Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773


Volume 4
Number 2



Continuing medical education

Stem cells in the skin

Células-tronco na pele

Marcia Regina Monteiro

Questions and answers of previous number

Abstract: This article assesses recent studies about stem cell research in dermatology. The interaction of stem cells in the maintenance and repair of the skin, as well as their participation in the hair follicle cycle and its pigmentation, are also discussed. Studying those mechanisms will increase understanding of the pathophysiology of diseases linked to dysfunctions in those processes, which will enable the development of therapeutic approaches to these situations.


Original Article

Glabellar region filling: examining the reasons for the high incidence of complications and blindness

Preenchimento na região glabelar – dissecando as razões da alta incidência de complicações e cegueira

Carlos R. Antonio, João R. Antonio, Alessandra C. Garcia, Adailza A. Correia

Abstract: Introduction: Fillings are currently one of the most sought-after treatments for aging. The glabella area is subject to complications arising from the application of fillers, the most common of which are transient erythema, granulomatous reactions, arterial occlusion, and blindness. Nevertheless, the pathogenic mechanisms that lead to a loss of sight following the injection of fillers in the glabellar region remain unknown. Objective: To evaluate the percentage of patients with severe obstruction of the internal carotid artery who present carotid flow reversal, in order to demonstrate a possible cause of a higher incidence of complications linked to the use of filling substances in the glabella. Methods: Prospective study carried out with duplex scan at the Radiology Department of the Hospital de Base de São José do Rio Preto, São Paulo, Brazil. Results: Advance detection of carotid flow reversal (external to internal carotid system) – which is a common event in patients with a hemodynamically significant obstruction of the internal carotid artery – can prevent serious consequences – the most critical of which is blindness. Conclusion: Filling procedures in the glabellar region must be avoided due to the risk of carotid flow reversal and subsequent occlusion of the central retinal artery, which causes blindness.


Versatility of the Limberg flap in reconstructions after resection of facial tumors

Versatilidade do Retalho de Limberg nas reconstruções pós-ressecção de tumores em face

Tiago Sarmento Simão, Felipe Rodrigues Máximo, Rafael Ribeiro Pinheiro, Fellipe Emanuel Amorim Santos Barbosa, Débora Nassif Pitol, Leão Faiwichow

Abstract: Introduction: Alexander Limberg created the Limberg flap in 1946 to repair rhomboid defects. The great advantage of using local flaps on the face is the similarity of color and texture of the tissues to the location of the defect to be repaired. Objective: To evaluate the advantage of using a Limberg flap to reconstruct facial defects created by the resection of tumors. Methods: Retrospective analysis of 12 cases in which Limberg flaps were used to reconstruct defects resulting from tumor resections in the face. Results: There were two epitheliosis cases; one developed partial necrosis of the flap, and both patients healed well with conservative treatment and daily changes of dressing. In one of the cases, the patient developed a post-operative hematoma requiring surgical drainage and flap repositioning, which resolved well, with only minor scar retraction. Discussion: The design of the flap requires precision. The main difficulty is the need to draw equal sides with accurate angles of 60 and 120 degrees. Conclusions: Limberg flaps are versatile and can produce good results in several areas of the face.


Clinical and histological evaluation of patients with refractory melasma treated with fractional Erbium:YAG laser

Avaliação clínica e histológica de pacientes com melasma refratário tratadas com laser de érbio: Yag fracionado

Giseli de Mattos Diosti, Fabiane Mulinari-Brenner, José Filus Neto, Betina Werner, Alexandre do Nascimento, Flávio Meingast Piva

Abstract: Introduction: Melasma is an acquired hyperpigmentation that affects primarily the face and occurs more frequently in women with darker skin. There are several therapies for treating melasma, however its long-term management remains a challenge. Objectives: To evaluate fractional Erbium:YAG laser's clinical effectiveness in treating refractory melasma through the histological analysis of usual characteristics and the amount of epidermal and dermal pigment before and after treatment. Methods: Ten patients underwent three fractional Erbium:YAG laser sessions at monthly intervals. Biopsies were obtained before and after treatment. Subjective and objective clinical evaluations were carried out before, during, and after treatment. Results: No statistical improvement in Melasma Area Severity Index score was observed during the treatment. Hyperpigmentation of the basal layer and pigment deposition in the dermis was observed histologically. In seven cases, there was a reduction in the degree of hyperpigmentation in the epidermis, which was not statistically significant. Conclusions: The treatment of melasma with fractional Erbium:YAG laser was ineffective. Nonetheless, a decrease in Melasma Area Severity Index scores and in the degree of hyperpigmentation of the epidermis was detected, suggesting that fractional Erbium:YAG laser can clinically and histologically improve the degree of hyperpigmentation of the skin.


Nutrient supplementation influence on keratinocytes’ metabolism: an in vitro study

Influência da suplementação de nutrientes no metabolismo dos queratinócitos: estudo in vitro

Flavia Alvim S Addor

Abstract: Introdução: Modern lifestyles often lead to eating habits that lack a balance of nutrients. Some of those substances directly interfere with the metabolism of skin appendages. Objective: To evaluate the combination of vitamins A, C, E, B complex, zinc, magnesium, and iron, and their effects at the cellular level. Methods: A controlled in vitro study involved culturing keratinocytes, with the incubation of a combination of nutrients containing ascorbic acid, retinol, tocopherol, B complex, zinc, magnesium, and iron at daily recommended doses. Results: There was a significant increase in cell maturation compared to the control. Conclusion: The combination of nutrients caused an increase in the expression of keratin synthesis.


Clinical evaluation of a formulation with osmotic effect in reducing symptoms after superficial burns: a pilot study

Avaliação clínica de formulação de efeito osmótico na redução da sintomatologia pós-queimaduras superficiais: estudo-piloto

Flávia Alvim Sant'Anna Addor, Patricia Camarano Pinto Bombarda, Felipe Fernandes de Abreu

Abstract: Introduction: The treatment of superficial burns is largely symptomatic, aimed at reducing the discomfort arising from the signs and symptoms and promoting skin repair. Some studies have evaluated the osmotic action mechanisms in the inflammatory process. Formulations with osmotic action can decrease the inflammatory exudate, which reduces the symptoms and even the risk of infections. Objective: To evaluate the action of an osmotic action hydrogel for topical use in reducing the symptoms of a superficial, first-degree burn. Method: Thirty-five patients with signs of first-degree burn were evaluated. The study product was applied on the injured area as a monotherapy. The analysis of symptoms (burning sensation), signs (erythema and edema), and clinical evaluation questionnaire were conducted after 5, 15, and 30 days, respectively. To evaluate the skin barrier's restorative effect, transepidermal water loss measurements were also carried out. Results: Thirty-three patients completed the study. There were no adverse reactions. The reduction of symptoms and signs was significant (p < 0.001).The complete recovery of the skin barrier was observed at the end of the study. Conclusion: The study product was effective and safe in reducing the signs and symptoms resulting from superficial burns.


Assessment of psychological, psychiatric, and behavioral aspects of patients with cellulite: a pilot study

Avaliação dos aspectos psicológicos, psiquiátricos e comportamentais de pacientes com celulite: estudo-piloto

Doris Hexsel , Carolina Siega, Juliana Schilling-Souza, Amanda Stapenhorst, Ticiana Costa Rodrigues, Cristiano Brum

Abstract: Introduction: About 50% of the population reports some kind of dissatisfaction related to their physical appearance. Patients' motivations for seeking cosmetic treatment are not yet fully understood. Objectives: To evaluate the behavioral, psychological, and psychiatric characteristics of patients with cellulite. Methods: In the first phase of this cross-sectional, descriptive and observational study, forty-six volunteers answered a self-administered questionnaire. In the second phase, a psychiatrist administered the M.I.N.I. questionnaire. Results: Most interviewees described the forthcoming of cellulite during puberty. Discomfort caused by cellulite was mainly felt at the beach (87%) and pool (67,4%). Almost half of patients reported having been subject to an embarrassing comment related to their cellulite, while 78.3% felt pressure to seek treatment. The eating disorders described included the use of drugs, compulsive ingestion of food, feeling guilty after eating, and self-induced vomiting. The most frequently found specific emotional disorder was generalized anxiety. Conclusions: Patients with cellulite can experience emotional distress and negative feelings in everyday situations. Changes in specific behaviors and the presence of psychological and psychiatric co-morbidities can be present in some patients.


In vitro and clinical efficacy of the use of phytoestrogens-based topical cosmetic use in photoaged skin

Eficácia in vitro e clínica do uso cosmético tópico de fitoestrógenos em pele fotoenvelhecida

Abstract: Introduction: Skin aging is a challenge to treat. Objectives: To evaluate the in vitro and in vivo efficacy and clinical safety of a phytoestrogens-based cosmetic in the management of photoaging. Methods: The in vitro investigation was performed using the analysis of the genic expression of fibronectin and procollagen, evaluation of the immunomodulatory activity (proinflammatory and anti-inflammatory cytokines synthesis) and histochemistry and immunofluorescence analyses of the skin and the dermoepidermal junction. The in vivo investigation – performed in 76 women randomized into Group A (phytoestrogens complex cream and SPF 20 twice daily) or Group B (the same product plus a commercially available anti-aging cream applied overnight). The study lasted for 120 days, with physician- and patient-led evaluations, in addition to monthly ultrasound (20 MHz) and photographic analysis. Skin biopsies of the face were performed before and after treatment. Results: The study showed In vitro: increase in the expression of fibronectin, in procollagen, immunomodulator potential, represented by an increase in IL-1a and a decrease in IL-10; improvement in the integrity of the dermoepidermal junction; increase in the viability and thickness of the epidermis; increase in collagen synthesis .In vivo: subjective global improvement of the skin's appearance; reduction in the count and intensity of spots, erythema, skin pores, and cutaneous porphyrin. The ultrasound and biopsy revealed increased dermal density (52.7%) and dermal fibers (22.3%), respectively. Conclusions: The topical use of phytoestrogens-based cosmetics improves the overall condition of the skin.


Evaluation of melasma classification methods based on response to treatment

Avaliação dos métodos de classificação do melasma de acordo com a resposta ao tratamento

Mariana Hammerschmidt, Suelen Mayara Lopes de Mattos, Heliane Sanae Suzuki, Camila Fernanda Novak Pinheiro de Freitas, Maira Mitsue Mukai

Abstract: Introduction: Melasma can be classified as epidermal, dermal, or mixed using clinical measures such as Wood's lamp and dermoscopy. The Melasma Area Severity Index and the Melasma Quality of Life Scale are additional subjective classification methods. Objectives: To compare noninvasive melasma classification methods according to response to treatment. Methods: Ten women with melasma were treated with 4% hydroquinone + 0.05% tretinoin + 0.01% fluociolone acetate for 90 days. They were evaluated before and after treatment using dermoscopy, Wood's lamp, and both subjective measures. Results: No significant correlations were found between the Melasma Area Severity Index and dermoscopic classification, Wood's lamp examination and the Melasma Quality of Life Scale. The average percentage improvement after treatment was 60.6% in the severity index and 41.1% in the quality of life scale. Dermoscopy revealed telangiectasia in most patients (60%), including those without prior treatment. Conclusions: The subjective assessment tools best reflected the patients' response to treatment. The classification using Wood's lamp did correlate with improvement measured by the severity index. The use of dermoscopy for classifying melasma requires further research, since the findings were not correlated with the expected response to treatment.


Review articles

Laserlipolysis: update and literature review

Laserlipólise: atualização e revisão da literatura

Sandra Tagliolatto, Vanessa Barcellos Medeiros, Oriete Gerin Leite

Abstract: Laser lipolysis is a therapeutic modality that is currently used to treat localized fat and promote cutaneous retraction. Compared to conventional liposuction, removing fat using laser lipolysis has a shorter post-operative recovery time and fewer adverse effects. Applying laser directly to adipose tissue causes fat liquefaction, blood vessel coagulation and collagen denaturation. The thermal damage induces neocollagenesis and skin contraction. The technique's safety is well documented. This study reviews the literature on laser lipolysis and describes its current status.


Reflectance skin confocal microscopy of basal cell carcinoma

Microscopia confocal reflectante a laser: carcinoma basocelular

Alessandra Cristine Marta, Giovanni Pellacani , Mariana de Figueiredo Silva, Rute Facchini Lellis, Marcus Maia

Abstract: Basal cell carcinoma is the most common malignant skin tumor. Reflectance confocal microscopy is a non-invasive technique that provides real-time, in vivo, horizontal tissue images, at a quasi-histological resolution, by employing a low-power laser beam of 830 nm. In this paper, we review the major morphological criteria for diagnosing this tumor using reflectance skin confocal microscopy.


Diagnostic Imaging

Non-traditional Indications in dermoscopy

Indicações não tradicionais da dermatoscopia

Carlos Augusto Silva Bastos

Abstract: Dermoscopy is a proven technique in the in vivo diagnosis of pigmented lesions. New uses in other dermatoses and in the control of clinical and surgical treatments are developing quickly. This article presents some examples of other such applications for dermoscopy.


New Techniques

Filling of the nasojugal fold and the lateral infraorbital depression with a 30G microcannula

Preenchimento do sulco nasojugal e da depressão infraorbital lateral com microcânula 30G

André Vieira Braz, Bruno Olavarria Aquino

Abstract: The techniques for filling the nasojugal fold with hyaluronic acid are widely discussed by dermatologists, plastic surgeons, and ophthalmologists but lack consensus in the recent literature reviews. Due to the location of the nasojugal fold – in a topographic region that has thin skin, is close to the eye, and is intensely vascularized – the application of hyaluronic acid with needles can cause undesired complications such as intravascular injection, echymoses, and hematomas. Thus, an innovative hyaluronic acid filling technique for this area was developed based on the careful evaluation of patients: retroinjection with the 30G microcannula.


Poly-L-lactic acid in the rejuvenation of the medial and anterior arms

Ácido Poli-L-láctico na região medial dos braços

Daniel Dal’Asta Coimbra, Adriana Gutstein da Fonseca Amorim

Abstract: Poly-L-lactic acid is an aliphatic polyester, a lactic acid polymer. It is a biocompatible, fully absorbable and immunologically inert substance. Its action mechanism is based on the increase of dermal tissue by stimulating collagen production. The application of this substance in the face is well known, however there are few publications on its use in other areas of the body. This article describes for the use of poly-L-lactic acid in the deep dermis to rejuvenate the medial and anterior region of the arms.


Case reports

Calcium hydroxylapatite-based treatment for rejuvenation of the hands

Tratamento para rejuvenescimento das mãos com hidroxiapatita de cálcio

Mariane Midori Shono, Ane Beatriz Mautari Niwa, Nuno Eduardo Sanches Osório

Abstract: Calcium hydroxylapatite is a biocompatible, non-antigenic, biodegradable, opaque material that is a viable treatment option for rejuvenating the hands by increasing their volume and reducing the visibility of blood vessels and tendons. This article describes 16 cases treated with a half syringe of calcium hydroxylapatite in the back of each hand. The results suggested that the treatment was safe, well tolerated and effective, with a high degree of satisfaction in 75% of cases and clinical improvement for up to 12 months after the injection.


Fractional CO2 laser and fusidic acid in Zoon’s balanitis: a case report

Laser fracionado de CO2 e ácido fusídico na balanite de Zoon: relato de caso

Sonia Maria Fonseca de Andrade, Fernanda Roberta Lorenski , Débora Chaves Silva Pinto, Antônio Tebcherani, Michele Cavalcante Pontes

Abstract: Zoon's balanitis is a benign chronic inflammatory lesion of unknown etiology. This article reports the case of a 66-year-old male patient who presented a 2-year history of a erythematous plaque located on the glans penis. The lesion had not been very responsive to conservative topical treatment with corticoid. A significant reduction in the plaque's size and an improvement in the pruritus was observed with the use of fractional CO2 laser combined with fusidic acid. The treatment was well tolerated and easy to carry out, and improved the patient's quality of life.


Interpolation flap for closing a surgical defect in the ear lobe

Retalho de interpolação para fechamento de defeito cirúrgico em lóbulo de orelha

Rogério Nabor Kondo, Rubenso Pontello Júnior, Vivian Cristina Holanda Lopes, Rodrigo Antonio Bittar , Allamandra Moura Pereira

Abstract: An interpolation flap is an effective method for reconstructing large and deep defects when the surrounding tissue does not allow direct closure. These flaps use tissue from non-adjacent areas with a vascular pedicle that supplies the flap until neovascularization between the flap and the recipient area occurs. This study describes the use of an interpolation flap to close a defect in the anterior ear lobe that resulted from the excision of two basal cell carcinomas.


Reconstruction of the lower lip using Karapandzic and Gilles flaps after the excision of squamous cell carcinoma

Reconstrução do lábio inferior com retalhos de Karapandzic e Gilles após excisão de carcinoma espinocelular

Leticia Arsie Contin, Mário Marques de Carvalho, Carlos D´Apparecida S. Machado Filho, Marcos Eiji Hayashida, Thaís Serranio Ferraz, Bones Ferreira Gonçalves Jr.

Abstract: Squamous cell carcinomas located on the lower lip represent 20-30% of all oral cancers, and present good prognosis when diagnosed early. Cervical lymph node metastases occur in 5-20% of cases. The case of a female patient with a nodular-ulcerated infiltrating lesion affecting one-third of the lower lip is described. The examination of lymph nodes yielded normal results. The excision of the lesion was carried out and the labial reconstruction performed using a Karapandzic flap on the right side and a Gilles flap on the left, with a commissuroplasty carried out in a second operation. The procedure produced a cosmetically acceptable result, with good recovery in speech and swallowing. No recurrences or metastases were observed within tho years of follow-up.


Giant soft fibroma located in the vulva: a case report

Fibroma mole gigante de localização vulvar: relato de caso

Lauro Lourival Lopes Filho, Ione Maria Ribeiro Soares Lopes, Edson Santos Ferreira Filho, Theodoro Ribeiro Gonçalves Neto, Lauro Rodolpho Soares Lopes

Abstract: This article describes the case of a soft fibroma of unusual size and development located in the vulva of a post-menopausal woman.



Performing Mohs Micrographic Surgery in a university hospital

A experiência da implantação da cirurgia micrográfica de Mohs em um serviço universitário

Heliane Sanae Suzuki, Mauricio Shigueru Sato

Abstract: Introduction: Mohs Micrographic Surgery is a surgical technique that produces the greatest cure rates and the lowest recurrence in the treatment of skin cancer. This article describes the experience of performing micrographic surgery in a university hospital, with the aim of introducing the process and disseminating the technique.


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