Reconstrucción de un defecto en mejilla tras la exéresis de un carcinoma basocelular extenso mediante la combinación de un colgajo romboidal y un injerto de Burow / Large Cheek Defect Reconstruction With a Rhomboid Flap and Burow's Advancement Flap After Excision of a Basal Cell Carcinoma

La reconstrucción de grandes defectos quirúrgicos de mejilla puede constituir un gran desafío para el cirujano dermatólogo. Se describe una paciente con un carcinoma basocelular de 10cm de largo por 10cm de ancho que ocupaba la región bucomandibular de la mejilla, en la que la reconstrucción del defecto resultante de la cirugía se cerró con una combinación de un colgajo romboidal modificado con un injerto de Burow. (AU)

Reconstruction of large surgical defects on the cheek can be challenging for dermatologic surgeons. We describe using a modified rhomboid flap and Burow's advancement flap to close a surgical defect resulting from the excision of a basal cell carcinoma measuring 10×10cm in the buccomandibular area of the cheek. (AU)

Large Cheek Defect Reconstruction With a Rhomboid Flap and Burow's Advancement Flap After Excision of a Basal Cell Carcinoma. / Reconstrucción de un defecto en mejilla tras la exéresis de un carcinoma basocelular extenso mediante la combinación de un colgajo romboidal y un injerto de Burow.

Reconstruction of large surgical defects on the cheek can be challenging for dermatologic surgeons. We describe using a modified rhomboid flap and Burow's advancement flap to close a surgical defect resulting from the excision of a basal cell carcinoma measuring 10×10cm in the buccomandibular area of the cheek.

Aporte de fluidos en el pacientes pediátricos hospitalizados / Fluid intake in hospitalized pediatric patients

El aporte de fluidos constituye un elemento central en la atención del paciente pediátrico hospitalizado, existiendo aún controversias acerca de cuál es la composición óptima, la dosis adecuada y la mejor estrategia para administrar los mismos. El propósito de este artículo de actualización es brindar al médico que se desempeña en las diferentes áreas de la internación pediátrica, conceptos y enfoques terapéuticos que lo ayuden en la asistencia de los pacientes que por diversos motivos requieren la administración de fluidos endovenosos. La recomendación de utilizar cristaloides en la reanimación es casi uniforme. Se observa una clara tendencia al uso de soluciones isotónicas balanceadas para la reposición del déficit previo y el aporte de fluidos de mantenimiento. En relación a la dosis y a la estrategia, es generalizada la recomendación de un enfoque más restrictivo en el aporte de volumen, aún en los pacientes con shock, donde es necesario lograr un balance entre una resucitación efectiva y el riesgo de sobrecarga de fluidos. Respecto a la administración de albúmina al 20% en el paciente crítico con hipoalbuminemia, la evidencia existente es escasa y no permite formular recomendaciones. Sin embargo, es frecuente su uso en la práctica asistencial

Intravenous fluids administration is a central element in the care of hospitalized pediatric patients, and there are still controversies about what is the optimal composition, the appropriate dose, and the best strategy for their administration. The purpose of this narrative review is to provide the physicians who works in the different areas of pediatric hospitalization, concepts and therapeutic approaches that help them in the care of patients who for diverse reasons require administration of intravenous fluids. The recommendation to use crystalloids in resuscitation is almost uniform. There is a clear trend towards the use of balanced isotonic solutions to replace the previous deficit and the supply of maintenance fluids. In relation to the dose and strategy, the recommendation of a more restrictive approach in volume administration is generalized, even in patients with shock, where it is necessary to strike a balance between effective resuscitation and the risk of fluid overload. Regarding the administration of 20% albumin in critically ill patients with hypoalbuminemia, the existing evidence is scarce and does not allow recommendations to be formulated. However, it is frequently used in healthcare practice

Modified keystone flap used to repair nose defect after Mohs micrographic surgery.

Mohs micrographic surgery (MMS) is a surgical technique used to remove skin tumors with a complete evaluation of the margins. The keystone flap technique is generally used to repair large surgical defects on limbs. We present a case where a modified keystone flap technique was used to close a large defect after Mohs micrographic surgery in a patient with a basal cell carcinoma on the nose. An excellent functional and aesthetic result was obtained with no complications during or after the procedure. We offer a novel indication for this technique for surgical defects in this area.

Ahorro de tejido tras la cirugía micrográfica de Mohs en los carcinomas de células escamosas / Tissue-Sparing Outcome of Mohs Micrographic Surgery in Squamous Cell Carcinomas

ANTECEDENTES: La cirugía micrográfica de Mohs (CMM) es la técnica que ofrece las tasas más altas de curación, así como la mayor capacidad de ahorro de tejido sano, en comparación con la extirpación estándar. OBJETIVO: Cuantificar la capacidad de ahorro del tejido de la CMM en el carcinoma de células escamosas (CCE) en comparación con la extirpación estándar (EE). MATERIAL Y MÉTODOS: Se realizó un estudio de tipo descriptivo bidireccional, para el cual se incluyeron un total de 94 casos de CCE. Los pacientes habían sido diagnosticados de un CCE (in situ, bien diferenciado, moderadamente diferenciado e indiferenciado) e intervenidos mediante CMM en el Hospital de Clínicas Dr. Manuel Quintela, en Montevideo, Uruguay, entre los años 2013 y 2018. Tanto el tamaño del tumor como el área resultante del defecto tras la CMM se midieron tomando las dos medidas del tumor perpendiculares entre sí. El área hipotética calculada del defecto tras la extirpación estándar se estimó agregando un margen de seguridad de 4mm en las lesiones de bajo riesgo y de 10mm en las lesiones de riesgo elevado. El resultado primario de este estudio fue determinar el tamaño del área del defecto tras la CMM en comparación con el área del defecto calculado si el tumor hubiera sido intervenido mediante una extirpación estándar. RESULTADOS: El tamaño medio del tumor fue de 1,41 mm2 y el tamaño medio del defecto tras la CMM fue de 4,12 mm2. El tamaño medio del defecto calculado para la extirpación quirúrgica estándar fue de 8,36 mm2. LIMITACIONES: No se utilizaron todos los criterios de la National Comprehensive Cancer Network (NCCN). Las lesiones de riesgo bajo y elevado se definieron teniendo en cuenta la ubicación anatómica de la lesión, el tamaño, la histopatología y si se trataba de un tumor primario o de una recidiva. CONCLUSIÓN: Los resultados del presente estudio demostraron un ahorro de al menos el 52% con la CMM en comparación con la EE

BACKGROUND: Micrographic Mohs Surgery (MMS) offers the highest cure rates and healthy skin tissue sparing effect compared with standard excision. OBJECTIVE: To quantify the tissue-sparing properties of MMS in squamous cell carcinoma (SCC) in comparison with standard excision (SE). Methods; A bidirectional, descriptive study, including 94 cases of SCC, was performed, on patients with histologic diagnosis of SCC (in situ, well differentiated, moderately differentiated, and undifferentiated), that where operated with MMS between 2013 and 2018 at Hospital de Clínicas Dr. Manuel Quintela in Montevideo, Uruguay. Tumor size and defect area after MMS were measured in 2 perpendicular directions. The suspected defect area was calculated with standard excision using a 4-mm margin for low risk lesions and a 10-mm margin for high risk lesions. The primary outcome of this study was the size of the defect area post MMS compared with the calculated defect area with standard excision. RESULTS: The median tumor size was 1,41mm2, and the median defect size after MMS was 4,12 mm2. The median defect size calculated for standard surgical excision was 8,36 mm2. LIMITATIONS: We do not use all National Comprehensive Cancer Network (NCCN) criteria. We define low and high risk lesions just taking into account anatomical location, size, histopathology and whether it was a primary or recurrent tumor. CONCLUSION: Our results show that MMS has a tissue-sparing effect of at least 52% compared to SE

Tissue-Sparing Outcome of Mohs Micrographic Surgery in Squamous Cell Carcinomas. / Ahorro de tejido tras la cirugía micrográfica de Mohs en los carcinomas de células escamosas.

BACKGROUND: Micrographic Mohs Surgery (MMS) offers the highest cure rates and healthy skin tissue sparing effect compared with standard excision. OBJECTIVE: To quantify the tissue-sparing properties of MMS in squamous cell carcinoma (SCC) in comparison with standard excision (SE). METHODS: A bidirectional, descriptive study, including 94 cases of SCC, was performed, on patients with histologic diagnosis of SCC (in situ, well differentiated, moderately differentiated, and undifferentiated), that where operated with MMS between 2013 and 2018 at Hospital de Clínicas Dr. Manuel Quintela in Montevideo, Uruguay. Tumor size and defect area after MMS were measured in 2 perpendicular directions. The suspected defect area was calculated with standard excision using a 4-mm margin for low risk lesions and a 10-mm margin for high risk lesions. The primary outcome of this study was the size of the defect area post MMS compared with the calculated defect area with standard excision. RESULTS: The median tumor size was 1,41mm2, and the median defect size after MMS was 4,12mm2. The median defect size calculated for standard surgical excision was 8,36mm2. LIMITATIONS: We do not use all National Comprehensive Cancer Network (NCCN) criteria. We define low and high risk lesions just taking into account anatomical location, size, histopathology and whether it was a primary or recurrent tumor. CONCLUSION: Our results show that MMS has a tissue-sparing effect of at least 52% compared to SE.

Colgajo este-oeste después de la cirugía micrográfica de Mohs / East-West Flap After Mohs Micrographic Surgery

La reparación de los defectos nasales distales producidos durante la cirugía micrográfica de Mohs representa un desafío para el cirujano. Existen múltiples técnicas por las cuales se puede optar para el cierre del defecto. Presentamos 3 casos en los que se realizó el colgajo este-oeste, un colgajo de avance, de fácil diseño, que consiste en un triángulo que cubre el defecto y un segundo triángulo de descarga con sus bases en la línea de desplazamiento. Con este colgajo se obtiene un óptimo resultado estético con un movimiento mínimo de los tejidos, preservando la arquitectura nasal y con líneas de sutura bien disimuladas

Repair of distal nasal defects resulting from Mohs micrographic surgery is a challenge, but surgeons can choose from a number of techniques. We present 3 cases in which an east-west flap was used to close the defect. The east-west flap is an easily conceived advancement flap that consists of a superior triangle used to cover the defect and an inferior triangle whose base is located along the advancement line. The flap results in an optimal cosmetic outcome and involves minimum movement of tissue (preserving the nasal architecture) and well-camouflaged suture lines

East-West Flap After Mohs Micrographic Surgery. / Colgajo este-oeste después de la cirugía micrográfica de Mohs.

Repair of distal nasal defects resulting from Mohs micrographic surgery is a challenge, but surgeons can choose from a number of techniques. We present 3 cases in which an east-west flap was used to close the defect. The east-west flap is an easily conceived advancement flap that consists of a superior triangle used to cover the defect and an inferior triangle whose base is located along the advancement line. The flap results in an optimal cosmetic outcome and involves minimum movement of tissue (preserving the nasal architecture) and well-camouflaged suture lines.

Afeitado profundo (super shaving) para la corrección del efecto en trampilla de colgajos nasales / The Super Shaving Technique to Correct the Trapdoor Effect in Nasal Flaps

Introducción y objetivos: El efecto en trampilla o trapdoor es una complicación posible en un colgajo cuando se utiliza especialmente en la zona facial. Consta de una deformidad elevada y abultada, que comienza 3 semanas después de la intervención, y hasta la fecha no existe consenso en su tratamiento. Es por ello que presentamos nuestra experiencia en esta afección, destacando la técnica de afeitado profundo o super shaving para la resolución del efecto en trampilla de colgajos nasales. Materiales y métodos: Estudio retrospectivo y descriptivo de 10 pacientes que desarrollaron un abultamiento posterior a un cierre mediante colgajo en la zona nasal, que fueron resueltos quirúrgicamente a través de la técnica de super shaving y su manejo postoperatorio. Resultados: La edad mediana de los 10 pacientes operados fue 67,7 años, y todos ellos presentaron abultamiento de colgajo de trasposición del área nasal, posterior a una cirugía micrográfica de Mohs o cirugía convencional. El tiempo de aparición de la complicación fue de aproximadamente 5 semanas, y el de cicatrización fue de 4 semanas. Ningún paciente presentó complicaciones mayores en el postoperatorio, y la cicatriz tuvo una incidencia estética baja comparada con el abultamiento. Todos los pacientes refirieron estar muy satisfechos con el resultado estético. Conclusiones: Consideramos que la técnica de super shaving es rápida, efectiva, simple, de bajo costo, se practica de manera ambulatoria, y ofrece resultados estéticamente excelentes para resolver este defecto

Introduction and objectives: The trapdoor effect is a possible complication in flap reconstructions, particularly those involving the face. It consists of a bulging, elevated deformity that appears 3 weeks after the intervention. To date there has been no consensus on how the trapdoor effect should be treated. The aim of this article is to report on our experience with this defect and describe how we use the 'super shaving' technique to resolve the trapdoor effect in nasal flaps. Material and methods: We performed a retrospective, descriptive study of 10 patients who developed a bulging deformity of a nasal flap that was treated surgically with the super shaving technique. We also report on postoperative management. Results: The median age of the 10 patients was 67.7 years and they all developed a bulging transposition flap in the nasal area after conventional or Mohs micrographic surgery. The complication occurred approximately 5 weeks after surgery and healing time was 4 weeks. There were no major postoperative complications and the outcome was of low aesthetic significance compared with the bulging flap. All the patients stated they were very satisfied with the aesthetic outcome. Conclusions: In our opinion, the super shaving technique is a fast, effective, simple, and cheap outpatient procedure that offers excellent aesthetic results

The Super Shaving Technique to Correct the Trapdoor Effect in Nasal Flaps. / Afeitado profundo (super shaving) para la corrección del efecto en trampilla de colgajos nasales.

INTRODUCTION AND OBJECTIVES: The trapdoor effect is a possible complication in flap reconstructions, particularly those involving the face. It consists of a bulging, elevated deformity that appears 3 weeks after the intervention. To date there has been no consensus on how the trapdoor effect should be treated. The aim of this article is to report on our experience with this defect and describe how we use the 'super shaving' technique to resolve the trapdoor effect in nasal flaps. MATERIAL AND METHODS: We performed a retrospective, descriptive study of 10 patients who developed a bulging deformity of a nasal flap that was treated surgically with the super shaving technique. We also report on postoperative management. RESULTS: The median age of the 10 patients was 67.7 years and they all developed a bulging transposition flap in the nasal area after conventional or Mohs micrographic surgery. The complication occurred approximately 5 weeks after surgery and healing time was 4 weeks. There were no major postoperative complications and the outcome was of low aesthetic significance compared with the bulging flap. All the patients stated they were very satisfied with the aesthetic outcome. CONCLUSIONS: In our opinion, the super shaving technique is a fast, effective, simple, and cheap outpatient procedure that offers excellent aesthetic results.

Reconstructive methods in Mohs micrographic surgery in Uruguay: A bidirectional descriptive cohort analysis / Métodos reconstructivos en cirugía micrográfica de Mohs en Uruguay: una cohorte bidireccional descriptiva

BACKGROUND AND OBJECTIVES: The primary goal of Mohs micrographic surgery (MMS) is to completely excise a cancerous lesion and a wide range of reconstructive techniques of varying complexity are used to close the resulting wound. In this study, we performed a descriptive analysis of patients who underwent MMS, with a focus on wound closure methods. MATERIAL AND METHODS: We conducted a bidirectional descriptive cohort analysis of all MMS procedures performed by a single surgeon between November 2013 and April 2016. Cosmetic outcomes were photographically assessed by a dermatologist after a minimum follow-up of 90 days. RESULTS: We analyzed 100 MMS procedures in 71 patients with a median age of 73 years. The tumors were basal cell carcinoma (70%), squamous cell carcinoma (29%), and dermatofibrosarcoma protuberans (1%); 75% were located on the head and neck. The reconstructive techniques used were flap closure (48%), simple closure (36%), closure by second intention (11%), and other (5%). Cosmetic outcomes were assessed for 70 procedures (47 patients) and the results were rated as excellent in 20% of cases, very good in 40%, good in 20%, moderate in 17%, and bad/very bad in 2.9%. No significant associations were observed between cosmetic outcome and sex, Fitzpatrick skin type, hypertension, diabetes mellitus, or smoking. Worse outcomes, however, were significantly associated with larger tumor areas and defects, location on the trunk, and flap and second-intention closure. CONCLUSIONS: Although there was a tendency to use simple wound closure for lesions located on the trunk and surgical defects of under 4.4 cm2, the choice of reconstructive technique should be determined by individual circumstances with contemplation of clinical and tumor-related factors and the preference and experience of the surgeon

INTRODUCCIÓN Y OBJETIVOS: El principal objetivo cirugía micrográfica de Mohs es la excisión completa del cáncer de piel, dando lugar a una gran variedad de métodos reconstructivos de distinta complejidad. OBJETIVO: describir nuestros pacientes operados con cirugía de Mohs, enfocados a métodos de cierre. MATERIALES Y MÉTODOS: Cohorte bidireccional descriptiva de todas las cirugías de Mohs operadas por un mismo cirujano desde noviembre 2013 hasta abril 2016. Tiempo mínimo de 90 días de seguimiento para calificar estética, por un dermatólogo usando fotografías. RESULTADOS: Setenta y un pacientes y 100 cirugías individuales. Mediana para la edad: 73 años. 70% carcinoma basocelular, 29% carcinoma espinocelular y 1% dermatofibrosarcoma protuberans. 75% en cabeza y cuello. Métodos reconstructivos: colgajos 48%, cierre simple 36%, segunda intención 11%, otros 5%. 70 cirugías (en 47 pacientes) completaron seguimiento a largo plazo para evaluación de resultado estético: 20% excelente, 40% muy bueno, 20% bueno, 17% regular y 2.9% malo/muy malo. No hubo diferencias estadísticamente significativas entre resultado estético y el sexo, fototipo, hipertensión, diabetes mellitus o tabaquismo. Vimos una asociación estadísticamente significativa para peor resultado estético en mayores áreas y defectos, localización en tronco, reconstrucción con colgajo y segunda intención. Limitaciones: Treinta pacientes se perdieron durante el seguimiento para calificar su resultado estético a los 90 días, el tiempo de evaluación fue altamente variable y no se registró la opinión del paciente. CONCLUSIONES: Aunque hubo una tendencia por escoger el cierre simple en tronco y defectos <4.4 cm2, la decisión debe ser individualizada, considerando las características clínicas/tumorales y preferencia/experiencia del cirujano

Reconstructive methods in Mohs micrographic surgery in Uruguay: A bidirectional descriptive cohort analysis.

BACKGROUND AND OBJECTIVES: The primary goal of Mohs micrographic surgery (MMS) is to completely excise a cancerous lesion and a wide range of reconstructive techniques of varying complexity are used to close the resulting wound. In this study, we performed a descriptive analysis of patients who underwent MMS, with a focus on wound closure methods. MATERIAL AND METHODS: We conducted a bidirectional descriptive cohort analysis of all MMS procedures performed by a single surgeon between November 2013 and April 2016. Cosmetic outcomes were photographically assessed by a dermatologist after a minimum follow-up of 90 days. RESULTS: We analyzed 100 MMS procedures in 71 patients with a median age of 73 years. The tumors were basal cell carcinoma (70%), squamous cell carcinoma (29%), and dermatofibrosarcoma protuberans (1%); 75% were located on the head and neck. The reconstructive techniques used were flap closure (48%), simple closure (36%), closure by second intention (11%), and other (5%). Cosmetic outcomes were assessed for 70 procedures (47 patients) and the results were rated as excellent in 20% of cases, very good in 40%, good in 20%, moderate in 17%, and bad/very bad in 2.9%. No significant associations were observed between cosmetic outcome and sex, Fitzpatrick skin type, hypertension, diabetes mellitus, or smoking. Worse outcomes, however, were significantly associated with larger tumor areas and defects, location on the trunk, and flap and second-intention closure. CONCLUSIONS: Although there was a tendency to use simple wound closure for lesions located on the trunk and surgical defects of under 4.4cm2, the choice of reconstructive technique should be determined by individual circumstances with contemplation of clinical and tumor-related factors and the preference and experience of the surgeon.

Exéresis en U para la onicocriptosis / Super U Technique for Ingrown Nails

Introducción y objetivos: La onicocriptosis (OC), problema común, afecta principalmente a adultos jóvenes, siendo a menudo el hallux el más afectado. Dependiendo de la gravedad y cronicidad existen 4 estadios, y de estos se derivan distintos tratamientos, abarcando tanto técnicas conservadoras como quirúrgicas. Presentamos nuestra experiencia en esta afección, destacando las características de nuestra población, y dentro de los tratamientos quirúrgicos la técnica de exéresis en U. Materiales y métodos: Estudio retrospectivo y descriptivo de pacientes que presentaron OC a nivel del hallux, que fueron resueltos quirúrgicamente a través de la exéresis en U y su manejo postoperatorio. Resultados: De 10 pacientes operados la edad media fue 35,7 años, en donde 9 tenían compromiso de un hallux y uno de ambos. El estadio II fue el predominante. La mitad había recibido tratamiento quirúrgico previo con una técnica distinta a la exéresis en U. El tiempo de cicatrización promedio fue 6 de semanas. Respecto a las complicaciones, solo un paciente sufrió una infección postoperatoria; y respecto del dolor posquirúrgico este fue leve-moderado, con duración de una semana. La mayoría estaba satisfecha con el resultado estético. Conclusiones: Consideramos que la exéresis en U es una técnica que ha demostrado ser de gran utilidad cuando la OC se encuentra en estadio II, y/o cuando el paciente ya ha recibido tratamiento quirúrgico que ha fallado. Además, sería de elección en los estadios iii y iv, donde lo que predomina es un exceso de tejido hipertrófico (AU)

Introduction and objectives: Ingrown nails are a common problem, seen mostly in young adults. Also known as onychcrypotisis, this condition typically affects the great toenail. Four stages have been defined according to the severity and duration of the condition, and treatment varies from conservative to surgical techniques depending on the stage. We present our experience with this condition, describing the characteristics of our population and surgical treatment, in particular the super U technique. Material and methods: This was a retrospective, descriptive study of patients with ingrown great toenail treated surgically using the super U technique. We also describe postoperative management. Results: Ten patients with a mean age of 35.7 years underwent operation, 9 for unilateral ingrown great toenail and 1 for bilateral disease. Stage II ingrown nail was the most common. Half of the patients had been treated previously using other surgical techniques. The mean time to healing was 6 weeks. The only postoperative complication was infection in 1 patient. Mild to moderate postoperative pain persisted for a week. The majority of patients were satisfied with the cosmetic result. Conclusions: We believe the super U technique is very useful in stage II ingrown nail and in disease that has recurred after previous surgery, and is the treatment of choice in stage III or IV disease in which excessive hypertrophic tissue is found (AU)

Dermoscopy of Disseminated Superficial Actinic Porokeratosis / Dermatoscopia de la poroqueratosis actínica superficial diseminada

We present a series of 6 cases of disseminated superficial actinic porokeratosis and describe their dermoscopic features. Dermoscopy is a noninvasive in vivo technique that is useful as a tool for the diagnosis and follow-up of porokeratosis. This condition has specific dermoscopic features that were observed in our series of cases and that are consistent with reports in the international literature (AU)

Presentamos una serie de 6 casos de poroqueratosis actínica superficial diseminada en los cuales se describen las características dermatoscópicas halladas en cada uno de ellos. La dermatoscopia es una técnica no invasiva in vivo útil como herramienta diagnóstica y de seguimiento en la poroqueratosis ya que se describen elementos dermatoscópicos específicos de esta entidad observados en nuestra serie de casos, que concuerdan con lo comunicado en la literatura internacional (AU)