The extended SCIP flap: An anatomical and clinical study of a new SCIP flap design.

PURPOSE: We describe a variation of the superficial circumflex inguinal artery perforator (SCIP) flap, based the superficial branch of the superficial circumflex inguinal artery (SCIA) METHODS: The vascular supply of the SCIP flap was prospectively studied in 91 preoperative CT angiograms in patients undergoing reconstruction with other flaps, and verified randomly with a hand-held doppler in 20% of them. Based on the results, a new SCIP flap was designed medial and cranial to the anterosuperior iliac spine (ASIS) using the superficial branch of the SCIA. This flap was used in 39 patients to reconstruct lower limb and head and neck defects RESULTS: The superficial branch of the SCIA was found in all patients and its exit point through Hesselbach's fascia was located within a 21 mm-radius circumference drawn 18 mm medial and 17 mm distal to the ASIS in 90% of the patients. Reconstruction with this SCIP flap was successful in 92.3% of the patients. Complications were present in 17.9% of the patients CONCLUSIONS: The design of the SCIP flap can be displaced cranially to obtain a larger flap with a long and constant vascular pedicle that is based on the main trunk of the SCIA. This facilitates the reconstruction of large and complex three-dimensional defects that require thin and pliable tissue, such as those located in the head and neck or limbs. Furthermore, supramicrosurgical expertise is not required. LEVEL OF EVIDENCE: IV.

Ankle joint salvage surgery with an ipsilateral mid-fibula osteocutaneous free flap and contralateral anterolateral thigh free flap: A case report and literature review.

The tibiofibular joint can be reconstructed after distal fibular sarcoma salvage surgery to maintain ankle stability and achieve early gait. Classical reconstructive options include ligamentoplasties, arthrodesis, prosthetic replacement, bone grafts, and pedicled ipsilateral or free contralateral fibular bone flaps. We present a novel strategy for reconstruction of the ankle in an elderly patient and a literature review. A 68-year-old man presented with a high-grade myxofibrosarcoma to his distal fibula. Wide resection of the tumor and adjacent structures left a 12 × 12 × 8 cm defect including the distal fibula (10 cm), a 2 cm fragment of the lateral cortex of the tibia, the lateral anterior and superficial posterior compartments, and the lateral compartment. A 3 cm distal fibula remnant was left in the ankle mortice. Reconstruction was performed using a free ipsilateral 13-cm diaphyseal osteocutaneous fibular flap telescoped into the distal fibula remnant and anastomosed to the anterior tibial artery. A pre-bent L-shaped locking plate was used to reconstruct a syndesmotic joint. A 21 × 13 cm suprafascial ALT flap was anastomosed to the proximal stump of the peroneal artery to cover the soft tissue defect. The patient had no complications and was ambulating with full weight bearing by postoperative week 11. He received postoperative chemo and radiotherapy. Three years postoperatively, he is tumor free, has complete ankle ROM and stability, and ambulates with no restrictions. Limb sparing surgery with a functional tibiofibular joint reconstruction should be considered to attain an early functional recovery after distal fibula sarcomas resection.

All for One and One for All: Voluntary Physicians in the Intensive Medicine Units During the COVID-19 Outbreak in Spain.

OBJECTIVES: Our purpose was to determine the intensive care units' (ICU's) medical staff surge capacity during the coronavirus disease 2019 (COVID-19) outbreak in Spring 2020 in Spain. METHODS: A multicenter retrospective survey was performed addressing the medical specialties present in the ICUs and the increase in bed capacity during this period. RESULTS: Sixty-seven centers (62.04%) answered the questionnaire. The ICU bed capacity during the pandemic outbreak increased by 160% (95% confidence interval [CI], 128.97-191.03%). The average number of beds per intensive care medicine (ICM) specialist was 1.5 ± 0.60 and 3.71 ± 2.44 beds/specialist before and during the COVID-19 outbreak, respectively. Non-ICM specialists and residents were present in 50 (74.63%) and 23 (34.3%) ICUs during the outbreak, respectively. The number of physicians (ICM and non-ICM residents and specialists) in the ICU increased by 89.40% (95% CI, 64.26114.53%). The increase in ICM specialists was, however, 4.94% (95% CI, -1.35-11.23%). Most non-ICM physicians were anesthetists, followed by pediatricians and cardiologists. CONCLUSIONS: The majority of ICUs in our study were able to rapidly expand critical care capacity by adapting areas outside of the normal ICU to manage critically ill patients, and by extending the critical care staff with noncritical care physicians working as force multipliers.

Preoperative Vascular Planning of Free Flaps: Comparative Study of Computed Tomographic Angiography, Color Doppler Ultrasonography, and Hand-Held Doppler.

BACKGROUND: Preoperative planning of microsurgical perforator free flaps continues to be a discussion topic among microsurgeons. The purpose of this study was to compare the ability of three methods of preoperative vascular mapping-hand-held Doppler imaging, color Doppler ultrasonography, and computed tomographic angiography-to detect perforators and their concordance with surgical findings. METHODS: A prospective study was performed to evaluate the sensitivity, specificity, and accuracy of hand-held Doppler imaging, color Doppler ultrasonography, and computed tomographic angiography to detect free flap perforators. Each patient undergoing a free flap reconstruction was studied preoperatively with the three methods, and the results were compared to the intraoperative findings. RESULTS: Fifty-three patients undergoing autologous tissue reconstruction were included. Most reconstructions (71.7 percent) were performed with anterolateral thigh flaps. The positive predictive value (color Doppler ultrasonography, 100 percent; computed tomographic angiography, 100 percent; hand-held Doppler imaging, 88.6 percent) and negative predictive value (color Doppler ultrasonography, 100 percent; computed tomographic angiography, 94.3 percent; hand-held Doppler imaging, 90.5 percent) rates were significantly different between methods. The high resolution of the color Doppler ultrasonography probe provided a direct vision of the vasculature arborization and efficiently detected vessels with diameters of less than 0.5 mm. The sensitivity, specificity, and accuracy of color Doppler ultrasonography were greater than those of both computed tomographic angiography and hand-held Doppler imaging. There was 100 percent concordance between color Doppler ultrasonography perforators and the surgical findings. CONCLUSIONS: Color Doppler ultrasonography provides a reproducible, harmless, and accurate way to visualize vascular anatomy. It has a high correlation with the surgical findings, signifying advantages over hand-held Doppler and computed tomographic angiography in sensitivity, specificity, and accuracy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Full Facial Allotransplantation Including the Temporomandibular Joints: A Radiologic and Anatomical Cadaveric Study.

BACKGROUND: Facial allotransplantation including the temporomandibular joints may improve the functional outcomes in face transplant candidates who have lost or damaged this joint. METHODS: Linear and angular measurements were taken in 100 dry skulls and mandibles and in 100 three-dimensionally-reconstructed facial computed tomographic scans to determine the variability of the temporomandibular joint, glenoid fossa, and mandible. A vascular study was performed in six fresh cadaveric heads, followed by harvest of the face allograft in three heads. Next, four heads were used for mock transplantation (two donors and two recipients). The full facial allograft included four different segments: a Le Fort III, a mandibular tooth-bearing, and two condyle and temporomandibular joint-bearing segments. Statistical analysis was performed using SAS software. RESULTS: In only one-third of the skulls, the condylar shape was symmetric between right and left sides. There was a wide variability in the condylar coronal (range, 14.3 to 23.62 mm) and sagittal dimensions (range, 5.64 to 10.96 mm), medial intercondylar distance (range, 66.55 to 89.91 mm), and intercondylar angles (range, 85.27 to 166.94 degrees). This high variability persisted after stratification by sex, ethnicity, and age. The temporomandibular joint was harvested based on the branches of the superficial temporal and maxillary arteries. The design of the allograft allowed fixation of the two condyle and temporomandibular joint-bearing segments to the recipient skull base, preserving the articular disk-condyle-fossa relationship, and differences were adjusted at the bilateral sagittal split osteotomy sites. CONCLUSION: Procurement and transplantation of a temporomandibular joint-containing total face allograft is technically feasible in a cadaveric model.

Photogrammetric Outcomes of Primary Nasal Correction in Unilateral Cleft Lip Patients: Early Childhood Results From a Single Surgeon's Experience.

BACKGROUND: Concerns of nonlasting results and potential nasal growth damage precluded cleft nasal correction at the time of initial cleft lip repair. Our goal was to evaluate the outcome of primary cleft nasal correction in our patients with unilateral cleft lip. METHODS: A retrospective review of patients with complete and incomplete unilateral cleft lip who underwent primary cleft nasal correction from 2010 to 2017 by the same surgeon was performed. The cleft-to-noncleft nostril height, width, one-fourth medial part of nostril height, nasal sill height, and nostril area ratios, as well as inner nostril height-to-width ratios were determined from standard basilar view photographs taken in different time points (T1, <3 months; T2, 3-12 months; T3, 12-36 months; and T4, >36 months after surgery). A 5-point visual analog scale (1 = worst, 5 = best) was used to assess each patient's nose appearance. RESULTS: Seventy-two patients were identified (66.7% male, 51.3% with a complete cleft lip). Average visual analog scale scores T1-T4 were 3.88 ± 0.85, 3.72 ± 0.93, 3.54 ± 0.99, and 3.40 ± 0.71, respectively. Intraclass correlation ranged from 0.61 to 0.94. A significant decrease [mean difference (SD)] was found for cleft-to-noncleft nostril width ratio [0.15 (0.18)] from T1 to T2, and an increase for one-fourth medial height ratio [-0.09 (0.07)] and for inner nostril height-to-width ratio in the noncleft side [-0.23 (0.25)] from T1 to T3. Thirteen patients required secondary surgical revision. CONCLUSION: Based on photogrammetry, primary cleft nasal correction in our patients with unilateral cleft lip achieved acceptable and stable outcomes during early childhood.

Donor skin allograft survival after bone marrow transplantation: Case report and systematic review of the literature☆.

BACKGROUND: We present a case of skin allograft survival in a patient who previously received a bone marrow transplant from the same HLA-matched donor. DNA fingerprinting of skin biopsies showed mixed cellularity originating from the donor and recipient (68% and 32% donor DNA in the allograft skin and the native recipient's skin, respectively). Histologic sections demonstrated both grade 3/4 rejection and graft-versus-host-disease. We have conducted a systematic review in search for other cases of donor skin allograft survival after a bone marrow or hematopoietic stem cell transplantation. METHODS: All reported cases in English, Spanish, French, and German were captured using the electronic databases. Bibliographies of relevant articles were manually searched. RESULTS: Nineteen patients (12 females) who received skin allografts from their bone marrow or hematopoietic stem cell donors were identified. Average age was 27.2 years (range: 5 months to 64 years). Skin allografts were used to treat graft-versus-host-disease, Herlitz junctional epidermolysis bullosa, and to test tolerance before a kidney transplantation from the same donor. Eight cases were not receiving immunosuppressive therapy. Allografts survived in all patients. In three patients, skin punch biopsies were taken, and these biopsies demonstrated mixed donor and recipient cellularity. The pathology result is specified in two more cases, with no signs of rejection. CONCLUSIONS: The same donor skin allografts may be a safe option to treat severe cutaneous conditions in recipients of a bone marrow/hematopoietic stem cell transplantation. However, future studies are needed to confirm these results.

[Energy expenditure prediction equations in burn patients; bibliographic review]. / Estimación del gasto energético en el paciente quemado mediante la utilización de ecuaciones predictivas; revisión bibliográfica.

INTRODUCTION: The estimation of the caloric requirements of the burn patient is based on the measurement of his resting energy expenditure (REE) via indirect calorimetry, which is not available in all Burn Units, or its estimation by means of predictive equations. GOALS: we analyze the history and state of art of the use of REE predictive equations in burn patients, and determine their validity. METHODS: bibliographic review of the studies and reviews written in English and Spanish between 1989 and 2013. RESULTS: More than 190 equations have been designed to estimate energy expenditure. These equations can be imprecise because they are based on measurements with a heterogeneous methodology and in heterogeneous groups. We describe the different parameters that are used in the different equations (stress and activity factors, total burn surface area, post-burn day, lean body mass), the influence of age in the calculation of the caloric requirements, and the most commonly used equations nowadays. We also describe the articles that evaluate the accuracy of the predictive equations when compared to REE indirect calorimetry measurements. CONCLUSIONS: Predictive equations are not precise in general in the burn patient. Until more accurate predictive equations are developed, we recommend calculation of the nutritional requirements in burn patients based on the energy expenditure measurement via indirect calorimetry.

Introducción: La valoración de las necesidades calóricas del paciente quemado se ha basado en la medición del gasto energético en reposo (GER) mediante calorimetría indirecta, no siempre disponible en las unidades de quemados, o en su estimación mediante el uso de ecuaciones predictivas. Objetivos: analizar la historia y estado del arte del uso de las ecuaciones predictivas de GER en el paciente quemado crítico, y determinar su validez. Métodos: revisión bibliográfica de estudios y revisiones en español y en inglés entre 1989 y 2013. Resultados: Se han diseñado más de 190 ecuaciones para estimar el gasto energético que pueden ser imprecisas por estar basadas en mediciones con metodología heterogénea y en grupos heterogéneos. Describimos los distintos parámetros que aplican las distintas fórmulas predictivas (factores de estrés y de actividad, superficie corporal quemada, tiempo desde la lesión, masa corporal magra), la influencia de la edad en el cálculo de las necesidades calóricas y las fórmulas más utilizadas en el momento actual. También describimos los artículos que evalúan exactitud de las fórmulas cuando se comparan con mediciones mediante calorimetría indirecta. Conclusiones: Las ecuaciones predictivas son poco precisas en general en el paciente quemado. Hasta que se desarrollen ecuaciones predictivas más precisas, recomendamos calcular los requerimientos nutricionales de los pacientes quemados basándose en la medición del gasto energético por calorimetría indirecta.

Estimación del gasto energético en el paciente quemado mediante la utilización de ecuaciones predictivas; revisión bibliográfica / Energy expenditure prediction equations in burn patients; bibliographic review

Introducción: La valoración de las necesidades calóricas del paciente quemado se ha basado en la medición del gasto energético en reposo (GER) mediante calorimetría indirecta, no siempre disponible en las unidades de quemados, o en su estimación mediante el uso de ecuaciones predictivas. Objetivos: analizar la historia y estado del arte del uso de las ecuaciones predictivas de GER en el paciente quemado crítico, y determinar su validez. Métodos: revisión bibliográfica de estudios y revisiones en español y en inglés entre 1989 y 2013. Resultados: Se han diseñado más de 190 ecuaciones para estimar el gasto energético que pueden ser imprecisas por estar basadas en mediciones con metodología heterogénea y en grupos heterogéneos. Describimos los distintos parámetros que aplican las distintas fórmulas predictivas (factores de estrés y de actividad, superficie corporal quemada, tiempo desde la lesión, masa corporal magra), la influencia de la edad en el cálculo de las necesidades caló- ricas y las fórmulas más utilizadas en el momento actual. También describimos los artículos que evalúan exactitud de las fórmulas cuando se comparan con mediciones mediante calorimetría indirecta. Conclusiones: Las ecuaciones predictivas son poco precisas en general en el paciente quemado. Hasta que se desarrollen ecuaciones predictivas más precisas, recomendamos calcular los requerimientos nutricionales de los pacientes quemados basándose en la medición del gasto energético por calorimetría indirecta (AU)

Introduction: The estimation of the caloric requirements of the burn patient is based on the measurement of his resting energy expenditure (REE) via indirect calorimetry, which is not available in all Burn Units, or its estimation by means of predictive equations. Goals: we analyze the history and state of art of the use of REE predictive equations in burn patients, and determine their validity. Methods: bibliographic review of the studies and reviews written in English and Spanish between 1989 and 2013. Results: More than 190 equations have been designed to estimate energy expenditure. These equations can be imprecise because they are based on measurements with a heterogeneous methodology and in heterogeneous groups. We describe the different parameters that are used in the different equations (stress and activity factors, total burn surface area, post-burn day, lean body mass), the influence of age in the calculation of the caloric requirements, and the most commonly used equations nowadays. We also describe the articles that evaluate the accuracy of the predictive equations when compared to REE indirect calorimetry measurements. Conclusions: Predictive equations are not precise in general in the burn patient. Until more accurate predictive equations are developed, we recommend calculation of the nutritional requirements in burn patients based on the energy expenditure measurement via indirect calorimetry (AU)

Bifid nose - a mild degree of frontonasal dysplasia. A case report.

Frontonasal dysplasia is an unusual congenital condition with a wide phenotypic range. Because of this, only a small number of cases and their management have been reported in the literature. The ideal surgical procedures to correct mild cases of frontonasal dysplasia, and the time to perform them, are still controversial. The case of a 9-month-old girl with a mild form of this condition (a congenital bifid nose and a duplicated frenulum), and its surgical management, is presented. The surgery achieved an early improvement of the patient's appearance and she had no complications. In the future, it is probable that she will need secondary rhinoplasty to aid in the projection of the tip and refine the shape of the nose.