Gender dysphoria: laparoscopic sigmoid vaginoplasty. Another utility of indocyanine green.

AIM: Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS: We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS: Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION: Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

Avoiding Above-the-Knee Amputation with a Free Tibiofibular-Talocalcaneal Fillet Flap and Free Latissimus Dorsi Flap.

Despite the advances achieved in reconstructive surgery, amputation is still the only option after some severe traumas. Preservation of the knee joint is considered a significant functional advantage. We present the case of a 39-year-old man with a comminuted Gustilo type IIIC open tibia fracture with massive bone loss. To achieve a well-fashioned amputation stump and preserve the knee joint, a free osteocutaneous fillet flap was performed, including the distal tibia and fibula, talus, and calcaneus bones. As a result, a sensate and long amputation stump covered with thick skin from the sole of the foot provided a stable coverage with an excellent functional result and adjustment to prosthesis.

Autologous Patellar Tendon Reconstruction after Total Knee Arthroplasty Infection with Skin Loss: Anatomical Study and Case Report.

Disruption of patellar tendon after total knee arthroplasty (TKA) is a devastating complication. If associated with infection or soft tissue defect, knee arthrodesis is usually indicated. The purpose of this study is to analyze, by means of an anatomical study, the feasibility of our novel technique for reconstruction of extensor apparatus after TKA infections with skin defects, combining gracilis (G) and semitendinosus (ST) tendon autografts and chimeric medial gastrocnemius-sural artery perforator (SAP) flap. In addition, to report on the use of this reconstruction, we described an illustrative clinical case. Ten fresh cadaver lower limbs were dissected. The width of the gastrocnemius, number of medial SAP, length of hamstrings tendons, and distance from the lower pole of the patella to anterior tibial tuberosity (ATT) were measured. A mean of 1.37 perforator branches (range 1-3) was found. In all cases, the tendon length for gracilis and ST, and the width in the middle third of gastrocnemius related to the patella-ATT distance were enough to make the reconstruction. We performed this technique in a 78-year-old man with an infected TKA with skin defect. After 1 year and two-stage procedure, the patient achieved full active knee extension and was able to ambulate without aids. Extensor apparatus reconstruction combining tendon autografts and chimeric medial gastrocnemius-SAP flap is an available technique and may be considered as an alternative to arthrodesis in extensor mechanism ruptures after infection in TKA.

Management of Hand Burn With Pedicled Converted Anterolateral Thigh Free Flap.

The upper limb is involved in burns in a high percentage of cases and its reconstruction is extremely important, given the functional impact of this anatomical region. Among the reconstruction choices for severe and large structural defects, the pedicled anterolateral thigh flap is an available option. This case study discusses the utilization of the pedicled anterolateral thigh flap for reconstruction of a complex full-thickness hand burn, when adequate arterial perforators were not available. Complex hand burns can often present challenges for reconstructive coverage, because of the complex anatomy of the upper extremity and the need to preserve as much function as possible. The use the anterolateral thigh free flap is one option that can be utilized for coverage of these large hand defects, in the face of poor local tissue advancement options. The finding of inadequate or lack of perforator vessels necessitates intraoperative changes in the surgical approach. In these cases, different alternatives exist depending on the dimensions and characteristics of the required coverage, the dissection of a pedicled flap being one of them. The pedicled anterolateral thigh flap represents an alternative for the coverage of large hand defects in the absence of valid perforators during free-flap dissection.

Masseter-to-Facial Nerve Transfer for Reanimation of a Patient With Long-Term Facial Paralysis.

Facial paralysis is a condition caused by a wide variety of etiologies, including neurologic, congenital, infectious, neoplastic, systemic, and iatrogenic causes. A patient suffering from long-term facial paralysis, with minimal innervation detected through electroneurography, who was successfully reanimated by performing a masseter-to-facial nerve transfer, was presented in this study. Facial paralysis had been caused after resection of an acquired middle ear cholesteatoma more than 5 years before.

Adenopatías por migración de silicona a axila contralateral 2 años después de rotura de prótesis mamaria / Contralateral silicone lymphadenopathies two years after implant rupture

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Free microvascular rotationplasty with nerve repair for rhabdomyosarcoma in a 18-month-old patient.

Rotationplasty is a limb-sparing surgical option in lower limb malignancies. Sciatic or tibial nerve encasement has been considered an absolute contraindication to this procedure. We report a case of an 18-month-old girl with a rhabdomyosarcoma that affected the leg and popliteal fossa, with neurovascular involvement. Knee and proximal leg intercalary resection was performed followed by reconstruction with free microvascular rotationplasty and neurorraphy from tibial division of sciatic nerve to sural and tibial nerves, and from saphenous nerve to superficial peroneal nerve. Postoperative course was uneventful and ambulation with a provisional prosthesis was restarted during the sixth week after surgery. Bone consolidation was observed after two months. Eighteen months later, the patient had a good gait pattern with a below-knee prosthesis and had recovered sensation in the whole foot and ankle area. This case shows that rotationplasty with nerve repair may provide a sensate stump, which is vital for successful prosthetic adaptation. We believe it may be considered as an alternative to above-knee amputation in tumors with sciatic involvement.

Vendaje autoadherente en el tratamiento integral y rehabilitador de la mano quemada / Autoadhesive bandage on comprehensive treatment and rehabilitation of burned hand

Antecedentes y Objetivo. Las quemaduras en las manos constituyen una patología de muy difícil manejo y cuyas secuelas son de vital importancia desde el punto de vista funcional. Su tratamiento debe incluir un desbridamiento precoz seguido de un proceso de rehabilitación temprana con férulas, fisioterapia y presoterapia. En nuestra Unidad de Quemados empleamos la venda Coban(R) 3M como inicio temprano de presoterapia. Se trata de una técnica probada procedente del tratamiento rehabilitador del linfedema, que aplicada a las quemaduras permite reducir el edema prolongado (agente causal de múltiples complicaciones y de la pérdida funcional) y la cicatrización hipertrófica. Pacientes y Método. Realizamos un estudio retrospectivo sobre 14 pacientes con quemaduras de 2º grado profundo o de 3er grado en mano, analizando sus características demográficas, características de la quemadura, cronología del empleo del vendaje Coban(R) 3M y uso de otras terapias, índice de complicaciones y tasa de recuperación funcional. Explicamos también de forma detallada el método de aplicación del vendaje. Resultados. Aplicamos el vendaje a una media de 17.93 días tras la cobertura o cierre por segunda intención de las quemaduras, manteniéndolo durante una media de 75.54 días, con bajas tasas de complicaciones (cicatrización hipertrófica leve: 28.57%; dolor: 7.14%: edema: 7.14%; prurito: 7.14%; infección: 0), así como altas tasas de recuperación funcional (completa: 64.28%; limitaciones leves: 14.28%). Observamos que la aplicación de este tipo de vendaje en el tratamiento rehabilitador de quemaduras presentó una baja tasa de complicaciones, mayoritariamente menores, y altas tasas de recuperación funcional (64.28% de recuperación completa y 14.28% con limitación leve). Hasta donde hemos podido comprobar, no existe ningún trabajo en la literatura que detalle un protocolo similar de aplicación de este vendaje en pacientes quemados. Conclusiones. En base a los resultados de nuestro estudio, consideramos que la aplicación precoz del vendaje autoadherente Coban(R) 3M como herramienta adicional en el tratamiento integral de las quemaduras, puede resultar interesante ya que reduce los niveles de edema y la incidencia de cicatrización hipertrófica. Nuestro estudio presenta unas bajas tasas de complicación y altos niveles de recuperación funcional (AU)

Background and Objective. Hand burns constitute pathology with very difficult management and which functional sequelae are hugely important. The treatment of these burns has to include an early debridement followed by a focused rehabilitation process, with splints, physiotherapy and pressotherapy. In our Burns Unit we employ Coban(TM) 3M bandage as early pressure therapy. This is a proven technique from the rehabilitation of lymphedema, which applied to burns reduces the prolonged edema (causal agent of numerous complications and functional impairment), as well as hypertrophic healing. Patients and Methods. We conduct a retrospective study with 14 patients with 2º deep grade and 3rd grade in hand, to analyze their demographic features, burn characteristics, chronology of Coban bandage usage and performance of other therapies, complications rate and functional recovery rate. Furthermore, we detail the application method of this bandage. Results. The application of Coban(TM) bandage was performed in average of 17.93 days after burns coverage or healing by 2nd intention, keeping its application for 75.54 days in average, with low complication rate (mild hypertrophic scars: 28.57 %; pain: 7.14%; edema: 7.14%: itching: 7.14%; infection: 0), as well as high functional recovery rate (complete recovery in 64.28%, with mild impairment in 14.28%). From the data collected in our study we show that the application of Coban(TM) rehabilitation treatment of burns showed a low rate of complications, which were mostly minor, accompanied by high rates of functional recovery (64.28% full recovery and 14.28% with slight limitation). To our knowledge, there are no references in the literature that detail an application protocol of this bandage on burn patients. Conclusions. Based on the results of our study, we believe that early application of self-adhesive bandage Coban(TM) 3M as an additional tool in the comprehensive treatment of burns may be interesting as it reduces levels of edema and the incidence of hypertrophic healing. Our study shows low complication rates and high levels of functional recovery (AU)

Periareolar augmentation mastopexy: A new approach dealing with the cases as tuberous breasts.

BACKGROUND: Periareolar augmentation mastopexy is one of the most demanded operations at Plastic Surgery clinics. Nevertheless, it is one of the leads of malpractice claims in United States caused by the high patient expectations and the standard surgical techniques which may result in common complications. The aim of this report is to present a new surgical approach to solve these complications. METHODS: After establishing a working hypothesis, we performed a revision study of our patients and we came to the following conclusion: in order to perform a periareolar mastopexy for ptosis correction, breast has to be tuberous at any level and to have abnormally short inferior pole. These findings may explain the main complications from periareolar augmentation mastopexy with the standard surgical techniques. Consequently, we started a prospective observational study including 56 patients following a new surgical technique which deals the cases as tuberous breasts. RESULTS: During three years, fifty-six periareolar mastopexies were performed with this new surgical approach with one year follow-up. No major complications were observed and 40 of the patients (71%) described the results as very positive. CONCLUSION: "If a periareolar mastopexy can be performed, then it must be a tuberous breast". According to this, a new surgical technique for periareolar augmentation mastopexy has been developed obtaining an improvement in our surgical results and achieving a totally different view on this pathology, which has not been reported in literature yet.

El colgajo fasciocutáneo dorsal ulnar en quemaduras eléctricas de la mano: un colgajo constante, rápido y seguro / Fasciocutaneous dorsal ulnar artery flap in electric hand burns: a constant, fast and secure flap

Antecedentes y Objetivos. La extremidad superior es el área más frecuentemente afectada en las quemaduras eléctricas de alto voltaje, con una alta tasa de amputaciones, síndromes compartimentales y defectos de partes blandas que precisan cobertura. La literatura en cuanto a la cirugía reconstructiva de la mano con quemaduras eléctricas es escasa, pero es fundamental en la fase aguda establecer un plan quirúrgico y una cobertura estable de estos frecuentes defectos en mano y muñeca. Pacientes y Método. Empleamos el colgajo fasciocutáneo dorsal ulnar en 3 pacientes con defectos cutáneos en muñeca secundarios a quemaduras eléctricas de alto voltaje, durante la fase aguda de estas lesiones, Resultados. Obtuvimos en todos los casos una cobertura estable y de alta calidad y sin registrar complicaciones relacionadas con el colgajo o con la zona donante. Conclusiones. Debido a la constancia de su pedículo, la rapidez y seguridad de su disección y la preservación de ambos ejes arteriales, el colgajo fasciocutáneo dorsal ulnar es una herramienta de primer uso en la cobertura de los defectos de la mano y de la muñeca tras quemaduras eléctricas de alto voltaje (AU)

Background and Objectives. Upper limb is the most frequently affected area in high-voltage electric injuries, with a high incidence of amputations, compartment syndrome and tissue defects requiring coverage associated. Published data when reviewing literature about reconstructive surgery of the hand with high-voltage electric injuries are scarce, but a surgical plan and a quality coverage of the frequent tissue defects in hand and wrist in the acute phase is essential. Patients and Methods. Fasciocutaneous dorsal ulnar artery flap was used to repair acute soft tissue defects on the wrist of 3 patients who had suffered high-voltage electric injuries. Results. The flap provided in all our cases a reliable and durable coverage, keeping both arterial axis of the hand intact. No complications of the flap or the donor site were registered. Conclusions. Because the flap does not compromise hand arteries and provides a stable coverage with direct dissection and constant pedicle, dorsal ulnar artery flap is an excellent choice for soft tissue reconstruction in hands with high-voltage electric injuries (AU)

Manejo terapéutico del linfedema de pene subagudo y secundario a erisipela mediante colgajos cutáneos / Therapeutic approach of subacute penile lymphoedema secondary to erysipela by means of cutaneous flaps

Presentamos la revisión clínica de un paciente de 38 años remitido a nuestro centro por linfedema de pene secundario a infección por Streptococcus pyogenes (erisipela) de 6 meses de evolución que como secuela presenta edema de consistencia gomosa sin lesiones dérmicas asociadas limitado al pene que imposibilita las relaciones sexuales y dificulta el vaciado vesical. La linfogammagrafía no evidenció acúmulo del radiofármaco a nivel genital mientras que la RMN mostró marcado engrosamiento cutáneo y subcutáneo alrededor de cuerpos cavernosos y glande con predominio del tejido fibroso. Se realizó resección quirúrgica del tejido fibroso cubriendo el defecto con colgajos laterales de piel peneana. El estudio anatomopatológico con utilización de marcadores específicos CD-31 y D2-40 confirmó la presencia de linfáticos infiltrados. El postoperatorio cursó sin complicaciones, mostrando aspecto cosmético satisfactorio sin presencia del edema ni síntomas urinarios y recuperando la función sexual a los 6 meses (AU)

Clinical review of a 38 years old patient referred to our hospital with penile lymphoedema secondary to a Streptococcus pyogenes (erysipela) infection 6 month ago. Physical exam revealed an uncircumcised penis with a soft consistency edema and no skin lesions. The patient was unable to maintain intercourse and had urine dripping caused by obliteration of the foreskin. Lymphogammagraphy revealed the absence of drug accumulation at genital area. MRI showed skin strengthening around the cavernous corpora and glans with fibrous tissue predominance. We performed a surgical resection of the fibrous tissue with lateral penis cutaneous flaps. There were no complications during the intervention and the post-operative period. The pathology report revealed the presence of lymphatic vessels with specific coloring DC-31 and D2-40. Six months after the intervention we observed an absence of edema with satisfactory cosmetic appearance, without urinary symptoms, and patient was able to maintain erections and perform intercourse (AU)