Adenocarcinoma del canal anal relacionado con fístula / Adenocarcinoma of the anal canal associated with a fistula

El cáncer del conducto anal es relativamente raro, constituye el 1 a 2 por ciento de los tumores gastrointestinales y el 3 a 4 por ciento de los colorrectoanales. El adenocarcinoma representa entre el 5 y 17 por ciento de los cánceres anales. El objetivo del trabajo es una presentación clínica de un paciente operado y la actualización bibliográfica en los aspectos anatomopatológicos de clasificación, origen, diagnóstico y tratamiento(AU)

Adenocarcinoma del canal anal relacionado con fístula / Adenocarcinoma of the anal canal associated with a fistula

El cáncer del conducto anal es relativamente raro, constituye el 1 a 2 por ciento de los tumores gastrointestinales y el 3 a 4 por ciento de los colorrectoanales. El adenocarcinoma representa entre el 5 y 17 por ciento de los cánceres anales. El objetivo del trabajo es una presentación clínica de un paciente operado y la actualización bibliográfica en los aspectos anatomopatológicos de clasificación, origen, diagnóstico y tratamiento

Endoscopic excision of the submandibular gland by an intraoral approach.

The recent advent of endoscopic procedures has compelled both plastic and neck and head surgeons to reconsider the conventional methods by which the excision of submandibular gland is classically achieved. An endoscopic intraoral approach for excision of the submandibular gland is described. This procedure is anatomically safe and can be made with minimal morbidity; a transcervical incision is avoided. Both specific instruments and solid anatomical knowledge are necessary to perform a safe and efficient glandular endoscopic excision. The essential surgical steps are as follows: 1) Careful identification of the Wharton duct and lingual nerve; 2) Retraction of the mylohyoid muscle; 3) Protection of the sublingual gland and lingual nerve; 4) Extraoral manipulation of the submandibular gland obtaining intraoral protrusion; and 5) Careful dissection of the posterior third of gland, avoiding injury on the facial artery and vein. Two patients were operated on with this technique and were very pleased with their results. No complications were registered. With advanced endoscopic instruments, new surgical technique, and surgeon experience, endoscopic intraoral excision of the submandibular gland can be the method of choice in benign neoplasia, sialolith, sialoadenitis and plunging ranula.

Fractures of mandible: is spontaneous healing possible? Why? When?

Closed and open reduction of fractures of the mandible constitutes an endless debate, and it is interesting that modern times have not brought a conclusion to this controversy. From 1995 to 1997 in the Plastic Surgery Department of Argerich Hospital in Buenos Aires, Argentina, 23 patients were evaluated with different fractures of the mandible in which neither closed nor open reduction was performed. Seventeen patients (74%) presented associated fractures in different areas of the mandible and 6 (26%) only had one fracture; 2 of them (9%) were edentulous. Three (13%) of the 23 patients had more than two fractures in different areas. Condylar fractures were the only lesion in 8 patients (35%), and they were associated with body fractures in another 6 patients (26%). Spontaneous healing of the fractures occurred in all 23 patients. No complications were found in any of them. All fractures presented the following characteristics: 1) Fractured fragments were aligned without displacement (or light displacement), 2) Occlusion was normal (or pretraumatic occlusion), 3) Facial symmetry was maintained, 4) Radiography demonstrated fractures without displacement, 5) Minor edema and hematoma were present in the area of the fracture, and 6) There was only pain during masticatory movements. The treatment was as follows: 1) Soft food and liquid diet (solid food was avoided 30 days after trauma), 2) Opening of the mouth was not permitted, 3) Oral antibacterial cleaning, and 4) Analgesic therapy. Spontaneous healing was produced by secondary bone repair mechanism as a "natural" process.

Surgical treatment of the senile upper lip.

Aesthetic changes in the aging upper lip constitute a troublesome problem for modern women. During the process of aging, the following alterations appear in the upper lip: (1) vertical wrinkles, (2) reduction in height of the vermilion border along with lengthening of the skin area of the lip, and (3) "disappearance" of the Cupid's bow. In 1993, Guerrissi and Sanchez described a surgical technique that allowed them to correct the effects of these senile changes in 19 patients. With the use of this surgical technique, a strip of skin on the vermilion border was deepithelialized. The remaining dermal flap was buried in the pocket, which was performed by undermining the superior third of the skin of the upper lip. The short-term results were satisfactory, although a slight reduction in height of the vermilion border and a decrease in the thickness of the lip were observed in five patients (26 percent) 4 years postoperatively. Beginning in 1994, the authors began using a new approach combining dermal flap reshaping with simultaneous lip augmentation using dermal-fat grafts, Gore-Tex (W. L. Gore and Associates, Flagstaff, Ariz.) or AlloDerm (LifeCell Corp., Branchburg, NJ.). No serious or definitive complications were observed. Scars on the vermilion border were not conspicuous. A peel was necessary at the same time for complete elimination of rhytids. With this method, both the patients and the surgeons were satisfied with the results.

Intraoperative injection of botulinum toxin A into orbicularis oculi muscle for the treatment of crow's feet.

The purpose of this investigation was to evaluate the degree of efficacy of eliminating crow's feet by means of direct injection of botulinum toxin A into orbicularis oculi muscles under direct surgical vision during either blepharoplasty or face lift operations. Eighteen patients were injected with Botox A-14 in each orbicularis oculi muscle. Dilution was obtained by adding 4 ml of preservative-free saline to 100 IU of Botox A. Doses ranged from 15 to 50 IU in each muscle, varying according to the severity of wrinkles and intensity of muscle contraction. In 10 patients (56 percent), the Botox was injected throughout the outer surface of both orbicularis oculi dissected during a face-lift operation. In eight other patients (44 percent), the toxin was injected into the inner surface of both orbicularis oculi exposed during classic blepharoplasty procedures. Most authors have demonstrated that the effect produced by transcutaneous Botox lasts between 4 and 6 months; the paralysis obtained by direct muscular injection was effective for 9 months in 14 patients (78 percent) and 10 months in the other 4 patients (22 percent). Results were documented by means of preinjection and postinjection photographs, videotapes, and electromyographs. Neither local nor general adverse effects were noted. The improvement obtained in crow's feet was satisfactory to the patient and to us. The use of Botox intraoperatively permitted at the same time not only the treatment of crow's feet by paralysis of orbicularis oculi muscles but also the correction of senile changes in the lids and face by means of either blepharoplasty or face-lift operations.

Cervical tumor by ectopic salivary gland.

Heterotopic salivary tissue is a rare lesion, although most authors agree that anomalous embryologic development of salivary tissue is the main cause. One case of cervical tumor by ectopic salivary gland is reported, and existent literature is reviewed. A 26-year-old woman was operated on for a cystic tumor in the midline of the neck diagnosed as thyroglossal cyst in the hyoid region. After Sistrunk operation, the recurrence was immediate. A second operation was performed, and a solid tumor located between muscles of the tongue was resected. A long tract opening in recurrent cervical cystic tumor was also removed. No recurrence was evident at 1 year after surgery. Pathological examination of the excised mass revealed an ectopic salivary gland with serous and mucinous acini located between muscles of the tongue. This is a rare case report of a cervical fistula by ectopic salivary gland surrounded by muscles of the tongue draining into a cystic tumor in the hyoid midline lesion. Recurrence of thyroglossal cyst after a correct surgical resection must be suspected as an ectopic salivary tissue. Also when a cystic neck tumor is present, an ectopic salivary gland must be suspected.

Reconstruction of large defects in the scalp with fasciocutaneous flaps.

Although recent reports have emphasised free microsurgical transfer for reconstruction of extensive defects in the scalp, in our experience a carefully planned scalp flap is a simpler and safer method than a free transfer. Twenty-one patients with defects as large as 10%-60% of the scalp surface area were reconstructed; the calvarium was resected in five cases and the dura mater in two. In 18 cases the flaps were based on a single pedicle: the superficial temporal artery. In three cases the blood supply of the flaps was based on three major homolateral arteries: the superficial temporal, the posterior auricular, and the occipital. The blood supply of all scalp flaps was based on the interconnected network of the aponeurotic plexus and the pedicles were included into flap in 18 cases. The principles of fasciocutaneous flaps were applied for all 21 scalp flaps. The reconstruction of the skull was delayed in all cases, and the dura was replaced by free autogenous periosteum. The donor area was covered with a skin graft in all cases. In all patients the aesthetic and functional results were considered excellent by them and by us. There were no postoperative complications.

Atypical Frey syndrome as a complication of Obwegeser osteotomy.

A patient with Frey syndrome on the left cheek area as a complication of an Obwegeser osteotomy is reported. Flushing, sweating of skin, and hypoesthesia of buccal mucosae were present 6 months after surgery. An injury to the auriculotemporal nerve during desperiostization of the posterior border of the mandibular ramus is believed to be the principal cause. The physiopathologic mechanism is thought to occur in relation to aberrant regeneration of the postganglionic secretomotor parasympathetic nerve fibers carried in this nerve. These regenerated fibers erroneously reach the sweat glands of the cheek skin through anastomosis with the buccal nerve and temporofacial ramus of the facial nerve. Direct injury of the buccal nerve may be another cause, because of its close anatomic course with the external pterygoid muscle and the mandibular ramus. An extensive literature review revealed no cases of this syndrome as a complication of Obwegeser osteotomy.

Local injection into mimetic muscles of botulinum toxin A for the treatment of facial lines.

The purpose of this clinical investigation is to confirm the efficacy of eliminating facial wrinkles by injecting botulinum toxin A into mimetic muscles. Fifty-four patients were injected with BOTOX A-14 in the corrugator superciliaris, 19 in the frontalis muscles, and 13 in the orbicularis oculis. Dilution was obtained by adding 4 ml preservative-free saline to 100 IU of BOTOX A. The dose used varied according to the patient. The severity of wrinkles and the intensity of muscle contraction (facial expression) were taken into account. The paralysis obtained in the mimetic muscles was effective for 6 months in 39 patients, 8 months in 10 patients, and 9 months in 1 patient. The results were documented by photographs, videotape, and electromyographies pre- and postinjection. To preserve the results, 21 patients (39%) demanded a second infiltration to achieve satisfactory results. Neither local nor general adverse effects were noted, except transitory eyebrow palsy in 2 patients, and edema and ecchymosis in 4 patients. The improvement obtained in facial mimetic wrinkles was satisfactory to the patient and to us.

Facial nerve paralysis after intratemporal and extratemporal blunt trauma.

Definitive facial nerve paralysis by intratemporal and extratemporal blunt injury is uncommon. Facial palsy as a result of closed temporal trauma is assumed to result if a petrous or temporal fracture is produced. Injury of the extratemporal trunk is extremely rare, but peripheral branches can be more easily injured. An exhaustive examination is necessary for an assessment if facial nerve damage is inside its bony canal or if it is severed distal to the stylomastoid foramen. Evaluation of facial muscle tone and motion, tear production, taste distribution, and stapedius muscle function must be evaluated. Electroneurography is mandatory because it is an important prognosis factor. Many prognosis factors must also be considered. Computed tomographic scan is also mandatory for providing localization of temporal fractures. Of 30 patients with facial paralysis registered by us between 1991 to 1996, 5 (17%) blunt trauma was the cause. In 2 of these patients with facial paralysis by extratemporal injury, showing selective facial branch injuries (one in the buccal branch and another in the marginal mandibular branch), recovery was complete and spontaneous. Another patient presented with a definitive selective buccal branch palsy after a complete facial paralysis produced by blunt preauricular injury. Of another 2 patients with facial paralysis by intratemporal injury without fracture, 1 recovered and the other did not. In 4 of the just-mentioned 5 patients, prednisolone was prescribed 1 week after trauma; no patients underwent surgical treatment. In conclusion, an extratemporal blunt trauma can produce a temporary facial palsy or paresis by injury of the main trunk or peripheral facial branch; however, recovery is usually complete. Intratemporal closed trauma with or without temporal fractures can produce a definitive facial nerve paralysis; recovery is uncertain.

Mobilization of the entire midfacial skeleton: "wing"-shaped midfacial osteotomy.

Hypoplasia and retrusion of the midfacial skeleton may only involve the dentoalveolar area or central facial region (nasal and paranasal [Binder's syndrome]) or the whole midface (paranasal, maxillary, malar, and zygomatic areas). The principal clinical findings are flattened paranasal, cheek, and malar areas. Class III malocclusion or normal dental occlusion can also be present. Treatment of midface retrusion is difficult because the final result depends on a high degree of harmonic aesthetic appreciation, the use of adequate surgical technique (adequate facial osteotomy), and the final relation obtained between soft tissue and facial bones. Many surgical treatments have been proposed for correction of midfacial retrusion. A new osteotomy is proposed involving advancement of maxillary and malar bones and the lower half of both zygomatic arches, when the whole midfacial skeleton is retrused and hypoplastic (both maxillary and malar bones are involved). The orbital osseous structures are not included in the osteotomy; the infraorbitary nerve remains intact. Using this technique, all clinical features are corrected. The advancement and mobilization of the whole body of the maxillary and malar bones along the lower part of the zygomatic arch contribute to three-dimensional facial reconstruction because they produce an increase in anteroposterior projection of the middle third facial region. Rigid internal fixation by means of miniplates and screw of 1.5 or 2 mm on four principal maxillary buttresses is used. No onlay bone grafts are used for obturing the gaps of osteotomy.

Maxillofacial injuries scale.

This new proposed maxillofacial categorization is based on the scoring of two groups: Group I and Group II. The information obtained in Group I permits evaluation of (1) life-threatening injuries; (2) maxillofacial etiological factors producing life-threatening injuries; and (3) other organ or anatomic areas that may also have been injured. This information permits a fast and correct categorization of the patient before hospitalization and helps achieve transportation to an adequate hospital in an adequate amount of time and adequate treatment. Using the score obtained for Group II categorization, the functional and aesthetic severity of soft tissues (skin, mucosa, scalp), skeletal facial areas, and other important tissues (e.g., facial nerve, ocular globe, palpebral tissues) is determined. The final score resulting in Group II categorization is based on three grades of different severity: Grade I (minor), 1 to 6; Grade II (moderate), 7 to 24; and Grade III (grave), greater than 25. By means of Group II categorization the following can be evaluated: (1) type and severity of functional and aesthetic lesions; (2) adequate timing of treatment; (3) convenient treatment; (4) type and severity of functional and aesthetic sequelae; and (5) probability of successful treatment of sequelae.

Lengthening of the mandible by distraction osteogenesis: experimental work in rabbits.

The purpose of this experimental work was to lengthen the mandible in rabbits by means of distraction osteogenesis. The excellent results on the lengthening of the extremities with the Ilizarov technique and the unpredictable results in the mobilization of the facial bones by means of osteotomies and grafts are reasons for the application of the gradual distraction method in mandibular lengthening. Bone lengthening was first performed in 1905; but Ilizarov rekindled interest in 1951 when he induced bone neoformation in the extremities by the distraction technique using multiplanar wires and external circular fixators. We lengthened the mandible in 12 New Zealand adult rabbits using different mountings of the Ilizarov apparatus by means of two fixation techniques: transfixion and nontransfixion. In the transfixion group (6 rabbits), the two wires were passed through both mandibular rami. In this group, a 2-cm lengthening was obtained. In the nontransfixion group (6 rabbits), only one mandibular ramus was included with the transfixion wires. In this group, 1-cm lengthening was achieved. Unilateral lengthening was obtained with the nontransfixion technique and the lengthening of both rami with the transfixion technique. The results were evaluated by clinical periodic postoperative radiographs and histological studies of newly formed bone and surrounding soft tissues (masticatory muscles, arteries, and so on). The results demonstrated that lengthening of the mandible is obtained by means of a mature and normal new bone that is produced in the osteotomized area.

An approach to the senile upper lip.

Senile changes in the upper lip produce not only alterations in the length and shape of the vermilion border but also elongation of the skin area and vertical wrinkles. Correction of these changes can be obtained by means of the surgical technique described in this paper. The surgical technique must be exact and performed patiently. The complications are temporary and not serious. The results are satisfactory.

Congenital absence of nasal bones.

Isolated congenital nasal malformation is rare; the isolated absence of any specific nasal structure is even rarer. They are related to craniofacial stenosis syndromes and to facial cleft, which are described in Tessier classification; also they can appear in 58 complex genetic syndromes. Nasal malformations may be acquired as a consequence of traumas, tumors, infectious diseases, or sequelae of aesthetic surgery. Gorham's syndrome is a rare disease that produces spontaneous and asymptomatic disappearance of any bone of the skeleton. In the world literature, there is no case of Gorham's syndrome with disappearance of the nasal bones. This case report is of a 20-year-old patient who sought correction of an aesthetic defect produced by a cartilaginous hump without the presence of the nasal bones. The absence of both nasal bones is produced by failure of the development of both centers of ossification. Through study of embryological development of the nasal structure, isolated absence of the nasal bones can be explained.

Selective myectomy for postparetic facial synkinesis.

Synkinetic movements are secondary to facial palsy because they appear like a late sequela to spontaneously healing facial nerve injury. They are produced by an involuntary contraction of a muscle group simultaneous with contraction of other homologous muscle groups. The disorderly regeneration of severed axons is responsible for these movements. According to the Lippschitz theory, the regenerating nerve fibers sprout into the wrong peripheral branches. Between 1975 and 1986, 71 patients with facial paralysis were evaluated. Spontaneous recovery from the facial paralysis occurred in 28 of these patients; 14 (50 percent) developed synkinetic movements, and surgical treatment was sought by only 6 patients. In all patients, the lesion of the facial nerve was in the trunk, proximal to the principal ramification. The most frequent clinical finding was simultaneous activation between the orbicularis oculi and the elevators of the corner of the mouth (12 patients) or the elevators of the upper lip (2 patients). In 8 patients, in whom the slight synkinesis was not noticed by the patients, surgical correction was not necessary, but in the other 6 patients with severe aesthetic disturbances, surgical treatment for "disconnection" of the wrong impulses was realized. I obtained this "disconnection" through resection of the involved perioral muscle groups instead of paralysis of the orbicularis oculi. Follow-up of the 6 patients operated with the surgical treatment proposed herein for between 4 and 8 years has shown good aesthetic results without functional or aesthetic sequelae.