Dimas André Milcheski

Atuação da cirurgia plástica no tratamento de feridas complexas

OBJECTIVE: To report the performance of plastic surgery in the treatment of complex wounds in a tertiary hospital, analyzing its characteristics, types of injuries and approaches adopted, with emphasis on surgical treatment. METHODS: We conducted a etrospective analysis of patients with complex wounds treated by plastic surgery in a tertiary hospital in a period of five years (2006 to 2010). Data collection was obtained from visits made, serial assessments and records of the medical charts. RESULTS: There were 1927 patients treated (32 queries / month), mean age 46.3 years, predominantly male (62%). The surgical specialties requested 1076 consultations (56%), and the clinical, 851 (44%). The distribution by type of wound showed predominance of pressure ulcers (635/33%), traumatic wounds (570/30%), complicated surgical wounds (305/16%) and necrotizing wounds (196/10%), with the remainder represented by vasculitis (83 / 4%), venous ulcers (79 / 4%), diabetes (41 / 2%) and post-radiation (18 / 1%). The treatment was surgical in 1382 patients (72%) and non-operative in 545 cases (28%). There were 3029 operations, predominantly debridement (1988/65%) and skin grafting (619/21%) associated or not with negative pressure therapy (vacuum), followed by pedicle flaps (237 / 8 %), digital reimplantation (81 / 3%), microsurgical flaps (66 / 2%) and other (38 / 1%). CONCLUSION: The plastic surgeon played an important role in the treatment of complex wounds by adopting early surgical treatment, contributing to the effective resolution of cases.

Tratamento cirúrgico de ferimentos descolantes nos membros inferiores: proposta de protocolo de atendimento

OBJECTIVE: Degloving injuries on the lowerextremities are often serious injuries. It is difficult to decide on the most appropriate treatment, whether flap repositioning and suturing or converting the avulsed flap tosplit-thickness skingrafting. METHODS: This study assessed patients with degloving injuries in lower extremities, reviewing the epidemiological profile and treatment performed. It is proposed a treatment protocol for management of those lower extremity avulsion injuries. RESULTS: Twenty-one patients were evaluated. The cause of trauma was running over in 11 patients (52,4%) and motorcycle accident in 10 (47,6%). All twenty-one patients had treatment with washing, debridement, resection of avulsed flap and converting the flap to split-thickness graft, in according with the following treatment protocol for management of those lower extremity avulsion injuries that came to our Emergency Unit: Patients were initially classified as unstable or stable (hemodynamically). In the unstable group (two patients),due to the patient condition, flap resection was performed and the skin kept in the tissue bank for later grafting. In the stable group (19 patients), flap viability was assessed using clinical parameters and fluorescein. If deemed viable the flap was sutured to its original position. If deemed unviable (all 19 patients), it was resected and converted to split-thickness skin and mesh grafting with vacuum-assisted device over the graft. CONCLUSION: In order to avoid flap necrosis and to add a new skin donor area is important to recognize the problem in the Emergency Room and to manage properly those injuries.

Influência da imunossupressão na regeneração nervosa com utilização de aloenxertos: Estudo experimental em ratos

PURPOSE: This paper was aimed to study nerve regeneration after allografting using conventional point counting technique. INTRODUCTION:The interest towards nerve allografting has been growing since the recent development of better immunosuppressant drugs. METHODS: Three groups were studied: Group A - Lewis rats receiving nerve grafts from isogenic donors; Group B - Lewis rats receiving nerve grafts from Brown-Norway donor rats and treated with saline solution; Group C - Lewis rats receiving nerve grafts from Brown-Norway donor rats and treated with cyclosporine. Nerve regeneration was evaluated by histological analysis and by histomorphometric studies after 6 and 12 weeks. RESULTS: At 6 weeks, nerve fiber density and the percentage of neural tissue in the immunosupressed allograft group (C) were significantly higher than in group B. Allograft groups (B and C) showed significantly lower nerve fibers density and percentage of neural tissue when compared to the autograft group A at 6 or 12 weeks. CONCLUSIONS: We conclude that the point counting method was simpler to use than the computerized model, and yielded accurate and reproducible results.

Terapia por pressão negativa na ferida traumática complexa do períneo

OBJECTIVE To review the experience (2011 and 2012) of Wound Center of Plastic Surgery Service, Clinics Hospital, Faculty of Medicine, University of São Paulo, with treatment of complex traumatic wounds in the perineal region with the association of negative pressure wound therapy followed by a surgical skin coverage procedure. METHODS This was retrospective analysis of ten patients with complex wound in the perineum resulting from trauma assisted by the Department of Plastic Surgery in HC-USP. Negative pressure was used as an alternative for improving local conditions, seeking definitive treatment with skin grafts or flaps. RESULTS Negative pressure was used to prepare the wound bed. In patients, the mean time of use of negative pressure system was 25.9 days, with dressing changes every 4.6 days. After negative pressure therapy, 11 local flaps were performed in nine patients, with fasciocutaneous anterolateral thigh flap used in four of these. Mean hospital stay was 58.2 days and accompaniment in Plastic Surgery was 40.5 days. CONCLUSION The use of negative pressure therapy led to improvement of local wound conditions faster than traditional dressings, without significant complications, proving to be the current best alternative as an adjunct for the treatment of this type of injury, always followed by surgical reconstruction with grafts and flaps.

Coverage of Deep Cutaneous Wounds Using Dermal Template in Combination with Negative-pressure Therapy and Subsequent Skin Graft

Background: We consider the use of dermal matrix associated with a skin graft to cover deep wounds in the extremities when tendon and bone are exposed. The objective of this article was to evaluate the efficacy of covering acute deep wounds through the use of a dermal regeneration template (Integra) associated with vacuum therapy and subsequent skin grafting. Methods: Twenty patients were evaluated prospectively. All of them had acute (up to 3 weeks) deep wounds in the limbs. We consider a deep wound to be that with exposure of bone, tendon, or joint. Results: The average area of integration of the dermal regeneration template was 86.5%. There was complete integration of the skin graft over the dermal matrix in 14 patients (70%), partial integration in 5 patients (25%), and total loss in 1 case (5%). The wound has completely closed in 95% of patients. Conclusions: The use of Integra dermal template associated with negative-pressure therapy and skin grafting showed an adequate rate of resolution of deep wounds with low morbidity.

Uso da terapia por pressão subatmosférica em feridas traumáticas agudas

OBJETIVO: avaliar a experiencia com o emprego de terapia por pressao subatmosferica no tratamento das lesoes traumaticas agudas das partes moles, em especial nos membros. METODOS: cento e setenta e oito pacientes com feridas traumaticas foram tratados pelo Centro de Feridas Complexas no periodo de janeiro de 2010 a dezembro de 2011 e, submetidos a terapia por pressao subatmosferica. RESULTADOS: dos 178 pacientes submetidos a terapia por pressao subatmosferica, 129 (72,5%) eram do sexo masculino e 49 (27,5%) apresentavam idade entre 18 e 40 anos. Os ferimentos descolantes nos membros foram o tipo de ferida traumatica mais comum, sendo responsaveis pela internacao de 83 (46,6%) pacientes. O tempo medio de internacao hospitalar foi 17,5 dias. Foram realizados 509 procedimentos cirurgicos (media de 2,9 por paciente). A terapia por pressao subatmosferica foi utilizada em 287 procedimentos, sendo 209 (72,8%) sobre feridas traumaticas e 78 (27,2%) sobre enxertos de pele. O numero de trocas de terapia por pressao negativa por paciente foi 1,6 e o tempo medio de utilizacao foi 8,5 dias por paciente. CONCLUSAO: os resultados foram considerados satisfatorios, diminuindo consideravelmente a morbidade e o tempo de cicatrizacao dessas lesoes em comparacao com tratamentos anteriormente executados como curativos. A terapia por pressao subatmosferica e um metodo util no tratamento de feridas agudas traumaticas, atuando como ponte entre o tratamento de urgencia e a cobertura cutânea definitiva destas lesoes, em comparacao com metodos mais tradicionais da cirurgia plastica.

Experimental model of degloving injury in rats: effect of allopurinol and pentoxifylline in improving viability of avulsed flaps.

Background Degloving injuries may be a challenge when it comes to deciding the surgical approach to be used. Repositioning of the flap and suturing are faster and more straightforward, but often these procedures often lead to total or partial loss of the avulsed flap. Pharmacological agents with vascular properties that enhance the viability of the reattached flap could be beneficial to patients with degloving injuries. Experimental models with which to test this hypothesis are scarce. An experimental model reproducing a degloving injury of the hind limb of rats was developed in our department, and the effects of pentoxifylline (Ptx) and allopurinol (Alp) were assessed. Methods In all, 3 groups of rats were studied (25 rats each). A hind limb degloving model was used in all groups, resulting in a reverse flow flap. The flap was then repositioned and sutured. The control (Ct) group received only saline solution, the Ptx group received pentoxifylline (25 mg/kg), and the Alp group received allopurinol (45 mg/kg). The rats were observed for 7 days, after which they were killed, and the flap was removed. The total area of the avulsed flap and the necrotic area were measured. Results The median total flap area (cm2) was 5.6 for the Ct group, 5.5 for the Ptx group, and 5.8 for the Alp group (P = 0.9465). Thus, the flaps were similar. The median necrotic flap area (cm2) was 3.3 for the Ct group, 2.3 for the Ptx group, and 1.9 for the Alp group (P = 0.0001). There was a statistical difference between the Ct and Ptx groups and the Ct and Alp groups (P < 0.05). Conclusions The areas of necrosis observed in the degloved flaps of the rats’ hind limbs were smaller in the pentoxifylline and allopurinol groups. Although allopurinol seems to be more efficient, the difference was not significant.

Sensory testing in patients with hemodialysis-associated carpal tunnel syndrome submitted to surgical decompression.

BackgroundCarpal tunnel syndrome (CTS) is the most common compression neuropathy of the upper limb. Close to 5% of patients with chronic renal failure who need hemodialysis present CTS. Clinical history and physical examination remain the most adequate tools for diagnosis, and there is still controversy regarding the most reliable test to complement it. Evaluation of sensory thresholds using Pressure-Specified Sensory Device (PSSD) has become an important instrumental test. MethodThis study aimed to determine the values of pressure sensory thresholds using the PSSD before and after treatment of CTS in a special group of patients who underwent chronic hemodialysis. The PSSD incorporates a pressure transducer linked to a computer capable of measuring the cutaneous pressure thresholds referred by the patient. Two groups were compared as follows: group 1, patients with hemodialysis-related CTS; and group 2, CTS in non–hemodialysis patients. The following measurements were assessed: static one point, moving one point, static two points, and moving two points. ResultsThere was improvement (lower thresholds) in the postoperative measurements in all parameters assessed in group 1, and improvements in all parameters except the moving one point test in group 2. ConclusionsNerve decompression, as expected, can be considered a good treatment of CTS even in more severe cases as in those patients under hemodialysis. The PSSD tests were reliable to confirm the diagnosis and thus to indicate the decompression. It is even more beneficial to provide a comparison between preoperative and postoperative data and different causes of CTS.

Brief hospitalization protocol for pressure ulcer surgical treatment: outpatient care and one-stage reconstruction

OBJECTIVE to evaluate a brief hospitalization protocol for the treatment of pressure ulcers, proposed by the Complex Wound Group of Clinical Hospital of University of Sao Paulo Medical School, particularly in regard to selection of patients, hospitalization time, cutaneous covering, complications and sore recurrence. METHODS retrospective cohort of 20 consecutive patients with 25 pressure lesions Grade IV. All patients were ambulatorily prepared and were hospitalized for surgical one time procedure for pressure lesion closing. RESULTS in total, 27 flaps were performed to close 25 wounds. Three patients showed minor dehiscence (11.1%). There was no recurrence during the post-surgical follow-up period. No patient suffered a new surgery and no flap showed partial or total necrosis. Median time of hospitalization was 3.6 days (2-6 days) and median follow-up was 91 months (2-28 months). All patients maintained their lesions closed, and there was no recurrence during follow-up. CONCLUSION the brief hospitalization protocol was considered adequate for the resolution of pressure wounds, showing an average time of hospitalization of 3.6 days and rate of minor surgical wound dehiscence of 11.1%.

Desenvolvimento de modelo experimental de avulsão de retalhos em membros inferiores de ratos

BACKGROUND: The purpose of this study was to develop an experimental model for degloving injuries of the hind limbs of rats and observe flap viability after its relocation to the wound bed to better study the changes related to the injury and to test the therapeutic modalities in avulsed flaps. METHODS: Ninety male Wistar rats were divided into 4 experimental groups. A flap avulsion model on the lower limb of a rats was established, using 4 different pedicles: proximal flow pedicled flap (G1), distal flow pedicled flap (G2), lateral flow pedicled flap (G3), and medial flow pedicled flap (G4). RESULTS: Comparison between the mean necrotic area of the degloved flap showed statistically significant differences among the 4 groups (P < 0.0001). CONCLUSIONS: The group with the distal flow pedicled flap (G2) showed a higher necrotic area relative to the total flap area and it is the most suitable group for testing therapeutic agents in avulsed flaps.