Breast reconstruction through exclusive lipomodeling or in addition to a flap: Current status in Franche-Comté.

INTRODUCTION: Breast reconstruction after cancer surgery through lipomodeling can be performed alone or in combination with a flap. Our objective is to describe the proportion of techniques used on patients who underwent autologous reconstructive surgery after tumorectomy or mastectomy in Franche-Comté. MATERIALS AND METHODS: A bicentric retrospective observational study was conducted between October 2017 and December 2021 (NCT06101732), including three groups: those who underwent exclusive lipomodeling reconstruction after mastectomy (1) or in addition to a flap (2), and those who underwent exclusive lipomodeling reconstruction after tumorectomy (3). Socio-demographic, medical, and surgical data were collected and recorded in a specially designed software. RESULTS: Two hundred and fifty-one lipomodeling procedures were performed on 91 patients. In group 1, the average transferred volume was 1191mL with an average number of sessions of 4.4 spreads over 19.4months. In group 2, the average transferred volume was 676mL with an average operative time of 2.5 spread over 16.1months. In group 3, the average transferred volume was 223mL with an average number of sessions of 1.5 spreads over 6.2months. Regarding postoperative complications, 11% had cysts of fat necrosis, 4.4% had infections, and 2.2% had hematomas. CONCLUSION: Lipomodeling is a technique that has clearly established itself in the field of breast reconstructive surgery. It results in a few complications and improves the final aesthetic outcome whether used exclusively or in addition to a flap.

[Comparison between different anchors for zone I flexor tendon repair]. / Comparaison des différentes ancres dans les réinsertions transosseuses de tendons fléchisseurs profonds en zone I.

INTRODUCTION: Transosseous reinsertion has been used to complement the Bunnell pull-out technique in the repair of zone I deep flexor tendon injuries. The aim of this study is to compare the different devices on the market in terms of complication, functional recovery and ease of use. MATERIAL AND METHOD: This is a single-center study including all patients who underwent transosseous anchor reinsertion from 2010 to 2021 with a minimum of 6 months of follow-up. Twenty-seven patients were included. The anchors used were of different types: Microfix® Quickanchor plus® and Miniquick anchor® from DePuy Mitek; Juggerknot® Soft Anchor 1.0mm from Zimmer-Biomet; or Kerifix® 4.0 from KeriMedical. We analyzed intraoperative data, complications and functional recovery by quickDASH score. RESULTS: The average age was 38.6 years (± 16.1), the demographic characteristics were identical in the different groups. There was a significant difference in the number of anchors used intraoperatively before definitive placement (P=0.02), to the disadvantage of the Juggerknot® anchors. There was no significant difference in terms of complications and functional recovery evaluated by the quickDASH. CONCLUSION: Our study did not find significant differences between the different anchors in terms of complications and functional recovery. Some anchors seem to have a better grip during placement than others.

Hand and wrist Osteo-articular bone defect: induced membrane technique indications.

Bone defect in the hand and wrist is the result of 3 main causes: traumatic, infectious or tumoral. Whatever the cause and possibility of emergency management, the site (hand or wrist) and anatomical location (articular or diaphyseal) guide the choice of surgical technique and timing. Functional sequelae do not vary, and the ultimate objective is not so much to fill a defect but to give a useful and accepted finger, hand or wrist.

[Emergency free flap in reconstruction of the lower limb: About 23 cases over 11 years]. / Reconstruction des pertes de substance des membres inférieurs par lambeau libre en urgence : à propos de 23 cas sur 11 ans.

OBJECTIVES: To study the coverage period influence and various parameters concerning the microsurgical act on the patient clinical outcomes. METHODS: We report 23 cases of reconstruction of lower limb loss of substance by free flap operated from 2010 to 2021. Among them, 9 patients were operated on as an emergency versus 14 in the secondary or late phase of the trauma. RESULTS: The average age of injured patients operated on emergency was 42 years (17-68 years) and 34 years for the patients who undergo deferred surgery (17-57 years). The sex ratio (female/male) was 22% in patients operated on urgently and 7% in patients operated on later. Regarding the type of free flap, it was Serratus anterior muscle flap in 10 cases, Latissismus dorsi flap in 9 cases, ALT flap in 3 cases and Gracilis muscle flap in 1 case. There were 2 failures of vascularized free transfer (8.7%) with complete necrosis of the flap and 3 revision surgeries on venous thrombosis which finally made it possible to obtain 3 flap successes. We analyze the results (complications/osteitis) according to the time to coverage. CONCLUSIONS: In our study, we did not find any significant difference between the groups operated in emergency and at a distance concerning the rate of infection and failure of the flaps.

[Complications and quality of life after bodylift: About 143 patients]. / Complications et qualité de vie après bodylift inférieur : à propos de 143 patients.

INTRODUCTION: The rise of bariatric surgery has led to a considerable increase in the demand for weight loss surgery. The lower body lift consists of removing the residual abdominal fat and skin excess and re-tensioning the surfaces. The objective of our study was to evaluate the associated complications, as well as the consequences of this surgery on the quality of life of the patients. MATERIALS AND METHODS: A retrospective monocentric study was conducted in patients operated on for lower body lift between 2010 and 2019 at the University Hospital of Besançon. We collected postoperative complications and studied the satisfaction and quality of life of the operated patients using the Body-QoL and SF-36 questionnaires. RESULTS: One hundred forty-three patients were included with a mean age of 41.2 years. The mean body mass index was 26.6kg/m2 with a mean weight of 73.8kg and a mean weight loss of 54.4kg. Forty-one patients (29.7%) had at least one complication. Most complications were minor, with 16.8% of scar disunions, and 7% of complications were major, requiring revision surgery. Ninety-three patients (65%) responded to the satisfaction questionnaires with improvement mostly in physical symptoms and social life. CONCLUSION: The lower body lift is an effective, safe procedure with mostly minor complications that do not influence quality of life. Patient satisfaction is high, and it is therefore justified to continue offering this procedure to correct the sequelae of massive weight loss.

Stent migration in the distal ulnar artery: A case report.

Angioplasty has taken an important place in treating cardiovascular ischemic lesions, and stenting has become a widespread routine practice. Stent loss is a complication that, although rare, can result in stent migration into a vessel with dramatic complications due to occlusion. We report the case of a 77-year-old woman who underwent surgery to remove a loose stent that had migrated into the right distal ulnar artery just before the superficial palmar arch following coronary angioplasty. The stent could be removed with the help of fluoroscopy and microscope while preserving vascular integrity. Different therapeutic strategies can be discussed in front of a stent lost in the general circulation, and those must be approached on a case by case basis.

Influence of the level of arterial resection on the replanting and revascularization results in hand surgery: prospective study over 22 months.

The objective of this work was to assess whether the injury mechanisms are responsible for histological arterial lesions. This prospective single-center study included adults with wrist or hand arterial injury. Arterial resection of at least 2 mm from the proximal and distal stumps was performed before the arterial anastomosis. Histological analysis of the arterial stumps was performed. An ultrasound was performed 1 month postoperatively to check arterial patency. A clinical and functional evaluation was done at 1 month postoperative, then every 3 months. From 2018 to 2020, 46 patients were included with a maximum follow-up of 13 months. There were 35 cuts, 2 crush injuries, 8 amputation and 1 blast injury. Macroscopically, 37% of the margins were considered damaged. Histological analysis showed significant damage in 59% of the sections (27 out of 46 patients) with 50% for crush injury, 55% for cuts by mechanical tool, 62% for cuts by power tool, 62% for amputations and 100% for blasts. The failure rate was 9%: 2 replantations and 2 asymptomatic thromboses diagnosed by ultrasound. Postoperative pain on VAS was 1.75/10, range of motion was 87%, Quick DASH was 8%, SF36 PCS was 69% and SF36 MCS was 70%. Factors influencing the success or failure of anastomosis were the mechanism of injury (p = 0.02), associated nerve damage (p = 0.014) and length of proximal arterial cut (p = 0.046). Histological arterial lesions seem to correlate with the injury mechanism. Cuts caused by glass or crush injuries do not seem to require arterial resections of more than 2 mm. A continuation of the study with a larger number of subjects may generate statistically significant results.

[Use of coupler for venous anastomoses in cervico-facial reconstruction. Retrospective study on 51 free flaps]. / Utilisation du coupleur pour les anastomoses veineuses en reconstruction cervico-faciale. Étude rétrospective sur 51 lambeaux libres.

OBJECTIVE: The aim of our study was to evaluate the interest of the mechanical anastomosic coupling device for venous anastomoses in a series of cervico-facial reconstructions after carcinologic excision. PATIENTS AND METHODS: Between January 2010 and December 2017, 46 patients underwent free flap cervico-facial reconstruction. We performed 54 venous anastomoses for 51 free flaps. Mechanical venous anastomoses were performed with a coupler (Coupler®). Thrombotic complications and choice of recipient vessels were assessed for the entire series. RESULTS: Venous anastomoses were performed using a coupler in 33.3% of the flaps (n=18). Mean operative time was lower for reconstructions with mechanical coupler anastomoses, and significantly for fibula flaps. Of eight thromboses, six were venous, two of which after the coupler anastomosis. The thrombosed veins were the branches of the internal jugular vein and the anterior jugular veins. The diameter of the couplers used was respectively 2.5mm and 2mm. CONCLUSION: The use of the microvascular coupling system for venous anastomoeis would help reduce the occurrence of venous thrombosis, but larger and prospective studies should be conducted. This coupling system, relatively easy to use, would overcome the lack of congruence of anastomosing veins and reduce the risk of intimal injury. Regarding the recipient vessels, the anterior jugular vein should not be used as first line because the risk of vascular complications seems more important.

Long-term functional results of digital replantation: A survey of 28 patients.

We sought to evaluate the long-term quality of life and functional outcome of patients who underwent digital replantation after amputation. A retrospective single-center study was conducted of patients treated between January 2010 to May 2016. Twenty-eight patients who underwent successful replantation after single or multiple digital amputation were reviewed in person after at least 2years' follow-up (mean 4.6years). Total active range of motion, grip and pinch strength were assessed. Functional outcomes were evaluated using the SF-36 and DASH questionnaires. The patients' occupational status and daily activities were reported. Mean total active range of motion was 42% of the contralateral healthy side. Better active mobility and higher grip strength were found when the amputation was distal to the insertion of the common flexor tendon. Mean grip and pinch strength were 80% and 65%, respectively. Fusion did not significantly influence active mobility. The mean DASH score was 22.3. In our study, 77% of the patients returned to the same job and 75% experienced cold intolerance. The majority of patients who underwent digital replantation maintain a quality of life that allows them to return to work. Fusion, especially in the thumb, can be performed with few functional consequences. Even many years after the replantation procedure, sensory recovery remains poor.

Fingertip amputations treated with occlusive dressings.

The aim of this study was to analyze a series of patients who suffered a distal finger amputation and who were treated with occlusive dressings. A retrospective study was done of 19 patients from a single hospital. At the review, an independent examiner evaluated the time required for wound healing, the number of occlusive dressings used, fingertip trophic skin changes, epicritic sensitivity using the Weber two-point discrimination (2PD) test, sensitivity based on the monofilament test, complications, the presence of dysesthesia or cold intolerance, and the QuickDASH score. The mean follow-up was 12.6 months (6-25). A mean of 3.2 occlusive dressings (3-5) were used per patient, and the mean healing time was 4.3 weeks (4-5). The skin texture, fingertips and nail bed were good or excellent in 18 cases. The 2PD test was good or normal in 16 cases. Eighteen patients were satisfied or very satisfied with the outcome. The mean QuickDASH score was 5.53 (0-20.45). In the literature, the recovery of tactile sensation is good after use of occlusive dressings (2PD of 2.5 to 4.0mm). The mean sensitivity reported in various studies is better than that observed after use of a skin flap. While the sample size in our study was small, the functional outcome and appearance were good. Thus we prefer using occlusive dressings in Zone 1 and 2 fingertip amputations, and flaps in zones 3 and 4 to ensure better fingertip viability and sensation.

Donor site morbidity after vascularized fibula free flap: gait analysis during prolonged walk conditions.

The aim of this study was to determine the effect of vascularized fibula free flap (VFFF) harvest on gait variables during the six-minute walk test (6MWT). Eleven patients who had undergone VFFF harvest and 11 healthy peers participated in this case-control study. The main evaluation consisted of the collection of gait variables using the GAITRite system during three periods of the 6MWT: beginning (0-1min), middle (2:30-3:30min), and end (5-6min). The 6MWT was significantly shorter in the VFFF group than in the reference group (-31%, P<0.001). Most gait variables differed significantly between the groups for each period (P-value range 0.04-0.0004), including toe in/out on the operated side (P-value range 0.005-0.01). The increase in toe in/out on the operated side suggests a functional modification caused by an imbalance of the agonist-antagonist muscles. On comparison of the different periods, gait velocity decreased between the beginning and middle periods and increased between the middle and end periods in both groups. However, a significantly lower velocity between the beginning and end periods was found only for the VFFF group (P=0.026), suggesting an alteration in physical management. In conclusion, these results suggest that VFFF harvesting could alter gait and joint integrity.

Functional assessment and quality of life in patients following replantation of the distal half of the forearm (except fingers): A review of 11 cases.

The aims of this study were to evaluate the function and quality of life in patients who have undergone replantation of the hand or forearm. We carried out a retrospective single-center study of cases performed between 1977 and 2015. Our hospital's database was searched for patients who underwent replantation of the distal half of the forearm and hand (except the fingers). The evaluation included sensitivity, joint mobility, strength and quality of life. Conventional functional scores were used. Seventeen replantation cases were identified. Four patients were lost to follow-up. Of the 13 available patients, two suffered a replantation failure. Ultimately 11 patients were included in the study. Three patients were evaluated based on their medical records and eight were reviewed in person. The mean patient age was 31±11.8 years. The sensory evaluation resulted in five patients being classified as S1 and one as S3+. The mean Kapandji score was 4.3±2.3 [0-6]. The mean grip strength was 39.4±20% [0-80], and the pinch strength was 36.2±16% [0-60] compared to the healthy contralateral side. The mean DASH was 36.2±30.4 [4.5-79.5]. According to Chen's classification, two patients were at stage IV. For 50% of patients, the overall quality of life was at least equivalent to that of the general population. Replantation of the distal half of the forearm and hand should be attempted whenever possible. Although replantation causes some disability, good quality of life seems to be maintained.

[Surgical management of a series of pressure ulcers: Report of 61 cases]. / Prise en charge chirurgicale d'une série d'escarres : à propos de 61 cas.

INTRODUCTION: Retrospective study about pressure ulcers surgical treatments in a series of 61 in 43 patients. OBJECTIVE: To assess the management of pressure ulcers in spinal cord injury patients who had been operated in our institution. RESULTS: On the 61 pressure ulcers, location was ischial in 35 cases, sacral in 15 cases, trochanteric in 7 cases, lateral malleolar in 2 cases, on the heel in 1 case, and 1 was located lateral to the fibular head. Comorbidities were searched pre- and postoperatively. Fifty-five muscular, cutaneous flaps or myocutaneous, 5 fasciocutaneous and 1 excision/suture were realized. The mean follow-up was 8.6 years, and we observed 9 pressure ulcers recurrences (14.8%). We had a total result of 15 (24.6%) complicated pressure ulcers, with 8 early complications (13.1%) and 7 delay (11.5%). Antibiotic therapy was prescribed in 54 (88.5%) surgery cases and 7 were operated without any (11.5%). CONCLUSION: Pressure ulcers are major public health focus that need to be improved. A multidisciplinary care, mixed with education of patients are mandatory to achieve these goals: reduce complications and recurrences. Thanks to muscle sparring, perforators flap should become the gold standard of pressure ulcers surgery.

[An original "double-arched" radial forearm flap for soft palate reconstruction. Case report]. / Conformation du lambeau antébrachial en arche sur mesure pour la reconstruction du voile du palais. Cas clinique.

INTRODUCTION: Reconstruction of the soft palate after oncologic resection remains a surgical challenge. Speech and swallowing problems are the consequences of velopharyngeal incompetence following soft palate resection. Free tissue transfer like radial forearm flaps can be used in larger defects for complex reconstruction. The conformation of the flap in order to be closer to the shape of the soft palate improves the functional outcome. In the same way, we describe an original "double-arched" flap design. METHODS: A double arch of the exact length of the soft palate tumor resection is designed. After suturing, the flap spontaneously formed a double arch of the exact dimensions of the resected piece. RESULTS: The patient achieved good functional recovery without any surgical complications. CONCLUSION: The original "double-arched" forearm flap design allows a tailored reconstruction with exactly the same shape and dimensions, preserving the functional requirements of speech and deglutition.

[Benefit of simultaneous contralateral breast symmetry procedure with unilateral breast reconstruction using DIEP flaps. About 33 cases]. / Intérêt de la symétrisation immédiate au cours de la reconstruction mammaire unilatérale différée par DIEP. À propos de 33 cas.

BACKGROUND: After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with DIEP flap. METHODS: We evaluated 33 consecutive patients (mean age, 52.1 years) who underwent DIEP flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed and 2 patients with delayed controlateral symmetry procedures. A single-stage breast cancer reconstruction is successful if after the original reconstruction no correction for revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction. RESULTS: In 24 patients (73%), breast reconstruction was completed after a single stage with one general anesthetic, and in 8 patients (24%), revisions were performed with two general anesthetic (7 patients) and three general anesthetic in one case. Reconstructions requiring more than one general anesthetic were due to 4 of 39 (10%) postoperative complications. Mean operating time was 485 minutes. CONCLUSIONS: For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.

Emergency repair of extensor tendon central slip defects with Oberlin's bypass technique: feasibility and results in 4 cases with more than 5 years of follow-up.

Treatment of soft tissues defects in the central slip of the extensor tendon at the proximal interphalangeal (PIP) joint is challenging because of the potential for stiffness and boutonniere deformity. The bypass procedure proposed by Oberlin for secondary injuries is an attractive solution. This salvage procedure uses a free tendon graft (palmaris longus) that is intercalated between the extensor indicis proprius muscle and the base of the middle phalanx. This study reports on the first cases of acute central slip defect treated in an emergency setting. Four patients with an average age of 37 years (range 11-69) were treated by the same surgeon using the bypass procedure. Clinical evaluations consisted of measuring the active range of motion in the PIP joint, QuickDASH, Total Active Motion (TAM) and strength with a Jamar® dynamometer. All patients had reintegrated their injured finger into their body image within three months. At the last follow-up, the average active mobility was 0-5-76.5°. The functional outcomes were similar at nine months, with an average mobility of 0-13-72°. The two patients who were working at the time of injury were able to return to work in the third month. Various procedures such as tendon plasty, transfer or graft have been described in the literature for posttraumatic chronic boutonnière deformity. In cases where significant defects exist not only in the tendon, but the bone and skin, the bypass procedure is an effective approach to achieving satisfactory functional outcomes.