Lower lip repair in Van der Woude syndrome

Van der Woude syndrome is an unusual congenital malformation. It combines lower lip sinuses with a cleft lip and/or palate. The asymmetry appears more pronounced due to lower lip hypotonia and procheilia, which are more unaesthetic than the fistulae themselves. The malformation of the orbicularis oris muscle in its medial part induces the hypotonic aspect of the lower lip, which contrasts with the retracted scarred upper lip after the cleft has been repaired. It is also responsible for a real bilabial asymmetry. For many years, the most common surgical treatment was simple excision of the sinuses. Bad functional repair results prompted the authors to try another surgical procedure, the split-lip advancement technique as described by Mutaf. The authors report here on 8 operated children out of 25 patients followed up for Van der Woude syndrome. They evaluated the results according to the appearance of the lip when relaxed, its functional aspect, and the satisfaction of the parents or the child. Our results point to the importance of early surgical treatment, radical excision of dysplastic tissue and the repair of lip muscles to restore good lip functionality and satisfactory bilabial symmetry. The technique now used in our department has made it possible for us to achieve these goals.

[Secondary reconstruction of stumps above the elbow. Five cases]

The authors report a serie of five patients with five stumps above the elbow who needed a secondary reconstruction to allow or facilitate a prosthesis. They used in the first case an expansion of the latissimus dorsi flap and of the axillary and prepectoral region in order to free the stump of the humerus sutured on the thorax. In the second case, a free parascapular flap covered an unstable scar of the clavicula after a scapulothoracic amputation. In the third case, the transfer of a free flap of fibula associated with a pedicled latissimus dorsi flap had allowed the elongation of the stump of the humerus. In the two last cases, a latissimus dorsi flap pedicled in one and free in the second one had allowed to preserved the length of the humerus for prosthesis. The technical choices are eclectic and different in every case. The purpose is to obtain an efficient trophicity and a thickness that can support the prosthesis and if possible a stump long enough to improve the adaptation of the prosthesis. The five operated patients were able to be apparated, reducing in this way their daily functional difficulties.

[Acute digital ischemia: a microsurgical emergency]

The authors are reporting their experience about the treatment of the acute finger ischemia concerning 14 patients. Twelve men and two women were concerned. The average age was 39 years old (18 to 65 years old). The acute finger ischemia was caused by emboli released by an ulnar aneurysm in nine cases and consecutive to an atrial fibrillation in five cases. The angiography was realized each time systemically in the emergency context. The medical or surgical etiological treatment was associated each time an emboli was found on the digital arteries. A microsurgical dissection of the digital collateral arteries permitted to perform a thrombectomy. The transversal arteriotomies were closed after collateral arteries were washed. The most proximal emboli were accessible to an extraction with a Fogarty's probe up to the superficial palmar arcade. An anticoagulant treatment was conducted in the early postoperative period. Considering this aggressive treatment, no secondary amputation was necessary up to today. The average follow-up was five years. This method has no indication for the chronic digital ischemias (diabetes, Buerger's disease) and for infectious or auto-immune arteriopathy.

[Failure of upper limb macro-implantations: surgery and outcome. 11 cases]

The failure of macro-implantation of the upper limb must not be considered as the end of a therapeutic method, but instead as a step in the functional rehabilitation of the upper limb. From a group of 24 patients that have been operated with a macro-implantation of the upper limb, we have seen 11 patients for who the reimplantation had failed. We have studied the surgical procedure of those failures, the mid-term evolution (prosthesis and operations), and a long-term evolution with the functional future of those patients. A surgical procedure with latissimus dorsi flap was necessary in six cases, in one hand to maintain a sufficient length of the stump for prosthesis and the other hand to preserve the articulation of the elbow. Nine patients on 11 were able to be "apparated" by a myoelectric prosthesis for the amputation below the elbow (seven cases), by prosthesis for the amputation above the elbow (two cases). On a long period of time (average time 51 months) only four patients had a permanent use of their prosthesis (myoelectric type). For us, the functional rehabilitation of the upper limb need two important elements: first a good quality of the stump with a sufficient length, and second an important motivation from the patient to live with his "new hand".