[Bilateral breast reconstruction by DIEP flap in two stages: Technical note]. / Reconstruction mammaire bilaterale par lambeau de DIEP en deux temps : note technique.

With the rise of risk prevention surgery, more and more bilateral mastectomies are performed. These present a challenge when patients desire autologous reconstruction. Some surgeons perform reconstructions using a double DIEP flap, but this technique, which requires rapid operation and extensive experience, can sometimes be difficult to implement. Other factors may also favor a two-stage reconstruction, one breast after the other. We present here our technique to harvest two hemi-DIEP during two distinct operating times, by modifying the design of the first flap and by performing a prior autonomization of the second.

[Synkinesis in facial palsy: What do we know about the physiopathology?] / Syncinésies dans la paralysie faciale : que savons-nous de la physiopathologie ?

INTRODUCTION: Synkinesis is a disabling sequelae of facial palsy, which worsens facial asymmetry and diminishes the patients' quality of life. Their physiopathology is partially known, but cannot explain all the synkinesis. MATERIAL AND METHODS: We report a literature review of the state of the art concerning the knowledge on synkinesis physiopathology, as well as their management. RESULTS: It is accepted that the physiopathological mechanism of synkinesis is mixed. The phenomena of cerebral plasticity, aberrant nerve regrowth, hyperexcitability of the facial nerve nucleus and ephaptic nerve transmission, have been observed. We propose a new physiopathological hypothesis: synkinesis could be the consequence of latent circuits activation, preexisting in the healthy subject. We could propose three potential latent circuits: physiological synergistic contractions, adjacent motor units recruitment, and reactivation of remote latent circuits for function compensation. The treatment options are multiple, dominated by chemodenervation, whose effectiveness is undeniable. Rehabilitation has also proven its effectiveness, particularly with feedback techniques. Finally, surgery helps with these options. However, the indications of the different treatments remain to be codified. CONCLUSION: The validation of our physiopathological hypothesis would allow a better understanding and a better screening of synkinesis, in order to propose a more adapted treatment.

Breast-implant texturing associated with delamination of capsular layers: A histological analysis of the double capsule phenomenon.

BACKGROUND: Macro-texturing of breast implants was developed with the double goal of improving implant stabilization within the breast cavity and decreasing the rate of capsular contractures. However, recent evidence suggests that double capsular formation, a potentially worrisome phenomenon associated with late seromas and biofilms, occurs with preponderance in macro-textured implants. Our objective was to analyze histologically different regions of double capsules to determine if they are more prone to mechanical movements. METHODS: A prospective analysis including patients undergoing second-stage expander to definitive breast-implant reconstruction post-mastectomy was conducted after intraoperative identification of the double capsule phenomenon. Two samples were collected from each capsules around the implant, located centrally and laterally. The specimens were sent for histological analysis by the institution's pathologist. RESULTS: In total, 10 patients were identified intraoperatively with partial double capsule phenomenon. Among samples retrieved from the lateral aspect of the breast implant, all were associated with delamination and fractures in the collagen matrix of the double capsules. This phenomenon was not observed in any sample from the dome of the breast. CONCLUSIONS: Breast-implant macro-texturing plays an important role on delamination of capsules on lateral portions of the breast, which may have an etiologic role in double capsule formation. Manufacturing implants with macro-texturing on one side and smooth surface on the other could diminish mechanical shear forces responsible for these findings.

Self-inflicted crossbow injury in the head: A case report.

Injuries and deaths from crossbows are uncommon, especially when self-inflicted. We present here the case of a 45 years old patient with history of mental illness, who attempted suicide with a crossbow. The bolt penetrated the chin, crossed the oral floor, the oral cavity, the bony palate, the left nasal cavity and exited at the level of the nasal bones. The main concern was the management of the airways, before proceeding to the removal of the bolt. A nasotracheal intubation through the right nasal cavity while the patient was conscious was performed, but the instruments needed for an emergency tracheotomy were in the operating room in case of failure. The intubation was successful, he underwent general anesthesia, and the bolt was removed from the face.

[Depressor anguli oris sign (DAO) in facial paresis. How to search it and release the smile (technical note)]. / Signe du Depressor Anguli Oris (DAO) dans les parésies faciales. Comment le rechercher et libérer le sourire (note technique).

INTRODUCTION: After facial paralysis recovery, it is common to note a co-contraction between depressor anguli oris (DAO) muscle and zygomatic muscles. This DAO co-contraction will "obstruct" the patient's smile. The purpose of this technical note is to show how to find the DAO sign and how to free up the smile. TECHNICAL: This co-contraction between the zygomatic muscles and DAO research is placing a finger on marionette line, asking the patient to smile: we perceive a rope under the skin corresponding to the abnormal contraction and powerful DAO. A diagnostic test with lidocaine injection into the DAO can be performed to confirm the diagnosis. The treatment of pathological DAO's contraction can be by injection of botulinum toxin in the DAO, or by surgical myectomy. In all cases, a speech therapy complete the treatment. CONCLUSION: The DAO sign is a semiological entity easy to find. His treatment releases smile without negative effect on the facial expression as the DAO is especially useful in the expression of disgust.

[Laparoscopy coupled with classical abdominoplasty in 10 cases of large rectus diastasis]. / Couplage cœlioscopie-abdominoplastie dans dix cas d'important diastasis des grands droits.

UNLABELLED: In 10 cases of abdominoplasty where an important rectus diastasis had to be corrected, we completed the plication of the rectus sheath included in a classical abdominoplasty with the laparoscopic positioning of an intraperitoneal prosthesis. PURPOSE: To assess the middle-term results of this technique and present its advantages and drawbacks. PATIENTS AND METHOD: Fifteen patients have been operated from 2007 to 2011 by two surgeon teams. Ten of them have accepted to be included in our survey. RESULTS: All the patients said they were satisfied with their surgery. Four of them reported mild pain during the first postoperative weeks, and two of them mentioned very moderate pain at the time of the survey. The surgeons were not satisfied with the results obtained in two cases. Only one of these two patients accepted revision abdominoplasty with a good result. CONCLUSION: Laparoscopic positioning of an intraperitoneal prosthesis, coupled with a classical plication of the rectus sheath, gives excellent results in difficult cases of rectus diastasis.

General principles of tendon transfers: The ten commandments.

Transferring a muscle's point of force application by modifying its distal insertion will modify its function. This is the basic principle of tendon transfers. Despite being less popular due to superior primary nerve repair results, hand surgeons must be familiar with them. When used according to the Ten Commandments we propose, they provide good and useful functional recovery. Obviously, it depends on the number of muscles available for transfer. Tendon transfer is useful not only in nerve trunk palsy and brachial plexus lesions but also in upper limb tetraplegia rehabilitation. Tendon transfers are active palliative treatments under voluntary command and can be combined with other palliative procedures (arthrodesis, tenodesis) to improve the functional result. Nevertheless, they are far from ideal, as they re-allocate the remaining forces of the limb but do not create new ones.

[Eyelid reconstruction according to Hübner's technique: About the use of 12 tarsomarginal grafts]. / Reconstruction palpébrale selon la technique de Hübner : à propos de l'utilisation de 12 greffons tarsomarginaux.

PURPOSE: The repair of full-thickness eyelid defect must fulfill multiple surgical requirements that are determined by the anatomical and functional features of the eyelids. Many reconstructive procedures are available, each and anyone of them presenting their own peculiar goals and constraints. Among them, we have tried to determine the place and the reliability of Hübner's tarsomarginal grafts. PATIENTS AND METHOD: Through a retrospective study of 11 patients treated with 12 grafts, over a period of 3 years, we evaluated our indications, technical principles and results of this procedure. RESULTS: The full-thickness eyelid defects represented between one quarter and three quarter of the marginal border length. They principally resulted from malignant tumors resection. In most of the cases, their management required a single graft, harvested on the contralateral homologous eyelid. Complications were minor and rare. Functional and aesthetical results were satisfactory. There was no functional sequel on the donor site. CONCLUSION: Tarsomarginal grafts in eyelid reconstruction provide multiple advantages. With this simple and versatile technique, wide and complex eyelid repairs can be managed in a one-step surgery. This procedure is very reliable; it gives good functional and aesthetical results. Hübner's technique is a major tool in eyelid reconstructive surgery.

[The main tunnel syndromes]. / Les principaux syndromes canalaires.

Several tunnel syndromes are responsible for substantial functional impairment. The diagnosis has to be made and treatment is most often very simple--nerve decompression--with excellent results. Of these syndromes, the most common are median and ulnar tunnel syndromes of the wrist and ulnar tunnel syndrome of the elbow, but other syndromes must be identified at the risk of therapy failure due to poorly adapted treatment. Finally, good knowledge of this pathology must lead to prevention of the iatrogenic forms (sequelae of inguinal hernia treatment, ileac crest graft harvesting) by educating all surgeons interested in peripheral nerve surgery.

[Molecular architecture of the sarcoplasmic reticulum and its role in the ECC]. / Architecture moléculaire du réticulum sarcoplasmique et son rôle dans le couplage excitation-contraction.

The sarcoplasmic reticulum (SR) plays a fundamental role in excitation-contraction coupling, which propagates the electric signal conversion along the muscle fiber's plasmic membrane to a mechanical event manifested as a muscle contraction. It plays a crucial role in calcium homeostasis and intracellular calcium storage control (storage, liberation and uptake) necessary for fiber muscle contraction and then relaxation. These functions take place at the triad, made up of individualized SR subdomains where the protein-specific organization provides efficient and fast coupling. Ryanodine receptors (RyR) and dihydropyridine receptors (DHPR) mainly act in calcium exchanges in the SR. This particular structural and molecular architecture must be correlated to its functional specificity.

[Anatomic bases of surgical approaches to the nerves of the lower limb: tips for young surgeons]. / Bases anatomiques des voies d'abord chirurgicales des nerfs du membre inférieur: à l'usage des jeunes neurochirurgiens.

For trainee surgeons, the surgical approaches of the lower limb's peripheral nerves remain partially or completely unknown, but traumatic nerve lesions are rather frequent at this level and nerve tumors require intervention. Young surgeons will also have to treat spasticity and perform selective neurotomies, which can provide dramatic improvement of the functional status of properly selected patients. Excellent knowledge of anatomy is the key point to successful surgery. For each nerve approach, the key points on the morphological data of the nerve and its surroundings are given, as are the typical indications for this surgery and certain particularities related to patient installation in the operating room. The surgical approach section details the incision, the nerve exposure and the technical pitfalls.

[Anatomic bases of surgical approaches to the nerves of the upper limb: tips for young surgeons]. / Bases anatomiques des voies d'abord chirurgicales des nerfs du membre supérieur: à l'usage des jeunes neurochirurgiens.

Peripheral nerve surgery requires a certain level of specialization. Surgeons must have solid knowledge of morphological anatomy of the different segments to be explored, decompressed, repaired, or even neurotized. This paper describes the most common approaches to the peripheral nerves of the upper limb.

[Mechanisms controlling axonal sprouting at the neuromuscular junction]. / Mécanismes contrôlant le bourgeonnement axonal à la jonction neuromusculaire.

This paper explores the specific roles of sprouting stimuli, perisynaptic Schwann cells and neuromuscular activity in axonal sprouting at the neuromuscular junction in partially denervated muscles. As for sprouting stimuli, insulin-like growth factor II which is generated from inactive muscle fibers in partially denervated and paralysed skeletal muscle is described. Likewise, perisynaptic Schwann cells can induce and guide axonal sprouting in partially denervated muscles. Finally, excessive neuromuscular activity significantly reduces bridging of the perisynaptic Schwann cell processes between denervated and innervated endplates and thereby inhibits axonal sprouting in partially denervated muscle. The lack of neuromuscular activity is also harmful in axonal sprouting, probably by impeding calcium influx into the nerve.

[Structural and molecular organization, development and maturation of the neuromuscular junction]. / Organisation structurale, moléculaire, formation et maturation de la jonction neuromusculaire.

The neuromuscular junction is made up of the apposition of highly differentiated domains of three types of cell: the motor neuronal ending, the terminal Schwann cell and the muscle postsynaptic membrane. These three components are surrounded by a basal lamina, dedicated to molecular signal exchanges controlling neuromuscular formation, maturation and maintenance. This functional and structural differentiated complex conducts synaptic neurotransmission to the skeletal muscle fiber. Nerve and muscle have distinct roles in synaptic compartment differentiation. The initial steps of this differentiation and the motor endplate formation require several postsynaptic molecular agents including agrin, the tyrosine kinase receptor MuSK. Neuregulin is essentially involved in Schwann cell survival and guidance for axonal growth.

[Medical and economic reflections on Restore and Itrel neurostimulation systems for neuropathic pain treatment]. / Réflexion sur l'intérêt médicoéconomique des boîtiers de neurostimulation Restore et Itrel dans le traitement des douleurs neuropathiques chroniques.

In 2007, four patients where implanted with the Restore neurostimulation system for intractable chronic leg pain at the Poitiers Hospital. The potential for improving the patients' quality of life and medical-economic concerns motivated this choice for these highly selected patients. In this paper, we propose brief clinical case reports and discuss the reasons for choosing this new rechargeable system, even though it was initially more expensive than the standard neurostimulation system (Itrel 3). All patients receiving implants declared that they were very satisfied with the quality of stimulation provided by Restore and noted a significant improvement in their quality of life. If this solution becomes advantageous from an economic point of view, clinical data should lend support to the utility of this technological innovation for patients who have hitherto been in treatment failure.

[Anatomy and physiology of the peripheral nerve]. / Organisation anatomique et physiologique du nerf périphérique.

The peripheral nerve provides the pathway for motor, sensory and vegetative axons belonging to the peripheral nervous system. It transmits information between these neurons and their peripheral effectors in both directions (sensory receptors, skeletal muscles and viscera). The afferences to the periphery correspond to the nerve motor content, whereas efferences from the periphery, in charge of delivering information to the central integrators, correspond to nerve-sensitive content. This information support depends on intrinsic properties of the nerve itself. Recent advances in cellular and molecular biology have provided a better understanding of nerve physiology, which are reviewed here as an indispensable basis to the study of its pathology.

[Synapse formation and regeneration]. / Formation et régénération synaptique.

Synapse formation is probably the key process in neural development allowing signal transmission between nerve cells. As an interesting model of synapse maturation, we considered first the neuromuscular junction (NMJ), whose development is particularly dependent on intercellular interactions between the motor nerve and the skeletal muscle. Nerve and muscle have distinct roles in synaptic compartment differentiation. The initial steps of this differentiation and motor endplate formation require several postsynaptic molecular agents including agrin, the tyrosine kinase receptor MuSK and rapsyn. The agrin or motoneuron dependence of this process continues to be debated while the following steps of axonal growth and postsynaptic apparatus maintenance essentially depend on neuronal agrin and a neuron-specific signal dispersing ectopic AChR aggregate remainders, possibly mediated by acetylcholine itself. Neuregulin is essentially involved in Schwann's cell survival and guidance for axonal growth. In this paper, we will discuss the similarities between Central Nervous System (CNS) synaptic formation and Motor innervation. The limited ability of the CNS to create new synapses after nervous system injury will be then discussed with a final consideration of some new strategies elaborated to circumvent the limitations of lesion extension processes.

[Major mechanisms involved in the synaptic transmission of the neuromuscular apparatus]. / Principaux mécanismes impliqués dans la transmission synaptique au sein de l'appareil neuromusculaire.

Neuromuscular transmission results from a double signal transduction from electric impulses to chemical messengers, taking place at a highly differentiated region, the neuromuscular junction (NMJ). A nerve cell responds to a specific stimulus by modifications of its plasmic membrane properties, generating an action potential (AP). This electric signal is transmitted along the axon to the NMJ, where it induces the voltage-gated calcium channels to open. Intracellular calcium entry leads to acetylcholine release in the synaptic space at the active zones but all scientists do not consider it the major release factor. Acetylcholine binding with its receptor at the muscle membrane generates an endplate potential when the induced depolarization is greater than the sodium voltage channel opening threshold. Muscle AP causes a muscle contraction involving the three phases. This paper will successively review the electrophysiological and molecular mechanisms involved at the pre-, inter- and postsynaptic levels. The last part of the article will discuss electromechanical considerations directly affecting the mechanical properties of the muscle fiber, most particularly the factors influencing the predetermined involvement of motor units, motor neuron electrical properties determining responses to synaptic inputs and finally the impact of recruited motor neurons and their electrical impulse rates on muscle contraction strength and velocity.

[Physiology of the injured peripheral nerve]. / Physiologie du nerf traumatisé.

Peripheral nerve injuries are frequent and generate significant deficits. Their treatment sometimes leads to functional recovery but is mostly incomplete or unpredictable, despite the regular use of sophisticated repair techniques. The clinician must clearly understand the peripheral nervous system's responses to injury, which reveal surprising degenerating and spontaneous regenerating abilities. This potential recovery is a peripheral nervous system specificity and follows a relatively complex process. Peripheral neurons depend on glial cell structure and metabolism, inducing a global and dynamic response of the whole axon environment, even in cases of focal lesion, modulated by the initial type and mechanism of injury. Today's progress remains insufficient to improve functional prognosis significantly, but a better understanding of peripheral nerve regenerating processes has opened the door to new medical and surgical advances.

[The anatomical substrate of muscle contractility]. / Le support anatomique de la contraction musculaire.

Muscle fiber action participates in a true contractile machinery associated with noncontractile components providing mechanical stability. The myofibril, the muscle fiber subentity, has an extremely consistent architecture, composed of longitudinal cylindrical units called sarcomeres, the skeletal muscle length functional unit, a highly important place in the transduction of chemical signal into mechanical contractile energy, for the most part mediated by calcium. The sarcoplasmic reticulum is the other major component of muscle fiber and is dedicated to calcium storage, liberation and distribution to the fiber, under the influence of action potential propagation. This phenomenon is called excitation-contraction coupling. This paper explores muscle anatomy from its main embryologic stages of development to its histochemical specificity, including its molecular constitution, and details the main morphofunctional relations supporting muscle contraction.