Reduced Anterolateral Thigh Flap Donor-Site Morbidity Using Incisional Negative Pressure Therapy.

BACKGROUND: Primary closure of the donor-site after harvest of a large anterolateral thigh flap (ALT) is associated with significant morbidity. Incisional negative pressure therapy (INPT) may decrease complications in high-risk incisions. This study assessed if the incidence of complications after primary closure of the ALT flap donor-site decreases with INPT. METHODS: Retrospective cohort study of a prospectively maintained database including patients who underwent upper and lower limb reconstruction, using an ALT free flap with primary closure of the donor-site. Two groups were defined: primary closure and INPT (study group) and primary closure with traditional dressings (control group). Nonparametric statistics were employed to identify prognostic factors, p < 0,05. RESULTS: Fifty-eight free ALT flaps in 58 patients (study group n = 28; control group n = 30) were included. Median flap width and length were 9 cm (range: 5-14) and 25 cm (range: 10-48), respectively. Median follow-up was 19 months (range: 3-78 months). No significant differences in age or flap size were identified in both groups (p > 0.05). The global complication rate was 7.14% (n = 2) in the INPT group, and 37% (n = 11) in the control group (p = 0.007). The study group had a lower dehiscence and skin necrosis rate (p < 0.05). Multivariate logistic regression analysis showed IPNT was associated with a significant reduction of donor-site complications (p = 0.006), especially in patients with defects > 8 cm (p = 0.003). CONCLUSION: In this cohort study the use of INPT significantly reduced the donor-site morbidity after ALT flap harvest.

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction.

BACKGROUND: As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. METHODS: In an effort to expand on Nahabedian's 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. RESULTS: The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. CONCLUSION: With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.

Mandibular Reconstruction in a Patient With Rosai-Dorfman Disease.

OBJECTIVE: The Rosai-Dorfman disease (RDD) is a rare disorder known as sinus histiocytosis with massive lymphadenopathy which affects other organs besides the lymphatic nodes. The most frequent clinical presentation is the skin involvement, but the most serious one is when the central nervous system is compromised. There are not clinical cases in the literature reporting the mandibular involvement and its management. The aim of this study is to report the case of a patient with this disease, her treatment, and her follow-up. STUDY: A 32-year-old woman with RDD, who underwent a right mandibulectomy to treat osteomyelitis, and who suffered hemolytic anemia, lymphoproliferative syndrome, and bacterial meningitis by meningococcus treated successfully, is presented. She also had osteosynthesis plate exposure in 3 occasions. The authors performed a mandibular reconstruction with a fibula free flap. Vertical osteogenic distraction was done to improve the vertical height of the bone for osteointegrated implants and later oral rehabilitation. METHODS: The senior authors performed mandibular reconstruction with a fibula free flap. Vertical osteogenic distraction was performed to improve the vertical height of the bone for osteointegrated implants and later oral rehabilitation. The patient achieved adequate function with a good mandibular height and occlusion. RESULTS: The patient had a follow-up of 6 months. She is highly satisfied with her result. Preoperative and postoperative photos are shown. DISCUSSION: In this rare case, the authors show the difficulties when treating this disease. The follow-up of the patient showed a successful reconstruction with good functional results.

Cleft Patient-Reported Postoperative Donor Site Pain Following Alveolar Autologous Iliac Crest Bone Grafting: Comparing Two Minimally Invasive Harvesting Techniques.

BACKGROUND: Autologous bone grafting is still considered the standard method for alveolar cleft repair. However, donor site morbidities remain a relevant problem in cleft care. Thus, the authors assessed postoperative donor site pain in cleft patients who underwent alveolar cleft repair by iliac crest bone graft transferring through a prospective randomized study comparing 2 minimally invasive harvesting techniques. METHODS: Fifty-six consecutive patients with cleft lip and palate who underwent iliac crest bone grafting for alveolar cleft repair were randomly divided into 2 groups: bone graft harvested by minimally invasive techniques without (group 1) and with (group 2) periosteum elevation. Postoperative donor site pain was evaluated using a unidimensional numerical pain intensity rating scale (0, "no pain;" 10, "worst pain imaginable") at 1, 3, 6, 9, and 12 hours after the procedures and on the 3rd, 7th, 14th, 21st, and 28th days after surgeries. Intergroup comparisons were performed. RESULTS: The mean measurements of donor site pain revealed no significant differences (all P > 0.05) in any of the evaluated postoperative period comparisons between groups 1 and 2. There was a greater number (P < 0.05) of group 1 patients who reported "no pain" in the donor site compared with group 2, suggesting that periosteum elevation may play a role in pain intensity measurement. CONCLUSIONS: This prospective randomized study showed no difference in pain intensity among cleft patients who had postoperative pain. However, a greater number of patients in group 1 reported "no pain" in comparison to patients in group 2.

Computed tomography image guidance for more accurate repair of anterior table frontal sinus fractures.

BACKGROUND: Anterior table frontal sinus fractures accompanied by nasofrontal duct injury require surgical correction. Extracranial approaches for anterior table osteotomies have traditionally used plain radiograph templates or a "cut-as-you-go" technique. We compared these methods with a newer technique utilizing computed tomography (CT)-guided imaging. METHODS: Data of patients with acute, traumatic anterior table frontal sinus fractures and nasofrontal duct injury between 2009 and 2013 were reviewed (n = 29). Treatment groups compared were as follows: (1) CT image guidance, (2) plain radiograph template, and (3) cut-as-you-go. Frontal sinus obliteration was performed in all cases. Demographics, operative times, length of stay, complications, and osteotomy accuracy were recorded. RESULTS: Similar demographics, concomitant injuries, operative times, and length of stay among groups were noted. No patients in the CT-guided group had perioperative complications including intraoperative injury of the dura, cerebrum, or orbital structures. In the plain radiograph template group, 25% of patients had inadvertent dural exposure, and 12.5% required take-back to the operating room for cranial bone graft donor site hematoma. In the cut-as-you-go group, 11% required hardware removal for exposure. There were no cases of cerebrospinal fluid leak, meningitis, or mucocele in any group (follow-up, 29.2 months). The CT image guidance group had the most accuracy of the osteotomies (95%) compared with plain radiograph template (85%) and the cut-as-you-go group (72.5%). CONCLUSIONS: A new technique using CT image guidance for traumatic frontal sinus fractures repair offers more accurate osteotomy and elevation of the anterior table without increased operative times or untoward sequelae.

Calvarial autogenous bone graft for maxillary ridge and sinus reconstruction for rehabilitation with dental implants.

Autogenous bone grafting is the gold-standard technique for bone augmentation procedures prior to implant placement. If the amount of available intraoral donor bone is insufficient, it is necessary to harvest bone graft from extraoral sites, such as calvaria. Although this technique is well established, only a few case reports show the histological analysis of the grafted bone at the moment of implant placement. This article reports the case of a 48-year-old female patient with a critical atrophic maxillary ridge reconstructed using autogenous calvarial bone graft prior to implant placement, with clinical and histological evaluation. Bone was collected under general anesthesia from the parietal bone. The outer cortical originated the bone blocks, and the medullar bone layer between was collected to be used in the sinus augmentation procedure, together with 5 of the bone blocks triturated. Six months after bone augmentation, 8 implants were placed in the grafted area and 2 biopsies were retrieved (anterior and the posterior regions), allowing the visualization of the bone-remodeling process in the grafted areas. The patient had a stable recovery. Our results showed that although necrotic bone could still be seen in the outer layer of the grafted area, the interface between this necrotic bone and the already remodeled bone was consistent with biocompatibility. Two-year radiographic evaluation showed success of the grafts and the implants in supporting an esthetic and functionally stable prosthesis. Summarizing, calvarial bone grafts are a viable alternative for the attainment of adequate bone volume prior to implant placement.

The primary closure approach of dog bite injuries of the nose.

The nose holds an outstanding position on the face, acquiring great importance within the context of facial aesthetics. Because of the functional, psychological, and social aspects of trauma in a society increasingly demanding about aesthetics, treatment institution must reduce, as accurate as possible, the sequelae that hinder social integration. This clinical report relates an immediate nasal reconstruction of a complex animal bite wound. A 7-year-old patient was victim of a dog bite with avulsion of the left nasal ala and part of the ipsilateral nasal tip. The treatment was immediate nasal reconstruction with auricular composite graft. After 1 year of follow-up, the shape of nasal ala was stable, and the color was consistent with the surrounding tissue. The 2 nasal sides exhibited satisfactory symmetry when evaluated. It can be concluded that the composite graft derived from the auricular helix is a safe option for reconstruction of nasal ala defects with compromised margins in pediatric patients when conditions of reimplantation do not exist.

Existen diferencias en la sobrevida de pacientes e injertos renales con 3 años de funcionamiento, según si su proveniencia fue de donantes vivos o fallecidos / Are there differences in the survival of patients with kidney graft functioning during 3 years, as if the donor was dead or alive?

Antecedentes: El trasplante renal (TxR) es el tratamiento de elección para la mayoría de los pacientes con insuficiencia renal crónica etapa 5. Clásicamente se ha comunicado que los TxR con donante fallecido presentan una menor sobrevida que los TxR con donante vivo. Objetivos: Determinar si existen diferencias significativas en la superviviencia de pacientes e injertos en trasplantados renales que han alcanzado los 3 años con un injerto funcionante, según si el donante fue un sujeto vivo o fallecido. Conocer si las causas de pérdida del injerto y las complicaciones presentadas durante la evolución del trasplante fueron diferentes entre ellos. Sujetos y Métodos: Se incluyeron 188 pacientes trasplantados en 3 hospitales entre 1976-2001 y que tenían un injerto funcionante al tercer año de la intervención. De ellos, 96 recibieron injerto de donante vivo y 92 de uno fallecido. Resultados: La supervivencia de injertos y pacientes fue similar en ambos grupos. La frecuencia de rechazo crónico como pérdida del injerto fue mayor en sujetos con donante vivo. Los pacientes con donante cadáver se hospitalizaron más frecuentemente por infecciones durante los primeros 3 años y presentaron más frecuentemente una función renal retardada. Conclusiones: No existieron diferencias significativas en la supervivencia de los pacientes o injertos según el tipo de donante en los trasplantados que alcanzaron lo 3 años con un injerto funcionante. Las causas de pérdida de los injertos y las complicaciones durante la evolución fueron similares, con excepción de una incidencia mayor de requirimiento de diálisis post-operatoria y de hospitalizaciones por infecciones en los que recibieron un injerto de un donante fallecido.

Background: Renal transplantation is the treatment of choice for most patients with chronic kidney disease stage 5. Traditionally, it has been reported that kidney transplants in patients with a deceased donor have a lower survival than the ones with a living donor. Aim: To determine whether there are significant differences in patients and grafts survival in kidney transplant recipients who have reached 3 years with a functioning graft, depending on whether the donor was a living or deceased individual. Also, to determine if the causes of graft loss and complications presented during the follow up were different between them. Subjects and Methods: 188 patients transplanted in 3 hospitals (1976 to 2001) and who had a functioning graft in the third year of the intervention. Of these, 96 received grafts from living donors and 92 from deceased donors. Results: Graft and patient survival was similar in both groups. The frequency of graft loss due to chronic rejection was higher in patients with living donors. Patients with deceased donors were hospitalized more frequently for infections during the first three years and more frequently had delayed renal function. Conclusions: No significant differences in the survival of patients or grafts that reached 3 years functioning normally were founded instead the type of donor. The complications during the follow up were similar between both groups, except for a higher incidence of dialysis requirement in the postoperative period and hospitalizations due to infections in patients receiving grafts from deceased donors.

Prospective clinical assessment of pulp sensitivity after chin bone harvesting.

PROPOSAL: Evaluate pulp vitality of mandibular teeth after chin bone harvesting. MATERIALS AND METHODS: Thirty patients underwent chin bone harvesting and accompanied for 12 months, being submitted to testing for pulp vitality with Endo Ice refrigerant spray to produce a local temperature of -50 °C. The statistical analysis was executed with McNemar test with P value < 0.05. RESULTS: Results show that canine teeth are most susceptible to alterations; 68.82% (181) of the teeth tested showed no loss of pulp sensitivity to cold 30 days after surgery (P < 0.05), and at the end of the study, that figure had risen to 100% (263) of all teeth included in the sample. CONCLUSIONS: Pulp vitality testing showed that 31.18% (82) of teeth experienced some loss of sensitivity, but by 12 months after surgery, all teeth had recuperated their pulp sensitivity to cold unaided.

Esthetic-functional recovery of permanent posterior tooth using autogenous biological restoration.

Occlusal morphology and difficult access for cleaning permanent molars result in the buildup of bacterial plaque and the development of caries. One method known as biological restoration was carried out. This technique known as biological restoration, has as main restorative material a fragment obtained from a duly donated extracted human tooth. This case report describes the restoration of an extensively decayed molar through the bonding of a fragment obtained from a third molar extracted from the patient himself. Biological restoration is a low-cost option that offers satisfactory aesthetic, morphological and functional results.The morphological/functional reestablishment of posterior teeth can be obtained through biological restoration, which allows the recovery of properties inherent to the dental structure, offers satisfactory aesthetic results and low cost.

Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction.

BACKGROUND: Breast reconstruction with autogenous tissue is a well-established technique, but there are some limitations related to donor-site morbidity. Among available techniques, the superficial inferior epigastric artery (SIEA) flap is the least invasive procedure because it does not require harvesting or incision of the rectus muscle or the abdominal fascia. Besides adequate flap choice, the proper selection of the recipient vessels is an important factor. Thus, the internal mammary perforator branches (IMPBs) have been an attractive option regarding recipient pedicle morbidity. METHODS: The investigators reported the use of the free SIEA flap with the IMPBs as a recipient site to reconstruct radical mastectomy. RESULTS: Five patients with invasive ductal carcinoma underwent modified radical mastectomy and reconstruction. The IMPBs were selected as the recipient site and a free SIEA flap was used. The donor defect was closed directly without synthetic mesh. Satisfactory breast shape was achieved, and no complications were observed. CONCLUSIONS: For selected patients, the SIEA flap and IMPBs may constitute a new alternative for immediate breast reconstruction, because of the possibility of large tissue transfer with minimal donor and recipient area morbidity. The SIEA pedicle size and the quality of IMPB vessels should be carefully evaluated.