El colgajo libre de arteria perforante sural medial: revisión sistematizada de casos publicados y experiencia en tres centros de Latinoamérica / The medial sural perforating artery free flap: systematized review of published cases and experience in three centers in Latin America

Introducción y objetivo: El colgajo libre perforante de la arteria sural medial es un colgajo versátil, que se caracteriza por ser relativamente delgado, maleable, con una anatomía vascular fiable y baja morbilidad en el sitio donador. Se popularizó en Asia como una buena alternativa en la reconstrucción de cabeza y cuello. Sorprendentemente, se usa con poca frecuencia en América. Este artículo, a través de una revisión de la literatura y nuestra experiencia en 3 centros en América Latina, pretende ayudar a los microcirujanos latinoamericanos a familiarizarse con este colgajo, presentando la técnica quirúrgica, sus aplicaciones más comunes y las posibles soluciones a los problemas más comúnmente encontrados. Material y método: Realizamos la revisión bibliográfica en cuatro plataformas; Medline, Google Scholar, PubMed Central y Embase, obteniendo después de criterios de exclusión 572 pacientes de 36 artículos. A estos agregamos nuestra serie de casos como estudio retrospectivo en los Departamento de Cirugía Plástica de 3 centros en América Latina, entre mayo de 2015 y diciembre de 2020, con un total de 34 pacientes. Resultados: En total reunimos 606 pacientes entre la revisión de casos publicados y nuestra propia serie; de ellos, 75.1% hombres y 24.9% mujeres, con edad media de 49.1 años. El colgajo se usó principalmente en reconstrucción oral. El tamaño promedio del colgajo fue de 54.5 cm2, con un grosor de 5.9 mm y una longitud del pedículo de 9.7 cm. El tiempo de disección del colgajo y de cirugía fue de 74 y 370 min. respectivamente. La tasa de complicaciones fue de 12.7%: 3% en la zona donadora, 4.3% de pérdida total del colgajo, 4.1% con pérdida parcial y 1.3% con congestión venosa transitoria. (AU)

Background and objective: The medial sural artery perforator flap is vastly versatile. It is characterized by being wide, thin, flexible, adequate pedicle length, reliable vascular anatomy, and has low donor site morbidity. It has been popular in Asia as a good alternative, especially in head and neck reconstruction. But surprisingly, it's not frequently used in America. In this article, through a review of the literature and our experience from 3 centers in Latin America, we intend to help Latin-American microsurgeons get familiarized with this flap by presenting the surgical technique, the most common applications, and possible solutions to the most common problems encountered. Methods: For the literature review, the search was performed on 4 different platforms: Medline, Google Scholar, PubMed Central, and Embase. They were gathered, after exclusion criteria, 572 patients from 36 different publications. In addition to the previous, 34 more patients were added from our own experience in 3 different Latin-American hospitals, from May 2015 to December 2020. Results: A total of 606 patients were gathered through the systematic review and our clinical series, 75.1% male and 24.9% females, average age of 49.1 years. This kind of flap is commonly used for oral reconstruction. The average flap size was 54.5 cm2, with a 5.9 mm thickness and an average pedicle length of 9.7 cm. The average time for the flap harvest and surgery was 74 and 370 min, respectively. The complications rate reported was of 12.7%: 3% from donor complications, 4.3% from total flap loss, 4.1% from partial loss and 1.3% from venous congestion. (AU)

Influence of BMI, Age, and Gender on the Thickness of Most Common Thinned Flaps.

BACKGROUND: Since the description of superficial fascia flap harvesting, a new window of opportunity has been open in obese patients, where a higher subcutaneous thickness of tissue is present. To our knowledge, the impact of body mass index on superficial fascial flaps has not been reported. METHODS: We recruited 122 patients from April 2019 to January 2020. From these patients, the 3 most common thinned flaps were selected: the superficial circumflex iliac perforator flap; the anterolateral thigh flap at the perforator A, B, and C; and the thoracodorsal flap. Two vertical measures were registered: the distance from the skin to the superficial fascia, and from this point to the deep fascia. RESULTS: The average flap measurement presented here was within the range, as previous clinical studies. The superficial fatty layer thickness in the superficial circumflex iliac perforator and anterolateral thigh flap was somewhat similar in thickness between overweight and obese patients, showing a minimal increase with higher body mass index. The anterolateral thigh flap was found thicker among women, and no statistical difference was shown between age groups in any of the flaps. CONCLUSIONS: A better understanding of the fat layers' thickness will result in better planning, minimizing secondary debulking procedures, decreasing operative time, and reducing general complications among obese patients. Thus, a better understanding of flap structure and physiology in obese patients will lower complications and give more predictable results.

Repair of a complex abdominal wall defect with anterolateral thigh flap: a good surgical alternative.

INTRODUCTION: Reconstruction of the abdominal wall with major defects usually represents a surgical challenge, especially in cases where the defects are recurrent and have a large size that avoids the use of adjacent tissues for an adequate closure. According to each region the abdomen topography is divided into three regions: upper, middle and lower. Several reconstructive alternatives have been described according to the affected area of the abdomen that include the separation of the muscularis aponeurotic components of the abdominal rectus sheath, the flap of the rectus abdominus muscle with or without cutaneous island, the flap dependent on the dorsal muscle and muscular or musculocutaneous thigh flaps to reconstruct the lower area of the abdomen which is called anterolateral thigh (ALT) flap. The ALT flap has become the best option for large recurrent defects in any of the thirds due to its great versatility. CASE REPORT: We present the case of a 50-year-old patient with an abdominal wall defect, loss of domain and exposure of prosthetic material. Patient had a surgical history of open cholecystectomy, necrosectomy due to acute pancreatitis with open abdomen management and attempted repair of the abdominal defect twice with mesh placement. The abdominal wall was reconstructed with an ALT free flap with a fascia lata component with anastomosis to superior epigastric vessels in a successful manner. Nowadays patient remains without evidence of recurrence of the hernia at 1 year follow-up. DISCUSSION/CONCLUSION: The aim of this paper is to illustrate the ALT flap with a fascia lata component anastomosed to the superior epigastric vessels as a good option to reconstruct complex defects of the upper third of the abdomen.

INTRODUCCIÓN: La reconstrucción de la pared abdominal con grandes defectos suele representar un desafío quirúrgico, sobre todo cuando los defectos son recurrentes y tienen un gran tamaño que dificulta la utilización de tejidos adyacentes para un cierre adecuado. La pared abdominal anterior se divide en tres regiones para su reconstrucción; superior, media e inferior. De acuerdo con cada región se han descrito diferentes técnicas de reconstrucción de pared, como la separación de componentes musculoaponeuróticos de la vaina de los rectos abdominales, el colgajo del músculo recto abdominal con o sin isla cutánea, el colgajo dependiente del músculo dorsal ancho y colgajos musculares o músculocutáneos del muslo para reconstruir el tercio inferior del abdomen, llamado colgajo anterolateral de muslo (ALT, por sus siglas en inglés). El ALT se ha convertido en una buena alternativa para los grandes defectos recurrentes en cualquiera de los tercios debido a su gran versatilidad. CASO CLÍNICO: Presentamos el caso de un paciente de 50 años con un defecto de pared abdominal, pérdida de dominio y exposición de material protésico (malla). Tenía el antecedente quirúrgico de colecistectomía abierta, necrosectomía por pancreatitis aguda con manejo de abdomen abierto (incisión en línea media supra-infraumbilical) e intento de reparación del defecto abdominal en dos ocasiones con colocación de malla (que se encontraba expuesta). El defecto existente se desmanteló y resecó en bloque desde el interior de la pared abdominal, dejando bordes aponeuróticos sanos, quitando todo el tejido cicatricial, la malla y los bordes cutáneos enfermos. Se realizó la reconstrucción de la pared abdominal con ALT con un componente de fascia lata con anastomosis a vasos epigástricos superiores, de manera exitosa. Actualmente no hay evidencia de recurrencia del defecto herniario tras 1 año de seguimiento. DISCUSIÓN/CONCLUSIÓN: El objetivo de este trabajo es describir el ALT con componente de fascia lata con anastomosis a los vasos epigástricos superiores como una buena alternativa para reconstruir defectos de pared complejos del tercio superior del abdomen.

Colgajo submentoniano: aplicaciones clínicas y variantes en su diseño / Submental flap: clinical applications and variations in the desig

Introducción y objetivo: El colgajo submentoniano ha sido descrito como alternativa para la cobertura de defectos cutáneos en tercio medio e inferior de la cara y como colgajo microquirúrgico para tratamiento del linfedema secundaria de extremidades, al incorporar en su diseño nódulos linfáticos vascularizados. El presente estudio pretende justificar el uso del colgajo submentoniano en sus distintas variantes con la incorporación tradicional de músculo digástrico, perforante de arteria submentoniana, de flujo reverso o microquirúrgico, y con mínima morbilidad del sitio donador. Material y método: Presentamos una serie de 8 pacientes en los que realizamos un colgajo submentoniano para cobertura de defectos en tercio medio e inferior de cara y de linfedema secundario de extremidad superior. Los colgajos tuvieron dimensiones de 40 a 84 cm2 (media de 62 cm2). Los colgajos fueron pediculados con base en la arteria submentoniana en 4 casos (50%), con preservación del músculo digástrico basado en un vaso perforante de la arteria submentoniana en 2 casos, como colgajo submentoniano de flujo reverso en 1 caso, y como colgajo submental linfático vascularizado en 1 caso. Resultados: Recogimos como complicación una necrosis parcial distal de un 20% en un colgajo submentoniano de flujo reverso, que fue tratada con cicatrización dirigida a segunda intención. La zona donadora se trató en todos los casos con cierre primario. Conclusiones: En nuestra opinión, el colgajo submentoniano es una herramienta útil en la reconstrucción de tejidos blandos del tercio medio e inferior de la zona facial, con un grosor, textura y coloración similares, así como una alternativa en el tratamiento del linfedema secundaria de la extremidad superior

Background and objective: The submental flap has been previously described as an alternative for the coverage of cutaneous defects or the middle and lower thirds of the face, as well as a vascularized lymph node flap for the treatment of secondary lymphedema of the extremities. Our goal is to justify its clinical application, and the use of the variants of the components of the flap and design, either with the inclusion of the digastric muscle, submental perforator, reverse flow or microvascular flap, with minimal complications. Methods: We present a series of 8 patients in which a submental flap was performed to restore cutaneous defects of the middle and lower thirds of the face, and the treatment of secondary lymphedema of the upper extremity. Flaps dimensions were between 40 to 84 cm2 (average of 62 cm2). The flap was designed as submental pedicled flap in 4 cases (50%), with preservation of digastric muscle based on a submental perforator in 2 cases, reverse flow submental flap in 1 case, and as a vascularized submental lymph node transfer flap y 1 case. Results: Complications occurred in 1 of the cases, presented as a partial necrosis of a 30% of a submental reverse flow flap, which healed by secondary intention. Donor site was closed primarily in all the cases. Conclusions: In our opinion, the submental flap is a good choice for the coverage of cutaneous defects of the middle and lower face, providing a thickness, texture and color similar to neighboring tissues, as well as an alternative for the treatment of secondary lymphedema of the upper extremity

Complex upper limb reconstruction using dorsoepigastric flap. Case report of a convenient resource.

INTRODUCTION: Dorsoepigastric flap (DF), first described by. Haddad and Jimenez, is a variant of the classic lattisimus dorsi musculocutaneous flap that only utilizes a minimum quantity of muscle tissue, through which the vascular pedicle passes by. It has been used primarily as an acceptable alternative in mammary reconstruction when the use of thoraco abdominal muscles is not viable, and offers several advantages such as adequate flap volume with generous cutaneous island dimensions and functional preservation of the latissimus dorsi. PRESENTATION OF A CASE: We report the case of a 12 year old male, who suffered a left upper limb injury secondary to high power firearm shot. He presented extensive damage to the skin, soft tissues and bone structures and was treated with primary reconstruction using DF and peroneal grafts. Three years later, a shoulder prosthesis was placed to improve limb function with unobjectionable results. CONCLUSION: DF is a useful resource that has been merely used in the context of complex upper limb reconstruction, and must be considered essential in the repertoire of the reconstructive surgeon when facing traumatic defects of the upper extremity.

Campañas de reconstrucción mamaria en Guanajuato, México / Breast reconstruction campaigns in Guanajuato, México

La reconstrucción mamaria se considera en la actualidad una parte integral del tratamiento del cáncer de mama, ya que otorga a la mujer calidad de vida, mejora de su imagen corporal y con ello, una mejora de su forma de percibir su enfermedad. En México, el cáncer de mama ocupa el primer lugar en neoplasias malignas en las mujeres y solamente una tercera parte de las que lo padecen se someten a una reconstrucción mamaria. Lamentablemente las instituciones de salud del país, así como los recursos materiales y humanos en el sector público, son insuficientes para cubrir el proceso de reconstrucción mamaria en esta población, por lo que tras al tratamiento oncológico, es muy común encontrar pacientes no reconstruidas en nuestro medio. Por esta razón, decidimos crear una organización altruista que, mediante la organización de campañas anuales, logra apoyar a las mujeres guanajuatenses que no tienen la oportunidad de recibir un tratamiento completo tras sufrir un cáncer de mama

Breast reconstruction is currently considered an integral part of the treatment of breast cancer, since it gives quality of life, improves the body image of women and thus improves their way of perceiving their disease. In México, breast cancer occupies the first place in malignant neoplasms in women and only one third of those who suffer from it are reconstructed. Unfortunately the health institutions of the country, as well as the material and human resources in the public sector, are insufficient to cover the process of mammary reconstruction in this population, so that after the oncological treatment, it is very common to find patients not reconstructed in our region. For this reason, we decided to create an altruistic organization that, through the creation of annual campaigns, manages to support women from Guanajuato who do not have the opportunity to receive a complete treatment after breast cancer

Craneoplastia en deformidad postraumática y postquirúrgica, 18 años de experiencia en el Hospital General de México: una opción reconstructiva segura / Craneoplasty in post-traumatic and postoperative deformity, a 18- year experience at Hospital General de México: a secure reconstructive option

Introducción y Objetivos. Los defectos craneales que llegan a nuestro hospital generalmente son secundarios a trauma o bien a su tratamiento neuroquirúrgico. La craneoplastia no suele ser inmediata, sin embargo el síndrome de trepanación o el deseo del paciente por mejorar su apariencia, son mandatorios para poder realizar la reconstrucción. El material ideal para una craneoplastia debe ser biocompatible, fácil de fabricar y biomecánicamente estable. En nuestro Servicio llevamos a cabo la reconstrucción craneal con una prótesis de metil-metacrilato diseñada mediante estereolitografía, cubierta completamente por un injerto de fascia lata. En nuestra experiencia esta nos brinda resultados predecibles, seguros y satisfactorios para los pacientes. Material y Método. Presentamos nuestra experiencia inicial en el uso de esta técnica a través de un análisis retrospectivo sobre 32 pacientes operados por un equipo multidisciplinario entre enero de 1996 y junio de 2014 en el Hospital General de México Dr. Eduardo Liceaga. Resultados. No tuvimos complicaciones importantes relacionadas con infección, hematoma o seroma. Los resultados estéticos obtenidos fueron de aceptables a buenos. Conclusiones. En esta serie de pacientes usando la técnica descrita, recogimos una tasa de complicaciones muy baja y un excelente grado de satisfacción de los pacientes en el seguimiento a largo plazo (AU)

Background and Objective. The skull defects in our center result from descompressive craniectomy after trauma, bony involvement by tumors or infarction, and the cranioplasty will be mandatory if the patient have the syndrome of the trephined or wish to improve their appearance. The ideal material for cranioplasty there will be biocompatible, simple to manufacture, and biomechanically reliable, at least. In our Department, the skull reconstruction is performed with methylmethacrylate prosthesis, designed by stereolithography, and then covered with an onlay fascia lata tendon graft. In our experience this kind of skull reconstruction has been demonstrated secure, predictable and satisfactory results. Methods. We report our initial experience using this technique with a retrospective analysis of 32 patients operated from January 1996 to June 2014 by a multidisciplinary team in the General Hospital of Mexico Dr. Eduardo Liceaga. Results. There were no significant complications related to infection, hematoma or seroma. The aesthetic results have been considered acceptable, to excellent. Conclusions. In our patient series using this technique we collected an extremely low complication rate and an excellent grade of patient satisfaction on long-term follow up (AU)