Reconstrução após ressecção bipalpebral com preservação do globo ocular: desafio estético e funcional / Reconstruction after bipalpebral resection with preservation of the eyeball: aesthetic and functional challenge

Introdução: A reconstrução palpebral pode ser realizada por fechamento primário, enxerto de diferentes lamelas e retalhos locais e/ou regionais, únicos ou combinados. Essa reconstrução se torna mais complexa quando a pálpebra superior e a inferior são ressecadas em espessura total e o globo ocular é preservado. O objetivo é relatar as técnicas utilizadas para reconstrução periorbital em casos de ressecção bipalpebral (superior e inferior) com preservação do globo ocular pelo Grupo de Cirurgia Órbitopalpebral da Divisão de Cirurgia Plástica e Queimaduras do HCFMUSP. Métodos: Foram revistos todos os casos que se encaixaram nos critérios de inclusão no período de 2000 a 2019, sendo descritos dados epidemiológicos, cirúrgicos e de seguimento pós-operatório. Resultados: Apenas dois casos foram submetidos à exérese total do tecido periorbital e permaneceram passíveis de preservação do globo ocular. Ambos foram reconstruídos com retalhos frontais com oclusão total do globo ocular no primeiro momento, seguido pela liberação em etapas, mantendo o globo viável após a finalização da reconstrução. Discussão: São escassos os relatos semelhantes na literatura e, nestes casos, os resultados cirúrgicos se mostraram funcionalmente aceitáveis, mas com limitações estéticas importantes. Conclusão: Sugerimos uma nova opção para a reconstrução total da pálpebra superior e inferior (com um único retalho pedicular, desprovido de enxerto conjuntivo e em múltiplos estágios) que fornece proteção e conservação do globo ocular durante as diferentes etapas da cirurgia. Os resultados foram funcionalmente favoráveis, considerando a gravidade dos casos.

Introduction: Eyelid reconstruction can be performed by primary closure, a graft of different lamellae, and local and/or regional flaps, single or combined. This reconstruction becomes more complex when the upper and lower eyelids are resected to total thickness, and the eyeball is preserved. The objective is to report the techniques used for periorbital reconstruction in bipalpebral resection cases (upper and lower) with preservation of the eyeball by the Group of Orthopalpebral Surgery of the Division of Plastic Surgery and Burns of HCFMUSP. Methods: All cases that met the inclusion criteria from 2000 to 2019 were reviewed, and epidemiological, surgical, and postoperative follow-up data were described. Results: Only two cases were submitted to total exeresis of the periorbital tissue and remained susceptible to eyeball preservation. Both were reconstructed with frontal flaps with complete occlusion of the eyeball at the first moment, followed by the release in stages, keeping the globe viable after reconstruction completion. Discussion: Similar reports are scarce in the literature, and, in these cases, surgical results were functionally acceptable but with significant aesthetic limitations. Conclusion: We suggest a new option for total reconstruction of the upper and lower eyelid (with a single pedicular flap, devoid of connective graft and in multiple stages) that protects and conserves the eyeball during the various stages of surgery. The results were functionally favorable, considering the severity of the cases.

Xantogranuloma juvenil gigante: acometimento palpebral difuso e simultâneo / Giant Juvenile Xanthogranuloma: diffuse and simultaneous palpebral involvement

O xantogranuloma juvenil (XGJ) é um tumor benigno e o mais comum do grupo das doenças histiocitárias proliferativas nãoLangerhans. Lesões; 2cm são consideradas XGJ gigantes, com relatos de lesões de até 18cm. Lesões oculopalpebrais podem necessitar de tratamento cirúrgico para controle de sintomas. Esse trabalho relata o caso de um menino de 8 anos que teve as 4 pálpebras acometidas por XGJ gigantes, além do terço médio. Ele foi submetido a 3 ressecções, sendo uma bastante profunda, necessitando enxerto de pele de espessura total diretamente sobre o músculo levantador da pálpebra superior. Posteriormente, 3 procedimentos de lipoenxertia foram realizados, atingindo resultado funcional e estético adequado, sem recorrência lesional.

Juvenile xanthogranuloma (JXG) is the most common benign tumor of the group of non-Langerhans histiocytic proliferative diseases. Lesions >2 cm are considered giant JXG, with reports of lesions of up to 18 cm. Oculopalpebral lesions may require surgical treatment to control symptoms. This study reports a case of an 8-year-old boy who had four eyelids and the middle third of the face affected by giant JXG. He underwent three resections, one of which was of great depth that required a full-thickness skin graft directly on the levator palpebrae superioris muscle. Subsequently, four fat-grafting procedures were performed and adequate functional and

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

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

Correction of severe ptosis with a silicone implant suspensor: 22 years of experience.

BACKGROUND: Patients with severe ptosis caused by poor or absent function of the levator muscle but with good frontalis muscle excursion usually benefit from a frontalis sling procedure. This is currently carried out using organic or inorganic material to connect the upper eyelid to the frontalis muscle. METHODS: The aim of this study was to evaluate retrospectively 112 patients who underwent frontalis sling procedures between 1989 and 2011 using a preformed silicone implant suspensor to correct severe ptosis. RESULTS: The results obtained using this technique were good or fair in 95.54 percent of the cases and poor in 4.46 percent of the cases. The authors discuss the results of the study and the cases in which the procedure should be indicated and highlight the advantages of the method. CONCLUSION: The availability of this low-cost sterile device, together with the fact that it is ready to use, requires less invasive surgery, saves time, and is sufficiently versatile to allow adjustments to be made at any time, makes the silicone eyelid sling an attractive choice for correcting ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tricoadenoma palpebral: tratamento cirúrgico associado à blefaroplastia estética / Eyelid trichoadenoma: surgical treatment associated with aesthetic lepharoplasty

O tricoadenoma é um tumor cutâneo benigno, assintomático, raro e de crescimento lento. Existem poucos casos relatados na literatura e identificamos apenas um descrito na região palpebral. Apresentamos o caso de uma paciente portadora de tricoadenoma no canto externo da pálpebra inferior direita, tratada com excisão cirúrgica associada a blefaroplastia.

Trichoadenoma is a benign cutaneous tumor that is asymptomatic, rare, and slow growing. There are few cases reported in the literature, and we could only identify one description of trichoadenoma occurring in the eyelid area. We describe the case of a patient with trichoadenoma in the outer corner of the lower eyelid that we treated with surgical excision associated with blepharoplasty.

Primary cutaneous melanoma: an 18-year study.

BACKGROUND: Primary cutaneous melanoma still constitutes the main cause of skin cancer death in developed countries, and its incidence in recent years has been increasing in a steady, worrisome manner. OBJECTIVES: This study evaluated the clinical, epidemiological and demographic aspects of this disease, and correlated them with patient prognosis. METHODS: Using epidemiologic and clinical data, we analyzed 84 patients with mild to severe primary cutaneous melanoma treated between 1990 and 2007. Slides containing surgical specimens were analyzed, and new slides were made from archived paraffin sections when necessary. RESULTS: The melanoma incidence was higher in areas of sun exposure, with lesions commonly observed in the trunk for males, and lower limbs for females. In addition to Breslow's thickness and ulceration (p = 0.043 and p < 0.001, respectively), the mitotic rate per mm(2) also correlated with worse patient outcome (p = 0.0007). The sum of ulceration (0 when absent or 1 when present), the Breslow index (1 when <1 mm, 2 when >1 mm and <4 mm, 3 when >4 mm) and the mitotic index (0 when absent or 1 when > or =1 per mm(2)) allowed the establishment of a prognostic score: if the sum was equal to or over three, nearly all (91.7%) patients had systemic disease. The 5-year survival was approximately seventy percent. CONCLUSION: Because American Join Committee of Cancer Staging will update the classification of malignant tumors (TNM) staging in the near future, and introduce mitosis as a prognostic factor, our results show the importance of such a feature. Additional studies are necessary to confirm the importance of a prognostic score as proposed herein.

Primary cutaneous melanoma: an 18-year study

BACKGROUND: Primary cutaneous melanoma still constitutes the main cause of skin cancer death in developed countries, and its incidence in recent years has been increasing in a steady, worrisome manner. OBJECTIVES: This study evaluated the clinical, epidemiological and demographic aspects of this disease, and correlated them with patient prognosis. METHODS: Using epidemiologic and clinical data, we analyzed 84 patients with mild to severe primary cutaneous melanoma treated between 1990 and 2007. Slides containing surgical specimens were analyzed, and new slides were made from archived paraffin sections when necessary. RESULTS: The melanoma incidence was higher in areas of sun exposure, with lesions commonly observed in the trunk for males, and lower limbs for females. In addition to Breslow's thickness and ulceration (p = 0.043 and p < 0.001, respectively), the mitotic rate per mm² also correlated with worse patient outcome (p = 0.0007). The sum of ulceration (0 when absent or 1 when present), the Breslow index (1 when <1 mm, 2 when >1 mm and <4 mm, 3 when >4 mm) and the mitotic index (0 when absent or 1 when >1 per mm²) allowed the establishment of a prognostic score: if the sum was equal to or over three, nearly all (91.7 percent) patients had systemic disease. The 5-year survival was approximately seventy percent. CONCLUSION: Because American Join Committee of Cancer Staging will update the classification of malignant tumors (TNM) staging in the near future, and introduce mitosis as a prognostic factor, our results show the importance of such a feature. Additional studies are necessary to confirm the importance of a prognostic score as proposed herein.

Comparative analysis of the influence of perichondrium on conjunctival epithelialization on conchal cartilage grafts in eyelid reconstruction: experimental study in rabbits.

BACKGROUND: Although the role of cartilage grafts in reconstruction of the posterior eyelid lamella is well established, spontaneous conjunctival epithelialization on such grafts has yet to be fully proven. The aim of this study was to perform a comparative analysis of the influence of perichondrium on conjunctival epithelialization over conchal cartilage grafts used in eyelid reconstruction in rabbits. METHODS: The posterior lamellae of 100 lower eyelids from 50 rabbits were reconstructed with autogenous grafts of conchal ear cartilage. In the right eyelids, cartilage was grafted with the perichondrium in direct contact with the eyeball, and the left eyelids were reconstructed in a similar manner but using cartilage grafts without perichondrium. The animals were killed after 1, 2, 3, 4, and 5 weeks, and their lower eyelids were analyzed macroscopically and histologically. RESULTS: The percentage difference in conjunctival epithelialization on the cartilage with perichondrium and that without perichondrium was 11.41 percent in the first week of the experiment, 13.64 percent in the second week, 18.69 percent in the third week, 10.38 percent in the fourth week, and 6.17 percent in the fifth week. The average percentage conjunctival epithelialization in the eyelids reconstructed with a cartilage graft with perichondrium was significantly higher throughout the 5 weeks of the experiment than in the eyelids reconstructed with cartilage without perichondrium (p < 0.0002). CONCLUSION: It was found that the perichondrium had an important role in conjunctival epithelialization in eyelids reconstructed with a cartilage graft in the present study.

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

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

The role of micro-anchor devices in medial canthopexy.

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

Fissura número 9 de Tessier: aspectos clínicos radiológicos e abordagem cirúrgica / Tessier number 9 cleft: clinical and radiological aspects and surgical approach

Devido a sua raridade, poucos relatos na literatura detalham os aspectos clínicos e radiológicos da fissura 9 de Tessier. A proposta do presente estudo é descrever cinco pacientes portadores desta fissura facial. No período entre 1999 e 2006, conco pacientes foram acompanhados em nosso serviço, com o diagnóstico de fissura 9 de Tessier. Destes, qutro eram do sexo feminino e apresentavam fissuras unilaterais. Em um único caso, a fissura 9 foi único achado clínico. Em dois pacientes, outras fissuras faciais foram observadas e, em outros dois pacientes, outras deformidades craniofaciais estavam associadas, incluindo microftalmia, ptose palpebral grave, além de deformidades em extremidades. As deformidades em partes moles e esqueléticas não eram porporcionais, observando-se deformidades leves em partes moles associadas a fissuras completas e deformidades graves de partes moles associadas a fissuras parciais. As deformidades orbitárias foram tratadas por meio de reconstrução palpebral, reposicionamento do canto lateral e cranioplastias. A presença de banda fibrosa ao longo da fissura foi essencial para reposicionamento tecidual adequado. As deformidades de partes moles e as deformidades esqueléticas não são proporcionais, tornando complexa uma única teoria etiológica para seu aparecimento e dificultando muitas vezes o diagnóstico. Investigação dos sinais clínicos de métodos de imagem é fundamental para o diagnóstico adequado e, conseqüentemente, para o tratamento cirúrgico apropriado.

Conjuntivo-müllerectomia no tratamento cirúrgico da ptose palpebral suave / Müller muscle-conjunctiva resection for treatment of blepharoptosis

A ptose palpebral suave constitui deformidade caracterizada por deslocamento da pálpebra superior até 4mm abaixo do limbo escleral. Pode ser decorrente de disfunção do músculo de Müller, diagnosticada pelo teste do colírio de fenilefrina a 10 por cento. Neste trabalho, realizou-se revisão bibliográfica orientada sobre os métodos corretivos da ptose palpebral suave, objetivando apontar o tratamento de escolha para correção dessa deformidade. Mostrou-se também a experiência da Divisão de Cirurgia Plástica do HC da FMUSP com a utilização deste procedimento durante o período de 1995 a 2006.

Mild blepharoptosis is a deformity characterized by malposition of the upper eyelid 4mm under scleral limb. Can be caused by malfunction of the Müller muscle, and it is diagnosticated by instilling several drops of 10 por cento phenylephrine. This is a review of the studies related to the methods applied in mild blepharoptosis, as well as discussion of its indications and technique of Müller muscleconjunctiva resection. The authors present the experience of the Divisão de Cirurgia Plástica HC-FMUSP with this procedure during the period between 1995 and 2006.

Correction of blepharophimosis with silicone implant suspensor.

BACKGROUND: Blepharophimosis is a rare autosomal-dominant syndrome involving the periorbital region. It is characterized mainly by eyelid ptosis, palpebral phimosis, telecanthus, and epicanthus inversus. METHODS: Ten patients ranging in age from 2 to 22 years who presented with blepharophimosis were retrospectively studied over the past 14 years; they had an average follow-up of 7 years and 5 months. They were treated at the Division of Plastic Surgery of the Faculty of Medicine, University of São Paulo. Eight patients presented with the complete form, including epicanthus, telecanthus, and severe palpebral ptosis, and two presented with the incomplete form. The epicanthi and telecanthi were corrected with Mustardé's technique, and the ptosis was treated by frontalis suspension with a soft, preformed silicone device called the silicone implant suspensor. RESULTS: The results were classified as good, fair, and poor, according to the postoperative position of the upper eyelid in relation to the scleral limbus, medial canthus position, and residual epicanthal fold. The results were assessed as good in seven cases and fair in three. CONCLUSIONS: The silicone eyelid suspensor was effective in improving the patients' difficult condition. It was a better alternative than the use of fascia lata, because it permitted an easier readjustment of the eyelid margin and it offered the possibility of creating a well-defined palpebral fold, which is usually absent in this group. The results were maintained with long-term follow-up. The silicone suspensor was safe and long-term results were good in both children and adults.

Rectangular flaps technique for treatment of congenital hand syndactyly

A sindactilia e uma das mais frequentes deformidades congenitas da mao. Neste estudo, sao analisados 22 pacientes submetiods a correcao de sindactilias congenitas da mao, utilizando-se a tecnica dos retalhos retangulares. Resultados considerados esteticamente e funcionalmente bons foram obtidos em 77,3 por cento dos casos, e complicacoes ocorreram em 13,6 por cento. A tecnica mostrou ser de simples execucao, e com resultados favoraveis podendo ser aplicada na maioria dos casos de sindactilias da mao

Tratamento cirúrgico do blefaroespasmo essencial: relato de dois pacientes / Surgical treatment of blepharospasm: report of 2 patients

Blefaroespasmo essencial pode ser tratado por diversas opções terapêuticas: clínicas em que se destaca entre outros o uso da toxina botulínica com suas vantagens e limitações, e algumas opções de tratamento cirúrgico. A técnica cirúrgica proposta por Gillum e Anderson oferece uma alternativa a pacientes resistentes ao tratamento clínico ou que durante a evolução da doença apresentem complicações secundárias. São analisados dois casos em que se indicou a miectomia dos músculos orbicular da pálpebra, prócero e corrugador do supercílio associados à blefaroplastia e ritidoplastia frontal por terem apresentado diminuição da resposta ao tratamento clínico. Ambos obtiveram bons resultados, retornando às suas atividades normais.

Tratamento cirúrgico da ginecomastia com pedículos lateral e medial / Surgical treatment of the gynecomastia with lateral and medial pedicles

Ginecomastia é o aumento da mama masculina que pode acometer até 65 por cento dos indivíduos deste sexo na fase infanto-puberal, compreendida entre 13 e 16 anos. Tem como principais cuasas hepatite ou cirrose hepática, carcinoma ou doenças inflamatórias pulmonares crônicas, carcinomas ou disfunções testiculares, tumores glandulares (pituitária, supra-renal), alterações dos níveis séricos de testosterona, síndromes genéticas (síndrome de Klinefelter, p.ex.), uso de drogas como heroína, maconha ou anabolizantes e hanseníase. Podemos classificar a ginecomastia quanto ao volume, quanto aos tecidos que a compõem (gordurosa ou pseudoginecomastia, glandular e mista), ou quanto ao tratamento necessário para sua correção cirúrgica (pequena, moderada e grave). O tratamento das formas mais graves de ginecomastia é muito diferente daquele aplicado às formas mais suaves, pois nas formas graves, além da ressecção dos tecidos gorduroso e glandular, existe a necessidade de ressecção da pele em excesso e o reposicionamento do complexo aréolo-mamilar. O objetivo deste trabalho é descrever uma técnica cirúrgica específica para estes pacientes portadores de formas graves de ginecomastia, através de dois pedículos dermogordurosos, um lateral e um medial, com aproximadamente 2cm de espessura, mantendo assim a nutrição do complexo aréolo-mamilar. Esses pedículos são delimitados entre as bissetrizes dos quadrantes súpero-lateral e ínfero-lateral, e súpero-medial e ínfero-medial, tendo o mamilo como vértice. Na área de pele excessiva periareolar, obtida através do pinçamento interdigital, é realizada a desepidermização dos pedículos lateral e medial e ressecção de toda pele e tecido celular subcutâneo até a fáscia peitoral nas regiões superior e inferior aos pedículos; a síntese é realizada em dois planos, sendo periareolar a cicatriz resultante. Foram operados com esta técnica vinte pacientes com forma grave de ginecomastia, com média etária de 23,3 anos; sendo seis pacientes da raça negra. O bom posicionamento do complexo aréolo-mamilar e uma cicatriz periareolar resultante, bem como a retirada de conteúdo suficiente, foram as principais vantagens observadas. Como complicações, tivemos assimetria das placas aréolo-mamilares em dois casos, nos quais havia acentuada diferença entre os dois lados na avaliação pré-operatória; cicatrização hipertrófica em um paciente da raça negra, cuja cicatriz foi atenuada com injeções intracicatriciais de triancinolona...

Correcao precoce das deformidades das maos na sindrome de Apert: comunicacao preliminar / Early correction of hand deformities in Apert's syndrome: preliminary communication

A correcao das deformidades cranianas e dos membros na sindrome de Apert exige a atuacao de equipe multidisciplinar. Preocupados com as recuperacoes esteticas e funcionais que essas anomalias impoe aos seus portadores, esforcos devem ser concentrados objetivando a reintegracao desses pacientes a sociedade. Recentemente especialistas em cirurgia da mao tem advogado intervencao cirurgica mais precoce, para obterem melhores resultados. No periodo de 1989 a 1992, cinco pacientes portadores de sindrome de Apert foram por nos operados e tiveram a correcao das deformidades em suas maos completada ate os tres anos de idade. A manipulacao cirurgica dessas maos em idade precoce foi perfeitamente factivel. A tecnica de retalhos retangulares tanto para a neocomissura como para revestir a borda dos dedos liberados pode ser aplicada, apesar de haver desvios esqueleticos.