When an auricular defect is caused by high-energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year-old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A "printed" ear made of silicone, based on the patient's CT-scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.
The use of free flaps is considered the "gold standard" for reconstruction of head and neck defects. Locoregional flaps allows a better aesthetic result compared to free flaps, whenever there's an external skin defect. However the use of free flaps is not always adequate in the presence of preoperative comorbidities or previous surgeries. Since the description of the trapezius myocutaneous flap in the 1980's, many authors have published the results of the applicability of this flap in head and neck salvage reconstructive surgery. Nonetheless, the concern with trapezius muscle function remains an important issue. The onset of free-style dissection perforator flaps has attenuated this problem. The authors present a case of a 68 year old man with a posterior cervical wound after a cervical spine trauma, who underwent multiple spine surgeries, successfully treated with an island muscle-sparing trapezius flap. All the details of the dissection technique are outlined. The authors found the trapezius perforator flap to be a reliable and accessible to raise flap with a negligible donor-site morbidity. This flap can be used for occiput, nuchal and spinal areas injuries without the local morbidity related to other flap options.
Face ao desenvolvimento científico ocorrido desde o I Consenso Brasileiro para o uso da Monitorização Ambulatorial da Pressão Arterial (MAPA) 1-3 e a ampla utilização do método em nosso país, as Sociedades Brasileira de Cardiologia e Nefrologia, através de seus Departamentos de Hipertensão Arterial, e a Sociedade Brasileira de Hipertensão, reuniram, em São Roque (SP), 20 especialistas com larga experiência em MAPA, para, à luz de suas experiências pessoais e de profunda e completa revisão da atual e abrangente literatura, revisarem o documento anterior e redigirem o documento que ora apresentamos.Os conceitos emanados dessa reunião de consenso estão contidos nesta publicação, que se almeja possa nortear a prática da MAPA em nosso país, consoante com o que se faz, atualmente, em todo o mundo.
The reconstruction of defects involving the nasolabial, paranasal, and periorbital regions may be challenging, because they often involve more than one facial aesthetic unit, and can lead to functional problems. An average of 5 facial artery perforators of caliber >0.5 mm can be found above the mandible. A reference point for the location of the most constantly encountered perforator was suggested as being 1.5 cm lateral to the oral commissure, and at its same level in height or slightly inferior to the commissure. Based on injection studies, it is known that these perforators can supply an average area of 8 cm. The authors have extended the use of the freestyle perforator flap in a 87-year-old woman presented with an advanced melanoma of the paranasal area and nasolabial region (Breslow depth: 9 mm; Clark level V). Complete resection of the lesion with 3 cm oncological margins was performed. One-stage reconstruction with superior cosmetic results was achieved. The need for a perforator dissection is not necessarily a drawback, and classic concerns should be abandoned. The face is highly vascularized, and flap congestion is a rare event, usually a consequence of excessive pedicle trimming. Although technically more demanding, it should become one of the first reconstructive options when dealing with similar defects, if our results are confirmed in larger series.
To the Editor:After we have described our previous method, 1,2 a novel system capable of quantitatively assessing facial muscle movements was developed and is here presented. It automatically describes a set of morphological measurements and uses depth cameras together with advanced computer vision techniques, to perform detailed 3-dimensional (3D) characterization ( Figure 1).The system is simple and of great clinical value. In a clinical setup, the clinician places ink dots/markers on the face of the subject identifying anatomical landmarks whose movement should be characterized. The face is recorded by the camera while performing prespecified movements. The analysis results are organized as an innovative and standard medical tool named FACEGRAM-3D. Given the complexity of facial musculature, it is not feasible to collapse the spatiotemporal analysis into a single plot. Instead, it aggregates a set of plots and measures (Supplemental Digital Content-1 [SDC1] available in the online version of the article).The report is organized in 3 information blocks: subject's data, static analysis, and dynamic analysis. Patient's information, such as name/age/sex/date are presented at the top, as well as a representative frame at each phase of the movement (with its duration in seconds, Figure 2). The quantitative analysis is divided into 2 different categories: static and dynamic.The components regarding static analysis are the 3D positions of each anatomical point at rest and at maximum extension, a table with maximum extensions for each marker and a symmetry index. This metric, between 0 and 1, is intended to provide information about the relative position of points at rest for each associated pair of anatomical landmarks (in the case of smile: R/L commissures and L/R midpoints). Figure 1. The Facegram (3D) concept.
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