Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773


Volume 3
Number 4



Continuing medical education

Understanding androgenetic alopecia

Entendendo a alopecia androgenética

Fabiane Mulinari-Brenner , Gabriela Seidel, Themis Hepp

Questions and answers of previous number

Abstract: Androgenetic alopecia is the most common type of alopecia in both women and men. Although there are clear clinical differences between its male and female patterns, there are physiopathogenic peculiarities in each gender. Changes in the hair cycle, with the shortening of the anagen phase, is responsible for the miniaturization process, transforming the terminal hair in a vellus hair. Treatment objectives are to increase the coverage of the scalp and to delay the progression of hair loss. In a didactic manner, this study goes over androgenetic alopecia’s physiopathogeny, clinical manifestations and therapeutic responses.


Original Article

Dermoscopic findings of radial streaming, blue hue and vascular structures as a tool to differentiate doubtful nevi and early melanomas: a comparative study

Achados dermatoscópicos com estrias radiadas, tonalidade azulada e estruturas vasculares como ferramenta na diferenciação entre nevos duvidosos e melanomas precoces: um estudo comparativo

Michelle Alvarenga Mansur, Gisele Gargantini Rezze, Maria do Rosário Dias de Oliveira Latorre, João Pedreira Duprat Neto

Abstract: Introduction: One of the most challenging dermoscopic situations is to distinguish between early melanomas and doubtful benign nevi. At times, suspicious melanocytic lesions have dermoscopic features similar to melanomas, thus leading to excessive excisions of lesions.
Objective: To develop a dermoscopic model that helps to differentiate the doubtful nevus from the early melanoma.
Material and methods: A total of 219 histopathologically confirmed dermoscopic images were analyzed and a comparison between doubtful nevi and early melanomas was then performed.
Results: The final model was based on three dermoscopic features: radial streaming, blue hue and vascular structures. If all three features were absent, it was most likely a nevus; if one dermoscopic feature was present, it could be a nevus or melanoma; if two features were present, there was a greater probability of melanoma diagnosis; if three features were present, it was melanoma.


Laserlipolysis experience: findings from 120 cases studied from 2004 to 2010

Experiência em laserlipólise: casuística de 120 casos no período de 2004 a 2010

Sandra Tagliolatto, Vanessa Barcellos Medeiros, Patrícia Cristiane de Sousa Teresani , Oriete Gerin Leite, Janaína Vilela Filipe, Carla Bassanezi Mazzaro, Patrícia Accione Rover, Renata Rita Oliveira Fernandes

Abstract: Introduction: Laserlipolysis is an emerging technique in the treatment for localized fat and Skin tightening. This therapy has a shorter post-operative recovery time and fewer adverse effects than conventional liposuction.
Objective: This study describes the authors’ experience in laserlipolysis and evaluates the technique’s safety and efficacy.
Methods: Retrospective study of 120 patients who underwent laserlipolysis, which was administered via two devices with different wavelengths: 1064-nm Nd:YAG laser and 924 nm/975 nm diode laser.
Results: According to clinical and photographic follow up, there was a significant improvement in localized fat in the definition of the body’s contour and in the skin tightening in all studied patients; 108 patients were satisfied with the technique. There were no cases of atrophic scars, hyperpigmentation, hypopigmentation or infection.
Conclusions: If properly recommended and carefully carried out, laserlipolysis is a safe and highly satisfactory option for the treatment localized fat and sagging skin.


Correction of dynamic wrinkles with incobotulinumtoxinA

Resultados da aplicação de incobotulinumtoxinA em pacientes para correção de rugas dinâmicas

Natalia Cymrot Cymbalista

Abstract: Introduction: Patients (n = 56) received incobotulinumtoxinA for the treatment of dynamic facial wrinkles.
Objective: To test the efficacy of incobotulinumtoxinA in correcting facial wrinkles.
Methods: The toxin was applied in in the usual doses and regions.
Results: Only 38 patients returned for evaluation after treatment. Of those, 19 complained about the low efficacy, short duration or absence of effects of the toxin. The total dose applied in patients who expressed satisfaction with the outcome (19 patients) was 872 units, while in the dissatisfied group (19 patients) it was 748 units – which was later increased by an additional 30.62% (229 units) of the initial dose.
Conclusion: Although some clinical studies demonstrate that this botulinum toxin has an efficacy similar to others available, this study has not succeeded in reproducing that fact.


Efficacy of lycopene, beta-carotene and Lactobacillus johnsonii in the maintenance treatment of melasma during the summer

Avaliação da eficácia do licopeno, beta- caroteno e Lactobacillus johnsonii no tratamento de manutenção do melasma durante o verão: um estudo comparativo

Fabiana Braga França Wanick, Beatrix Sabóia Zink, Raquel Ferreira Lopes

Abstract: Introduction: Melasma, a very frequent acquired hypermelanosis can be treated topically, however some studies have shown that oral antioxidants could reduce the deleterious effects of ultraviolet radiation on the skin.
Objective: To evaluate the effects of oral antioxidants and UVA/UVB sunscreen on the development of melasma during the summer months in Rio de Janeiro (RJ), Brazil – a period when the condition recurs more frequently.
Methods: Patients (n = 68) with melasma were randomized to receive one capsule/day of the nutri-concentrate (containing lycopene, beta-carotene and Lactobacillus johnsonii) and apply sunscreen every 3 hours (Group A) or sunscreen only (Group B). The patients were photographed and evaluated according to the Taylor Hyperpigmentation Scale and the Melasma Area Severity Index.
Results: The study was conducted from December 2010 to March 2011. Group A presented reductions in melasma of 8.5% on the Taylor scale and 19.5% on the Melasma Area Severity Index (p < 0.001). In Group B, the melasma worsened on the Taylor scale and improved 4.6% on the Index.
Conclusions: The use of a nutri-concentrate containing beta-carotene, lycopene and Lactobacillus johsonii combined with an SPF 60 sunscreen was an effective treatment for melasma during the summer. The treatment had a statistically significant reduction according to the Melasma Area Severity Index.


Treating cutaneous photoaging in women with an oral supplement based on marine protein, concentrated acerola, grape seed extract and tomato extract, for 360 days

Resultado de 360 dias de uso de suplemento oral à base de proteína marinha, acerola concentrada, extrato de semente de uva e extrato de tomate em mulheres portadoras de envelhecimento cutâneo

Adilson Costa, Elisangela Samartin Pegas Pereira, Raquel Fávaro, Margareth de Oliveira Pereira, Paula Luz Stocco, Elvira Cancio Assumpção, Fernanda Sayuri Ota, Stephanie Selma Barros Langen

Abstract: Introduction: Cutaneous aging affects (or will affect) all people at some point in their life, and its treatment represents a clinical challenge.
Objective: To evaluate the cutaneous effects of an oral supplement based on marine protein, concentrated acerola and extracts of grape seed and tomato in women with cutaneous aging.
Methods: Forty-five volunteers used 2 daily tablets of the supplement for 360 consecutive days. Clinical evaluations (carried out by both the investigator physicians and by the volunteers), ultrasonographic and photographic examinations were carried out every 30 days.
Results: Thirty-three volunteers (73.3%) completed the study. Clinically significant improvement was verified by the investigator physicians and the volunteers after 30 days of using the oral supplement (p < 0.05). The results were maintained after 330 days (p ¿ 0.05). The ultrasonographic analysis demonstrated increases in the dermal density of the photoexposed (132.3%; p < 0.001) and photoprotected areas (51.9%; p ¿ 0.001). Through medical analysis, statistically significant improvements were found in the following criteria: wrinkles, fine lines, solar melanoses, other hyperchromias, erythema, hydration, radiance , sebum, smoothness and overall appearance of the skin. Through the volunteers' self-evaluation, improvements in the wrinkles' pattern, fine lines, solar melanoses, other hyperchromias, erythema, hydration, radiance, sebum, smoothness and overall appearance of the skin were reported.
Conclusion: The long-term use (360 days) of an oral supplement based on marine protein, concentrated acerola and extracts of grape seed and tomato was proven to be a good adjuvant systemic approach for treating cutaneous aging.


Epidemiological profile and post-surgical evaluation of 8 glomus tumor cases

Estudo do perfil epidemiológico e avaliação pós-cirúrgica de oito casos de tumor glômico

Leandra Oliveira Teixeira, Ana Luiza Grizzo Peres Martins, Samira Oliveira Teixeira, Sadamitsu Nakandakari

Abstract: Introduction: Glomus tumors are rare benign lesions that are most often found on the tips of the fingers; they account for 1.0-4.5% of neoplasias on the hand. Subungual glomus tumors occur more frequently in women in their 30s and 50s.
Objective: This study evaluated glomus tumor patients' epidemiological profiles, their satisfaction with the treatment and the rate of recurrence due to incomplete removal.
Method: The records of patients that were treated for glomus tumors at a dermatology clinic between 1992 and 2011 were evaluated regarding gender, age, profession, affected area of the body, satisfaction with the treatment and possible recurrence.
Results: The patients (n = 8, average 63 years) were older than those usually described in the literature. The most frequently described profession was that of housewife. All patients were satisfied with the aesthetic results of the treatment. There was a total improvement of the pain in threepatients, while patients with a partial improvement in pain experienced a recurrence. The recurrence rate due to incomplete removal was 50%.
Conclusion: The surgery's effectiveness can be measured by the improvement of the pain; persistence of pain can indicate recurrence.


Treating melasma with (1540 nm) fractional non-ablative erbium laser: a pilot study

Estudo-piloto: tratamento de melasma com laser de Erbium fracionado não ablativo (1.540nm)

Mônica Manela-Azulay, Juliano Borges

Abstract: Introduction: Melasma is a common pigmentary disorder. Notwithstanding, its treatment is frustrating, and slow to take effect. Although depigmenters still are the main treatment modality, lasers have recently emerged as an innovative option. Objective: To preliminarily determine the effects of non-ablative photothermolysis on persistent melasma.
Methods: Ten patients with resistant melasma underwent three 1540 nm fractional nonablative erbium laser sessions (with one month intervals), with a 15 mm spot size handpiece. No additional treatment was carried out 3 months before or after. The energy level used ranged from 8 to 15 mJ/MB, and the pulse duration was 15 ms. Responses were evaluated by both the researcher physician and the patients.
Results: Seven patients completed the study; three patients left due to side effects. The researching physician reported that the patients who completed the study obtained 50-75% improvement one month after the last session. The patient's analysis resulted 50-75% improvement for 5 patients, and 75-100% for the remaining two. The physician and the patients reported that the improvement was maintained at the 3-month follow-up visit.
Conclusions: Although the preliminary results were satisfactory, further, longer-term studies are necessary to establish more efficient protocols and to observe possible recurrences.


Use of laser and other technologies by Brazilian Society of Dermatology members

Pesquisa sobre o uso de lasers e outras tecnologias pelos associados da Sociedade Brasileira de Dermatologia

Roberto A. de Mattos, Bogdana V Kadunc, Aldo Toschi, Samuel Mendes Peixoto, Anna C. Andriolo

Abstract: Introduction: An online questionnaire on the use of lasers and other technologies for treating cutaneous disorders or unattractive conditions was sent to 6517 members of the Brazilian Society of Dermatology.
Objective: To quantify the use of those technologies by dermatologists by region, in order to identify regional needs in Brazil.
Methods: The survey included 17 questions about the devices, relating to topics such as the place of application, ownership or rental equipment status, number of devices used, indications and types, and the member's region. The respondents used the Society's website to submit answers between February and March 2011. The answers were coded in graphs with percentages.
Results: The response rate was 859: 68% of Brazilian dermatologists perform the procedures at their private offices, 32% are owners of the equipment and 80% live in the southeast / south of Brazil.
Conclusions: While some results met the expectations -the Brazilian Southeast region had the greatest number of dermatologists who answered the questionnaire and use the technologies in question-, others were surprising -variety of equipment used-. This survey allowed the Brazilian Society of Dermatology to analyze how Brazilian dermatologists employ those devices, as well as the geographical locations that have a greater need for their use.


Review articles

In vivo confocal microscopy in the daily practice of the dermatologic surgeon

Perspectivas no uso da microscopia confocal in vivo na prática do cirurgião dermatológico

Thais Helena Bello Di Giacomo, Adriana Vanella D'Agostino Santiago, Juliana Casagrande Tavoloni Braga, Tatiana Cristina Moraes Pinto Blumetti, Juliana Arêas de S. Lima Beltrame Ferreira, Juliana Machado Canosa, David Serra, Gisele Gargantini Rezze

Abstract: New imaging methods, such as optical coherence tomography, magnetic resonance and high frequency ultrasonography, have been developed for use in dermatology. Among the new methods, in vivo reflectance confocal microscopy, has presented the fastest growth in large cutaneous oncology centers and has generated the greatest number of articles in the literature recently, due to its resolution – similar to histological resolution. In vivo confocal microscopy has been particularly useful given the many limitations of the dermoscopic diagnosis of cutaneous neoplasias, especially of achromic or hypopigmented lesions, lesions in the face or in mucous membranes. Some studies have also suggested considerable utility in the assessment of surgical margins and in determining the best area of the body for carrying out excisional biopsies. This study briefly describes how the confocal laser reflectance microscope works and discusses some of the issues that arise in its use in the daily practice of dermatologic surgeons.


Diagnostic Imaging

Detection of small melanomas

Detecção de melanomas pequenos

Sergio Yamada, Mauricio Mendonça do Nascimento, Sergio Henrique Hirata

Abstract: Four clinical cases of small melanomas detected by dermoscopy associated with clinical data and total body photographs with systematic monitoring are described. In small melanomas, dermatoscopic findings alone are not always sufficient to correctly indicate the excisional biopsies used in anatomical-pathological examinations.


New Techniques

Keloid treatment with intralesional cryosurgery: proposal of a low-cost device

Tratamento de queloides por criocirurgia intralesional: proposição de acessório de baixo custo

Flávio Barbosa Luz, Laura Boechat Bussade

Abstract: Cryosurgery is an established technique for treating keloids. The development of intralesional cryosurgery has been an important advance in that technique. In addition to producing better results in large and refractory keloids, intralesional cryosurgery presents a lower rate of complications. The authors present a new low-cost device for use in intralesional cryosurgery that allows easy handling in practically all body areas.


Untouched Strip: a technique to increase the number of follicular units in hair transplants while preserving an untou- ched area for future surgery

Untouched Strip: técnica para aumentar o número de unidades foliculares em transplante capilar preservando área intocada para futura cirurgia

Márcio Rocha Crisóstomo, Marília Gabriela R. Crisóstomo, Denize Campos Cavalcanti Tomaz, Manoela C. C. Crisóstomo

Abstract: In hair transplants, the donor area can supply only a limited number of follicular units in each procedure. In the treatment of more advanced degrees of baldness, removing both a scalp strip and follicular units, one by one, is an option that allows more units to be harvested in a single session, thus providing a better density and coverage of the bald area. This article describes a technique called Untouched Strip, which, in addition to increasing the number of follicular units with the combined procedure, preserves the donor area for a possible future transplant.


Case reports

Deep-fill of the tear trough with hyaluronic acid

Preenchimento profundo do sulco lacrimal com ácido hialurônico

Flávia Naranjo Ravelli, Juliana Sandin, Fernanda Dias Pacheco Sakai , Ana Carolina Lisboa de Macedo, Viviane Chehin Curi, Thais Adura Pepe

Abstract: The protrusion of the orbital fat, aggravated by local dyschromia, causes an unpleasant aesthetic appearance, which worsens with age. This study describes 15 cases of treating the tear trough with hyaluronic acid filling. The substance was deeply injected through retro injection. Eleven patients (73%) were satisfied with the procedure. Two cases (13%) presented edema in the treated area, one case (6%) developed hyperchromia of the lower eyelids, and another (6%) developed an irregularity on the cutaneous surface in the area that was filled, and was treated with hyaluronidase. This technique demonstrated good results, with no serious complications.


Rotation flap for closure of surgical defect on the dorsum of the hand

Retalho de rotação para fechamento de defeitos cirúrgicos nos dorsos das mãos

Paulo Morais Cardoso, Paulo Santos, Filomena Azevedo

Abstract: Malignant tumors are relatively common on the dorsum of the hand. Excision of such lesions may result in a large defect not suitable for direct closure, and its reconstruction often represents a challenge for the hand surgeon. Several reconstructive techniques can be used to close this defect. We herein describe the application of a rotation flap for closure of a defect on the dorsum of the hand secondary to excision of a keratoacanthoma, and explain the principles and advantages of this technique.


Surgical resolution of eclabium using a Limberg flap

Resolução cirúrgica do eclabio através do retalho de Limberg

Luciana Abreu, Maria Isabel Cárdenas, Fernanda Campany, Joaquim José Teixeira de Mesquita Filho

Abstract: Basal cell carcinomas are the most common type of skin cancer. Recurring basal cell carcinomas have lower cure rates than the primary tumors. Recurring tumors are usually treated with re-excision using micrographic surgery or by controlling the margins through freezing. A case of recurring basal cell carcinoma with large dimensions is reported. After total exeresis and correction using a rotation flap and total skin graft, the area developed eclabium, an unattractive complication that was corrected in a second surgery using a Limberg flap. This study presents an alternative correction for eclabium, and emphasizes the importance of training dermatologic surgeons how to resolve complications.


Giant proliferating trichilemmal cyst with latissimus dorsi bilateral myocutaneous flap closure

Tumor triquilemal proliferante gigante com fechamento por retalho miocutâneo bilateral de grande dorsal

Thiago Souza, Fabio Francesconi, Daniel Auade, Marcos Ricci

Abstract: This article reports the case of a 54-year-old male patient diagnosed with a recurrent gigantic trichilemmal tumor on the back, having undergone surgery six years earlier. After the exeresis of the lesion (with 1 cm margins), econstruction was carried out using a bilateral myocutaneous flap from the latissimus dorsi muscle to close the surgical wound. This report describes the clinical-epidemic characteristics of trichilemmal tumors, as well as treatment options.



Low efficacy in the use of 5% potassium hydroxide solution to treat contagious molluscum

Baixa eficácia do uso de solução de hidróxido de potássio a 5% por 28 dias no tratamento de molusco contagioso

Juliano Vilaverde Schmitt, Helena Zenedin Marchioro

Abstract: Although treating contagious molluscum with 5% potassium hydroxide solution is common, some studies challenge its efficacy. Ten patients (aged 4-13) with a total of 141 lesions were evaluated. After 28 days of treatment there were 105 lesions (75% of the initial amount), none of which achieved total resolution. Persistent lesions were curetted in up to two sessions; 28 of the 105 lesions remained after treatment. The percentages of reduced or completely resolved lesions were higher for curettage than potassium hydroxide (71% x 9%, p = 0 .01 vs. 80% x 0%, p = 0.02).


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