Dissolvable Carboxymethylcellulose Microneedles for Noninvasive and Rapid Administration of Diclofenac Sodium.

The aim of this study is to prepare dissolvable biopolymeric microneedle (MN) patches composed solely of sodium carboxymethylcellulose (CMC), a water-soluble cellulose derivative with good film-forming ability, by micromolding technology for the transdermal delivery of diclofenac sodium salt (DCF). The MNs with ≈456 µm in height displayed adequate morphology, thermal stability up to 200 °C, and the required mechanical strength for skin insertion (>0.15 N needle-1 ). Experiments in ex vivo abdominal human skin demonstrate the insertion capability of the CMC_DCF MNs up to 401 µm in depth. The dissolution of the patches in saline buffer results in a maximum cumulative release of 98% of diclofenac after 40 min, and insertion in a skin simulant reveals that all MNs completely dissolve within 10 min. Moreover, the MN patches are noncytotoxic toward human keratinocytes. These results suggest that the MN patches produced with CMC are promising biopolymeric systems for the rapid administration of DCF in a minimally invasive manner.

Deep Eutectic Solvent Formulations and Alginate-Based Hydrogels as a New Partnership for the Transdermal Administration of Anti-Inflammatory Drugs.

The transdermal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is a valuable and safer alternative to their oral intake. However, most of these drugs display low water solubility, which makes their incorporation into hydrophilic biopolymeric drug-delivery systems difficult. To overcome this drawback, aqueous solutions of bio-based deep eutectic solvents (DES) were investigated to enhance the solubility of ibuprofen, a widely used NSAID, leading to an increase in its solubility of up to 7917-fold when compared to its water solubility. These DES solutions were shown to be non-toxic to macrophages with cell viabilities of 97.4% (at ibuprofen concentrations of 0.25 mM), while preserving the anti-inflammatory action of the drug. Their incorporation into alginate-based hydrogels resulted in materials with a regular structure and higher flexibility. These hydrogels present a sustained release of the drug, which is able, when containing the DES aqueous solution comprising ibuprofen, to deliver 93.5% of the drug after 8 h in PBS. Furthermore, these hydrogels were able to improve the drug permeation across human skin by 8.5-fold in comparison with the hydrogel counterpart containing only ibuprofen. This work highlights the possibility to remarkably improve the transdermal administration of NSAIDs by combining new drug formulations based on DES and biopolymeric drug delivery systems.

Targeting cannabinoid receptor 2 (CB2) limits collagen production-An in vitro study in a primary culture of human fibroblasts.

Previous studies showed that cannabinoid 2 (CB2) receptor is involved in skin inflammation, fibrogenesis and re-epithelialization in mice, indicating that this receptor may be implicated in wound healing. Thus, topical use of cannabinoids may have a role in local fibrotic and wound healing diseases such as scars or keloids. We investigate the effect of the CB2 selective receptor agonist (6aR,10aR)-3-(1,1-Dimethylbutyl)-6a,7,10,10a-tetrahydro-6,6,9-trimethyl-6H-dibenzo[b,d]pyran (JWH133) and the CB2 selective receptor antagonist (6-Iodo-2-methyl-1-[2-(4-morpholinyl)ethyl]-1H-indol-3-yl)(4-methoxyphenyl)-methanone (AM630), on primary cultures of human fibroblasts. Primary cultures of adult human fibroblasts were obtained from abdominal human skin samples. Fibroblasts pretreated with JWH133 and/or AM630 were stimulated with TGF-ß (10 ng/ml). Fibroblast activation into myofibroblasts was quantified by the expression of alpha-smooth muscle actin (α-SMA) using Immunocytochemistry and Western Blot assays. Collagen content was quantified with the Sirius red staining assay. Upon human fibroblasts stimulation with TGF-ß, a significant increase on α-SMA and CB2 receptor expression was observed. In these cells, JWH133 decreased α-SMA expression and collagen content. However, this effect was not observed in resting human fibroblasts. AM630 decreased α-SMA expression and collagen content in both resting and activated fibroblasts. This effect was time- and concentration-dependent with an IC50 value of 11 µM. The CB2 receptor appears to be involved in fibroblast repair during skin wound healing in humans, as TGF-ß increases CB2 receptor expression and JWH133 produces an anti-fibrotic effect in human fibroblasts. AM630 also showed an anti-fibrotic effect hypothesizing that other cannabinoid receptors, such as TRPV, may be involved in this response.

AM251, a cannabinoid receptor 1 antagonist, prevents human fibroblasts differentiation and collagen deposition induced by TGF-ß - An in vitro study.

Previous studies showed that cannabinoid 1 receptor (CB1) is linked with skin fibrosis and scar tissue formation in mice. Therefore, the topical use of cannabinoids may have a role in the prevention or treatment of local fibrotic and wound healing diseases as hypertrophic scars or keloids. In this study, we asked whether CB1 activation or inactivation would change fibroblast differentiation into myofibroblast and collagen deposition in skin human fibroblast. Primary cultures of adult human fibroblasts were obtained from abdominal human skin. Cells were stimulated with transforming growth factor-beta (TGF-ß, 10ng/ml) and treated with a CB1 selective agonist (arachidonyl-2-chloroethylamide, ACEA 1 µM) and an antagonist (AM251 1, 5 and 10 µM). Alpha-smooth muscle actin (α-SMA) was quantified using Immunocytochemistry and Western Blot. Collagen was quantified with Sirius Red staining assay. Significance was assessed by One-way ANOVA. P < 0.05 was considered significant. TGF-ß significantly increases α-SMA expression. ACEA 1 µM significantly increases collagen deposition but does not change α-SMA expression. AM251 10 µM added in the absence and the presence of ACEA reduces α-SMA expression and collagen content in TGF-ß treated cells. AM251 shows a concentration-dependent effect over collagen deposition with a pIC50 of 5.5 (4.6-6.4). TGF-ß significantly increases CB1 receptor expression. CB1 inactivation with AM251 prevents fibroblasts differentiation and collagen deposition, induced by TGF-ß in human fibroblasts. The outcome supports that CB1 is a molecular target for wound healing disorders and in vivo and pre-clinical studies should be implemented to clarify this premise.

Experience in Management of Burn Injury During Pregnancy in a Burn Unit.

Burns injuries during pregnancy are rarely reported in developed countries, but an increasing in mortality and morbidity has been observed. The authors describe their experience in the treatment of pregnant women in a burn unit. A 12-year retrospective study of burns in pregnant women hospitalized was conducted. Since 2008, two pregnant women were admitted in their unit. Patient 1, a 32-year-old pregnant woman on second trimester (27s6d), suffered a second-degree burn injury, 16% total body surface area (TBSA), caused by fire. She was admitted in their burn unit and submitted to medical treatment, wound dressing, and surgical treatment. Cerium nitrate and silver sulfadiazine were used in burn lesions and the patient was submitted to debridement and skin graft surgery. No uneventful events occurred with the fetus. Patient 2 was a 32-year-old pregnant woman on second trimester (26s), HVC positive, admitted with a second-degree flash burn, 8% TBSA. She was submitted to endotracheal intubation before arriving to the hospital due to risk of airway burn. Dexamethasone was administered for fetus lung maturation. No uneventful events were observed. The incidence of thermal injury in pregnancy in Portugal is low. Active medical treatment together with conservative wound care should be the standard in each trimester of pregnancy. Although there is limited safety information on cerium nitrate or silver sulfadiazine during pregnancy, those were used with no adverse effects on one of their patients. Obstetrical management should be individualized.

A new role for anandamide: defective link between the systemic and skin endocannabinoid systems in hypertrophic human wound healing.

The use of cannabinoids to treat fibrotic skin diseases is an emergent issue. Therefore, we aimed to evaluate systemic and skin endocannabinoid responses in the wound-healing process in humans. A prospective study was performed in 50 patients who underwent body-contouring surgery. Anandamide (N-arachidonoylethanolamine, AEA), 2-arachidonoylglycerol (2-AG), palmitoylethanolamide (PEA) and oleoylethanolamide (OEA) were quantified using LC-MS/MS. Ten (20%) patients developed hypertrophic (HT) scars. No significant changes were observed between the normal (N) scar and HT scar groups in terms of plasma and skin endocannabinoids. Nevertheless, a positive correlation between plasma and skin AEA concentrations was found in the N group (r = 0.38, p = 0.015), which was absent in the HT group. Moreover, the AEA concentration was significantly lower in HT scar tissue than in normal scar tissue (0.77 ± 0.12 ng/g vs 1.15 ± 0.15 ng/g, p < 0.001). Interestingly, in all patients, the surgical intervention produced a time-dependent effect with a U shape for AEA, PEA and OEA plasma concentrations. In contrast, 2-AG plasma concentrations increased 5 days after surgery and were reduced and stabilized 3 months later. These results suggest crosstalk between systemic and local skin endocannabinoid systems during human wound healing. AEA appears to be the most likely candidate for this link, which is deficient in patients with HT scars.

Pullulan microneedle patches for the efficient transdermal administration of insulin envisioning diabetes treatment.

The present study reports the fabrication of dissolvable microneedle (MN) patches using pullulan (PL), a water-soluble polysaccharide with excellent film-forming ability, for the transdermal administration of insulin, envisioning the non-invasive treatment of diabetes. PL MNs patches were successfully prepared by micromoulding and revealed good thermal stability (Tdmax = 294 °C) and mechanical properties (>0.15 N needle-1), penetrating skin up to 381 µm depth, as revealed by in vitro skin tests. After application into human abdominal skin in vitro, the MNs dissolved within 2 h releasing up to 87% of insulin. When stored at 4, 20 and 40 °C for 4 weeks, insulin was able to retain its secondary structure, as shown by circular dichroism spectropolarimetry. The prepared PL MNs were non-cytotoxic towards human keratinocytes, being suitable for skin application. These findings suggest that PL MNs have potential to deliver insulin transdermally, thus avoiding its subcutaneous administration.

Cutaneous endocannabinoid system: Does it have a role on skin wound healing bearing fibrosis?

INTRODUCTION: Recently, the endocannabinoid system has been identified in skin and it has been linked with the formation of skin fibrosis and wound healing. We aimed to find and analyse reported data on compounds acting in the endocannabinoid system with significant effect in skin fibrosis. METHODS: A literature search on PUBMED was conducted for studies published in English until February 2020 on cannabinoids and skin fibrosis. The initial search was performed with terms: "cannabinoid" AND "skin". This search retrieved 296 publications from which 18 directly related to skin fibrosis or wound healing process were included in this review. RESULTS: CB1 receptor inactivation and CB2 receptor activation show anti-fibrotic effects on cellular and animal experimental models of cutaneous fibrosis. CB2 receptor activation also promotes re-epithelization. Other cannabinoid related receptors, like adenosine A2A receptors and PPAR-γ, are also involved. Their activation lead to a pro-fibrotic and anti-fibrotic effect, respectively. CONCLUSION: Several molecular drug targets for endocannabinoid system were identified in skin. It may be a promising approach for the treatment of excessive skin fibrosis disorders.

Swellable Gelatin Methacryloyl Microneedles for Extraction of Interstitial Skin Fluid toward Minimally Invasive Monitoring of Urea.

Urea, the main nitrogenous waste product of protein metabolism, is eliminated almost exclusively by the kidney, and hence, displays considerable clinical significance in the assessment of kidney disorders. The aim of this study is to prepare and investigate the potential of swellable cross-linked gelatin methacryloyl (c-GelMA) microneedles (MNs) as a platform for minimally invasive extraction of interstitial skin fluid (ISF) toward straightforward point-of-care healthcare monitoring of renal complaints, by quantification of urea. c-GelMA MNs are successfully prepared by photo-cross-linking and micromolding, faithfully replicating the master molds (387 ± 16 µm height, 200 µm base and 500 µm tip-to-tip distance). These MN patches display good mechanical properties, withstanding more than 0.15 N per needle without breaking. Ex vivo skin insertion assays reveal that the MNs penetrate up to 237 µm depth, reaching the dermis, where they should extract ISF considering a real application. In an in vitro application using an agarose skin model system, the c-GelMA MNs are able to efficiently recover urea (>98%). Additionally, these MNs exhibit noncytotoxic effects toward human keratinocytes. These findings suggest that c-GelMA MNs are promising devices for sampling ISF and offline analysis of urea, opening new avenues for simple point-of-care healthcare monitoring.

Anti-inflammatory and antioxidant nanostructured cellulose membranes loaded with phenolic-based ionic liquids for cutaneous application.

The utilization of natural compounds, such as phenolic acids and biopolymers, in the healthcare domain is gaining increasing attention. In this study, bacterial nanocellulose (BC) membranes were loaded with ionic liquids (ILs) based on phenolic acids. These ionic compounds, with improved solubility and bioavailability, were prepared by combining the cholinium cation with anions derived from caffeic, ellagic and gallic acids. The obtained BC-ILs membranes were homogeneous, conformable and their swelling ability agreed with the solubility of each IL. These membranes revealed a controlled ILs dissolution rate in the wet state and high antioxidant activity. In vitro assays performed with Raw 264.7 macrophages and HaCaT keratinocytes revealed that these novel BC-ILs membranes are non-cytotoxic and present relevant anti-inflammatory properties. Diffusion studies with Hanson vertical diffusion cells showed a prolonged release profile of the ILs from the BC membranes. Thus, this work, successfully demonstrates the potential of BC-ILs membranes for skin treatment.

Hypertrophic Scars: Are Vitamins and Inflammatory Biomarkers Related with the Pathophysiology of Wound Healing?

BACKGROUND: Hypertrophic scars are a consequence of wound healing. OBJECTIVE: The objective of the present study is to evaluate vitamin D and inflammatory biomarker plasma levels during wound healing. METHODS: A prospective study was performed in patients (n = 63) submitted to body contouring surgery. Blood samples were collected before (t 0) and 5 days after surgery (t 5). Blood cell count, protein inflammatory biomarkers, and circulating plasma levels of 25(OH)D, vitamin A and vitamin E were quantified. Six months after surgery, scars were evaluated and classified as normal or hypertrophic. RESULTS: At the end of the study, 73% of the patients developed a normal scar (control group, n = 46) and 27% of the patients presented hypertrophic scars (HT group, n = 17). The patients in the HT group presented higher eosinophil (0.145 × 109 /L vs. 0.104 × 109 /L, p = 0.028) and basophil count (0.031 × 109 /L vs. 0.22 × 109 /L, p = 0.049) and C-reactive protein levels (6.12 mg/L vs. 2.30 mg/L, p = 0.015) in t 0 than the patients in the control group. At t 5, the patients in the HT group showed a decrease in neutrophil (3.144 × 109/L vs. 4.03 × 109/L, p = 0.031) and an increase in basophil (0.024 × 109/L vs. 0.015 × 109/L, p = 0.005) and lymphocyte count (1.836 × 109 /L vs. 1.557 × 109/L; p = 0.028). Before surgery, vitamin D plasma levels were found to be decreased by almost 50% (23.52 ng/mL vs. 15.46 ng/mL, p = 0.031) in the patients who developed hypertrophic scars. Thirty-one percent of the patients submitted to bariatric surgery had more hypertrophic scars, versus 24% of the patients with no previous bariatric surgery. CONCLUSION: There is a different systemic inflammatory profile response in the patients during the formation of hypertrophic scars. Vitamin D plasma levels are marked reduced in these patients. Considering the powerful anti-inflammatory effect of vitamin D, these findings could be related.

Fine-needle aspiration cytology (FNAC): is it useful in preoperative diagnosis of parotid gland lesions?

BACKGROUND: Salivary gland tumors are an uncommon entity and its histopathology is highly varied due to heterogeneous cellular composition. The role of the preoperative fine-needle aspiration cytology (FNAC) remains controversial. The purpose of this study is to compare the cytologic findings of salivary gland lesions with the histologic diagnoses, in order to assess the usefulness and accuracy of fine-needle aspiration cytology in the diagnosis of parotid gland tumors. METHODS: A retrospective study was performed, regarding patients (n = 65) submitted to surgery for the treatment of parotid gland disease, who had performed preoperative FNAC, in our department between 2002 and 2012. A histologic diagnosis was considered as the gold standard for the assessment of sensitivity and specificity of FNAC. A cytohistologic correlation was done and appropriate statistical tests were applied. RESULTS: Concordance between FNAC and histological specimen analysis was 78%. FNAC specificity was 82% and sensitivity was 71%. Positive and negative predictive values were 65% and 86% and positive likelihood ratio and negative likelihood ratio were 3.92 and 0.35, respectively. The diagnostic accuracy for this test was 78%. CONCLUSION: Preoperative FNAC of parotid lesions is reasonably accurate and useful in diagnosing benign from malignant lesions and in planning appropriate approach for treatment.

Predictors of satisfaction in patient with silicone breast implants and its association with drug intake habits.

BACKGROUND: Satisfaction is an important outcome variable in surgical success. The purpose of this study is to evaluate predictors of satisfaction in women submitted to silicone textured breast implant surgery. METHODS: A retrospective evaluation of women receiving textured silicone breast implants was performed. Patients were divided in four groups: cosmetic cohort (n = 104), reconstructive cohort (n = 120), general population control cohort (n = 120) and aesthetic control cohort (n = 54). Data were collected based on information retrieved from patient records, a planned consultation and a self-administered structured questionnaire. RESULTS: Patient satisfaction was influenced by preoperative information (p = .007), cohort (p < .001), and occurrence of postoperative complications (p < .001). The degree of satisfaction was also related with drug intake habits: women using psychotropic drugs were 3-fold more likely to report poor satisfaction than those that never used these drugs (p < .001). CONCLUSION: The purpose of the surgery, preoperative information and the occurrence of postoperative complications have an impact on the degree of satisfaction of women submitted to silicone breast implant surgery. Women using psychotropic drugs are more likely to report poor satisfaction.

Correction of Residual Static and Dynamic Labial Deviations in a Paralyzed Face After Free Gracilis Muscle Transplantation.

Free muscle flap transfer is currently the procedure of choice for longstanding facial paralysis to restore symmetry both at rest and when smiling. However, movements obtained are generally localized, unidirectional, and philtrum centralization and lower lip movement is not proportionally achieved. The stability of free flap insertion at the lips also interferes with the results, as gradual disinsertion and shifting of the nasolabial fold can be caused by repetitive movements. Asymmetry of smile can also be caused by lip depressor inactivity due to marginal mandibular paralysis, and both dynamic and static procedures are often required after dynamic reanimation. Here, the authors report a technical refinement that can be used even years after facial reanimation, using concealed scars and with minimal morbidity for correction of static and dynamic labial deviations from the midline. Placement of a transfixed tendon graft in C-fashion tendon graft between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side allows the forces from muscle contraction to be transferred to the philtrum and lower lip. It allows correction of static and dynamic labial deviations from the midline, reducing rates of inadequate fixation and partial or total disinsertion of the muscle flap in the buccal region.

Resection and microvascular reconstruction of bisphosphonate-related osteonecrosis of the jaw: The role of microvascular reconstruction.

BACKGROUND: Current treatment guidelines caution against osseous reconstruction using free flap tissue to treat bisphosphonate-related osteonecrosis of the jaw (BRONJ). The primary rationale for this stance is the theoretical risk of nonunion and recurrence of disease within the reconstruction. Emerging evidence suggests that these theoretical risks may be overestimated. We performed a literature review of this procedure for the treatment of advanced BRONJ. We also present a new case report of resection and microvascular reconstruction in a 58-year-old man with stage III BRONJ. METHODS: A MEDLINE search was performed to gather all reports of maxillary and mandibular reconstruction using free tissue flap transfer for BRONJ. Inclusion criteria were confirmed stage II or III BRONJ, free tissue transfer and reconstruction, and reported complications. Articles were excluded if they contained only local flap reconstruction, wound closure without reconstruction, or osteoradionecrosis. Outcomes from our case report were added to the analysis. RESULTS: We identified 10 articles that met criteria. Adding our case, we identified 40 cases of free flap reconstruction. The rate of nonunion was 5% (2 of 40). Fistulas formed in 4 cases (10%). BRONJ recurred in 2 cases (5%). CONCLUSION: Complication rates after free flap microvascular reconstruction in BRONJ seem acceptable. Nonunion is relatively rare and should not be the sole reason to recommend against free flap reconstruction. A randomized clinical trial would help clarify the role of this procedure in refractory BRONJ; however, we believe that segmental resection and microvascular reconstruction is a viable option in select cases of BRONJ. © 2016 Wiley Periodicals, Inc. Head Neck 38:1278-1285, 2016.

Parotid metastasis of an amelanotic melanoma of the scalp: The great masquerader.

BACKGROUND: Cutaneous melanoma is often characterized by its pigmented appearance; however, up to 8.1% of such lesions contain little or no pigmentation. Amelanotic melanomas, lesions devoid of visible pigment, present a diagnostic quandary because they can masquerade as many other skin pathologies. Recognizing amelanotic melanoma is even more clinically challenging when it is first detected as a metastasis to the secondary tissue. METHODS: We report a rare case of metastasis of an amelanotic melanoma to the parotid gland. RESULTS: A 75-year-old man presented with an 8-month history of a painless, mobile, hardened mass in the right parotid region. Histopathological analysis of a fine-needle aspiration biopsy of the parotid mass indicated that the mass was melanoma. Careful clinical and radiological examination revealed an 8 mm erythematous papule in the right temporal scalp, initially diagnosed by visual examination as basal cell carcinoma. After right superficial parotidectomy, neck dissection, and excision of the temporal scalp lesion, histological examination revealed the scalp lesion to be amelanotic melanoma. CONCLUSION: Although metastatic amelanotic melanoma to the parotid gland is a rare diagnosis, the clinician should be familiar with this presentation to increase the likelihood of making the correct diagnosis and delivering prompt treatment.

Thrombosed Aneurysm of the External Jugular Vein: A Rare Cause of Cervical Mass.

BACKGROUND: External jugular vein aneurysm is a rare condition with few cases described in the literature. Complications include thrombus formation, thrombophlebitis, pulmonary embolism, rupture, and cosmetic complaint. METHODS AND RESULTS: The authors present a clinical case and treatment of thrombosed aneurysm of the external jugular vein in a 47-year-old man. CONCLUSIONS: Despite its rarity, external jugular vein aneurysm should be remembered in the differential diagnosis of a cervical mass. Surgical excision is indicated in symptomatic aneurysms and for aesthetic reasons. Excision eliminates the risk of complications and allows for histopathologic diagnosis.

Eleven Years of Parotid Gland Surgery in a Plastic and Reconstructive Department.

BACKGROUND: Salivary gland tumors are an uncommon entity, comprising 3% to 6% of all head and neck tumors. Approximately 75% to 80% occur in the parotid gland, and 80% are benign. It is difficult to establish epidemiologic characteristics of parotid gland tumors due to their low incidence. We performed a retrospective study to analyze clinical diagnostic and therapeutic features of patients submitted to parotid gland surgery. METHODS: A retrospective study was performed, regarding all the patients (n = 96) submitted to surgery for treatment of parotid gland disease in the Department of Plastic and Reconstructive Surgery of Centro Hospitalar de S. João (Porto, Portugal) between 2002 and 2012. Medical records were analyzed and the following data were collected: patient age at diagnosis, sex, tumor location, symptom, tumor position, preoperative diagnosis techniques, type of operation performed, pathology, postoperative complications, adjuvant therapy (radiotherapy or chemotherapy), follow-up time, and tumor recurrence. SPSS was used for statistical analysis. RESULTS: Fifty-two percent of the patients were males and 48% females and mean age of 52.02. In 68.75% of the patients, superficial parotidectomy was performed. Benign pathology was found in 72% patients, and pleomorphic adenoma the most common tumor (39%). Facial paralysis (41.7%), Frey syndrome (9.4%), and great auricular nerve hyposthesia (10.4%) were major complications. Tumor recurrence was observed in 16 patients (16.7%), which forced 17 reoperations (17.7%). There were 5 deaths (5.2%). CONCLUSION: For most tumors, superficial parotidectomy is an effective treatment with acceptable morbidity. In patients of malignancy, treatment should be aggressive.

Secondary rhinoplasty using the technique of Turkish Delight: a case report and a brief review of the literature.

Rhinoplasty is a demanding task, especially when augmentation of the nasal contour is required. Autologous cartilage grafts are challenging. Contour and alignment of the graft are difficult goals. It is presented a case of a successfully nasal dorsum augmentation in a secondary rhinoplasty with the Turkish Delight technique and a brief review of literature. A 33-years-old female, with history of complete unilateral cleft nasal deformity on the right, and severe nasal deformity, previously submitted to other procedures, was referred to our Center. As she presented a visible cartilage graft, it was decided to perform the Turkish Delight technique. The autograft was effective for increasing of the nasal dorsum, at four years post-operative. There was no evidence of extrusion. The patient is satisfied with the result. The technique is effective in the reconstruction of complex dimorphism of the nasal dorsum, particularly in secondary rhinoplasty.

A rinoplastia é um procedimento cirúrgico exigente, especialmente quando requer aumento do contorno. Os enxertos de cartilagem, que visam melhorar o contorno e o alinhamento do dorso nasal são metas difíceis de alcançar. Apresenta-se um caso de uma rinoplastia secundária para aumento do dorso utilizando a técnica de Turkish delight e uma breve revisão de literatura. Uma mulher de 33 anos, com antecedentes de fenda palatina unilateral completa nasal à direita, e deformidade nasal grave, previamente submetida a outros procedimentos, foi encaminhado para o nosso Centro. Apresentava um enxerto de cartilagem visível, pelo que se optou pela técnica de Turkish delight. O enxerto mostrou-se eficaz no aumento do dorso aos quatro anos. Não ocorreu extrusão da cartilagem e a paciente está satisfeita com o resultado estético da cirurgia. A técnica é eficaz na reconstrução de dimorfismos do complexo do dorso nasal, particularmente em rinoplastias secundárias.

Lehman syndrome: a new syndrome for pierre robin sequence.

Lehman syndrome, or lateral meningocele syndrome, is characterized by facial dysmorphism, multiple lateral meningoceles, and skeletal abnormalities. Only nine cases have been described. We present a case of a 2-year-old boy presenting with micrognathia, glossoptosis, and hypertelorism as well as associated severe obstructive sleep apnea. He was submitted to bilateral mandibular distraction with external nonresorbable devices to correct Pierre Robin sequence (PRS). Later, multiple lateral meningoceles were identified, and a diagnosis of Lehman syndrome was made. Lehman syndrome must be considered in syndromic infants with PRS. Distraction osteogenesis is a safe procedure that is effective as a first choice in the treatment of patients with Lehman syndrome presenting with micrognathia.