Interest of frozen section procedure in skin tumors other than melanoma.

BACKGROUND: Skin tumors are common. Recommended treatment in most cases is surgery, with margins adapted. Except in the case of simple resection and suture, it is necessary to know the status of the margins before reconstructing the defect. A one-stage technique is possible with frozen section analysis, which gives the surgeon an intraoperative assessment of resection quality. The aim of our work is to study the reliability of the frozen section procedure. METHOD: A retrospective study included 689 patients who underwent surgery for skin tumor (excluding melanoma) between January 2011 and December 2019 at the University Hospital of Caen, France. RESULTS: In 639 patients (92.75%), the frozen section analysis found healthy margins. There were 21 cases of discrepancy between the frozen section analysis and final histology. Infiltrating and scleroderma-like basal cell carcinomas showed a significantly higher frequency of affected margins on frozen section analysis (p < 0.001). The tumor size and location played a significant role in the margin status. CONCLUSION: In our department, the frozen section procedure is the reference examination indicating immediate flap reconstruction. The present study demonstrated its interest and overall reliability. However, it is to be used according to histologic type, size, and location.

Management after fibula free flap necrosis in maxillofacial reconstruction.

INTRODUCTION: Few articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction. MATERIAL & METHODS: Between 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy. RESULTS: In Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days. DISCUSSION: Based on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.

Improvement of patient care through hirudotherapy and the management of leeches from their reception to their disposal in France.

OBJECTIVE: Medicinal leech therapy - known as hirudotherapy (HT) - is an empirical medical technique that has become popular again in reconstructive surgery. However, at each step of leech management there are risks for blood contamination of the caregivers and severe infections for patients. This reduces the success of the treatment. The aim of this study was to improve the management of leeches from ordering to disposal to improve patient care. METHODS: First, a review of the literature was performed. Second, we conducted a retrospective study of patients' antibiotic prophylaxis from January 2018 to December 2019. The data we collected were patient characteristics, the specific care unit at the hospital, indication, contra-indication, posology, duration of HT, number of leeches delivered, antibiotic prophylaxis prescribed and microbial organism, if identified. Third, an interdisciplinary meeting was organised to review the entire leech circuit: ordering, maintenance, prescription, dispensing, application and disposal. RESULTS: At the end of the literature review, six articles based on practices implemented in France were selected for inclusion. These articles discussed antibiotic prophylaxis, iron supplementation, and leech storage, application and disposal. On the retrospective study performed, antibiotic prophylaxis for HT was performed for 60% (30/50) of patients, 77% (23/30) of the prescriptions followed the recommendations for antibiotic prophylaxis, and 20 patients did not receive antibiotic prophylaxis. The interdisciplinary meeting made it possible to define a collegially validated protocol, containing a computerised antibiotic prophylaxis prescription, including per os ciprofloxacin antibiotic prophylaxis, intravenous iron supplementation and biological monitoring. A leech application protocol was created, and the method of leech disposal was revised. CONCLUSION: Despite the absence of clear guidelines and heterogeneous practices, this study reveals the importance of a standard procedure including leech management practices before use, antibiotic prophylaxis and application and disposal guides. The interdisciplinary protocol allows improved patient care management and makes leech management safer for caregivers.

Focus on the use of maxillomandibular fixation in mandibular fracture oseosynthesis.

OBJECTIVES: The objective of this study was to evaluate the efficiency of three methods of isolated mandibular fracture intraoperative reduction. MATERIALS AND METHODS: This 6-year retrospective study included patients with isolated extra-articular mandibular fractures who would benefit from osteosynthesis. The endpoint was postoperative occlusion according to the type of intraoperative immobilization: screws, arch, or manual reduction. RESULTS: A total of 145 patients were included, with 233 fractures. Forty-five patients underwent manual reduction without maxillo-mandibular fixation (MMF), 51 MMF with screws, and 49 MMF with arch, with 11.1%, 5.9% and 4.1% of patients in these groups experiencing postoperative malocclusion, respectively. The overall malocclusion rate was 6.9%. There was no significant difference among the 3 methods according to univariate statistical analysis (p = 0.42) or after comparing MMF (grouping screws and arches) to manual reduction without MMF (p = 0.29). CONCLUSION: This study did not show a significant difference between the different methods of intraoperative reduction of isolated extra-articular mandibular fractures, even though intraoperative MMF was much more commonly used for complex fractures. However, there is a non-significant tendency to get a better post-operative occlusal result with MMF, which remains the reference traitement. Intraoperative manual reduction without MMF may be used within trained teams in some instances.

Rerouting the internal thoracic vessels as recipient vessels in head and neck reconstruction: Comparison of two anatomic approaches.

INTRODUCTION: The vessel-depleted neck situation is a challenge for the surgeon in search of suitable recipient vessels for microvascular reconstruction of the head and neck. The internal thoracic vessels (ITVs) have proven useful as "rescue" recipient vessel resource. The objective of this report is to assess the feasibility of using ITVs by rerouting the pedicle for free flap reconstruction of the head and neck by comparing two different approaches. MATERIAL AND METHODS: Two surgical approaches were assessed: the classical one is parasternal, but cardiac surgeons commonly use median sternotomy. We conducted an anatomical study, comparing on the same subject the lengths and diameters of both internal thoracic artery (ITA) and internal thoracic vein (ITV) at the sixth, fifth, and fourth intercostal spaces (ICSs) through parasternal approach on one side and by median sternotomy on the other side. RESULTS: The study was performed on 13 subjects. We found a superiority of length of the ITVs with the median sternotomy approach. Regarding the mean length of the ITA, the sternotomy approach allowed a significant greater length with 119/89/67 mm, compared with parasternal approach with 91/62/42 mm, respectively at the sixth, fifth, and fourth ICS (p<0.001). Similarly, we observed a significant greater length of the ITV with 116/85/63 mm versus 89/62/42 mm (p<0.001). The mean arterial and venous diameters were 2.9 mm and 2.1 mm in the sixth ICS, 3.3 mm and 2.3 mm in the fifth ICS, and 3.9 mm and 2.9 mm in the fourth ICS, respectively. CONCLUSION: These results help to guide the choice of surgical approach and the level of harvesting.

Towards an evolution in ambulatory surgery for orbital floor repair? Our experience over a period of 11 years.

INTRODUCTION: Orbital floor fracture repair is a complex surgery with intra-orbital hematoma being the most feared complication as it can lead to visual loss if not treated in good time. This is why currently patients are monitored for almost 48 hours as inpatients. The purpose of this study was to find out if orbital floor repair surgery could be safely undertaken as a day case by reviewing the experience of the last 11 years at the Caen University Hospital. MATERIALS AND METHODS: A retrospective, monocentric study was conducted at the Caen University Hospital. All patients undergoing orbital floor reconstruction in a trauma setting from January 2008 to December 2019 were included. RESULTS: Of the 130 included patients, none presented a post-operative complication such as intra-orbital hematoma. 3 patients had their surgery performed as a day case. DISCUSSION: In the literature, more and more surgeons are proposing orbital floor fracture repair to be undertaken as day case. Indeed, the theoretical risk of intra-orbital hematoma is greater within the first 6 hours after surgery and can persist up to 10 days postoperatively. Provided patients meet the classic criteria for outpatient surgery, and are provided with a precise post-operative care protocol. Under these conditions, orbital floor fractures may be repair in ambulatory surgery.

Labiomental sensation after segmental mandibulectomy and inferior alveolar nerve preservation for osteoradionecrosis.

Advanced mandibular osteoradionecrosis requires a segmental mandibulectomy with reconstruction using a free fibular flap. The conservation of labiomental sensation by lateralization of the inferior alveolar nerve is unusual during a segmental mandibulectomy. A protocol for the evaluation of labiomental sensation has been created for the clinical follow-up of operated patients. The patients included were patients with mandibular osteoradionecrosis who underwent a segmental mandibulectomy with reconstruction by free fibular flap and whose pre-operative labiomental sensation was preserved. All patients were followed-up by the same examiner and operated on by the same surgeon. The neuro-sensitive examination analyses the different forms of sensation at 1 week and at 12 months postoperatively. Between May 2017 and May 2018, 3 consecutive patients were assessed. The results of the labiomental sensitive evaluation using our evaluation protocol attest to the preservation of labiomental sensation. The operating time was increased by an average of 35 min per surgical procedure. The conservation and re-routing of the inferior alveolar nerve in segmental mandibulectomy with fibula free flap reconstruction in patients with osteoradionecrosis allows for the preservation of labiomental sensation, which improves the quality of life of patients. Our protocol can be used in all surgical procedure that affect sensibility.

In-house 3D printing: Why, when, and how? Overview of the national French good practice guidelines for in-house 3D-printing in maxillo-facial surgery, stomatology, and oral surgery.

3D-printing is part of the daily practice of maxillo-facial surgeons, stomatologists and oral surgeons. To date, no French health center is producing in-house medical devices according to the new European standards. Based on all the evidence-based data available, a group of experts from the French Society of Stomatology, Maxillo-Facial Surgery and Oral Surgery (Société Française de Chirurgie Maxillofaciale, Stomatologie et Chirurgie Orale, SFSCMFCO), provide good practice guidelines for in-house 3D-printing in maxillo-facial surgery, stomatology, and oral surgery. Briefly, technical considerations related to printers and CAD software, which were the main challenges in the last ten years, are now nearly trivial questions. The central current issues when planning the implementation of an in-house 3D-printing platform are economic and regulatory. Successful in-house 3D platforms rely on close collaborations between health professionals and engineers, backed by regulatory and logistic specialists. Several large-scale academic projects across France will soon provide definitive answers to governance and economical questions related to the use of in-house 3D printing.

A Unique Case of Lower Limb Soft Tissue Reconstruction with a Prefabricated Bipedicled Deep Inferior Epigastric Artery Flap.

Aesthetic lower-extremity reconstruction is a secondary field in lower limb reconstructive surgery. Nevertheless, it plays an important role in the final stages of patient rehabilitation after traumatic events, treatment of deformations, and oncoplastic surgery, and in unique cases of purely aesthetic reconstruction. We present a clinical case of lower limb reconstruction with a prefabricated bipedicled deep inferior epigastric artery (DIEP) flap in a young patient who underwent a massive congenital circular pigmented nevus excision surgery. Due to the lack of sufficient donor site tissues anywhere on the body, a bilateral DIEP flap was prefabricated using tissue expansion. Two expanders were used to prepare the donor site. Six months after expansion, lower limb reconstruction was performed. A large (50 × 25cm2) surgical defect was covered by a prefabricated DIEP flap. Flap positioning was regarded with extra care due to importance of proper venous outflow in accordance with lower limb venous anatomy. Treatment results were above the satisfactory level both aesthetically and therapeutically. Aesthetic and therapeutic incentives were assessed before surgical treatment decision. Large defects of the lower limbs require significant amount of excess tissue in the donor site and may require prefabrication. In young patients with low BMI, flap transfer is nearly impossible without prior expansion. In this case, we successfully performed giant pigmented nevus excision, with immediate reconstruction with a prefabricated bilateral DIEP flap. Venous outflow was problematic due to the anatomical structure of lower limb veins. This required extra venous drainage and special regard to positioning of the flap.

Salvage of a free flap by cephalic suspension with Tessier's diadem.

The authors present a case of a patient with a large occipital meningioma, treated by embolisation and surgery, in which skin necrosis occurred overlying the craniotomy bone flap. A free Latissimus dorsi flap was used to cover the tissue loss but poor healing and flap condition occurred due to contact with the anti-sore bed system making it impossible to maintain the patient on dorsal position. A cephalic suspension was carried out by Tessier's diadem making it possible to salvage the flap and to treat the patient.