Calcifying aponeurotic fibroma: a case report

Calcified aponeurotic fibroma is a rare benign fibrous tumor with well-characterized histopathologic features. It is usually seen in distal extremities of children and youngsters. A 23-year-old male patient underwent surgical excision of a free, painless soft tissue mass that developed in the palmar aspect of the left hand. Histopathologic examination showed fibroblastic proliferation areas and dense collagenous stroma surrounding calcifications and chondroid metaplasia. The diagnosis was made as calcified aponeurotic fibroma. No recurrences were detected within a year follow-up.     

Juvenile aponeurotic fibroma. A case report with a review of the literature

Juvenile aponeurotic fibroma is a rare benign tumour which occurs mainly in young patients under 20 years of age and especially during childhood. Clinical presentation is a unique, hard and painless tumour of the palm or sole. The treatment commonly accepted for this locally recurrent tumour is complete excision with function preservation. In this paper, we report on a case of juvenile aponeurotic fibroma of the thenar area with a thickening of the first metacarpal bone shaft. Bone involvement in juvenile aponeurotic fibroma is a very rare condition. We only found one report of a comparable case in literature.     

Dupuytren's disease of the radial side of the hand

The systematic examination and recording, ray by ray, using the author's method of assessment of Dupuytren's disease have revealed that there are more Dupuytren's disease cases affecting the radial side of the hand than usually believed. The aponeurotic structures of the thumb and first web space are described. The location of diseased tissue coincides with the normal aponeurotic structures. Radial involvement alone is rare; most often, radial-side involvement is associated with ulnar-side involvement. Radial-sided lesions in the older patient progress slowly and rarely require surgery. In the younger patient, however, progress can be rapid, can lead to significant contractures, and recurrence after partial fasciectomy is frequent. Surgical management of these aggressive forms requires a large approach and an extensive excision. These cases are the best indications for dermofasciectomies.     

Simplified aponeurotic ptosis surgery.

I present a simplified aponeurotic ptosis repair that minimizes surgical dissection and enhances the predictability of postoperative eyelid positions. Indications for the procedure are unilateral ptosis, bilateral ptosis where preaponeurotic fat excision is not indicated, mild congenital ptosis, and reoperations from standard levator surgery. The procedure is best suited for surgeons who have a thorough knowledge of the levator aponeurosis anatomy.     

Juvenile aponeurotic fibroma of the hand

Juvenile aponeurotic fibroma is a rare benign tumor found primarily in the extremities of children and young adults. Clinically, it presents as a painless, mobile solitary mass in the hand. It may represent the cartilage analog of fibromatosis. Since it has a distinct tendency toward local recurrence, wide excision without sacrifice of function is the indicated treatment. Two cases are presented illustrating the diagnostic features and treatment of this disease process.     

Darrier and Ferrand dermatofibrosarcomas--retrospective analysis of 81 cases over ten years (1983-1994)

Progressive and recurrent dermatofibrosarcoma, described by Darier and Ferrand in 1924, is a fibrous skin tumor with essentially local malignancy. This tumor is often only diagnosed after several recurrences. The authors present a retrospective study of eighty-one cases treated over a ten years period (1983-1994) and a review of the literature. The treatment is surgical: wide and deep excision with respection of the safe subjacent aponeurotic plane. Therapeutic modalities are defined, with particular emphasis of the need for primary surgical treatment by excision, the possibility of in this case being significantly greater than after salvage operations. The prognostical factors are clinical factors such as size of the tumor, the risk of malignant evolution or the need for repeated excisions.     

Surgical anatomy of the aponeurotic expansions of the anterior abdominal wall.

Dissection of the anterior abdominal wall in 40 fresh cadavers, with confirmation of the anatomical findings at operation in 25 patients, has enabled the patterns of distribution of the aponeurotic expansions of the abdominal muscles to be traced and the relation of structure to function to be determined. It is pointed out that the linea alba should no longer be regarded as the line of insertion of the abdominal muscles but as the area of decussation of the tendinous aponeurotic fibres of the muscular strata passing from one side to the other, for which the name "midline aponeurotic area" is proposed. Two separate functional areas are described, a "parachute respiratory mechanism" in the upper abdomen and a belly support in the lower abdomen. Attention is drawn to the functional derangement that may follow some of the standard abdominal incisions and to possible mechanisms of herniation through the midline aponeurotic area.     

A Case of Large Calcifying Fibroma of Tendo-achilles Managed by En-block Resection and Tendon Reconstruction

Calcifying aponeurotic fibroma is a rare benign fibrous tumor with typical radiological and histopathological features seen in young children and adolescents. It commonly involves the extremities and is characterized by a very high chance of local recurrence. A complete excision of the tumor is considered to be the treatment of choice. We report a case of the tumor involving the substance of achilles tendon and extending up till its insertion in the calcaneum. To the best of our knowledge, this is the largest reported case of calcifying fibroma, with the tumor measuring 10 cm in its largest diameter. The tumor was excised in toto followed by reconstruction of the tendon defect with V-Y plasty of the native tendon and supplemented with semitendinosus and gracilis graft. There was no evidence of recurrence during the follow up period of 1 year.     

Juvenile aponeurotic fibroma

A large aponeurotic fibroma situated on the dorsum of the hand of a fourteen-year-old Nigerian male is reported. Out of forty-three juvenile aponeurotic fibromata of the hand documented in the literature, only two cases occurred on the dorsum.     

Repair of neglected Achilles tendon ruptures: procedures and functional results

Surgical repair of neglected Achilles tendon ruptures presents the challenge of restoring the function of the Achilles tendon complex while repairing the large defect that is created by the delay in appropriate treatment. We present our preferred technique for delayed repair and the results of six patients who were available for complete follow-up evaluation. The combined surgical technique includes: V-to-Y gastrocnemius recession or advancement, excision of the fibroadipose defect, end-to-end anastomosis, gastrocnemius aponeurotic flap to reinforce the anastomosis. Each of six patients were interviewed and examined clinically and by Cybex II isokinetic strength testing. All six patients have been able to return to their pre-injury activities. Cybex II isokinetic strength testing demonstrated peak torque deficiencies in plantar flexion ranging from 2.5%–22% as compared with the unaffected limb. The overall results of the technique described indicate that very satisfactory functioning of a neglected Achilles tendon rupture can be obtained.     

Juvenile nodular aponeurotic fibroma in the area of the knee joint

A case of calcifying aponeurotic fibroma of the knee occurred in a 14-year-old boy. Review of the literature reveals that calcifying aponeurotic fibroma is an uncommon benign tumor with a tendency for local recurrence. It is manifested by a progressively growing mass involving fat, fascia, and aponeurosis. Chondroid tissue and calcification within the areas of proliferated spindle cells are the characteristic features of this lesion and differentiate it from the other forms of fibromatosis.     

Galea and subgalea graft for lip augmentation revision

In this paper we will review the results obtained during the last 2 years with the aponeurotic galea and subgalea for vermillion lip augmentation. The survey was carried out on 42 patients who displayed either an absence of or reduction in the vermillion of one or both lips or a senile lip. In all cases the surgical procedure introduced aponeurotic galea and subgalea in the space found between the orbicular lip muscle and the vestibular mucus, just behind the vermillion. All the operations were performed under local anaesthetic. The size of the aponeurotic galea fragment removed varied in length between 10 and 12 cms. and in width between 1 and 2 cms., using the following parameters for its dimensions: the previous volume of the lips, and the distance between the two buccal commissures when in the “smile position.”     

Upgaze eyelid position allows differentiation between congenital and aponeurotic blepharoptosis according to the neurophysiology of eyelid retraction

To differentiate between congenital and aponeurotic blepharoptosis, we investigated whether upgaze with stretching of the mechanoreceptor of Mueller muscle increases involuntary reflex contraction of the levator slow-twitch muscle fibers.In 50 cases each of unilateral congenital blepharoptosis and of asymmetric aponeurotic blepharoptosis, the mean increases by upgaze in the upper eyelid margin to the line between the medial and lateral canthi as upper eyelid retraction distance (UERD) of the ptotic eyelid 0.4 mm and 2.9 mm, respectively. These were significantly smaller and significantly larger than those of the corresponding nonptotic eyelid, 2.0 mm and 2.3 mm, respectively.Worsening of ptosis on upgaze is common in congenital ptosis and is an abnormal differentiating sign, lacking the involuntary reflex contraction. Improvement of ptosis on upgaze is common in aponeurotic blepharoptosis and likely represents a normal physiological process, restoring the involuntary reflex contraction.     

Pathogenesis and surgical correction of involuntary contraction of the occipitofrontalis muscle that causes forehead wrinkles

Assuming that an agonistic function is present to maintain an adequate visual field, we hypothesized that stretching of the mechanoreceptor of Mueller muscle induces involuntary contraction of the occipitofrontalis muscle, as well as the levator muscles. In patients with aponeurotic blepharoptosis, both unilateral instillation of phenylephrine to contact Mueller smooth muscle fibers and unilateral aponeurotic fixation ipsilaterally reduced the eyebrow height during primary and upward gazing. Bilateral aponeurotic fixation bilaterally reduced the eyebrow height, with fewer forehead wrinkles. Stretching of the mechanoreceptor of Mueller muscle induces involuntary contraction of the bilateral levator muscles. Its increased stretching may induce involuntary contraction of the ipsilateral occipitofrontalis muscle via the mesencephalic trigeminal nucleus and the facial subnucleus as another stretch reflex. The involuntary contraction of the occipitofrontalis muscle that causes forehead wrinkles during primary gazing can be corrected by the aponeurotic fixation to reduce the stretching of Mueller muscle.     

Healing of the aponeurosis during recovery from aponeurotomy: morphological and histological adaptation and related changes in mechanical properties.

Aponeurotomy, which is the transection of an aponeurosis perpendicular to its length, is performed to lengthen spastic and/or short muscles. During recovery, the cut ends of the aponeurosis are reconnected by new connective tissue bridging both ends. The aim of this study is to investigate the histological features of this new connective tissue as well as its mechanical properties after recovery from aponeurotomy. For this purpose, aponeurotomy was performed on the proximal aponeurosis of rat m. gastrocnemius medialis (GM), which was followed by six weeks of recovery. The lengths of aponeurotic tissues were measured as a function of active muscle length. The results are compared to a control group as well as to the acute effects and a sham operated group. Activation of the muscle at increasing lengths after aponeurotomy caused a gap between the cut ends of the aponeurosis. However, after recovery, new connective tissue is formed bridging the aponeurotic ends, consisting of thin collagen fibres, which are densely packed and generally arranged in the direction of the aponeurosis. The number of fibroblasts was three to five times higher than that of aponeurotic tissue of the intact parts as well as that of the acute and sham operated muscles. The strain of the new connective tissue as a function of active muscle length was shown to be about three times higher than that of the aponeurosis. It is concluded that the inserted new aponeurotic tissue is more compliant and that the aponeurosis becomes 10-15% longer than in untreated muscle. As a consequence, the muscle fibres located distally to the new aponeurotic tissue will become shorter than prior to aponeurotomy. This explains a shift of the length-force curve, which favours the restoration of the range of joint motion.     

Clinical significance of magnetic resonance imaging in the preoperative differential diagnosis of calcifying aponeurotic fibroma

BACKGROUND: Although the clinical and histological features of calcifying aponeurotic fibroma are well described, the magnetic resonance imaging (MRI) findings have been reported for only five cases. The purpose of this study was to describe a series of MRI findings in this rare entity to assess its utility in preoperative and differential diagnosis. METHODS: MRI findings together with the clinical signs and radiographs of six patients with pathologically proven calcifying aponeurotic fibroma were retrospectively reviewed. Distribution, morphology, margins, edematous changes, and relation to the surrounding structures together with signal intensity of each sequence of MRI were evaluated. RESULTS: MRI demonstrated subcutaneous distribution, ill-defined appearance, and a tendency to infiltrate into or adhere to the surrounding tissues. The masses were of isointensity to low intensity on T1-weighted images. T2-weighted images showed heterogeneous high signal intensity with minor areas of isointensity to low signal intensity. Postcontrast T1-weighted images demonstrated heterogeneous intense enhancement. CONCLUSIONS: MRI revealed several features that can contribute to the preoperative differential diagnosis of calcifying aponeurotic fibroma from other fibrous tumors, giant cell tumor of the tendon sheath, or soft tissue sarcoma. As a result, MRI would help orthopedic oncologists plan the surgery for this rare entity.     

Removable draining aponeurotic and muscular-aponeurotic sutures in the prevention of suppuration of laparotomy wounds

Clinico-instrumental investigations and experimental studying of the regeneration of laparotomy wounds sutured by removable draining aponeurotic and muscular-aponeurotic sutures have shown less pronounced course of aseptic inflammation in the wounds. It has been established that the removable aponeurotic sutures substantially decrease the frequency of postoperative suppurations of laparotomy wounds in patients operated on the colon mainly for colorectal carcinoma. The original authors' sutures provide the formation of a cicatrix of the laparotomy wound by the 20th day of the postoperative period and completely prevent the appearance of ligature fistulas.     

Abdominoplasty: the use of polypropylene mesh to correct myoaponeurotic-layer deformity

The aponeurotic layer is a very important element to consider during abdominoplasty. For most patients, a simple midline plication is enough to obtain good results. However, for in patients with severe aponeurotic laxity, some other maneuvers must be performed. The purpose of this study was to evaluate the use of polypropylene mesh in this group of patients. We analyzed the results for 20 patients in whom three types of mesh anchoring were used on the basis of intraoperative findings. Adequate long-term follow-up results were obtained, with no recurrence of rectus diastases, as shown by ultrasonography.This work was presented at the 35th anniversary meeting of the ASAPS, April 2002, Las Vegas, Nevada.     

Frontal stage in cervicofacial lift: the "helmet crest" technique associated with rapid expansion]

The frontal level is generally the less and the last concerned in facial ageing and the classical incisions of the cervicofacial facelift provide no changes in the frontal and glabellar wrinkles. To avoid such residual defects, the authors perform for the lost ten years an important push back of a central band of the vertex (the so called "Helmet crest") by means of a bilateral triangular excision subsequently closed by VY. This push back needs a very large undermining in the subgalea plan, from the eyebrow and glabellar region to the crest of the hemet itself. The VY closure is now really facilitated by a rapid expansion obtained by a special T shaped expander which allows not only cutaneous expansion but also aponeurotic expansion of the reputedly inextensible galea. This technique avoids the coronal incision and its serious sequelae and may be carried technique out at the same time as cervicofacial face lift. It allows a personal, equilibrated tension of the facial mask which is the essential condition for a good presentation of natural expression of the face.     

Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity.

32 patients with cerebral palsy underwent operations for pronation deformity. The deformity is classified into four groups. Patients in group 1 are capable of supination beyond neutral. No surgery is necessary. Those in group 2 are able to supinate to the neutral position. A pronator quadratus release is advised and may be combined with a flexor aponeurotic release. In group 3, patients have no active supination. However a full range of passive supination is readily achieved. A pronator teres transfer is advised. Patients in group 4 have no active supination. Full passive supination may be present, but is tight. A flexor aponeurotic release and a pronator quadratus release may unmask active supinator activity. An active transfer for supination is possible as a secondary procedure.