Plastic Surgery / Chirurgie Plastique

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue tumour of the dermis. Diagnosis may be very difficult from both a clinical and histopathological standpoint. DFSP has a peak incidence in patients between age 10 and 50 years old, occurs with relatively equal frequency in males and females and has a predilection to occur on the trunk or proximal limbs. The tumour has a very low metastatic potential but can be very locally aggressive, requiring wide surgical resection. The possible variants of DFSP may obscure diagnosis especially in the case of fibrohistiocytic lesions such as dermatofibroma, fibromatosis and malignant fibrous histiocytoma. Immunohistological testing, while not completely specific, shows promise in improving diagnostic accuracy. Wide local excision continues to be the mainstay of treatment, although Mohs’ micrographic surgery may ultimately provide superior cure rates.

With advances in magnetic resonance imaging (MRI) technology and observer experience, MRI is an established part of the diagnostic work-up for soft tissue injuries of the hand and wrist. It potentially minimizes the need for invasive procedures such as arthrography or arthroscopy. However, there are limitations of MRI, and many patients who undergo MRI of the wrist still need wrist arthroscopy for both diagnostic and therapeutic purposes. A review of the recent literature of the role of MRI in the assessment of soft tissue injuries of the hand and wrist is presented.

Breast reconstruction with transverse rectus abdominal myocutaneous (TRAM) flaps on pedicles was performed simultaneously with radical mastectomy in 73 patients with breast cancer. In the case of the tumour exceeding the breast borders, or edemo-infiltrative form of cancer, radical mastectomy was accomplished, and the wound defect on the chest wall was closed without technical difficulties, while simultaneously solving the aesthetic part of the operation. Complications were noted in 13 patients (17.8%), and with revision, complications were eliminated without impairing cosmetic effect. Recurrence of the breast cancer was noted in 9.6% of patients, which is explained by the presence of hidden separate metastases not located during the preoperational period or operation. An individual approach in solving the task of simultaneous breast reconstruction with radical mastectomy is necessary in each patient.

The ratio of morphological (bialar diameter [al-al]):anatomical (alar base width [ac-ac]) nose width defines the quality of the soft nose contours. Quantitative data on ac-ac and its relationship to al-al, and the relationship of both nose widths to face width (bizygomatic diameter) have not been available in the literature. To correct this, the anatomical and morphological widths of the nose were measured anthropometrically in an ethnically mixed group of 120 healthy, young adult, Caucasian Canadians, and the ratios of nose widths:face width (which greatly influences nasofacial harmony in the frontal view) calculated. In 80% of subjects, the morphological (classical) nose width was larger than the anatomical nose width, which has close contact with the underlying skeleton. Mean nose width was 24.9% (ac-ac) and 26.1% (al-al) of the face width. This study may help in the corrective surgery of disproportions between the two nose-width measurements in patients with cleft lip nose, and in the restoration of harmony between the nose and face widths.

Arthrodesis for small joints of the hand is a well established technique for the treatment of joint instability, deformity and pain. A technique for compression arthrodesis in small joints of the hand utilizing both Kirschner wire and cerclage is reviewed. The results of a retrospective series of 44 small joint arthrodesis in 33 patients are presented. Indications for arthrodesis were trauma (28.3%), rheumatoid arthritis (30.5%), osteoarthritis (14.7%) and traumatic arthritis (26.5%). Patient age ranged from 18 to 73 years, and 38% were male. Joint fusion as determined by radiography occurred in 41 of 44 cases, representing a 93% success rate, comparable with that cited in the literature. Complications included nonunion in three cases and infection in two cases, leading to eventual amputation. The present technique represents a simple, fast and effective method for small joint arthrodesis of the hand.

The anatomy of the fasciocutaneous branches of the first and second perforators were studied to help elaborate a flap for use in the reconstruction of the gluteal and perineal regions. After dissecting 40 thighs in fresh cadavers, it was found that the fasciocutaneous branches of the first and second perforators were 1.21 mm and 1.01 mm in diameter, respectively. The distances from the first and second perforators to the greater trochanter of the femur were 6.23 cm and 12.19 cm, respectively. The cutaneous area nourished by each one of the arteries was evaluated through the injection of dye.

The effects of viral infections on normal wound healing are discussed. The case report presented suggests that viruses can have a detrimental effect on the normal wound healing process.

By the use of dissections and ingenious experiments, Allen Kavanel clarified how hand infections spread along the various tissues and planes. This work enabled him to determine the best incisions to drain each type of infection and how to prevent its spread. Earlier, very little was known about how infections spread in the hand. Infections were often treated medically for long periods. Incision and drainage, when they were performed, in many cases were inadequate and focused in the wrong place. Even trivial infections often led to stiff useless digits or hands. Amputation and death were not unusual in the more serious infections. Representative cases are presented from Kavanel's classic textbook Infections of the Hand, published in 1912.