Alternativas quirúrgicas en hernias y eventraciones diafragmáticas crónicas / Surgical alternatives for chronic diaphragmatic hernias and eventrations

Introducción: las eventraciones y las hernias diafragmáticas crónicas son dos afecciones que en ocasiones se confunden; tienen una frecuencia relativamente baja y su estrategia quirúrgica varía. Objetivo: mostrar la experiencia del Hospital Universitario Clínico Quirúrgico Comandante Manuel Fajardo en la atención de enfermos con hernias y eventraciones diafragmáticas. Métodos: se presentan 11 pacientes atendidos desde 1998 hasta 2015 por afecciones del diafragma como eventraciones y hernias diafragmáticas crónicas. Del total, 7 fueron operadas con anillos de hasta 10 cm y dos con más de 10 cm. Resultados: se operaron 9 pacientes con hernias diafragmáticas y 2 con eventraciones. Ocho hernias fueron del lado izquierdo y una derecha. En 8 de las hernias el contenido era multivisceral. La hernia derecha tenía un anillo de más de 10 cm y con el hígado en su contenido. Cinco fueron reparadas mediante superposición de colgajos y en cuatro se necesitó una malla protésica. Las eventraciones se presentaron en dos mujeres, ambas parciales, una derecha y otra izquierda, tratadas con plicatura del hemidiafragma en dos planos. Conclusiones: las hernias y las eventraciones diafragmáticas son entidades parecidas con particularidades y terapéutica diferentes. En las eventraciones, la plicatura del diafragma es la técnica de elección, por vía abierta o de preferencia por toracoscopia. En las hernias diafragmáticas, la reparación depende del tamaño del anillo, hasta 10 cm se prefiere la reparación con superposición de colgajos y en defectos mayores el uso de mallas protésicas, preferentemente por una toracotomía(AU)

Introduction: Chronic diaphragmatic hernias and eventrations are two conditions sometimes mistaken for each other. They have a relatively low frequency and their surgical strategy varies. Objective: To show the experience at Comandante Manuel Fajardo Clinical Surgical University Hospital in the caring for patients with diaphragmatic eventrations and hernias. Methods: 11 patients attended from 1998 to 2015 were presented for diaphragmatic conditions, such as hernias and chronic diaphragmatic eventrations. Of the total, 7 were operated with rings of up to 10 cm. Two were operated for rings of more than 10 cm. Results: 9 patients with diaphragmatic hernias and 2 with incisional hernias were operated. Eight hernias were on the left side. One hernia was on the right side. In 8 of the hernias, the content was multivisceral. The right hernia had a ring of more than 10 cm, and had the liver in its content. Five hernias were repaired by flaps. Four hernias required a prosthetic mesh. The eventrations were presented in two women, both partial: one was on the right and the other was on the left, and both were treated with plication of the hemidiaphragm in two planes. Conclusions: Diaphragmatic hernias and eventrations are similar entities with different characteristics and therapeutics. In eventrations, the plication of the diaphragm is the technique of choice, either openly or preferably by thoracoscopy. In diaphragmatic hernias, repair depends on the size of the ring, up to 10 cm, flap repair is preferred, and in larger defects, it is the use of prosthetic meshes, preferably by thoracotomy(AU)

Reconstrucción de la pared abdominal con colgajo miocutáneo transverso de recto abdominal / Abdominal wall reconstruction with transverse rectus abdominis myocutaneous flap

Los defectos de pared abdominal son un desafío para los cirujanos plásticos. El sarcoma de partes blandas es muy recidivante y hay que hacer amplias exéresis con margen oncológico y como consecuencia quedan amplias zonas por reconstruir. El colgajo transverso de recto abdominal es una opción reconstructiva de esta región con buenos resultados estéticos y funcionales. El objetivo del trabajo es mostrar los resultados de la reconstrucción inmediata de la pared abdominal luego de una amplia exéresis oncológica. Se presenta una paciente femenina, mestiza, de 60 años, con diagnóstico de sarcoma de partes blandas, que abarcaba todo el hemiabdomen ínfero izquierdo hasta límites del reborde costal izquierdo, comprometía aponeurosis, el músculo recto izquierdo, y pequeña parte del peritoneo que se reparó. Se decidió una amplia exéresis y se planificó la reconstrucción con un colgajo miocutáneo transverso de recto del abdomen. Se utilizaron mallas de polipropileno. Se logró la reconstrucción inmediata del defecto oncológico con buenos resultados estéticos y funcionales(AU)

Abdominal wall defects are a challenge for plastic surgeons. Soft-tissue sarcoma is very recurrent and it is necessary to make extensive exeresis with oncological margin and, as a result, there are large areas to be reconstructed. The transverse rectus abdominis flap is a reconstructive option for this region and with good aesthetic and functional results. The objective of the work is to show the results of the immediate reconstruction of the abdominal wall after an extensive oncological exeresis. We present the case of a female patient, mestiza, aged 60 years, with a diagnosis of soft-tissue sarcoma, which encompassed all the left inferior hemiabdomen to the left costal margin limits, compromised the aponeurosis, the left rectus muscle, and a small part of the peritoneum that was repaired. A wide exeresis was decided and the reconstruction was planned with a transverse rectus abdominis myocutaneous flap. Polypropylene meshes were used. The immediate reconstruction of the oncological defect was achieved with good aesthetic and functional results(AU)

Oclusión intestinal por hernia de Littré / Intestinal Occlusion by Littré Hernia

La hernia de Littré se define como la presencia de un divertículo de Meckel en el interior de cualquier orificio herniario. Se reportan muy pocos casos en la literatura por lo infrecuente de la patología, con una incidencia de aproximadamente un 2 por ciento de la población general. Presentamos un paciente de 70 años de edad que acudió al servicio de urgencia por presentar una obstrucción intestinal debido a una hernia inguinoescrotal derecha incarcerada. Con este diagnóstico se intervino de forma urgente. Se abordó por vía preperitoneal inguinal derecha y se encontró en el interior del saco herniario un divertículo de Meckel gangrenado y perforado. Se realizó resección intestinal, cierre del cabo distal del íleon terminal cerca de la válvula, anastomosis íleocolon ascendente latero-lateral y reparación del defecto herniario con una malla de polipropileno. El paciente evoluciona bien y es dado de alta a los 7 días(AU)

Littré hernia is defined as the presence of a Meckel's diverticulum inside any hernial orifice. Very few cases are reported in literature because its rarity, with an incidence of approximately 2 percent of the general population. We report a 70-year-old man who came to the emergency department for filing an intestinal obstruction due to an incarcerated right inguinal scrotal hernia. He urgently underwent surgery because of this diagnosis. Surgery was addressed by right preperitoneal inguinal via. A gangrenous and perforated Meckel's diverticulum was found inside the hernia sac. Intestinal resection was performed. The distal end of the terminal ileum was closed near the valve, the íleocolon latero-side up anastomosis was performed and the hernia defect was repaired with a polypropylene mesh. The patient did well and was discharged 7 days later(AU)

Perfusión testicular en la hernioplastia de Lichtenstein / Testicular perfusion in Lichtenstein hernioplasty

Introducción: la hernioplastia de Lichtenstein es un proceder de buena aceptación con bajas tasas de recidiva. No existe consenso sobre el impacto que produce el contacto directo de la malla y la fibrosis que esta induce, sobre los elementos del cordón inguinal y su influencia en la perfusión testicular. Objetivo: evaluar el efecto del contacto directo de la malla sobre la perfusión testicular en la hernioplastia de Lichtenstein. Método: se realizó un estudio observacional, descriptivo, longitudinal y prospectivo en 43 pacientes intervenidos en el Hospital Universitario "Comandante Manuel Fajardo" de La Habana, de noviembre de 2010 a junio de 2015, a los que se les realizó hernioplastia de Lichtenstein. En cada paciente se estudió la perfusión testicular utilizando los índices de flujo sanguíneo de la arteria testicular. Resultados: no se encontraron alteraciones de la perfusión testicular asociado al uso de la prótesis de polipropileno en la hernioplastia de Lichtenstein. Conclusión: la colocación de la malla de polipropileno según la técnica de Lichtenstein no produce alteración de la perfusión testicular según nuestros resultados(AU)

Introduction: Lichtenstein hernyoplasty is a well-accepted procedure with low rates of recurrence. However, there is no consensus on the impact produced by direct mesh contact and the induced fibrosis, or on the elements of the inguinal cord and its influence on testicular perfusion. Objective: to evaluate the effect of direct mesh contact on testicular perfusion in the Lichtenstein hernyoplasty. Methods: an observational, descriptive, longitudinal and prospective study was carried out with 43 patients who underwent Lichtenstein hernyoplasty and were treated at Comandante Manuel Fajardo University Hospital of Havana, from November 2010 to June 2015. Testicular perfusion was studied in each patient using the blood flow rates of testicular artery. Results: no testicular perfusion abnormalities were found to be associated with the use of polypropylene mesh in Lichtenstein hernioplasty. Conclusion: according to our results, the use of a polypropylene mesh by Lichtenstein technique does not impair testicular perfusion(AU)

Estudo das telas cirúrgicas de polipropileno/poliglecaprone-25 e polipropileno monofilamentar no reparo de hérnias inguinais / Study of surgical meshes of polypropylene/poliglecaprone-25 and monofilament polypropylene in the repair of inguinal hernias

OBJETIVO: Aferir complicações pós-operatórias imediatas e tardias em pacientes portadores de hérnia inguinal submetidos à correção cirúrgica, comparando a utilização da tela de polipropileno monofilamentar com a tela de polipropileno/poliglecaprone-25. MÉTODOS: Estudo retrospectivo dos pacientes submetidos ao reparo inguinal com uso de tela cirúrgica, avaliando as complicações precoces e tardias por meio de levantamento de prontuários e contato telefônico. Foram utilizadas telas de polipropileno monofilamentar e telas polipropileno com poliglecaprone-25, sendo os pacientes alocados em cada um dos grupos de forma aleatorizada. RESULTADOS: Foram incluídos 114 pacientes no estudo submetidos ao reparo inguinal pela técnica de Lichtenstein. No grupo que utilizou a tela de polipropileno monofilamentar (81,5%), foram identificados quatro pacientes (4,30%) com seroma, dois (2,15%) com hematoma, dois (2,15%) apresentaram infecção de ferida operatória, três (3,22%) apresentaram hipoestesia, nove (9,67%) apresentaram dor ou desconforto crônico na região inguinal e não houve casos de recorrência da hérnia no período. No grupo que utilizou a tela de polipropileno/poliglecaprone-25 (18,5%), foram identificados um paciente (4,76%) com seroma e um (4,76%) com hipoestesia e dois pacientes (9,52%) apresentaram desconforto ou dor crônica. CONCLUSÃO: O reparo inguinal com uso de tela foi o meio mais eficiente para o tratamento da hérnia inguinal apresentando baixos índices de complicação e fácil aplicabilidade O uso das telas de polipropileno/poliglecaprone-25 ainda não está totalmente estabelecido, apresentando taxas globais de complicações iguais às telas de polipropileno monofilamentar.

OBJECTIVE: To assess postoperative early and late complications in patients with inguinal hernia undergoing surgical correction, comparing the use of monofilament polypropylene mesh with polypropylene/poliglecaprone-25 mesh. METHODS: A retrospective study of patients undergoing inguinal repair with the use of surgical mesh, evaluating early and late complications through the analysis of medical records, and telephone contact. Monofilament polypropylene mesh and polypropylene/polyglecaprone-25 mesh were used, with the patients being randomly allocated to each group. RESULTS:The study included 114 patients who underwent inguinal repair through Lichtenstein technique. In the group that used the monofilament polypropylene mesh (81.5%) 4 patients (4.30%) were identified with seroma, 2 patients (2.15%) with hematoma, 2 patients (2.15%) had surgical wound infection, 3 patients (3.22%) had hypoesthesia, 9 patients (9.67%) had chronic pain or discomfort in the groin, and there were no cases of recurrence of hernia in the period. In the group that used the polypropylene/poliglecaprone-25 mesh (18.5%), 1 patient (4.76%) had seroma, 1 patient (4.76%) had hypoesthesia, and 2 patients (9.52%) showed chronic discomfort or pain. CONCLUSION: The inguinal repair with mesh use is the most efficient treatment for inguinal hernia, showing low rate of complications, and being easy to apply. The use of polypropylene/poliglecaprone-25 mesh is not yet fully established, presenting overall rates of complications similar to monofilament polypropylene mesh.

Deformidad facial postraumática asociada a complicación por silastic orbitario 35 años después de implantado / Post-traumatic facial deformity associated with a complication caused by orbital silastic 35 years after implantation

Las alteraciones esqueléticas del macizo facial sin tratamiento quirúrgico o con un manejo inadecuado, pueden resultar en deformidad secundaria importante con implicaciones estéticas y funcionales que deben ser consideradas para su tratamiento. El objetivo de esta presentación fue caracterizar el caso de deformidad facial postraumática asociada a complicación por silastic orbitario, 35 años después de implantado este. Se trata de un paciente masculino de 67 años que refirió haber sido tratado al presentar enrojecimiento de un ojo y secreciones. Refiere que hace 35 años fue intervenido quirúrgicamente por fractura en la zona del ojo izquierdo, que le colocaron silastic, y que no había tenido problemas hasta el momento en esa área. En el examen físico facial se detectó asimetría facial: ligero enoftalmo del ojo izquierdo, con desnivel pupilar, disminución de la apertura palpebral, rasgo antimongoloide, con eritema de la conjuntiva, quémosis, y abundantes secreciones. Se comprobó limitación del movimiento súpero-externo. Se corrobora la presencia de una fístula en el fondo de saco del párpado inferior. Se diagnostica como deformidad facial postraumática complicada por reacción a cuerpo extraño (al silastic). Fue intervenido quirúrgicamente y se realizó la exéresis del material, y la reconstrucción de la antomía ausente en la zona con malla de titanio. Se obtuvo excelentes resultados. Las lesiones postraumáticas de la cara se asocian generalmente con grandes secuelas funcionales y estéticas. Si se añaden las complicaciones por el empleo de implantes de biomateriales, la determinación de la conducta terapéutica puede ser un reto(AU)

Skeletal facial alterations not treated surgically or inappropriately handled may result in considerable secondary deformity with esthetic and functional implications which should be considered for treatment. The purpose of the study was to characterize a case of post-traumatic facial deformity associated with a complication caused by orbital silastic 35 years after implantation. A male 67-year-old patient reported having been treated for redness of one eye and secretion. Thirty-five years before he had been operated on for a fracture in the area of the left eye. Silastic had been implanted and he had not had any problems until now. Physical examination revealed facial asymmetry: slight enophthalmos of the left eye with pupillary unevenness, reduced palpebral opening, antimongoloid feature, conjunctival erythema, chemosis and abundant secretion. Upper-outer movement was limited. A fistula was found in the bottom of the lower palpebral sac. It is diagnosed as post-traumatic facial deformity complicated by reaction to foreign body (silastic). Surgery was performed to remove the material and reconstruct the missing anatomy in the area with titanium mesh. Excellent results were obtained. Post-traumatic facial lesions are generally associated with large functional and esthetic sequelae. When complications are added due to the use of biomaterial implants, determination of the appropriate therapeutic management can be a challenge(AU)

Experiencia cubana en el uso de la malla Laparomesh / Cuban experience in the Laparomesh mesh use

Introducción: las hernias incisionales constituyen un problema que diariamente enfrentan los cirujanos. Las técnicas protésicas ofrecen múltiples formas de resolverlas y prevenirlas. Objetivo: interpretar los beneficios de la malla Laparomesh en la reparación y prevención de las hernias incisionales. Métodos: se realizó un estudio observacional, descriptivo, longitudinal y prospectivo en 37 pacientes intervenidos en los hospitales universitarios Comandante Manuel Fajardo de La Habana y Juan Bruno Sayas de Santiago de Cuba, de noviembre de 2008 a junio de 2013, con hernias múltiples de la línea media o riesgo de desarrollar hernias incisionales, a los cuales se les realizó hernioplastia con la malla Laparomesh. Resultados: la media de edad fue 46 años y predominó el sexo masculino. Se utilizó la anestesia espinal o general y cefazolina como profilaxis antibiótica. Conclusiones: no existieron hasta el momento manifestaciones de rechazo al material protésico, ni complicaciones inmediatas. No recidiva herniaria con seguimiento promedio de 36 meses(AU)

Introduction: incisional hernias are a regular problem faced by the surgeon where prosthetic techniques provide many choices for solution and prevention. Objective: to show the advantages of the Laparomesh mesh for the prevention and repair of incisional hernia. Methods: an observational, descriptive, longitudinal and prospective study was conducted in 37 patients who had been operated on in Manuel Fajardo and Juan Bruno Sayas teaching hospitals in Havana and Santiago de Cuba, respectively, from November 2008 to June 2013. They had midline incisional hernias or were at risk of developing them, so they underwent hernioplasty with Laparomesh mesh. Results: the average age was 46 and males prevailed. Spinal or general anesthesia was used as well as prophylaxis with cefazolin. Conclusions: there have been no manifestations of rejection to the prosthetic material up to now. Neither immediate complications norhernial recurrence have been so far observed with an average follow-up of 36 months(AU)

Using of polypropylene mesh for hernioplasty in calves

In this study polypropylene mesh was used to facilitate reconstruction of large tissue defects by tension-free repair in 5 crossbred calves with hernial ring sizes ranging from 4-9 cm. The mesh was anchored subcutaneously to strong supportive musculature with interrupted pattern using No. 3 polypropylene sutures. The results revealed that polypropylene mesh proved alternative for hernial repair when fixed subcutaneous in large hernial ring in male and female calves without complications. Therefore, prosthetic mesh represents a safely procedure in large hernial ring to avoid over-stretching on the edges of the wound which hinders wound healing

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

Evaluation of the mesh-bridged posterior partial fundoplication-a new technique in treatment of gastroesophageal reflux disease

Disruption of the wrap and slipping are the most frequent causes of deficient reflux control after anti-reflux surgery. Isolauri et al. [1997], after an experimental study, suggested that if scarring could be induced between the fundal wrap and the esophagus, it could probably help to prevent slippage and disruption of the fundoplication wrap. This study was randomly conducted in the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospital on 60 patients suffering from GERD during the period from May 2003 to June 2005. They were randomly classified into two groups; group I comprised 30 patients for whom posterior partial fundoplication [modified Toupet technique] was performed and group II comprised 30 patients for whom mesh-bridged posterior partial fundoplication was performed. At 24 months postoperatively, 4 out of the 30 patients belonged to group I developed recurrence of GERD while none of the 30 patients belonging to group II developed recurrence. The difference in the recurrence rate between the two groups was found to be statistically significant. [P<0.0412]. The mesh-bridged posterior partial fundoplication proved to be effective in achieving the advantages and avoiding the disadvantages of both total and partial fundoplication in short term and mid-term follow-up; good reflux control and low incidence of mechanical complications. Moreover, did not significantly prolong the operation time and did not add to the patients' morbidity

Role of titanium mesh in the reconstructive surgery after skull bone defects

The clinical records, radiological investigations and operative notes of twenty patients who had been diagnosed as having skull bone defects and who subsequently underwent surgical reconstructive technique with titanium mesh from April, 2000 to April, 2004 at Nasr Institute Hospital. There were 14 male patients [70%] the mean age was 36 years and 6 female's patients [30%] the mean age was 39 years. The initial presentation and the major clinical findings among these patients are skull bone defects for different causes; 80% of patients [16 cases] had past history of head injuries followed by skull bone defect, underwent the reconstructive procedure secondarily, as that reflected the timing of their referral, and 20% of the patients [4 cases] had oncology surgery was performed underwent reconstruction with the use of titanium mesh. In the present series of patients, the implant has been used for coverage of small, medium and large sized cranial defects in various locations. This experience suggests that the titanium mesh offers a safe, cosmetically equivalent alternative to standard other cranioplasty materials while ease of implantation shortens operation time and better quality of life for patients. We describe our surgical technique in which the titanium mesh is used and report our experience with it

use of allogenic crib for closure of chronic oro-antral fistula: a clinical study

Twenty patients attended the clinic for closure of oro-antral fistula. A simple operation for the closure had been done. Two different types of allogenic crib were used. Ten patients were treated by a technique involves the insertion of Dacron crib while the other ten patients were treated by insertion of biodegradable Dexon crib to insure closure of fistulae. Four weeks postoperatively, the wounds healed by fibrous tissues in most cases. Two weeks later, the tissues were epithelized and the defect was completely closed. The technique had proven successful in all cases without any undesirable side-effects with Dacron crib application, only four cases healed with some problems with insertion of Dexon crib. These results indicated that Dacron crib could be used successfully, as a crib, in cases of chronic oro-antral fistula closure

Hernioplastia sin tensión de Lichtenstein bajo anestesia local: estudio comparativo / Free tension opened hernioplasty with local anesthesia (Lichtenstein technique)

Antecedentes: En las últimas décadas se han intentado mejorar los resultados de la Cirugía Herniaria reduciendo la estancia, el período de incapacidad y las recidivas. Objetivo: La aplicación del principio de Hernioplastia sin Tensión, introducido por Lichtenstein y basado en evitar la tensión en las líneas de sutura y estimular la formación del tejido conjuntivo mediante el empleo de mallas, puede ser un método eficaz para conseguirlo. Pacientes y Métodos: Entre 1984 y 1995, se practicó la hernioplastia abierta sin tensión con anestesia local en el Lichtenstein Hernia Institute para tratar 5.000 hernias inguinales primarias de 4.000 varones adultos. Uno de los autores (ACU) operó entre 1991 y 1996, 169 hernias inguinales primarias de las cuales, las indirectas se repararon mediante la técnica de Lichtenstein, y en el resto se cerró simultáneamente el suelo del conducto inguinal y el anillo crural. Resultados: En la primera serie aparecierón cinco recidivas (1 por mil); cuatro corresponden a pacientes intervenidos al comenzar a desarrollar la técnica. En la segunda serie se encontro una recidiva (0,5 por ciento). Conclusiones: La hernioplastia sin tensión abierta con anestesia local, en el ámbito de la cirugía ambulatoria, ha contribuido a disminuir la estancia, las molestias postoperatorias, el período de recuperación, las recidivas y el coste

Corrección de las deformidades congénitas de pared torácica / Repair of congenital abnormalities of the thoracic wall

Se presentan 41 pacientes sometidos a reparación quirúrgica de alteraciones congénitas de la pared torácica. Quince casos fueron resueltos con alguna de las técnicas clásica; 26 con resección de esternón y cartílagos alterados, reemplazándose el defecto con malla irreabsorbible en 25 y reabsorbible en 1. En los pacientes operados con técnicas clásicas se logró diversos grados de estabilidad de la pared según la técnica utilizada y el resultado fue satisfactorio en 8 de 15 (53 por ciento). Los pacientes sometidos a reemplazo con malla irreabsorbible tuvieron una estadía postoperatoria más corta, levantada precoz y firmeza y estabilidad de la pared inmediatas. El resultado fue satisfactorio en 22 de 25 (88.8 por ciento). Se considera superior el resultado obtenido con técnica de reemplazo con malla, tanto desde el punto de vista cosmético como funcional