José Amarante

A new distally based fasciocutaneous flap of the leg

A distally based flap on the medial side of the lower leg is described. In ten cadaver dissections two perforating arteries from the posterior tibial artery were a constant finding and a flap has been designed based on these. It has been used successfully in four patients.

Fournier's gangrene: a review of 43 reconstructive cases.

Background: Fournier’s gangrene is a rare and potentially fatal infectious disease characterized by necrotic fasciitis of the perineum and abdominal wall, along with the scrotum and penis in men and the vulva in women. Fournier’s gangrene is a true surgical emergency. Skin loss can be very incapacitating and difficult to repair. Methods: The authors reviewed retrospectively the clinical records of a series of 43 patients with Fournier’s gangrene between the years 1985 and 2003 who, after initial treatment by the Departments of Urology and Surgery, were referred to the Department of Plastic Surgery for reconstruction. The following parameters were evaluated: age, gender, interval between onset of symptoms and diagnosis, clinical symptoms, lesion site, results of bacteriologic cultures, cause and predisposing factors, treatment and reconstructive procedures, length of hospital stay, and outcome. Results: The mean patient age was 56.6 years. Fifteen patients (34.9 percent) had diabetes mellitus. The cause of Fournier’s gangrene was found in 32 patients (74.4 percent). The most common presentation was scrotal swelling, and scrotal involvement was found in 40 cases (93.0 percent). All of the patients underwent surgical debridement, and several reconstruction techniques were used. The mean length of hospital stay was 73.6 days. Two patients died. Conclusions: Management of this infectious entity should be aggressive. Several techniques that are used to reconstruct the lost tissue have shown good results. The superomedial thigh skin flap has proven to be a reliable method of resurfacing large scrotal defects. Reconstructive surgery makes the return to a normal social life possible in many cases.

The distally based island superficial sural artery flap: clinical experience with 36 flaps.

The principles of neurocutaneous flaps, first described by Masquelet in 1992, represented a new concept in skin vascularization. The distally based superficial sural artery flap is an example of this kind of flap, which is supplied by the vascular axis that accompanies the sural nerve. The authors treated 36 patients with 36 distally based superficial sural artery flaps. All flaps survived, but six of them exhibited partial necrosis. No patient experienced anesthesia of the lateral side of the foot or neuroma at the donor site 12 months after surgery. The authors confirmed that this flap is very useful for soft-tissue reconstruction of the distal third of the leg and foot. Additionally they conclude that the principal advantages are that the blood supply is reliable, execution is easy and fast, the operation can be performed under regional anesthesia, the flap has a large arc of rotation, direct closure of the donor area is possible for small flaps, major arteries or nerves are not sacrificed, and excellent durability is achieved, even on weight-bearing areas. The major drawback is the donor site scar.

Further experience with the posterior interosseous flap

This paper describes and discusses some of the clinical applications of the posterior interosseous forearm flap in hand reconstruction, including the fact that larger areas of skin than previously reported can be used safely. It is based on a series of 21 patients, 50 anatomical dissections and 10 injection studies.

Scarpa fascia preservation during abdominoplasty: a prospective study.

BACKGROUND Preservation of the Scarpa fascia has been suggested as a way of lowering complications associated with conventional abdominoplasty. Objective evidence regarding this strategy is lacking. The purpose of this investigation was to evaluate the effect of preserving the Scarpa fascia in the infraumbilical area during a full abdominoplasty. METHODS A prospective study was performed at a single center from November of 2005 to November of 2007 of the patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, classic full abdominoplasty; and group B, full abdominoplasty with preservation of infraumbilical Scarpa fascia. Several variables were determined: age, body mass index, previous surgical procedures, comorbid conditions, specimen weight, time to suction drain removal, total volume of drain output, and length of hospital stay. RESULTS A total of 208 full abdominoplasties were performed (group A, 143 patients; group B, 65 patients). There was no statistically significant difference between groups with respect to body mass index, previous abdominal operations, comorbid medical conditions, or weight of the surgical specimen (p > 0.05). The group with preservation of the Scarpa fascia had an average reduction of the total amount of drain output of more than 50 percent (p < 0001). This group also had an average reduction of 2.0 days until the time to drain removal (p < 0.001) and 1.9 days of the hospital stay (p < 0.001). CONCLUSION Preservation of the Scarpa fascia during abdominoplasty has a beneficial effect on patient recovery, as it reduces the total drain output, time to drain removal, and length of hospital stay.

Etiology and patterns of pediatric mandibular fractures in Portugal: a retrospective study of 10 years.

Objective:To determine the pattern of occurrence of mandibular fractures in the pediatric population in Portugal. Materials and Methods:This retrospective study reviews the records of patients 18 years of age or younger from the 10-year period 1993 to 2002. Age, gender, anatomic site, cause of the accident, weekly and monthly variation, location and type of fractures, presence and location of associated injuries, treatment methods, and complications were reviewed. Results:During this 10-year period, 521 patients with 681 mandibular fractures were treated. Motor-vehicle accident (MVA) was the most common (53.9% patients) cause of fracture. Almost half of the patients (48.8%) were in the oldest age group (16 to 18 years old). The condyle of the mandible was involved in 31.0% of the fractures. Maxillomandibular (MMF) fixation was used in 534 (78.4%) fractures. Overall mortality in this series was 0.6% (3 patients); mortality was caused by multiple traumas, mainly head trauma. Conclusion:There is a need to reinforce legislation aimed to prevent MVA and the total enforcement of existing laws to reduce maxillofacial injuries among children and adolescents.

Long-term follow-up of breast capsule contracture rates in cosmetic and reconstructive cases.

Background: Silicone gel breast implants are associated with long-term adverse events, including capsular contracture, with reported incidence rates as high as 50 percent. However, it is not clear how long the follow-up period should be and whether there is any association with estrogen or menopausal status. In addition, the placement of Baker grade II subjects in the majority of reports has been in data sets of controls instead of capsular contracture. Methods: A retrospective medical study (1998 to 2004) was performed in women (n = 157) who received textured silicone breast implants for aesthetic or reconstructive procedures at the Hospital of S. João (Portugal). Medical data were collected that included the following: patient demographics, history, lifestyle factors, surgical procedures, and postoperative complications. Statistical analyses included Pearson chi-square testing, logistic regression modeling, and chi-squared automatic interaction detection (CHAID) methods. Results: The reconstructive cohort had a great incidence of capsular contracture compared with the cosmetic cohort. If one considered no capsular contracture versus capsular contracture, the follow-up period should be longer than 42 months. However, if considering no capsular contracture and grade II subjects versus grade III or IV subjects, a longer follow-up period of 64 months was determined. There was no association between capsular contracture and menopause/estrogen status. Conclusions: Increased frequencies of capsular contracture were recorded in breast reconstruction that were not attributable to estrogen or menopausal status. On the basis of these results, the authors propose a follow-up period longer than 42 months and the inclusion of Baker grade II subjects.

Burn patients in Portugal: analysis of 14 797 cases during 1993-1999

The incidence and cause of burns in Portugal are unknown. The present study seeks to collect these data as a basis for future studies in prevention and development of treatment regimes. The data used in this work was obtained from the registries existing in The Direcção Geral de Saúde (General Health Administration) and relates to burn patients admitted to 91 Portuguese hospitals--that serve all the territory--during the period of 1993-1999. All patients selected had at least one diagnosis of burn (ICD-9: 94.###) among all the diagnoses motivating an admission. A total of 14,797 burn patients were obtained. Among all the patients admitted to hospitals, 8731 (59.0%) were male and 6066 (41.0%) were female, with a male/female ratio of 1.44:1. The mean length of in-hospital stay was 15.5+/-21.0 days. Throughout this period, 553 (3.7%) patients died in Portuguese hospitals as a result of burn injury. There were no significant differences in the number of deaths in each year, P=0.45, in contrast to the decrease of burn mortality rates reported in other studies. It is likely that the reason for this situation is the lack of investment in the last years in this area and the delay in opening new Burn Centres.

A distally based median plantar flap.

The first metatarsophalangeal joint area is a very difficult one to reconstruct, needing skin that is thick, sensitive, and resistant to friction. Although the medial plantar island flap was initially described to resurface heel defects, we have used this flap as a cross-foot flap to recover the first metatarsophalangeal joint area. Its use has always required a second surgical procedure. To overcome this inconvenience, we describe the use of a flap based on the principle of reversing the direction of blood flow in a distal vascular pedicle to restore a defect of the anteromedial aspect of the foot. Good functional and aesthetic results were obtained.

One-staged coverage and revascularisation of traumatised limbs by a flow-through radial mid-forearm free flap

The concept of flow-through circulation in free flaps is an interesting and useful one. Its importance is paramount in the clinical field, if one applies it as a one-staged technique for cover and revascularisation in major trauma of the extremities. This paper describes the practical use of this concept in two clinical cases (hand and foot), in which an uninterrupted arterial and venous flow was established through the radial mid-forearm fasciocutaneous flap, allowing revascularisation of the ischaemic extremity.