Pilomatricoma in children: common but often misdiagnosed.

A pilomatricoma, also known as pilomatrixoma or calcifying epithelioma of Malherbe, is a benign skin tumor arising from the hair follicle matrix. This tumor is common in children and young adults, especially in the head and neck region. However, pilomatricomas are frequently misdiagnosed or not recognized. The history is typical of a slowly enlarging mass, irregularly contoured, it is fixed to the skin but slides freely over the, underlying tissues, often with a discolouration which varies from red to purple-bluish. Ultrasound examination, MRI-scan and fine-needle aspiration can be helpful if the diagnosis is uncertain. Spontaneous regression has never been observed and malignant degeneration is very rare. Surgical excision with clear margins is the treatment of choice, otherwise recurrence may occur due to incomplete resection.

Solid phase DNA amplification: characterisation of primer attachment and amplification mechanisms.

Different chemical methods used to attach oligonucleotides by their 5'-end on a glass surface were tested in the framework of solid phase PCR where surface-bound instead of freely-diffusing primers are used to amplify DNA. Each method was first evaluated for its capacity to provide a high surface coverage of oligonucleotides essentially attached via a 5'-specific linkage that satisfyingly withstands PCR conditions and leaves the 3'-ends available for DNA polymerase activity. The best results were obtained with 5'-thiol-modified oligonucleotides attached to amino-silanised glass slides using a heterobifunctional cross-linker reagent. It was then demonstrated that the primers bound to the glass surface using the optimal chemistry can be involved in attaching and amplifying DNA molecules present in the reaction mix in the absence of freely-diffusing primers. Two distinct amplification processes called interfacial and surface amplification have been observed and characterised. The newly synthesised DNA can be detected and quantified by radioactive and fluorescent hybridisation assays. These new surface amplification processes are seen as an interesting approach for attachment of DNA molecules by their 5'-end on a solid support and can be used as an alternative route for producing DNA chips for genomic studies.

Cyanoacrylate tissue adhesive for closing skin wounds: a double blind randomized comparison with sutures.

A comparative double blind randomized study was undertaken in the rat, to compare the external cosmetic and the morphologic aspect of skin wounds, treated by the local application of adhesive glue (ethyl-2-cyanoacrylate-Mediglue) or classical suture technique. Skin incisions were applied and treated by a plastic surgeon, then photographed or biopsied, and evaluated and scored by independent observers, not aware of the initial treatment. Small (1.5 cm) or long (8 cm) incisions were made, on both sides of the back, and treated randomly on one side by glue and on the other side by sutures. Evaluations were performed at 1, 2, 4 and 8 wk. Both small and large wounds scored identically, irrespective of the treatment (overall score 1.5 cm wounds: 8.8 +/- 1.4 for glue versus 8.8 +/- 1.0 for sutures; 8 cm wounds: 8.3 +/- 1.9 versus 8.3 +/- 1.5; P = not significant). A morphological study demonstrated no adverse effects for the adhesive treatment, with a minor inflammatory infiltrate. Sutured wounds had a higher tendency to develop abscesses and/or major inflammation. Adhesive-treated wounds scored better than non-treated wounds (8.9 +/- 1.3 versus 7.4 +/- 3.3, P < 0.01). In conclusion, this controlled comparative study shows no difference in cosmetic aspect between adhesive and suture-treated skin incisions. Morphologically, the glue treatment is not related to any adverse effect or damage to the skin structures.

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap.

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar. The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum. All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps. This article discusses the expanding indications of this versatile flap and the refinements in operative technique.

Soft tissue trauma of the face.

In this paper the principles of primary care of soft tissue trauma of the face are outlined. The importance of a complete preoperative evaluation is stressed. Atraumatic technique, conservative debridement, reconstruction of anatomical landmarks, coverage of skin defects and removal of foreign bodies are essential. Lesions to deep structures and associated facial fractures should, if at all possible, be repaired at the time of soft tissue repair. Special attention should be given to eyelid repair. Lesions to the lacrimal duct system, to the canthi and to the levator muscle should be dealt with primarily.

Esthetic blepharoplasty.

Esthetic blepharoplasty is the operation designed to correct excess skin and/or pseudoherniation of fat in the eyelids. These eyelid changes give the pateint a tired look and make him or her look (prematurely) old. The indications and contraindications for the procedure are reviewed. The possibilites and the limitations of the operation must be thoroughly discussed with the patient preoperatively. A psychological evaluation of the patient must be carried out by the surgeon in order to discard unsuitable candidates for the operation. The esthetic blepharoplasty is performed under local anesthesia, completed by intravenous sedation. The operative technique is outlined and consists of judicious skin excisions and resection of fat from the differenct orbital compartments. Atraumatic technique is of utmost importance. Complications are rare in experienced hands but are almost unavoidable in inexperienced hands. Ectropion of the lower eyelid is the most common complication. The cause, prevention and treatment of possible complications are discussed. If carried out properly in a well selected patient by a competent plastic surgeon, the esthetic blepharoplasty gives very satisfying results.

Subcutaneous mastectomy, indications and techniques.

In this paper the indications, the technique and our personal experience with 45 subcutaneous mastectomies (S.C.M.) are reviewed. A bilateral S.C.M. is mainly a prophylactic operation, indicated in patients with premalignant breast disease and in high risk patients with widespread fibrocystic disease. A unilateral S.C.M. is indicated in patients who have already had a mastectomy for carcinoma and whose remaining breast has an increased risk for also developing a carcinoma. The technique which we nowadays prefer, consists of a S.C.M. with immediate submuscular prosthetic reconstruction. The operation is done through a transverse incision for small non ptotic breasts and following a Mc Kissock reduction mammoplasty pattern for large ptotic breasts. The nipple-areola complex is transposed on a wide dermal pedicle. Both the subcutaneous and submuscular spaces are drained and early postoperative mobilisation of the prosthesis is advised. Our experience with 45 subcutaneous mastectomies is reviewed. The complications have been few and occurred mainly in earlier cases where the prosthesis was inserted subcutaneously. Neither necrosis nor circulatory embarrassment of nipple-areola complex were encountered.

[Surgical treatment of decubitus ulcer in paraplegics. Experience with 70 reconstructive procedures (author's transl)]. / De chirurgische behandeling van decubitus ulcera bij paraplegici. Ervaring met 70 rekonstruktieve ingrepen.

Based upon our own experience with 70 surgical procedures for 49 primary decubitus ulcers, 17 complications and 7 recurrences in 31 paraplegics, and upon the techniques described in the literature, the different reconstructive methods and their advantages and disadvantages are discussed and illustrated with representative cases. The surgical reconstruction of decubitus ulcers requires a thorough planning and an atraumatic surgical technique. Nevertheless complications are not seldom and recurrences are possible.

Muscle and myocutaneous flaps. An alternative to free flaps.

The evolution in the concept of flap transplantation is reviewed. Better knowledge of the vascular supply of skin and muscle has made possible the evolution from random skin flaps to axial skin flaps, muscle flaps, myocutaneous and fasciocutaneous flaps and free flaps. Pedicled flaps remain a very valuable alternative to free flaps as they are easier and more expedient to execute. Our experience with 35 pedicled muscle flaps and 23 pedicled myocutaneous flaps for reconstruction of difficult defects all over the body is reviewed. The overall results have been very satisfactory as in this entire series only two partial necroses occurred in the muscle flaps, of which one in a distally based soleus muscle flap. Except for three superficial skin losses which healed spontaneously, no flap necrosis occurred in our series of myocutaneous flaps. In two crossleg myocutaneous flaps, two stages were necessary. In one myocutaneous pectoralis flap, the pedicle was sectioned in a second stage and also transferred to the face in order to bring in additional tissue. The other reconstructions were on stage operations.

Orbital fractures.

In this paper the importance of the clinical, ophthalmological and radiological examination in the diagnosis of orbital fractures is stressed. Indications for operative treatment can be esthetic or functional, such as enophthalmos or diplopia. A plea is made for early diagnosis and treatment. An open approach is used for all displaced fractures in order to obtain an anatomical reduction. Currently, miniplates and screws are used more frequently for stabilization. Defects in the orbital floor should be covered preferably with autogenous bone or, if unavailable, with bovine cartilage or some synthetic material.

Soft tissue defects of the lower extremities.

Based upon our experience with 459 skin and soft tissue defects of the lower extremities, of which 326 were covered surgically, the different etiologies of these defects are listed and the factors influencing the choice of a method of coverage are discussed. The advantages and disadvantages of the different reconstructive methods are reviewed and illustrated with representative cases.

Application of the IFSSH(3)-classification for congenital anomalies of the hand; results and problems.

The extended classification proposed by the IFSSH was used to classify 1013 hand anomalies in 925 hands of 650 patients. We found associated anomalies in 26.7%. The classification was straightforward in 86%, difficult in 6.6% and not possible in 7.8%. In group I the radial and ulnar deficiencies, limited to the hand and without forearm deficiencies should be included. Group II was the most important group including 513 anomalies. We propose to include in this group the Madelung deformity, the Kirner deformity and congenital trigger fingers and trigger thumbs. Triphalangeal thumbs are a problem, we suggest to list this anomaly in group III and to consider it as a duplication in length. It is not always possible to evaluate the (transverse) absence of the fingers or hand. Longitudinal deficiencies (group IIB), symbrachydactyly group (V) and amniotic bands (group VI) occasionally develop a phenotype similar to the genuine transverse deficiency (group IA).