Reconstrução mamária: Experiência de 10 anos / Breast reconstruction: 10 years experience

Introdução: A reconstrução mamária pós-tratamento cirúrgico do câncer de mama (um dos principais cânceres que acometem as mulheres) tem sido progressivamente mais indicada, haja vista o benefício da recuperação psicológica e da qualidade de vida, seja utilizando implantes e/ou tecidos autólogos. O presente trabalho visa demonstrar a experiência da equipe, discutir técnicas operatórias e complicações em relação aos dados da literatura mundial, além de verificar a aplicabilidade da técnica na prática clínica da equipe. Método: Estudo observacional retrospectivo desenvolvido em hospital universitário em Juiz de Fora a partir da revisão de prontuários de pacientes submetidas a mastectomia com reconstrução mamária entre 2010 e 2020. Resultados: Das 860 mamas abordadas, 84% foram imediatas à cirurgia oncológica e 16% foram tardias; o principal acesso ao tecido mamário foi a incisão de Stewart, seguido de incisões inframamárias estendidas, periareolares e T invertido; quanto às técnicas reconstrutoras, destaca-se 35% dos casos com retalho com músculo grande dorsal, 25% com prótese pré-peitoral, 20% com retalho miocutâneo transverso do músculo reto abdominal e 10% com retalho muscular local. As complicações mais incidentes foram deiscência de sítio cirúrgico, seguida de necrose cutânea, seroma, infecção de sítio cirúrgico e hematoma, além de outros menos comuns como dor crônica e ruptura de prótese após mamografia. Conclusão: A reconstrução mamária pós-mastectomia é indispensável para a recuperação física e emocional da mulher, sendo as técnicas utilizadas nos últimos dez anos consistentes, confiáveis, de baixa morbidade e com ótimos resultados estéticos quando bem indicadas.

Introduction: Breast reconstruction after surgical treatment for breast cancer (one of the main cancers that affect women) has been progressively more recommended, given the benefits of psychological recovery and quality of life, whether using implants and/or autologous tissues. The present work aims to demonstrate the team's experience, and discuss operative techniques and complications concerning data from the world literature, in addition to verifying the applicability of the technique in the team's clinical practice. Method: Retrospective observational study developed at a university hospital in Juiz de Fora based on a review of medical records of patients who underwent mastectomy with breast reconstruction between 2010 and 2020. Results: Of the 860 breasts treated, 84% underwent immediate oncological surgery and 16% were late; the main access to the breast tissue was the Stewart incision, followed by extended inframammary, periareolar, and inverted T incisions; regarding reconstructive techniques, 35% of cases used a latissimus dorsi muscle flap, 25% used a prepectoral prosthesis, 20% used a transverse rectus abdominis myocutaneous flap and 10% used a local muscle flap. The most common complications were surgical site dehiscence, followed by skin necrosis, seroma, surgical site infection, and hematoma, in addition to other less common complications such as chronic pain and prosthesis rupture after mammography. Conclusion: Postmastectomy breast reconstruction is essential for a woman's physical and emotional recovery, with the techniques used in the last ten years being consistent, reliable, with low morbidity, and with excellent aesthetic results when correctly indicated.

Reconstrução da região superior do dorso com retalho musculocutâneo do trapézio em V-Y baseado na artéria dorsal da escápula / Reconstruction of the upper region of the back with a V-Y trapezius musculocutaneous flap based on the dorsal artery of the scapula

Introdução: Defeitos na região superior do dorso geralmente são de difícil tratamento, especialmente nos casos de exposição de vértebras, meninge ou material de síntese. O fechamento primário com retalho muscular ou musculocutâneo é a melhor escolha, mas a área doadora para tratar grandes defeitos pode requerer enxertia. A preservação da artéria dorsal da escápula parece assegurar um território cutâneo maior do que o do retalho musculocutâneo do trapézio clássico baseado apenas na artéria cervical transversa. Método: Foi concebida uma ampla ilha triangular de pele sobre o músculo trapézio baseado na artéria dorsal da escápula com transferência por movimento pendular e um procedimento tipo V-Y em cinco pacientes após a extirpação de tumores malignos. Resultados: Os defeitos e as áreas doadoras foram fechados primariamente com total viabilidade dos retalhos e não foram observadas complicações além da ocorrência de seroma. Conclusão: O retalho musculocutâneo do trapézio baseado na artéria dorsal da escápula oferece segurança no tratamento de exposição óssea na região superior do dorso.

Introduction: Defects in the upper region of the back are generally difficult to treat, especially in cases of exposure of vertebrae, meninges, or synthetic material. Primary closure with a muscular or musculocutaneous flap is the best choice, but the donor area to treat large defects may require grafting. Preservation of the dorsal artery of the scapula appears to ensure a larger cutaneous territory than that of the classic trapezius musculocutaneous flap based only on the transverse cervical artery. Method: A wide triangular island of skin was designed over the trapezius muscle based on the dorsal scapular artery with pendulum transfer and a V-Y type procedure in five patients after the extirpation of malignant tumors. Results: The defects and donor areas were closed primarily with full viability of the flaps and no complications were observed other than the occurrence of seroma. Conclusion: The trapezius musculocutaneous flap based on the dorsal artery of the scapula offers safety in the treatment of bone exposure in the upper back region.

Condrossarcoma gigante de corpo esternal: relato de caso / Giant chondrosarcoma of the sternal body: case report

Os tumores de parede torácicas são relativamente inusitados, representando 1 a 2% de todas as neoplasias, e cerca de 5% das neoplasias torácicas. Sarcomas são tumores raros e com apresentação heterogênea. São divididos em dois grandes grupos: tumores ósseos e de partes moles. A ocorrência na parede torácica é rara, representando 8% de todos os sarcomas. O tratamento de escolha é a ressecção com margens ampliadas e, quando ocorre a invasão de estruturas profundas, a toracectomia é indicada. A reconstrução do arcabouço ósseo é realizada com materiais de síntese, proporcionando estabilidade, e é seguida da reconstrução de partes moles com retalhos musculares, musculocutâneos ou locais ao acaso. Os tumores malignos primários da parede torácica correspondem a menos de 1% de todas as neoplasias e incluem grande variedade de lesões ósseas e de tecidos moles. Os condrossarcomas representam 20% dos tumores primários da parede torácica, sendo que 80% têm origem nas costelas e 20% no esterno.

Chest wall tumors are relatively uncommon, representing 1 to 2% of all neoplasms, and approximately 5% of thoracic neoplasms. Sarcomas are rare tumors with heterogeneous presentation. They are divided into two large groups: bone and soft tissue tumors. Occurrence in the chest wall is rare, representing 8% of all sarcomas. The treatment of choice is resection with wide margins and, when invasion of deep structures occurs, thoracotomy is indicated. The reconstruction of the bone framework is carried out with synthetic materials, providing stability, and is followed by the reconstruction of soft tissues with muscular, musculocutaneous, or random local flaps. Primary malignant tumors of the chest wall account for less than 1% of all neoplasms and include a wide variety of bone and soft tissue lesions. Chondrosarcomas represent 20% of primary tumors of the chest wall, with 80% originating in the ribs and 20% in the sternum.

Siguiendo la trayectoria de la abdominoplastia TULUA ­ Revelación de su evolución e impacto global / Tracing the Trajectory of TULUA Abdominoplasty ­ Unveiling its Evolution and Global Impact

La técnica de abdominoplastia TULUA, fue concebida por el Dr. Francisco Villegas en Colombia, su acrónimo en inglés refleja sus principios fundamentales: plicatura Transversal, Sin despegamiento, Liposucción sin restricción que incluye la línea media y flancos, Neo umbilicoplastia, ubicación baja de cicatriz y libre posición del ombligo. A lo largo de los últimos 12 años, la técnica TULUA ha ganado espacio en América Latina, Norteamérica, la zona árabe e India. Destacando su relevancia, se ha propuesto la publicación de un libro monográfico, programado para 2024, que abarcará desde los principios fundamentales hasta las experiencias internacionales con la técnica. Las indicaciones de la abdominoplastia TULUA han evolucionado, incluyendo casos estéticos, secundarios, hernias, cicatrices previas, pérdida masiva de peso, alta definición, aumento muscular y combinaciones con otras plicaturas. Ha sido aplicada con éxito en cierre del abdomen donante de reconstrucción mamaria. A través de investigaciones especializadas y revisiones de pares, la TULUA ha sido reconocida por su aplicabilidad y beneficios, especialmente en la realización segura de liposucción en abdominoplastias. Se sugieren estudios adicionales para evaluar los resultados y posibles complicaciones, abriendo oportunidades para una mayor comprensión y refinamiento. El futuro de la abdominoplastia TULUA parece prometedor, anticipando trabajos prospectivos, indicaciones adicionales y un enfoque gradual para cirujanos en formación. En última instancia, la técnica se presenta como una adición al repertorio de procedimientos estéticos abdominales, contribuyendo al avance de la cirugía abdominal estética.

The TULUA abdominoplasty technique, conceived by Dr. Francisco Villegas in Colombia, its acronym in English reflects its fundamental principles: Transverse plication, no Undermined flap above the umbilicus, Liposuction without restrictions including midline and flanks, Neo umbilicoplasty, low scar placement, and free umbilical positioning. Over the past 12 years, the TULUA technique has gained acceptance in Latin America, North America, the Arab region, and India. Highlighting its relevance, the publication of a monographic book has been proposed, its launch is scheduled for 2024, covering from fundamental principles to international experiences with the technique. Indications for TULUA abdominoplasty have evolved, including aesthetic cases, secondary cases, hernias, previous scars, massive weight loss, high definition, muscle augmentation, and combinations with other plications. It has been successfully applied in closing the donor abdomen for breast reconstruction. Through specialized research and peer reviews, TULUA has been recognized for its applicability and benefits, especially in safely performing liposuction during abdominoplasties. Additional studies are suggested to evaluate results and potential complications, opening opportunities for greater understanding and refinement. The future of TULUA abdominoplasty appears promising, anticipating prospective works, additional indications, and a gradual approach for surgeons in training. Ultimately, the technique presents itself as an addition to the repertoire of abdominal aesthetic procedures, contributing to the advancement of aesthetic abdominal surgery.

Outcomes after elevation of serratus anterior fascia flap versus serratus muscle flap in direct-to-implant breast reconstruction following mastectomy: a prospective study

Abstract Objective: The purpose of this study was to compare postoperative pain between SF flap and serratus anterior muscle (SM) in direct-to-implant breast reconstruction. Methods: This is a prospective cohort study that included 53 women diagnosed with breast cancer who underwent mastectomy and one-stage implant-based breast reconstruction from January 2020 to March 2021. Twenty-nine patients (54.7%) had SF elevation, and 24 patients (45.3%) underwent SM elevation. We evaluated patient-reported early postoperative pain on the first day after surgery. Also, it was reported that all surgical complications in the first month and patient reported outcomes (PROs) were measured with the BRECON 23 questionnaire. Results: The serratus fascia group used implants with larger volumes, 407.6 ± 98.9 cc (p < 0.01). There was no significant difference between the fascial and muscular groups regarding the postoperative pain score reported by the patients (2 versus 3; p = 0.30). Also, there was no difference between the groups regarding early surgical complications and PROs after breast reconstruction. Conclusion: The use of SF seems to cause less morbidity, which makes the technique an alternative to be considered in breast reconstruction. Although there was no statistical difference in postoperative pain scores between the fascia and serratus muscle groups.

Características epidemiológicas y quirúrgicas en pacientes con secuelas de enfermedad de Fournier / Reconstructive techniques in Fournier's disease sequels

Introducción: La gangrena de Fournier actualmente se define como una forma específica de fascitis necrotizante sinérgica, rápida, progresiva y de origen multibacteriano, que afecta principalmente la fascia muscular de región perineal, genital o perianal e incluso de pared abdominal; con punto de partida genitourinario, colorrectal o idiopático. Todo ello, acompañado de gangrena de piel de estas áreas debida a trombosis de vasos sanguíneos subcutáneos. Objetivos: Describir las características epidemiológicas y quirúrgicas de los pacientes secuelares de la enfermedad de Fournier en la Unidad de Cirugía Plástica del Hospital de Clínicas en un período de 2 años. Materiales y métodos: Estudio observacional, descriptivo, de corte transversal, temporalmente retrospectivo, tipo serie de casos. El tipo de muestreo fue no probabilístico a conveniencia. Se presentan 18 pacientes secuelares de enfermedad de Fournier reconstruidos en la Unidad de Cirugía Plástica de Hospital de Clínicas entre los años 2020 y 2021. Resultados: Durante el periodo del estudio se realizaron 395 cirugías en el Servicio de Cirugía Plástica del Hospital de Clínicas, de los cuales 18 pacientes fueron intervenidos quirúrgicamente por secuelas de enfermedad de Fournier, lo que representa el 5% del total. En lo que respecta a las variables demográficas, la edad osciló entre los 37 y 85 años con mayor afectación en la sexta década de la vida con un promedio de 61 años. El 94% de los pacientes fue de sexo masculino; el 89% de los pacientes tenía como patología de base la diabetes mellitus tipo 2, seguido de la obesidad en el 72% y la hipertensión arterial en el 56% de los casos; el 83% de los casos estuvo afectada la región escrotal seguido de la región perineal con el 56% de los pacientes y el pene en el 50% de los casos. La técnica reconstructiva empleada en mayor frecuencia fueron los colgajos en 10 pacientes, seguido del injerto de piel en 8 pacientes, y el cierre primario en 6 pacientes, cabe mencionar que en algunos pacientes se emplearon varias técnicas reconstructivas siguiendo el concepto de reconstrucción por sub-unidades anatómicas, entre los colgajos los más utilizados fueron el colgajo de perforante de la circunfleja femoral medial (perforante de gracilis) con el 50% de los casos seguido del colgajo de transposición fasciocutáneo de la pudenda interna con el 30%, y por último el colgajo de avance fasciocutáneo con el 20% (Tabla 3). La estancia hospitalaria promedio fue de 3 días, con un mínimo de 1 día y un máximo de 5 días post operatorio. Se reportó como complicación la dehiscencia de sutura en 3 pacientes, no se observó complicaciones en el 77% de los casos. Conclusión: Las secuelas de la enfermedad de Fournier sometidos a cirugías representan el 5% del total de cirugías realizadas en nuestro Servicio, son más prevalentes en la sexta década de la vida, afecta más al sexo masculino con diabetes mellitus tipo 2 como patología de base, las técnicas reconstructivas empleadas en las secuelas son variables de acuerdo a las regiones anatómicas afectadas y pueden abarcar desde el cierre primario hasta la utilización de colgajos para su reparación.

Introduction: Fournier's gangrene is currently defined as a specific form of synergistic, rapid, progressive and multibacterial necrotizing fasciitis, which mainly affects the muscular fascia of the perineal, genital, or perianal region and even the abdominal wall; with genitourinary, colorectal, or idiopathic starting point. All of this, accompanied by skin gangrene in these areas due to thrombosis of subcutaneous blood vessels. Objectives: To describe the epidemiological and surgical characteristics of the sequelae patients of Fournier's disease in the Plastic Surgery Unit of the Hospital de Clínicas in a period of 2 years. Materials and methods: Observational, descriptive, cross-sectional, temporally retrospective, case series type study. The type of sampling was non-probabilistic at convenience. Eighteen sequelae patients of Fournier's disease reconstructed in the Plastic Surgery Unit of Hospital de Clínicas between 2020 and 2021 are presented. Results: During the study period, 395 surgeries were performed in the Plastic Surgery Service of the Hospital de Clínicas, of which 18 patients underwent surgery for sequelae of Fournier's disease, which represents 5% of the total. Regarding demographic variables, age ranged between 37 and 85 years with greater impact in the sixth decade of life with an average of 61 years. 94% of the patients were male; 89% of the patients had type 2 diabetes mellitus as an underlying pathology, followed by obesity in 72% and high blood pressure in 56% of cases; In 83% of the cases, the scrotal region was affected, followed by the perineal region in 56% of the patients and the penis in 50% of the cases. The most frequently used reconstructive technique was flaps in 10 patients, followed by skin grafting in 8 patients, and primary closure in 6 patients. It is worth mentioning that in some patients several reconstructive techniques were used following the concept of reconstruction by sub- anatomical units, among the flaps the most used were the medial femoral circumflex perforator flap (gracilis perforator) with 50% of the cases followed by the fasciocutaneous transposition flap of the internal pudendal with 30%, and finally the fasciocutaneous advancement flap with 20% (Table 3). The average hospital stay was 3 days, with a minimum of 1 day and a maximum of 5 days postoperatively. Suture dehiscence was reported as a complication in 3 patients; no complications were observed in 77% of the cases. Conclusion: The sequelae of Fournier's disease undergoing surgeries represent 5% of the total number of surgeries performed in our Service, they are more prevalent in the sixth decade of life, it affects more males with type 2 diabetes mellitus as the underlying pathology, the reconstructive techniques used in the sequelae are variable according to the anatomical regions affected and can range from primary closure to the use of flaps for repair.

Anatomic study and clinical application of iliac crest chimeric tissue flap / 中国修复重建外科杂志

OBJECTIVE@#To conduct anatomical study on the iliac crest chimeric tissue flap and summarize its effectiveness of clinical application in repairing limb wounds.@*METHODS@#Latex perfusion and anatomical study were performed on 6 fresh adult cadaver specimens with 12 sides, to observe the initial location, distribution, quantity, and direction of the common circumflexa iliac artery, the deep circumflexa iliac artery, and the superficial circumflexa iliac artery, and to measure their initial external diameter. Between December 2020 and September 2022, the iliac crest chimeric tissue flap repair was performed on 5 patients with soft tissue of limbs and bone defects. There were 3 males and 2 females, with an average age of 46 years (range, 23-60 years). Among them, there were 3 cases of radii and skin soft tissue defects and 2 cases of tibia and skin soft tissue defects. The length of bone defects was 4-8 cm and the area of skin soft tissue defects ranged from 9 cm×5 cm to 15 cm×6 cm. The length of the iliac flap was 4-8 cm and the area of skin flap ranged from 12.0 cm×5.5 cm to 16.0 cm×8.0 cm. The donor sites were directly sutured.@*RESULTS@#Anatomical studies showed that there were 10 common circumflex iliac arteries in 5 specimens, which originated from the lateral or posterolateral side of the transition between the external iliac artery and the femoral artery, with a length of 1.2-1.6 cm and an initial external diameter of 0.8-1.4 mm. In 1 specimen without common circumflexa iliac artery, the superficial and deep circumflex iliac arteries originated from the external iliac artery and the femoral artery, respectively, while the rest originated from the common circumflex iliac artery. The length of superficial circumflex iliac artery was 4.6-6.7 cm, and the initial external diameter was 0.4-0.8 mm. There were 3-6 perforator vessels along the way. The length of deep circumflex iliac artery was 7.8-9.2 cm, and the initial external diameter was 0.5-0.7 mm. There were 3-5 muscular branches, 4-6 periosteal branches, and 2-3 musculocutaneous branches along the way. Based on the anatomical observation results, all iliac crest chimeric tissue flaps were successfully resected and survived after operation. The wounds at recipient and donor sites healed by first intention. All patients were followed up 8-24 months, with an average of 12 months. The tissue flap has good appearance and soft texture. X-ray film reexamination showed that all the osteotomy healed, and no obvious bone resorption was observed during follow-up.@*CONCLUSION@#The common circumflex iliac artery, deep circumflex iliac artery, and superficial circumflex iliac artery were anatomically constant, and it was safe and reliable to use iliac crest chimeric tissue flap in repairing the soft tissue and bone defects of limbs.

Sports rehabilitation in athletes with meniscal lesions based on electroacupuncture associated with sports therapy / Reabilitação esportiva de atletas com lesão meniscal baseada em eletroacupuntura combinada à terapia esportiva / Rehabilitación deportiva de atletas con lesión meniscal basada en electroacupuntura combinada con la terapia deportiva

ABSTRACT Introduction: Meniscal injury is a common condition that can lead to disability due to pain and proprioceptive failure, requiring immediate attention. Combination therapies involve advanced approaches aiming to accelerate rehabilitation in athletes, and electroacupuncture presents therapeutic benefits, although there is still no evidence of its combination with sports therapy. Objective: This paper analyzes the performance of sports rehabilitation in athletes with meniscal lesions using electroacupuncture combined with sports therapy. Methods: The intervention in the control group was based on a traditional range of motion work, muscle strength, proprioceptive training, and other exercise therapies, while the experimental group received a 30 min electro-acupuncture protocol three times a week for four consecutive weeks. The surrogate data (gender, age, disease course, location) are the same. Before treatment, joint activity, muscle strength, total joint scale score of the LYSHOLM questionnaire, and other observational indices were measured during the 6th and 12th week of treatment. The non-parametric statistical method and T-test were used to analyze the changes of each index before and after treatment. After 12 weeks of treatment, the difference between the experimental group and the combination before treatment was significant. Results: The treatment effect of the experimental group was significantly better than the control group. Conclusion: The effect of sports rehabilitation of athletes with meniscus injury based on electroacupuncture combined with sports therapy showed high resolutive application value, indicating an alternative for non-surgical treatment in knee meniscus injuries. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

RESUMO Introdução: A lesão meniscal é um acometimento comum que pode gerar incapacitação por dor e falha proprioceptiva, exigindo atenção imediata. Terapias combinadas envolvem abordagens avançadas com o objetivo de acelerar a reabilitação nos atletas, e a eletroacupuntura apresenta benefícios terapêuticos, embora ainda não possua evidencias de sua combinação com a terapia esportiva. Objetivo: Analisar o desempenho da reabilitação esportiva em atletas com lesão meniscal utilizando eletroacupuntura combinada à terapia esportiva. Métodos: A intervenção no grupo controle baseou-se no trabalho tradicional de amplitude de movimento, força muscular, treinamento proprioceptivo e outros tipos de terapias de exercício enquanto que ao grupo experimental foi adicionado um protocolo de eletro-acupuntura de 30 minutos de duração, 3 vezes por semana durante 4 semanas consecutivas. Os dados de substituição (sexo, idade, curso de doença, localização) são basicamente os mesmos. Antes do tratamento, a atividade articular, a força muscular, o escore total da escala articular do questionário LYSHOLM e outros índices de observação foram medidos na 6ª e 12ª semana do tratamento. O método estatístico não paramétrico e teste-T foram utilizados para analisar as alterações de cada índice antes e depois do tratamento. Após 12 semanas de tratamento, a diferença entre o grupo experimental e a combinação antes do tratamento foi significativa. Resultados: O efeito de tratamento do grupo experimental foi significativamente melhor do que o grupo controle. Conclusão: O efeito de reabilitação esportiva de atletas com lesão meniscal baseada em eletroacupuntura combinada à terapia esportiva demonstrou alto valor de aplicação resolutiva, indicada como alternativa para o tratamento não cirúrgico em lesões no menisco do joelho. Nível de evidência II; Estudos terapêuticos - investigação dos resultados do tratamento.

Resumen Introducción: La lesión meniscal es una lesión común que puede causar incapacidad por dolor y fallo propioceptivo, requiriendo atención inmediata. Las terapias combinadas implican enfoques avanzados con el objetivo de acelerar la rehabilitación en los deportistas, y la electroacupuntura presenta beneficios terapéuticos, aunque todavía no hay pruebas de su combinación con la terapia deportiva. Objetivo: Analizar el rendimiento de la rehabilitación deportiva en atletas con lesión meniscal utilizando electroacupuntura combinada con la terapia deportiva. Métodos: La intervención en el grupo de control se basó en el trabajo tradicional de amplitud de movimiento, fuerza muscular, entrenamiento propioceptivo y otros tipos de terapias de ejercicio, mientras que al grupo experimental se le añadió un protocolo de electroacupuntura de 30 minutos de duración, 3 veces a la semana durante 4 semanas consecutivas. Los datos sustitutivos (sexo, edad, evolución de la enfermedad, localización) son básicamente los mismos. Antes del tratamiento, se midieron la actividad articular, la fuerza muscular, la puntuación total de la escala articular del cuestionario LYSHOLM y otros índices de observación en la 6ª y 12ª semana de tratamiento. Se utilizó el método estadístico no paramétrico y la prueba T para analizar los cambios de cada índice antes y después del tratamiento. Tras 12 semanas de tratamiento, la diferencia entre el grupo experimental y la combinación antes del tratamiento era significativa. Resultados: El efecto del tratamiento del grupo experimental fue significativamente mejor que el del grupo de control. Conclusión: El efecto de la rehabilitación deportiva de atletas con lesión de menisco basada en la electroacupuntura combinada con la terapia deportiva mostró un alto valor de aplicación resolutiva, indicada como alternativa de tratamiento no quirúrgico en las lesiones de menisco de rodilla. Nivel de evidencia II; Estudios terapéuticos - investigación de los resultados del tratamiento.

Anatomy of rectus femoris muscle flap and anterolateral thigh muscle flap and their application in reconstruction of postoperative defects of oral malignant tumour / 中华显微外科杂志

Objective:To investigate the anatomy of rectus femoris muscle flap and the anterolateral thigh muscle flap and their clinical application in reconstruction of large soft tissue defects after the removal of oral malignant tumour.Methods:From December 2006 to June 2009, 8 specimens of Chinese adult cadavers fixed in 10% formaldehyde were dissected to perform anatomy of anterolateral thigh region at the School of Basic Medical Sciences, Kunming Medical University. Anatomical images were analysed using Image-Pro Plus 6.0. Then, a retrospective study was performed on 19 patients who had postoperative defects after oral malignant tumour surgery and the defects were reconstructed with the rectus femoris muscle flap and the anterolateral thigh muscle flap from March 2020 to July 2022 at the Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Kunming Medical University. The postoperative defects of the 19 patients ranged from 3.0 cm×6.0 cm to 5.0 cm×10.0 cm. Ten rectus femoris muscle flaps, 8 anterolateral thigh muscle flaps and 1 combined rectus femoris muscle flap and anterolateral thigh muscle flap were used. The muscular flaps sized from 4.0 cm × 8.0 cm to 6.0 cm × 11.0 cm. Regular postoperative outpatient follow-ups were conducted.Results:The lengths of vessels of the harvested rectus femoris muscle flap and anterolateral thigh muscle flap were 63.4 mm± 12.9 mm and 112.5 mm± 19.6 mm, respectively. The starting outer diameters of the lateral circumflex thigh artery, the oblique branch of the lateral circumflex thigh artery and the descending branch of the lateral circumflex thigh artery were 2.92 mm±0.72 mm, 1.88 mm±0.23 mm and 2.29 mm±0.43 mm, respectively. Postoperative follow-up lasted for 7 to 32 months, with 17.5 months in average. Seventeen flaps were completely survived and the rectus femoris muscle flap was completely mucosalised 5 weeks after surgery. However, 2 rectus femoris muscle flaps had necrosis of which one was changed to a tongue flap reconstruction and the other encountered flap necrosis during postoperative radiotherapy and healed after debridement and dressing changes. There was no postoperative complication in the donor sites. Other than the 2 patients, all other 17 patients had satisfactory clinical outcomes.Conclusion:Both of the starting outer diameters and length of vessels of the femoris muscle flap and the anterolateral thigh muscle flap meet the requirements for reconstruction of maxillofacial defects, and both muscular flaps are simple to prepare, in good reconstructive results with few complication, as well as an excellent outcome. They are feasible approaches for reconstruction of large soft tissue defects left after the removal of an oral malignant tumour.

A new surgical technique for dissecting iliac bone flap with deep iliac circumflex vessel—retrograde anatomical method / 中华显微外科杂志

Objective:To introduce a new surgical procedure for harvesting an iliac bone flap with deep iliac circumflex vessels—"retrograde anatomical method", and report the effect of preliminary application with this procedure.Methods:From June 2018 to May 2021, 15 patients who admitted in the Department of Hand and Microsurgery, Xiangya Hospital of Central South University received surgeries of iliac bone flap with deep iliac circumflex artery by "retrograde anatomical method". During the surgery, appropriate cutaneous perforators or muscular branches were found near the medial side of the iliac bone of iliac tubercle. The branches were dissected from surface inwards to the starting point of deep circumflex iliac blood vessel with microsurgery and micro Schlieren forceps. The iliac bone flap was chiselled out, inserted into femoral head, and then anastomosed with the transverse branches of deep circumflex iliac blood vessel and lateral circumflex femoral blood vessel. All patients were included in the postoperative follow-up at the outpatient clinic to evaluate the preliminary effect of this procedure. Harris scores before and after surgery were assessed with paired t test. P<0.05 was considered statistically significant. Results:The length of iliac bone flap was at 3.0-5.0(4.0±0.5) cm, and the length of vascular pedicle was at 4.0-7.0(5.3±1.0) cm. The time of iliac bone flap harvest was 35-55(45.0±6.1) minutes. During the operation, the success rate of harvesting iliac bone flap with deep iliac circumflex artery was 100%, and blood had oozed out of bone surface before the pedicle of all iliac bone flaps was cut-off. The volume of intraoperative autologous blood transfusion was 100-400(226.7±78.2) ml. One patient suffered from traction injury of lateral femoral cutaneous nerve in the operation. The numbness of anterolateral thigh area occurred on the 1st day after the surgery, and relieved 4 months later. Other 14 patients did not suffer from postoperative numbness in the area of anterolateral thigh. The amount of drainage from donor site for the iliac bone flap was 50-70 ml[(62.7±7.5) ml in average] after surgery. Incisions at the donor sites of iliac bone flap healed in stage I. Postoperative follow-up lasted between 3 months and 3 years. There was no incision hernia and other complication in the donor sites of the iliac bone flap. There was a significant difference in Harris scores between at 9, 12 and 18 months after surgery and that before the surgery, respectively( P<0.05). After 18 months, Harris score were at a better level. Conclusion:The "retrograde anatomical method" can quickly determine the nutrient vessels of an iliac bone flap with deep circumflex iliac vessels. The surgical procedure is relatively simple with safe and reliable anatomy. Donor site damage and postoperative complications are greatly minimised. This surgical technique can be considered to be applied clinically.

Functional muscular transfer of lateral femoral muscle superficial region in emergency reconstruction of traumatic defects of dynamical muscle: A report of preliminary clinical study / 中华显微外科杂志

Objective:To explore the feasibility and clinical effect of emergency lateral thigh muscle transfer in functional reconstruction of major traumatic muscle defects.Methods:Emergency surgeries for 8 patients(7 males and 1 female) with muscle defects were carried out subject to emergently reconstruct the power of lateral femoral muscle superficial region, between March 2020 and December 2021, in the Department of Hand and Foot Microsurgery Hospital, Xi'an Fengcheng Hospital. The 8 patients were 23 to 52 years old with an average of 37.6 years old. Five patients injured by machine crush, 2 by heavy object crush and 1 by traffic accident. Five patients were in Gustilo III B injury in forearm, including 2 with flexor muscle group defects, 2 with extensor muscle group defects and 1 with defect of dorsal metacarpal flexor muscle and extensor muscle. Among the 5 patients, 2 patients had the defects in left forearm and 3 in right forearm. One patient had defect of right 1st metacarpal bone and skin and thenar muscle. One patient suffered a complete right upper arm detachment with musculocutaneous nerve being drawn out from the bicipital muscle. One patient had Gustilo III C injury in the right calf with defects of extensor hallucis longus and extensor digitorum. The areas of soft tissue defect were 10.0 cm×8.0 cm-36.0 cm×11.0 cm and the size of flaps was 12.0 cm×6.0 cm-38.0 cm×12.0 cm with the volumes of excised muscle at 18.0 cm×9.0 cm×1.5 cm-10.0 cm×2.0 cm×1.0 cm. The anatomical cross-section and length of the corresponding muscle on the healthy side were measured by musculoskeletal ultrasound. The chimeric tissue flap was designed on the anterolateral side of the thigh. The flap was designed according to the size of the wound and the corresponding flap. Then 1 or 2 muscle tissue blocks were designed and cut from the superficial region of the lateral femoral muscle according to the condition of the muscle defect, to cover the wound and reconstruct the muscle power. Postoperative follow-ups were conducted by scheduled hospital visit. The contents of follow-up included dynamic observation, evaluation and record through musculoskeletal ultrasound, electromyography and strength of muscle.Results:For the 8 patients who were subject to a muscle reconstruction, the transferred muscles and flaps survived in stage-one without vascular event. Postoperative follow-ups lasted for 10 to 32 months with an average of 19.6 months. The strength of muscle was evaluated according to the M 4 strength of muscle. Strength of muscle restored to M 4 or above in 7 patients who could lift, hook or push a heavy object in 5-30 kg of weight, with free joint movement. One patient restored the strength of muscle to M 3+. Muscle contraction was detected 2-4 months after surgery by musculoskeletal B ultrasound. The average ratio of contraction to resting cross sectional area in 5 cases was 1.45±0.42. The shape of limb was bilaterally symmetrical. There was no discomfort in the donor site and knee joint. The flaps were soft and glossy, with protective sensation restored. Conclusion:Muscle transfer from the lateral femoral muscle superficial region in emergency surgery for functional reconstruction of traumatic muscle defects is feasible and effective with a good clinical effect.

Masseter muscle flap for reconstruction of intra-oral defects in patients with early cancer of posterior-inferior parts of the oral cavity / Retalho do músculo masseter para reconstrução de defeitos intraorais em pacientes com câncer inicial de partes póstero‐inferiores da cavidade oral

Abstract Introduction Early carcinomas of the oral cavity in the posterior-inferior regions poses a challenge for reconstruction due to the lack of muscle support underneath and the limited space available to use some of the frequently-used flaps. Objective This study was done to evaluate the efficacy of the superiorly based masseter muscle flap in reconstruction of intra-oral post- ablation defects in patients with early oral carcinoma of the posterior-inferior part of the oral cavity. Methods A superiorly based masseter muscle flap were used to reconstruct the post-surgical intra- oral defect in 60 patients with early squamous cell carcinoma (T < 4 cm) of the posterior-inferior part of the oral cavity. The patients were followed up at 1-week and 1-month postoperatively to check for flap viability, complications, change in mouth opening and deviation of the mandible on mouth opening. To rule out any recurrence in the oral cavity masseter flaps, the patients were followed up for 1 year. Results The flap was viable in all patients and underwent mucosalization. 7/60 patients had postoperative infections, while 2/60 patients developed an oro-cutaneous fistula which required a secondary corrective procedure. The mean ± standard deviation of change in mouth opening at 1 week postoperatively was +1.917 ± 3.36 mm, which increased to +2.633 ± 2.95 mm at 1 month after surgery. The Friedman test revealed that there was a statistically significant change in mouth opening from preoperative period to the1 week and 1 month postoperative periods (p = 0.000). Female patients showed better improvement in mouth opening postoperatively. The ipsilateral deviation of the mandible on mouth opening was between 0-5 mm in 39 patients, 5-10 mm in 17 patients and more than 10 mm in 4 patients. There were no recurrences noted in the masseter flaps used. Conclusion The study infers that the superiorly based masseter muscle flap is a reliable method for reconstruction in early oral cancer patients yielding good functional results and acceptable cosmesis with nominal postoperative complications.

Resumo Introdução Os carcinomas iniciais da cavidade oral nas regiões póstero‐inferiores representam um desafio para a reconstrução devido à falta de suporte muscular abaixo da região e ao espaço limitado disponível para o uso de alguns dos retalhos mais empregados. Objetivo Avaliar a eficácia do retalho do músculo masseter de base superior na reconstrução de defeitos intraorais pós‐ablação em pacientes com carcinoma oral inicial da parte póstero‐inferior da cavidade oral. Método Um retalho do músculo masseter de base superior foi usado para reconstruir o defeito intraoral pós‐cirúrgico em 60 pacientes com carcinoma espinocelular inicial (T < 4 cm) localizado na parte póstero‐inferior da cavidade oral. Os pacientes foram acompanhados após uma semana e um mês de pós‐operatório para verificação da viabilidade do retalho, complicações, alteração na abertura bucal e desvio da mandíbula na abertura bucal. Para descartar recidiva nos retalhos do masseter, os pacientes foram acompanhados por um ano. Resultados O retalho foi viável em todos os pacientes e foi submetido à mucolização; 7/60 pacientes tiveram infecções pós‐operatórias, enquanto 2/60 pacientes desenvolveram uma fístula orocutânea que exigiu um procedimento corretivo secundário. A média ± desvio‐padrão da alteração na abertura da boca em uma semana de pós‐operatório foi + 1,917 ± 3,36 mm, que aumentou para + 2,633 ± 2,95 mm em um mês de pós‐operatório. O teste de Friedman revelou que houve uma alteração estatisticamente significante na abertura da boca do período pré‐operatório para os períodos de uma semana e um mês de pós‐operatório (p = 0,000). Pacientes do sexo feminino apresentaram maior melhoria na abertura da boca no pós‐operatório. O desvio ipsilateral da mandíbula na abertura da boca ficou entre 0 a 5 mm em 39 pacientes, 5 a 10 mm em 17 pacientes e mais de 10 mm em 4 pacientes. Não foram observadas recidivas nos retalhos de masseter usados. Conclusão O retalho do músculo masseter com base superior é um método confiável para reconstrução em casos de câncer oral inicial, produz bons resultados funcionais e resultados cosméticos aceitáveis com complicações pós‐operatórias insignificantes.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults / Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos

Abstract Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (p= 0.032) and obesity (p= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (p= 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

Resumo Objetivo Os avanços da microcirurgia reconstrutiva na cirurgia ortopédica proporcionaram melhores resultados funcionais e estéticos, evitando as muitas indicações de amputação. Nos hospitais de ortopedia e traumatologia com um grande volume de atendimento, a reconstrução microcirúrgica é essencial, a fim de reduzir os custos e as complicações destes complexos defeitos ortopédicos. Descrevemos uma abordagem microcirúrgica para feridas traumáticas, ressecção tumoral, defeitos ósseos e transferência muscular livre realizada por uma unidade ortopédica especializada em microcirurgia. O objetivo do presente estudo é avaliar os fatores preditivos de resultados dos retalhos microcirúrgicos na reconstrução dos membros, fornecendo uma análise descritiva dos retalhos microcirúrgicos para as indicações ortopédicas. Métodos Estudo prospectivo transversal, que incluiu todos os casos consecutivos de retalhos microcirúrgicos com indicação ortopédica de 2014 a 2020. Foram coletados os dados do histórico clínico pessoal, procedimentos microcirúrgicos intraoperatórios e exames laboratoriais. As complicações e os desfechos de retalho livre foram estudados mediante uma análise descritiva e estatística. Resultados Avaliamos 171 retalhos em 168 pacientes. A indicação mais frequente para a realização de um retalho microcirúrgico foi a traumática, em 66% dos pacientes. Foram observadas complicações cirúrgicas em 51 retalhos, conforme a classificação de Clavien-Dindo do tipo III. A taxa de êxito global dos retalhos microcirúrgicos foi de 88,3%. Na análise multivariada, foram identificados como fatores de risco para complicações tempo de isquemia ≥ 2 horas (p= 0,032) e obesidade (p= 0,007). A perda parcial do retalho foi mais comum em pacientes com trombocitose, com contagem de plaquetas pré-operatória (p= 0,001). Conclusão Os fatores de risco independentes para complicações de retalhos microcirúrgicos para a reconstrução de membro são obesidade e tempo de isquemia do retalho ≥ 2 horas, e a presença de trombocitose como fator de risco para perda parcial do retalho.

Tratamiento quirúrgico de fibrolipoma gigante de espalda / Surgical treatment of giant fibrolipoma of the back

Introducción: Los lipomas son los tumores más numerosos de tejidos blandos. Se presenta un caso con enfermedad de Hoffman-Zurhelle asociado a lipoma gigante en región toracodorsal y lipomatosis tratado quirúrgicamente de conjunto con las especialidades de cirugía plástica y cirugía general del Hospital Ameijeiras. Objetivo: Mostrar los resultados del tratamiento quirúrgico de exéresis de tumor gigante de espalda. Caso clínico: Paciente masculino de 34 años de edad que se le realizó bajo anestesia general disección del colgajo dermograso en sentido cefálico hasta línea paravertebral y cuello. Se respetó un centímetro de grosor, abordaje a nivel de la interfase del músculo trapecio y dorsal ancho. Se identificó la cápsula del lipoma que se independizó de las fibras musculares y del plano profundo hasta realizar su exéresis y de la piel excedente con nevo lipomatoso cutáneo superficial. Cierre por planos sin tensión. Conclusiones: Se logró la resección de un fibrolipoma gigante en espalda con una planificación cuidadosa que respetó el aporte vascular de los colgajos, la cobertura cutánea sin tensión y conservó la función muscular en ausencia de complicaciones(AU)

Introduction: Lipomas are the most numerous soft tissue tumors. We present a case of Hoffman-Zurhelle disease associated with giant lipoma in the thoracodorsal region and lipomatosis treated surgically in conjunction with the plastic surgery and general surgery specialties of the Ameijeiras Hospital. Objective: To show the results of surgical treatment of excision of a giant tumor of the back. Clinical case: A 34-year-old male patient underwent dissection of the dermographic flap in cephalic direction up to the paravertebral line and neck under general anesthesia. One centimeter thickness was respected, approaching at the level of the trapezius and latissimus dorsi muscle interface. The lipoma capsule was identified and became independent of the muscle fibers and the deep plane until it was excised, as well as the excess skin with superficial cutaneous lipomatous nevus. Closure by planes without tension. Conclusions: Resection of a giant fibrolipoma on the back was achieved with careful planning that respected the vascular supply of the flaps, the skin coverage without tension and preserved muscle function in the absence of complications(AU)

Defecto oncológico maxilar reconstruido mediante colgajo de músculo temporal / Maxillary oncologic defect reconstructed with temporal muscle flap / Defeito oncológico maxilar reconstruído por aba muscular temporal

El macizo facial es una región anatómica compleja que alberga órganos sensoriales. El desarrollo de una enfermedad oncológica, así como su tratamiento, causan defectos funcionales y estéticos con un alto costo físico y psíquico para el paciente y su entorno. Es por ello que la reconstrucción representa un reto. Las diferentes posibilidades incluyen prótesis obturatríces, colgajos libres, pediculados o microvascularizados. En este artículo se describirá el colgajo de músculo temporal y se desarrolla un caso clínico de cirugía oncológica maxilar reconstruido mediante éste en un paciente que presenta una lesión exofítica en cuadrante superior derecho, que se extiende sobre el flanco vestibular, reborde alveolar y zona palatina, desde zona de premolares hasta la zona del segundo molar inclusive, impidiéndole usar la prótesis dental. Esta cirugía es una técnica económica, que requiere menor tiempo quirúrgico que otras técnicas, asociándose a poco porcentaje de fracaso y pocas complicaciones post operatorias.

The facial mass is a complex anatomical region that houses sensory organs. The development of an oncologic disease, as well as its treatment, causes functional and esthetic defects with a high physical and psychological cost for the patient and his environment. This is why reconstruction represents a challenge. The different possibilities include obturator-root prostheses, free, pedicled or microvascularized flaps. In this article the temporal muscle flap will be described and a clinical case of maxillary oncologic surgery reconstructed by means of it is developed in a patient who presents an exophytic lesion in the right upper quadrant, which extends over the vestibular flank, alveolar ridge and palatal area, from the premolar area up to and including the second molar area, preventing him from using the dental prosthesis. This surgery is an economical technique that requires less surgical time than other techniques, and is ass

A massa facial é uma região anatômica complexa que abriga órgãos sensoriais. O desenvolvimento de uma doença oncológica, assim como seu tratamento, causa defeitos funcionais e estéticos com alto custo físico e psicológico para o paciente e seu ambiente. A reconstrução é, portanto, um desafio. As diferentes possibilidades incluem as próteses de raiz obturadora, abas livres, pediculadas ou microvascularizadas. Este artigo descreve o retalho muscular temporal e descreve um caso clínico de cirurgia oncológica maxilar reconstruída utilizando-o em um paciente com lesão exofítica no quadrante superior direito, estendendo-se pelo flanco vestibular, rebordo alveolar e área palatina, desde a área do pré-molar até a área do segundo molar inclusive, impedindo-o de utilizar a prótese dentária. Esta cirurgia é uma técnica econômica, que requer menos tempo cirúrgico que outras.

Técnica com retalho muscular duplo e fasciocutâneo na correção de úlceras isquiáticas por pressão / Technique with double muscle and fasciocutaneous flap in the correction of sciatic pressure ulcers

Úlceras por pressão são lesões ocasionadas na pele e tecidos subjacentes devido à força de pressão local, geralmente em pontos de proeminências ósseas. Cita-se aqui o caso de uma paciente acamada devido à lesão medular por mielomeningocele que evoluiu com úlcera em região isquiática à direita, tratada com técnica de retalhos muscular e fasciocutâneo de face posterior da coxa. Por ser lesão rotineiramente encontrada nesses pacientes portadores de limitações funcionais, é fundamental a realização de tratamentos adequados que visem a melhora clínica do paciente e minimizar índice de recidivas. Além disso, é de suma importância a implementação de novas técnicas cirúrgicas, haja vista a enorme variedade de lesões por pressão

Pressure ulcers are injuries to the skin and underlying tissues due to local pressure force, usually at points of bony prominence. We mention here the case of a bedridden patient due to a spinal cord injury caused by myelomeningocele that evolved with an ulcer in the right sciatic region, treated with the muscle flap and fasciocutaneous flap technique of the posterior thigh. As it is a lesion routinely found in these patients with functional limitations, it is essential to carry out appropriate treatments aimed at improving the patients clinical condition and minimizing the rate of recurrences. In addition, the implementation of new surgical techniques is of utmost importance, given the enormous variety of pressure injuries

Alternativa de manejo miniinvasivo para el tratamiento de pacientes con diástasis abdominal y colgajo dermograso mediante la táctica VER: Vaser® + endoscopia + Renuvion® / Minimally invasive management alternative for the treatment of patients with abdominal diastasis and dermo-fat flap using the VER tactic: Vaser® + endoscopy + Renuvion®

El tratamiento de la diástasis abdominal en pacientes con colgajo dermograso no está estandarizado y puede realizarse mediante diferentes técnicas. Presentamos una alternativa para el manejo miniinvasivo de pacientes con diástasis abdominal asociada a colgajo dermograso mediante la combinación de tres procedimientos que denominamos "táctica VER": Vaser® + endoscopia + Renuvion®. Según nuestra experiencia preliminar, la combinación de los 3 procedimientos es segura y efectiva en los casos seleccionados

The treatment of abdominal diastasis in patients with a dermo-fat flap is not standardized and can be performed using different techniques. We present an alternative for the minimally invasive management of patients with abdominal diastasis associated with dermo-fat flap through the combination of three procedures that we call "VER tactic": Vaser® + Endoscopy + Renuvion®. Based on our preliminary experience, the combination of the 3 procedures is safe and effective in selected cases

Clinical effects of en bloc resection and debridement combined with gluteus maximus muscle flap in the treatment of ischial tubercle pressure ulcer complicated with chronic osteomyelitis / 中华烧伤杂志

Objective: To investigate the clinical effects of en bloc resection and debridement combined with gluteus maximus muscle flap in the treatment of ischial tubercle pressure ulcer complicated with chronic osteomyelitis. Methods: A retrospective observational study was conducted. From May 2018 to February 2020, 8 patients with pressure ulcers on the ischial tuberosity combined with chronic osteomyelitis who met the inclusion criteria were admitted to Fuyang Minsheng Hospital, including 5 males and 3 females, aged 38-69 years, with unilateral lesions in 6 patients and bilateral lesions in 2 patients. According to the anatomical classification of Cierny-Mader osteomyelitis, there were 6 patients (7 sides) with focal type, and 2 patients (3 sides) with diffuse type. The wound areas were 3 cm×2 cm to 12 cm×9 cm on admission. The pressure ulcer and chronic osteomyelitis lesions were completely removed by en bloc resection and debridement. The chronic infectious lesions were transformed into sterile incisions like fresh wounds by one surgical procedure, and the gluteus maximus muscle flaps with areas of 10 cm×6 cm to 15 cm×9 cm were excised to transfer and fill the ineffective cavity. The wounds of 5 patients were sutured directly, and the wounds of 3 patients were closed by local flap transfer. The intraoperative blood loss volume and blood transfusion, and length of hospital stay of patients were recorded. The incision healing and flap survival of patients were observed after operation. The recurrence of pressure ulcer and osteomyelitis, the appearance of the affected area, and the secondary dysfunction and deformity of the muscle flap donor site of patients were observed during followed up. Results: The intraoperative blood loss volume of the 8 patients was 220 to 900 (430±150) mL; 5 patients received intraoperative blood transfusion, of which 2 patients received 3 U suspended red blood cells and 3 patients received 2 U suspended red blood cells. The length of hospital stay was 18 to 29 (23.5±2.0) d for the 8 patients. In this group of patients, the incisions of 7 patients healed, while in one case, the incision suture was torn off during turning over and healed after secondary suture. The flaps survived well in 3 patients who underwent local flap transfer. During the follow-up period of 6-20 months, no recurrence of pressure ulcer or osteomyelitis occurred in 8 patients, the affected part had skin with good texture, mild pigmentation, and no sinus tract formation, and no secondary dysfunction or deformity occurred in the donor site. Conclusions: The en bloc resection and debridement combined with gluteus maximus muscle flap has good clinical effects on ischial tubercle pressure ulcer complicated with chronic osteomyelitis. Neither pressure ulcer nor osteomyelitis recurs post operation. The skin texture and appearance of the affected area are good, and the donor site has no secondary dysfunction or deformity.

Fabrication of functionally customized fixed prosthesis in a hemimandibulectomy patient with fibular graft using double scan technique: A case report / 대한치과보철학회지

Hemimandibulectomy and free fibular flap (FFF) in patients with squamous cell carcinoma could disturb the functional movement of the mandible. The muscular function in the sectioned side was compromised because of the incompetency of the muscle attachment to the mandible, leading to the unstable occlusal contact in the centric and eccentric occlusion. In this report, we present a case of a 63-year-old male who underwent cancer surgery and reconstruction with fibular graft, and he needed a fixed dental prosthesis to restore tooth loss in the anterior region. Occlusal contact change and instability were found according to the bite force in the centric relation and eccentric movement. This case report aimed to present the prosthetic procedure for fabricating the functionally optimized fixed prosthesis wherein the functionally generated path (FGP) technique and digital imaging method were applied to replicate mandibular movement and vertical dimension of the patient.

Reverse sural flap for lower limb reconstruction / Retalho sural reverso na reconstrução de membros inferiores

ABSTRACT Introduction: Reconstruction of distal wounds in lower extremities can be challenging due to the lack of tissue to perform local flaps. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap. Objective: To present an 18-month experience on ankle, calcaneus, and foot reconstruction using the reverse-flow sural flap, performed by the Complex Wounds Group of the Plastic Surgery Department of the University of São Paulo Medical School. Methods: An observational, retrospective and descriptive study was performed through data survey on medical records of all patients treated between November 2018 and June 2020. Results: Nine reverse-flow fasciocutaneous sural flaps were performed. All patients were men. The mean age was 38 years old. Five patients had acute wounds for traffic collision, one electrical trauma and three chronic post-traumatic injuries. The ankle was the most common injury site (6), followed by foot (2) and calcaneus (1). Four patients had complications, three of which were partial necrosis and one distal epitheliosis. No case of total necrosis was recorded. The average hospital stay was 30.1 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a viable, reproducible, and reliable option for distal lower limb reconstruction. Level of Evidence IV, Case Series.

RESUMO Introdução: Reconstrução de lesões distais de extremidades inferiores podem ser desafiadoras devido à limitação de tecido para retalhos locais. Retalhos fasciocutâneos e musculares são opções, como o retalho fasciocutâneo sural reverso. Objetivo: Apresentar a experiência de 18 meses do Grupo de Feridas Complexas do Serviço de Cirurgia Plástica da Faculdade de Medicina da Universidade de São Paulo no uso do retalho sural reverso para reconstruções de defeitos em tornozelo, calcâneo e pé. Métodos: Estudo observacional, retrospectivo e descritivo, com dados de prontuário de todos os casos operados no serviço entre novembro de 2018 e junho de 2020. Resultados: Foram realizados nove retalhos fasciocutâneos sural reverso. Todos os pacientes eram do sexo masculino, com idade média de 38 anos. Cinco foram vítimas de acidente automobilístico, um de trauma elétrico e três apresentavam sequelas pós-traumáticas. Seis lesões localizadas em tornozelo, dois em pé e um em calcâneo. Quatro pacientes apresentaram complicações, sendo três necroses parciais e uma epiteliólise distal. Não houve perda total de retalho. O tempo médio de hospitalização foi de 30,1 dias. Conclusão: O retalho fasciocutâneo sural reverso mostrou-se uma opção viável, reprodutível e segura para reconstrução de lesões complexas em terço distal de perna e pé. Nível de Evidência IV, Série de Casos.