Alain M. Danino

Flexibility of Thiel’s embalmed cadavers: the explanation is probably in the muscles

IntroductionThe flexibility of cadavers conserved using Thiel’s embalming method remains unexplained. We aimed to perform microscopic comparison of muscle and tendon fibres from fresh cadavers (FC), formaldehyde-preserved cadavers (FPC) and cadavers conserved by Thiel’s method (TC).MethodsMuscle and tendon biopsies performed on FC, FPC and TC were conditioned and stained by Masson’s trichrome, Sirius red and Ramon y Cajal, then studied under optical microscope. Alignment and integrity of the muscle and tendon fibres were studied.ResultsWe observed a modification of the muscle fibres in all specimens from TC, regardless of the type of staining used. The muscle fibres taken from FC and FPC were relatively well conserved, both in terms of alignment and integrity. We did not observe any modification of collagen in either muscle or tendon fibres.ConclusionsThe considerable fragmentation of the muscle proteins, probably caused by certain corrosive chemicals, (e.g. boric acid) present in Thiel’s embalming solution, could explain the suppleness of the TC. However, we cannot exclude the possibility of alterations in tendon or muscle collagen, since the experimental methods we used, did not allow for the study of collagen ultrastructure.

Étude au microscope électronique à balayage des surfaces des implants mammaires à texturation poreuse et de leurs capsules. Description de l'effet « velcro å des prothèses à texturation poreuse

Resume Lutilite de la texturation des protheses mammaires dans la prevention des coques est etablie depuis une vingtaine dannees. Cette constatation a amene les fabricants dimplants mammaires a mettre sur le marche de multiples modeles aux texturations de formes variees. Quatre protheses mammaires texturees ont ete etudiees : Arion® monobloc, CUI (McGahn®), Biocell (McGahn®), Sebbin® LS21. Une observation au microscope electronique a balayage de la surface texturee des differentes protheses a ete realisee a partir des echantillons neufs recus des fabricants. Lors dune etude prospective sur huit patientes, des fragments de capsules correspondant a ces quatre protheses ont ete preleves a la faveur dinterventions secondaires pour asymetrie ou malposition. Ils ont ete analyses au microscope electronique a balayage pour savoir sil existe une relation entre la texturation des protheses et laspect de la capsule. Nous rapportons des differences ultrastructurales significatives entre les differentes protheses etudiees. Seules les capsules des protheses CUI et Biocell® presentent une texturation en negatif avec correspondance des depressions sur la prothese et des plots sur la capsule. Cela semble lie a lexistence dune taille critique des pores constituant la texturation. Cette constatation nous conduit a emettre lhypothese dun effet « velcro a entre la prothese et sa capsule. Si ce dernier nest pas directement correle a la prevention des coques, il peut en revanche avoir un role stabilisant important dans les reconstructions mammaires primaires et dans les corrections secondaires dasymetrie ou de malposition.

Monitoring buried jejunum free flaps with a sentinel: a retrospective study of 20 cases.

The free jejunum transfer has become a widely used reconstruction option after total laryngopharyngectomy. The aim of this study was to evaluate the effectiveness of using an exteriorized jejunal segment for flap monitoring.

Chimaeric subscapular system free flap for complex oro-facial defects.

BACKGROUNDnAblation of locally advanced head and neck cancers generally results in large composite oro-facial defects. Due to the often-large segment of mandible missing, as well as the need to provide skin coverage and oral lining, reconstructive options are limited. We present our experience in oncologic head and neck reconstruction using chimaeric subscapular system free flaps.nnnMETHODSnWe performed a retrospective chart review of patients presenting important through-and-through oro-facial defects following ablation of T3, T4a or T4b tumours in two university centres between 2005 and 2011. All defects were reconstructed with a subscapular system free flap that was harvested in a dorsal decubitus position.nnnRESULTSnSixteen patients (15 M, 1 F; mean age=60 years) underwent mandibular reconstruction with latissimus dorsi flaps with one or two skin paddles and one bony component based on the angular branch of the thoracodorsal artery. Fifteen patients received adjuvant radiotherapy. We experienced no flap loss. Donor-site complications were minimal, albeit a limitation of shoulder range of motion was found in four patients. Eight patients presented postoperative complications requiring re-intervention. Fourteen patients were able to recommence oral nutrition and their diction returned to normal in all but one. The mean follow-up period was 25 months. Aesthetic results were satisfactory upon atrophy of the latissimus dorsi muscle.nnnCONCLUSIONSnIn cases of extensive oro-facial defects involving a large mandibular segment, reconstruction with subscapular system free-tissue transfer is a safe and reliable technique that offers satisfactory functional and aesthetic results.

[Is muscle the best coverage for leg Gustilo IIIb fractures? A retrospective comparative study].

UNLABELLEDnWell-vascularized muscle flaps have been the traditional gold standard for coverage of open fracture of the lower extremity. The last 15 years have brought the fasciocutaneous and perforator flaps and raised the issue of the type of coverage required for open fracture of the lower extremity. In recent years, in selected compromised patient, we have been using nonmuscular flaps for reconstruction. The goal of this study is to compare the results of fasciocutaneous reconstruction to those of classical muscular flaps.nnnPATIENTS AND METHODSnA comparative retrospective study, including all patients from 2002 to 2006 requiring a coverage of a Gustillo III b fracture of the lower extremity, is done. The type of flaps, the fracture localization, the infection rate, the time required for consolidation of the fracture and the complication rate are reviewed. An independent university laboratory verified the statistical analysis.nnnRESULTSnTwenty patients have experienced coverage by muscular flaps and 18 by fasciocutaneous flaps. We found a skin fistula and a chronic infection in the muscular-flap group, and two skin fistulae in the fasciocutaneous flaps group. The overall surgical results were comparable, except the bony union delay shorter in the fasciocutaneous flaps group.nnnCONCLUSIONnMuscle coverage is not mandatory to cover bone in the lower leg. The fasciocutaneous flaps can provide a good alternative for muscle-flap coverage. There is no significant difference as far as consolidation and infection are concerned, between the coverage by muscular or fasciocutaneous flaps.

Replantation vs revision amputation in single digit zone II amputations

The objective of this study was to compare the functional outcomes of zone II amputations treated with either replantation or revision amputation at our institution to better aid patients in their decision making process regarding these treatment options. We conducted a comparative retrospective study. All cases of single digit amputations received at our replantation center between 2007 and 2011 were screened for single digit zone II injuries. These patients were stratified based on the treatment received: replantation vs revision amputation. Patients were called and invited to participate in the research project. Those who accepted to enter the study were asked to complete the Quick-DASH, the Beck Depression Inventory-short form, and a custom made questionnaire. There were seventeen patients with single digit zone II replantation and fourteen patients with similar injuries who underwent revision amputation and agreed to take part in the study. Our data revealed that the duration of sick leave, occupation after injury, professional and social reintegration, discontinued activities, and self-confidence were not statistically different between the two groups. The average hospital stay and the follow-up period of replanted individuals were longer. The replantation group did not have higher levels of pain or cold intolerance, and the global functional and esthetic satisfaction levels were similar between the two groups. Also, Beck Depression Inventory and Quick-DASH scores were not statistically different. Yet, significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation. From a functional viewpoint, our study suggests that revision amputation is not superior to replantation in zone II single digit amputations. This is valuable information that should be given to patients when deciding on the treatment process and to insure a proper informed consent.

Pulmonary Artery Sealing Using the HARMONIC ACE+ Shears for Video-Assisted Thoracoscopic Surgery Lobectomy

BACKGROUNDnThe standard technique for pulmonary arterial (PA) branch sealing in video-assisted thoracoscopic surgery lobectomy consists of vascular endostaplers. We evaluated the immediate efficacy of an ultrasonic energy vessel-sealing device for sealing PA branches and compared it with the gold standard (endostapler) in an exxa0vivo model.nnnMETHODSnThis was a prospective cohort study. Immediately after anatomical lung resection, PA vessel sealing was achieved using the HARMONIC ACE+ Shears (ACE; Ethicon, Cincinnati, OH) sealing device or a vascular endostapler (VES) in a 3:1 ratio based on vessel diameter. The vessel was slowly pressurized, and the bursting pressure was recorded.nnnRESULTSnA total of 137 PA branches were sealed in specimens from 43 patients, of which 90 vessels were sealed with ACE and 47 were sealed with VES. The mean PA branch diameter was 6.0 mm (range, 1.7 mm to 24.0xa0mm; standard deviation, 3.1 mm Hg). The mean bursting pressure was 333.0 mm Hg (range, 84.0 mm Hg to 1415.1 mm Hg; standard deviation, 231.4 mm Hg) in the ACE group and 114.2 mm Hg (range, 0 mm Hg to 840.0 mm Hg; standard deviation, 124.7) in the VES group (p < 0.001). There were no complete sealing failures in the ACE group. Electron microscopy of ACE-sealed PA vessels demonstrated adventitial sealing with partial preservation of the collagen bundles and media with a sealed matrix of melted collagen.nnnCONCLUSIONSnPA branches sealed using the HARMONIC ACE+ in a simulated exxa0vivo model were able to sustain high intraluminal pressures. ACE-sealed vessels burst at mean bursting pressures equal to or greater than the VES-stapled vessels.

A new dorsal decubitus position for raising subscapular-based flaps

Flaps based on the subscapular vascular system are reliable and versatile tools that provide excellent coverage for a wide range of tissue deficits. Raising these flaps in the described dorsal decubitus position permits two surgical teams to work simultaneously while obviating the need for intra-operative position changes. In cases where a subscapular-based flap is deemed the most suitable option for reconstruction, the dorsal decubitus technique eliminates many of the limitations associated with the traditional lateral decubitus approach without compromising the range of tissue obtainable.

Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study

The most common complications of irradiated implant-based mammary reconstruction are fibrosis and capsular contracture. The indications for postmastectomy adjuvant radiotherapy have considerably broadened. Facing an increased number of patients who will require radiotherapy, most guidelines recommend delaying reconstruction after radiotherapy to prevent long-term fibrotic complications. Does radiotherapy permanently alter cellular properties which will adversely affect implant-based reconstruction? If so, is there a benefit in delaying reconstruction after radiotherapy? Our inxa0vitro model simulates two implant-based mammary reconstruction approaches: the irradiated implant and the delayed implant reconstructions by using an implant inset beneath healthy non-irradiated tissue post radiotherapy. We performed cell culture of fibroblasts and endothelial cells to simulate these two surgical conditions. Irradiated fibroblasts simulate the capsular tissue seen around the breast implant. The delayed reconstruction approach is simulated by non-irradiated fibroblasts conditioned with supernatant culture media obtained from irradiated endothelial cells. Irradiation induced fibrosis through fibroblast differentiation into myofibroblasts, as demonstrated by increased α-smooth-muscle actin levels in fibroblasts. This constitutes the basis for scar tissue contraction observed in irradiated implant-based breast reconstruction. Irradiation of endothelial cells induced irreversible cell cycle arrest known as senescence and secretion of the profibrotic connective tissue growth factor. Non-irradiated fibroblasts conditioned with culture media obtained from irradiated endothelial cells exhibited myofibroblast differentiation and the expression of fibrotic phenotype akin to capsular contracture. Our results demonstrate that radiotherapy causes irreversible cellular changes, which permanently alter the microenvironment in favor of fibrosis. Given that these changes are permanent, delaying reconstruction does not present an advantage in preventing capsular contracture.

Use of bone anchors for flap fixation in burned patients

UNLABELLEDnMitek or Arim anchors were developed for use in orthopaedic surgery to facilitate soft tissue fixation to bone. We believe this tool can be useful in difficult cases when securing various flaps to bone, we present a retrospective study of deep thickness burns patients.nnnMATERIALS AND METHODSnWe conducted a retrospective study, including severely burned patients who underwent flap reconstruction with Mitek or Arim anchor fixation between 1999 and 2007 in our unit. Characteristics analysed included indications for surgery, and postoperative complications.nnnRESULTSnNine patients (nine flaps) were included, seven men and two women with age ranging from 22 to 59 years old. Flaps were as follows: one gracilis, two latissimus dorsi, four medial gastrocnemius and two lateral gastrocnemius flaps. Indications for reconstruction were: open fractures or joint exposure in severely burned patient. Only one complication was noted: partial flap necrosis with infection of the bone anchor necessitating ablation and a new mobilisation of the flap.nnnCONCLUSIONnMitek anchors are a useful tool in plastic surgery. Suture anchors are used when coverage poses a risk of shearing away from the bone or adequate periosteum and soft tissue is not available for standard suture techniques. The anchor system provides a simple, fast, and efficient technique for flap fixation.