Biomedical subjects
Publications and source records attributed to M Lejour.
Two rare cases of hypoplastic heminose associated with a supernumerary nostril are presented. In both cases a patent nasal cavity was present on the hypoplastic side. The hypoplastic heminose was reconstructed with the skin and the lining of the second nostril.
A technique of curettage of giant congenital naevi in newborns was proposed by Moss in 1987. We used this technique in 6 children during the last 2 years. The long-term aesthetic results appear to be better than those observed after other methods of treatment. Light microscopy of the pigmented skin confirmed the presence of the majority of naevus cells in the upper dermis. For 3 patients, cultures of the curetted cells showed a melanocyte behaviour similar to that seen in malignant melanoma. These observations are limited to in vitro cultures and are not representative of the in vivo evolution as biopsies of the remaining naevus cells at 3 months of age did not show any malignant characteristics.
Since 1958, 900 children with cleft lip and palate were operated on at the University Hospital Brugmann in Brussels. Until 1981, the children were operated at 6 months for the lip and at 18 months for the palate with two flap palatoplasties. Since 1982, R. Malek's technique and sequence were adopted. The results after 5 years follow-up are analyzed between two groups of 50 and 49 children operated with the two techniques. Growth of the maxillary arch and phonation are well improved in the second group, but no improvement was observed in terms of hearing.
One hundred and fifty latissimus dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few immediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term results were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi flap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.
The abdominal wall function of 57 patients who have undergone TRAM flap breast reconstructions using the whole rectus muscle, on one side (33 patients) or both (24 patients), was evaluated 6 months to 2 years after surgery. The defect was repaired with a Teflon mesh buried in the rectus sheath. There was a perfect tolerance to the mesh, and no hernia or bulging of the abdominal wall developed. Patients had less back pain after (10 patients) than before (18 patients) the operation and found their sit-up and sport possibilities about the same as before. Detailed assessment of the abdominal muscles by the physiotherapist showed, however, a decreased function, more evident in bilateral cases. CT scans demonstrated a medialization of the lateral muscles, leaving only a small medial portion of the abdominal wall devoid of muscles. On the whole, no problem of clinical significance was encountered, and patients showed a high degree of satisfaction with the operation.
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Treatment of a large anterior fistula of the hard palate remains a problem. A new approach is presented by expansion of the palatal mucosa by custom-made implants, allowing closure in two layers without tension or extensive undermining.
A better understanding of the vascular anatomy of the breast has drastically reduced the risk of postoperative necrosis in breast reduction. Scars however remain a major concern, and techniques to reduce these have often been considered to be less satisfactory in terms of the shape and stability of the result. Our experience with more than 1,000 breasts operated on between 1984 and 1989 with a short inframammary scar technique has proved the contrary. The next step was to eliminate the inframammary scar, as proposed by Lassus, and to leave just a periareolar scar and a lower vertical scar which does not cross the inframammary fold. One hundred and four breasts, in sixty four patients--17 to 60 years old--have been operated on according to this vertical technique between April and September 1989. Twenty seven cases of ptosis correction in seventeen patients, and seventy seven reductions in forty seven patients, with a median excision weight of 460g, have been performed. By means of an individualized preoperative drawing and several technical devices, the results have proved that vertical mammaplasty is an excellent technique particularly indicated for women with elastic skin and a firm gland. Recent experience with liposuction at the beginning of the operation, has given new possibilities for breast modelling. In fatty juvenile hypertrophies, liposuction alone may even be adequate to reduce the volume, retaining a satisfactory shape for the breast with minimal scarring.
The anatomy of the orbicularis oris muscle was studied using histological sections of 18 operative specimens of unilateral cleft lip (14 incomplete and 4 complete). In incomplete clefts the intrinsic part of the orbicularis, located in the vermilion, is simply interrupted without distortion. The extrinsic part, lying higher in the lip, crosses the cleft but is distorted vertically according to the degree of the nasal deformity. In complete clefts the intrinsic bundle ends in the submucosa of the vermilion as in incomplete clefts. The extrinsic bundle is deviated towards the ala nasi on the lateral side. On the medial side, the fibres are rarer and more horizontal. Conclusions are drawn regarding reorientation of the muscle fibres during cheiloplasty.
The authors report three cases of pterygium colli. Two of them presented as part of Turner's syndrome and were treated following a personal technique. The third, which was probably due to jugular lymphatic obstruction, was treated according to the butterfly excision technique of Shearin.
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Breast cancer is now treated either by conservative therapy or by mastectomy. In the first case, no reconstruction is usually necessary, although some patients require additional surgery for asymmetry, distortion or even severe damage, by surgery or radiotherapy, of the treated breast. In these cases, reconstructive surgery should be performed very carefully, taking full account of the risk of operating in irradiated tissues. Minor procedures are usually adequate, but major surgery, reconstruction with abdominal flap, is sometimes the only solution to solve difficult postradiotherapy disasters. When a mastectomy is the choice of the patient and the surgeon, immediate reconstruction is now performed more often than before, as expansive prostheses are now available, allowing immediate implantation without endangering the skin flaps. In most cases of mastectomy, however, reconstruction is performed as a secondary procedure, in two stages if possible (volume and symmetry after the first, areola after the second). Most of the reconstructions are done by simple implantation of a prosthesis. When local conditions require a flap, the latissimus dorsi musculocutaneous has been the best choice for years, but the lower rectus flap is now taking over, as it gives the advantage of reconstructing a breast with autologous tissue.
The usefulness of leaving lateral strips of the rectus abdominis muscle in place during a transverse rectus abdominis musculocutaneous (TRAM) flap procedure is questioned. Since textbooks do not agree on the course of the intercostal nerves in the rectus fascia and no precise description is given of the exact site of penetration of the nerves in the rectus muscle, six fresh cadavers were dissected. It has been observed that the nerves enter the deep face of the muscle in its middle portion. Lateral parts of the muscle are consequently denervated during a transverse rectus abdominis musculocutaneous flap, which preserves them. This has been confirmed by CT scan of the abdominal wall in 10 patients 2 to 37 months after a transverse rectus abdominis musculocutaneous flap. In these patients, a progressive fibrosis and disappearance of the remaining muscle could be demonstrated. It is concluded that a partial taking of the rectus abdominis muscle does not preserve its muscular function.
It has been the experience of many surgeons that results following breast reconstruction change with time. To evaluate long-term results, the 350 breast reconstructions performed in the authors' department from January 1977 to April 1986 were reviewed. The results of the 326 cases in which there were sufficient data are presented here, and some late results are shown.
Reinsertion of the hump as a free graft, a technique based on the rhinoplasty described by Skoog, has been performed for more than 10 years in severely deviated noses to hide residual deformities of the septum after rhinoplasty. The results have been so encouraging that this technique is now routinely used in all rhinoplasties requiring a reduction of the profile. Grafting the hump after remodelling gives a natural aspect to the dorsum, especially in patients with thin skin where irregularities of sharp edges of the cut nasal bones are otherwise often seen. The hump is tailored into a thin composite graft (bone + cartilage) 3-4 cm long and 3-5 mm broad. No major complications have been observed. 32 cases have been reviewed after a mean delay of 24 months. 29 show radiographic evidence of bone graft survival although no fusion with the nasal bones is observed. It is suggested that facial bone grafts survive better in the nose than grafts taken from the iliac crest or the ribs.
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