Versatilidad del colgajo nasogeniano basado en perforantes de la arteria facial en reconstrucción facial / Versatility of the nasolabial flap based on facial artery perforators in facial reconstruction

Se conocen varios colgajos locales basados en la arteria facial al momento de reconstruir unidades estéticas faciales. Levantar estos colgajos basados en las ramas perforantes de la arteria facial, los hace más finos, móviles, fiables, y adaptables, y la posibilidad de realizarlos en un solo tiempo quirúrgico. El propósito de este estudio es demostrar nuestra experiencia con el colgajo perforante de la arteria facial en reconstrucciones faciales de defectos hasta tamaño de 5x4cm, utilizando su pedículo superior o su pedículo inferior. Método. Realizamos un estudio longitudinal retrospectivo con 15 pacientes de ambos sexos, con edades comprendidas entre 40 a 60 años, a quienes se realizó el colgajo perforante facial en un solo tiempo quirúrgico. Los defectos faciales tratados fueron de tamaño pequeño a mediano, localizados en subunidades de la mejilla, nariz, pliegue nasolabial, labios superior e inferior. Resultados. De los 15 pacientes de nuestro estudio, 13 evolucionaron sin complicaciones (84.6%); 1 paciente concurrió con leve dehiscencia de herida (7.7%) y 1 paciente al que se le realizó un colgajo de 5x4cm concurrió con una mínima necrosis en la parte distal del colgajo (7.7%). Estas complicaciones fueron leves y con resolución ambulatoria, sin requerir otro tiempo quirúrgico. Conclusiones: Gracias a su libertad de movimiento, este colgajo nos permite reconstruir varias unidades estéticas, y por su delgado espesor, mínimas complicaciones y una cicatriz de la zona dadora que se camufla en el surco nasogeniano, los resultados tanto funcionales como estéticos son superiores comparados con los tradicionales colgajos locales miocutáneos nasolabiales.

Several local flaps based on the facial artery are well known when reconstructing facial aesthetic units. Making these flaps based on the perforating branches of the facial artery makes them thinner, more mobile, reliable, and adaptable, and the possibility of performing them in a single surgical time. The purpose of this study is to demonstrate our experience with the perforating vessel of the facial artery flap, in facial reconstructions of defects up to a size of 5x4 cm, using its upper or lower pedicle. Method. We carried out a retrospective longitudinal study with 15 patients of both sexes, aged between 40 and 60 years, who underwent the facial artery perforator flap in a single surgical time. The facial defects treated were small to medium in size, located in subunits of the cheek, nose, nasolabial fold, upper and lower lips. Results. The complications that we obtained when doing this flap were hematoma, partial dehiscence of the suture and slight venous congestion. All of these were mild and with outpatient resolution, without requiring another surgical time. Conclusions. Due to its freedom of movement, this flap allows us to reconstruct several aesthetic units, and due to its thin thickness and with minimal complications, both functional and aesthetic results are superior compared to traditional nasolabial myocutaneous flaps.

Sistemática en el Tratamiento Quirúrgico de las Fracturas Panfaciales Aplicado a un Caso Clínico De Alta Complejidad / Systematic in the Surgical Treatment of Panfacial Fractures Applied to a Highly Complex Clinical Case

RESUMEN: Las fracturas panfaciales son aquellas que afectan de forma simultánea al tejido óseo de dos o más tercios del rostro. El manejo inicial de estos pacientes es resolver o estabilizar las urgencias médico - quirúrgicas que puedan presentar, debido a que la gran mayoría de estas fracturas están asociadas a traumatismos de alta energía cinética, las que determinan la presencia de lesiones concomitantes que pueden comprometer la vida del paciente. El tratamiento quirúrgico de las fracturas panfaciales puede abarcar desde la intervención quirúrgica inicial de control de daños, estabilización, reducción y fijación quirúrgica de los segmentos fracturados mediante osteosíntesis hasta intervenciones mediatas para la reconstrucción de los tejidos afectados por el traumatismo. Para el tratamiento de las fracturas panfaciales existe una sistemática quirúrgica que tiene por objeto contener y/o minimizar daños agudos y permitir una reducción morfológica y funcional. Reportamos un caso clínico de fractura panfacial cuyo tratamiento siguió esta sistemática terapeútica.

ABSTRACT: Panfacial fractures affect bone tissue in two or more thirds of the face simultaneously. The initial management of these patients is to resolve or stabilize the medical-surgical emergencies that they may present. Most of these fractures are associated to trauma of high kinetic energy, which determine the presence of concomitant inju- ries that can compromise the life of the patient. The surgical treatment of panfacial fractures may include from the initial surgical intervention of damage control, stabilization, reduction and surgical fixation of fractured segments through osteosynthesis, to mediate the reconstruction of tissues affected by the trauma. For the treatment of panfacial fractures there is a surgical approach that aims to contain and/or minimize acute damage and allow for morphological and functional reduction. We report a clinical case of panfacial fracture whose treatment followed this therapeutic approach.

Tratamento tardio de fratura do complexo zigomático-orbitário com uso de fixação interna rígida / Late treatment of the zygomatic-orbital complex fracture with rigid internal fixation

RESUMO: As fraturas do complexo zigomático-orbitário são bastante frequentes devido a sua localização e projeção na face, podendo gerar grandes transtornos funcionais e estéticos ao paciente. O osso zigomático é essencial na configuração da face, sendo a principal estrutura formadora do terço médio dela. Os traumas que mais frequentemente provocam fraturas do complexo zigomático-orbitário são agressões físicas, acidentes de trânsito e esportivos. O tipo de fratura, tempo decorrido, a severidade e o envolvimento de outras estruturas faciais influenciam a modalidade de tratamento a ser empregado. O presente trabalho apresenta um caso clínico de fratura do complexo zigomático-orbitário esquerdo, diagnosticada tardiamente, e tratada por meio de osteotomia, redução e fixação em três pontos com placas e parafusos do sistema 1.5, e reconstrução do assoalho orbitário com tela de titânio. (AU)

ABSTRACT: Fractures of the zygomatic-orbital complex are quite frequent due to their location and projection on the face, which can cause major functional and aesthetic disorders to the patient. The zygomatic bone is essential in the configuration of the face, being the main forming structure of the middle third of it. The traumas that most often cause fractures of the zygomatic-orbital complex are physical aggression, traffic accidents, and sports. The type of fracture, elapsed time, severity, and the involvement of other facial structures influence the type of treatment to be employed. The present work presents a clinical case of fracture of the left zygomatic-orbital complex, diagnosed late, and treated by osteotomy, reduction, and fixation in three points with 1.5 system plates and screws, and reconstruction of the orbital floor with titanium mesh. (AU)

Lipotransferencia: una alternativa para el tratamiento de la deformidad facial adquirida / Lipotransfer: an alternative for the treatment of acquired facial deformity / A lipotransferência: uma alternativa para o tratamento da deformidade facial adquirida

RESUMEN Se presentó el caso de un paciente masculino de 58 años, con antecedentes de salud aparente, que refiere haber recibido tratamiento quirúrgico por fractura compleja de tercio medio facial (fracturas tipo Lefort II y malar III derecha), el mismo refiere inconformidad estética por la deformidad facial postraumática que presenta. Se decidió su ingreso en el Servicio de Cirugía Maxilofacial del Hospital Universitario "General Calixto García" para su tratamiento. Se diagnosticó deformidad postraumática secundaria a una fractura facial compleja y su consiguiente daño estético. Los resultados alcanzados con la utilización de la lipotransferencia de tejido graso abdominal para el tratamiento de la deformidad facial fueron satisfactorios con permanencia y estabilidad en un año, a la vez que cumplió con las expectativas del paciente. La lipotransferencia resulta una alternativa viable en el tratamiento de las deformidades faciales adquiridas.

ABSTRACT The case of a 58-year-old male patient was presented, with a history of apparent health, who reported having received surgical treatment for a complex fracture of the middle facial third (fractures Lefort II and right malar III), the same refers to aesthetic disagreement for the deformity posttraumatic facial presenting. It was decided to enter the Maxillofacial Surgery Service of the University Hospital "General Calixto García" for treatment. Posttraumatic deformity was diagnosed secondary to a complex facial fracture and its consequent aesthetic damage. The results achieved with the use of abdominal fatty tissue lipotransfer for the treatment of facial deformity were satisfactory with permanence and stability in one year, while meeting the patient's expectations. Lipotransfer is a viable alternative in the treatment of acquired facial deformities.

RESUMO Foi apresentado o caso de um paciente do sexo masculino, 58 anos, com histórico aparente de saúde, que relatou ter recebido tratamento cirúrgico para uma fratura complexa do terço facial médio (fraturas de Lefort II e malar III direita), o mesmo se refere a discordância estética quanto à deformidade apresentação facial pós-traumática. Foi decidido entrar no Serviço de Cirurgia Maxilofacial do Hospital Universitário "General Calixto García" para tratamento. A deformidade pós-traumática foi diagnosticada secundária a uma fratura facial complexa e seu conseqüente dano estético. Os resultados obtidos com o uso da lipotransferência de tecido adiposo abdominal para o tratamento da deformidade facial foram satisfatórios com permanência e estabilidade em um ano, atendendo às expectativas do paciente. A lipotransferência é uma alternativa viável no tratamento de deformidades faciais adquiridas.

Abordagem de fratura panfacial em emergência: relato de caso / Emergency panfacial fracture approach: case report

Objetivo: O presente estudo consiste em relatar o caso clínico de um paciente com fratura panfacial e abordagem cirúrgica de emergência para realização de fixação interna rígida e sua reabilitação. Descrição do Caso: Paciente do gênero masculino, 46 anos, vítima de acidente automobilístico, deu entrada no serviço de emergência do Hospital Geral do Estado da Bahia (HGE-BA) cursando com múltiplas fraturas em face. Foi planejada abordagem, sob anestesia geral e intubação orotraqueal com derivação submentual, em razão de fratura de base anterior de crânio, fratura dos ossos próprios nasais e necessidade de bloqueio maxilomandibular no transcirúrgico. Paciente acompanhado no pós-operatório, evoluindo com projeção facial satisfatória, oclusão estável, boa permeabilidade nasal e sem deformidade dentofacial. Conclusão: As fraturas panfacias são desafiadoras, e seu planejamento cirúrgico deve ser estabelecido visando o posicionamento adequado dos fragmentos fraturados e a preservação das estruturas anatômicas faciais, devolvendo função e garantindo o mínimo de sequelas para o paciente(AU)

Purpose: The present study consists in reporting the clinical case of a patient with panfacial fracture, with an emergency surgical approach to perform rigid internal fixation for patient rehabilitation. Case description: A 46-year-old male patient, victim of an automobile accident, was admitted to the emergency department of the Hospital Geral do Estado da Bahia (HGE-BA), attending multiple fractures in the face. The approach was planned under general anesthesia and orotracheal intubation with submental shunt, due to anterior skull fracture, fracture of the nasal bones and the need for maxillomandibular block in the trans-surgical. Patient followed postoperatively, evolving with satisfactory facial projection, stable occlusion, good nasal permeability, and no dentofacial deformity. Conclusions: Panfacial fractures are challenging, and their surgical planning must be established aiming at the adequate positioning of fractured fragments and preservation of facial anatomical structures, restoring function and ensuring a minimum of sequelae for the patient(AU)

Reanimação estática do lábio inferior na paralisia facial como complicação de preenchimento / Static lower lip reanimation as a filler complication of facial paralysis

Procedimentos de rejuvenescimento facial substitutos da cirurgia tradicional tornaram-se cada vez mais populares para promover uma aparência jovial com procedimentos minimamente invasivos, como toxina botulínica injetável, preenchimento de tecidos moles e peelings químicos. No entanto, complicações podem ocorrer mesmo na presença de um injetor habilidoso e experiente. Apresentamos o caso de uma paciente submetida a reanimação labial estática usando retalho dermoadiposo para lesão do nervo facial direito após remoção de nódulos como complicação de preenchimento. A "abordagem modificada de bull horn" foi realizada para elevação do lábio superior em torno das asas nasais e columela e ao longo do sulco nasolabial direito. O retalho foi desepitelizado e obtido. Usando a ponta aberta de uma pequena cânula de lipoaspiração, a porção distal do retalho foi encapsulada e fixada diretamente em C-loop e foram utilizados pontos U, transfixando o retalho para o periósteo do arco zigomático. Nos três anos de seguimento não foram observadas complicações significativas e a paciente não relatou nenhuma limitação funcional ou insatisfação com o aspecto das cicatrizes no sulco nasolabial e ao redor das asas nasais e da columela.

Facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular to promote a youthful appearance with minimally invasive procedures such as injectable botulinum toxin, soft-tissue fillers, and chemical peels. Nevertheless, complications can occur even with an astute and experienced injector. Here we present the case of a patient who underwent static lip reanimation using a dermoadiposal flap for right facial nerve damage following nodule removal as a filler complication. A "modified bulls horn approach" to the upper lip lift was performed around the nasal wings and columella and along the right nasolabial fold. The flap was de-epithelized and harvested. Using the open tip of a small liposuction cannula, the distal portion of the flap was tunneled and fixed directly in a C-loop fashion using U stitches, transfixing the flap to the periosteum of the zygomatic arch. At 3 years follow-up, no significant complications were observed, and the patient reported no functional limitations or dissatisfaction with the scars in the nasolabial fold or around the nasal wings and columella.

Sequelas de queimadura em face: enxerto cutâneo autólogo mama-face, uma opção de tratamento. Relato de caso / Sequels of burns in the face: autologous skin graft breast-face, a treatment option. Case report

Introdução: As queimaduras constituem uma das lesões traumáticas mais graves e seu tratamento requer uma abordagem multidisciplinar, em que o papel do cirurgião plástico é fundamental. Restabelecer a função de proteção da pele, mas também recuperar a estética da área, queimada são objetivos desafiadores que o cirurgião plástico procura atingir. Relato de Caso: Paciente feminino de 27 anos submetida a mastopexia com inclusão de implantes, em que se aproveitou a pele retirada da mama para realizar um enxerto de espessura total em região mandibular e submentoniana para tratamento de cicatriz. A paciente teve uma integração completa do enxerto, sem evidenciar-se áreas de epidermólise. Os resultados estéticos foram excelentes, conseguindo a satisfação da paciente e melhoria das áreas discrômicas e hipertróficas cicatriciais. Conclusão: O enxerto autólogo a partir da pele da mama constitui uma boa alternativa para o tratamento de sequelas de queimaduras em face, possibilitando ótimos resultados estéticos.

Introduction: Burns are one of the most severe traumatic injuries and their treatment requires a multidisciplinary approach, where the role of the plastic surgeon is vital. The plastic surgeon is entrusted with the challenging goal of restoring the skin's protective function and simultaneously recovering the aesthetic aspect of the burnt area. Case report: A 27-year-old woman underwent a mastopexy with inclusion of implants, where the skin removed from the breast was used as a full-thickness graft in the mandibular and submental area for the treatment of a scar. The patient showed complete integration of the graft, and no areas of epidermolysis were observed. The aesthetic results were excellent, and the patient was completely satisfied; moreover, an improvement in the dyschromic and hypertrophic cicatricial areas was observed. Conclusion: An autologous graft using breast skin is a good alternative for the treatment of sequelae of burns on the face and provides excellent aesthetic results.

Ritidoplastia e paralisia facial: como lidar? / Facelift and Facial nerve injury: how to deal with?

Não é novidade para os cirurgiões plásticos, especialmente aos que se dedicam à cirurgia de face, que o nervo facial pode ser lesado virtualmente em qualquer cirurgia de ritidoplastia. Porém, apesar da importância contida nesse tema, não é tarefa simples encontrar na literatura artigos que abordem de forma objetiva a correlação entre lesão do nervo facial e cirurgia facial. Paralisias faciais, sejam elas completas ou não, podem se tornar situações potencialmente conflituosas na relação médicopaciente. Este artigo, portanto, visa propor de forma clara e sucinta, baseada na experiência dos autores, um guia de como evitar, identificar e tratar uma potencial lesão do nervo facial no contexto de uma cirurgia de face, em especial a ritidoplastia.

Is largely known that the facial nerve virtually can be injured in every facial lift. Even though its importance, it is difficult to find in the literature articles related to this theme. Complete or incomplete facial paralysis after a facial procedures, may become a very uncomfortable situation between the patient and the surgeon, that is why we propose in this article a guide which intends to help avoid, identify and manage a facial nerve injury in the event of a face lift. Identifying Facial palsy before the surgery: Intending to make the pre-op facial assessment as simple as possible, we suggest a systematic approach examination. Avoiding facial nerve injury during face lifting: Several technical details are discussed along the text aiming to minimize the risk of nerve damage during the surgical procedure. What to in the event of a post-operative facial palsy: The authors propose a logical approach to the facial palsy, suggesting a planning for diagnosis, classification of the lesion and a rational treatment for the injury. Conclusion: This article presents a guide showing some safe technical options to avoid nerve damage during rythidoplasty, how to identify the lesion and treat it if necessary.

Redução de seio frontal: abordagem bucomaxilofacial na terapia de reabilitação das fraturas panfaciais / Frontal sinus reduction: approach oral and maxillofacial rehabilitation therapy of pan facial fractures

Objetivo: relatar um caso clínico de fratura do seio frontal, com o manejo clínico e cirúrgico, as complicações e os benefícios dos tratamentos adotados. As lesões do seio frontal, na sua maioria, relacionam-se a traumas de grande amplitude, como acidentes com veículos automotores, agressões físicas, ferimentos com arma de fogo e acidentes em trabalhadores da construção civil, acometendo mais a população masculina entre 21 e 30 anos de idade, podendo afetar as paredes anterior e/ou inferior do seio frontal, incluindo fraturas naso- -órbito-etmoidal e zigomáticas. O seu envolvimento pode causar complicações relacionadas a cavidade intracraniana, órbita e/ou estruturas nasais, como sinusites recorrentes, osteomielite do osso frontal, mucocele ou mucopiocele, meningite, encefalite, abcesso cerebral ou trombose do seio cavernoso, podendo evoluir para o óbito do paciente. Os objetivos do tratamento são: prevenção de infecção, isolamento do conteúdo intracraniano, correção da drenagem de líquido cefalorraquidiano, restauração da função e da estética, podendo ser realizado por equipe multidisciplinar. Relato de caso: o presente trabalho expõe um caso de fratura fronto-naso-órbito-etmoidal com afundamento de seio frontal, confirmada por exame tomográfico de face, em um paciente masculino de 26 anos, vítima de acidente automobilístico, submetido a redução da parede anterior do seio frontal, imobilização e fixação interna rígida, com posterior redução fechada da fratura dos ossos nasais, tamponamento nasal anterior e contenção externa com micropore e gesso. Considerações finais: demonstrou-se com esse artigo a possibilidade de divergência de tomada de conduta das diferentes áreas envolvidas no tratamento e a importância do tratamento multidisciplinar. (AU)

Objective: to report a clinical case of frontal sinus fracture, clinical and surgical management, complications and benefits of the treatments adopted. Frontal sinus lesions, for the most part, are related to large-scale traumas such as accidents with motor vehicles, physical assault, gunshot wounds and accidents in construction workers, affecting more the male population between 21 and 30 years of age, and may affect the anterior and / or inferior wall of the frontal sinus including naso-orbito- ethmoidal and zygomatic fractures. Its involvement may cause complications related to the intracranial cavity, orbit and / or nasal structures such as recurrent sinusitis, osteomyelitis of the frontal bone, mucocele or mucopiocele, meningitis, encephalitis, cerebral abscess or thrombosis of the cavernous sinus, and may evolve to the death of these patients . The objectives of treatment are prevention of infection, isolation of intracranial content, correction of cerebrospinal fluid drainage, restoration of function and aesthetics, and can be performed by a multidisciplinary team. Case report: this paper reports a case of frontal-naso-orbito-orbito-ethmoidal fracture with frontal sinus sinking, confirmed by face tomography, in a 26-year-old male patient who had suffered an auto accident, submitted to a reduction of the anterior wall of the frontal sinus, immobilization and rigid internal fixation with posterior closed reduction of nasal bones fracture, anterior nasal packing and external restraint with micropore and gypsum. Final considerations: to demonstrate the possibility of divergence of the conduct of the different areas involved in the treatment and the importance of the multidisciplinary treatment. (AU)

Nivel de satisfacción de los pacientes postoperados de traumatismo facial: un estudio de cohorte de un Hospital Nacional en Perú / Satisfaction level of post-operated facial trauma patients: a cohort study of a National Hospital in Peru

Resumen Objetivo Determinar el nivel de satisfacción de los pacientes postoperados de traumatismo facial en el Hospital Nacional Dos de Mayo (HNDM). Material y Método Estudio cuantitativo, cohorte longitudinal, analítica. La población estuvo constituida por 36 pacientes con diagnóstico de traumatismo facial que se sometieron a cirugía en el servicio de cabeza y cuello del HNDM durante el periodo julio de 2014-febrero de 2015. Se utilizó un cuestionario sobre satisfacción global cuya confiabilidad es r = 0,95, que evalúa cinco dimensiones: Limitación funcional, apariencia facial, apariencia sexual y corporal, autoconcepto negativo y apariencia social. Los puntajes promedio obtenidos en la escala de Likert fueron comparados con la prueba T de student pareada. Se consideró un valor p < 0,05 como estadísticamente significativo. Resultados La satisfacción global de los pacientes postcirugía fue alta en comparación con lo alcanzado en la precirugía (p = 0,01). En las dimensiones limitación funcional, apariencia facial, autoconcepto negativo y apariencia social el 100% alcanzó un nivel de satisfacción alto en la postcirugía. En la dimensión de apariencia sexual y corporal, el 100% tuvo en el periodo postcirugía un nivel de satisfacción medio, respecto al nivel bajo obtenido en la precirugía. Conclusión Los pacientes postoperados de traumatismo facial en el Hospital Nacional Dos de Mayo presentan un alto nivel de satisfacción a nivel funcional, de apariencia facial, en autoconcepto y de apariencia social.

Objective To determine the level of satisfaction of patients who underwent surgery for facial trauma in the Dos de Mayo National Hospital (HNDM). Materials and Methods Quantitative, cross-sectional analytical study. The population consisted of 36 patients diagnosed with facial trauma who underwent surgery in the Head and Neck service of the HNDM during the period July 2014-February 2015. A Global satisfaction questionnaire, previously validated for this research, was used whose reliability is r = 0.95 and evaluates aspects of Limitation functional, facial appearance, sexual and physical appearance, negative self- concept and social appearance. The average scores on the Likert scale were compared with the paired Student t test. A p-value < 0.05 was considered statistically significant. Results Regarding the overall satisfaction of patients, the number of patients who reported having a high level of satisfaction was significantly higher in the post surgery compared to what was achieved in the pre surgery (p = 0.01). In respect of functional limitations, facial appearance, negative self-concept and social appearance 100% achieved a high level of satisfaction in the post surgery. In the dimension of sexual and physical appearance, 100% was in the post surgery a medium level of satisfaction, from the low level obtained in the pre surgery. Conclusions The patients operated after facial trauma in the Dos de Mayo National Hospital have a high level of satisfaction on a functional level, facial appearance, negative self-concept and social appearance.

Reconstrucción facial con colgajo libre lateral del brazo / Facial reconstruction with free lateral arm flap

ResumenLas lesiones faciales malignas complejas o muy extensas, tratadas mediante resección quirúrgica, a menudo constituyen un reto para el cirujano plástico, debido a la gran exposición social del sitio, así como la escasa oferta de tejido para la reconstrucción del defecto cutáneo residual. En estos casos es imperativa la obtención de márgenes libres de malignidad; en segundo lugar, intentar recuperar la funcionalidad del área quirúrgica, y por último, buscar resultados estéticos favorables. Cuando sea posible, la ausencia de cobertura cutánea debe ser restaurada con tejido de similar grosor, color y textura, para lo cual el cirujano debe evaluar cuidadosamente el tamaño del defecto, la localización, las capas de tejido involucradas, la relación con estructuras aledañas y la cantidad de tejido donador disponible, con el fin de conseguir el mejor resultado final. Para deformidades de gran extensión que involucran múltiples capas de tejido, el concepto del triángulo reconstructivo de Mathes y Nahai, puede brindar mejores resultados, dándole opción al cirujano de escoger entre transposición de colgajos locoregionales, colgajos libres o expansión tisular. Los colgajos libres pueden satisfacer mejor las necesidades de forma y función facial, y permiten una considerable oferta de tejido con adecuada vascularidad, similitud de color, textura y grosor. A continuación se presenta el caso clínico de un paciente masculino de 21 años con el diagnóstico de carcinoma basocelular de mejilla derecha recidivante, quien fue sometido a resección completa y reconstrucción del defecto mediante transferencia libre de un colgajo lateral del brazo derecho, con excelentes resultados anatómicos y funcionales.

AbstractComplex or very extensive malignant facial lesions that are treated by surgical resection are often challenging for the plastic surgeon because of the large social exposure of the site as well as for the limited supply of tissue for reconstruction of the residual skin defect. In these cases it is imperative to first obtain free margins from malignancy, secondly try to recover the functionality of the surgical area and finally seek for favorable aesthetic results. Whenever possible, the facial defect should be restored with tissue of similar thickness, color and texture, for which the surgeon should carefully evaluate the size of the defect, location, tissue layers involved, the relationship with surrounding structures and the available donor tissue, in order to obtain the best final result. For large deformities involving multiple layers of tissue, the Mathes and Nahai concept of the reconstructive triangle can provide better outcomes, giving the surgeon a choice among transposition of locoregional flaps, free flaps, or tissue expansion. Free flaps can better satisfy the need of facial contour and function, they allow a considerable supply of tissue with adequate vascularity, similarity of color, texture and thickness. The authors present a clinical case of a 21-year-old male patient with the diagnosis of recurrent basal cell carcinoma of the right cheek who underwentcomplete resection and reconstruction of the facial defect with a free right lateral arm flap with excellent anatomical and functional results.

Reconstrução nasal total: uso da "técnica em sanduíche" durante a residência / Total nasal reconstruction: use of the "sandwich technique" during residency

Introdução: Um dos locais mais comuns para o surgimento de câncer de pele é o nariz e, devido à sua distinta estruturação em três dimensões, a reconstrução do suporte da ponta nasal apresenta-se como um desafio para os cirurgiões plásticos. Métodos: Este artigo apresenta uma das opções de reconstrução nasal total utilizando como recursos o retalho frontal bilateral e o enxerto de cartilagem auricular bilateral em bloco. Apresentamos um relato do uso da "técnica em sanduíche", constituída por dois retalhos frontais intercalados pelas cartilagens auriculares. Enquanto o primeiro retalho origina o novo teto das fossas nasais, a cartilagem configura o formato tridimensional e garante o suporte da nova estrutura nasal. O segundo retalho fica, então, responsável pela cobertura exterior. Resultados: Neste caso comprovou-se tanto a mínima morbidade da área doadora quanto a excelente perfusão dos retalhos autonomizados, o que se considerou um resultado amplamente satisfatório. Conclusões: Embora a reconstrução nasal total seja um procedimento infrequente na vida do cirurgião plástico, a técnica aqui descrita mostra-se como uma opção atraente para estes casos.

Introduction: One of the most common sites of skin cancer is the nose, and because of its distinct three-dimensional structure, reconstruction of the nasal tip support is challenging for plastic surgeons. Methods: This article presents an alternative option for total nasal reconstruction using the bilateral frontal flap and the block bilateral auricular cartilage graft. We present an account of the use of the "sandwich technique", consisting of two frontal flaps interspersed by auricular cartilage. While the first flap gives rise to the new roof of the nasal fossa, the cartilage configures the threedimensional shape and provides support for the new nasal structure. The second flap is then responsible for the outer coverage. Results: In this case, both the minimal morbidity of the donor area and excellent perfusion of the autonomized flaps were verified, leading to a largely satisfactory result. Conclusions: Although total nasal reconstruction is an infrequent procedure in the career of a plastic surgeon, the technique described here is a viable option for these cases.

Uso de cuero cabelludo como zona donadora de injertos cutáneos de espesor parcial / Use of the scalp as a donor area for partial thickness skin grafts

Objetivo: Demostrar los beneficios del uso de cuero cabelludo como área donadora de injertos cutáneos de espesor parcial. Método: Estudio retrospectivo descriptivo realizado de 2013 a 2015 en la Unidad de quemaduras pediátricas del hospital Roosevelt de 111 pacientes en que se utilizaron injertos del cuero cabelludo. Resultados: La mayoría de los pacientes sufrieron quemaduras por inmersión en líquidos calientes con disponibilidad limitada de zonas donadoras de injertos. El otro uso que se le dio a los injertos de cuero cabelludo fue en quemaduras y lesiones faciales debido a la similitud de la pigmentación de estas áreas. Este estudió demostró el corto tempo de epitelización de esta zona donadora (3.5 días), lo que permitió que se utilizara en varias ocasiones. La principal complicación fue la alopecia (1.8%) resultado de una toma de un injerto muy grueso. Conclusión: El estudio sugiere que el cuero cabelludo es una zona donadora útil cuando las principales áreas donadoras están limitadas. Más investigación tendrá que realizarse para establecer otros beneficios observados del uso de esta región como zona donadora de injertos cutáneos.

Objectve: Demonstrate the benefts of using scalp as a donor area of partal split thickness skin grafs. Methods: Retrospectve descriptve study from 2013 to 2015 shows 111 patents that required a skin graf from the scalp in a pediatric burn unit. Results: Most of the patents were burn victms, but few other cases are described as well. The most common use of this donor area was for patents that had sufered pot immersion scalds where the back, gluteus and lower limbs were afected and no longer available as skin donor areas. The other main use was in facial burns and traumas, because the color similitude between the face and scalp renders a beter cosmetc result of facial skin grafs. This study demonstrates the short period of healing (3.5 days) of the donor area making possible its reuse in a shorter period of tme. The main complicaton was alopecia (1.8%) where the graf take was too deep. Conclusions: The study suggests the use of scalp donor area when other main donor areas are not available and for facial burns. Further studies should be performed in order to establish other observed benefts of the scalp as a donor area for split thickness skin grafs.

Procedimiento quirúrgico en un paciente con múltiples fracturas faciales / Surgical procedure in a patient with multiple facial fract

Se describe el caso clínico de un paciente de 45 años de edad que fue asistido en la Unidad de Cuidados Intensivos Emergentes del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, luego de sufrir una caída de una altura aproximada de 6 metros por un impacto de alta energía, que le produjo fracturas en los tres tercios de la región facial. Fue intervenido quirúrgicamente de urgencia por un equipo multidisciplinario. Luego de varios procedimientos quirúrgicos y de ser intubado con ventilación mecánica por espacio de 72 horas, se le trasladó, por su estado muy grave, a la Unidad de Cuidados Intensivos, donde permaneció durante 21 días y su evolución fue favorable

The case report of a 45 years patient that was assisted in the Emergency Intensive Cares Unit of "Saturnino Lora Torres" Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba is described, after falling down of an approximate height of 6 meters due to a high energy impact that provoked him fractures in the three thirds of the facial region. He was surgically treated as an emergency by a multidisciplinary team. After several surgical procedures and intubation with mechanical ventilation for 72 hours, he was referred to the Intensive Cares Unit due to his very serious state, where he stayed during 21 days and had a favorable clinical course

Reconstrucción mandibular en una deformidad posquirúrgica por trauma / Mandibular reconstruction of a post-surgical deformity due to trauma

La necesidad de una reconstrucción mandibular está dictada por la pérdida de hueso debido, entre otras causas, a trauma. El propósito de este trabajo es caracterizar un caso de reconstrucción mandibular de una deformidad posquirúrgica por trauma. Se trata de un paciente masculino de 34 años que acude a consulta por inconformidad estética y dificultad para masticar. Aproximadamente un año atrás había padecido un trauma facial, por lo cual fue atendido de urgencia e intervenido quirúrgicamente. Se realizó estabilización ósea y colocación de placa de reconstrucción mandibular. Presentaba asimetría facial, disminución del tercio inferior facial y movilidad de los segmentos óseos mandibulares, por tal motivo se decide realizar retirada de la placa existente, reacomodamiento de los segmentos óseos, colocación de injerto autólogo de cresta ilíaca y fijación. Se observó buena evolución posoperatoria. La repercusión estética y funcional, en un paciente joven con una deformidad posquirúrgica por trauma; motivó el planeamiento de una reconstrucción mandibular mediante placa rígida e injerto de creta ilíaca. El tratamiento de este caso constituyó un reto profesional por tratarse de una deformidad posquirúrgica provocada por un trauma de alta energía; pero el trabajo quirúrgico en equipo aseguró resultados satisfactorios(AU)

The need for mandibular reconstruction is dictated by bone loss due to trauma among other causes. The purpose of the study was to present a case of mandibular reconstruction of a post-surgical deformity due to trauma. A 34-year-old male patient presents with dissatisfaction with his dentofacial appearance and difficulty chewing. About one year before he had undergone facial trauma, for which had been cared for at the emergency service and had been operated on. Bone stabilization was performed as well as placement of a mandibular reconstruction plate. The patient presented facial asymmetry, a diminished lower facial third and mobility in mandibular bone segments. Therefore, it was decided to perform removal of the existing plate, rearrangement of the bone segments, placement of an autologous iliac crest bone graft and surgical fixation. Good post-operative evolution was observed. Esthetic and functional impairment in a young patient with a post-surgical deformity due to trauma led to planning a mandibular reconstruction with a rigid plate and an iliac crest graft. Treatment in this case was professionally challenging, for the post-surgical deformity had been due to high energy trauma, but the surgical work performed ensured satisfactory results(AU)

Sutura elástica como alternativa para o primeiro atendimento de ferida na urgência / Elastic suture as an alternative for the initial wound care in the emergency room

Relato do caso de um paciente do sexo masculino, 44 anos, que deu entrada pelo Serviço de Emergência, no dia 17 de novembro de 2013, vítima de acidente com disco de Makita, apresentando ferida extensa em toda face dorsal do primeiro quirodáctilo esquerdo e exposição tendínea. Demonstra a utilização de sutura elástica, em atendimento inicial na urgência, e a possibilidade de tratamento de ferida traumática com perda de substância, com resolução satisfatória em único tempo cirúrgico. A opção cirúrgica apresentou resultado funcional adequado e preservação estética.

This is a case report of a 44-year-old male patient who was admitted to the emergency room on November 17, 2013, after an accident with a Makita Disc. The patient presented with an extensive wound throughout the dorsal surface of the left thumb, with tendon exposure. The use of elastic suture is demonstrated as the initial care in the emergency department. We present satisfactory resolution in a single surgical procedure of traumatic wounds in a patient presenting with loss of tissue. The chosen surgical approach presented adequate aesthetic result and functional preservation.

Utilização do retalho de Karapandzic para reconstrução de lábio inferior após trauma / The use of the Karapandzic flap for reconstruction of the lower lip after trauma

A reconstrução labial representa um desafio ao cirurgião plástico. Os lábios são o centro dinâmico do terço inferior da face, sendo fundamentais para mímica e expressão facial, fala, deglutição, sucção e contenção de secreções salivares, sem esquecer-se do componente estético. Portanto, a reconstrução labial deve ter como objetivo o restabelecimento funcional da estrutura lesada e um bom resultado estético. Este artigo relata um caso de lesão labial traumática grave e sua reconstrução, com a utilização do retalho de Karapandzic. Os autores demonstram sua funcionalidade e fácil execução, assim como seu resultado final.

Lip reconstruction is a challenge to the plastic surgeon. The lips are the dynamic center of the lower third of the face, being essential for facial movements and expression, speech, deglutition, suction, and containment of salivary secretions, as well as esthetic appearance. Therefore, the objective of lip reconstruction should be functional recovery of the damaged structure and a good esthetic result. This article reports a case of severe traumatic labial injury and reconstruction, using the Karapandzic flap. The authors demonstrate its functionality and easy implementation as well as the final result.

Atención inicial al politraumatizado maxilofacial: evaluación de la vía aérea y la circulación / Initial care of maxillofacial polytrauma patients: evaluation of the airway and circulation

Introducción: la traumatología facial es una vertiente de la Cirugía Maxilofacial, donde son necesarios conocimientos profundos de disciplinas tales como anatomía, fisiología, patología, y la estrecha relación con otras especialidades (quirúrgicas o no). Objetivo: realizar una revisión bibliográfica sobre la atención al politraumatizado maxilofacial, enfatizando en aspectos relacionados con el Soporte Vital Avanzado en Trauma y dentro de él, el manejo de la vía aérea con la estabilización de la columna cervical, de la ventilación y la circulación. Métodos: se realizó una revisión bibliográfica en el periodo comprendido entre diciembre de 2014 y enero de 2015. Se evaluaron revistas de impacto de Web of Sciencies (41 revistas) y 6 libros. Se consultaron las bases de datos de sistemas referativos MEDLINE, PubMed y SciELO. Se utilizaron como descriptores maxilofacial trauma, maxilofacial emergency, emergency management, critical care y sus equivalentes en español. Se incluyeron artículos en idioma inglés y español, publicados preferentemente en los últimos 5 años. Se obtuvieron 147 artículos. El estudio se circunscribió a 50 que enfocaban estas temáticas de manera más integral. Análisis e integración de la información: al analizar el comportamiento de los artículos referidos al tema, en relación con su representatividad en las revistas científicas, se halló que 6 por ciento correspondió a la Journal of Oral and Maxillofacial Surgery. Conclusiones: la atención eficaz del politraumatizado maxilofacial asegura resultados satisfactorios, tanto en la conservación de la vida, como desde el punto de vista estético y funcional. En esta temática es imprescindible manejar las directrices del Soporte Vital Avanzado del trauma y dentro de él, el manejo de la vía aérea con la estabilización de la columna cervical, ventilación y circulación(AU)

Introduction: facial traumatology is a branch of maxillofacial surgery requiring deep knowledge about disciplines such as anatomy, physiology and pathology, as well as their close relationship to other specialties, either surgical or not. Objective: carry out a bibliographic review about the care of maxillofacial polytrauma patients, highlighting aspects related to advanced trauma life support, particularly management of the airway with cervical spine stabilization, ventilation and circulation. Methods: a bibliographic review was performed which covered the period from December 2014 to January 2015. The evaluation included high impact journals from theWeb of Sciences (41 journals) and 6 books. The databases MEDLINE, PubMed and SciELO were consulted, using the search terms maxillofacial trauma, maxillofacial emergency, emergency management and critical care, and their Spanish counterparts. The review included papers in English and Spanish, preferably published the last five years. Of the 147 papers obtained, the reviewers selected the 50 which approached the study topics in a more comprehensive manner. Data analysis and integration: Analysis of the representativeness of papers in scientific journals revealed that 6 percent corresponded to the Journal of Oral and Maxillofacial Surgery. Conclusions: effective care of maxillofacial polytrauma patients ensures satisfactory results, both in the preservation of life as from an esthetic and functional point of view. It is indispensable to have a good command of advanced trauma life support guidelines, particularly the management of the airway with stabilization of the cervical spine, ventilation and circulation(AU)

Anatomical reproducibility through 3D printing in cranio-maxillo-facial defects / Reproducibilidad anatómica a través de impresión 3d en defectos cranio-maxilo-faciales

The planning and 3D reconstruction in craniofacial defects based on anatomical principles of symmetry and passive adaptation has evolved radically the past few years. This article recounts the possibility to develop personalized and extensive craniofacial implants. We present a case of a patient with a 10-year trauma sequel evolution; the patient lost the right frontal bone, supraorbital wall and part of the temporal fossa. From the computerized tomography, and by using Materialise software (3-Matic and Mimics). Subsequently, the printing was performed using the virtual planning with a laser printer in titanium where the piece was elaborated with the determined specifications in the planning; surgery was performed without complications in which the implant was placed via a coronal approach, which did not require any type of adaptation. After a two-year follow-up we observed a correct position, symmetry, absence of infection or any other alteration. It is concluded that the planning and 3D printing are suitable to perform craniofacial reconstructions with a low morbidity, shorter surgical time, and with an adequate facial symmetry and aesthetic return.

La planificación y reconstrucción 3D en defectos craneofaciales se basa en principios anatómicos de simetría y pasividad en la adaptación, evolucionando rápidamente en los últimos años. El presente articulo presenta la posibilidad de rehabilitación de un paciente con trauma importante gracias a un implante craneofacial extenso. Se presenta el caso de un sujeto con evolución de 10 años de una secuela de trauma, donde perdió el hueso frontal, pared supraorbitaria y parte de la fosa temporal. A partir de una tomografía computadorizada, utilizando un software de planificación Materialise (3-Matic and Mimics) se construyó un modelo virtual a través de un implante de pieza única para cubrir íntegramente el defecto; se planificó la posición junto a la cantidad y longitud de tornillos a utilizar. A continuación se realizó la impresión de la pieza mediante una impresora laser de titanio donde la pieza fue construida según las especificaciones de la planificación; la cirugía fue realizada sin complicaciones en el cual el implante fue instalado a través de un acceso coronal sin necesidad de ningún tipo de adaptación. Después de dos años de seguimiento se observa una posición correcta, simétrica y en ausencia de infecciones u otro tipo de alteración. Se concluye que la planificación e impresión 3D es viable de realizar en reconstrucción craneofacial con baja morbilidad, disminución del tiempo quirúrgico, obteniendo una adecuada simetría y estética facial.

Facial Transplantation Surgery Introduction

Severely disfiguring facial injuries can have a devastating impact on the patient's quality of life. During the past decade, vascularized facial allotransplantation has progressed from an experimental possibility to a clinical reality in the fields of disease, trauma, and congenital malformations. This technique may now be considered a viable option for repairing complex craniofacial defects for which the results of autologous reconstruction remain suboptimal. Vascularized facial allotransplantation permits optimal anatomical reconstruction and provides desired functional, esthetic, and psychosocial benefits that are far superior to those achieved with conventional methods. Along with dramatic improvements in their functional statuses, patients regain the ability to make facial expressions such as smiling and to perform various functions such as smelling, eating, drinking, and speaking. The ideas in the 1997 movie "Face/Off" have now been realized in the clinical field. The objective of this article is to introduce this new surgical field, provide a basis for examining the status of the field of face transplantation, and stimulate and enhance facial transplantation studies in Korea.