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Habilitation Thesis
DOI
10.11606/T.5.2013.tde-18092013-103904
Document
Author
Full name
José Carlos Marques de Faria
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2009
Committee
Ferreira, Marcus Castro (President)
Brandao, Lenine Garcia
Cunha, Marcelo Sacramento
Malheiros, Carlos Alberto
Marchetti, Fernando Baldi
Title in Portuguese
Microcirurgia reconstrutiva - experiência pessoal de quinze anos - 1210 retalhos livres
Keywords in Portuguese
Cirurgia plástica
Microcirurgia
Procedimentos cirúrgicos reconstrutivos
Retalhos cirúrgicos
Abstract in Portuguese
A experiência clínica pessoal do autor na Microcirurgia Reconstrutiva acumulada ao longo de quinze anos foi analisada. Mil e duzentos e dez retalhos microcirúrgicos foram empregados na reconstrução de defeitos e deformidades em 1115 pacientes no período de 1995 a 2009. Oitenta e dois pacientes receberam mais de um retalho livre. A distribuição dos retalhos em grupos de acordo com a localização topográfica do defeito foi: cabeça e pescoço (CP) - 947 retalhos; membro inferior (MMII) - 164 retalhos; membro superior (MMSS) - 52 retalhos; mama (MAMA) - 43 retalhos; e tronco (TRONCO) - 4 retalhos. O diagnóstico mais comum nos pacientes submetidos a reconstruções em cabeça e pescoço, das mamas e tronco esteve relacionado às neoplasias e as suas conseqüências. Nas extremidades, trauma foi a etiologia mais freqüente. A taxa de sobrevida global dos retalhos foi de 93,9% (74 perdas). Nas cirurgias realizadas entre 1995 e 1999 o índice geral de perdas foi de 25%, entre 2000 e 2004 de 13,9%, e de 2005 até 2009 de 4,4% (p = 0,021). O índice de sucesso (retalhos viáveis) em cada grupo foi respectivamente de: CP - 4,9%; MMII - 14,0%; MMSS - 1,9%; MAMA - 4,6%; e tronco (TRONCO) - 25%. Os retalhos cutâneos foram os mais utilizados em CP: lateral do braço - 213 casos; ântero-lateral da coxa (ALT) - 173 casos; e antebraquial - 137 casos. Nos MMII os retalhos miocutâneos e musculares predominaram: reto abdominal - 34 casos; ALT - 32 casos e grande dorsal - 24 casos. Freqüência semelhante na indicação de retalhos cutâneos puros (lateral do braço e escapular) e de retalhos musculares/miocutâneos (reto abdominal e grácil) foi observada nas reconstruções dos MMSS. Na mama, o retalho abdominal e suas variantes (miocutâneo - TRAM, perfurante da artéria epigástrica profunda - DIEP, e cutâneo baseado na artéria circunflexa ilíaca superficial - SCIA) constituíram o método de escolha. Idade e gênero dos pacientes não influenciaram os resultados. Os índices de sucesso, segundo variáveis técnicas - tipo de anastomose (término-terminal ou término-lateral) e número de veias anastomosadas (uma ou duas), não apresentaram diferenças estatisticamente significativas em nenhum dos grupos estudados. Radioterapia realizada previamente ao procedimento reduziu significativamente os índices de sucesso em CP. O autor conclui que a transferência de retalhos livres é método seguro e eficiente na reparação de defeitos e deformidades independentemente da localização topográfica. Os índices de complicações locais diminuem com a aquisição de experiência ao longo do tempo.
Title in English
Reconstructive microsurgery: fifteen years of personal experience - 1210 free flaps
Keywords in English
Free Flaps
Microsurgery
Plastic surgery
Reconstructive surgical procedures
Surgical flaps
Treatment outcome.
Abstract in English
The author's personal clinical experience in Reconstructive Microsurgery over a fifteen-year period was analyzed. One thousand, two hundred and ten microsurgical flaps were used in the reconstruction of defects and deformities in 1,115 patients from 1995 to 2009. Eighty-two patients received more than one free flap. The distribution of the flaps in groups according to the location of the defect was: head and neck - 947 flaps; lower limb - 164 flaps; upper limb - 52 flaps; breast - 43 flaps; and trunk - 4 flaps. The most common diagnosis in the patients submitted to reconstruction of the head and neck, breast and trunk region was related to neoplasias and consequences thereof. As for the extremities, trauma was the most frequent cause. The total flap survival rate was 93.9% (74 losses). In the surgeries performed between 1995 and 1999, the overall percentage of losses was 25%, between 2000 and 2004 13.9%, and from 2005 to 2009 4.4% (p = 0,021). The rate of success (viable flaps) in each group was, respectively: head and neck - 4.9%; lower limb - 14.0%; upper limb - 1.9%; breast - 4.6%; and trunk - 25%. Cutaneous flaps were most used for head and neck reconstruction: lateral arm flap - 213 cases; lateral thigh - 173 cases; and radial forearm - 137 cases. Myocutaneous and muscle flaps were primarily used for lower limb reconstruction: rectus abdominis - 34 cases; lateral thigh - 32 cases and latissimus dorsi - 24 cases. The cutaneous flaps (lateral arm and scapular) and composite flaps (rectus abdominis and gracilis) were indicated for the upper limb reconstructions with similar frequency. The abdominal flap and its variants (myocutaneous - TRAM, muscle-sparing, deep inferior epigastric perforator - DIEP, and superficial circumflex iliac artery - SCIA) were the method of choice for breast reconstruction. Age and sex of the patients did not influence the results. The success rates, according to technical variables - type of anastomosis (end-end or endside) and number of anastomosed veins (one or two), did not present statistically significant differences in any group studied. Prior radiotherapy significantly reduced the success rates for head and neck reconstruction. The author concluded that free flap transfer is a safe and efficient method of repairing defects and deformities irrespective of location. Complications were reduced over time with the accumulation of experience.
 
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Publishing Date
2013-10-09
 
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