Sanguijuelas medicinales: utilidad en microcirugía. A propósito de un caso / Medical leeches: use in microsurgery. A case report

Las sanguijuelas medicinales han sido utilizadas en la práctica médica desde hace 3.500 años. En la actualidad su uso de halla bien establecido en la cirugía reconstructiva, para el tratamiento del éstasis venoso, especialmente en reimplantes digitales, auriculares y en los colgajos de todo tipo con problemas de retorno venoso. El mecanismo de acción es la disminución de la presión hidrostática tisular en el área adyacente, por la sangría provocada durnte la succión y en el períoso posterior. La hidruina, sustancia anticoagulante que se halla en la saliva de la sanguijuela, prolonga el efecto. Sus contraindiaciones son la presencia de obstrucción arterial, la infección local o sistémica y la presencia de trastornos de la coagulación. Presentamos un caso de reconstrucción microquirúrgica compleja del tercio facial inferior, en el que utilizamos, con éxito , sanguijuelas medicinales para tratar la obstrucción venosa de un colgajo fascio-cutáneo antebraquial (AU)

Extended V-Y flap: patient reports and reconsideration.

The extended V-Y flap, a modified V-Y advancement flap, is very useful in closing relatively large defects on the face. Its extension limb is hinged down as a transposition flap on the end of the V-Y advancement flap to close the most distal portion of the defect. We applied this flap in closing a defect following excision of skin tumors on the face with excellent cosmetic results in 11 patients. However, this flap tended to make a distortion at the base of the flap in the primary closure site. By drawing figures, we concluded that the distortion was due to the characteristic of this technique as a V-Y advancement-rotation flap or V-Y advancement flap with rotation.

Surgical treatment of nifedipine-induced gingival hyperplasia. A case report.

A surgical technique for treating nifedipine-induced gingival hyperplasia is described. A brief overview of nifedipine (trade name Procardia) is given, along with its use in the treatment of hypertension and its side effects, particularly as they relate to the induction of gingival hyperplasia. A detailed description and rationale for the surgical excision of the hyperplastic gingival tissue with a flap approach is given. A case is presented to illustrate the technique and post treatment results.

Surgical correction of submucous cleft palate with Furlow palatoplasty.

Many surgeons have favored using the pharyngeal flap as the primary treatment for the velopharyngeal insufficiency associated with submucous cleft palate. However, the increasing number of reports of sleep apnea and airway compromise as a result pharyngeal flap surgery support the need to eliminate any unnecessary pharyngeal flap surgery. From 1988 to 1993, 35 Chinese submucous cleft palate patients with velopharyngeal insufficiency received surgery. A Furlow palatoplasty was used in 30 patients (3 to 26 years old). The follow-up duration was 9 months to 5 1/2 years. These patients were selected after a thorough study for velopharyngeal insufficiency including intraoral examination, perceptual speech assessment, videonasopharyngoscopy, and/or multiview videofluoroscopy. The criteria for selection included age, intraoral finding of an obviously anterior inserted levator palatine muscle, size of velopharyngeal gap, pattern of velopharyngeal closure, degree of lateral pharyngeal wall movement, and response to biofeedback speech therapy. In general, younger patients with circular or sagittal pattern closure, a velopharyngeal gap less than 5 mm, or good response to biofeedback speech therapy were considered to be the best candidates for a Furlow palatoplasty. The 5 patients who did not fulfill these criteria and whose velopharyngeal function failed to improve on preoperative biofeedback therapy were treated by pharyngeal flap operation. Twenty-nine patients (96.7 percent) achieved competent velopharyngeal function after the Furlow palatoplasty. The procedure corrected the velopharyngeal insufficiency in 3 patients older than 20 years with a velopharyngeal gap of less than 2 mm. The only patient with an unsatisfactory result was a 26-year old woman who had very prominent action of the musculus uvulae before the surgery. The results show that a Furlow palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected submucous cleft palate patients and thus avoid the serious complications of pharyngeal flap surgery.

Controversy in breast reconstruction.

We have discussed the major controversies in the reconstruction of the breast. As trends in cancer ablative surgery have shifted toward breast conservation techniques, the reconstructive choices available to the plastic surgeon have evolved. Advances in oncology, adjuvant therapy, and surgical techniques have changed the defects left following ablative surgery. Patient preferences have also changed, with a greater number of patients presenting to the reconstructive surgeon having already decided the timing and type of reconstruction they prefer. We must continually remind ourselves that the best and least controversial option is the one reached through appropriate consultation among patient, oncologist, and surgeons.

The free revascularized rectus abdominis myocutaneous flap for the repair of tumour related defects in the head and neck area.

The present work reviews a series of 11 consecutive patients who have received free revascularized rectus abdominis myocutaneous flaps for primary reconstruction of soft tissues after ablative tumour surgery in the head and neck area. In 10 patients, a total or subtotal glossectomy had been performed and the flap was used to replace the resected tongue volume. In 5 of these cases, extensive perforating defects had resulted after additional resection of large portions of the chin and the cheek. Mandibular continuity was restored by a metal plate and the flap was divided into an intraoral and extraoral portion in these patients. In one patient, the flap had been used for closure of a full thickness defect of the calvarium. 9 of the 11 flaps healed uneventfully. In one case, a partial flap loss was encountered after thrombosis of the venous pedicle due to compression as a result of an unfavourable defect anatomy and flap positioning. Primary closure of the abdominal wall was achieved in all cases. A subcutaneous hematoma occurred at the donor site in one patient. According to our present experience, the rectus abdominis free flap may serve as an alternative to the frequently employed latissimus dorsi flap in maxillofacial reconstructions while it offers the possibility for flap elevation simultaneously to the surgical procedures in the head and neck area.

Reinnervation of the rat bladder with a somatic nerve and a striated muscle flap.

PURPOSE: Current techniques of ventral sacral root stimulation to regain voluntary motor control of the decentralized urinary bladder depend upon intact parasympathetic innervation of the detrusor. We investigated techniques that might allow restoration of motor control of the bladder after efferent parasympathetic impairment. MATERIALS AND METHODS: In a chronic rat model, we evaluated whether motor control of a peripherally denervated bladder could be restored by transplantation of autologous excitable tissues and subsequent electrostimulation. Either a somatic nerve or a striated muscle flap was used as the transplant. RESULTS: Four months after the initial surgery, electrostimulation of the somatic nerve implant provoked bladder contractions--a response that was blocked by atropine. Stimulation of the nerve innervating the striated muscle flap also provoked bladder contractions; these were not affected by atropine and were slightly reduced by hexamethonium. CONCLUSION: Reinnervation of the bladder with somatic nerves or striated muscles is possible in principle. Future experiments will clarify the clinical significance of electrostimulation of such implants.

Evaluation of osseointegration of endosseous implants in radiated, vascularized fibula flaps to the mandible: a pilot study.

PURPOSE: This study clinically evaluated the osseointegration of implants placed into vascularized fibula flaps used in mandibular reconstruction of cancer patients following radiation treatment and subsequent hyperbaric oxygen (HBO) therapy. MATERIALS AND METHODS: Five head and neck cancer patients had mandibular resection and immediate reconstruction with a vascularized fibula flap. Subsequent therapy included greater than 50 Gy of radiation to the fibula flap over a 6 to 8-week period. Two to 6 weeks following radiation therapy each patient received 20 90-minute daily sessions of HBO at 2.4 atmosphere pressure. Stage 1 implant surgery was performed placing two to six implants (15 mm in length and 3.75 to 4.0 mm in width) into each fibula flap. This was followed by 10 postoperative HBO sessions using the previously mentioned protocol. The stage 2 procedure was performed 6 months after the stage 1 procedure. Osseointegration was assessed clinically using manual force and an electronic device at the time the implants were uncovered and monthly over a 6-month period. RESULTS: All 20 implants placed in the fibula flaps were osseointegrated clinically at the time the implants were uncovered and during the 6-month follow-up. CONCLUSION: In this pilot study, mandibular reconstruction with a vascularized fibula flap and endosseous osseointegrated implants, following radiation of the fibula, was successful. It was concluded that factors such as the graft having its own blood supply and the use of HBO contributed to the successful osseointegration of these implants.

[Hemostasis in patients at high hemorrhagic risk]. / Emostasi in pazienti ad alto rischio emorragico.

Surgical treatment in patients with heavy coagulation disorders needs measures that minimize immediate and post-surgical hemorrhagic risk. Besides the subjects afflicted with constitutional coagulation pathologies such as haemophilia A, B, C, AB, Von Willebrand disease, platelet disorders and others, too many are the patients that need pharmacological therapy to impede the creation of intra-vascular coagula. Today, surgical treatment of these patients is possible with the use of human fibrin glue (Tissucol) that permits excellent surgical and post-surgical hemostasis without therapy suspension, independently of coagulation disorder. The purpose of this study is a clinical evaluation of a surgical procedure based on the use of human fibrin glue in association or not with suture, hemostatic sponge and lyophilized dura mater in patients with coagulation disorders. In a group of 309 patients in oral anticoagulant therapy have been done a total of 822 operations such as root fragments extraction with mucoperiosteal flap elevation, teeth or roots simple extractions, third molar extractions, cyst removal, apicoectomies. Only patients with PA over 20% have been treated. All the operations have been leaded with minimal trauma; after the extractions, alveolar margins have been regularized to improve flaps adaptation. Hemostatic sponge or dura mater have been used like basis for the flaps and the fibrin glue, that was injected in the residual cavity after surgical suture. In a few cases, for example with little extraction wounds, only fibrin flue without suture or sponge has been used. In all cases and after all operations, the presence or absence of bleeding has been evaluated after 2 hours, 24 hours, 7 days after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of neuropathic urinary and faecal incontinence with synchronous bladder reconstruction and the antegrade continence enema procedure.

OBJECTIVES: To report our experience with synchronous bladder reconstruction and the antegrade continence enema (ACE) procedure in the management of neuropathic urinary and faecal incontinence. PATIENTS AND METHODS: Eight patients (four boys, four girls) with a median age of 9 years 10 months (range 4.5-17) were treated. Five had spina bifida, two high ano-rectal malformations and one had been successfully treated for a spinal neuroblastoma. The appendix was used for the ACE procedure in five patients and a tubularized caecal or colonic flap in the other three. Seven patients had an augmentation cystoplasty and one a cystectomy with a continent diversion. A bladder neck reconstruction or an urethral lengthening procedure was performed in five patients and the bladder outlet was closed in two. Six patients required some form of revision. Four patients underwent a simultaneous Mitrofanoff procedure. RESULTS: The median length of follow-up was 11.5 months (range 3-29). Five patients were completely clean and the remaining three experienced minor faecal soiling only. They were all delighted with the result. Six patients were dry day and night, one was wet at night only while the final patient was wet day and night. CONCLUSIONS: Synchronous surgical procedures to make patients with neuropathic incontinence both clean and dry is effective, but most patients require revision surgery. Patient motivation and selection and the availability of a nurse specialist is crucial in obtaining satisfactory results.

[The surgical treatment of chronic sialodochitis]. / Khirurgicheskoe lechenie khronicheskogo sialodokhita.

A new method for plasty of the parotid duct with its appreciable dilatation is proposed. A semioval flap is cut from the wall of a dilated duct and sutured to the buccal mucosa. A proper opening of the parotid duct is thus created and injuries to facial nerve branches during surgery are prevented.

The thin tube pedicle: a valuable technique in auricular reconstruction after trauma.

We describe a three staged method of reconstruction for partial helical rim defects using a thin post auricular tube pedicle. The technique is illustrated by three case reports.

The Malone antegrade continence enema.

The previously reported Malone antegrade continence enema (MACE) was used in 21 children for intractable fecal incontinence or constipation. Twelve are completely clean, and three are much improved (71% success rate). However, only four of the 21 have not had some type of complication, either minor or major. Five of the 21 now have a colostomy, and one has abandoned the procedure.

The edentulous ridge expansion technique: a five-year study.

This study presents the clinical results of a surgical technique that expands a narrow ridge when its orofacial width precludes the placement of dental implants. In 170 people, 329 implants were placed in sites needing ridge enlargement using the endentulous ridge expansion procedure. This technique involves a partial-thickness flap, crestal and vertical intraosseous incisions into the ridge, and buccal displacement of the buccal cortical plate, including a portion of the underiying spongiosa. Implants were placed in the expanded ridge and allowed to heal for 4 to 5 months. When indicated, the implants were exposed during a second-stage surgery to allow visualization of the implant site. Occlusal loading was applied during the following 3 to 5 months by provisional prostheses. The final phase was the placement of the permanent prostheses. The results yielded a success rate of 98.8%.

The use of latissimus dorsi muscle flap in reconstructive heart surgery.

Dynamic cardiomyoplasty is a technique for ventricular assistance indicated for the correction of left ventricle aneurysm and for cardiomyopathies in which heart transplantation is contraindicated. In this article, our first four patients to undergo cardiomyoplasty (from February 1991 until April 1992) with a left latissimus dorsi island flap, rotated into the thorax after a 3-week training period, are reviewed. Therapeutic indications were cardiomyopathy with contraindication for heart transplant in patients 1 and 4 and associated to surgery for left ventricle aneurysm for patients 2 and 3. Patient 1 died 4 months after surgery because of a cerebral embolism when he was at functional class II. The other three patients remain at functional class I, carrying out normal activities. All the data were evaluated with the paired t test. Ejection fraction values (obtained through echocardiography and scintigraphy studies) and maximum minute flow rate of blood (measured with an echo-Doppler) have increased significantly (p < 0.001, p < 0.05, and p < 0.01, respectively) after heart surgery. Clinical improvement has been found after cardiomyoplasty, which correlates with an increase in ejection fraction and maximum minute flow rate of blood.

The use of medicinal leeches, Hirudo medicinalis, to restore venous circulation in trauma and reconstructive microsurgery.

Following replantation of complete or incomplete nonviable amputations of digits and hands, as well as microsurgical free tissue transfer, there is often a critical need for adjuvant therapy in order to restore sufficient venous drainage. In 24 out of 29 patients, venous insufficiency was successfully treated with the use of medicinal leeches. In a group of patients who had undergone replantation procedures (11 patients total), 9 patients (8 with digit and 1 with hand amputations) had venous drainage successfully restored with medicinal leeches, while in a group of patients who had free tissue transfers (18 patients total), 15 had the venous congestion treated successfully with leeches. The results indicate that medicinal leeches are a valuable, alternative method for the treatment of venous congestion in both replantation patients and those who have undergone free tissue transfer.

Nasal scarring by joss stick burns.

Vasomotor rhinitis is a common condition in Malaysia. Patients' dissatisfaction with medical treatment of this recurring condition leads them to seek other forms of traditional cures. This paper highlights the complications in such patients who seek traditional cures for their chronic condition.

Dynamic training of skeletal muscle ventricles. A method to increase muscular power for cardiac assistance.

BACKGROUND: Skeletal muscle can be used for cardiac assistance after electrical stimulation over a period of several weeks. This will adapt it to do chronic work with no resulting fatigue. The result of this procedure, however, is a reduction of 80% in muscle power, > 60% in muscle mass, and approximately 85% in contractile speed. To minimize these disadvantages, the following study was done to develop and test a method to dynamically train skeletal muscle ventricles (SMVs). METHODS AND RESULTS: Barrel-shaped SMVs were tested in 15 Jersey calves. They were made from the latissimus dorsi muscle, which was wrapped around an elastic silicone training device. Six SMVs were used extrathoracically in a single layer and nine intrathoracically in a double layer. With dynamic training preserving contractile speed, the output increased to approximately 5 L/min, the systolic pressure increased to > 200 mm Hg, and power developed to approximately 10 W after 3 months of dynamic training. The contractile speed of dynamically trained SMVs was between 250 and 700 mm/s. The diameter of the latissimus dorsi muscle increased to three times that of the corresponding contralateral muscle. CONCLUSIONS: The combination of electrical conditioning with dynamic training of the SMVs resulted in a strong muscle pump that did not develop fatigue. Dynamic training for skeletal muscle represents a new and promising method for providing powerful autologous cardiac assist.