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

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

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

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

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

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

Colgajo infrahioídeo: Reporte de un caso y revisión de la técnica quirúrgica

Introducción: El colgajo infrahioideo (CI) es una alternativa reconstructiva para defectos en cavidad oral, orofaringe e hipofaringe. Se trata de un colgajo musculocutáneo pediculado e inervado que suele ser bien tolerado en el postoperatorio. Caso Clínico: Se describe la técnica quirúrgica del CI en relación al caso de un paciente de 58 años con carcinoma escamoso de lengua izquierda, a quien se le realiza resección amplia de dicho tumor. Se reconstruye mediante CI, lográndose cobertura exitosa con buena evolución postoperatoria. Discusión: Los colgajos regionales y pediculados son un eslabón fundamental en el abanico de opciones reconstructivas frente a un paciente con cáncer oral. El CI es una opción adecuada para defectos medianos con excelentes resultados estéticos y funcionales. Conclusión: El CI constituye una opción reconstructiva sencilla y ampliamente disponible. Requiere de una adecuada planificación preoperatoria con una buena selección de los pacientes para obtener resultados satisfactorios.

Introduction: The infrahyoid flap (IF) is an alternative for reconstruction in defects of the oral cavity, oropharynx, and hypopharynx. It is a pedicled and innervated musculocutaneous flap that is usually well tolerated by patients. Clinical Case: We describe the surgical technique of IF with the description of the case of a 58-year-old patient with squamous cell carcinoma of the left tongue. He underwent wide resection and then reconstruction. We performed an IF achieving successful coverage with adequate postoperative course. Discussion: Regional and pedicled flaps are important reconstructive options for patients with oral cancer. The IF is a suitable option for medium defects with excellent aesthetic and functional results. Conclusion: IF is a simple and widely available reconstructive option. It requires adequate preoperative planning with a good selection of patients to obtain satisfactory results.

Reconstrução de terço distal do nariz: série de casos e revisão de literatura / Reconstruction of the distal third of the nose: case series and literature review

Introdução: O nariz apresenta grande importância estética e funcional, com alta incidência de lesões malignas. Existem várias técnicas de reconstrução do terço distal do nariz, não havendo uma indicação universal; irá depender das características da lesão. As opções cirúrgicas variam entre enxerto de pele, retalhos locais, regionais e microcirúrgicos. O objetivo é apresentar uma série de casos de reconstrução de terço distal do nariz com diferentes técnicas cirúrgicas, discutindo as peculiaridades e os resultados obtidos. Método: Trata-se de estudo retrospectivo realizado no Hospital do Servidor Público Estadual de São Paulo (HSPE), avaliando uma série de oito pacientes com diagnóstico de câncer de pele não melanoma localizados em terço distal de nariz e que foram submetidos a reconstrução pela equipe de Cirurgia Plástica. Resultados: Foram obtidos resultados satisfatórios para todos os pacientes submetidos a reconstrução distal do nariz, tendo sido utilizadas técnicas de enxerto de pele total (n=1) e retalhos locais (n=7), tais como o retalho bilobado, nasogeniano, dorsal do nariz, frontal paramediano, e transposição nasolabial. Conclusão: A reconstrução de defeitos do terço distal do nariz é desafiadora e com grande variabilidade técnica. Deve-se realizar avaliação criteriosa do paciente e da lesão, avaliar riscos e benefícios e compartilhar a decisão com o paciente.

Introduction: The nose has great aesthetic and functional importance, with a high incidence of malignant lesions. There are several techniques for reconstructing the distal third of the nose, but there is no universal indication; will depend on the characteristics of the injury. Surgical options vary between skin grafts and local, regional, and microsurgical flaps. The objective is to present a series of cases of reconstruction of the distal third of the nose using different surgical techniques, discussing the peculiarities and the results obtained. Method: This is a retrospective study carried out at the Hospital do Servidor Público Estadual de São Paulo (HSPE), evaluating a series of eight patients diagnosed with non-melanoma skin cancer located in the distal third of the nose and who underwent reconstruction by the team of Plastic Surgery. Results: Satisfactory results were obtained for all patients undergoing distal nose reconstruction, using total skin graft techniques (n=1) and local flaps (n=7), such as the bilobed, nasolabial, and dorsal nose flap. nose, paramedian frontal, and nasolabial transposition. Conclusion: Reconstruction of defects in the distal third of the nose is challenging and involves great technical variability. A careful assessment of the patient and the injury must be carried out, risks and benefits assessed and the decision shared with the patient.

Fasciotomia em membro superior após síndrome compartimental por acidente ofídico com posterior enxertia e plástica em Z: relato de caso / Fasciotomy in the upper limb after compartment syndrome due to snakebite with subsequent grafting and z-plasty: case report

Este relato de caso aborda o curso clínico de um envenenamento botrópico ocorrido no município de Jarinu, SP, no ano de 2021. O paciente necessitou de fasciotomia em membro superior após síndrome compartimental aguda com enxertia dermoepidérmica em um segundo momento cirúrgico. No pós-operatório tardio, o paciente evoluiu com retração, necessitando de reabordagem cirúrgica com correção de retração de membro superior esquerdo. Discute-se a gravidade do acidente ofídico, efeitos do veneno nos tecidos, complicações, síndrome compartimental aguda, indicação e técnica da fasciotomia descompressiva com base na literatura.

This case study examines the clinical course of a Bothrops snakebite poisoning that occurred in Jarinu, São Paulo, Brazil, in 2021. The patient required a fasciotomy in the upper limb due to acute compartment syndrome, followed by a second surgical procedure involving dermo-epidermal grafting. In the late postoperative period, the patient experienced retraction, leading to a subsequent surgical intervention to correct the retraction in the left upper limb. The severity of the snakebite accident, the effects of venom on tissues, complications, acute compartment syndrome, as well as the indications and techniques for decompressive fasciotomy, are discussed based on the available literature.

Incisões e retalhos: orientações e guia prático / Incisions and flaps: guidelines and pratical guide

Na cirurgia oral, dois princípios básicos são o acesso adequado e uma boa visualização. Em diversos casos, isto somente é alcançado afastando os tecidos moles adjacentes do local operado através de retalhos cirúrgicos. Os principais retalhos descritos na literatura para cirurgia oral são: envelope, em L ou triangular, trapezoidal e em Y. As técnicas para a realização de incisões e retalhos são essenciais para o acesso de determinados dentes ou patologias que surgem de maneira rotineira na clínica odontológica, além de também serem usadas para contornar complicações cirúrgicas, como fraturas radiculares. O objetivo deste trabalho é, através de um guia prático, expor os princípios para uma técnica adequada e a sequência para realização dos retalhos mais utilizados em cirurgia oral.

In oral surgery, two basic principles are access and good visualization. In many cases, this is only achieved by moving adjacent soft tissues away from the operated site using surgical flaps. The main flaps described in the literature for oral surgery are: envelope, L-shaped or triangular, trapezoidal and Y-shaped. Techniques for performing incisions and flaps are essential for accessing certain teeth or pathologies that arise routinely in the dental clinic, in addition to being used to circumvent surgical complications, such as root fractures. The objective of this work is, as a practical guide, to expose the principles for an adequate technique and a sequence for the realization of the most used flaps in oral surgery.

Research progress on wound repair of severe open injury of lower limbs / 临床外科杂志

Severe open injury of lower limbs is complex and difficult to cure in a short time,which can lead to serious infection,amputation and so on.For the treatment of open injury,wound repair is extremely important.A variety of new technologies such as new dressings,platelet-rich plasma(PRP),and vacuum sealing drainage(VSD)have recently been applied to lower limb wound repair,which can not only improve the functional prognosis and aesthetic effect,but also improve the quality of wound healing.This review will summarize the research progress of wound repair methods for open injury of lower limbs,so as to further guide clinical application.

Clinical application of three-dimensional CT angiography in repair of limb wounds with free lateral thoracic perforator flaps / 中华创伤骨科杂志

Objective:To explore the clinical application of three-dimensional CT angiography (3D-CTA) in repair of limb wounds with free lateral thoracic perforator flaps.Methods:A retrospective study was conducted to analyze the clinical data of 61 patients with limb soft tissue defects who had been treated at The Third Department of Orthopedics, Xingtai General Hospital of North China Medical and Health Group from January 2018 to September 2022. There were 37 males and 24 females with an age of (43.9±12.0) years. Thirty-three left and 28 right sides were injured. Soft tissue defects ranged from 4.0 cm × 3.0 cm to 17.0 cm × 8.0 cm, and flap areas from 5.0 cm × 4.0 cm to 18.0 cm × 9.0 cm. The patients were divided into 2 groups according to the different preoperative vascular exploration methods: an ultrasound group of 30 cases subjected to ultrasound Doppler examination and a 3D-CTA group of 31 cases subjected to 3D-CTA examination. The preoperative findings were compared with those of intraoperative exploration in the 2 groups. The operation time, flap survival rate, patient satisfaction with trauma repair, sensory recovery of the flap area, and the excellent and good rate of the donor area were also compared between the 2 groups.Results:The differences in preoperative general data between the 2 groups were not statistically significant, indicating the 2 groups were comparable ( P>0.05). In the ultrasound group, the inraoperative classification of the lateral thoracic perforator flaps showed a low concordance with preoperative classification (Kappa coefficient of 0.104, P=0.088). In the 3D-CTA group, the classification of lateral thoracic perforator flaps was consistent with the preoperative 3D-CTA examination (Kappa coefficient of 1.00, P<0.001). The preoperative measurements in the 3D-CTA group found that the diameter at the origin of the lateral thoracic artery was (1.2±0.3) mm, the vascular pedicle length (8.1±2.1) cm, and the diameter at the perforator exit (0.6±0.2) mm; the preoperative surface positioning at the perforator exit found that the perforator exit was (1.6±0.3) cm above the horizontal line of the subscapular angle and (5.3±1.4) cm outside the vertical line of the subscapular angle. These measurements were similar to the intraoperative ones [(1.1±0.3) mm, (8.3±2.4) cm, (0.7±0.2) mm, (1.5±0.4) cm, and (5.2±1.5) cm], showing no significant differences ( P>0.05). In contrast, the preoperative measurements of the above indexes in the ultrasound group did not coincide with the actual intraoperative measurements, and the differences were all statistically significant ( P<0.05). The operation time, flap survival rate, rate of patient satisfaction with wound repair, rate of sensory recovery in the flap area, and the excellence and good rate of the donor area in the 3D-CTA group were (52.9±16.7) min, 100.0% (31/31), 96.8% (30/31), 83.9% (26/31), and 87.1% (27/31), respectively, which were significantly better than those in the ultrasound group [(76.3±21.4) min, 86.7% (26/30), 76.7% (23/30), 60.0% (18/30), 63.3% (20/30)] ( P<0.05). Conclusions:As preoperative 3D-CTA examination can clarify the types and anatomical characteristics of the lateral thoracic artery and its perforators, it helps the design and harvest of the lateral thoracic perforator flaps. Compared with the ultrasound Doppler examination, preoperative 3D-CTA examination shortens operation time, raises survival rate of the flaps, and facilitates recovery of the appearance and function of the limb wounds, and leads to little impact on the donor site.

The effect of two different skin flaps on replantation repair of skin defect type severed fingers and their impact on finger function recovery / 中国医师杂志

Objective:To explore the effects of lateral finger flap and micro free venous flap on the replantation repair of skin defect type severed fingers and their impact on finger function recovery.Methods:A retrospective selection was conducted on the clinical data of 94 patients (94 fingers) with skin defect type finger amputation admitted to Affiliated Hospital of Jiangnan University from January 2020 to September 2022. According to the different design methods of the skin flap, there were 48 cases in the observation group (micro free venous flap) and 46 cases in the control group (finger side flap). We compared the repair effects, blood circulation, finger function recovery, and complications between two groups.Results:Two months after surgery, there was no statistically significant difference ( P>0.05) in the total effective rate of repair between the observation group [79.17%(38/48)] and the control group [76.09%(35/46)]. The blood flow velocity, skin temperature, and skin redness ratio of the observation group were higher than those of the control group, and the capillary filling time was shorter than that of the control group, with statistical significance (all P<0.05). There was no statistically significant difference (all P>0.05) in the scores of joint autonomy, daily living activities, and recovery between the two groups. The subjective sensation and appearance scores of the observation group were lower than those of the control group, and the differences were statistically significant (all P<0.05). The incidence of complications in the observation group was 10.42%(5/48), and there was no statistically significant difference ( P>0.05) compared to the incidence of complications in the control group [13.04%(6/46)]. Conclusions:For patients with severed fingers with skin defects, the lateral finger flap and mini free vein flap are effective methods for replantation. In clinical practice, reasonable skin flap repair methods can be flexibly selected based on the patient′s actual situation.

Flap of the sternocephalicus muscle in the repair of a partial defect in the trachea of a rabbit (Oryctolagus cuniculus)

Purpose: The current study aimed at evaluating the repair of a partial defect of the trachea with a muscle flap, an advanced technique that employs combined suture patterns. Methods: Sixteen healthy male New Zealand white rabbits were used as an experimental model. A partial defect in the trachea within the ventral region of the fourth to eighth tracheal ring was created. Subsequently, repair was initiated with a flap of the sternocephalicus muscle. The animals were divided into four groups for postoperative evaluation using clinical, tracheoscopic, and histopathological analyses. Each group was separated according to the time of euthanasia, programmed at interval of seven (G7), 15 (G15), 30 (G30), and 60 days (G60). Results: One animal from the G60 group died, whereas the other animals had good surgical recovery without serious changes in the breathing pattern. The major clinical signs observed were stridor and coughing. Tracheoscopy revealed secretions in the tracheal lumen, exuberant granulation, and stenosis. Histopathological analysis showed growth of the ciliary respiratory epithelium at the flap site 30 days after implantation. Conclusions: Partial repair showed satisfactory results owing to the anatomical location of the muscle, adequate vascular support, and structural and physiological maintenance without serious changes in the respiratory system.

Retalho plantar medial para reconstrução de defeitos em calcanhar após ressecção de melanoma lentiginoso acral: Uma série de 7 casos / Medial plantar flap for reconstruction of heel defects after resection of acral lentiginous melanoma: A series of seven cases

Introdução: A reconstrução da região plantar ainda é um dos grandes desafios da cirurgia plástica reconstrutiva. Os tecidos dessa região apresentam características únicas e que são essenciais para a manutenção da funcionalidade do membro. De toda a região plantar, a região do calcanhar é a área de maior sustentação do peso e submetida ao maior impacto. O retalho fasciocutâneo plantar medial é uma das opções reconstrutivas, pois representa tecido semelhante e mantém a sensibilidade para a área receptora. Método: Foi realizado um estudo retrospectivo através da coleta de dados de prontuário de pacientes que realizaram reconstruções da região do calcanhar com retalho plantar medial, no período de julho de 2013 a setembro de 2019. O estudo foi aprovado pelo Comitê de Ética para Análise de Projetos de Pesquisa do HCFMUSP (Número CAAE: 56849422.0.0000.0068). Resultados: A reconstrução de calcanhar após ressecção de melanoma lentiginoso acral foi realizada em 7 pacientes. Complicações cirúrgicas foram observadas em 3 pacientes, sendo que todos eles tinham idade acima de 50 anos e/ou alguma comorbidade associada. Houve 57,1% de complicações, sendo 37,5% relacionadas ao retalho e 12,5% relacionadas à área doadora. Ocorreram 3 necroses totais de retalho (42,9%) e 1 perda total de enxerto na área doadora (14,3%). Conclusão: O retalho plantar medial se apresenta como uma boa alternativa para a realização de reconstruções oncológicas de defeitos na região plantar do pé. Contudo, deve-se ponderar a escolha do paciente ideal e lembrar que a dissecção do seu pedículo vascular não é de fácil execução.

Introduction: Resurfacing the sole is still one of the great challenges of reconstructive plastic surgery. The tissues on the sole of the foot have unique characteristics essential for maintaining the limbs functionality. The heel has the most significant weight support and is subjected to the entire soles greatest impact. The medial plantar artery flap is one of the reconstructive options, as it represents similar tissue and maintains sensitivity to the recipient area. Methods: A retrospective study was performed by collecting data from medical records of patients who underwent reconstructions of the heel with a medial plantar artery flap from July 2013 to September 2019. The study was approved by the Ethics Committee for Analysis of Research Projects of HCFMUSP (CAAE number: 56849422.0.0000.0068). Results: Heel reconstruction was performed in 7 patients after acral lentiginous melanoma excision. Surgical complications were observed in 3 patients, all of whom were aged over 50 years or have associated comorbidity. There were 57.1% of complications, 37.5% related to the flap, and 12.5% related to the donor area. There were three total flap necroses (42.9%) and one total graft loss in the donor area (14.3%). Conclusion: The medial plantar flap presents itself as a good alternative for performing oncological reconstructions of defects in the plantar region of the foot. However, the choice of the ideal patient should be considered and we must remember that the dissection of its vascular pedicle is not easily executed.

Carcinoma de células escamosas de lábio inferior: Excisão e reconstrução com retalho nasolabial / Squamous cell carcinoma of the lower lip: Excision and reconstruction with nasolabial flap

Introdução: O carcinoma de células escamosas é o tumor maligno mais frequente dos lábios e acomete principalmente o lábio inferior. O tratamento adequado desta neoplasia deve ser precoce e radical, pois metástases podem ocorrer. Considerando que os lábios têm extrema relevância na dinâmica e motricidade da face, a reconstrução labial após grandes ressecções nesta região é um desafio para o cirurgião na busca de bons resultados estéticos e funcionais. Este estudo busca apresentar uma técnica já consagrada e confiável para a reconstrução do lábio inferior após ressecções tumorais, o retalho de Karapandizic. Método: Nesta revisão de casos são avaliados, retrospectivamente, 4 pacientes que tiveram o lábio inferior reconstruído por meio da técnica de Karapandzic no período de 2013-2022. Resultados: As complicações mais frequentemente observadas foram cicatriz hipertrófica, deiscência de sutura em vermelhão de lábio e microstomia (redução da abertura oral). A redução da fenda labial (microstomia) foi corrigida parcialmente através do uso de órteses odontológicas, não havendo necessidade de indicação de comissuroplastia em nenhum dos casos. Outra colaboração deste trabalho refere-se à utilização do ecoDoppler colorido pré-operatório, que permite o planejamento do retalho verificando a viabilidade do pedículo vascular e o real posicionamento deste pedículo, reduzindo as chances de lesão inadvertida dos vasos durante a cirurgia. Conclusão: Mesmo sendo a microstomia uma limitação deste retalho, concluímos que esta técnica atende à necessidade de reconstrução de lábio inferior em grandes ressecções, uma vez que é capaz de proporcionar resultados satisfatórios em termos oncológicos, funcionais e estéticos.

Introduction: Squamous cell carcinoma is the most common malignant tumor of the lips and mainly affects the lower lip. Adequate treatment of this neoplasm must be early and radical, as metastases can occur. Considering that the lips are extremely important in the dynamics and motricity of the face, lip reconstruction after major resections in this region is a challenge for the surgeon in the search for good aesthetic and functional results. This study seeks to present an already established and reliable technique for reconstructing the lower lip after tumor resection, the Karapandizic flap. Method: In this case review, 4 patients with lower lips reconstructed using the Karapandzic technique in 2013-2022 are retrospectively evaluated. Results: The most frequently observed complications were hypertrophic scar, lip vermilion suture dehiscence, and microstomia (reduction of oral opening). The cleft lip (microstomia) reduction was partially corrected through dental orthoses, with no need for commissuroplasty in any of the cases. Another contribution of this work is the use of preoperative color echoDoppler, which allows flap planning by checking the viability of the vascular pedicle and the actual positioning of this pedicle, reducing the chances of inadvertent injury to the vessels during surgery. Conclusion: Even though microstomy is a limitation of this flap, we conclude that this technique meets the need for lower lip reconstruction in large resections, as it can provide satisfactory results in oncological, functional, and aesthetic terms.

Cuidados pós-operatórios em reconstrução com retalhos de ferida traumática em membro inferior: revisão de escopo / Postoperative care in reconstruction with flaps of a traumatic lower limb wound: scope review / Cuidados postoperatorios en reconstrucción con colgajos de herida traumática de miembro inferior: revisión del alcance

Objetivo: mapear os cuidados pós-operatórios em reconstrução com retalhos cirúrgicos de ferida traumática em membro inferior. Método: revisão de escopo desenvolvida de acordo com as recomendações do Joanna Briggs Institute Reviewer's Manual em bases de dados referenciais, portais de informação e literatura cinzenta. Foram traçadas duas estratégias de busca para amplo alcance das publicações. Resultados: identificados dez cuidados pós-operatórios nas reconstruções com retalhos cirúrgicos em membro inferior relacionados a momentos específicos desta fase. Sendo categorizados em: 1) Cuidados no pós-operatório imediato, 2) Cuidados no pós-operatório mediato e 3) Transição do Cuidado. Conclusão: embora as reconstruções com retalhos cirúrgicos sejam um tratamento consolidado, a assistência pós-operatória ainda é incipiente quanto aos cuidados recomendados. Não há consenso sobre a implementação dos cuidados no manejo pós-operatório. O monitoramento dos retalhos cirúrgicos, clínico ou por dispositivos, foi o único cuidado contemplado em todas as publicações selecionadas, considerado essencial no pós-operatório independente da fase(AU)

Objective: to map postoperative care in reconstruction with surgical flaps of a traumatic wound in the lower limb. Method: scope review developed according to the recommendations of the Joanna Briggs Institute Reviewer's Manual in reference databases, information portals and gray literature. Two search strategies were designed for the wide reach of publications. Results: ten postoperative care procedures were identified and related to specific moments in this phase. Being categorized into: 1) Care in the immediate postoperative period, 2) Care in the mediate postoperative period and 3) Transition of Care. Conclusion: although reconstructions with surgical flaps are a consolidated treatment, postoperative care is still incipient in terms of recommended care. There is no consensus on the implementation of care in postoperative management. The monitoring of surgical flaps, clinical or by devices, was the only care considered in all selected publications, considered essential in the postoperative period, regardless of the phase(AU)

Objetivo: mapear los cuidados postoperatorios en la reconstrucción con colgajos quirúrgicos de una herida traumática en miembro inferior. Método: revisión del alcance desarrollada según las recomendaciones del Joanna Briggs Institute Reviewer's Manual (Manual del Revisor del Instituto Joanna Briggs) en bases de datos referenciales, portales de información y literatura gris. Se diseñaron dos estrategias de búsqueda para el amplio alcance de las publicaciones. Resultados: se identificaron diez procedimientos de cuidados postoperatorios relacionados con momentos específicos de esta fase. Siendo categorizados en: 1) Atención en el postoperatorio inmediato, 2) Atención en el postoperatorio mediato y 3) Transición de la Atención. Conclusión: si bien las reconstrucciones con colgajos quirúrgicos son un tratamiento consolidado, los cuidados postoperatorios aún son incipientes. No existe consenso sobre la implementación de los cuidados en el manejo postoperatorio. El seguimiento de los colgajos quirúrgicos, clínico o por dispositivo, fue el único cuidado abordado en todas las publicaciones seleccionadas, considerado fundamental en el postoperatorio, independientemente de la etapa(AU)

A new treatment of concealed penis: symmetrical pterygoid flap surgery

ABSTRACT Purpose: Considerable controversy exists regarding the surgery for concealed penis. We describe a new technique for repairing concealed penis by symmetrical pterygoid flap surgery. Methods: From January 2016 to July 2022, we evaluated 181 cases of concealed penis that were surgically treated using the symmetrical pterygoid flap surgery. We measured the penile size preoperative and 2, 4, 12 weeks, and 1 year postoperative to confirm the improvement. A questionnaire was administered to the patients and parents to assess satisfaction regarding penile size, morphology, and hygiene. Result: The perpendicular penile length was1.59±0.32cm preoperative and 3.82±1.02 cm after the procedure (p < 0.05), and 4.21±1.91cm after one year of postoperative (p < 0.05). The overall satisfaction of patients was 97.89%, while the overall satisfaction of older children patients (age>7) was 75.24%. Parents focus more on the penile exposure size, while patients focus more on the penile morphology. Almost every patient had postoperative penile foreskin edema. However, this symptom had spontaneously resolved by 4-6 weeks. The complications such as skin necrosis, tissue contracture, or wound infection were 4.42%. Conclusion: The symmetrical pterygoid flap surgery is an effective surgical technique for the management of concealed penis in children producing predictable results and excellent satisfaction of the parents and patients.

Retalho fasciocutâneo medial da coxa em V-Y bilateral na reconstrução perineal por hidradenite supurativa: Relato de caso / Bilateral V-Y medial fasciocutaneous thigh flap in perineal reconstruction for hidradenitis suppurativa: Case report

Introdução: A hidradenite supurativa (HS) é uma doença inflamatória crônica que afeta preferencialmente a pele intertriginosa e está associada a numerosas comorbidades sistêmicas. A área perineal é a segunda área mais comumente afetada depois da axila. A excisão ampla é o tratamento que tem maior probabilidade de atingir melhores resultados com menor risco de recorrência. Com a excisão cirúrgica extensa, o fechamento com retalho oferece maior probabilidade de tratamento definitivo. Alguns retalhos são descritos para reconstruir defeitos da região perineal após câncer, porém poucos deles são estudados no tratamento da HS. Relato de Caso: Mulher de 43 anos, com HS perineal, submetida a ressecção das lesões e reconstrução com retalho fasciocutâneo medial da coxa em V-Y bilateral como tratamento da doença. O retalho permitiu o fechamento completo do períneo total sem complicações graves. Conclusão: Este caso mostra que é útil e prático utilizar o retalho fasciocutâneo medial da coxa em V-Y para reconstrução perineal após ressecções amplas de pele, glândulas apócrinas e folículos pilosos no tratamento da HS, oferecendo boa cobertura de pele, e tecido celular subcutâneo com suprimento vascular confiável, que evita sequelas associadas a sacrifício de músculos e alcança dimensões maiores do que outros retalhos, podendo ser considerado em casos selecionados como uma alternativa no tratamento cirúrgico da HS perineal.

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory disease that preferentially affects the intertriginous skin and is associated with numerous systemic comorbidities. The perineal area is the second most commonly affected area after the armpit. Wide excision is the treatment most likely to achieve better results with a lower risk of recurrence. With extensive surgical excision, flap closure offers a greater likelihood of definitive treatment. Some flaps have been described to reconstruct defects in the perineal region after cancer, but few have been studied in treating HS. Case Report: A 43-year-old woman with perineal HS underwent resection of the lesions and reconstruction with a bilateral V-Y medial thigh fasciocutaneous flap to treat the disease. The flap allowed complete closure of the total perineum without serious complications. Conclusion: This case shows that it is useful and practical to use the V-Y medial thigh fasciocutaneous flap for perineal reconstruction after wide resections of skin, apocrine glands, and hair follicles in the treatment of HS, offering good skin coverage and subcutaneous cellular tissue with supply reliable vascular flap, which avoids sequelae associated with muscle sacrifice and reaches larger dimensions than other flaps, and can be considered in selected cases as an alternative in the surgical treatment of perineal HS.

Neurofibromatosis in the gluteus and posterior region of the thigh: case report / Neurofibromatose em glúteo e região posterior da coxa: relato de caso

Introduction: Neurofibromatosis is an autosomal dominant disorder, and type 1 is associated with an increased risk of tumor formation with neurocutaneous involvement. The variable evolution, often with limiting tumors, in addition to the significant incidence of cases requiring treatment, makes it fundamental to discuss procedures already performed in medical practice for early, careful, and individualized recognition of the diagnosis and treatment of the patient. The report aims to present a surgical case of neurofibromatosis, calling attention to the surgical technique, the characteristics of the disease, and the importance of the procedure in the quality of life of patients limited by the condition. Case Report: A 23-year-old male patient with a large mass neurofibroma in the gluteus and posterior surface of the right leg, in addition to café au lait stains in the distal third of the legs. He was treated with surgery to remove the tumor and a flap and graft in the affected region. The procedures were performed by a multidisciplinary team, allowing the total removal of the tumor mass, with subsequent skin grafting in the hip and thigh lesion on the right side and the fasciocutaneous flap in VY in the area. There were no significant complications in the immediate postoperative period. Conclusion: Neurofibromas can become limiting and impair patients' quality of life with neurofibromatosis type 1; therefore, early management and diagnosis are essential. Although the condition does not present a cure, there is a need for research into less invasive and preventive treatments for injuries.

Introdução: A neurofibromatose é um distúrbio autossômico dominante e o tipo 1 está associado a um aumento do risco de formação de tumores com acometimento neurocutâneo. A evolução variável, muitas vezes com tumorações limitantes, além da incidência significativa de casos que necessitam de tratamento, torna fundamental a discussão de condutas já realizadas na prática médica para um reconhecimento precoce, cuidadoso e individualizado do diagnóstico e do tratamento do enfermo. O relato objetiva apresentar um caso cirúrgico de neurofibromatose, chamando atenção para a técnica cirúrgica, as características da doença e a importância do procedimento na qualidade de vida de pacientes limitados pela afecção. Relato de Caso: Paciente de 23 anos, sexo masculino, com neurofibroma de grande massa em glúteo e face posterior da perna direita, além de manchas café com leite em terço distal de pernas. Foi tratado com uma cirurgia de retirada do tumor, além de retalho e enxerto na região acometida. Os procedimentos foram realizados por equipe multidisciplinar, possibilitando a retirada total da massa tumoral, com posterior realização de enxerto de pele na lesão do quadril e coxa em lado direito, e o retalho fasciocutâneo em V-Y na área. Não houve complicações significativas nos pós-operatórios imediatos.

Reparación quirúrgica por vía vaginal de fístulas vesicovaginales: una experiencia exitosa / Vaginal surgical repair of vesico-vaginal fistulas: a successful experience

OBJETIVO: Se presenta una serie de casos de reparación por vía vaginal de fístula vesicovaginal (FVV) de nuestro centro. MATERIAL Y MÉTODOS: Estudio observacional descriptivo. Se evaluaron todas las pacientes con reparación quirúrgica de FVV en el Centro de Innovación de Piso Pélvico del Hospital Sótero del Río entre 2016 y 2022. RESULTADOS: Se reportaron 16 casos, de los cuales el 81,3% fueron secundarios a cirugía ginecológica. En todos se realizó la reparación por vía vaginal, con cierre por planos. En el 94% (15/16) se logró una reparación exitosa en un primer intento. El tiempo de seguimiento poscirugía fue de 10 meses (rango: 3-29). No hubo casos de recidiva en el seguimiento. Una paciente presentó fístula de novo, la cual se reparó de manera exitosa en un segundo intento por vía vaginal. Se reportaron satisfechas con la cirugía 15 pacientes, con mejoría significativa de su calidad de vida. Una paciente reportó sentirse igual (6,3%), pero sus síntomas se debían a síndrome de vejiga hiperactiva que la paciente no lograba diferenciar de los síntomas previos a la cirugía. CONCLUSIÓN: Las FVV en los países desarrollados son secundarias a cirugía ginecológica benigna. La cirugía por vía vaginal en nuestra serie demostró una alta tasa de éxito, con mejora significativa en la calidad de vida de las pacientes.

OBJETIVE: We present a case series of vesico-vaginal fistulas (VVF) vaginal repair in our center. MATERIAL AND METHODS: Descriptive observational study. All patients with surgical repair of VVF at the Centro de Innovación en Piso Pélvico of Hospital Sótero del Río were evaluated between September 2016 and September 2022. RESULTS: 16 cases were reported. 81.3% were secondary to gynecological surgery. In all cases, a vaginal repair was performed, with a layered closure. 94% (15/16) had no contrast extravasation at the time of examination, confirming fistula closure. The follow-up time was 10 months (range: 3-29). There were no cases of recurrence during follow-up. 1 patient presented de novo fistula which was successfully repaired in a second attempt vaginally. 15/16 patients reported being satisfied with the surgery, with significant improvement in quality of life. 1 patient reported feeling the same (6.3%), but her symptoms were due to overactive bladder syndrome that the patient could not differentiate from the symptoms prior to surgery. CONCLUSION: VFV in developed countries are mainly secondary to benign gynecological surgery. Vaginal surgery in our series achieved a significant improvement in the quality of life of patients.

Cutaneous traction as a complement to the parascapular flap in major cancer loss: case report / Tração cutânea como complemento ao retalho paraescapular em grande perda oncológica: relato de caso

Introduction: Squamous cell carcinoma (SCC) is a malignant epidermal keratinocyte tumor closely related to sun exposure. When diagnosed, through biopsy, its staging, tumor resection with oncological safety margins must be performed, and lymph node dissection and treatment of metastases, if present, may be performed. Case Report: Skin traction is reported as a complement to the parascapular flap, used reconstructively after the excision of a large SCC in the left shoulder. Conclusion: The technique used proved effective for the satisfactory correction of large dehiscence in the postoperative period of the parascapular flap, promoting partial closure of the defect, reduced time to perform, and correction of the residual defect in a single step.

Introdução: O carcinoma espinocelular (CEC) é um tumor maligno dos queratinócitos epidérmicos e está intimamente relacionado à exposição solar. Quando diagnosticado, por meio de biópsia, deve ser realizado seu estadiamento, ressecção tumoral com margens de segurança oncológica, podendo ser feito esvaziamento ganglionar e tratamento de metástases, caso presentes. Relato de Caso: Reporta-se a utilização da tração cutânea como complemento ao retalho paraescapular, utilizado reconstrutivamente pós excisão de CEC de grande dimensão em ombro esquerdo. Conclusão: A técnica utilizada mostrou-se eficaz para correção satisfatória de grandes deiscências em pós-operatório de retalho paraescapular, promovendo fechamento parcial do defeito, tempo reduzido para realização e correção do defeito residual em tempo único.

Standardization of reconstructions with flaps after Fournier's gangrene / Padronização das reconstruções com retalhos após gangrena de Fournier

Introduction: Fournier's gangrene is characterized by tissue necrosis, which requires treatment employing debridement and antibiotics with wounds of varying sizes. The objective is to standardize the surgical techniques of reconstructions with flaps used to treat wounds after Fournier's gangrene. Method: A study was conducted by searching the PubMed/Medline, SciELO, and LILACS databases. Results: In wounds with skin loss of 25% to 50%, a local advancement cutaneous flap or a pudendal flap from the thigh was used; in wounds, greater than 50%, a superomedial thigh flap or myocutaneous flap from the gracilis muscle was used, with the aim of to enable proper reconstruction. Conclusion: Advancement and pudendal thigh flaps were used for wounds with up to 50% loss of scrotal skin substance, while the myocutaneous gracilis flap and supero-medial flap of the thigh were indicated for wounds with more than 50% of the total scrotal surface affected, after Fournier gangrene.

Introdução: Gangrena de Fournier é caracterizada por necrose tecidual, que necessita de tratamento por meio de desbridamento e antibióticos, com feridas de dimensões variadas. O objetivo é padronizar as técnicas cirúrgicas de reconstruções com retalhos utilizadas no tratamento das feridas após gangrena de Fournier. Método: Realizou-se estudo por meio da busca nas bases de dados PubMed/Medline, SciELO e LILACS. Resultados: Nas feridas com perdas cutâneas de 25% a 50%, foram utilizados retalho cutâneo local de avanço ou retalho pudendo da coxa, nas maiores de 50% foram necessárias as confecções do retalho superomedial da coxa ou retalho miocutâneo do músculo grácil, com intuito de possibilitar a reconstrução adequada. Conclusão: Os retalhos de avanço e pudendo da coxa foram utilizados para feridas com perda de substância cutânea escrotal de até 50%, enquanto os retalhos miocutâneo de músculo grácil e superomedial da coxa foram indicados para as feridas com mais de 50% da superfície escrotal total acometida, após gangrena de Fournier.

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

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

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