A cirurgia reconstrutiva em patologia oncológica do nariz : paralisia do nervo facial anatomia cirurgia do nariz

RESUMO: Os carcinomas localizados no nariz são muito frequentes em todas as séries conhecidas. São de diagnóstico clínico fácil e a sua confirmação por biópsia é muito segura. As terapêuticas mais indicadas são a cirurgia e a radioterapia, genericamente eficazes. Verifica-se, no entanto, que os pacientes continuam a solicitar tratamento em estádios muito avançados, mesmo conhecendo o diagnóstico e tendo acesso aos serviços sem custos. Esta situação poderá explicar-se face ao curso relativamente lento de muitos destes tumores e à idade geralmente avançada dos doentes que, de acordo com alguns inquéritos, receiam mais a terapeûtica do que a doença. Para obtenção de informação útil para condução deste problema, foram ainda analisados outros parâmetros. A maioria dos pacientes continua a solicitar tratamento quando as lesões envolvem duas subunidades nasais. Esta circunstância permite planear o tratamento cirúrgico com relativa facilidade, isto é, com exérese e reconstrução cujo resultado estético final é bastante aceitável. Os tumores de grandes dimensões, envolvendo várias subunidades, sendo frequentes, raramente implicam rinectomia total. Pelo contrário, são mais frequentes os tumores que envolvem metade do nariz e as estruturas vizinhas tais como o maxilar, a órbita e o lábio superior, atingindo mesmo a base do crânio. O controlo da doença nestes estádios é muito difícil. Não raramente, quando se crê que a doença está controlada, a cirurgia reconstrutiva bem como outras formas de reabilitação conjugadas, deixam ainda muita insatisfação. A nossa actividade tem-se desenvolvido seguindo os critérios adoptados nos melhores centros, isto é, as técnicas clássicas, complementadas com refinamentos recentes. Porém reflectindo sobre os resultados obtidos no tratamento de tumores do nariz, surge-nos um conjunto de questões para as quais ainda não encontrámos respostas cabais. Actuando de acordo com os princípios que definem o estado da arte, não obtivemos ainda resultados que satisfaçam tanto os doentes quanto os cirurgiões. Incessantemente procuramos novos dados técnicos e científicos que nos permitam sair deste ciclo vicioso em que o doente retarda a procura de assistência, receoso de que a terapêutica o deixe desfigurado. Tendo sempre em vista a obtenção dos melhores resultados com o mínimo de tempos cirúrgicos, valorizamos alguns detalhes praticados nos retalhos com padrão vascular bem definido. Dado que as sequelas na zona dadora de tecidos são uma incontornável preocupação, procuramos refinar a sua aplicação no sentido de as atenuarmos. A fronte, excelente zona dadora para reconstrucção nasal major, era sede de sequelas actualmente inaceitáveis. Estudado o comportamento dos tecidos na fronte, depois de levantado o retalho e efectuado o seu encerramento com uso da técnica de expansão intra-operatória, determinámos a presença do Factor de Crescimento Vascular Endotelial no próprio retalho e na zona dadora, tendo em vista que a sua presença poderá explicar o comportamento dos tecidos que foram submetidos a esta técnica. Procurou-se estudar a qualidade da reconstrução em 45 pacientes submetidos a cirurgia de exérese e reconstrução nasal major, assim como a qualidade de vida, relacionada com a doença e a terapêutica. Embora se possa admitir a existência de dados sugestivos de estratégias mais adequadas, não foi possível relacionar a qualidade da reconstrução com qualidade de vida dos pacientes. Poderá eventualmente concluir-se que a observação permanente da reconstrução, com qualidade estética e funcional, será o melhor método de alterar a ideia clássica, ainda muito divulgada, mas já ultrapassada, de que a cirurgia reconstrutiva do nariz não é mais que transformar um defeito horroroso num defeito ridículo.---------------ABSTRACT: Malignant tumours found in the nose are very frequent in all known series. Clinical diagnosis is simple and confirmation of biopsy diagnosis is accessible and safe. The most advisable therapies are surgery and radiotherapy. Despite everything patients continue to wait until the tumour is in an advanced stage before asking for therapy, although they know the diagnosis and have free access to specialised services. This situation could probably be explained by the slow development rate of the tumours which is associated with the age of the patient. Upon inquiry, it was found that a significant number of patients are more afraid of therapy than of the disease itself. Other parameters have been analysed in order to obtain useful information about the management of this problem. The majority of patients seek adequate treatment when the lesions involve two nasal subunits. This allows the programming of surgical therapy with relative ease as they may be removed and reconstructed with interesting final aesthetical results. Large tumours involving several subunits are frequent, but they rarely call for total rhinectomy. On the contrary, tumours more frequently involve half of the nose and their neighbouring structures: for example, maxillary, orbital and upper lip, even reaching as far as the base of the skull. The control of the disease is very difficult in these stages.In cases in which it is believed that the disease is under control, reconstructive surgery in conjunction with other forms of rehabilitation still result in a lot of dissatisfaction. In our activity we try to follow the criteria adopted by the best centres following classic techniques, complemented with recent refinements. Reflecting on the treatment of tumours of the nose has led us to a series of questions to which we haven’t yet found the answers. In accordance with the defined principles of ‘the state of the art’ it still doesn’t satisfy either the patients or the surgeons. We are looking for new technical and scientific data which allows us to leave this vicious cycle, in that the deferred patient avoids looking for assistance, based on the fear that therapy could leave them disfigured. We attach importance to some practiced details on the well-defined vascular pattern of the flaps, with the principle aim of obtaining a good result, from the minimum number of operations. It is known that sequels in donor sites are a concern, so applied refinements are used in order to reduce the defect. The forehead has been considered an excellent donor site for major nasal reconstruction but the area of sequel is nowadays unacceptable. We tried to study the behaviour of the tissues of the forehead after taking the flap and closing the wound, using the intraoperative expansion technique. We determined the presence of Vascular Endothelial Growth Factor in the flaps and in the donor site, in which its presence could explain the behaviour of the tissues of the forehead that are submitted to this technique. The quality of the reconstruction was studied in 45 patients who were submitted to surgical exeresisand major nasal reconstruction, as was the relationship between the disease and the therapy regarding quality of life. It was not possible to directely relate the quality of the reconstruction to the quality of patients life, although some suggestive data of more adequate manegement may be interesting. One might eventually conclude that, permanent exposure of the reconstruction with aesthetic and funcional quality would be the best method in order to modify the classic idea which is still known although overridden today, that nasal reconstruction could transform a horrible defect into a ridiculous one.-------RÉSUMÉ: Les carcinomes situés sur le nez sont très fréquents dans toutes les séries connues. Ils sont de diagnostic facile et la confirmation de ce dernier par une biopsie, est accessible et très fiable. La chirurgie et la radiothérapie sont les thérapeutiques les mieux indiquées. Toutefois les patients continuent de solliciter un traitement, seulement dans des états très avancés bien qu’ils aient eu connaissance du diagnostic et ayant accès aux services. Cette situation pourra probablement s’expliquer par l’évolution relativement indolente de beaucoup de tumeurs, associée à l’âge des malades; bien que selon quelques enquêtes réalisées un nombre élevé de malades craint davantage la thérapeutique que la maladie. D’autres paramètres sont analysés en vue d’obtenir des informations utiles pour l’accompagnement de ce problème. La majorité de nos patients sollicite le traitement adéquat quand les lésions entourent deux sous-unités nasales, ce qui permet de planifier le traitement chirurgique avec une certaine facilité, c’est à dire l’exérèse et la reconstruction ayant un résultat final esthétique généralement très acceptable. Les tumeurs de grandes dimensions entourant différentes sous-unités sont fréquentes mais elles impliquent rarement une amputation nasal total. Au contraire, les tumeurs les plus fréquentes sont celles qui entourent la moitié du nez et les structures voisines comme le maxillaire, l’orbite et la lèvre supérieure, parfois, elles peuvent même atteindre la base du crâne. Le contrôle de la maladie dans ces états est très difficile et quand nous pensons que la maladie est contrôlée, la chirurgie reconstructrice associée à d’autres formes de réhabilitation provoquent encore une grande insatisfaction. Nous exerçons notre activité en essayant de suivre les critères adoptés dans les meilleurs centres. Nous appliquons les techniques classiques complétées de retouches pour obtenir un meilleur resultat. Le fait de traiter les tumeurs nasales nous fait réfléchir et poser un ensemble de questions auxquelles nous n’avons pas pu trouver de réponses. En actuant en accord avec les principes qui définissent l’état de l’art, nous n’avons pas obtenu de résultats qui satisfassent les malades et les chirurgiens. Nous recherchons de nouvelles données techniques et scientifiques qui nous permettent de sortir de ce cercle vicieux dans lequel le patient retarde la recherche d’aide craignant que la thérapeutique le défigure. Nous valorisons certains détails pratiqués sur les lambeaux de patron vasculaire bien défini et ayant comme principaux objectifs l’obtention d’un bon résultat en moins de temps de chirurgie. Nous savons que les séquelles de la zone donneuse de tissus sont préoccupantes, ainsi, que les retouches qui ont été appliqués dans l’objectif de les atténuer. Le front, excellente zone donneuse pour la reconstruction nasale majeure, était une source de séquelle actuellement inacceptable. Nous avons étudié le comportement des tissus du front après avoir relevé le lambeau et effectué la fermeture avec la technique de l’expansion intraoperative. Nous avons déterminé la présence du Facteur de Croissance Vasculaire Endothéliale dans le propre lambeau et dans la zone donneuse, celle-ci pourra expliquer le comportement des tissus du front qui ont été soumis à cette technique. On a essayé d´etudier la qualité de la reconstruction sur 45 patients soumis à la chirurgie d´exérèse et la reconstruction nasal majeure, ainsi comme la qualité de vie en relation avec la maladie et la thérapie. Quoique l´on puisse conclure par l´existence des données subjectives des stratégies plus justes, il est impossible de faire un rapport sur la qualité de la reconstruction avec la qualité de vie des patients. Eventuellement l´on purrait conclure que l´observation permanente de la reconstruction avec qualité esthétique et fonctionnelle, se serait la meilleure méthod de changer l´idée classique, mais depassée, de que la rhinopoièse n´est pas que transformer un affreux défaut par un défaut ridicule.

Les Plus Anciens Mastodontes Tetralophodontes (Langhien inférieur Vb), évolution et remarques sur la Tetralophodontie

This study deals with mastodont teeth found near Lisbon in Lower Langhian (lower Middle Miocene) fluviatile, feldspathic sands (Vb division). Conclusions are as follows: 1. Tetralophodont molars (even if at a still primitive stade of the tetralophodont condition) do exist at least since lower Langhian times, and not only since late Middle Miocene as was previously known. 2. Tri- and tetralophodont structures may (and indeed do) coexist in the same individual: such examples do not correspond to transitional forms, but instead to a mosaic of juxtaposed characters (however this does not mean there are no transitional forms in other instances). 3. So these structures coexisted in a population not yet genetically separated beyond fertile cross-breeding, i.e. beyond species' level. 4. Origin of the tetralophodont molar was due to some mutation (s). but without crossing species, limits and even more genus'ones. 5. At this times probably soon after the first appearance of tetralophodont mutants, animals with such characters were a small but significant minority among the population (17% if account is taken on D4's: only 2% after M2's). 6. There was not then any direct and clear correlation between number of lophs (transversal crests) and tooth size, even if the increase of such number goes along with length's increase. 7. Dimensions (length in special) in tetralophodont teeth tend to exceed those in «normal» trilophodont teeth, this being particularly clear in D4, even if there is no clear distinction: the situation is quite the same, maybe less marked, with the M2. 8. According to the preceding conclusions there are no reasons to segregate different taxa among such mastodont population on the grounds of the presence in D4, M1 and M2 of 3 or 4 crests (this character being regarded as diagnostic of the genus Tetralophodon). 9. On the contrary, if any natural (in biological sense) classification is disregarded and a morphological parataxonomy is adopted there should be considered both Gomphotherium angustidens and Tetralophodon sp.: however this is absolutely not our opinion.

Notes sur la géologie et la paléontologie du Miocène de Lisbonne. XXI Primeira caracterização de dinoflagelados dos níveis mais baixos da série miocénica de Lisboa

This is the first report on Dinoflagellata from lowermost Miocene beds in Portugal (Tagus basin, Lisbon region, exposure at Benfica). Some general data about Dinoflagellata are presented. Descriptions are provided for some forms: Gonyaulacysta tenuitabulata, Spiniferites ramosus, Achomosphaera sp., Hystrichokolpoma rigaudae, Homotriblium cf. pallidum, Cordosphaeridium sp, and Lingulodinium machaerophorum. Lithostratigraphical study of an important section along Circular highway at Benfica has shown that there is a hitherto unknown sedimentary cycle in Lisbon's lowermost Miocene (upper Oligocene?). Pollen and Ostracoda point out to an Lower Aquitanian or even Upper Chattian age for the first Neogene marine transgression in Portugal, previously considered as Upper Aquitanian or Lower Burdigalian.

Notes sur la géologie et la paleontology du Miocène de Lisbonne. XXII - Une Espèce nouvelle Pokornyella Lusitanica (Ostrocoda), dans le Miocène Inférieur du bassin du Tage

A new species, Pokornyella lusitanica (Ostracoda), from the Lower Miocene (Aquitanian) of the Lisbon area, is described. Some palaeoecological data are presented.

Contributions à la paleontology du Miocène moyen continental du basin du tage

This study on middle Miocene Charophytes from the Tagus'basin indicates the presence of two species. hitherto undescribed from these strata in Portugal, Correlation diagrams of height and width of gyrogonite demonstrate that the populations of Nitellopsis (Tectochara) etrusca from the localities Póvoa de Santarém and Pêro Filho are identical to that from La Grenatière (Hérault, France), The population of Lychnothamnus duplicicarinatus from Tremês is identical to that already known from Anwill (Switzerland). The age of this flora is therefore suggested as being the upper part of the middle Miocene. The results of Charophyte studies are in accordance with stratigraphical conclusions from previously conducted mammalian studies (Antunes and Mein), A table showing the distribution of species in the three portuguese localities is given.

Contributions à la paleontology du Miocène moyen continental du basin du tage

The lignite-clays of Póvoa de Santarém dated as Upper «Vindobonian» (mammalian zone MN6), fielded abundant remains of animals and plants (spores, pollens, seeds, etc.). The forms identified are indicative of several environments. Plants, either aquatic or belonging to swampy areas are predominant (Nuphar sp., Sparganium sp., Stratiotes kaltennordheimensis, cf. Ranunculus sp.). There are also remains of plants characteristiques of a humid rather than a swampy soil such as Polypodiaceae, Myrica ceriferiformis, Toddalia maii, Spirematospermum wetzeleri. The genera Vitis and Ephedra, although rare, point fowards the existence of drier regions in the neighbourhood. The presence of polens such as Picea indicate the presence at some distance less warm upland forest areas.

Notes sur la géologie et la paleontology du Miocène de Lisbonne

This note deals with the stratigraphical and paleontological study of the Palença section on the southern bank of the river Tagus, Portugal, and specially with its coccolithophorids. Three main lithostratigraphical units may be recognized: the lowest one does correspond to the upper part of COTTER's division II, the intermediate one to divisions III and IV-a, the third corresponding to pratically the whole division IV-b, However other and higher levels are also represented. Higher beds are also represented in the same sections; they are less well exposed and were not studied in detail. Caracterisation of biozones on the basis of Coccoliths so far found at Palença section is difficultsince MARTINI's zones have been defined mainly by forms of Discoaster and other genera that are wanting. However we can recognize that the richest assemblage (from beds 17-18, the uppermost layers of blue clays IV-a) may correspond to NN4. This is not in opposition to the results of the study of planctonic foraminifera, that are characteristic of BLOW's N7. Coccoliths from lower beds do not allow at present any valid comparisons.

Contributions à la Paléontologie du Miocène moyen continental du Bassin du Tage. I - Quelques mollusques - Pero Filho, Póvoa de Santarém, Sítio do Mirante

Some land and freshwater mollusks (Gastropoda, Pelecypoda) from three middle Miocene localities: Pêro Filho, Póvoa de Santarém, Sítio do Mirante, all in Ribatejo province, Portugal, are summarily studied. On a systematical viewpoint it has been shown (see also Tableau): - the presence of the genus Janulus, whose species only survive now at Madeira and Canary's islands; - the presence of "Helix" cotteri that may indeed belong in the genus Megalotachea, common in western Europe since "Helvetian" to Messinian times; - Limax, Testacella, Acroloxus and Pseudamnicola are quoted for the first time in portuguese tertiary formations; Ferrisia has been identified for the first time in Iberian Peninsule; - the presence of other forms previously quoted by ANTUNES & ZBYSZEWSKI (1973), is confirmed: Bithynia, Theodoxus, Pisidium. Such faunules are compatible with a middle Miocene age. On a paleobiogeographical viewpoint, some forms suggest mediterranean affinities. Fossil associations do correspond ecologically to either palustrine or stagnant, calm and shallow water conditions (Sítio do Mirante, and essentially also Póvoa de Santarém), or to fluviatile conditions (Pêro Filho).

Contributions à la Paléontologie du Miocène moyen continental du Bassin du Tage. II - Observations sur les dents pharyngiennes de poissons cyprinidés - Póvoa de Santarém.

The study of Cyprinid fish pharyngeal teeth, collected by M. Telles Antunes in continental "Helvetian" sediments from Póvoa de Santarém, makes possible to demonstrate the occurrence of two distinct species. One remains undetermined. The other belongs to the recent genus Leuciscus CUV. Several dental types of this genus are described and figured as Leuciscus antunesi nov. sp. Palaeoclimatical and palaeoecological interpretations are proposed.

Contributions à la Paléontologie du Miocène moyen continental du Bassin du Tage. III - Mammifères - Póvoa de Santarém, Pêro Filho et Chões (Secorio). Conclusions générales

This study on middle Miocene mammalian faunas from Tagus'basin deals particularly with some small mammals hitherto undescribed from Portugal, including a new Glirid (Paraglirulus scalabicensis nov. sp.); it allows an accurate datation by biostratigraphical standards, Megacricetodon crusafonti, Fahlbuschia darocensis, Cricetodon jotae being characteristic of mammalian MN6 unit, thus their age is nearly that of Sansan and Manchones (however the presence of Peridyromys hamadryas and Lagopsis verus do suggest, amidst this biozone, a somewhat later age than Sansan's); it contributes with indirect correlation data with marine formations, as underlying oyster-bearing beds most probably are in correspondance to the apogee of the same transgression that deposed near Lisbon ”schlier" facies from VI-a division (Serravalian, Blow's zones 10-13, Globorotalia meyeri zone); the diversity of mammalian assemblages is surely related to an environement with varied biotopes, whose characterisation becomes easier if account is taken of the preceding papers on mollusks (G. Truc) and Cyprinid fishes (J. Gaudant), and also according to some unpublished paleobotanical data (J. Pais). A table with a synthesis of all paleontological data so far known is presented.

Le monument de “Pedras da Granja” ou de “Pedras Altas” dans la “Várzea de Sintra"

In the present work, the authors describe the excavation of the monument of "Pedras da Granja" or "Pedras Altas", in the Várzea de Sintra. The first part consists of the diary of the excavations, a description of the stratigraphy encountered and of the position of the finds. An inventory of all the material found in this monument is given in the second part. The conclusions show that the monument was built on the surface of a lapiás whose crevices were used for the insertion of the standing stones, and for the deposition of the dead. Three archaeological levels were shown to exist: - upper level: Bell Beaker level; - intermediate level containing some artifacts of the Bell Beaker culture; - lower, older level with human remains more or less in situ, belonging to a local Neolithic-culture influenced by cultural imports of foreign origin. The three levels are separated, at the southern edge of the site, by layers of fallen stones. The human remains belong to some old people, but mostly to young men, women and children.

Connaissances stratigraphiques sur la base du Mésozoique portugais

In Portugal, the Mesozoic lower part is principally composed of conglomeratic, arenitic and pelitic deposits, which are here and there associated with carbonates rocks and evaporites. The Germanic Triassic succession is not observed. The Muschelkalk facies do not exist. Carbonates formation, and some thick evaporites deposits (Keuper facies) are of early Jurassic in age. The thick red beds accumulations deposited in a continental environment are Triassic. In Coimbra area the oldest palynomorphs found are Camian-Norian. In South Portugal (Algarve), the triassic serie must be more complete with a lower Triassic rich in Stegocephales bone-beds.

Le Crétacé inférieur de la marge atlantique portugaise: biostratigraphie, organization séquentielle, evolution paléogéographique

This paper gives a short description of main stratigraphic unities from the early Cretaceous in Estremadura and Algarve, with their lithological, sedimentological and paleontological characteristics. The distribution of facies enable to propose a paleogeographic frame including eroded high areas and sedimentary low areas roughly parallel to the present coast. The early Cretaceous from Estremadura is splited up into three megasequences each one with regressive then transgressive tendencies: this fact must be connected with the leading action of distensive, slow or sudden, movements. Beyond the hercynian fault of Messejana, Algarve presents a different sedimentary evolution during the early Cretaceous.

Évolution géologique de la marge ouest-ibérique

This paper is a summary of the results of the authors recent researches about the Western Iberian continental margin. During the Mesozoic, the margin is affected by two consecutive extensional phases interpreted as the result from two episodes of rifting in the Atlantic. Then during Cenozoic, subsidence was interrupted by compression and related deformation, specially during Eocene time. Ante-mesozoic basement controls the structural and sedimentary evolution of the margin.

La marge continentale sud-portugaise: évolution structurale et sédimentaire

The structural and sedimentary evolution of the portuguese continental margin South of Setúbal Canyon is outlined from the study of many seismic reflection profiles and rocks samples. During Triassic and Early Liassic time, a distension affects the Algarve margin that belongs to the Mesogean area. Off Baixo Alentejo rifting phases at Late Jurassic and Early Cretaceous times induced opening or widening of the adjacent part of the Atlantic ocean. Alpine orogeny is inferred to explain the Eocene and Miocene deformation of the margin specially along the main NE-SW fractures.