Rinoplastia secundaria: infección nasal en el postoperatorio / Secondary rhinoplasty: postoperative nasal infection

La rinoplastia es una de las intervenciones más comunes en cirugía plástica. Se opera aquí una rinoplastia secundaria por vía abierta injertando los alares y la punta con cartílagos auriculares, mientras el tabique cartilaginoso fue usado para los spreader grafts. Se describe aquí una infección posoperatoria de su punta nasal. Al 9no día de su posoperatorio comienza con la punta nasal congestiva y levemente inflamada. Se medica con una crema con antibióticos, pero el día 14 aparece con la punta nasal muy inflamada y con colección. Cuando en el consultorio el cirujano la ve, como cualquier absceso, decide realizarle drenaje con un trocar 18G, 3 miniincisiones en la piel debajo de la punta nasal, de la que drena un líquido amarronado. Luego con el mismo trocar se realiza un lavado dentro de la cavidad con rifampicina solución. Se medica con trimetoprima-sulfametoxazol (Bactrimforte®) 2 comp/día. Al otro día se observa una notable mejoría. Se continuó con lavado diario durante 4 días con el mismo antibiótico evolucionando rápidamente bien. El Bactrim se lo continúa por 20 días. Al mes la punta nasal está muy bien, deshinchada con cicatrices apenas visibles. A los cuatro meses, la punta está muy blanda, las alas nasales y las narinas normales, la punta con buena proyección igual que el dorso con los spreader graft.

Rhinoplasty is one of the most common interventions in plastic surgery. A secondary open rhinoplasty was carried out grafting the allae and the tip of the nose with conchae cartilage, while the septum was used for spreader grafts. We are here describing this post operatory with a tip of the nose infection.In the control, at the 9th postoperative day, the nasal tip began to be congested and at the 14th post op day the patient showed a clear inflammatory collection. In the office, the surgeon decided to evacuate it with three punctureslike little incisions at the inferior part of the skin tip with a trocar 18G. Through them, drained brownish purulent secretion. With the same trocar, rifampicin solution was injected through these little incisions, like washing the subdermal area. It was medicated with trimethoprim-sulfamethoxazole (Bactrim forte®) 2 tablets/day. The following day, there was a clear improvement in the congestion and erythema of the nose. This procedure of washing was repeated for four days. There was a quick evolution of the inflammatory process and 20 more days, there was no sign of the infection. Four months later, the tip of the nose was soft and the result was considered optimal by the patient and doctors.

Editorial Commentary: Time-Zero Biomechanical Studies Show Suture Augmentation of a Soft-Tissue Graft Improves Its Properties, But They Need to Be Interpreted With Caution.

There is emerging evidence in biomechanical studies that suture augmentation of a soft-tissue graft can improve its elongation, stiffness, and load to failure. However, all biomechanical studies have the intrinsic drawback of not considering loosening, accommodation, and mainly, healing. In the past, many very strong and stiff synthetic grafts produced poor results for anterior cruciate ligament reconstruction, and synthetic material inside the joint was abandoned for awhile. Recent studies have shown that it is possible to use synthetic material to augment the graft instead of being the graft itself. But the question we need to ask ourselves is: Does it really work in the clinical scenario? Undoubtedly, there is still a way to go to incorporate suture augmentation into soft-tissue grafts in knee reconstruction, and it is mandatory to start high-level clinical studies to prove its real benefit to ligament reconstruction results.

Viability of acellular biologic graft for nipple-areolar complex reconstruction in a non-human primate model.

Many of the > 3.5 million breast cancer survivors in the US have undergone breast reconstruction following mastectomy. Patients report that nipple-areolar complex (NAC) reconstruction is psychologically important, yet current reconstruction techniques commonly result in inadequate shape, symmetry, and nipple projection. Our team has developed an allogeneic acellular graft for NAC reconstruction (dcl-NAC) designed to be easy to engraft, lasting, and aesthetically pleasing. Here, dcl-NAC safety and host-mediated re-cellularization was assessed in a 6-week study in rhesus macaque non-human primates (NHPs). Human-derived dcl-NACs (n = 30) were engrafted on the dorsum of two adult male NHPs with each animal's own nipples as controls (n = 4). Weight, complete blood counts, and metabolites were collected weekly. Grafts were removed at weeks 1, 3, or 6 post-engraftment for histology. The primary analysis evaluated health, re-epithelialization, and re-vascularization. Secondary analysis evaluated re-innervation. Weight, complete blood counts, and metabolites remained mostly within normal ranges. A new epidermal layer was observed to completely cover the dcl-NAC surface at week 6 (13-100% coverage, median 93.3%) with new vasculature comparable to controls at week 3 (p = 0.10). Nerves were identified in 75% of dcl-NACs (n = 9/12) at week 6. These data suggest that dcl-NAC is safe and supports host-mediated re-cellularization.

Manejo quirúrgico de heridas por mordeduras de perro en pacientes pediátricos: nuestra experiencia en 8 años / Surgical management of dog bite wounds in pediatric patients: our experience in 8 years

Introducción. Hasta un 90% de las mordeduras de animales son producidas por perros. Los niños son la población más vulnerable frente a las mordeduras ya que suelen afectar una mayor proporción de superficie corporal. Objetivo. Analizar la casuística de mordeduras de perro y su repercusión en nuestro entorno. Métodos. Estudio observacional, descriptivo, retrospectivo de un período de 8 años, que incluyó a todos los pacientes de 0 a 18 años con diagnóstico de mordedura de perro. Resultados. Se incluyeron 183 pacientes con diagnóstico de mordedura de perro. El promedio de edad fue de 6,1 años, y el grupo etario más afectado fue el de los niños de 3 a 5 años (38,3%). El tratamiento quirúrgico fue dividido en pacientes que requirieron rafia por planos (84,6%), colgajos (11,4%), injertos (3,4%) y puntos de aproximación (1%). Se reportaron 8 pacientes con complicaciones (4,4%). Conclusión. Los niños de 3 a 5 años son los más afectados por mordeduras de perro y la zona de cabeza y cuello es la más común. Un porcentaje importante de pacientes requirieron colgajos e injertos con buenos resultados.

Introduction. Up to 90% of animal bites are produced by dogs. Children are the most vulnerable population because bites tend to affect greater body surface area. Outcome. Analyze dog bites cases and their impact on our environment. Methods. An observational, descriptive, retrospective study during an 8 year period was carried out, which included all patients from 0 to 18 years with a diagnosis of dog bite. Results. A total of 183 patients with a diagnosis of dog bite were found. The average age was 6.1 years, and the age group most affected was children from 3 to 5 years old (38.3%). Surgical treatment was divided into: patients who required suture by planes (84.6%), flaps (11.4%) and grafts (3.4%) and approximation stitches (1%). Complications were reported in 8 patients (4.4%). Conclusion. Children from 3 to 5 years old are the most affected by dog bites, the head and neck area is the most common. A significant percentage of patients required flaps and grafts with good results.

Timing urinary tract reconstruction in rats to avoid hydronephrosis and fibrosis in the transplanted fetal metanephros as assessed using imaging.

Chronic kidney disease leads to high morbidity rates among humans. Kidney transplantation is often necessary for severe symptoms; however, options for new curative treatments are desired because of donor shortage. For example, it has been established that the kidneys can efficiently generate urine after transplantation of the metanephros, ureter, and bladder as a group. After transplantation, the urine can indirectly flow into the recipient's bladder using a stepwise peristaltic ureter system method where the anastomosis is created via the recipient's ureter for urinary tract reconstruction. However, the growth of the regenerated metanephros varies significantly, whereas the time window for successful completion of the stepwise peristaltic ureter system that does not cause hydronephrosis of the metanephros with bladder (ureter) is quite narrow. Therefore, this study was conducted to periodically and noninvasively evaluate the growth of the transplanted metanephros, ureter, and bladder in rats through computed tomography and ultrasonography. The ultrasonographic findings highly correlated to the computed tomography findings and clearly showed the metanephros and bladder. We found that the degree of growth of the metanephros and the bladder after transplantation differed in each case. Most of the rats were ready for urinary tract reconstruction within 21 days after transplantation. Optimizing the urinary tract reconstruction using ultrasonography allowed for interventions to reduce long-term tubular dilation of the metanephros due to inhibited overdilation of the fetal bladder, thereby decreasing the fibrosis caused possibly by transforming growth factor-ß1. These results may be significantly related to the long-term maturation of the fetal metanephros and can provide new insights into the physiology of transplant regeneration of the metanephros in higher animals. Thus, this study contributes to the evidence base for the possibility of kidney regeneration in human clinical trials.

Successful Endovascular Treatment for Very-Late-Onset and Acute Progressive Multiple Transplant Renal Segmental Artery Stenoses: A Case Report.

PURPOSE: To report the endovascular treatment for acute progressive and very-late-onset multiple segmental small-artery stenoses in transplanted kidney parenchyma presenting with rapidly deteriorating renal function and refractory hypertension in a 65-year-old man. CASE REPORT: Nineteen years ago, the patient received a living renal transplant via end-to-end anastomosis of the right internal iliac artery for kidney failure caused by chronic glomerulonephritis. His transplant renal function (creatinine: 0.9 mg/dL) and blood pressure were stable for 18 years. Then rapid worsening of renal function (creatinine: 2.5 mg/dL) and refractory hypertension occurred. Magnetic resonance angiography and renal angiography showed multiple small segmental artery stenoses in the transplanted kidney. At the 1-month follow-up consultation, total occlusion of 2 branches traversing the inferior pole of the kidney was observed, revealing acute progression of artery stenosis. Balloon angioplasty was successfully performed on those branches; renal function improved (creatinine: 1.3 mg/dL), and blood pressure was sufficiently controlled. CONCLUSIONS: This is a rare case that revealed very-late-onset multiple segmental renal artery stenoses with acute progression in the transplant kidney. Even multiple small segmental artery stenoses can reduce transplant renal function in the chronic phase and progress rapidly. Early percutaneous transluminal angioplasty may thus be feasible and important for preventing graft loss.

Reconstrucción palpebral inferior mediante colgajo de periostio y colgajo de Mustardé / Lower palpebral reconstruction by periosteum flap and Mustardé flap

Paciente masculino de 68 años con carcinoma basocelular lobulado recidivado en inferior izquierdo con colgajo de Hughes hace 5 años y posterior recidiva al siguiente año con escisión en cuña. Actualmente, con una segunda recidiva, se realiza una resección amplia del 75% del total del párpado cuya congelación informa márgenes libres, reconstruido en el mismo acto quirúrgico: la lamela posterior con colgajo pediculado de periostio y la anterior con un colgajo de Mustardé. El paciente evoluciona con un buen sostén y posición palpebral, sin recurrencia del tumor.

A 68-year-old man with recurrent lobulated basal cell carcinoma of the left lower eyelid. She has a history of reconstruction of the lower left eyelid with Hughes flap 5 year sago and later recurrence the following year with wedge excision. Currently, with a second recurrence, resection was performed under frozen section technique and the defect of 75% width free of tumor, is reconstructed in the same surgical act: the posterior lamella with a pedicled periosteal flap and the anterior with a Mustardé flap. One year follow-up, the patient evolves with good support and eyelid position, without recurrence of the tumor.

Living donor liver transplantation in small-for-size setting.

Small-for-Size Syndrome (SFSS) is one of the most feared complication of adult split liver and living donor liver transplantation. SFSS stems from a disproportionate/excessive portal vein flow relative to the volume of the implanted liver graft, and is currently one of the major practical limits to partial liver grafts' transplantation. In the last few decades many graft inflow modulation (GIM) techniques have been proposed to curtail the portal vein flow, allowing for successful transplantation of small partial liver grafts. Graft inflow modulation techniques span from Splenic Artery Ligation (SAL), to Splenectomy, Porto-Systemic Shunts and the lately proposed Splenic Devascularization. A patient tailored approach balancing the risk of SFSS with GIM specific morbidity, is more important than identifying the ideal GIM technique. Here we summarize the most recently published data to provide general indications in the challenging preoperative choice of a GIM techniques.

Cardiopulmonary bypass and internal thoracic artery: Can roller or centrifugal pumps change vascular reactivity of the graft? The IPITA study: A randomized controlled clinical trial.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response (SIRS) and affects the organ vascular bed. Experimentally, the lack of pulsatility alters myogenic tone of resistance arteries and increases the parietal inflammatory response. The purpose of this study was to compare the vascular reactivity of the internal thoracic arteries (ITAs) due to the inflammatory response between patients undergoing coronary artery bypass grafting (CABG) under CPB with a roller pump or with a centrifugal pump. METHODS: Eighty elective male patients undergoing CABG were selected using one or two internal thoracic arteries under CPB with a roller pump (RP group) or centrifugal pump (CFP group). ITA samples were collected before starting CPB (Time 1) and before the last coronary anastomosis during aortic cross clamping (Time 2). The primary endpoint was the endothelium-dependent relaxation of ITAs investigated using wire-myography. The secondary endpoint was the parietal inflammatory response of arteries defined by the measurements of superoxide levels, leukocytes and lymphocytes rate and gene expression of inflammatory proteins using. Terminal complement complex activation (SC5b-9) and neutrophil activation (elastase) analysis were performed on arterial blood at the same times. RESULTS: Exposure time of ITAs to the pump flow was respectively 43.3 minutes in the RP group and 45.7 minutes in the CFP group. Acetylcholine-dependent relaxation was conserved in the two groups whatever the time. Gene expression of C3 and C4a in the artery wall decreased from Time 1 to Time 2. No oxidative stress was observed in the graft. There was no difference between the groups concerning the leukocytes and lymphocytes rate. SC5b-9 and elastase increased between Time 1 and Time 2. CONCLUSION: Endothelium-dependent relaxation of the internal thoracic arteries was preserved during CPB whatever the type of pump used. The inflammatory response observed in the blood was not found in the graft wall within this time frame. TRIAL REGISTRATION: Name of trial study protocol: IPITA Registration number (ClinicalTrials.gov): NCT04168853.

Living-donor liver transplantation: Right versus left.

A dilemma of graft selection between right or left livers occurs during the planning of living-donor liver transplantation (LDLT) as well as splitting a whole liver graft into full right/full left grafts in deceased-donor liver transplantation. The right liver's relation to the whole liver could be considered as the trunk of a tree; it has a larger volume, the main axis of bile ducts, and the inferior vena cava mainly belongs to the right liver. Therefore, it was considered as the standard graft in LDLTs. Whether to procure the middle hepatic vein (MHV) with a right liver graft or to leave it attached to the left-liver remnant largely depends on the transplant institute. Recently, most transplant institutes tend to leave the MHV with the left liver for the sake of donor safety. Unlike hepatectomy for liver tumors, it is vital to preserve inflow and outflow for both the resected as well as the remaining livers. While procuring any graft type, the most important is to procure a liver graft with reconstructable portal veins, hepatic arteries, hepatic veins, and bile ducts, which should be well preoperatively planned using 3D-computed tomography with considerations given to graft volume and potential congestion areas.

Safety and Efficacy of Living Donor Hepatectomy Without Systemic Heparinization: Short- and Long-Term Outcomes.

There is no consensus regarding the use of systemic heparin, and long-term outcomes of living donor hepatectomy (LDH) without systemic heparinization have not yet been determined. This study was performed to determine whether systemic heparinization can be omitted during LDH, with a focus on donor safety and long-term outcomes. We retrospectively analyzed the outcomes of 175 cases of LDH performed in our institution between January 2011 and December 2014: group I (n = 79) received systemic heparinization, whereas group II (n = 96) did not, but liver graft was flushed with a heparinized perfusate. Postoperative bleeding requiring blood transfusion or intervention was more frequent in group I than in group II (P = .028). The decreases in donor hemoglobin and hematocrit levels, and platelet count during the early postoperative period, were greater in group I than in group II. In multivariate analysis, systemic heparin was the only independent risk factor for blood transfusion (odds ratio [OR] = 5.114; 95% confidence interval [CI]: 1.201-21.775; P = .027) and significant postoperative bleeding (OR = 7.731; 95% CI: 1.345-44.429; P = .022) after LDH. Most postoperative complications including graft vascular thrombosis were similar between the 2 groups, as was the survival rate, and neither graft loss due to vascular thrombosis nor non-anastomotic biliary stricture was evident. In conclusion, omission of systemic heparinization during LDH is a feasible and safe option without adverse effects.

Orthotopic Transplantation of Breast Tumors as Preclinical Models for Breast Cancer.

Preclinical models that faithfully recapitulate tumor heterogeneity and therapeutic response are critical for translational breast cancer research. Immortalized cell lines are easy to grow and genetically modify to study molecular mechanisms, yet the selective pressure from cell culture often leads to genetic and epigenetic alterations over time. Patient-derived xenograft (PDX) models faithfully recapitulate the heterogeneity and drug response of human breast tumors. PDX models exhibit a relatively short latency after orthotopic transplantation that facilitates the investigation of breast tumor biology and drug response. The transplantable genetically engineered mouse models allow the study of breast tumor immunity. The current protocol describes the method to orthotopically transplant breast tumor fragments into the mammary fat pad followed by drug treatments. These preclinical models provide valuable approaches to investigate breast tumor biology, drug response, biomarker discovery and mechanisms of drug resistance.

Double Single-Side Kidney Transplants With Bench Vascular Reconstruction: A Further Challenge Beyond the Marginality Without Future Preclusions.

BACKGROUND: Double kidney transplantation allows the use of marginal kidneys with a significant improvement in the recovery of renal function expected after transplantation, although with a greater anesthesiologic and surgical risk. One-sided positioning, more cautious in the event of functional exhaustion, can be complex due to vascular anomalies. MATERIALS AND METHODS: We report the case of 2 double unilateral kidney transplants with vascular reconstructions. The first is a double kidney transplant from a 83-year-old donor. Both kidneys (score 5) had 2 arteries and the arterial patch was not usable. A cryopreserved arterial graft was used for the packaging of an arterial axis with which a single T-L anastomosis was performed; the 2 veins were also joined with the packaging of a single anastomosis. The second case is a double kidney transplant from a cadaveric donor performed on a recipient suffering from severe diffuse atheromasia. The right kidney had 2 arteries and the left kidney had 3 arteries (both score 5). The aortic patches and veins of the 2 kidneys were joined together and a single arterial and venous anastomosis was performed. RESULTS: The course has been uneventful. In both cases there were no perioperative vascular complications. CONCLUSIONS: The use of marginal organs is an increasingly common reality. Bench vascular reconstructions can further increase donation resources, safely enhancing the transplantation of already marginal organs that would otherwise not be usable and allowing the contralateral vascular axis to be kept intact.

The role of normothermic machine perfusion in liver transplantation.

To expand the donor pool of suitable organs for transplantation, there is an increased interest in utilizing extended criteria donor grafts (ECD). Ex-situ machine perfusion has shown to be a promising new modality in the organ preservation field to reduce injury and recover ECD liver grafts. Machine perfusion (MP) is considered a significant improvement in the field of transplantation over the past 20 years. Normothermic machine perfusion has entered the clinical arena in the last decade and has shown promising results to improve the quality of marginal organs and to increase the pool of liver grafts. It allows assessment of viability and function of grafts prior to transplantation. In addition, it has the potential to serve as a platform for pharmacologic organ treatment and graft optimization. Machine perfusion moved from the experimental phase to a more mature phase after safety was confirmed by initial clinical trials. Now, it is time to confirm its superiority and cost-effectiveness before a broader clinical use. In this paper we review the history, current status including outcomes of all clinical trials, limitations, and future trends of normothermic machine preservation.

Hypothermic machine perfusion in liver transplantation.

Dynamic preservation strategies are a promising option to improve graft quality before transplantation, and to extend preservation time for either logistic or treatment reasons. In contrast to normothermic oxygenated perfusion, which intends to mimic physiological conditions in the human body, with subsequent clinical application for up to 24 hrs, hypothermic perfusion is mainly used for a relatively short period with protection of mitochondria and subsequent reduction of oxidative injury upon implantation. The results from two randomized controlled trials, where recruitment has finished are expected this year. Both ex situ perfusion techniques are increasingly applied in clinical transplantation including recent reports on viability assessment, which could open the door for an increased liver utilization in the future.

Inferior Long-Term Graft Survival of Suboptimal Kidneys After Living Donor Kidney Transplantation.

BACKGROUND: In living donors, if both kidneys are considered to be of equal quality, the side with favorable anatomy for transplant is usually selected. A "suboptimal kidney" is a kidney that has a significant abnormality and is chosen to maintain the principle of leaving the better kidney with the donor. We hypothesized that the long-term outcome of suboptimal kidney is inferior to that of the normal kidney. METHODS: In a retrospective analysis of 1744 living donor kidney transplantations performed between 1999 and 2015 at our institution, 172 allografts were considered as a suboptimal kidney (9.9%). Median length of follow-up after living donor kidney transplantation was 59.5 months (interquartile range 26.3-100.8). This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor source. RESULTS: The reasons for suboptimal kidneys were cysts or tumors (46.5%), arterial abnormalities (22.7%), inferior size or function (19.8%), and anatomic abnormalities (11.0%). Suboptimal kidneys showed worse long-term overall graft survival regardless of the reasons (5-year: control vs suboptimal kidney; 88.9% vs 79.3%, P = .001 and 10-year: 73.6% vs 63.5%, P = .004). Suboptimal kidneys showed a 1.6-fold higher adjusted hazard ratio (aHR) of all-cause graft loss (95% confidence interval [CI]: 1.1-2.5, P = .025) and had the same impact as older donor age (≥ 54 years old, aHR: 1.6, 95% CI: 1.1-2.4, P = .008). CONCLUSIONS: The impact of suboptimal kidney should be factored into the donor selection process.

Current update in domino liver transplantation.

Orthotopic liver transplantation is an established treatment for end stage liver diseases as well as for some severe metabolic disorders. With increasing number of patients on the waiting list and the ongoing shortage of livers available, domino liver transplantation (DLT) became an option to further expand the organ donor pool. DLT utilizes the explanted liver of one liver transplant recipient as a donor graft in another patient. Despite being a surgically, and logistically demanding procedure, excellent results could be achieved in experienced high-volume transplant centers. In this review we present the current world status of DLT.

Case Report: Portal Vein Thrombosis, Surgical Alternatives in Liver Transplantation.

INTRODUCTION: Liver transplant remains a surgical challenge in cases of portal vein thrombosis. Ten percent of patients listed for liver transplant have this diagnosis preoperatively. Although several techniques of portal revascularization are available, sometimes the best result is not achieved, depending on the extent of thrombosis. OBJECTIVE: The aim of this article is to report our experience in 2 particular cases of liver transplant with portal vein thrombosis. MATERIAL AND METHODS: We present the cases of 2 patients with partial portal thrombosis that extended to the porto-spleno-mesenteric system. The first case is a 36-year-old woman with recurrence of autoimmune liver disease requiring a second graft; the second case concerns a 64-year-old man with alcoholic liver cirrhosis. RESULTS: Both patients had a splenorenal shunt. A portal bypass with a Y venous graft was performed using the cavoiliac veins of the donor. The anastomosis was performed to the superior mesenteric and left renal veins. DISCUSSION AND CONCLUSIONS: These clinical cases demonstrate that portal vein thrombosis is not an absolute contraindication for transplantation and that surgical alternatives exist in cases of grade III portal vein thrombosis.