El proceso reconstructivo en cirugía de cabeza y cuello / The corrective process in head and neck surgery

El cirujano de cabeza y cuello enfrenta tres desafíos: la resección con mérgenes oncológicos del tumor primario, el tratamiento de las áreas ganglionares y la conducta con el hueso mandibular cuando está invadido o dificulta el abordaje. Las secuelas anatómicas, funcionales y estéticas producto de esta cirugía, son directamente proporcionales a la extensión de la misma. Es así que la etapa reconstructiva adquiere, en ocasiones, una importncia equivalente a la resección misma del tumor. Solamente las resecciones menores pueden solucionarse con sutura primaria, injertos de piel parcial o total o aún con cicatrización por segunda. Para pérdidas de sustancia mayores se debe recurrir a los colgajos; tejidos de constitución variada y adecuadamente irrigados, que se movilizan hacia la zona de exéresis para proveer de cobertura mucosa, muscular, cutánea y ósea, según las necesidades del caso. Para reparar resecciones intermedias el cirujano cuenta con una variada gama de colgajos locales que se adecuan a los distintos sectores de la cabeza y el cuello. La reparación de las cirugías extensas fue evolucionando merced a la aparición de colgajos que fueron marcando épocas de predominio a lo largo de los años. Los colgajos facio-cutáneos como el de Mc.Gregor y el de Bakamjian dominaron la escena reconstructiva durante casi veinte años. Luego, los colgajos miocutáneos pediculados como el de pectoral mayor de Ariyan o el de trapecio lateral de Demergasso fueron rápidamente adoptados por su mayor viabilidad y alcance y la posibilidad de transportar un sector óseo...

The head and neck surgeon faces theree challenges: oncologic resection margins of the primary tumor, the treatment of the nodal areas and the management of the jaw, when it is either invaled or hinders the surgical approach. The anatomica, functional and aesthetic sequelae are in direct proportion to the extention of the procedure, Thus, the reconstuctive stage acquieres, on occasions, an importance equivalent to the resection of the tumor itself. Only minor resections can be solved with primary suture, partial or total skin grafting or even secondary healing. For greater areas, tissure flaps must be used in order to provide well irrigated coverge of mucosa, muscle etc. according to the needs of the specific case...

An evaluation of the effectiveness and predictability of transpositional flap vs connective tissue graft for coverage of Miller's class-I and class-II facial marginal tissue recession lesions: A clinical study.

Background: There has been no study to date comparing the effectiveness and predictability of transpositional flap (TF) with that of the gold standard connective tissue graft (CTG) for root coverage. This study was performed during 2001-2002 at Government Dental College and Hospital, Mumbai India. Objectives: To evaluate the effectiveness and predictability of TF vs CTG for coverage of Miller's class I and class II facial marginal tissue recession defects. Materials and Methods: Twenty cases fulfilling the selection criteria were identified and randomly allotted to two groups: group I (TF, 10 cases) and group II (CTG, 10 cases). Registered parameters included plaque index (PI), defect-specific plaque index (DPI), gingival index (GI), defect-specific gingival index (DGI), recession depth (RD), recession width (RW), probing depth (PD), attachment level (AL), width of keratinized tissue (KT), percentage defect coverage (DC), and percentage root coverage (RC). Results: For group I: preoperative PI, DPI, GI, DGI, RD, PD, KT, and RC were 0.38±0.14, 1.1±0.57, 0.02±0.02, 0.36±0.29, 4.45±2.0, 1.5±0.71, 1.45±1.30, and 68.57±14.36, respectively; the corresponding postoperative values were 0.38±0.11, 0.36±0.29, 0.01±0.01, 0.10±0.16, 3.2±2.44, 1.1±0.32, 2.65±1.03, and 77.40±17.23. For group II the preoperative PI, DPI, GI, DGI, RD, PD, KT, and RC were 0.77±0.5, 1.53±0.63, 0.12±0.18, 0.59±0.62, 4.95±1.59, 1.9±0.74, 0.50±1.08, and 65.05±11.22, respectively, and the corresponding postoperative values were 0.49±0.32, 0.8±0.50, 0.03±0.53, 0.03±0.10, 0.90±0.88, 1.2±0.42, 4.4±1.07, and 93.65±6.18, respectively. Conclusion: The TF technique for coverage of single tooth buccal recession defects of Miller's class I and class II types in mandibular anterior teeth was neither effective nor predictable in defect coverage and defect elimination.

Comparative study between two different flap designs on peri-implant interproxirnal crestal bone loss around a single implant in the pre-loading stage

Today, one of the most challenging aspects of esthetic implant modalities is to obtain a predictable pen-implant papilla in the esthetic zone starting with the facts about the morphology of periimplant tissues, to various parameters influencing papilla reconstruction around implants. This prospective study investigates the interproximal alveolar crestal bone loss occurring after placement of mandibular single posterior implant using two different flap designs. Ten patients were included in this study [6 females and 4 males] with missing posterior mandibular teeth, their age ranged between twenty to forty years. The designed flap was performed with a conventional wide type flap on the distal side of the implant and records obtained from this side were referred to as group I, while the mesial side of the same implant was performed with a limited or a papillary preserved flap and records obtained from this side were referred to as group II. Each patient was evaluated clinically and radiographically at immediate, 1.5, 3 and 6 months post-operatively. There was high rate of crestal bone loss in group one with widely mobilized flap compared with that in group two of limited flap design through out the follow up periods. The use of a limited flap design [papillary preserved flap] for single-tooth implants is indicated to avoid possible loss of interdental papillae and to minimize interproximal crestal bone loss with subsequent implant exposure. During application of the conventional flap, it is better to insert the implant 1mm beneath the cortex by about to compensate the amount of bone loss during healing stage

Outcomes of breast reconstruction with pedicled transverse rectus abdominis myocutaneous [TRAM] flap at cancer institute: a retrospective study of 10 years of experience

Reconstruction of breast with transverse rectus abdominis myocutaneous [TRAM] flap is the standard for reconstruction of breast following mastectomy. In this article, authors report their experience with pedicled TRAM flap reconstruction of the breast. Records for the patients who had undergone breast reconstruction with pedicled TRAM flap were retrieved. Records of outpatient followups were also obtained. Patient satisfaction with the outcome of surgery was assessed using a detailed questionnaire including a linear visual analogue scale ranging from zero [not satisfied] to ten [most satisfied]. There were 61 reconstructions in 59 patients. In 42 [71.2%] cases a synthetic mesh and in 14 [23.7%] cases dermal graft was used for closure of the abdominal fascial defect. The mean hospital stay was 10.67 [1 - 72] days. Patients were followed up for a mean period of 621 days. The overall rates of complications were as follows: partial flap necrosis: 11 [18.6%], flap hematoma: 2 [3.4%], flap seroma: 7 [11.9%], flap wound infection: 7 [11.9%], abdominal wound hematoma: 9 [15.3%], abdominal wound seroma: 5 [8.5%], abdominal wound ischemia: 1 [1.7%], abdominal wound incisional hernia: 6 [10.2%], deep vein thrombosis: 1 [1.7%], complication requiring rehospitalization: 9 [15.3%], complication requiring reoperation: 8 [13.6%]. There were no abdominal wound infection, no umbilical necrosis, and no pulmonary embolism. Aesthetic results were classified as excellent [62%], good [28%], fair [10%]. The mean satisfaction score was 9.5 [range 6-10]. Breast reconstruction with pedicled transverse rectus abdominis myocutaneous flap was associated with a low complication rate and a high level of patient satisfaction in our center

Reconstrução nasal com retalho frontal: nossa experiência / Nasal reconstruction with forehead flap: our experience

Introdução: o pai da reconstrução nasal foi Sushuta Samhita que criou a técnica do retalho frontal (retalho indiano) para reparação do nariz amputado como punição ao crime de adultério. (Índia,1000-2000a.C). Objetivos: o estudo visa uma auto-avaliação da técnica de reconstrução nasal com retalho frontal e análise dos resultados obtidos em nosso serviço. Métodos: foi realizado um estudo retrospectivo de nove casos de reconstrução nasal com retalho frontal realizados no Núcleo de Cirurgia Plásticado HUda Universidade Federal de Santa Catarina de Setembro de 2002 a Dezembro de 2006. Resultados: das nove reconstruções nasais com retalho frontal, uma evoluiu com necrose distal do retalho, uma com necrose total e os sete demais com boa evolução. Atualmente os nove pacientes já foram submetidos ao segundo tempo cirúrgico com secção do pedículo e transposição da região proximal do mesmo para região frontal. Discussão: as indicações de reconstrução nasal parciais dacorrem de múltiplas causas, dentre elas, principalmente após ressecção de tumores e após traumas. Normalmente as reconstruções são realizadas em mais de uma etapa até o refinamento e melhor resultado final. No estudo, dos nove casos, oito foram após tratamento de tumores nasais e um após trauma. Em dois casos fez-se necessário o uso do retalho nasogeniano para reconstituição do forro nasal, e, em um caso foi necessário o uso de enxerto de cartilagem conchal para molde do nariz. Foram utilizados pelo menos dois tempos cirúrgicos para reconstrução nasal. Conclusão: a reconstrução nasal visa o restabelecimento de sua unidade estética o mais próximo do natural. Isto posto, em virtude de sua cor e textura, a pele da região frontal consiste na melhor área doadora para retalhos utilizados na reconstrução nasal.

Background: the father of the nasal reconstruction was Sushuta Samhita who created the technique of the forehead flap for mending of nose amputated as a punish mentto the crime ofadultery.(Índia1000-2000b.C) Objectives: the study aims at an auto - evaluation of the technique of the nasal reconstruction with the forehead flap and also an analysis of the results obtained in our service. Methods: It was carried out a retrospective study of nine cases of nasal reconstruction with the forehead flap, which has been made in the Nucleus of Plastic Surgery of the HU of the Federal University of Santa Catarina. Results: one of the nine nasal reconstruction with forehead flap evolved with distal necrosis of the flap, one with total necrosis and the other seven had good evolve. At present, the nine patients have already been in the surgical second stage with the section of the pedicle. Discussion: the partial indications of nasal reconstruction result from multiple causes, among them, mainly after resection of tumors and after traumas. Usually the reconstruction is carried out in more than one stage up to the refinement and better final result. In the study, eight cases were made after a treatment of nasal tumours and one case after a trauma. In two cases it was necessary to use the nasolabial flap to reconstruction of the inner of the nose. One case was necessary to use a cartilage conchal graft to shape the nose. At least, two surgical stages were used to reconstruction nasal. Conclusion: among the possibilities of nasal reconstruction the one which was carried out with the forehead flap is the most suitable because of managing to restore the unity of aesthetic nasal near the natural appearance.

Tratamento cirúrgico reconstrutivo de cancêr de mama bilateral: relato de caso e revisão bibliográfica / Therapeutic surgery in bilateral breast cancer case report and bibliography

Introdução: O câncer de mama é um dos tipos mais comuns de câncer na mulher, sendo a mastectomia radical uma das terapias utilizadas. Objetivo: é relatar um caso em que, na presença de neoplasia mamária metacrônica. Método: Por ter apresentado particularidades, optou-se pela reconstrução autóloga da mama nos dois momentos de apresentação desta neoplasia. Discusão: A reconstrução autóloga da mama, por recriar uma mama natural e simétrica, é uma opção que ajuda na recuperação da auto-estima e no sentimento de bem estar. Em casos onde se faz necessário uma segunda mastectomia, o uso de retalhos diferentes do retalho TRAM se faz necessário, sendo fundamental o domínio de outras técnicas. São discutidas as opções de reconstrução mamária apresentadas neste caso. Conclusão: A aplicação de retalhos miocutâneos na reconstrução de mama , em câncer metacrônico, com bom favoráveis.

Background: The breast cancer is one of the most common type of cancer in women, and among therapeutic possibilities, radical mastectomy is an option commonly used. Objective: we report a case in which the presence of metachronous breast cancer. Methods: Representing these particularities. Discussion: Autologous breast reconstruction, for recreating a natural and symmetrical mamma, is an option that helps in the recovery of the self-esteem and in the feeling of well being. In cases where is necessary a second mastectomy, the use of different flaps from TRAM flap is ade necessary, being fundamental the knowledge ofo thertechniques.wereport a case in which the presence of metachronous breast cancer was opted for the autologous reconstruction in the two moments of the presentation of this neoplasia. The options of mammary reconstruction are discussed in this case. Conclusion: The miocutaneous flap use in breast reconstruction, in a metachronous breast cancer case, with good results.

A modified double pedicle graft technique and other mucogingival interceptive surgeries for the management of impacted teeth: a case series.

Maxillary canine is one of the most common teeth that are impacted. This accounts for 1-2% of all patients who attend orthodontic treatment. The key to achieve maximal eruption of these teeth is their surgical exposure and the role of periodontist in such situations is to provide a functional and satisfactory width of attached gingiva on the labial surface. There are different techniques to surgically expose the impacted teeth, namely--gingivectomy technique, apically positioned flap, closed eruption technique, modified apically positioned flap, double pedicle flap and free gingival graft. Selection of the procedure is dependent on the positioning of the tooth in relation to mucogingival junction and attached gingiva. In the present case series we describe three different techniques for uncovering of impacted teeth, which are apically positioned flap, closed eruption technique and a modified double pedicle graft specially planned for the situation. These procedures when selected diligently using sound selection criteria will create adequate width of attached gingiva which minimizes or eliminates the future mucogingival problems.

Aporte del US Doppler color de alta resolución en la evaluación pre y postoperatoria en cirugía de colgajos / Role of the high resolution color Doppler ultrasound in the pre and postoperative evaluation in tissue trans-plantation surgery

Se efectúa descripción de las técnicas de cirugías de colgajos, de las implicancias de la circulación cutánea en el éxito de estas cirugías y aporte del ultrasonido Doppler color de alta resolución como método de estudio vascular no invasivo, en la evaluación pre y postoperatoria.

Rhomboid flap versus fasciocutaneous V-Y advancement flap in treatment of pilonidal sinus

Pilonidal sinus of the natal cleft is one of the common surgical problems and represents a challenge to many surgeons, because the high incidence of recurrence and long postoperative morbidity course. Although many methods of surgical and non surgical approaches have been proposed to overcome these problems, an optimal treatment modality has not been achieved yet. Evaluation of two different types of surgical procedures for surgical treatment of Sacrococcygeal pilonidal sinus; Rhomboid flap technique and V-Y advancement flap technique, comparing the results of each one separately. 30 patients with chronic pilonidal sinus disease were admitted to surgical department in Ain Shams University hospital during the period from December 2002 to August 2003. The patients were divided into two groups. Group [A]. 15 patients, 13 of them were classic cases while 2 cases were recurrent cases. This group was treated by excision of the sinus and closure the wound by Rhomboid flap technique. Group [B] 15 patients, 12 of them were classic cases while 3 cases were recurrent cases. This group was treated by excision of the sinus, and closure the wound by V-Y advancement flap technique. In group [A], mean hospital stay was 5 days, mean healing time was 15 days, and only 2 cases developed wound infection, while in group [B], mean hospital stay was 7 days, mean healing time was 17 days, and only one case of wound infection. No recurrence detected in both groups during the whole period of follow up [12 months]. Treatment of chronic pilonidal sinus of the natal cleft can be efficient using one of the both techniques mentioned above, as both techniques having the same principles [flattening of the natal cleft and keeping the scar away from the midline]. We advise the use of one of both techniques for the treatment of chronic pilonidal sinus disease, specially the V-Y flap advancement for treatment of recurrent complex cases allowing removal of all pathological tissues, and rhomboid flap for simple classic cases

Retalho galeal baseado nos vasos temporais superficiais para reconstrução dos defeitos da cavidade oral, orofaringe e hipofaringe: estudo anatômico em cadáver / Galeal flap based on superficial temporal vessels for oral cavity, oropharynx and hypopharynx reconstruction: a cadaveric anatomic study

O trabalho tem por objetivo estudar a viabilidade anatômica do retalho constituído pela gálea da região têmporo-parietal que, baseado nos vasos temporais superficiais, seria utilizado para reconstrução dos defeitos pós-excisionais da cavidade oral, orofaringe e hipofaringe. Foram realizadas 40 dissecções em cadáveres nas quais, após infusão de resina nos vasos temporais superficiais, confeccionou-se um retalho galeal pediculado nestes vasos e testou-se a possibilidade deste retalho reconstruir diversos sítios da cavidade oral e faringe. O retalho apresentou bom alcance e cobertura para a maioria das regiões analisadas, além de características favoráveis para as reconstruções propostas.The aim of this paper is to study the anatomic viability of a flap that, based on superficial temporal vessels and constituted by the galea of temporoparietal region, would be used for oral cavity, oropharynx, and hypopharynx reconstruction after tumor ablation. Forty cadaveric dissections were performed with latex injection into the superficial temporal vessels. A galeal flap was harvested pedicled on these vessels and simulations of oral cavity and pharynx reconstruction were realized. The flap showed success to reach and cover the majority of analyzed sites as well as favorable characteristics for the proposed reconstructions...

Colgajos musculares y musculocutáneos: conceptos generales / Muscle and musculocutaneous flaps. General concepts

El concepto de colgajo implica el transporte de tejido(s) desde un área dadora hasta un área receptora, manteniendo conexión vascular con el sitio de origen. Excepción es el colgajo libre, en el cual el nexo vascular es interrumpido, pero luego restituido con microcirugía en el área receptora. Los colgajos musculares corresponden a colgajos simples, ya que aportan un solo tipo de tejido (musculo). Cuando son empleados para cubrir a una herida, generalmente deben asociarse a un injerto de piel. Los colgajos musculocutáneos corresponden a colgajos compuestos, ya que aportan más de un tipo de tejido (musculo y piel). La piel recibe irrigación a través de vasos perforantes musculocutáneos. Se discuten algunos aspectos en relación a sus indicaciones, clasificación y complicaciones de estos colgajos.

Reconstrucao mamaria pos-mastectomia com tecido autogeno: avaliacao comparativa de resultados e complicacoes / Breast reconstruction with autologous tissue results and complications

A reconstrucao mamaria por mastectomia com tecido autogeno e advogada por uma serie de autores oferecendo melhores resultados a longo prazo quando comparados aos materiais aloplasticos. Entre as opcoes, o retalho transverso do musculo reto abdominal (TRAM pediculado e microcirurgico) apresenta...

Manejo quirúrgico de fístula oroantral / Surgical management of oroantral fistula

Las fístula oroantral es generalmente complicación de la cirugía bucal. Ocurre principalmente en procedimientos de exodoncia del segundo molar. Las fístulas pequeñas, de 5 mn o menos tienden a cerrarse espontáneamente en las primeras 2 semanas. Las mayores, muchas veces requieren de tratamiento quirúrgico. Una vez transcurridas 2 semanas sin evolución favorable, se plantea el cierre quirúrgico, despúes de descartar la presencia de una neoplasia originada en el seno o hueso maxilar. Existen varias alternativas para ello, que incluyen los colgajos locales, a distancia e injertos. En este artículo se presentan las alternativas publicadas en la literatura y sus principales resultados

Rectangular flaps technique for treatment of congenital hand syndactyly

A sindactilia e uma das mais frequentes deformidades congenitas da mao. Neste estudo, sao analisados 22 pacientes submetiods a correcao de sindactilias congenitas da mao, utilizando-se a tecnica dos retalhos retangulares. Resultados considerados esteticamente e funcionalmente bons foram obtidos em 77,3 por cento dos casos, e complicacoes ocorreram em 13,6 por cento. A tecnica mostrou ser de simples execucao, e com resultados favoraveis podendo ser aplicada na maioria dos casos de sindactilias da mao

Reconstrucción con colgajos microquirúrgicos en cirugía de cabeza y cuello: experiencia inicial multicéntrica / Microvascular free flaps to repair head and neck lesions: initial experience

Objetivo y población: Entre septiembre de 1991 y julio de 1996 se practicaron 37 colgajos libres en 35 pacientes para reparar defectos en el área de Cabeza y Cuello. La mayor parte de las lesiones que dieron lugar a la cirugía eran carcinomas espinocelulares es estadío avanzado o recidivados, siendo la piel el sitio de origen más común. Método: En 86 por ciento de los casos se practicó resección y reconstrucción inmediata. El colgajo más frecuentemente usado fue el radial, en 17 oportunidades. Resultados: Se observaron complicaciones del colgajo en un 30 por ciento de los mismos y de la zona dadora en un 19 por ciento. La necrosis irreversible del colgajo ocurrió en 5 casos (13,5 por ciento). La mortalidad perioperatoria fue de 5,4 por ciento. No se demostró influencia directa de la edad avanzada o la radioterapia en relación a complicaciones microquirúrgicas. Conclusiones: En la población estudiada, y a pesar de los resultados mejorables, la reconstrucción microquirúrgica resultó un método confiable para defectos complejos en Cabeza y Cuello

Colgajo de Tranquilli Leali en la reconstrucción del pulpejo digital / Tranquilli Leali flap for reconstruction of the tip of fingers

Se realizó un estudio retrospectivo de 45 pacientes con amputación del extremo distal del dedo que fueron tratados quirúrgicamente con colgajo deslizado triangular en el Hospital ABC de 1971 a 1992. Se valoraron los resultados en cuanto a función, parestesias, hipoestesias, dolor, 2 puntos discriminativos, retorno a la actividad laboral y cosmesis

Colgajos libres en la reconstrucción de cabeza y cuello / Free flaps in head and neck reconstruction

Los colgajos libres en la reconstrucdon de cabeza y cuello han sido utilizados tradicionalmente para la reconstruccion de defectos ocasionados por amplias resecciones de carcinomas localizados. Sin embargo, las tecnicas de trasplante libre de tejidos han tenido un impacto dramático en la reconstrucción de cabeza y cuello. Se presenta la experiencia de 13 colgajos libres para este tipo de reconstruccion en pacientes con diferentes patologias, como quemaduras, trauma, complicaciones de cirugia craneofacial, heridas por arma de fuego, asimetria facial, etc. La documentacion fotográfica de 4 casos ilustra la tecnica quirurgica de algunos de estos colgajos

Cirugía plástica, reconstructiva y estética: una visión global para el médico general / Plastic, reconstructive and esthetical surgery: a global view by general psysicians

Existe poco material que oriente lo que debe conocer un médico general respecto a esta especialidad.Quizás el sólo nombre de Cirugía Plástica, conlleva una connotación estética o de ultraespecialidad. El propósito del presente trabajo es dar una visión global de lo que es la Cirugía Plástica y algunos conceptos generales que creemos que debe adquirir el médico general en su formación

Aspectos anatomo-quirúrgicos de la irrigación muscular / Aspect anatomical surgical of the muscle irrigation

En los últimos tiempos las modernas técnicas de cirugía plásticas y recostructivas han utilizado colgajos musculares y músculos cutáneos para reparar las perdidas de las sustancias superficiales de origen traumático o quirúrgico. El presente trabajo tiene por objeto estudiar las características anatómicas de la irrigación de los músculos glúteos maximus, tensor de la fasciae latae, rectus femoris y vastus laterales. Presentamos las conclusiones correspondientes a 56 miembros inferiores que corresponden a igual número de músculos estudiados. Se clasifican los músculos según su tipo de irrigación y se establece la correlación anatomo quirúrgica con las ventajas y desventajas para la utilización de los musculares y sus áreas de aplicación