Reconstruction of penile skin loss by superficial circumflex iliac perforator (SCIP) pedicled flap after Fournier's gangrene.

INTRODUCTION: Fournier's gangrene is a serious pathology with a high mortality rate. Treatment requires a large debridement of necrotized tissues, conducing to a skin loss, requiring a reconstruction, which may involve different surgical techniques, depending on the context as well as the size and location of the skin loss. The most common covering technique uses split-thickness skin grafting, which however presents a risk of contracture. CASE: Our 63 years old patient presented a Fournier's gangrene, leading to pubic and circular penile skin defects after multiple debridements. We decided to practice a right superficial circumflex iliac perforator (SCIP) pedicled flap to reconstruct the penile skin sheath. The flap was rotated 180 degrees and rolled around the penis. DISCUSSION: The inguinal pedicle flap is described for penile reconstruction, the SCIP flap for perineal reconstruction, and even bilateral SCIP flaps for performing phalloplasty, but SCIP pedicled flap is not already described for isolated penile skin sheath reconstruction. Skin loss in our patient was not extensive, permitting us to perform this surgical technique. To go further, note the possibility of carrying out this reconstruction by a super-thin SCIP flap, as a pure skin graft flap. CONCLUSION: The SCIP pedicled flap seems us to be a safe technique for penile skin reconstruction and a good alternative to the usual skin grafts, especially regarding the lower risk of contracture, and low donor-site morbidity.

[Satisfaction and quality of life after DIEP-flap breast reconstruction]. / Satisfaction et qualité de vie après reconstruction mammaire par lambeau de DIEP.

Satisfaction and quality of life of patients who have undergone DIEP-flap breast reconstruction have been assessed by many authors in many countries using standardized tools. However, some simple and practical information is often not found in these studies. The aim of our work was to carry out a practical satisfaction survey of patients reconstructed by DIEP flap in our center. Our cohort was made up of 207 patients who underwent DIEP-flap breast reconstruction in Marseille between January 2014 and December 2020. A letter containing our original satisfaction survey was sent to all the patients in our sample. We received 104 responses, which were statistically analyzed using the flat sorting method. Nine-two percent of patients were globally satisfied with the result of their breast reconstruction. A large majority of patients are in favor of the idea of performing their reconstruction again using a DIEP flap. Fifty-five percent of participants were "not bothered at all" by their abdomen after their surgery. The DIEP flap is a versatile technique that allows surgeons to offer it in multiple breast reconstruction situations and to obtain a high degree of patient satisfaction.

Assessing the effect of PRP addition to facial micro-lipofilling for patients suffering from Scleroderma: A prospective routine care analysis.

BACKGROUND: Combining fat graft with platelet derived products is now common practice in regenerative surgery. We proposed to assess the safety and efficacy of Platelet-Rich Plasma (PRP) addition to a micro-lipofilling protocol for facial treatment of patients suffering from Systemic Sclerosis (SSc). OBJECTIVE: Main objective was to evaluate the improvement of the Mouth Handicap In Systemic Sclerosis (MHISS) scale score at 6 months post-therapy. METHOD: Included SSc patients had a MHISS score equal or up to 20. Surgery was performed under general anesthesia. Micro-fat and PRP (CCA-NA from DEPA Classification) were mixed in a 70/30 ratio, before injection in peri-oral sites according to a specific protocol. Efficacy criteria were recorded at baseline, 3 and 6 months. Moreover, we compared this cohort (current study) to a former (2015) non-enriched micro-lipofilling cohort in the same indication, using the same protocol. RESULTS: Thirteen women patients with mean age of 53.2 years (±14.3) have been included. At baseline, mean MHISS score was 29.5 (±8.7) and significantly decreased to 22.5 (±7.8) at 6 months (P=0.016), corresponding to a 22.0% of improvement from baseline, with a mean decrease of 6.5 points (±7.5) at 6 months. Patients received a mean volume of 30.8ml PRP-micro-fat (±8.1ml). CONCLUSION: PRP addition appeared beneficial, however, controlled studies are required to determine its superiority to facial micro-lipofilling.

Ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis.

There is increasing evidence that a minority of adults with acute appendicitis have gastric contents, posing an increased risk of pulmonary aspiration. This study aimed to evaluate the proportion of children with acute appendicitis who have gastric contents considered to pose a higher risk of pulmonary aspiration. We analysed point-of-care gastric ultrasound data routinely collected in children before emergency appendicectomy in a specialist paediatric hospital over a 30-month period. Based on qualitative and quantitative antral assessment in the supine and right lateral decubitus positions, gastric contents were classified as 'higher-risk' (clear liquid with calculated gastric fluid volume > 0.8 ml.kg-1 , thick liquid or solid) or 'lower-risk' of pulmonary aspiration. The 115 children studied had a mean (SD) age of 11 (3) years; 37 (32%; 95%CI: 24-42%) presented with higher-risk gastric contents, including 15 (13%; 95%CI: 8-21%) with solid/thick liquid contents. Gastric contents could not be determined in 13 children as ultrasound examination was not feasible in the right lateral decubitus position. No cases of pulmonary aspiration occurred. This study shows that gastric ultrasound is feasible in children before emergency appendicectomy. This technique showed a range of gastric content measurements, which could contribute towards defining the risk of pulmonary aspiration.

[Classification of mammary asymmetries and principles of treatment]. / Classifications des asymétries mammaires et indications chirurgicales.

Constitutional breast asymmetries are responsible not only for esthetic unsightliness, but also, at times, for psychological disorders, and medical management is necessitated. While surgical treatment is the only viable therapeutic option, given the wide variety of morphological presentations of mammary asymmetries, the surgeon is called upon to be well versed in breast surgery techniques. The authors have put forward a classification of mammary asymmetries and principles of treatment.

Position statement on classification of basal cell carcinomas. Part 2: EADO proposal for new operational staging system adapted to basal cell carcinomas.

BACKGROUND: No simple staging system has emerged for basal cell carcinomas (BCCs), since they do not follow the TNM process, and practitioners failed to agree on simple clinical or pathological criteria as a basis for a classification. Operational classification of BCCs is required for decision-making, trials and guidelines. Unsupervised clustering of real cases of difficult-to-treat BCCs (DTT-BCCs; part 1) has demonstrated that experts could blindly agree on a five groups classification of DTT-BCCs based on five patterns of clinical situations. OBJECTIVE: Using this five patterns to generate an operational and comprehensive classification of BCCs. METHOD: Testing practitioner's agreement, when using the five patterns classification to ensure that it is robust enough to be used in the practice. Generating the first version of a staging system of BCCs based on pattern recognition. RESULTS: Sixty-two physicians, including 48 practitioners and the 14 experts who participated in the generation of the five different patterns of DTT-BCCs, agreed on 90% of cases when classifying 199 DTT-BCCs cases using the five patterns classification (part 1) attesting that this classification is understandable and usable in practice. In order to cover the whole field of BCCs, these five groups of DTT-BCCs were added a group representing the huge number of easy-to-treat BCCs, for which sub-classification has little interest, and a group of very rare metastatic cases, resulting in a four-stage and seven-substage staging system of BCCs. CONCLUSION: A practical classification adapted to the specificities of BCCs is proposed. It is the first tumour classification based on pattern recognition of clinical situations, which proves to be consistent and usable. This EADO staging system version 1 will be improved step by step and tested as a decision tool and a prognostic instrument.

Position statement on classification of basal cell carcinomas. Part 1: unsupervised clustering of experts as a way to build an operational classification of advanced basal cell carcinoma based on pattern recognition.

BACKGROUND: No simple classification system has emerged for 'advanced basal cell carcinomas', and more generally for all difficult-to-treat BCCs (DTT-BCCs), due to the heterogeneity of situations, TNM inappropriateness to BCCs, and different approaches of different specialists. OBJECTIVE: To generate an operational classification, using the unconscious ability of experts to simplify the great heterogeneity of the clinical situations into a few relevant groups, which drive their treatment decisions. METHOD: Non-supervised independent and blinded clustering of real clinical cases of DTT-BCCs was used. Fourteen international experts from different specialties independently partitioned 199 patient cases considered 'difficult to treat' into as many clusters they want (≤10), choosing their own criteria for partitioning. Convergences and divergences between the individual partitions were analyzed using the similarity matrix, K-mean approach, and average silhouette method. RESULTS: There was a rather consensual clustering of cases, regardless of the specialty and nationality of the experts. Mathematical analysis showed that consensus between experts was best represented by a partition of DTT-BCCs into five clusters, easily recognized a posteriori as five clear-cut patterns of clinical situations. The concept of 'locally advanced' did not appear consistent between experts. CONCLUSION: Although convergence between experts was not granted, this experiment shows that clinicians dealing with BCCs all tend to work by a similar pattern recognition based on the overall analysis of the situation. This study thus provides the first consensual classification of DTT-BCCs. This experimental approach using mathematical analysis of independent and blinded clustering of cases by experts can probably be applied to many other situations in dermatology and oncology.

A new surgical approach in the treatment of tracheostomy scars.

The tracheostomy procedure presents some long term complications such as the depressed scar. It can be responsible for a tracheal tug, invaginated scar, inaesthetic scar or all of them. No consensus has emerged in the treatment of this type of pathological scarring. We want to propose a new surgical approach to correct all these three pathological scarring mechanism by a subcutaneous flap in single operation.

[Secondary surgery of breast reconstructions by breast implant. Assessment of patient satisfaction based on surgical technique implant conservation vs. autologous conversion]. / Chirurgie secondaire des reconstructions mammaires par prothèses. Évaluation de la satisfaction des patientes selon la technique chirurgicale : conservation d'implant vs conversion autologue.

INTRODUCTION: Breast reconstruction with implants has long-term disadvantages and is leading an increasing number of patients to request secondary corrective surgery. Two surgical strategies are possible: implant replacement (associated with capsulectomy/capsulotomy and/or lipofilling procedures) and implant removal associated with the provision of autologous tissue (flap and/or lipofilling). METHOD: Between 2010 and 2018, 54 patients underwent secondary surgery for correction of a first implant breast reconstruction. The reasons for dissatisfaction with the initial reconstruction, the procedures performed, and postoperative complications were analysed. Patient well-being and satisfaction were evaluated using the BREAST-Q questionnaire. RESULTS: Thirty-four patients benefited from a prosthesis change and 20 patients benefited from a permanent removal of their prosthesis combined with the addition of autologous tissue. The presence of a periprosthetic shell, pain, fixed appearance of the breast and breast asymmetry were the most frequent reasons for dissatisfaction. With a mean follow-up of 2.6 years, autologous conversion patients were generally more satisfied with the appearance of their breasts than patients who retained a breast implant (P<0.0001). CONCLUSION: In cases of poor esthetic or functional outcomes of implant-based breast reconstruction, removal of the prosthesis in combination with autologous reconstruction provides better results in terms of well-being and satisfaction than implant replacement.

The two-stage free flap strategy: An alternative to reconstruct major oncological surgical defects with noble organ exposure.

BACKGROUND: To minimize the risk of viscera exposure for parietal or calverial reconstruction after tumor removal, we used the two-stage free flap strategy. The flap was transferred a few days before tumor resection and left in a standby position until the second stage. PATIENTS AND METHOD: We conducted a retrospective monocentric study. All patients who underwent reconstruction with the two-stage free flap strategy after tumor resection since 2000 were included. RESULTS: We performed 14 two-stage flaps (8 for calvaria, 3 for abdomen, and 3 for thorax) on 12 patients. The average skin paddle surface was 318 cm2. The mean operative time was 274min for the first stage and 172min for the second stage. The average time between the two stages was 8.8 days (2 to 24 days). One flap necrosis, one venous thrombosis, and one hematoma were observed after the first stage. Partial skin paddle necrosis (2 flaps) and infections (3 flaps) occurred after the second stage. The mean follow-up was 20 months (6 to 61 months), and two patients had tumor recurrence. CONCLUSIONS: The two-stage free flap strategy is another option for major oncological reconstructions, to be safe and reliable some rules must be followed. The flap must contain a large skin paddle to ensure flap autonomization and to allow for complete tight plication of the flap between the two stages, which limits germ colonization. A short delay between the two stages (<12 days) decreases the risk of infection. The presence of a plastic surgeon during the second stage decreases the risk of pedicle trauma.

Full moonlight-induced circadian clock entrainment in Coffea arabica.

BACKGROUND: It is now well documented that moonlight affects the life cycle of invertebrates, birds, reptiles, and mammals. The lunisolar tide is also well-known to alter plant growth and development. However, although plants are known to be very photosensitive, few studies have been undertaken to explore the effect of moonlight on plant physiology. RESULTS: Here for the first time we report a massive transcriptional modification in Coffea arabica genes under full moonlight conditions, particularly at full moon zenith and 3 h later. Among the 3387 deregulated genes found in our study, the main core clock genes were affected. CONCLUSIONS: Moonlight also negatively influenced many genes involved in photosynthesis, chlorophyll biosynthesis and chloroplast machinery at the end of the night, suggesting that the full moon has a negative effect on primary photosynthetic machinery at dawn. Moreover, full moonlight promotes the transcription of major rhythmic redox genes and many heat shock proteins, suggesting that moonlight is perceived as stress. We confirmed this huge impact of weak light (less than 6 lx) on the transcription of circadian clock genes in controlled conditions mimicking full moonlight.

Fast Gate-Based Readout of Silicon Quantum Dots Using Josephson Parametric Amplification.

Spins in silicon quantum devices are promising candidates for large-scale quantum computing. Gate-based sensing of spin qubits offers a compact and scalable readout with high fidelity, however, further improvements in sensitivity are required to meet the fidelity thresholds and measurement timescales needed for the implementation of fast feedback in error correction protocols. Here, we combine radio-frequency gate-based sensing at 622 MHz with a Josephson parametric amplifier, that operates in the 500-800 MHz band, to reduce the integration time required to read the state of a silicon double quantum dot formed in a nanowire transistor. Based on our achieved signal-to-noise ratio, we estimate that singlet-triplet single-shot readout with an average fidelity of 99.7% could be performed in 1 µs, well below the requirements for fault-tolerant readout and 30 times faster than without the Josephson parametric amplifier. Additionally, the Josephson parametric amplifier allows operation at a lower radio-frequency power while maintaining identical signal-to-noise ratio. We determine a noise temperature of 200 mK with a contribution from the Josephson parametric amplifier (25%), cryogenic amplifier (25%) and the resonator (50%), showing routes to further increase the readout speed.

Arm reconstruction.

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

[Surgical treatment of recurrent pressure ulcers in spinal cord injured patients]. / La chirurgie secondaire des escarres chez le blessé médullaire.

Not to burn one's bridges. This is the basic principle that comes immediately to the mind of the plastic surgeon when one brings up the secondary surgery of pressure ulcers, which is a common pathology in the spinal cord injured patients. Which ones are good candidates for surgical treatment? When? What preoperative, infectious, rehabilitative management is most likely to minimize the number of failures and recurrences? Which operative technique to prefer in first intention? And in case of secondary surgery, how to choose the best strategy? We will see that some cases can be treated by primarily closing or flap remobilization but, in case of greater loss of substance the realization of a flap from another anatomical region will be essential.

[To harvest a SIEA flap instead of a DIEP flap in breast reconstruction: A technical note]. / Prélever un SIEP à la place d'un DIEP en reconstruction mammaire : note technique.

Breast reconstruction by abdominal flap has evolved to ensure minimal donor-site morbidity with the description of Deep Inferior Epigastric artery Perforator flap (DIEP flap). Being of the same thickness and the same surface, the Superficial Inferior Epigastric Artery flap (SIEA flap) does not require, for it harvesting, to open the abdominal fascia or to dissect through the muscles minimizing again donor-site sequelae. However, it is little used because of the variability of its vascularization and a higher failure rate than the DIEP in the literature. We believe that it is reasonable, in some cases, to harvest a SIEA flap instead of DIEP flap in mammary reconstruction. We present a technical note explaining our operative strategy for reliably taking a SIEA when the caliber of the vessels allows.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study.

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Toward the adoption of cementochronology in forensic context.

Because acellular dental cementum is considered to be formed continually throughout life and to not undergo remodeling processes, cementochronology is considered to be a method with the potential for directly assessing chronological age. Considering that most previous studies on humans have assumed the superior performance of this method, it is surprising that this technique is not more widely adopted in anthropology. To understand this controversy, we highlight that there is no standardized procedure for sample preparation. The numerous technical approaches that exist impact the reliability of the method, and the recent creation of an international work group (Cementochronology Research Program) demonstrates the need for researchers to share their experience to overcome these obstacles. This paper aims to address this paradox by debating the aspects that contribute to the limited use of this method and by illustrating its potential through an application on forensic cases. A protocol, which was recently certified according to the ISO-9001, was applied to nine anthropological cases from the Forensic Medicine Institute of Lille (northern France) and compared with routine osteological and dental methods. The results show that traditional methods matched the known age due to the wide extent of their range, while the accuracy and precision of cementochronological estimates was also notable. This paper establishes that cementochronology may serve as a particularly important tool for age estimation for forensic anthropologists and should, at least, be used in addition to other methods.

Production of platelet-rich plasma gel from elderly patients under antithrombotic drugs: Perspectives in chronic wounds care.

Platelet-Rich Plasma (PRP) is an autologous biological therapy obtained by centrifuging the patient's own blood to concentrate platelets. The addition of autologous thrombin and calcium chloride to PRP allows the production of a semi-solid form called PRP gel. PRP gel is increasingly used in a variety of tissue defects and predominantly in the management of non-healing chronic wounds. The topical application of PRP gel seems promising due to the capability of platelets to store and secrete growth factors (GF), fibrin and cytokines, which are essentials for wound healing. Most patients who suffered from chronic wounds are elderly patients with co-morbidities and polypharmacy including antithrombotic drugs such as antiplatelet agents (AP) or anticoagulants (AC), which could hamper the feasibility of this autologous platelet-derived therapy. To date, no study has investigated PRP gel formation in patients with AP or AC. The aim of this study was to evaluate the influence of AP or AC drugs on the production of PRP gel formation from elderly patients. Different biological characteristics were determined to qualify the production of PRP gel from such patients (Interquartile range (IQR) = 75-92 years) compared to healthy volunteers (IQR = 23-37 years). No significant difference was observed in the volume, composition (quantity of platelets, leukocytes and red blood cells) and functionality of platelets from PRP except a higher ADP-induced P-selectin expression in healthy donors compared with elderly patients. Autologous thrombin characteristics were similar in the two groups. Gel time formation (IQR: 120-195 seconds for controls and 135-210 seconds for elderly patients) and final composition of PRP gel were not significantly modified. Concentrations of theoretical thrombin generated in the serum and in the gel were inversely correlated with the time of formation of PRP gel (r2 = 0.57, p = 0.012). Altogether these data indicate that PRP gel preparation is not impacted by the use of antithrombotic drugs. Such results support the feasibility of using this innovative autologous biotherapy in the management of elderly patients with non-healing chronic wounds.

[Treatment of wrinkles of the upper lip by emulsified fat or "Nanofat": Biological and clinical study about 4 cases]. / Traitement des ridules de la lèvre supérieure par graisse émulsifiée ou « Nanofat ¼ : étude biologique et clinique à propos de 4 cas.

OBJECTIVE: Emulsified fat injection showed its interest in aesthetic facial surgery. The adipose tissue harvested is mechanically emulsified and filtered. The suspension obtained is injected into the dermis through small diameter needles (27 to 30 gauges). The objective of our study was to evaluate the biological composition of emulsified fat and its clinical effectiveness in the treatment of peri-oral wrinkles in 4 patients aged 50 to 59 years. MATERIAL AND METHOD: Each patient received an intradermal injection of emulsified fat in the peri-oral wrinkles prepared from abdominal fat under local anesthesia. The cell viability, stromal vascular fraction (FVS) composition in emulsified fat and the adipocyte differentiation capacity of mesenchymal stem cells (MSC) were studied. The clinical results were evaluated by standardized photographs, 3D microphotography, confocal microscopy, and self-evaluation of patient satisfaction over a period of 4 months. RESULTS: The biological study of the emulsified fat found a lysis of all the adipocytes. The mean number of FVS cells was 126,330±2758 cells by cc of emulsified fat with preserved cell viability (85.1±6.84 %) and a good proportion of regeneratives cells (18.77±6.2 %). The clinical study found a tendency to decrease the volume of wrinkles on standardized photography and 3D microphotography no significative. Patients were satisfied with treatment with an average score of 7±1.15/10 to 4 months. CONCLUSION: Intradermal injection of emulsified fat seems to be an interesting treatment of face wrinkles. Our study has shown its safety, but additional studies seems necessary to confirm its clinical efficacy.