Method of closing fasciotomies by progressive tissue traction / Método de fechamento de fasciotomias por tração tecidual progressiva

High-energy trauma has increased significantly in the last decade, mostly in the lower limbs, in many cases requiring fasciotomy due to the subsequent compartment syndrome. In this context, its closure often leads to a delay in the patient's comprehensive treatment and the return to their activities and may lead to local infection, in addition to generating high costs. There are many options for the plastic surgeon to try to bring the edges together and reconstruct the extremities, such as flaps, grafts, vacuum dressings, and elastic sutures, in addition to expansion devices, sometimes with a combination of the above.

O trauma de grande energia vem aumentando de maneira expressiva na última década, em boa parte de membros inferiores, necessitando, em muitos casos, de fasciotomia devido à síndrome compartimental subsequente. Neste contexto muitas vezes seu fechamento acaba por levar a um retardo no tratamento integral do paciente, do retorno a suas atividades e podendo levar a infecção local, além de gerar altos custos. Há muitas opções ao cirurgião plástico para a tentativa de aproximação de bordos e reconstrução das extremidades, como retalhos, enxertos, curativo a vácuo e sutura elástica, além de dispositivos de expansão, sendo, às vezes, com combinação das anteriores. O método de fechamento apresentado através do alongamento progressivo da pele com fio de Kirschnner representa uma forma de baixo custo e facilmente reproduzível para lidar com este tipo de ferida.

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin / Onfalocele gigante: Uma nova abordagem para reparo primário no período neonatal utilizando toxina botulínica

ABSTRACT Introduction: Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience. Methods: patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect. Results: while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects. Conclusion: this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

RESUMO Introdução: onfalocele gigante (OG) é uma condição complexa para a qual muitas alternativas terapêuticas foram desenvolvidas; no entanto, não há consenso sobre qual o melhor tratamento. Os benefícios e eficácia da toxina botulínica A (TBA) no reparo de grandes defeitos da parede abdominal em adultos foram comprovados, e o relato de uso em crianças cresceu recentemente. O objetivo deste estudo é descrever uma nova técnica para reparo primário de OG utilizando TBA durante o período neonatal e relatar nossa experiência inicial. Métodos: os pacientes foram acompanhados de agosto de 2020 a julho de 2022. A TBA foi aplicada na parede abdominal lateral nos primeiros dias de vida, seguida de correção cirúrgica do defeito abdominal. Resultados: enquanto aguardavam a cirurgia, os pacientes tiveram mínima manipulação, sem ser exigida ventilação mecânica, permaneceram em alimentação enteral plena e mantiveram contato com os pais. A linha média foi aproximada sem tensão e sem necessidade de técnicas adicionais ou uso de prótese. Os pacientes receberam alta com o defeito reparado. Conclusão: essa abordagem representa um meio-termo entre o reparo estagiado e o tratamento não-operatório. Não requer intervenções agressivas no início da vida, permitindo a manutenção do vínculo materno-infantil e a alta do paciente com defeito reparado sem a necessidade de uso de técnicas adicionais ou prótese. Acreditamos que esta técnica deva ser considerada como um novo possível recurso no manejo desta complexa condição.

Uso concomitante de sutura elástica associada ao curativo a vácuo no fechamento de grandes perdas de partes moles / Concomitant use of elastic suture associated with vacuum dressing in the closure of large soft tissue losses

O tratamento das feridas complexas com grande perda de partes moles é um desafio para a cirurgia plástica, principalmente quando a ferida encontra-se infectada. Várias opções são consideradas para o tratamento, como sutura, enxertos, retalhos, expansores. Devido à complexidade dos casos, frequente associação de morbidades, necessidade de intervenções multidisciplinar e longos internamentos, os custos do tratamento são frequentemente elevados. Este trabalho vem demonstrar a técnica de sutura elástica empregada em um caso clínico, utilizando tração contínua da pele em associação ao curativo a vácuo, que possibilitou reabilitação do paciente sem a necessidade de intervenções mais agressivas para o fechamento da ferida traumática extensa.

Treating complex wounds with great loss of soft tissues is a challenge for plastic surgery, especially when the wound is infected. Several options are considered for treatment, such as sutures, grafts, flaps, and expanders. Due to the complexity of the cases, the frequent association of morbidities, the need for multidisciplinary interventions, and long hospital stays, treatment costs are often high. This work demonstrates the elastic suture technique used in a clinical case, using continuous skin traction in association with a vacuum dressing, which enabled patient rehabilitation without the need for more aggressive interventions to close the extensive traumatic wound.

Retalho sural reverso como alternativa à reconstrução microcirúrgica de ferimento extenso em pé após queimadura elétrica: relato de caso / Reverse sural flap as an alternative to microsurgical reconstruction of extensive foot wound after electrical burn: case report

Introdução: Apresentar um relato de caso de confecção de retalho sural reverso como alternativa ao retalho microcirúrgico na reconstrução de pé após trauma elétrico. O relato apresentado é de um paciente atendido pelos grupos de Queimaduras e Feridas Complexas do Serviço de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no ano de 2020. Relato de Caso: Paciente masculino, 35 anos, sem comorbidades, vítima de trauma elétrico de alta voltagem (1300V) em domicílio, acometendo membros superiores e inferiores bilateralmente. Devido à gravidade das lesões, foi submetido a amputação transtibial à esquerda e desbridamentos seriados no membro contralateral, resultando em defeito em face medial, hálux e todo dorso do pé direito, com exposição óssea. Devido ao insucesso de reconstrução com retalho microcirúrgico de músculo vasto lateral, optou-se por reconstrução com retalho sural reverso. Evoluiu com necrose distal, sendo necessário novo desbridamento e reavanço do retalho. No seguimento, apresentou evolução favorável, e está em processo de reabilitação. Conclusão: O retalho sural reverso mostrou-se adequado para o tratamento de resgate de lesão extensa em pé após falha da terapia microcirúrgica, oferecendo cobertura estável e ótimo contorno, permitindo, assim, reabilitação satisfatória do paciente.

Introduction: To present a reverse sural flap case report as an alternative to microsurgical flap in foot reconstruction after electrical trauma. The report presented is of a patient treated by the Burns and Complex Wounds groups of the Plastic Surgery Service of the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo in 2020. Case Report: Male patient, 35 years old, without comorbidities, victim of high voltage electrical trauma (1300V) at home, affecting upper and lower limbs bilaterally. Due to the severity of the injuries, he underwent left transtibial amputation and serial debridement in the contralateral limb, resulting in a defect in the medial face, hallux and entire dorsum of the right foot, with bone exposure. Due to the failure of reconstruction with a microsurgical flap of the vastus lateralis muscle, reconstruction with a reverse sural flap was chosen. It evolved with distal necrosis, requiring new debridement and re-advancement of the flap. In the follow-up, he presented a favorable evolution and is in the process of rehabilitation. Conclusion: The reverse sural flap proved to be suitable for the salvage treatment of extensive foot injuries after the failure of microsurgical therapy, offering stable coverage and excellent contour, thus allowing satisfactory patient rehabilitation.

Treatment of soft tissue defect by progressive stretch skin suture technique / 中华全科医师杂志

Clinical data of 14 patients with skin and soft tissue defects treated by progressive stretch skin suture (stretch suture) in Zhongnan Hospital of Wuhan University from September 2016 to January 2021 were retrospectively analyzed. There were 10 male and 4 female aged 13-73 years. The ankle and calf were the main defect sites with the defect area ranged from 2-3 cm×2-3 cm to 3-6 cm×5-9 cm. According to the wound skin condition, patients received progressive stretch suture 2-4 times after debridement and anti-infection treatment until the wounds were completely healed. Two patients with fractures underwent skin stretch after fracture fixation with external fixators. There were 4 patients with wound infection, including 2 cases infected with Staphylococcus aureus, 1 with Escherichia coli, and 1 with Enterobacter cloacae, all of whom received antibiotic therapy and infection was controlled and the progressive stretch suture was performed. In 3 patients with severe degloved skin injury, the infection was treated with debridement on the first day, and stretch suture was not performed until the second debridement. The soft tissue defect wound healed completely in 10-23 days, with an average of (17.2±3.8)days. None of the patients had skin necrosis during the stretch suture treatment. The postoperative follow-up time was more than 6 months and the skin softness, sensory function and blood supply of the patients were normal, and the average Vancouver Scar Scale score was 3.1, among whom 9 cases were scored as excellent (0-3 points)　and 5 as good (4-7 points). The patients were satisfied with the effect of skin stretch,the study suggests that the progressive stretch skin suture technique is simple and effective in treatment of soft tissue defect.

Custos diretos dos curativos de úlceras vasculogênicas realizados por uma unidade de tratamento integral de ferida / Direct costs corresponding to vasculogenic ulcer dressings performed in a comprehensive wound care unit / Costos directos de las curaciones de úlceras vasculogênicas realizadas en una unidad de tratamiento integral de heridas

RESUMO Objetivo: aferir os custos diretos médios de curativos de úlceras vasculogênicas realizados por profissionais de enfermagem em pacientes atendidos por uma Unidade de Tratamento Integral de Ferida. Método: Pesquisa quantitativa, exploratório-descritiva, conduzida numa Unidade de Tratamento Integral de Ferida, localizada em Vitória da Conquista, Bahia - Brasil, em março, agosto e setembro de 2020. Calcularam-se os custos multiplicando-se o tempo despendido (cronometrado) pelos profissionais pelo custo da mão de obra direta, somando-se aos custos dos insumos. Análise de dados com estatística descritiva. Resultados: O custo direto médio total foi de US$11.90 (DP±10.79) para os curativos ambulatoriais (n=42), US$7.22 (DP±8.69) para os domiciliares (n=22) e US$3.10 (DP±2.57) para os hospitalares (n=11), com expressiva contribuição dos custos com terapia tópica: US$9.82 (DP±10.55), US$5.60 (DP±8.43) e US$1.30 (DP±0.22) respectivamente. Conclusão: os resultados poderão subsidiar a revisão dos insumos requeridos para os curativos de úlceras vasculogênicas, notadamente, das terapias tópicas e materiais/soluções.

ABSTRACT Objective: to assess the mean direct costs corresponding to vasculogenic ulcer dressings performed by Nursing professionals on patients treated at a Comprehensive Wound Care Unit. Method: A quantitative and exploratory-descriptive research study, conducted in March, August and September 2020 at a Comprehensive Wound Care Unit located in Vitória da Conquista, Bahia, Brazil. The costs were calculated multiplying the time spent (timed) by the professionals by the cost of direct labor, adding the costs of the inputs. Data analysis was performed by means of descriptive statistics. Results: The total mean direct costs were as follows: US$ 11.90 (SD±10.79) for outpatient dressings (n=42), US$ 7.22 (SD±8.69) for home dressings (n=22) and US$ 3.10 (SD±2.57) for hospital dressings (n=11), with a significant contribution from the costs of topical therapies: US$ 9.82 (SD±10.55), US$ 5.60 (SD±8.43) and US$ 1.30 (SD±0.22), respectively. Conclusion: the results may support a review of the inputs required for vasculogenic ulcer dressings, notably, regarding topical therapies and materials/solutions.

Objetivo: medir los costos directos medios correspondientes a curaciones de úlceras vasculogénicas realizadas por profesionales de Enfermería en pacientes atendidos por una Unidad de Tratamiento Integral de Heridas. Método: investigación cuantitativa y exploratoria-descriptiva realizada en marzo, agosto y septiembre de 2020 en una Unidad de Tratamiento Integral de Heridas situada en Vitória da Conquista, Bahía, Brasil. Los costos se calcularon multiplicando el tiempo empleado (cronometrado) por los profesionales por el costo de la mano de obra directa, sumando los costos de los insumos. Los datos se analizaron por medio de estadística descriptiva. Resultados: El costo directo medio total fue de US$ 11,90 (DE±10,79) para las curaciones ambulatorias (n=42), US$ 7,22 (DE±8,69) para las domiciliarias (n=22) y US$ 3,10 (DE±2,57) para las hospitalarias (n=11), con una significativa contribución de los costos de las terapias tópicas: US$ 9,82 (DE±10,55), US$ 5,60 (DE±8,43) y US$ 1,30 (DE±0,22), respectivamente. Conclusión: los resultados pueden sustentar una revisión de los insumos necesarios para las curaciones de úlceras vasculogénicas, en particular, las terapias tópicas y los materiales/soluciones.

Comparación entre suturas para cierre profundo y superficial en reemplazo total de rodilla: seguimiento a un año / A comparison of sutures for deep and superficial wound closure in total knee arthroplasty: One-year follow-up

Introducción Aunque diferentes materiales y técnicas se han desarrollado para el cierre superficial y profundo en reemplazo total de rodilla (RTR), no hay evidencia que permita dar recomendaciones respecto a una técnica especifica que disminuya complicaciones postoperatorias de la herida. El propósito de este estudio es comparar el uso de dos técnicas de cierre profundo (Sutura barbada vs. Sutura absorbible trenzada) y superficial (grapas vs. sutura de polipropileno) en RTR. Materiales y métodos Estudio observacional retrospectivo en 240 pacientes. Se excluyeron pacientes con antecedente de cirugía abierta previa de rodilla, RTR previo por lesiones tumorales o artrofibrosis. Seguimiento mínimo de 1 año. Resultados Se usaron grapas en 176 pacientes y Prolene® en 64 pacientes. El cierre profundo se realizó con Stratafix® en 164 pacientes y con Vicryl® en 75 pacientes. Encontramos complicaciones relacionadas con la herida y la funcionalidad al año de seguimiento. La infección superficial para el cierre con prolene presento un HR de 2.6 con un intervalo de confianza (IC) de 95%=1.1-6.2; p=0.029 y en el cierre profundo encontramos un HR a favor del Vicryl® de 0.22, IC 95%=0.96-5.8; p=0.05. Conclusiones Este estudio demostró un incremento significativo de la incidencia de infección superficial después de un RTR cuando el cierre profundo se realiza con suturas barbadas y el cierre superficial se realiza con sutura de polipropileno. Sin embargo, no se presentaron diferencias significativas en otras complicaciones relacionadas con la herida y en la funcionalidad postoperatoria con las diferentes técnicas de cierre superficial y profundo evaluadas.

Introduction Different materials and techniques have been developed for superficial and deep closure in total knee replacement (TKR), but there is no solid evidence that allows to recommend a specific technique that decreases the surgical post-operative complications. The purpose of this study is to compare the use of two deep closure techniques (barbed suture vs. braided absorbable suture) and superficial (staples vs. polypropylene suture) in TKR. Materials and methods An observational retrospective study was carried out in 240 patients. Those individuals were excluded with previous open knee surgery, arthrofibrosis, patients who underwent TKR due to tumor lesions or a follow up for less than one year. Results The skin was closed in 176 patients with staples and in 64 patients with Prolene®. Deep closure was performed with Stratafix® in 164 patients and with Vicryl® in 75 patients. Also, complications related to the wound and functionality were recorded in the first postoperative year. Superficial infection for closure with prolene presented an HR in favor of 2.6 with a confidence interval (CI) of 95%=1.1­6.2; p=0.029 and in deep closure a HR in favor of Vicryl® of 0.22, 95% CI=0.96­5.8; p=0.05 Conclusions This study demonstrated a significant increase in the incidence of superficial infection after TKR when deep closure is performed with barbed sutures and superficial closure with polypropylene suture. However, there were no significant differences in other complications related with the wound neither postoperative functionality with the different superficial and deep closure techniques that were evaluated.

Studies on the minimally invasive percutaneous suture technique of eight times for repairing closed injury extensor tendon zone I of finger / 中华骨科杂志

Objective:To discuss the clinical curative effect of the minimally invasive percutaneous suture technique of eight times for repairing closed injury extensor tendon zone I of finger.Methods:From February 2017 to January 2020, 12 patients (male 8, female 4) with mallet finger deformity were retrospectively studied, with an average age of 35 years (range, 18-50 years). And all the affected fingers were acute closed rupture of extensor tendon in zone I of single finger, 5 cases of the left finger and 7 cases of the right finger. There were 1 case of the thumb finger, 2 cases of the index finger, 3 cases of the middle finger, 4 cases of the ring finger and 2 cases of the little finger. 12 patients with fresh sputum mallet fingers were with 3-0 thread monofilament suture on extensor tendon zone I of finger in the minimally invasive percutaneous suture technique of eight times, and the distal end of the tendon was fixed to the base of the distal phalanx through the bone hole. Removal of the Kirschner wire 6-8 weeks, the brace was used to fix the affected finger in the dorsal extension. The flexion and extension of the affected finger was gradually strengthened. The function of the affected finger was evaluated according to the Crawford standard after operation and follow-up. The active flexion and extension range of motion of each joint of the affected finger and the contralateral healthy finger were measured, and the total action movement (TAM) of the finger were recorded. Finger function was evaluated according to TAM of the American Association of Hand Surgeons.Results:All operations were successfully completed, the operation time of the patients ranged from 18 to 25 min, with an average of 20.1±0.2 min. There was only a small amount of bleeding in the surgery. All 12 cases were followed up and the follow-up periods ranged from 6 to 14 months, with an average of 10.2±1.1 months. Mallet finger deformities were all corrected postoperatively; there were no knot exposure, skin necrosis and other complications. According to the Crawford standard, 9 cases were excellent, 2 cases were good, and 1 case was fair. The excellent and good rate was 91.7% (11/12). The mean active flexion of distal interphalangeal joints on the wounded finger and healthy finger were 82.11°±2.02° and 84.09°±2.01°, the mean active extension of distal interphalangeal joints on the wounded finger and healthy finger were -2.04°±3.01° and 0.02°±1.02°, there were significant differences between them ( t=2.447, 3.246; P=0.019, 0.004). The degrees of active joint activity of wounded finger were: 91.02°±4.01° of the metacar-pophalangeal joint, 94.04°±2.11° of the proximal interphalangeal joint, 83.01°±2.02° of the distal interphalangeal joint, and 265.05°±13.04° of total active activity; the degrees of active joint activity of healthy finger were: 93.01°±3.21° of the metacar-pophalangeal joint, 94.03°±3.07° of the proximal interphalangeal joint, 85.02°±2.01° of the distal interphalangeal joint, and 269.02°±12.10° of total active activity. The TAMs of the healthy side were 269.02°±12.10°, and the TAMs of the affected side were 265.05°±13.04°, there was no significant difference between them ( P>0.05). According to TAM system assessment criteria: excellent in 9 patients, good in 3 patients, and the excellent and good rate was 100% (12/12). Conclusion:The minimally invasive percutaneous suture technique of eight times can well repair closed injury extensor tendon zone I of finger, can have satisfactory treatment outcome in mallet finger with a simple procedure and good outcome. It is a simple, safe, effective method with minimal invasion.

Temporary abdominal closure combined with continuous negative pressure drainage in management of patients with severe pancreatic trauma / 中华肝胆外科杂志

Objective:To study the use of temporary abdominal closure combined with continuous negative pressure drainage in management of patients with severe pancreatic trauma.Methods:A retrospective analysis was conducted on the data of 33 patients with severe pancreatic trauma treated at the 908th Hospital of the Joint Logistics Support Force of PLA from June 2014 to June 2020. There were 28 males and 5 females, with an average age of 43.1 years. Sixteen patients were treated with temporary abdominal closure combined with continuous negative pressure drainage (the combined group), and 17 patients with direct abdominal closure and traditional drainage (the control group). The body temperature, heart rate, intra-abdominal pressure, length of hospital stay and postoperative complications were compared between groups.Results:There was no significant difference in the preoperative intra-abdominal pressure between the two groups ( P>0.05). The intra-abdominal pressure on the first, second and third postoperative days in the combined group were (11.7±2.6) mmHg (1 mmHg=0.133 kpa), (11.1±3.2) mmHg and (10.2±3.7) mmHg respectively, which were significantly lower than those in the control group of (18.1±5.3) mmHg, (15.6±6.2) mmHg, and (15.0±6.7) mmHg, respectively (all P<0.05). The total in-hospital and ICU stays in the combined group were (29.2±17.8) days and (7.1±3.2) days respectively, which were significantly less than those in the control group of (49.5±26.3) days and (11.8±7.6) days (both P<0.05). The decreases in body temperature and heart rate in the combined group were (-0.1±0.9)℃ and (18.2±17.2) times/min respectively, which were significantly more than those in the control group of (-1.2±0.7)℃ and (-5.9±17.2) times/min respectively (both P<0.05). The incidence of postoperative complication in the combined group was 18.8% (3/16), which was significantly lower than that in the control group of 52.9% (9/17)(χ 2=4.164, P=0.041). Conclusion:Significant advantages were obtained by using temporary abdominal closure combined with continuous negative pressure drainage to treat patients with severe pancreatic trauma. There were significantly lower abdominal pressure, less abdominal complications, and shorter hospital and ICU stays. This treatment is worthy of promotion in management of patients with severe pancreatic trauma.

Application of tension-reducing distraction of external fixators for limb wound closure / 中华创伤杂志

Objective:To explore the effect of tension-reducing distraction of external fixators for limb wound closure.Methods:A retrospective case series study was made on data of 21 patients with refractory limb wounds admitted to 920th Hospital of Joint Logistics Support Force of PLA from January 2016 to July 2019. There were 15 males and 6 females，aged 11 to 56 years ［ （37.8 ± 11.2）years］. The lower-limb wounds were found in 15 patients and the upper-limb wound in 6 patients. The area of wound defect ranged from 1.2 cm × 1.0 cm to 22.0 cm × 17.1 cm. After debridement of the limb wound，the tension-reducing distraction of Ilizarov external fixators was used according to the shape and location of the wound. Distraction was applied at a rate of 1 mm/d starting at postoperative day 1 and the direction of distraction was adjusted according to the angle of skin closure of the trauma. The wound reduction distraction time and wound healing time were recorded. The wound healing score was used to evaluate wound healing at postoperative 5 days and 30 days. Complications were recorded according to the Paley classification. The wound survival curve was plotted to observe the time of wound tension reduction and traction and wound healing. The final wound healing was detected as well.Results:All patients were followed up for 3 to 9 months ［（4.5 ± 1.7）months］. The wounds were significantly reduced after reduction and distraction，with the reduction time of 6-23 days ［（7.8 ± 2.3）days］ and the wound healing time of 15-47 days ［（23.0 ± 3.3）days］. The wound healing score was （3.2 ± 0.9）points at postoperative 5 days and （0.7 ± 0.2）points at postoperative 30 days （ P < 0.05）. There were 15 problems，0 disorder，and 0 sequelae according to the Paley classification of complications. The wound survival curve showed the median time of reduction and distraction and wound healing was 16 days and 34 days，respectively. All patients showed wound healing without recurrence，of which 10 were healed directly，8 by implants and 3 by sutures. Conclusion:For patients with limb wounds difficult to be treated by flap coverage，the tension-reducing distraction of external fixators can effectively close the wound，fasten wound healing，shorten treatment period，and has fewer complications and a low recurrence rate.

Keep it simple. A ten-year experience in reconstructions after Mohs micrographic surgery

Abstract Background: Mohs micrographic surgery is worldwide used for treating skin cancers. After obtaining tumor-free margins, choosing the most appropriate type of closure can be challenging. Objectives: Our aim was to associate type of surgical reconstructions after Mohs micrographic surgery with the characteristics of the tumors as histological subtype, anatomical localization and especially number of surgical stages to achieve complete excision of the tumour. Methods: Transversal, retrospective analyses of medical records. Compilation of data such as gender, age, tumor location, histological subtype, number of stages to achieve clear margins and type of repair used. Results: A total of 975 of facial and extra-facial cases were analyzed. Linear closure was the most common repair by far (39%) and was associated with the smallest number of Mohs micrographic surgery stages. This type of closure was also more common in most histological subtypes and anatomical locations studied. Using Poisson regression model, nose defects presented 39% higher frequency of other closure types than the frequency of primary repairs, when compared to defects in other anatomic sites (p< 0.05). Tumors with two or more stages had a 28.6% higher frequency of other closure types than those operated in a single stage (p< 0.05). Study limitations: Retrospective study with limitations in obtaining information from medical records. The choice of closure type can be a personal choice. Conclusions: Primary closure should not be forgotten especially in surgical defects with fewer stages and in non-aggressive histological subtypes in main anatomic sites where Mohs micrographic surgery is performed.

Transferência de retalho à distância com secção do pedículo vascular em segundo tempo / Distant flap transfer with the vascular pedicle section in second stage

Introdução: Ocasionalmente não há possibilidade de se cobrir uma ferida com enxertos ou retalhos locais. O objetivo deste trabalho foi avaliar a resolutividade da transferência de retalho à distância com secção do pedículo vascular em segundo tempo para cobertura de região que sofreu perda de substância. Métodos: Cinco pacientes com perda de substância, sem opção de reconstrução com enxertos ou retalhos locais, tiveram suas feridas cobertas por retalhos transferidos à distância, com secção dos pedículos vasculares em segundo tempo. Resultados: Os retalhos transferidos foram eficazes na cobertura das feridas. Conclusão: A transferência de retalho à distância com secção do pedículo vascular em segundo tempo é procedimento simples e eficaz, que deve ser dominado por todo cirurgião plástico.

Introduction: Occasionally, there is no possibility of covering a wound with local grafts or flaps. This study aimed to evaluate the capacity of the distant flap transfer with the vascular pedicle section in second stage to cover the region that suffered a loss of substance. Methods: Five patients with substance loss, with no reconstruction option using grafts or local flaps, had their wounds covered by distant flap transfer with the vascular pedicle section in second stage. Results: The transferred flaps were useful in covering the wounds. Conclusion: distant flap transfer with the vascular pedicle section in second stage is a simple and effective procedure. Every plastic surgeon must master that.

Manejo da orelha constricta: abordagem do serviço de cirurgia plástica do Hospital de Clínicas de Porto Alegre, Brasil / Management of constricted ear: plastic surgery service approach at the Hospital of Clinics in Porto Alegre, Brazil

Introdução: A prevalência de malformações da orelha chega a 5% quando considerada toda a população mundial. Primariamente descrita em 1975 a orelha constricta representa um grupo de deformidades envolvendo o terço superior da cartilagem auricular com características em comum. O impacto estético e o estigma social dessas deformidades podem levar a danos psicológicos ao paciente quando não corrigidos. Métodos: Descrevemos a seguir a técnica utilizada no serviço de cirurgia plástica do Hospital de Clínicas de Porto Alegre. Resultados: O resultado pode ser evidenciado com 30 dias de pós-operatório. Conclusão: O método descrito, de reacomodação da cartilagem, é uma opção para o tratamento dessa deformidade com adequado resultado estético.

Introduction: The prevalence of ear malformations reaches 5% when considering the entire world population. Primarily presented in 1975, the constricted ear represents a group of deformities of the upper third of the auricular cartilage with common features. The aesthetic impact and social stigma of these deformities can cause psychological harm to the patient when not corrected. Methods: We describe below the technique used in the plastic surgery department of the Hospital de Clínicas de Porto Alegre. Results: Result can be evidenced with 30 days postoperatively. Conclusion: The described method, cartilage resettlement, is an option for treatment of this deformity with adequate aesthetic result.

Fio de sutura elástico / Elastic suture thread

Introdução: O tratamento de grandes e médias feridas é um desafio para os cirurgiões quando precisam fechálas e, normalmente, são utilizadas técnicas cirúrgicas de enxertias ou retalhos, que podem deixar sequelas e até mesmo mutilações. Ao longo do tempo desenvolveu-se a técnica de "sutura elástica" que promove a cicatrização em curto espaço de tempo com sequelas menores, entretanto o procedimento tem sido realizado com material improvisado. Objetivo: Desenvolver um fio de sutura elástico cirúrgico que possa ser esterilizado e confeccionado nos moldes dos produtos médicos cirúrgicos. Métodos: Revisão das patentes existentes por meio da busca de anterioridade e comparação com o dispositivo do estudo. Pesquisa de materiais com as características necessárias como elasticidade e tensão. Teste destas características em laboratórios especializados. Resultados: O produto desenvolvido é um fio elástico com duplo agulhamento para suturas, com matéria prima de silicone que apresenta elasticidade e resistência a tensão. Conclusão: O fio de sutura elástico, com duplo agulhamento, para feridas de médio e grande porte foi desenvolvido.

Introduction: Closing large and medium wounds is challenging for surgeons and often leads to the use of graft or flap surgical techniques. These procedures can leave sequelae and even mutilations. An "elastic suture" technique was developed to promote wound healing in a short time span with minor sequelae; however, improvised materials have been used in this procedure. Objective: To develop a surgical elastic suture thread that can be manufactured and sterilized following the standards of surgical medical products. Methods: We conducted a patent search, compared the findings with the study device, and researched materials with necessary characteristics such as elasticity and tension. Testing these characteristics in specialized laboratories. Results: The developed device is a double-needled elastic suture made of silicone that presents tensile strength. Conclusion: Here, we developed a double-needled elastic suture for medium and large wounds.

A simple modification of the conventional figure-of-eight sternal closure technique

Abstract Objective: To describe a new technique of sternal closure, modified from the conventional figure-of-eight approach, which can provide a secure closure and prevent sternal complications. Methods: The modified technique is based on the intercalation of the caudal portion of each steel wire passed along the sternum. This is a retrospective analysis of patients operated with this modified technique at our institution between January 2014 and December 2016. Results: One hundred and forty-three patients underwent sternal closure with the modified technique. In-hospital mortality rate was 1.4% (n=2). No sternal instability was observed at 30 days postoperatively. Two patients developed mediastinitis that required extraction of the wires. Conclusion: Short-term results have shown that the modified sternal closure technique can be used safely and effectively, with complications rates being consistent with worldwide experience.

Herida toracoabdominal izquierda como causa de hernia diafragmática. Presentación de tres casos / Left thoraco-abdominal wound as a cause of diaphragmatic hernia. Presentation of three cases

RESUMEN Las lesiones por arma blanca en la región toracoabdominal tienen la posibilidad potencial de dañar dos cavidades anatómicas: tórax y abdomen, con la subsiguiente lesión del músculo diafragma y la producción de una hernia de contenido visceral, asociada o no a lesión visceral. En caso de que esta entidad clínica sea pasada por alto, existe una alta probabilidad de complicaciones que ponen en riesgo la vida; por tanto, realizar un manejo adecuado constituye un reto para el cirujano general, que precisa de un alto índice de sospecha para formular el diagnóstico. Se presentan tres casos de víctimas de agresión con arma perforo-cortante en región toracoabdominal izquierda, atendidos en instalaciones donde se disponía de limitados recursos diagnósticos. Se exponen datos clínicos, pruebas de apoyo al diagnóstico, procedimiento quirúrgico, curso posoperatorio y evolución. El abordaje quirúrgico abdominal es la regla de oro para reparar el diafragma lesionado, y la pleurostomía mínima es eficaz cuando existe compromiso torácico.

ABSTRACT Injuries caused by white arms in the thoraco-abdominal region have the potential to damage both anatomical cavities: thorax and abdomen, with the subsequent injury of the diaphragm muscle and the production of a visceral hernia, associated or not with visceral injury. In case this clinical entity is overlooked, there is a high probability of life-threatening complications; therefore, adequate management is a challenge for the general surgeon, who needs a high index of suspicion to formulate the diagnosis. Three cases of victims of assault with a perforating-cutting weapon in the left thoraco-abdominal region are presented, attended in facilities where limited diagnostic resources were available. Clinical data, diagnostic support tests, surgical procedure, postoperative course and progress are explained. The abdominal surgical approach is the gold rule for repairing the injured diaphragm, and the minimal thoracostomy is effective when there is thoracic involvement.

Utilidad de la técnica de Lichtenstein y RutkowRobbins en el tratamiento de la hernia inguinal / Usefulness of the technique of Lichtenstein and Rutkow Robbins in the treatment of inguinal hernia

RESUMEN Introducción: la práctica de nuevas técnicas y métodos en la cirugía entraña un complejo proceso cuyo resultado puede modificarse con la experiencia, el desempeño y la dedicación de los cirujanos. Las clasificaciones de las hernias inguinales han permitido agrupar las alteraciones anatomo-funcionales de la región en grados para guiar el tratamiento quirúrgico. Objetivo: exponer los resultados de la realización individualizada de las hernioplastias de Lichtenstein y RutkowRobbins. Método: se realizó un estudio descriptivo transversal prospectivo, el universo de estudio estuvo constituido por 150 pacientes intervenidos quirúrgicamente por hernia inguinal en el Hospital Celia Sánchez Manduley, Manzanillo, entre enero y diciembre de 2017. Se conformaron dos grupos: uno donde se utilizó la técnica de Lichtenstein y en otro se utilizó la técnica de Rutkow y Robbins. Se analizaron variables cualitativas y cuantitativas. Resultados: predominó la hernia tipo II, IIIb y IIIa, fueron más frecuentes en el sexo masculino y de localización derecha. La hernioplastia de Lichtenstein resultó la técnica más utilizada. Se encontraron diferencias muy significativas entre ambas técnicas. La hernioplastia de Lichtenstein se realizó en un tiempo quirúrgico menor que la hernioplastia de Rutkow - Robbins. Las complicaciones encontradas fueron independientes de la técnica utilizada. Conclusiones: la hernioplastia de Lichtenstein resultó la técnica más utilizada y se realizó en un tiempo quirúrgico menor que la hernioplastia de Rutkow - Robbins. Se encontraron diferencias muy significativas entre ambas técnicas.

ABSTRACT Introduction: the practice of new techniques and methods in surgery involves a complex process whose result can be modified with the experience, performance and dedication of surgeons. The inguinal hernia classifications have allowed grouping the anatomo-functional alterations of the region in degrees to guide the surgical treatment. Objective: to present the results of the individualized realization of the hernioplasties of Lichtenstein and Rutkow Robbins. Method: a prospective, cross-sectional descriptive study was carried out. The study universe consisted of 150 patients surgically treated for inguinal hernia at the Celia Sánchez Manduley Hospital, Manzanillo, between January and December 2017. Two groups were formed: one where the Lichtenstein technique and in another the technique of Rutkow and Robbins was used. Qualitative and quantitative variables were analyzed. Results: the hernia type II, IIIb and IIIapredominated, they were more frequent in the male sex and of right location. Lichtenstein hernioplasty was the most used technique. Significant differences were found between both techniques. The Lichtenstein hernioplastywas performed at a shorter surgical time than the Rutkow - Robbins hernioplasty. The complications found were independent of the technique used. Conclusions: Lichtenstein hernioplasty was the most used technique and was performed at a shorter surgical time than the Rutkow - Robbins hernioplasty. Significant differences were found between both techniques.

Effect of three-layer close suture and Allgöwer-Donati suture on incision healing after calcaneal fracture surgery / 中华骨科杂志

Objective@#To compare the efficacy between three-layer suture and Allgöwer-Donati suture on wound healing.@*Methods@#From September 2016 to June 2018, patients with Sanders type III calcaneal fracture were randomly divided into two groups: three-layer close suture group (26 cases, 18 males and 8 females, aged 19-48 years, with an average age of 33.69±8.84 years) and Allgöwer-Donati group (26 cases, 19 males and 7 females, aged 19-49 years, with an average age of 32.38±8.45 years). The traditional L-shaped incision was used in all patients. The inflammatory reaction area of incision, skin temperature change at the corner of L-shaped incision line and the healing grade of incision were compared between the two groups.@*Results@#52 pa-tients were followed up for 6 months. At 2 weeks after operation, the inflammatory reaction area of incision skin in the three-layer close skin suture group (26.46±9.37 mm2) was smaller than that in Allgöwer-Donati suture group (33.16±9.33 mm2). There was a significant difference between the two groups (t=2.584, P=0.013). There was no difference in skin temperature at the corner of L-shaped incision between the two groups before and on the first day after operation. However, the incision skin temperature of the three-layer close suture group on the 2nd and 3rd day after operation[ (36.47±0.33) ℃ and (36.54±0.22) ℃]was higher than that of Allgöwer-Donati group[ (36.20±0.42) ℃ and (36.22±0.43) ℃]. The difference was statistically significant (t=2.61, P=0.01; t= 3.48, P=0.001). There were 25 cases of Class A healing and 1 case of Class B healing in three-layer close suture group, with Class A healing rate of 96.15% (25/26). In Allgöwer-Donati group, there were 22 cases of Class A healing, 1 case of Class B healing, and 3 cases of Class C healing, with Class A healing rate of 84.62% (22/26). Among all grade B healing incisions, 1 case had a small amount of local hemorrhagic exudation in the three-layer close suture group, while 1 case had a black necrosis at the edge of the in-cision, 3 cases had a purulent incision and exposed steel plate in the Allgöwer-Donati group.@*Conclusion@#In the treatment of L-shaped incision of calcaneal fracture, three-layer close suture is a better method than Allgöwer-Donati suture because of smaller in-flammatory reaction area of incision, higher skin temperature change at the corner of L-shaped incision on the 2nd and 3rd day af-ter operation, higher rate of first-degree healing of incision and slighter incision complications.

Effect of three-layer close suture and Allg(o)wer-Donati suture on incision healing after calcaneal fracture surgery / 中华骨科杂志

Objective To compare the efficacy between three-layer suture and Allg(o)wer-Donati suture on wound healing.Methods From September 2016 to June 2018,patients with Sanders type Ⅲ calcaneal fracture were randomly divided into two groups:three-layer close suture group (26 cases,18 males and 8 females,aged 19-48 years,with an average age of 33.69±8.84 years) and Allg(o)wer-Donati group (26 cases,19 males and 7 females,aged 19-49 years,with an average age of 32.38±8.45 years).The traditional L-shaped incision was used in all patients.The inflammatory reaction area of incision,skin temperature change at the corner of L-shaped incision line and the healing grade of incision were compared between the two groups.Results 52 patients were followed up for 6 months.At 2 weeks after operation,the inflammatory reaction area of incision skin in the three-layer close skin suture group (26.46±9.37 mm2) was smaller than that in Allg(o)wer-Donati suture group (33.16±9.33 mm2).There was a significant difference between the two groups (t=2.584,P=0.013).There was no difference in skin temperature at the comer of Lshaped incision between the two groups before and on the first day after operation.However,the incision skin temperature of the three-layer close suture group on the 2nd and 3rd day after operation [(36.47±0.33)℃ and (36.54±0.22)℃] was higher than that of Allg(o)wer-Donati group [(36.20±0.42)℃ and (36.22±0.43)℃].The difference was statistically significant (t=2.61,P=0.01;t=3.48,P=0.001).There were 25 cases of Class A healing and 1 case of Class B healing in three-layer close suture group,with Class A healing rate of 96.15％ (25/26).In Allg(o)wer-Donati group,there were 22 cases of Class A healing,1 case of Class B healing,and 3 cases of Class C healing,with Class A healing rate of 84.62％ (22/26).Among all grade B healing incisions,1 case had a small amount of local hemorrhagic exudation in the three-layer close suture group,while 1 case had a black necrosis at the edge of the incision,3 cases had a purulent incision and exposed steel plate in the Allg(o)wer-Donati group.Conclusion In the treatment of L-shaped incision of calcaneal fracture,three-layer close suture is a better method than Allg(o)wer-Donati suture because of smaller inflammatory reaction area of incision,higher skin temperature change at the comer of L-shaped incision on the 2nd and 3rd day after operation,higher rate of first-degree healing of incision and slighter incision complications.

A enfermagem frente às tecnologias no tratamento de lesões de alta complexidade: elaboração de guia de prática clínica sobre terapia por pressão negativa da lesão por pressão / Nursing in relation to technologies in the treatment of highly complex injuries: development of a clinical practice guide on negative pressure therapy for pressure injuries

A abordagem adequada das lesões constitui um oneroso problema para os portadores, cuidadores, profissionais e gestores de saúde. A Terapia por Pressão Negativa destaca-se de todas as demais alternativas de tratamento existentes (não cirúrgicas), principalmente por se tratar de uma terapia com abordagem bioquímica e mecânica. Tecnologias educacionais podem colaborar para o bom gerenciamento dos processos assistenciais dos profissionais de enfermagem aos pacientes portadores de lesões por pressão complexas em uso desta tecnologia. O objetivo geral deste estudo é o desenvolvimento de um guia de prática clínica para enfermeiros sobre o uso da terapia por pressão negativa na assistência em saúde aos pacientes portadores de lesões por pressão complexas. E como objetivos específicos, identificar os pontos/temas pertinentes para a elaboração do guia sobre o uso da terapia por pressão negativa na prática assistencial em saúde aos pacientes portadores de lesões por pressão complexas. Metodologia: elaboração de tecnologia a partir de uma pesquisa de desenvolvimento metodológico com abordagem qualitativa em formato de Guia de prática clínica para utilização da terapia de lesões por pressão negativa na assistência em saúde aos pacientes portadores de lesões por pressão complexas realizada em três etapas: 1ª: identificação dos temas por meio da revisão de literatura e do Consenso de Terapia por Pressão Negativa, documento elaborado pela European Wound Management Association; 2ª: estruturação da tecnologia com base no conteúdo abordado na etapa anterior; 3ª: elaboração da tecnologia, contendo ilustrações. Resultados: os temas apresentaram 8 artigos pertinentes ao objetivo do estudo na revisão integrativa, uma revisão de literatura e considerações importantes extraídas do Consenso de Terapia por Pressão Negativa. Conclusão: a Terapia por Pressão Negativa se propõe como um tratamento benéfico ao processo de cicatrização de lesões por pressão complexas. A Terapia por Pressão Negativa promove uma cicatrização rápida, prevenindo complicações significativas na lesão por pressão complexa, além de diminuir o tempo de internação hospitalar, oferecendo bom custo de amparo à saúde do paciente. São necessários novos estudos a fim de oferecer caminhos comunicacionais possíveis para popularizar o uso da Terapia por Pressão Negativa no tratamento das lesões por pressão complexas.

Appropriate approach to injury is an onerous problem for carriers, caregivers, practitioners and health managers. The Negative Pressure Therapy stands out from all other alternatives of treatment (non-surgical), mainly because it is a therapy with a biochemical and mechanical approach. Educational technologies can contribute to the good management of care processes of nursing professionals to patients with complex pressure injuries using this technology. The general objective of this study is the development of a clinical practice guide for nurses on the use of negative pressure therapy in health care for patients with complex pressure lesions. And, as specific objectives, identify the relevant points / themes for the development of the guide on the use of negative pressure therapy in the health care practice of patients with complex pressure injuries. Methodology: elaboration of technology from a methodological development research with a qualitative approach in the form of a Clinical Practice Guide for the use of negative pressure injury therapy in health care for patients with complex pressure injuries performed in three stages: 1st: identification of the themes through literature review and Negative Pressure Therapy Consensus, document prepared by the European Wound Management Association; 2nd: structuring the technology based on the content addressed in the previous stage; 3rd: elaboration of the technology, containing illustrations. Results: the themes presented 8 articles pertinent to the objective of the study in the integrative review, a literature review and important considerations drawn from the Consensus of Negative Pressure Therapy. Conclusion: Negative Pressure Therapy is proposed as a beneficial treatment to the healing process of complex pressure injuries. TPN promotes rapid healing, preventing significant complications in the complex pressure injury, in addition to reducing the length of hospital stay, offering a good cost of protection to the patient's health. Further studies are needed in order to provide possible communication paths to popularize the use of Negative Pressure Therapy in the treatment of complex pressure injuries.