Characteristics of fingertip injuries and proposal of a treatment algorithm from a hand surgery referral center in Mexico City.

BACKGROUND: Fingertips are the most commonly injured anatomical structures in the upper extremity. The aim of this work is to present our experience in the management of fingertip injuries. METHODS: All patients with fingertip injuries managed by Plastic and Reconstructive Surgery Division of Hospital General “Dr Manuel Gea Gonzalez” in Mexico from July 2010 to June 2015 were included; their demographic characteristics were described, as well as patterns of injury and management. RESULTS: A total of 1,265 patients were included in the study, 75% were males. The mean age of presentation was 20.5 ± 16.46 years; the age group most commonly affected was younger than 15 years (46.7%). Right and left-sided injuries were almost equally prevalent (51 vs. 49%). The most commonly injured fingers were the third (27.2%), and second (25.8%). Eighty-seven percent of the patients presented with single-digit injuries. Fingertip amputations were the most common type of injury with 620 cases (49%), followed by simple fingertip lacerations (574 cases, 45%), and nail bed injuries in 71 cases (5.6%). Surgical management was necessary in 95.8% of the cases. CONCLUSIONS: Fingertip injuries remain the most common reason for consultation in hand emergencies. A structured approach for their treatment is necessary to obtain the best clinical outcomes.

Facial reanimation surgery in Möbius syndrome: Experience from 76 cases from a tertiary referral hospital in Latin America.

INTRODUCTION: Möbius syndrome is defined as a combined congenital bilateral facial and abducens nerve palsies. The main goal of treatment is to provide facial reanimation by means of a dynamic surgical procedure. The microneurovascular transfer of a free muscle transplant is the procedure of choice for facial animation in a child with facial paralysis. OBSERVATION: Between January 2008 and January 2017, 124 patients with the syndrome have been approached at our institution. Distribution according to Möbius Syndrome classification presents as follows: Complete Möbius syndrome (n=88), Incomplete Möbius syndrome (n=28), Möbius-Like syndrome (n=8). Seventy-nine female and 45 male patients. Sixty-one percent have undergone a microsurgical procedure (n=76), in all of them, a free gracilis flap transfer was performed. DISCUSSION: Our proposed treatment protocol for complete Möbius syndrome is determined by the available donor nerves. We prefer to use the masseteric nerve as first choice, however, if this nerve is not available, then our second choice is the spinal accesory nerve. For this purpose, all patients have an electromyography performed preoperatively. Overall, dynamic facial reanimation obtained through the microvascular transfer of the gracilis muscle have proved to improve notoriously oral comissure excursion and speech intelligibility. CONCLUSION: The free gracilis flap transfer is a reproducible procedure for patients with Möbius syndrome. It is of utmost importance to select the best motor nerve possible, based on an individualized preoperative clinical and electromyographic evaluation. To our best knowledge, this is the largest series of patients with Möbius syndrome globally, treated at a single-institution.

Reanimación palpebral con colgajo frontal miofuncional. Caso clínico / Eyelid reanimation with myofunctional frontal flap. Clinical case

El párpado es una estructura crítica para la protección y función del globo ocular, y parte primordial en la estética facial. Su reconstrucción está determinada por la extensión de la lesión y el compromiso de las diferentes capas. Siempre se preferirán tejidos loco-regionales debido a su mayor similitud y disposición. Los métodos de reanimación palpebral se pueden dividir en estáticos y dinámicos, considerando a estos últimos como el único medio para restaurar el parpadeo. Presentamos un caso de celulitis orbitaria preseptal con lesión de espesor total del párpado superior y su reconstrucción miofuncional utilizando un colgajo frontal. Este colgajo frontal miocutáneo logró la restauración funcional del párpado comprometido mediante la adición de fibras musculares y permitiendo el fenómeno de reinervación (AU)

The eyelid is a critical and protective structure for the eyeball, and a principal part for the facial aesthetic. The extension of the injury and the affected layers determine the kind of reconstruction. It's always preferred a loco-regional tissues because their similitude and availability. The reanimation methods can be separated in statics and dynamics, always considering the last mentioned like the unique option for blink restoration. We present a case report of orbital preseptal cellulitis with upper eyelid total thickness injury and the reconstruction with a myofunctional forehead flap. This flap allowed the functional eyelid reestablishment by using the muscle fibers and the reinervation phenomenon (AU)

Reconstrucción mamaria con expansor tisular e implante. Indicaciones y experiencia en 24 casos / Breast reconstruction with tissue expander. Indications and experience in 24 cases

En la actualidad, la reconstrucción mamaria forma parte integral del tratamiento del cáncer de mama; la selección de la paciente es crítica para obtener resultados satisfactorios. El presente trabajo recoge nuestra experiencia en reconstrucción mamaria con expansión tisular e implantes, haciendo hincapié en la selección de las pacientes candidatas a este método reconstructivo. Revisamos las reconstrucciones mamarias realizadas en un período comprendido entre los años 1998 y 2008 por la misma cirujana, analizando factores como tipo de mastectomía, edad, tiempo de la reconstrucción (inmediata o diferida), causa de la mastectomía, tipo de expansor y prótesis utilizados, complicaciones y satisfacción de las pacientes. En todas excepto en una, la reconstrucción se realizó en dos tiempos operatorios; durante el primero se hizo la colocación del expansor tisular y en el segundo, el cambio por la prótesis mamaria definitiva. Se realizaron un total de 24 reconstrucciones mamarias en 19 pacientes en el período de 10 años revisado, 14 unilaterales y 5 bilaterales. Las complicaciones presentadas en este grupo de pacientes fueron del 16,6 %. El seguimiento de las pacientes fue de 2 a 10 años. Solamente en 1 caso de cuadrantectomía, se realizó la reconstrucción de forma diferida por antecedente de radioterapia (4,1 %). En nuestra opinión, la reconstrucción mamaria con expansor tisular e implante es un procedimiento seguro, reproducible y con bajo índice de complicaciones, sin el inconveniente añadido de ocasionar morbilidad en el a área donante (AU)

Nowadays, breast reconstruction is part of breast carcinoma treatment; patient's selection plays an important role in satisfactory results. The present paper reports our experience in breast reconstruction with tissue expander/implant and emphasizes the importance of choosing the candidates for this method of reconstruction. We review the breast reconstructions realized in a 10 year period (1998-2008) by the same surgeon. We analyzed factors like type of mastectomy, age, time of the reconstruction (immediate or delayed), etiology, tissue expander and implant used complications and patients' satisfaction. All the patients except one underwent breast reconstruction in two stages, first submuscular tissue expander, and second reconstruction replacement of tissue expander with implant. A total of 24 breast were reconstructed in 19 patients using tissue expander/implant in a 10 years period, 14 unilateral and 5 bilateral. In terms of complications, they were present n 16,6 % cases. The follow up period was between 2 and 10 years. There was only 1 patient with previous quadrantectomy who received radiotherapy (4,1 %). In our opinion, breast reconstruction with tissue expander/implant remains a safe and reliable method with minimal complications and without morbidity at the donor site (AU)

Experiencia en reconstrucción auricular en cáncer de piel con colgajo en «quesadilla» / Experience in auricle reconstruction after skin carcinoma with «quesadilla» flap

La reconstrucción auricular es una de las más difíciles ya que implica reproducir las sofisticadas y delicadas formas del pabellón auricular. Cuando hay que resecar piel en la oreja por un cáncer cutáneo y dejamos expuesto el cartílago, sin pericondrio, suele suceder que al colocar injertos no hay una integración adecuada de los mismos por las caprichosas formas y relieves del pabellón auricular; cuando es necesario resecar el pericondrio estamos obligados a cubrir el defecto con un colgajo y no con un simple injerto. Frente a esta dificultad técnica, diseñamos un colgajo ricamente vascularizado que preserva el cartílago no afectado con una buena cubierta y al mismo tiempo respeta la anatomía de la oreja. Para la cobertura del cartílago auricular anterior usamos un colgajo fasciocutáneo posterior que se asemeja a un plato típico de la cocina mexicana que llamamos “quesadilla”, donde el cartílago por su color blanco recuerda el queso y el gran colgajo fasciocutaneo recuerda la tortilla que cubre al queso. Este colgajo incluye la piel enrollada del hélix, que en un segundo tiempo retornará a su lugar de origen anatómico mediante una z-plastía asimétrica. Presentamos, de entre una serie de 13 pacientes con carcinoma de pabellón auricular, 2 casos resueltos mediante esta técnica (AU)

Auricle reconstruction is one of the most difficult techniques because of the sophisticated and delicates forms of the ear. When we need to remove the auricular skin, preserving the cartilage is very important to keep the shape of the auricle. If treating an auricular skin cancer we find an unaffected cartilage, we can use a skin grafting, but in such delicates forms and curves many times it results inappropriate or the lack of pericondrium difficult skin graft integration. When pericondrium is affected, we will need ask in flap to cover de defect. We designed a rich vascularized flap that preserves the unaffected cartilage with an adequate coverage and that keeps anatomy of the auricle. For coverage of anterior cartilage we use the hole posterior skin fasciocutaneous flap which resembles a “quesadilla”, a Mexican food made of white cheese (resembles cartilage) covered by a “tortilla” (fasciocutaneous flap).This flap includes the rolled skin of the helix and, in a second time, we use an asymmetric z-plasty to return the rolled skin of the helix to the margin of the auricle. We report, from a serie of 13 patients with auricle carcinoma,2 cases reconstructed with this technique (AU)

Secuelas de mastectomía subcutánea profiláctica: caso clínico / Prophilactic subcutaneous mastectomy sequeal: case report

La mastectomía subcutánea profiláctica es un procedimiento controvertido, sin embargo, es un hecho que disminuye la incidencia de cáncer mamario hasta en un 100% en pacientes con alto riesgo de padecerlo. Presentamos el caso de una paciente de 26 años de edad a quien se le realizó dicho procedimiento sin una indicación precisa y que presentó complicaciones(dehiscencia de heridas, infección y exposición de ambas prótesis mamarias) que requirieron varios procedimientos reconstructivos, con un seguimiento de 8años. La mastectomía subcutánea profiláctica es un procedimiento irreversible con implicaciones importantes para las pacientes, por lo que consideramos que debe estar plenamente justificada por estrictos criterios de prevención de cáncer mamario en pacientes con alto riesgo (AU)

Prophylactic subcutaneous mastectomy is controversial, in fact this procedure has proved its efficacy in decreasing mammary carcinoma in high risk patients up to 100 per cent. We report a case of 26 years old patient, in whom was performed a prophylactic bilateral subcutaneous mastectomy without a clear indication, and who presented several complications as suture dehiscence, infection and mammary implants exposition requiring several reconstructive procedures, with a follow up of 8 years. Prophylactic subcutaneous mastectomy is an irreversible procedure with important implications for the patient; we consider that it should be limited to patients with precise indications and at high risk for mammary carcinoma (AU)