Nostril Surgery: Indications, Surgical Procedures and Outcomes-A Systematic Review of Published Cases

INTRODUCTION

To achieve adequate nasal proportions, nostril surgery can be a complementary technique useful in facial surgery. To help surgeons with the decision to realize nostril surgery, we conducted a systematic review to summarize reported cases on surgical procedures with a specific interest on indications, surgical procedures and postoperative outcomes. A therapeutic algorithm is also proposed.

METHOD

We carried out this review in accordance with the PRISMA criteria. Twenty-two eligible studies were identified using Medical databases, including 1599 patients. A qualitative and quantitative analysis was carried out.

DISCUSSION

Excision techniques were realized on 728 patients (45.5%), followed by cinching sutures on 642 patients (40%) and combined techniques: excision techniques with flap advancement techniques in 189 cases (12%), excision techniques with flap advancement techniques and cinching suture in 40 patients (2.5%). When excessive alar flaring was present, alar wedge resection was preferred in the 92% of followed by alar and sill resection. Cinching sutures were realized when excessive alar flaring was associated with a vertical alar axis, in cases of wide alar base, of associated orthognathic surgery. When excessive alar flaring was associated with wide alar bases, indications changed basing on the associated deformities. In 795 patients, nostril surgery was conducted simultaneously with rhinoplasty.

CONCLUSION

Nostril surgery through excision techniques, cinching sutures or flaps advancement techniques, reveals good outcomes and can be complementary to rhinoplasty or orthognathic surgery. Through this systematic review, we tried to orient surgeons to find the best treatment for nostril base surgery.

LEVEL OF EVIDENCE III

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 .

Lower limb perforator flaps: Current concept

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

[Complications of autologous breast reconstruction]

Flap reconstruction techniques are increasingly desired by French's patients and it represents almost half of breast reconstruction indications in 2017. The main reasons of this statistics are the growing concerns of the patients with breast implant of developing BIA-ALCL, as well as their desire of having a more natural reconstruction results without having any foreign bodies. The multiplication of autologous reconstruction techniques, especially microsurgical techniques which has been popularized in the recent years, makes possible to propose a reconstruction to the majority of patients without an implant. This type of reconstructions is associated with a significant number of complications; thus, a proper selection of patient should be done and a good knowledge of the surgical technique by the surgeon to reduce the complication. Our proposed study is divided into two main parts, the complications of the flap and the complications at the donor site. Based on the experience of our plastic surgery department in immediate and delayed breast reconstruction, the objective of this article is to describe and to analyze the possible complications of breast reconstruction by a flap and their surgical management in intra and post operatively. Our goal is to provide an algorithm for our young colleagues in order to obtain better understanding of this type of interventions difficulties and to provide an appropriate care in the event of complication, also to provide optimal care to the patients who wish to undergo autologous flap reconstructions.

[Two cases of primary malignant melanoma of the larynx: a rare pathology]

INTRODUCTION

Primary malignant melanoma of the larynx is a very rare entity. There are less than sixty cases described in the literature. Through both cases, we describe and discuss the clinical management of melanoma of the larynx.

CLINICAL CASES

Two men aged 80 and 61 years were supported for MPL. The tumor was revealed by persistent dysphonia for the first. For the second, it was a second melanoma of laryngeal location. In both cases it was performed a total laryngectomy extended to the first tracheal rings with bilateral lymphadenectomy associated with adjuvant radiotherapy.

DISCUSSION

Excision margins with oncological safety are necessary to except a curative surgery. Still controversial, the adjuvant radiotherapy seems to provide a benefit in terms of local control. The place of targeted therapies remains unclear. However, no prognostic factor is currently clearly identified for this disease.

CONCLUSION

Rare tumor, the MPL is associated with a very poor prognosis. Resective surgery followed by adjuvant radiotherapy is for us the treatment of choice.

Use of a 3-D imaging technique for non-invasive monitoring of the depth of experimentally induced wounds

BACKGROUND/PURPOSE

Experimental studies of wound healing lack methods for standardized wounding and in situ depth assessment. Consequently, in this pilot study, an Erbium (Er):YAG laser has been used for wound induction with a non-invasive 3-D imaging technique as an alternative to histology.

METHODS

Erbium:YAG ablation of human skin ex vivo was performed with total fluences of 10, 50 and 200 J/cm(2), removing the stratum corneum, epidermis/papillary dermis and deeper dermis, respectively. Wound depth was measured with the 3-D method and histologically.

RESULTS

Wound depth was proportional to fluence for both techniques : 3-D, 17.7+/-1.7, 43.9+/-16 and 245.2+/-61 microm; histology, 14.6+/-1.7, 50.6+/-11.6 and 238+/-102 microm, respectively.

CONCLUSIONS

The 3-D technique compares well with and is an improvement on histological measurement, providing true wound depth measurement, avoiding shape changes inherent with histology. Furthermore, the Er:YAG laser is a highly appropriate means of wound induction due to its rapidity and precision.

Reconstruction mammaire prothétique après expansion préalable prolongée. À propos de 247 cas

SUBJECT

The purpose of this study was to analyse the complications and the aesthetic results in case of slow tissue expansion in prosthetic breast reconstruction.

PATIENTS AND METHODS

We tracked 237 patients representing 247 mammary reconstructions operated between 1992 and 2004. These patients were distributed in two series, a series of 148 operated mammary reconstructions between 1992 and 2000 and a series of 99 reconstructions operated between 2001 and 2004. For every reconstruction, we analysed the progress of the expansion, the complications and the quality of the aesthetic results according to the radiotherapy and the type of implant used.

RESULTS

The radiotherapy increases the risk of failure of the breast reconstruction and degrades the quality of the aesthetic results. Capsular contractures are rare and their frequency does not depend on the irradiation. Prosthesis infections and exposure are more frequent on irradiated ground.

DISCUSSION

The tissue expansion in prosthetic breast reconstruction is a technique studied well in the literature, but few authors use a chronic expansion and compare the long-term results according to the radiotherapy. If our study confirms the noxious role of the radiotherapy as for the complications and for the aesthetic aspect of the results, it is not a question for us of an absolute contraindication. The weak rate of capsular contracture is attributable to the chronic character of the expansion, which allows the maturation of the capsule. The use of silicone gel implants decreases the deflations but does not improve the results.

CONCLUSIONS

The radiotherapy increases the risks of failure of the tissulaire expansion and decreases the quality of the aesthetic results. The chronic character of the expansion allows to obtain a rate of capsular contracture weak, even on irradiated ground. The silicone gel implants make it possible to obtain a perennial result.

Critères intervenant dans le choix entre prothèse préremplie au gel de silicone et prothèse remplie au sérum physiologique en chirurgie mammaire d'augmentation

The use is to oppose silicone and saline implants. Both are used in regular practice. What are the arguments to choose in between the two types? We separated three different criteria groups: prosthesis characteristics, surgical procedures and complications. For each criterion we made a review of literature looking for arguments in favour or against silicone or saline implants. The number of criteria to choose the correct type of prosthesis is very important. We conclude that surgeon experience; desires of the patient and evolution of prosthesis are the most important criteria.

« Morphosein » : gestion d'une base de données patients pour le choix objectif du volume de l'implant dans les hypotrophies mammaires

Good selection of mammary implant volume is essential to satisfy patient's real desire of breast augmentation. The authors have developed a data processing called "Morphosein": it is an active press-i-book, allowing recording and exploitation of basic morphologic datas before and after operating procedure. They use Filemaker Pro as basic software and database, which is fed with personnal patients. This tool allows a comparative research on patients having a similar morphologic and on results obtained with different types of implants. These datas, store since 4 years, give to the authors' objective informations to help the patient's choice.

[Poland'syndrome and hand's malformations: about a clinic series of 37 patients]

INTRODUCTION

Poland's syndrome is a rare malformation which associates thoracic anomalies and anomalies of homolateral upper end. We wish to know the frequency of hand's malformations in this syndrome in our clinical experience.

MATERIAL AND METHODS

We have revised 37 patients who were seen initially for a thoracomammary anomaly. This clinical series from plastic surgery service of Toulouse has been revised to know the importance of hand's malformations.

RESULTS

Hand's malformations in Poland's syndrome are rare in your study, they touch only 12% patients. We find only 4 malformations in 33 patients, four were lost. They were only females, we find three brachymesophalangies and a major form.

DISCUSSION

Hand's malformations in Poland's syndrome are less frequent than classically. There is no parallelism between gravity of thoracic malformation and that one of upper end. In this series, we find only one case with syndactyly; originally, Poland's syndrome was named << Poland's syndactyly >>. Finally, we think that we can talk about Poland's syndrome without anomaly of homolateral upper end, the major element is musculary agenesia of sternocostal pectoralis major. The search of homolateral upper end has to be systematic in front of suspicious of Poland's syndrome.

Complications des abrasions du visage par laser

Laser resurfacing is a burn of the superficial skin layers: it's a controlled burn in its depth, that can destroy epidermis and the dermis superficial part, but not deeper for avoiding healing complications. All complications and the normal postoperative follow-up can be explained by the fact that laser resurfacing is a burn of the dermis and epidermis, with the destruction, partial or total, of their components. It's essential to understand the normal postoperative process and complications to avoid them and to treat them in the beginning. Infection, persistent erythema, pigmentation troubles like hyperpigmentation or depigmentation and demarcation surrounding the resurfacing area, healing troubles like hypertrophic scarring, keloids, excess of skin retraction are the main complications. Careful preoperative explanation of laser-resurfacing follow-up will help the patient adjust more easily to postoperative care.

[The tuberous breast: a review]

The tuberous breast is one of the most challenging problem in breast surgery. Pediatricians, gynaecologists and plastic surgeons are particularly concerned with the treatment of these young patients. A good assessment of the pathology and a precise knowledge of the surgical procedures are keypoints for a successful treatment. A case report will precede a literature overview of this very complex problem.

[Deflation of breast implants, pre-filled with saline or hydrogel. Results and analysis of 650 treated patients]

SUBJECT

The main mechanical side effect of saline or hydrogel filled implants is deflation. The aim of this study was to analyse the prosthetic deflation rate in the last 7 years in the plastic surgery unit of Toulouse.

PATIENTS AND METHODS

We tracked 650 patients operated on between july 1993 and july 2000 (representing 1117 primary implants) which we separated in two groups: the first group contained patients in need of breast reconstruction; the second group contained all the patients with implants placed for aesthetic or breast asymMetry reasons. For each of the two groups we determined the number and the type of implants, as well as the rate and the mean delay after which deflation occurred.

RESULTS

During this period, we've determined that: rate of deflation of group 1 (reconstruction) is highest than group 2 (aesthetic), despite sort of implant; rates of deflation of pre-filled hydrogel implants are highest than rates of deflation of pre-filled saline implants.

DISCUSSION

Only a few series concerning implants deflation have been described in the literature. We can find a large difference in results which vary from 2 to 76%. We were surprised by the result of our series with a rate of deflation up to 15% with a medium follow-up 5 years in both groups and a mean delay before the fourth year. Deflation's factors are numerous: type of sterilisation, rippling, texture, valve's incompetence, prosthetic patch, guarantee control and iatrogenic causes. Because the silicone gel implants (the one uncomplicated by deflation) were taken off the french market, the saline implants tried to supplant them but without satisfactory results.

CONCLUSIONS

With the unacceptable rate deflation of implants in our study, the return in the french market of silicone gel implants seems us an acceptable alternative.

[Skin necrosis after prophylactic treatment with heparin]

The authors present a case of cutaneous necrosis following local injection of heparin. The physiopathology and the clinical aspect are discussed.

[Large abdominal parietectomy for late abdominal wall recurrence of colonic cancer: reconstruction with latissimus dorsi free flap with delayed insertion]

Parietal recurrence following conventional treatment of colorectal cancer is an infrequent event and is usually associated with an intra-abdominal recurrence. The study aim was to report a large solitary abdominal wall recurrence observed 80 months after the resection of a sigmoid adenocarcinoma and treated by a left hemiparietectomy associated with a segmental colectomy. The abdominal wall reconstruction combined a prosthesis and a latissimus dorsi myocutaneous free flap with delayed insertion after initial transfer.

[Angiomyoma of the hand: a post-traumatic tumor?]

A 69-year-old woman presented with a tumor of the lateral aspect of the proximal phalanx of the little finger of the right hand. The finger was injured by a ring during a handshake. Excision and histopathological examination revealed the diagnosis of angio-myoma, a benign vascular tumor originating from the smooth muscle cells of arterial or venous walls. Angiomyomas belong to the family of leiomyomas and rare, small tumors (less than one centimeter), preferentially occurring in women between the ages of 40 and 60 years. They may be painful. Only one case of sarcomatous degeneration has been described in the literature. Trauma has never been previously reported as a cause of angio-myoma, but in this case the traumatic origin of the tumor was not in doubt.

Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry

A variety of breast deformities of differing appearances can be grouped together within an extensive syndrome that is characterized by anomalies of the breast base and preferentially involves the lower quadrants. Tuberous breasts are the most typical, but not the only, form of the deformity. The authors studied a series of 37 patients who had breast surgery, and they used a classification of three types: I, II, and III (in increasing order of severity). In type I breasts (minor form), only the lower medial quadrant is deficient; in type II breasts, both lower quadrants are deficient; and in type III breasts, all four quadrants are deficient. The study showed a predominance of minor forms (54 percent of breasts operated on) and of combinations including at least one minor form (81 percent of patients). Seventy percent of women had a breast asymmetry of more than 100 g. Only 27 percent of breasts operated on were hypotrophic, 45 percent were of normal volume, and 28 percent were hypertrophic. The authors propose a procedure to treat the minor forms of the deformity, using a mammaplasty with a superior pedicle and a lower lateral dermoglandular flap to fill the deficient lower medial quadrant. They define the indications of the classic techniques according to the type of deformity and stress the frequent need for secondary revision.

Surgical treatment of sacrococcygeal pilonidal sinus disease by excision and skin flaps: the Toulouse experience

OBJECTIVE

To compare various techniques for the treatment of pilonidal sinus.

DESIGN

Retrospective study

SETTING

University Hospital of Toulouse, France.

SUBJECTS

246 consecutive patients who presented between 1979 and 1996. The male:female ratio was 2:1, and the mean age 26 years (range 18-69).

INTERVENTIONS

218 one or two stage excision and rotation skin flaps, and 28 simple incisions.

RESULTS

16 sinuses recurred, and no flaps necrosed.

CONCLUSION

Excision and rotation skin flaps offers an effective and elegant alternative to the more classic operations for pilonidal sinus as it causes less postoperative pain and shortens convalescence.

[Incisional hernia. Patient management. Approach to the future operated patients]

Incisional hernia, an abnormal orifice of the midline abdominal wall secondary to an operation, presents in a wide range of forms to the plastic surgeon: small orifice (< 6 cm) in a young, muscular subject, or vast defect (> 10 cm) in an obese subject who has undergone multiple operations, or who presents one or more diseases. Regardless of this presentation, the approach to the patient must always be just as rigorous, based on a precise assessment of the clinical signs. This clinical examination is irreplaceable, but is often insufficient, incomplete, and misleading. Only CT imaging of the abdominal wall provides a good analysis of the damage. Beyond the simple orifice, a large incisional hernia is responsible for a whole range of disease. This "incisional hernia disease", with its visceral and respiratory components, requires a multidisciplinary assessment. The anaesthetist and respiratory physician must assess the repercussions of this lesion and detect any risk factors. Based on this assessment, major incisional hernias (2/3 of the 350 operated patients of our series) require specific preparation involving the following elements: eradication of any site of wound infection, weight loss, muscle building, abdominal and chest physiotherapy, and pneumoperitoneum. Pneumoperitoneum according to the Goni Moreno protocol is an essential element of the preparation of the most difficult forms (irreducible, double, or complicated incisional hernias). Only this gaseous expansion of the abdomen can facilitate reintegration of the viscera and reconstruction of the abdominal wall. In our practice, the operation itself consists of 2 types of procedures: simple local abdominoplasty (e.g. Judd's technique) for small incisional hernias (about 20% of cases), or a combination of reconstitution of the deep fascia by extensive cleavage of the posterior sheath of the rectus abdominis and prosthesis. This prosthesis, which lines the fascial plane, is placed extraperitoneally. This technique, with several variants described here, is based on a similar concept to that promoted by Rives et al. and Stoppa et al. It is the preferred procedure in all large incisional hernias (80% in our experience). Patient selection, intensive preparation, meticulous technique, and intensive postoperative nursing give stable, solid results (90% of patients) and ensure optimal security, bearing in mind that repair of a large incisional hernia is always difficult and sometimes dangerous (1% mortality, 6 to 10% morbidity in all large series).

[Incisional hernia repair techniques for the abdominal wall]

Incisional hernia repair has been the subject many publications over the last century. Suture techniques in one plane (Judd, 1912) or in several planes (Quenu, 1896) were described first. They remain suitable for the closure of small incisional hernias. Rectus abdominis sheath dissection techniques, also known as fascioplasties, then reinforced hernia repair by prolonging the anterior (Welti-Eudel, 1941) or posterior leaflet (Gibson, 1920) of the sheath. These plasties are still widely used, either alone, to repair medium-sized hernial orifices, or in combination with a prosthesis to repair large hernial orifices. Autologous tissues, such as fascia graft (Mac Arthur, 1901) or skin graft (Gossec, 1949) are now used because of the marked capacity of prostheses for secondary distension and their sensitivity to infection. Flaps, especially the tensor fasciae latae flap (Nahai, 1974), are indicated in infraumbilical incisional hernias in a septic context. Currently, only reinforcement prostheses can achieve lasting repair of large incisional hernias. Some teams still use intraperitoneal mesh implantation, but most teams prefer extraperitoneal implantation, generally associated with fascioplasty. Extraperitoneal mesh may be placed in a pre-musculo-aponeurotic or retromuscular position. Based on their experience, the authors opted for a pre-fascio-aponeurotic retromuscular prosthesis. They describe in detail the technique used and the results obtained based on the analysis of a series of 252 patients.

[Tools of the Internet in maxillofacial surgery and oral medicine. Practical applications]

Internet has a wide range of functions applicable in the medical domain. Its use has had a clear impact on routine medical practice. The user can consult colleagues, send and receive multimedia files, order books from the library, access specialized reviews or worldwide scientific data on-line as well as publish results, and participate in forums, telephone or organize teleconferences in real time. Faced with the abundance of the available information flow and the methodological difficulty in extracting precisely useful data, the ordinary user can wander a long time in cyber-space before learning the skills required for efficient navigation. We recall here the fundamental principles of the Internet and describe the types of information the maxillofacial surgeon can use in his everyday practice. Certain unanswered questions are debated as well as certain difficulties related to the use of the Internet in its present state of development.

["Saphenous vascular loop" technique in the treatment of lower limb defects. Report of five cases]

Five patients with high energy trauma of the lower limb with tissue defect located in the knee or the proximal third of the leg underwent reconstruction with a free latissimus dorsi flap. This flap was connected to a vascular saphenous loop which initially creates an arterioveous shunt between proximal femoral vessels. This was performed in a single operation with two teams of surgeons. This technique was chosen because a healthy recipient pedicle was not available in the vicinity of the defect. Application of vein grafts is not the usual procedure but there are situations in which it becomes necessary. Our aim in this paper is to discuss these situations, to describe the technique used in our Hospital and to analyze the advantages and disadvantages of a one or two-stage operation.

A predetermined design for easier aesthetic abdominoplasty

The authors have presented a predetermined design of cutaneous resection for abdominoplasty without relocation of the umbilicus. The design is characterized by two lateral tips, pointing upward, and a central dome. The upper and lower edges of the cutaneous incision are of the same length, which prevents puckers and allows optimal evolution of the scar. The median cutaneous resection removes the horizontal base of the triangular area of pubic hair, producing a lower final scar and giving the mons pubis a more youthful appearance. The lateral cutaneous resections allow transverse redraping of the abdominal skin, and the oblique scars, placed in the natural folds, are easily concealed even under brief attire. Unlike individual resection techniques that require practice and experience, this technique is perfectly codified and can be carried out by less experienced surgeons.

[Breast reconstruction after mastectomy for cancer]

In spite of advances in breast cancerology, partial or total mastectomy still has wide indications and remains a mutilative procedure. Since its introduction over thirty years ago, breast reconstruction has become an accepted, codified and efficient procedure. The techniques which can be used can be broadly divided into two categories: reconstructions with implants, which have been greatly improved by skin expansion techniques, and reconstructions using myocutaneous flaps. Whatever method is used, the breast is modeled during the reconstruction procedure and surgery is frequently necessary to obtain a symmetric opposite breast; a good knowledge of plastic surgery is thus a requisite.

[Effect of irradiation fields on the results of breast reconstruction with skin expansion after radiotherapy]

Deferred prosthetic breast reconstruction after skin expansion is considered to be difficult after radiotherapy. The authors report a series of 14 cases of reconstruction after radiotherapy, compared with 6 cases of reconstruction without radiotherapy. They reported a similar quality of results after radiotherapy not including irradiation of the chest wall and in the absence of radiotherapy (p = 0.742). On the other hand, a significant deterioration of the results was observed when radiotherapy included chest wall irradiation (p = 0.0015). Finally, no direct correlation was observed between the macroscopic appearance of the skin and presence or absence of a history of irradiation of the chest wall. They conclude that the indications for reconstruction by tissue expansion after radiotherapy must be based more on the irradiation protocol than on the macroscopic appearance of the skin.

[Morphological anomalies of breasts in adolescent girls and their surgical correction]

BACKGROUND

Morphological anomalies of the breast in adolescent girls cause considerable psychological distress. Plastic and reconstructive surgery offer the possibility of improving such conditions. The aims of this work were to define and illustrate the various types of anomalies, clarify their distribution and present the repair methods that can be used and the results obtained.

POPULATION AND METHODS

A consecutive series of 33 girls under the age of legal majority, admitted over a 1-year period for surgical modifications of breast shape, was studied. The basic anomalies were classified as mammary hypertrophy, hypotrophy, asymmetry, and abnormal shape, among which were Poland's syndrome, tuberous breasts, thelorism and pute ptosis. The basic techniques used were reduction, augmentation with placement of an implant and breast remodeling. Distribution of anomalies was as follows: symmetrical bilateral hypertrophy, 33%; asymmetric bilateral hypertrophy, 30%; unilateral hypertrophy, 6%; combined hyper- and hypotrophy, 3%; unilateral hypotrophy with abnormal shape, 9%; abnormal shape with normal size, 15% and bilateral hypotrophy, 0.3%. Mean hospital stay was 3 days and there were no serious postoperative complications.

DISCUSSION

Bilateral hypertrophy was the most frequent disorder and the main drawback was residual scaring. Bilateral hypotrophy was rarely seen since only congenital absence of mammary glands is surgically treated before legal coming of age. The main problem of implants was formation and contraction of fibrous capsules around the implants in 5% of cases. Asymmetry and anomalies of shape were more difficult to treat because each breast requires a different procedure. At the present time, because of the cost/benefit ratio of such procedures, they are reimbursed by health services.

CONCLUSION

Although the results are not perfect, the psychological impact of such treatment is highly positive, suggesting that the requests of adolescent girls for this type of surgery may be encouraged.

[Imaging of abdominal wall eventration: role and value of x-ray computed tomography]

The role of imaging in preoperative investigation of incisional hernia was studied in a series of 332 operated patients. CT scan (220 patients) remains the reference investigation. Magnetic resonance imaging (8 patients) does not provide any supplementary information at the present time. The classical features of median and lateral incisional hernia are described and the importance of evaluation of the elasticity and strength of the abdominal wall is stressed. In the authors' experience, this evaluation has implications for pre- and intraoperative strategy.

[Severe cutaneous necrosis after ultrasound lipolysis. Medicolegal aspects and review]

The authors report the case of a young patient who developed extensive skin necrosis after ultrasound liposuction of the medial surface of the thigh. These lesions required excision, split-skin graft and installation of an expansion prosthesis. The medicolegal aspects of this case are discussed, in particular the responsibility of the doctor who performed this damaging procedure, from three points of view: damage, fault, causality. In this case, the damage corresponded to necrosis which can be due to a chemical, infectious or thermal mechanism. It is responsible for serious damages due to the number of operations, the length of hospital stay, immobilization, rehabilitation and the time off work. The aesthetic damage, the pretium doloris, and the inconvenience are certainly considerable, but was there fault in this case? Fault by clumsiness if the equipment was used abnormally; fault by negligence or imprudence when the equipment was not approved or when the operator was not a qualified physician, submitting his patient to undue risks. The causality is envisaged in the case of chemonecrosis and burns. It would be strongly presumed in a civil procedure in case of non-approved equipment. The authors are in favour of a hypothesis of a burn and review the current state of ultrasound liposuction, which was the subject of an intense media campaign several years ago.

[Occipital forehead pedicle for one-stage repair of defects of the upper third of the face]

The authors describe a reconstruction technique for defects of the superior third of the face using a fascio-cutaneous flap with a forehead paddle supplied by an occipital pedicle. This flap has been successfully used in three cases to cover defects of the temporo-zygomatic area indeed, the superior part of the cheek. Our three patients presented recurrent cutaneous carcinoma, a local and general poor condition. This process suits reliability and easiness to a good carcinologic, functional and aesthetic result.

[Reconstruction of the shape of the shoulder after scapulothoracic amputation]

Few papers have been published in the international literature on reconstruction of the shape of the shoulder stump after scapulothoracic amputation. The authors report a case of reconstruction using a solid silicone implant after prior skin expansion. The essential objective of this reconstruction is to eliminate the need for an external prosthesis, which constitutes a major handicap for these patients.

[Reconstruction of the anterior chest wall by a sandwich-type combination of a synthetic support and a muscle flap from the latissimus dorsi. Apropos of a case]

Reconstruction of the chest wall after balistic or other trauma requires good and muscle cover and creation of a new, stable and airtight wall. The authors present a case of balistic trauma of the right anterolateral chest wall which was urgently debrided and subsequently reconstructed by sandwich combination of a latissimus dorsi muscle flap and synthetic material composed of a sheet of PTFE and creation of two methylmethylacrylate ribs. The advantage of this technique is that it avoids the use of autologous tissue from an already weakened chest wall and confers a new chest stability in several sites corresponding to the wall defect with easily available and easy-to-use materials.

[Large eventrations: deep extensive cleavage of the abdominal wall and prosthetic repair]

The objective for surgical repair of major defects of the abdominal wall is an anatomical reconstruction and reinforcement with a support prosthesis. Wall reconstruction should be obtained without tension. This requires deep extensive cleavage so the deep musculo-aponevrosis can be advanced approximately 10 cm. This manoeuvre is anatomic and preserves vascularization and innervation. A prosthesis covers the orificies and reinforces the anatomic construction. In peripheral defects, cleavage is necessary for closure. The prosthesis is anchored on deep solid structures (ribs, iliac crests) guaranteeing solidity. In a series of 252 operated patients, abdominal wall solidity was achieved in 91% of the cases with a mean follow-up of 2 to 13 years. Mortality was 1.2% and morbidity 8%, emphasizing the importance of rigorous indications. Intensive preparation including the Goni Moreno pneumoperitoneum is required for surgery in all major abdominal wall defects.

[Merkel cell carcinoma of the skin]

This study reports five cases of Merkel-cell carcinoma of the skin. Then the authors review the present state of the art from the data already available in the literature concerning this malignant primary skin tumor. A part from local excision, no standard procedures are described. The literature provides a lot of discrepancies concerning the additional treatments such as lymph mode excision, radio and chemotherapy. The prognosis of this tumor remains poor because of a high incidence of local recurrence, a frequent spread to regional lymph modes and the development metastases.

[Difficult diagnosis of a hypervascularized tumor: "angiomatous epulis"]

Based on a case presented by the patient himself, the authors describe the difficult management of a very large, recurrent epulis arising in a context of flat angioma of one half of the face according to a vascular mode. After a brief review of the clinical and aetiopathogenic aspects, the authors discuss the value of complete surgical treatment and raise the question of the possible relation, in this particular case, between angioma and this recurrent so-called angiomatous epulis.

Histologic assessment of low-voltage electrical burns: experimental study with pigskin

The authors have carried out an experimental protocol on pigs, producing identical electrical burns to examine clinically and histologically the evolution of these burns with time. A clinical lesion in the form of a rosette was observed. It was composed of three zones: a central zone of carbonization, a pale ischemic intermediate zone, and an erythematous peripheral zone. Microscopic observation showed vascular thrombosis in the intermediate and peripheral zones in addition to necrosis of the central zone. These vascular lesions can be classified in three stages, I, II and III, according to the degree of vascular damage. The evolution of the lesions was stabilized at 72 hours after burn injury. These observations are important in determining the surgical treatment, particularly debridement, on postburn day 3, when the prognosis of the intermediate and peripheral zones must be taken into account.

[Launois Bensaude disease. Focus apropos of 16 cases]

After a review of the clinical, pathological and aetiological features, the authors describe the various surgical techniques used (conventional surgery or liposuction) to restore a normal social life to these patients, deformed by their disease. They confirm the predominant role of conventional surgery and define the limited indications in which liposuction can be used. Based on a review of 16 cases, the surgeon must make sure that the patient has ceased his or her alcohol abuse before performing this difficult treatment associated with a number of complications.

[Iliac transosseous transposition of rectus abdominis muscle flap to cover a sacral pressure sore]

The use of an inferiorly based rectus abdominis myocutaneous flap to cover a pelvic pressure sore offers a solution when the possibilities of other local flaps have been exhausted. For sacral pressure sores, the iliac bone is an obstacle for the transposition of this flap. In this case report, we describe how this obstacle can be overcome by creating a trans-osseous tunnel in the ala of the iliac bone through which the flap takes the most direct route to the recepient site.