Pedro Salomão Piccinini

Utilização do retalho microcirúrgico do músculo grande dorsal para a reconstrução da mão torta congênita

DOI: 10.5935/2177-1235.2018RBCP0078 A reconstrução do segmento distal do antebraço, sobretudo a região do punho, pode representar um grande desafio. A Mão Torta Radial (MTR) é uma deficiência longitudinal congênita do rádio que varia desde uma hipoplasia até a ausência completa deste osso longo, com consequente desvio da posição normal dos ossos do carpo, o que confere ao indivíduo uma posição antifuncional e prejuízo na aquisição da pinça digital. A reparação do defeito ortopédico impõe a exposição dos ossos do punho, tendões e eixo vascular. O presente relato demonstra a utilização do retalho microcirúrgico do músculo grande dorsal para a cobertura das estruturas profundas da região do punho na criança. ■ RESUMO

De-epithelialized turnover dorsal flap for coverage of finger injuries: a modified technique:

Complex hand injuries present functional and aesthetic problems. Knowledge of the cutaneous circulation has allowed the use of safe and well-nourished flaps (Biswas et al., 2014). Hand dorsal skin is ideal for resurfacing soft-tissue defects of fingers because it is thin and pliable (Sandeep et al., 2011). With regard to dorsal hand skin perfusion, the dorsal metacarpal artery perforator (DMAP) emerges when the DMA reaches the distal margin of the junctura tendinae, 10 mm proximal to the MCP joint (De Rezende et al., 1996). These cutaneous ‘Quaba’s perforators’ have a trajectory towards the subcutaneous tissue anastomosing with the rete carpi dorsale (Vuppalapati et al., 2004). The choice of flap depends on the size/location of the digital injury. A decision to choose a metacarpal artery or a de-epithelialized flap is based on whether one or more digit is involved. The authors have modified a de-epithelialized dorsal hand flap (DDHF) for coverage of an injury to the dorsal aspect of the fingers. A 22-year-old man with a combined degloving, burn and crush finger injury was treated with debridement that removed the extensor tendons (>50% of the extensor tendons had been destroyed by the initial injury) and exposed the bone. The third finger presented a 50% loss of the lateral band, which was reconstructed with a ‘banana split’ technique as described by Foucher. To cover the injury, a longitudinal midline and two transverse dorsal incisions were performed. Subdermal undermining was performed along the full extent of the dorsal hand in an ‘open book’ pattern (Figure 1). The DDHF was performed by anterograde undermining of the subcutaneous tissue 1 cm proximal to the MCP joint, maintaining the extensor peritenon. The flap is turned over and trimmed to adjust to each finger. Finally, the dorsal hand skin is repositioned and sutured into place and a full-thickness skin graft (FTSG) is placed on the de-epithelialized flap (Figure 2). Bone fixation is performed with Kwires and compressive gauze dressings are placed over the skin graft for 5–7 days; we do not use bolster-type dressings.

Cellulite: A Surgical Treatment Approach

Background Cellulite is one of the most common skin and subcutaneous tissue conditions, affecting predominantly the thighs and hips in postadolescent women. Its etiology is not well defined, and multiple available treatments show variable efficacy. Objectives To describe a technique for treatment of cellulite of the gluteal region, thighs, and hips through superficial liposuction utilizing a special cannula, combined with subcutaneous autologous fat grafting. Methods A retrospective review was performed of patients treated over 26 years at the Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil. Patients underwent pretreatment evaluation as to the extent of their cellulite, and pretreatment and posttreatment photographs were obtained for visual evaluation of the results. Results Procedures were performed on 126 patients: 121 (96%) women and 5 (4%) men. The majority considered their results good or excellent. The complication rate was low, with the most common complications being ecchymosis, contour irregularities, partial recurrence of cellulite, seroma, and numbness. Conclusions We describe an effective method for the treatment of cellulite. Whereas subcision techniques utilize a needle or microblade to cut fibrous septa, we utilize a special cannula; larger areas can be treated than with subcision. Fat grafting is utilized to correct depressions and improve skin quality, which are added benefits compared to traditional subcision. Considering the multiple available cellulite treatments and their limitations, and the high patient satisfaction rate we achieved, with a low recurrence and complication rate, this technique can be a safe and effective option for patients with cellulite. Level of Evidence 4

Commentary On: Several Opinions on Quantifying Dynamic Deformity after Dual-Plane Breast Augmentation

Dear Editor, We appreciate the authors’ comments on our paper, in which we demonstrate a simple method for quantification of dynamic breast deformity (DBD) following dual-plane breast augmentation (DPBA). The technique includes the well-known benefits of improved upper and medial implant coverage, decreased rippling and capsular contracture, and excellent versatility, as DPBA can be performed in a wide variety of patients, including those with a slight degree of ptosis, as well as patients with constricted lower poles or tuberous breasts. However, as with any submuscular breast augmentation (BA), there is a risk of animation, or DBD with contraction of the pectoralis major muscle (PMM). The authors correctly pointed out that we did not include a control group of different BA implant planes, as the senior author has performed DPBA exclusively over the past 16 years. We agree that some patients may have a certain degree of lateral and superior breast displacement with PMM contraction prior to implant placement. During the planning phase of the study, we performed preoperative measurements on four patients to evaluate changes in breast shape or position with PMM contraction, but there was no statistically significant change in measurements, nor was preoperative breast deformity a presenting complaint in any of our patients. Therefore, we decided not to include these measurements in the study. Because an overwhelming majority of BA patients have very little parenchyma overlying the PMM, it is likely that this type of deformity is not clinically significant. Additionally, the goal of our study was not to explain the mechanism of DBD, which has been studied by multiple authors, although an exact causal relationship between preexisting patient anatomy and iatrogenic PMM release (or lack thereof) is yet to be shown. We agree with Tebbetts [1] in that we avoid any degree of sternal release of PMM, avoiding ‘‘window shading’’ of the PMM. Indeed, the selective disinsertion of PMM fibers, preserving sternal attachments, is likely what causes less animation deformity when compared to total submuscular placement. We differ from the author’s opinion that total submuscular BA may cause less DBD, as we have seen multiple patients referred to us after total submuscular BA with significant DBD, which is likely due to the tight PMM overlying the implant and displacing it cranially with contraction (Figs. 1, 2, 3, 4). Subglandular BA evidently does not cause DBD as the muscle is not manipulated. Biplanar muscle-splitting BA may cause less DBD, as neither PMM origins nor insertions are divided; this has been described by multiple & Marcelo Recondo Cheffe marcelo@cheffe.com.br

Cutaneous approach in toxic epidermal necrolysis

Introduction: Toxic epidermal necrolysis is a severe acute mucocutaneous condition usually induced by drugs associated with a high rate of morbidity and mortality. The care of the mucous lesions and skin and a multidisciplinary approach are very important for the prognosis and future sequelae. Objectives: To discuss the main aspects of this syndrome through a literature review illustrated by a clinical case. Methods: Review of the literature using the PubMed and SciELO online databases was performed. Articles in English, Portuguese, French, and Spanish were included and illustrated with a pediatric clinical case. The keywords used were as follows: “toxic epidermal necrolysis,” “Stevens-Johnson overlap,” “necrólise epidérmica tóxica,” and “síndrome Stevens-Johnson.” Results: We presented data to guide the management of patients with toxic epidermal necrolysis for plastic surgeons, pediatricians, intensivists, dermatologists, and emergency physicians. The case treated had a favorable disease course without sequelae. Conclusion: A high level of suspicion is necessary for an adequate diagnosis and risk stratification, and early support measures and treatment should be performed by a multidisciplinary team trained to minimize damage and mortality. ■ ABSTRACT

History of plastic surgery: Sir Harold Gillies, a pioneer of reconstructive plastic surgery

Historically, wars have been among the greatest catalysts for advances in medicine in general, and surgery in particular. Without doubt, the greatest practitioner of plastic surgery in the early decades of the twentieth century was Sir Harold Delf Gillies, a New Zealander living in England, who advocated the treatment of patients with facial injuries in the context of the First World War. This article examines Gillies’ personal life and the legacy he left for modern plastic and reconstructive surgery; many of his teachings are timeless and serve as an inspiration for the surgeons of today. ■ ABSTRACT

De-epithelialized dorsal digital turnover flap for coverage of volar digital lesions: a modified technique

Volar digital injuries represent a challenge to hand surgeons. Anatomical studies demonstrate the existence of dorsal digital branches of the ulnar and radial arteries at predictable and regular distances from the PIP joint, bilaterally. Moreover, as there are also small veins that accompany the arterial branches, we designed a novel de-epithelialized dorsal finger turnover flap, which can be performed on the ulnar and radial sides of fingers where it is important to maintain the paratenon to support the dorsal skin flap. A 21-year-old female presented with traumatic injury to the middle phalanx of the third finger associated with loss of substance and damage to the flexor tendons in zone II. The dorsal part of the finger was used to provide coverage for a volar injury. There was no scar retraction or functional limitation of the reconstructed finger. This novel, de-epithelialized dorsal finger turnover flap can be safely used for coverage of volar finger lesions, due to a reliable and well-described arterial supply, with no skin necrosis of the donor site, post-surgical infection, or scarring complications. Level of Evidence: Level V, therapeutic study.

Distal phalanx amputation with delayed presentation and successful reconstruction with reposition and flap after 2 weeks

Traumatic finger amputations are common, causing significant functional and cosmetic deficits. Microsurgical replantation techniques are the mainstay of treatment for most such injuries although they require adequate conservation of the amputated segment for a successful result. In distal finger amputations, replantation is the procedure of choice, as long as the amputated fragment is viable. If replantation is not an option, reposition + flap using a neurovascular flap can be an efficient option, as this offers improved skin coverage. To the best of our knowledge, this case illustrates the longest cold ischaemic time with a successful outcome.