Successful breastfeeding after breast reduction surgery or mastopexy: A retrospective comparative study.

Breastfeeding has been widely encouraged by health care systems for many years. Breast reduction or mastopexy, are very frequent procedures often performed on young women. The main objective of this study is to evaluate the impact of breast surgery on breastfeeding by comparing the success rate of breastfeeding in operated women versus unoperated women. Secondary objectives are to evaluate the breastfeeding success rate according to the surgical technique or the weight resected. A retrospective comparative study was conducted. Women of childbearing age who underwent breast reduction surgery or mastopexy at Henri-Mondor Hospital were contacted to answer a questionnaire about their pregnancies. Two hundred nine patients answered and two groups of patients were constituted, a preoperative group of 104 women who had a pregnancy before surgery and a postoperative group formed by 61 women who had a pregnancy after surgery. Breastfeeding success rate was 82% in the preoperative group versus 41% in the postoperative group. A statistically significant difference was found on the success rate of breastfeeding, as well as the rate of exclusive breastfeeding, with significantly lower rates in the postoperative group. In contrast, there was no significant difference between the different pedicles used, neither according to the weight of the resected gland. The cause of failure in the postoperative group was in most cases insufficient milk. Breast reduction surgery or mastopexy seems to have negative impact on the ability of operated women to breastfeed. This impact is multifactorial so these results should be interpreted with caution and further studies are needed to improve the management of these patients.

Targeting human langerin promotes HIV-1 specific humoral immune responses.

The main avenue for the development of an HIV-1 vaccine remains the induction of protective antibodies. A rationale approach is to target antigen to specific receptors on dendritic cells (DC) via fused monoclonal antibodies (mAb). In mouse and non-human primate models, targeting of skin Langerhans cells (LC) with anti-Langerin mAbs fused with HIV-1 Gag antigen drives antigen-specific humoral responses. The development of these immunization strategies in humans requires a better understanding of early immune events driven by human LC. We therefore produced anti-Langerin mAbs fused with the HIV-1 gp140z Envelope (αLC.Env). First, we show that primary skin human LC and in vitro differentiated LC induce differentiation and expansion of naïve CD4+ T cells into T follicular helper (Tfh) cells. Second, when human LC are pre-treated with αLC.Env, differentiated Tfh cells significantly promote the production of specific IgG by B cells. Strikingly, HIV-Env-specific Ig are secreted by HIV-specific memory B cells. Consistently, we found that receptors and cytokines involved in Tfh differentiation and B cell functions are upregulated by LC during their maturation and after targeting Langerin. Finally, we show that subcutaneous immunization of mice by αLC.Env induces germinal center (GC) reaction in draining lymph nodes with higher numbers of Tfh cells, Env-specific B cells, as well as specific IgG serum levels compared to mice immunized with the non-targeting Env antigen. Altogether, we provide evidence that human LC properly targeted may be licensed to efficiently induce Tfh cell and B cell responses in GC.

[Malignant Triton tumour: A case report]. / Tumeur Triton maligne : à propos d'un cas.

Malignant Triton tumour (MTT) is a subtype of malignant peripheral nerve sheaths tumour (MPNST) with exclusive heterologous rhabdomyosarcomatous contingent. MTT is rare and of poor prognosis. This entity illustrates the great heterogeneity of MPNST, the diagnosis of which is difficult in the absence of a specific marker, especially in sporadic forms. Although MTT preferentially develop in patients with type 1 neurofibromatosis, sporadic cases may occur. We herein present a case of MTT of the left arm, occurring in a 74-year-old patient, without clinical context of NF1. The fast-growing tumour reached 9.2cm of greater dimension at the time of surgical excision. Histology showed a spindle cell sarcoma with rhabdoid cell areas expressing myogenin. In the absence of neural crest markers expression, the diagnosis of MPNST was based on a significant loss of expression of the histone 3 tri-methylated lysine 27, a classical although not specific epigenetic mark for this sarcoma group, and on the identification of the heterologous rhabdomyosarcomatous contingent, previously described in the context of MTT.

Efficacy of Autologous Platelet Concentrates as Adjuvant Therapy to Surgical Excision in the Treatment of Keloid Scars Refractory to Conventional Treatments: A Pilot Prospective Study.

BACKGROUND: After conventional treatments, keloid scars show varying degrees of recurrence. The aim of this study was to assess the efficacy and safety of platelet-rich plasma in the treatment of postoperative keloid scars refractory to conventional treatments. METHODS: This pilot prospective study was conducted in 17 patients with keloid scars who did not respond to 4 injections of cortisone or radiotherapy after extralesional resection of keloid. Platelet-rich plasma was injected intraoperatively and then 3 times with a 1-month interval. The primary end point was the complete remission of keloid scars 2 years posttreatment. Scar pruritus severity was scored before and after treatment. The study protocol was approved by the ethics committee and authorized by the French National Agency. This trial was registered at ClinicalTrials.gov, identifier NCT02922972. RESULTS: Nine keloid scars (53%) were completely resolved at 2 years, and 5 (29%) completely relapsed after treatment. Pruritus severity score was significantly lower at 2 years compared with baseline (1.33 ± 0.97 before treatment and 0.40 ± 0.63 at 2 years, P < 0.003). The mean Vancouver Scar Scale score significantly improved (8.18 ± 2.38 before treatment and 3.82 ± 1.98 at 2 years, P < 0.001). CONCLUSIONS: Injecting platelet-rich plasma is an effective and safe method as adjunctive therapy to resection for treating keloid scars refractory to conventional therapy.

Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: Further evidences of a reliable and time-sparing procedure.

AIM: Venous congestion is a common cause of DIEP flap failure. When identified intraoperatively, an additional venous anastomosis can improve the venous outflow and prevent flap failure. The aim of this study was to assess if the retrograde limb of the internal mammary vein (IMV) could be considered a good recipient vessel to be used when persistent flap congestion is present, and a second venous anastomosis is required. PATIENTS AND METHODS: A retrospective study was conducted in 74 patients who had undergone DIEP flap breast reconstruction. Patients were classified into two groups: SVA (single venous anastomosis) and DVA (dual venous anastomosis). In the SVA group (n = 38), the IMV antegrade limb was used for venous drainage. A single DIEV (Deep Inferior Epigastric Vein) was anastomosed to the superior arm of the IMV. In the DVA group (n = 36), both the antegrade (superior) and retrograde (inferior) stumps of the IMV were used, connecting the larger DIEV to the antegrade IMV and the other DIEV or the SIEV (Superficial Inferior Epigastric Vein) to the IMV retrograde limb. RESULTS: No venous congestion or flap loss was observed when two venous anastomoses were performed using both the IMV antegrade and retrograde limbs (P = 0.3271). In the DVA group, no major complication occurred (P = 0.0453). Operative explorations were significantly reduced in the DVA group (P = 0.0242). CONCLUSION: These findings suggest that when an additional venous outflow is required, the use of the IMV retrograde limb may help to avoid flap venous congestion. © 2016 Wiley Periodicals, Inc. Microsurgery 36:447-452, 2016.

Necrotizing Fasciitis of the Upper Limb: Optimizing Management to Reduce Complications.

BACKGROUND: Necrotizing fasciitis (NF) is a severe, potentially life-threatening condition. The aim of this study is to identify strategies aimed at reducing complications in patients with NF of the upper limb. METHODS: We conducted a retrospective study on patients admitted to our Unit for suspected NF of the upper limb. The analyzed data included patient characteristics, delay before primary care, clinical and biological signs upon arrival, pathogens involved, and the rate of amputations and mortality. RESULTS: A total of 21 patients presented with confirmed necrotizing bacterial dermohypodermitis-NBDH with NF (NBDH-NF) affecting the upper limb. The mean delay between the onset of symptoms and the clinical examination in the Emergency Dermatology Unit was 48 h (range: 6 to 72 h). The mean delay between admission and primary surgery was 150 min (range: 60 min to 280 min). No amputations were performed. All patients were alive one year after the first surgical procedure. CONCLUSIONS: Our study demonstrated that it is possible to reduce mortality and morbidity rates in NF of the upper limb. Timely diagnosis and early treatment and a multidisciplinary medico-surgical dedicated team providing care can significantly modify the outcomes. Early surgical debridement is the most important factor affecting the prognosis of these infections.

Oncological and aesthetic outcome following surgical management of orbito-palpebral skin cancers: A retrospective study of 132 patients.

BACKGROUND: The incidence of facial skin cancers continues to rise, with major studies on their impacts still lacking in the literature. This study reports on the oncological and aesthetic results following surgical management of an orbito-palpebral skin cancer. METHODS: This retrospective, monocentric study included patients treated for a non-melanoma skin cancer of the eyelid and orbit. Risk factors, location, histological type, invaded or insufficient margins, healing time, surgical management by excision and direct closure, skin graft or local flaps, self-evaluated aesthetics, and quality of life results were all compared. RESULTS: The study included 132 patients operated for basal cell carcinoma (71.9%), squamous cell carcinoma (22.9%), or for another type (5.2%) between November 2011 and January 2017. Average tumor size was 9.6 ± 6.3 mm. Surgical management resulted in excision and open healing (9.1%), excision and direct closure (3.9%), skin graft (31.1%), local flap (21.9%), or another type of reconstruction (3.0%). Significant links between invaded or insufficient margins and basal cell type (OR = 3.37, p = 0.014), tumor size over 7 mm (OR = 2.7, p = 0.011), double location (OR = 8.44, p = 0.04), flap-based reconstruction (OR = 0.290, p = 0.02), and female gender (OR = 0.418, p = 0.034) were reported throughout our multivariate analysis. CONCLUSIONS: This study brings out consequential information on factors linked with invaded or insufficient excision margins. Larger cohorts should evaluate the aesthetic outcomes in such a population.

Efficacy of injecting platelet concentrate combined with hyaluronic acid for the treatment of vulvovaginal atrophy in postmenopausal women with history of breast cancer: a phase 2 pilot study.

OBJECTIVE: Approximately 50% to 70% of breast cancer survivors are affected by one or more symptoms of vulvovaginal atrophy (VVA). For those who cannot take hormone therapy, autologous platelet-rich plasma combined with hyaluronic acid (A-PRP-HA) may provide a new alternative therapy for the treatment of VVA in postmenopausal women with history of breast cancer. METHODS: We enrolled 20 postmenopausal breast cancers survivors with VVA and a score of <15 on the Gloria Bachman Vaginal Health Index (VHI) comprised of five items including: vaginal pH, elasticity, fluid volume (secretions), epithelial integrity, and moisture.We administered intramucosal injections of A-PRP combined with HA (Regenkit) and performed clinical evaluations at 0, 1, 3, and 6 months. Primary endpoint: evaluation of vulvovaginal mucosa changes using the VHI; secondary endpoint: evaluation of dyspareunia and sexual dysfunction based on the Female Sexual Distress (FSD) score. RESULTS: All participants (20 women) showed improvement in the clinical symptoms of vaginal dryness and dyspareunia. The VHI score showed a significant increase at 6 months, going from a total baseline score (pretreatment) of 10.7 ±â€Š2.12 to 20.75 ±â€Š4.8 (P < 0.0001) at 6 months. Improvement in hydration and vaginal epithelial integrity was reported. A VHI score of > 15 showed a successful treatment outcome. The FSD score decreased significantly during the study, from a baseline score of 36.35 ±â€Š2.53 pretreatment to 30.15 ±â€Š2.47 6 months after treatment, representing improvement of 17% (P < 0.0001, respectively). No adverse events were reported. CONCLUSIONS: The injection of A-PRP-HA appeared to be a promising method to improve the trophicity and hydration of vaginal mucosa for the treatment of VVA in postmenopausal breast cancer survivors with contraindications to hormone therapy.

The procurement of allotransplants for ballistic trauma: a preclinical study and a report of two clinical cases.

BACKGROUND: Maxillofacial trauma caused by severe ballistic injuries requires many steps of reconstruction and is often associated with disappointing results. The authors report on two clinical cases of facial allografting. METHODS: After a preclinical anatomical study of 10 fresh cadavers, the authors performed allotransplantation of the lower two-thirds of the face in two patients in March and August of 2009. The grafts included all perioral muscles, facial nerves, parotid glands, the anterior region of the maxilla, and part of the mandible. The mandibular osteotomy included only the chin in one case, and the mandibular arch from one angle to the other in the second case. RESULTS: The cadaveric study confirmed that relying only on the anastomoses between the facial and the maxillary artery for vascularization of the posterior part of the maxilla was unsafe. Periosteal vascularization seemed essential. The clinical results confirmed that complete revascularization from a single facial pedicle was possible: the first end-to-end arterial anastomosis to the left external carotid artery was sufficient for full perioperative revascularization of the flap and immediate reestablishment of bilateral venous flow. The facial appearance of both recipients improved gradually, with the development of changes in expression and the appearance of nasolabial folds. Preoperatively placed gastrostomies and tracheostomies were able to be removed in both patients within 6 weeks postoperatively. The procurement part of the operation was performed in 7 hours. CONCLUSION: Partial facial composite tissue allotransplantation of the lower two-thirds of the face along with parts of the maxilla and mandible (chin or entire-toothed mandible) is technically feasible, with a good cosmetic and functional outcome in typical cases of attempted suicide with rifles.

Procurement of total human face graft for allotransplantation: a preclinical study and the first clinical case.

BACKGROUND: The authors report the technical difficulties involved in the procurement of a total human face graft for allotransplantation. METHODS: After completing a preclinical study that involved 13 fresh cadavers, the authors harvested a total face graft for allotransplantation onto a patient in April of 2009. The harvested tissue specimen included the entire face along with the scalp and the auricles. The authors then removed the unnecessary parts, specifically, the lips and the skin overlying the chin. RESULTS: The preclinical study and clinical results confirmed that complete revascularization of a total face graft, complete with the scalp and auricles, from a single external carotid vascular pedicle was possible. All dissections were completed in less than 6 hours during the preclinical study. Graft procurement for the clinical case took 11 hours. Facial soft tissues were harvested en bloc to decrease graft harvest time and prevent tissue injury. A resin mask that covered the entire face of the donor provided excellent cosmetic results. All nerves and eyelid structures were easily reattached. One month after transplantation, skin necrosis necessitated several stages of excision. Biopsy specimens from the transplanted tissue were negative for immune-mediated rejection. Unfortunately, the patient experienced a cardiac arrest during follow-up surgery and died 2 months after the transplant procedure. CONCLUSIONS: A composite tissue allotransplantation of the total face along with the scalp and the auricles is technically feasible. The authors' flap provided reliable vascularization and was obtained in a standardized fashion in less than 11 hours. The graft contained all of the perioral muscles, branches of the facial nerve, eyelid structures, and major salivary glands.

[Hand reconstruction by microsurgical free toe transfer]. / Reconstructia mâinii prin transfer liber microchirurgical de degete de la picior.

Reconstruction of complex hand mutilations with multi-digital or thumb amputations are best treated with microsurgical toe transfers. We present the results of the first 15 cases operated by the first author, of which 12 are thumb reconstructions (6 great toe and 6 second toe transfers) and 3 long fingers reconstructions with combined second and third toe transfers. There were no microsurgical complications. Cortical integration and functional integration was achieved for all transferred toes, with discriminatory sensibility (m2PD between 5 and 13 mm) and active mobility range between 30 and 60 degrees.