[Masseter oncocytoma of parotid origin]

INTRODUCTION

Tumors developed in a salivary ectasia of the parotid gland are very rare. The authors describe a case of oncocytoma developed in such an ectopy.

OBSERVATION

The tumor located in the parotid region was observed in a 79-year old man. There was no facial palsy, no pain, and no cervical adenopathy. MRI was the most helpful to localize and characterize the tumor. Surgical resection was performed after a parotidectomy. Histology confirmed the diagnosis.

DISCUSSION

The physiopathology of this rare entity is discussed with a literature review. It might correspond to a mitochondrial anomaly.

[Tumeral calcinosis: case report of an erosive form affecting the long finger]

Tumoral calcinosis is characterised by deposits of hydroxyapatite in the soft tissues. The authors report an observation of localization at the level the P.I.P. joint of a ring finger. The lesion appeared to be a subcutaneous tumour but had completely eroded the distal epiphysis of the middle phalanx. The diagnosis was made radiographically and was confirmed by histology. Calcinosis presents in two very different forms; either disseminated or localised. The localised form can invade the juxta-articular gliding spaces. It may exhibit one of two clinical courses: one is acute and diffuse. The other is chronic, localised and insidious and gives rise to tumoral masses arising near joints, but without invading them. An erosive tumoral calcinosis is exceptional. It is characterized by bony right up to the articular surfaces. At the level of the wrist and the hand, tumoral forms are rare and we could only find one other case in the literature and it was localized in the middle finger.

[Skin, wrinkles and botulinum toxin]

OBJECTIVE

To present an up-to-date analysis about the use of botulinum toxin for treating facial lines and wrinkles.Method. - A systematic search of the literature was conducted to select the most recent or relevant publications on this topic, through Medline.

RESULTS

Out of the 583 articles retrieved, 90 were finally selected for the study.

DISCUSSION

Validity of using botulinum toxin for cosmetic use is demonstrated, together with contra-indications and different methods to objectivate the results. The different available types of toxin are presented and compared. Modalities of preparation, conservation, and waste disposal are detailed. Anatomical bases of muscular facial balance are reviewed, with techniques of injection presented for each site, and also with adjunctive procedures. Complications and side effects are described and analysed. Most complications can be prevented through: perfect knowledge of local anatomy;use of small volumes;orientation of the needle bevel towards the muscle body, injection within the muscle body if thick, more superficial if thin;application of ice on the skin pre- and post-injecting. Adding epinephrin or diluting with xylocaïne and epinephrin is not commonly used.

CONCLUSION

Botulinum toxin has found its way as a major component of the therapeutic armamentarium. Its efficacy for facial rejuvenation has made it extremely popular, but its use does follow strict rules, and should be restricted to soundly trained practitioners.

[Ganglions of the wrist: proposals for topographical systematization and natural history]

PURPOSE OF THE STUDY

We looked for the anatomic origin and mechanism of constitution of the so-called "ganglions" of the wrist.

MATERIAL AND METHODS

Fifty-nine formations considered to be synovial ganglions were dissected and removed according to the same protocol by the same surgeon. Eleven were re-examined by a pathologist. All ganglions were extra-articular but had intra- and extra-capsular components. The extra-capsular part was the clinically palpable main cyst. The intra-capsular part was composed of the cystic stalk and its base of implantation. An intra-capsular stalk was present in 58 cases. The stalk was situated between the joint synovium and the capsula which it perforated at a weak point between two ligaments, forming a collar before expanding outwardly. Based on our findings, we propose a topographical systematization and natural history of ganglions of the wrist.

RESULTS

The stalk's implantation base was always located on bone and found in the intermediate area of Colomniati and Soubbotine, which lies outside the articular cartilage between the synovium and the ligamentous capsula. This area is exposed to mechanical stress initiating histological degenerative lesions, particularly mucoid degeneration. At the radiocarpal joint, the stalk's base of implantation was located at the distal end of the lateral dorsal or volar edge of the lunate bone or at the corresponding part of the scaphoid. The collar of the proximal ganglions was situated between the dorsal radiocarpal and transverse scaphotriquetral ligament. The collar of distal dorsal ganglions was situated between the transverse scaphotriquetral and the trapezotriquetral ligament. The collar of the lateral ganglions was situated between the lateral collateral and the transverse ligament. The collar of the volar ganglions was situated between the stylocarpal ligament and the radiolunotriquetral ligament, or between the different stylocarpal ligaments. At the level of the scaphotrapezal joint, the stalk's base of implantation was located near the collateral edge of the distal surface of the joint with the collar between the distal scaphoidal ligaments. The palmar cysts exhibited a collar between the stylocarpal ligaments and the radiolunotriquetral ligament or between the different stylocarpal ligaments.

DISCUSSION

At pathology examination, the lesions were not found to be different from those observed in other connective tissues exposed to overuse or repeated microtrauma (sports, occupational exposure). Anatomic conditions inside the joint capsula excluded extension of the mucoid degeneration transversally. The only issue was through the capsula, allowing the mucus enclosed in the connective tissue fibers to form the main cyst.

CONCLUSION

Knowledge of these different processes enabled a topographical systematization useful for complete surgical or arthroscopic removal of the ganglion. Complete resection would prevent recurrence.

Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results

A retrospective study was done on a population of 258 women who had undergone surgery for abdominal dermolipectomy between January of 1991 and May of 1996. The postoperative complications and flaws seen at long-term follow-up are discussed. The surgical techniques used, with or without lipoaspiration, were the infraumbilical plasty and full plasties with horizontal or inverted T scars. Six types of postoperative complications were noted: hemorrhage in 1.2 percent, lymphorrhea in 10.9 percent, infection in 7 percent, skin necrosis in 6.6 percent, secondary dehiscence of the scar in 2.3 percent, and thromboembolic accidents in 1.2 percent. No significant difference was found in the rate of necrosis development between patients who did and did not undergo lipoaspiration. However, a statistically significant difference was seen in the rate of skin necrosis between the T-type plasty (35.5 percent) and the other two procedures (1.43 percent for infraumbilical plasties and 4.60 percent for full plasties with horizontal scar). With regard to the flaws found at long-term follow-up, the rate of above-scar fat folds and/or dog-ears was 27.9 percent, and the rate of defective scars was 26 percent. No significant difference was found with regard to the rate of flaws. The rate of all secondary surgical procedures was 29.1 percent, but performance of secondary procedures depended on the willingness of the patient and on the surgeon's judgment. Abdominoplasty procedures involve a high risk of early complications. The rate of skin necrosis is clearly augmented in cases of T-type plasty. The need for secondary surgical correction is frequent, and the patient should be reminded of this possibility during preoperative consultation.

Hormonal regulation of apoptosis in breast cells and tissues

Few studies have referred to the implication of apoptotic processes following hormonal treatment. No data are available on the effects of progesterone in breast cells. In order to gain insights on the effects of the gonadal steroids and antiestrogens in breast cells, we have carried out studies on apoptosis in different breast materials. We have developed a model of normal breast cells in cultures that remain hormone-dependent. On these cells and in some hormone-dependent breast cancer cell lines (T-47-D, ZR75-1, MCF-7) we have observed an antiapoptotic effect of estradiol (E(2)) and a potent proapoptotic effect of some antiestrogens. Progestins were also proapoptotic in normal as well as in hormone-dependent breast cancer cells. In order to understand the mechanisms of these hormones on apoptosis, we studied the bcl-2 family proteins. We demonstrated that E(2) increased the antiapoptotic proteins, bcl-2 and bclx(L), whereas, the progestins drastically decreased bcl-2 expression and weakly bclx(L) levels. We investigated the mechanisms by which E(2) increased bcl-2 expression. Our results using quantitative RT-PCR showed that E(2) increased bcl-2 mRNA levels at 48 h of treatment via a transcriptional mechanism. None of the hormone treatments altered the proapoptotic protein levels, bax and bak. We also studied the in vivo expression of bcl-2 and other members of its family in biopsies of normal breast tissues according to the menstrual cycle. Bcl-2 displayed a strong cyclical variation and seemed to be the most hormone-dependent member of the family.

[Action of SERM and SAS (tibolone) on breast tissue]

SERMs are developed in HRT in order to provide the beneficial effects of estradiol on bone and the cardiovascular system. SERMs are antiestrogens and their properties depend upon the pharmacological class they belong to. Tibolone is a progestin with mixed properties. Our studies on breast cells in vitro demonstrated that it behaves as a progestin in these cells. The clinical data obtained with these various therapies on breast are presented.

The importance of the posteromedial fragment and its specific pinning in fractures of the distal radius

In fractures of the lower end of the radius, the presence of a posteromedial fragment should be recognized if present. This fragment with two articular surfaces, if not reduced, will damage the radiocarpal and inferior radioulnar articulations. The diagnosis needs to be made on 3/4 X-ray views, as the fracture is often mistaken for a Colles' fracture. The author advises reduction and fixation by a method of double pinning. By comparing two sets of statistics, the overall results are shown to be improved without more complications.

[Hashimoto's thyroiditis and silicone breast implants: 2 cases]

The silicone implant controversy wavers between reassuring epidemiological studies and about 300 case reports of patients developing a definite or incomplete/atypical connective tissue disease (CTD) after receiving a silicone gel-filled breast implant (SBI). Since Hashimoto's thyroiditis (HT) is rarely reported in this context, we report here two new cases of HT associated with a history of bilateral cosmetic SBIs. The first patient was a 45-year-old white woman who had SBIs in 1976. In 1991 she developed HT, evolving to thyroid deficiency which was compensated with levothyroxine treatment. In addition, the patient complained of fatigue, arthralgia, morning stiffness and developed a sicca syndrome necessitating artificial tears. The 1995 evaluation disclosed the presence of antinuclear antibodies at a titre of 1/640, and high level anti-thyroid microsomal antibodies (1/256,000). Gamma globulins rose to 22.6%. Thyroid ultrasonography showed an enlarged thyroid gland with a diffusely hypoechogenic pattern. The implants were painful, and in 1996 they were removed. Microscope examination of the fibrous capsule surrounding the prostheses showed extremely dense connective tissue with fibrosis. The second patient was a 55-year-old white woman who had SBIs in 1984. In 1995, she developed HT with clinical pain and tenderness of the thyroid gland, with mild hyperthyroidism and positive antithyroglobulin antibodies, and was given corticosteroid treatment for 5 months. In 1996, the implants were again painful and the patient developed positive antinuclear antibodies with a titre of 1/200. Ultrasonography showed a heterogeneous thyroid gland, and implant removal was advised. Hashimoto's thyroiditis is recognized as a subset of chronic auto-immune thyroiditis, and its association with SBI is rare. In these 2 observations, an association without relation is possible, but a future survey of similar cases seems warranted.

[Complications related to the existence of a lunotriquetral synostosis]

The authors report the observation of a patient, in whom coexisted a hypersolicitation of the wrists, a congenital lunatotriquetral fusion, a stress fracture of the hook of the hamate and a VISI, giving evidence of a medial carpal instability. They analyse the factors, which allow to understand the relations between these different elements. They caution against arthrodesis, advocated in the treatment of VISI.

[Painful extensor digitorum brevis]

A boxer suffered from a painful extensor digitorum brevis muscle. The pathology involved the proximal insertion on the lunate and caused a specific form of carpal instability. On excision of the muscle the pain disappeared.

[Extravasation of paclitaxel (Taxol)]

Paclitaxel is a new antimitotic derived from yew-tree, used for the treatment of ovarian and breast cancers. The local toxicity of paclitaxel is still poorly known. We report one of the first observations of accidental subcutaneous extravastion of paclitaxel. Local epidermic necrosis was observed and evolution was good with local treatment only. Treatments of such extravasation are discussed.

[Increased viability of skin flaps using naftidrofuryl. An experimental study in the Wistar rat]

The effect of a vasodilator (naftidrofuryl) was evaluated in an experimental study in rats concerning the viability of a skin flap. The reference flap is a dorsal skin flap deliberately shaped very long in order to obtain necrosis of its distal extremity. This necrosis is measurable and sufficiently reproducible. Using a comparative study between a control group of ten rats and a group of rats treated by intraperitoneal injections of naftidrofuryl for ten days, the authors demonstrated a significant difference between necrosis in the two groups. Naftidrofuryl treatment increases the length of the viable part of the skin flap in rats. This product achieves a kind of medicinal autonomy much easier than a surgical autonomy.

[The posterior interosseous artery. Descriptive anatomy. Possibilities of clinical and orthopedic applications]

Study of 25 forearms of fresh cadavers, whose the arteries have been injected with colored latex. The posterior interosseous artery is known for its superficial branches, which allow to autonomise cutaneous dorsal flaps. Its way, along the ulna allows to imagine other possibilities by use of the constant branches of this artery, which supplies the proximal and the distal extremities of the bone. The proximal branch is the posterior recurrent radial artery, which supplies the posterolateral face of the proximal pars of the diaphysis, in touch of the insertions of the supinator muscle, and the lateral edge of the olecranon. The distal arteries shape 2 or 3 fascicles, which disperse on the extremity of the diaphysis and the cervical pars of the ulna. To realize a vascular pedicle with the posterior interosseous artery, two cases can be envisaged: use of the distal ulnar epiphysis and creating of a direct pedicle. use of the proximal ulnar epiphysis and creating of a recurrent pedicle.

The nutrient flap: a new concept of the role of the flap and application to the salvage of arteriosclerotic lower limbs

The nutrient flap is a new concept of the role of the flap. It has three functions: (1) it provides supplementary blood flow to ischemic zones, (2) it assists venous drainage in regions of venous insufficiency, and (3) it induces the formation of a capillary network. Its skin covering role is only accessory. We have applied this principle to osteitis, pseudoarthrosis, and arteriosclerosis. The nutrient flap constitutes a new type of treatment for stage IV arteriosclerosis of the lower limbs when classical revascularization techniques cannot be performed and when high amputation is indicated. Four clinical cases and the surgical techniques used are described. The flap, usually raised from the latissimus dorsi, is anastomosed to the popliteal artery by means of an inverted saphenous vein graft. It is applied to the distal extremity of the limb after excision of the necrotic tissues. The nutrient flap preserves weight-bearing by maintaining the heel.

Burns in the elderly

This report describes the treatment and prognosis of 37 burned patients over 70 years of age.

Boutonniere Deformity in Dupuytren’s Disease

The boutonnière deformity in Dupuytren’s disease has been found to be due to fibrous contraction of the transverse retinacular ligament which anteriorly displaces the fibres of the extensor apparatus.

Complete ablation of this ligament and liberation of the extensor apparatus arrows easy extension of the finger when operating on severe cases of Dupuytren’s contracture.

[The nutrient flap. Its application in saving lower limbs involved in stage IV arteritis]

The skin covering role of the nutrient flap is only accessory. However, this role is essential for an ordinary flap. In stage IV arteriosclerosis of the lower limbs when classical revascularization techniques cannot be performed, the nutrient flap can be spread over the distal extremity of the limbs. It provides a supplementary blood flow to ischaemic zones and it induces the neoformation of a vascular network. The nutrient flap avoids the need for high amputation and preserves weight bearing by maintaining the heel. Four clinical cases are detailed and the surgical techniques are described. The flap usually raised from latissimus dorsi, is anastomosed to the popliteal artery by means of an inverted saphenous vein graft, and is spread over the extremity of the limb after a wide excision of all the necrotic tissues.

[Pseudotumoral chondrocalcinosis and carpal tunnel syndrome. Apropos of a case report]

Review of the literature of chondrocalcinosis and rheumatologic osteoarticular causes of the carpal tunnel syndrome. Presentation of one observation of chondrocalcinosis of the wrist with presence of a pseudotumor, developed in the carpal tunnel and having induced a carpal tunnel syndrome, at first subacute, then particularly painful by direct irritation of the median nerve.

Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid

A bone graft, taken from the medial part of the radial epiphysis can be pedicled on the radial branch of the volar carpal arch, freed back to its origin. The graft can be transferred into the proximal row of the carpus to fill up a loss of bony substance or to provide vascularised bone. This permits the treatment of chronic pseud-arthrosis of the scaphoid where a Matti-Russe operation has failed. In the first three cases operated upon, favourable results have been obtained.

Treatment of elbow contractures in burns

Contractures of the elbow after burn injury are frequent and are often connected with other contractions. Surgical correction must take into consideration the topography, the likelihood of possible heterotopic ossification and the condition of the surrounding skin. A study of 66 contractures allowed us to reach the following conclusions: Linear contractures surrounded by normal skin require IC-type local flaps. Widespread contractures can be treated with thoracic flaps if healthy skin remains or else with the 'backwards flap'. Surgery on existing associated heterotopic ossification must be in two stages starting with the cutaneous step.

Vascularized Bone Graft Pedicled on the Volar Carpal Artery for Non-Union of the Scaphoid

A bone graft, taken from the medial part of the radial epiphysis can be pedicled on the radial branch of the volar carpal arch, freed back to its origin. The graft can be transferred into the proximal row of the carpus to fill up a loss of bony substance or to provide vascularised bone.

This permits the treatment of chronic pseud-arthrosis of the scaphoid where a Matti-Russe operation has failed. In the first three cases operated upon, favourable results have been obtained.

Recent burns of the hand. Early excision-graft versus conventional treatment. A retrospective study during two years

Early excision-graft of burned hands seems to have totally superseded the conventional method of progressive detorsion often with late grafting. Does this treatment merit acceptance under these conditions? Do the theoretical advantages of aggressive methods counter-balance the primary difficulty of diagnosing the initial depth of burn? Are these fewer difficulties and risks in early excision-graft than in the slower methods? Can we ascribe the failure of conventional method to a poor technical realisation? Following a short summary of the principles of the two methods, we attempt to answer these questions by a retrospective study comparing identical series of patients. We have begun a prospective randomized trial and present the preliminary results here.

Rebuilding the cervico-mandibular angle--correcting a deformity of neck burns

Repairing the cervico-mandibular angle following neck burns is a major problem. Several artistic landmarks show its aesthetic importance. From a functional point of view, the authors show the positive consequences of rebuilding using the results from 101 patients with neck burns. In principle, the treatment involves maximal use of healthy skin, and the separate reconstruction of the horizontal and vertical parts of the neck.

[Fracture of the trapezoid bone. Apropos of a case report]

Although very rare, fractures of the lesser multiangular (trapezoid) bone may be suspected clinically and demonstrated radiographically by special projections.

[Sub-epitrochlear apophysis. A source of median nerve compression. Review of the literature]

The supracondylar process in an osseous spur located above the medial condyle of the humerus. It may be responsible for compression of the median, as well as the ulnar, nerves. Diagnostic must be directed in this direction whenever a deficit is found in the nerve distribution territory of one of these nerves.