Biomedical subjects
Publications and source records attributed to G Magalon.
The history of skin gaining techniques, concerns suture, skin extension and skin expansion. Although, for a very long time, suture and skin extension were intimately related and constitute the basis for current techniques, it was only from the second part of the 20th century that skin expansion was developed and that skin extension was submitted to specific studies.
Skin expansion material has progressed and now covers all needs in plastic and reconstructive surgery. Breast reconstruction occupies a special place among expansion techniques and requires specific material. The skin expansion technique was approved by French Social Security in 1995 and is now covered in both the public and private sectors. The skin expansion protocol is rigorous with no room for improvisation. It is only in this way that the quality of the result justifies the use of this technique.
Skin expansion in breast reconstruction presents several specificities related to mastectomy, retromuscular dissection, and the oncological context. In delayed reconstruction (DR), the local clinical examination is essential to select indications and to eliminate high-risk cases (sequelae of radiotherapy, Halsted, etc.). Immediate reconstruction (IR) must be reserved for motivated patients in whom mastectomy represents the last stage of treatment. The patient must be well informed before the operation. The choice of expander depends on the width of the breast to be reconstructed. Precise drawings are made in the standing position. In the case of DR, the prosthesis is inserted retropectorally superiorly and subcutaneously inferiorly. In IR, a complete retromuscular compartment must be created. Inflation begins after healing at a weekly rhythm until the desired volume has been exceeded. Inflation is performed more slowly in the case of previous irradiation. The second stage is performed three months after the end of inflation. After removal of the expander, the periprosthetic capsule of the compartment can be modified when necessary. The choice of the final prosthesis, preferably with an anatomical shape, is critical in order to obtain the correct volume. When necessary, the inframammary sulcus can be reinforced by internal or external procedures. Other reconstructive procedures (symmetrization, areolar reconstruction) can be associated. The most serious complications are infection and exposure. Serous effusion, thoracic deformity, malposition and capsular retractions can affect the result. Apart from breast reconstruction, expansion of the mammary region is useful in congenital malformations (glandular aplasia, Poland syndrome, severe asymmetry) and in acquired developmental abnormalities. Expansion has several indications in cosmetic surgery for certain cases of augmentation mammoplasty, correction of tuberous breasts and revision of certain mammoplasties.
The indications for skin expansion in the limbs are now well defined. This technique is particularly irreplaceable below the knee, and allows the resection of very large lesions despite a minimal skin capital. More than in other sites, it is a difficult technique which requires rigour and a sound basis in reconstructive surgery. The operative plan must include precise assessment of the tissue gain with selection of prostheses adapted to local conditions. The techniques of insertion, filling and resection must be irreproachable. The functional and aesthetic indications are numerous and the technique often provides a minimal residual scar.
Although the complication rate during skin expansion has decreased, they can still occur. The authors describe the various possible complications. Complications during insertion of the expander include skin effraction, infection, pain and filling difficulties. During the filling phase, they consist of infection, leaks, cutaneous ischaemia, ulcerations underneath folds of the prosthesis, valves or tubing. Insufficient filling and impairment of the arterial or venous blood supply of the flap can occur during the final operation. Long-term complications essentially consist of persistent oedema, filling of the reconstructed contours, widening of scars, loss of sensitivity and occasionally bone deformities induced by compression. The prevention of these complications is based on an irreproachable technique and regular follow-up.
The repair of defects by skin extension involves various procedures which are thoroughly described by the author. Skin extension is an original concept reflecting the viscoelastic properties of the skin and histological changes. It is based on 3 phenomena: "mechanical creep", "stress relaxation" and mobility of the skin. Although the various skin extension procedures present many advantages concerning the application and removal of the device, the conduct and monitoring of treatment as well as closure of the defect, its disadvantages must not be ignored. They are related to the material and to local conditions. The indications for skin extension are fairly wide. However, its ideal indication consists of closure of skin defects with loss of skin capital.
"Vacuum Assisted Closure" (VAC) is a noninvasive negative pressure healing process indicated in the treatment of chronic wounds associated with unfavourable local or systemic factors. It is indicated for the treatment of traumatic and/or surgical skin defects in order to accelerate the healing process. VAC is based on a simple technology of controlled depression of the lesion which healing process. It exerts a mechanical force on the tissues and attracts the wound edges centripetally. It induces an increased peripheral blood flow, improved local oxygenation and promotes angiogenesis and proliferation of good quality granulation tissue. Wound healing in a humid medium is complete or may require secondary surgical management (skin graft, flaps). The preferential indications for Vacuum Assisted Closure include pressure sores, leg ulcer, wounds with skin defects, burns, complications of surgical wounds and delayed healing.
Excision and grafting in deep partial and full skin thickness burns of the anterior cervical region in a series of 40 patients treated between 1982 and 1992 is reported. The advantages of surgical management of deep burns in this region in a single staged operation have proved its efficacy compared to the severe sequelae which appear when the standard conservation treatment is used. A comparative study of two groups of patients treated either by early excision and grafting (n = 19/40), or by delayed excision and grafting (n = 21/40) demonstrated the advantages of elective early excision and grafting with respect to: length of hospital care, complications and their severity, and surgical repair.
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 trimethoprim-sulfamethoxazole for 3 weeks. There was no recurrence of infection 3 months after surgery, and flexion and extension were complete at that time.
A series of thirty patients who underwent skin expansion have been followed up for at least three years. The residual scars were analysed with respect to site and disturbed sensitivity in expanded skin. In the head and neck region, the mean width of definitive scars was 3.5 mm for lesions that had originally measured a mean of 40 mm. On the trunk the postoperative width was 14 mm for lesions that had originally measured a mean of 82 mm. In the limbs, the corresponding lesions were 11 mm and 80 mm. The best cosmetic results were obtained on the forehead and limbs, taking into account the original lesions. There was objective disturbance on sensitivity (hypoaesthesiae) whatever the site of the lesion.
Thorek's technique for reduction mammaplasty with free nipple graft, described in 1922, has progressively been superseded by procedures using a dermo-glandular pedicle. Following a description of the surgical procedure used, we present a series of 50 patients operated with an average follow-up of 14.6 months; the outcome of the nipple graft was particularly studied. It appeared that the faults which are usually seen with this technique (loss of pigmentation, loss of sensitivity and contractility of the nipple and areola) were only observed in a minority of cases and were never considered to be unsatisfactory for the patients. Thorek's technique also presents advantages: short surgical procedure, simplicity of the glandular resection, minimising the risk of cytosteatonecrosis. This seems to us to be a preferential procedure for the treatment of major hypertrophy in patients presenting vascular risk factors of with a history of tumour.
Subcutaneous extravation of antimitotic agents in the upper limb is a rare complication of chemotherapy. The functional integrity of the limb can be compromised due to severe skin damage. Extensive soft tissue necrosis is difficult to manage and cannot always be repaired without sequellae. Based on an analysis of a series of patients and a review of the literature, we report the main pathophysiological features and clinical signs of such accidents as well as the still debated therapeutic management. Two points are essential: the emergency situation created by these accidents requiring adequate and rapid treatment despite the apparently benign appearance of the extravation and imperative prevention which is the main therapeutic tool.
Skin grafting is one of the most widely used techniques for healing wounds with soft tissue damage. Autologous grafts of various thicknesses are usually used and the properties of the graft depend on its thickness. These include thin, split-thickness and full-thickness skin grafts. Two complementary technical innovations have optimized the use of harvesting sites: mesh expanded autografts for thin and split-thickness grafts and skin expander implants for full-thickness skin grafts. Thorough knowledge of the different types of graft will permit fast, good quality healing if the receiving beds are well vascularized.
Thirty cases of mandibular defects were reconstructed with a free iliac flap vascularised by the deep circumflex iliac vessels. Twenty five of these cases involved soft tissue damage with a defect of the mandible. The surgical procedure described by I. Taylor was used. Three anatomical variations of the pedicle were found. The features of the iliac bone are particularly suitable for mandibular reconstruction. The natural shape of the iliac bone does not require complex osteotomies and its healing capacity allows simple osteosynthesis. The thickness of the muscular pedicle, and thus the flap, is determined by the position of the lower edge of the skin components with respect to the iliac crest. This type of flap currently remains very useful in reconstruction of major mandibular and adjacent soft tissue destruction because of the very low incidence of failure (2 cases) and complications.
We report our experience with 23 patients with rheumatoid arthritis who presented 48 tendon lesions involving 32 extensor tendons and 16 flexion tendons. Translocations of healthy tendons, overlapping with adjacent healthy tendons and tendon grafts were performed. Results for extensor tendons, expressed as defect in residual extension were excellent in 8 patients, good in 5 and mediocre in 4. For flexor tendons, there were 2 excellent results and 5 mediocre results in terms of thumb-palm contact. Prevention by early synovectomy is particularly important.
From 1987 to 1993, surgery combining two techniques was performed for 12 patients with uncomplicated abdominal wall eventration and excess subcutaneous adipose tissue. In order to meet both the functional and aesthetic needs of these patients, the operations required the co-operation between the plastic surgery and the abdominal surgery teams. Abdominal plasty was required to repair muscle and aponeurosis damage and remove abdominal dermolipodystropy with minimal, good quality scars. The early and late results were evaluated on the basis of several parameters including: global abdominal morphology, parietal containment, scar formation, complications, and the effect of treatment. Optimal results require a pluri-disciplinary approach.
We report our experience of tissue expansion for removal of skin tumors in 62 patients treated between 1985 and 1991. Thirty-nine complete and 23 partial excisions were performed. Major complications with complete failure occurred in 3 percent of the cases, and minor complications in 10 percent. Skin expansion constitutes a considerable advance in the treatment of benign skin tumors as it reduces the risk of permanent scars and provides a skin that is normal in both quality and colour. In cases where the tumor cannot be entirely removed in one step (e.g. giant hairy naevus, haemolymphangioma) expansion brings quality skin within the most visible areas, enabling complete excisions by re-expansion or skin graft to be contemplated.
The authors report a case of Hailey-Hailey disease or familial benign chronic pemphigus and review the literature concerning the surgical treatments used for this disabling disease. The majority of authors recommend excision followed by split skin graft, while others prefer excision followed by directed healing or simple excision-suture. The case reported here is the first reported case of cure of Hailey-Hailey disease combined with mammaplasty in a single stage.