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      Aplicación de la Microcirugía en el tratamiento del paciente quemado eléctrico Translated title: Application of Microsurgery in the treatment of the electric burned patient

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          Abstract

          Resumen Introducción y objetivo. La Microcirugía como técnica dentro de la Cirugía Plástica no puede faltar en cualquier unidad de quemados para garantizar el tratamiento completo de sus pacientes. Sobre todo en los quemados eléctricos que presentan lesiones muy graves con exposición de tejidos nobles en los que es la primera opción reconstructiva. El objetivo de este artículo es mostrar la experiencia de la Unidad de Quemados del Hospital Universitario Vall d'Hebron de Barcelona, España, en los últimos 10 años en el uso de la Microcirugía en el paciente quemado agudo de etiología eléctrica. Material y método. Revisión retrospectiva de 19 colgajos realizados entre enero de 2010 y agosto de 2019 en 15 pacientes con quemaduras eléctricas, recogiendo datos de sexo, edad, localización del defecto, superficie corporal quemada (SCQ), colgajo empleado, días hasta la cobertura, tipo de anastomosis arterial, número de venas usadas, supervivencia de los colgajos y complicaciones. Resultados. Destaca que los 15 pacientes fueron varones, con edad media de 36.5 años; SCQ media del 19.5%; el colgajo más usado fue el ántero-lateral de muslo con 9 casos (47.37%), seguido por el de dorsal ancho con 4 casos (21.05%), el colgajo inguinal y el de músculo recto femoral con 2 casos cada uno (10.53% en cada caso) y el de perforante tóraco-dorsal y de fascia temporal superficial con 1 caso cada uno (5.26% en cada caso). La localización más frecuente fue en extremidades inferiores con 12 casos (63.16%), seguida por las extremidades superiores con 5 casos (26.31%) y la cabeza con 2 casos (10.53%). La cirugía de cobertura con el colgajo libre se realizó de media a los 24 días. La anastomosis arterial fue término-terminal en 15 casos (79%). La anastomosis venosa fue término-terminal siempre, anastomosando 2 venas en 5 casos (26.31%) y solo 1 en el resto (73.69%). Dos colgajos fracasaron por congestión venosa (10.53%) y 2 colgajos se complicaron por infección (10.53%). Conclusiones. La reconstrucción de defectos complejos tras quemadura eléctrica es un reto por el escaso número de casos que se presentan y por la propia idiosincrasia de la injuria eléctrica y del paciente quemado. El desbridamiento correcto, la selección del vaso receptor y decidir el momento óptimo para la reconstrucción son los puntos más importantes a tener en cuenta. Por estos motivos consideramos que esta patología debe ser abordada en unidades de quemados multidisciplinares con personal altamente entrenado.

          Translated abstract

          Abstract Background and objective. Microsurgery as a technique in Plastic Surgery cannot miss any burn unit for complete treatment of their patients. Especially in electric burns that have very serious lesions with exposure of noble tissues where Microsurgery is the first reconstructive option. The objective of this paper is to show the experience of the Burn Unit of the Vall d'Hebron University Hospital in Barcelona, Spain, over the last 10 years in the application of Microsurgery in the burned patient of electrical etiology. Methods. A total of 19 flaps performed between January 2010 and August 2019 in patients with electrical burn injury were reviewed retrospectively. The data collected were sex, age, location of the defect, total burned surface area (TBSA), flap used, days until coverage, type of arterial anastomosis, number of veins used, flap survival and complications. Results. It is noteworthy that all the 15 patients treated were male, with an average age of 36.5 years; average TBSA was 19.5%; the most frequently flap used was the antero-lateral thigh in 9 cases (47.37%), followed by the latissimus dorsi muscle in 4 cases (21.05%), the inguinal and the rectus femoris muscle in 2 cases each (10.53% in each case) and the thoraco-dorsal artery perforator and the superficial temporal fascia on 1 occasion each of them (5.26% in each case). The most frequent location was in the lower extremities in 12 cases (63.16%), followed by the upper extremities in 5 cases (26.31%) and the head in 2 cases (10.53%). On average, coverage surgery with the free flap was performed at 24 days. Arterial anastomosis was performed end-to-end in 15 cases (79%). The venous anastomosis was always end-to-end anastomosing 2 veins in 5 cases (26.31%) and only 1 in the rest (76.69%). Two flaps failed due to venous congestion (10.53%) and 2 flaps were complicated with infection (10.53%). Conclusions. The reconstruction of complex defects associated with an electrical burn has been, is a challenge for plastic surgeons because of the small number of cases that occur and, because of the idiosyncrasy of the electrical injury and the burned patient. A correct debridement, the selection of the recipient vessel and deciding the optimal time for reconstruction are the most important points to consider. For these reasons we believe that this pathology should be addressed in multidisciplinary burn units with highly trained personnel.

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          One versus two venous anastomoses in microvascular free flap surgery.

          The authors' goal was to determine whether one or two venous anastomoses results in superior blood flow through microvascular free flaps.
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            Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity.

            As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded. The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures. In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction. The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.
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              Current Techniques for Postoperative Monitoring of Microvascular Free Flaps.

              Free tissue transfer (FTT) is used in patients with complicated reconstructive needs; it can provide stable wound coverage, improved aesthetic appearance, and restore functional deficits. Despite the high success rates of free flaps, vascular occlusion is a significant risk leading to flap failure. Many studies have demonstrated that the salvage rate for flaps is inversely related to the time between onset of a vascular problem and its surgical correction. As a result, ongoing postoperative monitoring of free flaps for adequate perfusion is imperative to allow timely and accurate diagnosis of vascular compromise. Close monitoring and prompt notification of the physician if vascular compromise occurs are typically undertaken by first-line nurses. We conducted an integrative literature to identify and evaluate commonly used techniques for monitoring vascular free flaps during the postoperative period. We searched PubMed and Science Direct electronic databases, using the key words: "free-flap" and "monitoring." This article discusses commonly monitoring modalities, along with their advantages and limitations. Whereas large academic institutions may have an experienced nursing staff specifically trained in effective methods for monitoring free flap patients, this situation may not exist in all hospitals where free flap surgeries are performed. We describe techniques that allow easy and timely detection of flap compromise by nursing staff while reducing interuser variability.
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                Author and article information

                Journal
                cpil
                Cirugía Plástica Ibero-Latinoamericana
                Cir. plást. iberolatinoam.
                Sociedad Española de Cirugía Plástica, Reparadora y Estética (SECPRE) (Madrid, Madrid, Spain )
                0376-7892
                1989-2055
                2020
                : 46
                : suppl 1
                : 121-132
                Affiliations
                [2] orgnameHospital Universitario Vall D'Hebron orgdiv1Servicio de Cirugía Plástica España
                [3] orgnameHospital Universitario Vall D'Hebron orgdiv1Servicio de Cirugía Plástica orgdiv2Unidad de Quemados España
                [1] orgnameHospital Universitario Vall D'Hebron orgdiv1Servicio de Cirugía Plástica orgdiv2Unidad de Quemados España
                Article
                S0376-78922020000200121 S0376-7892(20)04600000121
                10.4321/s0376-78922020000200019
                1981d958-25a6-4696-8e23-7c42fbc82bcf

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

                History
                : 10 December 2019
                : 30 September 2019
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 14, Pages: 12
                Product

                SciELO Spain

                Categories
                Quemados

                Free flaps,Quemadura eléctrica,Quemaduras,Lesión eléctrica,Electrical burns,Burns,Reconstructive surgery,Microsurgery,Electrical injury,Cirugía reconstructiva,Microcirugía,Colgajos libres

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