Bevacizumab effect on viability of free groin flaps in rats / Efeito do bevacizumabe na viabilidade de retalho inguinal livre em ratos

Introduction: Bevacizumab is among the most frequently used drugs in cancer treatment. There is evidence that some anti-angiogenic drugs reduce flap survival, but it is unclear whether this applies to Bevacizumab. We investigated the effect of Bevacizumab on the viability of free flaps in rats. Methods: The animals were randomly assigned to one of three groups. The Graft group received intravascular saline and was submitted to a full-thickness skin graft. The Flap-Saline and the Flap- BVZ groups underwent a free groin flap after receiving, respectively, intravascular saline solution or intravascular administration of Bevacizumab. Results: The Graft group showed a lower percentage of the viable area (22.81%) relative to the Flap- Saline (83.98%; p<0.0001) and the Flap-BVZ groups (60.50%; p=0.0048). The lowest vascular pedicle patency was observed in the Flap-BVZ group, but the difference relative to the Flap-Saline was not significant (arteries, p=0.0867; veins, p=0.9999). A significant difference was observed in the occurrence of necrosis (p=0.0010), which was higher in the histological samples of the Graft (87.50%) and the Flap- BVZ (60.00%) relative to the Flap-Saline Group (0%). Inflammation occurred less frequently in the Flap-Saline (33.33%) compared to the Graft (87.5%) and Flap- BVZ group (70.00%), but the difference did not reach significance (p=0.0588). No significant differences emerged in the occurrence of hemorrhage or intraluminal thrombosis. Conclusion: The increase in inflammation, decrease in patency and reduction of viable area, though not significant, are in line with the histological analysis and call for further research on the potential adverse effects of the drug.

Introdução: Bevacizumabe é um dos fármacos mais utilizados no tratamento do câncer. Existem evidências de que drogas antiangiogênicas reduzem a taxa de sobrevivência dos retalhos, porém não está claro se isso se aplica ao bevacizumabe. Investigamos o efeito de bevacizumabe na viabilidade de retalhos livres em ratos. Método: Os animais foram randomizados em três grupos. O grupo Enxerto recebeu injeção intravenosa de soro fisiológico 0,9% (SF 0,9%) e foi submetido a uma enxertia de pele total. Os grupos Retalho-SF e Retalho-BVZ foram submetidos a retalhos inguinais livres e receberam injeções intravenosas, respectivamente, de SF 0,9% e Bevacizumabe. Resultados: O grupo Enxerto apresentou menor percentual de área de retalho viável (22,81%) em relação ao grupo Retalho-SF (83,98%; p<0,0001) e Retalho-BVZ (60,50%; p=0,0048). Os pedículos do grupo Retalho-BVZ apresentaram menor patência, mas a diferença em relação ao grupo Retalho-SF não foi significante (artérias, p=0,0867; veias, p=0,9999). A ocorrência de necrose foi significativamente maior nos grupos Enxerto (87,50%) e Retalho-BVZ (60,00%) em relação ao grupo Retalho-SF (0%) (p=0,0010). A ocorrência de inflamação foi menor no grupo Retalho-SF (33,33%) em relação aos grupos Enxerto (87,5%) e Retalho-BVZ (70,00%), porém essa análise não atingiu significância (p=0,0588). Não houve diferenças significantes na ocorrência de hemorragia ou trombose intraluminal entre os grupos. Conclusão: O aumento da inflamação, redução da patência e das áreas viáveis dos retalhos, apesar de não significantes, corroboram com efeitos deletérios do bevacizumabe evidenciados na análise histológica e demandam futuros estudos dos potenciais efeitos adversos da droga.

Description of the S-Apple mixed rotation and transposition flap: preliminary note / Descrição do retalho misto de rotação e transposição S-Apple: nota prévia

Introduction: The flaps, whose function is to reduce or redirect tension during a closure, are classified based on their primary movement: transposition, advancement, and rotation, each with its characteristics, indications, and peculiarities. Combining the qualities of the transposition flaps with those of rotation, which make up the S-Apple flap, makes it more versatile and with better aesthetic results than the bilobed flap, which denotes the archetype for the appearance of the S-Apple. Method: Having the rotation and transposition flaps as an archetype, four flaps are made in the S-Apple flap, which are rotated and transposed to close the defect. This is excised in a circular format for the oncological safety of margins. The "S" of the flap is traced at a 30º angle in relation to the defect. The arm dimension must be the same diameter as the defect, with the flaps transposed as in a z-plasty, and the flap rotated to cover the defect, resulting from the exeresis of the lesion. Results: No necrosis, infection, dehiscence, recurrences, trapdoor scars, or rotation point elevation were observed. The scars were classified as satisfactory and extremely satisfactory. Conclusion: The S-Apple flap proved versatile and easy to mark with excellent aesthetic and functional results.

Introdução: Os retalhos, com função de reduzir ou redirecionar a tensão durante um fechamento, são classificados com base em seu movimento primário: transposição, avanço e rotação, cada um com suas características, indicações e peculiaridades. O arregimentar das qualidades dos retalhos de transposição com os de rotação, que compõem o retalho S-Apple, tornam-no mais versátil e com melhores resultados estéticos em relação ao retalho bilobado, que denota o arquétipo para o surgimento do S-Apple. Método: Tendo como arquétipo os retalhos de rotação e transposição, no retalho S-Apple são confeccionados quatro retalhos, que são rotacionados e transpostos para fechamento do defeito. Este é excisado em formato circular para segurança oncológica de margens. O "S" do retalho é traçado em um ângulo de 30º em relação ao defeito. A dimensão do braço deve ser do mesmo diâmetro do defeito, sendo os retalhos transpostos como em uma zetaplastia e o retalho rotacionado para cobrir o defeito, resultante da exérese da lesão. Resultados: Não foram observadas necroses, infecção, deiscências, recidivas, cicatrizes em alçapão e elevação em ponto de rotação. As cicatrizes foram classificadas como satisfatórias e extremamente satisfatórias. Conclusão: O retalho S-Apple se mostrou um retalho versátil de fácil marcação com excelentes resultados estéticos e funcionais.

Comparison of Free Flap Outcomes at a University Hospital versus County Hospital Setting for Head and Neck Reconstruction

Abstract Introduction Patients at public county hospitals often have poorer access to healthcare with advanced disease on presentation. These factors, along with limited resources at county hospitals, may have an impact on outcomes for patients requiring complex head and neck reconstruction. Objectives To delineate differences in the frequency of complications in two different care settings, a public county hospital and a private university hospital. Methods Retrospective review of otolaryngology patients at a university hospital compared with a publicly-funded county hospital. The main outcome measure was major complications including total flap loss or unplanned reoperation in 30 days. Secondary outcome measures included medical complications, partial flap loss, and unplanned hospital readmission in 30 days. Results In the county hospital sample (n = 58) free flap failure or reoperation occurred in 20.7% of the patients, and minor complications, in 36.2% of the patients. In the university hospital sample (n = 65) flap failure or reoperation occurred in 9.2% of the patients, and minor complications, in 12.3% of the patients. Patients at the private hospital who had surgery in the oropharynx were least likely to have minor complications. Conclusions Patients at the county hospital had a higher but not statistically significant difference in flap failure and reoperation than those at a university hospital, although the county hospital experienced more minor postoperative complications. This is likely multifactorial, and may be related to poorer access to primary care preoperatively, malnutrition, poorly controlled or undiagnosed medical comorbidities, and differences in hospital resources.

Reconstruction of nail bed and fingertip defects with free nail flap / 中国医师杂志

Objective:To explore the application value of free nail flaps in reconstruction of nail bed and fingertip defect.Methods:From January 2018 to June 2020, nine patients with free nail flap transplantation to treat fingertip injuries in Lishui People′s Hospital were included in this study. According to the Allen classification, 6 patients were characterized as type Ⅱ and 3 were characterized as type Ⅲ. Evaluation was based on the patients′ medical records and follow-up, including postoperative healing of recipient and donor sites, two-point discrimination, the Chinese Medical Association Hand Surgery Society′s evaluation of the function of severed finger replantation, and Michigan Hand Outcomes Questionnaire (MHQ) and Foot Function Index (FFI).Results:All patients successfully completed the operation, the operation time was 3.0-5.0 h (average 4.1 h), the intraoperative blood loss was 100-250 ml (average 178 ml), and the follow-up time was 12-40 months (average 25 months). The nails and flaps of all patients survived with primary healing. No complications were observed after surgery. The appearance of the reconstructed finger of 9 patients was similar to that of the uninfected side; the flap two-point discrimination was 5.0-7.5 mm; the replantation score and MHQ results were satisfactory. The toenail of the donor site grew well, and no deformity or pain with walking was noted.Conclusions:The free toenail flap was used to treat fingertip defects, with satisfactory clinical results in repairing tissue defects, reconstructing nail bed and maintaining finger length.

Harvesting sural flap with covered pedicle / Coleta de retalho sural com pedículo coberto

ABSTRACT Objectives: The aim was to evaluate the viability and the outcomes of the sural flap performed with the pedicle covered by a strip of skin. Methods: A prospective cohort of 20 consecutive cases were evaluated in terms of flap viability, complication rate, and the amount of skin graft required. The location of the defects was the middle third of the tibia in 3 cases, the ankle and hindfoot in 15 cases, the middle foot in 1 case, and the forefoot in 1 case. The flap design was the same as described by Masquelet. The only modification included a strip of skin over the entire length of the pedicle. The intermediary skin between the donor site and the defect was incised and the skin was undermined to accommodate the pedicle without compression. Results: All cases had a satisfactory evolution, with adequate healing and without flap loss. Both the donor site and the pedicle were primarily closed in all cases. In one patient, the flap developed a limited area of superficial epidermolysis that healed spontaneously. Conclusion: the modified sural flap with a covered pedicle is feasible and reliable with a lower rate of complications when compared with the conventional sural flap. Level of Evidence IV, Cohort Studies.

RESUMO Objetivo: O objetivo foi avaliar a viabilidade e os resultados do retalho sural realizado com o pedículo coberto com uma faixa de pele. Material e Métodos: Pelo estudo de coorte prospectivo, foram avaliados 20 casos consecutivos considerando a viabilidade do retalho, a taxa de complicações e a quantidade de enxerto de pele necessária. A localização dos defeitos foi no terço médio da tíbia em 3 casos, tornozelo e retropé em 15 casos, pé médio em 1 caso e antepé em 1 caso. O desenho do retalho foi o mesmo que o descrito por Masquelet. A única modificação foi a inclusão de uma tira de pele em todo o comprimento do pedículo. A pele intermediária entre o local doador e o defeito foi incisada e a pele foi descolada para acomodar o pedículo sem compressão. Resultados: Todos os casos tiveram uma evolução satisfatória, com cicatrização adequada e sem perda dos retalhos. Tanto o local doador quanto o pedículo foram primariamente fechados em todos os casos. Em um paciente, o retalho desenvolveu uma área limitada de epidermólise superficial que cicatrizou espontaneamente. Conclusão: O retalho sural modificado com pedículo coberto é viável e confiável com uma menor taxa de complicações quando comparado ao retalho sural convencional. Nível de Evidência IV, Estudos de Coorte.

Recipient vessels for free flaps in advanced facial oncologic defects

Abstract Objectives To prospectively compare the results of microvascular flap reconstruction of midface and scalp advanced oncologic defects using superficial temporal versus cervical as recipient vessels. Methods This is a parallel group clinical trial with 1:1 allocation ratio of patients who underwent midface and scalp oncologic reconstruction with free tissue flap from April 2018 to April 2022 in a tertiary oncologic center. Two groups were analyzed: those in whom superficial temporal vessels were used as the recipient vessels (Group A) and those in whom cervical vessels were used as the recipient vessels (Group B). Patient gender and age, cause and localization of the defect, flap choice for reconstruction, recipient vessels, intraoperative outcome, postoperative course, and complications were recorded and analyzed. A Fisher's exact test was used to compare outcomes between the 2 groups. Results On the basis of the different recipient vessels, 32 patients were randomized into 2 groups, and of these 27 patients completed the study: Group A with superficial temporal recipient vessels (n = 12) and Group B with cervical recipient vessels (n = 15). There were 18 male and 09 female patients with an average age of 53.92 ± 17.49 years. The overall flap survival rate was 88.89%. The overall complication rate for vascular anastomosis was 14.81%. The total flap loss rate in patients with superficial temporal recipient vessels was higher than the complication rate in those with cervical recipient vessels but with no statistical significance (16.67% vs. 6.66%, p= 0.569). Minor complications occurred in 05 patients without statistical significance between the groups (p= 0.342). Conclusion In the group with superficial temporal recipient vessels, the postoperative rate of free flap complications was similar than the cervical recipient vessel group. Therefore the use of superficial temporal recipient vessels for midface and scalp oncologic reconstruction could be a reliable option.

Combination of surgical techniques and reconstructive devices as an alternative treatment after fibula free flap mandibular reconstruction failure: a case report

Loss of mandibular continuity and functionality in cancer patients undergoing extensive mandible resections is challenging. In these situations, the gold standard treatment is fibula free flap reconstruction. The major challenge occurs when there is a failure of the transplanted fibula. Here we report the case of a patient who underwent right hemimandibulectomy with disarticulation and immediate mandibular reconstruction with a fibula free flap. Subsequently, the flap viability was lost, and there was necrosis of the transplanted bone segment in the short-term follow-up. Considering the best form of rehabilitation for the patient, minimizing the risks of loss and optimizing the reconstructive quality, we opted to install a customized prosthesis including a condylecavity joint component associated with a new free flap and subsequent rehabilitation of the dental occlusion with an implant-supported fixed prosthesis.

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.

Serratus anterior muscle flap for reconstruction of extremity injuries / Retalho do músculo serrátil anterior para reconstrução de lesões em extremidades

ABSTRACT Objective: To report the use of the serratus anterior free tissue transfer in the treatment of traumatic injuries. Methods: Twenty-six free flaps or serratus pedicled flaps were performed for reconstruction of traumatic extremity injuries. Results: Complete flap survival was recorded in 20 limbs and 3 patients had circulatory complications. Even with the review of vascular anastomoses, partial flap necrosis could not be prevented and required a skin graft after debridement in the necrotic area. Another flap also required reexploration as a result of heavy congestion due to impaired venous return. Superficial wound infection was found in three patients and treated with conservative measures. Regarding the donor area, seroma formation was found in 8 cases; drainage was necessary in 2, and the others were resolved spontaneously. In 2, bruises formed and were later drained. In 1 limb there was long thoracic nerve injury and scapular winging. Conclusion: According to this study, the serratus anterior muscle flap is an excellent tool for treating small complex lesions in the extremities. Level of Evidence IV; Case series .

RESUMO Objetivo: Relatar o uso da transferência de retalho livre do serrátil anterior no tratamento de lesões traumáticas. Métodos: Vinte e seis retalhos livres ou pediculados do serrátil anterior foram realizados para reconstrução de lesões traumáticas de extremidades. Resultados: A sobrevida completa do retalho foi registrada em 20 membros e 3 pacientes tiveram complicações circulatórias. Mesmo com a revisão das anastomoses vasculares, a necrose parcial do retalho não pôde ser prevenida e exigiu enxerto de pele após desbridamento da área necrótica. Outro retalho também necessitou reexploração em decorrência de forte congestão por dificuldade de retorno venoso. Infecção de ferida superficial foi encontrada em três pacientes, tratados com medidas conservadoras. Em relação à área doadora, a formação de seroma foi encontrada em 8 casos; em 2 foi necessária drenagem e os demais foram resolvidos espontaneamente. Em 2 houve formação de hematomas, que foram drenados. Em um membro havia lesão longa do nervo torácico e deformidade do tipo escapula alada. Conclusão: De acordo com este estudo, o retalho do músculo serrátil anterior é uma excelente ferramenta para o tratamento de lesões complexas e pouco extensas nas extremidades. Nível de Evidência IV; Série de casos .

Emergency ectopic embedment of a large extruded bone mass for open lower limb bone defects / 中华创伤骨科杂志

Objective:To explore the efficacy of emergency ectopic embedment of a large extruded bone mass in the treatment of open lower limb bone defects.Methods:From June 2015 to June 2019, 11 patients were treated for open lower limb bone defects at Department of Traumatic Orthopedics & Microsurgery, Renmin Hospital of Wuhan University by primary ectopic embedment of a large extruded bone mass. They were 8 males and 3 females, aged from 18 to 57 years (mean, 35.3 years). The time from injury to operation ranged from 4 to 12 hours (mean, 6.3 hours). The size of free bone mass ranged from 3 to 16 cm (mean, 8.7 cm). At the emergency primary stage, following vascular and nerve anastomosis, large extruded bone masses were embedded ectopically to the sites with rich blood supply after cleaning and disinfection. The embedment was lateral to the thigh in 9 cases and in the groin in 2 cases. Wound repair was performed at the second stage, and bone replantation at the third stage, followed by internal plate fixation in 6 cases and external fixation in 5 cases. Fracture union was evaluated by regular X-ray follow-ups. At the last follow-up, Paley score was used to evaluate the curative outcomes, SF-36 score to evaluate functional recovery, and complications were recorded.Results:All patients were followed up for 6 to 50 months (mean, 15.5 months). Follow-ups observed no osteomyelitis. Fracture union was delayed in the 2 cases with external fixation but eventually achieved after bone graft and internal fixation. All fractures united after 5 to 12 months (mean, 8.5 months). The total treatment time ranged from 8 to 16 months (mean, 12.5 months). According to the Paley scores at the last follow-up, 7 cases were excellent, 3 good and one was poor, giving an excellent to good rate of 90.9% (10/11). The SF-36 scores for the postoperative quality of life averaged 86.7.Conclusion:Emergency ectopic embedment of a large extruded bone mass is a feasible treatment for open lower limb bone defects, with advantages of simplicity in operation and a low incidence of osteomyelitis.

Hypoalbuminemia in microsurgical flaps of the musculoskeletal apparatus / A hipoalbuminemia em retalhos microcirúrgicos do aparelho musculoesquelético

ABSTRACT Objective: To evaluate if the levels of serum total protein and serum albumin are risk factors for surgical complications of free flap limb reconstruction. Methods: Consecutive inclusion of all patients undergoing microsurgical flaps for limb reconstruction of complex injuries. We recorded epidemiological and laboratory data, including total proteins and fractions, for descriptive and analytical statistics. Results: Our study analyzed one microsurgical flap from 35 patients that underwent complex injuries of the limbs. In total, 23 patients were men, and mean age of all patients was 35 years. After statistical analysis, no influence of pre or postoperative hypoalbuminemia was observed on the incidence of complications. Patients with hypoalbuminemia had a higher length of stay than those with normal albumin levels (p = 0.008). Conclusion: We observed that 71% of patients had hypoalbuminemia in early postoperative period and we suggest a nutritional support for patients requiring complex traumatic limb reconstruction. Hypoalbuminemia in patients subjected to microsurgical flaps for the treatment of complex traumatic limb injuries did not influence the complications that required surgical reintervention; However, it was associated with prolonged hospital stay. Level of Evidence II, Retrospective study.

RESUMO Objetivo: Avaliar a influência dos níveis totais de proteína sérica e albumina como fator de risco para complicações de retalhos microcirúrgicos para reconstrução de membros. Métodos: Inclusão consecutiva de todos os pacientes submetidos a retalhos microcirúrgicos para reconstrução de membros de lesões complexas. Foram registrados dados epidemiológicos e laboratoriais, incluindo proteínas e frações totais, para fins estatísticos descritivos e analíticos. Resultados: 35 retalhos microcirúrgicos foram estudados em 35 pacientes com lesões complexas dos membros. A idade média dos pacientes foi de 35 anos, e 23 pacientes eram do sexo masculino. Após análise estatística, não foi observada influência da hipoalbuminemia pré ou pós-operatória na incidência de complicações. Pacientes com hipoalbuminemia permaneceram mais tempo hospitalizados do que aqueles com níveis normais de albumina (p = 0,008). Conclusão: Observamos 71% dos pacientes com hipoalbuminemia no início do período pós-operatório e sugerimos fornecer suporte nutricional para pacientes que necessitam de reconstrução traumática complexa dos membros. A presença de hipoalbuminemia em pacientes submetidos a retalhos microcirúrgicos para o tratamento de lesões traumáticas complexas nos membros não influenciou a presença de complicações que exigiam reintervenção cirúrgica, mas foi associada ao tempo de hospitalização prolongado. Nível de Evidência II, Estudo retrospectivo .

Arterial variations within the lateral cervical region: a multidetector CT angiography study / Variaciones arteriales en la región cervical lateral: estudio angiográfico por tomografía computarizada multidetector

It is important to know the arterial anatomy within the lateral cervical region before the flap-planning. We evaluated the arterial anatomy in this area using multidetector computed tomography (CT) angiography and our aim was to establish the arterial variations. Both sides of individuals in a total number of 155 carotid CT angiographies are reviewed by using 64-detector CT, retrospectively. The variations of suprascapular artery, superficial cervical artery, dorsal scapular artery that are inclusive of the lateral cervical region were assessed. Three arteries originated individually in 67 (23.8 %) sides. They arose by trunk formation in 214 (76.2 %) sides. The most common type of trunk formation was cervicodorsal trunk (107; 38 %). The others were cervicoscapular trunk, cervicodorsoscapular trunk, dorsoscapular trunk and detected in 66 (23.4 %), 40 (14.3 %), 1 (0.3 %) sides, respectively. The origins of arteries within the lateral cervical region may show variations and they may originate from subclavian artery or its branches individually or by trunk formations. It may be beneficial to know these variations before the reconstructive surgical procedures in head and neck. CT angiography is a non-invasive method that enables to evaluate the arterial anatomy and variations in this area.

Es importante conocer la anatomía arterial de la región cervical lateral antes de la planificación de un colgajo. Evaluamos la anatomía arterial en esta área mediante angiografía con tomografía computarizada (TC) multidetector con el objetivo de establecer las variaciones arteriales. Se revisaron retrospectivamente un total de 155 angiografías de ambos lados de la región cervical lateral por tomografía computarizada multidetector. Se evaluaron las variaciones anatómicas de las arterias supraescapular, cervical superficial y escapular dorsal. Las tres arterias se originaron individualmente en 67 casos (23,8 %). Surgieron por formación de un tronco en 214 casos (76,2 %). El tipo más común de formación del tronco fue el tronco cervicodorsal (107 casos; 38 %). Los otros troncos hallados fueron: el tronco cervicoescapular, el tronco cervicodorsoescapular, el tronco dorsoescapular, en 66 casos (23,4 %), 40 casos (14,3 %) y 1 caso (0,3 %), respectivamente. Los orígenes de las arterias en la región cervical lateral pueden mostrar variaciones y las arterias pueden originarse desde la arteria subclavia o sus ramas, individualmente o por formaciones de tronco. Puede ser beneficioso conocer estas variaciones antes de los procedimientos quirúrgicos reconstructivos en cabeza y cuello. La angiografía por TC es un método no invasivo que permite evaluar la anatomía arterial y las variaciones en esta área.

Is obesity a risk factor for free vascularized fibular flap complications? / A obesidade é fator de risco para complicações do retalho livre de fíbula vascularizada?

ABSTRACT Objective: Although our knowledge of bone reconstruction through microsurgery has increased, the vascularized fibula flap remains one of the most difficult free flap reconstructions to perform, and complications remain a challenge. The incidence of obesity is increasing and is associated with higher rates of free flap complications, which can lead to disastrous results. Since there is no consensus in literature regarding the influence of obesity on free flap outcomes in orthopedic surgeries that require segmental bone reconstruction, the objective of this study was to determine whether obesity increases the risk of post-operative complications (Clavien-Dindo grade III) after free vascularized fibular flap surgery. Methods: A cohort study was conducted in all patients undergoing free flap limb reconstructions between July 2014 and July 2018. Patients were separated in two groups based on their body mass index (BMI): non-obese and obese (BMI≥30 kg/m2). Results: Twenty-three free vascularized fibular flaps were studied. The indications included trauma in 13, tumors in 7, and congenital pseudarthrosis of the tibia in 3. Obese patients were associated with an increase in surgical complications (p=0.038). During the final follow-up, consolidation was obtained in 17 patients (74%). Conclusion: Obesity is a risk factor for complications in free vascularized fibular flap surgery. Level of evidence IV, original article.

RESUMO Objetivo: Apesar do crescente conhecimento em reconstrução óssea por meio de microcirurgia, o retalho livre de fíbula vascularizada ainda permanece como uma das reconstruções mais difíceis de ser executada, e suas complicações ainda são um desafio. A incidência da obesidade tem aumentado e está associada a taxas mais altas de complicações de retalhos livres, o que pode levar a resultados desastrosos. Uma vez que não há consenso na literatura a respeito da influência da obesidade nos desfechos dos retalhos livre em cirurgias ortopédicas que requeiram reconstrução de segmento ósseo, o objetivo deste estudo foi avaliar se a obesidade aumenta o risco de complicações pós-operatórias (Clavien-Dindo grau III) após a cirurgia de retalho livre de fíbula vascularizada. Métodos: Foi realizado um estudo de coorte transversal, com a inclusão de todos os pacientes submetidos à reconstrução de membros com retalho livre de fíbula vascularizada, entre julho de 2014 e julho de 2018. Os pacientes foram separados em dois grupos, com base no índice de massa corporal: não obesos e obesos (no índice de massa corporal ≥ 30 kg/m2). Resultados: Foram analisados 23 retalhos livres de fíbula vascularizada. As indicações foram trauma em 13 casos, tumor em sete e pseudoartrose congênita da tíbia em três. Pacientes obesos foram associados a aumento nas complicações cirúrgicas (p = 0,038). No final do acompanhamento, a consolidação óssea foi obtida em 17 pacientes (74%). Conclusão: A obesidade é um fator de risco para complicações no retalho livre de fíbula vascularizada. Nível de evidência IV, artigo original.

Planificación virtual y modelo de impresión en 3D para reconstrucción mandibular con colgajo libre de peroné en ameloblastoma mandibular / Virtual planning and 3D printing model for mandibular reconstruction with free fibular flap in mandibular ameloblastoma

El ameloblastoma es un tumor benigno, localmente agresivo, que ocasiona deformidades faciales y con tendencia a la recurrencia. El objetivo del tratamiento del ameloblastoma es la remoción completa del tumor, la restauración de la función y el mantenimiento del aspecto estético. Se presenta el caso de un varón de 19 años que presenta tumoración en región mandibular y acude a consulta para tratamiento quirúrgico. Se realizó planificación virtual y modelo de impresión en 3D para reconstrucción mandibular con colgajo libre de peroné y modelo estereolitográfico para el manejo de su patología. Se observó una evolución post operatoria favorable; y una patología compatible con ameloblastoma mandibular intraóseo de patrón plexiforme. Si bien la cirugía es el tratamiento de elección para el diagnóstico de ameloblastoma; la planificación virtual y el modelo de impresión en 3D para la reconstrucción son herramientas útiles en el manejo de esta patología.

Ameloblastoma is a benign, locally aggressive tumor that causes facial deformities and a tendency to recur. The objective of the treatment of ameloblastoma is the complete elimination of the tumor, the restoration of function and the maintenance of the aesthetic appearance. The case of a 19-year-old male presenting a tumor in the mandibular region is presented and a consultation for surgical treatment is accessed. Virtual planning and 3D printing model were performed for mandibular reconstruction with fibula-free flap and stereolithographic model for the management of its pathology. A favorable post-operative evolution evolved; and a pathology compatible with intraosseous mandibular ameloblastoma of the plexiform pattern. Although surgery is the treatment of choice for the diagnosis of ameloblastoma; Virtual planning and the 3D printing model for reconstruction are useful tools in the management of this pathology.

O uso de enxerto e retalho de periósteo em Oftalmologia / The periosteal graft and flap use in Ophthalmology

Resumo Objetivo: Os autores revisaram o uso de periósteo em cirurgias oftalmológicas e seus resultados. Métodos: Uma revisão de literatura usando os bancos de dados do Google Scholar, PubMed e SciElo com todos os artigos sobre o uso de periósteo em Oftalmologia publicados de 1977 até 2018. Resultados: Um total de 21 estudos cumpriram o objetivo do estudo: 9 relatos de caso, 9 séries de casos, 1 coorte retrospective e 2 coortes prospectivas. 206 pacientes foram submetidos aos procedimentos cirúrgicos com uso de periósteo nas duas formas principais: enxerto e retalho. Os principais motivos para uso do periósteo foram: recobrimento de implante orbitário e reconstrução palpebral. Resultados cirúrgicos foram satisfatórios com baixas taxas de complicação de 10.67% e mínima necessidade de nova intervenção cirúrgica de 2.42%. Conclusão: O uso de periósteo em Oftalmologia é uma técnica promissora com bons resultados até o momento e deve sempre ser uma opção terapêutica para o Oftalmologista. Todavia, mais estudos com poder estatístico para sedimentação do conhecimento sobre o tema são recomendados.

Abstract Purpose: The authors reviewed the periosteum use in ophthalmic surgery and its results. Methods: A comprehensive review of the literature using Google Scholar, PubMed and SciElo databases with all articles about the periosteum use in Ophthalmology published from 1977 to 2018. Results: A total of 21 studies followed the review's purpose: 9 case reports, 9 case series, 1 retrospective cohort and 2 prospective cohorts. 206 patients were submitted to the procedures with the periosteum use in the two main forms: graft and flap. The principal reasons for periosteal use were: orbital implant covering and eyelid reconstruction. Surgical outcomes were very satisfactory with low complication rates of 10.67% and minimal necessity of new surgical intervention of 2.42%. Conclusion: The periosteum use in Ophtalmology is a promising technique with good results so far and should always be a therapeutic option for the ophthalmologist. However, based on available data in the literature, more studies with statistical power for knowledge sedimentation in this subject are recommended.

Application of reverse dermal revascularization combined with vacuum sealing drainage in the large area of skin avulsion of the lower extremities / 中国骨伤

OBJECTIVE@#To summarize the clinical effect of emergency subcutaneous vascular network reverse skin replantation combined with vacuum sealing after drainage of large area skin avulsion injury.@*METHODS@#Clinical data of 30 patients with extensive skin avulsion of the lower limb treated between July 2010 and March 2018 were collected. There were 20 males and 10 females, ranging in age from 16 to 67 years old, with an average of(48±13) years old. Cause of injury: 19 cases of car accident injury, 11 cases of crush injury. The surgery time was 3 to 10 h, with an average of (5±1) h. All cases were completely debrided in stage I. The subdermal vascular network was reversed and skin grafted with multiple incision drainage combined with negative pressure closed drainage technique for 7 to 10 days. The wounds were removed by VSD observation:if the necrotic area is large, debridement is required. After the granulation growth of the wound is satisfactory, the skin grafting is performed again after electrification; the small area of necrotic skin strengthens the dressing and heals.@*RESULTS@#30 patients were followed up for 7 to 48 months, with an average of (20±11) months.No infection in 1 case appeared, 30 patients, living area more than 85% of the wound after treatment survival in the stage I; The skin necrosis ranged from about 12% in 5 patients in the stage II. The second stage was healed after redebriding free skin grafts. The other patients were healed after the dressing, capillary meshwork layer of skin color, good elasticity, feeling, wearable pressure, each joint activities is good, no obvious skin adhesion cause physical activity is limited.@*CONCLUSIONS@#Reverse skin grafting combined with VSD for the treatment of large skin avulsion of lower limb can greatly reduce wound infection rate, promote the application of skin and wound, conducive to drainage, improve the survival rate of reverse skin grafting and improve the function of lower limb joints.

A 20-year experience of immediate mandibular reconstruction using free fibula osteocutaneous flaps following ameloblastoma resection: Radical resection, outcomes, and recurrence

BACKGROUND: The mandible is an important structure that is located in the lower third of the face. Large mandibular defects after tumor resection cause loss of its function. This study assessed the outcomes and tumor recurrence after immediate mandibular reconstruction using a free fibula osteocutaneous flap following radical resection of ameloblastoma. METHODS: This is a retrospective non-randomized study of outcomes and tumor recurrence of all patients diagnosed with mandibular ameloblastoma from August 1997 until August 2017 (20 years) requiring free fibula osteocutaneous flap reconstruction at a single institution. The patients were identified through an electronic operative database; subsequently, their medical records and photo documentation were retrieved. RESULTS: Twenty-seven patients were included in this study. Eighteen patients were male, while nine were female. The majority of the patients (48.1%) were in their third decade of life when they were diagnosed with ameloblastoma. All of them underwent radical resection of the tumor with a surgical margin of 2 cm (hemimandibulectomy in cases with a large tumor) and immediate mandibular reconstruction with a free fibula osteocutaneous flap. Two patients required revision of a vascular anastomosis due to venous thrombosis postoperatively, while one patient developed a flap recipient site infection. The flap success rate was 100%. There was no tumor recurrence during a mean follow-up period of 5.6 years. CONCLUSIONS: Mandibular ameloblastoma should be treated with segmental mandibulectomy (with a surgical margin of 2 cm) to reduce the risk of recurrence. Subsequent mandibular and adjacent soft tissue defects should be reconstructed immediately with a free fibula osteocutaneous flap.

Subtotal calvarial vault reconstruction utilizing a customized polyetheretherketone (PEEK) implant with chimeric microvascular soft tissue coverage in a patient with syndrome of the trephined: A case report

The syndrome of the trephined is a neurologic phenomenon that manifests as sudden decline in cognition, behavior, and sensorimotor function due to loss of intracranial domain. This scenario typically occurs in the setting of large craniectomy defects, resulting from trauma, infection, and/or oncologic extirpation. Cranioplasty has been shown to reverse these symptoms by normalizing cerebral hemodynamics and metabolism. However, successful reconstruction may be difficult in patients with complex and/or hostile calvarial defects. We present the case of a 48-year-old male with a large cranial bone defect, who failed autologous cranioplasty secondary to infection, and developed rapid neurologic deterioration leading to a near-vegetative state. Following debridement and antibiotic therapy, delayed cranioplasty was accomplished using a polyetheretherketone (PEEK) implant with free chimeric latissimus dorsi/serratus anterior myocutaneous flap transfer for vascularized resurfacing. Significant improvements in cognition and motor skill were noted in the early postoperative period. At 6-month follow-up, the patient had regained the ability to speak, ambulate and self-feed—correlating with evidence of cerebral/ventricular re-expansion on computed tomography. Based on our findings, we advocate delayed alloplastic implantation with total vascularized soft tissue coverage as a viable alternative for reconstructing extensive, hostile calvarial defects in patients with the syndrome of the trephined.

The effectiveness of an enhanced recovery after surgery protocol in head and neck cancer surgery with free-flap reconstruction

PURPOSE: An enhanced recovery after surgery (ERAS) protocol incorporates up-to-date perioperative care principles; the primary aim in using an ERAS protocol is to reduce issues that delay the recovery and cause the complications. The aim of this study was to compare outcomes associated with head and neck cancer surgery with free-flap reconstruction before and after implementation of an ERAS protocol. METHODS: Outcomes were analyzed by dividing patients into 2 groups: 29 patients in the non-ERAS group and 60 patients in the ERAS group. The ERAS group performed a prospective observational cohort study of patients who underwent a head and neck cancer surgery with free-flap reconstruction in Ajou University Hospital from August 2015 to December 2017. The non-ERAS group retrospectively reviewed the medical records of patients who had undergone the same surgery from August 2012 to July 2015. RESULTS: Demographics, comorbidities, hospital length of stay (LOS), postoperative complications, starting time of rehabilitation, and postoperative periods before radiotherapy for the non-ERAS and ERAS groups were compared. Hospital LOS was significantly lower for patients whose care followed the ERAS protocol than for patients in the non-ERAS group (30.87 ± 20.72 days vs. 59.66 ± 40.43 days, P < 0.0001). CONCLUSION: In this study, hospital LOS was reduced through fast recovery after the implementation of the ERAS protocol. Therefore, the ERAS protocol appeared feasible and safe in head and neck cancer surgery with free-flap reconstruction.

Comparison of Skin Graft for the Defect of the Radial Forearm Free Flap / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: This study compared two types of skin graft reconstruction for the defect of the radial forearm free flap. SUBJECTS AND METHOD: Ten cases of split-thickness skin graft (STSG) harvested from the thigh were analyzed. Also, ten cases of full-thickness skin graft (FTSG) harvest from the inguinal area applied with vacuum-assisted closure (VAC) system were analyzed. RESULTS: The defect size of the radial forearm was increased more in the STSG group than in the FTSG group (p<0.05). Skin grafts were recovered completely sooner in the FTSG group than in the STSG group although it was not statistically significant (p=0.082). Five complications (pruritus, hypertrophic scar) were found in the donor site in the STSG group (p<0.05). FTSG gave better scores according to the Vancouver Scar Scale in terms of pigmentation, pliability, and height (p<0.05). CONCLUSION: FTSG harvested from the inguinal area with the application of VAC system has many advantages for the defect of the radial forearm free flap although it is usually used for smaller size defects than for STSGs.