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Background Achilles tendinopathy remains often chronic and rebel to a thorough conservative treatments. In this context, autologous platelet-rich plasma (PRP) could represent an interesting alternative. Methods This prospective, monocentric, descriptive study, conducted from January 2011 to May 2011, included 32 patients practicing sports at the competitive or amateur level and suffering from chronic Achilles tendinopathy diagnosed by ultrasound (US). The treatment consisted on a single injection of PRP directly into the Achilles tendon under US guidance. Hence, the cracks were gently filled without damaging the surrounding healthy tendon. PRP was systematically characterized before its administration. Tendon regeneration was followed using algofunctionnal testing and US examination at 1, 2, and 3 months post-injection. A satisfaction score was proposed at 6 and 12 months by phone call. Results Twenty-two patients (69%) at 1 month and 18 patients (88%) at 2 months were completely healed, associated with a widespread improvement of fibrillar echo-structure of the tendon and improvement reduction of the hypervascularity during power Doppler examination at 3 months. Of the 22 responses collected to the end of the protocol, 14 patients declared a complete improvement in term of satisfaction with a significant reduction of pain ( P P Conclusions A single autologous PRP injection was effective in the treatment of rebel Achilles tendinopathy. US guidance allows PRP injection directly into the degenerated part of the tendon with great accuracy.

The cutaneous infectious pathology of the child is varied and frequent. Authors deal with surgical infections seen in current pediatrics, which often have to appeal to a plastic pediatric surgeon for their treatment. Superficial infections of skin and pilo-sebaceous follicles are common in big children. The folliculitis and the boil are the most frequent. Their treatment is medical and surgical and does not require an antibiotic treatment in most of the cases. The primitive abscesses or following an anterior lesion recover from a similar treatment. Some localizations or risky context need a particular follow-up. The whitlow is a particular example and needs to have a particular follow-up because of the risk of hand cellulitis. Nails embodied of the child require a specialized notice because of their numerous clinical forms, which must be distinguished according to the age. Finally the necrotizing cellulitis and fasciitis are surgical emergencies and have a well-codified treatment. These infections in children must benefit from an attentive care because when they are badly treated, they can involve the aesthetic, functional and vital forecast.

Children with severe congenital blepharoptosis are at risk of developing amblyopia. For this reason, ptosis repair is indicated as soon as the diagnosis is made. Frontalis suspension of the upper lid is an effective and simple method of treatment. This study reports on the long-term outcome of frontalis suspension surgery for congenital ptosis using autogenous sling material. Twelve children with severe congenital ptosis underwent frontalis suspension surgery using autologous fascia lata or temporal fascia. The results were assessed with a mean follow-up period of 8 years. Eleven children had good or excellent functional and aesthetic results. There were no cases of recurrence or overcorrection. Frontalis suspension using autologous material is a harmless procedure, which does not alter the upper eyelid structures. It is an effective procedure in the long term. In our opinion, it is the technique of choice to treat young children with severe congenital ptosis.

Resume Le syndrome des brides amniotiques (SBA) est une entite clinique desormais bien decrite, qui comprend diverses anomalies congenitales. Les malformations de la main sont les plus caracteristiques et les plus frequentes, associant avec une localisation tres variable, sillons de constriction, acrosyndactylies et amputations congenitales. De nombreuses associations malformatives sont possibles, le plus souvent letales. Les malformations crâniofaciales, viscerales ou de la paroi fœtale, sont alors regroupees sous le terme de limb body wall complex (LBWC). Il existe diverses denominations pour ce syndrome, du fait de la grande variabilite des anomalies morphologiques et des incertitudes concernant ses etiologies. En effet, plusieurs hypotheses pathogeniques se sont opposees au fil des annees, laissant une certaine confusion. De recents travaux experimentaux, de genetique notamment, pourraient aider a unifier ces diverses malformations congenitales. Le diagnostic, de plus en plus souvent pose avant la naissance, plonge la famille dans un grand desarroi. Un diagnostic antenatal precoce et precis est l’element clef de la prise en charge pre- et perinatale et pourrait rendre parfois possible un geste chirurgical in utero. Les traitements chirurgicaux ameliorent la morphologie, mais n’ameliorent la fonction que si les elements construits sont integres par l’enfant dans son schema corporel. Les interventions doivent etre entreprises tres tot : en urgence, a la naissance, en cas de trouble vasculaire, ou precocement en cas d’aggravation des deformations par une croissance rapide.

Resume Sujet Malformation de la paroi thoracique anterieure la plus frequente, le thorax en entonnoir reste l’objet de nombreuses controverses. D’etiologie incertaine, son retentissement psychologique, cardiaque et pulmonaire est diversement apprecie. Plus discutee est sa prise en charge chirurgicale, avec des techniques plus ou moins radicales selon les equipes. Il n’existe ainsi aucun consensus etabli quant aux indications chirurgicales, la technique a utiliser ou l’âge d’intervention. Materiel et methodes Nous presentons ici notre etude, retrospective, interessant dix patients porteurs d’un thorax en entonnoir operes dans notre service entre 1989 et 2002. Neuf patients ont beneficie d’une correction par prothese thoracique sur mesure en silicone, et une patiente de la mise en place d’une seule prothese mammaire. Chaque patient a ete interroge et examine afin de completer une fiche de renseignements et d’evaluation. Le retentissement et d’eventuelles anomalies associees etaient objectives par des examens complementaires cardiopulmonaires, et la severite de l’entonnoir evaluee par l’index radiographique de Haller. Resultats Le recul moyen etait de plus de cinq ans. Le retentissement du thorax en entonnoir etait chez nos patients essentiellement psychologique, du fait de la disgrâce esthetique. Bien que deux tiers des entonnoirs soient juges severes, le retentissement cardiopulmonaire etait mineur chez nos patients. Tous etaient satisfaits du resultat, et ce independamment de l’appreciation chirurgicale. Les complications aigues relevees regroupaient cinq seromes et une desunion cicatricielle minime. Discussion Apres comparaison de nos resultats a ceux de la litterature, et au regard des differentes possibilites de traitement existantes (prothese, sternochondroplastie, transfert graisseux), les indications et les modalites de prise en charge chirurgicale du thorax en entonnoir sont discutees.

Summary Introduction Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high – from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. Patients and methods Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. Results The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72h in all cases. After good granulation was obtained, two patients required a thin skin graft. Discussion All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.

Apert’s syndrome is the most common of the acrocephalosyndactylies with complex malformations of the hands. Treatment of the Apert hand is complex, and numerous procedures are required. The aim of this study is to propose a strategy for hand management. Sixteen Apert’s syndrome hands were submitted to early surgery, which included opening of the first web, separation of the fingers, realigninment of the thumb, and correction of the clinodactylies. We performed an average of six operations per child. Treatment of the first web depended on the classification of Upton: For the severe stages, we used a dorsal hand flap. Radical clinodactyly was treated by osteotomy of the delta phalanx and Z-plasty. We treated nine hands with four fingers and seven hands with five fingers. There was always bilateral opposition and symphalangism excluding the fifth finger. All of the children have a rudimentary but functional pinch grip. Revision of the webs was necessary in 16% of the cases. The Apert hand requires early and specialized treatment that aims to provide a functional hand before 2 or 3 years, with the least surgical complications. The functional prognosis is adversely affected by symphalangism.

Advancing the posterior pharyngeal wall is a classic technique to treat velopharyngeal insufficiency. Injection of autologous fat behind the posterior pharyngeal mucosa according to the Coleman Lipostructure technique is a recent development. The authors report their experience in six cases using this modification. The preoperative work-up was performed by a speech therapist with a physical examination and measurement of the nasal air loss was performed using an aerophonometer. Fat was harvested either on the abdominal wall or on a buttock and then centrifuged. Fat injection was performed using a curved blunt cannula under the mucosa of the lateral and posterior pharyngeal walls. Injecting fat is an autologous graft of fat tissue: after a postoperative period of three months, the volume of fat becomes permanently stable. In five out of the six patients who presented moderate velopharyngeal insufficiency, speech improvement was significant. The single failure was a patient with bilateral cleft lip and palate sequels after previous pharyngoplasty using the Orticochea procedure. Treatment of moderate velopharyngeal insufficiency using fat injection is an efficient method. The advantages are its innocuousness and that scaring of the pharynx is avoided.

The understanding of vascular anomalies (vascular tumours and vascular malformations) was obscured, for a long time, by confusion and uncertainties in nosology and terminology. The International Society for the Study of Vascular Anomalies (ISSVA) recently adopted a classification scheme, clearly separating vascular tumours (hemangiomas of different types) which result from active cell proliferation, from vascular malformations, which are inborn defects in vascular morphogenesis. These two types of lesions have different clinical behaviour and require different diagnostic and therapeutic strategies. The most frequent vascular tumour is infantile hemangioma. Its clinical aspects and evolution are well-known. New data have been recently obtained concerning the phenotype of tumour cells and its histogenesis. Of the numerous new vascular tumours, which have been recently described, only the congenital hemangiomas, the vascular tumours associated with the Maffucci syndrome and the tumours that may be complicated by a profound thrombocytopenia (Kasabach and Merritt phenomenon) will be considered. Vascular malformations can be classified according to the vessel(s) types they are composed of. A classification table is presented, separating the malformations of vascular trunks from tissular malformations which are more intimately embedded in the surrounding tissues. The different syndromes associated with vascular anomalies take also place in this table. The clinical, imaging and histological aspects of the most frequent malformations (capillary, venous, lymphatic and arteriovenous) are presented. This classification intend to clarify the nosology and terminology of the complex field of vascular tumours and malformation and to offer a common language to the different physicians and specialists contributing, preferably with a interdisciplinary approach, to the diagnosis and treatment of these difficult lesions.

INTRODUCTION: Nerve injury compromises sensory and motor functions. Techniques of peripheral nerve repair are based on our knowledge regarding regeneration. Microsurgical techniques introduced in the late 1950s and widely developed for the past 20 years have improved repairs. However, functional recovery following a peripheral mixed nerve injury is still incomplete. STATE OF ART: Good motor and sensory function after nerve injury depends on the reinnervation of the motor end plates and sensory receptors. Nerve regeneration does not begin if the cell body has not survived the initial injury or if it is unable to initiate regeneration. The regenerated axons must reach and reinnervate the appropriate target end-organs in a timely fashion. Recovery of motor function requires a critical number of motor axons reinnervating the muscle fibers. Sensory recovery is possible if the delay in reinnervation is short. Many additional factors influence the success of nerve repair or reconstruction. The timing of the repair, the level of injury, the extent of the zone of injury, the technical skill of the surgeon, and the method of repair and reconstruction contribute to the functional outcome after nerve injury. CONCLUSION: This review presents the recent advances in understanding of neural regeneration and their application to the management of primary repairs and nerve gaps.

In the wake of three consecutive cases of microscopical examination of resection specimens following breast reduction revealing an adenocarcinoma, we wanted to point out the interest of a complete preoperative senological examination including mammography and postoperative anatomopathological examination. A retrospective study concerning 837 patients over a three-year period was conducted. We found seven patients (0.83%) with malignant breast cancer diagnosed on anatomopathological examination, which is comparable to the incidence found in literature. Of these seven cases there were four ductal adenocarcinomas (0.47%), all of them in situ (DCIS), and three lobular adenocarcinomas (0.36%) of which one invasive (ILA), one in situ (LCIS) and one mixed. The majority was aggressive, multifocal and bilateral. Treatment consisted of mastectomy with or without adjuvant therapy with curative intent in five out of seven cases, and this within two months after a esthetic surgery. In our opinion this shows that breast reduction can help in tracking down breast cancer and underlines the need for systematic and meticulous microscopic examination of resection specimens after breast reduction.

The methods additional or substitution for the surgery of facial skin ageing are dramatically rising before 40 years. These methods are addressed more to the wrinkles and others signs of aging skin. They can constitute a door of entry in the aesthetic treatments and needs a professional approach. These noninvasive methods (within the meaning of the incision) can present complications this the more so as the tendency is with the vulgarizing and with under considerations of the initial diagnosis and the treatment itself. The devices of thermal effects consist of lasers, pulsed flashlamps and radiofrequency. The objective of this development is to consider the bonds, which link the initial diagnosis and the proposal for a treatment by considering side effects and complications of each method.

Resume Fond. – Le relissage laser constitue un des traitements du rajeunissement facial de pratique courante et peut dans certains cas etre une alternative aux techniques traditionnelles, chimiques et mecaniques. Cependant, des complications existent avec une frequence variable, qui tient compte toujours de la selection du patient au depart et des souhaits qu'ils expriment aux praticiens. Objectif. – Faire le point sur la frequence des complications observees au cours de nos huit premieres annees de relissage laser en tenant compte des possibilites preventives. L'experience de l'auteur sera discutee conjointement a une revue de la litterature. Methode. – Analyse retrospective de 749 patients ayant beneficie de relissage laser par un meme operateur avec les lasers CO2 et Erbium. Les effets secondaires et les complications post-operatoires precoces et tardives sont presentes sous forme de tableaux. Resultats. – L'erytheme post-operatoire est constant et regresse habituellement avant la sixieme semaine. L'hyperpigmentation a ete rencontree dans 32 % des cas et doit etre traitee precocement. La dermite irritative est la complication precoce la plus frequente (10,6 %). Des infections sont survenues dans moins 2 % des cas. L'hypopigmentation est rare ( Conclusion. – Le relissage laser par les lasers CO2 et/ou Erbium est une technique efficace et sure moyennant une bonne connaissance de l'interaction laser–tissu. Le plus souvent, des complications de faible importance peuvent survenir et sont rapidement traitees.

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.

Purpose The aim of this study was to report our experience in embolization of high flow peripheral arteriovenous malformations (AVMs) with Onyx. Material and methods Nineteen patients (10 men, 9 women) with peripheral high-flow AVMs who were treated with arteruial embolization using Onyx were retrospectively included. AVMs were located in the head and neck (6), extremities (5), chest (2), kidney (2), uterus (2), pelvis (1) and parietal (1). In 13 patients, embolization was done using Onyx only. One patient underwent embolization by direct puncture, the others by transarterial approach. Embolization was performed in one or multiple sessions (up to 5). A total of 28 sessions were performed. Follow-up was performed with a delay between 10 and 34 months. Results Technical success was achieved in all patients. Complete devascularization was obtained in 12 patients. Surgical excision was performed in 9 patients. Non-target Onyx embolization was not observed. One patient developed stroke. In 1 patient microcatheter fracture occured. One patient presented severe pain and bradycardia during the procedure that disappeared shortly after. One patient had persistent but less frequent epistaxis after embolization. Another patient had persistent pain without improvement. One patient was lost to follow-up. Other patients were free of symptoms on follow-up. Conclusions Embolization with Onyx ® is an interesting option for management of peripheral high-flow AVMs either preoperatively or as a single treatment.

L'aplasie cutanee congenitale est une malformation rare pouvant atteindre le scalp et parfois les tissus sous-jacents. Elle peut etre isolee ou associee a des malformations congenitales, souvent dans un contexte familial. La mortalite y est elevee, a l'occasion de complications vasculaires ou infectieuses. Les auteurs rapportent leur experience dans la prise en charge de 5 nouveaux-nes atteint d'ACC du vertex dans un contexte familial. Le traitement par cicatrisation dirigee semble etre la meilleure attitude, meme dans les formes severes. Apres la periode aigue, enquete familiale et expansion cutanee complete la prise en charge.

We describe two cases of giant-cell fibroblastoma (GCF) with dermato fibro sarcoma protuberans (DFSP) component, occurring in two children in a chest wall localization. One case recurred 1 year later. The two patients were tumor-free 12 and 8 years later. GCF is a rare mesenchymal cutaneous and subcutaneous tumor reported mostly in the first two decades of life. Dermato fibro sarcoma protuberans, occurring preferentially in adults, is a rare skin tumor with a pronounced tendency to local recurrence. Some cases of association of recurrence of GFC under the form of DFSP have been reported, raising the question of a continuum between the two tumors. The treatment of choice of the two tumors is a wide local excision.

In birth palsy of the brachial plexus, the mixed interference pattern recorded for the brachial biceps on the electromyogram often conflicts with the muscle's inability to flex the elbow. We report our observations of a six-month-old infant who presented paralysis of the upper and medial elements of the brachial plexus, in whom we demonstrated early biceps-triceps co-contractions, which may explain this discrepancy and 'pseudo-paralysis' of the biceps. We analyse and discuss the practical consequences of these findings, and notably the possible therapeutic use of triceps-to-biceps surgical transposition.

Early curettage of giant congenital naevi in new-born infants, if performed during the first few weeks after birth, can have a substantial effect on the pigmentation of the lesions, reducing the number of pigmented cells and leaving only moderate scars. We describe our experience in a series of nine congenital naevi treated by curettage between the first and seventh week after birth. Histological changes that occur in the naevus during the first few days after birth mean that early treatment is needed to obtain a cosmetic improvement. Curettage as an early treatment for giant congenital naevi in new-born infants provides cosmetic improvement and might decrease the risk of malignancy; however, the lesions are not cured. Naevus cells persist in the deep dermal layers and may come to the surface, such that close monitoring is needed long after curettage. The cosmetic improvement is likely to benefit the child's psychological development.

Nevus spilus is clinically defined as a pigmented skin lesion composed of a light brown macule on which darker, circumscribed macular or papular lesions appear at a later stage. Histologically, nevus cells have been found both in pigmented spots and in the background stain. Cases of transformation into melanoma have been reported in the literature and the excision of these lesions is therefore justified. We discuss surgical techniques used in seven patients with nevus spilus and define their indications with respect to the characteristics of the lesion.

Background: Following kidney transplantation, ischemia-reperfusion injury contributes to adverse outcomes. The purpose of this study was to determine whether a cold-storage solution saturated with noble gas (xenon or argon) could limit ischemia-reperfusion injury following cold ischemia. Methods: Sixty Wistar rats were randomly allocated to 4 experimental groups. Kidneys were harvested and then stored for 6 h before transplantation in cold-storage solution (Celsior®) saturated with either air, nitrogen, xenon or argon. A syngenic orthotopic transplantation was performed. Renal function was determined on days 7 and 14 after transplantation. Transplanted kidneys were removed on day 14 for histological and immunohistochemical analyses. Results: Creatinine clearance was significantly higher and urinary albumin significantly lower in the argon and xenon groups than in the other groups at days 7 and 14. These effects were considerably more pronounced for argon than for xenon. In addition, kidneys stored with argon, and to a lesser extent those stored with xenon, displayed preserved renal architecture as well as higher CD-10 and little active caspase-3 expression compared to other groups. Conclusion: Argon- or xenon-satured cold-storage solution preserved renal architecture and function following transplantation by reducing ischemia-reperfusion injury.

Summary Background Autologous fat graft, by virtue of its volumetric qualities and its action on skin trophicity, can be considered as a gold standard implant. Current techniques do not allow very superficial or subdermal injections of adipose tissue. The authors report technical modifications that enable fat transfer through a 25-gauge cannula. The viability of grafted fat was assessed after subcutaneous injection on a murine model. Methods Micro-fat grafting consists of harvesting fat tissue using a multiperforated cannula with holes of 1 mm. Fat tissue is refined as described by SR Coleman and transferred through a micro-cannula. Initially, human fat was first harvested using two different procedures: Coleman's technique and the modified harvesting technique. Preliminary comparative histologic analyses were performed. Sixteen nude mice received human fat tissue: one side was filled with 0.7 cc through a 17-G cannula using Coleman's technique, and the opposite side was grafted using smaller cannulae (20G, 23G and 25G) following the modified harvesting technique. Mice were euthanised at 12 weeks and skin biopsies were performed. Results Experimental fat grafts on mice were observed and analysed: macroscopically, the fat tissue of each side showed the same healthy aspect. Haematoxylin–eosin–saffron staining revealed intact adipocytes and anti-CD31 antibody immunohistochemical staining highlighted an abundant neo-vessel network. Conclusion Fat graft obtained by the modified technique maintains a normal histologic structure. Fat injection with micro-cannulae extends the application of lipostructure to the superficial layers of the skin.

The incidence of the rare facial clefts is between 1.43 and 4.85 per 100.000 births. We report a case of right associated Tessier no. 3, 7 and 11 craniofacial clefts with cardiac malformation. The epidemiology, classification, embryology and pathogenesis of each craniofacial malformation are briefly reviewed. After an extensive review of the literature, we conclude that this association has not previously been reported.

The presentation of thumb duplication is variable depending on the level of bifurcation, the relative sizes of the two thumbs and their possible symmetry along a longitudinal axis. Resection of the supernumerary thumb often leads to disappointing results when both thumbs are hypoplastic. The principle of the "Bilhaut-Cloquet" procedure involves central resection of the duplication followed by fusion of the remaining lateral portions, in order to obtain a thumb of satisfactory volume. Thirteen children with unilateral thumb duplication were treated using the "Bilhaut-Cloquet" procedure. Nine cases involved duplication of the distal phalanx (Wassel type II). Five of these duplications were symmetrical and four were asymmetrical with an associated proximal delta phalanx. In these cases, a corrective osteotomy of the delta phalanx was performed at the same time. Four cases involved symmetrical duplications of both proximal and distal phalanges (Wassel type IV). The mean age at time of surgery was 11.5 months. Patients were reviewed with a mean follow-up of four years. The aesthetic aspect of the nail was judged as good in 12 cases. In one case, the aesthetic aspect of the nail was judged as fair due to a prominent longitudinal ridge. Bony fusion was obtained in all cases but one. The alignment was corrected in all cases but four, involving asymmetrical duplications. Joint mobility was limited in all patients. The "Bilhaut-Cloquet" technique leads to a satisfactory volume of the thumb in selected cases. Good correction of preoperative angular deformity is obtained in symmetrical cases. A precise technique of bone and nail approximation yields good functional and aesthetic results. The "Bilhaut-Cloquet" technique is indicated in balanced and symmetrical duplications, when the two thumbs are severely hypoplastic. It can be used either in the distal or proximal phalangeal types of thumb duplication.

Obliterating arteriopathy of the lower limbs is a classic contraindication for neurocutaneous islands flaps, particularly the sural flap. But recent literature reports examples of its successful application in arteritic patients. The aim of this work was to study the vascular anatomy of the sural flap in patients suffering from arteriopathy and its possible clinical application. Twenty-four specimens of leg amputation were studied. The mean age of the amputated patients was 68.5 years. The clinical signs of arteriopathy had been present for 3–16 years. In 10 cases amputation was carried out directly, in 14 cases after failed revascularization. The results of the dissection showed the theoretical possibility of a sural flap in almost all the cases (23 of 24) despite certain anatomical peculiarities. In the upper part of the leg the arterial network of the sural communicating nerve dominates that of the sural nerve; this should allow the use of a sural flap centered on this vascular axis. In the lower part, the arterial network of the sural communicating nerve is sustained by the perforators of the peroneal artery, then by the branches of the calcaneal artery, and finally by the lateral tarsal artery, which should allow the use of a sural flap with a very distal pedicle. The authors propose a theory which suggests that the progressive evolution of arteriopathy and the concomitant development of a supply network involving the vascularization of the sensory nerves induces the "anticipation" of a sural flap.

Infantile digital fibroma is a benign lesion, but it is sometimes a locally aggressive proliferative lesion. After having examined the literature, we analysed 11 cases of infantile digital fibroma among children between 1 to 16 years, with a long-term follow-up (14 years). We had 4 recurrences. Treatment was surgical. The histological diagnosis has required special stains to put in evidence the typical cytoplasmic eosinophil elements. Surgery usually involved excision and grafting. We also discuss therapeutic measures.

We report an unusual case of tenosynovitis in the hand. A female farm worker aged 66 developed swelling of the middle and little fingers. Extensive synovectomy of the flexor tendon sheaths was performed, and the synovitis was found to be due to Listeria monocytogenes, which is unusual in this area. Treatment with amoxycillin and gentamicin for 10 days was replaced by trimethoprimsulfamethoxazole for 3 weeks. There was no recurrence of infection 3 months after surgery, and flexion and extension were complete at that time.

We report a 65-year-old patient who presented a rapid eruption of keratoses on sun-exposed areas and an explosive transformation into several squamous-cell carcinomas, occurring during the accelerated phase of a chronic granulocytic leukemia. Clinical findings resembled those usually descibed in xeroderma pigmentosum. The role of immunosuppression, chemotherapy and possible genetic predisposition is discussed.

Emergency or early surgery for brachial plexus injury is advisable because emergency nerve surgery is technically easier and because the overall results are better. In cases involving vascular injury, preoperative arteriography is indispensable. The blood supply must be reestablished and the brachial plexus completely explored and, if possible, repaired. In cases not involving vascular injury, violent trauma with fractures of the shoulder often produces lesions in the same brachial plexus. Regardless of associated vascular or bone injuries, brachial plexus lesions should be repaired within the first days after injury (provided that there are no contraindications related to age or general health). If combined vascular and nerve injuries are involved, immediate emergency surgery is mandatory. With early surgery, exploration is easier, shorter grafts are needed, and neurotization is possible in lesions in which the roots have been pulled out.