Variation of the proximal insertion of the abductor digiti minimi muscle: correlation with Guyon's canal syndrome? Case report and literature review.

We describe the case of an original insertion and course of the abductor digiti minimi muscle on the medial part of the palmaris longus tendon. The anomalous muscle was only present on the left side. Various studies have reported the frequency of anomalous muscles in approximately 22 to 35% of hands and it was in majority an anomalous abductor digiti minimi muscle. The knowledge of this original insertion is important because it can sometimes be correlated with ulnar nerve compression at Guyon's canal. But Guyon's canal syndrome is less common than carpal tunnel syndrome, and the incidence of ulnar nerve compression in relation with anomalous muscle is approximately 2.9% of cases. It is possible to diagnose the anomalous muscle through ultrasound or MRI. This variation should be taken into consideration by surgeons during surgical procedures for ulnar nerve decompression at Guyon's canal and when performing anteromedial approach to the wrist between flexors tendons and ulnar bundle.

[Composite midfacial flap vascularized by the facial artery: a preliminary anatomic study]. / Lambeau composite médiofacial vascularisé par l'artère faciale: étude anatomique préliminaire.

INTRODUCTION: Extended facial tissue defects are difficult to reconstruct because of the anatomical and functional complexity of the area. Recently, composite facial allotransplantation was used for reconstruction. This could be performed because of specific facial blood supply and its facial and maxillary anastomoses. Could a composite naso-labio-mental flap rely on the sole blood supply of a facial artery anastomosis? We performed an anatomic study of a naso-labio-mental composite flap vascularized by the facial artery. MATERIAL AND METHOD: The study relied on arteriographies made on cadaveric heads and in vivo. The following data was analyzed: caliber of facial and maxillary arteries, terminal branch of facial arteries, and vascular territories. RESULTS: Sixteen facial arteries and six maxillary arteries were studied. The mean facial artery caliber was 2.06 mm (1-3.2mm). The facial artery ended in the nasal area in 68.8% of the cases. The latero-nasal artery was always present; it was a branch of the facial artery in 66.7% of cases. The two facial arteries, when injected bilaterally, always allowed complete facial composite flap circulation. The nasal territory of the flap was not opacified by the homolateral facial artery in 16.7% of the cases. DISCUSSION: Both facial artery anastomoses are recommended as blood supply for composite midfacial flaps. Preoperative imaging should be used systematically to assess the vascular network before harvesting.

Antero-medial approach to the wrist: anatomic basis and new application in cases of fracture of the lunate facet.

The Henry approach is the classical anterolateral surgical exposure of the volar aspect of the distal radius. This approach does not allow good access to the medial side of the volar distal radius (lunate facet) and the distal radio-ulnar joint, unless it is extended proximally, retracting the tendons and the median nerve medially, which can cause some trauma. The purpose of our study was to investigate the anatomic basis and to outline the advantages of the unusual anteromedial approach, reporting our experience in the treatment of 4 distal radius fractures, with a 90° or 180° twist of the lunate facet, and 10 wrist dissections on cadavers. The average follow-up was 68.8 months (range 18 to 115 months). In our series, this approach did not cause any nerve injuries or any sensory loss of the distal forearm and the palm. All the fractures of the lunate facet and of the radial styloid process healed. One patient with an ulnar styloid process fracture associated showed pseudarthrosis, but with no instability of the distal radio-ulnar joint or pain on the ulnar side. Using the criteria of Green and O'Brien, modified by Cooney, the results were: excellent in two cases, good in one case, and average in another. The evaluation of arthritis according to Knirk and Jupiter's classification showed grade 0 in three cases and grade 3 in one case with osteochondral sclerosis. We showed that the anteromedial approach is reliable and convenient in the case of fractures situated in the antero-medial portion of the radius, for the double objective of reducing the fracture under direct control and checking the congruence of the distal radio-ulnar joint.

[Absence of the musculocutaneous nerve and its distribution from median nerve: About two cases and literature review]. / Absence du nerf musculocutané et distribution à partir du nerf médian : à propos de deux cas et revue de la littérature.

Musculocutaneous nerve arises mostly from the lateral cord of brachial plexus. Nevertheless, variations have been reported and, among them: the total absence of musculocutaneous nerve (from 1.4 to 15%), the absence of its passage through the coracobrachial muscle, its variable level of penetration as measured from the tip of the coracoid process, and its communicating branches with the median nerve. We report two cases of unilateral musculocutaneous nerve absence in a 66-year-old male and a 95-year-old female cadavers, on the right and the left side, respectively. The nerve fibers normally coming from musculocutaneous nerve emerged from the median nerve. The knowledge of this anatomical variation is important specially when performing plexus bloc or Latarjet's procedure.

[Tongue reconstruction with a bilateral infrahyoid flap innervated by Ansa Cervicalis after total glossectomy]. / Le lambeau infrahyoïdien bilatéral innervé par l'Ansa Cervicalis pour la reconstruction des glossectomies totales.

INTRODUCTION: Reconstruction after total glossectomy remains a functional challenge. It must provide a large volume to ensure adequate phonation and swallowing. We present the larynx sparing bilateral infrahyoid flap reconstruction procedure after total glossectomy. PATIENTS AND METHOD: Three patients managed for an epidermoid carcinoma of the tongue, classified T4N0, underwent total glossectomy. The tongue was reconstructed with a bilateral infrahyoid flap pedicled on two superior thyroid arteries and innervated by Ansa Cervicalis. RESULTS: Oral food intake was resumed after 8 to 20 days. No false route was observed. The muscular flap mobility was clinically satisfactory. It was assessed by EMG in one case. Esophageal transit confirmed the absence of stasis and false route for one patient. DISCUSSION: This short series proves the feasibility of bilateral innervated and pedicled infrahyoid flap procedure. It is an alternative to volumetric and functional reconstruction after total glossectomy. The indications are rare and restricted to patients without IIa nodal region invasion. Our results are still limited and need to be confirmed by a larger series and by a more systematic assessment.

Approach to the pterygomaxillary space and posterior part of the tongue by lateral stair-step mandibulotomy.

Fifteen patients underwent surgery for retromandibular parotid, pharyngeal, or posterior tongue tumors. Surgical approach to the pterygomaxillary fossa, parapharyngeal space, and posterior tongue was performed by external cervical incision and lateral stair-step mandibulotomy. After resection of the tumors, the mandibular segments were replaced and secured with miniplates. The plates were removed after six weeks whenever postoperative radiation therapy was planned. By reflecting the ascending ramus, this method provides excellent exposure of the concerned areas. It makes unnecessary both incision of the lower lip and intermaxillary fixation with arch bars, thus allowing a quick resumption of oral feeding. A review of 15 patients demonstrated satisfactory results for mandibular function and morphologic appearance, with minimal complications.

Modified approach for ethmoid and anterior skull base surgery.

The use of combined craniofacial resection is well established for tumors of the ethmoid bone and the anterior aspect of the base of the skull. Mobilization of the medial fronto-orbital ridge improves the transbasal approach and can be performed with a monobloc bone flap. We describe an en bloc bifrontal craniotomy including the supraorbital ridges and the nasal bones. This provides a wider angle of approach to the anterior aspect of the base of the skull than any other method and avoids retraction of the frontal lobes. This type of bone flap procedure can be performed after a wide periosteal dissection in the coronal area of the scalp alone, without facial skin incision.

Cranio-facial trauma and cerebral SPECT studies using N-isopropyl-iodo-amphetamine (123I).

Cerebral SPECT studies with N-isopropyl-iodo-amphetamine (123I) (IMP) were performed in patients who had suffered cranio-facial trauma, with and without loss of consciousness (LOC). The results were compared with computed tomography (CT). Nine out of ten of those with LOC had normal CT scans and evident photopaenia in IMP studies. It is clear that IMP SPECT scans complement CT in the investigation of patients who have suffered cranio-facial trauma.

The buccinator muscle: an original morphogenetical study.

The buccinator muscle, a cutaneous muscle derived from the second arc, is innervated by the facial nerve. It is made of 3 bundles extended into the cheek, from the pterygo-mandibular ligament to the modiolus. It is used for diverse buccal functions. This study attempts to give a better insight of the embryogenesis and the development of the muscle. After taking samples by microdissection under binocular microscope, of this region of embryos and foeti, we performed histological sections. They were then coloured by Masson's trichome for their observation under photon microscopy. From seventieth week we observed the presence of a peri-mucous mesenchyma between the cartilaginous condensation of the "pre premier arc" and Meckel's cartilage. The buccinator presents an insertion on the modiolus, sliding under the latter it runs forwards, it is at the origin of the formation of the orbicularis internus of the lips (musculus orbicularis oris). This muscle displaces its posterior insertion downwards, with the development of the face in the child and the adolescent, notably with the modification in vertical dimension due to the arrival of the deciduous teeth before the permanent dentition. Furthermore it appears that buccinator does not play a role as a sphincter in the secretion of the parotid glands.

[When should an orthoptic evaluation be prescribed in the management of orbital floor fracture? A prospective study of 47 fractures]. / Quand demander un examen orthoptique dans la prise en charge des fractures du plancher de l'orbite ?

INTRODUCTION: We evaluated the indication of orthoptic evaluation for the management of orbital floor fractures in a prospective series. MATERIAL AND METHOD: Forty-seven patients presenting with an orbital floor fracture were included in our prospective study. Consultations in orthoptics and maxillo-facial surgery were regularly carried out. Diplopia and motility were systematically assessed as well as a coordimetric examination according to Hess-Lees's technique. RESULTS: Nineteen percent of coordimetric motility disorders were observed among asymptomatic patients, after trauma. No diplopia or clinical motility disorder were observed 1 and 2 months after trauma, and coordimetric examinations came back to normal 2 and 3 months after trauma respectively for non-operated (26) and operated (21) patients. CONCLUSIONS: An orthoptic evaluation is necessary for the management of orbital floor fractures to diagnose the type of diplopia, motility disorders, and to indicate a coordimetric examination if diplopia is present. We suggest this orthoptic evaluation for patients presenting with diplopia between 5 and 10 days following trauma, 1 month after trauma for non-surgical treatment and 2 months after trauma for surgical treatment.

Relationships between geometry and kinematic characteristics in the temporomandibular joint.

Motions of the temporomandibular joint (TMJ) involve both translation and rotation; however, there may be substantial variations from one human to another, and these variations present significant difficulties when designing TMJ prostheses. The disc-condyle glides along the temporal bone and the condyle centre describe a curve that depends on the individual morphology. This study analyses disc-condyle rotatory and translatory displacements moving all along the temporal bone facets which are mainly composed of two areas: the articular tubercle slope (ATS) and the preglenoid plane separated by the articular tubercle crest. Displacements were quantified using 3D video analysis, and this technique was computer-assisted. From a population of 32 volunteers, we were able to establish a correlation between the kinematic characteristics of the joint and the disc-condyle trajectories. This study quantifies the geometrical characteristics of the ATS and their inter-individual variations, which are useful in TMJ prosthesis design.

Bilateral variation of the pectoralis minor muscle discovered during practical dissection.

We describe a case of an original insertion of the pectoralis minor on the coracohumeral ligament, supraspinatus tendon and the capsule of the glenohumeral joint. This variation has been described in anatomy textbooks since the nineteenth century. The peculiarity of this case is that the right shoulder presented type 2 and the left type 1 of the three varieties described by Le Double in 1897. Le Double (1843-1913) was a French anatomist who wrote a treaty on anatomical variations, in particular those of the muscle. Lately, only three publications have reported this variation in anatomic studies. Some authors have described the rotator cuff syndrome caused by this variation and an ultrasound study has demonstrated a frequency of 9.57% for the detection of this variation. It is possible to try and find this variation while investigating in order to diagnose impingement, through ultrasound, CT arthrography or MRI. We believe that this variation should be taken into consideration by surgeons during surgical procedures and arthroscopy.

Congenital coronary arteries anomalies: review of the literature and multidetector computed tomography (MDCT)-appearance.

The prevalence of coronary arteries congenital anomalies is 1 to 2% in the general population. Although the spectrum of their clinical manifestations is very broad from total inocuity to lethal, anomalies of coronary arteries need to be recognized by clinicians in certain circumstances: they are the first cause of death in young adults under physical exercise and an abnormal course of a coronary artery can complicate a cardiac surgery. Therefore, a non-invasive test is highly suitable for detecting anomalies of coronary arteries and multidetector computed tomography (MDCT) is likely to be the best one. To understand how anomalies of coronary arteries may occur, we have reviewed the recent literature about their development. Then, the main types of anomalies are presented with their clinical context, and representative MDCT images from our personal database are used for illustration.

[Anatomy of the labial region]. / Anatomie de la région labiale.

The phylogenetic and embryologic basis, as well as compared anatomy allow for a greater grasp of the multiform organization, as of the complex functions for the cosmetic appearance of the facial expression, which, as it grows older, will not touch to the magical beauty of the first smile, as it always was.

[Anatomy of the abdominal wall]. / Anatomie de la paroi abdominale.

The anatomy of the abdominal wall describes the superficial and extra peritoneal planes: skin, fat and muscles. Inguinal and lumbar anatomy are excluded. Phylogenetic, embryologic and comparative anatomy allow better integration of evolution, growth, and congenital syndromes. Classical anatomy is adapted to modern aspects, more useful for plastic surgeons.

[The retro-orbicularis oculus fat (ROOF) or Charpy's fat pad. Descriptive and functional anatomy. Surgical concepts applied to the design of a frontotemporal lift procedure]. / Le coussinet adipeux de Charpy. Anatomie descriptive et fonctionnelle. Applications aux nouveaux liftings.

The eyebrow fat pad, or retro-orbicularis oculus fat (ROOF) is a syssarcosis, described as an anatomic and functional unity by M. Charpy in 1909. Our anatomic study on 12 (24 half-head) fresh cadaver specimens confirm anatomic variations, mainly according to age and sex. Synthesis of recent literature shows the renewed interest for this fat pad and its involvement in the eye's lateral flare. We will describe its detailed ultrastructure and the physiopathological mechanisms of aging, causing an earlier lateral eyebrow ptosis. So we can evolve new anatomic concepts applied to recent facial rejuvenative procedures, particularly frontotemporal facelifts (endoscopic or classical procedures), by a harmonious repositioning of the eyebrow and in order to restore the lateral flare of the eye.

[Anatomy of the hypoglossal nerve and the hypoglossal ansa cervicalis]. / Anatomie du couple nerf hypoglosse, anse cervicale.

The hypoglossal nerve is the motor nerve of the tongue and the ansa cervicalis is a motor nerve for the sub-hyoid muscles. The hypoglossal nerve seems to give the innervation of the thyrohyoid although it is a sub-hyoid muscle. Most of axons in the ansa cervicalis arise from the three first cervical nerves. These nerves are in close contact because of the cervical ontogeny of the tongue and the hypoglossal nerve. Nerve impulse in the superior root of the ansa cervicalis runs caudally to rostrally. This is why neurotization techniques using the superior root of the ansa cervicalis produce poor results in the treatment of facial palsy sequelae.

[Surgical strategy of osteocutaneous free transfer of the fibula in complex mandibular reconstructions: technical notes]. / Stratégie opératoire des transferts libres ostéo-cutanés de péroné dans les reconstructions mandibulaires complexes: notes techniques.

The fibula osteocutaneous free flap now has a recognized place in the therapeutic arsenal of microsurgical mandibular reconstructions. Based on a review of the literature and their own experience, the authors propose a preoperative and intraoperative strategy adapted to reconstructions of mandibular defects. The place of complementary investigations, the site of the skin flap, the choice of osteotomy, the type of fixation, and spatialisation of the skin flap are presented. They conclude on the excellent plastic and vascular qualities of the fibula flap in complex mandibular reconstructions.

["Total SMAS lift" or deep facial lift by temporal approach. Initial report]. / "Total SMAS lift" ou le lifting facial profond par voie temporale. Rapport préliminaire.

The authors present a new technique of face lift via a temporal approach which allows them to perform a "Total SMAS Lift" of the supra- and infra-zygomatic region. They use the passage on the deep side of the superficial layer of the temporal fascia, which avoids damage to the frontal branch of the facial nerve. Undermining of the periorbital area is performed under the muscle, but above the periosteum of the malar bone. This technique is situated between the subcutaneous face lift and the superiostal mask-lift. This technique can also be combined with a frontal or cervico-facial lift. This "Total SMAS Lift" is essentially indicated in patients with early ptosis of the cheek, the peri-orbital area ant the naso-labial folds and the aesthetic results are gratifying.

Jaw dystonia triggered by biting into hard food.

We report an unusual case of eating dystonia induced by attempts to bite into hard food and resulting in prolonged jaw opening spasms. Mastication was severely impeded. Simultaneous bilateral electromyogram (EMG) of the masticatory muscles during mastication of hard food showed an abnormal prolonged activity in the anterior digastrics with an abnormal cocontraction of these muscles during contraction of the jaw-closers and a prolonged inhibition of the jaw-closers until the hard bolus was softened. This action dystonia seems to be triggered when more than a certain pressure is exerted on the peridontal mechanoreceptors and could result from a defective central command control of their sensory inputs. Local injections of botulinum toxin had little effect.