Comparison of vertical and extended vertical rectus abdominis myocutaneous flaps. An anatomical study.

The extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap could be insufficient. To compare the dimensions of VRAM and eVRAM flaps an anatomical study was performed. Ten VRAM and ten eVRAM flaps were dissected in ten fresh adult cadavers. Length, width and volume of all the flaps were measured. Length and volume were significantly larger in eVRAM flap compared to VRAM flap (36.55 cm vs. 30.15, p=.005; and 315.5 vs. 244 mL, p=.012, respectively). No differences were observed in flap width. The eVRAM flap could be a better option than traditional VRAM for reconstruction of big pelviperineal defects when bulkier tissue, larger skin paddle and/or longer arch of rotation are needed for reconstruction.

Using a V-Y Advance Flap for Alar Rim Defect After Human Bite: A Case Report.

A human bite is a traumatic injury that often occurs in the recipient's nasal area. In this report, we describe the case of a 38-year-old man who was bitten by his roommate and sustained an alar rim defect. After reviewing the literature and professional recommendations for managing human bite wounds in the nasal area, we found both were unclear as to whether it is best to implement primary reconstruction or to defer reconstruction to a later date. We utilized a V-Y flap for secondary reconstruction in our patient.

Therapeutic management of traumatic tension hematoma with potential skin necrosis: a retrospective review of 180 patients.

INTRODUCTION: Tension hematoma is a frequent traumatic condition in elderly population under anticoagulation treatments. However, scarce literature exists focused in the management of this condition. In this article, a retrospective study of patients that suffered from traumatic tension hematomas treated at a plastic surgery department is reported. The objective was to evaluate the approach that provided better clinical outcomes, and the establishment of an evidence-based protocol. METHODS: This retrospective study comprised 180 patients suffering from tension hematomas. Patients were divided in four groups: the first and second groups included patients that underwent debridement and coverage in one stage and two stages, respectively. The third group included patients that required debridement without skin grafting, and the fourth group, patients with hematomas that only necessitated drainage. Demographic variables, comorbidities, timing and complication rates of each technique were evaluated. RESULTS: Length of hospital stay, medical complication and mortality rates were significantly higher in patients who underwent debridement and coverage surgeries in two separate procedures (p < 0.05). Patients with small-sized hematomas (avg 0.63% of total body surface) required only debridement. Patients that only required hematoma drainage, were treated during the first 24 h after injury (p < 0.03). CONCLUSIONS: Treatment of tension hematomas through early drainage should be performed as soon as possible from the time of injury. An evidence-based protocol should be established in every emergency department to improve patient clinical outcomes. When debridement and coverage surgery are required, they should be performed in one stage, to reduce length of hospital stay and the incidence of medical complications.

A Protocol for Performing Reconstructive Microsurgery on Patients With COVID-19.

On March 11, 2020, the World Health Organization declared COVID-19 to be a pandemic, challenging health care systems all over the world. National health care systems have reorganized to cope with the disease. Surgical services departments around the world have been affected and elective surgical procedures have been postponed to conserve medical resources. When a patient with COVID-19 requires an urgent microsurgical free flap due to trauma or a tumor, personnel from the health care facility must have a protocol in place to follow for the patient's care and follow-up. In this article, we present our protocol for patients with COVID-19 requiring reconstructive microsurgery.

A Randomized Controlled Trial of Three Noninvasive Analgesic Techniques for the Prevention of Pain During Facial Injections.

BACKGROUND: Injections are associated with a certain amount of pain, the tolerance of which can vary between individuals. With regard to noninvasive pain control techniques in subcutaneous injections, few studies with adequate levels of evidence and design quality exist to support any specific analgesic method. OBJECTIVES: In this study, we evaluated the efficacy of 3 noninvasive analgesic techniques (cold, anesthetic cream, and vibration) during subcutaneous forehead injections in 100 healthy volunteers. METHODS: This randomized, single-blind, controlled trial comprised 100 healthy volunteers. Every patient received 4 forehead injections of 0.1 mL physiological saline through 29G needles after 1 of 3 noninvasive analgesic techniques (cold, vibration, or anesthetic cream) or control treatment was applied to each injection site. The results were evaluated through a survey that included a visual analog scale for pain measurements. RESULTS: All analgesic methods demonstrated better pain control than the no-treatment arm (P < 0.001), of which vibration performed better than the other analgesic techniques (P < 0.015 vs cold and P < 0.015 vs anesthetic cream). No differences were observed between cold and anesthetic cream. The average amount of pain per injection in males was higher than in females (P < 0.014). CONCLUSIONS: Vibration analgesia effected significantly better pain control than cold and anesthetic cream. Nevertheless, the choice of anesthetic method should be adapted to the preferences and experiences of each patient to optimize pain control in procedures that involve subcutaneous injections.

Augmentation of Scarred Vocal Folds With Centrifuged and Emulsified Autologous Fat Grafts.

OBJECTIVE: To review the results of a series of patients with glottic insufficiency caused by scarred vocal folds who underwent injection laryngoplasty with centrifuged and emulsified autologous fat. STUDY DESIGN: Prospective cohort. SETTING: Single center, tertiary institution. SUBJECTS AND METHODS: Examination of the medical records of 21 patients operated on through injection laryngoplasty with fat grafts for the treatment of dysphonia was performed. All patients were operated on between January of 2015 and September of 2019. The voice variables measured were the GRABS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, the Voice Handicap Index-10 (VHI-10), maximum phonation time, jitter, shimmer, and harmonic/noise ratio before surgery and 8 months later. RESULTS: Twenty-six injection laryngoplasties were performed in 21 patients during the reviewed period. Seventeen were men, and 4 were women. Mean age was 57.2 (range, 18-80) years. Mean (SD) follow-up time was 20.7 (9.3) months. Etiology of dysphonia was scarring after tumor resection in 17 patients and sulcus vocalis in 4. Five patients received an additional injection laryngoplasty. Statistically significant improvements were observed in all the parameters evaluated (P < .05). CONCLUSIONS: Injection laryngoplasty with fat grafts processed through centrifugation and emulsification is an effective technique for the treatment of dysphonia caused by glottic insufficiency related to scarred vocal folds, with minimal complication rates.

Avoiding Above-the-Knee Amputation with a Free Tibiofibular-Talocalcaneal Fillet Flap and Free Latissimus Dorsi Flap.

Despite the advances achieved in reconstructive surgery, amputation is still the only option after some severe traumas. Preservation of the knee joint is considered a significant functional advantage. We present the case of a 39-year-old man with a comminuted Gustilo type IIIC open tibia fracture with massive bone loss. To achieve a well-fashioned amputation stump and preserve the knee joint, a free osteocutaneous fillet flap was performed, including the distal tibia and fibula, talus, and calcaneus bones. As a result, a sensate and long amputation stump covered with thick skin from the sole of the foot provided a stable coverage with an excellent functional result and adjustment to prosthesis.

Simultaneous Opponensplasty and Free Gracilis Muscle Flap for Thenar Reconstruction after Arteriovenous Malformation Resection.

We report the case of a thenar eminence arteriovenous malformation presenting with continuous growth and pain that was treated with surgical excision after embolization. Extracapsular resection compromised thenar muscles which function was reconstructed with extensor indicis proprius transfer for opposition and abduction, and neurotized free gracilis muscle flap for opposition and adduction, as well as thenar eminence reconstruction.

Situación actual de la Microcirugía en quemados. Revisión sistemática / Current status of Microsurgery in burns. Systematic review

INTRODUCCIÓN Y OBJETIVO: El empleo de transferencias de tejido libre vascularizado se ha consolidado en los últimos años dentro del tratamiento quirúrgico de los pacientes quemados. El objetivo de este trabajo es establecer conclusiones extrapolables a la práctica habitual para la optimización de resultados en el uso de colgajos libres en estos pacientes. MATERIAL Y MÉTODO: Realizamos una revisión de las bases de datos Pubmed y Scielo utilizando los términos "colgajo libre" o "microcirugía" o "transferencia tisular libre" y "quemadura" o "lesión térmica". Identificamos 1366 artículos que posteriormente revisamos para seleccionar aquellos con información relevante sobre: incidencia de colgajos libres en pacientes quemados, complicaciones, estrategias para mejorar la tasa de éxito, preparación preoperatoria, control y manejo postoperatorio. RESULTADOS: Incluimos finalmente 31 artículos. Los trabajos publicados reflejan que entre el 1.5 y el 1.8% de los pacientes con quemaduras quirúrgicas reciben cobertura mediante colgajos libres. La tasa de complicaciones mayores se eleva respecto a otros grupos de pacientes; sin embargo desciende en gran medida si la cirugía no se realiza entre los días 5 y 21 postquemadura. La realización de pruebas de imagen para la selección de vasos receptores no es indispensable. Se recomienda mantener temperatura por encima de 36 °C, normovolemia y hematocrito entre 30 y 40%, evitando la transfusión en caso de valores de hemoglobina superiores a 70 g/l. En caso de necesidad de drogas vasoactivas, serían de elección la noradrenalina o la dobutamina. CONCLUSIONES: Aunque la Microcirugía es infrecuente en el tratamiento de las quemaduras, es un recurso esencial en determinados pacientes. Esta revisión puede ser de utilidad para orientar el manejo clínico de los colgajos libres en pacientes quemados así como futuras investigaciones en este ámbito

BACKGROUND AND OBJECTIVE: The use of microvascular free tissue transplantation in burn patients has consolidated over the last years. The purpose of this article is to establish practical conclusions in order to optimize the results of free flaps in this group of patients. METHODS: A review of the PubMed and Scielo databases was performed using a combination of the search terms "free flap" or "microsurgery" or "free tissue transfer" and "burn" or "thermal injury". The search returned 1366 articles that were analyzed to include those with relevant information about: incidence of free flaps in burn patients, complications, strategies to increase success and pre-operative and post-operative management. RESULTS: Following revision 31 articles were included. Published works report an incidence of free flaps transplantations in burn patients ranging between 1.5 and 1.8%. Complication rate is high compared to other groups of patients, however, it decreases considerably if surgery is not performed between day 5 and 21 after burn injury. Imaging tests are not indispensable to select recipient vessels. It is advisable to keep body temperature over 36 °C, normovolemia and hematocrit between 30 and 40% avoiding hemoglobine values over 70 g/l. In the need of vasopressors norepinephrine and dobutamine are the drugs of choice. CONCLUSIONS: Microsurgery is uncommon but sometimes essential in burn treatment. This review may be valuable guiding not only clinical management of free flaps in burn patients but pointing towards new lines of research

Evolución histórica del tratamiento del paciente quemado / Historic evolution of burn care

El tratamiento de las quemaduras es una ciencia tan antigua como los conflictos humanos, que ha debido refinarse y adaptarse a las mejoras de la tecnología armamentística a lo largo de la historia. El fuego ha sido probablemente una de las primeras armas de doble filo con las que el ser humano ha topado durante su desarrollo tecnológico. Históricamente, este elemento ha servido tanto para mejorar las condiciones de vida de las sociedades como para destruirlas y ocasionar terribles sufrimientos. En este trabajo realizamos una exposición cronológica de la evolución del tratamiento de las quemaduras, presentando a las figuras científicas más relevantes de cada momento y sus aportaciones. Además, destacamos los conflictos y desastres coincidentes en el tiempo de vida de cada uno de estos médicos, ya que, en muchos casos, fue el trabajo desarrollado durante estas catástrofes lo que permitió la progresión de este ámbito. El objetivo de esta revisión histórica es proporcionar al lector cierto conocimiento sobre el camino que esta ciencia del tratamiento de las quemaduras ha seguido hasta alcanzar el punto de desarrollo actual, Desde el primer registro histórico sobre tratamientos para las quemaduras en un papiro egipcio del 1500 a.C., cada figura relevante de la Medicina en su tiempo ha propuesto su propio remedio para las quemaduras; la mayoría de ellos sin fundamento científico según los paradigmas actuales. No obstante, desde el siglo XVI ha habido aportaciones puntuales hasta alcanzar un importante desarrollo durante los siglos XIX y XX, coincidiendo en el tiempo con la revolución industrial y científica de las Grandes Guerras, en las que la cantidad de víctimas por quemaduras fue inmensa, proporcionando un extenso campo observacional y experimental. Gracias a todo ello, los pacientes quemados alcanzan actualmente unas tasas de supervivencia impensables hace siglos. Ponemos pues en evidencia que la adversidad, estudiada desde un enfoque científico, puede servir como oportunidad para mejorar la calidad de vida de las generaciones venideras

Burn treatment is such an ancient science as human conflicts, and it has had to be refined and adapted to the improvements in military technology throughout history. Fire has probably been one of the first double sided weapons developed by humanity during its technologic development. This element has both served to improve life conditions of societies, and to destroy them causing terrible suffering. In this article, we perform a chronological exposition of the evolution of burn treatment, presenting the more relevant scientific figures of each time, and their contributions. Also, conflicts and disasters that coincided with these scientists are described, as in most cases, the work developed during those catastrophes eased the advancement of this field. The objective of this historical review is to provide the reader with certain knowledge about the path this science has followed until reaching its actual state. The first existing reference to burn treatment goes back to an egyptian papyrus written around the year 1500 b.C. Since then, each relevant figure in the field of Medicine of their time proposed their own treatment for burns; which in most cases, had no scientific basis according to current paradigms. However, since the 16th century, certain advancements in different fields of burn care were described, reaching an important development during the 19th and 20th centuries, when industrial and scientific revolution coexisted with the Great Wars, which provided wide experimental and observational fields. Therefore, and thank to scientific discoveries of the last centuries, burned patients present survival rates that were unconceivable years ago. We remark that highlighting that adversity, studied through scientific methodology, might serve as an opportunity to improve quality of life of upcoming generations

Reconstruction of Middle-Third Helical Traumatic Defects With a Two-Stage Approach: Retroauricular Flap and Costal Graft.

In this article, we describe the case of a patient suffering from middle-third helical rim avulsion after a bicycle accident, which was reconstructed with a two-stage procedure: (1) performing a postauricular pedicled flap and (2) reconstruction using a costal graft. The article also includes a brief summary of recommendations in the scientific literature about the reconstruction of middle-third auricular defects.

Use of the Meek Micrografting Technique for Coverage of Extensive Burns: A Case Report.

Traditional mechanical meshing methods have generally been the first-choice treatment of patients with extensive burns (>20% total body surface area). The limited availability of donor areas has sparked the development of resources such as the Meek micrografting technique. We present the case of a 43-year-old male patient with an 85% total body surface area third-degree flame burn. After the initial stabilization, there was a need for rapid and effective coverage of as much burned surface as possible. Thus, Meek micrografting was chosen. Its results in this patient are presented and discussed. The Meek technique is a useful method of skin expansion. It is indicated in patients with extensive burns, where donor areas are limited. The high rates of graft take and quality of the coverage attained make this technique appealing, albeit at a greater economic cost than with traditional mechanical meshing methods.

Inguinal Reconstruction Using Pedicled Rectus Abdominis Flap: A Useful Option for the Application of Radiotherapy.

Given their high rate of complications, radical surgical procedures of anorectal and gynecological tumors require a reliable and individualized reconstruction. The latter is influenced by the frequent indication of adjuvant chemo/radiotherapy that they present. We describe the case of a patient with medical history of vulvar carcinoma that required radical surgery and bilateral inguinal lymphadenectomy. Because of the stage of the tumor, the application of postoperative radiotherapy was clinically indicated; however, after surgery, the patient developed bilateral inguinal ulcers that made postoperative radiotherapy application impossible. Using a radical surgical approach in combination with postoperative radiotherapy increases survival in patients with these types of tumors. Therefore, delaying its use because of wound complications or inadequate reconstruction cannot be justified. The pedicled abdominal rectus flap is an excellent option for this purpose in patients with moderate- to large-sized defects.