Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide.

BACKGROUND: Currently, botulinum toxin (BoNT) injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face. The therapeutic use of botulinum toxin has generally been safe and well tolerated. Adverse effects are considered mild, transient, and self-limited. However, as with all other injectable procedures, this one is also susceptible to adverse events and complications. When the safety zones are respected, the chance of any of these complications is practically null. Thus, this review aims to describe the main complications of treatment with BoNT on the upper face and to present a practical guide based on current evidence on how to avoid them. METHODS: The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. RESULTS: The main complications secondary to BoNT injections on the upper face are: ptosis of eyelid or eyebrow, eyebrow asymmetry, diplopia, Lakeophthalmos, Palpebral ectropion, and prominence of the palpebral bags. To avoid such complications, it is necessary to have knowledge of the anatomy of this region and adequate and individualized planning based on the existing patterns of the frontalis muscle, glabella, and crow's feet. This review presents the specificities of each of these regions and practical suggestions to obtain satisfactory results, avoiding complications. CONCLUSION: Particularly on the upper face treatment with BoNT offers predictable results, has few adverse effects, and is associated with high patient satisfaction. However, it is suggested that the commented parameters and safety areas be incorporated into daily practice so that the possibilities of complications are minimized as much as possible. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Periorbital Filling With The MD Codes™ Algorithm: A Narrative Review and a Practical Guide.

INTRODUCTION: The hyaluronic acid dermal fillers are employed to bring balance and facial harmony, improving the proportions and asymmetries of the structures, besides acting to reverse the signs of facial aging. The periorbital region is one of the first to show the signs of aging with periocular wrinkles, deepening of the nasojugal and palpebromalar folds, prolapse of the fat bags, excess palpebral skin, ptosis of the eyelashes, disappearance of the upper eyelid crease due to excess skin and hollowing of the upper eyelid. AIMS: To describe the lines and grooves of the periorbital region and present a practical guide to the MD CODES™ algorithm for filling this region based on a narrative review of the literature. METHODS: The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. RESULTS: MD CODES™ algorithm maps anatomical points of the face (anatomical codes) that, when treated with fillers, promote instantaneous lifting and rejuvenation. In addition to defining the points for treatment, this method identified the order of the points to be treated, that is, which points should be prioritized to cause greater aesthetic impact. The MD CODES aim to standardize facial rejuvenation and is of particular interest for young as well as more experienced physicians. CONCLUSION: Was presented in detail the regions, the aesthetic effects of the application, the technique, the volume, and the target structure undertaken in the remodeling of the tear trough, periorbital, temporal, brow, and frontal regions.

Childhood Maltreatment Linked with a Deterioration of Psychosocial Outcomes in Adult Life for Southern Brazilian Transgender Women.

A history of childhood maltreatment (HCM) has been associated with detrimental psychiatric outcomes. This is particularly true for transgender, for whom there is initial evidence that HCM may be associated with psychiatric morbidity. Our study aimed to further characterize the relationship between HCM and the development of mental disorder in adult life, based on a sample of Brazilian transgender women. Cross-sectional data were collected from a consecutive sample of 289 transgender women who attended the Hospital Clínicas clinic for gender dysphoria, in Porto Alegre, between 1998 and 2014. Our results demonstrated a greater risk of deteriorating mental health amongst participants who had experienced HCM. Given the disproportionally high rate of HCM in transgender persons, we advocate for greater assistance for transgender persons.

BIRTH ORDER AND ANDROPHILIC MALE-TO-FEMALE TRANSSEXUALISM IN BRAZIL.

Previous research has indicated that biological older brothers increase the odds of androphilia in males. This finding has been termed the fraternal birth order effect. The maternal immune hypothesis suggests that this effect reflects the progressive immunization of some mothers to male-specific antigens involved in fetal male brain masculinization. Exposure to these antigens, as a result of carrying earlier-born sons, is hypothesized to produce maternal immune responses towards later-born sons, thus leading to female-typical neural development of brain regions underlying sexual orientation. Because this hypothesis posits mechanisms that have the potential to be active in any situation where a mother gestates repeated male fetuses, a key prediction is that the fraternal birth order effect should be observable in diverse populations. The present study assessed the association between sexual orientation and birth order in androphilic male-to-female transsexuals in Brazil, a previously unexamined population. Male-to-female transsexuals who reported attraction to males were recruited from a specialty gender identity service in southern Brazil (n=118) and a comparison group of gynephilic non-transsexual men (n=143) was recruited at the same hospital. Logistic regression showed that the transsexual group had significantly more older brothers and other siblings. These effects were independent of one another and consistent with previous studies of birth order and male sexual orientation. The presence of the fraternal birth order effect in the present sample provides further evidence of the ubiquity of this effect and, therefore, lends support to the maternal immune hypothesis as an explanation of androphilic sexual orientation in some male-to-female transsexuals.

Reduced serum concentrations of brain-derived neurotrophic factor (BDNF) in transsexual Brazilian men.

Serum BDNF levels are significantly decreased in transsexual Brazilian women when compared to cis-sexual men. Since transsexual men are also exposed to chronic social stress and have a high prevalence of associated psychopathologies, it is plausible to inquire if BDNF serum levels are altered in transsexual men as well. Therefore, our objective was to evaluate differences in BDNF serum level of transsexual men when compared to cis-sexual men and women. Our sample comprises 27 transsexual men, 31 cis-sexual women and 30 cis-sexual men recruited between 2011 and 2015. We observed that BDNF serum concentration is decreased in transsexual men comparing to cis-sexual men and women. Cross-sex hormone treatment, chronic social stress or long-term gender dysphoria (GD) could explain the variation found in BDNF serum levels.

Complications and Management of Polymethylmethacrylate (PMMA) Injections to the Midface.

BACKGROUND: Polymethylmethacrylate (PMMA) has been used as an injectable filler to treat hollows and reduce rhytids. PMMA injections have been associated with several side effects, however, the literature is scarce on periorbital complications and their treatments. OBJECTIVES: The purpose of this study is to report a series of complications after periorbital PMMA injections to the midface and to describe their management. METHODS: Retrospective chart review, including photography and histopathology when available. RESULTS: The authors identified 11 cases of complications of PMMA injections to the midface. Patient ages ranged from 36 to 62 years (mean, 47 years; median, 44 years). Two (18%) were males and 9 (82%) were females. Adverse effects began between 2 to 24 months after injection (mean, 7.2 months; median, 6 months). All patients had edema, erythema, and contour irregularity. Seven (64%) patients had nodules, 4 (36%) had yellow, xanthomatous skin changes, and 2 (18%) had eyelid malposition. Histopathology demonstrated a giant cell inflammation in 5 of 6 cases. Corticosteroid injection was tried in 6 cases but was associated with minimal clinical improvement. Surgical debulking of the implanted material was performed in 9 (82%) cases and was effective in improving edema, erythema, and nodularity. CONCLUSIONS: PMMA injection to the midface may be associated with chronic inflammation, fibrotic nodules, yellowing of the skin, and eyelid malposition. Intralesional corticosteroid injections yielded minimal or no improvement; surgical debulking achieved favorable results. LEVEL OF EVIDENCE 4: Therapeutic.

Mean intrasellar pressure, visual field, headache intensity and quality of life of patients with pituitary adenoma.

Intrasellar pressure (ISP) measurement technique has recently opened a new line of research in neuroendocrinology. The absolute and mean ISP values were investigated in 25 patients consecutively operated at the Brasilia University Hospital (DF). These data were correlated with serum prolactin levels, number of visual quadrant affected, tumor size, quality of life (measured through the SF-36 scale) and graded headache (measured through the HIT-6 scale). No correlation was observed. The p values were 0.887; 0.137; 0.892; 0.812 and 0.884; respectively. The HIT-6 values were inversely and moderately correlated with total RAND SF-36 and its mental and physical dimensions.

Mean intrasellar pressure, visual field, headache intensity and quality of life of patients with pituitary adenoma / Pressão intra-selar média, campo visual, intensidade de cefaléia e qualidade de vida em portadores de adenoma hipofisário

Intrasellar pressure (ISP) measurement technique has recently opened a new line of research in neuroendocrinology. The absolute and mean ISP values were investigated in 25 patients consecutively operated at the Brasilia University Hospital (DF). These data were correlated with serum prolactin levels, number of visual quadrant affected, tumor size, quality of life (measured through the SF-36 scale) and graded headache (measured through the HIT-6 scale). No correlation was observed. The p values were 0.887; 0.137; 0.892; 0.812 and 0.884; respectively. The HIT-6 values were inversely and moderately correlated with total RAND SF-36 and its mental and physical dimensions.

A técnica da medida da pressão intra-selar (PIS) abriu, recentemente, uma nova linha de pesquisa em neuroendocrinologia. O objetivo deste estudo foi aferir os valores absolutos da PIS e calcular a pressão intra-selar média (PIM) em uma população de 25 pacientes operados consecutivamente no Hospital Universitário de Brasília (DF). Não se observou correlação significativa entre a PIM e o número de quadrantes visuais comprometidos (p=0,137), área do tumor (p=0,892), nível de qualidade de vida mensurado pela escala SF-36 (p=0,812) e a presença e a intensidade da cefaléia mensurada pela escala HIT-6 (p=0,884). Contudo, o HIT-6 correlacionou-se de forma inversa e intensidade moderada com os valores de HIT-6 e suas dimensões mental e física.

Proteção da gema e épocas de forçamento da brotação na enxertia da lima ácida 'Tahiti' / Bud protection and timing of bud break treatments on scion, in grafting of Tahiti lime

A produção de mudas de citros em recipientes é uma tecnologia recente, portanto o sistema de produção encontra-se em aperfeiçoamento, havendo necessidade de informações em várias etapas do sistema produtivo, entre elas os métodos de forçamento da brotação pós-enxertia. Objetivou-se, neste trabalho, estudar o efeito da cobertura das gemas com fitas plásticas e da época de forçamento da brotação sobre o pegamento e desenvolvimento de enxertos da lima ácida 'Tahiti'. O porta-enxerto utilizado foi o limoeiro 'Cravo' (Citrus limonia Osbeck), oriundo da germinação de sementes, e a variedade copa a limeira ácida 'Tahiti' (Citrus latifolia Tanaka). Foram testadas épocas de forçamento de brotação da enxertia (10, 15, 20, 25, 30 e 35 dias após a realização da enxertia) e formas de proteção do enxerto (gema coberta e gema exposta). Após a enxertia as plantas foram mantidas em casa de vegetação com esquema de irrigação por gotejamento. O delineamento experimental foi em blocos casualizados, com cinco repetições e 3 plantas por parcela. Não houve interação entre os fatores estudados, sendo que o índice de pegamento dos enxertos não foi influenciado pelos tratamentos e a cobertura total da borbulha pela fita plástica favoreceu a dormência da gema. O forçamento da brotação do enxerto de lima ácida 'Tahiti', utilizando o método de curvamento do porta-enxerto apresentou os melhores resultados quando esse foi realizado aos 10 dias após a enxertia.

The production of citrus nursery trees in portable containers is a new developing technology and requires investment in research to acquire information on various stages of their production, including the methods to force post grafting bud break. The aim of this work was to investigate the effect of the coverage of buds with plastic tapes as well as the time to force bud break on the establishment and development of 'Tahiti' lime scions. The rootstock used was the 'Rangpur' lime (Citrus limonia Osbeck), obtained from the germination of seeds, while the lime variety 'Tahiti' (Citrus latifolia Tanaka) was used as the scion. The treatments tested were buds covered with plastic tape and uncovered buds at 10, 15, 20, 25, 30, and 35 days after the completion of the budding. After budding, the plants were kept in a greenhouse with dripping irrigation. The experimental design was the randomized blocks, with five replicates and three plants per plot. There was no interaction among the factors studied, while the index of positive grafting was not influenced by the treatments and total coverage of the buds with plastic tape encouraged dormancy of the buds. The bud break of 'Tahiti' lime using the method of bending showed the best results when applied 10 days after grafting.

Relação entre função hipofisária e síndrome metabólica com a pressão intrasselar em média em pacientes com adenoma de hipófise / Relationship between pituitary function and metabolic syndrome with the pressure intrasselar on average in patients with pituitary adenoma

Avaliar a relação entre a pressão intrasselar média e a ocorrência de síndrome metabólica e hipoituitarismo no pré-operatório e em reavalia-ção tardia.

To evaluate the relationship between pressure intrasselaraverage and the occurrence of metabolic syndrome andhipoituitarismo preoperatively and reevaluateding late.

Hiponatremia prolongada após traumatismo cerebral, tratada com fludrocortisona / Prolonged hyponatremia after brain trauma treated with fludrocortisone

A hiponatremia é uma freqüente complicação do traumatismo craniano e surge, usualmente, nos primeiros dez dias depois do trauma e tem evolução limitada a poucos dias. Os autores apresentam um paciente que desenvolveu hiponatremia no nono dia após um acidente de motocicleta, a qual se prolongou por mais de vinte dias. Essa demorada hiponatremia pôde ocorrer porque o paciente foi tratado, inicialmente, com furosemida, como se tivesse a síndrome inapropriada da secreção do hormônio antidiurético, e com glicocorticóide, como se tivesse insuficiência glandular supra-renal. Contudo, o paciente teve síndrome cerebral perdedora de sal, que pode ocorrer após lesões do sistema nervoso central. Foi tratado com fludrocortisona (0,3 mg/dia) com reposição de sódio e de líquidos. Houve gradual desaparecimento da hiponatremia, e seu perfil físico e neural apresentou progressiva melhora. A fludrocortisona é um mineralocorticosteróide, e seu uso em pacientes com síndrome cerebral perdedora de sal é indicado pela ocorrência de secreção inapropriada do peptídeo natriurético cerebral, que inibe a secreção da aldosterona e, assim, provoca a perda renal de sódio.

Hyponatremia is a frequent complication following cranial traumatism and usually appears in the first ten days after the trauma, usually limited to a few days. The authors report a patient that developed hyponatremia on the 9th day after a motorcycle accident and it lasted twenty more days. The long period of hyponatremia could be explained by the treatment with furosemide, initially given with the assumption that he had inappropriate secretion of antidiuretic hormone syndrome, toghether with glucocorticoid, as if he had adrenal insufficiency. However, the patient had cerebral salt-wasting syndrome, which can happen after lesions of the central nervous system. Then, he was correctly treated with fludrocortisone (0.3 mg/day) and sodium plus fluid replacement. He gradually recovered from the hyponatremia and his physical and neural profile showed progressive improvement. Fludrocortisone is a mineralocorticosteroid and its use in a patient with cerebral salt-wasting syndrome is justified by its counter effect against the oversecretion of brain natriuretic peptide, which inhibits the aldosterone secretion, eventually leading to renal loss of sodium.

Translocaçäo bacteriana na obstruçäo aguda do cólon esquerdo / Bacterial translocation in the acute obstruction of left colon

O cólon esquerdo é sede freqüente de obstruçäo intestinal e os resultados do tratamento cirúrgico nessa situaçäo estäo associados a maior morbi-mortalidade pós-operatória. O objetivo deste trabalho foi o de investigar experimentalmente a ocorrência de translocaçäo bacteriana na obstruçäo aguda do cólon esquerdo. 26 ratos Wistar foram submetidos a laparotomia mediana sendo obstruídos no cólon esquerdo com um nó de linho a 2,5 cm acima da reflexäo peritoneal (grupo obstruçäo; n=13) ou näo (grupo controle; n=13). 24h após, foram novamente reoperados para coleta dos linfonodos mesentéricos, fígado, baço e de uma amostra de sangue caval. As peças foram homogeneizadas e enviadas para cultura. Observou-se uma maior incidência de culturas positivas nos animais do grupo obstruçäo tanto nos linfonodos (8/10 vs. 3/13; p<0.01) quanto no fígado (7/10 vs. 1/13; p<0.01) e no baço (8/10 vs. 4/13; p<0.05). No sangue, 6 dos 10 ratos obstruídos apresentaram cultura positiva enquanto que isso näo ocorreu em nenhum rato do grupo controle (p<0.01). As bactérias mais freqüentes nas culturas foram a Escherichia coli, Proteus vulgaris e Klebsiella pneumoniae. A obstruçäo aguda do cólon esquerdo neste modelo animal determina a ocorrência de translocaçäo bacteriana