Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773


Volume 5
Number 2


| English

Continuing medical education

Photography in dermatologic surgery and cosmiatry-Part I

A fotografia na cirurgia dermatológica e na cosmiatria – Parte I

Maria Valéria Bussamara Pinheiro

Questions and answers of previous number

Abstract: Photography is an essential tool in the dermatologist's daily practice and can be used in various ways. From simple records of lesions verified in dermatological examinations to illustrations of a treatment's result, photographs document more clearly and concisely what is seen due to the utterly descriptive nature of this medium. Nevertheless, it is important to note that the present article refers specifically to what is known as Medical Photography, a type of photography that reproduces subject matter with maximum detail and relevant information. To achieve this, it is necessary to master the basics of photographic technique, including knowledge of available equipment and the fundamentals of digital technology, and also to establish a photographic routine that includes the standardization of the images.


Original Article

Microneedling experimental study and classification of the resulting injury

Microagulhamento: estudo experimental e classificação da injúria provocada

Emerson Vasconcelos de Andrade Lima, Mariana de Andrade Lima, Daniela Takano

Abstract: Introduction: A trend is currently observed towards the indication of less invasive procedures, isolated or combined, in the treatment of stretch marks, scars, and the effects of aging. Microneedling is an option that stimulates collagen production without causing the total de-epithelization observed in ablative techniques. Objective: To carry out an experimental study aimed at establishing the correlation between the lengths of the cylinder's needles used for microneedling with the depth of the damage inflicted to the skin. Methods: Biopsies were performed in skin areas of alive pigs that underwent microneedling with cylinders containing 192 needles of 0. 5 - 1, 1. 5 -2 and 2. 5 mm. Results: Microscopic examination carried out immediately after the procedure revealed vascular ectasia with extravasation of red blood cells, affecting the papillary dermis with 0. 5 mm needles and reaching the reticular dermis with longer needles. The authors propose classifying the inflicted injury as mild (0. 5 mm needles), moderate (1. 0 and 1. 5 mm needles), and deep (2. 0 to 2. 5mm needles). Conclusion: The microneedling procedure can be indicated for a broad spectrum of skin alterations when the goal is to stimulate the production of collagen. Establishing the relationship between the length of the needle used and the resulting damage to the skin assists in choosing the microneedling tool used in different directions.


Reconstruction of nasal defects after tumor excision through Mohs micrographic surgery

Reconstrução dos defeitos nasais após exérese de tumores pela cirurgia micrográfica de Mohs

Emerson Henrique Padoveze, Selma Schuatz Cernea

Abstract: Introduction: The reconstruction of surgical defects resulting from the excision of tumors in the nose is a challenge for dermatologic surgeons due to its rigid structure and low mobility. The Mohs Micrographic Surgery technique allows the preservation of healthy tissue and leads to a smaller surgical wound. Objective: To demonstrate techniques for surgical correction of defects after removal of tumors of the nose through Mohs Micrographic Surgery, according to the anatomical location of the tumor. Methods: Descriptive study of patients operated on using Mohs Micrographic Surgery during the period 1996-2010. Patient images taken pre-, intra-, and post-operatively were analyzed with the aim of classifying the defect's anatomic location and the type of surgical reconstruction adopted. Results: 170 patients (totaling 203 lesions) were included in the study. The most common locations for tumors were (in descending order): nasal ala, dorsum, tip, and lateral wall. The advancement flap was the most common reconstruction type for lesions located in the lateral wall and in the nasal ala. Grafts were most often used in lesions located in the tip of the nose. Grafts and advancement flaps were more frequently used in the dorsum of the nose. Conclusions: The parameters that provide guidance on choosing the best reconstruction method must take into consideration the size and location of the surgical defect.


Skin barrier in atopic dermatitis: the importance of an appropriate cleansing agent

Barreira cutânea na dermatite atópica: o valor de um limpador adequado

Flávia Alvim Sant’Anna Addor, Vanessa de Melo Silva

Abstract: Introduction: Skin xerosis commonly occurs in atopic dermatitis, promoting pruritus and inflammation. Hygiene with syndets (synthetic detergents) is gentle and preserves the skin barrier. Objective: To evaluate the skin's tolerance, and improvement of the xerosis, with the use of a shower gel specially developed for atopic skin. Methods: Thirty-three patients (18 to 50-years-old) were evaluated during four weeks, when using exclusively this product. Hydration, transepidermal water loss, and skin surface pH measurements were taken from the forearm at baseline and after a single application, and were compared to the untreated control area (contralateral forearm). Results: All patients completed the study and there were no adverse reactions. Higher levels of hydration and a reduction of transepidermal water loss were verified in the area washed with the shower gel when compared to the area washed with pure water. Significant improvement was observed in the pruritus and skin smoothness, and there was less irritation and dryness after continued use. Conclusions: A cleansing process using a syndet gel was demonstrated as capable of preserving not only the skin's integrity, but also the skin barrier in atopic patients, in addition to improving clinical signs and symptoms related to xerosis, such as dryness and pruritus.


Treatment of Nevus of Ota in patients from Western populations with high phototypes

Tratamento do nevo de Ota em ocidentais de fototipos altos

Milena Cordeiro Afradique, Danielle de Paula Aguiar, Maluf Marcos Gabbay Belicha, Dina Zylberztejn, Bruna Souza Félix Bravo

Abstract: Introduction: Nevus of Ota is a dermal melanocytic nevus located in the skin area that is innervated by the second and third branches of the facial nerve. It occurs mainly in patients of Asian ethnic background. The present study was aimed at evaluating the therapeutic response in the Western population, where higher skin types and characteristics diverse from those that have already been studied are common. Methods: A retrospective study based on the analysis of medical records, an active search of patients and the application of a questionnaire. All study patients were treated with 1,064 nm Q-Switched Nd:YAG laser, with or without a 532 nm tip, with 1 to 4-month intervals between sessions, 10ns pulse duration, 3mm spot size, 1 to 3 Hz frequencies and 2 to 12 J/cm2fluences. Results: According to the research physicians' evaluation, from the seven assessed patients, three had excellent improvement (greater than 75%), two had good response (51-75%) and one had moderate response (25-50%). The analysis of the degree of patient satisfaction showed that four patients reported being very satisfied and three, satisfied. The best results were observed in patients with phototypes up to grade IV and after having undergone seven sessions. Conclusions: QS lasers have proven a useful tool for treating patients with Nevus of Ota and high skin phototypes.


Nail surgery: followup on cases conductedduring a practical course of a Dermatological Meeting

Cirurgia das unhas. Seguimento de casos operados em curso prático realizado em Congresso Dermatológico

Nilton Gioia Di Chiacchio, Flávia Regina Ferreira, Samuel Henrique Mandelbaum, Nilton Di Chiacchio, Eckart Haneke

Abstract: Introduction: Workshops are offered during Dermatological Meetings in order to teach surgical procedures, both live and in detail. Nevertheless, access to post-operative developments, as well as to the results obtained, are restricted to the physicians from the medical services responsible for organizing these events. Objective: To assess, and make known, the progress and results of previously operated cases. Methods: Eight patients with different pre-operative diagnoses were operated on the nail surgery workshop that occurred during the Brazilian dermatological meeting RADESP 2011, with a nine-month follow up. The results were evaluated using photographs, taken every three months, by the surgeons responsible for the surgeries. Results: Of the eight operated cases, two were considered as yielding satisfactory results (one with mild dystrophy of the nail plate and the other with time considered insufficient for better assessment), and five were deemed as cured. One case did not return for the follow-up visits. Conclusion: Following up and presenting the post-operative development of these patients as well as publishing the responsible surgeons' evaluations, complements the knowledge acquired by the workshops' attendees, and that of other participants at the meetings.


Treatment of gynoid lipodystrophy with unipolar radiofrequency: clinical, laboratory, and ultrasonographic evaluation

Tratamento da lipodistrofia ginoide com radiofrequência unipolar: avaliação clínica, laboratorial e ultrassonográfica

Bruna Souza Felix Bravo, Maria Claudia Almeida Issa, Raul Luiz de Souza Muniz, Carolina Martinez Torrado

Abstract: Introduction: Gynoid lipodystrophy may affect up to 95% of post-pubertal women. Treatments are aimed at improving the skin's appearance. Invasive procedures have long recovery times and may cause complications. Non-invasive methods, such as radiofrequency, are increasingly becoming popular. Objective: To evaluate unipolar radiofrequency's safety and efficacy in the treatment of gynoid lipodystrophy. Methods: Eight women with gynoid lipodystrophy grades II and III, in the gluteus region and thighs, underwent treatment with four sessions of unipolar radiofrequency at fortnightly intervals. Clinical-photographic, laboratory, and ultrasound evaluations of the patients were performed before, during, and 30 days after the end of the last session. Results: Improvement in the sagging of the skin was clinically observed in all treated patients. Four patients also had improvement in morphology. The ultrasound evaluation showed a statistically significant increase (p <0. 05%) in dermal thickness after the treatment in seven of eight patients. There were no laboratory abnormalities. Conclusions: Unipolar radiofrequency is an effective and safe method in the treatment of gynoid lipodystrophy in the gluteus region and thighs.


Inframammary hyperhidrosis: clinical and gravimetric characterization

Hiperidrose inframamária: caracterização clínica e gravimétrica

Gabriel A. de A. Sampaio, Ada Regina Trindade de Almeida, Ana Flávia Nogueira Saliba, Natássia Pinheiro de Lavor Queiroz

Abstract: Introduction: Hyperhidrosis is characterized by excessive, generalized, or focal sweating. The idiopathic or primary forms are usually focal. The inframammary location is atypical, being underrepor-ted. The severity of hyperhidrosis is evaluated through objective methods (gravimetry) or measures of impact on the quality of life (Hyperhidrosis Disease Severity Scale). Objectives: To characterize inframammary hyperhidrosis regarding its prevalence associated factors, impact on quality of life, and gravimetry. Methods: An observational, descriptive, and transversal study was carried out, in which all patients seen during a certain week were asked about the presence of excessive inframammary sweating. Those who answered positively were administered a questionnaire, were assessed according to the severity scale, and underwent gravimetry. The data were analyzed using descriptive statistics and chi-square test (x2). Results: A total of 678 patients were seen, of whom 39 (5. 7%) confirmed the complaint of inframammary hyperhydrosis. Statistical association between the gravimetry's result and body mass index was detected. Conclusions: The prevalence of inframammary hyperhydrosis was demonstrated as an important location for primary focal inframammary hyperhydrosis. The characterization of inframammary hyperhydrosis-up until now a condition that has been little studied-can serve as a basis for future studies on therapeutic options that could improve patients' quality of life.


Review articles

Platelet-rich plasma in dermatology

Plasma rico em plaquetas em dermatologia

Marcia Regina Monteiro

Abstract: The present article describes Platelet-Rich Plasma, with emphasis on its use in dermatology. The application of this procedure in medicine has become increasingly frequent during the last decade. Most publications on the topic arise from areas such as Orthopaedics, Sports Medicine, and Odontology. In the dermatologic field, Platelet-Rich Plasma has been used in order to promote accelerated wound healing, as an adjuvant treatment in rejuvenation and alopecia, and even after laser sessions. In the present review, the authors used articles published on the subject, attributing the Oxford Centre for Evidence Based Medicine's "Level of Scientific Evidence" classification.


Diagnostic Imaging

Talon noir: dermoscopy assisted differential diagnosis of pigmented lesions

Talon noir: auxílio da dermatoscopia no diagnóstico diferencial de lesão pigmentada

Fred Bernardes Filho, Maria Victória Quaresma, Karoline Silva Paolini, Natalia de Carvalho Rocha, Bernard Kawa Kac, Luna Azulay-Abulafia

Abstract: Talon noir was first described in 1961 by Peachey as atraumatic petechial eruption characteristic of basketball players' heels, and were originally called calcaneal petechiae. It is a dermatosis linked to trauma, with asymptomatic lesions, marked by the presence of blood within the stratum corneum. It presents varied clinical manifestations, with the location depending on the involved provocative fac-tor. The present study describes a case of talon noir in a patient with psoriasis vulgaris and demonstrates the importance of the correlation of clinical, dermoscopic, and histopathological characteristics.


New Techniques

Reconstruction of the superior helix

Reconstrução da região superior da hélice

Guilherme Augusto Gadens, Paulo Rodrigo Pacola, Arash Kimyai-Asadi

Abstract: The ear is a complex anatomical structure in which each subunit has unique characteristics. No single reconstruction technique could work in all situations; therefore, knowing different ways to reconstruct surgical defects in each one of these subunits is essential to achieving the best cosmetic results. We report here a detailed explanation of a superior helical advancement flap designated to repairs of the upper helical rim.


Case reports

Thioglycolic acid peeling in Schamberg’s disease

Peeling de ácido tioglicólico na doença de Schamberg

Mariana Hammerschmidt, Arthur Conelian Gentili, Themis Hepp, Maira Mitsue Mukai

Abstract: Schamberg's disease is a progressive pigmentary dermatosis of chronic course. The present article describes the use of thioglycolic acid peelings in Schamberg's disease, with histological and photographic analyses. A 43-year-old female patient with clinical and histological diagnoses of Schamberg's disease underwent five sessions of 10% thioglycolic acid peeling in gel with an interval of 15 days between each session. The patient had considerable whitening of the lesions, with clinical improvement of 68.7%. Thioglycolic acid solubilizes the haemosiderin, being a treatment option that leads to the whitening of the lesions with good tolerance and few side effects.


Treatment of folliculitis decalvans with Nd: YAG laser

Tratamento da foliculite decalvante com laser Nd:YAG

Márcia Raquel Horowitz, Emmanuel Rodrigues de França, Silvana Maria de Morais Cavalcanti, Ângela Cristina Rapela Medeiros, Marcela de Lima Vidal, Manuela Oliveira Resende

Abstract: Treatment of folliculitis decalvans is a major challenge, with a great number of recurrences and required maintenance of disease activity over a long period. Laser-based hair removal has been used in the management of scarring follicular disorders. The present case report aims to illustrate the case of a patient bearing folliculitis decalvans in the lower limb who underwent five therapeutic sessions of neodymium:YAG laser (Nd:YAG), achieving complete remission of the inflammatory lesions with the treatment.


Dermatofibrosarcoma protuberans: atypical location and the importance of Mohs micrographic surgery

Dermatofibrossarcoma protuberans: localização não usual e a importância da cirurgia micrográfica de Mohs

Michelle dos Santos Diniz, Daniel Gontijo Ramos, Mauricio Buzelin Nunes

Abstract: Dermatofibrosarcoma protuberans is a spindle cell neoplasm of intermediate malignancy, nonetheless it presents a high risk of local recurrence. It mainly affects the trunk and limbs, and is rare on the face. The treatment of the tumor can be carried out using conventional surgery with wide surgical margins or Mohs micrographic surgery. Radiation and chemotherapy can be indicated in selected cases. The present article reports the case of a 39-year-old male patient with a 0.7cm yellowish papule on the forehead, whose biopsy and immunohistochemistry confirmed the tumor's diagnosis. The lesion was treated through Mohs micrographic surgery with good aesthetic results.


Case report: Palisaded encapsulated neuroma simulating a Basal Cell Carcinoma

Neuroma encapsulado em paliçada - simulando carcinoma basocelular: Relato de caso

Flávia Naranjo Ravelli, Jayme de Oliveira Filho, Nilceo S. Michalany, Irina Andrea Pires Afonso, Thais Berti Franchin, Ana Carolina Lisboa de Macedo

Abstract: Palisaded encapsulated neuromas are solitary neural skin tumors characterized by the presence of compact and parallel bundles of Schwann cell fascicles. The present article reports a case of this type of tumor, which was confirmed by anatomic pathological examination of a 55-year-old female patient who reported hypochromic macula growth, which had evolved into a smooth domed superficial papule with telangiectasias, simulating a basal cell carcinoma. Having knowledge of this entity is crucial in order to carry out differential diagnoses-comparing it to other lesions-especially basal cell carcinomas, skin appendage tumors, nevi, and epidermal cysts.


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