The Lasso Suture: Ex Vivo Testing of an Alternative to the High-Tension Deep Dermal Stitch.

SUMMARY: Wound dehiscence, with an estimated occurrence rate greater than 4% in plastic surgery, is generally underreported, and can be an indicator of increased mortality and remission rates. The authors developed the lasso suture as a stronger alternative to the current standard patterns. The lasso suture takes less time to perform than the standard high-tension wound repair method. The authors dissected caprine skin specimens to create full-thickness wounds for suture repair using simple interrupted, vertical mattress, horizontal mattress, and deep dermal with running intradermal (DDR) sutures ( n = 10) and lasso sutures ( n = 9). They then conducted uniaxial failure testing to quantify the suture rupture stresses and strains. They also measured the suture operating time with medical students and residents (PGY or MS programs) performing wound repair (10-cm wide, 2-cm deep, 2-0 polydioxanone sutures) on soft-fixed human cadaver skin. The lasso stitch had a greater first-suture rupture stress compared with all other patterns ( P < 0.001): 2.46 ± 0.27 MPa for lasso versus 0.69 ± 0.14 MPa for simple interrupted, 0.68 ± 0.13 MPa for vertical mattress, 0.50 ± 0.10 MPa for horizontal mattress, and 1.17 ± 0.28 MPa for DDR sutures. Performing the lasso suture was 28% faster than performing standard DDR (264 ± 21 versus 349 ± 25 seconds; P = 0.027). In summary, the authors showed that the lasso has superior mechanical properties compared with the studied traditional sutures, and that the new technique can be performed more quickly than the current standard (DDR stitch) for high-tension wounds. Future animal and in-clinic studies will be helpful to confirm the authors' findings in this proof-of-concept study. CLINICAL RELEVANCE STATEMENT: The authors propose the lasso suture, a new suturing method with improved tensile performance compared with traditional techniques and a faster operative time than the deep dermal stitch typically used for high-tension wounds in reconstructive surgery to prevent wound dehiscence.

Acquisition of robotic surgical skills does not require laparoscopic training: a randomized controlled trial.

BACKGROUND: Robotic surgery is a valid option for minimally invasive surgery in most surgical specialties. However, the need to master laparoscopy is questionable before starting specific training in robotic surgery. We compared the development of basic robotic surgery skills between individuals randomized to train in conventional, laparoscopic, or robotic skills. METHODS: We conducted a single-centered, single-blinded randomized trial. Medical students were randomly assigned to 20 h of conventional, laparoscopic, or robotic surgical training. Students with previous surgical experience were excluded. Participants were evaluated pre- and post-training on the dV-Trainer robotic surgical simulator with the following exercises: Camera Targeting 1, Peg Board 1, Ring and Rail 1, and Ring and Rail 2. RESULTS: Sixty-six students were randomly assigned to each training group. Eight individuals did not complete the study (2 in the conventional group, 3 in the laparoscopic group, and 3 in the robotic group). All groups demonstrated significant improvement in the composite score and in each task following the training period (p < 0.001). No differences were seen between the conventional and laparoscopic groups in the composite score or individual tasks. The robotic group showed greater improvement in number of errors, economy of motion, workspace utilization, and time for completion compared to the other groups. The laparoscopic group showed improved camera manipulation skills compared to the conventional group, while the conventional group showed improved errors and economy of motion compared to the laparoscopic group. CONCLUSION: There was no difference in the acquisition of basic robotic surgical skills between individuals trained in basic conventional or laparoscopic surgical skills. We believe surgeons mastery in laparoscopy is not needed before initiating robotic surgical training. However, basic principles of laparoscopy remain applicable to robotic surgery. Future studies should compare transferability of conventional and laparoscopic training to robotic skills in the operating room.

Small Finger Osteocutaneous Fillet Flap for Reconstruction in Ring Finger Trauma.

Finger amputations are common injuries which result in significant long-term morbidity and loss of function. In this report, we describe a creative operative solution for a 21-year-old man who was in a motorcycle crash and sustained severely comminuted open fractures of the left small and ring fingers with severe crush injury and soft tissue avulsion. Of the tissues and bones in the small finger, only the distal half of the proximal phalanx remained intact and was vascularized via the remaining ulnar neurovascular bundle. In the ring finger, the extensor mechanism and ulnar neurovascular bundle were avulsed and the distal half of the proximal phalanx was absent, but the flexor tendons were intact. A small finger ray amputation was performed. Then, using an osteocutaneous fillet flap based on the ulnar neurovascular bundle from the small finger, the bony gap and soft tissue deficits in the ring finger were reconstructed. The ring finger extensor tendon was then reconstructed. Subsequently, the patient had evidence of bony union on follow-up X-rays and he had a sensate filet flap over the ulnar aspect of the ring finger. This case demonstrates the creative use of a "spare-parts" osteocutaneous fillet flap in the reconstruction of a traumatic finger injury. This example highlights the importance of assessing all available reconstructive options to avoid the morbidity of a finger amputation.

Abdominal skin tensile strength in aesthetic and massive weight loss patients and its role in ventral hernia repair.

BACKGROUND: Clarifying the biomechanics of abdominal skin could lead to different uses for this tissue such as the ventral repair of hernias in patients with excess skin and incisional hernias. The objective of this study was to compare the maximum tensile strength of abdominal skin to commercial meshes and to verify whether or not it varies between aesthetic patients and massive weight-loss patients. METHODS: Experimental cross-sectional study. Skin samples sized 32 × 20 mm were taken from 15 abdominoplasties and 10 panniculectomies. The skin specimens were analyzed in vertical and horizontal tensile strength tests. Results were compared between the two groups including their traction directions. Commercial meshes were also tested. The results were analyzed using the Generalized Estimating Equation. RESULTS: The maximum tensile strength supported vertically by abdominal dermis was 403.5 ± 27.4 N in the abdominoplasty group and 425.9 ± 33.9 N in the panniculectomy group. Horizontally, the values were 596.5 ± 32.2 N and 612.5 ± 43.9 N respectively. The strengths between traction directions were significantly different (p < 0.001). There were no differences between the groups with regard to the maximum tensile strength (p = 0.472). Tested commercial meshes had the following values: polypropylene 104.6 N, low-weight polypropylene 54.4 N, polytetrafluorethylene (PTFE) 82.2 N, and hydrated porcine small-intestinal submucosa 60.0 N. CONCLUSION: In our study, the tensile strength of the tested human abdominal dermis samples, both aesthetic and post-bariatric, was superior to the commercial meshes. Therefore, in selected cases, abdominal dermis could be an alternative tool in abdominal reconstruction during panniculectomies with concomitant hernia repair.

The Boomerang Thigh Flap: Optimizing the Donor Site for an Extended Skin Island Flap.

BACKGROUND: The anterolateral region of the thigh is one of the most used donor areas for flaps. However, there are cases in which large defects require more than the conventional skin island provided by the anterolateral thigh flap (ALT). For an extended skin island flap, we developed a new boomerang thigh flap (BTF), in which a boomerang design includes perforators from multiple branches of the lateral circumflex femoral artery (LCFA), providing a single-pedicle, large, reproducible, and reliable flap. We report the anatomical study and the use of the new BTF in a clinical series. METHODS: We dissected 20 flaps in fresh cadavers to determine the anatomical landmarks, vascular pedicle pattern, perforator distribution, and BTF flap dissection technique. After achieving a reproducible and reliable technique, with primary closure of the donor site based on the pinch test, the BTF was applied for microsurgical reconstructions in the head and neck, lower limb, and upper limb regions. RESULTS: The BTF corresponds to a 45° confluence of the ALT and the tensor fascia lata (TFL) elliptical skin islands. It includes the perforators from the transverse/ascending and the descending branches of the LCFA , which conjoined into a single arterial LCFA pedicle in 85% (17) of the cadaver dissections. All the venous branches drained into a single lateral circumflex femoral vein. ALT perforator distribution followed literature descriptions, while TFL perforators were mainly septocutaneous and projected into a virtual rectangle of 6 × 4 cm at the lateral margin of the TFL. Average BTF dimensions were 40 × 8.6 cm. For the clinical cases, flap dimensions and pedicle characteristics were equivalent to the anatomical findings. The BTF was separated into two skin islands in four cases and no major complications were reported. CONCLUSION: The BTF is a reliable, reproducible, and divisible flap that provides extended skin island for reconstruction of large defects.

A New Pedicled Internal Mammary Osteomyocutaneous Chimeric Flap (PIMOC) for Salvage Head and Neck Reconstruction: Anatomic Study and Clinical Application.

Well-vascularized composite tissue offers improved outcomes for complex head and neck reconstruction. Patients with vessel-depleted necks and failed reconstructions require alternative reconstructive options. We describe a pedicled internal mammary artery osteomyocutaneous chimeric flap (PIMOC) for salvage head and neck reconstruction. Bilateral dissections of 35 fresh cadavers were performed to study individual tissue components and vascular pedicles to develop the PIMOC technique. The flap was then utilized in a series of patients with vessel-depleted neck anatomy. The PIMOC was dissected bilaterally in all cadavers and there were no statistical differences in vascular pedicle caliber or length with regards to laterality or gender. Five patients subsequently underwent this procedure. The flaps included a vertical rectus abdominis myocutaneous component and a 6th or 7th rib with adjacent muscle and skin to restore bone defects, internal lining, and external coverage. All donor sites were closed primarily. There were no flap losses and all patients gained improvements in facial contour, speech and swallow. Although technically complex, the PIMOC is reproducible and provides a safe and reliable option for salvage head and neck reconstruction. The harvest of the 6th or 7th rib and rectus abdominis muscle renders an acceptable donor site.

Impacto na qualidade de vida em pacientes usuários de medicação retroviral e submetidos à gluteoplastia: estudo de coorte histórica / Gluteal contour restoration in antiretroviral users and its quality-of-life related impacts: a historical cohort study

INTRODUÇÃO: Desde a introdução do tratamento do HIV com uso da terapia antirretroviral altamente ativa, a mortalidade por essa doença foi reduzida drasticamente em todo o mundo. Um dos parefeitos relacionados à utilização desses fármacos é a lipodistrofia glútea. O objetivo deste trabalho é verificar o impacto da correção dessa deformidade na qualidade de vida de pacientes com HIV. MÉTODOS: Foi conduzido um estudo de coorte histórica com 23 pacientes submetidos à gluteoplastia com implante intramuscular, entre janeiro de 2010 e dezembro de 2014, avaliando a qualidade de vida por meio do em Nottingham Health Profile em. As informações foram coletadas de julho a agosto de 2015. A análise estatística foi feita utilizando-se o em Related-Samples McNemar Test em. RESULTADOS: strong Houve diferença significativa entre o pré-operatório e pós-operatório em 19 das 38 perguntas. CONCLUSÃO: É possível afirmar que a reconstrução glútea melhora a qualidade de vida de pacientes HIV positivos acometidos por lipodistrofia glútea relacionada a antirretrovirais.

INTRODUCTION: Since the introduction of highly active antiretroviral therapy for the treatment of human immunodeficiency virus (HIV), disease mortality has been dramatically reduced worldwide. One related side effect from the use of these drugs is gluteal lipodystrophy. The aim of this study is to assess the quality-of-life impact of correcting this deformity in HIV patients. METHODS: A historical cohort study was conducted between January 2010 and December 2014 with 23 patients, assessing the quality of their lives using the Nottingham Health Profile. A statistical analysis was performed using the McNemar test for related samples. RESULTS: There was a significant difference between preoperative and postoperative response in 19 of the 38 questions. CONCLUSION: We may say that gluteal reconstruction plays a role in improving quality of life for HIV patients who have been affected by antiretroviral related gluteal lipodystrophy.

Management of a Complex Basilar Invagination Case with Multiple Revision Surgeries ­ Case Report

We describe a Basilar Invagination (BI) case with craniocervical instability and many previous failure surgeries and poor wound coverage. The patient had been submitted to a large posterior fossa craniectomy (which greatly limited the availability of an adequate area for bone fixation) and showed a poor quality of the surgical wound in the posterior craniocervical region. We performed an occipito-cervical fixation, using the bone overlying the torculla as a point of cranial fixation. Craniocervical realignment was achieved by the use of distractive maneuvers with occipital rods, followed by coverage of the hardware via a pedicled longitudinal trapeze myocutaneous flap. We used local ribs removed from the region where the myocutaneous flap was harvested as autologous bone grafts for craniocervical fusion. Post-operatively, the patient was placed in a halo-vest for three months. The patient improved substantially after the procedure, recovered some muscular strength and experienced total relief of her pain. We hereby discuss the surgical strategy used for treating this complex case in details, with illustrative pictures.

Descrevemos caso de paciente com diagnóstico de invaginação basilar e instabilidade crânio cervical com múltiplas cirurgias prévias e deiscência de ferida operatória. Devido a falha de osso na escama occipital, assim como da cobertura cutânea adequada, realizamos realinhamento craniocervical, com descompressão indireta anterior, fixação occipitocervical na região da tórcula e cobertura da pele com flap miocutâneo longitudinal pediculado de trapézio. As costelas removidas da região do retalho miocutâneo foram transferidas para serem usadas como enxerto autólogo de osso para fusão craniocervical. No pós-operatório, a paciente utilizou um halo-vest por 3 meses. No presente artigo, apresentamos nuances ilustrados de manobras para realinhamento craniocervical por via posterior na invaginação basilar, bem como estratégias para otimizar a artrodese e o fechamento cutâneo.

Mucinous adenocarcinoma associated with chronic suppurative hidradenitis: Report of a case and review of the literature.

INTRODUCTION: Chronic suppurative hidradenitis (CSH) is a benign condition that can affect the perineal region and often leads to the formation of abscesses and fistulas. It is rare for CSH to undergo malignant degeneration into mucinous adenocarcinoma. PRESENTATION OF CASE: We report a case of a 55-year-old male patient with perineal CSH who suffered worsening long-term pain despite multiple surgical procedures to alleviate his symptoms. Pelvic magnetic resonance imaging (MRI) showed multiloculated cystic lesion on the left side wall of the distal rectum with gluteal extension. Pathological examination revealed mucinous adenocarcinoma. The patient underwent an abdominoperineal resection (APR) of the rectum with cutaneous muscle flap reconstruction. Although histopathological sections showed clear margins, the tumor recurred 6 months following surgery. DISCUSSION: Perineal mucinous adenocarcinoma arising in a patient with CSH is an extremely rare condition. This diagnosis is often difficult, due to the paucity of signs of malignant degeneration as well as the rarity of the disease itself. Surgical resection of the lesions is a well-established approach. In this case, diagnosing the tumor at such a late stage likely compromised his outcome. CONCLUSION: Malignant degeneration to mucinous adenocarcinoma must be suspected in patients with a history of long-term CSH. In such cases, local biopsies and a radiological examination, such as MRI can help in the diagnosis.

O impacto de ações assistenciais na percepção da qualidade do Sistema Único de Saúde (SUS), Brasil: um estudo transversal / The impact of care actions on the perception of the quality of the Single Health System (SUS), Brazil: a cross-sectional study

INTRODUÇÃO: O tumor de pele não melanoma é o câncer mais frequente no Brasil. A ressecção cirúrgica é um dos pilares do manejo e ações assistenciais como mutirões de cirurgias são formas de reduzir o tempo de espera por tratamento. MÉTODOS: Nesse trabalho, conduziu-se um estudo transversal com 40 pacientes, 20 deles participantes de mutirão e 20 controles. Coletaram-se dados epidemiológicos, além de nove perguntas relacionadas à qualidade do Sistema Único de Saúde (SUS). RESULTADOS: Observou-se diferença significativa entre as respostas relacionadas ao tempo de espera por cirurgias no SUS (p < 0,05). CONCLUSÃO: Pode-se verificar melhora na impressão dos pacientes em relação ao SUS quando incluídos em ações assistenciais.

INTRODUCTION: Non-melanoma skin cancer is the most prevalent cancer in Brazil. Surgical resection is one of the pillars of management, and care actions, such as surgical task forces, are one way to reduce treatment waiting time. METHODS: In this research, we conducted a cross-sectional study with 40 patients; 20 of whom were treated by a surgical task force and 20 were controls. Epidemiological data were collected in addition to answers to nine questions related to the quality of the Single Health System (SUS in Portuguese). RESULTS: A significant difference was observed in responses related to the waiting time for surgery in the SUS (p < 0.05). CONCLUSION: One can observe an improvement in the perception of patients, with regard to the SUS, when included in care actions.

Face transplantation in rats. Reproducibility of the experimental model in Brazil.

PURPOSE: To investigate the reproducibility of the experimental model of face allotransplantation in rats in Brazil. METHODS: Eighteen rats were operated, nine-nine donors recipients. Animals underwent transplantation of the left hemiface, with periorbital and scalp. Transplants were made from donor Wistar rats to recipients Lewis rats. Flaps were based on the common carotid artery and the external jugular vein of the donor animal and the anastomosis in the recipient area was performed in common carotid artery (end-to-side) and in external jugular vein (end-to-end). RESULTS: Of the nine recipient animals operated, six survived and three progressed to death in the first days after surgery (survival rate = 67%). The mean time of the procedure was 252 minutes and the mean time of flap ischemia was 95 minutes. The five surviving animals were sacrificed at 14 days, in good general condition and without signs of tissue rejection. CONCLUSIONS: The experimental model of face allotransplantation in rats is reproducible in our midst. Duration of surgery, time of flap ischemia, animal survival rate and complications observed were similar to those described in the literature.

Face transplantation in rats. Reproducibility of the experimental model in Brazil

PURPOSE: To investigate the reproducibility of the experimental model of face allotransplantation in rats in Brazil. METHODS: Eighteen rats were operated, nine-nine donors recipients. Animals underwent transplantation of the left hemiface, with periorbital and scalp. Transplants were made from donor Wistar rats to recipients Lewis rats. Flaps were based on the common carotid artery and the external jugular vein of the donor animal and the anastomosis in the recipient area was performed in common carotid artery (end-to-side) and in external jugular vein (end-to-end). RESULTS: Of the nine recipient animals operated, six survived and three progressed to death in the first days after surgery (survival rate = 67%). The mean time of the procedure was 252 minutes and the mean time of flap ischemia was 95 minutes. The five surviving animals were sacrificed at 14 days, in good general condition and without signs of tissue rejection. CONCLUSIONS: The experimental model of face allotransplantation in rats is reproducible in our midst. Duration of surgery, time of flap ischemia, animal survival rate and complications observed were similar to those described in the literature. .

Lymph fasciocutaneous lateral thoracic artery flap: anatomical study and clinical use.

BACKGROUND: The lateral thoracic flap was first studied in the mid-1970s but its use has been limited because of pedicle anatomical variations. However, after the development of lymph node transfer surgery, the axilla/upper lateral thorax presented as a promising donor area. Through a detailed anatomical study, the lateral thoracic flap was evaluated regarding its vascularization and composition. Later, it was used for pedicle and free flap reconstructions. METHODS: A total of 40 flaps were dissected in fresh cadavers and the characteristics of the lateral thoracic pedicle and its relationship to the upper lateral thoracic axillary lymph nodes (LTLN) were analyzed. We performed six pedicle flap reconstructions around the shoulder area and a free lymph node transfer for lower limb lymphedema. RESULTS: In the cadaveric dissections, the lateral thoracic pedicle branched off the axillary vessels and was found to be a primary level I axillary lymph node irrigator before reaching the skin. The cutaneous portion of the artery was present in 87.5% of the dissections. Arterial caliber was an average of 1.3 and venous, 2.6 mm. Five to seven lymph nodes were isolated with each pedicle and a lymph fasciocutaneous flap could be designed. In seven clinical cases, all of the flaps survived. Functioning lymph nodes were visualized on lymphoscintigraphy after their transfer to the ankle. Donor area had an inconspicuous evolution. CONCLUSION: Lateral thoracic flap is a feasible flap with low donor area morbidity in a concealed region that can be harvested with upper LTLN for transplantation.

Análise retrospectiva de pacientes pós-bariátrica submetidos à abdominoplastia com neo-onfaloplastia: 70 Casos / Retrospective analysis of 70 patients who underwent post-bariatric abdominoplasty with neo-omphaloplasty

Introdução: Com o crescente aumento do tratamento cirúrgico da obesidade, surge para o cirurgião plástico um grupo de pacientes com grande flacidez cutânea após perda ponderal. Para aqueles submetidos à gastroplastia redutora convencional ou aberta, a abdominoplastia vertical, em âncora ou em T invertido, tem sido largamente utilizada para a melhoria do contorno abdominal, e no presente trabalho foi associada à amputação umbilical seguida de neo-onfaloplastia. Método: Foram operados 70 pacientes, com peso estável há no mínimo 18 meses, procedentes do ambulatório de Cirurgia Plástica da UNICAMP, no período de março de 2011 a abril de 2013. Em todos foi utilizada a técnica de abdominoplastia em âncora com exérese do umbigo original, juntamente com a peça cirúrgica e confecção de neo-umbigo, através de retalhos dermo-gordurosos bilaterais. Procedeu-se à análise retrospectiva dos prontuários médicos e arquivo fotográfico dos mesmos. Resultados: Nos 70 pacientes operados, houve predominância do sexo feminino (91%) e da raça branca (83%), com média de 40 anos. Após tempo de espera de aproximadamente 16 meses, foram submetidos à abdominoplastia em âncora associada a neo-onfaloplastia, que durou em média 2 horas. Observaram-se complicações pós-operatórias em 29,85% - deiscências pequenas, cicatrizes inestéticas, alargadas ou hipertróficas, queloides, seromas, excessos dermo-gordurosos relevantes e infecção de ferida operatória. Os neoumbigos obtidos são muito semelhantes aos umbigos originais. Não observamos necroses, estenoses, distorções morfológicas e nem mau posicionamento dos mesmos. Conclusão: Esta técnica tem permitido a obtenção de umbigos com aspecto natural, é de fácil execução e reduz o tempo operatório.

Introduction: With the increasing surgical treatment of obesity, a new group of patients is being attended by plastic surgeons: those with large flaccid skin following weight loss. For patients treated with conventional or open bariatric surgery, vertical, anchorline, or inverted "T" abdominoplasty has been widely used to improve the abdominal contour. In this study, abdominoplasty was associated with umbilical amputation followed by neo-omphaloplasty. Methods: Seventy patients with stable weight for at least 18 months underwent surgery at the UNICAMP Plastic Surgery Outpatient Clinic, from March 2011 to April 2013. In all patients, anchor-line abdominoplasty with excision of the original navel was executed, together with the surgical specimen and preparation of neo-umbilicus, through bilateral dermal-fat flaps. A retrospective analysis of medical records and photographic archives was performed. Results: The 70 patients were predominantly female (91%) and white (83%) with a mean age of 40 years. After a wait time of approximately 16 months, they were subjected to anchorline abdominoplasty associated with neo-omphaloplasty, which lasted an average of 2 hours. There were post-operative complications in 29.85% of the patients, including small dehiscence, unsightly, enlarged, or hypertrophic scars, keloid, seroma, relevant dermo-fatty excesses, and wound infection. The neo-umbilicus obtained from the surgery is very similar to the original umbilicus. We did not observe necrosis, stenosis, morphological distortions, or bad positioning. Conclusion: This technique has made it possible to obtain an umbilicus with a natural look, is easy to perform, and shortens operating time.

Estudo da anatomia dos retalhos pediculados da artéria torácica interna e sua aplicabilidade na reconstrução de cabeça e pescoço / The anatomy of the internal mammary artery pedicled flaps and their use in head and neck reconstructions

INTRODUÇÃO: As reconstruções com tecidos combinados e bem vascularizados permitem a melhor reabilitação para defeitos extensos em cabeça e pescoço. O padrão-ouro tem sido as transferências microcirúrgicas de tecidos. Porém, há pacientes em que não há vasos receptores cervicais adequados para os transplantes de tecidos livres devido à múltiplas recidivas, ressecções e reconstruções; linfadenectomias cervicais; fístulas e infecções; e o tratamento com radioterapia. Com o aprimoramento do controle oncológico, pacientes nestas circunstâncias são cada vez mais frequentes e há poucas alternativas para reconstrução. OBJETIVO: Descrever a dissecação anatômica de um retalho osteomiocutâneo combinado, pediculado nos vasos torácicos internos, para reconstrução de defeitos complexos em cabeça e pescoço. MÉTODO: Retalhos osteomiocutâneos contendo 6ª e 7ª costelas e músculo reto abdominal foram dissecados bilateralmente em 35 cadáveres, 26 do sexo masculino e 9 do sexo feminino. Estudou-se a vascularização cutânea do abdome superior pelas perfurantes da artéria epigástrica superior superficial (SSEA); e os padrões de vascularização do 6º e 7º arcos costais e músculo reto abdominal a partir dos vasos torácicos internos, musculofrênicos e intercostais. O arco de rotação para segmento cefálico com ponto pivô na margem inferior da primeira costela foi avaliado. RESULTADOS: Foram dissecadas 114 perfurantes SSEA, 62 à direita e 52 à esquerda, com calibre arterial médio homogêneo de 0,68 mm. A maior frequência de perfurantes encontradas foi no grupo de 0,5 a 1,0 mm, com 60 (52,7%) ocorrências. Não houve diferença estatisticamente significativa para localização e calibre em relação ao lado. Também não houve correlação dos calibres com localização, idade, peso e altura dos cadáveres. Sessenta e dois retalhos osteomiocutâneos com pedículo nos vasos torácicos internos, 6° e 7° arcos costais e músculo reto abdominal foram divididos em 3 tipos de acordo com o padrão de vascularização...

INTRODUCTION: The use of combined well-vascularized flaps offers better results and rehabilitation for complex head and neck defects. Microsurgical reconstructions are the gold standard. However, there are patients with vessel-depleted necks from multiple recurrences and resections, failed reconstructions, neck dissections, infections, fistulas and radiotherapy, which impair adequate free tissue transfers. With better oncologic therapies, these patients have become more common and lack reconstructive options. OBJECT: To describe a combined ostemyocutaneous pedicled flap based on the internal mammary artery for complex head and neck reconstructions. METHOD: Osteomyocutaneous flaps with 6th and 7th ribs and the rectus abdominis muscle were dissected bilaterally on 35 cadavers, 26 male and 9 female. We studied the upper abdominal irrigation through isolation of the superficial superior epigastric artery perforators (SSEA) and the vascular pedicles to the 6th and 7th ribs, and the rectus abdominis muscle arising from the internal mammary, the musculophrenic and the intercostal arteries. The arc of rotation of the flap to the cephalic segment was tested with the pivot point on the lower margin of the first rib. RESULTS: We dissected 114 SSEA, 62 on the right side and 52 on the left. They had an homogeneous mean arterial diameter of 0,68 mm. Sixty perforators (52,7%) were on the group that ranged from 0,5 to 1,0 mm. After statistical analysis, there were no differences in relation to the side as for location and caliber of the perforators. Neither there was any relation of the arterial calibers to the location, age, weight and height of the cadavers. Sixty-two internal mammary artery pedicled osteomyocutaneous flaps, that carried the 6th and 7th ribs and the rectus abdominis muscle, were divided in 3 types depending on the vascular pattern to the 6th costal arch. Type 1, where the pedicle to the 6th rib branches from the musculophrenic artery, was the most...

Reconstruções pelveperineais com uso de retalhos cutâneos baseados em vasos perfurantes: experiência clínica com 22 casos / Reconstruction of pelviperineal injuries with perforator flaps: clinical experience with 22 cases

INTRODUÇÃO: As lesões pelveperineais representam grande parcela das interconsultas para o cirurgião plástico em hospitais gerais. O objetivo do presente trabalho é apresentar a experiência obtida no tratamento de pacientes com lesões perineais, sacrais e de quadril com o uso de retalhos com vasos perfurantes. MÉTODO: Foram estudados, retrospectivamente, os pacientes submetidos a avaliação pela equipe da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, nos meses de fevereiro a maio de 2009, que apresentavam feridas em região pelveperineal e no quadril. No total, 22 pacientes foram submetidos a reconstrução com retalhos cutâneos e fasciocutâneos baseados em vasos perfurantes, de acordo com os critérios de inclusão. O período de seguimento médio foi de 6 meses. RESULTADOS: A lesão pelveperineal foi úlcera por pressão em 20 (91 por cento) casos, infecção profunda em 1 (4,5 por cento), e hidradenite perineal em 1 (4,5 por cento). A opção dos retalhos foi previamente estabelecida, dependendo do local da ferida: úlceras sacrais, retalho baseado nas perfurantes da artéria glútea superior em 15 (68,2 por cento) casos; úlceras isquiáticas, retalho baseado nos vasos perfurantes da artéria glútea inferior em 3 (13,6 por cento) casos; e úlceras trocantéricas, retalho tensor da fascia lata perfurante em 2 (9,1 por cento) casos. Retalho fasciocutâneo inervado gluteofemoral foi a opção para a reconstrução pós-síndrome de Fournier em um paciente e após ressecção de hidradenite perineal em outro. Houve necessidade de nova sutura para fechamento primário tardio em deiscência < 10 por cento do perímetro da lesão em 3 (13,6 por cento) casos, durante os primeiros 15 dias de pós-operatório. Não houve casos de necrose > 3 por cento da superfície do retalho. Os resultados foram mantidos no período de seguimento avaliado. CONCLUSÕES: Os resultados obtidos no presente estudo foram satisfatórios e ficou demonstrada a utilidade de retalhos cirúrgicos sem incorporação de músculo para reconstruções pelveperineais. Essa alternativa para tratamento é menos mórbida para as áreas doadoras e preserva o tecido muscular para possível intervenção futura.

INTRODUCTION: Plastic surgery consultation is commonly sought for the treatment of pelviperineal injuries in general hospitals. The objective of this study was to present the experience acquired in the treatment of perineal, sacral, and hip injuries with the use of perforator flaps. METHODS: Patients referred to the Plastic Surgery Division of the Clinical Hospital of Medicine College of Universidade de São Paulo for evaluation of pelviperineal and hip wounds from February to May 2009 were retrospectively evaluated. A total of 22 patients underwent reconstruction with skin and fasciocutaneous flaps based on the perforator vessels, according to the inclusion criteria. The average follow-up period was 6 months. RESULTS: Pelviperineal injuries consisted of pressure ulcers in 20 cases (91 percent), deep infection in 1 case (45 percent), and perineal hidradenitis in 1 case (4.5 percent). The choice of flap for reconstruction was dependent on the local wound: 15 cases (68.2 percent) of sacral ulcers were repaired with a superior gluteal artery perforator flap; 3 cases (13.6 percent) of ischial ulcers were repaired with an inferior gluteal artery perforator flap; and 2 cases (9.1 percent) of trochanteric ulcers were repaired using a tensor fascia lata perforator flap. A fasciocutaneous gluteofemoral flap was selected for reconstruction of post Fournier' syndrome in 1 patient and was used after resection of perineal hidradenitis in 1 patient. A new suture for late primary closure was necessary in 3 (13.6 percent) cases in which the suture line dehiscence was < 10 percent of the injury perimeter during the first 15 post-operative days. There were no cases of > 3 percent necrosis of the flap surface. These results were maintained during the follow-up evaluation period. CONCLUSIONS: The results of the study were satisfactory, and the utility of surgical flaps without the incorporation of muscle for pelviperineal reconstruction was demonstrated. This treatment alternative decreases donor site morbidity and preserves the muscular tissue for future interventions.