The medial adipofascial flap for infected tibia fractures reconstruction: 10 years of experience with 59 cases.

OBJECTIVE: The purpose of this study was to evaluate the results of the medial adipofascial flap (MAF) in infected tibia fractures reconstruction and to identify criteria for success or failure. PATIENTS AND METHODS: Fifty-nine patients treated with a MAF were enrolled. Age, BMI, tobacco use and bone status were recorded. Early and late postoperative complications were assessed. Bone healing and flap success were systematically evaluated at 12 months. RESULTS: Tibia fractures were initially open in 48 cases (81%) and closed in 11 cases (19%). Infection was acute (<30 days) in 9 cases (15%) and chronic in 50 (85%). Thirty-one patients (53%) experienced no early postoperative complications (<30 days). There were 10 (17%) cases of necrosis of the skin graft, 2 (3%) cases of necrosis and 4 (7%) haematomas in the harvesting area, 7 (12%) cases of partial flap necrosis at its tip and 4 (7%) flap failures. None of the criteria was statistically correlated with the occurrence of a complication. At 12 months, 53 flaps (90%) were successful. Immediate skin graft were significantly correlated with flap success (P=0.05). Forty-six patients (78%) had complete bone healing documented by CT scan. CONCLUSION: The MAF provides a reliable alternative for lower leg reconstruction. Its major advantages are sparing of the major leg vessels, no donor site morbidity and relatively easy and rapid dissection.

The esthetic outcome of lower limb reconstruction.

BACKGROUND: In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. OBJECTIVES: This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. DATA SOURCES: A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. STUDY ELIGIBILITY CRITERIA: All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. PARTICIPANTS, AND INTERVENTIONS: One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. RESULTS: We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. LIMITATIONS: The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. CONCLUSIONS: Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

A New Approach to Upper Eyelid Reconstruction.

BACKGROUND: Reconstruction of large defects of the upper eyelid is challenging because of its complex anatomy and specialized function. The aim of this work is to develop a single-stage reconstruction procedure based on a new approach. The technique consists of the advancement of an orbicularis oculi myocutaneous flap designed within the blepharoplasty skin excision pattern. METHODS: After the tumor's excision is completed with clear margins, the borders of the flap are incised down to the submuscular plane inside the classical pattern of upper eyelid blepharoplasty. Two myocutaneous triangles are excised on both sides of the flap to allow its advancement to cover the defect. When it is necessary to repair the posterior lamella, we harvest a mucochondral graft. RESULTS: From 2012 to 2015, we performed upper eyelid reconstruction with this technique on six patients. The flap survived in all the patients, without total or partial necrosis. No patient required surgical revision. The results were aesthetically satisfying, and no tumor recurrence was noted. CONCLUSIONS: Our new approach to upper eyelid reconstruction maximizes the cosmetic outcome respecting the principles of radicality. This flap is better suited for lesions involving the median or paramedian eyelid border from the marginal zone up to the palpebral crease. The approach we propose is safe and versatile, and it ensures either a functional or a good aesthetic reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The localization of the distal perforators of posterior tibial artery: a cadaveric study for the correct planning of medial adipofascial flaps.

PURPOSE: The adipofascial flap, introduced by Lin in 1994, has many advantages compared to fasciocutaneous or free flaps. Its dissection is relatively easy and fast with low donor-site morbidity, and it does not alter the shape of the leg. The aim of this dissection study is to evaluate the anatomic localization of the most distal perforator of the posterior tibial vessels to provide an anatomical rationale for the safe harvesting of distally based medial adipofascial flaps of the leg. MATERIALS AND METHODS: 30 Lower limbs from 15 cadavers were used for this study. The most distal perforator from posterior tibial perforator artery, accompanied by at least one vein, was identified and its distance from the medial malleolus was noted. RESULTS: A distal perforator was found in all specimens; the mean caliber was 0.77 mm. In all cases, the perforator artery passed in the septum between flexor hallucis longus m. and flexor digitorum longus m. and was accompanied by two veins. In our series, the distance between the lowest perforator and the medial malleolus ranged from 3.5 to 8.2 cm. The median was 6.75 cm, the 5th percentile 4 cm and the 95th percentile 8.1 cm. The mean distance of the perforator from the medial tibial border was 1.23 cm. The mean ratio between the distance of perforator from the medial malleolus and the total leg length was 21%. CONCLUSION: Compared to all previous researches, our study has found more distal perforators from posterior tibial perforator artery. This fact may have important clinical consequences, because the anteromedial adipofascial flap would cover more distal soft tissue defects. Moreover, our data suggest some safety parameters to make the rising of a medial adipofascial leg flap safer in surgical practice.

A new contrast agent for radiological and dissection studies of the arterial network of anatomic specimens.

PURPOSE: The aim of the present study is to propose a new contrast agent that can be easily applied both to CT and dissection studies to replace lead oxide based formulas for comparative anatomical analyses of the vascularisation of cadaveric specimens. METHODS: The infusion material was an epoxy resin, especially modified by the addition of barium sulphate to enhance its radiopacity. The final copolymer was toxicologically safe. To test the properties of the new material, several cadaveric limb injections were performed. The injected specimens were both CT scanned to perform 3D vascular reconstructions and dissected by anatomical planes. RESULTS: There was a perfect correspondence between the image studies and the dissections: even the smallest arteries on CT scan can be identified on the specimen and vice versa. The properties of the epoxy allowed an easy dissection of the vessels. CONCLUSIONS: The new imaging techniques available today, such as CT scan, can evaluate the vascular anatomy in high detail and 3D. This new contrast agent may help realising detailed vascular studies comparing CT scan results with anatomical dissections. Moreover, it may be useful for teaching surgical skills in the field of plastic surgery.

[Intra-articular distal radial fracture with lunate fossa rotated, about 4 cases: interest of surgical procedure by volar medial approach]. / Fracture articulaire du radius distal avec fragment de fossette lunarienne retourné, à propos de 4 cas : intérêt du traitement chirurgical par voie antéro-médiale.

INTRODUCTION: Intra-articular distal radial fractures in young subjects occur in severe trauma. Articular reduction needs to be anatomical. We report four cases with the particularity of having a 90° or 180° rotated lunate fossa. Our goal is to bring out the positive aspects of surgical procedure by volar medial approach and to assess long-term functionnal and radiological results. MATERIAL AND METHODS: Our study focused on four men whose average age was 27 (age range from 19 to 43). The fractures were type IV according to Melone's classification. The associated lesions included: one fracture of the base of the ulnar styloid, one fracture of the distal quarter of the ulnar diaphysis and one scapho-lunate diastasis. We used a volar medial approach between the flexors tendons and the ulnar bundle in order to pin the fragment of lunate fossa. The rest of the radial epiphysis was pinned after a 5mm skin incision. In two cases, this pinning was complemented with a brachial-antebrachial-palmar cast and in the other two cases with an external fixator. RESULTS: The follow-up period averaged 68.8 (18 to 115) months, all the patients were clinically examined through antero-posterior, lateral and dynamic X-rays. The objective results assessed according to Green and O'Brien's criteria, later modified by Cooney, were as follows: two very good, one good, one average. The X-rays showed consolidated fractures. According to Knirk and Jupiter's classification of arthritis, we had three grades 0, one of which showed a subchondral sclerosis of the lunate fossa, and one grade 3. DISCUSSION AND CONCLUSION: Imaging with simple radiographs is not sufficient and needs to be complemented with CT scan. Our approach allows for direct access to the fragment of the lunate fossa and easier visualization of the distal radioulnar, compared to Henry's approach, thereby avoiding excessive traction of the median nerve. TYPE D'ÉTUDE: Niveau IV.

A case series study on complications after breast augmentation with Macrolane™.

BACKGROUND: The use of Macrolane™ seems to have several advantages compared to the other standard methods for breast augmentation: it is faster, less invasive, and requires only local anesthesia. Nevertheless, various complications associated with the use of Macrolane™ have been described, e.g., encapsulated lumps in breast tissue, infection, and parenchymal fibrosis. We report the results of our case series study on the clinical and imaging evaluations of patients who came to our attention after breast augmentation with Macrolane™ injection and evaluate the effect of this treatment on breast cancer screening procedures. METHODS: Between September 2009 and July 2010, seven patients, treated elsewhere with intramammary Macrolane™ injection for cosmetic purposes, presented to our institution complaining of breast pain. In all patients, Macrolane™ had been injected under local anesthesia in the retromammary space through a surgical cannula. RESULTS: On mammography, nodules appeared as gross lobulated radiopacities with polycyclic contours. On breast ultrasound, the nodules showed hypo-anaechogenic cystlike features. In all cases, image analysis by the radiologist was hindered by the presence of the implanted substance, which did not allow the complete inspection of the whole breast tissue. CONCLUSIONS: From our experience, although safe in other areas, injection of Macrolane™ into breast tissue cannot be recommended at this time. Our study, along with other reports, supports the need to start a clinical trial on the use of injectable fillers in the breast to validate their safety and effectiveness. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

[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.

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.

Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage.

The vascular architecture within a perforator flap is different from a conventional muscle or myocutaneous flap. The purpose of this paper is to understand the correlation between flow rate and flap size in perforator flaps. With extrapolation of these data, we have provided an indirect analysis of the venous drainage and its correlation with flap size. A prospective study was planned. Twenty-five patients were enrolled in this study: six patients were operated on using an anterolateral thigh (ALT) flap and 19 using a deep inferior epigastric artery perforator (DIEAP) flap. One month postoperatively, echo-colour-Doppler measurements were performed on pedicle and perforator arteries to calculate blood flow rate in the flaps. A correlation between weight and flow rate was analysed. Spearman rho statistic was calculated. A linear regression model was made from patient data of flow rate/flap weight and predicted values of flow per flap weight were calculated. Then, flow rate values of veins of various diameters were estimated using Hagen-Poiseuille's formula. Our data show that flow rate measured postoperatively on flap arteries is significantly correlated with flap weight [rho(23 d.f.)=0.725, P<0.01 (two-tailed)]. Moreover, we have calculated the minimum size of veins able to drain flaps of increasing weights with different patterns, i.e. our data show that veins of 1.30, 1.50 and 1.75 mm diameter could safely drain flaps of, respectively, 300, 500 and 900 g in weight. This can be useful preoperatively to estimate the risk of flap congestion and in planning additional drainage.

Biological activity of phenolic compounds from Alchornea glandulosa.

From the isopropyl acetate fraction obtained by partition of the leaves ethanolic extract of Alchornea glandulosa, six phenolic compounds were isolated and identified. General lethality of the extract, fractions and compounds were assayed with Brine Shrimp Test (BST) and with Antifeedant Activity Bioassay (AAB) against neonate larvae of Spodoptera frugiperda. Aqueous fraction and ethyl gallate, one of the major constituents of the polar fraction, have shown the highest toxicity in BST. Ethanolic extract, isopropyl acetate fraction and gallic acid reduced significantly larval growth of S. frugiperda neonates.

Experimental obstructive coronary atherosclerosis in the hyperlipidemic hamster.

The evolution of coronary atherosclerotic lesions induced by a hyperlipidemic diet was examined in male hamsters subjected for up to 40 weeks to a standard chow supplemented with 3% cholesterol and 15% butter. Control animals were fed standard chow only. Five to seven hamsters were monthly sacrificed and investigated for serum lipids and coronary artery lesions. As compared with control animals, the hamsters fed the fat diet showed a progressive increase in serum cholesterol which reached maximum values up to 17 fold in the 10th month. The serum of the hyperlipidemic hamster examined by agarose electrophoresis, Laurell immunoelectrophoresis and cross-immunoelectrophoresis showed at most a 14 fold increase in low density lipoproteins after 10 months diet. The examination of coronary arteries revealed morphologic changes already detectable at 2 weeks of diet. The earliest modifications observed were characterized by proliferation of the subendothelial matrix or/and the appearance of liposome-like structures in the intima. After 2-3 weeks of diet, smooth muscle cells appeared occasionally in the intima and monocytes adhered and penetrated through the endothelium. Later on, smooth muscle cells and macrophage displayed lipid deposits. Focally, in areas of intimal proliferation and foam cells, endothelial cells were also lipid-loaded. Like in human atherosclerotic plaque, in the late stages of hamster coronary lesions, there was a progressive accumulation of extracellular unesterified cholesterol, calcium deposition and necrosis. Lesions evolved to a progressive narrowing of the coronary branches affected, with complete obstruction of some small arterial ramifications. Hamster appears to be a suitable model for studying the molecular and cellular events leading to obstructive coronary atherosclerosis.

The hyperlipidemic hamster as a model of experimental atherosclerosis.

Male hamsters were fed a hyperlipidemic diet consisting of standard chow supplemented with 3% cholesterol and 15% commercial butter for 12 months. In about 3 weeks serum total cholesterol doubled, raised 4-fold after the 4th week and after 10 months attained a 17-fold value. Low density lipoproteins (LDL)-cholesterol increased 4-fold after 4 weeks and about 13-fold after 10 months compared to control animals. In the first 2 weeks mononuclear cells began to adhere to the endothelium and a very intense stromal reaction appeared in the intima of the aortic arch. At the end of the 4th week of diet, Oil Red O stainable deposits were visible on the thoracic aorta, mostly on the arch, some of them as isolated, lipid-laden cells and others distributed on focal areas. Smooth muscle cells (SMC) appeared also in the intima of hyperlipidemic hamsters, compared to normal animals which had no macrophages or smooth muscle cells in the intima of the aortic specimens examined. Up to 6 months, smooth muscle cells in the intima and media began to load with lipids, as well as endothelial cells. After 10 months the affected zones looked like human atherosclerotic plaque with huge cholesterol crystal deposits, calcium deposits and necrosis. The endothelium, though very thinned and loaded with lipids, was morphologically intact.

Cellular events in the development of valvular atherosclerotic lesions induced by experimental hypercholesterolemia.

The onset and evolution of ultrastructural changes in the cardiac valves induced by a cholesterol-rich diet were investigated in rabbit and hamster. In both animal models, the atrioventricular and sigmoid valves were comparably affected by lesions intermediary between fatty streak and fibrous plaque. The earliest detectable modification was the progressive accumulation in the subendothelium of extracellular liposome-like structures rich in unesterified cholesterol, associated with the proliferation of a basal lamina-like material. This was followed by the diapedesis of blood monocytes in the same location, which became macrophages increasingly loaded with lipid deposits. Resident interstitial cells accumulate lipids, as well. In advanced stages, the macrophage-derived foam cells clustered, deforming the valve leaflets. The resident macrophages accumulated lipids later and more slowly, while partly preserving their ultrastructure. The advanced lesions are characterized by marked stromal proliferation, massive intra- and extracellular deposition of lipids and cholesterol crystals and the appearance of a necrotic core. The salient findings of these studies were: (1) the appearance of extracellular liposomes as the earliest event in atherogenesis; (2) the capability of the valvular interstitial cells to accumulate lipids; and (3) the slow response of resident macrophages to the cholesterol-rich diet. The results revealed that hypercholesterolemia produces in the cardiac valves atherosclerotic lesions of an intermediate type, which can deform the leaflets thus altering their normal function.

The exceedingly high burden of acute and chronic respiratory diseases--global situation and prospects.

Mortality data are presented for acute and chronic respiratory diseases, on a world-wide basis for the period 1970-1982, encompassing 76-88 countries, with a population of 1.1-1.3 billion. Despite the declining trend of respiratory conditions, mortality from acute respiratory infections is still rampant at the two extremes of the lifespan and pneumonia attains unacceptably high mortality rates in developing countries. Chronic respiratory diseases claim a significant proportion of lives in the old age groups in both developed and developing countries. It is now sufficient evidence that respiratory diseases are preventable and the reduction of mortality is possible through appropriate intervention programmes.

Plasma exchange-induced biological stress of the Hagemann-mediated systems: results of contact activation and plasma substitution.

Plasma exchange can induce changes in the biological systems of coagulation, fibrinolysis, complement and kinins, either by contact activation or plasma substitution. In order to know which of the two is responsible, the actual initial and final values and theoretical calculated final values were compared. Fibrinogen, Antithrombin III and platelets fell more than expected, and there was a significant increase in Platelet-Factor four and Betathromboglobulin which was greater than would produced by plasma substitution alone. Fibrinolysis is shortened and white cells rise. Complement and kinins were not significantly changed. During plasma exchange, contact activation actually triggers coagulo-fibrinolytic pathway and stresses cellular components.