Keratoacanthoma or cutaneous squamous cell carcinoma revealing a DNA mismatch repair default (Muir-Torre Syndrome).

Keratoacanthoma (KA) and well-differentiated cutaneous squamous cell carcinoma (cSCC) are hardly distinguishable clinically and histologically. They both can be seen in patients with hereditary non-polyposis colorectal cancer (HNPCC) or Lynch Syndrome, corresponding to DNA microsatellite instability. In our case, a young man had the excision of two rapidly growing skin tumours for which distinction between KA and cSCC was initially clinically and pathologically challenging. The diagnosis of well-differentiated cSCCs was made and the patient was treated with surgery. Ten years after the first cSCC, he was diagnosed with Muir-Torre syndrome, a variant of Lynch syndrome, with an heterozygote mutation of the MSH2 gene. This later diagnosis allowed to screen his family members for the same mutation and to adopt an appropriate follow-up regarding the risk of digestive tumours for him and his family. Furthermore, it is important to know that, in case of non-resectable cSCC occurring in this patient, immunotherapy using anti-PD1 antibody would probably be effective due to the known increased immunogenicity of MMR deficient tumours.

Superficial temporal artery capillary perforator-based island flap for conchal bowl and external auditory canal reconstruction.

BACKGROUND: Reconstruction of the auricle is challenging to surgeons as a result of its complex anatomy. Defects including the conchal bowl and the external auditory canal (EAC) do not accept imperfection as functional consequences may add to aesthetic ones. Local flaps that are relying mainly on posteriorly based auricle flaps do not represent ideal solutions. This study aims to report the perforator modification of an anteriorly based pre-auricular flap that matches all requires goals of reconstruction. METHODS: From 2015 to 2019, three capillary perforator-based island flaps (c-PBIF), with the Superficial Temporal Artery (STA) as source pedicle, were performed to reconstruct a combined Conchal Bowl-External Auditory Canal (CB-EAC) defect, secondary to basal cell carcinoma resection. Free margins were obtained via the Tubigen micrographic approach. All three flaps were raised on the perforator originating from the superficial temporal pedicle. In 2 of the cases, the perforator was found at the level of the tragus while in the last case, it was found 1cm more distal. Capillary perforators were isolated and dissected down to their origin from the STA thereby increasing their arc of rotation and pliability. The median follow-up time was 4 years. RESULTS: All flaps survived. Aesthetic results were excellent leaving no distortion of the external ear and the hollow aspect of the conchal was well supported. The tragus mount was preserved, EAC lining was secured, and good audition was restored with no bulging of the flap into the canal in all the cases. CONCLUSION: Harvesting pre-auricular flaps as c-PBIFs are safe and acts as an excellent solution for the reconstruction of the challenging combined CB-EAC defect. It allows a one-stage reconstruction that does not need a secondary revision, it also gives excellent correction and functional results. We would recommend it as a useful option for the reconstruction of the conchal-EAC defects.

Lymphaticovenous anastomosis: Treatment of a persistent breast seroma.

Lymphaticovenous anastomoses are mainly used in secondary limbs lymphedema. They also can be used to treat iatrogenic seroma. This technique was used to treat a patient with a painful breast seroma that appeared after a mastectomy with axillary dissection, resistant to multiple ponctions and persistent 8 months after. Pre operative both lymphoscintigraphy and lympho-MRI have been performed and we identified lymphatic ducts responsible for the seroma. The one involved in the seroma was also the preferential drainage network of the arm. Innoperative, we performed an indocyanine green angiography to map those lymphatic ducts. A total capsulectomy of the breast seroma has been performed. An incision was made in front of lymphatics selected for lymphaticovenous anastomoses on the anterior axilla face. We performed two microscopic lymphaticovenous anastomoses. The patient was followed up at one, three, six months and one year post operative. No recurrence occurred during the follow-up. At six month the arm perimeter reduced of two centimeters. Lymphoscintigraphy and lympho-MRI were performed at six month showing a disappearance of the drainage asymmetry and collateralities of the upper limb; and no measurable volume in projection of the right breast area. Lymphaticovenous anastomoses may be an effective therapeutic solution for resistant seroma after node dissection. Lymphoscintigraphy and lympho IRM are very useful in those cases.

[Comparing outcomes of Immediate Breast reconstruction with and without use of radiotherapy]. / Comparaison des résultats de reconstruction mammaire immédiate par prothèse avec et sans radiothérapie.

BACKGROUND: Breast cancer and its treatment remains a public health problem. There is still a lack of epidemiological data concerning complications and aesthetic results bound to radiotherapy after an immediate breast reconstruction. The objective of this study was to compare outcomes of immediate breast reconstruction regardless to the use of radiotherapy (history of radiotherapy or adjuvant radiation therapy), in order to determine risk factor of complications and bad aesthetic results. METHODS: We conducted a retrospective study between January 2014 and December 2016 at the hospital "Gustave Roussy" in Paris, concerning breast cancer patients who needed immediate breast reconstruction after total mastectomy. The primary endpoint was to assess the failure rate of reconstruction and the aesthetic result, the secondary endpoint assessed the early and late rate of complications. We realized a multivariate analysis in order to identify risks factors that may predict complications. RESULTS: Three hundred and thirty three patients have been included: 157 in the "radiotherapy group" compared to 176 in the "no radiotherapy group". Preoperative characteristics were comparable. Average follow-up was between 1 and 3years without missing. Patients who benefited from radiotherapy had an equal risk failure of reconstruction. The subgroup analysis revealed non-significant differences: 12.7% failure rate reconstruction in the "radiotherapy group" vs. 12.5%. We could notify a better rate of "excellent results" in the "no radiotherapy group": 35% vs. 8.2%. Secondary outcomes were comparable. CONCLUSIONS: Radiotherapy related to immediate breast reconstruction didn't increase the failure rate of reconstruction or aesthetic results, comparatively to non-irradiated patients. It is therefore permissible to suggest an immediate breast reconstruction to any patients which would benefit from a total mastectomy followed by radiotherapy; in order to prevent them from a secondary breast reconstruction, who could be physically and psychologically more impactful.

Primary clear cell sarcoma of the tongue and surgical reconstruction: About a rare case report.

Clear cell sarcomas (SCC), also called "soft-tissue melanoma", are rare and aggressive tumors that preferentially affect the lower limbs (tendons and fasciae) and which have also been described in head and neck localizations. Their clinical and immunohistochemical mimicry with melanoma makes it difficult to diagnose sarcomas. SCC treatment is mainly focused on large-scale resection surgery with adjuvant radiotherapy because of their low chemo-sensitivity and extreme lymphophilia. In case of head and neck localization, these treatments may lead to function and aesthetic sequelae thus requiring the use of modern techniques of reconstructive surgery. The authors describe the diagnosis, treatment and follow-up of large lingual SCC case using a DIEP free flap reconstruction according to an original technique developed in the department. Given the characteristics of patients with SCC (a high proportion of women between 20 and 40 years old) and its inherent qualities (low morbidity of the donor site, volume delivered and excellent plasticity), the fascio-cutaneous free flap type "DIEP" "taken according to the design of the" Cathedral triptych seems to be a viable choice among the range of reconstruction solutions.

Sentinel lymph node biopsy in cutaneous head and neck melanoma.

PURPOSE: Sentinel lymph node biopsy (SLNB) is now a standard of care for cutaneous melanoma, but it is still controversial for cutaneous head and neck melanoma (CHNM). This study aims to confirm the feasibility, accuracy and low morbidity of SLNB in CHNM and evaluate its prognostic value. METHODS: A monocentric and retrospective study on patients with CHNM treated in our tertiary care center (Gustave Roussy) between January 2008 and December 2012 was performed. The feasibility, morbidity and prognostic value of this technique were analysed. RESULTS: One hundred and twenty-four consecutive patients were included. SLNB was realized in 97.6% of the cases. No significant post-operative morbidity was observed. Nineteen percents of patients had a positive SN while only 14.3% of complete lymph node dissections (CLND) had additional nodal metastasis. The risk of recurrence after positive SN was significantly higher (69.2 vs 30.8%, p = 0.043). The false omission rate was low with 7.1%. Overall survival and disease-free survival were better in the negative SN group (82 vs 49%, p < 0.001 and 69.3 vs 41.8%, p = 0.0131). The risk of recurrence was significantly higher in the positive SN group (p = 0.043) and when primary tumour was ulcerated (p = 0.031). Only the mitotic rate of the primary tumour was associated with SN positivity (p = 0.049). CONCLUSION: As in other sites, SLNB status is a strong prognostic factor with comparable false omission rate and no superior morbidity.

The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction.

Today's customary techniques for pharyngo-esophageal reconstruction are jejunum and radial forearm free flaps. In this type of reconstruction, the jejunum flap is considered as the reference, but when its harvesting is not possible, the radial forearm flap is used. Since perforator flaps have begun to be developed, the anterolateral thigh flap (ATF) has become increasingly prominent in pharyngo-esophageal reconstruction. The aim of our study was to describe the use of the anterolateral perforator flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks as regards oral feeding and esophageal speech.

[Lumbar artery perforator flap for breast reconstruction]. / Reconstruction mammaire autologue par lambeau perforant lombaire.

Even though DIEP-SIEA flaps or latissimus dorsi musculocutaneous flap are the most frequently used, a wide variety of flaps have been described for autologous breast reconstruction. Concerning the choice of donor-site, the aim is to prevent and to limit the morbidity. That is why the donor-site should be carefully chosen, according to the morphology of the patient. Lumbar artery perforator flap (LAP) is an option for breast reconstruction, but it is not well known and its use is limited. This study summarizes the authors' early experience with free LAP flap for breast reconstruction. Three patients underwent immediate or delayed autologous breast reconstruction using a LAP flap. No vascular by pass was required to lengthen the pedicle. No partial or complete flap necrosis has been reported. There was no surgical donor-site complication. Mean operative time was 7hours. LAP flap can be considered as a good option for autologous breast reconstruction, especially in patients with unfavorable abdominal donor-site, and impossibility to use a DIEP flap.

[Use of indocyanine green angiography in oncological and reconstructive breast surgery]. / Utilisation du vert d'indocyanine en chirurgie sénologique et reconstruction mammaire.

The Indocyanine green (ICG) is a soluble dye that is eliminated by the liver and excreted in bile. When illuminated by an near-infrared light, the ICG emits fluorescence in the near-infrared spectrum, which can be captured by a near-infrared camera-handled device. In case of intravenous injection, ICG may be used as a marker of skin perfusion. In case of interstitial injection, it may be useful for lymphatic network mapping. In oncological and reconstructive breast surgery, ICG is used for sentinel lymph node identification, to predict mastectomy skin flap necrosis, to assess the perfusion of free flaps in autologous reconstruction and for diagnosis and treatment of upper limb secondary lymphedema. Intraoperative indocyanine green fluorescence might also be used to guide the excision of nonpalpable breast cancer.

The ongoing emergence of robotics in plastic and reconstructive surgery.

Robot-assisted surgery is more and more widely used in urology, general surgery and gynecological surgery. The interest of robotics in plastic and reconstructive surgery, a discipline that operates primarily on surfaces, has yet to be conclusively proved. However, the initial applications of robotic surgery in plastic and reconstructive surgery have been emerging in a number of fields including transoral reconstruction of posterior oropharyngeal defects, nipple-sparing mastectomy with immediate breast reconstruction, microsurgery, muscle harvesting for pelvic reconstruction and coverage of the scalp or the extremities.

[Decision algorithm in immediate breast reconstruction]. / Algorithmes décisionnels en reconstruction mammaire immédiate.

Immediate breast reconstruction showed many advantages in terms of aesthetic and functional results and improvement of quality of life when compared to delayed breast reconstruction. Previous radiotherapy or the use of adjuvant treatments such as radiation therapy, or chemotherapy are no longer a contraindication for immediate breast reconstruction. However, it is important to respect certain rules in order to decrease the risk of complications: the choice of reconstruction technique, the management of the skin envelope according to the breast shape you want to create, the time delay between the first and the second stage of reconstruction depending on a possible adjuvant treatment.

[Mastectomy and immediate reconstruction: Indications, techniques and decision algorithm]. / Mastectomie avec reconstruction mammaire immédiate : indications et techniques, algorithme de décision d'une reconstruction immédiate.

Immediate breast reconstruction indications extend to infiltrating carcinomas, due to new matrix implant coverage techniques and the development of perforator flaps. These techniques allow adjuvant treatments. However, the decision of immediate reconstruction must be discussed with the oncological multidisciplinary team and the benefits/risks must also be evaluated in relation to the morphology of the patients and their co-morbidities. The chosen type of mastectomy: conventional or skin sparing and/or nipple sparing depends on the shape and volume of the breast, the localization of the tumor in the breast and the distance from the nipple areola complex (NAC). We describe an algorithm to allow, in the case of therapeutic mastectomy with or without adjuvant radiotherapy, an immediate reconstruction with implants or free or pedicled flaps.

[The thin ALT perforator flap for oropharyngeal robotic-assisted reconstruction]. / Le lambeau libre perforant antérolatéral de cuisse fin dans les reconstructions oropharyngées robot-assistées.

Since a few years, the transoral robotic surgery reduced the morbidity of oropharyngeal tumors excision. Large posterior tumors can now be removed without any scar visible on the face. In this context and to respect the thinness required for reconstructions at the junction of the upper aerodigestive tract, the free radial forearm flap still remains the solution of choice. However, if the transoral robotic surgery respects the anatomy and the aesthetics of patients at the visible and social area that represents the face, the forearm flap provides visible scars on the other region of social interaction that represents the upper limb. The aim of our work was to prove the feasibility and the benefits in terms of reducing sequelae when using a thin anterolateral perforator flap harvested above the plane of the superficial fascia. We present this new original method in detail and the advantages it offers to patients after surgery.

[Fasciae latae perforator flap for breast reconstruction: An attractive alternative in case of DIEP contraindication]. / Le lambeau perforant de fascia lata en reconstruction mammaire : une option intéressante en cas de contre-indication au DIEP.

The musculocutaneous tensor fascia latae flap was one of the first free flaps described. It is possible to harvest a flap with the same skin paddle, vascularized by a septo-cutaneous perforator running through the tensor fascia lata muscle septum and coming from the ascending branch of the lateral circumflex femoral artery. The DIEP is currently the workhorse of autologous breast reconstruction, but there are some contraindications. The septo-cutaneous tensor fascia latae perforator flap may be an alternative for women with lateral upper thigh lipodystrophy. Between 2010 and 2014, three flaps have been performed in two patients for delayed breast reconstruction (one case of unilateral reconstruction, and one bilateral). Perforators were identified by preoperative angiography. The intervention was performed in a two-team approach, in only one operative position. Perforators were located in the horizontal axis of the upper rim of the pubis bone. One perforator artery was dissected for each flap. The mean caliber of the pedicle was 2.8mm, and the mean length was 6.4cm. The operative time was 240minutes for unilateral flap, 375minutes for bilateral flap. There was no case of total or partial necrosis, or complications on the donor site. Cosmetic results were considered satisfying by patients and surgeons with the reconstructed breast as well as the donor site. Septo-cutaneous fascia lata perforator flap is an attractive flap for breast reconstruction in patients with DIEP contraindication and lateral upper thigh lipodystrophy. It has many advantages: easy to harvest, length and calibre of the pedicle, double team approach, only one operating position, quality of reconstruction. It is necessary to carry out a larger series of cases to study the complication rate in the donor site.

[Complex carcinological head and neck reconstruction in pediatric surgery]. / Reconstructions complexes par lambeaux libres en cancérologie cervicofaciale pédiatrique.

Head and neck reconstruction in pediatric oncology, even if it is based on adult experience, presents important characteristics including age-related growth, the type of tumor and donor sites features. Indications of free flaps are rare but required care that should be codified, taking into account the details specific to context, and not giving place for improvisation as it is important that surgical outcomes must be as simple as possible. The objective of this article is not to present the technical details of free flaps harvesting in children because it is what is certainly the least different with adults. The aim is to share our experience of the specificities and singularities of pediatric head and neck reconstruction in order to focus attention to everything that makes this surgery demanding. We present the most common indications, the types of free flaps used for reconstruction, facial location modalities of reconstruction and the perioperative management.

[Harvesting technique of chimeric multiple paddles fibular flap for wide oromandibular defects]. / Technique de prélèvement du lambeau de fibula chimérique multipalettes pour la reconstruction des larges defects oromandibulaires.

Carcinological head and neck reconstruction still remains a challenge due to the volume and varied tissues needed. Large and wide oromandibular defects require, not just the bone but also soft tissues for the pelvilingual reconstruction and therefore, a second free flap may become necessary in addition to a fibular flap. The option of an unique chimeric flap based on the fibular artery and its branches is less known whereas it offers the advantage of a unique flap with bone, muscle and multiple skin paddles, independent of each other. The aim of this technical note is to present step by step the surgical procedure of this chimeric flap and share this method that avoids a second free flap.

Comparison of the classically conditioned withdrawal reflex in cerebellar patients and healthy control subjects during stance: 2. Biomechanical characteristics.

This study addresses cerebellar involvement in classically conditioned nociceptive lower limb withdrawal reflexes in standing humans. A preceding study compared electromyographic activities in leg muscles of eight patients with cerebellar disease (CBL) and eight age-matched controls (CTRL). The present study extends and completes that investigation by recording biomechanical signals from a strain-gauge-equipped platform during paired auditory conditioning stimuli (CS) and unconditioned stimuli (US) trials and during US-alone trials. The withdrawal reflex performance-lifting the stimulated limb (decreasing the vertical force from that leg, i.e. 'unloading') and transferring body weight to the supporting limb (increasing the vertical force from that leg, i.e. 'loading')-was quantified by the corresponding forces exerted onto the platform. The force changes were not simultaneous but occurred as a sequence of multiple force peaks at different times depending on the specific limb task (loading or unloading). Motor learning, expressed by the occurrence of conditioned responses (CR), is characterized by this sequence beginning already within the CSUS window. Loading and unloading were delayed and prolonged in CBL, resulting in incomplete rebalancing during the analysis period. Trajectory loops of the center of vertical pressure-derived from vertical forces-were also incomplete in CBL within the recording period. However, exposing CBL to a CS resulted in motor improvement reflected by shortening the time of rebalancing and by optimizing the trajectory loop. In summary, associative responses in CBL are not absent although they are less frequent and of smaller amplitude than in CTRL.

Super-microdissected local flaps for the coverage of temporal defects.

INTRODUCTION: Skin graft is still a method of choice for the coverage of temporal defects. But there are some disadvantages like a "patch" appearance, the need of dressing or longer healing time. Numbers of local flaps have been described for closing skin defects on temporal region. Yet, they may cause distortion of the surrounding tissues, especially in the temporal hairline and eyebrow. We present a series of seven local flaps based on small branches (SB) of the superficial temporal artery (STA) for the coverage of temporal defects, and discuss their advantages. PATIENTS AND METHODS: Supermicrodissection of SB of the STA was performed to obtain local flaps for reconstruction of temporal defects after skin cancer excisions in seven patients. Patient's age ranged from 70 to 88 years old and the diameter of defects ranged from 4 to 6 cm. All procedures were performed under local anesthesia except one. In all cases, defects were obtained after skin cancer excisions. RESULTS: The operative time ranged from 55 to 75 min. All flaps survived with an average follow-up of 8 months, reconstructions have maintained a cosmetically pleasing result. CONCLUSION: We believe that SB flaps may be a new option for reconstruction of temporal defects with the advantages of local flaps, without the inconvenience of a skin pedicle. Moreover, these flaps raise the question of the use of SB based flaps for the coverage of moderate-sized skin defects anywhere in the body, and open new fields in reconstructive surgery.

Comparison of the classically conditioned withdrawal reflex in cerebellar patients and healthy control subjects during stance: I. electrophysiological characteristics.

The aim of this study was to demonstrate the involvement of the human cerebellum in the classically conditioned lower limb withdrawal reflex in standing subjects. Electromyographic activity was recorded from the main muscle groups of both legs of eight patients with cerebellar disease (CBL) and eight control subjects (CTRL). The unconditioned stimulus (US) consisted of electrical stimulation of the tibial nerve at the medial malleolus. The conditioning stimulus (CS) was an auditory signal given via headphones. Experiments started with 70 paired conditioning stimulus-unconditioned stimulus(CSUS) trials followed by 50 US-alone trials. The general reaction consisted of lifting and flexing the stimulated (stepping) leg with accompanying activation of the contralateral (supporting) leg. In CTRL, the ipsilateral (side of stimulation) flexor and contralateral extensor muscles were activated characteristically. In CBL, the magnitudes of ipsilateral flexor and contralateral extensor muscle activation were reduced comparably. In CTRL, the conditioning process increased the incidence of conditioned responses (CR), following a typical learning curve, while CBL showed a clearly lower CR incidence with a marginal increase, albeit, at a shorter latency. Conditioning processes also modified temporal parameters by shortening unconditioned response (UR) onset latencies and UR times to peak and, more importantly in CBL, also the sequence of activation of muscles, which became similar to that of CTRL. The expression of this reflex in standing subjects showed characteristic differences in the groups tested with the underlying associative processes not being restricted exclusively to the CR but also modifying parameters of the innate UR.