[Workhorse flaps for breast reconstruction]. / La reconstruction mammaire par lambeau.

Breast reconstruction is a crucial step in the treatment of breast cancer providing a durable solution for patients seeking to restore their physical and psychological integrity. If only part of the breast parenchyma is removed, local glandular flaps are used to restore breast shape and volume. After total mastectomy, when prosthetic reconstruction is contraindicated because of poor skin quality, distant flaps are preferred. Most of the time, two types of flaps are used: the pedicled myocutaneous latissimus dorsi flap and the deep inferior epigastric perforator (D.l.E.P.) free flap. The first flap is simple to execute and reliable, but requires some breast prosthetic material to add volume to the reconstruction. The second flap allows performing autologus reconstructions, providing a high quantity of supple tissues, while remaining a significantly more complex technique.

The reverse turnover latissimus dorsi flap for closure of midline lumbar defects.

The surgical treatment of wounds located in the median lumbar area is difficult. When occurring after neurosurgical procedures, they may display a high level of complexity because of dural exposure, deep irregular three-dimensional contours, and bacterial contamination of the wound. The difficulty of reconstruction in that region of the body is made greater by the few possible regional flaps available in the vicinity. In order to obtain well-vascularised tissue, with good resistance to bacterial contamination and easy to shape into such defects, the reverse turnover latissimus dorsi flap is a useful surgical option. Between 1998 and 2003, four patients presented with complex lumbar wounds in our department. Three patients were adults (mean age: 63 years) and one patient was 1 year old. In all cases, reconstruction was needed in the lumbar area after surgery on the spine. All wounds presented with bacterial contamination. In three cases, dural exposure was present, while in the fourth case, a small remnant of the posterior vertebral bony lamina was still present after debridement. In all four cases, the reconstruction was successfully achieved by turning over the latissimus dorsi to reach the lumbar midline defect. In one case, the adult paraplegic patient, only the inferior part of the muscle was harvested, to preserve an innervated upper part of the muscle for upper limb function. In the four cases, long term results were excellent (the mean follow up was 3.5 years), with no residual infection.

Post-surgical pyoderma gangrenosum: a clinical entity.

Post-surgical pyoderma gangrenosum (PSPG) represents a specific entity: it shares some clinical aspects of pyoderma gangrenosum (PG), but has a series of its own features. In this paper, two cases of PSPG associated with breast surgery are presented: their analysis, combined with a review of the few other cases reported in the literature, show the particular clinical presentation and evolution of this condition. Firstly, the onset of PSPG follows a sequence. After an apparently normal evolution of scar formation following a surgical procedure, the scar presents with many small dehiscences, which will progressively coalesce to some larger areas of wound ulceration, with no visible granulation tissue. Secondly, the delay between surgery and the beginning of symptoms is variable, from 4 days to sometimes 6 weeks. The process will evolve well beyond what would be expected for the initial wound that was created by surgery, with no self-limitation. The skin ulcerations become larger, despite any local treatment or antibiotics. Thirdly, PSPG can affect any anatomical location with the exception of the nipple-areolar complex. Fourthly, a dramatic response to immunomodulatory drugs will be observed. The pain is an inconstant symptom. Present in the first week after surgery, it can be severe and disproportionate regarding clinical presentation.

Does a foamy-block mattress system prevent pressure sores ? A prospective randomised clinical trial in 1729 patients.

BACKGROUND: Pressure ulcers are a frequent complication of bed rest. The development of an efficient and low cost pressure relieving system for the prevention of bed-sores would be of considerable hospital health and economic interest. Our study was designed to determine the effectiveness in pressure-sore prevention of an interface pressure-decreasing mattress, the Kliniplot mattress, used in our institution since 1978. METHODS: In a prospective randomised controlled 7-month clinical trial we compared the Kliniplot mattress with our standard hospital mattress in 1729 patients admitted to medical and surgical departments (neurology, cardiology, oncology-haematology, neurosurgery, thoracic surgery and orthopaedic surgery). Two groups (Klinipot mattress and standard hospital mattress) were monitored for the prevention of pressure sores. The patients were evaluated on a daily basis from their admission until the eventual occurrence of a bed-sore. Patients' characteristics and pressure-sore risk factors were similar at the baseline in both groups. Patients presenting with a pressure sore at the time of admission were excluded. RESULTS: Forty-two of the 1729 patients (2.4%) who entered the study developed at least one pressure sore. Twenty-one of the 657 patients (3.2%) nursed on the Kliniplot mattress, and 21 of the 1072 patients (1.9%) on the standard mattress developed bed-sores (p = 0.154). The median time for the occurrence of pressure sores was 31 days (range 6-87) with the Kliniplot mattress and 18 days (range 2 to 38) with the standard mattress (p < 0.001). The risk categories for developing bed-sores using the modified Ek's scale were no different at the baseline between both groups (p = 0.764). The severity of the pressure sores was no different between both groups (p = 0.918). CONCLUSIONS: Our results show that the occurrence of pressure sores is not reduced but is delayed when patients are nursed on a Kliniplot pressure-decreasing mattress.

Extracranial meningioma and pregnancy: a rare diagnosis.

We report the first case of pregnancy-related primary cutaneous meningioma of the scalp in a 27-year-old female. Types, differential diagnosis, pregnancy-related growth and treatment of extracranial meningiomas are discussed.

[A case report of desmoid tumor of the finger]. / A propos d'un cas de fibromatose desmoïde digitale.

We report the case of a 20-year-old woman with a desmoid fibroma of the finger, which is an extremely rare location. Desmoid fibromas are benign but very infiltrative tumors, known for their frequent recurrences. Because of the many vascular and nervous structures concentrated in the finger, complete surgical excision is difficult.

One-stage elbow interposition arthroplasty with a fasciocutaneous distally planned lateral arm flap.

We report a case of severe posttraumatic ankylosis of the elbow with chronic osteomyelitis of the lateral condyle of the humerus. The triple problem of restoring elbow mobility, providing for coverage, and controlling infection was treated in a one-stage procedure. A distally planned fasciocutaneous lateral arm flap was used for elbow interposition arthroplasty. Clinical examination at 27 months showed restoration of a useful range of elbow motion and good pain relief.

The nerve supply of the trapeziometacarpal joint.

Ten forearm and hand specimens from fresh cadavers were dissected and examined under magnification for articular branches to the trapeziometacarpal joint arising from the thenar and palmar cutaneous branches of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm. In all but one specimen the thenar branch of the median nerve sent an articular branch to the trapeziometacarpal joint. Multiple branches from the palmar cutaneous branch of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm were also found. All these branches need to be divided during a "complete" denervation of the trapeziometacarpal joint.

Do multiple consecutive head and neck reconstructions improve the patients functional outcome?

BACKGROUND: The purpose of this study was to determined the functional outcome of surgically treated head and neck cancer patients who required more than "standard" microsurgical reconstruction. METHODS: Data concerning all patients with head and neck cancers, who underwent free-tissue transfers in our institution between January 1, 1994 and August 31, 1999 were reviewed. The cases of tumor recurrences and those with micro-surgical complications were excluded. Among 68 primary microsurgical reconstructions, we identified five cases where limitations in speech and/or swallowing required additional flap procedures. An objective assessment of speech and swallowing could be performed in four patients. RESULTS: In these five patients up to three consecutive additional procedured including three free-tissue transfers in one case, had to be performed mainly because of secondary contraction of the surrounding irradiated tissue. A total of 13 pedicled and free flaps were transferred to the head and neck. Three patients underwent two consecutive free tissue transfers. The additional reconstructions were requested to improved tongue mobility in three patients and to enlarge the upper digestive tract in two patients. The mean follow-up was 23 months (range : 9-53 months). Functional evaluation was rated average in three patients and poor in one patient. One patient died before functional evaluation could be performed because of disease. The four patients judged the final cosmetic result as satisfactory. CONCLUSION: We report five cases of head and neck microsurgical reconstructions where additional flap procedures were requested because of inadequately restored speech or nutrition capabilities. We show that, maybe because of extensive fibrosis, only limited improvement in the functional outcome can be expected despite the use of even sophisticated microsurgical reconstructions. This paper supports the idea that every effort should be put in the initial reconstruction, as further procedures are of poor functional prognosis.

[Thenar branch of the median nerve and innervation of the trapeziometacarpal joint]. / Rameau thénarien du nerf médian et innervation trapézométacarpienne.

INTRODUCTION: Denervation has been proposed successfully for chronic wrist pain. This procedure is not commonly performed for degenerative osteoarthritis of the trapeziometacarpal joint. According to the classic anatomical descriptions of the wrist innervation, it seems that the thenar branch of the median nerve (TBMN) is the only nerve of the wrist for which no articular branches are clearly defined. The aim of this study is to complete the few anatomical descriptions of the trapeziometacarpal joint innervation with microdissections of the TBMN. MATERIALS AND METHODS: Ten wrist and hand specimens from fresh cadavers were dissected by the same operator under magnification (3.5-12x). The TBMN was identified at its origin from the median nerve and followed in the thenar muscles. All the divisions of the TBMN were identified and followed to their terminal branches. RESULTS: The TBMN divided in at least two main branches, one each to the opponens and to the abductor pollicis brevis. In all but one specimen, the branch to the opponens pollicis muscle passed over or into its medial aspect to spread on the palmar side of the trapezium. Each dissected articular branches were histologically confirmed. DISCUSSION: Our results show a clear participation of the TBMN in the innervation of the trapeziometacarpal joint. The lack of knowledge of this anatomical feature may explain the inconstant results obtained with selective denervation of the trapeziometacarpal joint.

The contribution of image cytometry to the characterization of clinical subgroups of lipomas.

The aim of the present study was to investigate whether biological features determined through image cytometry are able to characterize clinical subpopulations of lipomas. Forty lipomas excised from 36 patients were studied. On the one hand, the tumors were clinically characterized by means of patient-related and pre- and post-operative features. On the other, the tumors were analyzed by means of the computer-assisted microscopy analysis of Feulgen-stained nuclei. This analysis generated 3 groups of biological quantitative variables describing morphonuclear aspects (i.e. the chromatin pattern of the cell nuclei), the nuclear DNA content (DNA ploidy level), and architectural features (such as the cell density and the topographical cell nuclei organization). Possible relations between the clinical and the biological features of the lipomas were investigated by means of univariate and multivariate statistical analyses. The results show the existence of such relations, in particular between the morphonuclear and architectural features of lipomas, on the one hand, and their consistency, volume and weight, on the other. Furthermore, multivariate analysis made it possible to distinguish two subpopulations of lipomas exhibiting different biological characteristics in terms of morphonuclear patterns.

One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap.

In this paper, the treatment of a complicated Achilles tendon defect with a composite lateral arm flap with distal design of the skin paddle has been presented. The extended portion of the flap was sufficient to restore adequate contour to the posterior aspect of the ankle, and reinervation showed good protective sensation at 1 year. In terms of resurfacing, the use of the reinervated lateral arm flap with a distal design of the skin paddle seems advantageous. The weakening of the reconstructed Achilles tendon, although without clinical incidence and impairment of elbow extensors at this stage, may indicate that a better substitute than the triceps tendon has to be found. Nevertheless, we would best reconstruct such an Achilles tendon defect by the same technique because of the well vascularized autologous tissue it provides, limiting the risk of infection.

Contribution of quantitative lectin histochemistry to characterizing well-differentiated, dedifferentiated and poorly differentiated liposarcomas.

OBJECTIVE: To find new diagnostic markers in the group of lipomatous tumors. STUDY DESIGN: The histochemical lectin staining pattern was characterized in a series of 45 lipomatous lesions, including 10 typical lipomas, 6 atypical lipomas, 8 well-differentiated, 6 myxoid, 5 dedifferentiated and 10 pleomorphic liposarcomas. Three lectins were used-peanut (Arachis hypogaea) agglutinin, which binds to terminal Gal(beta 1,3)GalNAc residues; wheat germ (Triticum vulgare) agglutinin (s-WGA, the succinylated form of WGA), which binds to ((1-4)-D-GlcNAc)n and Neu5NAc residues; and jack bean (Concanavalia ensiformis) agglutinin which binds to alpha-D-Man and alpha-D-Glc residues. Histochemical staining was quantitatively measured by means of a cell image processor. RESULTS: In the case of certain carbohydrate residues, typical lipomas closely resemble atypical lipomas, which in turn closely resemble well-differentiated liposarcomas; typical lipomas differ significantly from well-differentiated liposarcomas. This indicates that atypical lipomas, or at least some of them, could represent a biologic link between typical lipomas and well-differentiated liposarcomas. While well-differentiated and pleomorphic liposarcomas differed significantly from each other, the poorly differentiated component of dedifferentiated liposarcomas included histochemical lectin properties, which were common to both well-differentiated and pleomorphic liposarcomas. CONCLUSION: Some atypical lipomas exhibit glycohistochemical characteristics that are common to those of well-differentiated liposarcoma. The poorly differentiated component of dedifferentiated liposarcomas remains more differentiated in terms of glycohistochemical markers than do poorly differentiated pleomorphic liposarcomas.

Characterization of the nuclear deoxyribonucleic acid content and nuclear morphometry in 71 primary cutaneous melanomas.

BACKGROUND: While the determination of nuclear deoxyribonucleic acid (DNA) content (DNA ploidy level) and nuclear morphometry characterization has proved to be of prognostic value in melanocytic lesions, there are several ways of performing these determinations. OBJECTIVE: To identify which of 9 DNA ploidy- and 2 nuclear morphometry-related variables are of prognostic and/or diagnostic value in 71 primary melanomas. METHODS: Histological typing, Breslow depth determination, the evaluation of Clark's level of invasion and the 11 quantitative variables (calculated in Feulgen-stained nuclei using computer-assisted microscope analysis) determined for each melanoma were submitted to discriminant analysis. RESULTS: The discriminant analysis of image cytometric variables enabled specific cell subpopulations to be identified in histological and the Breslow-related groups, but not in the Clark-related ones. CONCLUSION: The characterization of melanoma heterogeneity by means of the identification of specific DNA ploidy level-related cell subpopulations in specific Breslow-related groups enables the problem of intra- and interobserver variability in Breslow depth determination to be reduced and therefore can help dermatologists in their daily routine.

Quantitative measurements of desmin and vimentin immunostains and cell density in leiomyomas and leiomyosarcomas.

The distinction between benign and malignant smooth muscle tumours relying on histological features such as the mitotic index and pleomorphism remains a generally acknowledged difficulty in modern pathology. A cell image processor was therefore used to quantitatively assess the desmin and vimentin immunostain in 39 smooth muscle tumours which included 26 benign (leiomyomas) and 13 malignant (leiomyosarcomas) cases. The 13 leiomyosarcomas were primary (non-recurrent and non-metastatic). Ploidy level and cell density were also assessed on each of these 39 tumours by means of the computer-assisted microscopic analysis of 5-microns thick Feulgen-stained histological sections. The results show that while neither the ploidy level determination nor the quantitative assessment of the vimentin immunostain made it possible to distinguish between leiomyomas and leiomyosarcomas, cell density determination and the quantitative assessment of the desmin immunostain enabled such a distinction to be made. Indeed, the leiomyomas exhibited a much higher level of desmin positivity than the leiomyosarcomas, as did diploid tumours as compared to the aneuploid (benign or malignant) ones. Furthermore, the leiomyoma group exhibited a significantly lower mean cell density value than the leiomyosarcoma group. The present study further confirms the lack of relationship between ploidy level and cytological malignancy in smooth muscle tumours.

The contribution of image cytometry and artificial intelligence-related methods of numerical data analysis for adipose tumor histopathologic classification.

Thirty-five lipomatous tumors were quantitatively described using 47 variables generated by means of computer-assisted microscope analysis. Of these 47 quantitative variables, 27 were computed on Feulgen-stained specimens (25 on cytologic and 2 on histologic samples) and, of the remaining 20, 8 related to vimentin and S-100 protein immunostaining patterns and the other 12 to the glycohistochemical staining patterns of peanut agglutinin, succinylated wheat germ agglutinin, and concavalin A agglutinin. The 35 lipomatous tumors included 6 atypical lipomas and 8 well differentiated, 5 dedifferentiated, 6 myxoid, and 10 pleomorphic liposarcomas. The actual diagnostic value contributed by each of the 47 variables with respect to the 5 lipomatous tumor groups was determined by means of the decision tree technique, an artificial intelligence-related algorithm that forms part of the supervised learning algorithms. Of the 47 quantitative variables, the decision tree technique retained 8: i.e., 2 tissue architecture-, 2 DNA ploidy level-, 2 morphonuclear-, 1 lectin histochemical-, and 1 vimentin immunostain-related variables. The decision tree technique made use of these 8 variables to set up logical rules that make it possible to identify atypical lipomas from well differentiated liposarcomas, on the one hand, and dedifferentiated liposarcomas from those that are well differentiated and pleomorphic, on the other. Thus, the combination of an artificial intelligence algorithm analyzing quantitative variables generated by means of the computer-assisted microscope analysis of cytologic and histologic samples from lipomatous tumors can be considered an expert system contributing significant diagnostic information to conventional diagnosis.

Image cytometry analysis of Feulgen-stained nuclei in 72 lipomatous lesions including atypical lipomas and well-differentiated liposarcomas.

Well-differentiated lipomatous tumors constitute a histopathologic category whose nomenclature has been controversial, particularly with respect to the distinction between atypical lipomas of the extremities and well-differentiated liposarcomas of the retroperitoneum. To determine whether there were differences in image analytic parameters between these neoplasms, 72 lesions including 21 typical lipomas, 7 atypical lipomas, 16 retroperitoneal and 5 nonretroperitoneal well-differentiated, 9 dedifferentiated, and 14 pleomorphic liposarcomas were submitted to the computer-assisted microscopic analysis of Feulgen-stained nuclei. This methodology enabled four groups of variables to be calculated. These included: (1) quantitative chromatin pattern description (14 variables); (2) the measurement of proliferative activity (1 variable); (3) nuclear DNA content (DNA ploidy level, 5 variables); and (4) the measurement of cell density and topographical cell nuclei organization (2 variables). The results strongly suggest that atypical lipomas, whether superficial or deep, and well-differentiated liposarcomas, whether retroperitoneal or not, belong to the same category in terms of the variables analyzed.

The characterization of biological features in dedifferentiated liposarcomas by means of principal components and discriminant analyses of 25 computer-generated variables from Feulgen-stained nuclei and histological slides.

Several groups of lipomatous tumors are not yet clearly characterized on the biological level. In order to attempt to classify the dedifferentiated liposarcomas with respect to other types of malignant liposarcomas, 80 adipose tumors were submitted to the combination of two computer-assisted methodologies. These two methodologies consisted of i) the determination of 25 variables, and ii) the analysis of the diagnostic information contributed by these 25 variables by means of two complementary techniques, i.e. principal components and discriminant analyses. The 25 variables were computed by means of image cytometry on Feulgen-stained nuclei and histological slides, quantitatively describing distinct biological characteristics relating to morphonuclear (chromatin pattern) features (14 variables), nuclear DNA content distribution (9 variables), and tissue architecture pattern (2 variables). The 80 adipose tumors included 21 typical lipomas, 7 atypical lipomas (defined as extremity adipose tumors with a histopathological pattern of well-differentiated liposarcomas), 16 retroperitoneal and 5 non-retroperitoneal abdominal well-differentiated liposarcomas, 9 dedifferentiated liposarcomas, 8 myxoid (intermediate-grade tumor) and 14 pleomorphic (high-grade tumor) liposarcomas. The data strongly suggest that the dedifferentiated liposarcomas exhibit biological characteristics which are distinct from those of low- and high-grade liposarcomas, but similar to those of intermediate ones. The results also show that typical and atypical lipomas are two distinct biological entities. In contrast, the atypical lipomas and the well-differentiated retroperitoneal and non-retroperitoneal liposarcomas exhibited a high number of similar biological characteristics. Computer-assisted methods contribute valuable information to characterize lipomatous tumor biology.