Wilson Cintra

Surgical treatment of lymphedema of the penis and scrotum

PURPOSE Lymphedema of the penis and scrotum, regardless of its etiology, is determined by reduced lymphatic flow with subsequent enlargement of the penis and scrotum. The clinical course of this condition is characterized by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse, and voiding in the standing position. The purpose of the present study is to present the experience and results of the treatment of lymphedema of the penis and scrotum by removing affected tissues and correcting the penoscrotal region. MATERIALS AND METHODS Seventeen patients with lymphedema of the penis and scrotum were treated with a modified Charles procedure, which consists of the excision of the affected skin followed by scrotoplasty and midline suture simulating the scrotal raphe. The penis is covered with a split-thickness skin graft by means of a zigzag suture on its ventral surface. RESULTS Regression of symptoms and improvement of previous clinical conditions were verified in the follow-up which ranged from 6 months to 6 years. One patient who had undergone lymphadenectomy with radiation therapy due to penile cancer had recurrent scrotum lymphedema. CONCLUSIONS The modified Charles procedure for the treatment of penoscrotal lymphedema is easily reproducible and allows better local hygiene, easier ambulation, voiding in the standing position, resuming sexual intercourse, and finally, better cosmetic results in the affected area with remarkable improvement in quality of life.

Circumferential Abdominoplasty for Sequential Treatment after Morbid Obesity

Background:The severely obese patient, after considerable loss of weight, has large remaining skin folds. Classic transverse abdominoplasties leave bulges in the flanks. This article presents an alternative procedure, circumferential abdominoplasty, which involves the perimeter of the abdomen. Methods: Average age of the patients was 39.5 years, consisting of 10 females and two males. Incisions were made like those of the classic transverse abdominoplasty, but were extended dorsally without tension on the suture-line. Results: Pre and postoperative aspects revealed the huge impact achieved after resection of the excess panniculus, with improvement of body contour, posture, ambulation, social and psychological integration, hygiene and sexual performance. In some patients, seromas, partial dehiscences, flap infection and atelectasis were immediate complications. Hyperthopric scars and some remaining skin folds were late complications. Conclusion:The major disadvantage of the circumferential abdominoplasty is the resulting scar. However, this procedure should be taken into consideration as an option to achieve a more harmonious body contour. Complications are not enough to contraindicate the surgery, because the patients preferred better social and professional integration, as well as behavioral improvement due to enhancement in their self-confidence.

Massive Localized Lymphedema (MLL) in Bariatric Candidates

Background: Mild lymphedema of lower limbs and eventually abdomen is not exceedingly rare in morbid obesity. However, few large symptomatic masses have been reported. In a consecutive series of patients, all requiring resection of the lesion before bariatric treatment, clinical features and surgical findings are described, aiming to clarify the nature of this intricate problem. Methods: Subjects (n=4, 50% females, age 34.0±13.7 years (19-53), BMI 56.4±10.5 kg/m2 (44.1-73.1) displayed lesions on the anteromedial aspect of the thigh (n=3) and hypogastrium (n=1). All reported episodes of intertrigo of local skin-folds in the preceding years, managed by local care and antibiotics. The mass was described as a serious nuisance, impairing walking, dressing and personal hygiene. Results: The mass was surgically removed without requirement for blood transfusion except in the case of one huge mass. Complications were relatively minor and consisted of partial skin dehiscence and lymph leakage for 2-3 weeks. Histologically, a complex pattern was observed including skin hypertrophy, edema, fibrosis, foci of microabscesses and dilated blood vessels, along with the pathognomonic lymphangiectasia. On follow-up to 6 months, improvement or restoration of the ability to walk occurred, with no additional skin infection and no recurrence. Conclusions: 1) Surgical treatment was effective. 2) Functional rehabilitation was achieved. 3) No recurrence was observed within the follow-up period.

Histological comparison of the alar nasal cartilages in unilateral cleft lip

UNLABELLED Patients with unilateral cleft lip display characteristic nasal changes that are independent of the degree of deformity. Defenders of the intrinsic theory consider these deformities to be due to embryogenic alterations of the alar nasal cartilages. Those that propose the extrinsic theory defend the thesis that the deformity is due to disorganization of the perioral muscles deformed by the cleft. The purpose of this study is to contribute histological evidence to help clarify the issue. PATIENTS AND METHODS Specimens of the lateral portion of both the healthy and the cleft side of the alar cartilages were obtained from 18 patients. These uniformly cut specimens were stained by hematoxylin and eosin. Samples from 2 patients were excluded due to imperfections. The same pathologist examined all the slides. He was unaware of the origins of the specimens; he counted the number of chondrocytes and quantified the cartilage matrixes. RESULTS All data was analyzed statistically, and no significant statistical differences were apparent, either in the number of chondrocytes or the cartilage matrix between the healthy side and the cleft side. DISCUSSION These results apparently support the group that defend the extrinsic theory; nevertheless, the doubt about the composition of the cartilage matrix remains, not only concerning the glycosaminoglycans that compose them, but also regarding elastin and collagen and its linkages that can cause different degrees of collagen consistency.

Aesthetic Rehabilitation After Bariatric Surgery

Sustained and lifelong weight loss for severely obese people is not anymore an impossible dream, and a Swedish article suggests, half jokingly, that this is the new fairy tale of the ugly duckling (Olbers, Lakartidningen 108:2570–2573, 2011). The example is appropriate because for health care professionals, resolution of obesity means reversal of diabetes, hyperlipidemia, and other cardiovascular risk factors. For the majority of the patients all these results are secondary. Priority is getting beautiful and achieving a rich and fulfilling emotional life. That is the reason why plastic interventions are the most frequent new operations after bariatric treatment, and as many as 85 % of this population desire subsequent body contouring maneuvers (Gusenoff et al., Plast Reconstr Surg 122:951–958, 2008; Highton et al. J Plast Reconstr Aesthet Surg 65:426–432, 2012). Fortunately this specialty has responded to the challenge, and both old and new techniques are being successfully adapted to the specificities of the patients who shed much weight and suffer from lax and redundant skinfolds and widespread lipodystrophy. Principal procedures such as abdominoplasty, mammaplasty, thigh lift, brachioplasty and others are described, emphasizing the experience of the Hospital das Clinicas Service during more than 15 years.

Quality of Life After Abdominoplasty Following Bariatric Surgery

Postoperative assessment for plastic surgery interventions, especially those that follow massive weight loss induced by antiobesity procedures, is not complete with aesthetic criteria only. Quality of life is a variable that should not be overlooked because it mirrors the personal, social, and emotional impact that patients cherish.