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INTRODUCTION: Merkel cell carcinoma (MCC) is a very rare and aggressive neoplasm. Due to its rarity, therapeutic guidelines are not well established, especially for regionally advanced disease. Hyperthermic isolated limb perfusion (HILP) with Melphalan and either with or without tumor necrosis factor-alpha (TNF-alpha) is becoming more common in clinical practice, yet the long-term response is not clear. Previous reports have established indications for treatment of unresectable MCC as well as the outcome of MCC patients receiving perfusion treatment in combination with other therapies (e.g., radiation). METHOD: A review was performed of the most important articles in MEDLINE from the last 20 years related to HILP and MCC. It was possible to collect all cases of HILP from the literature. Details of one case of MCC where HILP was administered was included in the literature review. RESULTS: A total of nine cases of MCC receiving ILP were identified in the literature; of these, seven achieved a complete response, one a partial response and one no response. All five patients treated without TNF-alpha had a complete response. Of the four patients treated with TNF-alpha, two had complete, one partial and one no response. CONCLUSION: Based on the cases described, isolated limb perfusion is an acceptable option to treat regional advanced cases of MCC, and the use of TNF-alpha does not impact the overall response.

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We report the case of a 47-year-old woman with a large keloid scar on the sternum who was submitted to a simultaneous scar removal with bilateral breast-reduction mammaplasty. Breast reduction was performed to reduce local skin tension and to provide a skin flap for the full reconstruction of the scar-removal site. The association of these surgical procedures stands as a viable alternative for the reconstruction of the sternum region, producing less keloid scarring.

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Cutaneous injuries of the inferior third of the leg and dorsum of the foot represent a great challenge for plastic surgeons. The poor vascularization and subsequent poor healing encountered in these regions demand detailed knowledge of the local anatomy to select the best surgical alternative for each patient. In patients in whom local or free muscular flaps are not suitable, the fasciocutaneous flaps seem to be a good alternative. The distal pedicled fasciocutaneous flap of the calf was used to cover skin defects of the leg and foot in 22 patients. In 4 patients the authors designed an island flap to prevent a large defect in the donor area and to decrease the time of hospitalization and recovery of the patient. In a severe defect, the flap was used as a cross-leg flap. The results were satisfactory because the flap provided stable coverage for different defects with few complications. The island flap is a good option for achieving a better aesthetic result and can be used in select patients.

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The clinical features of the toxic shock syndrome are well established. It is rapidly developing disease and may be lethal if not recognized and treated in time. Once the syndrome was associated with the use of tampon by menstruating women. Recently this syndrome has been reported as due to Staphylococcus aureus infection. A severe case of toxic shock syndrome in a 18-years-old patient after reduction mammoplasty is reported, and the importance of an early diagnosis is emphasized.

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One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results.

PIP: Between January 1983 and July 1991, well trained surgical teams performed either standard abdominoplasty or miniabdominoplasty on 103 patients who also underwent tubal ligation, total abdominal hysterectomy, or cholecystectomy to determine whether surgeons can effectively combine abdominoplasty with other intraabdominal procedures. Prescribed preoperative procedures included respiratory exercises. Physicians advised patients to stop smoking 2 weeks before surgery. Physicians also instructed them not to take any aspirin or other drugs with anticoagulant effects 2 weeks before surgery. Tubal ligation patients who also underwent standard abdominoplasty were in the operating room for 3 hours and for 2 hours if they underwent miniabdominoplasty. Total abdominal hysterectomy patients were in the operating room for either 3-4 hours (standard abdominoplasty) or 2.5-3 hours (miniabdominoplasty). Surgeons performed cholecystectomy in those patients who only underwent standard abdominoplasty. They were in the operating room for 4-5 hours. The combination of intraabdominal procedure and standard abdominoplasty increased the time in the operating room by 40-90 minutes. Number of days in the hospital for standard abdominoplasty patients included 2-3 for tubal ligation, 5 for total abdominal hysterectomy, an 5-7 for cholecystectomy. Miniabdominoplasty patients were in the hospital 1-2 days for tubal ligation and 5 days for total abdominal hysterectomy. Only 2 minor complications occurred: a seroma and a minor skin slough. 3 patients required transfusion of autologous units of blood and non of them lost more than 500 ml of blood. The physicians encouraged all patients to become ambulatory soon after the operation and to wear elastic stockings to prevent thromboembolic events. As a result, none of the patients suffered a pulmonary embolism. In conclusion, good surgical teams can safely and effectively combine abdominoplasty with intraabdominal procedures.

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Com o advento dos expansores de tecidos surgiu uma nova opçao no tratamento da alopecia pela expansao do couro cabeludo adjacente ao defeito, evitando-se desvantagens das tecnicas anteriormente utilizadas, tais como, sequelas nas areas doadoras e deficiencia na densidade de foliculos pilosos na area reparada. Apresentamos a experiencia do grupo no tratamento de 32 pacientes portadores de alopecia com a utilizacao de expansores de tecido. As areas de alopecia variaram entre 30 e 150 cm quadrados. As patologias consistiram de 12 sequelas de queimadura, dez sequelas de trauma, dez sequelas de resseccao tumoral, quatro nevus pilosos gigantes e dois casos de calvice (padrao masculino). Em todos os casos foi possivel a remocao da area da alopecia e substituicao por couro cabeludo com pilificacao normal, sem sequelas nas areas doadoras. Como desvantagem citamos a necessidade de dois procedimentos cirurgicos e o periodo de dois a quatro meses de expansoes semanais, durante o qual ocorre deformidade evidente do segmento cefalico.

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Tissue expanders have emerged recently as a new option for the treatment of alopecia. The method consists in expanding the scalp beyond the defective area. In this way, some disadvantages like the alterations in the donor area and low density of hair follicles, that may result from other techniques, are avoided. We present our experience with tissue expanders in the treatment of 32 patients with alopecia. The extent of these areas varied from 30 to 150 cm2, and the causes were: burn sequels in 12 patients; trauma sequels in ten; tumoral resections in ten; giant nevus pilosus in four and baldness (male standard) in two patients. The resection of the area with alopecia and the replacement by normal adjacent tissue was possible without any complications in all cases. However some disadvantages were observed. They included the necessity for a second surgical procedure because of marked deformity of the cephalic segment.

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Fifty nine patients with extensive traumatisms of the external ear, including 3 total amputations, 10 partial amputations with maintenance of reduced pedicle and 46 extensive lesions without further vascularization, have been attended in the Emergency Unit of Hospital das Clinicas at University of São Paulo Medical School from 1979 to 1989. Surgical behaviors performed in each case are described and explained in detail. The main purpose of the study was to show the outliving possibilities of the ear even in serious traumas and to emphasize the need of immediate repair of the ear in order to obtain a satisfactory result.

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Ten patients had their vulvar and perineal areas reconstructed using musculocutaneous flaps of the gracilis muscle. Seven patients had extensive resections done for skin carcinomas, two due to traumas and one due to a sequel of Fournier's Syndrome. Reconstruction in tumor cases were performed primarily and the other secondarily. The skin island measured 12 x 8 centimeters and the muscle was taken entirely. The results were satisfactory in all cases. The muscle survived completely, but there was partial skin island loss in 8 instances. In 3 of those cases, there was need for a revision of the flap and skin grafting. The authors concluded that there is always a risk to take the skin island together with the gracilis muscle and the use of the isolated muscle with skin grafting should be considered im most cases.

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