD VH R FDVR GH XPD PXOKHU GH DQRV VXEPHWLGD D WU¬V VHVV·HV GH OLSRHQ[HUWLD SHOD W«FQLFD GH &ROHPDQ XWLOL]DQGR HQ[HUWR DXWµORJR GH JRUGXUD DEGRPLQDO 2 SURFHGLPHQWR PHOKRURX D HVW«WLFD IDFLDO H D TXDOLGDGH GH YLGD FRP DOWD VDWLVID©¥R GR SDFLHQWH $SHVDU GH WHU RFRUULGR UHDEVRU©¥R SDUFLDO H LPSUHYLV¯YHO GD JRUGXUD GXUDQWH R VHJXLPHQWR HVVD W«FQLFD FRQWLQXD D VHU XPD DOWHUQDWLYD YL£YHO SDUD D FRUUH©¥R GDV GHIRUPLGDGHV IDFLDLV Palavras-chave: 7UDQVSODQWH DXWµORJR +HPLDWURřD IDFLDO *RUGXUD DEGRPLQDO

Universidade Federal do Pará (UFPA), Dermatology Service, Belém (PA), Brazil 2 Universidade Federal do Pará (UFPA), School of Medicine, Belém (PA), Brazil

Correspondence: Nivin Mazen Said E-mail: nivinmsaid@gmail.com

Funding: None Conﬂict of interest: None Submitted on: 03/04/2025 Final decision: 08/26/2025

How to cite this article: Said NM, Sousa DL, Motizuki AK, Cerqueira ERD, Rocha FS. Lipofilling in a patient with Parry-Romberg syndrome: from diagnosis to treatment. Surg Cosmet Dermatol. 2025;17:e20250447.

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Said NM, Sousa DL, Motizuki AK, Cerqueira ERD, Rocha FS

Parry-Romberg syndrome, also known as Progressive Hemifacial Atrophy, is a rare dermatological condition characterized by progressive and asymmetric atrophy of the skin and underlying tissues on one side of the face. First described by 3HUU\ LQ DQG ODWHU GHWDLOHG E\ 5RPEHUJ LQ WKH V\QGURPH SULPDULO\ DǡHFWV FKLOGUHQ DQG DGROHVFHQWV ZLWK QR SUHGRPLQDQFH RI HLWKHU VH[ ,Q JHQHUDO LW EHJLQV LQ WKH ǦUVW RU VHFRQG GHFDGH RI OLIH SURJUHVVHV RYHU D SHULRG RI WR \HDUV DQG then becomes inactive. ,W LV FKDUDFWHUL]HG E\ FUDQLRIDFLDO DWURSK\ WKDW PD\ DǡHFW part or all structures of the face, including skin, muscle, fat, bone tissue, the trigeminal nerve, and even brain parenchyma. These alterations often result in three-dimensional asymmetries associated with severe functional and psychological complications. Generally, treatment for the syndrome aims at improving facial aesthetics. There are various approaches for correcting facial defects, including autologous fat grafting, orthognathic surJHU\ ORFDO ǧDSV DQG VROLG RU OLTXLG VLOLFRQH LPSODQWV ,Q %UD]LO the use of silicone implants for this syndrome is neither recomPHQGHG QRU DXWKRUL]HG JLYHQ WKH DYDLODELOLW\ RI PRUH HǡHFWLYH WUHDWPHQWV VXFK DV OLSRǦOOLQJ Moreover, there are reports in WKH OLWHUDWXUH UHJDUGLQJ WKH OLPLWHG HǡHFWLYHQHVV RI KHWHURORJRXV ǦOOHUV LQ SDWLHQWV ZLWK 3DUU\ 5RPEHUJ V\QGURPH GXH WR WKH KLJKHU ULVN RI YDVFXODU LQIHFWLRXV DQG LQǧDPPDWRU\ DGYHUVH events. Their use is only recommended in cases where autologous fat grafting do not yield unsatisfactory or long-lasting results. Adipose tissue is the most widely used option because it is fully biocompatible, abundant in the body, compatible with surrounding tissues, and capable of restoring deformed facial structures, thereby restoring three-dimensional appearance.1 7KLV FDVH UHSRUW GHVFULEHV WKH XVH RI OLSRǦOOLQJ LQ WKH WUHDWPHQW RI D \HDU ROG ZRPDQ GLDJQRVHG ZLWK 3DUU\ 5RPberg syndrome. The report is supported by a literature review FRQGXFWHG LQ WKH 3XE0HG DQG 6FLHQWLǦF (OHFWURQLF /LEUDU\ 2QOLQH 6FL(/2 GDWDEDVHV ,Q DGGLWLRQ WKH VWXG\ IROORZHG WKH &$5( FKHFNOLVW JXLGHOLQHV IRU FDVH UHSRUWV DQG FDVH VHULHV The case was based on the patient’s medical records and complementary examinations, which helped guide her clinical and therapeutic follow-up. Data collection was conducted in FeEUXDU\ LQ DFFRUGDQFH ZLWK DOO HWKLFDO SULQFLSOHV DQG ZDV performed after obtaining the patient’s informed consent. $ \HDU ROG ZRPDQ IURP 0DUDE£ VWDWH RI 3DU£ DQG UHVLGLQJ LQ %HO«P KDG EHHQ WUHDWHG DW WKH GHUPDWRORJ\ RXWSDWLHQW GHSDUWPHQW VLQFH 6HSWHPEHU DIWHU EHLQJ GLDJQRVHG with Parry-Romberg syndrome with right hemifacial atrophy. She reported frequent headaches and a “sinking” sensation in the right parietal region.

Dermatological examination revealed a hypochromic atrophic plaque with areas of bony depression in the right parietal region, atrophy of the right mandibular area and chin, and a sclerotic brownish plaque in the right cervical region. $ FUDQLDO PDJQHWLF UHVRQDQFH LPDJLQJ 05, VFDQ SHUIRUPHG LQ -XQH VKRZHG WKH IROORZLQJ ILQGLQJV WKLQQLQJ and irregularity of the right frontotemporal skin and subcutaneous tissue, with apparent thinning of the frontal calvarium; QRUPDO FHUHEUDO SDUHQFK\PD DV ZHOO DV QRUPDO VXOFL ILVVXUHV DQG RWKHU LQWHUQDO VWUXFWXUHV QRUPDO IORZ LQ WKH PDMRU YHUWHEUREDsilar and carotid arteries; and a midline that remained centered. ,Q 6HSWHPEHU WKH SDWLHQW SUHVHQWHG ZLWK DFWLYH disease, and treatment with methotrexate 10 mg/week and foOLF DFLG PJ ZHHN ZDV LQLWLDWHG DORQJ ZLWK IROORZ XS E\ DQ ophthalmologist, a neurologist, and a dentist. She achieved cliQLFDO VWDELOLW\ DQG GLVHDVH LQDFWLYLW\ E\ 1RYHPEHU ZLWK improvement of headaches, and was subsequently referred to a plastic surgeon for evaluation of surgical treatment. 7KH SDWLHQW XQGHUZHQW OLSRILOOLQJ XVLQJ WKH &ROHPDQ technique, with abdominal fat harvesting performed under geQHUDO DQHVWKHVLD )RU WKH VXUJLFDO SURFHGXUH D PP FDQQXOD FRQQHFWHG WR D P/ V\ULQJH ZLWK PDQXDO VXFWLRQ QHJDWLYH SUHVVXUH ZDV XVHG WR REWDLQ P/ RI DGLSRVH WLVVXH IURP WKH abdomen. The harvested material was prepared by fat decantation and washing to remove blood and other components. After DGHTXDWH SUHSDUDWLRQ WKH IDW ZDV WUDQVIHUUHG WR P/ V\ULQJHV DQG LQMHFWHG LQWR WKH DIIHFWHG IDFLDO DUHDV $OO KDUYHVWHG PDWHULDO was used for the grafting. Three surgical procedures were performed, approximately one year apart, using the same technique in DOO SURFHGXUHV DQG LQMHFWLQJ P/ RI IDW SHU VHVVLRQ Figure 1 Surgical outcomes were assessed by comparing preopeUDWLYH SKRWRJUDSKV ZLWK LPDJHV REWDLQHG ILYH PRQWKV DIWHU WKH third procedure, as well as by the patient’s self-evaluation, who reported satisfaction with the results ()LJXUH Parry-Romberg syndrome has an unknown etiology, although genetic, autoimmune, and environmental factors are believed to contribute to its development. The severity of the FRQGLWLRQ LV FODVVLILHG DFFRUGLQJ WR WKH H[WHQW RI DWURSK\ RI WKH skin, subcutaneous tissue, bone tissue, and involvement of the branches of the trigeminal nerve. %HFDXVH WKH FRQGLWLRQ PDQLIHVWV DV WKUHH GLPHQVLRQDO craniofacial deformities, complete restoration of facial symmetry LV RIWHQ GLIILFXOW In general, treatment aims at improving facial function and aesthetics. In such cases, once clinical inactivity of the disease is observed, reconstructive surgical treatments should be considered. Autologous grafts are preferred for replacing tissue lost GXH WR DWURSK\ GXH WR WKHLU ORZHU ULVN RI WLVVXH UHMHFWLRQ OHDGLQJ WKHUHIRUH WR OHVV ORFDO DQG V\VWHPLF LQIODPPDWRU\ UHVSRQVH WKDW FRXOG RWKHUZLVH OHDG WR JUDIW ORVV %HFDXVH DGLSRVH WLVVXH LV PROGDEOH UHDGLO\ DYDLODEOH DQG HDV\ WR KDUYHVW OLSRILOOLQJ LV WKH PRVW IUHTXHQWO\ XVHG WHFKQLTXH 428

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ĎČĚėĊ ͕ǣ A and Ǧ Ƥ Ǥ B and Ǧ Postoperative photographs of the patient after the procedure

6WUXFWXUHG OLSRILOOLQJ LQ 3DUU\ 5RPEHUJ V\QGURPH SUR-vides a simple, reproducible method with satisfactory results that contribute to treatment success, with low morbidity and the possibility of additional interventions for further corrections. Coleman and other authors hypothesize that structural fat transplantation presents both advantages and disadvantages for

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correcting soft-tissue defects, such as low graft-survival rates due to early resorption, probably because of the lack of a well-vascularized graft bed. In addition, various methods have been propoVHG WR LQFUHDVH IDW JUDIW VXUYLYDO EXW WKHUH DUH QR GHǦQLWLYH WUHDWment protocols for clinical practice, and long-term maintenance of grafts is required because of the unpredictable resorption of fat by the body. Robby et al. systematically described the predominance

Said NM, Sousa DL, Motizuki AK, Cerqueira ERD, Rocha FS

ĎČĚėĊ ͖ǣ A and Ǧ Patient before the procedure. B and Ǧ Surgical outcome of the procedure

RI WKH &ROHPDQ WHFKQLTXH LQ OLSRǦOOLQJ DQG WKDW WKH DEGRPHQ is the most common donor site used in surgical procedures for Parry-Romberg syndrome. The authors argue that this technique, associated with choosing the abdomen as the donor site, offers a minimally invasive approach capable of achieving aesthetic results with lower risk and fewer complications, and provides PRUH DGYDQWDJHV WR WKH SDWLHQW FRPSDUHG ZLWK ǧDS WHFKQLTXHV 11 Moreover, it has been documented that the main complication of this procedure is early fat resorption. The aesthetic EHQHǦWV LQFOXGH LPSURYHG VNLQ TXDOLW\ DQG PRUH QDWXUDO IDFLDO

contours and expressions, which corroborates the postoperative outcomes described in this case report and the patient’s high level of satisfaction.11 In conclusion, autologous fat grafting can mitigate severe DQDWRPLFDO LPSDLUPHQW LQ SDWLHQWV DǡHFWHG E\ 3DUU\ 5RPEHUJ V\QGURPH LQ DGGLWLRQ WR VKRZLQJ D KLJK GHJUHH RI HǡHFWLYHQHVV and aesthetic satisfaction, as measured by the patient’s self-assessment. O

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ǣ 1. Alencar JCG, Andrade SHC, Pessoa SGP, Dias IS. Lipoenxertia autóloga no tratamento da atrofia hemifacial progressiva (síndrome de Parry-Romberg): relato de caso e revisão da literatura. An Bras Dermatol. 2011;86(4 suppl 1):85-8. 2. Amaral CER, Denadai R, Buzzo CL, Amaral CAR. Abordagem terapêutica da síndrome de Parry-Romberg baseada em um sistema de classificação de gravidade. Rev Bras Cir Plást. 2014;29(1):57-65. 3. Leite LA, Oliveira Júnior CJLA, Souza IFL, Angelim CL, Lins MEE, Bivar GCC, et al. Síndrome de Parry-Romberg: avaliação clínica e cirúrgica no tratamento da atrofia hemifacial progressiva. Rev Contemp. 2024;4(6):e4830. 4. Vasconcelos‐Berg R, Varella Maire B, Navarini AA. Treating Parry‐Romberg syndrome with hyaluronic acid: insights after 2.5 years of successive treatments. An Bras Dermatol. 2025;100(3):606–8. 5. Cedrola JPV, Castro CC, Aboudib JH, Turini T, Castro M, Serra F, et al. Análise do tratamento da Síndrome de Parry-Romberg por lipoenxertia estruturada no Hospital Universitário Pedro Ernesto-HUPE-UERJ. Rev Bras Cir Plást. 2011;26(3 Suppl.1):28. 6. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24(2):347-67.

7. 8.

10. 11.

Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg. 2001;28(1):111-9. Guerrerosantos J. Long-term outcome of autologous fat transplantation in aesthetic facial recontouring: sixteen years of experience with 1936 cases. Clin Plast Surg. 2000;27(4):515-43. Chang Q, Li J, Dong Z, Liu L, Lu F. Quantitative volumetric analysis of progressive hemifacial atrophy corrected using stromal vascular fraction-supplemented autologous fat grafts. Dermatol Surg. 2013;39(10):1465-73. Arif T, Fatima R, Sami M. Parry-Romberg syndrome: a mini review. Acta Dermatovenerol Alp Pannonica Adriat. 2020;29(4):193-9. Rodby KA, Kaptein YE, Roring J, Jacobs RJ, Kang V, Quinn KP, et al. Evaluating autologous lipofilling for Parry-Romberg syndrome-associated defects: a systematic literature review and case report. Cleft Palate Craniofac J. 2016;53(3):339-50.

AUTHOR’S CONTRIBUTION: Nivin Mazen Said $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Denise Lima Sousa $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Airton Kenji Motizuki $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH manuscript. Emanuella Rosyane Duarte Cerqueira $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Franklin Sousa Rocha $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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Use of large-volume facial fat grafting in the treatment of Barraquer-Simons syndrome: A case report Uso de lipoenxertia facial em grandes volumes no tratamento da Síndrome de Barraquer-Simons: Relato de caso

Case report Authors: Decio Luis Portella1 Hamilton Aleardo Gonella1 Luciana Canabarro1 Karine Helena Bocoli1 1

Pontifícia Universidade Católica de São Paulo; School of Medical and Health Sciences, Surgery, Sorocaba, São Paulo (SP), Brazil

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170448 ABSTRACT Barraquer-Simons syndrome is characterized by progressive atrophy of the subcutaneous cellular tissue limited to the upper part of the body. The condition manifests during childhood or adolescence. Usually, there is no previous family history and the etiology remains obscure. Fat grafting has been shown to be DQ HǡHFWLYH VLPSOH VDIH DQG ORZ FRVW WKHUDSHXWLF DSSURDFK LQ WKH WUHDWPHQW RI WKLV V\QGURPH EXW ORQJHU follow-up times are necessary to enable conclusions about long-term tissue preservation. Fat grafting alORZV ZLGH GLǡXVLRQ RI WKH PHWKRG EHFDXVH LW SURYLGHV D OHVV LQYDVLYH WUHDWPHQW DQG JRRG DHVWKHWLF UHVXOWV Keywords: Lipodystrophy, Familial Partial; Transplants; Face

Correspondence: Luciana Canabarro E-mail: kanabarro@pucsp.br / lcandrade@pucsp.br

Funding: None Conﬂict of interest: None RESUMO $ V¯QGURPH GH %DUUDTXHU 6LPRQV « FDUDFWHUL]DGD SRU DWURřD SURJUHVVLYD GR WHFLGR FHOXODU VXEFXW¤QHR OLPLWDGD ¢ SDUWH VXSHULRU GR FRUSR $ GRHQ©D VH PDQLIHVWD GXUDQWH D LQI¤QFLD RX DGROHVF¬QFLD (P JHUDO Q¥R K£ KLVWµULD IDPLOLDU SUHJUHVVD H D HWLRORJLD SHUPDQHFH REVFXUD $ OLSRHQ[HUWLD WHP VH PRVWUDGR XPD DERUGDJHP WHUDS¬XWLFD HřFD] VLPSOHV VHJXUD H GH EDL[R FXVWR QR WUDWDPHQWR GHVVD V¯QGURPH PDV « QHFHVV£ULR VHJXLPHQWR SURORQJDGR SDUD SHUPLWLU FRQFOXV·HV D UHVSHLWR GD SUHVHUYD©¥R WHFLGXDO HP ORQJR SUD]R $ W«FQLFD GH OLSRHQ[HUWLD SHUPLWH DPSOD GLIXV¥R GR P«WRGR SRLV SURSRUFLRQD XP WUDWDPHQWR PHQRV LQYDVLYR H FRP ERQV UHVXOWDGRV HVW«WLFRV Palavras-chave: /LSRGLVWURřD 3DUFLDO )DPLOLDU 7UDQVSODQWH )DFH

Submitted on: 03/06/2025 Final decision: 08/26/2025

How to cite this article: Portella DL, Gonella HA, Canabarro L, Bocoli KH. Use of large-volume facial fat grafting in the treatment of Barraquer-Simons syndrome: A case report. Surg Cosm Dermatol. 2025;17:e20250448.

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INTRODUCTION Barraquer-Simons syndrome (BSS), also known as progressive partial lipodystrophy, is a rare condition characterized by the gradual and symmetric loss of subcutaneous fat in a craQLR FDXGDO GLUHFWLRQ DǡHFWLQJ WKH IDFH QHFN FKHVW DQG XSSHU limbs.1-3 First described by Mitchell (1886) and later by Barraquer (1906) and Simons (1911), BSS usually manifests in childhood or adolescence, without a family history. It has been associated with viral infections, and genetic analyses point to a mutation in the LMNB2 gene, suggesting a genetic component linked to nuclear instability and the pathogenesis of the clinical presentation.4 %66 DǡHFWV PRVWO\ ZRPHQ ZKR RIWHQ SUHVHQW IDW DFFXmulation in the buttocks and lower limbs. In men, lipoatrophy predominates. Facial changes are the primary complaint, but 20% to 30% of patients present autoimmune diseases (such as lupus and glomerulonephritis) or neurological or metabolic manifestations (such as type 2 diabetes, dyslipidemia, and insulin resistance).5,6 %66 LV FODVVLǦHG LQWR WKUHH VXEW\SHV VXEW\SH , DVVRFLDWHG with panniculitis; subtype II, associated with systemic diseases, mainly hypothyroidism, dermatomyositis, dermatitis herpetiformis, systemic lupus erythematosus, leukocytoclastic vasculitis, and mesangiocapillary glomerulonephritis; and subtype III (or idiopathic), which represents more than 50% of cases and is not associated with systemic diseases.7 7KHUH LV QR GHǦQLWLYH FXUH IRU %66 8 Treatment focuses on managing renal and autoimmune complications, as well as DHVWKHWLF LQWHUYHQWLRQV VXFK DV IDW JUDIWLQJ PXVFOH ǧDSV DQG KHWHURORJRXV IDW ǦOOHUV $XWRORJRXV IDW JUDIWLQJ KDV SURYHQ WR EH DQ HǡHFWLYH RStion, accessible in both private practice and public healthcare VHWWLQJV VXFK DV WKH %UD]LOLDQ 8QLǦHG +HDOWK 6\VWHP 686 DV it is associated with low morbidity and improves facial contour and patient quality of life.9

bilaterally in the middle third of the face, producing localized depressions. In addition to the face, physical examination also found WKH FHUYLFDO UHJLRQ QHFN DQG XSSHU WKRUD[ ZHUH DOVR DǡHFWHG Treatment consisted of two fat-grafting sessions, spaced 4 months apart, following the structural Coleman technique.10 Using a 3-mm cannula attached to a 20-mL Luer Lock syringe, 100 mL of abdominal fat were harvested and processed by decantation for 15 minutes. After antisepsis with chlorhexidiQH DQG SODFHPHQW RI VXUJLFDO GUDSHV ORFDO DQHVWKHWLF LQǦOWUDWLRQ was performed with lidocaine 0.4%, bupivacaine 0.0005%, and epinephrine 1:200,000, in accordance with maximum doses of lidocaine (7 mg/kg) and bupivacaine (2 mg/kg) in the facial recipient areas. Grafting was performed with a 1.2-mm microcannula attached to a 5-mL syringe, injecting small amounts of fat into multiple tunnels to maximize contact with the recipient WLVVXH ,Q WKH ǦUVW VHVVLRQ DSSUR[LPDWHO\ P/ RI IDW ZDV JUDIWHG into various facial regions; in the second session, 90 mL was grafted following the same protocol. After each procedure, micropore dressings and compression were applied to the liposuctioned area for 7 days. The patient remained under observation for 3 hours and was discharged in the absence of complications in the donor and recipient areas. Figure 1 shows major facial lipoatrophy, most apparent in the middle third of the face, with signs of facial aging and masculinization. The patient presented with lipoatrophy of the cervical region, upper third of the thorax, and proximal upper limbs, without LQYROYHPHQW RI WKH DEGRPLQDO UHJLRQ DV VKRZQ LQ ǦJXUH

OBJECTIVE 7R HYDOXDWH WKH HǡHFWLYHQHVV RI DXWRORJRXV IDW JUDIWLQJ for volumetric restoration and facial harmonization in a patient with Barraquer-Simons syndrome. METHODS A 54-year-old female patient was admitted to the “Professor Linneu Mattos da Silveira” Plastic Surgery Service in Sorocaba, São Paulo, for evaluation and specialized treatment. She reported progressive adipose tissue atrophy since childhood.The process began in the middle third of the face and later extended to the temporal and bilateral orbital regions, eventually progressing to the upper thorax. She denied comorbidities, similar family history, alcohol consumption, smoking, drug use, or other systemic complaints.10 Physical examination revealed major lipoatrophy (loss of adipose tissue) involving multiple body areas, more pronounced

ĎČĚėĊ ͕ǣ Preoperative appearance

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RESULTS The patient was diagnosed with BSS, subtype III. Fat grafting provided a considerable improvement in facial contour, with the near-complete disappearance of depressions and irregularities.There was an initial resorption of 40% of the grafted fat, but the results were maintained after the second session, with a 5-month follow-up. Areas such as the malar and orbital regions showed remarkable harmonization, reducing the appearance of hollow eyes and facial masculinization (Figures 3 and 4). At the 7-day postoperative mark, there was substantial improvement in facial symmetry and harmony between the facial thirds, with adequate PDODU ǦOOLQJ ,Q ǦJXUHV DQG FRUUHVSRQGLQJ WR WKH PRQWK SRVWRSHUDWLYH PDUN D ORVV RI ǦOOLQJ LQ WKH PLGGOH WKLUG RI WKH IDFH DQG temporal region can be observed, with partial loss of the grafWHG YROXPH +RZHYHU WKH IDFLDO OLQHV DQG GHSUHVVLRQV DUH FOHDUO\ smaller compared with the preoperative images.

ĎČĚėĊ ͖ǣ Lipoatrophy of the cervical region

This study was conducted in accordance with the ethiFDO SULQFLSOHV RI WKH 'HFODUDWLRQ RI +HOVLQNL $OWKRXJK D IRUPDO informed consent form was not used, all participants were previously informed about the objectives, procedures, and possible implications of the research. Verbal authorization was obtained and documented in the medical record through a medical reliability statement, ensuring that clinical data and any images XVHG ZRXOG EH NHSW FRQǦGHQWLDO DQG HPSOR\HG H[FOXVLYHO\ IRU VFLHQWLǦF SXUSRVHV 7KH VWXG\ ZDV DSSURYHG E\ WKH PHGLFDO WHDP LQ FKDUJH DQG IROORZV WKH FULWHULD RI FRQǦGHQWLDOLW\ DQRQ\PLW\ and non-exposure of participants.

DISCUSSION Restoring facial contour in cases of lipodystrophy can be SHUIRUPHG XVLQJ GLǡHUHQW WHFKQLTXHV HDFK ZLWK VSHFLǦF DGYDQtages and limitations. Among the available options are the use of DOORSODVWLF PDWHULDOV DQG ǦOOHUV VXFK DV SRO\PHWK\O PHWKDFU\ODWH (PMMA), which are regulated and authorized for use under speFLǦF FRQGLWLRQV DQG LQGLFDWLRQV VXFK DV LQ UHFRQVWUXFWLYH SODVWLF surgery, in addition to autologous tissues, whether devascularized or vascularized. Selection of the optimal treatment must take into account the individual needs of the patient, the severity of the lipodystrophy, and the surgeon’s preferences.11 /LSRǦOOLQJ RU DXWRORJRXV IDW JUDIWLQJ LV ZLGHO\ XVHG GXH WR LWV HǡHFWLYHQHVV VDIHW\ DQG UHODWLYHO\ ORZ FRVW ,W FRQVLVWV RI harvesting fat from donor areas, such as the abdomen or thighs, ZKLFK LV WKHQ SURFHVVHG DQG LQMHFWHG LQWR WKH DUHDV DǡHFWHG E\ lipodystrophy.8 One of its main advantages is that using the paWLHQWÞV RZQ WLVVXH HOLPLQDWHV WKH ULVN RI UHMHFWLRQ +RZHYHU SDUW

ĎČĚėĊĘ ͗ Ćēĉ ͘ǣ Before Ƥ orbital regions of the face

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Portella DL, Gonella HA, Canabarro L, Bocoli KH

ĎČĚėĊĘ ͙ Ćēĉ ͚ǣ Middle third of the face and temporal region before and 4 months after the procedures

of the grafted fat may undergo resorption, requiring multiple sessions to achieve satisfactory results.8 Patients with progressive lipodystrophy often seek treatment at advanced stages of the disease, when they present marked facial characteristics such as volume loss in the temporal, infra-malar, and periorbital regions.These losses accentuate concavities, producing an appearance of premature aging due to fat loss.12 Therapeutic options for correcting facial lipoatrophy include facial reconstruction techniques such as fat grafting and ǦOOLQJ ZLWK VXEVWDQFHV OLNH SRO\ / ODFWLF DFLG RU 300$ ,Q more severe cases, particularly those involving metabolic alteraWLRQV SHGLFOHG RU IUHH ǧDSV PD\ EH XVHG ,Q DGGLWLRQ UHFRPELnant leptin has been used to assist in regulating glucose metabolism and adipocyte storage.2 Fat grafting involves transferring fat from one area of the body to another, using low negative pressure for aspiration and injecting small amounts of fat through multiple tunnels. This favors integration with the recipient tissue and minimizes risks and complications.2 'XULQJ ǦOOHU SURFHGXUHV RU DGLSRVH WLVVXH JUDIWLQJ VSHFLǦF WHFKQLFDO SUHFDXWLRQV DUH HVVHQWLDO WR PLQLPL]H WKH ULVN RI aesthetic complications such as overcorrection, irregularities, asymmetries, and nodules, since adequate preservation of viable adipocytes is crucial for success. This is especially true in autologous fat grafting techniques, in which adipocyte preservation is favored by several technical measures, such as: Gentle fat aspiration with cannulas of appropriate diameter, avoiding excessive negative pressure; Delicate processing of adipose tissue, without vigorous centrifugation or prolonged exposure to air; Avoiding mechanical trauma during injection by using blunt cannulas and retrograde injection in multiple planes; Implanting small volumes per tunnel, ensuring greater surface contact with

the recipient bed and, therefore, better integration and revascularization.2,3 During the 5-month follow-up period, two fat-grafting sessions were performed, with preservation of grafted volume after an initial loss estimated at 40%. No intercurrences or comSOLFDWLRQV ZHUH UHSRUWHG GHPRQVWUDWLQJ WKH HǡHFWLYHQHVV DQG safety of the treatment. The simplicity of the procedure and the DEVHQFH RI D QHHG IRU VSHFLDO PDWHULDOV VLJQLǦFDQWO\ UHGXFH FRVW which favors its wide adoption.9 $OWHUQDWLYHV VXFK DV WKH XVH RI IUHH RU PLFURVXUJLFDO ǧDSV LQFOXGLQJ WKH UHFWXV DEGRPLQLV PXVFOH ǧDS GHHS LQIHULRU HSLJDVWULF DUWHU\ SHUIRUDWRU ',(3 ǧDS DQG DQWHURODWHUDO WKLJK ǧDS PD\ DOVR EH FRQVLGHUHG +RZHYHU WKHVH WHFKQLTXHV PD\ UHVXOW LQ donor-site scarring, ptosis, hernias, and local reactions, in addition to generally presenting high cost, which limits their use in many centers.10,12,13 Autologous fat grafting stands out as a valuable treatment option for reducing the stigma associated with facial lipodystroSK\ SURYLGLQJ DHVWKHWLF EHQHǦWV DQG LPSURYLQJ SDWLHQW TXDOLW\ of life. Early diagnosis and continuous treatment are essential to prevent the disease from progressing to advanced stages, in whiFK SK\VLFDO DQG SV\FKRORJLFDO FKDQJHV EHFRPH PRUH GLǤFXOW WR manage.10,12,13 CONCLUSION )DW JUDIWLQJ SURYHG WR EH DQ HǡHFWLYH DQG ORZ FRVW WKHrapeutic approach for treating BSS, promoting aesthetic and psychological improvements. Although long-term studies are needed to assess the durability of results, the method stands out for its simplicity and safety, making it widely applicable in both SXEOLF DQG SULYDWH KHDOWK FDUH VHWWLQJV 7KH WHFKQLTXH RǡHUV D less invasive and more accessible alternative for patients with this rare condition. O

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REFERENCES: 1. Santos M, Rabelo R, Vilasboas V, Talhari S. Do you know this syndrome? An Bras Dermatol. 2011;86:391. 2. Franco FF, Spencer LB, Mendes FD, Lopes RG, Braga EVB, Pinheiro AF, et al. Tratamento cirúrgico do paciente com síndrome de Barraquer-Simon: revisão bibliográfica e relato de caso. Rev Soc Bras Cir Craniomaxilofac. 2007;10:152-5. 3. Mansouri HN, Lahmiti S, Aimadeddine S. Barraquer Simons syndrome. Rev Stomatol Chir Maxillofac. 2011;112:172-3. 4. Hegele RA, Cao H, Liu DM, Costain GA, Charlton-Menys V, Rodger NW, et al. Sequencing of the reannotated Lmnb2 gene reveals novel mutations in patients with acquired partial lipodystrophy. Am J Hum Genet. 2006;79(2):383-9. 5. Ferrarini A, Milani A, Bottigelli M. Two new cases of Barraquer-Simons syndrome. Am J Med Genet A. 2004;126:427-9. 6. Misra A, Peethambaram A, Garg A. Características clínicas e desequilíbrios metabólicos e autoimunes na lipodistrofia parcial adquirida: relato de 35 casos e revisão da literatura. Medicina (Baltimore). 2004;83:18–34. 7. Requena Caballero C, Angel Navarro Mira M, Bosch IF, Bauxauli JM, Aliaga Boniche A. Barraquer-Simons lipodystrophy associated with antiphospholipid syndrome. J Am Acad Dermatol. 2003;49:768-9.

10.

11.

12.

13.

Cedrola JPV, Castro CC, Aboudib JH, Turini T, Castro M, Serra F. Análise do tratamento da síndrome de Parry-Romberg por lipoenxertia estruturada no Hospital Universitário Pedro Ernesto HUPE-UERJ. Rev Bras Cir Plást. 2011;26(Suppl):1-102. Ducours JL, Poizac P, Ardanza B, Modschiedler T, Caix P. Barraquer- Simons syndrome and facial lipo-filling. apropos of a case. Rev Stomatol Chir Maxillofac. 1991;92(2):105-11. Coleman SR. Structural fat grafting. In: Bartlett SP, Beasley RW, Aston SJ, Gurtner GC, Scott L, Spear SL, ed. Grabb and Smith’s plastic surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins/Wolters Kluwer; 2006. p. 480- 5. Spranger S, Spranger M, Tasman AJ, Reith W, Voigtländer T, Voigtländer V. Barraquer-Simons syndrome (with sensorineural deafness): a contribution to the differential diagnosis of lipodystrophy syndromes. Am J Med Genet. 1997;71(4):397-400. Panse I, Vasseur E, Raffin-Sanson Ml, Staroz F, Rouveix E, Saiag P. Lipodystrophy associated with protease inhibitors. Br J Dermatol. 2000;142:496-500. Dornelas MT, Corrêa MPD, Netto GM, Barra FML, Alves SGS, Dornelas MC, et al. Bioplastia na lipodistrofia de pacientes com Hiv/Aids. Rev Bras Cir Plást. 2012;27(3):387-91.

AUTHOR’S CONTRIBUTION: Decio Luis Portella 0000-0002-7375-4407 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ the propaedeutic and/or therapeutic approach to the cases studied, Critical revision of the manuscript Hamilton Aleardo Gonella 0000-0001-9302-2919 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDpeutic approach to the cases studied, Critical review of the literature Luciana Canabarro 0000-0003-1461-3695 6WDWLVWLFDO DQDO\VLV 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH Critical revision of the manuscript Karine Helena Bocoli 0009-0001-1476-4904 Acquisition, analysis and interpretation of data

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Vermilionectomy: report of two cases comparing classical excision and W-plasty Vermelhectomia: relato de dois casos comparando a excisão clássica com a W-plastia

Case report Authors: Rogerio Nabor Kondo1 Amanda Alencar dos Anjos1 Karoline Rodrigues Crevelim1 Marcos Vinicius Borges Martins1 1

Universidade Estadual de Londrina (UEL), Clinical Medicine, Londrina (PR), Brazil

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170454

ABSTRACT Vermilionectomy is a surgical procedure for the partial or total removal of the vermilion border, used primarily for the treatment of actinic cheilitis. W-plasty has been considered superior to classic elliptical excision because it avoids linear scars and, therefore, lip retractions. However, the classic elliptical excision is still widely used. This article reports two cases treated with both techniques that achieved similar satisfactory aesthetic results. Keywords: Keratosis, Actinic; Lip; Surgery, Oral

RESUMO A vermelhectomia é um procedimento cirúrgico para a remoção parcial ou total do vermelhão labial, utilizado principalmente no tratamento da queilite actínica. A W-plastia tem sido considerada superior à técnica clássica de excisão elíptica por evitar uma cicatriz linear e, logo, retrações do lábio. No entanto, a excisão elíptica clássica ainda é amplamente utilizada. Este artigo relata dois casos tratados com ambas as técnicas que obtiveram resultados estéticos satisfatórios semelhantes. Palavras-chave: Ceratose Actínica; Lábio; Cirurgia Bucal

Correspondence: Rogerio Nabor Kondo E-mail: kondo.dermato@gmail.com / kondo.dermato@uel.br

Funding: None Conﬂict of interest: None Submitted on: 03/22/2025 Final decision: 06/05/2025

How to cite this article: Kondo RN, Anjos AA, Crevelim KR, Martins MVB. Vermilionectomy: report of two cases comparing classical excision and W-plasty. Surg Cosmet Dermatol. 2025;17:e20250454.

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Kondo RN, Anjos AA, Crevelim KR, Martins MVB

INTRODUCTION Actinic cheilitis (AC) is a premalignant lesion resulting IURP FKURQLF VXQ H[SRVXUH WKDW DǡHFWV WKH YHUPLOLRQ RI WKH ORwer lip, characterized by erythema, atrophy, hyperkeratosis, and erosions.1 In treatment, it is essential to minimize the risk of malignant transformation while preserving local function and aesthetics. Nonsurgical therapeutic options for AC include topical imiquimod, chemical cauterization with trichloroacetic acid (TCA), photodynamic therapy, topical diclofenac, and laser treatPHQWV ZLWK YDULDEOH HǤFDF\ 2 If clinical treatment of AC fails, one surgical option is vermilionectomy, which consists of partial or total removal of the lip vermilion. In the classic form of the procedure, the excision is elliptical or fusiform (spindle-shaped).3 In the W-plasty variant, the excision has a jagged outline.4 Some authors consider W-plasty superior to the classic technique because it avoids a linear scar and therefore lip retraction.4 However, the classic elliptical or fusiform excision remains widely used because it is technically easier to perform.3 This article reports two cases using both techniques (classic and W-plasty), with satisfactory aesthetic and functional outcomes and no recurrence of AC after 4 years of follow-up.

Patient 1: male, 69 years old, white, nonsmoker, presenting a scaly plaque with severe keratosis, erythema, and atrophy involving almost the entire lower lip (Figure 1). Description of technique (patient 1): • • • • • •

• • •

Patient in horizontal supine position; Preoperative marking with surgical pen in fusiform outline (Figure 1A); Antisepsis with topical 10% polyvinyl iodine; Placement of surgical drapes; ,QǦOWUDWLYH DQHVWKHVLD ZLWK OLGRFDLQH DQG YDVRconstrictor; Incision with no. 15 blade following the preoperative markings. En bloc resection of lesion down to the muscle layer; Hemostasis; Suturing with 5-0 polyglactin with simple stitches (Figure 2A); Cleaning with saline solution.

Patient 2: male, 73 years old, white, nonsmoker, presenting a scaly plaque with severe keratosis, erythema, atrophy, and ulcerated areas involving almost the entire lower lip (Figure 3).

METHODS Two patients with AC underwent two sessions of 70% TCA without improvement and were subsequently selected for vermilionectomy. Both techniques were used, the classic approach and W-plasty. Histopathological examinations of the incisioQDO DQG ODWHU H[FLVLRQDO ELRSVLHV FRQǦUPHG $&

Description of technique (patient 2): • •

Patient in horizontal supine position; Preoperative marking with surgical pen in jagged outline, with “broken lines” (Figure 3A);

Figure 1: A - Elliptical or fusiform marking (classic vermilionectomy). B - Excision wound

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ĎČĚėĊ ͕ǣ A - Elliptical or fusiform marking (classic vermilionectomy). B - Excision wound

ĎČĚėĊ ͗ǣ A - W-plasty vermilionectomy marking. B - W-plasty excision

• • • •

• • •

Antisepsis with topical 10% polyvinyl iodine; Placement of surgical drapes; ,QǦOWUDWLYH DQHVWKHVLD ZLWK OLGRFDLQH DQG YDVRconstrictor; Incision with no. 15 blade following the preoperative markings. En bloc resection of lesion down to the muscle layer; Hemostasis; Suturing with 5-0 polyglactin with simple stitches (Figure 2A); Cleaning with saline solution.

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RESULTS 7KH SDWLHQWV KDG QR LQWHUFXUUHQFHV LQ WKH ǦUVW SRVWRperative days. There was good healing and satisfactory aesthetic outcomes in the late postoperative period (Figures 2B and 4C). DISCUSSION Resolution of AC is important to prevent malignant transformation, regardless of the method used. However, when choosing vermilionectomy as the surgical technique, it is essential to avoid complications such as retraction, commissure deviation, microstomia, and hypochromia.1-4 In 1956, Kwapis and Gibson described vermilionectomy as the partial or total excision of the lip vermilion, with mucosal

Kondo RN, Anjos AA, Crevelim KR, Martins MVB

Figure 4: A - Surgical specimen. B - Immediate postoperative period. C - Postoperative appearance after 4 years

ĎČĚėĊ ͙ǣ Interlocking movement of the suture edges in W-plasty

advancement and its suture to the skin for closure of the defect.4 Elliptical or fusiform excision came to be known as the classic method (Figure 1A). In this technique, the scar is linear, increasing the risk of retraction.3,4 In 1989, Vozmediano described vermilionectomy using W-plasty.4 In this method, the excision has a jagged or serrated outline, and the resulting scar forms a broken line that distributes tension more evenly, reducing suture tension and lowering the likelihood of retraction (Figures 3A and 4B).

In 2011, Rossoe et al. compared 32 patients treated with the two vermilionectomy techniques (classic vs.W-plasty, 15 and 17 patients, respectively). In that study, W-plasty provided better aesthetic results.4 The advantage of the classic technique is that it is easier to perform. Primary linear closure reduces procedure time. In contrast, W-plasty requires interlocking the pointed projections with the corresponding recesses, which demands additional adjustments and extends the surgical time (Figure 5).3,4

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The results of these techniques may depend on several factors, including age, comorbidities, smoking, postoperative care, and surgeon experience. It is important that dermatologic surgeons master both techniques so that they can be applied according to the needs of individual cases.4

REFERENCES: 1. Baltazar IL, Ferreira FR, Nascimento LFC, Mandelbaum SH. Tratamento da queilite actínica com terapia fotodinâmica com a luz do dia - avaliação clínica e histopatológica. Surg Cosmet Dermatol. 2019;11(4):295-8. 2. Lai M, Pampena R, Cornacchia L, Pellacani G, Peris K, Longo C. Treatments of actinic cheilitis: a systematic review of the literature. J Am Acad Dermatol. 2020;83(3):876-87.

In the two cases presented in this report, after 4 years of follow-up, similar results were observed, with no retraction, dyschromia, commissure deviation, or microstomia. CONCLUSION Both vermilionectomy techniques, the classic method and W-plasty, can provide similar aesthetic and functional results in the treatment of AC. O

Chang SH, Huang ZS, Chen WL, Zhou B, Zhong JL. Vermilionectomy followed by reconstruction of the vermilion mucosa using allograft dermal matrix in patients with actinic cheilitis of the lower lip. J Cosmet Dermatol. 2021;20(1):263-6. Rossoe EW, Tebcherani AJ, Sittart JA, Pires MC. Actinic cheilitis: aesthetic and functional comparative evaluation of vermilionectomy using the classic and W- plasty techniques. An Bras Dermatol. 2011;86(1):65-73.

AUTHOR’S CONTRIBUTION: Rogerio Nabor Kondo 0000-0003-1848-3314 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Amanda Alencar dos Anjos 0000-0002-5819-7315 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD &ULtical review of the literature, Critical revision of the manuscript. Karoline Rodrigues Crevelim 0009-0006-6141-2633 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFtive participation in the conduct of the study, Critical review of the literature, Critical revision of the manuscript. Marcos Vinicius Borges Martins 0009-0003-2433-5083 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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Ƥ ǣ a case report Fibroxantoma atípico gigante em tronco: relato de caso

Case report Authors: Camila Medyk1 Victória Prudêncio Ferreira1 Milene Cripa Pizzato de Araújo1 Rogerio Nabor Kondo1 Cássio Rafael Moreira1 1

Universidade Estadual de Londrina (UEL), Dermatology, Londrina (PR), Brazil

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RESUMO $W\SLFDO řEUR[DQWKRPD $); LV D UDUH PHVHQFK\PDO WXPRU WKDW W\SLFDOO\ DŔHFWV HOGHUO\ PDOH SDWLHQWV LQ VXQ H[ SRVHG DUHDV ,W LV PRUH IUHTXHQWO\ IRXQG RQ WKH KHDG DQG QHFN EXW PD\ DOVR RFFXU RQ WKH WUXQN DQG H[WUHPLWLHV ,W LV FXUUHQWO\ UHJDUGHG DV D EHQLJQ WXPRU GLDJQRVHG E\ H[FOXVLRQ ZLWK D ORZ UDWH RI UHFXUUHQFH DQG PHWDVWDVLV 7UHDWPHQW LV SHUIRUPHG E\ VXUJLFDO H[FLVLRQ ZKLFK DOORZV IRU GLDJQRVLV E\ KLVWRORJLFDO DQG LPPXQRKLVWRFKHPLFDO HYDOXDWLRQ Keywords: 7KRUD[ 6XUJLFDO 2QFRORJ\ 'HUPRVFRS\ 1HRSODVPV ,PPXQRKLVWRFKHPLVWU\ 6DUFRPD

Correspondence: Camila Medyk E-mail: medykcamila@gmail.com / kondo.dermato@uel.br

Funding: None Conﬂict of interest: None Submitted on: 04/25/2025 Final decision: 07/13/2025

How to cite this article: Medyk C, Ferreira VP, Araújo MCP, Kondo RN, Moreira CR. Giant atypical fibroxanthoma on thoracic trunk: a case report. Surg Cosmet Dermatol. 2025;17:e20250466.

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ĎČĚėĊ ͕ǣ Exophytic erythematous-violaceous lesion with areas of ulceration on the anterior thorax, measuring approximately 6 cm at its greatest diameter

ĎČĚėĊ ͖ǣ Close-up view of the lesion, showing lobulated areas and bleeding spots

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ĎČĚėĊ ͗Ǥ Focused dermoscopy of the lesion revealing homogeneous reddish areas and central ulceration

ĎČĚėĊ ͘ǣ ơ malignant neoplasm characterized by a proliferation of spindle and epithelioid cells in the reticular dermis, in a storiform pattern ȋ Ƭ ǡ ͔͘έ Ƥ Ȍ

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ǣ 1. Iglesias-Pena N, Martínez-Campayo N, López-Solache L. Relation between atypical fibroxanthoma and pleomorphic dermal sarcoma: histopathologic features and review of the literature. Actas Dermo-Sifiliográficas (English Edition). 2021;112(5):392–405. 2. Ríos-Viñuela E, Pons Benavent M, Monteagudo C, Nagore E, Sanmartín O. Fibroxantoma atípico y sarcoma pleomórfico dérmico: estúdio bicéntrico retrospectivo de 74 casos. Actas Dermo-Sifiliográficas. 2022;113(6):654–6.

3. 4.

Jara N, Solé Z S. Fibroxantoma atípico. Caso clínico. Revista médica de Chile. 2019;147(10):1346–9. De la Fuente EG, Sols M, Pinedo F, Álvarez-Fernández JG, Vicente FJ, Naz E, et al. Fibroxantoma atípico. Estudo clinicopatológico de 10 casos. Actas Dermo- Sifiliográficas. 2005;96(3):153–8. Iorizzo LJI, Brown MD. Atypical Fibroxanthoma: a Review of the Literature. Dermatol Surg. 2011;37(2):146–57.

AUTHOR’S CONTRIBUTION: Camila Medyk $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (I IHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Victória Prudêncio Ferreira $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Milene Cripa Pizzato de Araújo 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUH WDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Rogerio Nabor Kondo 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Cássio Rafael Moreira 6WDWLVWLFDO DQDO\VLV $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW

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ISSN-e 1984-8773 APOIO CIENTÍFICO:

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Cutaneous loxoscelism in a digital extremity: surgical approach with a polypropylene prosthesis via the Figueiredo technique Loxoscelismo cutâneo em extremidade digital: abordagem cirúrgica com prótese de polipropileno pela técnica de Figueiredo

Case Report Authors: Alessandra Encarnação de MoraisI Lizandra Cunha De Carvalho1 Beatriz Cavalcante de Carvalho1 Bruno dos Santos Vásquez2 Luciana Mendes dos Santos1 Virgínia Vilasboas FigueirasI Rima de Souza Raad1

Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Dermatology, Manaus (AM), Brazil Fundação Hospital Adriano Jorge, Manaus (AM), Brazil

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170473

ABSTRACT Loxoscelism is caused by the bite of a spider of the genus Loxosceles and can result in severe skin lesions. This report describes a case of cutaneous loxoscelism in a young patient with type 1 diabetes mellitus who underwent surgical debridement and coverage with a polypropylene prosthesis using the Figueiredo technique after administration of antiloxoscelic serum and antibiotic therapy. This approach proved to be D ORZ FRVW DQG HǡHFWLYH DOWHUQDWLYH DOWKRXJK LW UHVXOWHG LQ ORVV RI PRELOLW\ DQG ORFDO DWURSK\ Keywords: Wounds and Injuries; Prostheses and Implants; Spider Bites

RESUMO O loxoscelismo é causado pela picada de aranhas do gênero Loxosceles e pode resultar em lesões cutâneas graves. Este relato descreve um caso de loxoscelismo cutâneo em um paciente jovem com diabetes mellitus tipo 1 que, após administração de soro antiloxoscélico e antibioticoterapia, foi submetido a desbridamento cirúrgico e cobertura com prótese de SROLSURSLOHQR SHOD W«FQLFD GH )LJXHLUHGR $ DERUGDJHP GHPRQVWURX VHU XPD DOWHUQDWLYD HřFD] H GH EDL[R FXVWR HPERUD WHQKD UHVXOWDGR HP SHUGD GH PRELOLGDGH H DWURřD ORFDO Palavras-chave: Ferimentos e Lesões; Próteses e Implantes; Picada de Aranha

Correspondence: Alessandra Encarnação de Morais E-mail: aleencarnacao@hotmail.com

Funding: None Conﬂict of interest: None Submitted on: 05/18/2025 Final decision: 08/28/2025

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Morais AE, Carvalho LC, Carvalho BC, Vásquez BS, Santos LM, Figueiras VV, Raad RS.

INTRODUCTION Loxoscelism is a clinical condition resulting from bites by spiders of the genus Loxosceles FKDUDFWHUL]HG E\ QHFURWLF VNLQ OHVLRQV DQG LQ PRUH VHYHUH FDVHV V\VWHPLF PDQLIHVWDWLRQV 1 SeYHUDO WKHUDSHXWLF LQWHUYHQWLRQV KDYH EHHQ SURSRVHG LQFOXGLQJ WKH XVH RI DQWL /R[RVFHOHV DQWLYHQRP GDSVRQH FRUWLFRVWHURLGV and antibiotics.2 +RZHYHU D GHǦQLWLYH WKHUDSHXWLF DSSURDFK KDV QRW \HW EHHQ HVWDEOLVKHG HVSHFLDOO\ LQ FDVHV LQYROYLQJ WKH H[WUHPLWLHV ZKLFK UHTXLUH VSHFLDO DWWHQWLRQ JLYHQ WKHLU DQDWRPLFDO complexity and functional importance.3 The Figueiredo techniTXH ZKLFK XVHV SRO\SURS\OHQH SURVWKHVHV IDVKLRQHG IURP VDOLQH EDJV UHSUHVHQWV D ORZ FRVW DOWHUQDWLYH IRU FRYHUDJH RI OHVLRQV LQ extremities and may prevent amputations.4 METHODS This is the case report of an 18-year-old male patient with poorly controlled type 1 diabetes mellitus ZKR VRXJKW PHdical care 36 hours after a spider bite on the distal phalanx of WKH ULJKW VHFRQG GLJLW &OLQLFDO ODERUDWRU\ DQG LPDJLQJ H[DPLQDWLRQV ZHUH SHUIRUPHG IROORZHG E\ FOLQLFDO DQG VXUJLFDO WUHDWment as described below. RESULTS 2Q SK\VLFDO H[DPLQDWLRQ WKH SDWLHQW SUHVHQWHG ZLWK D necrotic ulcer with drainage of purulent exudate on the second GLJLW RI WKH ULJKW KDQG PHDVXULQJ FP DW LWV JUHDWHVW GLDPHWHU DVVRFLDWHG ZLWK EOLVWHUV HGHPD HU\WKHPD DQG ZDUPWK LQYROYLQJ ǧH[RU ]RQHV DQG ZLWK GRUVDO H[WHQVLRQ )LJXUH 'XH WR WKH FOLQLFDO FRXUVH DQG HSLGHPLRORJ\ D GLDJQRVLV RI FXWDQHRXV OR[RVFHOLVP ZDV FRQVLGHUHG DQG DQWL /R[RVFHOHV antivenom and antibiotic therapy were initiated. In complemenWDU\ WHVWV WKH SDWLHQW SUHVHQWHG OHXNRF\WRVLV ZLWK QHXWURSKLOLD

EXW QR ǦQGLQJV LQGLFDWLYH RI KHPRO\VLV &UHDWLQH NLQDVH ZDV PRQLWRUHG DW DGPLVVLRQ DQG DJDLQ DIWHU KRXUV UHPDLQLQJ ZLWKLQ reference values. Blood and urine cultures were negative. Soft-tissue ultrasonography and radiographs were requested to assess WKH H[WHQW RI WKH FRQGLWLRQ DQG UXOH RXW GLǡHUHQWLDO GLDJQRVHV 7KH H[DPLQDWLRQV UHYHDOHG D F\VWLF WKLFNHQHG IRUPDWLRQ LQFUHDVHG VNLQ WKLFNQHVV DQG EOXUULQJ RI WKH DGMDFHQW DGLSRVH SODQHV FRPSDWLEOH ZLWK DQ LQǧDPPDWRU\ LQIHFWLRXV SURFHVV VXJJHVWLYH RI DEVFHVV ZLWK QR VLJQV RI QHFURWL]LQJ IDVFLLWLV RU RVWHRP\HOLWLV 6XUJLFDO GHEULGHPHQW ZDV SHUIRUPHG H[SRVLQJ WKH GHHS ǧH[RU WHQGRQ RI WKH VHFRQG GLJLW IROORZHG E\ UHSHDW GHEULGHPHQW E\ WKH KDQG VXUJHU\ VHUYLFH ZLWK FRPSOHWH UHVHFWLRQ RI QHFURWLF WLVVXH 7KLV H[SRVHG YLWDO VWUXFWXUHV LQFOXGLQJ WKH UDGLDO DQG XOQDU GLJLWDO QHUYHV WKH VXSHUǦFLDO DQG GHHS ǧH[RU WHQGRQV DQG WKH GLJLWDO DUWHULHV 7KH RSWLRQV IRU FRYHUDJH RI WKHVH YLWDO VWUXFWXUHV ZHUH D PLFURVXUJLFDO IUHH ǧDS D SHGLFOHG ǧDS or the Figueiredo technique. Given the comorbidity of poorly controlled type 1 diabetes mellitus FRYHUDJH E\ WKH )LJXHLUHGR WHFKQLTXH ZDV FKRVHQ XVLQJ D SRO\SURS\OHQH SURVWKHVLV IDVKLRned from a saline bag and cut to match the dimensions of the lesion. Fixation was performed at the edges of intact skin with VLPSOH FORVHO\ VSDFHG VXWXUHV DYRLGLQJ H[FHVVLYH WHQVLRQ 7KH prosthesis was positioned in direct contact with the wound and ZLWK WKH YLWDO VWUXFWXUHV ZLWKRXW H[HUWLQJ SUHVVXUH LQ RUGHU WR provide mechanical protection and a favorable environment for FHOOXODU UHJHQHUDWLRQ )LJXUH $IWHU VXWXULQJ D GU\ GUHVVLQJ ZLWK VWHULOH JDX]H DQG PLFURSRUH WDSH ZDV DSSOLHG ǦUVW FKDQJHG after 7 days. Dressings were changed weekly until the prosthesis was removed at 60 days postoperatively. The patient remains XQGHU PXOWLGLVFLSOLQDU\ RXWSDWLHQW IROORZ XS ZLWK JRRG FOLQLFDO SURJUHVVLRQ OLPE SUHVHUYHG EXW ZLWK UHGXFHG UDQJH RI PRWLRQ (Figures 3 and 4).

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Morais AE, Carvalho LC, Carvalho BC, Vásquez BS, Santos LM, Figueiras VV, Raad RS.

DISCUSSION Surgical management of loxoscelism with involvement of H[WUHPLWLHV UHSUHVHQWV D FOLQLFDO FKDOOHQJH SDUWLFXODUO\ LQ SDWLHQWV with comorbidities such as type 1 diabetes mellitus ZKLFK LPSDLUV tissue healing. The decision to proceed with early surgical deEULGHPHQW ZDV HVVHQWLDO WR FRQWDLQ WKH LQIHFWLRQ DOORZ DGHTXDWH ZRXQG FOHDQVLQJ DQG SUHVHUYH WKH H[SRVHG YLWDO VWUXFWXUHV 7KH XVH RI WKH )LJXHLUHGR WHFKQLTXH RULJLQDOO\ GHVFULEHG IRU FORVXUH RI WUDXPDWLF ǦQJHUWLS LQMXULHV KDV SURYHQ WR EH DQ HǡHFWLYH VDIH DQG ORZ FRVW DSSURDFK HVSHFLDOO\ LQ UHVRXUFH-limited settings and in patients at high risk of surgical complications.4 ,Q UHFHQW FDVH VHULHV WKH WHFKQLTXH KDV DFKLHYHG JRRG IXQFWLRQDO DQG FRVPHWLF RXWFRPHV LQ DGGLWLRQ WR HQDEOLQJ DGHTXDWH FRYHUDJH RI WHQGRQV QHUYHV DQG YHVVHOV LQ H[WUHPLWLHV ZLWKRXW UHTXLULQJ PLFURVXUJLFDO ǧDSV 5 ,Q WKLV FDVH UHSRUW DSSOLFDWLRQ RI WKH SRO\SURS\OHQH SURVWKHVLV IDVKLRQHG IURP D VDOLQH EDJ SURYLGHG D PRLVW VWDEOH DQG SURWHFWHG HQYLURQPHQW SURPRWLQJ JUDQXODWLRQ DQG SURJUHVVLYH HSLWKHOLDOL]DWLRQ RI WKH ZRXQG 7KH PDWHULDO SURYHG FRPSDWLEOH ZLWK WKH ZRXQG EHG DQG ZDV ZHOO WROHUDWHG VXSSRUWLQJ SUHYLRXV UHSRUWV UHJDUGLQJ LWV ELRFRPSDWLELOLW\ DQG HǡHFWLYHQHVV 6 'HVSLWH WKH IDYRUDEOH RXWFRPH SDUWLDO ORVV RI UDQJH RI PRWLRQ RI WKH DǡHFWHG GLJLW ZDV REVHUYHG DW WKH HQG RI WKH KHDling process. This functional limitation is consistent with studies highlighting the need for early rehabilitation and multidiscipli-

REFERENCES: 1. Isbister GK, Fan HW. Spider bite. Lancet. 2011;378(9808):2039–47. 2. Lopes PH, Squaiella-Baptistão CC, Marques MOT, Tambourgi DV. Clinical aspects, diagnosis and management of Loxosceles spider envenomation: literature and case review. Arch Toxicol. 2020;94(5):1461–77. 3. Olan-De Los Santos AI, Manzo-Castrejón HA, Corona-Díaz E, et al. Surgical versus medical management in cutaneous loxoscelism: systematic review and update. Cir Gen. 2023;45(3):160-74. 4. Figueiredo LA, Ribeiro RS, Melo ALB, Lima AL, Terra BB, Ventim FC. Uso da prótese de polipropileno para o tratamento das lesões em ponta de dedo. Descrição de técnica cirúrgica e resultados. Rev Bras Ortop. 2017;52(6):685–92.

nary follow-up after healing of deep injuries to the hands and ǦQJHUV 7 This case report contributes to the literature by emphaVL]LQJ WKH HǡHFWLYHQHVV RI D ORZ FRVW DQG IXQFWLRQDO VXUJLFDO DSSURDFK DV ZHOO DV XQGHUVFRULQJ WKH LPSRUWDQFH RI FDUHIXO DVsessment and a multidisciplinary approach in patients with complex lesions. CONCLUSION This case report demonstrates that the Figueiredo techQLTXH XVLQJ D SRO\SURS\OHQH SURVWKHVLV UHSUHVHQWV DQ HǡHFWLYH ORZ FRVW DQG WHFKQLFDOO\ VLPSOH VXUJLFDO DOWHUQDWLYH IRU WKH PDQDJHPHQW RI GHHS VNLQ OHVLRQV RI H[WUHPLWLHV DǡHFWHG E\ OR[RVFHOLVP &RYHUDJH RI WKH FULWLFDO VWUXFWXUHV ZLWK DQ LQHUW DQG PDOOHDEOH PDWHULDO HQDEOHG OLPE SUHVHUYDWLRQ HYHQ LQ D SDWLHQW ZLWK risk factors for impaired wound healing. Although the functional outcome was limited by atrophy DQG ORVV RI PRELOLW\ WKH FOLQLFDO RXWFRPH ZDV VDWLVIDFWRU\ JLYHQ WKH LQLWLDO VHYHULW\ RI WKH FRQGLWLRQ DYRLGLQJ DPSXWDWLRQ 7KH importance of early functional rehabilitation and multidiscipliQDU\ IROORZ XS VKRXOG EH VWUHVVHG 7KXV WKH )LJXHLUHGR WHFKQLque should be considered a valid therapeutic option in similar VFHQDULRV SDUWLFXODUO\ LQ UHJLRQV ZLWK UHVWULFWHG DFFHVV WR PRUH complex resources. O

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Carrai LHM, Alves VCA, Leite WCM, Silveira NFG, Martins JAS. Fechamento cirúrgico tardio (segunda intenção) pela técnica de Figueiredo: série de casos. Surg Cosmet Dermatol. 2022;14:e20220103. Gomes ACS, Barreto FP, Medeiros RMC, Ferreira DO, Chaves CC. Use of Figueiredo’s technique for treating extensive infected skin lesions – case report. J Foot Ankle. 2024;18(1):70–3. Araújo JJ, Marques TFO, Sousa AL, Pacheco DM, Oliveira LRL. Uso da técnica de Figueiredo em lesões com exposição ósseo-tendínea: revisão de literatura. Cad Pesq. 2025;32(1):e14605.

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AUTHOR’S CONTRIBUTION: Alessandra Encarnação de Morais 0000-0001-8991-9109 &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD ,QWHOOHFWXDO SDUticipation in the propaedeutic and/or therapeutic approach to the cases studied. Lizandra Cunha de Carvalho 0009-0007-4638-116X &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD Beatriz Cavalcante de Carvalho 0009-0008-8775-7407 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULtical review of the literature. Bruno dos Santos Vásquez 0000-0002-6892-3659 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH Luciana Mendes dos Santos 0000-0002-3598-8237 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Virgínia Vilasboas Figueiras 0000-0003-1960-5328 ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW Rima de Souza Raad 0009-0008-8059-1854 (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHUDSHXWLF DSSURDFK WR WKH FDVHV VWXGLHG &ULWLFDO UHYLHZ RI WKH OLWHUDWXUH &ULWLFDO UHYLVLRQ RI WKH PDQXVFULSW

450

ISSN-e 1984-8773 APOIO CIENTÍFICO:

www.surgicalcosmetic.org.br/

Post-traumatic nail deformity presenting as a painful keel-like ridged nail and its surgical treatment Deformidade ungueal pós-traumática apresentando-se como uma unha estriada em forma de quilha dolorosa e seu tratamento cirúrgico

Case report Authors: Monika Sekar1 Sankararaman Balasubramanian2 Srivenkateswaran Kothandapany1 Vinitha Kumari1 Jayamaliga Vijayananth1 1

Vinayaka Mission's Medical College and Hospital, Department of Dermatology, Karaikal, Puducherry, India Vinayaka Mission's Medical College and Hospital, Department of General Surgery, Karaikal, Puducherry, India

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170479

ABSTRACT Trauma to the nail is a common cause of nail dystrophies and deformities. When not managed properly at initial presentation, nail injuries may result in permanent deformities and can cause functional and aesthetic abnormalities. This article reports on the case of a man who presented with a painful, ridged nail following trauma. The condition was treated with surgical excision of the keel-like nail plate and UHPRYDO RI WKH RǡHQGLQJ PDWUL[ Keywords: Nails; Nails, Malformed; Wounds and Injuries; Surgical Procedures, Operative

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Correspondence: Sankararaman Balasubramanian E-mail: mayurambsr@gmail.com

Funding: None Conﬂict of interest: None Submitted on: 05/30/2025 Final decision: 10/15/2025

How to cite this article: Sekar M, Balasubramanian S, Kothandapany S, Kumari V, Vijayananth J. Post-traumatic nail deformity presenting as a painful keel-like ridged nail and its surgical treatment. Surg Cosmet Dermatol. 2005;17:e20250479.

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Sekar M, Balasubramanian S, Kothandapany S, Kumari V, Vijayananth J.

INTRODUCTION Fingernails play an important role in hand function.They SURWHFW WKH GRUVDO VXUIDFH RI WKH GLVWDO SKDODQJHV LQFUHDVH ǦQgertip sensitivity, facilitate pinching and scratching, and have an aesthetic role. Injuries to the nail apparatus are common. Crush WUDXPD LV WKH PRVW FRPPRQ FDXVH RI ǦQJHUQDLO LQMXULHV LQ FKLOdren and young adults.These injuries may later present with nail deformities.1 Proper initial management is essential to prevent functional or aesthetic abnormalities. CASE REPORT $ \HDU ROG PDOH ǦVKHU SUHVHQWHG ZLWK SDLQ LQ WKH left thumbnail of 4 months’ duration. There was no discharge, itching, or swelling beneath the nail plate. The patient reported a cut injury 2 years prior. There was no history of animal handling or gardening. Other causes were ruled out. Dermatological examination revealed nail discoloration with a deep, T-shaped longitudinal ridge and thickening impinging on the nail bed at midline beneath the left thumbnail (Figure 1), resembling the keel of a ship (Figure 2). Total nail plate excision was planned to remove the painful ridge, along with the germinal matrix to prevent re-growth.

ĎČĚėĊ ͕ǣ Clinical photograph at presentation showing the ridge and underlying keel-like deformity

ĎČĚėĊ ͖ǣ “Keel of a ship” comparable to the ridged keel-like nail deformity

Preliminary investigations found no abnormalities. Clinical features were distinctive and imaging examinations were deemed unnecessary. A digital block was administered using plain xylocaine. A tourniquet was applied around the base of the ǦQJHU 7KH HQWLUH QDLO SODWH ZLWK WKH ORQJLWXGLQDO ULGJH ZDV VHSDrated from the nail bed and removed (Figure 3). Two longitudinal incisions were made on either side of the proximal nail fold, DQG ǧDSV ZHUH FUHDWHG WR H[SRVH WKH JHUPLQDO PDWUL[ )LJXUH The length of the crater in the nail bed and germinal matrix causing this keel-like deformity (Figure 5) was excised. The wound in the nail bed was sutured with 4-0 Vicryl Rapide (Figure 6). Postoperative healing was satisfactory. Nail growth was complete in a few weeks as the two separate parts grew very close together (Figure 7) and the patient experienced complete pain relief.

ĎČĚėĊ ͗ǣ Complete nail plate excision showing excised nail with keel

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ĎČĚėĊ ͘ǣ Longitudinal incisions over the proximal nail fold ƪ

ĎČĚėĊ ͚ǣ ƪ ͘Ǧ͔ Vicryl Rapide

ĎČĚėĊ ͙ǣ Germinal matrix responsible for the keel excised

ĎČĚėĊ ͛ǣ Post-operative healed new nail after 3 months

DISCUSSION Nails are ectodermal appendages that cover the dorsal aspects of the digits. They provide protection and integrity to WKH ǦQJHUWLS LQ DGGLWLRQ WR IDFLOLWDWLQJ ǦQH KDQG PRYHPHQWV Anatomical abnormalities of the nail unit may interfere with

these functions.3 Nail injuries are common in both industrial and domestic settings and can result in acute and chronic nail deformities.4 Proper knowledge and understanding of nail anatomy (Figure 8) are essential for the treatment of nail injuries.

453

Sekar M, Balasubramanian S, Kothandapany S, Kumari V, Vijayananth J.

Epidermis

Germinal matrix

Sterile matrix

Nail Nail plate plate Hyponychium

Epidermis

Bone

Vertical collagen Ƥ

ĎČĚėĊ ͜ǣ Parts of the nail showing germinal matrix responsible for the keel

Distal margin of lunula

Nail anatomy and growth Nails begin to develop at around 10 weeks of intrauteULQH OLIH IURP D NHUDWLQL]HG SODWH RQ WKH GRUVXP RI WKH ǦQJHU The perionychium includes the nail and its adjacent structures: hyponychium, nail bed, and nail folds. The eponychium is the proximal soft tissue on the dorsal aspect of the nail continuous with the dorsal skin.The white arc just distal to the eponychium is called the lunula. Beneath the nail plate lies the nail bed. The nail bed distal to the lunula is called the sterile matrix, and proximal to that is the germinal matrix. The distal attachment of the nail is the hyponychium, a pulp of keratinous mass rich in polymorphonuclear leukocytes and lymphocytes. The nail fold on either side is called the paronychium. Approximately 90% of nail growth originates from the germinal matrix, while the sterile matrix contributes about 10% and provides adherence of the nail plate to the nail bed. Fingernails grow at a rate of 0.1 mm per day, faster than toenails. Nail injuries and regrowth Nail growth ceases for approximately 21 days after trauma. An increase in growth is seen for the next 50 days, then a decrease for the following 30 days. Normal nail growth usually resumes 100 days after trauma. Permanent loss or deformity may occur when the germinal matrix, which is responsible for nail growth, is lost or damaged.2 Complete regrowth of an avulsed ǦQJHUQDLO RU WRHQDLO WDNHV PRQWKV DQG PRQWKV UHVpectively.3 Nail injuries include being crushed by machinery, road WUDǤF DFFLGHQWV VSRUWV LQMXULHV LDWURJHQLF FDXVHV VHOI LQǧLFWHG LQMXULHV VXFK DV QDLO ELWLQJ LQVHUWLRQ RI DUWLǦFLDO QDLOV LPSURSHU manicure, and direct damage to the nail matrix or nail bed, such as crushing, cutting, or avulsion.

The pathophysiology of traumatic ridged nails involves disruption in normal nail growth. The traumatic event directly injures the germinal matrix and nail bed, temporarily slowing or halting of nail growth.This can cause the formation of scar tissue, altering nail growth rates and creating ridges and lumps, as well as potentially complete nail loss or separation from the nail bed. Damage to nail matrix and nail fold can result in characteristic post-traumatic defects such as split nails, nonadherent nails, or dull streaks.5 In the present case, an old trauma may have driven the germinal matrix into the subungual tissue. This embedded matrix, along with the normal matrix, may have continued to grow. The embedded matrix would then have formed a nail plate structure beneath the nail, causing pain. A longitudinal ridge ran the whole length of the nail, extending from its deep aspect, akin to the keel of ship (Figure 2). 7UDXPDWLF QDLO EHG LQMXULHV FDQ EH FODVVLǦHG LQWR WZR types, closed and open injuries. Depending on the nature and anatomic location of the injury, they are divided into simple or complex lacerations, avulsion injuries, amputations, injuries involving the paronychium, or fractures. Avulsion injuries result from crush or grinding mechanisms. Sharp lacerations occur when objects penetrate the nail SODWH ZLWK VXǤFLHQW IRUFH 0LOG FUXVK LQMXULHV WR WKH GLVWDO SKDODQ[ RU ǦQJHUWLS FDQ SURGXFH D VXEXQJXDO KHPDWRPD 2SHQ LQjuries may occur with or without nail bed loss.2 Left untreated, these nail injuries can result in various deformities, including eponychial loss, onycholysis, ridged nails, split nails, pincer nails, and bony irregularities.2 They can also cause functional and aesthetic abnormalities.1 Phalangeal fractuUHV DUH SUHVHQW LQ RI ǦQJHUQDLO LQMXULHV

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Longitudinal ridges may also have other non-traumatic causes, including peripheral vascular disease, myxoid cyst, median nail dystrophy, habit-tic nail deformity, Darier’s disease, lichen planus, or may even be seen in otherwise normal nails. 0HGLDQ FDQDOLIRUP G\VWURSK\ W\SLFDOO\ DǡHFW WKXPEQDLOV SURducing a longitudinal depression with transverse ridges, creating D àZDVKERDUGá RU àǦU WUHHá SDWWHUQ 6 Longitudinal ridges with V-shaped nicks at the free end are found in Darier’s disease. 7UDFK\RQ\FKLD ZKLFK SURGXFHV D URXJK VXUIDFH DǡHFWLQJ the entire nail plate, is often associated with longitudinal ridging. It can be idiopathic or related to alopecia areata, psoriasis, lichen planus, and ichthyosis vulgaris.7 In surgical management of nail injuries, closed injuries with subungual hematoma may be treated with trephination. For open injuries, the nail plate is partially or completely avulsed to assess the nail bed for lacerations or fractures. If present, nail bed lacerations are repaired using 6-0/7-0 chromic catgut. Replacement of nail plate is indicated in cases of lacerations of ǣ 1. Tos P, Titolo P, Chirila NL, Catalano F, Artiaco S. Surgical treatment of acute fingernail injuries. J Orthop Traumatol. 2012;13(2):57-62. 2. Bharathi RR, Bajantri B. Nail bed injuries and deformities of nail. Indian J Plast Surg. 2011;44(2):197-202. 3. Pandhi D, Verma P. Nail avulsion: indications and methods (surgical nail avulsion). Indian J Dermatol Venereol Leprol 2012;78:299-308. 4. Karthi Sundar V. Surgical management of fingertip injuries. Int J Res Orthop. 2017;3(1):19-22. 5. Khodaee M, Kelley N, Newman S. Median nail dystrophy. CMAJ. 2020;192(50):E1810.

the nail bed or eponychial fold to prevent synechiae formation. Further nail bed loss can be managed with split-thickness nail bed grafts harvested from an adjacent nail bed or the great toe, RU ZLWK D ORFDO 9 < DGYDQFHPHQW ǧDS ,Q FDVHV RI FRPSOHWH QDLO bed loss with scarring, vascularized nail bed grafts may be used. Phalangeal fractures require protective splinting with a volar slab RU ǦQJHU VSOLQW IRU WKUHH ZHHNV ZKLOH GLVWDO IUDFWXUHV PD\ UHTXLUH . ZLUH Ǧ[DWLRQ DQG VSOLQWLQJ RI WKH QDLO SODWH 2 CONCLUSION In the case presented, the patient’s initial nail injury may not have been adequately treated, resulting in a painful ridged nail with a keel-like deformity.This type of deformity has not been previously reported in literature. Surgical management provided pain relief. However, since the matrix in the deformed area was excised, the regrown nail plate was divided into two juxtaposed halves. A partial germinal matrix graft might have yielded a better outcome. O

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Pradhan S; Debopriya P; Shahid R. Trachyonychia in children: a comprehensive review with recent updates. Ind J Paed Dermatol. 2024;25(2):88-93. Keel. Encyclopædia Britannica. Chicago: Encyclopædia Britannica. 1911. Acuña Pinzon C, Nieves Condoy J, Rivera Marquez D A. Nail Cancer: Review of the two main types of an underestimated disease. Cureus. 2022;14(4):e23856.

AUTHOR’S CONTRIBUTION: Monika Sekar 0009-0004-1909-5166 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (Ifective participation in the conduct of the study, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Sankararaman Balasubramanian 0000-0002-1990-964X $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Srivenkateswaran Kothandapany 0000-0002-3855-1858 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Vinitha Kumari 0009-0009-5179-7535 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Jayamaliga Vijayananth 0009-0008-8683-6779 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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Collision tumor of melanoma and basal cell carcinoma: case report with exuberant dermoscopy Tumor de colisão entre melanoma e carcinoma basocelular: relato de caso com dermatoscopia exuberante

Case Report Authors: Sabrina Covre JaquesI Isadora Busto Silva2 Beatriz Azevedo Nunes1 Carlos Augusto Silva Bastos2 Betina Werner3

DOI: http://www.dx.doi.org/10.5935/scd1984-8773.2025170487 ABSTRACT A collision tumor is a rare condition that occurs when two or more cutaneous tumors coexist in the same anatomic region. The objective of this study is to present the case of a 70-year-old male patient with a collision tumor of melanoma in situ and a nodular basal cell carcinoma, discussing clinical, histological, DQG WKHUDSHXWLF DVSHFWV KLJKOLJKWLQJ WKH LPSRUWDQFH RI GLǡHUHQWLDO GLDJQRVLV LQ FRPSOH[ FXWDQHRXV QHRplasms. Given the limited number of cases in the literature, predicting the biological behavior of collision tumors is challenging. Therefore, careful patient follow-up and further studies are necessary to better understand this condition. Keywords: Collision Tumor; Melanoma; Basal Cell Carcinoma; Dermoscopy

RESUMO Um tumor de colisão é uma condição rara que ocorre quando dois ou mais tumores cutâneos coexistem na mesma região anatômica. O objetivo deste estudo é apresentar o caso de um paciente do sexo masculino, 70 anos, com um tumor de colisão entre melanoma in situ e carcinoma basocelular de padrão nodular, abordando os aspectos clínicos, histológicos e terapêuticos ressaltando a importância do diagnóstico diferencial em neoplasias cutâneas complexas. Dado o número limitado de casos na literatura, é difícil prever a evolução biológica dos tumores de colisão. Assim, faz-se necessário o seguimento rigoroso dos pacientes e mais estudos que contribuam para o entendimento sobre essa condição. Palavras-chave: Tumor de Colisão; Melanoma; Carcinoma Basocelular; Dermatoscopia

Universidade Federal do Paraná (UFPR), Medicine, Curitiba (PR), Brazil Complexo Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Clinical Medicine Department, Dermatology, Curitiba (PR), Brazil Complexo Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Pathology Department, Curitiba (PR), Brazil

Correspondence: Sabrina Covre Jaques E-mail: sabrinajaquess@gmail.com / sabrina.jaques@hotmail.com

Funding: None Conﬂict of interest: None Submitted on: 06/26/2025 Final decision: 09/22/2025

How to cite this article: aques SC, Silva IB, Nunes BA, Bastos CAS, Werner B. Collision tumor of melanoma and basal cell carcinoma: case report with exuberant dermoscopy. Surg Cosmet Dermatol. 2025;17:e20250487.

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Jaques SC, Silva IB, Nunes BA, Bastos CAS, Werner B.

INTRODUCTION The simultaneous presence of two distinct neoplastic cell SRSXODWLRQV LQ DGMDFHQW DUHDV PDLQWDLQLQJ ZHOO GHǦQHG KLVWRORJLFDO ERXQGDULHV GHǦQHV FROOLVLRQ WXPRUV 7KLV LV DQ H[WUHPHO\ rare event when it involves two malignant neoplasms.1,2 The literature on this entity remains limited, both in terms of the number of documented cases and the elucidation of the mechanisms that lead to the coexistence of two distinct patterns of tumor GLǡHUHQWLDWLRQ This case report describes a patient with a collision tumor of melanoma and basal cell carcinoma (BCC), addressing clinical, histological, and therapeutic aspects and highlighting WKH LPSRUWDQFH RI GLǡHUHQWLDO GLDJQRVLV LQ FRPSOH[ FXWDQHRXV neoplasms. CASE REPORT A 70-year-old male construction worker was referred to the Dermatology service due to a lesion on his back.The patient could not report how long the lesion had been present, possible ectoscopic changes over time, or associated symptoms. His comorbidities included hypertension and cardiac arrhythmia Complete dermatological examination revealed an asymmetric plaque with irregular borders measuring approximately 2.94 × 2.55 cm, consisting of two adjacent lesions with distinct characteristics (Figure 1). On the left, the lesion was HU\WKHPDWRXV SRRUO\ GHǦQHG HOHYDWHG ZLWK FRDUVH DUERUL]LQJ telangiectasias and small ulcerations on dermoscopy, measuring approximately 1.41 × 2.55 cm. On the right, the lesion was darNO\ SLJPHQWHG ZHOO GHǦQHG PHDVXULQJ FP ZLWK a multicomponent dermoscopic pattern, showing an atypical

network, branched streaks, amorphous areas, and a blue-gray YHLO )LJXUH 1R O\PSKDGHQRSDWK\ ZDV LGHQWLǦHG RQ SK\VLFDO examination. The lesion was excised, and histopathological examinaWLRQ FRQǦUPHG WKH GLDJQRVLV RI D FROOLVLRQ WXPRU FRPSRVHG RI melanoma in situ (on the right) and nodular BCC (on the left). 7KH PHODQRPD ZDV FODVVLǦHG DV &ODUN OHYHO , DQG VKRZHG DEVHQFH RI XOFHUDWLRQ DEVHQFH RI PLWRVHV O\PSKRYDVFXODU HPEROL]DWLRQ DQG QHXURWURSLVP PRGHUDWH O\PSKRF\WLF LQǦOWUDWLRQ SUHVHQFH of tumor regression of less than 75%, absence of microsatellitosis, and free lateral and deep margins (Figure 3). The melanocytic neoplasm consisted of isolated cells and nests of atypical epithelioid cells, with multifocal pagetoid scatter and abundant pigmentation. In the underlying dermis, pigment incontinenFH PRGHUDWH O\PSKRF\WLF LQǦOWUDWH DQG VLJQV RI VHYHUH DFWLQLF damage were observed. The BCC exhibited nodular, solid, and DGHQRLG SDWWHUQV ZLWK LQǦOWUDWLYH DUHDV DQG IRFDO SLJPHQWDWLRQ ulceration; involvement up to the mid-reticular dermis; absence RI SHULQHXUDO LQǦOWUDWLRQ DQG IUHH ODWHUDO DQG GHHS PDUJLQV The patient underwent margin widening, and histopathological examination revealed actinic damage, cicatricial chanJHV DQG GLǡXVH PHODQRF\WLF K\SHUSODVLD ZLWK D UHDFWLYH SDWWHUQ During follow-up, the surgical wound was intact, with QR VLJQV RI UHODSVH $ QHZ QRQ PHODQRF\WLF OHVLRQ ZDV LGHQWLǦHG on the right pectoral region, and histopathological examination FRQǦUPHG WKH GLDJQRVLV RI SLJPHQWHG DQG XOFHUDWHG %&& ZLWK an expansive growth pattern. The patient remained under regular follow-up at the service, with no new lesions or suspicion of local relapse.

ĎČĚėĊ ͕ǣ Collision tumor on the back. Photo courtesy of the Dermatology Service

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ĎČĚėĊ ͖ǣ Dermoscopy of collision tumor. Photo courtesy of the Dermatology Service

Figure 3: Photomicrograph of collision tumor of melanoma in situ on the left and basal cell carcinoma on the right. Hematoxylin-eosin, 40× e 200× (inserts) DISCUSSION Among collision tumors, reports of melanoma associated with BCC are uncommon. Collision tumors, whether benign RU PDOLJQDQW UHVXOW IURP WKH SUROLIHUDWLRQ RI FHOOV IURP GLǡHUHQW lineages and may coexist within the same lesion, forming tumor combinations.3 &ROOLVLRQ WXPRUV DUH GHǦQHG DV WKH RFFXUUHQFH RI WZR neoplasms in close proximity that maintain sharply distinct boundaries.1 Some authors suggest the possibility of a single histogenesis with unknown biological behavior.4 Others consider

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these combinations to occur by coincidence, while still others K\SRWKHVL]H WKDW WKH SUHVHQFH RI RQH WXPRU PD\ LQGXFH VWURPDO changes responsible for the development of a second tumor.2 In cases of collision between melanoma and BCC, the melanoma may arise randomly from nests of melanocytic cells present within the BCC.5 The association of two malignant neoplasms is a rare HYHQW 7KH ǦUVW GRFXPHQWHG FDVH RI PHODQRPD DVVRFLDWHG ZLWK BCC was reported by Kao in 1983.2 The largest review on the

Jaques SC, Silva IB, Nunes BA, Bastos CAS, Werner B.

VXEMHFW DQDO\]HG VNLQ FDQFHU ELRSVLHV DQG LGHQWLǦHG RQO\ 11 cases of collision of melanoma and BCC.3 Of these, seven were located on the trunk and four on the upper limbs. Among WKH SDWLHQWV VL[ ZHUH PHQ DQG ǦYH ZHUH ZRPHQ ZLWK D PHDQ age of 53 years.3 The literature still contains few reports on this condition, DV ZHOO DV WKH H[DFW HWLRORJ\ XQGHUO\LQJ WKLV ELGLUHFWLRQDO GLǡHrentiation, and reports of collision tumors of BCC and melaQRPD DUH HYHQ VFDUFHU $ OLWHUDWXUH UHYLHZ LGHQWLǦHG FDVHV RI collision tumors involving melanoma and BCC, most of which VKRZHG QR LQWHUPLQJOLQJ RI WXPRU FHOOV DQG KDG ZHOO GHǦQHG margins.6 Given the rarity of these cases, there is ongoing debate regarding the most appropriate terminology. Terms proposed in the literature include “malignant melanocytic basal tumor,” describing a biphasic tumor composed of BCC and malignant melanoma7 àFRORQL]DWLRQ á UHIHUULQJ WR WKH XQLTXH VLWXDWLRQ LQ ZKLFK PHODQRPD LQ VLWX H[WHQGV DQG FRORQL]HV D %&&3; and “melanoma associated with BCC.”2 Studies indicate that collision tumors, such as melanoma associated with BCCs and squamous cell carcinomas (SCCs), occur more frequently in patients under intense sunlight expoVXUH RU ZLWK JHQHWLF SUHGLVSRVLWLRQ UHǧHFWLQJ WKH FRPSOH[LW\ RI carcinogenic processes.8 In the present case, the patient had risk factors such as a low phototype and marked sunlight exposure. &ROOLVLRQ WXPRUV VHHP WR DǡHFW PHQ PRUH IUHTXHQWO\ WKDQ ZR-

men, with a higher incidence after 50 years of age.3 Case reports of tumor collision involve various anatomical sites, including the back, cervical region, ears, and face.5,9,10,11 Although melanomas associated with BCC or SCC may, in some situations, exhibit less aggressive behavior, there are case reports of fatal outcomes, often associated with Breslow’s depth greater than 1.5 mm.3 Prognosis and treatment depend on the most aggressive tumor; however, early intervention and excision with adequate margins generally result in favorable outcomes, as observed in the present case.6 Outpatient follow-up for a period of 5 to 10 years is essential to assess for possible local relapse and for the early diagnosis of a second primary melanoma at another site. Patients with a prior history of melanoma have a 10% risk of developing a second melanoma within 5 years.6 After a second episode, this likelihood increases to 30%.6 In this case report, a new BCC was diagnosed in the pectoral region during follow-up, with no RWKHU VXVSLFLRXV PHODQRF\WLF OHVLRQV LGHQWLǦHG WKURXJK HDUO\ 2025. CONCLUSION Given the limited number of case reports available in the literature, predicting the biological behavior of these lesions is challenging. Therefore, rigorous patient follow-up and further studies aimed at improving our understanding of this condition are necessary. O

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REFERENCES: 1. Boyd AS, Rapini RP. Cutaneous collision tumors: an analysis of 69 cases and review of the literature. Am J Dermatopathol. 1994;16:253-7. 2. Papa G, Grandi G, Pascone M. Collision tumor of malignant skin cancers: a case of melanoma in basal cell carcinoma. Pathol Res Pract. 2006;202:691-4. 3. Satter EK, Metcalf J, Lountzis N, Elston DM. Tumors composed of malignant epithelial and melanocytic populations: a case series andreview of the literature. J Cutan Pathol. 2009;36(2):211-9 4. Scruggs JM, Rensvold EA, Parekh PK, Butler DF. Cutaneous collision cancers: a report of two squamomelanocytic malignancies and review of the literature. Dermatol Surg. 2011;37(11):1679-83. 5. Hirakawa E, Miki H, Kobayashi S, Nomura Y, Ohmori M. Collision tumor of cutaneous malignant melanoma and basal cell carcinoma. Pathology - Research and Practice, 1998;194(9):649–53. 6. Medeiros PM, Alves NRM, Silva CC, Faria PCP, Barcaui CB, Piñeiro-Maceira J. Colisão de neoplasias malignas na pele: melanoma associado a carcinoma basoescamoso. An Bras Dermatol. 2015;90(3 Supl 1):S38-41.

8. 9. 10.

11.

Pool SE, Manieei F, Clark WH, Harrist TJ. Dermal squamomelanocytic tumor: a unique biphenotypic neoplasm of uncertain biological potential. Hum Pathol 1999;30:525. Sahu, AK. "Coexistence of melanoma and non-melanoma skin cancer: a rare occurrence." Clin Exp Dermatol. 2019;44(5):510-3. Coskey RJ, Mehregan AH. The association of basal cell carcinomas with other tumors. J Dermatol Surg Oncol. 1987;13:553–5. Burkhalter A, White WL. Malignant melanoma in situ colonizing basal cell carcinoma: a simulator of invasive melanoma. Am J Dermatopathol. 1997;19:303–7. Wang H, Benda PM, Piepkorn MW. Parasitism of basal cell carcinoma by lentigo maligna melanoma. J Am Acad Dermatol. 2003;48:S92–4.

AUTHOR’S CONTRIBUTION: Sabrina Covre Jaques 0000-0001-5617-0533 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ analysis and interpretation of data, Critical review of the literature, Critical revision of the manuscript Isadora Busto Silva 0000-0003-3502-1840 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ analysis and interpretation of data, Critical review of the literature, Critical revision of the manuscript. Beatriz Azevedo Nunes 0000-0001-8057-0799 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ analysis and interpretation of data, Critical review of the literature, Critical revision of the manuscript. Carlos Augusto Silva Bastos 0000-0003-0255-2696 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript. Betina Werner 0000-0002-9671-5603 $SSURYDO RI WKH ǦQDO YHUVLRQ RI WKH PDQXVFULSW &RQFHSWLRQ DQG GHVLJQ RI WKH VWXG\ 3UHSDUDWLRQ DQG ZULWLQJ RI WKH PDQXVFULSW $FTXLVLWLRQ DQDO\VLV DQG LQWHUSUHWDWLRQ RI GDWD (ǡHFWLYH SDUWLFLSDWLRQ LQ WKH FRQGXFW RI WKH VWXG\ ,QWHOOHFWXDO SDUWLFLSDWLRQ LQ WKH SURSDHGHXWLF DQG RU WKHrapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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Facial rosacea outside the nasal region: case report and surgical approach Ƥ ǣ ï

Case Report Authors: Sarah de Oliveira Mendes1 Thamires Alcântara Bezerra de Assis1 Ana Beatriz Araújo Leite1 Conceição Virgínia Costa Batista1 1

Universidade de Pernambuco (UPE), Dermatology, Recife (PE), Brazil

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Correspondence: Sarah de Oliveira Mendes E-mail: sarahmendesmed@gmail.com

RESUMO $ URV£FHD « XPD GRHQ©D FXW¤QHD LQŚDPDWµULD FU¶QLFD TXH SRGH VH PDQLIHVWDU FRP DOWHUD©·HV řPDWRVDV LVRODGDV (VWH UHODWR GH FDVR GHVFUHYH XP SDFLHQWH FRP DSUHVHQWD©¥R FO¯QLFD UDUD H H[XEHUDQWH WUDWDGR FRP VXFHVVR SRU PHLR GH XPD DERUGDJHP FLU¼UJLFD FRQYHQFLRQDO Palavras-chave: 5RV£FHD 3URFHGLPHQWRV &LU¼UJLFRV $PEXODWµULRV 'HUPDWRORJLD Funding: None Conﬂict of interest: None Submitted on: 07/16/2025 Final decision: 08/26/2025

How to cite this article: Mendes SO, Assis TAB, Leite ABA, Batista CVC. Facial rosacea outside the nasal region: Case report and surgical approach. Surg Cosmet Dermatol. 2025;17:e20250495.

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ĎČĚėĊ ͗ǣ Ǧ ͗ ǡ VWLOO QR XQLYHUVDOO\ DFFHSWHG WUHDWPHQW PHWKRG IRU WKH FRQGLWLRQ ZLWK H[FLVLRQDO VXUJLFDO DSSURDFKHV DQG DEODWLYH ODVHUV SUHGRPL QDWLQJ LQ WKH PHGLFDO OLWHUDWXUH 7KH PRVW IUHTXHQWO\ UHSRUWHG PHWKRGV LQFOXGH FRQYHQWLRQDO VXUJHU\ HOHFWURVXUJHU\ FU\RVXU JHU\ DQG UDGLRIUHTXHQF\ $PRQJ DEODWLYH WHFKQLTXHV &2 ODVHUV QP DQG (U <$* HUELXP GRSHG \WWULXPÛDOXPLQXPÛ JDUQHW ODVHUV QP VWDQG RXW 7KHUH DUH QR VWXGLHV GHPRQVWUDWLQJ WKH VXSHULRULW\ RI RQH WHFKQLTXH RYHU DQRWKHU DQG JLYHQ WKH ZLGH UDQJH RI WKHUDSHXWLF REFERENCES: 1. Fink C, Lackey J, Grande DJ. Rhinophyma: a treatment review. Dermatol Surg. 2018;44(2):275-82. 2. Oliveira CMM, Almeida LMC, Bonamigo RR, Lima CWG, Bagatin E. Consensus on the therapeutic management of rosacea – Brazilian Society of Dermatology. An Bras Dermatol. 2020;95(Suppl 1):53–69. 3. Schaller M, Almeida LMC, Bewley A, Cribier B, Del Rosso J, Dlova NC. Recommendations for rosacea diagnosis, classification and management: update from the global rosacea consensus 2019 panel. Br J Dermatol. 2020;182(5):1269-76.

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Suzuki NN, Palo JS, Magalhães RF, Buffo TH, Stolf HO. Full thickness cross-shaped excision for rhinophyma in a patient with multiple comorbidities. Surg Cosmet Dermatol. 2020;12(Suppl 1):124–7. Tan J, Almeida LMC, Bewley A, Cribier B, Dlova NC, Gallo R. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global rosacea consensus (ROSCO) panel. Br J Dermatol. 2017;176(2):431-8. Van Zuuren EJ, Arents BWM, van der Linden MMD, Vermeulen S, Fedorowicz Z, Tan J. Rosacea: new concepts in classification and treatment. Am J Clin Dermatol. 2021;22(4):457-65.

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