Optimización del injerto conectivo subepitelial en la cobertura de recesiones gingivales múltiples contiguas: presentación de un caso clínico / Optimization of the subephitelial connectivetissue graft to treat adjacent multiple gingivalrecessions. Clinical case presentation

Objetivo: describir, mediante un caso clínico, una técnica quirúrgica para la optimización del injerto conectivo libre subepitelial en la cobertura de recesiones gingivales contiguas múltiples. Caso clínico: Una paciente de sexo femenino, de 57 años de edad, concurrió a la consulta con recesiones clase III de Miller, abfracciones, erosiones y malposición. El procedimiento quirúrgico elegido fue la técnica de desplazado coronal con incisiones oblicuas. Se realizó la toma de un injerto conectivo subepitelial y se lo optimizó en seis porciones trian-gulares, de manera tal que cada una abarcara una recesión desde el 13 hasta el 23. Se efectuó el seguimiento de la cicatrización y de la estabilidad de la cobertura radicular a los 90 días.Conclusión: Este nuevo abordaje quirúrgico es una alternativa válida para cubrir recesiones gingivales múltiples en un solo procedimiento, al poder aprovechar al máximo la utilización de un injerto conectivo libre subepitelial.

Aim: to present the surgical resolution of a clinical caseof multiple gingival recessions treated with a novel approach.Case report: A 57 year-old non-smoking female patientwith Miller Class III gingival recessions abfractions, erosionsand tooth malposition came to the consultation. The treatmentthat was chosen consisted in covering the gingival recessionswith a coronal advanced flap with oblique incisions. A subephitelialgingival graft was harvested from the palate andan optimization in triangular portions was made, in order touse one portion for each recession. Healing and stability wererecorded for a 90 days follow-up period.Conclusion: This new surgical approach could be analternative for the treatment of multiple gingival recessionsin a single procedure, as the use of the ILS could be maximized.

Técnica rollo modificado en H para mejorar el perfil de emergencia en implantes unitarios: reporte de un caso / H-modified roll technique to improve the emergence profile in single implants: report of a case

Uno de los principales problemas que tiene que afrontar la terapia periodontal e implantológica es la preservación del reborde alveolar y los tejidos blandos luego de la colocación de un implante dental más aún si se trata de la zona anterior en donde se requiere de una alta estética. Presentamos el caso de una paciente de sexo femenino que presenta defecto I de Seibert en lazona del implante inmediato post exodoncia de la pieza 1.2. Se decide realizar la Técnica de Rollo modificado en H para mejorar el aspecto vestibular del reborde reabsorbido. Se obtienen óptimos resultados, y una mejora substancial del aspecto estético vestibular al cabo de 3 meses de cicatrización.

Hiperplasia gingival fibrosa en sitio estético: enfoque quirúrgico ante recidiva / Fibrous gingival hyperplasia in esthetic zone: surgical approach on recurrence

Objetivo: aportar evidencia clínica sobre el abordaje de lesiones hiperplásicas en sitios estéticos y enfatizar la importancia de la planificación quirúrgica para reducir al mínimo su recidiva. Caso clínico: una paciente de 65 años de edad se presentó a la consulta con lesión nodular localizada en encía vestibular de pieza 21, con un período de evolución de 18 meses. Se describe el procedimiento quirúrgico inicial llevado a cabo para su tratamiento, el diagnóstico anatomopatológico, su evolución y recidiva, y un nuevo enfoque quirúrgico para su eliminación. Conclusiones: este informe enfatiza la importancia de una completa escisión de la lesión con margen de seguridad para evitar su recidiva, como objetivo primario en el abordaje quirúrgico. En sitios estéticos, la biopsia escisional, junto con la cirugía plástica periodontal, puede ser una opción para restaurar la salud gingival y devolver la estética y función al sitio

Recesión única en el maxilar superior, tratamiento mediante colgajo desplazado lateral avanzado coronalmente: reporte de casos / Isolated recession in the upper maxillary, treatment by means of coronally advanced lateral flap: report of cases

Describir el tratamiento quirúrgico realizado, como también evaluar la cicatrización y cobertura gingival obtenida en dos pacientes con recesiones gingivales únicas en vestibular del maxilar superior. Casos clínicos: en los dos casos presentados en este reporte se trataron quirúrgicamente dos recesiones clase I y II de Miller, mediante colgajo desplazado lateral avanzado coronalmente. Conclusiones: es de suma importancia preservar y/o recuperar los tejidos gingivales, no solamente desde el punto de vista estético sino también funcional. Debemos considerar los factores anatómicos locales que influyen en el resultado final y hacer un diagnóstico correcto del caso. Aprovechando las ventajas de esta técnica disminuiremos los fracasos...

Técnica quirúrgica antifuga en el implante de catéter de Tenckhoff para diálisis peritoneal / Antileaking surgical technique in implantation of Tenckhoff's catheter for peritonal dialisis

Se realizó un estudio experimental, prospectivo, comparativo, de selección aleatoria y ciego en los Hospitales Nuevo Civil y México Americano de Guadalajara, de enero a diciembre de 1994, en que se analizaron dos procedimientos utilizados para disminuir hiperazoemia en pacientes con insuficiencia renal crónica o aguda, con la finalidad de establecer eficiencia obtenida mediante la aplicación de catéteres de diálisis peritoneal rectos y curvos a la cavidad peritoneal. En ambas técnicas se fijo firmemente el catéter a la aponeurosis peritoneal o posterior del músculo recto anterior del abdomen. Distribuimos 90 pacientes en dos grupos de 45, para comparar la técnica quirúrgica original de colocación de catéter de diálisis frente a una técnica que denominamos "antifuga". El objetivo principal es demostrar que utilizando la técnica antifuga y clasificando la consistencia de la aponeurosis posterior del músculo recto anterior del abdomen (APRA) y utilizando el grosor de la sutura según su firmeza, pudiera existir un menor número de fugas, infecciones del túnel subcutáneo e infección en el sitio de salida de la pared abdominal, además de disminuir otras complicaciones secundarias, como son: dehiscencia, herniación e infección de la herida quirúrgica. Con base a los resultados de este estudio experimental concluimos que existe correlación entre la fuga temprana de soluciones con la técnica original y con la edad, grado de obesidad y APRA de los pacientes. Además, que el de catéteres en espiral fallan que menor frecuencia que los rectos, por lo que recomendamos la técnica antifuga y el empleo de catéteres en espiral en el manejo de diálisis peritoneal ambulatoria para pacientes con insuficiencia renal crónica

Reparación de grandes defectos cutáneos con colgajos libres microvasculares / Skin coverage after surgical removal of extensive skin cancers with microvascular free flaps

Antecedentes: La reparación de grandes defectos cutáneos post-resección de tumores malignos representó durante años un desafío difícil de solucionar para el cirujano oncológico debido a las limitaciones impuestas por los procedimiento reconstructivos. Objetivo: Se analizó la experiencia de la División de Cirugía Oncológica del Hospital de Clínicas en las reconstrucciones post-resección de tumores cutáneos con colgajos libres microquirúrgicos entre los años 1986-1997. Diseño: Estudio retrospectivo. Población: Se analizaron 37 enfermos (31 con lesiones de cabeza y cuello, 4 en miembro superior y 2 en miembro inferior) en quienes se realizaron 39 colgajos sobre un total de 147 pts. reconstruidos con 153 colgajos, en quienes se realizaron 24 colgajos radiales, 14 paraescapulares, y 1 dorsal ancho. Métodos: Se realizó la revisión de las historias clínicas de pacientes portadores de tumores cutáneos, analizándose la aplicabilidad del método, las complicaciones y un análisis de resultados categorizándolos en buenos, regulares y malos. Resultados: Se registró un índice global de complicaciones de 13 por ciento (5 casos). En 2 casos necrosis del colgajo. No hubo mortalidad operatoria. 94 por ciento de los pts. tuvieron resultados buenos o regulares. Conclusiones: Las reconstrucciones con colgajos microquirúrgicos tienen distintas ventajas sobre las técnicas hasta ahora utilizadas. Por esta razón son preferidas para la reconstrucción de grandes defectos planos, en dos y o en tres dimensiones; en un tiempo operatorio, con escasa morbilidad y nula mortalidad, y resultados estéticos y funcionales superiores. El colgajo radial tiene un pedículo, puede disecarse y requiere el uso de injerto sobre la zona dadora. El paraescapular de fácil disección, provee una isla de piel delicada de gran extensión, tiene un pedículo confiable y permite el cierre primario de la zona dadora

Arteriovenous cross-flow flap in rats: a novel skin flap.

Angiosomes are blocks of tissues, composed of the integument and underlying deep structures, supplied and drained by a named artery and its accompanying vein. The purpose of the current study is to describe a new principle, which allows extension of the territory of an angiosome into the adjacent angiosome, thus enabling the creation of a large skin flap (arteriovenous cross-flow flap). Epigastric skin flaps, measuring 8 x 8 cm, were raised in 30 Sprague-Dawley male rats. In group A (single-pedicle flap), the flaps were based on the epigastric artery and vein on the ipsilateral side, and the contralateral pedicle was divided. In group B (cross-flow flap), the epigastric vein on the ipsilateral side and the epigastric artery on the contralateral side of the flap were divided. In group C (skin graft), the vascular pedicles were divided bilaterally. A definitive assessment was made on the seventh day. Digital images of the flaps were analyzed using an imaging software and the areas of skin survival and necrosis were determined. Lead oxide microangiogram was performed in another set of flaps both acutely and 1 week after flap elevation. The percent survival flap area in group A was 69.94, in group B was 89.07, and in group C was 13.00. All the groups are statistically different, with a p value < 0.001. The microangiograms showed striking differences in the vascular pattern in the cross-flow and the single-pedicle flaps. It is clearly demonstrated that the arteriovenous cross-flow flaps have increased survival of skin when compared with the conventional axial-pattern flaps.

Surgical management of persistent mediastinitis after coronary bypass grafting.

Persistent mediastinitis despite primary revision, closed irrigation therapy, and additional secondary omental plasty is a life threatening situation in cardiac surgery. We managed this rare complication in one instance by sternectomy and hemirectus plasty as well as bilateral pectoralis plasty.

Mandibular anterior ridge extension: a modification of the Kazanjian vestibuloplasty technique.

PURPOSE: A modification of the secondary epithelization vestibuloplasty technique described by Kazanjian that eliminates the sharp V in the depth of the extended vestibule and counteracts shallowing of the sulcus is presented. PATIENTS AND METHODS: Ten consecutive patients indicated for anterior mandibular secondary epithelization vestibuloplasty were treated. A bipedicled mucosal flap was developed in the labioalveolar mucosa for lining the extended vestibular depth. A comparison was made of the vestibular depth measured from the crest of the ridge to the junction of the attached mucosa both preoperatively and postoperatively. RESULTS: Healing of raw surfaces was uneventful. The mean preoperative anterior mandibular vestibular depth was 3.5+/-1.1 mm. After 6 months, the mean anterior mandibular vestibular depth was 9.2+/-1.7 mm, a statistically significant difference (P < .05). The mean gain in vestibular depth was 5.7+/-2.2 mm. CONCLUSION: Overcorrection is unnecessary with this modification. Elimination of the sharp V in the extended vestibular depth enables denture fabrication with better flange extension and improved oral hygiene.

Cross-leg free flaps for difficult cases of leg defects: indications, pitfalls, and long-term results.

BACKGROUND: Cross-leg free flaps have been described for reconstruction of leg defects in cases of trauma with no suitable recipient vessels in the vicinity of the defect. The pitfalls, however, have not been well documented in the literature. The technique of transfer and the length of time required before pedicle division depend on the nature of the flap and the contact surface. METHODS: Eight cross-leg free flap reconstructions were performed on seven patients between 1986 and 1993. These included three latissimus dorsi muscle flaps, three fibula osteomyocutaneous flaps, one tensor fascia lata myocutaneous flap, and one posterolateral thigh flap. The important technical considerations are outlined. RESULTS: One latissimus dorsi flap failed, whereas the rest of the flaps completely survived. The morbidity of the recipient and donor sites are listed. CONCLUSION: We conclude that the technique offers the possibility of salvaging limbs that are, otherwise, nonreconstructable. It is useful for young patients. When the flap is long, it can function as a nutrient flap for the distal limb even though the pedicle has been divided. It is a backup procedure in an urgent situation of re-exploration in which reestablishment of circulation should take place as soon as possible.

Nail transfer: evolution of the reconstructive procedure.

Reconstruction of a missing or deficient nail is an interesting and challenging undertaking for plastic surgeons, but little has been published concerning this topic. In the past 23 years, from 1973 to 1995, we performed 24 operations for nail reconstruction in 19 patients. A free nail graft was used in 14 operations, and a vascularized nail flap was used in 10. Vascularized nail flaps were divided into three categories: long-pedicle vascularized nail flaps (3 nails), vascularized nail flaps supplied by arterial inflow from the venous system (termed venous flaps, 3 nails), and short-pedicle vascularized nail flaps (4 nails). In only one case of free nail graft did the grafted nail necrose secondary to infection. The other 23 nails (13 free nail grafts, 10 vascularized nail flaps) survived completely, and good nail growth was obtained. With progress in plastic surgery, reconstructive procedures for nails have changed. In this paper, we will report the evolution of our reconstructive procedure and current strategy of nail reconstruction.

Comparison of onlay and tubularized island flaps of inner preputial skin for the repair of proximal hypospadias.

PURPOSE: Transverse island flaps of inner preputial skin have provided a reliable technique for the repair of proximal hypospadias. The flap may be used to create a neourethra by tubularizing the flap after urethral transection or applying the flap as an onlay patch onto an intact urethral plate. We retrospectively analyzed our experience with these 2 techniques to compare outcomes. MATERIALS AND METHODS: During 11 years 132 patients underwent hypospadias repair by a single surgeon using an onlay (58) or tubularized (74) island flap technique. Surgical results were reviewed retrospectively. RESULTS: At a mean followup of 20.3 months the overall complication rate was 36% for tubularized and 31% for onlay repair, and fistula rates were 14 and 17%, respectively. Despite similar fistula rates tubularized repairs tended to have larger fistulas that required more complex repair (p = 0.0147). In 9 patients who underwent tubularize repair diverticula developed, whereas no diverticula developed after onlay repair (p = 0.0162). The rates of urethral stricture, wound infection, residual chordee and cosmetic complications were not statistically significantly different between repairs. The use of double faced repair in 30 patients provided no difference in outcome in comparison to the overall study cohort. CONCLUSIONS: Hypospadias repair using transverse island flaps offers reliable and durable outcomes. While overall complication rates were not greatly different between tubularized and onlay flap repairs, onlay repair tended to result in fistulas of smaller size and diverticula did not develop.

Reconstruction of the high urogenital sinus: early perineal prone approach without division of the rectum.

PURPOSE: Reconstruction of the vagina and external genitalia in the infant is quite challenging, particularly when a urogenital sinus is associated with high confluence of the vagina and urethra. Many surgeons believe that children with such a malformation should undergo staged or delayed reconstruction, so that vaginoplasty is done when the child is older and larger. Vaginoplasty early in life is thought to be difficult due to patient size and poor visualization. The posterior sagittal approach has been beneficial for acquiring exposure to high urogenital sinus anomalies but it has been thought to require splitting of the rectum and temporary colostomy. We report a modification of this technique. MATERIALS AND METHODS: In the last 5 years all patients with urogenital sinus anomalies underwent reconstruction using a single stage approach regardless of the level of confluence. In 8 patients with a high level of confluence reconstruction was performed using a perineal prone approach. Exposure was achieved without division of the rectum. The operative technique is presented in detail. RESULTS: This midline perineal prone approach has allowed excellent exposure of the high vagina even in infants. In all 8 patients reconstruction was done without difficulty and no patient required incision of the rectum or colostomy. This procedure did not preclude the use of a posteriorly based flap for vaginal reconstruction. CONCLUSIONS: While patients with low confluence can be treated with single posteriorly based flap vaginoplasty, those with higher confluence may benefit from a perineal prone approach to achieve adequate exposure for pull-through vaginoplasty. This prone approach to the high urogenital sinus anomaly can be performed without division of the rectum, provides excellent exposure of the high confluence even in small children and does not preclude the use of posterior flaps for vaginal reconstruction.

The non-refluxing gastrostomy: an evaluation.

A gastrostomy is often essential to deliver adequate and safe nutrition. Various types are now available such that the technique can be tailored to the specific needs of the patient. This paper explores the non-refluxing gastrostomy for long-term intermittent gastrostomy feeding, avoiding the need for a permanent indwelling appliance. A full-thickness vascularized flap based on the right gastroepiploic vessels is raised from the greater curve of the stomach. The proximal half of the tubularized flap is buried in a submucosal tunnel and the free distal end is brought to the skin surface as a catheterizable stoma. Fifteen children with varied mental and physical disabilities formed the cohort of the study. There were 3 stomal stenoses and 3 mild mucosal eversions requiring minor surgical adjustments. One child had a wound dehiscence 10 days postoperatively. Once the stoma had healed, the majority fed by intermittent catheterization and bolus feeds at conventional feed times during the day. Intermittent catheterization was painless and easy and was well accepted by caregivers and patients. Perhaps the most important advantages were the increased patient and caregiver confidence and independence, as well as the reduction in anxiety and hospital attendance.

Vascular delay in skeletal muscle: a model for microcirculatory studies.

Dynamic myoplasty is a relatively new use for muscle flaps and has led us to revisit the mechanisms of vascular delay as a means of optimizing blood supply to muscle flaps. Despite the well-documented effectiveness of vascular delay in skin flaps, vascular delay in muscle flaps has not been widely reported. Regardless of the many mechanisms postulated in the literature as contributors to the delay effect in skin, the one element common to all these hypotheses is the importance placed on changes in the microcirculation. Based on this factor, in the present study we developed and validated an animal model in which delay-induced microvascular changes could be measured in skeletal muscle flaps. We used the hairless mouse latissimus dorsi muscle flap because its vascular distribution is similar to that of humans and its thin structure will enable us in future studies to directly view and measure its microvasculature using videomicroscopy. In 12 animals, we found that delay significantly (p < 0.01) reduced necrosis of the distal part of the muscle from 57 +/- 9 percent in nondelayed flaps (n = 7) to 22 +/- 3 percent in delayed (n = 5) flaps. In these studies, we also determined that the hairless mouse latissimus dorsi muscle flap will serve as an excellent model for defining microvascular changes throughout delay.

Bone flap fixation: a new technique. Technical note.

A new fixation technique for bone flaps is described. This technique avoids the use of hardware external to the skull in hairless areas where it may prove unsightly in patients with a thin scalp. The insertion of pins into the middle table of the skull firmly fixes bone flaps at one edge, eliminating the need for external plates at that site.