[Microsurgical breast reconstruction: for whom and how?]

Breast reconstruction is now an integral part of breast cancer treatment. There are several different procedures that make use of flaps or prostheses, or a combination of the two. Which of these procedures is indicated depends on the sequelae of the initial treatment and the patient's wishes and morphology. However, the constraints caused by the prosthetic material and the now regular use of microsurgical techniques have greatly favoured the purely autologous options. The different surgical techniques and their respective advantages and disadvantages will be described, before considering the timing of the various stages of the procedure. We will also give a summary of our experience with free flaps.

[Free flap pedicle loss: clinical study on 8 cases]

The authors report on 8 cases of free flaps with vascular pedicle disruption that were encountered between postoperative days 8 to 18. In one case, the inflow disappeared 18 months after the transfer without any trouble. This resulted in 2 partial and one complete flap losses. The 4 other flaps survived completely. This complete survival is related to the angiogenesis process coming from the surrounding tissues. The most obvious causal factor responsible for the 2 partial losses was the coverage of large, non viable areas, such as a prosthetic material and bone deprived of periosteum. The only causal factor that could be assessed in the case of total necrosis was the presence of an immunosuppressive treatment. Variables participating in the installation of an adequate angiogenic response are then discussed in accordance to this experience and to the literature. Limited contact with viable tissue, ischemia-reperfusion or drugs limiting the angiogenesis seems to promote failure when the pedicle is quickly disrupted. Hypoxia seems to be the most important cellular mechanism promoting the angiogenesis in this context.

[Vascular complications after cranio-facial trauma]

Despite recent advances in automobile safety, facial trauma remains a common event. Cranio-facial trauma, which usually occurs within a context of multiple trauma, can, in some patients, lead to serious life-threatening vascular complications. Such injury usually involves the carotid system (hemorrhage, aneurysm, dissection). Management of these vascular injuries must be given the same priority as other multiple trauma injuries. We present few typical cases illustrating carotid-cavernous or vertebro-vertebral fistulae, false aneurysms, arterial dissections or oro-facial bleeding. Bleeding is generally controlled by ligation or compression, other lesions being diagnosed secondarily by arteriography depending on the particular clinical situation. Treatment may involve endovascular procedures to achieve intravascular embolism or vascular occlusion.

Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest

Bone exposure constitutes a frequent and difficult problem in burn patients. Where free flaps remain indicated in tibial osteomyelitis, a pedicled fascial or adipofascial flap provides an excellent alternative for coverage of simple tibial crest exposure. In fact, the adipofascial tissue of the anteromedial aspect of the leg can be mobilized over the whole length of the tibia. It is vascularized by the saphenous artery and the posterior tibial artery perforators. This pattern of blood supply allows a wide range of use for any size of burn defect in this area. Therefore, this local pedicled flap provides an excellent solution for coverage of the exposed tibia after severe burns.

[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.

[Deep vein thrombosis in a burn patient]

Association between deep venous thrombosis (DVT) and pulmonary embolism is probably an underestimated problem in the thermally injured patients. However, those patients display important risk factors according to Virchow's triad. This article reports on three unrecognised DVT's accompanying burns which were characterized by absence of healing or edema. The pathophysiology of this issue is then discussed with respect to the specific area of the thermally injured patient. It is our belief that local inflammatory phenomenon play a major part in the genesis of DVT associated with chronic non-healing burns.

[Arterial revascularization with free tissue transfer for salvage of ischemic limbs with extensive tissue loss: an alternative to amputation]

Severe limb ischemia is a common problem encountered in medical practice. Aggressive attempts at revascularization have extended the limits of limb salvage. However, in certain cases, extended tissue loss compromises the healing process. It often results in amputation despite bypass graft patency. Microvascular free tissue transfer combined with arterial revascularization allows healing of these wounds and limb preservation. This combined approach is the ultimate alternative to amputation.

[Chronic ulcer and wound dehiscence..when the origin is unknown and therapy is ineffective!]

The authors report on two cases of factitious disorders in the field of surgery. The discussion is focused on the different aspects of this pathology that are encountered by a plastic surgeon, in order to provide him with more confidence when dealing with this too-often ignored disease.

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.