Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: Preliminary results of the feasibility EPIONE trial.

BACKGROUND AND OBJECTIVE: Quality of life preservation after anti-cancer therapy is a major challenge for breast cancer survivors. Approximately 42-70% of patients who receive systemic therapy for breast cancer, including endocrine therapy, will develop vulvovaginal atrophy (VVA). For these patients, the commonly proposed gel-based treatments for topical applications are restrictive. Recently, innovative, non-hormonal therapeutic approaches, such as laser therapy, have emerged. The purpose of this feasibility study is to investigate the safety and efficacy of CO2 laser therapy in women with a history of breast cancer. MATERIAL AND METHODS: This prospective monocentric study included 20 patients with vulvovaginal atrophy who were treated at Henri Mondor University Hospital between 2017 and 2018. We included patients with a vaginal health index (VHI) score<15 and a contraindication for hormone administration due to a history of breast cancer. Two carbon dioxide laser sessions were used. The treatment was delivered using the following settings: vaginal tightening, FinePulse (pulse width 0.9ms), and energy density of 11.5J/cm2 that allows coverage of 70% of the targeted vaginal area to be treated. All patients had their follow-up visit at one (M1), three (M3), and six (M6) months after the first treatment to evaluate efficacy of the treatment on vulvovaginal atrophy. Vaginal health index score and female sexual distress (FSD) score were used to assess treatment efficacy and its impact on sexual quality of life. A score≥11 was associated with sexual dysfunction. The vaginal health index and female sexual distress scores were evaluated at baseline, M1, M3, and M6 of follow-up. RESULTS: The mean age of the patients was 56.1±8.8 years (range, 27-69 years). Seventeen of the 20 patients had experienced menopause (mean menopausal age, 51.25±1.5 years). At inclusion, the mean vaginal health index and the female sexual distress scores were 10.58±1.71 and 21.36±15.10, respectively. Fourteen out of 20 patients (70%) had FSD scores≥11 at the baseline. At M1, the mean vaginal health index score increased significantly to 13.42±2.3 (P=0.03), which represented an improvement of 21% from the baseline. A persistent and significant improvement in the vaginal health index score was observed at M6, with the score increasing to 16.75±4.23 post-treatment (P<0.0001), representing a 34% improvement from the mean baseline score. The mean female sexual distress at M1 was 19.83±13.57, representing a 7% decrease compared to the baseline scores (P<0.01). At M3, the female sexual distress significantly decreased to 13.88±15.58, representing an improvement of 35% (P=0.006). It increased to 10.35±14.7 at M6, representing an improvement of 52% (P=0.001). At M3, 35% of the patients had a female sexual distress score>11, and at M6, only 15% had a female sexual distress score>11. No side effects were reported during follow-up. CONCLUSION: This pilot feasibility study showed that carbon dioxide laser treatment appears to be an effective and safe method to improve the trophicity and decrease vaginal mucosal dryness in women with vulvovaginal atrophy that developed after systemic breast cancer therapy.

Immediate vaginal reconstruction following pelvic exenteration using the pedicled vertical Deep Inferior Epigastric Perforator (DIEP) flap: A technical note.

Immediate vaginal reconstruction is usually offered following pelvic exenteration for recurrent cervical cancer in women previously treated with radiotherapy or with severe radiation-induced fistulae. Introduction of muscle-sparing flaps, such as the pedicled vertical deep inferior epigastric perforator (DIEP) flap, provides viable tissues for vaginal reconstruction and is associated with reduced donor-site morbidity. This report describes the surgical technique, which is one of the procedures of choice for vaginal reconstruction. It is safe and beneficial, especially for women with gynecologic cancer who have undergone pelvic exenteration after failed radiation therapy.

Pathogen identification by shotgun metagenomics of patients with necrotizing soft-tissue infections.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) are life threatening, requiring broad-spectrum antibiotics. Their aetiological diagnosis can be limited by poor performance of cultures and administration of antibiotics before surgery. OBJECTIVES: We aimed (i) to compare 16S-targeted metagenomics (TM) and unbiased semiquantitative panmicroorganism DNA- and RNA-based shotgun metagenomics (SM) with cultures, (ii) to identify patients who would best benefit from metagenomics approaches and (iii) to detect the microbial pathogens in surrounding non-necrotic 'healthy' tissues by SM-based methods. METHODS: A prospective observational study was performed to assess the analytical performance of standard cultures, TM and SM on tissues from 34 patients with NSTIs. Pathogen identification obtained with these three methods was compared. RESULTS: Thirty-four necrotic and 10 healthy tissues were collected from 34 patients. The performance of TM was inferior to that of the other methods (P < 0·05), whereas SM performed better than standard culture, although the result was not statistically significant (P = 0·08). SM was significantly more sensitive than TM for the detection of all bacteria (P = 0·02) and more sensitive than standard culture for the detection of anaerobic bacteria (P < 0·01). There was a strong correlation (r = 0·71, Spearman correlation coefficient) between the semiquantitative abundance of bacteria in the culture and the bacteria-to-human sequence ratio in SM. Low amounts of bacterial DNA were found in healthy tissues, suggesting a bacterial continuum between macroscopically 'healthy' and necrotic tissue. CONCLUSIONS: SM showed a significantly better ability to detect a broader range of pathogens than TM and identify strict anaerobes than standard culture. Patients with diabetes with NSTIs appeared to benefit most from SM. Finally, our results suggest a bacterial continuum between macroscopically 'healthy' non-necrotic areas and necrotic tissues. What's already known about this topic? Necrotizing soft-tissue infections (NSTIs) are characterized by rapidly progressive necrosis of subcutaneous tissues and high mortality, despite surgical debridement combined with broad-spectrum antibiotics. The spectrum of potentially involved pathogens is very large, and identification is often limited by the poor performance of standard cultures, which may be impaired by previous antibiotic intake. Metagenomics-based approaches show promise for better identification of the pathogens that cause these infections, but they have not been evaluated in this medical context. What does this study add? Shotgun metagenomics (SM) showed higher sensitivity than 16S rRNA gene sequencing and a better ability than culture to detect anaerobic bacteria. As a result, a significant proportion of infections with bacteria, such as Pasteurella multocida or Clostridium perfringens, were detected only by SM. SM bacterial quantification enabled better detection of low amounts of bacterial DNA from macroscopically 'healthy' tissue, suggesting a subclinical infectious extension. What is the translational message? The high analytical performance of SM shown in this study should allow its future implementation for the diagnosis of necrotizing fasciitis, complementing or replacing routine methods. The large amount of data, including additional information on antimicrobial resistance, virulence profiles and metabolic adaptation of the pathogens, will improve microbiological documentation. Our results will improve our understanding of infectious pathophysiology in the future, leading to potentially better medical care.

[Acellular dermal matrix and synthetic mesh in implant-based immediate breast reconstruction: Current concepts]. / Matrices dermiques acellulaires et matrices synthétiques : évolution des pratiques en reconstruction mammaire immédiate par prothèse.

The use of acellular dermal matrices and synthetic meshes is gaining popularity in direct-to-implant breast reconstruction, allowing the complete coverage of the prosthesis with greater pocket control and improved cosmesis. In this concise review, we present the advantages of acellular dermal matrices and resorbable or nonresorbable synthetic meshes in implant-based breast reconstruction, we discuss the risk of postoperative complications, and we raise their contribution in the growing interest of prepectoral breast reconstruction.

Intraoperative augmented reality with heads-up displays in maxillofacial surgery: a systematic review of the literature and a classification of relevant technologies.

Although the term augmented reality appears increasingly in published studies, the real-time, image-guided (so-called 'hands-free' and 'heads-up') surgery techniques are often confused with other virtual imaging procedures. A systematic review of the literature was conducted to classify augmented reality applications in the fields of maxillofacial surgery. Publications containing the terms 'augmented reality', 'hybrid reality', and 'surgery' were sought through a search of three medical databases, covering the years 1995-2018. Thirteen publications containing enough usable data to perform a comparative analysis of methods used and results obtained were identified. Five out of 13 described a method based on a hands-free and heads-up augmented reality approach using smart glasses or a headset combined with tracking. Most of the publications reported a minimum error of less than 1mm between the virtual model and the patient. Augmented reality during surgery may be classified into four categories: heads-up guided surgery (type I) with tracking (Ia) or without tracking (Ib); guided surgery using a semi-transparent screen (type II); guided surgery based on the digital projection of images onto the patient (type III); and guided surgery based on the transfer of digital data to a monitor display (type IV).

Skin-reducing oncoplasty: A new concept and classification in breast cancer surgery.

BACKGROUND AND OBJECTIVES: Breast-conserving surgery and skin-sparing mastectomy are nowadays widely accepted as the standard of care in selected patients with early breast cancer. After an accurate review of the literature, it appeared that no ordered list of the numerous techniques described for conservative breast surgery has been established so far. The aim of this study was to develop a simple classification of the different skin incision patterns that may be used in breast surgery. METHODS: A systematic review of the English literature was conducted using the PubMed database to identify all the articles reporting breast-conserving surgery and skin-sparring mastectomy techniques up to the 31st of December 2016. RESULTS: Among the 1426 titles identified, 230 were selected for review. Based on the reviewed papers, the skin-reducing oncoplasty incision pattern (SROIP) classification was elaborated. CONCLUSIONS: Breast cancer surgery should nowadays optimise aesthetic outcomes by improving the final breast shape, volume and scar location. This may be achieved using different procedures that we grouped together under the term skin-reducing oncoplasty (SRO). Depending on the breast cancer location, the SROIP classification helps in the choice of the best technique to be used.

Study of medical education in 3D surgical modeling by surgeons with free open-source software: Example of mandibular reconstruction with fibula free flap and creation of its surgical guides.

INTRODUCTION: Benefits of 3D printing techniques, biomodeling and surgical guides are well known in surgery, especially when the same surgeon who performed the surgery participated in the virtual surgical planning. Our objective was to evaluate the transfer of know how of a neutral 3D surgical modeling free open-source software protocol to surgeons with different surgical specialities. METHODS: A one-day training session was organised in 3D surgical modeling applied to one mandibular reconstruction case with fibula free flap and creation of its surgical guides. Surgeon satisfaction was analysed before and after the training. RESULTS: Of 22 surgeons, 59% assessed the training as excellent or very good and 68% considered changing their daily surgical routine and would try to apply our open-source software protocol in their department after a single training day. The mean capacity in using the software improved from 4.13 on 10 before to 6.59 on 10 after training for OsiriX® software, from 1.14 before to 5.05 after training for Meshlab®, from 0.45 before to 4.91 after training for Netfabb® and from 1.05 before and 4.41 after training for Blender®. According to surgeons, using the software Blender® became harder as the day went on. DISCUSSION: Despite improvement in the capacity in using software for all participants, more than a single training day is needed for the transfer of know how on 3D modeling with open-source software. Although the know-how transfer, overall satisfaction, actual learning outcomes and relevance of this training were appropriated, a longer training including different topics will be needed to improve training quality.

Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting.

OBJECTIVE: The aim of this study was to describe a technique for midface rejuvenation combining lower blepharoplasty, midcheek lift and autologous fat transfer. METHODS: All patients who underwent a midface rejuvenation procedure performed by the same surgeon and using a classic subciliary blepharoplasty surgical approach were identified. The technique combined three distinct procedures: lower blepharoplasty with use of a transposition flap of orbital adipose tissue in the medial and central compartment to reduce the subpalpebral bags and attenuate the palpebrojugual sulcus; midcheek lift in the preperiosteal plane with trans-osseous fixation exerting traction on the soft tissues of the cheek along several vectors; autologous fat transfer to offset the loss of volume in the target area. RESULTS: Between January 2011 and December 2015, 14 patients were operated with the described technique. Long-term results were good and stable over time. Two complications in the form of ectropion were observed in the series but resolved with daily massages. CONCLUSIONS: The combination of lower blepharoplasty, midcheek lift and autologous fat transfer appear to enable treatment of midface ageing. The results were satisfactory and durable, and the procedure was well tolerated. The procedures could be combined with others for the treatment of the upper and lower face during the same surgical procedure.

[How to make your own custom cutting guides for both mandibular and fibular stair step osteotomies?] / Ostéotomies fibulaires et mandibulaires en marche d'escalier. Comment réaliser ses propres guides de coupe pour les reconstructions maxillofaciales ?

INTRODUCTION: Using tailored cutting guides for osteocutaneous free fibula flap in complex mandibular reconstruction after cancer resection surgery constitutes a substantial improvement. Autonomously conceiving and manufacturing the cutting guides within a plastic surgery department with computer-aided design (CAD) and three-dimensional (3D) printing allows planning more complex osteotomies, such as stair-step osteotomies, in order to achieve more stable internal fixations. METHODS: For the past three years, we have been producing by ourselves patient-tailored cutting guides using CAD and 3D printing. Osteotomies were virtually planned, making the cutting lines more complex in order to optimize the internal fixation stability. We also printed reconstructed mandible templates and shaped the reconstruction plates on them. We recorded data including manufacturing techniques and surgical outcomes. RESULTS: Eleven consecutive patients were operated on for an oral cavity cancer. For each patient, we planned the fibular and mandibular stair-step osteotomies and we produced tailored cutting guides. In all patients, we achieved to get immediately stable internal fixations and in 10 patients, a complete bone consolidation after 6 months. CONCLUSION: Autonomously manufacturing surgical cutting guides for mandibular reconstruction by free fibula flap is a significant improvement, regarding ergonomics and precision. Planning stair-step osteotomies to perform complementary internal fixation increases contact surface and congruence between the bone segments, thus improving the reconstructed mandible stability.

Mortality of necrotizing fasciitis: relative influence of individual and hospital-level factors, a nationwide multilevel study, France, 2007-12.

BACKGROUND: Necrotizing soft-tissue infections (NSTI) are rare, life-threatening conditions. OBJECTIVES: To assess whether admitting hospital characteristics were associated with NSTI mortality. METHODS: We studied the French nationwide hospital discharge database (retrospective national cohort). All patients admitted in the period 2007-12 with an International Classification of Diseases 10 code of necrotizing fasciitis were eligible. We extracted data on the patients (age, sex, intensive care unit admission, comorbidities) and hospitals (public vs. private proprietary; for public hospitals, teaching, yes/no; and number of NSTI admissions, ≥ 3 NSTI cases/year, yes/no). Multivariable analyses were performed to identify independent predictors of 28-day mortality and in-hospital mortality using mixed logistic regression and Cox proportional hazards models, respectively. RESULTS: We identified 1537 patients (915 males) with a median age of 60 years (interquartile range 48-75), admitted to 326 hospitals, public (82%) and admitting < 3 NSTI cases/year (93%). Overall, 364 patients died [23·7%; 95% confidence interval (CI) 21·6-25·9]. Patients treated in public teaching centres with ≥ 3 NSTI cases annually had lower 28-day mortality (adjusted odds ratio 0·68; 95% CI 0·46-0·99; P = 0·045) and in-hospital mortality rates than patients treated in local hospitals, even after adjusting for potentially relevant individual risk factors. No significant association was found between mortality and interhospital transfer. CONCLUSIONS: Our findings highlight an increased survival in teaching centres with high-volume NSTI procedures. If confirmed in other settings, these findings reinforce the importance of expertise in early diagnosis and management of this condition.

[Identification of perforating vessels by augmented reality: Application for the deep inferior epigastric perforator flap]. / Repérage des vaisseaux perforants par réalité augmentée : application au lambeau perforant d'artère épigastrique inférieure profonde.

The augmented reality on smart glasses allows the surgeon to visualize three-dimensional virtual objects during surgery, superimposed in real time to the anatomy of the patient. This makes it possible to preserve the vision of the surgical field and to dispose of added computerized information without the need to use a physical surgical guide or a deported screen. TECHNIQUE: The three-dimensional objects that we used and visualized in augmented reality came from the reconstructions made from the CT-scans of the patients. These objects have been transferred through a dedicated application on stereoscopic smart glasses. The positioning and the stabilization of the virtual layers on the anatomy of the patients were obtained thanks to the recognition, by the glasses, of a tracker placed on the skin. We used this technology, in addition to the usual locating methods for preoperative planning and the selection of perforating vessels for 12 patients operated on a breast reconstruction, by perforating flap of deep lower epigastric artery. The "hands-free" smart glasses with two stereoscopic screens make it possible to provide the reconstructive surgeon with binocular visualization in the operative field of the vessels identified with the CT-scan.

Mandibular reconstruction after cancer: an in-house approach to manufacturing cutting guides.

The restoration of mandibular bone defects after cancer can be facilitated by computer-assisted preoperative planning. The aim of this study was to assess an in-house manufacturing approach to customized cutting guides for use in the reconstruction of the mandible with osteocutaneous free flaps. A retrospective cohort study was performed, involving 18 patients who underwent mandibular reconstruction with a fibula free flap at three institutions during the period July 2012 to March 2015. A single surgeon designed and manufactured fibula and mandible cutting guides using a computer-aided design process and three-dimensional (3D) printing technology. The oncological outcomes, production parameters, and quality of the reconstructions performed for each patient were recorded. Computed tomography scans were acquired after surgery, and these were compared with the preoperative 3D models. Eighteen consecutive patients with squamous cell carcinoma underwent surgery and then reconstruction using this customized in-house surgical approach. The lengths of the fibula bone segments and the angle measurements in the simulations were similar to those of the postoperative volume rendering (P=0.61). The ease of access to 3D printing technology has enabled the computer-aided design and manufacturing of customized cutting guides for oral cancer treatment without the need for input from external laboratories.

Surgical management of necrotizing cellulitis: Results of a survey conducted in French plastic surgery departments.

OBJECTIVE: Necrotizing cellulitis (NC) is a severe infection of the skin and soft tissues, requiring an urgent multidisciplinary approach. We aimed to clarify the surgical management of NC in French plastic surgery departments. PATIENTS AND METHOD: Thirty-two French plastic surgery departments were invited to complete a survey sent by email. Questions focused on diagnostic and therapeutic management of NC in France. RESULTS: Twenty-five plastic surgery departments completed the survey (78%) and each center had a lead plastic surgeon. Overall, 88% of surgeons declared to have managed at least five NC patients within the year. The plastic surgeon was the lead surgical specialist for NC in 80% of cases. Conversely, 76% of interviewed facilities reported not to have any lead medical specialist. Time between surgical indication and surgical management was less than six hours in 92% of cases. Overall, 24% of responding facilities declared that access to the operating room never delayed management. Finally, 80% of facilities declared to be in favor of dedicated care pathways to improve the management of necrotizing cellulitis patients. CONCLUSION: Our study results highlight the heterogeneity of necrotizing cellulitis management in France. The lack of a dedicated care pathway may lead to diagnostic and treatment delays.

[Use of hyaluronidase to correct hyaluronic acid injections in aesthetic medicine]. / Utilisation de la hyaluronidase pour la correction des injections d'acide hyaluronique en médecine esthétique.

Hyaluronic acid (HA) is the most commonly used filler in aesthetic medicine. However, overcorrections are frequent even with experienced practitioner. Hyaluronidase is an enzyme that hydrolyzes HA. Hyaluronidase has been recently proposed to correct unsatisfactory results of HA injections in aesthetic medicine (overcorrection, asymmetry, Tyndall effect) and to treat immediate complications such as arterial or venous thrombosis. The objective of this technical note was to summarize the literature data regarding the efficacy, safety and technique of use of hyaluronidase. Hyaluronidase may be responsible for allergies. The practitioner should take this risk and the possible drug interactions into account before using this antidote in order to weigh up the risk/benefit ratio.

Nasal basal cell carcinomas. Can we reduce surgical margins to 3mm with complete excision?

BACKGROUND: The purpose of this study was to evaluate the incomplete excision rate of nasal basal cell carcinomas (BCC) resected with different margins to demonstrate that 3-mm surgical margins could be used as safety margins to reduce esthetic consequences with a low risk of incomplete excision. METHODS: All patients with BCC of the nose excised from January 1st 2008 to December 31st 2011 were included. Data were analyzed and reviewed retrospectively. Tumors were treated with different surgical margins of excision: 3mm, 4mm, and 5mm. The primary outcome variable was the rate of incomplete excision. Other study variables were the histologic subtype, size, and recurrent lesions. RESULTS: Of the 132 patients, 115 were included corresponding on with 127 BCC. Median age was 75.5 (64-83) and sex ratio M:F=1.05. Of the 127 BCC, 80 were aggressive histologic subtype (63%), and 11 were recurrent (8.7%). The overall rate of incomplete excision was 17.3% (n=22). Of these 22, 17 (77.3%) were of an aggressive subtype. The incomplete excision rates within the groups were 12.5% (n=4), 22.2% (n=10), and 16% (n=8), respectively within the group with 3-, 4- and 5-mm surgical margins. No significant difference was observed between the groups (P=.519). The incomplete excision rate was not independently associated with the surgical margins, histologic subtype and recurrent type (P>.05). CONCLUSION: Three-millimeters margins could possibly be used to treat nasal BCC in chosen cases. Regarding the high rate of incomplete excision, reconstruction should be performed after receiving the pathologic report.

[Techniques to enhance the accuracy and efficiency of injections of the face in aesthetic medicine]. / Techniques visant à améliorer la précision et l'efficacité des injections de la face en médecine esthétique.

The common principle of injections in esthetic medicine is to treat and to prevent the signs of aging with minimal doses and with more precision and efficiency. This relies on functional, histological, ultrasound or electromyographic analysis of the soft tissues and of the mechanisms of facial skin aging (fine lines, wrinkles, hollows). These injections may be done with hyaluronic acid (HA) and botulinum toxin. The aim of this technical note was to present four delivery techniques allowing for more precision and low doses of product. The techniques of "vacuum", "interpores" and "blanching" will be addressed for HA injection and the concept of "Face Recurve" for botulinum toxin injection.