Fabio de Freitas Busnardo

Nerve sources for facial reanimation with muscle transplant in patients with unilateral facial palsy: clinical analysis of 3 techniques.

Ninety-one patients with long-standing unilateral facial palsy and submitted to reanimation of the face with muscle transplant were divided into 3 nonrandomized groups: group I: 2-stage facial reanimation, cross face followed by gracilis muscle transplant, 58 patients; group II: 1-stage reanimation with latissimus dorsi muscle transplant, 11 patients (a branch of the facial nerve on the nonparalyzed side of the face was used as the nerve source for reanimation in groups I and II); group III: 1-stage reanimation with gracilis muscle transplant and neural coaptation of the respective nerve and the ipsilateral masseteric branch of the trigeminal nerve, 22 patients. No microvascular complications were observed. The average interval between surgery and initial muscle contractions was 11.1 months, 7.2 months, and 3.7 months in group I, group II, and group III, respectively. The quality (intensity and shape) of the smile, voluntary or involuntary, obtained on the reanimated side in relation to the unaffected side was considered good or excellent in 53.4%, 54.5%, and 86.3% of the patients in groups I, II, and III, respectively. In group I, the average age of the patients with excellent or good results (19.8 + 10.5 years) was significantly lower than that of the patients with fair or poor results or absence of movement (36.5 + 13.3 years). The smile was considered emotional or involuntary in 34% of the patients in group I and 45% in group II. Most of the patients in each group were only able to produce “voluntary smiles”. Crossed synkinesis with lip puckering was observed in 48% of the patients in group I and 90% in group II. The results obtained with 1-stage facial reanimation with masseteric nerve were more uniform and predictable than those obtained with the other techniques evaluated in this study.

Lymph fasciocutaneous lateral thoracic artery flap: anatomical study and clinical use.

BACKGROUND  The lateral thoracic flap was first studied in the mid-1970s but its use has been limited because of pedicle anatomical variations. However, after the development of lymph node transfer surgery, the axilla/upper lateral thorax presented as a promising donor area. Through a detailed anatomical study, the lateral thoracic flap was evaluated regarding its vascularization and composition. Later, it was used for pedicle and free flap reconstructions. METHODS  A total of 40 flaps were dissected in fresh cadavers and the characteristics of the lateral thoracic pedicle and its relationship to the upper lateral thoracic axillary lymph nodes (LTLN) were analyzed. We performed six pedicle flap reconstructions around the shoulder area and a free lymph node transfer for lower limb lymphedema. RESULTS  In the cadaveric dissections, the lateral thoracic pedicle branched off the axillary vessels and was found to be a primary level I axillary lymph node irrigator before reaching the skin. The cutaneous portion of the artery was present in 87.5% of the dissections. Arterial caliber was an average of 1.3 and venous, 2.6 mm. Five to seven lymph nodes were isolated with each pedicle and a lymph fasciocutaneous flap could be designed. In seven clinical cases, all of the flaps survived. Functioning lymph nodes were visualized on lymphoscintigraphy after their transfer to the ankle. Donor area had an inconspicuous evolution. CONCLUSION  Lateral thoracic flap is a feasible flap with low donor area morbidity in a concealed region that can be harvested with upper LTLN for transplantation.

The thoracodorsal artery perforator flap in the treatment of axillary hidradenitis suppurativa: effect on preservation of arm abduction.

Summary: Hidradenitis suppurativa is a chronic, recurrent inflammatory disease of the skin characterized by abscesses and scars. The axillary region is predominantly affected, leading to limited mobility of the arm due to scar retraction. This prospective study aimed to analyze the surgical treatment of severe lesions of axillary hidradenitis suppurativa by using the thoracodorsal artery perforator flap while focusing on the preservation of arm abduction. We enrolled 12 patients with severe axillary hidradenitis suppurativa who underwent bilateral surgical treatment of their lesions by radical excision, followed by immediate reconstruction with the thoracodorsal artery perforator flap. The amplitude of arm abduction was measured preoperatively and 6 months postoperatively by goniometry, and statistical analysis was performed using Students t test. Preoperative and 6-month postoperative mean amplitude of arm abduction were 98.7 degrees and 152.7 degrees, respectively, with a significant mean increase of 54 degrees (p < 0.0001). The thoracodorsal artery perforator flap can be used as a good option for axillary reconstruction after radical excision of severe lesions of hidradenitis suppurativa, and its use would allow a significant increase in the amplitude of arm abduction. It has several other advantages when compared with other types of coverage, including its anatomical proximity to the axilla, similar thickness, and high-quality skin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Sensibility of the Ear After Otoplasty

Changes in skin sensibility occur in various postoperative plastic surgeries, especially when they involve major skin and subcutaneous dissection. There were no studies so far that objectively compared changes of ear sensibility. This prospective study was conducted to compare ear sensibility before and after otoplasty. Patients with prominent ears (n = 15) underwent bilateral otoplasty. Ear tactile sensibility was tested preoperatively and 6 and 12 months after surgery by Pressure Specified Sensory Device, an apparatus that quantifies cutaneous pressure sensation (g/mm2). Comparison between preoperative and 6-months postoperative results indicated an increment on mean skin pressure thresholds; however, mean thresholds between pre- and 12 months postoperative period were similar. Vibratory and hot/cold sensibility did not present any difference during this period. This is the first comparative assessment of ear tactile sensibility using quantitative methods. After otoplasty, initially there was reduction in an ear tactile sensibility, followed by a return to levels similar to preoperative sensibility.

Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions

BACKGROUND In oncological perineal reconstructions, the internal pudendal artery perforator (IPAP) flap is our flap of choice, supplied by perforator vessels from the internal pudendal artery and innervated by branches from the pudendal nerve and the posterior femoral cutaneous nerve. Data related to the evaluation of its cutaneous sensibility are scarce, discrepant, and subject to methodological criticism. OBJECTIVE The objective of this study was to evaluate the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction and compare it with the preoperative cutaneous sensibility of the gluteal fold (flap donor area). METHODS A prospective study of 25 patients undergoing abdominoperineal excision of rectum (APER) and reconstruction with bilateral VY advancement IPAP flap was conducted. The tactile, pain, thermal, and vibration sensibilities were analyzed in four areas of the gluteal fold preoperatively and in the four corresponding areas of the flap 12 months after surgery. Tactile sensibility was assessed using the Pressure Specified Sensory Device™ (PSSD™), which measures the pressure applied to the skin. The other types of sensibility were analyzed using a needle for pain, hot/cold contact for thermal, and a tuning fork for vibration sensibility. RESULTS A comparison between tactile sensibility thresholds on the gluteal fold preoperatively and on the flap 12 months after surgery showed no statistically significant difference, with p values>0.05 in all four areas evaluated. All patients had preserved pain, thermal, and vibration sensibility in all four areas, postoperatively. CONCLUSION In oncological perineal reconstructions after APER, it is expected that the cutaneous sensibility on the IPAP flap be maintained.

Incidência de coronariopatia após o transplante cardíaco ortotópico

O presente estudo tem por finalidade analisar tardiamente o padrao anatomico evolutivo das arterias coronarias do coracao transplantado. Para cumprir tal proposicao foram selecionados 22 pacientes submetidos ao transplante cardiaco ortotopico, com seguimento pos-operatorio superior a 36 meses. As variaveis eleitas para este fim foram aferidas anualmente ate o quinto ano de pos-operatorio. A analise da ventriculografia mostrou a estabilidade da fracao de ejecao (p=0,99) em valores normais. A cineangiocoronariografia sequencial evidenciou incidencia crescente de lesoes arteriais com comprometimento da funcao contratil. As lesoes obstrutivas acometeram as arterias coronarias difusamente, com predominio no territorio distai. Os episodios de rejeicao aguda e a etiologia da cardiomiopatia nao modificaram a evolucao natural da aterosclerose coronaria.

Anatomical comparison among the anterolateral thigh, the parascapular, and the lateral arm flaps

This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps.

The descending branch of the lateral femoral circumflex artery is a good option in CABG with arterial grafts

INTRODUCTION The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. OBJECTIVE To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. METHODS Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P<0.05). RESULTS Descending branch of the lateral femoral circumflex artery wDescending branch of the lateral femoral circumflex artery was used in 26 patients, as its use was not viable in six patients (18%). It was used as composite graft in all cases. The anterior descending branch was revascularized by the left internal thoracic artery in all cases. Patency rates of the descending branch of the lateral femoral circumflex artery were 96% and 92%, respectively. No occlusions were observed in the left internal thoracic artery (LITA) and no ischemic events were observed in the descending branch of the lateral circumflex. Descending branch of the lateral femoral circumflex artery increased the lumen diameter in the middle (P=0.001) and distal portions (P=0.006); the left internal thoracic artery (LITA) increased in the middle portion (P=0.001). CONCLUSION Similar to the left internal thoracic artery, the descending branch of the lateral femoral circumflex artery showed high patency rate and positive luminal adaptation. This early evaluation confirms the descending branch of the lateral femoral circumflex artery as a potential alternative for grafting. Due to anatomical variations, preoperative femoral angiographic evaluation appears to be mandatory.

Hematoma intraneural experimental em ratos: avaliação da recuperação funcional e histomorfometria neural

Emergence of intraneural hematoma with involvement of peripheral nerves can occur after trauma or coagulation disorders. The decision for expectant management or decompressive surgical techniques is still controversial. Forty male Wistar rats were divided into 4 groups. In group A, an intraneural injection of autologous blood was provided at the right sciatic nerve. In group B, after the hematoma creation, a longitudinal epineurotomy was performed. In the group C (sham-operated), the sciatic nerve was exposed without hematoma. In group D. immediately after the hematoma creation, an interfascicular neurolysis was performed. Nerve function recovery was assessed using the Bain-Mackinnon-Hunter Sciatic Function Index (SFI). At the end of the study, the animals were sacrificed and a specimen of the sciatic nerve at compression midpoint was removed for morphometric analysis. Group A displayed an initial SFI of -28.43, with full functional recovery on the fifth day. Immediate drainage of the hematoma by longitudinal epineurotomy (group B) promoted recovery of normal sciatic function on the first day (SFI -14.42). Addressing the hematoma via interfascicular neurolysis resulted in an initial SFI of -23.69 and recovery of normal sciatic function on the third day. The morphometric variables indicated an improvement of ischemic parameters following both types of surgical intervention.

Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects

BACKGROUND: There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE: The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN: This was a prospective case series. SETTINGS: This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS: A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS: The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES: Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien–Dindo grades) were measured. RESULTS: The means of the perineal defect, hospital stay, and healing time were 51.62 cm2, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien–Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm2 (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS: As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS: Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.