Biomedical subjects
Publications and source records attributed to V Mitz.
Endoscopy during rhinoplasty is an advance that permits the surgeon to obtain better results in cartilage and bony resections. It should decrease the number of secondary nasal revisions for small cartilaginous or bony irregularities. From May 1993, 30 patients have undergone primary and secondary rhinoplasties with complementary resections in all cases obtained with endoscopic control after the normal rhinoplastic procedure was completed.
Total scalp avulsion is an uncommon and dramatic accident. Replantation is the only way for acceptable aesthetic final results. However, partial loss of tissue can result, and secondary procedures can be required. A total avulsion of a scalp involving the upper part of the right ear and both eyebrows was replanted after a long delay in our department. As a result, loss of a third of the hair-bearing area occurred. Secondary expansion of the replanted scalp achieved complete reconstruction.
In 18 cases the authors used a free tissue transfer during the first 24 hours of the treatment of a complex trauma of the upper limb involving osteoarticular and neurovascular loss combined with loss of skin cover. The various flaps include: lateral arm flap (8 cases), latissimus dorsi flap (4 cases), toe to hand transfer (4 cases), radial forearm flap (2 cases). The series includes 2 failures salvaged without further sequelae by means of a groin flap. With regard to complex one-stage reconstructions, particularly those requiring replacement of bone, the outcome is improved if the selected method permits early mobilisation and complete cover. Free transfers are to be compared with loco-regional flaps which are more reliable but suffer limitations such as a small cutaneous element and, frequently, involvement of the pedicle in the mechanism of the trauma. For the severe cases in this series, only free tissue transfers provided the adequate, immediate cover required to save the traumatised limb.
Large open elbow fractures with extensive soft-tissue loss must be treated as an emergency. Vessels and nerves are often alvulsed. One stage reconstruction is very challenging. Ischemia of the distal part of the upper extremity is limited by a synthetic arterial shunt (SAS). After debridement, the authors install the SAS, then the complex procedure can begin. The authors purpose a new four-stage classification and prognostic factors. Debridement concerns crushed, devitalised soft and osteo-articular tissues. If it appears possible to salvage the hand and forearm with necessity of complex reconstructions (vessels, nerves, osteosynthesis, soft tissues) SAS is used. SAS was used 3 times on the group of large avulsions with ischemia (5 cases); it was quickly installed between the humeral and a distal artery and allowed section of the best distal artery for revascularisation. Seven external fixation devices allowed intra operative and post operative management of the wound. The coverage of these large, complex wounds was performed by the latissimus dorsi transposition flap (2 muscular and 5 musculo-cutaneous flaps). It should be considered the flap of choice. Local flaps, which include local skin transposition, muscle transposition or vascular axis, would be contra indicated in a wide zone of injury (the base of these local flaps are damaged by high energy trauma) or when distal ischemia is present because of arterial axis sacrifice. The dorsal decubitus position, the specific dissection of neurovascular pedicle proximally as far as the axillary artery, the muscular and cutaneous design can be used to cover anterior, posterior, internal and external parts of the elbow. Restoration of elbow function uses an innervated latissimus dorsi muscle (3 cases). If only coverage is wanted, this flap has significant advantages over local flaps and free transfer procedures when the recipient vessels are within the area of injury. Between the donor site and the recipient site, the muscular part of the latissimus dorsi flap is placed in an arm counterincision. It ensures closure of the elbow joint. Early progressive range of movement exercises can be performed.
Total scalp avulsion is an uncommon accident. Three recent cases illustrate our surgical procedure. Small and central hair-bearing avulsed scalps can be treated by secondary scalp expansion (1 case). Large hair-bearing scalp (> 400 cm2) or including aesthetic relief should be treated by microsurgical reimplantation. Venous grafts allow vascular anastomoses beyond the intimal trauma area. Secondary expansion of reimplanted tissue (2 cases) eliminates scalp defects after initial necrosis. Thus, in the cases of total scalp avulsion even with high risk of failure (long time elapsed since injury, significant crush, part being in bad condition, two levels avulsion...), reimplantation has to be performed according to localization and size of avulsion. A secondary procedure with using expansion of the remaining replanted scalp is possible.
During the last three years, eleven lateral upper arm flaps were used in the reconstruction of skin defects of the upper limb. These flaps were applied: 7 times on the hand; 2 times on the fore-arm; 2 times on the elbow. Ten flaps had a free transfer, one was vascularised by the distal pedicle. In 4 cases we used an emergency free transfer in the treatment of a traumatic defect. In the other cases the flaps were used in the treatment of post-traumatic sequelae such as contracture and/or osteitis. The series contains 10 fascio-cutaneous flaps and 1 osteo-cutaneous flap. We had one failure with an emergency free flap, salvaged without further sequelae by means of a groin flap. The proximity of the donor site in an upper limb reconstruction makes the lateral upper arm flap a good alternative when a pedicle locoregional flap cannot be used due to a lesion of its pedicle in the mechanism of the trauma.
Since 1989, we have operated 38 patients with breast ptosis with or without hypertrophy according to a technique which leaves a periareolar scar. The principles of this technique are: periareolar skin resection, dissection between the skin and gland over the entire surface of the gland, mastopexy, insertion of an absorbable mesh onto the anterior surface of the gland which constitutes an internal support, closure by the isolated periareolar scar. In our hands, this technique cannot be used to treat all forms of breast ptosis, but gives excellent results in certain selected indications such as tuberous breasts, breast asymmetry with one normal breast, ptosis and moderate hypertrophy. The reliability of the technique despite extensive dissection is remarkable and the stability with a follow-up of 3 years is good when the indication has been correctly defined. In comparison with other periareolar techniques, our approach has the advantage of not leaving any nonabsorbable elements in the wound, the only guarantee of reliability of clinical and radiological surveillance of the breast.
The authors report the use of a new polyurethane dressing, studied in 20 patients undergoing breast surgery. Based on objective criteria, this study analyses the contribution of this dressing in the postoperative course.
18 patients suffering from PIP stiffness in extension were treated by dorsal teno-arthrolysis. PIP joint stiffness was due to 3 cases of fracture of P1, 2 cases of fracture of P2, 2 cases of extensor tendons, 8 fractures of P1 associated with section of the extensor tendon, 2 cases of PIP closed trauma (1 sprain, 1 dislocation), and 2 crush injuries of the extensor tendon at the PIP joint. The surgical technique combined a dorsal sinuous approach, tenolysis of the extensor tendon on the dorsum of first phalanx dorsal capsulotomy, and more rarely (3 cases), section of collateral ligaments. The mean pre-operative active flexion was 44 degrees and the mean post operative active flexion was 78 degrees, which represents a gain of 34 degrees of active movement. Thanks to a classification which incorporates the range of active flexion in PIP joint, and the lock of active extension we rated 3 results as excellent, 4 as good, 8 as useful and 4 as insufficient. We therefore improved the range of movement in 15 out of 19 cases, which seams very encouraging.
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After studying a series of thumbs reconstructed by 2nd toe transfer, we devised a new dexterity test: the "five matches test" or "Take Five Test" (R.S.). This test consists of the standardised timed and comparative pick-up of 5 identical fine objects (matches), permitting a simple and quick evaluation which objectively quantifies dexterity in fine pinches. The specificity of our test is that it is bilateral and comparative providing a narrow range of normality. In fact, a marked variability of time-scores is found between different individuals of a normal population, making it difficult to determine a "normal dexterity" criterion. But in the same person, there is little variability between two successive experiments or between the dominant and non-dominant hands. Examining a reconstructed hand, we have chosen as the "normal dexterity" criterion the time-score of the contralateral spared hand, timed first. The final score (from 0 to 4 points) is based on the difference between time-scores of the 2 hands (delay tested hand/spared hand). The "Take Five Test" (five matches pick-up test) has largely proven its efficiency in studying a series of thumbs reconstructed by 2nd toe transfer (operated on by V.M.). Fine pinch dexterity is satisfactory in 45% of cases (65% when long digits are spared), scoring at least 2 points (delay less than 4 seconds). The average score is 1.6 pts (range: from 0 to 4). This test could prove the functional value of parameters such as phalangeal mobility and a short delay between injury and reconstruction.
Pulp reconstructions use numerous techniques ranging from simple debridement to local and microsurgical flaps. The authors analyse the various treatments, in which directed healing still retains numerous indications. Local flaps have a definite place, but they are not devoid of risks (iatrogenic stiffness). The indications are presented schematically in table form together with several examples. A wide range of techniques is necessary in order to treat the various lesions appropriately. Large defects are best treated by microsurgical transfer of great toe pulp with satisfactory results, which justifies their management in specialised centers.
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The authors present a foot replantation case at the ankle level followed six months later by a tibial lengthening using the Ilizarov procedure. Performing the aforementioned lengthening following a replantation enables good nervous and vascular sutures, tension-free and ensures a satisfactory result.
The evaluation of 58 breast reconstructions operated in Boucicaut Hospital demonstrated positive result. The authors review the techniques used for contralateral breast symmetrization. The policy generally adapted has been to perform two sequential operations: 1st step: implantation of a prefilled prosthesis and contralateral breast symmetrization; 2d step: reconstruction of areolo-nipple complex and refinement of contralateral breast. Radiotherapy seems to be a problem in reconstruction. A 12% recurrence rate has been quoted in this group. Tram flap has been exceptionaly used by our team, as we tend to prefer the latissimus dorsi myocutaneous flap. Very few expanders have been implanted.
The aim of this operation is to preserve the sensitivity whenever when a finger has to be amputated. We have reviewed 9 patients operated according to this technique, out of 14 patients for whom an amputation or a shortening arthrodesis was discussed. The results of pulp recession were most encouraging. The incision were located on both sides of the finger and distant from the ungueal matrix. The dorsal skin was elevated in the sub-periosteal plane. Resection of the necessary amount of 2nd phalanx to obtain an extended finger was performed. An osteosynthesis with pins is preferred for a duration of 6 weeks. This operation can be performed for very stiff finger, hooked fingers or dystrophic fingers with a good pulp. In extreme cases of shortening, the nail with its bed ar sacrificed, and the entire pulp is used to cover the distal stump. This principal of pulp recession has been used in two other cases in emergency surgery. The postoperative was marked by finger swelling and some pain of the distal sutured skin. Overall the results were satisfactory and patients were very satisfied to keep their finger, which would otherwise have been doomed.
Since 1976, anatomical studies intensively performed in France have demonstrated the surgical interest in using the superficial musculo-aponevrotic system in the face, and also a subperiosteal malar approach. The SMAS is mostly a surgical structure. It could be considered as a remnant of a primitive subcutaneous muscle which would have been located in the superficialis fascia; its stays outward the parotid gland. Muscular fibers have been found inside, uniting from-down the patysma muscle toward the periphery of the frontalis muscle at the top. Risorius muscle is included in this structure. Its surgical interest is that it allows to relieve skin tension during a face lift by a fibromuscular associated stretch. The modern way in face lifting should prevent the fixed appearance of a too tight skin-pull, when skin is redraped alone. Risks of facial nerve injury are minimal when the proper technique is used. It is possible, in the same way, during a blepharoplasty to stretch the orbicularis oculi muscle, like the muscular resuturing of an inguinal hernia repair. Each of this technique has its own different indications now well defined. The authors shows this experience after 150 cases of face lift operations and makes an analysis of the advantages and draw backs of using the SMAS in cases of rejuvenating face operations.
Cold sensitivity often occurs after upper limb nerve injuries. 82 patients were reviewed retrospectively with an average follow-up of 42 months. Cold sensitivity occurred after 50% of median nerve injuries and after 75% of ulnar nerve injuries. Symptoms are localized to the damaged sensory nerve territory, and are related to the level of the lesion after median nerve injury. They are increased by associated arterial damage even when it is repaired. The less attened is the two-point discrimination lest, the less severe are the disorders. The origin is not really known, but we think that cold sensitivity is related to a disturbance of sympathetic and sensory fibers.