"Proximal to distal" sequence of the release of the upper extremity post-burn contracture: Rule or case-based approach? / 中华创伤杂志(英文版)

Post-burn contractures are common entities seen in developing countries. There are multiple reasons for the development of contractures, most are preventable. In extensive contractures, a strategic plan is necessary to release all contractures and yet not antagonize post-operative positions. It is also necessary to be cost-effective and minimize the number of surgeries needed. Conventionally the release sequence in extensive burn contractures is proximal to distal. In this case report, we discuss an unusual sequence where we released distal contractures before the proximal to achieve optimum results. A 3-year-old child with post-burn contracture of hand, wrist, elbow, and axilla was treated in 2 stages, with the release of wrist contracture and cover with pedicled abdominal flap in the first stage and division of pedicled flap with the release of axilla and elbow contracture in the second stage. Thus, the release of all contractures was achieved without antagonizing post-operative positions and minimized the number of surgeries. A case-based approach may be crucial in making a strategic surgical plan to minimize the rehabilitation phase, rather than following known dictums.

Colgajos en la reconstrucción de los miembros con lesión traumática / Flaps In The Reconstruction Of Limbs With Traumatic Injury

Introducción: Las opciones para el manejo de tejidos blandos en los defectos traumáticos han aumentado con el desarrollo de la microcirugía, con una mejor comprensión de los colgajos pediculados y los avances con terapia con esponja de presión negativa. Objetivo: Revisar y poner a disposición de los especialistas algunos de los tópicos relacionados con estos procederes quirúrgicos de colgajos en las lesiones traumáticas de los miembros. Métodos: Se realiza una búsqueda en PubMed entre los años 2010-2020, en inglés con los términos: cirugía de colgajos en lesiones traumáticas, tratamiento de las lesiones de partes blandas relacionadas con trauma de los miembros, reconstrucción de las lesiones traumáticas de partes blandas de extremidades. Se revisaron también, artículos accesibles de forma libre, o a través del servicio Clinical Key y Hinari. Conclusiones: Existen controversias acerca del momento óptimo para el cierre de las heridas. La definición de reconstrucción primaria versus secundaria depende del tiempo de lesión y del tipo de procedimiento quirúrgico. La terapia de heridas con presión negativa sirve como parte del arsenal para la reconstrucción de tejidos blandos en un trauma de extremidades(AU)

Introduction: Options for soft tissue management of traumatic defects have increased with the development of microsurgery, with a better understanding of pedicle flaps and advances with negative pressure sponge therapy. Objective: To review and make available to specialists some of the topics related to these surgical procedures for flaps in traumatic limb injuries. Methods: A PubMed search was carried out from 2010 to 2020, in English with the terms: flap surgery in traumatic injuries, treatment of soft tissue injuries related to trauma of the limbs, reconstruction of the limbs. traumatic soft tissue injuries of extremities. Articles freely accessible or through the Clinical Key and Hinari service were also reviewed. Conclusions: There are controversies about the optimal time for wound closure. The definition of primary versus secondary reconstruction depends on the time of injury and the type of surgical procedure. Negative pressure wound therapy serves as part of the arsenal for soft tissue reconstruction in extremity trauma(AU)

Tratamiento quirúrgico de las úlceras por radionecrosis con colgajos músculo y fasciocutáneos / Surgical treatment of radionecrosis ulcers with myocutaneous and fasciocutaneous flaps

Resumen Introducción: La Ulcera con radionecrosis debe ser resecada ampliamente y reparada con colgajos miocutáneos y fasciocutáneos. Objetivo: Presentar el tratamiento quirúrgico de las úlceras por radionecrosis mediante colgajos Miocutáneos y Fasciocutáneos pediculados y microquirúrgicos. Materiales y Método: La casuística es de 31 pacientes portadores de úlceras por radionecrosis resueltas con colgajos miocutáneos y fasciocutáneos. Ellos han sido pediculados y microquirúrgicos. Las edades fluctuaron entre 30 y 75 años operados entre el 2000 y el 2019. Resultados: Se realizaron 19 colgajos musculares o miocutáneos y 12 fasciocutáneos en diferentes zonas del organismo. Los colgajos correspondieron a: temporal, latissimus dorsi de pedículo central y en reversa, latissimus dorsi microquirúrgicos, recto abdominal, escapular microquirúrgico, para escapular, gracilis, gastrocnemius, rectus femoris, cubital microquirúrgico, fasciocutaneos: cone flap y de rotación local. Las complicaciones fueron dehiscencia de herida operatoria suturada y celulitis tratada con antibióticos. No hubo necrosis completa de los colgajos. El seguimiento fue de 3 a 6 meses. Discusión: En esta serie hemos utilizados los colgajos músculo cutáneos de preferencia, los fasciocutáneos los hemos reservados para aquellos casos en los que por razones anatómicas, de localización de las úlceras, era más adecuado usar estos últimos, como en las lesiones planas o poco profundas. Generalmente los colgajos fueron pediculados y en determinados casos, cuando el tejido vecino de reparación no estaba disponible, realizamos colgajos con microcirugía. Conclusión: El tratamiento de las úlceras por radionecrosis es efectivo cuando se realiza desbridamiento exhaustivo con cobertura inmediata con colgajos musculares o músculocutáneos y fasciocutáneos. Fueron colgajos pediculados y microquirúrgicos.

Introduction: The radionecrosis ulcer have to be widely resected and repaired trough flaps with good blood supply who contibute with oxigen, nutrients and antibiotics. Thinking on this the more suitable flaps are the myocutaneous ones and in special conditions the fasciocutaneous. Aim: The objetive of this paper is to show the surgical treatment of radionecrosis ulcers with myocutaneous and fasciocutaneous flaps. Materials and Method: Casuistic is 31 patients with radionecrosis ulcers treated with, mainly, myocutaneous flaps and in special areas with fasciocutaneous ones. The majority were pedicle flaps and in less number microsurgical flaps. The age of patients were betwee30 and 75 years old. Results: 19 muscle or myocutaneous flaps and 12 fasciocutaneous flaps were made. Flaps were latissimus dorsi, temporal, escapular, para escapular, rectus abdominis, rectus femoris, gracilis, gatrocnemius, cone flap and local fasciocutaneous flaps. Complications were sutured operative wound dehiscence and cellulitis treated with antibiotics. There were no complete necrosis of any flap. Discusion: In this serie we used muscle or myocutaneous flaps because they give good blood supply, oxigen, nutrients and arrival of antibiotic with filling of the deep ulcers. When the ulcers were shallow we use fasciocutaneous flaps. The majority of our flaps were pedicles and microsurgical flaps were used when there was no near avialable tissue. Conclusion: The treatment have to be wide debridement of the ulcer. The surgical treatment is with myocutaneous and fasciocutaneous flaps sometimes pediculates and in others conditions microsurgicals.

Colgajo sural reverso más injerto libre en reconstrucción del talón y tobillo / Reverse Sural Flap plus Free Graft in Heel and Ankle Reconstruction

Introducción: Las lesiones traumáticas con pérdida de cobertura cutánea de la región del tobillo y pie, constituyen un gran reto para el cirujano ortopédico por la exposición y destrucción de tejidos nobles, difíciles de solucionar por ser una zona que presenta escaso tejido adiposo, múltiples tendones, poco volumen muscular, varias prominencias óseas y piel poco elástica. Objetivo: Presentar el colgajo sural de flujo reverso como una buena alternativa para tratar la fractura conminuta cerrada de tibia con pérdida masiva de la piel del tobillo y calcáneo en toda su circunferencia, incluida la almohadilla adiposa de la cara plantar. Presentación del caso: Se presenta paciente de 24 años que sufrió accidente de tránsito con fractura conminuta y cerrada de tibia derecha, además de una herida tipo colgajo que dejó expuesto el calcáneo y la región del tobillo. Luego de colocar fijador externo RALCA para fijar la fractura, se realizó colgajo sural en isla de flujo reverso para cubrir el defecto en la cara plantar y posterior del calcáneo, más injerto libre de piel tomado de la cara antero externa del muslo ipsilateral. Estos procedimientos fueron realizados en dos tiempos quirúrgicos. Conclusiones: El colgajo sural de flujo reverso demostró ser una de las mejores alternativas para la cobertura de lesiones desde el tercio medio de la pierna hasta el pie, por lo que debería ser conocido no solo por cirujanos plásticos, sino también por cirujanos ortopédicos y traumatólogos que lo incorporen a su arsenal terapéutico para su realización(AU)

Introduction: Traumatic injuries with loss of skin coverage of the ankle and foot region constitute great challenge for the orthopedic surgeon due to the exposure and destruction of noble tissues, difficult to solve because this area has little adipose tissue, multiple tendons , little muscle volume, several bony prominences and not very elastic skin. Objective: To establish that the reverse flow sural flap is a good alternative to treat closed comminuted fracture of the tibia with massive skin loss of the entire circumference of the ankle and calcaneus, including the plantar face fat pad. Case report: We report the case of a 24-year-old patient who suffered a traffic accident with a comminuted and closed fracture of the right tibia, as well as a flap-type wound that exposed the calcaneus and the ankle region. After placing RALCA external fixator to fix the fracture, a reverse flow island sural flap was made to cover the defect on the plantar and posterior aspect of the calcaneus, and a free skin graft taken from the anterior external aspect of the ipsilateral thigh. These procedures were performed in two surgical stages. Conclusions: The reverse flow sural flap proved to be one of the best alternatives for the coverage of injuries from the middle third of the leg to the foot, which is why it should be known not only by plastic surgeons, but also by orthopedic surgeons and traumatologists and to incorporate this alternative into their therapeutic arsenal(AU)

Colgajo bilobulado para reconstrucción de defectos por tumores nasales del tercio inferior / Bilobed flap for reconstruction of tumoral defects on the lower third of the nose

Introducción. Los defectos de cobertura en la región nasal secundarios a resecciones oncológicas deben ser cubiertos con tejido de las mismas características que el resecado, idealmente con tejido vascularizado adyacente. El colgajo bilobulado reúne las condiciones doble transposición, con una estructura y diseño que permite una adecuada distribución de las fuerzas de tensión a lo largo de su eje de rotación, evitando deformidades y excedente cutáneo generados por otros colgajos o cierre primario, respetando las unidades estéticas de la nariz. Método. Se presentan 48 casos clínicos en el periodo abril 2018 - abril 2020 describiendo la técnica de realización del colgajo bilobulado para la reconstrucción de secuelas de resección oncológica nasal por los diferentes tipos de tumores de piel. Para defectos de dorso nasal 26, punta nasal 14 y alares 8 casos. Resultados. La vitalidad de los colgajos fue de un 100%, 6 casos presentaron dehiscencia en extremo distal que requirió revisión. Adecuado resultados estéticos con similitud de textura y color de piel del colgajo. Cicatrices resultantes en área dadora y receptora ocultas en líneas de sombra. Disminución de complicaciones agregando resección triangular adicional. Conclusiones. Los defectos de tegumento en región nasal deben ser cubiertos por tejido vascularizado. Las resecciones de hasta 3 cm de diámetro pueden ser cubiertas con colgajos bilobulados adyacentes. El adecuado planeamiento de las cicatrices tanto en área dadora como receptora permite mejores resultados estéticos. Siempre deben tenerse en cuenta las regiones estéticas para obtener mejores resultados.

Background. Coverage defects in the nasal region secondary to oncological resections should be covered with tissue of the same characteristics as the resected, ideally with adjacent raised vascular tissue. The bilobed flap meets the conditions, is a double transposition flap, with a structure and design that allows an adequate distribution of the tension forces along its axis of rotation, avoiding deformities and excess skin generated by other flaps or primary closure. Respecting the aesthetic units of the nose. Methods. 48 clinical cases are presented in the period April 2010- April 2020 describing the technique of making the bilobed flap for the reconstruction of the sequelae of nasal oncological resection by the different types of skin tumors. For dorsal defects 26, nasal tip 14 and alares 8 cases. Results. The vitality of the flaps was 100%, 6 cases presented dehiscence in the distal end that required revision. Adequate aesthetic results with similarity of texture and skin color of the flap. Resulting scars in donor and recipient area hidden in shadow lines. Decrease complications by adding additional triangular resection. Conclusions. Integument defects in the nasal region should be covered by vascularized tissue. Resections up to 3 cm in diameter can be covered with adjacent bilobed flaps. The adequate planning of the scars in both the donor and recipient areas allows for better aesthetic results. Aesthetic regions should always be taken into account to obtain better results

Colgajo giratorio retroauricular / Retroauricular flip-flop flap

Resumen El colgajo retroauricular en isla (flip-flop flap) fue descrito por Masson en 1972 y consiste en tejido dermoepidérmico irrigado por un pedículo de patrón aleatorio subcutáneo de ramas de la arteria auricular posterior. Proviene de la región mastoidea y retroauricular y aporta buena cobertura para la región anteromedial del pabellón auricular. Se describen dos casos, en que se realizó cobertura inmediata secundario a un defecto de la concha auricular posterior a resección neoplásica, obteniendo resultados satisfactorios y sin complicaciones.

Abstract The retroauricular island flap (flip-flop flap), was described by Masson in 1972 and consists on dermoepidermal tissue irrigated by a random subcutaneous pedicle of branches of the posterior auricular artery. It comes from the mastoid and retroauricular region and provides a good coverage for the anteromedial region of the pinna. Two cases are described, in which immediate coverage was performed secondary to a defect in the auricular concha after a neoplastic resection, obtaining satisfactory results without complications.

Colgajo en cometa como tratamiento de secuelas de quemadura en pulgar / Kite flap for correction of thumb deformities after burn

Introducción. Múltiples técnicas han sido descriptas para la reconstitutición de la función del pulgar quemado, aunque sin relación costo-beneficio. El colgajo en cometa, descripto por Foucher en 1979, aporta cobertura cutánea, sensibilidad y permite mejoría funcional. El objetivo de este trabajo es presentar nuestra experiencia y resultados utilizando el kite flap. Materiales y métodos. Se realiza un estudio restrospectivo, descriptivo, de 4 casos de secuelas de quemaduras en pulgar de la mano atendidas en el Servicio de Cirugía Plástica y Reparadora del Hospital de Quemados de la Ciudad de Buenos Aires en un periodo comprendido desde el año 2016 al 2019. Se realizan colgajos en cometa en isla o tunelizados y posterior rehabilitación kinésica. El seguimiento mínimo de la serie es de 3 meses y se toman registros fotográficos pre-, intra- y posoperatorios. Las variables analizadas incluyen: sufrimiento de colgajos, dehiscencia, congestión venosa, prendimiento de injertos en zona dadora, reintervenciones y mejoría en la función de abducción del pulgar y pinza de la mano. Resultados. Se realizaron 3 colgajos en cometa tunelizados y 1 en isla. La totalidad se presentaron vitales aunque con congestión venosa en las primeras 72 hs. No se registraron complicaciones y no fueron necesarias reintervenciones. La mejoría en la función de pinza y de abducción del pulgar fue objetivable mediante la observación y referida por los pacientes y/o familiares según correspondiera. Conclusiones. Creemos que el colgajo en cometa es la mejor opción de tratamiento para las secuelas de quemadura en pulgar por aportar adecuada cobertura cutánea, ser técnicamente sencillo y poder hallar el pedículo en el 100% de la población. La congestión venosa es la regla, aunque también la supervivencia, siendo la morbilidad de la zona dadora mínima y la mejoría en la función de pinza y abducción del pulgar francamente objetivable.

Introduction. Multiple techniques have been described for repair the burned thumb function, although without cost-benefit ratio. The kite flap described by Foucher in 1979, provides skin coverage, sensitivity and allows functional improvement. The goal of this study it to present our experience and results obtained using the kite flap Materials and methods. A retrospective, descriptive study of 4 cases of burned hand's thumb treated in the Plastic Surgery Unit of the Hospital de Quemados on Buenos Aires in a three year's period from 2016 to 2019. Island or tunneled's kite flaps and subsequent kinesic rehabilitation are performed. The minimum follow-up of the series is 3 months and fotographic records pre, intra and postoperative are taken. The variables analyzed include: suffering from flaps, dehiscence, venous congestion, grafting losts on the donor zone, reinterventions and improvement in the function of thumb abduction and hand clamp . Results. 3 tunelled kite flaps and 1 on island were made. All of them were vital, although with venous congestion in the first 72 hours. No complications were recorded and no reinterventions were necessary. The improvement in hand clamp function and thumb abduction was marked through observation and when it posible, referred by patients. Conclusions. We believe that kite flap is the best option of treatment for sequelae of burns affecting hand's thumb for providing adequate skin coverage, being technically simple and being able to find the pedicle at 100% of the population. Venous congestion is the rule, although survival is also. Donor zone´s morbidity is minimal and the improvement in thumb function is clear

Colgajo bigemelar para lesiones extensas de rodilla / Bigemelar flap for extensive knee injuries

El traumatismo de miembros inferiores representa un reto para el cirujano plástico en cuanto a su reconstrucción cuando no se dispone de técnicas microquirúrgicas. En el presente trabajo se presentan tres casos de reconstrucción de rodilla con doble colgajo muscular de gemelo en donde se demuestra que la utilización simultánea de los dos gemelos puede ser aplicada sin dejar ninguna secuela en la parte funcional y estética en la deambulación de los pacientes. No existe en la literatura nacional ni internacional un reporte de casos con esta aplicación, ya que siempre se ha limitado al uso de un solo músculo precisamente por el temor de alterar la función en cuanto a la flexoextensión del pie.

Lower limb trauma is a challenge for plastic surgeons in their reconstruction when microsurgical techniques are available. In this paper we present three cases of reconstruction of the knee with twin double-muscle flap where it is shown that the simultaneous use of the twins can be applied without leaving any sequel partly functional and aesthetics in ambulation of patients. For there is in the national or international literature a repost of cases with this application as it has always been limited to using just a single muscle for fear of disrupting the function in terms of flexion and extension of the foot.

Manejo de la fístula anorrectal compleja: LIFT, colgajo de avance y otras técnicas / Management of complex anorectal fistula: LIFT, endorectal advancement flap and others techniques

Resumen Las fístulas anorrectales complejas son un desafío para el coloproctólogo. Son una patología frecuente que afecta la calidad de vida de los pacientes. La patogénesis aún no está clara, estarían involucradas citoquinas y el proceso de transición de epitelio a mesénquima. El gold standard para su estudio es la resonancia nuclear magnética, su uso por sí mismo disminuye la recurrencia. El objetivo del tratamiento es lograr la curación sin afectar la función del esfínter evitando las recidivas. Existen múltiples técnicas, siendo la de mayor aceptación la ligadura interesfinteriana del trayecto fistuloso, con tasa de curación sobre el 70%, con mínimo impacto en continencia. Esta revisión incluye otras técnicas como el colgajo endorrectal de avance, uso de sellante, permacol, células madres, Anal fistula plug, Video asisted anal fistula treatment, Over the scope clip y fistula laser closure.

Complex anal fistula are a challenge for colorectal surgeons. It is a common pathology in population. Pathogenesis is still unclear, it would be involved citokines and the process of epitelial to eesenchymal transition. The gold standard for study is MRI, its use reduces recurrences. The goal of treatment is heal the fistula without damaging the function of the sphincter and avoid recurrences. There are multiple techniques, the most accepted is ligation of intersphincteric fistula tract with cure rate over 70%, with minimal impact in continence. This review includes other techniques like rectal advancement flap, fibrin glue, permacol, stem cells, anal fistula plug, video asisted anal fistula treatment, over the scope clip and fistula laser closure.

Variante de colgajo de rotación tipo Hamstring para reconstrucción de úlcera isquiática / Hamstring rotation fl ap variant for ischial ulcer reconstruction

Antecedentes. El colgajo Hamstring es una opción válida para la reconstrucción de úlceras isquiáticas. Las úlceras por presión representan un verdadero desafío para el cirujano plástico. Requieren un tratamiento especializado y multidisciplinario por su alta probabilidad de recidiva y las complicaciones en su manejo. Por lo general, ocurren por presión sostenida sobre la tuberosidad isquiática. Caso clínico. Se presenta el caso de un paciente parapléjico desde el nacimiento secundario a mielomeningocele con diagnóstico actual de úlcera isquiática. Se le realizaron durante 3 años múltiples intentos de cierre quirúrgico alternando medidas conservadoras, sin éxito. A la exploración física presenta una úlcera isquiática izquierda de 6x6 cm a la que se le realizó aseo y desbridación quirúrgica más cierre por medio de un colgajo Hamstring modificado. A los 7 días presentó dehiscencia de herida la cual se manejó de manera conservadora y cierre primario diferido a las 4 semanas. A 8 meses de posoperatorio el paciente se encuentra con buena evolución y con resultado estético y funcional aceptable, por otra parte, se encuentra sin recidiva, lo que ha permitido su reinserción laboral y un buen equilibrio físico-psico-emocional. Conclusión. El objetivo de este colgajo es brindar cobertura al área isquiática sin afectar estructuras adyacentes, lo cual requiere de un amplio conocimiento de la anatomía de la región femoral, así como de los colgados tanto locales como regionales que podemos utilizar para la reconstrucción. Actualmente este colgajo es una opción terapéutica efectiva para el tratamiento de úlceras isquiáticas refractarias en centros que cuentan con cirujanos plásticos no especializados en microcirugía.

Background. The Hamstring fl ap is an adequate option for ischial ulcers reconstruction. Pressure ulcers represent a real challenge for the plastic surgeon. They require specialized and multidisciplinary treatment due to their high recurrence probability and complications in their management. Regularly, pressure ulcers occur when sustained pressure is applied on the ischial tuberosity. Case report. We report a case of a 23-year-old paraplegic male with myelomeningocele complaining for an ischial ulcer. Multiple attempts to surgical closure were made during three years along with conservative management, without success. Physical examination revealed a 6x6 cm left ischial ulcer, which was managed with surgical debridement and closure with a modifi ed Hamstring fl ap. After 7 days, the patient presented wound dehiscence, which was managed conservatively and primary delayed closure after 4 weeks. 8 months postoperatively the patient has a good evolution and an acceptable functional and aesthetic result, without recurrence, which has allowed his reintegration into work and a good physical-psycho-emotional balance. Conclusion. The objective of this fl ap is to provide coverage to the ischial area without aff ecting adjacent structures, which requires a broad knowledge of the anatomy of the femoral region, as well as the local and regional fl aps that can be used for reconstruction. Nowadays this fl ap is an eff ective therapeutic option for the treatment of refractary ischial ulcers in plastis suergery centers without microsurgery.

Injerto de tejido conectivo subepitelial y colgajo reposicionado coronal modificado para tratamiento de recesiones periodontales / Subepithelial connective tissue graft and a modified coronal repositioned flap for treatment of periodontal recessions

RESUMEN Introducción: La recesión periodontal es un problema mucogingival frecuente, de origen multifactorial que usualmente se asocia a hipersensibilidad dentinaria, caries radicular y problemas estéticos. La cobertura radicular es parte integral de su tratamiento quirúrgico. Las técnicas bilaminares con injerto de tejido conectivo subepitelial son las más predecibles. Objetivo: Describir los resultados clínicos obtenidos al realizar en recesiones periodontales múltiples, injerto de tejido conectivo subepitelial cubierto por colgajo reposicionado coronal modificado. Presentación del caso: Paciente masculino, blanco, obrero, de 43 años, con antecedentes personales y familiares de salud que acudió al Servicio de Periodoncia de la Clínica Estomatológica "III Congreso del PCC", Matanzas, Cuba, por "cambio de posición de la encía en algunos dientes". Clínicamente existía exposición radicular en los dientes 13, 53 y 14, ausencia del 12, higiene bucal adecuada, no presencia de bolsas periodontales. Se diagnosticó recesión periodontal clase I de Miller localizada en dichos dientes. Para su tratamiento quirúrgico se realizó injerto de tejido conectivo subepitelial y colgajo desplazado coronal sin incisiones verticales de 11 a 15. A la semana, se retiró sutura de zona donante, se observó buena cicatrización. Se citó a los siete días para retirar cemento quirúrgico y sutura de la zona injertada; existía discreto edema, materia alba, biopelícula y cobertura radicular completa del 13, 53 y 14. Al año del procedimiento, las superficies expuestas estaban completamente cubiertas con tejido gingival posicionado en 13 y 53, ganancia de encía insertada y armonía de color entre sitio injertado y área adyacente. El 14 mostró 1 mm de raíz expuesta. Conclusiones: La técnica empleada, cubrió totalmente la superficie radicular del 13, del 53 y parcialmente la raíz del 14. Se obtuvo incremento de encía queratinizada, óptimo aspecto estético y buena evolución posoperatoria(AU)

ABSTRACT Introduction: periodontal recession is a frequent mucogingival problem, of multifactorial origin that is usually associated to dentin hypersensibility, radicular caries and esthetic problems. Root coverage is an integral part of its surgical treatment, considering bilaminar techniques with subepithelial connective tissue graft as the most predictable ones. Objective: to describe the clinical results obtained when making a sub epithelial connective tissue graft covered by a modified coronal repositioned flap, in multiple periodontal recessions. Case presentation: a male, white, worker patient, aged 43 years, with health personal and family antecedents, who assisted the Periodontics service of the Dental Clinic "III Congreso del Partido", of Matanzas, Cuba, for "a change of the gum position in some teeth". Clinically, there it was a root exposition of the 13, 53 and 14 teeth, lack of the 12 one, adequate oral hygiene and absence of periodontal´s pockets. A Miller´s Class I periodontal recession located in those teeth was diagnosed. A subepithelial connective tissue graft and coronally advanced flap was performed without vertical incisions from 11 to 15 teeth. After a week, the suture of the donor zone was retired, showing good healing. He was cited at the seventh day to retire surgical cement and suture form the grafted zone, observing a discrete edema, debris, biofilm and complete root coverage of the 13, 53 and 14 teeth. At the year after the procedure, the exposed surface was completely covered with gingival tissue positioned in the 13 and 53 teeth, with a gaining of inserted gum and color harmony between the grafted site and adjacent areas. The 14 tooth showed 1 mm of exposed root. Conclusions: the used technique totally covered the root of the 13 and the 53, and most of the root of the 14 tooth, reaching an increase of the keratinized gum, and optimal esthetic aspect and post-surgery evolution(AU)

Colgajo temporal en la reconstrucción de un defecto maxilar por exéresis de carcinoma ameloblástico / Temporalis muscle flap in the reconstruction of a maxillary defect caused by exeresis of ameloblastic carcinoma

RESUMEN Introducción: El carcinoma ameloblástico es una entidad rara que surge como una neoplasia primaria o a partir de un ameloblastoma preexistente. El colgajo de músculo temporal es una opción terapéutica frecuentemente empleada para la reconstrucción del defecto resultante luego de la exéresis quirúrgica. Objetivo: Presentar un caso clínico de restauración estética y funcional mediante reconstrucción con colgajo temporal de un defecto maxilar por exéresis de carcinoma ameloblástico, dada la infrecuente presentación de esta entidad. Caso clínico: Mujer de 49 años de edad, que refiere "una bola" en el paladar de 9 meses de evolución. Al examen físico facial presenta aumento de volumen en región infraorbitaria izquierda. Se realizó una tomografía axial computarizada en la que se constató la presencia de imagen hiperdensa en seno maxilar izquierdo con calcificación en su interior, produciendo lisis del hueso nasal y hueso cigomático infiltrando partes blandas. Se tomó muestra para biopsia que informó tumor de alto grado de malignidad correspondiente a carcinoma ameloblástico. En estudio radiográfico de tórax no se apreció presencia de metástasis pulmonar. Se realizó maxilarectomía de infra y mesoestructura, resección de la lesión con margen oncológico de seguridad y se reconstruyó el defecto palatino con colgajo pediculado del músculo temporal. Se indicó quimio y radioterapia como terapia adyuvante al tratamiento quirúrgico. Se mantuvo el chequeo posoperatorio mostrándose buena evolución clínica y una epitelización secundaria del músculo temporal en el área palatina con restauración de las funciones. Conclusiones: Se presentó un caso clínico de carcinoma ameloblástico, entidad patológica de escasa frecuencia. La cirugía constituyó el pilar de tratamiento utilizado. Una vez realizada la resección quirúrgica se reconstruyó el defecto palatino, utilizándose el colgajo del músculo temporal, opción útil para lograr el restablecimiento de las funciones estéticas y funcionales como la deglución y fonación(AU)

ABSTRACT Introduction: Ameloblastic carcinoma is a rare condition emerging as a primary neoplasm or from a preexisting ameloblastoma. Temporalis muscle flap is a therapeutic option frequently used for reconstruction of the defect resulting from surgical exeresis. Objective: Present a clinical case of esthetic and functional restoration by reconstruction with temporalis muscle flap of a maxillary defect caused by exeresis of an ameloblastic carcinoma. The case is presented because of the infrequent occurrence of this condition. Clinical case: A female 49-year-old patient reports "a lump" in her palate of nine months evolution. Physical examination finds an increase in volume in the left infraorbital region. Computed axial tomography was indicated, which revealed the presence of a hyperdense image in the left maxillary sinus with internal calcification causing lysis of the nasal bone and the zygomatic bone, and infiltrating soft tissue. A sample was taken for biopsy, which reported a tumor with a high degree of malignancy corresponding to ameloblastic carcinoma. Chest radiography did not show the presence of lung metastasis. Infra- and mesostructure maxillectomy was performed, the lesion was removed with a surgical safety margin, and the palatine defect was reconstructed with a pediculated temporalis muscle flap. Chemo- and radiotherapy were indicated as adjuvants to the surgical treatment. Postoperative follow-up found good clinical evolution and secondary epithelization of the temporalis muscle in the palatine area with restoration of functions. Conclusions: A clinical case was presented of ameloblastic carcinoma, a condition with a low frequency of occurrence. Surgery was the basic component of the treatment applied. Once surgical resection was performed, the palatine defect was reconstructed by means of a temporalis muscle flap, a useful option to achieve the restoration of esthetic and biological functions, such as swallowing and speech(AU)

Correção de fenda palatina secundária traumática em cão - relato de caso / Correction cleft palate secondary traumatic in dog - case report

A fenda palatina é a comunicação entre a cavidade oral e a nasal através de um orifício no palato. Tem diversas etiologias, podendo ser congênita, traumática, por deficiência mineral ou por fatores hormonais. O diagnóstico é realizado por meio de exame físico da cavidade oral, e a correção cirúrgica é o tratamento de escolha. Em animais adultos, pode ser corrigida com o auxílio de retalho mucoperiosteal, apresentando bons resultados. Já em filhotes, a correção cirúrgica é mais complicada, com prognóstico menos favorável. Este trabalho relata o caso de um canino, fêmea, sem raça definida, adulta, com histórico de fenda palatina secundária, de origem traumática, no palato mole por ingestão de osso. Para a correção cirúrgica, primeiramente foi utilizada membrana biológica de pericárdio bovino, mas não se obteve êxito. O segundo procedimento foi realizado com retalho mucoperiosteal simples autólogo e, dois meses após o procedimento, já havia cicatrização completa. A técnica de retalho mucoperiosteal simples autólogo se mostrou eficaz no tratamento da fenda palatina, aliada aos cuidados adequados no pós-operatório.(AU)

The cleft palate is the communication between the oral and nasal cavity through an aperture in the palate, it's causes include an infinitude of factors: congenital, traumatic, mineral deficiency or hormonal. Examination of the oral cavity determines if the diagnosis and treatment is surgical. Correction in adult animals is performed with mucoperiosteal flap showing good results. However, surgical correction in puppies is more complicated with less favorable prognosis. This current work reports a case of an adult, female dog of undefined breed, with a history of secondary clef palate of traumatic origin in the soft palate due to bone ingestion. For correction, a biological membrane of bovine pericardium was used, but it was not successful, requiring a second surgical procedure performed with autologous simple mucoperiosteal flap. The last technique combined with adequate postoperative care was effective.(AU)

Reconstrucción postraumática de una pérdida parcial auricular / Posttraumatic reconstruction of a partial ear loss

RESUMEN Introducción: Los objetivos de la reconstrucción auricular son mantener la permeabilidad del canal auditivo externo y restaurar la forma general y la proyección. Objetivo: caracterizar un caso clínico de reconstrucción postraumática de una pérdida parcial auricular, enfatizando en la importancia de la secuencia terapéutica empleada. Presentación del caso clínico: Acude a consulta externa un paciente masculino de 26 años. Refiere haber sido tratado en el cuerpo de guardia 10 días atrás, al haber perdido un fragmento de oreja por una mordida en una riña. Al examen físico se constata la existencia de una pérdida parcial irregular de la oreja derecha. Se decide esperar tres semanas, e indicar chequeo preoperatorio. Al cabo de este tiempo se realiza el primer tiempo reconstructivo quirúrgico, con injerto autólogo de cartílago auricular de la oreja izquierda, que fue colocado en forma de "bolsillo" en la región temporal. A las tres semanas del primer tiempo quirúrgico, se realiza, bajo anestesia local, el segundo tiempo reconstructivo con la liberación de la región auricular del "bolsillo" creado, el avance de un colgajo posterior y la colocación de un injerto libre de piel. El paciente refirió una gran satisfacción por los resultados estéticos obtenidos. Principales comentarios: se empleó una secuencia terapéutica ante un defecto traumático parcial del pabellón auricular en sus tercios superior y medio. Este tipo de secuela traumática requirió el empleo de procederes quirúrgicos en varios tiempos operatorios que garantizaran un buen aporte sanguíneo de los tejidos, ausencia de tensión y adecuados resultados estéticos finales(AU)

ABSTRACT Introduction: The aims of auricular reconstruction are to maintain the permeability of the external auditory canal and restore general shape and projection. Objective: Characterize a clinical case of posttraumatic reconstruction of a partial ear loss, highlighting the importance of the therapy sequence followed. Clinical case presentation: A male 26-year-old patient attends outpatient consultation. He reports that he was treated in the emergency service 10 days before upon having lost a section of his ear due to a bite in a fight. Physical examination reveals irregular partial loss of the right ear. It is decided to wait three weeks and indicate preoperative checkup. At the end of that period the first surgical reconstruction session is conducted, with autologous graft of auricular cartilage from the left ear, which was placed in the form of a "pocket" in the temporal region. Three weeks after the first surgical session, the second reconstruction is performed under local anesthesia, with release of the "pocket" from the auricular region, advancement of a posterior flap and placement of a free skin graft. The patient reported great satisfaction with the esthetic results obtained. Main remarks: A therapy sequence was followed in response to a partial traumatic defect of the outer ear in its upper and middle thirds. This type of traumatic sequel required the performance of surgical procedures at several operative moments, ensuring good blood supply to tissues, absence of tension and appropriate final esthetic results(AU)

Reconstruções mamárias: estudo retrospectivo de 16 anos / Breast reconstructions: a 16-year retrospective study

Introdução: Câncer de mama é o segundo tipo mais comum de câncer entre mulheres no Brasil. Estimam-se 59.700 casos novos de câncer de mama para o biênio 2018-2019. Reconstrução mamária é um procedimento seguro e vários procedimentos cirúrgicos são descritos para sua realização: técnicas conservadoras, retalhos de vizinhança, materiais aloplásticos, retalhos miocutâneos pediculados e microcirúrgicos. O objetivo deste estudo foi analisar os casos de reconstrução mamária pósmastectomia por câncer de mama, realizados em um período de 16 anos. Métodos: Foi realizada revisão de prontuários de pacientes submetidas à reconstrução mamária pós-mastectomia por câncer de mama, no período de janeiro de 2002 a dezembro de 2017. Resultados: No período analisado, 586 pacientes foram submetidas à reconstrução mamária. Em 160 pacientes a reconstrução mamária foi realizada com retalho miocutâneo do músculo retoabdominal (TRAM), 107 com técnicas conservadoras, 156 com retalho miocutâneo do músculo grande dorsal (RGD), 113 com próteses e 50 secundárias. Previamente a outubro de 2007, a porcentagem de pacientes submetidas a cirurgias bilaterais, somando-se TRAM e RGD, era de 30%, e a partir desse período a porcentagem passou para 83,3%. Houve algum tipo de complicação ou intercorrência em 203 (34,64%) pacientes operadas, totalizando de 335 complicações. Grande maioria apresentou intercorrências tratadas ambulatorialmente sem necessidade de reabordagem cirúrgica. Conclusão: Houve aumento da incidência de cirurgias bilaterais, fato atribuído ao aumento das mastectomias profiláticas na mama contralateral e aumento do número de reconstruções utilizando RGD em comparação com o TRAM, bem como o aumento significativo das reconstruções com implante de silicone.

Introduction: Breast cancer is the second most common type of cancer among women in Brazil. An estimated 59,700 new cases of breast cancer were reported in the 2018­2019 biennium. Breast reconstruction is a safe procedure, and various surgical procedures have been described, including conservative techniques and use of neighborhood flaps, alloplastic materials, and pedicled and microsurgical myocutaneous flaps. The objective of this study was to analyze cases of breast reconstruction after mastectomy for breast cancer performed over a period of 16 years. Methods: We reviewed the medical records of patients who underwent breast reconstruction after mastectomy for breast cancer between January 2002 and December 2017. Results: Within the study period, 586 patients underwent breast reconstruction. Breast reconstruction was performed with a transverse rectus abdominis myocutaneous muscle (TRAM) flap in 160 patients, with conservative techniques in 107 patients, with a latissimus dorsi myocutaneous flap (LDMF) in 156 patients, with prostheses in 113 patients, and secondarily in 50 patients. Before October 2007, the proportion of patients who underwent bilateral surgeries with a TRAM flap and LDMF was 30%, and since then, the percentage has increased to 83.3%. One or more types of complications occurred in 203 patients (34.64%) who underwent surgery, with a total of 335 complications . Most outpatient complications did not require surgical reassessment. Conclusion: The incidence of bilateral surgery increased, which is attributed to the increase in the number of prophylactic mastectomies in the contralateral breast and in the number of reconstructions using a LDMF compared with that using a TRAM flap. A significant increase in the number of reconstructions with silicone implants was also observed.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

Reconstrução de pálpebra inferior com uso do retalho de transposição da pálpebra superior de espessura total / Reconstruction of the lower eyelid using a full-thickness upper eyelid transposition flap

Introdução: O melhor método para reconstruir uma unidade anatômica é substituir a área lesada pelos mesmos tecidos. Métodos: Três pacientes que apresentavam carcinomas basocelulares na pálpebra inferior foram submetidos à excisão, seguida de reconstrução imediata com a transposição em espessura total de tecido da pálpebra superior em um só tempo. Resultados: Os pacientes evoluíram quase sem complicações, as pálpebras mantiveram suas funções de fechamento total e proteção do globo ocular. Conclusão: O retalho se mostrou factível e é mais uma alternativa para reconstruir a pálpebra inferior.

Introduction: The best method to reconstruct an anatomical unit is to replace the injured area with the same tissues. Methods: Three patients with basal cell carcinoma in the lower eyelid underwent full-thickness lower eyelid excision, followed by immediate reconstruction with a single-stage fullthickness transposition of the upper eyelid tissue. Results: The patients had almost no complications, and the functions of total closure and protection of the eyeballs of the eyelids were maintained. Conclusion: The flap proved to be feasible and is an alternative choice for reconstruction of the lower eyelid.

Retalho retroauricular ilhado para reconstrução parcial de orelha: relato de casos / Retroauricular island flap for partial ear reconstruction: case reports

Defeitos parciais de orelha podem ser tratados de diversas formas, dentre elas o fechamento primário, cicatrização por segunda intenção ou retalhos. Diversas opções técnicas foram descritas para a sua reconstrução de modo a manter o contorno natural da orelha, sem sacrificar tecido sadio ou alterar sua estética e função. Apresentamos neste artigo dois casos atendidos no Instituto do Câncer do Hospital de Base de São José do Rio Preto de reconstrução de defeitos condrocutâneos de orelha após ressecção de carcinoma basocelular em região central da orelha, com a confecção de retalho retroauricular ilhado transposto através de uma janela cartilaginosa e com o pedículo desepidermizado. Área doadora com fechamento primário. Tal procedimento constitui técnica segura, pois a região retroauricular é ricamente vascularizada, é de fácil execução, em único estágio e com resultado estético e funcional satisfatório.

Partial ear defects can be treated in several ways, including primary closure, healing by secondary intention, or flaps. Several surgical options have been described for reconstruction in order to maintain the natural contour of the ear, without sacrificing healthy tissues or changing the aesthetics and function. In this article, we present two cases of reconstruction of chondrocutaneous defects of the ear after resection of basal cell carcinoma in the central region of the ear, with the production of a retroauricular island flap transposed through a cartilaginous window with the de-epidermized pedicle. The donor area healed following a primary closure. This procedure can be performed in a single stage, yields satisfactory aesthetic and functional results, and is safe because the retroauricular region is richly vascularized.

Versatilidad del colgajo dorsal en cirugía de reconstrucción de sarcoma de pared torácica. Reporte de caso / Versatility of the dorsal flap in reconstruction surgery of toracica wall sarcoma. Case report

Entre los tumores malignos de la pared torácica, los sarcomas representan menos del 1% de los casos. A pesar de ser infrecuentes, es importante resaltar el manejo multidisciplinario de estos tipos de tumores ya que se caracterizan por ser de gran tamaño y afectar una amplia superficie torácica y por consiguiente de los tejidos blandos anexos a los mismos. De ahí la real importancia de la participación de cirujanos plásticos, torácicos y oncólogos en el tratamiento de estos tumores. La confección del colgajo dorsal en cirugías de sarcomas de la pared torácica ha permitido completar el tratamiento resectivo de dichos tumores. Presentamos el caso de un paciente varón de 64 años, con un sarcoma de la parrilla costal, quien fue sometido a resección amplia de la lesión que comprometia a la 7ma, 8va y 9na costillas, reconstrucción inmediata con próstesis de titanio y malla de polipropileno y cobertura del defecto con confección de colgajo del dorsal ancho. A 5 meses de seguimiento, sin evidencia de actividad de la enfermedad

Among malignant tumors of the chest wall, sarcomas account for less than 1% of cases. Despite being infrequent, it is important to highlight the multidisciplinary management of these types of tumors since they are characterized by being large and affecting a wide chest area and therefore the soft tissues attached to them. Hence the real importance of the participation of pásticos, thoracic and oncologos surgeons in the treatment of these tumors.The confection of the dorsal flap in surgeries of sarcomas of the thoracic wall has allowed to complete the treatment of these tumors. We present the case of a 64-year-old male patient with a sarcoma of the rib cage, who underwent extensive resection of the lesion involving the 7th, 8th and 9th ribs, immediate reconstruction with titanium prosthesis and mesh. polypropylene and coverage of the defect with flap made of the latissimus dorsi. At 5 months of follow-up, without evidence of disease activity.

Retalho de peitoral maior estendido e pediculado para reconstrução de região orbito-fronto-parietal direita após exérese de carcinoma espinocelular invasivo / Extended and pedicled pectoralis major flap for right orbitofrontal-parietal reconstruction following invasive squamous cell carcinoma resection

Introdução: O retalho miocutâneo de peitoral maior é um dos mais usados na reconstrução de defeitos da cabeça e pescoço, porém com restrição ao terço médio da face. Com técnicas de dissecção de perfurantes, consegue-se alongar mais o pedículo, obtendo coberturas da região orbito-fronto-parietal. Relato de Caso: Paciente masculino de 63 anos apresentando carcinoma espinocelular invasivo pouco diferenciado, que após sua ressecção cirúrgica apresentou defeito final de 12,0 x 18,0cm na região órbito-fronto-parietal direita com exposição de dura-máter, seio frontal e órbita superior direita. Foi desenhado retalho de peitoral maior com ilha cutânea de dimensões iguais ao defeito na região paraesternal direita, desde o quarto espaço intercostal até a região subcostal (estendido). O pedículo foi seccionado após 4 semanas. A cobertura foi efetiva, sem complicações maiores e resultado estético satisfatório. Conclusão: Este retalho mostrou ser uma excelente opção para reconstrução do terço superior da cabeça quando existam limitações para a realização de microcirurgia.

Introdução: O retalho miocutâneo de peitoral maior é um dos mais usados na reconstrução de defeitos da cabeça e pescoço, porém com restrição ao terço médio da face. Com técnicas de dissecção de perfurantes, consegue-se alongar mais o pedículo, obtendo coberturas da região orbito-fronto-parietal. Relato de Caso: Paciente masculino de 63 anos apresentando carcinoma espinocelular invasivo pouco diferenciado, que após sua ressecção cirúrgica apresentou defeito final de 12,0 x 18,0cm na região órbito-fronto-parietal direita com exposição de dura-máter, seio frontal e órbita superior direita. Foi desenhado retalho de peitoral maior com ilha cutânea de dimensões iguais ao defeito na região paraesternal direita, desde o quarto espaço intercostal até a região subcostal (estendido). O pedículo foi seccionado após 4 semanas. A cobertura foi efetiva, sem complicações maiores e resultado estético satisfatório. Conclusão: Este retalho mostrou ser uma excelente opção para reconstrução do terço superior da cabeça quando existam limitações para a realização de microcirurgia.