False aneurysm of a brachial artery in a very premature newborn.

The authors reported a case of false aneurysm in the lower third of the right brachial artery in a premature newborn (25 weeks of amenorrhea) subsequent to puncture performed 48 hours before. The treatment was surgical: resection of the false aneurysm and anastomosis (Monobrin 11-0 sutures) to restore the continuity of the brachial artery. After 6 months of follow-up, the course is favorable, with improvement in healing and absence of any functional disorder of the arm.

[Surgical treatment for giant congenital nevi: what are the psychosocial consequences for the child and family?]. / Prise en charge chirurgicale des naevi géants congénitaux : quel retentissement psychosocial sur l'enfant et son entourage ?

Giant congenital nevus is a rare pathology. The incidence of malignant transformation exists and his unsightly aspect requires a early surgical treatment. All techniques of plastic surgery must have to be used. The management of the skin capital is a real surgical challenge with complications which are difficult to bear psychologically and physically for these young children. Authors present psychosocial effects of this pathology then surgical practice through 105 cases analysed. The majority of the patients had axial disposition of the nevus (head and trunk) and tissue expansion was the most utilised technique. A questionnaire estimated the notion of other's looking, congenital deformity's acceptance, surgical story's transmission, family's opinion of the surgical treatment. More than the half of families feel that their child was cast-off because of deformity. A lot of family would forget the nevus and never photographed their child with nevus. Sometimes, children could not explain their scars. Despite many hospitalisations, all the children have normal schooling and extra-school activities. It's important to begin surgical plan very early so that child could integrate their scars in their corporal schema.

[Use of a vascularized fibula for spinal reconstruction in neurofibromatosis]. / Intérêt d'un péroné vascularisé pour la reconstruction du rachis dans le cadre d'une neurofibromatose de type 1.

We report a case of reconstruction of a dysplasic thoracic spine with vascularized fibula in Recklinghausen's disease. We present the case of a thirteen-year-old lady with neurofibromatosis type 1 who developed a dystrophic thoracic kyphoscoliosis. A T9 compression due to a severe scaloping of the thoracic spine caused an important deformation and a medullar compression (with dorsal pain, right sciatica and a pyramidal syndrome). The surgery consisted in medullar liberation by a T9-T10 corporectomy and an osteosynthesis with arthrodesis T3-L3. A free vascularized fibula bone graft, with an end-to-end anastomosis on a thoracic pedicle, was realized to fill the T8-T11 spinal defect. All the symptoms decreased after surgery and the patient could walk normally few months later. At one-year follow-up the radiographs showed a stable montage and a solid bony fusion. Analysing the literature, vascularized bone graft can be recommended to fill the bony spinal defect due to surgery in cases of tumor, infection, trauma or severe scoliosis. Compared to non-vascularized grafts, which are exposed to resorption, fatigue fracture and then instability, the vascularized fibula grafts provide a rapid fusion, a biomechanically stable and long-standing support with low risks of infection.

[Use of muscle free flaps in lower limbs reconstruction in children]. / Utilisation de lambeaux libres dans la reconstruction des membres inférieurs chez l'enfant.

A series of 12 muscle free flaps was performed from 2000 to 2005 in 11 children 3 to 15 years of age (mean: 10.6): seven serratus anterior, four latissimus dorsi and one rectus abdominis. The defects (acute or as a result of sequelae) were always located in lower limbs: seven in feet, three in the lower third of the leg and one in the knee. None of the children was re-operated within 72 hours. Total necrosis due to venous thrombosis occurred at Day 5 in one case. After mean follow-up of 2.5 years (minimum: 1 year), the flaps show good integration. Functional or esthetic sequelae are considered acceptable by the health-care team as well as the children's parents. No repercussions on growth have been observed. Our series confirms the results of previous studies, indicating that free flaps should be part of the therapeutic arsenal in pediatric surgery.

[Surgical technique and advantages of the free temporal fascia flap for covering loss of substance of the dorsum of the foot and around the ankle: report of 12 cases]. / Particularités de la couverture des pertes de substance au niveau de la cheville et de la face dorsale du pied : intérêt du lambeau de fascia superficialis temporalis et précision technique du protocole opératoire: a propos de 12 cas.

The authors report a series of twelve patients with loss of substance of the dorsum of the foot or around the ankle who underwent coverage with a free temporal fascia flap. There were no failure of flaps and no vascular complication at the microanastomosis. There were three complications: partial burn of the flap with a lamp, failure of the split thickness skin graft and an area of scar alopecia at the donor site. With one year of follow up, there were no problems of cicatrisation and no patients had difficulty to the use of normal footwear. The different advantages of this flap led us to recommend it for the covering of wound in this area.

[Free-flap reconstruction in the elderly patient]. / La reconstruction par lambeau libre chez le sujet âgé

The objective of the study was to evaluate the safety and the efficacity of microsurgery in the elderly patient population. Between 2003 and 2005, 10 free-flaps were performed in 10 patients who were aged 70 years or older. One flap underwent reexploration, for an overall success rate of 100%. Medical complications in the postoperative period were further evaluated. Effects of American Society of Anesthesiologists (ASA) status, operation time, and age on complication rate were evaluated. Only ASA status was significant for the occurrence of postoperative medical complications; class 3 and 4 patients were at higher risk than class 1 and 2. Neither operation time nor age was predictive of postoperative complications. Microvascular free-tissue transfer is a safe and reliable option in the elderly population. The success rate of free-flaps is not different from that for other age groups. The rate of postoperative medical complications was 20%: most complications were in ASA class 3 and 4 patients.

[Pectus excavatum: what treatment in plastic surgery? About 10 cases]. / Le thorax en entonnoir: quelle prise en charge en chirurgie plastique? A propos de 10 cas.

SUBJECT: Several controversial issues concern pectus excavatum (funnel chest), the most common chest wall deformity. The pathogenesis of this deformity is uncertain, and there is no agreement as to its psychological, cardiac and pulmonary effects. An even more debatable point is the choice of surgical treatment among the more or less radical proposals made by different teams. No consensus exists concerning the indications for surgery, the technique to be used, or the suitable age of the patient. MATERIALS AND METHODS: This retrospective study concerns 10 patients with funnel chest who underwent reconstruction surgery in our unit between 1989 and 2002. Nine patients received a silicone chest implant made to measure, and one a single breast implant. Each patient was interviewed and examined to obtain information and provide a basis for evaluation. The effects of possible associated abnormalities were evidenced by complementary cardiopulmonary examinations, and the severity of funnel chest was evaluated according to the Haller pectus index. RESULTS: The mean period after surgery was 5 years. The effects of funnel chest deformity were essentially psychological, relating to aesthetic disgrace. Although two-thirds of the deformities were considered severe, cardiopulmonary repercussions were minor. All 10 patients were satisfied with the repair performed, and this judgment was independent of surgical assessment. Acute complications concerned 5 seromas and one minimal scar separation. DISCUSSION: The indications for surgery and the means of surgical treatment for funnel chest are considered after comparison of our results with those in the literature and a survey of the different existing possibilities for treatment (implant, chondrosternoplasty, fat transplant).

[Effectiveness of Integra in the management of complete forearm degloving injury. A case report]. / Intérêt de l'Intégra dans la prise en charge d'un dégantage complet de l'avant-bras. A propos d'un cas.

A 43-year-old man suffered complete skin degloving of the right forearm in a work accident with a farm machine. Initial treatment using a total skin flap graft after fat removal failed because of nearly complete necrosis after ten days. Artificial dermis (Intégra) was then used to ensure skin cover and reduce adherence phenomena. Postoperative complications were minor, and a split-thickness graft performed after three weeks led to healing five weeks later. At one year of follow-up, scar quality was considered very good, with normal and symmetric mobility. This case suggests that Intégra could be a valid surgical alternative in the management of skin degloving injuries.

[Anatomic study and clinical application of the skin paddle of the serratus anterior free flap]. / Etude anatomique et applications cliniques des caractéristiques de la palette cutanée du lambeau libre de grand dentelé.

SUBJECT: Several authors used musculocutaneous free flaps of serratus anterior. However, the localization and dimensions of its skin paddle are not clearly defined in the literature. Thus, we realized an anatomical study trying to prove the reality of this skin paddle and its localisation, before considering clinical applications. PATIENT AND METHODS: Twenty-six dissections on 13 fresh anatomical subjects were realized. The protocol consisted in catheterization the thoracic branch of the thoracodorsal artery to inject a mixture of iodized product and methylene blue. The results were obtained by direct measurement of the blue cutaneous area and by radiographic evaluation of the radiopaque area, compared to reproducible anatomical reference marks. RESULTS: Twenty-five dissections were interpretable with superposable results. The skin paddle was always located compared to the 5th, 6th and 7th ribs between the anterior axillary line and the mamelonnary line. The area of the skin paddle was 11,75 cm of length (10-14), 10,75 cm of width (9-12) and 125 cm(2) from surface (110-140). Then, we realized between January and December 2003 several clinical applications of this anatomical study. We report 12 cases of free flaps of serratus anterior with skin paddle for the monitoring of the flap (4 musculocutaneous, 5 osteo-musculo-cutaneous, 3 of fascia with skin paddle). CONCLUSION: This study comes to the support from the anatomical observations from Salmon, the per-operational observations of several authors and our own clinical experiment. It certifies the autonomy of cutaneous vascularization by branches resulting from the surface fascia of the muscle. It specifies the localization and dimensions of the skin paddle of the serratus anterior flap in its muscular, osteo-muscular or fascial form, which still increases its versatility of use.

[The orbitonasolabial flap. Anatomical and clinical study]. / Le lambeau orbitonasogénien. Etude anatomique et clinique.

How to use the orbitonasolabial flap in vascular island thanks to his pedicle based an angular vessel. An anatomic study based on 11 cadavers allows to check the existence of a constant pedicle. This flap was used on 6 patients aged 62 to 90 years old on an average period of 16 months to fill up jugular, orbital, nasolabial and inner canthal defects. Two complications have occurred, a superficial necrosis of the lower part of the flap having spontaneously healed and an ectropion on a senile part. It has been necessary to degrease a second time in 50% of the cases. Nevertheless, the flap can be considered reliable and able to cover tissue defect in the central facial region with minor aesthetic and functional sequel on the donor site.

Cement burns: retrospective study of 18 cases and review of the literature.

SUBJECT: Cement is increasingly used in the construction industry, but the occurrence of cement burns is rarely reported. This retrospective study concerns patients treated for cement burns in our unit between 1997 and 2002. MATERIALS AND METHODS: Eighteen patients 18-64 years of age, treated previously in our unit for cement burns, were interviewed by telephone for evaluation. RESULTS: The mean time since treatment was 39 months. Burns were predominantly seen on the lower limbs, and a third occurred during an accident on the job. All deep burns were excised, and 16 patients received grafts. Mean hospital stay was 10 days, and mean sick leave 2 months. Our study indicated that all patients were poorly informed about cement-related risks. DISCUSSION: Surgical treatment of full-thickness cement burns at diagnosis enables rapid healing with a minimum of sequelae and reduces the high socioeconomic costs resulting from these lesions. CONCLUSION: This study indicates once again the need to improve preventive measures; which are very often inadequate because of lack of awareness of risks.

[The serratus anterior free flap in limb reconstruction. About 30 cases]. / Le lambeau de serratus anterior en chirurgie reconstructrice du membre inférieur. A propos de 30 cas.

Between 2001 and 2003, 30 serratus anterior free flaps have been realized in our unit for reconstruction of lower limb. The flaps were indicated for repair of traumatic soft tissue defect in 19 cases, for chronic wound in six cases, for purpura fulminans in two cases, for pressure sore in one case and after tumor resection in 1 case. There were 29 patients: 25 males and four females. They ranged in age from 5 to 64 years. The size of the soft tissue defects ranged between 15 and 180 cm(2). Four different types of serratus anterior flaps were used: 20 muscle flaps ; four myocutaneous flaps ; five costo-osteomuscular flap ; one costo-osteomyocutaneous flap . In all cases we used osteo flap (8 th rib) in order to restore bone defect, which ranged from 9 to 15 cm. Necrosis occurred in two flaps because of venous thrombosis. The functional outcome was good for all patients and the aesthetic sequelae at the donor site were considered as minor. The serratus anterior flap can be used in many different ways: different kinds of flaps (osteo-cutaneous-muscle); very variable size of flap (15 to 180 cm(2) in our series) , different length of pedicle possible. Because of his versatility and his absence of major functional or aesthetic sequelae the serratus anterior free flap has become day by day our favourite option in limb reconstruction.

[Anatomical study of the nerve supply of the trapeziometacarpal joint. Fifteen dissections]. / Etude anatomique de l'innervation de l'articulation trapézo-métacarpienne. A propos de 15 dissections.

PURPOSE OF THE STUDY: When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation. MATERIAL AND METHODS: This anatomical study was performed by dissection under magnification (4.5-x350) of 15 upper limb cadaver specimens. The median nerve, its thenar and volar cutaneous branches and the terminal sensorial branches of the radial nerve were dissected. Articular branches to the TMCJ were carefully identified. Histological samples were taken to verify the neurological nature of the elements dissected. RESULTS: All TMCJs dissected exhibited radial and median nerve supply. Branches of the median nerve predominated in number and caliber. The volar cutaneous branch gave rise to articular branches in eleven dissections and the thenar branch gave rise to articular branches via a retrograde arciform trajectory between the short abductor and the opponens digiti pollicis in thirteen. For five dissections, the TMCJ branches arose directly from the median nerve within the carpal tunnel. At histological analysis the dissected elements were identified as nerves. DISCUSSION: There have been few anatomic studies concerning the nerve supply of the TMCJ. Unlike the findings reported by Cozzi in 1960, we did not find the dorsal sensorial branch of the radial nerve to play an exclusive or preponderant role in the innervation of the TMCJ. The median nerve supply to the TMCJ appeared to be more significant, particularly for the volar cutaneous and especially thenar branches. CONCLUSION: Total and definitive selective denervation of the TMCJ appears to be a most difficult procedure which would require a very wide access and extensive dissection, including the thenar branch which would raise the risk of significant complications.

A silver sulphadiazine-impregnated lipidocolloid wound dressing to treat second-degree burns.

OBJECTIVE: To evaluate the efficacy and tolerance of Urgotul SSD dressing (Laboratoires Urgo) in the treatment of second-degree burns. METHOD: This was a national multicentre phase III non-comparative open-label prospective study involving 10 burns units. The 41 subjects were non-immunosuppressed adults with second-degree thermal burn(s), which were clinically non-infected, less than 24 hours old, had a surface area less than 500 cm2 and warranted the local use of silver sulphadiazine. For four weeks, subjects were followed up weekly with a clinical assessment, bacteriological swabs and photographic recording. RESULTS: Of the 41 patients, 24 healed within a mean of 10.8 days and 13 had a skin graft on the study burn within a mean of 11.5 days. There were four premature study withdrawals. The total number of cumulative treatment days was 445, and 298 treatments were performed (including 257 dressing changes). Mean dressing wear time was 1.73 days. None of the subjects acquired a secondary infection. Researchers took 121 bacteriological samples, and wound colonisation with Staphylococcus aureus was found in only one patient. At follow-up nursing staff reported that dressing acceptability was good. CONCLUSION: Use of Urgotul SSD led to a good wound outcome--wounds healed or were grafted.

[The "vessel case flap". About one case in the lower limb]. / Le "vaisseau porte lambeau". A propos d'un cas clinique au niveau du membre inférieur.

The authors report an atypical case of lower limb repair in a 69-year-old patient, who presented a closed fracture of the tibia initially fastened with a plate. Skin necrosis developed after osteosynthesis, exposing the plate and the fracture bone. Because of the vascular state of the patient (smoking, arteritis, diabetes), any microsurgical procedure seemed likely to fail. The incisions previously performed contraindicated any form of pedicle flap in the leg area. An original solution was then proposed, involving the long extensor muscle of the great toe pedicled proximally on the anterior tibial artery. After six months of follow-up, healing and bone consolidation have been achieved. The interest of this exceptional technique is considered with respect to therapeutic choices for lower limb repair.

[Surgical treatment of facial lipoatrophy]. / Traitement chirurgical des lipoatrophies faciales.

The lipodystrophy syndrome is one of the major event of potent antiretroviral therapy. This treatment results in lipoatrophy, lipohypertrophy or mixed syndrome. Lipoatrophy is characterized by a loss of subcutaneous fat. The psychological impact may be severe when it is localized at the face. The aim of this study was to show the possibilities of improve lipoatrophy by autologuous fatty tissue transplantation with the Coleman method. Since december 1999 we have a plastic surgery consultation for lipodystrophy. From December 1999 to march 2002 we have seen 87 patients in consultation and 29 patients have been treated for facial lipoatrophy with Coleman method. The patients were evaluated clinically and with serial photography at 1 and 6 months post operatively. Coleman method is the ideal treatment for facial lipoatrophy in HIV infected patients. This technique is reliable and preliminary results show durability of fat graft after 6 months. Nevertheless, Coleman method is restricted by fat availability and can not be used for all lipoatrophy.

[Intracranial hemorrhages associated with oral anticoagulant therapy. Analysis of 38 cases]. / Hémorragies intracrâniennes associées à un traitement anticoagulant oral. Analyse de 38 observations.

The major risk of oral anticoagulant therapy is haemorrhage potentially affecting all organs. Bleeding in the central nervous system is a rare but severe complication of anticoagulant therapy. This study aimed to analyse a series of intracranial haemorrhages. This series from the Regional Pharmacovigilance Center of Amiens included spontaneously reported and retrospectively collected cases from January 1999 to December 2000. During this period, 38 cases of intracranial bleeding possibly related to oral anticoagulant administration were reported; 19 women and 19 men, median age 69.5 (29 to 87) years. In 34% of the cases, patients died and in 18% neurologic sequelae were still present at the time of the evaluation. In 21 cases (62%), the INR (International Normalized Ratio) was higher than the therapeutic range recommended for the indication. Among the most frequent risk factors, hypertension and recent minor trauma are highlighted in this series. In 17 cases, oral anticoagulants were associated with potentially potentiating drugs. Mental status changes or headache were prominent early symptoms which had often been present for days. Our data confirm that anticoagulant-associated intracranial haemorrhages are not rare, can be severe, potentially fatal and are probably underestimated by physicians. The fact that more than 50% of patients in this series were overanticoagulated at the time of bleeding suggests that many cases of intracranial haemorrhage could be prevented by improved anticoagulation control. Epidemiological studies are needed in order to prospectively evaluate the incidence of this type of complication and its avoidance. The value of anticoagulation clinics can be discussed.

[Efficacy and tolerance of Algosteril (calcium alginate) versus Jelonet (paraffin gauze) in the treatment of scalp graft donor sites in children. Results of a randomized study]. / Evaluation de l'efficacité et de la tolérance d'Algostéril (compresse d'alginate de calcium) versus Jelonet (gaze paraffinée) dans le traitement du site donneur de greffe dermo-épidermique du cuir chevelu. Résultats d'un essai pédiatrique.

Split skin graft is frequently needed in the treatment of burned patients. Scalp is often free of burns. Due to its good skin quality and important surface, scalp is a very interesting skin donor site, specially in case of children. A controlled, randomised clinical trial was carried out in 10 French Plastic Surgery or Burns Units. It assessed the efficacy and the acceptability of calcium alginate dressing (Algosteril) versus paraffin gauze dressing (Jelonet) in the treatment of scalp donor sites in children. 67 children (mean age 54 months) entered the study, 34 in the alginate group and 33 in the control group. Follow-up visits were on day 2/d3, d5/d6, Day complete healing, d30 and d60 after surgery. The two groups were comparable on inclusion (demographic characteristics, burn nature and surface, donor site surface and thickness of split skin graft). The mean healing time was 10 and 11 days for Algosteril and Jelonet group respectively (ns). The quality of the newly formed tissue was estimated to permit a sooner skin reharvesting in the Algosteril group than in the control group (p = 0.003). Bleeding through dressing was significantly less important in the Algosteril group (p = 0.02). Changes were considered by investigators less painful with Algosteril on day complete healing (p = 0.0096). Hair growth is homogenous in both groups on day 30 and day 60 (ns). These results showed that scalp is a very interesting skin donor site and that Algosteril is of a real interest in donor site treatment.