Downregulation of Caveolin-1 and Upregulation of Deiodinase 3, Associated with Hypoxia-Inducible Factor-1α Increase, Are Involved in the Oxidative Stress of Graves' Orbital Adipocytes

Background: Even though the clinical features of Graves' orbitopathy (GO) are well known, its exact pathogenesis remains controversial. The imbalance of redox homeostasis in the connective tissue could play a crucial role leading to an inflammatory state and edema of soft orbital tissues, thus contributing to orbital hypoxia and increase in hypoxia-inducible factor (HIF)-1α. This oxidative stress appears to target the orbital cells such as fibroblasts and also adipocytes. This study aims to explore which pathways can lead to the aforementioned oxidative stress in GO adipose cells and therefore offers new plausible therapeutic targets. Methods: Orbital fat samples were obtained from patients with GO (Western blot [WB]: n = 8, immunohistochemistry [IHC]: n = 8) and from control patients (WB: n = 5, IHC: n = 3-5). They were processed for WB analysis and IHC of the antioxidants (catalase, superoxide dismutase 1) and for HIF-1α. The expression of caveolin-1 (Cav-1) and deiodinase 3 (DIO3), known to be regulated by HIF-1α, was also analyzed by WB and IHC, as well as the targets of Cav-1: glucose transporter type 4 (Glut-4), NADPH oxidase (NOX)-2, and endothelial nitric oxide synthase (eNOS). Triiodothyronine (T3) expression was also analyzed by IHC. Results: In GO adipocytes, the expression of catalase was reduced, whereas that of HIF-1α was strongly increased. A decreased local T3 supply was associated with DIO3 upregulation. The low expression of Cav-1 in GO adipocytes was associated not only with low expression of Glut-4 but also with an increased expression of NOX-2 and active eNOS phosphorylated on serine 1177. Conclusions: Cav-1 and DIO3, both sensitive to hypoxia and to the increase of HIF-1α, play a pivotal role in the oxidative stress in GO adipocytes. DIO3 regulates the cellular supply of T3, which is essential for the cell homeostasis. Cav-1 determines the cellular glucose supply through Glut-4 and regulates the activity of NOX-2 generating superoxide anions and that of eNOS generating nitric oxide (NO).

Pioglitazone, a PPARγ Agonist, Upregulates the Expression of Caveolin-1 and Catalase, Essential for Thyroid Cell Homeostasis: A Clue to the Pathogenesis of Hashimoto's Thyroiditis

BACKGROUND

Peroxisome proliferator-activated receptor γ (PPARγ) is a transcription factor that regulates the expression of multiple target genes involved in several metabolic pathways as well as in inflammation. The expression and cell localization of caveolin-1 (Cav-1), thyroperoxidase (TPO), and dual oxidase (DUOX), involved in extracellular iodination, is modulated by Th1 cytokines in human normal thyroid cells and in Hashimoto's thyroiditis (HT).

OBJECTIVES

The objectives of this study were (i) to analyze the PPARγ protein and mRNA expression at the follicular level in HT versus controls in correlation with the one of Cav-1; (ii) to study the effects of Th1 cytokines on PPARγ and catalase expression in human thyrocyte primary cultures; and (iii) to study the effects of pioglitazone, a PPARγ agonist, on thyroxisome components (Cav-1, TPO, DUOX) and on catalase, involved in antioxidant defense.

RESULTS

Although the global expression of PPARγ in the whole gland of patients with HT was not modified compared with controls, there was great heterogeneity among glands and among follicles within the same thyroid. Besides normal (type 1) follicles, there were around inflammatory zones, hyperactive (type 2) follicles with high PPARγ and Cav-1 expression, and inactive (type 3) follicles which were unable to form thyroxine and did not express PPARγ or Cav-1. In human thyrocytes in primary culture, Th1 cytokines decreased PPARγ and catalase expression; pioglitazone increased Cav-1, TPO, and catalase expression.

CONCLUSION

PPARγ may play a central role in normal thyroid physiology by upregulating Cav-1, essential for the organization of the thyroxisome and extracellular iodination. By upregulating catalase, PPARγ may also contribute to cell homeostasis. The inhibitory effect of Th1 cytokines on PPARγ expression may be considered as a new pathogenetic mechanism for HT, and the use of PPARγ agonists could open a new therapeutic approach.

Involvement of mTOR and Regulation by AMPK in Early Iodine Deficiency-Induced Thyroid Microvascular Activation

Iodine deficiency (ID) induces TSH-independent microvascular activation in the thyroid via the reactive oxygen species/nitric oxide-hypoxia-inducible factor-1α/vascular endothelial growth factor (VEGF) pathway. We hypothesized the additional involvement of mammalian target of rapamycin (mTOR) as a positive regulator of this pathway and AMP-activated protein kinase (AMPK) as a negative feedback regulator to explain the transient nature of ID-induced microvascular changes under nonmalignant conditions. mTOR and AMPK involvement was investigated using an in vitro model (human thyrocytes in primary cultures) and 2 murine models of goitrogenesis (normal NMRI and RET-PTC mice [a papillary thyroid cancer model]). In NMRI mice, ID had no effect on the phosphorylation of ribosomal S6 kinase (p70S6K), a downstream target of mTOR. However, rapamycin inhibited ID-induced thyroid blood flow and VEGF protein expression. In the RET-PTC model, ID strongly increased the phosphorylation of p70S6K, whereas rapamycin completely inhibited the ID-induced increase in p70S6K phosphorylation, thyroid blood flow, and VEGF-A expression. In vitro, although ID increased p70S6K phosphorylation, the ID-stimulated hypoxia-inducible factor/VEGF pathway was inhibited by rapamycin. Activation of AMPK by metformin inhibited ID effects both in vivo and in vitro. In AMPK-α1 knockout mice, the ID-induced increase in thyroid blood flow and VEGF-A protein expression persisted throughout the treatment, whereas both parameters returned to control values in wild-type mice after 4 days of ID. In conclusion, mTOR is required for early ID-induced thyroid microvascular activation. AMPK negatively regulates this pathway, which may account for the transient nature of ID-induced TSH-independent vascular effects under benign conditions.

Oxidative Stress and Upregulation of Antioxidant Proteins, Including Adiponectin, in Extraocular Muscular Cells, Orbital Adipocytes, and Thyrocytes in Graves' Disease Associated with Orbitopathy

BACKGROUND

Graves' orbitopathy (GO) is the main extrathyroidal manifestation associated with Graves' disease (GD). It is characterized by reduced eye motility due to an increased volume of orbital fat and/or of extraocular muscles (EOMs) infiltrated by fibrosis and adipose tissue. The pathogenetic mechanisms leading to fibrosis and adipogenesis are mainly based on the interaction between orbital fibroblasts and immune cells (lymphocytes and mast cells) infiltrating the GO EOMs.

METHODS

Analysis of the morphological status, oxidative stress (OS), and antioxidant defenses in the orbital muscular cells and adipocytes in GO patients compared with controls was conducted.

RESULTS

Both cell types are affected by OS, as shown by the increased expression of 4-hydroxynonenal, which leads to apoptosis in muscular cells. However, the EOMs and the adipocytes possess antioxidant defenses (peroxiredoxin 5 and catalase) against the OS, which are also upregulated in thyrocytes in GD. The expression of adiponectin (ApN) and proliferator-activated receptor gamma (PPARγ) is also increased in GO muscular cells and adipocytes. OS and antioxidant proteins expression are correlated to the level of blood antithyrotropin receptor antibodies (TSHR-Ab).

CONCLUSION

Even when TSHR-Ab level is normalized, OS and antioxidant protein expression is high in EOM muscular cells and adipocytes in GO compared with controls. This justifies a supplementation with antioxidants in active as well as chronic GO patients. Orbital muscular cells are also the sources of PPARγ and ApN, which have direct or indirect local protective effects against OS. Modulation of these proteins could be considered as a future therapeutic approach for GO.

Requirements analysis and preliminary design of a robotic assistant for reconstructive microsurgery

Microanastomosis is a microsurgical gesture that involves suturing two very small blood vessels together. This gesture is used in many operations such as avulsed member auto-grafting, pediatric surgery, reconstructive surgery - including breast reconstruction by free flap. When vessels have diameters smaller than one millimeter, hand tremors make movements difficult to control. This paper introduces our preliminary steps towards robotic assistance for helping surgeons to perform microanastomosis in optimal conditions, in order to increase gesture quality and reliability even on smaller diameters. A general needs assessment and an experimental motion analysis were performed to define the requirements of the robot. Geometric parameters of the kinematic structure were then optimized to fulfill specific objectives. A prototype of the robot is currently being designed and built in order to providing a sufficient increase in accuracy without prolonging the duration of the procedure.

Recent insights into the cell biology of thyroid angiofollicular units

In thyrocytes, cell polarity is of crucial importance for proper thyroid function. Many intrinsic mechanisms of self-regulation control how the key players involved in thyroid hormone (TH) biosynthesis interact in apical microvilli, so that hazardous biochemical processes may occur without detriment to the cell. In some pathological conditions, this enzymatic complex is disrupted, with some components abnormally activated into the cytoplasm, which can lead to further morphological and functional breakdown. When iodine intake is altered, autoregulatory mechanisms outside the thyrocytes are activated. They involve adjacent capillaries that, together with thyrocytes, form the angiofollicular units (AFUs) that can be considered as the functional and morphological units of the thyroid. In response to iodine shortage, a rapid expansion of the microvasculature occurs, which, in addition to nutrients and oxygen, optimizes iodide supply. These changes are triggered by angiogenic signals released from thyrocytes via a reactive oxygen species/hypoxia-inducible factor/vascular endothelial growth factor pathway. When intra- and extrathyrocyte autoregulation fails, other forms of adaptation arise, such as euthyroid goiters. From onset, goiters are morphologically and functionally heterogeneous due to the polyclonal nature of the cells, with nodules distributed around areas of quiescent AFUs containing globules of compact thyroglobulin (Tg) and surrounded by a hypotrophic microvasculature. Upon TSH stimulation, quiescent AFUs are activated with Tg globules undergoing fragmentation into soluble Tg, proteins involved in TH biosynthesis being expressed and the local microvascular network extending. Over time and depending on physiological needs, AFUs may undergo repetitive phases of high, moderate, or low cell and tissue activity, which may ultimately culminate in multinodular goiters.

Split temporalis muscle flap anatomy, vascularization and clinical applications

INTRODUCTION

For more than a century, the temporalis muscle has been used for facial reconstructions. More recently, a split temporalis muscle flap elevated on the superficial temporal pedicle has been described, for which the resulting gain of length makes crossing of the midline possible, as well as reconstruction of substance losses exceeding the midline.

MATERIALS AND METHODS

Fourteen fresh cadaveric dissections were performed to study the different techniques for splitting the temporalis muscle. Dissections with catheterization and injection of radio-opaque contrasting agent in the external carotid artery were then performed to specify the vascularization of the flap split on the superficial temporal pedicle.

RESULTS

The duplication of the superficial temporal pedicle grants greater length compared to that of the deep pedicles, 57 mm versus 40 (p = 0.036). The middle temporal artery is capable of ensuring the vascularization, and therefore the viability, of the split flap. From these results, we spoke about the limitations of this study and we have inferred the main indications.

Targeted Hypoglossal Neurostimulation in Obstructive Sleep Apnea

Objective: Airway management is the standard approach for the treatment of obstructive sleep apnea (OSA). CPAP remains the gold standard to treat OSAS, but about one-quarter of the patients are poorly compliant or tolerant to the mask. The aim of the study was to evaluate the safety and efficacy of targetted neurostimulation of the hypoglossal nerve (THN Sleep Therapy) in CPAP non-compliant subjects using the aura6000™ System from ImThera Medical Inc.

Method: The study was a single arm, prospective feasibility study on 13 OSA subjects. Apnea-hypopnea indices (AHI) were measured at 3 and 12 months. A multi-contact cuff electrode was implanted unilaterally on the proximal hypoglossal nerve and an implantable pulse generator placed subcutaneously in the ipsilateral upper chest wall.

Results: Significant improvement was found in the apnea hypopnea index: baseline 45.2 ± 17.8, 3 months 21.7 ± 19.9, and 12 months 21.0 ± 16.5 calculated for the 13 patients. Ten patients were classified as responders (76.92%) with a 65.55% improvement in the AHI at 3 months and 68.19% at 12 months and with a 67.09% improvement in the ODI at 3 months and 66.23% at 12 months.

Conclusion: THN Sleep Therapy™ proved to be a feasible and effective procedure for the treatment of the moderate to severe CPAP noncompliant OSA subjects.

[Facial graft, archetype of microsurgical innovation?]

Is innovation breaking of the way of thinking, breaker of taboos, concretisation of chimeras or simple benefit of an ineluctable evolution? The surgical act should be considered as innovation itself? From the first facial allotransplantation, innovation is declined in various ways, which could constitute the different answers regarding the planning and management to prepare such surgery, the realisation of the transplantation and also the multiple developments in terms of science and medicine. It is exactly in that meaning that could be really mentioned the term archetypal.

The use of grafting material in rhinoseptoplasty

Grafting is one of the current range of instruments that rhinoplasticians deploy to achieve durable and desired aesthetic and functional outcomes. Grafts can be classified according to anatomical site and, in the vast majority of cases, they involve augmentation rhinoseptoplasty. Visible grafting material is used for aesthetic purposes and functional grafting may involve invisible grafts. This article reviews the more widely described and more common indications for grafts in rhinoseptoplasty. The authors' rhinoseptoplasty philosophy involves a preference for autogenous grafts rather than alloplastic implants to achieve both aesthetically and functionally favourable results, particularly in long-term follow-up. They also prefer grafts in an open approach, reserving graft insertion with an endonasal approach for selected cases. The rate of complications associated with grafting is very low. The aim of this paper is to discuss the relevant anatomy, functional purpose and terminology, and to describe the authors' philosophy for grafting in rhinoseptoplasty.

Differential interactions between Th1/Th2, Th1/Th3, and Th2/Th3 cytokines in the regulation of thyroperoxidase and dual oxidase expression, and of thyroglobulin secretion in thyrocytes in vitro

Hypothyroidism, together with glandular atrophy, is the usual outcome of destructive autoimmune thyroiditis. The impairment in the thyroid function results either from cell destruction or from Th1 cytokine-induced alteration in hormonogenesis. Here, we investigated the impact of the local immune context on the thyroid function. We used two rat thyroid cell lines (PCCL3 and FRTL-5) and human thyrocytes incubated with IL-1alpha/interferon (IFN) gamma together with IL-4, a Th2 cytokine, or with TGF-beta, or IL-10, two Th3 cytokines. We first observed that IL-4 totally blocked IL-1alpha/interferon gamma-induced alteration in dual oxidase and thyroperoxidase expression, and in thyroglobulin secretion. By contrast, TGF-beta and IL-10 had no such effect. They rather repressed thyrocyte function as do Th1 cytokines. In addition, IL-4 blocked IL-10-induced repression of thyrocyte function, but not that induced by TGF-beta. In conclusion, Th1 cytokine- and IL-10-induced local inhibitory actions on thyroid function can be totally overturned by Th2 cytokines. These data provide new clues about the influence of the immune context on thyrocyte function.

The versatility of the sub-mental flap: a case report

The sub-mental flap has been used in four elderly patients (mean age: 83 years) for reconstruction of defects after oncological resection: three had basal cell carcinoma (cheek, temporal region and fronto-temporal region). One had a squamous cell carcinoma of the hard palate. We believe that the latter example is original and present it in this article. This case shows that the sub-mental flap in addition to its intrinsic qualities is a reliable flap which may be useful in difficult repairs. It can be used to repair wide palatal fistula which occurs after oncological resections.

Outcomes 18 months after the first human partial face transplantation

BACKGROUND

We performed the first human partial face allograft on November 27, 2005. Here we report outcomes up to 18 months after transplantation.

METHODS

The postsurgical induction immunosuppression protocol included thymoglobulins combined with tacrolimus, mycophenolate mofetil, and prednisone. Donor hematopoietic stem cells were infused on postoperative days 4 and 11. Sequential biopsy specimens were taken from a sentinel skin graft, the facial skin, and the oral mucosa. Functional progress was assessed by tests of sensory and motor function performed monthly. Psychological support was provided before and after transplantation.

RESULTS

Sensitivity to light touch, as assessed with the use of static monofilaments, and sensitivity to heat and cold had returned to normal at 6 months after transplantation. Motor recovery was slower, and labial contact allowing complete mouth closure was achieved at 10 months. Psychological acceptance of the graft progressed as function improved. Rejection episodes occurred on days 18 and 214 after transplantation and were reversed. A decrease in inulin clearance led to a change in immunosuppressive regimen from tacrolimus to sirolimus at 14 months. Extracorporeal photochemotherapy was introduced at 10 months to prevent recurrence of rejection. There have been no subsequent rejection episodes. At 18 months, the patient is satisfied with the aesthetic result.

CONCLUSIONS

In this patient who underwent the first partial face transplantation, the functional and aesthetic results 18 months after transplantation are satisfactory.

Anatomical bases for the radiological delineation of lymph node areas. Upper limbs, chest and abdomen

Cancer spreads locally through direct infiltration into soft tissues, or at distance by invading vascular structures, then migrating through the lymphatic or blood flow. Although cancer cells carried in the blood can end in virtually any corner of the body, lymphatic migration is usually stepwise, through successive nodal stops, which can temporarily delay further progression. In radiotherapy, irradiation of lymphatic paths relevant to the localisation of the primary has been common practice for decades. Similarly, excision of cancer is often completed by lymphatic dissection. Both in radiotherapy and in surgery, advanced knowledge of the lymphatic pathways relevant to any tumour location is an important information for treatment preparation and execution. This second part describes the lymphatics of the upper limb, of the thorax and of the upper abdomen. Providing anatomical bases for the radiological delineation of lymph nodes areas in the axilla, in the chest and in the abdomen, it also offers a simplified classification for labeling the mediastinal and intra-abdominal nodal levels, grouped in each location inside three major functional areas (called I, II and III) which are all divided into three sublevels (named a, b or c).

Clinicopathologic Monitoring of the Skin and Oral Mucosa of the First Human Face Allograft: Report on the First Eight Months

BACKGROUND

The first human face allograft was performed in France on November 27, 2005. We report herein the clinicopathologic findings from the skin and oral mucosa of this allograft during the first eight months.

METHODS

Sequential biopsies were taken from the facial skin (n = 3), oral mucosa (n = 20), and sentinel skin graft (n = 11) from day 3 to day 220 postgraft and examined (immuno)histologically, using a pathological score previously proposed for evaluation of rejection in composite tissue (hand) transplantation.

RESULTS

The patient developed clinically rejection episodes at day 20 and during the eighth month postgraft, manifesting with redness and edema of the facial skin, oral mucosa, and sentinel graft skin. Pathologically, changes suggestive of rejection grades 0, I, II, and III were seen in 1, 1, 1, and 0 biopsies of facial skin, 7, 2, 1, and 1 biopsies of sentinel skin graft and 3, 5, 8, and 4 biopsies of oral mucosa, respectively. Pathological changes were generally more severe in the oral mucosa than in facial and sentinel graft skin (mean scores 1.85, 0.64, and 1, respectively).

CONCLUSIONS

As it happens with other composite tissue allografts, close clinicopathologic monitoring of the skin (and oral mucosa) seems to be the most reliable way to detect rejection in the setting of human facial tissue allotransplantation. Apart from these rejection episodes, the skin and mucosa maintained a normal microscopic structure, paralleling functional recovery.

First human face allograft: early report

BACKGROUND

Extended soft tissue defects of the face are difficult to reconstruct, and autologous tissue transfers usually lead to poor cosmetic and functional outcomes. We judged that composite tissue transplantation could be valuable in facial reconstructive surgery.

METHODS

We transplanted the central and lower face of a brain-dead woman onto a woman aged 38 years who had suffered amputation of distal nose, both lips, chin, and adjacent parts of the cheeks. Transplantation consisted of revascularisation of right and left facial arteries and veins (ischaemic time 4 h), mucosal repair of oral and nasal vestibules, bilateral anastomoses of infraorbital and mental sensitive nerves, joining of mimic muscles with motor nerve suture on mandibular branch of the left facial nerve, and skin closure. Immunosuppressive treatment was with thymoglobulin, tacrolimus, mycophenolate mofetil, and prednisone. Two infusions of donor bone-marrow cells were given. Follow-up included routine tests, biopsies, physiotherapy, and psychological support.

FINDINGS

The initial postoperative course was uneventful. No surgical complication occurred. Bone-marrow graft and immunosuppression were well tolerated. Mild clinical signs of rejection were seen at day 20. Increased corticoids initially did not reverse rejection, but signs of rejection disappeared after three boluses of prednisone. Anatomical and psychological integration and recovery of sensation were excellent. At the end of the first postoperative week, the patient could eat, and speech improved quickly. Passive transmission of muscle contractions to the graft already exists; physiotherapy is being done to restore dynamic motions around the lips.

INTERPRETATION

The 4-month outcome demonstrates the feasibility of this procedure. The functional result will be assessed in the future, but this graft can already be deemed successful with respect to appearance, sensitivity, and acceptance by the patient.

Effects of irradiation on bone remodelling around mandibular implants: an experimental study in dogs

This research focuses on the effects of radiotherapy on bone remodelling around mandibular implants in dogs. After bilateral extraction of the mandibular premolars and first 2 molars, each of 11 beagles received 8 mandibular implants. Four animals were irradiated 4 weeks after implantation and 4 others 8 weeks before implantation; the remaining 3 did not receive radiotherapy. Irradiation consisted of 10 daily fractions of 4.3Gy (60)Co. Fluorochromes were given at implantation and irradiation to allow the measurement of bone apposition. The dogs were killed 6 months after implantation. Each hemi-mandible was processed according to bone-specific histological techniques. New bone formation was visible around 85 of the 88 implants. Stimulated mandibular remodelling was attested in both irradiated groups by increased porosity and numerous labelled osteons. Resorption was more pronounced in the group irradiated after implantation, but osteon formation appeared unvarying. Osseointegration was thus shown to be compatible with bone irradiation as bone turnover activities were maintained throughout the experiment. As the apposition stage of the remodelling cycle appears crucial to achieve optimal osseointegration, its normal completion should be taken into account in clinical practice by respecting a 6-month period between irradiation and implantation.

Solitary fibrous tumour of the soft tissue of the face: a case report

INTRODUCTION

Solitary fibrous tumour (SFT) is a rare mesenchymal neoplasm described first in the pleura. Recently, SFTs have been found in various extra-serosal locations, including the head and neck region.

CASE PRESENTATION

We report a case of SFT originating from the periorbital region of the face. Preoperative cytological examination by fine needle aspiration biopsy diagnosed a mesenchymal tumour. The patient underwent surgical resection. The mass was completely resected. Definitive histopathologic and immunohistologic examination confirmed the diagnosis of SFT.

DISCUSSION

The rare localisation in extrapleural sites and the multiplicity of histological patterns can explain the difficulty in arriving at a definitive diagnosis in SFT. Usually, SFT is a benign tumour, although malignant variants exist. Clinical behaviour is unpredictable and recurrence or malignant transformation can also occur, especially in cases with macroscopically or microscopically invaded margins. Complete surgical excision and long follow-up is therefore always recommended. The recent increase in reports of extrapleural SFT indicates that this rare tumour should be included in the differential diagnosis of soft tissue head and neck tumours.

[Extended nasal skin reconstruction with a retroauricular free flap harvested on the superficial temporal pedicle]

The microsurgical coverage of large nasal skin avulsion was performed in a 40 years old patient after a human bite. Widely exposing the columelle, the alar cartilages and the distal part of the septum, the defect was covered with a retroauricular free flap harvested on the superficial temporal pedicle and transferred on the upper labial vessels in the nasogenian area. Thanks to its excellent colour and texture match with the nose integuments, this flap enjoyed of an optimal integration in the centrofacial area. Its potential indications, advantages, drawbacks and technical variants are discussed in the present paper.

The deep belly of the temporalis muscle: an anatomical, histological and MRI study

In order to achieve a better functional and clinical knowledge of a masticatory muscle called the sphenomandibularis that is suspected to be responsible for headaches by compressing the maxillary nerve, bilateral dissections of the infratemporal fossa were performed on ten human cadavers and completed by histological and radiological studies of the same areas. Both macroscopic and microscopic observations obviously showed that the so-called sphenomandibularis muscle corresponds to the deep portion of the temporalis muscle, since there is no epimysial septum between these two structures, which previously have been described as being completely independent from each other. In spite of the close topographic relationship between the deep belly of the temporalis and the lateral pterygoid muscle, as well as their similar innervation pattern, the sphenomandibularis in fact has to be considered functionally as an original but non-isolated positional fascicle of the temporalis muscle itself. Our observations, correlated with MR images, suggest indeed that the deep belly of the temporalis muscle is of functional importance in the masticatory movements, but is not involved by its neurovascular vicinity in the genesis of specific headaches. Its surgical release, however, should be discussed in the case of a temporal myoplasty.

Conservation laryngeal surgery for selected pyriform sinus cancer

AIMS

This study reports the treatment of a cohort of patients with pyriform sinus squamous cell carcinoma, using conservative surgery and radiotherapy.

METHODS

Thirty-four patients with pyriform sinus SCC were treated between 1986 and 2001, using partial laryngopharyngectomy with or without complementary radiotherapy. Seventy-six percent had stage III-IV lesions. Quality of life questionnaire and clinical examination were used for evaluation of laryngeal function.

RESULTS

Conservation surgery was undertaken. All patients underwent neck dissection. Two thirds of the patients received post-operative radiotherapy. Reconstruction was achieved by local muscular flap in 13 cases, radial forearm free flap in 18 and pectoralis major flap in three. Five-year overall and disease-specific survival rates were 50 and 65%, respectively. Successful laryngeal function preservation with local control was achieved in 80% of the patients.

CONCLUSION

Partial laryngopharyngectomy is a suitable treatment for early and selected advanced stage pyriform sinus carcinoma with a good functional and oncologic outcome.

[A dart and a microscope for the King--imaginary memoirs of a current microsurgery specialist addressing the Sun King about diseases of the Great Century]

Based on the facts described in King's Louis XIV medical journal, this lecture makes the amazing inventory of the illnesses and the poor state of the medical art in a period when medical empiricism was prevalent. It is, however, the courage of patients and their resistance to utterly absurd and painful treatments that foremost arouse our admiration. By the way, this historical journey also provides the author with a pretext for valorising current developments--in comparison with treatments of the past--such as in the field of microsurgery where some pathologies that were up till now considered to be inaccessible to any possibility of surgical anatomical or functional restoration, are now controlled.

[About the rational use of intrathoracic transfers. Anatomical and surgical bases for the selection of twelve different muscular and omental flaps]

Because of their rich blood supply and of their original detersive and filling properties, the muscular pedicled flaps harvested from the trunk or the omental flap elevated from the abdomen may be very usefull to treat large defects or major septic problems in pleural, pericardic or mediastinal cavities. We here describe the main principles to be followed in such intrathoracic reconstructions performed in order to control severe mediastinites, aortic prosthetic infections, pleural empyemas and broncho-pleural, tracheo-esophageal or broncho-esophageal fistulas. In all these circumstances, the muscular or omental flaps which are transferred into the chest are selected according to the recipient field and to their respective access to the upper, middle and lower portions of the pleural space or mediastinum. Twelve different flaps so appear available to achieve the adequate reconstruction, filling or coverage of nine distinct topographic sites. Their rational use, based on various anatomical guidelines, allows to prevent or to cure efficiently 90% of the infectious or fistular complications frequently observed in the postoperative course of aggressive, functional or oncological, intrathoracic surgical procedures.

[The face, the mask and the times. Natural history of the segmental architecture of the face]

Extending from the supra-occipital region down to both clavicles, the face is an original anatomical entity which constituTes the main field of interaction between the brain and the external world. We here demonstrate that essential structures arise from the neural crest cells and that the segmental migratory pathway of these cells leads to the segmental ontogenesis of the head, and of the anterior neck area from seven distinct morphogenetic units which enjoy each of an independEnt growth potential. In the adult, the neural and segmental origin of the face is temporarily masked by the superficial musculoaponevrotic system which supports its cutaneous cover. Nevertheless, this fundamental architecture appears fugitively in the mimics of facial expression, then more obviously in the ptotic and folding phenomenons involved in cephalic skin ageing.

Anatomy and embryology of the parathyroid glands

The embryology and anatomy of the parathyroid glands is described and the implications for surgery are discussed.

[Anastomoses and sutures in cervical laryngotracheal and pharyngoesophageal surgery]

Head and neck anastomosis techniques present common aspects with any type of anastomosis but their localisation at the junction of the respiratory and digestive tracts makes them often delicate to perform. In the present article, we first review the different surgical indications and the laryngeal, tracheal, pharyngeal and oesophageal anastomosis techniques. The main types of flaps also used for this purpose are highlighted. We then review the cases observed during the 5 last years in our department, type and technique of surgery used. In this general review, we illustrate our stand point although aware of the multiple variants favoured by different schools.

Conservation surgery for laryngeal and hypopharyngeal cancer

The charts of 173 patients treated by conservation laryngectomy and pharyngolaryngectomy were retrospectively reviewed. The patients treated by endoscopic laser resection were excluded of this study. Glottic carcinoma was diagnosed in 101 patients, supraglottic carcinoma in 44 patients, hypopharyngeal carcinoma in 24 patients and oropharyngeal carcinoma in 4 patients. The median follow-up period was 44 months, 84/101 glottic cancer, 34/44 supraglottic cancer, 23/24 hypopharyngeal cancer and 2/4 oropharyngeal cancer were staged as T1 and T2. A voice-sparing external approach was carried on in 20 patients with locally advanced tumor (T3-T4). At time of the last follow-up, 132 patients (77%) were alive when 41 patients (23%) died. Overall survival rates for patients treated for T1-T2 glottic cancer at 3, 5 and 10 years were 90, 90 and 78% respectively. Overall survival rates for patients treated for T1-T2 supralottic cancer at 3, 5 and 10 years were 73, 68 and 48% respectively. Overall survival rates for patients treated for T1-T2 hypopharyngeal cancer at 3 and 5 years were 74 and 37% respectively. The site of the primary tumor (glottic versus supraglottic or hypopharynx) showed significant impact on survival (P = 0.0025)). Regarding survival, T stage and N stage were not found statistically significant.

New challenges in head and neck bone and soft tissue reconstruction

Emphasizing the major impact of reconstructive microsurgery on the treatment of head and neck tumors, the present paper makes a synthesis of the ideal transplants now commonly used to repair specific cephalic bone and soft tissue defects. It also explores and discusses the new perspectives actually developed to improve their present anatomical, functional and aesthetic results. By extending the use of chimaeric or prefabricated flaps, neurovascular allografts or dynamic transfers, all these new challenges combine the progresses made in surgical skill, conceptual inventivity and basic molecular biology.

Distraction osteogenesis of a fibula free flap used for mandibular reconstruction: preliminary report

The authors report the first case of mandibular distraction osteogenesis applied to a fibula microvascularized flap used to reconstruct an almost entire mandible. The technique and complications are described. The literature is reviewed. The biological and physiological process of bone elongation by Ilizarov's method is explained according new studies on chondroid tissue. Preoperative planning of vectors of device placement and trajectory is essential for good results.

Embryonic origin and fate of chondroid tissue and secondary cartilages in the avian skull

BACKGROUND

Chondroid tissue is an intermediate calcified tissue, mainly involved in desmocranial morphogenesis. Often associated with secondary cartilages, it remained of unprecise embryonic origin.

METHODS

The latter was studied by performing isotopic isochronic grafts of quail encephalon onto 30 chick embryos. The so-obtained chimeras were sacrificed at the 9th, 12th, and 14th day of incubation. The contribution of graft- and host-derived cells to the histogenesis of chondroid tissue, bone, and secondary cartilages was analyzed on both microradiographs of thick undecalcified sections and on classical histological sections after several DNA or ECM specific staining procedures.

RESULTS

Chondroid tissue is deposited in the primitive anlage of all membranous bones of the avian skull. Also present on their sutural edges, it uniformly arises from the neural crest. In the face, bone and secondary cartilages share this mesectodermal origin. However, secondary cartilages located along the basal chondrocranium and bone formed on the chondroid primordium of the cranial vault, originate from the cephalic mesoderm.

CONCLUSIONS

These facts provide evidence that chondroid tissue arises from a specific differentiation of neural crest derived cells and that this original skeletogenic program differs from that of secondary chondrogenesis. Moreover, they obviously indicate that in membraneous bone ontogenesis, chondroid tissue replaces functions devoted to mesodermal primary cartilages of the cranial base, and so corroborates at the tissue level, the dual embryonic and phyletic origin of the skull.

Chondroid tissue in the early facial morphogenesis of the chick embryo

The calcified tissues involved in the early morphogenesis of the so-called intramembranous bones of the facial skeleton were studied by microradiographic and histological techniques in 22 chick embryos at the 9th, 12th and 14th days of incubation. On the 9th day, the bones of the upper face and palatal vault are made up of thin sheets of chondroid tissue, deposited in their respective mesenchymal condensations. Woven and lamellar bone formation subsequently takes place in each of them from the 12th day of incubation, mainly on the external side of their chondroid primordia. The same phenomena occur in the lower facial and mandibular bones. These facts indicate that the primitive facial desmocranium of the chick embryo, which is classically considered to be formed by intramembranous ossification, first consists of chondroid tissue. As in the cranial vault, this tissue thus represents the initial modality of the skeletogenic differentiation within the avian facial mesenchyme.

Skeletal growth and chondroid tissue

Membranous and endochondral ossification processes are insufficient to describe all the aspects observed in the growing skeleton. The presence of chondroid tissue that we have identified by means of all modern histological techniques, including those able to detect the different types of collagen, has also to be explained. Present in the mandibular symphysis of either the human or cat fetuses, chondroid tissue has also been observed in the other parts of the mandible, in the sutural areas of the skull and in all the bones of both axial and appendicular skeleton. The differentiation of the mesenchyme into chondroid tissue could probably be related with mechanical forces exerted simultaneously in opposite directions or with a transient ischemia.