[The tube in tube thoracodorsal perforator flap phalloplasty]. / Phalloplastie par Lambeau perforant thoracodorsal « tube in tube ¼.

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.

[State of affairs and optimization of plastic surgery training in France]. / État des lieux et optimisation de la formation à la chirurgie plastique en France.

BACKGROUND: Concerns have been growing for several years among masters, as to the quality and quantity of training in plastic surgery in France. They are mainly based on the reduction in the working time of residents, the appearance of new residents from generation Z to be trained, and finally the multidisciplinarity of plastic surgery in the current context of overspecialization of training center. METHODS: In order to objectify these concerns, a survey was carried out among French residents and young heads of plastic surgery to assess their training in the specialty since 2019. We then looked in the law for possibilities to alleviate these concerns. RESULTS: All the respondents think that their training in the specialty is incomplete, and few of them have been able to supplement it with rotations outside the subdivision or visits from private practitioners. However, in the law, it is possible to carry out: three residents rotations outside the subdivision, clinics rotations and international exchanges. DISCUSSION: At the end of this analysis, we propose three solutions to optimize training in plastic surgery in France: a system of exchange of residents, the opening of residents rotations in clinics, and finally, to facilitate the realization of operating aids with private practitioners. CONCLUSION: With these solutions, the field of training for residents could extend from one region to the whole of France. These solutions could easily be applied to other specialties, surgical and medical.

Breast reconstruction in France, observational study of 140,904 cases of mastectomy for breast cancer.

OBJECTIVES: In France, there are few up-to-date epidemiological data on breast reconstruction after mastectomy for breast cancer. The objective of the present study was to measure immediate and delayed breast reconstruction (IBR and DBR, respectively) rates and thus the proportion of patients not benefiting from any reconstruction. METHODS: We performed an observational study by assessing data from the French nationwide discharge summary database (Programme de Médicalisation des Systèmes d'Information) for the period 2008-2014. All women having undergone a total mastectomy for breast cancer during this period were included. We then searched for reconstructive surgery during the initial or subsequent hospital stays, and recorded the time interval between mastectomy and reconstruction. RESULTS: Among the 140,904 mastectomies included, the IBR rate was 16.1% on average, and increased over the study period. The time interval between mastectomy and DBR was≤3 years in 92% of cases. For patients included in 2008 and 2009, the DBR rate was 17.8%, and the non-reconstruction rate was 66.4%. CONCLUSION: The high proportion of women not undergoing breast reconstruction after mastectomy suggests that access to this procedure should be improved.

[The surgical portfolio: A new educational tool for the French plastic surgery residents?] / Le portfolio de l'interne de chirurgie plastique : un outil d'aide à la formation des internes de chirurgie plastique en France ?

A recent reform of the French government has shortened the plastic surgery residency from 5 to 4 years. Until today, the evaluation and validation of the residency was shared between the local coordinator for practical skills and, after the residency, by the French College of Plastic Surgery for theorical knowledges. The new reform suggests to add a portfolio that will follow the resident during his surgical training. Based on the French reform and syllabus of others medical specialities, we designed a surgical portfolio that will help the resident both with his practical progression and his knowledges acquisition. The aim of the portfolio is to get a national unity of the plastic surgery training. As a first step we will describe the actual plastic surgery residency. Then, we will detail what the reform is going to change. At last, we will introduce the surgical portfolio, its content, its use and its goals.

[Harvesting method of thoracodorsal perforator flap: Adaptation]. / Technique de prélèvement d'un lambeau perforant thoracodorsal : mise au point.

The thoracodorsal artery perforator (TDAP) flap is a reliable method of reconstruction by which the indications were on a constant rise during the last few years. Several surgical variants exist and different harvesting techniques were described. However, with our experience using this flap for substance-loss coverage, we frequently faced a complex and relatively time-consuming pedicle dissection. This brought us to adapt our harvesting technique according to the anatomical situations of the neighboring structures. The purpose of this study is to revisit and adapt the method of the pedicle dissection for the TDAP flap. The conservation of both the nervous network and a section of a circumferential muscular collar with a diameter of two centimeters are the main keys of our study.

Triple flap technique for vulvar reconstruction.

OBJECTIVE: Perineal defects are encountered ever more frequently, in the treatment of vulvar cancers or abdominoperineal resection. The surgical treatment of vulvar cancer leads to significant skin defect. The aim of the reconstruction is not to provide volume but rather to resurface perineum. We propose a new solution to cover the extensive skin defect remaining after excision. METHODS: We report 3 patients who underwent large excision for vulvar cancer, with lymph node dissection. For reconstruction, we performed 3 advancement flaps. Two V-Y flaps cantered on the infra-gluteal folds and based on pudendal perforator arteries were used to cover the postero-lateral parts of the defect. The third advancement flap from the superior aspect of the defect was a Y-V Mons pubis flap. RESULTS: The defects were successfully covered by the 3 flap technique. The first patient suffered a non-union that slowly healed by secondary intention. For the other cases, we used the same technique, but applied negative pressure wound therapy on the sutures, with excellent results. CONCLUSION: The 3 flap technique is a simple and reliable method and the donor site morbidity is minimal. It can be realised without changing the position of the patient after tumour excision, and does not require delicate perforator dissection. This surgical option can be easily applied, allowing better management of these cases.

[Anatomical basis for rejuvenation surgery]. / Bases anatomiques du tégument facial appliquées à la chirurgie du rajeunissement facial.

The understanding of the face anatomy is mandatory before to be able to appreciate the different surgical techniques of face lifting. Despite numerous controversies and anatomical variations, we can find in the literature several keystone works that allows us to understand that the soft tissues of the face are not only a superposition of layers but also a tridimensionnal structure with a fibrous system that links the different layers. This structures creates a mix loose spaces, fat and retaining ligament that can be describe in a quite systematic manner. This systematisation can help the surgeon during the surgical procedure to search and find the area where there is no danger and alert him around the retaining for example, which is where we can often find a vessel or a branch of the facial nerve that we want to avoid. This article summarizes these anatomical knowledge.

Dorsal median lipectomy (the arrow technique): A new approach for the treatment of the circumferential truncal skin and fatty tissue excess.

The increase in the number of patients who undergo massive weight loss surgery has led to an increasing number of patients who complain of circumferential abdominal skin and soft tissue excess. Currently, the only surgical option to treat soft tissue excess is vertical median abdominal lipectomy (fleur-de-lys technique). However, many patients are reluctant to undergo this surgery because of the position of the scar. We presented a new surgical approach to manage circumferential excess - dorsal median lipectomy (arrow technique) - in which the dorsal scar is well-tolerated by patients.

[Superficial Circumflex Iliac Artery Perforator flap (SCIP flap): Revival of the inguinal donor site?] / Lambeau de SCIP : renouveau du site donneur inguinal ?

The SCIP flap based on a superficial circumflex iliac perforator artery (SCIA) was described for the first time by Koshima in 2004 as a large and thin groin flap, with a low morbidity. The purpose of this study is to demonstrate the benefits of SCIP flap to cover cutaneous defects. We present a retrospective study from January 2007 to August 2016. Twelve patients had a SCIP flap reconstruction in the plastic surgery department of Amiens hospital. Thirteen flaps were performed. The average preoperative doppler mapping time was 8minutes. The average size of flaps was 62.5cm2 [21; 180cm2]. The average time required for raising flaps was 61min [52; 82min]. It has not been observed any complication of the flap or donor site. The SCIP flap has a thin paddle and the donor site morbidity is minimal. The surgical technique is safe, accessible and precision is increased by preoperative color doppler mapping. The many strengths of the SCIP flap make it a must in the algorithm for defects management and come to revitalize the inguinal donor site.

[Extension of the thoracodorsal artery perforator flap's pedicle: Anatomical study]. / De l'allongement du pédicule du lambeau perforant thoracodorsal : étude anatomique.

PURPOSE: In recent years, the indications of latissimus dorsi myocutaneous flap decreased in favor of its version preserving muscle: the thoracodorsal artery perforator flap (TDAP). The intramuscular dissection reduce donor site morbidity but also allows an extension of the pedicle compared to conventional latissimus dorsi flap pedicle. The purpose of this study was to quantify objectively elongation of the pedicle when the perforator is dissected through the muscle. METHOD: Sixteen TDAP flap were dissected in 9 cadavers. The pedicle was divided into 4 distinct parts: (1) hypodermis, (2) subcutaneous fat, (3) intramuscular, (4) conventional pedicle. RESULTS: The length of the pedicle is significantly increased when the pedicle is dissected through the muscle. This extends the theoretical length from 5.25cm up to 9.19cm if the dissection is extended to the deep fat. Indeed, this results in a potentially exploitable TDAP pedicle length of 20.66cm. CONCLUSION: The dissection of the perforator allows an extension of the pedicle of about 5 or 9cm if we continue the dissection in the subcutaneous fat. A long pedicle may be interesting in lower limb reconstructive surgery and facial reconstruction where microsurgery is not feasible.

[Ring finger reconstruction by Colson's flap]. / Reconstruction d'un arrachement digital par lambeau-greffe de Colson.

Surgical treatment of complete cutaneous ring finger avulsion is a challenge in hand surgery. When replantation of the avulsed fragment is not technically feasible, the surgeon must consider reconstruction of soft tissue. Many surgical techniques have been described. We report a case of complete avulsion of the cutaneous sheath and nail of the fourth finger with preservation of mobility and collateral nerves. The reconstruction of soft tissue was performed by a Colson flap-graft. This simple and reliable technique of reconstruction allowed to obtain a functional and sensitive finger with a satisfactory cosmetic result.

[Thin flaps in the management of hand and upper limb defects]. / Les lambeaux cutanés minces dans la prise en charge des pertes de substance cutanée de la main et du membre supérieur.

Cutaneous defect of the hand and the upper limb expose the underlying anatomical structures. The reconstruction therefore often resorts to flaps. The ideal flap must be thin and flexible, allowing a good resurfacing and a satisfactory functional result. The objective of this study is to analyze the various thinned flaps, to reveal their advantages and to underline their limits. We presented a literature review on the various techniques of thin skin flaps developed over the last 20 years, bringing together 18 articles, and including 225 patients. For 3 articles, the skin flaps were thinned down by preliminary expansion and for the 15 others they were surgically thinned during the harvesting of the flap. Thinning the flap seems to be an interesting surgical alternative in the management of cutaneous defect of the hand and the upper limb, but it would be interesting to be able to compare the results of these thin flaps to those of the conventional ones. This study also led us to propose a classification of thin flaps according to their thickness in order to clarify the terminology.

[Algorithm for surgical treatment of limb lymphedema]. / Traitement chirurgical du lymphœdème des membres : algorithme de prise en charge.

Whether primary or secondary, limb lymphedema is a relatively common disease whose impact on the quality of life of patients is important. Although the microsurgical reconstruction techniques seem to be the techniques of choice in the treatment of limb lymphedema, no consensus about treatment of limb lymphedema has yet been defined. Considering the advantages and disadvantages of surgical techniques and their impact on the quality of life of patients, we propose a surgical treatment algorithm of limb lymphedema.

[Anatomical study of men's nipple areola complex]. / Étude anatomique du complexe aérolo-mamelonnaire (CAM) chez l'homme.

The surgical approach of gynecomastia, sexual reassignment surgery in female-to-male transsexuals and the increase of number of obese wishing to turn to plastic surgery led us to deepen the anatomical knowledge of the nipple areola complex (NAC) in men, poorly retailed in the literature. By inspiring us of the methodology of a Japanese study, we studied 50 healthy volunteers male, from 18 to 55 years old, from July till August 2015. We measured various distances relative to the NAC to define its vertical and horizontal position, as well as the internipple distance according to the size, to the weight and to the body mass index (BMI). At the end of the analysis, we were able to underline a lower vertical thoracic position of the NAC in the tall category of person, a more side horizontal position to the subject presenting a high BMI and a linear relation between the BMI and the internipple (Em) defined by (Em)=8.96×BMI. The surgeon's judgment and the desires of the patient are essentials basis of therapeutics decisions that could be lean on this anatomical study, which allowed to establish an idea of the cartography of the NAC in man. It will be interesting and necessary to confront it with other studies with larger scale.

Change of paradigm in thoracic radionecrosis management.

Classically, muscular or omental flaps are the gold standard in the management of thoracic defects following radionecrosis debridement. Their vascular supply and antibacterial property was supposed to enhance healing compared with cutaneous flaps. The evolution of reconstructive surgery allowed us to challenge this dogma. Therefore, we present five consecutive cases of thoracic radionecrosis reconstructed with cutaneous perforator flaps. In four patients, we performed a free deep inferior epigastric perforator (DIEP) flap and one patient had a thoracodorsal perforator (TDAP) flap. Median time healing was 22.6 days with satisfactory cutaneous covering and good aesthetic results. There were no flap necrosis, no donor site complications. We believe that perforator flaps are a new alternative, reliable and elegant option that questions the dogma of muscular flaps in the management of thoracic radionecrosis.