Shoulder function after latissimus dorsi transfer in breast reconstruction

BACKGROUND/AIMS

Latissimus dorsi (LD) transfer in the case of breast reconstruction remains frequently used because this muscle provides a good size source of tissue in reconstructive surgery. Given that, the consequences of the LD removal on shoulder function and the actual loss of maximal strength developed must be investigated.

METHODS

Twenty women (50 ± 7.5 years old) were evaluated before surgery, 3 and 6 months after an unilateral transfer of a pedicle flap of LD muscle used for breast reconstruction. Women performed a bilateral shoulder isokinetic assessment [for the internal rotators (IRs) and external rotators and for the abductor and adductor (ADD) muscles] allowing the establishment of bilateral muscular deficit status and the study of agonist/antagonist muscle ratios. The algofunctional and clinical status of the shoulders was analysed by the means of Constant score and specific shoulder clinical tests. The women did not perform any specific strengthening of muscle shoulder after surgery.

RESULTS

The isokinetic assessment showed a muscle weakness 3 and 6 months after LD transfer, mainly on the ADDs (33 ± 9% at 6 months) and on the IRs (16 ± 11% at 6 months). The Constant score significantly decreased after surgery on the operated shoulder. Women with a Constant score impairment showed pain during specific shoulder clinical tests. We also found a correlation between Constant score impairment and internal rotators weakness or rotator muscle imbalance.

CONCLUSION

Given those results, we could advocate a specific shoulder strengthening after LD transfer, focused mainly on the IRs and ADDs.

Munchausen′s syndrome in plastic surgery practice: A bewildering situation!

The plastic surgeon rarely encounters patients expressing factitious disorders. Through their incredible imagination, these patients conjure numerous lesions for themselves and willingly accept to undergo invasive diagnostic procedures and risky therapies. We report four cases of Munchausen′s syndrome in the field of plastic surgery and follow with a discussion of as to when should the alarm bells start ringing for the unsuspecting plastic surgeon, to assist him in dealing with these too often-ignored disorders.

Expansion tissulaire et seins tubéreux: à propos de dix cas

INTRODUCTION

Tuberous breast is a deficiency of mammary development, principally in the lower lateral and medial quadrants. In types II and III of the Grolleau classification, we perform a two-stage correction by tissue expansion associated with an implant in order to avoid the double bubble deformity and the difficulty of medial infra-mammary fold reconstruction.

MATERIALS AND METHODS

Between February 2003 and February 2006, ten patients have been treated by implantation of an anatomical expander associated with a vertical and horizontal Puckett plasty. The second operation consisted in the replacement of the expander by an anatomical prosthesis associated, if necessary, with a second Puckett plasty and lipofilling.

RESULTS

There was no double bubble deformity. Three patients required a complementary lipofilling to improve the result of the lower medial fold. One prosthesis had to be repositioned and one expander infection was responsible of a three-month delay in the reconstruction procedure.

CONCLUSION

Tuberous breast correction is a therapeutic challenge in quite psychologically distressed patients. In types II and III, tissue expansion associated with a Puckett plasty increase the volume of the lower pole and reduces the risk of the double bubble deformity. The implantation of an anatomical prosthesis gives more natural effect to the contour of the glandular lower pole. This therapeutic attitude gives the chance of achieving a completely satisfactory result.

Necrotizing fasciitis: case report and review of literature

We report a case of necrotizing fasciitis of the lower limb. This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles. Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to clinical findings. Paucity of cutaneous findings early in the course of the disease makes diagnosis challenging. The confirmation of the diagnosis is often made after surgical debridement. Delay in diagnosis and/or treatment correlates with poor outcome, leading to sepsis and/or multiple organ failure. Radiologic studies including plain radiographs, CT-scan or MRI may help to diagnose necrotizing fasciitis. Prompt surgical debridement, intravenous antibiotics, fluids and electrolytes management and analgesia are mainstays of the therapy. Adjuvant treatments like clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed.

[Surgical treatment of chest wall tumors]

The observation of a primary chest wall desmoid tumor discovered incidentally in a young patient is an opportunity to review the nosology, diagnosis and treatment of this uncommon pathology. Surgical intervention should aim at resecting completely the lesion with sufficient margins. Subsequent reconstruction of the bony thorax uses synthetic materials and muscle or myocutaneous flaps.

Liposuction: review of the techniques, innovations and applications

Liposuction is currently the most frequently performed aesthetic operation in the world. Despite its wide-spread popularity, it should nevertheless be stated that it is not trivial surgery, not always benign and not as safe as intimated in the glossy office brochures. Since the initial description of liposuction, numerous changes have taken place. Today, surgical indications are well defined and the liposuction procedure is well codified. However, several surgeons and manufacturers have developed new equipment and techniques. We propose to survey all the techniques showing the real place of each of them. Their advantages and disadvantages will be discussed. The various techniques dealt with are: the wetting solution techniques, standard liposuction or Suction-Assisted Lipoplasty (SAL), internal Ultrasound-Assisted Liposuction (iUAL), VASSER assisted liposuction, external Ultrasound-Assisted Liposuction (eUAL), Laser-Assisted Liposuction (LAL), Power-Assisted Liposuction (PAL) and Vibroliposuction (VL). On the basis of this review of the literature and of our clinical experience, we conclude that VL is the safest, most effective and precise surgery that can be used in any of the modern indications for liposuction. We concluded that VL seems to have all the advantages and none of the disadvantages associated with iUAL.

[Necrotizing fasciitis: diagnosis and treatments]

The necrotizing fasciitis is a medico-surgical emergency, characterized by the rapid speard of the infection in the subcutaneous tissue, involving fascia superficialis. Peaucity of cutaneous findings early in the course of the disease makes diagnosis a challenge for physician. Pain out of proportion to clinical findings, fever and signs of systemic toxicity are the keys in identification of necrotizing fasciitis. Delayed diagnosis lead to sepsis syndrom and/or multiple organ failure and correlate with poor oucome. Radiolographs, CT-scan or MRI are main radiologic studies, but such procedures should never delay surgical intervention. Intravenous antibiotics, fluid and electrolyte management and analgesia are needed in addition to radical debridment. Clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed treatments. Only prompt recognition and immediat care warrant a lower mortality and morbidity for this life-threatening infection.

Thromboprophylaxis in microsurgery

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture.

[How I treat...fibroproliferative scars]

Following a skin injury like burn, surgery or a trauma, fibroproliferatives scars are responsible of cosmetic, psychologic and symptomatic disorders. Keloids are benign and occur secondary to an imbalance between the synthesis of extracellular matrix and its degradation. There is a lot of therapeutic modalities available. Despite this, recurrence and sometimes increasing lesions are the major complications. Surgery with adjuvant therapy like steroids injections, radiotherapy, silicone materials seems today the best therapeutic choice. A best physiopatholgy's comprehension is at the base of new treatments, but their efficacity still need to be demonstrate in larger studies.

Prothèses lisses ou texturées : que choisir ?

Envelope structure has evolved since the seventies. Indeed, low-bleed implants allow an important reduction of capsular contracture for silicone filled implants. Later, textured implants permit an additional reduction of capsular contracture, especially when positioned in a retroglandular pocket. Whereas many studies confirm these findings, the interest of textured implants in the retromuscular plane is not really clear, even if some authors recommend it. Due to the need of a tissular anchorage, anatomical implants are not manufactured with smooth envelopes.

Covering small defects on the weight bearing surfaces of the foot: the free temporal fasciocutaneous flap

Although defects in the weight bearing area of the heel can be covered by local flaps, radiodermatitis is a contraindication to these flaps. Thin free flaps, as grafted fascial or muscles flaps and thin fasciocutaneous flaps, are usually the option of choice in these particular defects. These reconstructions are prone to shearing strains resulting in ulceration, hypertrophic scars and hyperkeratosis. The authors present a retrospective study of the reconstruction of six small heel defects with the fasciocutaneous temporal free flap performed between 1996 and 2001. The mean size of the defect was 20 cm(2). All arterial anastomoses were performed end to side on the posterior tibial artery. Despite the flap thinness, swelling was present during 12-25 months and one debulking had to be performed. With a mean follow-up of 32 months, all flaps regained protective sensibility after 7 months. No sliding of the flaps could be noted but there was one transient hyperkeratosis. Although the amount of hair on the transferred flaps decreased spontaneously with time, laser hair removal was performed in two patients for psychological reasons. In conclusion, it seems that in selected cases where local flaps are contraindicated, the fasciocutaneous temporal free flap can offer an excellent alternative for heel reconstruction. Due to its particular architecture, it resembles the complex tissue of the sole of the foot resulting in fewer complications and maintenance of flap durability.

La maladie de Mondor : une complication de la chirurgie mammaire

Mondor's disease is a rare but not uncommon complication of breast surgery. This problem is commonly described as the thrombophlebitis of the superficial thoracoabdominal veins. Symptoms combine painful contracture occurring in the sub-mammary region and/or in the axillary region, rising during arm abduction. The contracture located in the axillary region usually join the epitrochlea. Based on a serie of 8 patients, the fascial hypothesis is developed. All the patients were treated by LPG and myo-fascial techiques with a complete relief of pain in 10 days.

Tip of the greater horn of the hyoid bone: a landmark for cervical surgery

The purpose of this study was to assess the relevance of the tip of the greater horn of the hyoid bone (THB) in the localization of the carotid bifurcation, the superior thyroid and lingual arteries, and the hypoglossal and superior laryngeal nerves. Measurements of these structures with respect to the THB were also made. Thirty perfusion-fixed human cadavers (60 specimens) were studied. Sharp measurements were made along two orthogonal axes crossing exactly on the THB. The vertical axis was parallel to the craniocaudal axis of the body. Taking the THB as a landmark, the five structures were identified in all the specimens. The mean value, standard deviation, and range of measurements for each structure studied are given in the text. This study shows the THB to be a useful landmark which is an aid to locating the aforementioned structures with confidence, and concludes that knowledge of this landmark would be beneficial for the surgeon dealing with the mid neck area.

Combined Reconstruction of the Diabetic Foot Including Revascularization and Free-Tissue Transfer

Diabetic patients, presenting with both peripheral vascular disease and large soft-tissue defects, are too often treated by primary amputation. A combined revascularization and free-tissue transfer procedure can extend limb salvage in these patients. The authors report their experience over 4 years with 19 diabetic patients with peripheral vascular disease and large soft-tissue defects of the foot requiring free-tissue transfer. Although there was a 100 percent flap survival, early local wound problems occurred in three patients (16.6 percent). The recurrence rate was about 18.7 percent, but no complementary flap procedures were mandatory. With a mean follow-up of 38 months (range: 23 to 55 months), the limb salvage rate was 94.4 percent. Although there was one limb loss and one patient with ambulation difficulties, 16 patients (84.2 percent) were fully rehabilitated and were able to function independently. Despite a rather small series, this study confirms that in selected diabetic patients, a combined approach of vascular and reconstructive surgeons can reduce the limb amputation rate with acceptable complication rates. This combined approach offers major benefits to these patients, especially stable coverage and preservation of ambulation, and should always be considered before amputation.

[Severe paroxysmal drug eruptions]

Some drug reactions showing cutaneous expression exhibit a paroxysmal course. These diseases encompass the toxic epidermal necrolysis, the drug hypersensitivity syndrome, and the acute generalized exanthematic pustulosis. These syndromes are associated with dismal outcome. They represent medical emergencies needing hospitalization in specialized care units.

Breast implants. A review

Breast implants have been used for about four decades for both reconstructive and aesthetic purposes. In 1963, the quality of the artificial implants was revolutionized by the introduction of the silicone gel-filled implant. Since, this modern prosthesis has gone through an evolution of change and improvement with several types of devices with many variations and styles within each class. Actually, for the last three decades, approximately one million women have received silicone breast implants in the USA. But, in 1992, the American FDA banned silicone from the market, leaving saline implants as the only product generally available as an alternative until now. Other filler materials were introduced, but have never progressed beyond the experimental stage in the USA (in contrast with Europe). The evolution of the different implants through time, with their advantages and disadvantages will be discussed, but also the controversy on silicone implants in the USA and their suspected association with systemic diseases.

Abdominal aplasia cutis congenita: case report and review of the literature

A case of bilateral abdominal aplasia cutis congenita without skull defect is reported and was treated successfully by a combination of allografts and growth factors delivered by allogenic cultured keratinocytes.

[Coverage of defects: principles]

The coverage of defects is a broad field with which the plastic surgeon is confronted daily within traumatic, tumoral or other context. The various techniques used are skin graft and flaps, forming both heterogeneous groups. Indeed, there are various types of skin graft although a common denominator is the need for a good recipient site in order to allows an adequate "take". On the other hand, flaps carry their own vascularization. Thus, they are not dependent of the recipient site for their survival. Those are divided into three groups: local flaps, pedicled flaps and free flaps. The choice of the adequate technique with respect to the defect to be covered depends on the characteristics of the defect, its localization, the functional requirements of the area, the exposed structures, the medical status of the patient. The possible morbidity left on the donor site the aesthetic and functional goals are taken into consideration. For each case, there are often several good options as well as others less optimal solutions. The existing solutions are often so numerous that the plastic surgeon is frequently able to solve all the types of defects.

[Free flap pedicle loss: clinical study on 8 cases]

The authors report on 8 cases of free flaps with vascular pedicle disruption that were encountered between postoperative days 8 to 18. In one case, the inflow disappeared 18 months after the transfer without any trouble. This resulted in 2 partial and one complete flap losses. The 4 other flaps survived completely. This complete survival is related to the angiogenesis process coming from the surrounding tissues. The most obvious causal factor responsible for the 2 partial losses was the coverage of large, non viable areas, such as a prosthetic material and bone deprived of periosteum. The only causal factor that could be assessed in the case of total necrosis was the presence of an immunosuppressive treatment. Variables participating in the installation of an adequate angiogenic response are then discussed in accordance to this experience and to the literature. Limited contact with viable tissue, ischemia-reperfusion or drugs limiting the angiogenesis seems to promote failure when the pedicle is quickly disrupted. Hypoxia seems to be the most important cellular mechanism promoting the angiogenesis in this context.

[Our experience with geniopexy in the treatment of OSAS]

OBJECTIVE

We examine geniopexy efficacy in OSAS treatment.

STUDY DESIGN

Seven patients, aged 36 to 61 years, were studied. The mean body mass index was normal.

RESULTS

Surgical late complications (modified symphysis proprioception) occurred in 4 patients. No patient was improved in sleep problems. Retromaxilly and retromandibuly were found in all patients by cephalometric study.

DISCUSSION

Our results are quite different from these described successfully by other centers. Geniopexy do not move maxillar and mandibular skeletal bones, which are retruded in our serie. This explains maybe our bad results. Actually, we propose for this patients maxillo-mandibular advancement.

Surgical management of maxillomandibular advancement in sleep apnea patients: specific technical considerations

Maxillomandibular advancement is an integral part of the surgical treatment of patients suffering from obstructive sleep apnea. A number of publications report its efficacy and have attempted to define predictive success criteria. However, few authors have shown an interest in the surgical specificity of this intervention and in the difficulties that can be encountered, which differ from those seen in conventional orthognathic surgery. In this article, a series of patients treated with maxillomandibular osteotomy to correct obstructive sleep apnea syndrome (n = 17) are compared with patients who underwent surgery for the correction of dentofacial disharmonies (n = 33). Observations emphasized the importance of respecting a strict surgical and postsurgical protocol to avoid any technical traps linked to maxillomandibular advancement, both in preoperative simulations and during and after surgery. Results concerning sleep parameters will be the subject of a future publication.

[Vascular complications after cranio-facial trauma]

Despite recent advances in automobile safety, facial trauma remains a common event. Cranio-facial trauma, which usually occurs within a context of multiple trauma, can, in some patients, lead to serious life-threatening vascular complications. Such injury usually involves the carotid system (hemorrhage, aneurysm, dissection). Management of these vascular injuries must be given the same priority as other multiple trauma injuries. We present few typical cases illustrating carotid-cavernous or vertebro-vertebral fistulae, false aneurysms, arterial dissections or oro-facial bleeding. Bleeding is generally controlled by ligation or compression, other lesions being diagnosed secondarily by arteriography depending on the particular clinical situation. Treatment may involve endovascular procedures to achieve intravascular embolism or vascular occlusion.

Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest

Bone exposure constitutes a frequent and difficult problem in burn patients. Where free flaps remain indicated in tibial osteomyelitis, a pedicled fascial or adipofascial flap provides an excellent alternative for coverage of simple tibial crest exposure. In fact, the adipofascial tissue of the anteromedial aspect of the leg can be mobilized over the whole length of the tibia. It is vascularized by the saphenous artery and the posterior tibial artery perforators. This pattern of blood supply allows a wide range of use for any size of burn defect in this area. Therefore, this local pedicled flap provides an excellent solution for coverage of the exposed tibia after severe burns.

[Myxoma of the mandible. A case report]

Maxillo-mandibular myxomas are rare lesions and their pathogeny remains unclear. The poor clinical picture and the absence of pain makes the diagnosis difficult. Because of the long lasting course, the tumor is usually large at the time of diagnosis. Although this tumor is benign, the local aggression and the high rate of recurrence dictate a radical treatment.

[Deep vein thrombosis in a burn patient]

Association between deep venous thrombosis (DVT) and pulmonary embolism is probably an underestimated problem in the thermally injured patients. However, those patients display important risk factors according to Virchow's triad. This article reports on three unrecognised DVT's accompanying burns which were characterized by absence of healing or edema. The pathophysiology of this issue is then discussed with respect to the specific area of the thermally injured patient. It is our belief that local inflammatory phenomenon play a major part in the genesis of DVT associated with chronic non-healing burns.

[Arterial revascularization with free tissue transfer for salvage of ischemic limbs with extensive tissue loss: an alternative to amputation]

Severe limb ischemia is a common problem encountered in medical practice. Aggressive attempts at revascularization have extended the limits of limb salvage. However, in certain cases, extended tissue loss compromises the healing process. It often results in amputation despite bypass graft patency. Microvascular free tissue transfer combined with arterial revascularization allows healing of these wounds and limb preservation. This combined approach is the ultimate alternative to amputation.

[Chronic ulcer and wound dehiscence..when the origin is unknown and therapy is ineffective!]

The authors report on two cases of factitious disorders in the field of surgery. The discussion is focused on the different aspects of this pathology that are encountered by a plastic surgeon, in order to provide him with more confidence when dealing with this too-often ignored disease.

[Systemic infections of dental origin]

Microorganisms harbored in the oral cavity have long been recognized to cause systemic disease with a well known mechanism of spread via the blood stream. Different factors, including the presence of periodontal disease, the number of dental extractions or the duration of dental surgery have an influence on the risk of bacteremia. Infectious endocarditis is classically cited, but there are other potential problems including brain abscess, meningitis, lung or lie abscess, and even for some authors, a risk of thrombotic heart disease. It is important to keep in mind that some of these focal infections may be possible complications of dental (or buccal) infection. Prevention is crucial.

[Hypothenar hammer syndrome]

The hypothenar hammer syndrome is an uncommon but underestimated lesion of the cubital artery caused by repetitive trauma at the level of the hamate bone. It characteristically occurs in patients with a history of manual work as metal workers, carpenters and motor mechanics. We present a case of a patient who developed this syndrome following intensive use of a dig. Clinical finding, diagnosis and treatment are discussed.

[Adipofascial flaps of the frontal-internal part of the leg: an alternative to free flaps for the repair of skin loss from the knee to the ankle. Report of a clinical experience with 17 cases]

Leg coverage remains a difficult challenge for plastic surgeon, especially in certain areas. Although treatment of osteomyelitis is well established, coverage of bone, tendinous or hardware exposure remain controversial. In these selected cases, adiposofascial pedicled flaps should constitute a interesting solution. The multiples vascular supplies to the adiposofascial tissue of the medial side of the leg constitute de basis of this flap family. These condition allows an extreme adaptability to a wide range of defect with maximal satisfaction.

Isolated adenomatous polyposis of the appendix: report of a case

This case study describes a 61-year-old patient who had previously undergone sigmoid polypectomy. A follow-up colonoscopy revealed a polyp prolapsing into the colonic lumen through the base of the appendix. A laparoscopic-assisted appendectomy was performed, in which the cecum was exteriorized through the trocar hole so that a wide excision of the base could be performed. Fifty-eight polyps were observed in the appendix, but the base was free of polyps. Histologic studies reveal well-differentiated villous adenomatous polyposes. The patient was symptom free four years after surgery.

Lesser curvature Roux-en-Y gastric bypass as an alternative procedure to failed vertical banded gastroplasty: surgical technique and short-term results

PURPOSE

The incidence of revisional surgery for failed vertical banded gastroplasty has increased markedly over the last years. Conversion to gastric bypass is considered as a good alternative with satisfactory long term weight loss without further revisional surgery. Nevertheless, significant morbidity and mortality is still associated with this procedure. New technical aspects make it safer and more effective. The aim of the work is to expose a surgical bypass technique to attempt to reduce morbidity.

PATIENTS AND METHODS

Thirty patients have undergone conversions from failed vertical banded gastroplasty to a lesser curvature Roux-en-Y Gastric Bypass. Surgical technique is described in detail and early complications and initial weight loss were analyzed (mean follow-up: 12 months).

RESULTS

The key points of the operation were the small vertical pouch, the complete transection of the distal bypassed stomach, the interposition of a jejunal limb between the two gastric shares and the latero-lateral gastrojejunal anastomosis without proximal ring interposition. For the entire series, we noticed one major complication, an acute pancreatitis causing anastomotic fistula and four mild complications, one bleeding on the excluded stomach, one bronchopneumonia, one pleural effusion and one wound dehiscence. The percentage of excess weight loss attained 56.1% at one year follow-up.

CONCLUSIONS

There have been tremendous improvements in the safety of gastric bypass over the years. One year follow-up indicates that our surgical bypass procedure is secure with a low complication rate.

[Management of hemangiomas and vascular malformations]

Vascular anomalies can be classified as hemangiomas or vascular malformations. Hemangiomas are benign neoplasms, frequently diagnosed in infancy. The vast majority of these anomalies are totally harmless and spontaneously regress, although they often worry the parents because of esthetic reasons. Only a few (1/4), however, are endangering and will require therapy. Vascular malformations are rather vessel abnormalities which, unlike hemangiomas, persist. They require a thorough evaluation and most will benefit from an intervention. The recent development of informative imaging techniques (ultrasonography, Dopplerflow imaging and magnetic resonance) has permitted significant advances in the etiology and therapy of these vascular anomalies. All too often, these patients shuffle from physician-to-physician seeking help. Thus the authors recommend a multidisciplinary approach. This team should include a plastic surgeon, a radiologist and a paediatrician.

[Scuba diving: risks for whom and why?]

Scuba diving is an occupation with a still growing expansion. Like every sport it has its own specific pathologies. Some accidents can be very serious and life-threatening. We discuss the 3 main groups of accidents: barotraumatism, gas toxicity and accidents related to aquatic environment. The knowledge of the mechanisms underlying these accidents leads to a less risky approach of scuba diving.

Metastatic involvement of ceco-appendicular segment: a diagnosis of right lower quadrant abdominal pain in patient receiving chemotherapy

Metastases are a common feature during the evolution of breast cancer. However, gastrointestinal metastases, and especially ceco-appendicular ones, are very rare. Melanoma however frequently metastasize in the gastrointestinal tract. Ceco-appendicular metastases do not display any specific signs in cancerous patients. These rare metastases must be considered in the diagnosis of right lower quadrant pain in cancerous patients. The main differential diagnosis includes neutropenic enterocolitis, acute appendicitis, malignant intestinal obstruction and perforation of the bowel. The morbidity of gastrointestinal complications in patients with metastatic cancer receiving chemotherapy is significant and surgery is often the only chance of survival. The major clinical decision is whether or not to operate.

[Indications and implications of surgical maxillary expansion in orthodontic surgery]

Surgically assisted rapid maxillary expansion is an accepted method for correction of transverse skeletal and dental discrepancies. The surgical technique includes a Lefort I osteotomy with medial palatine osteotomy. The maxillary must be totally released to achieve the desired expansion. There are several advantages: bone apposition in osteotomy sites, reduced risk of dental version or extrusion compared with orthopedic care, secondary surgical cure of complex dysmorphism requiring fewer segmentary osteotomies. Finally, we examined skeletal side effects induced by surgically assisted rapid maxillary expansion in the vertical and sagittal dimension of the face.

Recurrent pleomorphic solitary angiomyxoma of the face

The historical background of solitary and multiple myxoid tumors of the dermis is accompanied by a confusing conglomeration of names. We report a case whose histologic features do not fit exactly with previous classifications. It appeared as a solitary angiomyxoma of the face containing stellate pleomorphic cells and exhibiting a locally infiltrative behavior with tendency for recurrences over more than 25 years. This recurrent pleomorphic solitary angiomyxoma appears to be distinct from cutaneous myxomas that exhibit a very low local recurrence rate and from malignant tumors with myxoid deposits. The treatment consisted of a wide surgical excision.

Fractal quantification of the microvasculature heterogeneity in cutaneous melanoma

BACKGROUND

Recent advances in angiogenesis research have led to the introduction of new prognosis factors. Although the vessel count is effective in breast cancer, the prognosis of primary cutaneous melanoma (PCM) does not seems to be directly influenced by this parameter. However, the microscopic examination of PCM suggests variability in the repartition of the microvasculature.

OBJECTIVE AND METHOD

To explore the possibility of extracting information about the vessel distribution by performing a textural analysis on the grey level of histological sections by means of fractal characterization by both Fourier spectrum and multifractal analysis.

RESULTS

Three different patterns of vasculature were identified according to the vessel density and distribution.

CONCLUSION

It is possible to differentiate and quantify clearly the differences in the microvessel profile organization using the fractal and multifractal methods.

[How I treat...decubitus ulcers surgically]

Although pressure sores occur frequently during the evolution of paraplegic patients, they can present in patients confined to bed or in casts. Ischiatic, sacral and trochanteric sores are the most frequent. For stade III & IV lesions surgical excision followed by a coverage with healty tissue remain the only right principle. Usually, flap transfert meats these requirements. However, the selection of the surgical procedure and the post-op care are the main factors for a successful treatment.

Is fractal geometry useful in medicine and biomedical sciences?

Fractal geometry has become very useful in the understanding of many phenomena in various fields such as astrophysics, economy or agriculture and recently in medicine. After a brief intuitive introduction to the basis of fractal geometry, the clue is made about the correlation between Df and the complexity or the irregularity of a structure. However, fractal analysis must be applied with certain caution in natural objects such as bio-medical ones. The cardio-vascular system remains one of the most important fields of application of these kinds of approach. Spectral analysis of the R-R interval, morphology of the distal coronary arteries constitute two examples. Other very interesting applications are founded in bacteriology, medical imaging or ophthalmology. In our institution, we apply fractal analysis in order to quantitate angiogenesis and other vascular processes.

Extravasation injuries and emergency suction as treatment

To evaluate the efficiency of emergency suction in extravasation injuries of contrast medium, records of 11 patients treated for extravasation injuries with a combination of suction and saline washout were reviewed. All of the patients were treated in the first 2 hours after injury. The mean extravasated volume was 55 cc. There were no surgery-related complications, and all the patients experienced a relief of their preoperative pain. Except for two patients with blisters at admission, none of them suffered skin or soft-tissue necrosis. Mean time to complete healing was 9 days. Emergency suction therapy is safe and effective in preventing the skin and soft-tissue necrosis associated with extravasation injuries of hyperosmolar contrast medium.

Popliteal venous aneurysms. Report of a case and review of the literature

Venous aneurysms are uncommon in the vascular pathology of the lower limb. They are more commonly encountered in the neck, thoracic veins and visceral veins. Involvement of the popliteal veins is not often encountered. These aneurysms often cause thrombosis and subsequently pulmonary embolism. Phlebography and duplex scanning give the most accurate diagnosis. As the risk of associated pulmonary embolism is high, elective surgery is recommended since it has been proven that proper anticoagulation treatment does not prevent the risk of pulmonary embolism.

Vascular retardation in dormant growth-stunted malignant melanomas

Progression and metastatic spread of primary cutaneous melanoma (PCM) is largely predicted by the thickness of the primary tumor. However, the accretive or proliferative pattern of growth of PCM is another aspect that might affect the prognosis. We retrieved from our histopathological files 11 superficial spreading PCM which had been documented to show an almost stable size for at least 3 years before excision. The area of the PCM at the skin surface had been measured by planimetry on the excision specimens. Histological sections were used to measure the maximum thickness of the neoplasms. A PCM volume estimate was derived by multiplying the surface area by the thickness of the tumors. In addition, the vessel area was determined beneath and outside the PCM lateral margins on Ulex europaeus agglutinin-1-stained sections using computer-assisted image analysis. Peritumoral vascularity was significantly more developed than at distance of the neoplasms. A significant negative exponential correlation was yielded between the peritumoral vascularity and the PCM volume estimate. Such vascular eclipse might be the cause of clinical PCM dormancy. However, other possible independent mechanisms are not ruled out by the present study.