RESUMEN
Chronic sympathetic denervation leads to the development of supersentivity to adrenergic agents. Free flap surgery results in the disruption of the autonomic nerve fibers running along the anastomosed vessels. We therefore investigated the early effect of surgical sympathectomy on the reactivity of cutaneous microcirculation challenged to adrenergic agents. Two epigastric flaps were elevated and exposed in 15 rats. On the right flap (Side A), a circular adventitiectomy of the feeder vessels was realized to provide surgical sympathectomy. On the left flap (Side N), vessels were kept intact. The following drugs were then given intravenously successively: phenylephrine (10 and 15 microg kg(-1)), norepinephrine (10 microg kg(-1)), prazocin (1 mg kg(-1)) followed by norepinephrine (10 microg kg(-1)). Cutaneous microcirculation was assessed using Laser-Doppler Flowmeters simultaneously on the two flaps after each drug administration. Mean arterial pressure was also measured. On side N, phenylephrine and norepinephrine resulted in a transient increase in cutaneous microcirculation followed by a more prolonged reduction. On side A, only the initial increase was observed, which was greater and longer as compared with side N, and paralleled the increase in mean arterial pressure. After prazocin pre-treatment, norepinephrine produced a transient increase in cutaneous microcirculation similar on both sides, and parallel to the changes in arterial pressure. No decrease in cutaneous microcirculation was observed. Immediately after surgical adventitiectomy, the vasoconstriction produced by alpha-adrenergic agents is prevented. No denervation-induced hypersentivity is observed. Surgical sympathectomy might protect cutaneous flaps from vasoconstriction induced by endogenous catecholamines release.
Asunto(s)
Agonistas alfa-Adrenérgicos/farmacología , Tejido Conectivo/cirugía , Microcirculación/efectos de los fármacos , Colgajos Quirúrgicos/irrigación sanguínea , Simpatectomía/efectos adversos , Animales , Femenino , Flujometría por Láser-Doppler , Masculino , Microcirculación/fisiología , Modelos Animales , Norepinefrina/farmacología , Fenilefrina/farmacología , Prazosina/farmacología , Ratas , Ratas WistarRESUMEN
BACKGROUND: The existence of intratissular lymphaticovenous anastomoses has often been suggested, but it has never been demonstrated. This study aims at demonstrating the presence of such anastomoses. METHODS AND RESULTS: The free flap model was used to investigate the drainage of radiolabeled colloid particles whose size prevents direct passage to the blood vessels. The tracer was injected into the muscle or the skin during the surgical procedure. Blood samples were sequentially drawn from the venous pedicle over the 30 minutes that followed the tracer injection. The blood samples were counted using a gamma well-counter. In all 14 patients, the venous blood radioactivity steadily increased over time. Radiochemical analyses performed on the blood samples demonstrated that the radioactivity is related to the labeled colloids and not to free pertechnetate. Planar imaging performed 24 hours after the surgical procedure showed a significant liver uptake, and no accumulation in the area of normal lymphatic relays. CONCLUSIONS: As, in the free flap model, there is no lymphatic drainage through the classical pathways whatsoever, and since the size of the radiolabeled particles prevents them from directly entering the blood stream, the results strongly suggest the presence of functional intratissular lymphovenous anastomoses.
Asunto(s)
Sistema Linfático/anatomía & histología , Sistema Linfático/fisiología , Azufre Coloidal Tecnecio Tc 99m/administración & dosificación , Azufre Coloidal Tecnecio Tc 99m/sangre , Butanonas/sangre , Humanos , Inyecciones Intramusculares , Hígado/metabolismo , Azufre Coloidal Tecnecio Tc 99m/farmacocinéticaRESUMEN
BACKGROUND: In lower leg defects with bone, hardware, or articular exposure, a free tissue transfer is often the only valuable option. However, in well-selected clinical cases, pedicled flaps are still indicated because they provide an alternative for the more demanding and risky microsurgical procedure. The medial adipose-fascial flap of the leg represents an ideal local regional fascial flap. METHODS: Twenty-two medial adipose-fascial flaps (performed in 21 patients) were reviewed retrospectively and compared with a series of 22 free gracilis flaps (22 patients) selected out of 150 muscular free flaps for lower leg reconstruction. All patients with defects larger than 40 cm, peripheral vascular disease, deep defects, and osteomyelitis were excluded in order to obtain the same surgical indications in which the local medial adipose-fascial flap could have been used. RESULTS: The overall surgical results were comparable, but more medical complications, a longer operative time, and a longer hospital stay were seen in the free muscle group. Moreover, patients reconstructed with a medial adipose-fascial flap appeared to be more satisfied with the aesthetic result of their reconstruction. CONCLUSIONS: Muscle coverage is not mandatory to cover bone in the lower leg. The medial adipose-fascial flap can provide a good alternative for free flap coverage. This flap seems to have fewer medical complications, requires a shorter operative time and hospital stay, and can provide better aesthetic results than a free muscle flap.
Asunto(s)
Traumatismos de la Pierna/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Traumatismos del Tobillo/cirugía , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Procedimientos de Cirugía Plástica , Estudios Retrospectivos , Colgajos QuirúrgicosRESUMEN
Although unexplained thrombotic failures still exist, the majority of free-flap failures are due to identifiable technical failures, indicating that an excellent operative technique remains the key point. However, some clinical circumstances, such as damaged or deeply located vessels, are related to a higher thrombotic risks, demanding refinements of the microsurgical procedure to avoid higher failure rates. We reviewed 195 free flaps in the lower leg in order to quantify these situations and how we dealt with them. In total, six flaps were performed with a T-interposition to cope with difficult end-to-side anastomoses on damaged vessels. In two cases, the use of a funnel-shaped vein graft facilitated difficult end-to-side anastomoses in the popliteal area. The authors believe that these refinements of microsurgery should not be first-choice procedures, but they have proven to be a useful tool for certain microsurgical reconstructions.
Asunto(s)
Pierna/irrigación sanguínea , Microcirugia/métodos , Colgajos Quirúrgicos/irrigación sanguínea , Trombosis/prevención & control , Algoritmos , Anastomosis Quirúrgica/métodos , Arteriosclerosis/complicaciones , Humanos , Pierna/cirugía , Microcirugia/efectos adversos , Estudios Retrospectivos , Colgajos Quirúrgicos/efectos adversos , Trombosis/etiologíaRESUMEN
Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.
Asunto(s)
Traumatismos de la Pierna/cirugía , Colgajos Quirúrgicos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Colgajos Quirúrgicos/irrigación sanguínea , Arterias Tibiales , Recolección de Tejidos y ÓrganosRESUMEN
Vascular injection techniques for anatomic studies are often complementary. Use of colored gelatinous mixtures with methylene blue provides precious data about descriptive anatomy by the contrast that it produces in the tissues. The introduction of radiopaque medium, such as lead oxide, into the gelatinous mixture can be used as a complement by means of x-ray examination, in order to facilitate and to reduce the time of investigation. Addition of rhodamine B to the radiopaque mixture keeps the advantages of the contrast medium, but also permits further dissection to demonstrate some details shown by prior x-ray examination. This article compares these different injection techniques in the study of the nasal vascular network. Moreover, it depicts a new injection approach that allows the investigation of vascular territories depending on thin caliber arteries by selective reinjection, defining microangiosomes. Each above-cited technique was used in ten facial territories of fresh cadavers. The patterns of the vessels shown by these techniques were identical, with a constant visualization of infra-millimetric arteries. However, selective reinjection was the only method that permitted characterization of the proper vascular territory of the lateral nasal artery.
Asunto(s)
Vasos Sanguíneos/anatomía & histología , Colorantes/administración & dosificación , Plomo/administración & dosificación , Azul de Metileno/administración & dosificación , Nariz/irrigación sanguínea , Óxidos/administración & dosificación , Rodaminas/administración & dosificación , Cadáver , Disección , Humanos , Inyecciones IntravenosasRESUMEN
In 60 consecutive cases, a gracilis free muscle flap was used to reconstruct defects in the lower extremity. Although the harvest of the gracilis free flap is straightforward, the flap is not frequently considered as a valid option for reconstruction because of its "gracile" shape. Hence, it is not considered voluminous enough to cover defects of significant size in the lower leg. However, once the epimysium is separated, the muscle flap spreads out and covers a large surface area, large enough to reconstruct wide rectangular wounds or extended spindleshaped defects. Especially in young patients, the volume of the gracilis muscle is much larger than expected from its descriptive but misleading name. Often it is precisely this patient population that gets involved in motorcycle accidents or traumas caused by contact sports. For the treatment of Gustilo type III open tibia fractures with moderately large-sized soft-tissue defects and for chronic lower leg defects with osteomyelitis, the gracilis muscle flap is an excellent choice. Fifty-nine out of the 60 flaps in long-term follow-up (minimally 3 years) fully healed. The pedicle can be more than 7 cm in length when the final dissection under the long adductor muscle is carried up to the origin at the deep femoral vessels. The functional and aesthetic outcomes at the donor site at the inner thigh are minimal, compared to alternative transfers for such defects, while the reconstructive features of the gracilis muscle flap are excellent.
Asunto(s)
Músculo Esquelético/trasplante , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos , Heridas y Lesiones/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Traumatismos de la Pierna/cirugía , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Melanotic schwannoma is a pigmented nerve tumor that may be located in the skin and express local aggressivity. This tumor may occur singly. It may also be part of the Carney complex which consists of various, but specific, tumors. OBJECTIVE: We report two cases of subcutaneous melanotic schwannoma localized on the trunk in two men aged 37 and 45 years. METHODS: Conventional histology and immunohistochemistry were performed. RESULTS: One melanotic schwannoma was associated with a cutaneous atypical myxoma and multiple melanocytic lesions, all being part of the Carney complex. The other case had no associated signs. In both cases, the melanotic schwannoma was completely excised and did not recur. CONCLUSION: Melanotic schwannoma is rare and curable by surgery. It must not be confused with malignant melanoma and other pigmented neoplasms. The Carney complex should be carefully ruled out.
Asunto(s)
Melaninas/metabolismo , Neurilemoma/metabolismo , Neurilemoma/cirugía , Neoplasias Cutáneas/metabolismo , Neoplasias Cutáneas/cirugía , Adulto , Humanos , Masculino , Persona de Mediana Edad , Mixoma/diagnóstico , Mixoma/cirugía , Neurilemoma/diagnóstico , Neoplasias Cutáneas/diagnósticoRESUMEN
Benign symmetric lipomatosis is a rare form of typical fat distribution in the shoulders, the arms, and the neck that can compromise the respiratory, nutritional, and psychological status of the patient. Alcoholism, malignant tumors of the upper airways, endocrine tumors, hypothyroidism, diabetes, and hypertriglyceridemia are often associated with its occurrence. Surgical removal via lipectomy or liposuction can give good cosmetic results, although recurrences often occur. Liposuction has become the first choice to treat this disorder in patients with smaller masses. We have operated on four such cases in which liposuction failed and surgical excision had to be performed. We present a summary of the clinical characteristics of all four patients and discuss the different treatment options.
Asunto(s)
Lipectomía , Lipomatosis Simétrica Múltiple , Adulto , Alcoholismo/complicaciones , Complicaciones de la Diabetes , Femenino , Humanos , Lipectomía/métodos , Lipomatosis Simétrica Múltiple/etiología , Lipomatosis Simétrica Múltiple/cirugía , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
The authors present an overview of the various techniques which can be used to achieve coverage of exposed bone, particularly in cases of bone exposure associated with an underlying fracture or osteomyelitis. Adequate debridement, possibly in several stages, is necessary in all cases to prepare the receptor site for the next step which is soft tissue coverage, achieved using various types of surgical procedures. Adequate reconstruction can be achieved with pedicled flaps in some cases but in cases with exposure of bone, free flaps usually represent a better option in cases where the condition of the patient is not a limiting factor. Thin fascio-cutaneous free flaps may be used in some cases with small and simple soft tissue loss, so as to minimise donor site mobidity. Free muscle flaps, such as from the latissimus dorsi, are preferable in cases with bone loss in order to fill any dead space; in cases with major bone loss, a free vascularised bone graft can be used, or composite grafts including bone, muscle and/or skin (fibula or crista iliaca flaps). Some reconstructions require a functional approach, such as over an exposed joint, or for the weight-bearing area of the foot or the soft tissues over the Achilles tendon. Survival of a free flap requires perfect, permeable microsutures; thrombosis of the anastomosis is a major complication which jeopardizes flap survival; close surveillance of the flap is required during the first few days, with hourly Doppler monitoring of the pedicle on the first day. The success rate can be as high as 90 to 100% in simple cases; failures may be related to surgical technique, inadequate choice of the flap, or specific features of the patient. In cases with an underlying bone infection, recurrence of infection occurs in 5 to 20% of cases; this requires additional treatment, possibly with repeat debridement, prolonged antibiotic therapy and sometimes a second free flap.
Asunto(s)
Fracturas Abiertas/complicaciones , Fracturas Abiertas/cirugía , Procedimientos Ortopédicos/métodos , Osteomielitis/complicaciones , Osteomielitis/cirugía , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos , Humanos , Osteítis/complicaciones , Traumatismos de los Tejidos Blandos/patología , Traumatismos de los Tejidos Blandos/cirugía , Técnicas de Sutura , Resultado del Tratamiento , Soporte de PesoRESUMEN
Tricholemmal carcinoma is a rare entity. It must be distinguished from the benign proliferating variant of the tricholemmal cyst. We report a case of tricholemmal carcinoma massively invading the nose. The neoplasm was excised surgically with a satisfactory outcome.
Asunto(s)
Carcinoma de Células Escamosas/patología , Neoplasias Nasales/patología , Anciano , Diagnóstico Diferencial , Epitelio/patología , Humanos , MasculinoRESUMEN
One of the most common symptoms of obstructive sleep apnea syndrome (OSAS) is daytime drowsiness. It is associated with a high cardiovascular morbidity and mortality, and an elevated incidence of car crashes. In general, young patients don't want conservative treatment because symptomatic and to prevent secondary effects. In this article, we briefly define sleep disorders and the interest of cephalometric examination. We describe the different treatment possibilities and stress the important role of orthognathic surgery in this syndrome.