Search

A series of 112 mastectomies with immediate breast reconstruction performed in women with invasive cancer of the breast were followed for a mean of 30 months to determine cancer outcome, morbidity and aesthetic results of the different surgical techniques. The patients were divided into 3 groups according to indications: 49 cases with local recurrence after conservative treatment; 37 cases of large or multifocal tumours operated after chemotherapy and radiotherapy; 26 cases after tentative conservative surgery with incomplete tumourectomy. A total of 98 patients (87.5%) were irradiated before mastectomy with immediate breast reconstruction. Twenty-eight simple implants, 50 musculocutaneous flaps using the latissimus dorsi with implant and 34 musculocutaneous flaps with the rectus abdominis. During follow-up 16 patients died and cancer relapsed in 13 surviving patients. Seven local recurrences were observed. In all cases of early relapse, which may have possibly been triggered by immediate breast reconstruction, the patients had very poor prognosis criteria. Surgery took longer for mastectomy with immediate breast reconstruction using the rectus abdominis flap and required transfusion in 88% of the cases. Combining all the techniques, 19% of the patients had postoperative complications and 25% late sequellae. The aesthetic results were considered as good immediately after surgery in 14% of the patients with a simple implant, in 45% of those with a latissimus dorsi flap and in 81% of those with a rectus abdominis flap. Second surgical procedures to improve the aspect were performed in half the patients with a simple implant giving 50% good results, in 40% of the patients with a latissimus dorsi flap giving 68% good results and in 12% of the patients with a rectus abdominis flap giving 84% good results. In this series, patient satisfaction was closely related to the aesthetic quality of the results. Integrated into a well-planned multidisciplinary protocol, mastectomy with immediate breast reconstruction does not appear to affect the cancer outcome. Immediate breast reconstruction is a complex procedure and requires experience in plastic surgery to reduce the number of complications and to improve aesthetic results. Reconstruction with a rectus abdominus flap appears as the superior technique.

Two women (63 and 68 years) presented with primary angiosarcomas of the skin which had developed on an area of chronic lymphoedema after radiosurgical treatment for breast cancer 4 and 13 years earlier. Immunohistochemistry tests formally eliminated epithelial metastasis and produced evidence in favour of lymphatic or capillary vascular proliferation. Endothelial affinity for anti-factor VIII and positive tests for certain markers of intermediary filaments (actin, vimentin) confirmed the vascular and conjunctive tissue origin of the tumours.

Four successful cases of expanded free latissimus dorsi myocutaneous flaps are reported. Expansion of free latissimus dorsi flaps has 2 distinct advantages: moulding of the flap prior to its transfer to a convex surface (cranium); primary closure of the donor site. The latissimus dorsi myocutaneous flap seems to be the flap of choice for pre-transfer expansion.

The authors report their experience with immediate breast reconstruction following salvage mastectomy for local recurrence of invasive breast cancer after conservative treatment. From January 1987 to December 1992, among 91 immediate breast reconstructions, 41 were performed for this indication. The results and complications were analyzed for each of the three techniques used: simple prosthesis (n = 5), latissimus dorsi flap with prosthesis (n = 26), trans abdominalis musculocutaneous flap--TRAM flap (n = 10). Immediate flap reconstruction appears to be required in cases of either early or late local relapse since the skin has been irradiated and the mastectomy must be extensive. The transrectus abdominalis flap allows more extensive resection and gives better cosmetic results without the need for a prosthesis.

Since 1978 (Lauritzen), several experimental and clinical procedures of end-in-end vascular microanastomosis have been described, including that proposed by Wang (1986) in which the tubulisation is accompanied by a counter-incision of the recipient vessel. Our experimental study was designed to assess the reliability of this procedure, to quantify it in relation to the diameter of the artery and direction of flow and to verify the existence of absence of any particular intraluminal histological phenomena. 42 Wistar rats were operated under general anaesthesia. 42 microanastomoses were performed: 15 carotid and 15 femoral in the direction of arterial blood flow, and 15 carotid anastomoses in the opposite direction to flow. The 15 carotid anastomoses performed in the direction of flow were all patent at each of the postoperative examinations (D0, D + 15, D + 90). Patency decreased in the anastomoses performed in the opposite direction to blood flow (10 out of 15 carotid anastomoses were patent) and as a function of the arterial diamenter (5 out of 12 femoral anastomoses were patent). Horizontal and transverse histological sections performed on the 15th and 90th days demonstrated continuity of the intimal endothelial lining and thickening of the adventitia of the two internalised and recipient walls in every case. In practice, although this experimental study demonstrates the clinical reliability of this internalised microanastomosis procedure in rat carotid arteries, the other results and the anatomo-clinical discrepancy do not justify its clinical use in all circumstances, particularly in the opposite direction to blood flow and in arteries with a diameter less than or equal to 1 mm.

The authors present the use of semi-free parascapular flap for coverage of defects on the distal part of the leg and the foot. 3 cases illustrate this technic. This is a microsurgical cross-leg flap. The flap is temporarily anastomosed on vessels on the opposite leg when local and free flaps are not suitable on the ipsilateral limb. This procedure needs one or two separating operations. The cross-leg fasciocutaneous flap must be discussed.

The purpose of this study is to demonstrate the development of angiogenesis spreading from a vascular pedicle stretched by an expander, and to determine its potential to supply blood to an adjacent skin area. In the pig model (9 animals), we inserted an expander under the saphenous vessels after interrupting all the connections between the pedicle and the related inguinal skin. The opposite side was used as a control with a non-expanded silicone sheet, 1 mm (2 animals) and 3 mm (7 animals) thick. After 6 weeks of expansion, vascular island skin flaps were elevated on the saphenous vessels. 6 out of 7 expanded flaps were totally successful. Of the 5 flaps elevated above the 3 mm silicone sheet, 1 flap was successful and 4 partially failed. The 2 flaps elevated above the 1 mm silicone sheet failed. An anatomical arteriovenous pedicle stretched by an expander can supply a skin area located distal to it. Angiogenesis also occurs in contact with a thick silicone sheet but the blood supply of the skin is less effective. The newly formed vascular network is visualized on the angiograms.

The authors present the use of a free latissimus dorsi myocutaneous flap for closure of large orbital exenterations. Five cases illustrate different tumor involvements and coverage possibilities. Several technical details are studied. The vascular anastomoses are performed on cervical vessels: external carotid artery internal jugular vein. The latissimus dorsi myocutaneous flap is particularly suited for reconstruction of large facial soft tissue defects around the orbit when obliteration of the orbital cavity and restoration of deficient facial skin are necessary with correct morphological results.

The authors have studied 48 chinese forearm free flaps operated since 1982 at St-Louis, Hospital Paris. Analysis of early complications and failures shows that the few problems that occurred seem to involve hemodynamics more than technical problems. The results support the hemodynamic theory about radial forearm free flaps: low-flow flap which contrasts with the wide diameter of the radial artery. This kind of free flap may not support interpositional vein graft for arterial bridging (stasis, distension of the graft then thrombosis), which must be taken into account in the operating procedure. When the radial artery needs to be lengthened, we therefore systematically reduce the risk of thrombosis by re-establishing radial artery outflow for safety: either by distal radial artery anastomosis, or with an arteriovenous shunt.

Over a period of ten years the authors have performed 176 elective free tissue transfers. Flaps used were 99 latissimus dorsi, 46 chinese forearm flaps, 12 fibula, 6 toes, 5 omentum, 4 parascapular, and 4 others flaps. Recipient sites were lower limbs in 106 cases, head and neck in 50 cases, forearm and hand in 13 cases, thorax, abdomen, and buttocks in 7 cases. The overall failure rate was 5.7 per cent. Analysis of these failures taught us some original principles. Among these principles, the risk of vascular thrombosis is very important when a venous graft is performed on one end of the artery of a low blood flow flap such as chinese forearm or fibular flaps when the other end of this artery is ligated. When such a graft is done we think that the best way to avoid thrombosis is to suture the other end of the flap artery to a recipient vessel which can be even the distal end of the flap vein itself. Pretransfer expansion of a latissimus dorsi flap was successfully performed in 4 cases. Migrating semi-free flap method, in which the vascular pedicle of a flap is temporarily sutured to recipient vessels located far from the defect, was performed in 12 cases, in most cases on lower limbs where this method constitutes a modern variant of the cross-leg. Folded free-flap method, in which a flap is folded on itself during some days before excision of the recipient site, was performed in 14 cases. Analysis of this series also allowed us to review in detail our usual strategic principles for vascular anastomoses in the head and lower limbs.

The authors report a case of double island forearm flap for a double defect on the inferior part of the leg. The chinese flap is the only flap which has a segmental and staged vascularisation allowing multiple island skin flaps to be performed separated only by the vascular pedicle.

The authors present a technique of palliative treatment of trapezius paralysis after injury to the spinal accessory nerve. The transfer of the levator scapulae associated, or not, with the rhomboid minor allows regression of functional signs and a return to normal function of the shoulder. Five cases are exposed, with results ranging from 3 months to 15 years.

Electrophysiological studies of the rather strange, enigmatic, likely vestigial omohyoid muscle led the authors to point out the dual nature of its two bellies. Electromyographically, the inferior belly with a nearly constant activity may be opposed to the superior belly with intermittent activity. Motor nerve stimulation combined with electromyographic study demonstrated the superior belly to be supplied by the ansa cervicalis while the inferior belly is supplied by the accessory nerve. Based on these findings, anatomical studies conducted with histological examination were consistent with this double innervation.

From the anatomic element known with the man by the name of soft palatal-pharyngeal sphincter and which takes a major part in the phonation, the swallowing, the breathing, we have studied the evolutive morphology of the soft palatal-pharyngeal unity in several mammals. This unity which includes the levator palati and palatopharyngeus muscles is confirmed by the phylogenic and embryologic investigations. The comparative anatomy of the rat, rabbit, sheep and lion, allows to make obvious a evolutive line characterized by the gradual divergence of the axis of the two muscles common to the soft palatal and pharyngeal musculature, which could correspond with a phylogenic evolution.

The authors report three cases of streptococcal cellulitis of the hand with gangrene. The severity of this disease is underlined. Occasionally, segmentary amputation may be necessary. Onset of gangrene may be explained by a double mechanism : streptococcal infection may induce vasculitis obliterans of the regional vessels, extensive edema with ecchymosis may be a factor of segmental compression. Treatment should include excision of the entrance door, antibiotherapy and fasciotomy as needed.

The authors describe the soft palatal-pharyngeal unity, composed of the levator palati and palatopharyngeus muscles in the adult man, the new-born and the Saimiri. They recall the importance of the soft palatal-pharyngeal sphincter in the man's phonation. After having described the general evolution of the aerodigestive tract in the no human mammals and the man, notions of evolutive morphology of the soft palatal-pharyngeal unity are established. They are characterized by the gradual divergence of the axis of the 2 muscles forming the soft palatal-pharyngeal unity ending in the appearance met in the adult man, indispensable in view of a soft palatal-pharyngeal ability allowing a articulated language.

Six further cases of retrocostoxiphoid hernia in children are reported, the postoperative course being uncomplicated following supraumbilical laparotomy. The relevant literature is reviewed and emphasis placed on the value of peritoneography for establishing diagnosis prior to operation.