A role for metformin in the treatment of Dupuytren disease?

Dupuytren disease (DD) is a hand-localized fibrotic disorder characterized by a scar-like, collagen-rich cord. Treatment usually comprises surgical removal of the cord, but is associated with a high relapse rate, in some cases requiring finger amputation. There is currently no consensual medical approach for treating DD. Numerous preclinical studies have highlighted antifibrotic properties of metformin, and the aim of this study was to assess a potential antifibrotic role of metformin in DD. Fibroblasts from DD cords (DF) and phenotypically normal palmar fascia (PF) were extracted from surgical specimens and cultured. The fibrotic status of DF and PF was compared at baseline, and under profibrotic (TGF-ß stimulation) and antifibrotic (metformin stimulation) conditions, using quantitative RT-PCR, western blot, immunocytochemistry, and a functional fibroblast contraction assay. At baseline, DF showed higher levels of fibrotic markers and contraction capacity compared with PF. Both types of fibroblasts responded to TGF-ß stimulation. Treatment of DF and PF with metformin did not affect basal levels of fibrotic markers and contraction but largely prevented their induction by TGF-ß. In conclusion, our data show that metformin inhibits TGF-ß-induced expression of fibrotic markers and contraction in hand-derived fibroblasts. This supports the case for a clinical trial to assess the repurposing of metformin as an adjuvant to surgery, to prevent, reduce, or delay recurrence in at-risk DD patients.

Flow-Through Arterialized Posterior Interosseous Nerve Grafts for Digital Neurovascular Bundle Defects: Anatomical Study.

BACKGROUND: Digital neurovascular bundle defects are often encountered during crush or avulsion injuries and require complex reconstruction. Use of an arterialized nerve graft (neurovascular graft) serving both as an interpositional arterial conduit and as a nerve graft could be a reconstructive option in these cases. In this anatomical study, the authors aimed to describe a neurovascular graft of the posterior interosseous nerve and a branch of the anterior interosseous artery for neurovascular bundle reconstruction of the fingers. METHODS: Eighteen forearms were injected with red latex in order to collect the anatomical characteristics of the posterior interosseous nerve and the artery running near it. RESULTS: In all cases, the posterior interosseous nerve was followed by a branch of the anterior interosseous artery: the distal dorsal branch of the anterior interosseous nerve. The origin of this artery was proximal to the radiocarpal joint, at an average of 56.5 ± 11.1 mm. The proximal and distal diameters of the branch of the anterior interosseous artery were 1.6 ± 0.2 and 1.1 ± 0.2 mm, respectively. The proximal and distal diameters of the posterior interosseous nerve were 1.2 ± 0.3 mm and 1.1 ± 0.3 mm, respectively. CONCLUSIONS: These results show that a potential free neurovascular graft using the posterior interosseous nerve as nerve graft and the anterior interosseous artery as an arterial bypass to reconstruct both the nerve and arterial tree of the finger could be a useful approach. The authors speculate that this graft could be used to reconstruct the neurovascular bundle of amputated or devascularized digits.

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report.

INTRODUCTION: Trauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities. PRESENTATION OF CASE: The patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up. DISCUSSION: Hepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance. CONCLUSION: Delayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.

Posttraumatic pseudoaneurysm of a superficial branch of the ulnar artery: A case report.

INTRODUCTION: Hand and Upper limb pseudoaneurysms are uncommon and misdiagnosed. The delayed diagnostic and treatment lead to severe vascular and nerve complications. Many mechanisms are involved like acute injury, chronic micro traumatism of the hand, with specific clinic and para clinic signs. PRESENTATION OF CASE: The patient was a 30-years old woman, right-handed, admitted at the emergencies for a penetrating hand injury at the junction of the middle third - distal third of the left forearm, palmar surface, with a good radial and ulnar pulse, without sensory or motor deficit. No vessels injuries observed per operatively. A post-operative worsened pain opposite to the scar with a purplish pulsatile swelling appeared after 20 days of complete wound healing. A needle puncture with a red blood contain, motivated an US Doppler revealing a pseudoaneurysm of a superficial artery of the ulnar artery, surgically resected, without complication. DISCUSSION: Two main mechanisms are involved in upper limb especially hand pseudoaneurysm: penetrating trauma and repeated micro traumatism. Superficial vessels are rarely damaged compare to deep subfascial vessels according to Laplace law. The diagnostic is clinical confirmed with the medical imaging. A pseudoaneurysm is suspected in front of a pulsatile painful tumefaction following a vessel path, with medical imaging in favor. A delayed misdiagnosis lead to a delayed care with severe complications as thrombosis, embolism and vessel. The therapeutic care is mainly surgical. CONCLUSION: This case reports a delayed diagnostic of posttraumatic pseudoaneurysm of a superficial branch of the ulnar artery, managed with a surgical resection.

The infraorbital artery: From descriptive anatomy to mucosal perforator flap design.

BACKGROUND: The terminal and perforating branches of the infraorbital artery (IOA) are poorly described. Its anatomical situation and mucosal component could provide an interesting donor site for mucosal reconstruction. The aims of the following study were to establish an anatomical description and to assess the feasibility of mucosal perforator flaps for eyelid and nasal reconstruction. METHODS: Twenty-three fresh cadaver hemifaces were studied in order to perform an IOA anatomical classification by recording the artery's characteristics, its course, number, type, and diameter of terminal branches. We also examined the feasibility of local flaps for facial reconstruction. RESULTS: We highlighted five different types of courses. All cadavers had at least one superior vestibular branch with a caliber of ≥0.4 mm. A pedicled flap arising from the vestibular branch was raised in all dissections. CONCLUSION: The vestibular perforator flap based on the IOA seems to be a reliable flap in reconstruction of mucosal defects.

Combination of blood and biphasic calcium phosphate microparticles for the reconstruction of large bone defects in dog: A pilot study.

We previously reported that biphasic calcium phosphate (BCP) microparticles embedded in a blood clot induces ectopic bone formation in mice and repairs a critical femoral defect in rat. The present pilot study aimed to evaluate in dog and in two models of large defects the efficacy of this composite named "blood for reconstruction of bone" (BRB). We show here that BRB is a cohesive biomaterial easy to prepare from dog autologous blood and to mold to fill large bone defects. First in a model of cylindrical femoral condyle defect, the BRB was compared with BCP particles alone. After 8 weeks, this revealed that the amount of mature bone was slightly and significantly higher with BRB than with BCP particles. Second, in a model consisting in a 2 cm-long critical interruptive defect of the ulna, the BRB was compared with autologous bone. After 6 months, we observed that implantation of BRB can induce the complete reconstruction of the defect and that newly formed bone exhibits high regenerative potential. Comparison with the results obtained with autologous bone grafting strongly suggests that the BRB might be an efficient biomaterial to repair large bone defects, as an alternative or in addition to autologous bone. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 1842-1850, 2018.

Calcium supplementation decreases BCP-induced inflammatory processes in blood cells through the NLRP3 inflammasome down-regulation.

Interaction of host blood with biomaterials is the first event occurring after implantation in a bone defect. This study aimed at investigating the cellular and molecular consequences arising at the interface between whole blood and biphasic calcium phosphate (BCP) particles. We observed that, due to calcium capture, BCP inhibited blood coagulation, and that this inhibition was reversed by calcium supplementation. Therefore, we studied the impact of calcium supplementation on BCP effects on blood cells. Comparative analysis of BCP and calcium supplemented-BCP (BCP/Ca) effects on blood cells showed that BCP as well as BCP/Ca induced monocyte proliferation, as well as a weak but significant hemolysis. Our data showed for the first time that calcium supplementation of BCP microparticles had anti-inflammatory properties compared to BCP alone that induced an inflammatory response in blood cells. Our results strongly suggest that the anti-inflammatory property of calcium supplemented-BCP results from its down-modulating effect on P2X7R gene expression and its capacity to inhibit ATP/P2X7R interactions, decreasing the NLRP3 inflammasome activation. Considering that monocytes have a vast regenerative potential, and since the excessive inflammation often observed after bone substitutes implantation limits their performance, our results might have great implications in terms of understanding the mechanisms leading to an efficient bone reconstruction. STATEMENT OF SIGNIFICANCE: Although scaffolds and biomaterials unavoidably come into direct contact with blood during bone defect filling, whole blood-biomaterials interactions have been poorly explored. By studying in 3D the interactions between biphasic calcium phosphate (BCP) in microparticulate form and blood, we showed for the first time that calcium supplementation of BCP microparticles (BCP/Ca) has anti-inflammatory properties compared to BCP-induced inflammation in whole blood cells and provided information related to the molecular mechanisms involved. The present study also showed that BCP, as well as BCP/Ca particles stimulate monocyte proliferation. As monocytes represent a powerful target for regenerative therapies and as an excessive inflammation limits the performance of biomaterials in bone tissue engineering, our results might have great implications to improve bone reconstruction.

Visfatin expression analysis in association with recruitment and activation of human and rodent brown and brite adipocytes.

Human brown adipocytes are able to burn fat and glucose and are now considered as a potential strategy to treat obesity, type 2 diabetes and metabolic disorders. Besides their thermogenic function, brown adipocytes are able to secrete adipokines. One of these is visfatin, a nicotinamide phosphoribosyltransferase involved in nicotinamide dinucleotide synthesis, which is known to participate in the synthesis of insulin by pancreatic ß cells. In a therapeutic context, it is of interest to establish whether a potential correlation exists between brown adipocyte activation and/or brite adipocyte recruitment, and adipokine expression. We analyzed visfatin expression, as a pre-requisite to its secretion, in rodent and human biopsies and cell models of brown/brite adipocytes. We found that visfatin was preferentially expressed in mature adipocytes and that this expression was higher in brown adipose tissue of rodents compared to other fat depots. However, using various rodent models we were unable to find any correlation between visfatin expression and brown or brite adipocyte activation or recruitment. Interestingly, the situation is different in humans where visfatin expression was found to be equivalent between white and brown or brite adipocytes in vivo and in vitro. In conclusion, visfatin can be considered only as a rodent brown adipocyte biomarker, independently of tissue activation.

Inferior Cubital Artery Perforator Flap for Soft-Tissue Coverage of the Elbow: Anatomical Study and Clinical Application.

BACKGROUND: Soft-tissue defects surrounding the elbow can be a challenging problem for the orthopaedic surgeon. Reliable reconstruction with use of muscular flaps or even perforator flaps derived from the surrounding vessels has been described. The inferior cubital artery (ICA) is an indirect septocutaneous perforator branch that most frequently arises from the lateral side of the radial artery. The purposes of the present study were to characterize the capillary cutaneous perforators of the ICA and to evaluate the potential of a local perforator flap procedure for soft-tissue coverage of the elbow. METHODS: Twenty fresh cadaveric forearms were dissected in order to describe the ICA anatomy, and in ten additional forearms the ICA was selectively injected with a red ink solution to detail the ICA vascular territory. For each artery, we recorded the site of origin, the diameter of the artery at its source, the course of the artery, and the number, type, and diameter of capillary cutaneous perforators. RESULTS: A total of seventy-eight ICA capillary perforators were analyzed from the twenty dissected forearms: forty-six were in-transit capillary perforators, nineteen were terminal capillary perforators, and thirteen were musculocutaneous capillary perforators. Of these seventy-eight perforators, sixteen (21%) had a caliber of <0.5 mm and sixty-two capillary perforators (79%) had a caliber of ≥0.5 mm. Ten ICAs were selectively injected, and the mean size of all stained skin areas was 30.9 ± 11.9 cm(2). A perforator pedicled flap was readily feasible for all dissections. We also describe the case of a patient with a medial soft-tissue defect of the elbow that was covered with a pedicled perforator flap based on an ICA. The patient had satisfactory healing at two months. CONCLUSIONS: The ICA flap is a reliable and useful flap for elbow soft-tissue reconstruction. CLINICAL RELEVANCE: The perforator flap procedure is a major advancement in reconstructive surgery. One potential application of the perforator flaps is the use of tissue adjacent to a defect as a perforator-based island flap. The use of this tissue allows for thinner flaps to be tailored for more accurate reconstruction. A flap that depends on a perforator branch of the radial artery called the inferior cubital artery seems to be an excellent solution for soft-tissue coverage of the elbow.

Acquired Localized Longitudinal Pachyonychia and Onychomatrical Tumors: A Comparative Study to Onychomatricomas (5 Cases) and Onychocytic Matricomas (4 Cases).

BACKGROUND: Besides onychomatricoma (OM), which shows a clinical band pattern of nail plate thickening, 2 new onychomatrical tumors with this clinical feature have recently been described: onychocytic matricoma (OCM) and in situ onychocytic carcinoma. OBJECTIVE: The purpose of this study was to present 4 cases of OCMs and compare their clinical and histopathologic characteristics with usual OMs. METHODS: We studied 4 cases of OCMs with nail clipping in 3 cases and an extensive immunohistochemical study for hair-related keratins and epithelial keratins. Nail clipping of OCMs was compared with the distal nail plate of 5 cases of OMs. RESULTS: All cases showed an acquired localized longitudinal band pattern of a thickened nail plate with yellow discoloration in 2 cases and a black streak in 2 cases. All cases showed a V-shaped keratogenous epithelial tumor with a papillomatous pattern of growth. The nail plate was thickened with small holes in a honeycomb pattern. In contrast, the 5 OMs showed the classical pattern of a panonychoma fibropapilliferum. The nail plate showed large cavities in a honeycomb pattern. CONCLUSIONS: This case series raises awareness of the clinical value of longitudinal pachyonychia coupled with nail clipping in the early detection of onychomatrical tumors as generic diagnosis with a limited differential diagnosis and a simple therapeutic approach. Nail clipping could be an aid in the surgical planning of onychomatrical tumor. A diagnosis of a benign growth could be suggested when the average dimensions of cavities are superior to 0.15 mm sparing the patient from an excisional procedure with its risk of subsequent permanent nail dystrophy. In contrast, nail clipping with a honeycomb pattern of minute cavities with average dimension inferior to 0.10 mm should prompt a biopsy of the distal matrix to rule out a malignant lesion.

A Cadaveric Study of the Arterial Blood Supply of the Labia Minora.

BACKGROUND: Labiaplasty has become a rather common operation. The main complication of the different surgical techniques is the dehiscence of the suture line. The dehiscence rate varies among the different techniques, and this may imply that the vascular anatomy is not respected in some cases. The detailed arterial anatomy of labia minora is not well described, so the aim of the authors was to describe this anatomy with a cadaveric study. METHODS: Eleven fresh cadavers were dissected, and arterial study was made with injected computed tomography scans and rotational angiography. At the end, a cast of the arterial network was made and chemically exposed to verify the radiological findings. RESULTS: The findings of this study allowed identification of a dominant central artery that was named "C" artery, two posterior arteries named "P1" and "P2," and one small anterior artery, "A." Furthermore, a connection between the anterior system of the external pudendal artery and the posterior system of the internal pudendal artery was confirmed. CONCLUSIONS: The arterial network of the labia minora was identified with this study. This may help surgeons orientate the wedge excision when they perform labiaplasties. More precisely, when this wedge is placed at the most anterior part of the labia minora, the least perfused area is removed, and a posterior flap is created that will preserve a robust blood perfusion.

Adaptive immune response inhibits ectopic mature bone formation induced by BMSCs/BCP/plasma composite in immune-competent mice.

A combination of autologous bone marrow stromal cells (BMSCs) and biomaterials is a strategy largely developed in bone tissue engineering, and subcutaneous implantation in rodents or large animals is often a first step to evaluate the potential of new biomaterials. This study aimed at investigating the influence of the immune status of the recipient animal on BMSCs-induced bone formation. BMSCs prepared from C57BL/6 mice, composed of a mixture of mesenchymal stromal and monocytic cells, were combined with a biomaterial that consisted of biphasic calcium phosphate (BCP) particles and plasma clot. This composite was implanted subcutaneously either in syngenic C57BL/6 immune-competent mice or in T-lymphocyte-deficient Nude (Nude) mice. Using histology, immunohistochemistry, and histomorphometry, we show here that this BMSC/BCP/plasma clot composite implanted in Nude mice induces the formation of mature lamellar bone associated to hematopoietic areas and numerous vessels. Comparatively, implantation in C57BL/6 results in the formation of woven bone without hematopoietic tissue, a lower number of new vessels, and numerous multinucleated giant cells (MNGCs). In situ hybridization, which enabled to follow the fate of the BMSCs, revealed that BMSCs implanted in Nude mice survived longer than BMSCs implanted in C57BL/6 mice. Quantitative expression analysis of 280 genes in the implants indicated that the differences between C57BL/6 and Nude implants corresponded almost exclusively to genes related to the immune response. Gene expression profile in C57BL/6 implants was consistent with a mild chronic inflammation reaction characterized by Th1, Th2, and cytotoxic T-lymphocyte activation. In the implants retrieved from T-deficient Nude mice, Mmp14, Il6st, and Tgfbr3 genes were over-expressed, suggesting their putative role in bone regeneration and hematopoiesis. In conclusion, we show here that the T-mediated inflammatory microenvironment is detrimental to BMSCs-induced bone formation and shortens the survival of implanted cells. Conversely, the lack of T-lymphocyte reaction in T-deficient animals is beneficial to BMSCs-induced mature bone formation. This should be taken into account when evaluating cell/biomaterial composites in these models.

The anatomy of the pectoral nerves and its significance in breast augmentation, axillary dissection and pectoral muscle flaps.

BACKGROUND: In many plastic surgeries, a detailed understanding of the pectoral nerve anatomy is often required. However, the information available on the anatomy of pectoral nerves is sparse and unclear. The purpose of this study is to provide detailed anatomical information on the pectoral nerves to allow for their easy intra-operative localisation and to improve the understanding of the pectoral muscle innervation. METHODS: We dissected 26 brachial plexuses from 15 fresh cadavers. The origins, locations, courses and branches of the pectoral nerves were recorded. RESULTS: We found three constant branches of the pectoral nerve. The superior branch travelled in a straight course to the pectoralis major to innervate the clavicular aspect. The middle branch coursed on the under-surface of the pectoralis major near the pectoral branch of the thoraco-acromial artery to innervate the muscle's sternal aspect. The inferior branch passed beneath the pectoralis minor muscle to innervate the pectoralis minor muscle and the costal aspect of the pectoralis major muscle. CONCLUSIONS: Knowing the pectoral nerves' origins, courses and connections, in addition to understanding the functional consequences of iatrogenically severing these nerves, leads to a better understanding of the pectoral muscle's innervation. Precise anatomical data on the pectoral nerve allow for its easy localisation during axillary breast augmentation, axillary dissection, removal of the pectoralis minor muscle and harvesting the pectoralis major muscle island flap.

[Juvenile ossifying fibroma: a misgiving tumor of the jaws]. / Une tumeur maxillaire à ne pas méconnaître : le fibrome ossifiant de type juvenile.

Juvenile ossifying fibroma is a rare benign tumour of childhood. It is hardly distinguishable from others fibro-osseous lesions because of their overlapping microscopic features. Juvenile variant of ossifying fibroma may be mistaken for malignancy, particularly osteosarcoma. Radiology is central to their diagnosis because of the very limited nature of the tumour. Microscopically, the lack of cytologic atypia or abnormal mitosis, and the presence of bone maturation or cementum deposits are consistent with an ossifying fibroma. This entity should be kept in mind regarding any bone lesion jaws in children.

Fate of bone marrow stromal cells in a syngenic model of bone formation.

Bone marrow stromal cells (BMSCs) have been demonstrated to induce bone formation when associated to osteoconductive biomaterials and implanted in vivo. Nevertheless, their role in bone reconstruction is not fully understood and rare studies have been conducted to follow their destiny after implantation in syngenic models. The aim of the present work was to use sensitive and quantitative methods to track donor and recipient cells after implantation of BMSCs in a syngenic model of ectopic bone formation. Using polymerase chain reaction (PCR) amplification of the Sex determining Region Y (Sry) gene and in situ hybridization of the Y chromosome in parallel to histological analysis, we have quantified within the implants the survival of the donor cells and the colonization by the recipient cells. The putative migration of the BMSCs in peripheral organs was also analyzed. We show here that grafted cells do not survive more than 3 weeks after implantation and might migrate in peripheral lymphoid organs. These cells are responsible for the attraction of host cells within the implants, leading to the centripetal colonization of the biomaterial by new bone.

Onychomatricoma in the light of the microanatomy of the normal nail unit.

Onychomatricoma (OM) is an uncommon benign tumor of the nail thought to exhibit differentiation limited toward the nail matrix. Four recent articles from our laboratory have shown, in some respect, a morphological and immunohistochemical homology between the nail unit and the hair follicle at the level of the matrix and isthmus. The purposes of this article are as follows: to investigate whether the sequential pattern of hair keratin expression in the normal nail matrix is maintained in OM, to compare and contrast follicular tumors with matrix differentiation in OM, and to furnish morphological and immunohistochemical markers of the onychogenic capacity of OM. Formalin-fixed paraffin sections from 6 OM were examined using specific keratin (K) antibodies for the matrix, nail bed, and nail isthmus. Hair keratins were expressed in a sequential pattern similar to normal nail matrix. In 3 cases where the cavities were completely lined by the fibroepithelial projections, the morphological aspect and the pattern of expression of K5, K17, K6, K16, and K75 suggested a differentiation toward the nail bed and the nail isthmus. This study shows for the first time that OM can recapitulate the entire nail unit with differentiation toward the nail bed and the nail isthmus. We have identified new histopathological and immunohistochemical features in OM, and we have abridged the diversity of its histological presentation in 2 main patterns: a lobulated or foliated pattern, observed principally on transverse section, and a "glove-finger" mono- or multidigitate pattern, observed mainly on longitudinal section. We have also concluded that OM is not a nail variant of trichoblastoma, pilomatricoma, or other pilar tumors. The concept of epithelial onychogenic tumor with onychogenic mesenchyme could shed more light about the true nature of this peculiar mixed tumor. However, the term OM is short and sanctioned by usage, which justifies keeping it.

Biphasic calcium phosphate microparticles for bone formation: benefits of combination with blood clot.

Particulate forms of biphasic calcium phosphate (BCP) biomaterials below 500 µm are promising bone substitutes that provide with interconnected open porosity allowing free circulation of fluids and cells. Dispersion of the particles in the surrounding tissues at the time of implantation is a major drawback preventing from an easy use. We have asked whether blood clot could be a convenient natural hydrogel for handling BCP microparticles, and we hypothesized that blood clot might also confer osteoinductive properties to these particles. We show here that blood clotted around BCP microparticles constitutes a cohesive, moldable, and adaptable biomaterial that can be easily implanted in subcutaneous sites but also inserted and maintained in segmental bone defects, conversely to BCP microparticles alone. Moreover, implantation in bony and ectopic sites revealed that this composite biomaterial has osteogenic properties. It is able to repair a 6-mm critical femoral defect in rat and induced woven bone formation after subcutaneous implantation. Parameters such as particle size and loading into the clot are critical for its osteogenic properties. In conclusion, this blood/BCP microparticle composite is a moldable and osteoinductive biomaterial that could be used for bone defect filling in dental and orthopedic surgery.

Immediate functional loading of an implant-supported fixed prosthesis at the time of ablative surgery and mandibular reconstruction for squamous cell carcinoma.

The authors describe a case of squamous cell carcinoma of the oral cavity managed by ablative surgery, mandibular reconstruction with a fibula free flap, and implant placement during the same session. Immediate functional implant loading, respecting the principles of basal implantology, was performed 48 hours later using a highly rigid, screw-secured fixed prosthesis that served as an external fixator for the implants and grafted bone. Implant loading before external beam radiotherapy improves flap stability, bone consolidation, and quality of life. Functional and esthetic outcomes were evaluated 2 years after radiotherapy was completed.

Double breast contour in primary aesthetic breast augmentation: incidence, prevention and treatment.

The goal of this study was to define the incidence of double breast contour in primary aesthetic breast augmentation and to analyze its risk factors. An independent plastic surgeon analyzed the data of 200 patients who had a primary aesthetic breast augmentation with silicone gel implant and with a minimum 12-month follow-up. All patients had pre and postoperative standardized photography. Mastopexy-augmentations, breast reconstructions, breast malformations (tuberous breasts and Poland syndrome), and patients with incomplete data were excluded from the study. Assessment was achieved using an original standardized evaluation form (preoperative breast morphology, surgical options, postoperative aesthetic results). Patients were also asked to complete an exhaustive satisfaction form. A double breast contour was assessed clinically using Massiha's classification. The mean follow-up was 36 months. The double breast contour incidence was 7%. All of them were type I (the so called waterfall deformity). There was no type II (double inframammary crease). They were minor for 6.5% and major for 0.5%. They were related to a preoperative breast ptosis, subpectoral placement, and implant upper malposition. The rate of the type I was 10.5% of submuscular augmentation and 15% of preoperative breast ptosis. A double breast contour was primitive for 6% and secondary for 1% (pregnancy and breast-feeding postaugmentation). It was bilateral for 4.5% (3 cases of upper malposition, 1 case of medial malposition, 2 cases of pregnancy with breast-feeding postaugmentation and 1 patient refused a mastopexy-augmentation). It was unilateral for 2.5% related to a preoperative breast asymmetry with ptosis asymmetry and skin quality asymmetry. The satisfaction rate in the group "double contour" (14 patients) was 85.7% (vs. 91.9%). One patient had revision surgery (upper malposition). These types of deformities are fundamentally different with consideration on their clinical aspects, physiopathogeny, prevention and treatment. Type I major risk factor is subpectoral augmentation of ptotic breasts (with medium to bad skin quality and loses muscle to gland attachments). The muscle at the inferior pole of the breast is a "brake" preventing implant to fill the envelope. This risk is increased with implant malposition, constitutional ptosis asymmetry with symmetrical implant placement and selection of an insufficient implant projection or dimensions. This deformity can be avoided with selection of a subglandular or dual plane (type II or III) placement, a sufficient implant volume or projection and anatomic prosthesis. Type II is related to a lowering of a well-defined submammary fold more commonly in constricted and dens glandular breasts. This deformity can be avoided with respecting the inframammary fold, radial incisions on the gland's posterior surface, and selection of anatomic implants.