[The biplane microlift. Principles, technic, results]

There has been a growing number of patients asking for a lighter face lift than the classical biplane procedure with wide undermining; This explains the popularity of medical threads lifts. A surgical approach is nevertheless possible by performing a new technique, derived from minilfts, but with a dissection elevating skin and SMAS layers together, preserving as much retaining ligaments as possible, and allowing a predesigned skin excision. Thirty-two patients have been operated this way since 2014; 3 asked and sustained for a redo because of skin relapse at one year postoperatively. Few complications have occurred, mostly limited hematomas, or skin problems because of suture threads rejection. The best indications seemed to be young patients presenting a jowl ptosis or cervical skin laxity, and patients who require a secondary facelift as a lighter procedure.

[Vascular leiomyoma of the hand. Report of a case and review of literature concerning a rare pathology]

Vascular leiomyoma is a benign painful tumour that occurs most frequently in the lower extremity. We report an uncommon case in the hand. Only surgical removal of the tumour allows establishing the diagnosis histologically. A review of the literature confirms the rarity of the tumour in the hand. The purpose of this case report is furthermore to consider the differential diagnosis in painful masses of the hand.

[Morbid obesity: laparoscopic gastroplasty prior to plastic surgery]

OBJECTIVES

Reduction of the weight in obese patients is a pre-condition for the aesthetic improvement of obesity or its after effects by plastic surgery. The aim of this study was to evaluate the effectiveness and advantages of gastric banding, using a ring positioned under laparoscopic guidance.

PATIENTS AND METHODS

Thirty-nine patients with morbid obesity were operated on. For the first nine patients, gastric restriction was obtained by Mason's traditional technique. In the remaining thirty, a Kuzmak ring was positioned a few centimeters under the cardia, under laparoscopic guidance. The study concerned the evolution of weight, associated pathologies, and complications.

RESULTS

Three months after surgery, all patients had lost weight (mean loss: 15 kg). At six months, a mean weight loss of 26 kg was observed. At one year, the mean weight loss was 35 kg. Two patients experienced postprandial vomiting that justified widening of the ring; one ring was poorly tolerated and was removed 10 days after surgery.

CONCLUSION

This new surgical technique is effective for reducing the weight of obese patients. The laparoscopic approach to the stomach reduces parietal complications and enables subsequent abdominal plastic surgery to be performed.

Computerized morphometric quantitation of elastin and collagen in SMAS and facial skin and the possible role of fat cells in SMAS viscoelastic properties

Recently, the superficial musculoaponeurotic system (SMAS) was found to be a composite tissue comprising collagen, elastic fibers, and fat cells in an extracellular viscous matrix. Both SMAS and facial skin tissues exhibit viscoelastic properties, but SMAS tissue has delayed stress relaxation. As a consequence, SMAS is viewed as a firmer elastic foundation for the more viscous facial skin. In some patients, a slackening effect of SMAS tissue takes place over a period ranging from weeks to months after tightening. To determine the relative quantity of viscoelastic components and better understand their biomechanical behavior, a quantitative morphometric study of the elastic and collagen fibers in the SMAS and facial skin was conducted. Thirty-four SMAS preparations were taken from 17 patients during either primary face lift operations (12 women) or reoperative face lift procedures (4 women, 1 man), which were performed 4 to 9 months after the original surgery, to examine the elastin and collagen content. For comparison, preauricular skin was also gathered from these patients. The specimens were stained with Weigert's staining to identify elastin and collagen fibers. Using a computerized morphometric analysis, 100 fields of each SMAS and skin specimen were examined. According to our findings, the average percentage of elastin and collagen fibers in SMAS and facial skin was as follows: (1) the percentage of elastin fibers in the SMAS was 4.71 +/- 1.2 (standard error of mean +/- 0.0291); (2) the percentage of elastin fibers in the skin was 6.1 +/- 1.8 (standard error of mean +/- 0.0436); (3) The percentage of collagen fibers in the SMAS was 38.7 +/- 5.9 (standard error of mean +/- 0.1430); and (4) the percentage of collagen fibers in the skin was 48.47 +/- 6.96 (standard error of mean +/- 0.1688). A statistical significance of p < 0.0001 was demonstrated between the collagen and elastin groups. A different percentage of elastin and collagen fibers was found among the 17 patients and within each of them separately. Neither gender nor age differences were found regarding elastin and collagen fiber content. No statistical differences were demonstrated between specimen sources, i.e., whether the operations were primary or reoperative face lift procedures. Findings from previous studies indicate that the cheek has two viscoelastic layers, the skin and the SMAS. The proportional similarity in average percentages of elastin and collagen in SMAS and facial skin cannot explain the relatively delayed stress relaxation effect of the SMAS. Therefore, the fat cells that are found exclusively in the SMAS probably lend a certain degree of firmness to this layer and play a significant role in the long-term efficacy of SMAS surgery.

[Late infection of breast implant, complication of colonic perforation. Review of the literature. Role of preventive treatment]

The authors report a cases of breast implant infection, 40 years after augmentation mammoplasty. The infection developed 6 weeks after colonoscopy complicated by acute peritonitis due to colonic perforation. Bacteroides fragilis, a usual organism of the gastrointestinal tract flora, was identified in the two septic sites (peritoneal and periprosthetic). Contamination of the implant was haematogenous in a context of bacteraemia. Other authors have already suspected this route of contamination without any bacteriological proof. The risk of infection of breast implants is known, but the late infection rate is poorly documented. It is probably very low in view of the rare cases reported in the literature. Breast implants are not at high risk of sepsis, in contrast with prosthetic heart valves. The authors therefore do not recommend any particular preventive treatment in the case of distant infection or dental treatment. Women with breast implants must be informed and reassured: late infection of their implant is possible, but very unlikely. Recognition and prevention of this risk could be based on better long-term follow-up of breast implants.

[Intraluminal absorbable device to assist in vascular microanastomosis. Experimental study on 20 rat aortas]

The subject of this experimental study is a cylindrical device, with a gauge adjusted to the vessel lumen, which disintegrates in a few minutes. The goal of this device is to increase the reliability of vascular microanastomosis. This study was designed to assess the efficacy and drawbacks of the device. The device is a cylindrical sugar stick, 5 mm long and with a gauge of 1 mm. Ten Wistar rats underwent a standard end-to-end aortic anastomosis with interrupted sutures and ten underwent the same anastomosis with the device placed in the lumen of the proximal and distal vessel. The same surgeon performed all anastomoses. Clamp application time was recorded and anastomotic patency was tested in each case; the vessels were also examined histologically. The clamp application time was significantly lower (p < 0.01), and the patency rate significantly higher (p < 0.01) in the group in which the device was used. There was no histologic sign of intima injury in either group. This very simple device facilitates microanastomosis. It reduces the ischemia time and increases the reliability of the anastomosis, avoiding transfixing sutures. These results suggest that clinical trials are warranted.

Is it necessary to suture the platysma muscles on the midline to improve the cervical profile? An anatomic study using 20 cadavers

To ameliorate the cervicomental angle, most surgeons suggest different techniques of platysmaplasty. The aim of this anatomic study is to find a simple answer to the following question: Is suturing of the anterior edges of the platysma muscles during platysmaplasty the best procedure to use to obtain the best concave anterior neck angle? Three different surgical techniques using platysma muscle flaps were used on 20 cadavers prepared for anatomic dissection. Each piece of dissection was controlled by a radiograph of the profile of the cervical region before and after the application of these different techniques. Cephalometric measures were made and statistically analyzed. The analysis of the results demonstrates that the best concave anterior neck angle to perform platysmaplasty is one in which the platysma muscle flap is shifted posterosuperiorly but without suturing the medial borders of the platysma muscles. Suturing the midline does not deepen the concavity in the front of the neck.

[Fasciitis following face lift]

Facial fasciitis or non infectious facial retractions are rare and surprising events after a facelift performed at any age. The signs are firm retraction located on one or both sides of the face or neck. They differ from salivary fistula, localised oedema, and limited hematoma, which may be the initial factor responsible for this curious outcome. We found a particular psychological status in these patients, who are often fragile and depressed and who obtain a secondary gain from this impaired status. The treatment of facial retraction (facial fasciitis is non surgical: we recommend local massage, patience and psychological help for quite a long time (6 months-one year). The outcome is spontaneously favorable, unless the patient automanipulates. A psychosomatic link must be considered. This transient facial retraction may correspond to some forms of hand retraction (such as Dupuytren's disease with spontaneous healing) or some thoracic retractions after insertion of mammary prosthesis. Facial fasciitis is a rare complication in our practice (1.4% of all patients) but must be recognized.

Viscoelastic properties of the superficial musculoaponeurotic system (SMAS): a microscopic and mechanical study

A study was undertaken to determine the physical properties and microscopic structure of the superficial musculoaponeurotic system (SMAS) tissue. Forty virginal specimens and eight reoperated specimens were examined. The following findings were discovered. 1) Microscopic appearance shows the SMAS to consist of collagen fibers, a relatively high concentration of elastic fibers interspersed with fat cells. 2) On scanning electron microscopy, the virginal SMAS shows the collagen fibers to have a similar convoluted appearance as in the dermis. There is some evidence of parallelization of the collagen fibers in the reexcised SMAS specimens. 3) Mechanical testing (Instron) demonstrates that both the SMAS and preauricular skin were subjected to a series of loading/ unloading tests at various rates, amplitudes, and stress relaxation tests. Both sets of specimens indicated definite viscoelastic properties. Although the mechanical behavior of both tissues was somewhat similar, the viscoelastic effect of the SMAS was less pronounced. A slackening effect of the SMAS indicated a gradual expansion of the SMAS postoperatively. These results could provide some indication of the long-term effects of SMAS surgery.

[Indications and results of breast implant replacement with implants pre-filled with silicone gel]

Based on a series of 74 patients, the authors report their experience of reoperation on unsatisfactory breast implants by the implant replacement technique using silicone prefilled implants. In 92 (57.8%) of the 160 cases, the implant was modified because of a peri-implant capsule, with a satisfactory aesthetic result after only a single operation. However, this leaves the problem of repeated surgical operations, especially in the context of Baker stage IV capsules, which are only partially improved after two to three surgical operations. A particular surgical revision technique is required in the cases, while the role of in situ cortivazol is under investigation. This series comprises two patients with auto-immune disease and dysimmune profiles, not exarcerbate by secondary surgery. Analysis of this series clearly argues in favour of reoperation for unsatisfactory breasts implants. Squeezing manoeuvres appear to be dangerous and useless. Textured implants filled with very cohesive silicone gel should be maintened in view of the absence of any reported serious complications.

[Results of biplane face lifts with maximal skin underlining and vertical SMAS flap]

It is difficult to evaluate the medium and long-term results of facelift due to loss to follow-up of a large number of patients. The authors developed a questionnaire which they sent to their patients. 148 patients (143 women and 5 men) answers this questionnaire and 54 patients returned for review. This subjective evaluation of the results nevertheless had the advantage of identifying three target organs specifically treated by the surgical techniques used: the nasolabial folds, the jowls and the neck. Improvement or deterioration of the results was therefore evaluated and reported on a series of tables. The results are analysed in this paper. 70.3% of patients studied reported a satisfactory objective result with a mean follow-up of 26.8 months. The least favourable results were observed in the neck, due to the small number of technical procedures performed on the platysma, which would appear to justify greater surgical attention. Among the complications reported, 9.2% of cases indicated inadequate results, especially concerning the "lion's wrinkle", which emphasizes the value of a complementary endoscopic procedure at this site. Perioral wrinkles were a source of dissatisfaction in 14.8% of cases, and can be treated by dermabrasion. Lastly, a number of minor complications such as malposition of the ear lobe, facial redness or scar abnormalities were also mentioned and are easily accessible to an ambulatory secondary improvement procedure. This study therefore validated the operative technique of biplane facelift with a satisfactory stability of the results over time. Objective review of dissatisfied patients, who generally returned for review after receiving the questionnaire, led to a number of reoperations, which appear to be useful in the case of early deteriorations occurring during the first postoperative year and which concern about 5% of patients. The ultimate objective of this paper was to try to establish a methodology for the analysis of the long-term results of facelift, without directly involving the examiner or operator, who may ignore what the patient really feels.

Thenar flap rehabilitated: a review of 20 cases

The thenar flap is a satisfactory reconstruction technique for the treatment of extensive loss of the distal phalanx of the index and middle fingers. As we observed in this series of 20 patients, this flap is reliable and provides tissue that closely matches the missing finger pulp. Flap sensibility is good (average Weber of 6.5 mm). Transferring a distally based flap prevents proximal interphalangeal joint contracture and allows the surgeon to better reconstruct the outlines of the distal phalanx, thereby reducing the risk of a clawed nail. Finally, we did not observe major postoperative complications at the donor site.

[In situ thrombolysis. Correlation between creatine phosphokinase increase and local thrombolysis. An experimental study in the rat]

This study proposes intraarterial in situ thrombolysis for the treatment of microthrombi occurring after tissue crushing. In order to assess the efficacy of the thrombolytic, the authors assayed the serum creatine phosphokinase (CPK) level in the crushed muscle capillary bed. The action of thrombolytics has now been clearly established. In contrast, the correlation between local thrombolysis and the serum CPK variation in crush injuries of striated muscle constitutes the originality of this paper. This experiment was conducted in twenty Wistar rats in which striated muscle crushing was performed. The serum CPK level assayed in venous blood, obtained from the capillary bed concerned, before and after local thrombolysis. The increased CPK level provided an objective indication of the efficacy of intra-arterial thrombolysis after crush injury. The authors now apply local thrombolysis according to a prospective clinical protocol for hand emergencies associated with a crush mechanism.

Mechanical properties and microstructure of the superficial musculoaponeurotic system

Because of the widespread reliance on SMAS tightening procedures in present-day face lift surgery, a study was undertaken to examine the physical properties and microscopic structure of both virginal (40 specimens) and reoperated (8 specimens) SMAS tissue. The findings could be of practical value to the surgeon and are reported herewith: First, the SMAS is a composite fibrofatty layer comprising collagen and elastic fibers interspersed with fat cells. Second, microscopic appearance shows a considerable amount of elastic fibers in close relationship to the collagen fibers. Third, on scanning electron microscopy, the collagen fibers in the virginal SMAS show a convoluted appearance similar to that found in the dermis. In the reexcised SMAS tissue, there is some evidence of parallelization of the collagen fibers as seen in the stretched dermis. Fourth, mechanical testing (Instron), i.e., a series of loading/unloading tests at various rates and amplitudes, and stress relaxation tests were performed on samples of preauricular skin and SMAS. These indicated definite viscoelastic properties for both sets of specimens, with the tendency of an increased stiffness and a reduction in viscoelastic effects on repeated working of the samples. Overall, the mechanical behavior of both tissues was somewhat similar, the viscoelastic effects in SMAS being less pronounced. A nonlinear viscoelastic model is under development to represent the behavior of both tissues. The implications of these results may help to explain the slackening effect observed in some postoperative patients.

[Value of scaphal graft in secondary rhinoplasties]

The scaphal cartilaginous area is a most suitable anatomic site for cartilaginous graft harvesting. These grafts allow reconstruction of a flat dorsum, or a rounded dome, or alar cartilages or can be used for an extended tip graft. In some cases, both scaphes may be harvested. Raising of the grafts does not leave any sequelae when performed correctly. We have an experience of 20 cases. The main advantage of this graft is its flatness, which makes it ideal for the nasal dorsum. It has to be tailored, moderately crushed and included in a collagen "surgicel" in order to break the shape memory, slightly curved at its borders. We have used scaphal autografts in 15 cases of secondary rhinoplasties, 2 cases of cleft lip repair and in 3 cases of tertiary rhinoplasties. They solved most problems of missing cartilage, when minor defects had to be treated. These grafts will not solve major tissue defects which must be repaired by bone autografts, mostly iliac bone harvesting in our experience. The results of scaphal autografts are stable after 5 years. Resorption is moderate when the graft is correctly inserted, in an extramucosal pocket. The aesthetic result is maintained with a mean follow up of 2 years for 15 cases. The scaphal area of the ear therefore appears to be a favorable donor site for secondary, nose repair; it is easy to harvest, with inconspicuous morbidity and allows the raising of a good, flat and sculpturable material for cartilaginous nose replacement. Achieves the objectives of ore informed patients asking for artistic perfection.

[Experimental cervicoplasty: correction of the cervicomental angle by postero-superior suspension of the hyoid bone. A study of 20 anatomical dissections]

The elegance of the cervical region is due to a certain balance between concave and convex surfaces, and is based on the presence of a well-defined cervicomental angle, generally between 90 degrees to 110 degrees. An excessively wide-open cervicomental angle makes the cervical profile inelegant. Numerous surgical techniques can improve this angle. There is however a certain limit to this correction: an excessively caudal and anterior hyoid bone. In this case the last proposal is a modification of the hyoid bone position in order to replace it in a backward and upper location. To achieve this goal we studied postero-superior suspension of the hyoid bone by plication of the tendon of the digastric muscle in 20 anatomic dissection. Each an dissection was controlled by x-ray of the profile of the cervical region before and after application of this technique. Cephalometric measures were performed and statistically analysed using the "Paired t-test" on Statview II. Analysis of the results after the plication of the tendon of the digastric muscle, demonstrated an average closing of the cervicomental angle of 25.6 degrees with an average ascent of the hyoid bone of 13.27 millimeters and an average posterior transposition of 3.75 millimeters. This experimental cervicoplasty appears to be feasible. A precise surgical technique has been developed with an easy approach to the digastric tendon during standart faced lift procedures. The effect of the compression generated on the pharyngo-oesophageal complex by posterior transposition of the hyoid bone is unknown. This problem is now under investigation.

[Reconstruction of digital pulp by pulp tissue transfer of the toe. Apropos of 15 cases]

PURPOSE OF THE STUDY

The authors report their experience of digital pulp reconstruction by free toe pulp transfer. Fifteen patients were treated with the lateral great toe hemipulp.

MATERIAL AND METHODS

15 cases of post-traumatic finger tip reconstruction were reviewed including 9 thumbs, 5 index, 2 medius, and one ring finger. There were 6 emergency cases and 9 secondary reconstructions (7 after inconvenient spontaneous healing and 2 after groin flap coverage).

RESULTS

We noted 2 partial necrosis, and 4 patients suffered from cold intolerance. The flap sensibility, according to the American Society for Hand Surgery criteria, was excellent in 1 case good in 6 cases, fair in 7 cases and bad in 1 case. The value of the mean two point discrimination test was 10 mm, the mean moving two points discrimination test equalled 9 mm. We had 1 excellent functional result, 6 good, 6 fair and 2 bad. The subjective evaluation found 12 patients satisfied and 3 disappointed.

DISCUSSION

A wide range of procedures from spontaneous healing to thenar flap, neuro vascular flap or toe pulp transfer can be proposed to treat digital pulp loss. In the case of moderate thumb pulp avulsion and homodigital volar flap can be proposed; if microsurgery is contra-indicated, an hetero-digital flap from the index can be performed. When the other fingers are concerned, a homodigital flap can be proposed for moderate defects. For more important trauma, the thenar flap is convenient to cover the index and the medius pulp. Ring and little fingers can be treated by a reverse digital artery flap or by a cross finger flap. When a toe pulp transfer is indicated we recommend the lateral great toe hemipulp for the thumb and a second or third toe pulp transfer for the other fingers when digital vascular anastomosis are possible. The great toe hemipulp transfer represented a good indication for complete digital pulp loss reconstruction where the thumb is concerned. Performing this reconstruction during the acute phase may improve the management of those trauma by reducing the time needed for cicatrisation and the length of work inability.

Association of latissimus dorsi muscle expansion with electrostimulation before cardiomyoplasty

BACKGROUND

The principle of cardiomyoplasty is chronic electrostimulation of the latissimus dorsi muscle (LDM) flap wrapped around the heart to obtain a phasic activity that can be integrated to ventricular kinetics. In clinical cardiomyoplasty procedures, a complete wrap of both ventricles by the LDM cannot always be obtained in cases of extremely dilated hearts. This is due to the limited LDM length available for wrapping. In most of these cases, benefits of cardiomyoplasty are very limited. We have investigated the feasibility of progressive LDM expansion associated with electrostimulation. The aim was to increase the muscle area before cardiomyoplasty, while preserving the electrophysiologic characteristics of muscle fibers.

METHODS

In 5 goats, a silicone LDM expander with two incorporated muscular pacing electrodes was inserted deep into the LDM through a paravertebral incision along the posterior edge of the muscle. The pacing leads were connected to a myostimulator implanted in a subcutaneous pocket. The expander was progressively inflated over 8 weeks, up to 500 mL. Simultaneously the LDM was electrostimulated.

RESULTS

At 2 months planimetric studies demonstrated an increase of the LDM surface from 175 +/- 12 to 229 +/- 17 cm2 (+31% +/- 4%; p < 0.05). The expanded LDM showed preserved electrophysiologic characteristics. The analysis of biopsy samples revealed histologic integrity of muscle fibers and preservation of their mean diameter.

CONCLUSIONS

Potential benefits of this procedure are (1) increase of muscle surface, (2) training of muscular fibers and preservation of muscular tone, and (3) division of the distal vascular supply at implantation, which may potentiate vascularization from the LDM main pedicle. An LDM expansion could be considered before cardiomyoplasty in cases of significant heart dilatation. This device was successfully implanted in 2 patients, 2 months before cardiomyoplasty. Cardiomyoplasties were performed without difficulty, and a complete biventricular wrap was obtained in both patients in spite of massive cardiomegaly.

Secondary expansion of a totally replanted scalp for aesthetic adjustment

Total scalp avulsion is an uncommon and dramatic accident. Replantation is the only way for acceptable aesthetic final results. However, partial loss of tissue can result, and secondary procedures can be required. A total avulsion of a scalp involving the upper part of the right ear and both eyebrows was replanted after a long delay in our department. As a result, loss of a third of the hair-bearing area occurred. Secondary expansion of the replanted scalp achieved complete reconstruction.

[Replantation of the ring finger]

Tearing of a finger caught by a ring or by another similar mechanism is a rare but spectacular accident. The lesions vary from simple cutaneous erosion to complete separation of the extremity, which is the most spectacular and most difficult to treat. Reimplantation techniques are now well developed and involve very long vascular by pass to perform sutures in healthy zones. The operation is thus technically difficult, it can have a favourable course in some cases whereas in others, despite the use of meticulous technique, it can lead to thrombosis and failure of reimplantation. Alternatives to reimplantation can nevertheless obtain an esthetic hand, by regularisation or by intracarpal osteotomy. However, it appears of interest in young, motivated patients to propose reimplantation using microsurgery.

[Monitored cicatrization]

Directed healing is a therapeutic process that Raymond Vilain conceived as a sequence of: cleaning, granulation and formation of the epidermis. He suggested, to aid healing, the use of sofra-tulle and washing with isotonic solution or tap water, we have added the use of a hair dryer, in order to decrease the exudation from the wound. Such directed healing is particularly of interest for the integument and is difficult to apply to such structures as fat, fibrous tissues, bone and cartilage, or nerves and vessels. The "star" of directed healing is the granulation tissue. If healthy, it will support progressive marginal formation of the epidermis if the loss of tissue is not too great; if this loss is extensive, a graft will easily take on top of the layer of granules. If abnormal, the granules will lack tone. Healing will have to be renewed by appropriate treatment. We are all programmed to heal, except if we hinder the process by technical and psychological errors.

[Free transfer in the emergency treatment of complex injuries of the arm. Apropos of 18 cases]

In 18 cases the authors used a free tissue transfer during the first 24 hours of the treatment of a complex trauma of the upper limb involving osteoarticular and neurovascular loss combined with loss of skin cover. The various flaps include: lateral arm flap (8 cases), latissimus dorsi flap (4 cases), toe to hand transfer (4 cases), radial forearm flap (2 cases). The series includes 2 failures salvaged without further sequelae by means of a groin flap. With regard to complex one-stage reconstructions, particularly those requiring replacement of bone, the outcome is improved if the selected method permits early mobilisation and complete cover. Free transfers are to be compared with loco-regional flaps which are more reliable but suffer limitations such as a small cutaneous element and, frequently, involvement of the pedicle in the mechanism of the trauma. For the severe cases in this series, only free tissue transfers provided the adequate, immediate cover required to save the traumatised limb.

[Severe injuries of the elbow: emergency coverage and transient revascularization. Apropos of 13 cases over a 3-year period]

Large open elbow fractures with extensive soft-tissue loss must be treated as an emergency. Vessels and nerves are often alvulsed. One stage reconstruction is very challenging. Ischemia of the distal part of the upper extremity is limited by a synthetic arterial shunt (SAS). After debridement, the authors install the SAS, then the complex procedure can begin. The authors purpose a new four-stage classification and prognostic factors. Debridement concerns crushed, devitalised soft and osteo-articular tissues. If it appears possible to salvage the hand and forearm with necessity of complex reconstructions (vessels, nerves, osteosynthesis, soft tissues) SAS is used. SAS was used 3 times on the group of large avulsions with ischemia (5 cases); it was quickly installed between the humeral and a distal artery and allowed section of the best distal artery for revascularisation. Seven external fixation devices allowed intra operative and post operative management of the wound. The coverage of these large, complex wounds was performed by the latissimus dorsi transposition flap (2 muscular and 5 musculo-cutaneous flaps). It should be considered the flap of choice. Local flaps, which include local skin transposition, muscle transposition or vascular axis, would be contra indicated in a wide zone of injury (the base of these local flaps are damaged by high energy trauma) or when distal ischemia is present because of arterial axis sacrifice. The dorsal decubitus position, the specific dissection of neurovascular pedicle proximally as far as the axillary artery, the muscular and cutaneous design can be used to cover anterior, posterior, internal and external parts of the elbow. Restoration of elbow function uses an innervated latissimus dorsi muscle (3 cases). If only coverage is wanted, this flap has significant advantages over local flaps and free transfer procedures when the recipient vessels are within the area of injury. Between the donor site and the recipient site, the muscular part of the latissimus dorsi flap is placed in an arm counterincision. It ensures closure of the elbow joint. Early progressive range of movement exercises can be performed.

[Scalp reconstruction after avulsion: emergency microsurgery and secondary tissue expansion. Apropos of 3 cases caused by farming machines]

Total scalp avulsion is an uncommon accident. Three recent cases illustrate our surgical procedure. Small and central hair-bearing avulsed scalps can be treated by secondary scalp expansion (1 case). Large hair-bearing scalp (> 400 cm2) or including aesthetic relief should be treated by microsurgical reimplantation. Venous grafts allow vascular anastomoses beyond the intimal trauma area. Secondary expansion of reimplanted tissue (2 cases) eliminates scalp defects after initial necrosis. Thus, in the cases of total scalp avulsion even with high risk of failure (long time elapsed since injury, significant crush, part being in bad condition, two levels avulsion...), reimplantation has to be performed according to localization and size of avulsion. A secondary procedure with using expansion of the remaining replanted scalp is possible.

Endoscopic control during rhinoplasty

Endoscopy during rhinoplasty is an advance that permits the surgeon to obtain better results in cartilage and bony resections. It should decrease the number of secondary nasal revisions for small cartilaginous or bony irregularities. From May 1993, 30 patients have undergone primary and secondary rhinoplasties with complementary resections in all cases obtained with endoscopic control after the normal rhinoplastic procedure was completed.

[Contribution of polyurethane dressing in mammary reconstructive surgery]

The authors report the use of a new polyurethane dressing, studied in 20 patients undergoing breast surgery. Based on objective criteria, this study analyses the contribution of this dressing in the postoperative course.

[Repair of mammary ptosis by insertion of an internal absorbable support and periareolar scar]

Since 1989, we have operated 38 patients with breast ptosis with or without hypertrophy according to a technique which leaves a periareolar scar. The principles of this technique are: periareolar skin resection, dissection between the skin and gland over the entire surface of the gland, mastopexy, insertion of an absorbable mesh onto the anterior surface of the gland which constitutes an internal support, closure by the isolated periareolar scar. In our hands, this technique cannot be used to treat all forms of breast ptosis, but gives excellent results in certain selected indications such as tuberous breasts, breast asymmetry with one normal breast, ptosis and moderate hypertrophy. The reliability of the technique despite extensive dissection is remarkable and the stability with a follow-up of 3 years is good when the indication has been correctly defined. In comparison with other periareolar techniques, our approach has the advantage of not leaving any nonabsorbable elements in the wound, the only guarantee of reliability of clinical and radiological surveillance of the breast.

[Use of an external brachial flap in the reconstruction of the upper limb. Apropos of 11 cases]

During the last three years, eleven lateral upper arm flaps were used in the reconstruction of skin defects of the upper limb. These flaps were applied: 7 times on the hand; 2 times on the fore-arm; 2 times on the elbow. Ten flaps had a free transfer, one was vascularised by the distal pedicle. In 4 cases we used an emergency free transfer in the treatment of a traumatic defect. In the other cases the flaps were used in the treatment of post-traumatic sequelae such as contracture and/or osteitis. The series contains 10 fascio-cutaneous flaps and 1 osteo-cutaneous flap. We had one failure with an emergency free flap, salvaged without further sequelae by means of a groin flap. The proximity of the donor site in an upper limb reconstruction makes the lateral upper arm flap a good alternative when a pedicle locoregional flap cannot be used due to a lesion of its pedicle in the mechanism of the trauma.

[Dorsal tenolysis and arthrolysis of the proximal interphalangeal joint. 19 cases]

18 patients suffering from PIP stiffness in extension were treated by dorsal teno-arthrolysis. PIP joint stiffness was due to 3 cases of fracture of P1, 2 cases of fracture of P2, 2 cases of extensor tendons, 8 fractures of P1 associated with section of the extensor tendon, 2 cases of PIP closed trauma (1 sprain, 1 dislocation), and 2 crush injuries of the extensor tendon at the PIP joint. The surgical technique combined a dorsal sinuous approach, tenolysis of the extensor tendon on the dorsum of first phalanx dorsal capsulotomy, and more rarely (3 cases), section of collateral ligaments. The mean pre-operative active flexion was 44 degrees and the mean post operative active flexion was 78 degrees, which represents a gain of 34 degrees of active movement. Thanks to a classification which incorporates the range of active flexion in PIP joint, and the lock of active extension we rated 3 results as excellent, 4 as good, 8 as useful and 4 as insufficient. We therefore improved the range of movement in 15 out of 19 cases, which seams very encouraging.

[Emergency pulp reconstructions]

Pulp reconstructions use numerous techniques ranging from simple debridement to local and microsurgical flaps. The authors analyse the various treatments, in which directed healing still retains numerous indications. Local flaps have a definite place, but they are not devoid of risks (iatrogenic stiffness). The indications are presented schematically in table form together with several examples. A wide range of techniques is necessary in order to treat the various lesions appropriately. Large defects are best treated by microsurgical transfer of great toe pulp with satisfactory results, which justifies their management in specialised centers.

[A new test for the functional evaluation of the hand and its contribution to the study of toe transfers: the 5 matches test called "Take Five"]

After studying a series of thumbs reconstructed by 2nd toe transfer, we devised a new dexterity test: the "five matches test" or "Take Five Test" (R.S.). This test consists of the standardised timed and comparative pick-up of 5 identical fine objects (matches), permitting a simple and quick evaluation which objectively quantifies dexterity in fine pinches. The specificity of our test is that it is bilateral and comparative providing a narrow range of normality. In fact, a marked variability of time-scores is found between different individuals of a normal population, making it difficult to determine a "normal dexterity" criterion. But in the same person, there is little variability between two successive experiments or between the dominant and non-dominant hands. Examining a reconstructed hand, we have chosen as the "normal dexterity" criterion the time-score of the contralateral spared hand, timed first. The final score (from 0 to 4 points) is based on the difference between time-scores of the 2 hands (delay tested hand/spared hand). The "Take Five Test" (five matches pick-up test) has largely proven its efficiency in studying a series of thumbs reconstructed by 2nd toe transfer (operated on by V.M.). Fine pinch dexterity is satisfactory in 45% of cases (65% when long digits are spared), scoring at least 2 points (delay less than 4 seconds). The average score is 1.6 pts (range: from 0 to 4). This test could prove the functional value of parameters such as phalangeal mobility and a short delay between injury and reconstruction.

Advances in aesthetic surgery

The evolution of aesthetic surgery began centuries before the birth of Christ. Since Sushutra's first attempts, surgeons still try to achieve or reconstruct the perfection of individual beauty. Surgeons who are engaged in this field of plastic surgery are called cosmetic or aesthetic surgeons. Aesthetic surgery is not just a specialization concerned largely with the removal of the outward signs of aging, nor is it limited to plastic surgery for improvement by restoration of damaged areas of skin and removal of blemishes. Aesthetic surgery crosses the dividing line between surgery for reconstruction and alteration of deviations (which do not in themselves constitute objective deformities) and is sometimes even performed without medical indication, but just for the gratification of individual vanity. This article summarizes the progress of aesthetic surgery during the last decade in some aspects of the field and tries to estimate its' lasting value.

[Cold sensitivity after median or ulnar nerve injury based on a series of 82 cases]

Cold sensitivity often occurs after upper limb nerve injuries. 82 patients were reviewed retrospectively with an average follow-up of 42 months. Cold sensitivity occurred after 50% of median nerve injuries and after 75% of ulnar nerve injuries. Symptoms are localized to the damaged sensory nerve territory, and are related to the level of the lesion after median nerve injury. They are increased by associated arterial damage even when it is repaired. The less attened is the two-point discrimination lest, the less severe are the disorders. The origin is not really known, but we think that cold sensitivity is related to a disturbance of sympathetic and sensory fibers.

[Functional treatment of closed boutonnière deformity using a dorsal digito-palmar dynamic extension splint]

We advise dynamic extensor splintage put on as early as possible within the first 6 weeks after the diagnosis of boutonniere deformity. This splintage runs from the dorsal aspect of the hand to the DIP joint which is left free to flex actively. This apparatus is left on for at least six weeks post injury. Sixteen patients have been treated in this way. Seven of them were monitored carefully. Only one had a bad result with DIP flexion still preserved. The others averaged a mean extension loss of 23 degrees, and no loss of extension in DIP joints. Active flexion both in PIP and DIP was perfectly preserved. The functional treatment without surgery seems to be a good technique in management of fresh rupture of the extensor mechanism in PIP joints.

Risk and consequence of infection at the site of microsurgical repair: an experimental model

The consequences of postoperative infection at the site of microsurgical repair were studied. The experiment used 60 Wistar rats which were divided into 3 groups of 20 each. The femoral artery, vein, and nerve were transected unilaterally and repaired using microsurgical techniques. Staphylococcus aureus was then inoculated into the wound of group 1. Beta-hemolytic Streptococcus was inoculated into the wound of group 2. Group 3 rats served as controls. Clinical, anatomical, bacteriological and histopathological examinations were performed on postoperative days 8 and 30. Wounds in which S. aureus was inoculated demonstrated a significant tendency toward vascular thrombosis with extensive tissue destruction. In the majority of these cases, the necrosis caused by the primary infection engendered an associated, opportunistic infection. Streptococcal inoculations in group 2 demonstrated less severe changes than in group 1. These changes were characterized by injury of the vascular structures themselves with a significant tendency for thickening of the arterial wall, perivascular inflammation, and hematoma formation at the site of the repair. This model allows demonstration of the enzymatic and toxic consequences of bacterial infection in a postoperative site characterized by cellular destruction and interstitial edema surrounding foreign bodies represented by sutures.

Second toe to thumb transfer with extensor digitorum brevis opponensplasty

A second toe to hand transfer is described for thumb reconstruction which includes the extensor digitorum brevis as a simultaneous opponensplasty. This procedure was effective in a young man injured in a bomb explosion that completely destroyed the first ray. The second toe was dissected in continuity with the extensor digitorum brevis muscle, its nerve was anastomosed to the motor branch of the median nerve. Thus a one-stage operation allowed a complete reconstruction of the first ray proximally to the trapezium. Recovery at 2 years is good, and the muscle transfer can be demonstrated to work.

Current face lifting procedure: an attempt at evaluation

There are many techniques currently available for face lifting. The individual choice should be made based upon solid knowledge of anatomy and physiology as well as upon knowledge of long-term results in operated patients. In the absence of scientific information regarding deterioration of skin and muscle tension after operation, the only valid basis for judgement is a combination of the surgeon's assessment and the patient's degree of satisfaction 10 years after the operation. The latter is often impossible to obtain. The recently proposed deep undermining of the superficial musculoaponeurotic system (SMAS) seems both excessive and potentially dangerous. An evaluation of 30 consecutive patients would seem to indicate that a segmental approach, along with tightening of the platysmal and genioparotid layers of the SMAS, gives good immediate results and may be responsible for longer-lasting results.

The fasciocutaneous flap as an alternative solution in difficult reconstructive problems

Fasciocutaneous flaps are available anywhere in the body, literally from head to foot. Some hair-bearing flaps, the parasternal flap, and some forearm and lower extremity flaps may be useful for coverage of soft tissue defects when a relatively simple one-stage procedure is preferred. The fasciocutaneous flaps described here are long and narrow, with a length to width ratio of up to 5:1. Although these flaps are not the ultimate solution to all reconstructive problems, they are especially useful in the treatment of burn scar contractures and chronic ulcerations such as those that result from the extravasation caused by chemotherapeutic agents. Of particular importance is the fact that the use of these flaps does not preclude the use of other flaps later, should this be necessary. Specific indications for these flaps must always be kept in mind in relation to other reconstructive alternatives.

Experimental cardioplasty using the latissimus dorsi muscle flap

This study was undertaken to examine the possibility of using the latissimus dorsi muscular flap, divided in two parts thus covering the surfaces of the heart, and inserting it into the thoracic cavity by means of a segmental resection of the second rib. After cadaver case studies, 15 operations were performed on 5 Beagle dogs. The first group of 5 operations consisted of a latissimus dorsi flap graft over the heart. The second group and third group of operations (3 and 6 months later) consisted of reoperating for muscular and cardiac biopsies and electrical stimulation tests on the heart-muscle complex. The latissimus dorsi flap provided a sizable mass of contractile tissue. The haemodynamic studies showed no compressive or constrictive phenomenon of the muscle on the heart and revealed the preservation of an appropriate cardiac output for short intervals of time (2 hours), through phasic electrostimulation of the flap. The histopathological studies showed conserved muscular structure. The technical feasibility, histological adaptability and electrophysiological properties of this muscular flap makes it appropriate to develop a functional stimulation programme and perhaps adequate for the treatment of dysplasic, ischemic, tumoral and other acquired or congenital myocardial diseases.

Functional sequelae after ulnar nerve repair. Study of forty-nine cases

The full picture of functional ulnar deficiency, following suture or grafting, was studied and analyzed by two of the authors, who followed this series of patients on a long-term basis. The patients were tested using sphygmometric rubber bulbs in other to determine the overall closing force of the hand (making a fist), and the force of the pinch between the thumb and index ("energetic pinch"). Moreover, radionuclide vascular tests were used in order to find an eventual etiology of the "cold" disease, present in 2/3 of these injured hands. The principal functional deficiencies which bothered the patients and which we were able to demonstrate are as follows: deficient adduction of the thumb: the pinch between the thumb and index is diminished by approximately 50%, impairment, in the spreading of fingers, impairment in the overall force of the grasp, ulnar clawing which may embarrass function of the hand one year after the operation in one fourth of the cases. Therefore it appeared logical to propose an adduction plasty at the same time of repair, whether it was a primary suture or a secondary nerve graft. This adduction plasty uses the flexor digitorum sublimis of the ring finger which is rerouted and passed behind the profondus tendons and brought over to the lateral sesamoid bone of the thumb. This transfer is prolonged and tacked to the extensor pollicis longus in order to prevent the hyperflexion of the proximal phalanx of the thumb of which patients hardly ever complain but which denotes the severeness of ulnar nerve injury. An excellent correlation exists between the severeness of the functional deficiency and the importance of Froment's sign. The study of the other residual deficiencies shows that the restoration of the first dorsal interosseus, the reinforcement of the force of the flexores digitorum profundus of the middle and fourth fingers and of the intrinsics does not seem to be justified on an emergency basis. Zancolli's operation, which has been advocated by certain authors as an emergency procedure, does not seem to be necessary at this stage of repair, but remains a very interesting palliative procedure one year after the nerve repair if still judged necessary. Several clinical examples illustrate the value of long-term follow-up of these operated patients.

[Carpal tunnel syndrome. Cosmetic incision (author's transl)]

The median nerve compressed in the carpal tunnel can be released by an incision in the "line of life", a natural fold along the axis of the third metacarpal bone. By sectioning the carpal tunnel in the palm of the hand, on the cubital side of the median nerve, division of the external branch and of the sensory cutaneous rami of the nerve can be avoided. Hypertrophic scars are prevented. The part of the carpal tunnel situated in the forearm can be freed by a subcutaneous incision if needed, but compression at that level is much less frequent than in the palm of the hand.

[Retromuscular implantation of mammary prosthesis for reconstruction of the breast: report on 56 cases (author's transl)]

Though retromuscular implantation of mammary prosthesis for breast reconstruction presents certain advantages, a retrospective study of the results of 56 such prostheses implanted in 38 patients demonstrated certain complications related to this procedure. These included: ectopy, secondary migration, poor aesthetic appearance during muscle contractions, formation of a hard shell (33 p. cent of cases), and residual mammary asymmetry. However, the advantages related to the retromuscular site of implantation are sufficiently marked for this technique, described in detail, to be employed in certain chosen indications: sequelae to subcutaneous fatty mammectomies ("benign" breast), mammary reconstruction after resection for cancer or radiodermatitis, and perhaps after the use of musculocutaneous flap from the large dorsal muscles ("malignant" breast), and to increase mammary size in cases of agenesis or total aplasia (Poland's syndrome, "unesthetic"" breast).

A new microinstrument: the cutting microneedle holder

A cutting needleholder has been designed for microsurgery. After a little practice, the surgeon will find that the advantages of this instrument outweigh some disadvantages.