RESUMO
This study explores the quality of life in 118 patients following severe and major hand injury with a Hand Injury Severity Score >50. Each patient answered five different validated outcome measures (DASH (Disability of the Arm, Shoulder, and Hand), FLZ(M) ('Fragen zur Lebenszufriedenheit'), HADS (Hospital Anxiety and Depression Score), BDDE-SR (Body Dysmorphic Disorder Examination-Self Report) and FBeK ('Fragebogen zur Beurteilung des eigenen Körpers'), which were incorporated into a single questionnaire. Each of these questionnaires covered one or more of the established quality-of-life domains. Patients with pain and pressure sensations were significantly less satisfied in life, showed lower levels of health satisfaction, had higher levels of anxiety and depression and showed higher body dysmorphic disorder levels (all p < 0.001). General life satisfaction in this hand-injury study group is highly dependent on the patients` satisfaction with their health and appearance as well as self-confidence. The quality-of-life outcomes improve with time, and despite evidence of continued impairment in the injured hand, the majority of patients had a normal quality of life.
Assuntos
Traumatismos da Mão/psicologia , Qualidade de Vida , Adolescente , Adulto , Análise de Variância , Distribuição de Qui-Quadrado , Criança , Avaliação da Deficiência , Feminino , Traumatismos da Mão/cirurgia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Recuperação de Função Fisiológica , Análise de Regressão , Estudos RetrospectivosRESUMO
BACKGROUND: In the treatment of esophageal cancer neoadjuvant radiotherapy often leads to vascular damage of the usual recipient arteries for free jejunal transfer. End-to-side anastomosis to the carotid artery could be a potential alternative. PATIENTS AND METHODS: A total of 70 patients with locally advanced carcinoma of the esophagus underwent esophagectomy after neoadjuvant radiochemotherapy. In all patients reconstruction was carried out with a free jejunal transfer. Smaller vessels could be used for anastomoses in 54 of these patients and in 16 cases the jejunal flap artery was attached to the carotid artery. RESULTS: Out of 54 patients 9 (17%) with microvascular anastomoses to the smaller vessels needed surgical intervention for ischemia. In 16 patients with anastomosis to the carotid artery no significant failure of perfusion occurred. CONCLUSION: The carotid artery as recipient vessel in free jejunal transfer seems to be a safe therapeutic option for intestinal reconstruction of preradiated esophageal cancer with good functional results.
Assuntos
Anastomose Cirúrgica/métodos , Artéria Carótida Primitiva/cirurgia , Neoplasias Esofágicas/radioterapia , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Jejuno/transplante , Microcirurgia/métodos , Terapia Neoadjuvante , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias/efeitos da radiação , Artérias/cirurgia , Estudos de Coortes , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/patologia , Esôfago/irrigação sanguínea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias/cirurgia , Lesões por Radiação/cirurgia , Reoperação , Estudos Retrospectivos , Veias/efeitos da radiação , Veias/cirurgia , Adulto JovemRESUMO
BACKGROUND: Therapeutic strategies for cervical oesophageal squamous cell carcinoma (SCC) are controversial. Treatment options range from definitive radiotherapy to multimodal treatment. Outcome after limited resection and reconstruction with a free jejunal graft interposition was evaluated retrospectively. METHODS: Patients with clinical T1-4 Nx M0 tumours treated between 1986 and 2006 were included. RESULTS: Of 109 patients, 94 underwent preoperative chemoradiotherapy and 15 had a primary resection. Complete or partial preservation of the larynx was achieved in 93 patients (85.3 per cent). Minor and major complications occurred in 74.3 per cent, with 44.0 per cent of all patients having more than one complication. Reoperation was necessary in 29.4 per cent. The 30-day mortality rate was 1.8 per cent, and the in-hospital mortality rate 2.8 per cent. The complete R0 resection rate was 72.5 per cent. Median overall survival was 34.3 months; 1-, 3- and 5-year survival rates were 83.8, 47.0 and 47.0 per cent respectively. Survival was not influenced by complications (P = 0.401) or reoperation (P = 0.428). CONCLUSION: Despite high complication and reoperation rates, the mortality rate was low, even after preoperative chemoradiation. This complex surgical strategy is a treatment option for cervical SCC in oncological centres with an infrastructure providing multidisciplinary management.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Esôfago/cirurgia , Jejuno/transplante , Complicações Pós-Operatórias/etiologia , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/radioterapia , Quimioterapia Adjuvante , Intervalo Livre de Doença , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/radioterapia , Feminino , Humanos , Laringectomia/métodos , Masculino , Pessoa de Meia-Idade , Reoperação , Retalhos Cirúrgicos , Resultado do TratamentoRESUMO
The final outcome of severe hand injuries is not solely determined by the residual functional impairment, but is also a function of non-functional criteria, including the sequelae of the accompanying psychological trauma. This paper reviews the literature with respect to the psychological impact of severe hand injuries, including the special impact of amputations, adaptation processes, adaptation stages, prognostic criteria and aesthetic issues influencing the final individual outcome, including present recommendations for promoting a positive outcome. Motivated and psychologically stable people are reported to do well irrespective of the severity of a hand injury. In patients who find it difficult to cope mentally, successful treatment strategies have been proposed. Their implementation is in a constant state of evolution and includes not only improved surgical techniques and advanced pharmacological pain management but also early psychotherapeutic input and involvement of patients in decision making for treatment.
Assuntos
Amputação Traumática/psicologia , Traumatismos da Mão/psicologia , Adaptação Psicológica , Traumatismos da Mão/complicações , HumanosRESUMO
Myelomeningocele is a common dysraphic defect leading to severe impairment throughout the patient's lifetime. Although surgical closure of this anomaly is usually performed in the early postnatal period, an estimated 330 cases of intrauterine repair have been performed in a few specialized centers worldwide. It was hoped prenatal intervention would improve the prognosis of affected patients, and preliminary findings suggest a reduced incidence of shunt-dependent hydrocephalus, as well as an improvement in hindbrain herniation. However, the expectations for improved neurological outcome have not been fulfilled and not all patients benefit from fetal surgery in the same way. Therefore, a multicenter randomized controlled trial was initiated in the USA to compare intrauterine with conventional postnatal care, in order to establish the procedure-related benefits and risks. The primary study endpoints include the need for shunt at 1 year of age, and fetal and infant mortality. No data from the trial will be published before the final analysis has been completed in 2008, and until then, the number of centers offering intrauterine MMC repair in the USA is limited to 3 in order to prevent the uncontrolled proliferation of new centers offering this procedure. In future, refined, risk-reduced surgical techniques and new treatment options for preterm labor and preterm rupture of the membranes are likely to reduce associated maternal and fetal risks and improve outcome, but further research will be needed.
Assuntos
Procedimentos Neurocirúrgicos/tendências , Disrafismo Espinal/cirurgia , Animais , Malformação de Arnold-Chiari/diagnóstico por imagem , Malformação de Arnold-Chiari/fisiopatologia , Malformação de Arnold-Chiari/cirurgia , Modelos Animais de Doenças , Feminino , Fetoscopia/efeitos adversos , Fetoscopia/tendências , Humanos , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/fisiopatologia , Hidrocefalia/cirurgia , Histerotomia/efeitos adversos , Histerotomia/tendências , Recém-Nascido , Meningomielocele/diagnóstico por imagem , Meningomielocele/fisiopatologia , Meningomielocele/cirurgia , Regeneração Nervosa , Defeitos do Tubo Neural/diagnóstico por imagem , Defeitos do Tubo Neural/etiologia , Defeitos do Tubo Neural/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Cuidados Pós-Operatórios , Gravidez , Disrafismo Espinal/diagnóstico por imagem , Disrafismo Espinal/fisiopatologia , Ultrassonografia Pré-Natal , CicatrizaçãoRESUMO
BACKGROUND: The objective of this study was the prospective evaluation of quality of life in patients undergoing aesthetic plastic surgery procedures. We examined pre- and postoperative changes in quality of life, and performed a comparison of our data with a representative random sample. METHOD: 228 patients agreed to participate in the present study. Measurements were taken preoperatively as well as 3 and 6 months postoperatively. One hundred and thirty two patients completed the three months postoperative evaluation (T1), 82 answered the 6 months follow-up evaluation (T2). The testing instrument included a standardised self-assessment test on satisfaction and quality of life (FLZ(M)), consisting of three modules: satisfaction with general life, health and appearance. Further, a postoperative complication questionnaire was used in order to evaluate the satisfaction with the surgical outcome and to estimate postoperative complications and side effects. RESULTS: Significantly increasing values in two aspects of quality of life were found: health and appearance. Whereas the positive influence on health is persistent, there is a diminishing influence of appearance 6 months postoperatively. Although higher values for some of the individual items of the FLZ(M) modules of the norm data were found in comparison to our study group, a general preoperative lower level of quality of life of the aesthetic surgery patients could not be confirmed. Over 84% were satisfied or very satisfied with the aesthetic result. 85% would undergo the same treatment again and 94% of the patients would further recommend their operation. More than half of the study group did not report a decrease in physical fitness or reduced social contacts in the direct postoperative period. CONCLUSION: Our study reveals that aesthetic plastic surgery increases most aspects of quality of life, especially regarding body satisfaction and health. It is very well tolerated by the patients and is therefore a recommended option.
Assuntos
Satisfação do Paciente/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/psicologia , Qualidade de Vida/psicologia , Adolescente , Adulto , Idoso , Imagem Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
Facial hemi atrophy is seen after trauma, Parry-Romberg syndrome and on other rare occasions. Since the aesthetic deficit is very obvious and irritating, facial reconstruction is often requested by these patients. In most cases the only option for sufficient reconstruction is free flap reconstruction, which represents the standard treatment. Recently in plastic surgery, various new techniques have been developed with the potential for multiple applications. Lipofilling has been presented primarily for the correction of cosmetic lesions or the reconstruction of minor soft tissue defects, but even reconstruction of larger soft tissue deficits is possible. The concept of using 3-D technology in facial reconstruction has multiple advantages. Primarily, the ideal final aesthetic outcome can be simulated by virtual reconstruction. Mathematic calculations deliver exact numbers in volume deficits, enabling precise planning of soft tissue substitution especially in lipofilling, ideally avoiding unnecessary corrections. Since autologous soft tissue reconstruction represents a dynamic process with periods of swelling as well as atrophy, quality control is required for achieving optimal results. Use of 3-D scanning has the advantage of reliable visualisation in soft tissue reconstruction without the limitations of harmful side effects. We present the history of a female suffering from the posttraumatic consequences of head injuries related to a car accident and the successful correction of her hemi facial atrophy by autologous lipofilling. Technical details and the potential of 3-D scanning in plastic surgery are discussed.
Assuntos
Gordura Abdominal/transplante , Hemiatrofia Facial/cirurgia , Traumatismos Faciais/complicações , Procedimentos de Cirurgia Plástica/métodos , Cirurgia Assistida por Computador/métodos , Estética , Hemiatrofia Facial/etiologia , Feminino , Humanos , Imageamento Tridimensional , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodosRESUMO
Squamous cell carcinoma in a Zenker diverticulum is a very rare condition. We report a case of a patient with a Zenker carcinoma, who was primarily functionally inoperable and therefore received neoadjuvant radiochemotherapy before cardiac bypass surgery. After a complicated course with cardiogenic shock and myocardial infarction, a re-evaluation of functional risk analysis and the tumor situation revealed operability. Subsequently, partial hypopharyngectomy and partial cervical esophageal resection with lymphadenectomy was performed. Reconstruction of the gastrointestinal continuity was made by interposition of a free small bowel graft and microvascular anastomosis. The postoperative course showed a small anastomotic leakage of the hypopharyngeal-small bowel anastomosis, which was successfully treated conservatively.
Assuntos
Carcinoma de Células Escamosas/patologia , Neoplasias Esofágicas/patologia , Divertículo de Zenker/patologia , Idoso , Anastomose Cirúrgica , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/terapia , Esofagectomia , Esofagostomia , Humanos , Hipofaringe/cirurgia , Intestino Delgado/transplante , Excisão de Linfonodo , Masculino , Terapia Neoadjuvante , Divertículo de Zenker/terapiaRESUMO
In this experimental study on 96 CD rats, microvascular end-to-end anastomoses created via suture or alternatively by means of a VCS-Clip-Application-System, were compared. The aorta abdominalis of the animals, with a diameter of 1.5 +/- 0.2 mm, was experimentally dissected, and the free ends of the vessel then anastomosed. The results were evaluated using sonography, microangiography, histologic examination, and vascular imprints. Postoperative examination was carried out after 1, 3, 7, 14, or 30 days. Major advantages of the VCS-Clip technique over suturing were that it was easy to learn, significantly faster to perform (execution of anastomosis 10.9 +/- 2.6 min versus 19.4 +/- 5.0 min), and produced significantly more favorable histologic results in terms of less inflammatory response, foreign body reaction, necrosis of the tunica media, hyperplasia of the intima, and thrombosis of the vessel lumen. The main disadvantage of the clip technique was a significantly higher rate of stenoses (15.8 +/- 6.0 versus 4.1 +/- 6.6 percent).
Assuntos
Anastomose Cirúrgica/instrumentação , Microcirurgia/instrumentação , Técnicas de Sutura , Procedimentos Cirúrgicos Vasculares/métodos , Animais , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/patologia , Aorta Abdominal/cirurgia , Aortite/prevenção & controle , Aortografia , Constrição Patológica/etiologia , Desenho de Equipamento , Reação a Corpo Estranho/prevenção & controle , Hiperplasia , Microrradiografia , Modelos Animais , Necrose , Complicações Pós-Operatórias/prevenção & controle , Ratos , Ratos Endogâmicos , Suturas/efeitos adversos , Trombose/prevenção & controle , Fatores de Tempo , Túnica Íntima/patologia , Túnica Média/patologia , UltrassonografiaRESUMO
Three-dimensional recording of the surface of the human body or of certain anatomical areas has gained an ever increasing importance in recent years. When recording living surfaces, such as the human face, not only has a varying degree of surface complexity to be accounted for, but also a variety of other factors, such as motion artefacts. It is of importance to establish standards for the recording procedure, which will optimise results and allow for better comparison and validation. In the study presented here, the faces of five male test persons were scanned in different experimental settings using non-contact 3D digitisers, type Minolta Vivid 910). Among others, the influence of the number of scanners used, the angle of recording, the head position of the test person, the impact of the examiner and of examination time on accuracy and precision of the virtual face models generated from the scanner data with specialised software were investigated. Computed data derived from the virtual models were compared to corresponding reference measurements carried out manually between defined landmarks on the test persons' faces. We describe experimental conditions that were of benefit in optimising the quality of scanner recording and the reliability of three-dimensional surface imaging. However, almost 50% of distances between landmarks derived from the virtual models deviated more than 2mm from the reference of manual measurements on the volunteers' faces.
Assuntos
Face/anatomia & histologia , Imageamento Tridimensional/métodos , Lasers , Modelos Anatômicos , Adulto , Artefatos , Cefalometria/métodos , Humanos , Masculino , Movimento (Física) , PosturaRESUMO
BACKGROUND: Nowadays, the array of methods for reconstruction of the female breast following mastectomy is vast. In this study, we investigate and compare quality of life after breast reconstruction and satisfaction with the results of two commonly used techniques (autologous tissue vs. expander/implant). METHODS: Ninety-one consecutive patients who underwent breast reconstruction at a German clinic between 1996 and 2001 were included in the study. Patient satisfaction and quality of life were assessed retrospectively using self-evaluation questionnaires. RESULTS: Patients were generally more satisfied with the outcome of the operation when autologous tissue was used. This was significant in the following areas: breast size, form, definition of the lower breast fold, softness of the breast, and symmetry of the breasts. In both groups the quality of life following breast reconstruction at least 2 years after the operation was equal to that of healthy women of the same age group. CONCLUSION: Although patients were more satisfied with the results of autologous breast reconstruction, procedure choice did not affect quality of life.
Assuntos
Implante Mamário , Mamoplastia/métodos , Satisfação do Paciente , Qualidade de Vida , Adulto , Idoso , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Humanos , Mastectomia , Pessoa de Meia-Idade , Estudos Retrospectivos , Retalhos Cirúrgicos , Inquéritos e Questionários , Fatores de TempoRESUMO
Breast cancer remains to be one of the most malignant diseases in the female population. It affects an essential part of female self-consciousness, and therefore causes a wide range of psychological traumas. The incidence in Europe and North America varies between 70 up to 100 new cases in 100.000 inhabitants per year. According to contemporary literature, mastectomy remains one of the most effective methods in the laborious effort to treat and overcome cancer. In this report the history of breast reconstruction is presented. The established methods which are taken into consideration after mastectomy and their clinical outcome are portrayed. The authors propose the free TRAM and DIEP flap as the methods of first choice after mastectomy, which offer most reliable transfer and low morbidity. In the recent past, increasing interest is observed for the SIEA flap. The free S-GAP flap is proposed for patients who are not candidates for a TRAM, DIEP or SIEA flap. Moreover, the pedicled Latissimus Dorsi flap remains still as a reliable, versatile alternative, particularly in case of contraindications for the above mentioned free flaps or when complications occurred.
RESUMO
Soft tissue defects after knee arthroplasty are a severe problem, which can even result in a loss of the prosthesis or the limb. Well-planned strategies are necessary for sufficient soft tissue reconstruction, resulting in optimal functional and aesthetic results. This report provides information on the classification of the tissue defects and the appropriate options for surgical reconstruction. Besides the basic therapy principles of immobilisation, débridement, planned lavages and antibiotic therapy, defect-dependent surgical techniques of reconstructive surgery are implemented. These include skin transplantation, local fasciocutaneous flaps, local pedicled muscle flaps and free flaps. For best results, interdisciplinary treatment by orthopaedic surgeons, plastic surgeons, microbiologists and physiotherapists is mandatory.
Assuntos
Artroplastia do Joelho/efeitos adversos , Doenças do Tecido Conjuntivo/cirurgia , Tecido Conjuntivo/lesões , Tecido Conjuntivo/cirurgia , Instabilidade Articular/prevenção & controle , Prótese do Joelho/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Doenças do Tecido Conjuntivo/etiologia , Humanos , Instabilidade Articular/etiologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Falha de Prótese , Reoperação/métodosRESUMO
Now-a-days, high-resolution ultrasound allows an accurate and relatively early diagnosis of congenital malformations. In a limited number of such conditions foetal surgery may be lifesaving. However, premature labour has been the major drawback for open foetal surgery. Recently, improvement of video-endoscopic technology has boosted the development of operative techniques for feto-endoscopic surgery, which has been demonstrated to be less invasive than the open approach. Main clinical application of fetoscopic procedures today is the treatment of feto-foetal transfusion syndrome. Although still in development, feto-endoscopic surgery seems to offer new hope for surgical foetal therapy not only in cases of life threatening conditions. Experimental intrauterine correction of cleft lip and palate (CLP) has been lately performed using the feto-endoscopic approach. This procedure offers two major advantages: first, scarless foetal wound healing and bone healing without callus formation, which would also allow a better/normal maxillary growth, and second, significant decrease of foetal and maternal morbidity. Herein, we report the current status of experimental and clinical foetal surgery and propose possible directions for continuing research to make intrauterine procedures safer. Furthermore, we discuss current knowledge and new perspectives of experimental foetal cleft lip and palate repair, which in the future may lead to such excellent results in the operative treatment of clefts, that less or no secondary corrections and therapies, such as orthodontic, dental, logopedic, etc. would be needed. Only if these conditions can be fulfilled, will we be able to improve substantially our therapy for the human foetus with a cleft lip and palate. In spite of all efforts, however, it must be considered that it may not ever be possible to find the optimal treatment method for this or other craniofacial malformations.
Assuntos
Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Doenças Fetais/cirurgia , Fetoscopia/métodos , Animais , Cefalometria/métodos , Modelos Animais de Doenças , HumanosRESUMO
Flap prefabrication represents a new trend in microsurgical tissue transfer. Based on the concept of neovascularisation, in Chinchilla Bastard rabbits (n=40), an isolated venous pedicle dissected from the femoral and saphena magna vein was arterialised by end-to-end anastomosis to the femoral artery at the inguinal ligament. This arterialised venous loop was implanted beneath a random-pattern vascularised abdominal fasciocutaneous flap as large as 8 x 15 cm(2) to investigate the development of neovascularisation at various evaluating times of 4, 8, 12, 16 and 20 days. To prevent neoangiogenesis from occurring between the underlying vascular bed and abdominal flap, a silicone sheet with the corresponding dimension of 8 cm x 15 cm x 0.25 mm was placed and fixed on the abdominal wall. The flap viability and the neovascularisation process in the prefabricated abdominal skin flaps were evaluated by macroscopic observation, blood analysis, selective microangiography and histology. The experimental results showed that newly formed vessels originating from the implanted isolated venous pedicle were evident on the angiograms 4 days after pedicle implantation. In the 8- and 12-day groups, newly formed vessels became larger and some were connected to the originally available vasculature in the abdominal fasciocutaneous flaps. In the 20-day group, entire flaps were perfused by the blood flow supplied from the newly implanted venous pedicles through newly formed vessels and their vascular connections. This study indicated that large flap prefabrication can be created by implantation of an isolated arterialised venous pedicle into a random-pattern vascularised fasciocutaneous flap. Twenty days appears to be the minimal length of time required after arterialised venous pedicle implantation for the maturation of neovascularisation in the prefabricated flap.
Assuntos
Neovascularização Fisiológica , Transplante de Pele/métodos , Retalhos Cirúrgicos/irrigação sanguínea , Animais , Derivação Arteriovenosa Cirúrgica , Chinchila , Fáscia/transplante , Feminino , Sobrevivência de Enxerto , Microrradiografia , Microcirurgia/métodos , Período Pós-Operatório , Coelhos , Pele/irrigação sanguíneaRESUMO
Prediction of necrosis has a clinical relevance in all fields of plastic surgery. The new application of indocyanine green (ICG) fluoroscopy in plastic surgery allows an objective quantification of skin perfusion and a high topographical resolution. The aim of the present study is to determine threshold values for flap perfusion under well-defined experimental conditions. Twenty random pattern flaps with a length to width ratio of 4:1 (8 x 2 cm(2)) were dissected on the anterior abdominal wall of 20 male Sprague-Dawley rats. ICG fluoroscopy was performed at the end of the operation. The animals were sacrificed at the seventh postoperative day with a reliable necrosis of the distal part of the flaps. Postoperative ICG fluoroscopy then was analysed both in regions that will survive and undergo necrosis. At day 7 a mean area of 5.5 cm(2) (57% of the total flap area) survived and a mean of 3.8 cm(2) (43%) became necrotic. The surviving part of the flap had a mean perfusion index of 62% compared to reference skin. The distal parts of the flap that necrotised showed an average perfusion index of only 19% postoperatively. Differences were statistically highly significant (p<0.001). Indocyanine green fluoroscopy is a useful tool to evaluate perfusion topographically and predict necrosis. From a statistical point of view a perfusion index of less than 25% of the reference skin can be considered as a sign of developing flap necrosis.
Assuntos
Retalhos Cirúrgicos/patologia , Animais , Corantes , Modelos Animais de Doenças , Fluorescência , Fluoroscopia , Rejeição de Enxerto/patologia , Verde de Indocianina , Lasers , Masculino , Microcirculação , Necrose/diagnóstico , Prognóstico , Ratos , Pele/irrigação sanguínea , Retalhos Cirúrgicos/irrigação sanguíneaRESUMO
In severe facial burn injuries with extensive destruction of anatomical structures, cosmetic and functional outcome of treatment are frequently not satisfactory. Although operative therapy is being continuously refined, the variety and proximity of structures in the facial region is considered a major challenge in reconstructive surgery. We present the case of a 16-year-old patient with a severe facial burn injury. In planning the reconstructive procedures, we used a multimodal approach employing data from computerized tomography imaging, as well as from surface laser scanning, which provided three-dimensional visualization of facial soft tissues. Amount and pattern of structural loss could thus be determined more precisely and studied more vividly than by inspection of two-dimensional imaging alone. Anatomical features to be reconstructed could be projected onto the skin area of the prelaminated vertical rectus abdominis muscle (VRAM) flap that has been chosen to cover the defect. Prior to surgery, correction of the defects was simulated and the results of the virtual procedure superimposed on a three-dimensional head model of the patient. Tissue elasticity and thickness of the flap, however, could not be ascertained in advance, indicating the limitations of the method.
Assuntos
Queimaduras/cirurgia , Traumatismos Faciais/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Cirurgia Assistida por Computador/métodos , Adolescente , Feminino , Humanos , Imageamento Tridimensional/métodos , Lasers , Modelos Anatômicos , Lesões dos Tecidos Moles/cirurgia , Retalhos Cirúrgicos , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
A regular tissue functioning requires the adequate supply of oxygen and nutrient via blood vessels. The sequences of formation and maturation of vessels are initiated and maintained by different growth factors. The VEGF growth factor plays an exceptional role in these mechanisms. The creation of sublethal ischemia as an angiogenic stimulus known as "Delay" is a well established procedure in plastic surgery, although the underlying molecular biological mechanisms still remain unknown. The important role of VEGF and its regulation depending on oxygen pressure suggest a strong connection between this growth factor and the delay phenomenon. The VEGF concentration in skin and underlying muscle was measured in overdimensioned random pattern flaps on 32 male Sprague-Dawley rats after either VEGF gene therapy or circumcision without elevation of the flap and compared to controls. Additional random pattern flaps were raised seven days post gene therapy or delay. The effect on the flap perfusion was measured postoperatively using Indocyanine green Laser Fluoroscopy and the size of the surviving and necrotic areas of the flaps were analysed. The skin of the random pattern flaps showed both in the Delay group and in the VEGF gene therapy group a significantly elevated VEGF concentration compared to the controls. The underlying rectus abdominis muscle showed no significant differences in VEGF concentration between the groups. The flap perfusion postoperatively was significantly increased solely in the VEGF gene therapy group. The analysis of the surviving area of the flaps showed a significant increase over the controls in the gene therapy group. The Delay procedure results in a significantly and locally raised concentration of the VEGF growth factor. The gene therapeutical use of this growth factor allows us to raise flap perfusion and to reduce necrosis. Both VEGF gene therapy and Delay seem to promote similar mechanisms whereas the gene therapy produced superior results in this setting.
Assuntos
Técnicas de Transferência de Genes , Terapia Genética , Neovascularização Fisiológica/genética , Retalhos Cirúrgicos/irrigação sanguínea , Fator A de Crescimento do Endotélio Vascular/genética , Animais , Expressão Gênica/fisiologia , Masculino , Necrose , Ratos , Fluxo Sanguíneo Regional/fisiologia , Pele/irrigação sanguínea , Pele/patologia , Fatores de Tempo , Sobrevivência de Tecidos/genéticaRESUMO
Prediction of necrosis in critically perfused skin flaps is difficult and rarely precise. An early detection of insufficiently perfused skin is highly desirable since it may lead to surgical decisions such as operative flap revision or early resection. The application of laser-induced indocyanine green (ICG) fluoroscopy allows an objective quantification of skin perfusion and a high topographical resolution. Aim of the present study is to determine a threshold value for flap perfusion under well-defined experimental conditions and test the validity of the results in the clinical application. Twenty overdimensioned random pattern flaps with a length to width ratio of 4 : 1 (8 x 2 cm) were dissected at the anterior abdominal wall of 20 male Sprague-Dawley rats weighing 365 g on average. ICG fluorescence was performed at the end of the operation by intravenous injection of 1 g ICG/kg bodyweight into a tail vein and digital recording. On the seventh postoperative day, both the necrotic and surviving areas of the flaps were measured and the ICG-fluorescence was analysed in the areas that had undergone necrosis. 41 flaps with areas of critical perfusion (18 skin flaps, 13 muscle flaps, 8 replantations) were analysed in 39 patients. The surviving part of the flap had a mean perfusion index of 62 % compared to reference skin. The distal parts of the flap that necrotized during the experiment showed an average perfusion index of 19 % postoperatively. Differences were statistically significant (p < 0.001). In clinical application, a number of 13 flaps were found to have a perfusion index less than 25 % in a region of critical perfusion. Eleven of these developed a partial necrosis in that region, one flap underwent total necrosis. Indocyanine green fluoroscopy allows a detailed topographical analysis of flap perfusion and the prediction of necrosis. Experimental findings presented a threshold value for the perfusion index of 25 % which could be confirmed in clinical application.
Assuntos
Terapia Genética , Verde de Indocianina , Isquemia/diagnóstico , Lasers , Retalhos Cirúrgicos/irrigação sanguínea , Fator A de Crescimento do Endotélio Vascular/genética , Animais , Angiofluoresceinografia , Humanos , Masculino , Necrose , Prognóstico , Ratos , Ratos Sprague-Dawley , Fluxo Sanguíneo Regional/fisiologia , Sobrevivência de Tecidos/fisiologiaRESUMO
BACKGROUND: Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis. VEGF A also plays an important role in wound healing of the skin by promoting angiogenesis and by stimulating blood vessel growth. Therefore we tested the hypothesis that flap survival could be increased by the preoperative injection of AdVEGF(165). METHODS: We studied the effect of AdVEGF(165) in an overdimensioned ischemic random-pattern-flap model in the rat (n = 50) with a length-to-width ratio of 4 : 1. VEGF cDNA was administered in two concentrations of 5 x 10(8) plaque-forming units (pfU) and 1 x 10(9) pfU using a recombinant adenoviral vector. Recombinant virus was injected subdermally 7, 3 or 0 days prior to flap harvest for the lower concentration and 7 days prior for the higher concentration. Flap survival and necrosis were observed at day 7, the day the animals were sacrificed. RESULTS: Adenoviral gene transfer with VEGF(165) 3 and 7 days before flap harvest showed a significantly increased flap survival of 50% together with a significantly reduced necrosis (p < 0.01). Injection using a titer of 1 x 10(9) pfU 7 days prior to surgery increased flap survival even more, though failing to reach statistical significance compared to the lower concentration. VEGF protein concentration in the injected skin was significantly higher than in controls (p < 0.01). Flap perfusion was increased as well, demonstrated by indocyanine green (ICG) fluoroscopy (p < 0.001). CONCLUSIONS: Our results confirm the important role of VEGF(165) on angiogenesis in ischemic flaps. Indeed by injecting VEGF(165) at 3 to 7 days preoperatively in a concentration of 1 x 10(9) pfU our data show that length-to-width ratio for random-pattern-flaps could be increased from 2 : 1 to 3 : 1 and therefore may allow a wider range of applications of this simple flap technique.