Doença de Madelung: abordagem cirúrgica combinada de lipectomia e lipoaspiração / Madelung's disease: combined surgical approach of lipectomy and liposuction

A doença de Madelung (DM) ou lipomatose simétrica múltipla é uma patologia caracterizada pelo acúmulo de tecido adiposo não encapsulado e depositado simetricamente ao redor do pescoço e tronco superior (tipo I - forma mais comum). Sua etiologia ainda é pouco esclarecida, porém apresenta evidente associação com o consumo crônico excessivo de bebidas alcoólicas. As deformidades físicas são o que levam o paciente a buscar serviço médico, juntamente com eventuais sintomas de acometimento cervical como redução de mobilidade e afecções respiratórias. O diagnóstico da lipomatose simétrica múltipla é clínico, podendo ser complementado com exame de imagem para afastar demais hipóteses diagnósticas e avaliar a extensão do acometimento. O tratamento pode ser realizado por duas modalidades: clínico ou cirúrgico (lipectomia ou lipoaspiração). Relata-se o caso de paciente com lipomatose simétrica múltipla tipo I abordado cirurgicamente com ambas as técnicas: lipectomia cervical e lipoaspiração abdominal. Paciente evoluiu de maneira satisfatória, com redução de queixas e sem recidivas até o presente momento.

Madelung's disease or Multiple Symmetric Lipomatosis is a condition characterized by the accumulation of unencapsulated adipose tissue deposited symmetrically around the neck and upper trunk (type I - most common form). Its etiology is still unclear, but it is clearly associated with chronic excessive consumption of alcoholic beverages. Physical deformities lead the patient to seek medical care, along with possible symptoms of cervical involvement such as reduced mobility and respiratory disorders. Multiple Symmetric Lipomatosis diagnosis is clinical and can be complemented with imaging to rule out other diagnostic hypotheses and assess the extent of involvement. Treatment can be performed in two ways: clinical or surgical (lipectomy or liposuction). We report the case of a patient with Multiple Symmetric Lipomatosis type I surgically treated with both techniques: cervical lipectomy and abdominal liposuction. The patient evolved satisfactorily, with a reduction in complaints and no recurrences so far.

Reconstrução de couro cabeludo com retalho livre de músculo grande dorsal após escalpelamento por mordida de cachorro / Scalp reconstruction with large dorsal muscle-free flap after dog bite scalping

RESUMO Introdução: O escalpelamento é caracterizado pelo trauma em região do couro cabeludo, que pode ser classificado como parcial ou total. O trauma por escalpelamento é extremamente mutilante e estigmatizante, principalmente quando expõe o osso sem periósteo, que pode levar a quadro de osteomielite crônica e erosão de tábua externa. Quando há lesões extensas de couro cabeludo acima de 200cm² e com lesão de periósteo é necessária grande quantidade de tecido com retalho microcirúrgico, que não está disponível em todos os centros. O objetivo deste trabalho é relatar caso de paciente de 69 anos, feminina, que sofreu trauma por avulsão total de couro cabeludo de grande extensão de 550cm² com exposição de calota craniana sem periósteo e inviabilização total do escalpe após mordida de cachorro. Devido à inviabilização total do escalpe avulsionado, optou-se pelo transplante de retalho livre de músculo grande dorsal com anastomose microvascular do pedículo toracodorsal com os vasos temporais superficiais. O retalho evoluiu com boa perfusão e na área cruenta foi realizado enxertia parcial. Métodos: Análise retrospectiva de prontuário da paciente em questão. O presente trabalho segue os padrões de declaração de Helsinque e aprovação do comitê de ética e pesquisa. Conclusão: O retalho livre de músculo grande dorsal mostrou-se eficaz neste caso de reconstrução de lesão extensa do couro cabeludo (550cm²) com lesão parcial de periósteo devido ao escalpelamento. O retalho recuperou a forma do crânio e a função de proteção da calota craniana.

ABSTRACT Introduction: Scalping is characterized by trauma in the scalp region, which can be classified as partial or total. Scalping trauma is extremely mutilating and stigmatizing, especially when exposing the bone without periosteum, leading to chronic osteomyelitis and external table erosion. When there are extensive scalp lesions above 200cm², and with periosteum, the lesion is required a large amount of tissue with microsurgical flap, which is not available in all centers. This work aims to report a case of a 69-year-old female patient who suffered trauma due to total avulsion of a big scalp of 550cm² with exposure of a skull cap without periosteum and total unviability of the scalp after a dog bite. Due to the total unviability of the avulsed scalp, we opted to transplant a large dorsal muscle free flap with microvascular anastomosis of the thoracodorsal pedicle with the superficial temporal vessels. The flap evolved with good perfusion, and partial grafting was performed in the bloody area. Methods: Retrospective analysis of the medical records of the patient in question. This paper follows the Declaration of Helsinki's standards and the approval of the Ethics and Research Committee. Conclusion: The free flap of the large dorsal muscle proved effective in this case of reconstruction of the scalp's extensive lesion (550cm²) with partial periosteum lesion due to scalping. The flap recovered the shape of the skull and the protective function of the skull cap.

Supraclavicular flap as a salvage procedure in reconstruction of head and neck complex defects.

The supraclavicular island flap (SCIF) is an interesting therapeutic option in head and neck reconstruction. Since popularized by Pallua in the late 90s, several clinical series have been published showing its versatility and usefulness. However, only a few studies have focused on factors associated with complications from SCIF use. In this study, we analyzed the factors contributing to SCIF unreliability. We performed a retrospective review of the data of 87 patients undergoing SCIF reconstruction between 2008 and 2015. No significant differences in mean complication rates were observed when the SCIF was used for primary or salvage reconstruction (28% versus 25%, respectively, p = 0.816) or for cutaneous or intraoral reconstruction (27% versus 28%, respectively, p = 0.932). Flap folding, preoperative radiotherapy, and microsurgery were associated with significantly increased complication rates (p = 0.002, p = 0.043, and p = 0.001, respectively), whereas smoking (p = 0.431) had no impact with regard to this. In conclusion, the SCIF is a versatile flap and an important therapeutic tool for use in salvage surgeries, particularly in those performed in patients with poor clinical conditions and limited flap options.

Contralateral Botulinum Toxin Improved Functional Recovery after Tibial Nerve Repair in Rats.

BACKGROUND: There is clinical and experimental evidence that botulinum toxin applied to the healthy side of patients with facial paralysis positively affects functional recovery of the paralyzed side. The authors created an experimental model to study the effects of botulinum toxin injection in the gastrocnemius muscle contralateral to the side of tibial nerve lesion/repair in rats. METHODS: Fifty rats were allocated into five groups: group I, control; group II, tibial nerve section; group III, tibial nerve section and immediate neurorrhaphy; group IV, tibial nerve section, immediate neurorrhaphy, and botulinum toxin injected into the contralateral gastrocnemius muscle; and group V, botulinum toxin injected into the gastrocnemius muscle and no surgery. Assessment tools included a walking track, electromyography, gastrocnemius muscle weight measurement, and histologic analysis of the nerve. RESULTS: Paralysis in group V was transient, with function returning to normal at 8 weeks. At 12 weeks, group V had lower latency levels. At week 12, group IV showed higher functional outcomes and amplitude levels than group III, and lower muscle atrophy on the side injected with botulinum toxin compared with group V. CONCLUSION: Transient paralysis of the contralateral gastrocnemius muscle by botulinum toxin type A improved functional recovery in rats that underwent section and repair of the tibial nerve.

A systematic comparison of bar-clips versus magnets.

STATEMENT OF PROBLEM: Currently, which type of suprastructure is preferred when fabricating implant-retained craniofacial prostheses is unknown. PURPOSE: The purpose of this systematic review was to identify the best retention system (bar-clips versus magnets) for implant-retained craniofacial prostheses. MATERIAL AND METHODS: This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic search of Medline/PubMed and Web of Science databases for clinical trials was conducted on implant-retained craniofacial prostheses published between 2005 and 2015. English-language studies that directly compared different types of retention systems or presented information on implant survival, periimplant soft tissue reactions, and prosthetic complications were included. Nonclinical studies were excluded to eliminate bias. RESULTS: A total to 173 studies were identified, of which 10 satisfied the inclusion criteria. In total, 492 participants were included in these studies. Four selected studies displayed detailed information with regard to the number of implant failures according to the retention system. As reported, 29 (18.2%) of 159 implants with magnets failed, whereas 25 (31.6%) of 79 implants with bars failed. Overall auricular superstructures showed the highest survival (99.08%). In addition, 55.4% of all participants in the selected studies showed grade 0 of periimplant soft tissue reactions. CONCLUSIONS: A systematic search for clinical studies resulted in few studies with a short-term follow-up and small number of participants. The limited data collected indicated that magnets show fewer complications than bar superstructures; however, no hard conclusions could be drawn. Further research, preferably in the form of clinical trials, is needed to validate these findings.

Tibial and fibular nerves evaluation using intraoperative electromyography in rats.

PURPOSE: To evaluate a new model of intraoperative electromyographic (EMG) assessment of the tibial and fibular nerves, and its respectives motor units in rats. METHODS: Eight Wistar rats underwent intraoperative EMG on both hind limbs at two different moments: week 0 and week 12. Supramaximal electrical stimulation applied on sciatic nerve, and compound muscle action potential recorded on the gastrocnemius muscle (GM) and the extensor digitorum longus muscle (EDLM) through electrodes at specifics points. Motor function assessment was performaced through Walking Track Test. RESULTS: Exposing the muscles and nerves for examination did not alter tibial (p=0.918) or fibular (p=0.877) function between the evaluation moments. Electromyography of the GM, innervated by the tibial nerve, revealed similar amplitude (p=0.069) and latency (p=0.256) at week 0 and at 12 weeks, creating a standard of normality. Meanwhile, electromyography of the EDLM, innervated by the fibular nerve, showed significant differences between the amplitudes (p=0.003) and latencies (p=0.021) at the two different moments of observation. CONCLUSION: Intraoperative electromyography determined and quantified gastrocnemius muscle motor unit integrity, innervated by tibial nerve. Although this study was not useful to, objectively, assess extensor digitorum longus muscle motor unit, innervated by fibular nerve.

Tibial and fibular nerves evaluation using intraoperative electromyography in rats

ABSTRACT PURPOSE: To evaluate a new model of intraoperative electromyographic (EMG) assessment of the tibial and fibular nerves, and its respectives motor units in rats. METHODS: Eight Wistar rats underwent intraoperative EMG on both hind limbs at two different moments: week 0 and week 12. Supramaximal electrical stimulation applied on sciatic nerve, and compound muscle action potential recorded on the gastrocnemius muscle (GM) and the extensor digitorum longus muscle (EDLM) through electrodes at specifics points. Motor function assessment was performaced through Walking Track Test. RESULTS: Exposing the muscles and nerves for examination did not alter tibial (p=0.918) or fibular (p=0.877) function between the evaluation moments. Electromyography of the GM, innervated by the tibial nerve, revealed similar amplitude (p=0.069) and latency (p=0.256) at week 0 and at 12 weeks, creating a standard of normality. Meanwhile, electromyography of the EDLM, innervated by the fibular nerve, showed significant differences between the amplitudes (p=0.003) and latencies (p=0.021) at the two different moments of observation. CONCLUSION: Intraoperative electromyography determined and quantified gastrocnemius muscle motor unit integrity, innervated by tibial nerve. Although this study was not useful to, objectively, assess extensor digitorum longus muscle motor unit, innervated by fibular nerve.

Comparison of the efficacy of onabotulinumtoxinA and abobotulinumtoxinA at the 1: 3 conversion ratio for the treatment of asymmetry after long-term facial paralysis.

BACKGROUND: Botulinum toxin A injection into the nonparalyzed side is used to treat asymmetry resulting from facial palsy. OnabotulinumtoxinA and abobotulinumtoxinA units are not equivalent. The authors compared the conversion ratio of 1:3 in patients with facial palsy. METHODS: Fifty-five patients (age, 16 to 67 years; 43 women) with longstanding facial palsy were randomly treated with either onabotulinumtoxinA (n = 25) or abobotulinumtoxinA (n = 30) injections into the nonparalyzed side. Adverse effects, facial symmetry, subjective satisfaction, and Facial Disability Index were assessed after 1 and 6 months. RESULTS: The incidence of adverse effects was higher with abobotulinumtoxinA (93.3 percent versus 64.0 percent; p = 0.007). Clinical scores of the nonparalyzed side decreased after 1 month and increased again at 6 months, with no between-group differences. Scores of the paralyzed side were lower in the onabotulinumtoxinA group before treatment, but similar in both groups thereafter. The paralyzed side scores increased after 1 month, and at 6 months were still higher than the pretreatment scores in both groups. Subjective assessment improved at all time points compared with pretreatment scores and differed between the two groups only at 1 month, when the abobotulinumtoxinA group was a bit too paralyzed. The physical function and social/well-being function subscales of the Facial Disability Index did not differ between the two groups. CONCLUSIONS: Both toxins efficiently reduced asymmetry in patients with facial palsy. Adverse effects were higher with abobotulinumtoxinA at an equivalence ratio of 1:3. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Evaluation of nerve regeneration in diabetic rats.

PURPOSE: To compare sciatic nerve regeneration between non-diabetic (control) and streptozotocin-induced diabetic Wistar rats. METHODS: Four subgroups were evaluated. CN: Non-diabetic rats submitted to neurorrhaphy (n=9); DN: Diabetic rats submitted to neurorrhaphy (n=9); CG: Non-diabetic rats submitted to nerve grafting (n=10); DG: Diabetic rats submitted to nerve grafting (n=9). The nerve regeneration was evaluated by walking track analysis (sciatic functional index), electrophysiological test, histomorphometric analysis and triceps surae muscle weight. RESULTS: At 60 days post-surgery, functional recovery of DN was similar to that of the non-diabetic rats (CN, CG), but DG didn't achieve the same. Evoked potential amplitudes showed no statistically significant differences among subgroups. Triceps surae muscle was heavier in CN. No statistically significant differences were observed between the control and diabetes subgroups with respect to histomorphometric analysis. CONCLUSION: After 60 days, DN had a functionally similar recovery to that of the control animals, whereas nerve grafting in diabetic rats didn't allow the same. The muscle atrophy was lower in CN. In the rest of evaluations, as electrophysiological and histomorphometric, diabetic rats were not different from control ones.

Evaluation of nerve regeneration in diabetic rats

PURPOSE: To compare sciatic nerve regeneration between non-diabetic (control) and streptozotocin-induced diabetic Wistar rats. METHODS:Four subgroups were evaluated. CN: Non-diabetic rats submitted to neurorrhaphy (n=9); DN: Diabetic rats submitted to neurorrhaphy (n=9); CG: Non-diabetic rats submitted to nerve grafting (n=10); DG: Diabetic rats submitted to nerve grafting (n=9). The nerve regeneration was evaluated by walking track analysis (sciatic functional index), electrophysiological test, histomorphometric analysis and triceps surae muscle weight. RESULTS:At 60 days post-surgery, functional recovery of DN was similar to that of the non-diabetic rats (CN, CG), but DG didn't achieve the same. Evoked potential amplitudes showed no statistically significant differences among subgroups. Triceps surae muscle was heavier in CN. No statistically significant differences were observed between the control and diabetes subgroups with respect to histomorphometric analysis. CONCLUSION: After 60 days, DN had a functionally similar recovery to that of the control animals, whereas nerve grafting in diabetic rats didn't allow the same. The muscle atrophy was lower in CN. In the rest of evaluations, as electrophysiological and histomorphometric, diabetic rats were not different from control ones.

Swallowing, speech and quality of life in patients undergoing resection of soft palate.

The aim of this study was to evaluate swallowing, speech and quality of life in patients undergoing surgery for malignant tumors involving soft palate. We performed a cross sectional study of 23 patients (aged 32-80 years), submitted to soft palate resection, free of disease for at least 1 year. Primary closure of the surgical defect was performed in 5 patients (21.7 %), adaptation of a palatal obturator prosthesis in 2 (8.7 %), myocutaneous flap in 5 (21.7 %), local flap in 2 (8.7 %) and microsurgical free flap in 9 (39.1 %). All patients were submitted to fibreoptic endoscopic evaluation and completed functional and quality of life questionnaires. Functional evaluation of swallowing showed higher prevalence of pooling of food in the nasopharynx in patients submitted to regional flap reconstruction or primary closure (53.9 %). Swallowing difficulties were predominantly related to solid foods (54.5 %) and were associated with more extensive palatal resections. Most individuals submitted to reconstruction with microsurgical flaps had satisfactory velopharyngeal mobility (87 %). The presence of nasal air escape or velopharyngeal gap was minimal in most of the sample. Hypernasality contributed minimally to imprecisions in speech articulation or intelligibility. Vocal alteration did not impact patients' quality of life. Pharyngeal phase of swallowing was satisfactory in most patients. However, nasal reflux and penetration were present in a few patients. Most patients had minimal phono-articulatory alterations as a global outcome. Scores of swallowing and speech parameters regarding the questionnaires used were high, demonstrating minor impact on quality of life.

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

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

Estudo prospectivo dos traumas orbitários e suas repercussões oftalmológicas no Hospital de Referência Regional da PUC-Campinas

Objetivo: O objetivo deste trabalho é analisar os casos de traumatismo orbitário atendidos no Hospital da PUC-CAMPINAS, comparando dados epidemiológicos, lesões associadas, intercorrências durante o atendimento inicial e, principalmente, as repercussões oftalmológicas agudas no trauma de órbita. Método: Por meio de análise prospectiva dos pacientes vítimas de traumatismo facial atendidos e/ou encaminhados à unidade de emergência do Hospital da PUC-CAMPINAS, foram analisados os dados de 49 pacientes com fratura de órbita constatada através de tomografia computadorizada (TC) atendidos no período compreendido entre abril de 2007 a janeiro de 2008, com base em um protocolo específico de atendimento do Serviço de Cirurgia Plástica da PUC-CAMPINAS. Dos 49 pacientes estudados, 6 apresentaram fratura de órbita bilateral. Portanto, houve 55 fraturas orbitárias, sendo 32 na órbita direita e 23 na órbita esquerda. As variáveis oftalmológicas analisadas foram motilidade ocular extrínseca (MOE), acuidade visual (AV), biomicroscopia (BIO), fundocospia (FO) e pressão intra-ocular (PIO). Resultados: O sexo masculino foi o mais acometido (40 casos - 81,6%). A faixa etária variou de 1 ano a 67 anos, com média de 33 anos. Quanto à etnia, maior incidência entre brancos (19 casos - 39,7%), seguida de pardos (18 casos -36,7%), negros (11 casos - 22,4%) e mestiços (1 caso - 2%). O mecanismo de trauma mais freqüente foi acidente motociclístico (15 casos - 30,6%), seguido pelas quedas (11 casos - 22,4%) e por agressão física (10 casos - 20,4%). Outros mecanismos encontrados foram: acidente automobilístico (5 casos - 10,2%), acidente biciclístico (4 casos - 8,1%), mordedura de cão (2 casos - 4%) e FPAF (2 casos - 4%).

Análise prospectiva das fraturas faciais no período de um ano do Hospital da PUC-CAMPINAS

Objetivo: O objetivo da presente pesquisa é relatar a experiência dos autores traçando um perfil epidemiológico das traumas de face, analisando os resultados obtidos por meio de um estudo prospectivo de 95 casos, dando ênfase a variáveis como gênero, faixa etária, etiologia e distribuição totpográfica das fraturas, comparando os achados clínicos com outros estudos da literatura. Método: Por meio de análise prospectiva dos pacientes vítimas de traumatismo facial atendidos ou encaminhados à unidade de emergência do Hospital da PUC-CAMPINAS, foram analisados os dados de 95 pacientes com fratura de ossos da face, atendidos no período compreendido entre abril de 2007 a março de 2008, com base em um protocolo específico de atendimento do Serviço de Cirurgia Plástica - PUC-CAMPINAS. As seguintes variáveis foram analisadas: sexo, idade, etnia, mecanismo de trauma, co-morbidades (alcoolismo e tabagismo), uso de cinto de segurança e/ou capacete e localização da fraturas. Para classificação das fraturas, os ossos foram anatomicamente divididos em terço superior (osso frontal), terço médio (nariz, complexo naso-etmoido-orbitário e órbito-zigomático-maxiliar) e terço inferior (mandíbula). Todos os pacientes foram submetidos a avaliação oftalmológica e/ou neurocirúrgica especializada quando necessário e realização de exame de imagem para diagnóstico e planejamento terapêutico. Resultados: O sexo masculino foi o mais acometido (70 casos - 73,6%). A faixa etária variou de 1 ano a 84 anos, com média de 34,8 anos. Quanto à etnia, maior incidência entre pardos (39 casos - 41%), seguida de brancos (34 casos - 35,7%), negros (20 casos - 21%) e mestiços (2 casos - 2,1%)...

Reconstrução total de nariz: podemos oferecer algo melhor que a prótese?

Objetivo: Apresentar a solução encontrada para reconstrução total de nariz em dois pacientes submetidos a rinectomia total, associando enxerto de ulna e retalho microcirúrgico; e sua evolução. Introdução: A reconstrução total de nariz representa um desafio nos pacientes submetidos a rinectomia total por motivos oncológicos. A obtenção de resultados favoráveis inclui não somente a erradicação da doença, mas também aspectos funcionais e estéticos. O estigma de mutilação, bem como a confecção e a aquisição de prótese de boa qualidade e a necessidade de fixação e manutenção da mesma são fatores que comprometem a qualidade de vida do paciente de forma significativa. A opção de retalhos locais é limitada e não oferece possibilidades para adequada reparação. Muitas vezes, a utilização destes retalhos na tentativa de reconstrução após a rinectomia total leva a maior comprometimento estético da face. A associação de enxerto ósseo da crista ulnar e retalho autólogo microvascular representa uma solução para este problema, oferecendo um resultado favorável, tanto do ponto de vista estético quanto funcional. Método: Caso 1 - paciente do sexo masculino, 68 anos, caucasiano, foi diagnosticado com recidiva de tumor de fossa nasal, tratado previamente com radioterapia exclusiva. Realizada ressecção com controle intra-operatório de margens por biópsia de congelação, havendo necessidade de rinectomia total. Optou-se pela reconstrução com retalho antebraquial microvascular, associado com enxerto de ulna. Tal enxerto foi fixado com parafusos ao remanescente do osso nasal. O retalho microvascular foi confeccionado baseado na artéria radial e, no leito receptor, foram utilizadas a artéria tireóidea superior e a veia facial. O retalho foi suturado inicialmente para reconstrução do lado mucoso, sendo suturado à mucosa nasal remanescente e, foi dobrado sobre si mesmo e suturado à pele da face após cobertura do enxerto ósseo...

Reconstrução microcirúrgica de deformidades cervicais pós queimadura com o retalho anterolateral da coxa / Microsurgical reconstruction of post burn neck deformities with free anterolateral thogh flap

Deformidades cervicais pós queimadura apresentam problemas funcionais e estéticos que desafiam Cirurgiões Plásticos. Quando essas deformidades envolvem pequenas áreas nós podemos realizar z-plastias, retalhos locais e enxertos cutâneos, mas em áreas ex- tensas nós temos que considerar os retalhos microcirúrgicos. O retalho ânterolateral da coxa tem sido utilizado em casos severos de contratura cervical, com bons resultados estéticos e funcionais.

Introduction: post burn neck contractures present with function alanda esthetic problems thatare achallenge for Plastic Surgeons. When theses deformities involve small areas we can perform Z-plasties, local flaps and skin graft, but in extensive areas we have to consider free flaps transfer. Free anterolateral thigh flap has been used in severe cases of neck contractures, with good aesthetic and functional results. Materials and Methods: 8 patients with extensive anterior neck contractures underwent free flap reconstruction with anterolateral thigh flap. There were 3 women and 5 men with mean age of 24,4 years (range 10 to 51). All cases resulted from flame burns. We have included in these series, patients that underwent to another procedure before, functional deficit (limited extension and rotation) and aesthetic consideration. After 60 days of surgery, 7 patients have been submitted to deffating procedure (liposuction) of the flap. Results: in all patients, release of contractures was excellent. All flaps survived well. One case presented with marginal necrosis of 3 x 1 cm of the flap, and another case with a marginal necrosis of burned area (receptor site).

Comparação entre os retalhos microcirúrgicos antebraquial e lateral do braço em reconstruções de boca e orofaringe / Comparison between the forearm and lateral arm flaps for microsurgical reconstruction of the oral cavity and oropharynx

Introdução: A reconstrução microcirúrgica de tecidos moles após ressecção de neoplasias de boca e orofaringe tem impacto significativo na qualidade de vida do paciente. Dois retalhos freqüentemente utilizados são o antebraquial e o lateral do braço. Objetivo: Comparar a evolução do leito receptor e da área doadora em pacientes submetidos a um desses dois retalhos. Pacientes e Método: Estudo retrospectivo com análise de 31 pacientes submetidos aos retalhos previamente descritos. Resultados: Houve predomínio do gênero masculino (56%). A idade média foi de 56,5 anos. Vinte e dois pacientes (71%) foram submetidos à reconstrução com retalho lateral do braço. Houve diferença significativa no tempo de uso de sonda naso-enteral (p=0,037) e no tipo de fechamento da área doadora do retalho (p<0,001). Discussão: Os retalhos, apesar de similares, têm indicações distintas em nosso serviço. Consideramos o retalho lateral do braço como primeira escolha para reconstrução de defeitos de tamanho médio de tecidos moles em boca e orofaringe. Conclusão: Consideramos que os retalhos antebraquial e lateral do braço são seguros e adequados para reconstrução de boca e orofaringe.

Introduction: the microsurgical reconstruction of soft tissues after ablative surgery of oral cavity/oropharynx neoplasms impacts on the patients´ quality of life. Two frequently used options are the forearm and the lateral arm flaps. Objective: to compare the evolution of the receptor and donor sites. Patients and Methods: retrospective study of 31 patients submitted to one of the previously mentioned flaps. Results: Most patients were male (56%). The mean age was 56.5 years old. Twenty-two patients (71%) underwent the reconstruction using the lateral arm flap. There was a statistically significant difference in the duration of enteral tube use (p=0.037) and the closure of the donor area (p<0.001). Discussion: although similar, the flaps have distinct indications in our service. We consider the lateral arm flap as the first choice in medium sized soft tissue defects of the oral cavity/oropharynx region. Conclusion: We consider both flaps to be reliable and adequate for oral cavity/oropharynx reconstruction.

Analysis of Swallowing After Retromolar or Oropharynx and Reconstruction with Myocutaneos or Microvascular Free Flaps

Objective: Evaluate swallowing in retromolar or oropharyngeal cancer patients submitted to surgical resection and microvascular free flap (MFF) or pedicled myocutaneous flap (MC) reconstruction. Study: Retrospective case series. Patients and methods:Eighteen previously untreated patients with squamous cell carcinoma of the retromolar area or oropharynx submitted to surgical treatment and reconstruction between January. 2000 and July, 2003, were submitted to videofluoroscopic evaluation.The reconstruction was performed with MFF in 12 cases and MC in 6 cases. Parameters analyzed were: oropharyngeal motility alterations, stasis, laryngeal penetration and/or aspiration and dysphagia severity. Results: Oral phase was worsefor MC than for MFF patients, with premature bolus leakage (66.7% and 16.7%), increased oral transit time (66.7% and 16.7%), reduced anterior-posterior tongue movement (66.7% and 25%), nasal regurgitation (50% and 0%) and oral stasis (83.3% and 41.6%), respectively. In pharyngeal phase, results were similar in both groups. Main alterations in MFF andMC were, respectively, pharyngeal swallowing delay (83.3% and 100%), nasal regurgitation (58.3% and 83.3%), increased pharyngeal transit time (50% and 83.3%), reduced laryngeal elevation (41.7% and 66.7%), pharyngeal stasis (50% and16.7%) and laryngeal aspiration (50% and 66.7%). Conclusion: Oropharyngeal swallowing after retromolar or oropharyngeal cancer surgery seems to differ depending on the type of reconstruction. Microvascular free flaps seemed to allow a more efficient oropharyngeal deglutition.

Management of extensive osteoradionecrosis of the mandible with radical resection and immediate microvascular reconstruction.

PURPOSE: Osteoradionecrosis (ORN) is a severe and devastating late complication of radiotherapy in patients with head and neck cancer. Management of ORN remains controversial and the current approach has been focused on debridement, systemic antibiotics, and eventually hyperbaric oxygen therapy for small and limited ORN. However, this conservative approach is ineffective in controlling extensive bone and soft-tissue necrosis. Microvascular composite flaps have been used in a variety of head and neck ablative surgeries but its use for the management of ORN has not been fully explored. MATERIALS AND METHODS: From 1999 to 2002, 5 patients with refractory ORN of the mandible underwent radical resection and reconstruction with immediate microvascular-free fibular composite flap. All patients had been treated initially with conservative procedures and hyperbaric oxygen therapy. RESULTS: All patients had initially successful vascularized reconstruction by clinical examination with minimal postoperative morbidity. One patient had complete flap loss at 20 days due to orocutaneous fistula and infection. CONCLUSIONS: Radical resection followed by microvascular composite flap reconstruction is a reliable procedure in the management of patients with extensive ORN of the mandible.