"Extensive necrosis following extravasation of alkali in the crease of the elbow after voluntary intravenous injection: A case report"

Chemical burns are often deep with difficult initial clinical evaluation, especially those due to alkalic agents, which have a strong penetrating power. They therefore require specialized care in a Burn Unit. Self-inflicted burns are infrequent but their management represents a real challenge. We report the case of a 47-year-old referred to our Burn Center for the evaluation of a self-inflicted corrosion with an alkalic agent (soda), injected at the crease of the left elbow. The patient, right handed, was a nurse and had notably a psychiatric history of depressive syndrome. We observed a deep, well-defined necrosis area, associated with intense peri-lesional inflammation and extensive cellulitis. Faced with this unusual clinical appearance for a chemical burn, the patient's questioning was repeated and the patient finally admitted to having injected himself with a basic caustic product intravenously. Surgical treatment was carried out in two stages: debridement with exposure of vascular and neural structures then coverage with a free anterolateral thigh flap. The postoperative consequences were uneventful with a satisfactory functional result. Factitious disorders are underestimated and often misleading. Among factitious disorders, self-inflicted wounds remain a real challenge requiring multidisciplinary management. Many etiologies exist, among which injection of drugs or substances, in any anatomical localization, leading to variable loss of substance. The use of a free flap for acute extravasation is rare but sometimes essential. The anterolateral thigh flap allows good resurfacing on areas with important functional requirements.

Clinicopathological study of 13 cases of squamous cell carcinoma complicating hidradenitis suppurativa

BACKGROUND

To the best of our knowledge, only 52 cases of squamous cell carcinoma (SCC) complicating hidradenitis suppurativa (HS) have been reported since 1958. We describe 13 new cases.

METHODS

We propose a clinical and histological analysis of our cases. We include these results in a review of previously reported cases to analyze a total of 65 patients. In our series of 13 cases, we also investigate the presence of human papillomavirus (HPV) in tumor samples, by polymerase chain reaction (PCR) on paraffin-embedded material.

RESULTS

Malignant transformation affects mainly men with a long-term history of genitoanal HS. Although our cases were 7 well-differentiated carcinomas and 6 verrucous carcinomas, lymphatic and visceral metastasis occurred in 2 and 3 cases, respectively. With PCR, we demonstrated presence of HPV in genitoanal tumoral lesions, principally HPV-16.

CONCLUSION

SCC complicating HS evolves poorly, despite a good histological prognosis. Our results sustain the implication of HPV in the malignant transformation of HS.

[Detection of melanoma relapse: a retrospective study of 100 patients]

BACKGROUND

There is no international consensus on practical methods of monitoring melanoma following surgical removal of a primary tumour. The chief aim of such monitoring is to ensure detection of relapse where early diagnosis is crucial for survival (i.e. in-transit and lymph node metastases amenable to surgical removal) and the emergence of any first recurrence of primary melanoma.

AIM

The aim of our study was to identify the role of various agents and diagnostic tools both in first recurrence of primary melanoma and in clinical relapse of melanoma.

PATIENTS AND METHODS

This was a retrospective study covering all patients with in-transit or regional lymph node metastasis seen between January 2005 and December 2007. The type of recurrence and method of detection were studied.

RESULTS

Ninety-four patients presented recurrence, with 66% of relapses comprising regional lymph node metastasis and 34% consisting of in-transit metastases. Thirty-three percent of cases of recurrence were detected by patients themselves, 21% by our department, 22% by a private dermatologist, 18% by a radiologist and 6% by a general practitioner. Fifty-four percent of recurrences among patients aged under 50 years were self-detected compared to 18% among patients aged over 70 years. A second melanoma was detected in six patients.

DISCUSSION

This study underscores the great importance of self-examination in melanoma follow-up with over one third of recurrences being self-detected by patients. Self-examination was more effective for younger patients, emphasizing the need to increase awareness among older patients. This study also demonstrates the essential part played by dermatologists in terms of regular follow-up of melanoma.

[Efficacy and tolerance of Algosteril (calcium alginate) versus Jelonet (paraffin gauze) in the treatment of scalp graft donor sites in children. Results of a randomized study]

Split skin graft is frequently needed in the treatment of burned patients. Scalp is often free of burns. Due to its good skin quality and important surface, scalp is a very interesting skin donor site, specially in case of children. A controlled, randomised clinical trial was carried out in 10 French Plastic Surgery or Burns Units. It assessed the efficacy and the acceptability of calcium alginate dressing (Algosteril) versus paraffin gauze dressing (Jelonet) in the treatment of scalp donor sites in children. 67 children (mean age 54 months) entered the study, 34 in the alginate group and 33 in the control group. Follow-up visits were on day 2/d3, d5/d6, Day complete healing, d30 and d60 after surgery. The two groups were comparable on inclusion (demographic characteristics, burn nature and surface, donor site surface and thickness of split skin graft). The mean healing time was 10 and 11 days for Algosteril and Jelonet group respectively (ns). The quality of the newly formed tissue was estimated to permit a sooner skin reharvesting in the Algosteril group than in the control group (p = 0.003). Bleeding through dressing was significantly less important in the Algosteril group (p = 0.02). Changes were considered by investigators less painful with Algosteril on day complete healing (p = 0.0096). Hair growth is homogenous in both groups on day 30 and day 60 (ns). These results showed that scalp is a very interesting skin donor site and that Algosteril is of a real interest in donor site treatment.

[Cleft lip and palate treatment in the plastic surgery department in the university hospital center in Lille]

The aim of cleft care is to favor a normal socialization of patients with fewer therapeutic coercion. It supposes a full multidisciplinary team including psychologist, speech therapeutic, dental orthopedist, oto-rhino-laryngologist and surgeons. All of them have to be well trained which supposes a sufficient amount of cases: anglo-saxon studies have proven that a mean of at least 20 new cases per year of primary cleft were necessary. With purposes to enhance the effectiveness of treatment: prospective studies and measurements of results must be evaluated with the help of objective criteria. These are the goals of our team in lille. Our surgical principles are those of functional procedures, which privilege the muscle function's repair.

Neonatal permanent jaw constriction because of oral synechiae and Pierre Robin sequence in a child with van der Woude syndrome

OBJECTIVE

To report a newborn with van der Woude syndrome, Pierre Robin sequence, and oral synechiae. Pierre Robin sequence is a rare manifestation of van der Woude syndrome as are oral synechiae. We speculate that the oral synechiae may be causally related to the development of Pierre Robin sequence in this patient.

Pure ectodermal dysplasia: retrospective study of 16 cases and literature review

OBJECTIVE

To review the possible craniomaxillofacial deformative consequences associated with ectodermal dysplasias and embryonic malformations, which include dental ageneses.

SETTING

Oral and Maxillofacial Surgery Department, University Hospital, Lille, France.

PATIENTS

Sixteen patients (seven boys and nine girls, aged 4 to 34 years) with pure ectodermal dysplasia (no ectodermal dysplasia syndromes).

INTERVENTIONS

All patients had a clinical examination. Seven (two boys and five girls, aged 4 to 25 years) had undergone plaster casts and radiographic and Delaire's cephalometric studies before being treated.

MAIN OUTCOME MEASURES

All patients had tooth ageneses (from hypodontia to anodontia), associated with cutaneous dyshidrosis and hair and nail dystrophy. Most of them had a short face, with an unusual facial concavity, a maxillary retrusion, and a relative mandibular protrusion. MANAGEMENT RESULTS AND DISCUSSION: Depending on their ages and their orthopedic abnormalities, patients underwent either dental or prosthodontic, orthodontic, orthopedic, orthognathic, or implant treatment. So as not to interfere with the growth pattern, we preferred to reserve implant and orthognathic surgery for full-grown cases.

CONCLUSIONS

Oral and maxillofacial surgeons must undertake a comprehensive approach to these patients to improve their dental, masticatory, growing, and orthognathic conditions.

[Arm ischemia revealing Kawasaki disease]

An aneurysm of the medium arteries is one of the major complications of Kawasaki syndrome. Eleven cases of giant coronary aneurysm have been reported.

CASE REPORT

We report a new case in a nine-month-old child. Ischemia of the left hand was the first symptom. Diagnosis was made 30 days later. Anticoagulant and fibrinolytic treatments did not prevent necrosis of four fingers.

CONCLUSION

The prognosis of Kawasaki disease depends on early diagnosis and management. Infants younger than seven months of age are more susceptible to developing coronary and midartery aneurysms, which therefore justifies a close observation during the acute phase and later on. In the case of a coronary artery aneurysm, Doppler echography of the upper and lower limbs is mandatorily recommended. Anticoagulant therapy should be started once the diagnosis of mid-artery aneurysms is made. Ischemia of the extremities can lead to necrosis and amputation. Until now, anticoagulants, vasodilators and fibrinolytic agents were not proven to be effective.

[Teleradiographic analysis of velopharyngeal insufficiency in CATCH 22 association]

The CATCH 22 association (Cardiac defect, Abnormal facies, Thymic hypoplasia, Cleft palate, Hypocalcemia) combines certain signs common to various syndromes (Di-George syndrome, velocardiofacial syndrome, etc.) in combination with a 22q11 chromosomal microdeletion. Velopharyngeal insufficiency can be a complementary sign, or even a presenting sign of this chromosomal anomaly. After clinical examination of these patients, velopharyngeal insufficiency appeared to be due to a deep nasopharynx rather than to a short soft palate. We therefore reviewed 11 patients with teleradiography. We studied the length of the soft palate, the depth of the nasopharynx, the ratio of the depth of the nasopharynx over the length of the soft palate, and we compared our results with those observed in reference populations. The results demonstrate nasopharyngeal disproportion with a normal length of the soft palate and increased depth of the nasopharynx. This anatomical finding therefore encourages us to propose sphincteroplasty rather than velopharyngoplasty.

Survival after malignant tumors of the orbit and periorbit treated by exenteration

PURPOSE

In order to further assess the survival value of orbital exenteration in malignant orbital and periorbital tumors.

METHODS

The charts of 44 patients exenterated for a neoplasm of the orbit or periorbit were reviewed in a retrospective study.

RESULTS

The overall 4-year survival was 45%. 26 patients had free margins on histological examination and 24 patients had developed local recurrence or metastasis. Local recurrence or metastasis were significantly more common in the group with transected margins than in the group with free-margins (p= 0.01). Survival between the group of patients with local recurrence or metastasis and the group without local recurrence or metastasis showed statistically significant difference (p=0.0025). In contrast, survival between the group of patients with free margins and the group with transected margins did not show statistically significant difference (p=0.13).

CONCLUSION

Surgical free margins section is a key element in successful cancer surgery but seems not the only prognosis variable.

[Role of surgery in the treatment of hemangiomas. A retrospective study apropos of 29 surgically treated children]

Conservative management is usually proposed for common childhood hemangiomas because most lesions resolve spontaneously. The authors report 29 cases of children with hemangiomas treated surgically. Surgical indications were defined at various stages. The study concerned 29 children operated in our pediatric surgery and plastic surgery departments between 1989 and 1995. The average postoperative follow-up was 3 years and 8 months. The average age of the patients was 5 years; two-thirds of children were girls. The hemangioma was a very large lesion, subcutaneous and cutaneous (mixed) in 23 cases, only subcutaneous in 2 cases, only cutaneous in 4 cases, and was located on the face in 19 cases. Six complications (5 ulcerations, 1 Kassabach-Merritt syndrome) were observed.

Dermal endothelial cells and keratinocytes produce IL-7 in vivo after human Schistosoma mansoni percutaneous infection

The parasite Schistosoma mansoni infects its definitive mammalian host through an obligatory cutaneous penetration. In this work, we studied early immune response following migration of larvae through human skin, the first immunocompetent organ encountered by the parasite. For this purpose we used an experimental model of severe combined immunodeficient mice engrafted with human skin and injected with autologous PBL. Six days after percutaneous infection, we observed an infiltration of lymphocytes within the human skin, predominantly composed of CD4+ T cells. Moreover, among the cytokines potentially present in the infected skin, immunohistochemistry analysis revealed an in vivo expression of IL-7 in the epidermal layers and strikingly at the level of vascular endothelium. Using an in vitro coculture system, we showed that the S. mansoni larvae directly trigger IL-7 production by human dermal microvascular endothelial cells but not by keratinocytes. Finally, measurements of IL-7 concentrations in plasma of 187 S. mansoni-infected individuals showed that the youngest, which are also the most infected, displayed the highest IL-7 levels. Together, these findings describe dermal endothelial cells as a novel source of IL-7, a cytokine particularly important in schistosomiasis.

[Gynecomastia. Management of diagnosis and therapy. Apropos of 52 cases]

Gynecomastia is the commonest breast lesion in males. Fifty-two patients (mean age 24 years) operated in our department were reviewed with a mean follow-up of two years and a half. Gynecomastia occurred most frequently during puberty (63%), was bilateral (75%) and idiopathic (65%). The size of the enlargement was evaluated according to Simon's-classification based on breast-volume and skin-redundancy. 18 stage 1, 22 stage 2A, 9 stage 2B, 3 stage 3. Clinical examination and mammography determined the consistency of gynecomastia: adipose or firm. 4 different surgical managements were used: 32 subcutaneous mastectomies, 12 liposuctions, 6 liposuctions assocaited with subcutaneous mastectomy, 1 total mastectomy. One patient had liposuction on one side and subcutaneous mastectomy on the other one. All techniques gave good morphologic results. Nonetheless, the authors recommend the combination "liposuction and subcutaneous mastectomy", as this technique presents many advantages: small intraoperative blood loss, good skin redraping, short hospital stay, complete histologic examination of the material removed.

[Closure of anterior oro-nasal communications, sequelae of cleft palate, using a retro-incisal flap]

The persistence of a residual communication between mouth and nose, is an important sequela a after primary closing of cleft palate. This retrospective study reports twenty-one cases of a new technique (retro-incisive flap) used for closing this residual communication. This flap is an easy and reliable method with an 85% success rate, so we recommend it as the first choice in this indication.

[Evaluation of the treatment of cystic lymphangioma by percutaneous injection of Ethibloc in 20 patients]

BACKGROUND

Surgical treatment of cystic lymphangioma (CL) is so often followed by local and general complications that non invasive treatment must be considered.

POPULATION AND METHODS

Between 1987 and 1993, 20 patients with a superficial macrocystic lymphangioma were treated by percutaneous injection of Ethibloc in order to reduce the volume of the CL, with a minimum follow-up of 1 year. Fourteen CL were cervico-facial and six were located in the upper half of the body. The size of the lesion was determined by echography: three CL were less than 5 cm in diameter, 12 between 5 and 10 cm, five more than 10 cm. Two to 5 mL of Ethibloc were injected during one (15 cases) or several sessions (five cases).

RESULTS

Reduction in volume was excellent in 12 patients after one session and in four patients after several sessions. Four patients had a poor result. All the patients suffered from an important inflammatory reaction for 2 or 3 days followed by exteriorisation of the Ethibloc in seven patients, with a discrete final scar.

CONCLUSION

These fair results suggest that intracystic injection of Ethibloc represents an effective alternative to surgery.

[Focus on skin pre-suturing. Apropos of 12 cases]

Presuture is a rapid skin expansion technique performed in a 2-stage operation. On the day before the operation, a square of skin sutures is inserted along the lesion to be invaginated, under local anaesthesia. Resection with direct suture can be performed on the following day. Twelve patients presenting with extensive (3 x 3 cm to 7 x 24 cm) lesions of the lower limbs (3 congenital naevi, 7 melanomas, 2 areas of scar tissue) were treated. The scar results were excellent in 2 cases, inter-mediate in 8 cases and poor in 2 cases. The limits of this technique are the risk of malunion due to ischaemia and especially secondary enlargement of the scar.

[Reconstruction of loss of substance on the nose by composite auricular grafts. Apropos of 30 cases]

The authors report 31 cases of nasal reconstruction by composite grafts taken from the ear. Tissue loss concerned the base of the ala (10 cases), the free edges of the ala (15 cases), the nasal tip (3 cases) and the whole of the ala (3 cases). The graft was taken essentially from the root of the helix or from the retro-auricular region. All grafts contained cartilage. Eight vascular flaps were made in order to increase the surface area of contact with the graft. No complete necrosis and five partial necroses were observed. Each of these cases of partial necrosis, were able to be repaired surgically. No side effects at the donor site were observed in 26 patients. The composite graft is a simple and reliable method of nose reconstruction.

[Obstruction: a rare complication of congenital giant blue nevus]

BACKGROUND

The blue nevus is an acquired or congenital dermal melanosis, usually small in size. It is sometimes giant and responsible for complications.

CASE REPORT

A newborn had a large infiltrated blue news located on buttocks, lombosacral and perianal areas. He was admitted at the age of 3 weeks for an intestinal obstruction which was due to an impassable anal stenosis secondary to the infiltrated nevus. The tumor was excised twice, completed by plastic surgery at the age of 10 months.

CONCLUSIONS

This rare congenital giant blue nevus was responsible for an unreported intestinal obstruction. The risk of malignant transformation was another reason for complete excision.

[Mento-sternal fistulae. Review of the literature. Apropos of 4 cases]

Mentosternal fistula is a very rare entity. 70 cases had been reported in the French literature up until 1984. Mentosternal fistula is very different from cyst and fistula of the thyroglossal duct. There is no consensus concerning both pathologically and embryologically, the ethiopathogenesis of mentosternal fistula, but the most widely accepted embryological theory seems to be inclusion of ecto or endodemic material at the time of fusion of the branchial tissues in the cervical midline. Clinical features, in the complete form, are very typical and must be distinguished from thyroglossal duct anomalies. No thyroid exploration is required before the surgical procedure which must be simple and complete.

Comparative study of split thickness skin grafts taken from the scalp and thigh in children

We compared 29 split thickness skin grafts taken from the thigh (group I) and 37 taken from the scalp (group II). The study was prospective with a follow-up period of 1 year. The average age was 29 months. Included in group I were those children whose parents refused permission for their hair to be shaved and those with burns to the head. We compared ease of technique, percentage of graft accepted, quality of the graft and after-effects of the donor site. Acceptance of the graft was close to 100 per cent in both groups. Harvesting was more difficult from the scalp (P < 0.0001). The quality of the grafts was identical in both groups. After-effects at the donor site were absent in group II and evident in group I (P < 0.0001). There was no alopecia. The scalp represented a better donor site for split-thickness skin grafting than the thigh in the child.

[Palmar burns of the hand in children. 81 cases]

The authors reviewed 81 children between the ages of 5 months and 3 years suffering from palmar burns of hands from 1988 to 1992. Most burns were unilateral (53), superficial 2nd degree (48), due to contact (55), in boys (48) and only affecting the palm (69). The initial treatment consisted of directed healing followed by a split-skin graft in 8 cases. The initial scar was not retracted in 58 cases, retracted in 17 cases and hypertrophic in 8 cases. 79% of children had no sequelae at 12 months. At more than three years, 15% of children (12) had sequelae: 9 adhesions of the first commissure, 5 flexion deformities of long fingers, 3 clinodactylies, 1 syndactyly. All were operated by trident plasties, Colston flaps or full-thickness skin graft. A final functional assessment was performed. 90% of children had no sequelae. Four children still presented moderate functional discomfort (3 adhesions of the first commissure requiring reoperation, one case of decreased sensitivity). Palmar burns in children have a good prognosis. Factors of severity are: involvement of the 1st commissure, associated dorsal burn, deep 2nd degree, poor social conditions, delayed management.

[Forum: reconstruction of the traumatised thumb. Covering losses of cutaneous substance of the thumb]

The authors proposed their preferential indications to repair cutaneous loss of the thumb. The choice of the flap depend on localisation: to repair a frontal amputation, a triangular volar flap (Atazoy) performed, to repair a tangential distal amputation, a neurovascular island flap (O'Brien-Moberg) was used. To repair a tangential palmar amputation, a flap with advancement and rotation (Hueston) was performed--Free toe to finger tip neurovascular flap was necessary to restore sensation after complete avulsion of pulp. The island kite flap transfer from the dorsum of the index to the thumb (Foucher) was used to repair loss of dorsal and palmar side of the first phalanx. For tangential dorsal amputation, cross finger and free toe to thumb "custom-made" transfer were possible. The authors explained why they preferred these flaps.

Two patients with multiple facial clefts including cleft lip and palate

Report of 2 patients with cleft lip and palate and multiple facial clefts are described using the anatomical classification of Tessier. The first patient was severely polymalformed, with heart, vertebral, and facial malformations. He was examined clinically and with an experimental three-dimensional computer reconstruction that identified an association of a classic cleft lip and palate with cleft nos. 4 and 11 on the right side and cleft nos. 3 and 11 on the left. The second patient, a partial form, with cleft lip and palate and cleft nos. 3 and 11 on the right side, also presented with bilateral cleft no. 7, preauricular tags, and an important microgenia. This second patient was operated for the cleft lip using the principles of Millard and Onizuka with a supplementary Z plasty. We comment on the difficulties of delimitation and treatment when the clefts are very close together and the difference in "quality" of the tissues compared with classic cleft lip and palate.