[Myxoma of the mandible. A case report]

Maxillo-mandibular myxomas are rare lesions and their pathogeny remains unclear. The poor clinical picture and the absence of pain makes the diagnosis difficult. Because of the long lasting course, the tumor is usually large at the time of diagnosis. Although this tumor is benign, the local aggression and the high rate of recurrence dictate a radical treatment.

Thyrolingual trunk arising from the common carotid artery: a case report

During a cadaver dissection in the anatomy department of the University of Liege, Belgium, an anatomic variation of the superior thyroid and lingual arteries was observed on the right side in a 68-year-old woman. Both arteries arose from a common trunk located 30 mm beneath the carotid bifurcation. After a 5.2 mm course, the thyrolingual trunk divided into superior thyroid and lingual arteries which followed an unusual course towards their respective organs. Knowledge of this anomaly is important for those who are involved with neck surgery and anatomy.

Bilateral case of superficial ulnar artery originating from axillary artery

During the dissection of an 86-year-old male human cadaver, superficial ulnar arteries were found in both upper limbs. These arteries branched from the axillary arteries. In the left arm, the artery crossed ventral to the medial root of the median nerve before running towards the medial part of the arm. The persistence of the median artery was noted. In the right arm, the ulnar artery had a common origin with the subscapular artery. It crossed anterior to the lateral root of the median nerve and then, in the arm, ran alongside the anterolateral aspect of the median nerve, near the biceps brachii muscle, which was supplied by this superficial ulnar artery. Then the artery crossed the median nerve and the brachial artery. The embryology, incidence and clinical relevance of this anatomical variation are discussed. So this was a rare case where the ulnar arteries originated from the axillary artery on both sides, but then followed different courses in the arm and, on the right side, the superficial ulnar artery partly supplied the biceps brachii muscle.

[Adipofascial flaps of the frontal-internal part of the leg: an alternative to free flaps for the repair of skin loss from the knee to the ankle. Report of a clinical experience with 17 cases]

Leg coverage remains a difficult challenge for plastic surgeon, especially in certain areas. Although treatment of osteomyelitis is well established, coverage of bone, tendinous or hardware exposure remain controversial. In these selected cases, adiposofascial pedicled flaps should constitute a interesting solution. The multiples vascular supplies to the adiposofascial tissue of the medial side of the leg constitute de basis of this flap family. These condition allows an extreme adaptability to a wide range of defect with maximal satisfaction.

[Breast implants: state of the controversy]

The controversy that occurred during the 1990 years concerning the breast implants has revealed several new problems, related to comfort surgery. Considering that this surgery has developed considerably, we found useful to outline the difficulties and the drifts that appeared with the breast implants. They were present at all levels: patients, implant factories, judges and lawyers, media, certified laboratories. An increased vigilance was found to be necessary in order to provide the safety and the quality of this type of surgery.

[Management of hemangiomas and vascular malformations]

Vascular anomalies can be classified as hemangiomas or vascular malformations. Hemangiomas are benign neoplasms, frequently diagnosed in infancy. The vast majority of these anomalies are totally harmless and spontaneously regress, although they often worry the parents because of esthetic reasons. Only a few (1/4), however, are endangering and will require therapy. Vascular malformations are rather vessel abnormalities which, unlike hemangiomas, persist. They require a thorough evaluation and most will benefit from an intervention. The recent development of informative imaging techniques (ultrasonography, Dopplerflow imaging and magnetic resonance) has permitted significant advances in the etiology and therapy of these vascular anomalies. All too often, these patients shuffle from physician-to-physician seeking help. Thus the authors recommend a multidisciplinary approach. This team should include a plastic surgeon, a radiologist and a paediatrician.

Recurrent pleomorphic solitary angiomyxoma of the face

The historical background of solitary and multiple myxoid tumors of the dermis is accompanied by a confusing conglomeration of names. We report a case whose histologic features do not fit exactly with previous classifications. It appeared as a solitary angiomyxoma of the face containing stellate pleomorphic cells and exhibiting a locally infiltrative behavior with tendency for recurrences over more than 25 years. This recurrent pleomorphic solitary angiomyxoma appears to be distinct from cutaneous myxomas that exhibit a very low local recurrence rate and from malignant tumors with myxoid deposits. The treatment consisted of a wide surgical excision.

[How I treat...decubitus ulcers surgically]

Although pressure sores occur frequently during the evolution of paraplegic patients, they can present in patients confined to bed or in casts. Ischiatic, sacral and trochanteric sores are the most frequent. For stade III & IV lesions surgical excision followed by a coverage with healty tissue remain the only right principle. Usually, flap transfert meats these requirements. However, the selection of the surgical procedure and the post-op care are the main factors for a successful treatment.

Is fractal geometry useful in medicine and biomedical sciences?

Fractal geometry has become very useful in the understanding of many phenomena in various fields such as astrophysics, economy or agriculture and recently in medicine. After a brief intuitive introduction to the basis of fractal geometry, the clue is made about the correlation between Df and the complexity or the irregularity of a structure. However, fractal analysis must be applied with certain caution in natural objects such as bio-medical ones. The cardio-vascular system remains one of the most important fields of application of these kinds of approach. Spectral analysis of the R-R interval, morphology of the distal coronary arteries constitute two examples. Other very interesting applications are founded in bacteriology, medical imaging or ophthalmology. In our institution, we apply fractal analysis in order to quantitate angiogenesis and other vascular processes.

Hypnosedation: a valuable alternative to traditional anaesthetic techniques

Hypnosis has become routine practice in our plastic and endocrine surgery services. Revivication of pleasant life experiences has served as the hypnotic substratum in a series of over 1650 patients since 1992. In retrospective studies, followed by randomised prospective studies, we have confirmed the usefulness of hypnosedation (hypnosis in combination with conscious IV sedation) and local anaesthesia as a valuable alternative to traditional anaesthetic techniques. The credibility of hypnotic techniques and their acceptance by the scientific community will depend on independently-confirmed and reproducible criteria of assessing the hypnotic state. Based on the clinical success of this technique, we were interested in confirming this phenomenon in healthy volunteers. The revivication of pleasant life experiences thus served as the cornerstone of a basic research program developed to objectify the neurophysiological attributes of the hypnotic state. We compared hypnosis to normal alertness with similar thought content. In our experience, the activation profile obtained during the hypnotic state was completely different from simple re-memoration of the same subject matter during normal alertness. This represents an objective and independent criteria by which to assess the hypnotic state.

[Aesthetic surgery update]

Aesthetic surgery has its origin in plastic surgery. It has considerably developed to such a point that the number of procedures performed at the present time is well over the reconstructive procedures. After having emphasized the importance of patient's motivation and the high level of specific technical training of the plastic surgeon, the most common procedures are illustrated. Their major advantages and pitfalls are outlined.

Tensile properties of relaxed excised skin exhibiting striae distensae

Tensile properties of skin determine some important physical attributes of skin. They may be conveniently assessed using recent technologies. The aim of the study was to compare ex vivo the tensile properties of normal looking skin and striae distensae. The Cutometer was used with 2 and 4 mm diameter probes. Skin distensibility values were dependent on the suction force and area of the skin tested. Conversely, tensile ratios yielding elasticity parameters were not affected by the same variables. Although tensile properties of excised normal skin resembled those previously reported in vivo, striae distensae showed markedly different properties in vivo and ex vivo. The ex vivo and in vivo evaluations of the tensile properties and functions of skin are complementary particularly when the connective tissue is abnormal.

Video-microsurgery: a new tool in microsurgery

Endoscopic surgery is slowly becoming an increasing part of plastic surgical practice. Besides its most obvious advantages, related to small incisions, the endoscope provides excellent magnification of the operative field. We thus decided to investigate the possibility of using the endoscope as an alternative to the operative microscope for performing microsurgical procedures. Before starting a clinical investigation, digital artery, nerve, vein microsutures, and neck dissections were performed in fresh human cadavers. Magnification, working distance, depth of focus, diameter and temperature of the operative field, and resolution were measured using either the operating microscope or the endoscope. Working conditions were compared. The advantages of the endoscope as compared to the microscope were: less bulk, sterility, mobility, versatility and cost-effectiveness. The disadvantages were: short working distance, inferior resolution and two-dimensional images. Overall, the endoscope was found to be an interesting alternative to the operating microscope. We are now using the endoscope routinely in the clinical arena, and we believe that it has a great potential and a promising future as a microsurgical tool.

Microsurgical repair of Stensen's duct using an interposition vein graft

Facial wounds are frequently associated with bone fractures and multiple trauma; however, disruption of the parotid gland or Stensen's duct is rare and is often associated with facial nerve palsy. Lesions are often undiagnosed on first assessment of the multiple trauma patient. If microsurgical repair of Stensen's duct provides good functional results, ignoring such lesions often leads to later complications such as fistulae and sialocoeles. Although simple ligation of Stensen's duct has been reported to give satisfactory results, the authors prefer a more anatomic reconstruction of this structure whenever possible. A case of Stensen's duct microsurgical repair using a vein graft are reported.

[External rhinoplasty: a useful approach for a young plastic surgeon]

Among the frequently performed plastic surgery operations, rhinoplasty is the most difficult to obtain consistently good results. It is very challenging for young plastic surgeons to modify the external appearance of the nose and restore or maintain a good airway. The external approach has alleviated some of the problems due to understanding and learning of the rhinoplasty operation. Actually, open rhinoplasty allows better visualization of anatomical deformities and better manipulation of tissues allowing better integration of nasal anatomy and physiology. This paper reviews a personal series of 82 patients operated via an open approach between October 94 and October 97. During the same period, 24 patients were operated via an endonasal or percutaneous approach (osteotomies). Indications, advantages and disadvantages of the open approach are discussed. The various techniques used in this series are described and then critically analyzed. In open rhinoplasty, our present revision rate is 8.5%. In conclusion, the open approach seems to be useful for young rhinoplastic surgeons.

[Nasal obstruction. Physiology, etiology and review]

Nasal obstruction is a major epidemiologic medical problem. The cost of its medical and surgical treatment is considerable. The frequency of the symptoms and their usual benign course often lead the physician to pay little attention to them. Occasionally, life-threatening problems, such as Wegener's granulomatosis may first present as nasal obstruction. Frequently, nasal obstruction deteriorates the quality of life by causing serious discomfort and by altering with the sense of smell and taste.

[Surgical anatomy of the nose. I]

Since a few years, more and more papers are published in the international literature about nasal anatomy, probably because of the growing popularity of the open rhinoplasty. So, new concepts, new anatomic entities have been established without equivalent in the French literature. The authors review the most recent notions of the surgical anatomy of the nose and propose a french terminology for several concepts developed in the international literature (e.g. supratip breakpoint). The surgical anatomy of the external nose is described.

[Surgical anatomy of the nose. II]

Over recent years, an increasing number of papers are published in the international literature about nasal anatomy, probably because of the growing popularity of open rhinoplasty. New concepts and new anatomical entities have been established without any equivalent in the French literature. This paper reviews the most recent concepts of surgical anatomy of the nose and proposes a French terminology for several concepts developed in the international literature (e.g. supratip breakpoint). In this second part, the surgical anatomy of the nasal cavities is analyzed together with a glossary including the main concepts, some of them unpublished in the French literature.

Necrotizing fasciitis: a life-threatening infection

Necrotizing fasciitis is a rapidly progressing, synergistic bacterial infection of fascia with a reported average mortality of about 40%. Fournier's disease, necrotizing fasciitis of the genital sphere, is also included in this study. Seven patients were studied over a one-year period between May 1991 and October 1992. Most commonly, they were infected by perineal diseases, medical procedures and cutaneous ulcers. The local clinical signs are cellulitis, oedema, blisters, necrosis and crepitus; general septic symptoms may also be present. Associated chronic diseases were present in 4 patients. Three infections were polymicrobial. Control of this potentially lethal soft-tissue infection is based on early clinical diagnosis, timely, wide surgical debridements and appropriate antibiotic treatment. The overall mortality rate was 1 of 7 (14%). Death was due to persistent wound sepsis and systemic septic complications, but mainly to delay in surgical treatment. The presence of chronic debilitating diseases (diabetes, alcohol abuse, renal insufficiency, ...) contribute to increase rate of both local and systemic infection.

[Lipoma, multiple lipomas and lipomatosis]

Lipomatous tumors are very frequent; simple lipoma is the most common variety. According to Enzinger, lipomatous tumors are classified into five different groups: simple lipomas, variant lipomas forms, heterotopic lipomas, infiltrating lipomas and lipomatosis, and finally hibernomas. Usually, lipomatous tumors are characterized by a slow, unpainful, growth. Classical treatment includes surgical resection. The clinical diagnosis is confirmed by histology. Liposucion can be a therapeutic option in certain cases.

Psychological approaches during conscious sedation. Hypnosis versus stress reducing strategies: a prospective randomized study

Stress reducing strategies are useful in patients undergoing surgery. Hypnosis is also known to alleviate acute and chronic pain. We therefore compared the effectiveness of these two psychological approaches for reducing perioperative discomfort during conscious sedation for plastic surgery. Sixty patients scheduled for elective plastic surgery under local anesthesia and intravenous sedation (midazolam and alfentanil upon request) were included in the study after providing informed consent. They were randomly allocated to either stress reducing strategies (control: CONT) or hypnosis (HYP) during the entire surgical procedure. Both techniques were performed by the same anesthesiologist (MEF). Patient behavior was noted during surgery by a psychologist, the patient noted anxiety, pain, perceived control before, during and after surgery, and postoperative nausea and vomiting (PONV). Patient satisfaction and surgical conditions were also recorded. Peri- and postoperative anxiety and pain were significantly lower in the HYP group. This reduction in anxiety and pain were achieved despite a significant reduction in intraoperative requirements for midazolam and alfentanil in the HYP group (alfentanil: 8.7 +/- 0.9 microg kg(-1)/h(-1) vs. 19.4 +/- 2 microg kg(-1)/h(-1), P < 0.001; midazolam: 0.04 +/- 0.003 mg kg(-1)/h(-1) vs. 0.09 +/- 0.01 mg kg(-1)/h(-1), P < 0.001). Patients in the HYP group reported an impression of more intraoperative control than those in the CONT group (P < 0.01). PONV were significantly reduced in the HYP group (6.5% vs. 30.8%, P < 0.001). Surgical conditions were better in the HYP group. Less signs of patient discomfort and pain were observed by the psychologist in the HYP group (P < 0.001). Vital signs were significantly more stable in the HYP group. Patient satisfaction score was significantly higher in the HYP group (P < 0.004). This study suggests that hypnosis provides better perioperative pain and anxiety relief, allows for significant reductions in alfentanil and midazolam requirements, and improves patient satisfaction and surgical conditions as compared with conventional stress reducing strategies support in patients receiving conscious sedation for plastic surgery.

Mechanical properties of skin and liposuction

BACKGROUND

Liposuction removes fat, setting the skin under tension, and could therefore alter the overall viscoelastic properties of the teguments.

OBJECTIVE

To measure in vivo the mechanical properties of skin at the site of liposuction and to compare the viscoelastic values with those of the inner aspect of the forearms.

METHODS

The Cutometer SEM 474 equipped with a 8-mm probe was used.

RESULTS

Data show that cutaneous laxity, which is characteristic for an aging aspect, is not higher at the liposuction sites than on the reference area.

CONCLUSION

Liposuction does not increase the clinical aspects of skin aging.

Hypnosis as adjunct therapy in conscious sedation for plastic surgery

BACKGROUND AND OBJECTIVES

Sedation is often requested during local and regional anesthesia. However, some surgical procedures, such as plastic surgery, require conscious sedation, which may be difficult to achieve. Hypnosis, used routinely to provide conscious sedation in the authors' Department of Plastic Surgery, results in high patient and surgeon satisfaction. The authors conducted a retrospective study to investigate the benefits of hypnosis in supplementing local anesthesia.

METHODS

The study included 337 patients undergoing minor and major plastic surgical procedures under local anesthesia and conscious intravenous sedation. Patients were divided into three groups depending on the sedation technique: intravenous sedation (n = 137) using only midazolam and alfentanil; hypnosis (n = 172), during which patients achieved a hypnotic trance level with age regression; and relaxation (n = 28), comprising patients in whom hypnosis was induced without attaining a trance level. In all three groups, midazolam and alfentanil were titrated to achieve patient immobility, in response to patient complaints, and to maintain hemodynamic stability. Midazolam and alfentanil requirements; intra- and postoperative pain scores; as well as pre-, intra-, and postoperative anxiety score, reported on a 10-cm visual analog scale, were recorded and compared in the three groups.

RESULTS

Intraoperative anxiety reported by patients in the hypnosis group (0.7 +/- 0.11) and in the relaxation group (2.08 +/- 0.4) was significantly (P < .001) less than in the intravenous sedation group (5.6 +/- 1.6). Pain scores during surgery were significantly greater in the intravenous sedation group (4.9 +/- 0.6) than in the hypnosis group (1.36 +/- 0.12; P < .001) and the relaxation group (1.82 +/- 0.6; P < .01). Furthermore, midazolam requirements were significantly lower in the hypnosis group (P < .001) and in the relaxation group (P < .01) as compared with the intravenous sedation group: respectively, 0.04 +/- 0.002, 0.07 +/- 0.005, and 0.11 +/- 0.01 mg/kg/h. Alfentanil requirements were significantly decreased in the hypnosis group, as compared with the intravenous sedation group: 10.2 +/- 0.6 microgram/kg/h versus 15.5 +/- 2.07 micrograms/kg/h; P < .002. In the relaxation group, alfentanil requirements were 14.3 +/- 1.5 micrograms/kg/h (ns). Postoperative nausea and vomiting were reported by 1.2% of patients in the hypnosis group, 12.8% in the relaxation group and 26.7% in the intravenous sedation group. Greater patient satisfaction with the anesthetic procedure and greater surgical comfort were also reported in the hypnosis group.

CONCLUSIONS

Successful hypnosis as an adjunct sedation procedure to conscious intravenous sedation provided better pain and anxiety relief than conventional intravenous sedation and allowed for a significant reduction in midazolam and alfentanil requirements. Patient satisfaction was significantly improved.

Anatomical basis for a safe and easier approach to composite rhytidectomy

The authors present the anatomical findings that have made an easier approach to composite rhytidectomy possible. The lower lateral border of the orbicularis oculi muscle (OOM) overlies the zygomaticus major muscle (ZMM), the upper third of which tightly adheres to the malar bone. The OOM is innervated throughout over its circumference by a plexus of small facial nerve branches. From its deeper surface, the ZMM is innervated by two to four branches in its upper third and middle third. These branches are jeopardized in an extended sub-SMAS dissection as this tends to go deep into the ZMM. The malar fat pad is superficial to the SMAS layer that invests the zygomaticus and levator labii muscles and, with age, tends to slide downward, medially deepening the nasolabial folds. An extended dissection beyond the OOM tends to remain superficial to the upper part of the ZMM, zygomaticus minor, and levator muscle complex. We have found that extending the suborbicularis dissection inferiorly and laterally offers three major advantages: (1) The correct deep subcutaneous plane just above the ZMM, zygomaticus minor muscle, and levator complex can be found easily, leaving all of the fat attached to the skin. The only structures at risk are some minor motor branches to the OOM that can be divided without any morbidity because of the extensive plexiform innervation.(ABSTRACT TRUNCATED AT 250 WORDS)

True aneurysm of digital artery in hemophilia. A case report

A case of a true aneurysm of the radial digital artery of the thumb is presented. Treatment by ligation and excision resulted in relief of symptoms. To our knowledge, this is the first reported case of true digital aneurysm of the thumb.

The cutaneous territory of the transverse tensor fascia lata flap: further anatomical considerations

The cutaneous territory and the anatomical variations of the lateral circumflex femoral artery (LCFA) were studied on 20 fresh cadavers. This territory extends transversally on an average of 20 per 18 cm on the supero-lateral aspect of the thigh. The LCFA divides into three terminal branches as it enters the tensor fascia lata muscle. The posterior transverse branch is constant and makes the transverse tensor fascia lata (TFL) flap highly reliable, as opposed to the classical longitudinal TFL flap. The latter is based on the descending branch of the LCFA which is missing in 5 out of 20 cadavers. The lateral circumflex femoral artery also gives 1 to 2 ascending branches running toward the iliac crest and providing its periosteal blood supply. Based on these branches, it might be possible to raise an osteomyocutaneous flap of tensor fascia lata and iliac crest.

[Evaluation of the Mustardé technique in the treatment of prominent ears. Apropos of 1100 patients]

The analysis of a homogenous series of 1,100 patients with prominent ears confirmed the reliability of the Mustardé technique and the reversibility of the iatrogenic deformities related to this procedure.

Anatomical rationale for use of the latissimus dorsi flap during the cardiomyoplasty operation

The cardiomyoplasty procedure involves the use of a transformed skeletal muscle to augment cardiac pump function or to substitute for the heart after parietal resection. This study of the intramuscular vascularization of latissimus dorsi was carried out in order to establish the relationship between the dominant thoracodorsal blood supply and the distal supply issued from the intercostal and lumbar arteries. This data is mandatory for the safe manipulation of the muscle flap during cardiomyoplasty. Thirty human latissimus dorsi flaps were carefully studied. We confirmed anatomically as well as angiographically previous macroscopic anatomical reports, as well as the constancy of the neurovascular pedicle. Three principal branching patterns were observed for the thoracodorsal artery. The thoracodorsal artery divides into three main tributaries in 20/30 (67%), and into two tributaries in 10/30 (33%) of the flaps observed. When three tributaries were observed, one of them was a small recurrent artery for the proximal third of the latissimus dorsi (14/20, 70%). Thus the distal vascularization is actually dependent on three principals in 6/30 (20%) and two principals in 24/30 (80%). From these two or three principals emerge several subsequent longitudinal branches (5 to 9) that have a straight course until their distal anastomoses with segmental arterial pedicles issued from intercostal and lumbar arteries. The latter ligation can thus occur without ischemic damage to the medial and distal aspect of the flap. This study emphasizes that, due to macroscopic anatomic features and systematic intramuscular vascular distribution, the latissimus dorsi is probably the most suitable muscle for the purpose of cardiomyoplasty.

[Intramuscular vascularization of the human latissimus dorsi]

The anatomical data concerning to the latissimus dorsi and its neurovascular pedicle are revised with its applications in reconstructive surgery. The use of this muscle in cardiomyoplasty depends upon a good understanding of its vascularisation and the intramuscular innervation. Our angiological study of the human latissimus dorsi demonstrates clearly the topographic distribution of the branches of the thoraco dorsal artery ant the peripheral blood supply after interrupting the intercostal and lumbar perforating vessels. These findings demonstrate the vascular reliability of the muscle for cardiomyoplasty.

The use of the free parascapular flap in midpalmar soft tissue defect

Clinical applications of a new free flap are presented. The parascapular flap is a cutaneous unit whose blood supply is provided by a posterior branch of the inferior scapular artery. It is a safe and relatively large flap (approximately 8 by 12 cm or more) with a constant pedicle. It has no sensory nerve. The donor site is easy to close directly. As suggested by Baudet, we think it is useful in reconstruction of the palm and, in some cases, the dorsum of the hand.