Case Letter
Old but gold – Antia and Buch chondrocutaneous advancement flap for helical reconstruction: a series of cases
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Desenho do retalho, com triângulo de compensação ao nível do lóbulo auricular. (B), Defeito cirúrgico composto (pele e cartilagem) e incisão linear na face anterior da orelha. (C), Visão posterior do movimento de avanço, após ressecção do triângulo de compensação retroauricular. (D‐E), Sutura por planos e pós operatório imediato. 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array:1 [ 0 => "paulasakiyama@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Thiago Augusto" "apellidos" => "Ferrari" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Raíssa Rigo" "apellidos" => "Garbin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Roberto Gomes" "apellidos" => "Tarlé" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Hospital Santa Casa de Curitiba, Curitiba, PR, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Discipline of Dermatology, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1571 "Ancho" => 2508 "Tamanyo" => 259513 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Classic chondrocutaneous flap (A.1) Helical defect, dashed lines indicate skin and cartilage incisions. (A.2) Incision on the anterior surface of the ear, including the cartilage, without transfixing the retroauricular skin. (A.3) Advancement movement and cartilage suturing. (A.4) Skin suturing. (B) Full-thickness chondrocutaneous flap. (B.1) Helical defect. (B.2) Incision on the anterior and posterior surface of the ear, including cartilage, transfixing the retroauricular skin. (B.3) Advancement movement. (B.4) Suture by planes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0060" class="elsevierStylePara elsevierViewall">The auricle or pinna is a frequent target of malignant neoplasms. Half of the tumors are located in the helix, and many defects involve both skin and cartilage, making surgical reconstruction a challenge.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this article, the authors describe three cases of skin neoplasms in the helix repaired with Antia and Buch chondrocutaneous advancement flap.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes step-by-step the technique.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The first patient presented an <span class="elsevierStyleItalic">in situ</span> squamous cell carcinoma (SCC), measuring 13<span class="elsevierStyleHsp" style=""></span>mm in its largest diameter, submitted to Mohs micrographic surgery (MMS) and removed in the first stage. The second patient had an infiltrative basal cell carcinoma (BCC), measuring 8<span class="elsevierStyleHsp" style=""></span>mm in its largest diameter, removed in 2 stages, using MMC. Finally, the third case was a well-differentiated SCC, measuring 10<span class="elsevierStyleHsp" style=""></span>mm in its largest diameter, resected using the conventional technique (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Surgical planning is essential to attain good results in the management of tumors in the auricular region. Among its peculiarities, a significant amount of cartilage is present which may not resist distortions secondary to scar contracture. Additionally, there is an increased risk of necrosis due to the thinness of the auricular skin. In the case of the helix, the choice of repair is based on the location, size of the defect, and the amount of cartilage loss. Small defects (<1‒1.5<span class="elsevierStyleHsp" style=""></span>cm) are easily reconstructed with wedge excision and primary closure, unlike larger defects, which require the use of grafts or flaps.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Grafts require a preserved cartilaginous structure, with viable perichondrium or cartilage perforations to allow irrigation through the contralateral bed. In composite defects, the structural loss of the helix margin requires cartilage and skin for its repair, which can be performed using the following techniques: composite graft from the contralateral auricle; interpolated flaps using cartilage; chondrocutaneous flap.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3–5</span></a> The latter is frequently used and can be performed through a skin incision on only one surface of the ear and cartilage, as described by Antia and Buch, or through a full-thickness incision including the skin of the two surfaces and cartilage (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The chondrocutaneous flap was first described by Antia and Buch, in 1967. The principle of the procedure is to advance the skin and cartilage of the intact portion of the helix adjacent to the defect, based on a wide and secure retroauricular pedicle, with greater preservation of the vascularization of the posterior auricular artery.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, the classic technique has lost prominence since the initial report and several modifications have been made ‒ including the incision of the transition line from the helix to the dorsum of the ear, limiting irrigation by restricting the pedicle to the lower portion of the flap only, which carries the risk of local vascularization impairment.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Therefore, Antia and Buch flap, despite having been described more than 50 years ago, maintains its role among the techniques of helix reconstruction, and its knowledge is important for dermatological surgeons. It is an effective and safe method, performed in a single step with the additional advantage of preserving local vascularization, reducing the risk of necrosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0095" class="elsevierStylePara elsevierViewall">Paula Hitomi Sakiyama: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature; critical review of the manuscript.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thiago Augusto Ferrari: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature; critical review of the manuscript.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Raíssa Rigo Garbin: Approval of the final version of the manuscript; design and planning of the study; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Roberto Gomes Tarlé: Approval of the final version of the manuscript; design and planning of the study; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:2 [ "identificador" => "xack673268" "titulo" => "Acknowledgments" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-07" "fechaAceptado" => "2021-01-03" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Dermatology Service, Hospital Santa Casa de Curitiba, Curitiba - Paraná, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2918 "Ancho" => 2925 "Tamanyo" => 1334785 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Clinical lesion and margin delimitation. Design of the flap, with a compensation triangle at the level of the auricular lobe. (B) Composite surgical defect (skin and cartilage) and linear incision on the anterior surface of the ear. (C) Posterior view of the advancement movement, after resection of the retroauricular compensation triangle. (D‒E) Suture by planes and immediate postoperative period. (F) Late postoperative period.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1571 "Ancho" => 2508 "Tamanyo" => 259513 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Classic chondrocutaneous flap (A.1) Helical defect, dashed lines indicate skin and cartilage incisions. (A.2) Incision on the anterior surface of the ear, including the cartilage, without transfixing the retroauricular skin. (A.3) Advancement movement and cartilage suturing. (A.4) Skin suturing. (B) Full-thickness chondrocutaneous flap. (B.1) Helical defect. (B.2) Incision on the anterior and posterior surface of the ear, including cartilage, transfixing the retroauricular skin. (B.3) Advancement movement. (B.4) Suture by planes.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1)</span><p id="par0005" class="elsevierStylePara elsevierViewall">Antisepsis</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0010" class="elsevierStylePara elsevierViewall">Demarcation of the surgical margin</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Local anesthesia and lesion excision</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Drawing of the flap, showing a line at the limit anterior to the helix, inferior to the defect, extending to the lobe, and the retroauricular compensation triangle</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Linear incision on the anterior surface of the ear, along the helix curvature up to the lobe, including the cartilage, without transfixing the retroauricular skin. A compensation triangle can be drawn on the lobe</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Retroauricular detachment over the cartilage with blunt scissors (flap pedicle)</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Hemostasis</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8)</span><p id="par0040" class="elsevierStylePara elsevierViewall">Chondrocutaneous flap advancement through the cartilage suture</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9)</span><p id="par0045" class="elsevierStylePara elsevierViewall">Resection of the retroauricular compensation triangle</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10)</span><p id="par0050" class="elsevierStylePara elsevierViewall">Suture of the skin</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">11)</span><p id="par0055" class="elsevierStylePara elsevierViewall">Compressive dressing</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Steps for performing Antia and Buch flap.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ear Reconstruction after Mohs Cancer Excision: Lessons Learned from 327 Consecutive Cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Sanniec" 1 => "M. Harirah" 2 => "J.F. Thornton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2019" "volumen" => "144" "paginaInicial" => "719" "paginaFinal" => "729" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chondrocutaneous advancement flap for the marginal defect of the ear" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.H. Antia" 1 => "V.I. Buch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006534-196705000-00006" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1967" "volumen" => "39" "paginaInicial" => "472" "paginaFinal" => "477" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5336914" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Helical Rim Reconstruction with Chondrocutaneous Hatchet Flap-Z Plasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Durğun" 1 => "S. Baş" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SAP.0000000000001774" "Revista" => array:7 [ "tituloSerie" => "Ann Plast Surg" "fecha" => "2019" "volumen" => "82" "paginaInicial" => "533" "paginaFinal" => "536" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30882403" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0007091220309624" "estado" => "S300" "issn" => "00070912" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reconstrução da região superior da hélice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.A. Gadens" 1 => "P.R. Pacola" 2 => "A. Kimyai-Asadi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Surg Cosmet Dermatol" "fecha" => "2013" "volumen" => "5" "paginaInicial" => "161" "paginaFinal" => "163" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reconstruction of marginal ear defects with modified chondrocutaneous helical rim advancement flaps" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.E. Butler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.PRS.0000056834.94472.4C" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2003" "volumen" => "111" "paginaInicial" => "2009" "paginaFinal" => "2013" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12711964" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack673268" "titulo" => "Acknowledgments" "texto" => "<p id="par0120" class="elsevierStylePara elsevierViewall">The authors would like to thank Kellen Cristina Ferrari Bana for making the drawings and Dr. Gerson Dellatorre for suggestions and critical review of the manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009700000006/v2_202306261757/S036505962200188X/v2_202306261757/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009700000006/v2_202306261757/S036505962200188X/v2_202306261757/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S036505962200188X?idApp=UINPBA00008Z" ]
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