Álvaro Silva

Fournier's gangrene: a review of 43 reconstructive cases.

Background: Fournier’s gangrene is a rare and potentially fatal infectious disease characterized by necrotic fasciitis of the perineum and abdominal wall, along with the scrotum and penis in men and the vulva in women. Fournier’s gangrene is a true surgical emergency. Skin loss can be very incapacitating and difficult to repair. Methods: The authors reviewed retrospectively the clinical records of a series of 43 patients with Fournier’s gangrene between the years 1985 and 2003 who, after initial treatment by the Departments of Urology and Surgery, were referred to the Department of Plastic Surgery for reconstruction. The following parameters were evaluated: age, gender, interval between onset of symptoms and diagnosis, clinical symptoms, lesion site, results of bacteriologic cultures, cause and predisposing factors, treatment and reconstructive procedures, length of hospital stay, and outcome. Results: The mean patient age was 56.6 years. Fifteen patients (34.9 percent) had diabetes mellitus. The cause of Fournier’s gangrene was found in 32 patients (74.4 percent). The most common presentation was scrotal swelling, and scrotal involvement was found in 40 cases (93.0 percent). All of the patients underwent surgical debridement, and several reconstruction techniques were used. The mean length of hospital stay was 73.6 days. Two patients died. Conclusions: Management of this infectious entity should be aggressive. Several techniques that are used to reconstruct the lost tissue have shown good results. The superomedial thigh skin flap has proven to be a reliable method of resurfacing large scrotal defects. Reconstructive surgery makes the return to a normal social life possible in many cases.

Etiology and patterns of pediatric mandibular fractures in Portugal: a retrospective study of 10 years.

Objective:To determine the pattern of occurrence of mandibular fractures in the pediatric population in Portugal. Materials and Methods:This retrospective study reviews the records of patients 18 years of age or younger from the 10-year period 1993 to 2002. Age, gender, anatomic site, cause of the accident, weekly and monthly variation, location and type of fractures, presence and location of associated injuries, treatment methods, and complications were reviewed. Results:During this 10-year period, 521 patients with 681 mandibular fractures were treated. Motor-vehicle accident (MVA) was the most common (53.9% patients) cause of fracture. Almost half of the patients (48.8%) were in the oldest age group (16 to 18 years old). The condyle of the mandible was involved in 31.0% of the fractures. Maxillomandibular (MMF) fixation was used in 534 (78.4%) fractures. Overall mortality in this series was 0.6% (3 patients); mortality was caused by multiple traumas, mainly head trauma. Conclusion:There is a need to reinforce legislation aimed to prevent MVA and the total enforcement of existing laws to reduce maxillofacial injuries among children and adolescents.

Scarpa fascia preservation during abdominoplasty: randomized clinical study of efficacy and safety.

Background: Scarpa fascia preservation has been suggested as a way of reducing complications associated with conventional abdominoplasty. A prospective randomized study was conducted to evaluate the effect on results and complications of preserving the Scarpa fascia during a full abdominoplasty. Methods: This was a single-center study conducted from August of 2009 to February of 2011. Patients were assigned randomly to one of two procedures: classic full abdominoplasty (group A) or a similar type of abdominoplasty except for the preservation of the Scarpa fascia and the deep fat compartment in the infraumbilical area (group B). Four surgeons were involved in the study. Several variables were determined: general characteristics, time to suction drain removal, total volume of drain output, length of hospital stay, systemic complications, local complications, and aesthetic result. Results: A total of 160 full abdominoplasties were performed in women (group A, 80 patients; group B, 80 patients) equally divided by the four involved surgeons. There were no statistically significant differences between groups with respect to general characteristics, complications (except for the seroma rate), and aesthetic result. The Scarpa fascia preservation group had a highly significant reduction of 65.5 percent on the total drain output, 3 days on the time to drain removal, and 86.7 percent on the seroma rate. Conclusion: Preservation of the Scarpa fascia during an abdominoplasty had a beneficial effect on patient recovery, as it reduced the total drain output, time to drain removal, and seroma rate without compromising the aesthetic result. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Reverse dorsal metacarpal osteocutaneous flap

There are a number of possibilities for local and vascularized bone transfer when a small amount of cortico-cancellous bone is required in the hand and fingers. The authors describe the dissection technique and a clinical application of a reverse dorsal metacarpal osteocutaneous flap to reconstruct the proximal phalanx of a fifth finger. They emphasise the bone vascularisation, studied 48 hours postoperatively with a bone scan and confirmed with bone healing 4 weeks later. The advantages are: it is a compound flap, easy to dissect under tourniquet in one operation, it can be done in an emergency care situation and it does not require ligation of an important vascular axis. The essential precaution is to visualise the patency of the fourth dorsal metacarpal artery before flap dissection, acknowledging that in only 63% of cases is there a vascular pattern that allows flap dissection with a long arc of rotation.

Microsurgical Soft-Tissue Hand Reconstruction: An Algorithm for Selection of the Best Procedure

Microsurgical hand reconstruction can be the first option to consider in some particular and complex clinical situations. An algorithm based on anatomical considerations and functional outcomes, may be useful for the plastic surgeon that deals with these challenging cases.

Effect of exercise during pregnancy, graded as a percentage of aerobic capacity: Maternal and fetal responses of the rat

1. A number of variables were studied in pregnant rats that underwent strenuous exercise during pregnancy. They were: total weight gain, daily weight gain, length of pregnancy, number of offspring. Also the weight, the heart weight and fibre/capillary ratio of the newborn male rats and their VO2 max at 90 days were measured. 2. The exercise was graded in accordance to previous aerobic capacity as determined by VO2 max with relative loads of 60% (E60), 70% (E70), 80% (E80) and 90% (E90) of VO2 max being applied to the various groups (N = 6 per group). 3. The total weight gain and daily weight gain was significantly less in the E70, E80 and E90 groups. Weight gain in the anabolic phase (0-14d) was not different, but during the first week the weight gain in the E90 group was significantly less than control group. In the catabolic phase the observations were similar the first week of the anabolic phase. 4. Length of pregnancy, heart weight offspring and VO2 max of 90-day-old male rats were not significantly different. The number of offspring of the E90 group was significantly smaller than the control, E60 and E70 groups. 5. The offspring body weight was less in the E70, E80 and E90 groups than control group and was significantly less in the E90 group compared to the E60 and E70 groups. 6. The fibre/capillary ratio of the offspring was different in the E90 group compared to the control group. 7. These results suggest that the effect of exercise depends on the relative work load applied to the mother and these effects are particularly marked at high work loads.

Head and neck reconstruction: a review of 117 cases

Abstract The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed.

Dissection Technique for Abdominoplasty: A Prospective Study on Scalpel versus Diathermocoagulation (Coagulation Mode)

Background: The purpose of this study was to evaluate the effect of the dissection technique on outcomes and complications after a full abdominoplasty, comparing 2 different techniques used to raise the abdominal flap: the steel scalpel and the diathermocoagulation device on coagulation mode. Methods: A prospective study was performed at a single center from January 2009 to December 2011 of patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, abdominoplasty performed with steel scalpel/knife; and group B, abdominoplasty performed with diathermocoagulation on coagulation mode. Several variables were determined: general characteristics, time until drain removal, daily and total volume of drain output, length of hospital stay, operative time, readmission, reoperation, emergency department visits, and local and systemic complications. Results: A total of 119 full abdominoplasties were performed in women (group A, 39 patients; group B, 80 patients). There were no statistically significant differences between groups with respect to general characteristics, except for body mass index, comorbidities, and weight of the surgical specimen; there were no differences for operative time, systemic complications, hematoma, and necrosis incidence. The scalpel group had a highly significant reduction of 54.56% on total drain output, and a 2.65 day reduction on time to drain removal and no reported cases of seroma or healing problems (difference of 81.25% and 90.00%, respectively, between the 2 groups). Conclusions: Performing abdominal dissection with scalpel had a beneficial effect on patient recovery, as it reduced time requested for drain removal, total drain output, and incidence of seroma and wound healing problems.

Factors associated with mortality and length of stay in the Oporto burn unit (2006–2009)

Retrospective studies are essential to evaluate and improve the efficiency of care of burned patients. This study analyses the work done in the burn unit of Hospital de S. João in the north of Portugal. A retrospective review was performed in patients admitted from 2006 to 2009. The study population was characterised regarding patient demographics, admissions profile, burn aetiology, burn site, extension and treatment. Multiple linear and logistic regression models were done in order to elucidate which of these factors influenced the mortality and length of stay. The characteristics before and after the creation of the burn unit, as well as the similarities and differences with the published data of other national and international burn units, are analysed.

Pyoderma gangrenosum after breast reduction: A rare complication

Pyoderma gangrenosum (PG) is a chronic, recurrent and often destructive, inflammatory disease that belongs to the spectrum of neutrophilic dermatoses. The incidence is low, making recognition difficult, one report estimates it to be three cases per million per year in the United States. Diagnostic criteria include the presence of a rapidly progressive, painfull necrolytic ulcer with an irregular, violaceous and undermined border and exclusion of other causes for cutaneous ulceration and at least one of the following: history suggestive of pathergy or clinical finding of cribiform scarring; systemic diseases associated with PG; histophatologic findings (sterile dermal neutrophilia, mixed inflammation, lymphocitic vasculitis); treatment response (rapid response to systemic steroid treatment). The criteria cannot be used in isolation, but when used together, they support a diagnosis of PG. 3 In asmany as 70% of cases, PG is associated with a variety of diseases, with inflammatory bowel disease, rheumatoid arthritis, hematologic disease, and malignancy being the most frequent. Workup for PG should begin with a thorough history and physical that focuses on the risk factors and associated disorders. Wound culture for bacteria, acid-fast bacillus, and fungus can rule out an infection. Full-thickness biopsy should be performed peripherally in the erythematous halo, often showing a lymphocytic or neutrophilic vasculitis; although histopathologic findings in PG are nonspecific, its main value lies in the exclusion of other diseases. PG can occurs after any surgical procedure and its recognition is often delayed, leading to significant morbidity, including prolonged therapy, numerous hospitalizations, persistence of severely painful ulcerations, psychological trauma and extensive scarring with