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The authors report a new local combined flap involving the distally based Latissimus dorsi muscle pedicled on the lumber perforating arteries and prolonged by the last three digitations of the Serratus anterior muscle supplied by the thoracic branch of the thoraco-dorsal artery. This artifice, never previously described, increased the bulk and arc of rotation of the dorsalis flap. It was thus possible to cover a wide defect on the posterior aspect of the sacro-iliac region in a patient previously operated for a highly malignant histiocytofibroma. The anatomic considerations, harvesting technique and advantages and drawbacks of this flap are discussed.

A latissimus dorsi myocutaneous flap now appears to be the best solution to closing large carcinological exeresis of the breast. After an analysis of a series of 14 cases of advanced cancer (T3 or T4) or of progressive cancers (PeV3) of the breast treated by inductive chemotherapy and which underwent surgery at the Strasbourg CRLCC (France), the authors stress the simplicity and reliability of the method, which can make it possible to carry out an extensive and complete exeresis, which is of primordial importance in the control of the local tumor. Its excellent trophic quality made it possible to start radiochemotherapeutic adjuvant treatments rapidly. The other methods (myocutaneous flap of the rectus abdominis, Kiricuta's epiploic flap, neighboring autoplasties) now persist only in cases of advanced breast tumor in which the greater dorsal flap is contraindicated.

We report on two cases of traumatic desinsertion of levator aponeurosis. After a blunt trauma diagnosis between levator aponeurosis desinsertion and neurogenic ptosis is important in planing the treatment: early surgery for the first and foregoing for the later.

On the base of 3 cases of mandibular osteosarcoma, the current role of surgery is specified. The most often used procedure is Rosen's protocol, which includes: preoperative chemotherapy, radical surgery with reconstruction, and postoperative chemotherapy. The key element is the pathological study of the surgical specimen. This will determine the response of the tumor to preoperative chemotherapy and, by comparing the histology of the initial biopsy specimen to that of the surgical specimen, will be used as a basis to select the postoperative chemotherapy. For this type of tumor, chemotherapy has completely substituted for radiation therapy, which is no longer used in the initial treatment. Prophylactic lung radiation therapy has also been given up due to the risks of pulmonary fibrosis entailed by the effective doses. Surgery still has a role of choice in the therapeutic schedule, even if it cannot be contemplated as the sole treatment. Considering the usually young age of the patients, we currently think that reconstruction must be immediate and must resort to all the techniques likely to produce the best possible functional and morphological result.

The authors review the notes of 40 patients who underwent surgery for large sacral pressure sore over the last 10 years. In most cases a gluteus maximus flap with skin graft has been employed to cover sacral sore, as originally described by Ger in 1971. The results of this series are then compared with those published by other authors using different techniques, with particular attention to gluteus maximus musculo-cutaneous island flaps and purely cutaneous flaps. All procedures carry a small mortality rate because of the advanced age and frail conditions of most patients. In our series 2 patients died in the postoperative period; in all the others we eventually achieved a sound healing of the sacral sore. We conclude that the gluteus maximus rotation flap is a safe and effective for the treatment of this condition. Its only major drawback is represented by the prolonged period required for the epithelisation by secondary intention of some fairly frequent areas of failure on the skin graft. The importance of a multidisciplinary team approach in the management of these patients cannot be overemphasised.

The outcome of surgical of small, ptotic breasts is reported in a retrospective series of fifteen patients operated between 1983 and 1989. Seven patients underwent breast augmentation by insertion of breast implant supplemented in one case by a dermopexy while eight patients underwent cutaneous and glandular remodeling alone. Simple breast augmentation with breast implant gave good results with mild to moderate ptosis (i.e. when the distance between the inferior margin of the clavicle and the upper margin of the areola was equal to or less than 17 cm) provided that: the subareolar segment III did not exceed 5 cm, the skin had good static qualities for breast suspension, the amount of glandular, adipose and cutaneous tissue present allowed the prothesis to be covered by a sufficiently thick layer. With breast ptosis greater than 17 cm or when segment III exceeded 5 cm, cutaneous remodeling by dermopexy was associated with insertion of breast implant. In this group of patients treated, either by breast implant alone, or associated with dermopexy, results were good in 33%, and satisfactory in 50% of cases. Better results were obtained in patients with marked ptosis and breasts which, although hypotrophic, conserved a amount of adipose and glandular tissue sufficient to allow breast reconstruction by soft tissue remodeling alone (without the insertion of an implant). Patients in this group were treated by glandular and cutaneous remodeling with good to excellent results in 80% of cases.

Capsular contracture around breast prostheses still represents a challenge, in spite of the numerous papers published on this topic. The etiology and pathogenesis of this condition are perplexing resulting in considerable controversy concerning the rationale for surgical treatment. The authors report two cases of recurrent disease: one patient with recurrent contracture after breast augmentation, the other patient with recurrence after breast reconstruction. Both patients were operated according to an original technique which consists in a square-shaped incision of the pectoralis major muscle via an inframammary approach. This surgical technique allows the prosthesis to sink into deeper layers leading to a better shape of the breast and providing satisfactory skin cover of the prosthesis.

19 patients presenting with saddle deformity of the nose were operated upon between 1981 and 1988. Either a bony or a cartilagenous autograft has been employed according to the nature of the deformity. The mean follow-up was two and a half year. The results confirm the high rehability of cartilagenous grafts in the treatment of partial deformities. Treatment of total saddle deformities proved to be less satisfactory with spontaneous resorption of two grafts out of six, one of which was a homologue bony graft from the bank.

Out of 3,340 thyroidectomies (237 for cancer), the authors report 5 cases of thyroid metastases due to clear cell renal cancer. They emphasize the slow development of these metastases. Two cases were operated on 11 years after nephrectomy and one after 27 years. In one case, an intrathyroid metastasis led to the discovery of renal carcinoma. In 3 cases, evolution was rapidly fatal (within the first year). One patient is still alive 6 years after thyroidectomy. The authors emphasize clinical grounds for diagnosis and expose pathology findings that favor longer survival when there is early removal of intrathyroid metastases.