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ARTICLES
Microsurgery: A NEW TECHNIQUE FOR TREATMENT OF DISEASES congenital,
acquired and Trauma AVAILABLE IN ECUADOR.
Dr. Walter
Francis Huaraca.
Plastic Surgeon - microsurgeon.
Specialized in Brazil.
Prof. Dr. Fausto Viterbo.
Head of service discipline of Plastic Surgery - Microsurgery of the
Paulista State University, Botucatu, Brazil.
Dr. Jacqueline Freire Freire.
Resident clinical Samborondon Kennedy.
History:
In 1921 a Swiss named Nylen otolaryngologist performed an operation
in the inner ear with a surgical microscope. Carl Zeiss in 1953
began the mass production of surgical microscopes.
The first transfer of free flap was first described by Daniel and
Taylor in 1973 revolutionized reconstructive surgery and
microcirugía.1 In Latin America, Brazil was the pioneer where
transposition was performed the first microsurgical and today are
still performing surgical procedures complex as liver
transplantation among others.
This type of complex microsurgical procedures are performed in major
countries like USA, France, Spain, Taiwan, Japan, Brazil and now is
available in our country.
Summary:
Microsurgery is an important technique in plastic surgery enables
the surgeon experienced in microsurgery to repair any defects in the
body, be it congenital, acquired or traumatic. It can be applied
safely in adults and children.2
The success of these microsurgical procedures lie in the
preoperative planning, which is a significant task and will have
direct bearing on the outcome of the proceedings, the patient
selection, surgical planning, site selection donor tissue viability
and technical aspects transferred of microvascular anastomosis are
very important, however an error in one of these aspects will lead
to the failure of free flap. There are some factors such as age,
patients undergoing radiation therapy, chemotherapy and several
systemic diseases such as atherosclerosis, diabetes, cardiovascular
limiting their aplicación.3-4
Keywords:
Microsurgery, free flaps, autologous tissue Reinplantes, plastic
surgery reconstructive surgical procedures.
Microsurgery is the most important breakthrough occurred in plastic
surgery, this technique allows tissue transfers (dermal,
myocutaneous, osteomyocutaneous) safely.
INTRODUCTION:
Microsurgery is an important technique in plastic surgery, this
procedure allows for reimplantation of fingers, arms, legs, penis,
ears, face, digital downloads toe to the hand, lower limb
revascularization at tibiofibular trunk or tibial anterior.5-6-7-8
enables still free flap transposition (muscle, bone or soft tissue)
for correction of major congenital abnormalities, post-traumatic and
post-tumor resection that were previously considered inoperable due
to the complexity of injuries and depth. 9-10-11-12-13-14 With this
tool we are able to perform various reconstructive procedures and
make the area coverage bloody head, neck, chest, pelvic limb or any
other area that needs coverage for a defect caused by an accident as
brachial plexus palsy or disfiguring disease such as facial palsy or
soft tissue cancer. Currently all of these disorders can be treated
safely with new and efficient techniques of reconstruction, these
free flaps (Free flap) are intimately attached to its vascular
pedicle consisting of arteries, veins, which need blood supply for
survival. Graphic: 1, Photo 1
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Figure 1 - Fibula free flap osteomyocutaneous, which
is in close relationship with its vascular pedicle
(artery and vein). |
The dissections
were performed with the aid of a microscope or magnifying lenses
called loupes. (Photos 2-3). This is achieved with a better
technique in the management structures and with less damage to
tissues.
Is essential to have proper equipment such as mini clamps, needle
holders, scissors, clamps and so on. This instrument is delicate and
difficult to manufacture in many countries of America (photo 2,3,4).
What is a free flap?
It is the well-vascularized tissue transfer are these skin,
myocutaneous, osteomyocutaneous to anywhere in the body, a vascular
pedicle (artery vein nerve) that guarantees the survival of
colgajo.1-13
Materials and Methods:
This work was performed at the Hospital of the Paulista State
University, Botucatu (Brazil) and Cosmetic Surgery Clinic, Dr.
Fausto Viterbo Microsurgery, during the period of 16 April 2008 -
March 31, 2010.
Reconstructions were performed for various diseases using free
flaps, the flaps were used more latissimus dorsi muscle, gracilis
muscle, fibula flap of osteomyocutaneous, skin flap DIEP.15 Each
procedure has its indications, and the ideal choice of technique
depends on individual factors such as : age, health status,
anatomical characteristics, presence of associated conditions,
assessment of damage and the tissue conditions by transplantar.14-16
These microsurgical procedures performed by plastic surgeon trained
in microsurgery, prepares blood vessels in the recipient area and
donor, then with the aid of a microscope or magnifying glass,
connecting the arteries and veins of the transplanted tissue to the
area to rebuild.
Advantages of free flaps:
1 .- Provides security and full coverage of large defects in the
body caused by various diseases
2 .- Less surgical procedures to achieve a satisfactory result.
2.-The possibility of transferring specific tissues according to the
needs of each patient. bone, muscle, skin, mucous membranes or
different combinations, achieving better results.1-16
Results:
This type of microsurgical procedures should be performed in
hospitals that provide security guarantees for the patient and have
the necessary equipment and microscopes for microsurgery
appropriate. Photos :2-3-4.
In all operated cases had favorable, according to plan, we obtained
a success rate of 95%. Photos: 5-9
There were small contingencies as dermoepidermolisis, photo 6 in
such cases conservative treatment was performed healings.
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Figure 2: Free flap. The deep inferior epigastric
perforator (DIEP) flap for breast reconstruction. |
Discussion:
These microsurgical interventions are performed in a single
surgical, two surgical teams need to shorten the operating time.
Each microsurgery is a surgical time average of 6 -10 to 12
hours depending on what type of surgery accordingly. This found
that the use of the microscope improves the quality of
anastomosis in relation to use of magnifiers.
The choice of recipient vessels is very important, because they
possess identical vascular diameters and its proximity to the
area to rebuild. The dissection and preparation of the vessels
must be very sensitive and accurate, because the vascular
endothelium is injured very easily, compression and / or
excessive tension leads to vascular spasm which can result in
thrombosis. Another factor to consider is the length of the
vascular pedicle, if this is too short causes tension on the
anastomosis, we must also avoid redundancy in length which can
cause twisting and compression of the pedicle leading to loss of
flap.
The use of saphenous vein grafts and recipient vessels between
the free flap should be used with caution because potentiates
thrombosis of the vessels. Vascular thrombosis in most cases is
technical error in the anastomosis and / or use of a glass with
the injured endothelium. The type of anastomosis used is termino-lateral
and / or end to end, the latter presenting greater
effectiveness. When we are faced with an imbalance in the
diameter of the vessels should be performed
end-to-lateral.17-18-19-20 is considered microanastomosis
process is the most important determinant of vessel patency.
The flap ischemia time is the amount of time that passes from
the free flap vascular pedicle is severed from the donor area to
be anastomosed in the recipient vessels and restore blood flow.
The ideal time for this procedure is up to 4 hours in skin flaps
and myocutaneous, while up to 6 hours in free flaps
osteomiocutáneos.21-22-23-24-25
The medication is added in the immediate postoperative heparin
is the use of low molecular weight sodium 5,000 IU. subcutaneous
c / day for 3-5 days during their hospitalization, subsequently
added to treatment with pentoxifylline or aspirin.
Close monitoring is performed in the post-surgery in order to
identify any changes in the hemodynamics of the flap. Caution
should be exercised after 20 minutes post-anastomosis, the next
critical period is 24-72 hours, the success of a free flap is to
reach the 5 days without filing trombosis.26-27-28-29- 30-31-32
-
In some countries, and other hospitals recommend performing
vascular pedicle control by using color Doppler ultrasound every
2 hours during the first 12 hours, then every 6 hours to
complete the 72 hours. 33-34
Conclusions:
The use of microsurgical flaps is safe, effective, it is
performed in an operating time can be applied in adults and
children allowing tissues to restore large areas of previously
inoperable with good results, improving the quality of life for
these patients. Reconstructions also allows functional and
aesthetic results with minimal commitment from the donor area.
References:
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microvascular anastomoses: a clinical technique. Plast Reconstr
Surg 52: 111-117, 1973
2.-Joseph Upton, M.D. Free-Tissue Transfer Pediatric Plastic and
Reconstructive Surgery • December 2009.
3. Bernstein EF, Sullivan FJ, Mitchell JB, et al. Biology of
chronic radiation effect on wound healing and Tissues. Clin
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