Cost-effectiveness of system-level mental health strategies for young people in the Australian Capital Territory: a dynamic simulation modelling study

BACKGROUND

Regional mental health planning is a key challenge for decision makers because mental health care is a complex, dynamic system. Economic evaluation using a system dynamics modelling approach presents an opportunity for more sophisticated planning and important evidence on the value of alternative investments. We aimed to investigate the cost-effectiveness of eight systems-based interventions targeted at improving the mental health and wellbeing of children, adolescents, and young adults in the Australian Capital Territory (ACT).

METHODS

We assessed eight interventions for children and young people (aged ≤25 years) with low, moderate, and high-to-very-high psychological distress: technology-enabled integrated care, emergency department-based suicide prevention, crisis response service, family education programme, online parenting programme, school-based suicide prevention programme, trauma service for youths, and multicultural-informed care. We developed a system dynamics model for the ACT through a participatory process and calibrated the model with historical data, including population demographics, the prevalence of psychological distress, and mental health services provision. We calculated incremental cost-effectiveness ratios compared with business as usual for cost (AU$) per: quality-adjusted life-year (QALY), suicide death avoided, self-harm related hospital admissions avoided, and mental health-related emergency department presentation, using a 10-year time horizon for health-care and societal perspectives. We investigated uncertainty through probabilistic sensitivity analysis and deterministic sensitivity analysis, including using a 30-year timeframe.

FINDINGS

From a societal perspective, increased investment in technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care were expected to improve health outcomes (incremental QALYs 4517 [95% UI -3135 to 14 507] for technology-enabled integrated care; 339 [91 to 661] for family education; 724 [114 to 1149] for the online parenting programme; and 137 [88 to 194] for multicultural-informed care) and reduce costs ($-91·4 million [-382·7 to 100·7]; $-12·8 million [-21·0 to -6·6]; $-3·6 million  [-6·3 to 0·2]; and $-3·1 million [-4·5 to -1·8], respectively) compared with business as usual using a 10-year time horizon. The incremental net monetary benefit for the societal perspective for these four interventions was $452 million (-351 to 1555), $40 million (14 to 74), $61 million (9 to 98), and $14 million (9 to 20), respectively, compared with business as usual, when QALYs were monetised using a willingness to pay of $79 930 per QALY. Synergistic effects are anticipated if these interventions were to be implemented concurrently. The univariate and probabilistic sensitivity analyses indicated a high level of certainty in the results. Although emergency department-based suicide prevention and school-based suicide prevention were not cost effective in the base case (41 QALYs [0 to 48], incremental cost $4·1 million [1·2 to 8·2] for emergency department-based suicide prevention; -234 QALYs [-764 to 12], incremental cost $90·3 million [72·2 to 111·0] for school-based suicide prevention) compared with business as usual, there were scenarios for which these interventions could be considered cost effective. A dedicated trauma service for young people (9 QALYs gained [4 to 16], incremental cost $8·3 million [6·8 to 10·0]) and a crisis response service (-11 QALYs gained [-12 to -10], incremental cost $7·8 million [5·1 to 11·0]) were unlikely to be cost effective in terms of QALYs.

INTERPRETATION

Synergistic effects were identified, supporting the combined implementation of technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care. Synergistic effects, emergent outcomes in the form of unintended consequences, the capability to account for service capacity constraints, and ease of use by stakeholders are unique attributes of a system dynamics modelling approach to economic evaluation.

FUNDING

BHP Foundation.

Modification of the pedicled osteomuscular dorsal scapula flap to include a skin paddle

This article describes a reliable surgical alternative for the repair of wide oromandibular defects that require bone and soft tissues, which was applied in two patient cases. While microvascular free flap transfer, especially the fibula flap, is the gold standard for mandibular reconstruction, this reconstruction is challenging in patients with a vessel-depleted neck and/or severe arteriosclerosis. The pedicled osteomuscular dorsal scapular (OMDS) flap is a surgical alternative to free flap transfer in this clinical setting. The technique described involves harvesting of the OMDS flap to include a skin paddle, which is often required to close wide oral mucosal defects.

Improving access to mental health care: a system dynamics model of direct access to specialist care and accelerated specialist service capacity growth

OBJECTIVE

To simulate the impact on population mental health indicators of allowing people to book some Medicare-subsidised sessions with psychologists and other mental health care professionals without a referral (direct access), and of increasing the annual growth rate in specialist mental health care capacity (consultations).

DESIGN

System dynamics model, calibrated using historical time series data from the Australian Bureau of Statistics, HealthStats NSW, the Australian Institute of Health and Welfare, and the Australian Early Development Census. Parameter values that could not be derived from these sources were estimated by constrained optimisation.

SETTING

New South Wales, 1 September 2021 - 1 September 2028.

MAIN OUTCOME MEASURES

Projected mental health-related emergency department presentations, hospitalisations following self-harm, and deaths by suicide, both overall and for people aged 15-24 years.

RESULTS

Direct access (for 10-50% of people requiring specialist mental health care) would lead to increases in the numbers of mental health-related emergency department presentations (0.33-1.68% of baseline), hospitalisations with self-harm (0.16-0.77%), and deaths by suicide (0.19-0.90%), as waiting times for consultations would increase, leading to disengagement and consequently to increases in adverse outcomes. Increasing the annual rate of growth of mental health service capacity (two- to fivefold) would reduce the frequency of all three outcomes; combining direct access to a proportion of services with increased growth in capacity achieved substantially greater gains than an increase in service capacity alone. A fivefold increase in the annual service growth rate would increase capacity by 71.6% by the end of 2028, compared with current projections; combined with direct access to 50% of mental health consultations, 26 616 emergency department presentations (3.6%), 1199 hospitalisations following self-harm (1.9%), and 158 deaths by suicide (2.1%) could be averted.

CONCLUSION

The optimal combination of increased service capacity growth (fivefold) and direct access (50% of consultations) would have double the impact over seven years of accelerated capacity growth alone. Our model highlights the risks of implementing individual reforms without knowledge of their overall system effect.

Efficacy of cognitive behavioral therapy on aggressive behavior in children with attention deficit hyperactivity disorder and emotion dysregulation: study protocol of a randomized controlled trial

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is frequently associated with emotional dysregulation (ED). ED is characterized by excessive and inappropriate emotional reactions compared to social norms, uncontrolled and rapid shifts in emotion, and attention focused on emotional stimuli. Few studies have evaluated non-pharmacological interventions to improve ED in children with ADHD. The current randomized controlled trial assesses the efficacy of a cognitive behavioral therapy (CBT) intervention compared with a theater-based intervention (TBI) in children with ADHD and ED.

METHODS

Sixty-eight 7- to 13-year-old children with ADHD and ED will be recruited and randomly assigned to the CBT or TBI group. CBT aims to reduce ED by teaching anger management strategies. TBI seeks to reduce ED by improving emotion understanding and expression through mimics and movement. In both groups, children participate in 15 1-h sessions, and parents participate in 8 sessions of a parent management program. The primary outcome measure is the change in the "Aggression" sub-score of the Child Behavior Checklist (CBCL). Secondary outcome measures include overall impairment (Children's Global Assessment Scale, Strengths and Difficulties Questionnaire), personality profile (Hierarchical Personality Inventory for Children), executive function (Behavioral Rating Inventory of Executive Function), quality of life (Kidscreen-27), parental stress (Parenting Stress Index, 4th edition), parental depression (Beck Depression Inventory-II), and impact of child disorders on the quality of the family life (Parental Quality of Life and Developmental Disorder).

DISCUSSION

Children with ADHD and ED are at risk of functional impairment and poor outcomes and have specific therapeutic needs. This randomized controlled trial wants to assess non-pharmacological treatment options for this population.

TRIAL REGISTRATION

Clinicaltrials.gov. NCT03176108 . Registered on June 5, 2017.

Sound Decision Making in Uncertain Times: Can Systems Modelling Be Useful for Informing Policy and Planning for Suicide Prevention?

The COVID-19 pandemic demonstrated the significant value of systems modelling in supporting proactive and effective public health decision making despite the complexities and uncertainties that characterise an evolving crisis. The same approach is possible in the field of mental health. However, a commonly levelled (but misguided) criticism prevents systems modelling from being more routinely adopted, namely, that the presence of uncertainty around key model input parameters renders a model useless. This study explored whether radically different simulated trajectories of suicide would result in different advice to decision makers regarding the optimal strategy to mitigate the impacts of the pandemic on mental health. Using an existing system dynamics model developed in August 2020 for a regional catchment of Western Australia, four scenarios were simulated to model the possible effect of the COVID-19 pandemic on levels of psychological distress. The scenarios produced a range of projected impacts on suicide deaths, ranging from a relatively small to a dramatic increase. Discordance in the sets of best-performing intervention scenarios across the divergent COVID-mental health trajectories was assessed by comparing differences in projected numbers of suicides between the baseline scenario and each of 286 possible intervention scenarios calculated for two time horizons; 2026 and 2041. The best performing intervention combinations over the period 2021–2041 (i.e., post-suicide attempt assertive aftercare, community support programs to increase community connectedness, and technology enabled care coordination) were highly consistent across all four COVID-19 mental health trajectories, reducing suicide deaths by between 23.9–24.6% against the baseline. However, the ranking of best performing intervention combinations does alter depending on the time horizon under consideration due to non-linear intervention impacts. These findings suggest that systems models can retain value in informing robust decision making despite uncertainty in the trajectories of population mental health outcomes. It is recommended that the time horizon under consideration be sufficiently long to capture the full effects of interventions, and efforts should be made to achieve more timely tracking and access to key population mental health indicators to inform model refinements over time and reduce uncertainty in mental health policy and planning decisions.

Anatomic study of the arterial territories of the face depending on the external carotid artery branches

AIM OF THE STUDY

Blood supply of the skin of the face is mainly provided by 3 branches of the external carotid artery: facial artery (FA), superficial temporal artery (STA) and transverse facial artery (TFA) which is a branch of the STA. The aim of the study was to describe the arterial territories of the skin of the face depending on the external carotid branches.

MATERIAL AND METHODS

After dissection of the first two centimeters of these arteries on one side, we performed an injection of India ink of different colors in the arteries in order to describe the arterial territories (angiosomes) of the face on 24 embalmed cadavers.

RESULTS

The lips and the tip of the nose were vascularized in most cases by the FA. The STA vascularizes the temporal and frontal areas and a part of the auricle. The buccal area blood supply is coming from the FA with a participation of the TFA which is variable (10/24 cases), and the zygomatic area blood supply is coming from the STA with a participation of the TFA (9/24 cases).

CONCLUSIONS

Variations in the angiosomes of the face have to be considered in reconstructive surgery, and in face transplantation.

The transverse facial artery and the mandibular condylar process: An anatomic and radiologic study

INTRODUCTION

In surgical approaches to condylar fractures, there is a risk of damage to the transverse facial artery (TFA) which may in turn account for impaired blood supply to the temporomandibular joint (TMJ). In order to investigate the risk of damage to the TFA, and prevent lesions to this artery resulting from TMJ surgical procedures, we studied the distance between the TFA and the head of the condylar process.

METHODOLOGY

A dissection study was conducted on 10 fresh cadavers (20 condylar specimens dissected), involving fifty CT scans of the face with intravenous contrast. Vertical distance from the TFA to the top of the mandibular condyle head and distance from the TFA to the lateral aspect of the mandibular condyle were measured.

RESULTS

The lateral aspect of the mandibular condyle is vascularized by branches emanating from the superficial temporal artery (STA) and the TFA. The TFA was located 1.84 ± 0.6 cm below the condylar process of the mandible and ran 1.09 ± 0.54 mm lateral to the head of the mandibular condyle.

DISCUSSION

In order to spare the TFA in fractures involving the condylar neck, surgical approaches to the condyle should preserve the uppermost 2 cm of the lateral surface of the condyle during dissection. Due to the necessity for periosteal elevation of the lateral surface of the condyle in condylar head fractures, it is possible to spare the TFA, running lateral to the condylar neck, and the medial condylar surface in order to leave the branches that derive from the maxillary artery (MA) intact.

Gain of exposure provided by extended incision in lateral rhinotomy approach: A cadaveric study

OBJECTIVE

To assess the gain of exposure provided by extensions of the lateral rhinotomy (LR) incision, including subciliary extension, lip-splitting extension, or both (Weber-Fergusson incision), by comparing the surgical field obtained with every incision. The final goal is to better delineate the indications of each approach.

MATERIALS AND METHODS

Prospective study on fresh frozen specimens. A LR incision was first performed, and then extended by subciliary and/or lip-splitting incisions. The exposure of the anterior facial skeleton and of the deep retromaxillar spaces (pterygopalatine fossa and infratemporal fossa) were assessed. The distance between the nasal bone and the most lateral part of the exposure was measured.

RESULTS

Dissection was performed on 4 specimens, with 7 LR. Three LR incisions were extended with subciliary incision, 3 with lip-splitting incision, and 4 with Weber-Fergusson incision. LR incision alone gave only limited access to the lateral orbital rim, the zygomatic arch and the maxillary tuberosity. Both subciliary and lip-splitting incisions gave access to the lateral orbital rim and to the zygomatic arch, but only upper lip incision provided a good access to the maxillary tuberosity. Weber-Fergusson did not significantly increase the surgical field obtained with lip-splitting extension alone. The exposure of the deep retromaxillar spaces was the same in all cases.

CONCLUSION

LR incision with lip-splitting extension provided an optimal access to the anterior facial skeleton and to the maxillary tuberosity. In terms of exposure, it was equivalent to Weber-Fergusson approach. The exposure of deep spaces was the same regardless of the incision.

Groin reconstruction using a pedicled anterolateral thigh flap

INTRODUCTION

This article describes an attractive approach to the reconstruction of the groin after loss of substance: the skin, subcutaneous tissue and fascia of the rectus abdominis and oblique muscles were reconstructed using an anterolateral thigh flap based on a proximal vascular pedicle.

CLINICAL CASE REPORT

A 70-year-old female with a strangulated inguinal hernia that had been neglected for eight days presented initially with intestinal necrosis and necrotizing infection of the abdominal wall in the right groin. After debridement of necrotic tissue, reconstructive surgery was necessary. We opted for an anterolateral thigh flap based on a proximal vascular pedicle.

DISCUSSION

In this case, there was a major loss of substance that included the rectus abdominis fascia below the level of the arcuate line. This situation required a fascial reconstruction of the abdominal wall; a defect of this size would typically require synthetic mesh for closure. The anterolateral thigh flap allowed us to avoid the use of foreign material by repairing the defect with a pedicle flap including fascia lata and the quadriceps aponeurosis.

CONCLUSION

The use of an anterolateral thigh flap based on a proximal vascular pedicle seems to be a simple straightforward solution for reconstruction of the skin and fascia of the inguinal region.

Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study

PURPOSE OF THE STUDY

The management of the severe blunt splenic injuries remains debated. The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management (surgery, embolization, non-operative management [NOM]).

METHODS

A prospective multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury. We evaluated severity according to the AAST classification, the presence of hemoperitoneum or a contrast blush on initial CT scan. The initial hemodynamic status, patients co-morbidities, the ISS (injury severity score), management and morbidity were also noted.

RESULTS

Between May 2010 and May 2012, 91 patients were included. Thirty-seven patients (41%) had mild splenic injury (AAST I or II and a small hemoperitoneum) while 54 patients (59%) had severe splenic injury (AAST III or greater). The management included 18 splenectomies (20%), 15 embolizations (16%). Among 67 patients undergoing NOM without initial embolization, five (7%) developed secondary bleeding, five required surgery and nine underwent secondary embolization. No patient died and morbidity was 44% (n=40), 13% for mild injuries vs. 65% for severe injuries (P<0.01). For severe injuries, total morbidity was 58% after NOM, 73% after embolization and 70% after surgery. Specific morbidity related to the management was 10% after NOM vs. 47% after embolization (P=0.02). Specific morbidity after surgery was 15%.

CONCLUSION

Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding.

[Comparison of the Latissimus dorsi insertions on the iliac crest in chimpanzee (Pan troglodytes) and in man]

INTRODUCTION

Comparing to other primates, one of the most important specificities of the human anatomy are consequences of bipedalism. Although bone consequences are well known (lumbar lordosis, horizontal position of the foramen magnum, lengthening of the lower limbs, reduction of the pelvis, specialization of the foot), consequences of our locomotion on the Latissimus dorsi are still unclear.

MATERIALS AND METHODS

One dissection of a chimpanzee Latissimus dorsi (Pan troglodytes) has been performed and compared to 30 human Latissimus dorsi dissections (10 fresh cadavers and 20 formoled cadavers). In each dissection, the existence of direct muscular insertions on the iliac crest has been investigated and the constitution of the thoracolumbar fascia has been described.

RESULTS

In chimpanzee dissection, a muscular direct insertion of the Latissimus dorsi was present on the iliac crest of 9 cm long. The TLF was made of the superficial and the deep fascias of the Latissimus dorsi and the superficial fascia of the erector spinae muscles which was deeper. In man, there was no direct muscular insertion of the Latissimus dorsi in 90 % of cases, the TLF was constituted the same way.

CONCLUSION

This study suggests that the Latissimus dorsi has been separated from the iliac crest in man during the evolution because of the permanent bipedalism and that it stayed inserted on the iliac crest in chimpanzee because of the brachiation.

[The chin fat pad]

The chin fat pad is poorly described in anatomic publications. To improve its knowledge, we performed 10 dissections, we studied 10 CT Scanners and ten RMN from patients without mental scar, and we performed a CT scanner of this area in a man at rest and during the lips protraction. A histological study has been performed comparing the chin fat pad with the subcutaneous fat and the buccal fat pad. The chin fat pad was cylindric, measuring 20 mm long, 7,5 mm wide and 4 mm high. It became thinner during the lips protraction. The histological study revealed a lot of fibrous septa. It was more similar to the subcutaneous fat than to the buccal fat pad.

Splenic injury: management in the Languedoc-Roussillon region

GOAL OF STUDY

Treatment of splenic injury is not standardized. We conducted an inventory of splenic injury treatment modalities of splenic injury in the Languedoc-Roussillon region of France.

METHODS

A questionnaire was sent by e-mail to 33 surgeons practicing in 10 hospitals in that region. Surgeons were asked: how many cases were treated per year (PMSI databank for the last three years), local resources (resuscitation bay or intensive care unit, availability of CT and interventional radiology), indications (surgery, embolization, nonoperative management [NOM]), prognostic criteria, NOM modalities (duration of bed rest, hospital stay, restriction of physical activity, thromboembolic prophylaxis, and imaging schedule).

RESULTS

Thirty-one surgeons replied. An average of 185 patients were treated per year. There was consensus concerning the indication for urgent splenectomy, NOM was practiced in the stable patient (even with diffuse hemoperitoneum) and splenic artery embolization was performed for active bleeding (blush on CT) (for the six centers who have interventional radiology at their disposal). Disparities existed between centers concerning the modalities of NOM excepting imaging monitoring, initial surveillance in resuscitation bay or intensive care and in the therapeutic indications when bleeding persisted.

CONCLUSION

Based on the consensus observed in this study and an analysis of the literature, a uniform treatment policy can be proposed.

Arterial vascularization of occipital scalp: mapping of vascular cutaneous territories and surgical applications

Although the vascular supply of the occipital region of the scalp is usually considered as depending on the occipital arteries, in our clinical experience the importance of the posterior auricular arteries seems to have been underestimated. Most of the authors consider that the occipital artery is the main artery to the vascular supply of this region. The role of the posterior auricular artery has not been clearly investigated. In order to describe the cutaneous territories of these two arteries, 20 occipital areas have been dissected after bilateral injection of coloured latex (40 occipital and 40 posterior auricular arteries studied), and 4 occipital areas have been dissected after selective injection of china ink in the occipital and posterior auricular arteries (4 occipital and 4 posterior auricular arteries injected). The occipital artery was deep from its origin to the arch constituted by the insertions of the trapezius and sternocleidomastoid muscles. Then the occipital artery was becoming superficial while ascending to the vertex. The cutaneous territory of the occipital arteries was paramedian and median (38% of the occipital area). The posterior auricular artery was superficial in the auriculomastoid sulcus and divided into three branches: auricular and mastoid as usually described and also a third terminal branch that we called "transverse nuchal artery". The posterior auricular arteries supplied the major part of the occipital area of the scalp (62%).

[Use of the pedicled superficial temporoparietal fascial flap for reconstructing soft tissue defects of oral cavity]

INTRODUCTION

The temporoparietal fascial flap is rarely described for the treatment of oral cavity loss of substances. In our experience, it is can a good alternative for the reconstruction of the lateral part of the oral cavity. The aim of this study is to describe the anatomical basis of this technique and to report our recent experience of this flap in this indication.

MATERIAL AND PATIENTS

Three fresh cadavers have been dissected in order to determine the maximal length of the flap and the best technique to pass the flap in the oral cavity. Two patients have been operated after surgical resection of an oral epidermoid carcinoma. In one case, the flap has been used to cover a loss of substance of the retromolar and internal cheek areas and in the second case to cover a lateral floor of the mouth loss of substance.

RESULTS

The anatomical study showed that the feasibility of the flap was good, the surface of the flap was 12 x 12 centimetres, and the temporal ramus of the facial nerve was easy to preserve if the dissection was prudent in the anterior part of the flap. The clinical results were good, no necrosis of the flap and no facial paralysis were observed.

DISCUSSION

In our opinion, this flap can be proposed to cover the lateral loss of substance of the oral cavity. The main advantages of this flap are the absence of visible scar of the donor site, this is a regional flap possible to harvest in the same surgical field, it is independent from the movements of the head and it can be a sensitive flap when the auriculo-temporalis nerve is harvested.

[Anatomic study of the location of the thoracoacromial pedicle. Application to the pectoralis major musculocutaneous flap]

AIM OF THE STUDY

The thoracoacromial pedicle is the major pedicle of the pectoralis major flap which is still frequently used in cervicofacial loss of substances reconstruction. The classical landmark of this pedicle is the intersection between the acromioxyphoid line and the medioclavicular line. The aim of this study was to determine the exact location of the pedicle compared to the classical landmark in case of narrow pectoralis major flap.

PATIENTS AND METHOD

Twenty-one pectoralis major pedicles have been dissected from 12 fresh cadavers. For each dissection have been determined: the medial or lateral situation of the pedicle compared to the intersection of the medioclavicular line and the acromioxyphoid line and the distance between these two points, the angle between the real axis of the pedicle and the acromioxyphoid line.

RESULTS

The pedicle was lateral to the acromioxyphoid line in 19 cases, in close contact to the lateral border of the muscle.

CONCLUSION

A narrow pectoralis major flap has to be harvested between the acromioxyphoid line and the lateral border of the pectoralis major.

[Anatomic bases of the infrahyoid flap: vascular pedicles and innervation]

The infrahyoid flap is used in head and neck reconstruction, especially in oral defect. This study is designed to determine vascular pedicles and innervation of the infrahyoid muscles and flap.

MATERIALS AND METHOD

The neck regions of 12 injected cadavers were investigated bilaterally.

RESULTS

The arterial pedicles of the infrahyoid muscles are the superior and inferior thyroid arteries. The arterial pedicles of the flap are the superior thyroid artery. The venous pedicles of the muscles and flap are the superior thyroid, lingual and facial veins. The infrahyoid flap is innervated by the ansa cervicalis.

CONCLUSION

The infrahyoid flap seems to be an excellent flap for oral, oropharynx and superior facial part reconstruction. It can be harvested easily in the same operation area.

[Are dissections still needed in the faculty of medicine ?]

The relevance of anatomical dissection is questioned in France by some authors who think that it is an archaic method in the time of virtual-anatomy softwares. In our opinion, anatomic dissection keeps a unique interest in medical students learning both in the first years of medicine and in the surgery learning and the techniques used in medical specialities. The research of new surgical techniques, anatomical variations as for example of peripheric nerves, also has a strong need of dissections.

The osteomuscular dorsal scapular (OMDS) flap: an alternative technique of mandibular reconstruction

Free tissue transfer has become the dominant reconstructive tool for segmental defects of the mandible, except in case of severe peripheral vascular disease. In these cases, we propose to use the osteomuscular dorsal scapular (OMDS) flap as an alternative technique. This flap is pedicled on the dorsal scapular vessels with the harvesting of the medial border of the scapula and the lateral part of the rhomboid muscles.

METHODS

Thirteen cadaveric dissections have been performed after arterial injection of coloured latex in order to describe the surgical landmarks of the dorsal scapular pedicle. Six patients have been operated after lateral resection of the mandible.

RESULTS

The mean length of the pedicle was 66 mm (+/-2.61). The pedicle was located 41.2 mm (+/-5.51) lateral to the superior angle and 24.6 mm (+/-7.50) lateral to the medial angle. The size of the medial border that could be used for mandibular reconstruction was 116.4 6 mm (+/-7.48). The width of the medial border was 2.62 mm (+/-0.77) on the upper part and 3.35 mm (+/-0.90) on the inferior part. The clinical results were satisfying; good symmetry of the mandible was restored with normal opening of the mouth. Normal elevation of the shoulder was retained without recourse to physiotherapy.

DISCUSSION

The advantages of this method over other pedicled flaps include the length of the bone that can be harvested (>12 cm) allowing reconstruction of defects from the condylar process to the canine region and the preservation of scapular elevation. The superior part of the trapezius was not harvested, in order to allow passage of the flap in the tunnel under the upper trapezius to preserve the scapular elevation. The main disadvantages of the OMDS flap are the impossibility of placing implants in the bone that have been harvested because of its thickness and the lateral position that has to be changed to supine to allow access for resection of the tumour.

The osteo-muscular dorsal scapular (OMDS) flap. Anatomic basis of a new pedicled flap for mandibular reconstruction

The fibula free flap has become the dominant free flap for all mandible reconstructions, except in case of severe peripheral vascular disease. In these cases we propose to use the pedicled osteo-muscular dorsal scapular flap as an alternative technique. This flap is an original technique, it is pedicled on the dorsal scapular vessels with harvesting of the medial border of the scapula and the lateral part of the rhomboid muscles. We carried out an anatomic study of the scapular region on 33 subjects in order to describe the surgical landmarks of the dorsal scapular pedicle. We determined the feasibility of this technique using a ten fresh cadavers and performed this flap on three patients. In most cases (58%), the dorsal scapular artery passed very close to the superior angle of the scapula and ran lateral to the medial border of the scapula, in 42% of cases the artery divided into a lateral branch which stayed deep to the medial border of the scapula and a medial branch which ran deep to the rhomboid muscles. In all cases an anastomosis between the dorsal scapular artery and the descending branch of the transverse cervical artery was present. In this technique, after harvesting the medial border of the scapula and the lateral part of the rhomboid muscles, the flap has been transposed in the cervical region through a tunnel under the superior part of the trapezius. This technique has been used in three patients after lateral resection of the mandible. The functional results were good, allowing the preservation of the scapular elevation.

Anatomical modifications of the mid palatal suture during ageing: a radiographic study

In transverse maxillary deficiencies it is important to know if the mid palatal suture is obliterated or not, to decide which treatment to perform (orthodontic expansion or surgical disjunction of the suture). The maxillary sutures obliteration has been used in forensic medicine in estimating adult age at death. In order to determine the proportion of mid palatal suture obliteration in the elderly in man, we examined 100 consecutive CT scans of the palate. This study has shown that the age of mid palatal total obliteration was variable. The obliteration begins in the anterior and in the superior part of the palate. The inferior part of the junction between the palatal processes is the last part of the suture to be obliterated.

[Mandibular hemangiopericytoma, a malignant vascular tumor]

INTRODUCTION

Hemangiopericytoma is a rare tumor, arising from pericytes, which are perivascular cells belonging to the capillar walls.

OBSERVATION

A 41 year old man consulted for a mandibular tumor. The clinical and radiographic diagnosis was difficult. The biopsy performed in the operative room led to an embolization decided in emergency, and proved the definitive diagnosis. Despite the embolization, bleeding during surgical excision of the tumor compelled us to perform an external carotid artery ligature. The mandibular reconstruction was performed using a trapezium osteo-muscular flap.

DISCUSSION

As reported in the literature, the radiographic diagnosis of hemangiopericytoma is difficult, the malignant potential is variable and the recommended treatment is surgical excision.

Anatomic study of tongue architecture based on fetal histological sections

Tongue muscles are difficult to study by dissection and imaging methods because of the intermeshing of the muscular fibers. The study of the architecture of the tongue was based on 853 tongue sections of a fetus aged 32 weeks after conception. The analysis of the sections allowed demonstration of the different intrinsic and extrinsic muscles of the tongue, to determine their situation from the palatoglossus arch to the apex of the tongue. The tongue muscles are organized in different layers from cranial to caudal and from lateral to medial, one medial for the genioglossus muscle, one paramedial for the hyoglossus, the styloglossus and the inferior longitudinal muscles. In the anterior third of the tongue, the muscles presented a concentric organization.

The intra-lingual course of the nerves of the tongue

The intra-lingual course of the nerves of tongue has never been studied in the human by the Sihler method. This technique was applied to six human tongues and allowed coloration of the nerves and illustration of the tongue. The course of the hypoglossal, glossopharyngeal, and lingual nerves was defined. Constant anastomoses between the lingual and hypoglossal nerves, between the glossopharyngeal nerve and the hypoglossal and lingual nerves, were demonstrated and may help explain the "neck-tongue" syndrome. This cartography of the nerves of the tongue allowed the definition of the motor and sensory consequences of tongue surgery.

Changes in the edentate mandible in the elderly

Resorption of alveolar bone is the best recognized feature of mandibular aging in the edentate subject. The other consequences of the loss of teeth in the elderly are less well known. An anthropometric study of the mandible by antero-posterior and lateral radiographs of subjects older than 70 years both dentate and edentate but without any maxillo-mandibular dysmorphosis has been done to demonstrate the differences, which exist between the dentate and edentate mandible. The edentate mandibles showed a diminution in the height of the symphysis and increase in the height of the mandibular incisure. A diminution in the height of the body and an increase in the gonial angle in the significant manner. No significant difference was seen for the height of the ramus and the length of the mandible, the minimum width of the ramus and the bigonial width. The diminution in the height of the mandibular symphysis and of the body is explained by the resorption of the alveoli part of the mandible. The increase in the mandibular angle and the diminution in the height of the mandibular incisure may be explained by disequilibrium between the elevator and depressor muscles of the mandible, as a function of the elevator muscles or by the absence of the molar buttress.

[The epiglottis, a glosso-laryngeal structure: an anatomic study of its innervation]

The epiglottis is known as a laryngeal structure. The authors studied the innervation of epiglottis using the Sihler method on six human epiglottises. Innervation of the epiglottis depended on the rami from the vagus, glossopharyngeal and hypoglossal nerves. By its innervation, epiglottis seems to be a glosso-laryngeal structure, as is confirmed by embryology, histology and clinical applications.

Anatomical modifications of the temporomandibular joint during ageing

It is essential to know the normal and pathological changes of ageing in the temporomandibular joint (TMJ) because of the frequency of pathology in this joint and the increased duration of life in current populations. A study was done on 70 TMJs harvested from 35 subjects older than 75 years. These joints were studied macroscopically, radiologically and histologically. Degenerative pathology of the TMJ affected more than 50% of the subjects studied and the disc was perforated in 7%. Ageing of the TMJ without any degenerative pathology is marked by radiographic signs which are not specific to the TMJ (cortical thinning, demineralisation). Histologically, amyloid degeneration was present in nearly 50% of TMJs studied.

The anatomical basis of the osteo-musculo-cutaneous trapezius flap in mandibular reconstruction

The osteo-musculo-cutaneous trapezius flap has seen its indications in mandibular reconstruction reduced since the appearance of micro-anastomotic flaps. However, it may still be useful when the patient has marked atheroma contraindicating a free flap. While the arterial supply of this flap is well known, the same is not true for its venous drainage. The preservation of the accessory nerve and its limits in mandibular reconstruction has been little studied. We carried out a study on 30 subjects (60 cadaveric dissections of trapezius flaps) in order to address these questions. The study has been completed by a surgical series of five patients. The cadaveric study allowed demonstration of the variability of venous drainage of this flap, which depended on the external jugular vein in 80% of cases, the subclavian vein in 12% of cases and on both veins in about 8% of cases. The accessory nerve in one third of cases passed through the middle of the arteriovenous pedicle making its preservation impossible. The segment of the scapular spine allowed reconstruction of about 9 cm of mandible including the mental protuberance in 95% of cases. The surgical study confirmed the data of the cadaveric study and showed the value of this flap when free flaps are contraindicated.

[Anatomy of the marginal mandibular branch of the facial nerve]

INTRODUCTION

the position of the marginal branch of the mandicular nerve is crucial for the surgical approach to the sub-mandibular region.

MATERIAL AND METHOD

we performed 54 dissections of 30 fresh cadavers to study the anatomy of this branch.

RESULTS

we found a unique marginal branch in 43% of the cases, two branches in 44% and three branches in 13%. In the sub-mandibular region the branch ran lateral to the vessel bundle in 51 cases, was medial to the artery but lateral to the vein in two. In one case, the nerve was lateral to the artery and medial to the vein. The lowest marginal branch was situated 17.5 mm from the inferior border of the mandible and crossed the facial vessels at a point situated 24 mm posteroinferiorly from the mandibular angle.

DISCUSSION

our study demonstrated the wide variability of the marginal branch of the mandibular nerve. We found a variable number of branches, different from earlier reports which have generally described two branches in about 50% of the cases. These differences can be explained by the difficulty in recognizing the marginal branch arising from the inferior buccal branch during dissection. The technique of ligaturing the marginal branch of the facial nerve is not reliable in all cases, since the branch sometimes passes lateral to the artery and vein.

Anatomie du couple nerf hypoglosse, anse cervicale

The hypoglossal nerve is the motor nerve of the tongue and the ansa cervicalis is a motor nerve for the sub-hyoid muscles. The hypoglossal nerve seems to give the innervation of the thyrohyoid although it is a sub-hyoid muscle. Most of axons in the ansa cervicalis arise from the three first cervical nerves. These nerves are in close contact because of the cervical ontogeny of the tongue and the hypoglossal nerve. Nerve impulse in the superior root of the ansa cervicalis runs caudally to rostrally. This is why neurotization techniques using the superior root of the ansa cervicalis produce poor results in the treatment of facial palsy sequelae.

Morphometric study of the cervical course of the hypoglossal nerve and its application to hypoglossal facial anastomosis

The hypoglossal nerve is used classically in salvage of facial paralyses in the absence of spontaneous recovery. A variety of ways of transferring and suturing the hypoglossal nerve to the distal segment of the facial nerve have been reported. In order to determine which mode of reconstruction is the best for neurotisation of the facial nerve, the caliber of the hypoglossal nerve was studied in ten subjects at the level of proximal and distal parts of the trunk and the cervical loop. The fascicular surface area of the cervical branch is inadequate for use. The distal extremity of the hypoglossal nerve has an ideal caliber to be sutured to the facial nerve trunk and the proximal part is large enough to allow partial harvesting of the hypoglossal nerve for neurotisation of the facial nerve.

Modelling the spatial configuration of refuges for a sustainable control of pests: a case study of Bt cotton

The 'high-dose-refuge' (HDR) strategy is widely recommended by the biotechnology industry and regulatory authorities to delay pest adaptation to transgenic crops that produce Bacillus thuringiensis (Bt) toxins. This involves cultivating nontoxic plants (refuges) in close proximity to crops producing a high dose of Bt toxin. The principal cost associated with this strategy is due to yield losses suffered by farmers growing unprotected, refuge plants. Using a population genetic model of selection in a spatially heterogeneous environment, we show the existence of an optimal spatial configuration of refuges that could prevent the evolution of resistance whilst reducing the use of costly refuges. In particular, the sustainable control of pests is achievable with the use of more aggregated distributions of nontransgenic plants and transgenic plants producing lower doses of toxin. The HDR strategy is thus suboptimal within the context of sustainable agricultural development.

[Anatomic facial and behavioral features of Australopithecus africanus. Apropos of the Taung child]

INTRODUCTION

Taung's skull was first Australopithecus described. The initial description did not mentioned premaxillary bone (os incisivum).

MATERIALS AND METHODS

Photographs of Taung's skull were studied to investigate the presence of a suture between a maxillary bone and a premaxillary bone. These photographs were compared to a dissected macaca's head and earlier publications.

RESULTS

A suture is clearly visible on the anterior aspect of the face of Taung's skull as it is on the non-human primate face.

DISCUSSION

Among the anatomic features of Australopithecus africanus, some are humanoid (the cranium is over the face), others are anthropoid (presence of a separate premaxilla, presence of a supra-orbital torus, absence of a mental prominence). Unlike homo individuals, there is no proof Australopithecus africanus made tools. The definition of Man is not an anatomic definition but rather a socio-cultural definition.

Anatomical study of the variations in innervation of the orbicularis oculi by the facial nerve

While the divisions of the facial nerve in the face are well known, the innervation of the orbicularis oculi by the different distal branches of the facial nerve is poorly described. To determine which branches of the facial nerve play a role in this innervation, the facial nerve was dissected in 30 fresh cadavers. The innervation of this muscle was in the form of two plexuses, a superior one, most often (93%) formed by the union of the temporal and superior zygomatic branches, and an inferior one, usually formed (63%) by the union of the inferior zygomatic and superior buccal branches. This new mode of innervation explains how, without damage to both plexuses, innervation of orbicularis oculi by the facial nerve remains functional. It also explains the often unsatisfactory results of treatment of primary blepharospasm, and the unusual character of palsies of this muscle in cervicofacial lifts.

The fascial planes of the temple and face: an en-bloc anatomical study and a plea for consistency

Many investigators have detailed the soft tissue anatomy of the face. Despite the broad reference base, confusion remains about the consistent nature of the fascial anatomy of the craniofacial soft tissue envelope in relation to the muscular, neurovascular and specialised structures. This confusion is compounded by the lack of consistent terminology. This study presents a coherent account of the fascial planes of the temple and midface. Ten fresh cadaveric facial halves were dissected, in a level-by-level approach, to display the fascial anatomy of the midface and temporal region. The contralateral 10 facial halves were coronally sectioned through the zygomatic arch at a consistent point anterior to the tragus. These sections were histologically prepared to demonstrate the fascial anatomy en-bloc with the skeletal and specialised soft tissues. Three generic subcutaneous fascial layers consistently characterise the face and temporal regions, and remain in continuity across the zygomatic arch. These three layers are the superficial musculo-aponeurotic system (SMAS), the innominate fascia, and the muscular fasciae. The many inconsistent names previously given to these layers reflect their regional specialisation in the temple, zygomatic area, and midface. Appreciation of the consistency of these layers, which are in continuity with the layers of the scalp, greatly facilitates an understanding of applied craniofacial soft tissue anatomy.

[Diagnostic contribution of minor salivary gland biopsy: statistical analysis in 100 cases]

INTRODUCTION

The minor salivary glands biopsy is a very common diagnostic procedure in oral medicine rather its efficiency has not been statistically proved.

MATERIAL AND METHODS

One hundred biopsies have been studied with special attention to the suspected diagnosis before biopsy and the final histologic result.

RESULTS

The minor salivary gland biopsy confirmed the initial diagnosis in 13 cases.

DISCUSSION

Although if the minor salivary gland biopsy is in most cases not contributive it is a very simple procedure which gives the diagnosis of Gougerot-Sjögren disease, amylosis and sarcoidosis.

Factors and consequences of conversion in laparoscopic sigmoidectomy for diverticular disease

BACKGROUND

The disadvantages of laparoscopic elective sigmoidectomy for diverticular disease include the risk of conversion to open operation and longer operative time. The aim of this study was to analyse the causes and consequences of conversion in 168 consecutive patients who underwent a laparoscopically assisted colectomy between January 1994 and June 2001.

METHODS

Data were collected prospectively to analyse the causes and consequences of conversion to open surgery in terms of postoperative morbidity and patient recovery.

RESULTS

Postoperative mortality, morbidity, conversion and reoperation rates were zero, 21.4 per cent (n = 36), 14.3 per cent (n = 24) and 3.0 per cent (n = 5) respectively. The reasons for conversion were presence of intraperitoneal adhesions and/or inflammatory pseudotumour (n = 21), an intraoperative diagnosis of sigmoid cancer (n = 1), hypercapnia (n = 1) and abdominal bleeding (n = 1). Three preoperative factors were associated with a significant higher risk of conversion: surgical expertise, the presence of sigmoid stenosis or fistula, and the severity of diverticulitis on pathological examination. Morbidity was no different between laparoscopic sigmoidectomy (30 of 144; 20.8 per cent) and converted procedures (six of 24; 25.0 per cent). Open conversion was associated with a longer operative time and significantly delayed patient recovery and hospital discharge.

CONCLUSION

Surgical experience and severe diverticular disease are predictive factors for conversion in laparoscopic elective sigmoidectomy. Even if necessary, conversion does not increase the morbidity rate.

Is laparoscopic left pancreatic resection justified?

BACKGROUND

We reviewed our experience of laparoscopic left pancreatectomy to establish the feasibility of this approach and the characteristics of the operating procedure.

METHODS

Thirteen patients with a mean age of 60 years were deemed for a left pancreatectomy. Preoperative diagnoses were: nine mucinous cystadenoma and one insulinoma, intraductal mucinous ectasia, chronic pancreatitis with ductal stenosis, and distal pancreatic tumor.

RESULTS

Operative mortality was nil. Two patients required conversion for bleeding from splenic vein injuries leading to a splenectomy in one case. The spleen was preserved in 10 cases. Postoperative course was uneventful in nine cases. Four patients experienced postoperative complications: one pancreatic fistula, two liquid cysts on the pancreatic margin, and one reoperation for bleeding from a trocar port. Length of stay ranged from 5 to 22 days.

CONCLUSION

These preliminary results confirm that in selected cases laparoscopic resection of the left pancreas is feasible and safe.

Surgical anatomy of the nose in the elderly: value of conservative rhinoplasty by transoral route

Functional or aesthetic rhinoplasty is being done later and later in life. It is essential to know the characteristics of morphological ageing of the nose in order to modify surgical techniques. An anatomical study was carried out on 40 fresh cadavers more than 70 years old. All the subjects studied were measured to define the external morphology of the nose. Amongst these 40 subjects, 20 were dissected plane by plane, 10 were operated on by a new conservative rhinoplasty technique utilizing a strictly transoral route and 10 were operated on by a classical rhinoplasty technique. The anatomy of the nose in the elderly subject is characterized by thinner skin, subcutaneous fat infiltrating in the muscles in 50% of cases and the small muscles of the tip of the nose undergoing complete involution. The technique of rhinoplasty described here shows the value of better respecting lesions at the tip of the nose which is particularly fragile in the aged subject. It may be extended to post-traumatic rhinoplasties or to the nose which has already been operated on.

[Laparoscopic re-establishment of digestive continuity following Hartmann's procedure. Retrospective study of the French Society of Endoscopic Surgery]

STUDY AIM

Reversal of the Hartmann's procedure is associated with a high morbidity. The aim of this study was to evaluate the feasibility and results of laparoscopic reversal of the Hartmann's procedure.

PATIENTS AND METHOD

Thirty eight consecutive patients, mean age 60 +/- 13.5 years were included in this retrospective study. The most common indication for the primary procedure was diverticular disease (70%). The mean time from the primary operation to the reconstruction was 136 +/- 124 days. The stoma was first dissected in 24 patients, allowing introduction of the first port. In the remaining 14 patients a standard umbilical port was inserted. The amount of adhesions was classified as low in 13 patients, mild in 15 patients and severe in 10 patients. All patients had a mechanical anastomosis.

RESULTS

The conversion rate was 15%, due to adhesion problems in 5 patients and for a positive leakage test in one. The morbidity rate was 23.5% including 8 surgical complications. One patient died after post operative peritonitis complicating an anastomic leakage. The average hospital stay was 10 +/- 4.4 days.

CONCLUSION

Our results indicate that laparoscopic reversal after Hartmann's procedure is feasible. The morbidity is lower than after classical open reconstruction. The presence of diffuse peritonitis at the primary operation as well as a short delay before the reconstruction, are important factors of conversion.

Vascularization of the palate in maxillary osteotomies: anatomical study

Le Fort 1 maxillary osteotomy carries a risk of injury to the descending palatine arteries which vascularize the bulk of the mucosa of the bony palate. Some authors believe that injury to these arteries in the greater palatine canal is intrinsic to the procedure without any consequence for the trophicity of the mucosa or bony palate. In order to assess the risk of injury to the descending palatine arteries during such surgery, and to demonstrate the supplementary vascularization which would avoid ischemia of the palate, we carried out a study of the vascularization of the palate on 11 fresh cadavers. We used intra-arterial injection of colored latex and dissection of the vessels running to the palate. The study was done without osteotomy in the first subject, after a Le Fort 1 osteotomy in the five following subjects and after a Le Fort 1 osteotomy and ligation of the two descending palatine arteries in the last five subjects. Our results show that injury of the descending palatine arteries is not intrinsic to the procedure in spite of mobilization of the palatine plateau. When the descending palatine arteries are ligated there is diminution in coloration of the mucosa of the bony palate but there is substitution by the arteries vascularizing the soft palate, essentially the ascending palatine artery and the pharyngeal branch arising from the ascending pharyngeal artery. However, this substitute vascularization has individual variations.

Incisive suture (fissure) in the human fetus: radiographic and histologic study

OBJECTIVE

An anatomic study, in man, of the structure commonly known as the incisive suture (sutura incisiva) or incisive fissure has been performed to determine whether this structure belongs to the morphofunctional concept of a facial suture.

MATERIAL

Eighteen palates of human fetuses of 9 weeks to 29 weeks after conception.

METHOD

Anatomic, radiographic examination of the palate. Histologic study of sagittal and parasagittal sections of the palates (3 mm each).

RESULTS

The histologic aspect is that of a facial suture, with very poor vascularization. This suture is partial, limited laterally by osseous trabeculae.

CONCLUSIONS

This particular suture, whose function in growth of the palatal process of the maxilla is discussed, could represent the phylogenetic vestige of the incisive-maxillary suture present in all nonhuman mammals.

[The growth of the maxilla in humans. What place for the premaxilla?]

INTRODUCTION

The growth of the maxilla in man is still debated. Many authors described an anterior part of the maxillary bone, called premaxilla distinct from the maxilla proper. This description referred to the existence in animals of an incisive or premaxillary bone which does not exist in man. Is this distinction pertinent in the human facial growth?

MATERIAL AND METHODS

To settle this question, we performed a histologic study in eight embryos and fetuses aged from 40 days to 10 weeks post conceptional (PC) and an anatomic dissection of 3 palates of fetuses aged from 22 to 30 weeks PC.

RESULTS

We found only one maxillary point of ossification, and the growth of the anterior part of the maxilla cannot be separated from the global growth of the maxilla.

DISCUSSION

The independence of the anterior part of the maxilla in man is very limited during the growth and cannot justify the term of premaxilla.