[The history of vaginoplasty: Technical and sociological advances]. / Histoire de la vaginoplastie : évolution technique et sociologique.

Technical advances in gender-affirming genital surgery have allowed the modern surgeon to create a vagina, vulva and clitoris from a male sex. This surgery, commonly known as vaginoplasty, should in fact be identified as aidopoiesis, since it is not a question of improving an already existing vagina but of creating a female sex. Numerous technical advances made since 1930 throughout the world now offer a safe and proven surgical strategy for female genital gender affirmation. Most of these techniques are derived from advances in intersex genital surgery. The first vaginoplasties described in the context of gender affirmation were performed in Berlin in the 1930s. After the Second World War, the greatest advances in vaginoplasty were made in Denmark. It was not until Geroges Burou in Casablanca and Harold Gillies, aided by Ralph Millard in England, in the mid-fifties that the modern technique of invagination of the penile skin took over from neo-vaginal grafting techniques. The creation of the clitoris from the glans penis and a more aesthetic vulva were the major advances from the 1970s. Other flap or intestinal transplant techniques were also developed, often to correct the failure of penile skin invagination. Some of the patients who benefited from these early technical advances, such as Lili Elbe and Christine Jorgensen later on, helped to make this surgery, which had long remained taboo, popular with the general public. Pioneers such as the gynaecologist Georges Burou in Casablanca have contributed, with the greatest discretion, to the well-being of gender-affirmed people by improving these techniques. Today, this hard-won heritage cannot be ignored by surgeons interested in vaginoplasty.

Intra Articular Injection of Autologous Microfat and Platelets-Rich Plasma in the Treatment of Wrist Osteoarthritis: A Pilot Study.

No injection treatment has been proven to be effective in wrist osteoarthritis. When conservative measures fail, its management involves invasive surgery. Emergence of biotherapies based on adipose derived stem cells (ADSC) offers promising treatments for chondral degenerative diseases. Microfat (MF) and platelets-rich plasma (PRP) mixture, rich in growth factors and ADSC could be a minimally invasive injectable option in the treatment of wrist osteoarthritis. The aim of this uncontrolled prospective study was to evaluate the safety of a 4 mL autologous MF-PRP intra-articular injection, performed under local anesthesia. The secondary purpose was to describe the clinical and MRI results at 12 months of follow-up. Patients' data collected were: occurrence of adverse effects, Visual analog scale (VAS), Disabilities of the Arm, Shoulder and Hand score (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, wrist strength, wrist range of motion and 5-level satisfaction scale. No serious adverse event was recorded. A statistically significant decrease in pain, DASH, PRWE and force was observed at each follow-up. Our preliminary results suggest that intra-articular autologous MF and PRP injection may be a new therapeutic strategy for wrist osteoarthritis resistant to medical symptomatic treatment prior to surgical interventions.

Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair.

BACKGROUND: Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. METHODS: This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. RESULTS: At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. CONCLUSION: We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

[Total reconstruction of the lower lip: Lip suspension technique by double nasolabial rigging and review of the literature]. / Reconstruction totale de la lèvre inférieure : technique de suspension labiale par double haubanage nasogénien et revue de la littérature.

BACKGROUND: Total lower lip defect is rare and its reconstruction difficult. The challenges are both aesthetic and functional. Suspension of the lower lip is essential for restoring oral competence. We report an original and simple technique of suspension by double nasolabial rigging. METHOD: Two upper base orbitonasolabial flaps, extended over several centimeters below the lip commissures are raised. The epidermis is completely removed. Then, the flaps are tunneled under the skin and fixed to the reconstructed lower lip in order to provide it with effective suspension to the maxillary. RESULTS: In our experience, we used the nasolabial rigging associated with a total reconstruction of the lower lip for three patients. Lip continence is effective in the long term. The review of literature shows that the use of conventional locoregional flaps restores a good labial competence but is limited to subtotal lower lip defect. Distant pedicled flaps or free flaps made without suspension of the lower lip don't restore the labial competence. Several procedures to suspend the lower lip with strips of fascia lata or tendon of palmaris longus, associated or not with a free flap, seem to provide satisfactory oral competence. All these techniques are poorly standardized and technically difficult. CONCLUSION: The technique of the double nasolabial rigging that we describe seems to be an effective and interesting alternative by its simplicity, its reproducibility and its adaptability. It allows to obtain a perfectly fixed posterior plane, able to receive any reconstruction of the lower lip.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments. METHODS: This randomized, non-inferiority trial enrolled patients who underwent skin excision (>30 cm2), which was left open to heal by secondary intention. They received ALGINATE or NPWT by a centralized randomization. Follow-up was performed weekly until optimal granulation tissue was obtained. The primary outcome was time to obtain optimal granulation tissue for a split thickness skin graft take (non-inferiority margin: 4 days). Secondary outcomes were occurrence of adverse events (AEs) and impact of the treatments on the patient's daily life. RESULTS: ALGINATE and NPWT were applied to 47 and 48 patients, respectively. The mean time to optimal granulation was 19.98 days (95% CI, 17.7-22.3) with ALGINATE and 20.54 (95% CI, 17.6-23.5) with NPWT. Between group difference was -0.56 days (95% CI -4.22 to 3.10). The non-inferiority of ALGINATE versus NPWT was demonstrated. No AE related to the treatment occurred with ALGINATE versus 14 AEs with NPWT. There was no difference in the impact of the treatments on the patient's daily life. CONCLUSION: This trial demonstrates that ALGINATE has a similar healing efficacy to that of NPWT and that is markedly better with regard to patient safety.

Supportive use of platelet-rich plasma and stromal vascular fraction for cell-assisted fat transfer of skin radiation-induced lesions in nude mice.

BACKGROUND: External radiotherapy has become indispensable in oncological therapies. Unfortunately, radiation is responsible for serious side effects, such as radiodermatitis. The skin is weakened and ulcerated. Our study aimed to evaluate the subcutaneous transfer of microfat (MF) alone and two mixes: MF+Platelet-rich plasma (PRP) and MF+stromal vascular fraction (SVF) to treat radiation-induced skin lesions. METHOD: We defined randomly five experimental groups of nine mice: 1 healthy control group and 4 irradiated (60 Grey) and treated groups. The skin lesions were treated 3 months after irradiation by MF, MF+PRP (50%-50%), MF+SVF (90%-10%) or Ringer-lactate subcutaneous injections. Wound healing was evaluated at 1, 2 and 3 months post-injection and histological wound analysis at 3 months, after euthanasia. RESULTS: All the irradiated mice presented with wounds. After sham-injection, the wound area increased by 91.1±71.1% versus a decrease of 15.9±23.1% after MF alone (NS), 27.3±23.8% after MF+SVF (NS) and 76.4±7.7% after MF+PRP (P=0.032). A significative reduction of skin thickness in wound periphery was measured for the three treated groups compared to sham-injection (P<0.05) but not in the healed wounds (NS). The most important subcutaneous neo-vessel density was shown after MF+SVF injection. CONCLUSION: The MF+PRP mix was the most efficient product to increase healing. The MF+SVF mix showed the highest rate of neo-angiogenesis but was disappointing in terms of healing. LEVEL OF EVIDENCE: Not gradable.

The Use of Higher Proportions of Platelet-Rich Plasma to Enrich Microfat Has Negative Effects: A Preclinical Study.

BACKGROUND: Platelet-rich plasma improves engraftment after fat transfer. However, the effects of platelet dose have never been investigated. The authors used magnetic resonance imaging to compare surviving graft volumes in mice after administration of four different formulations (microfat alone, and three platelet-rich plasma-enriched microfat mixes). METHODS: The authors used a random, double-blinded, fat transfer protocol using three different platelet levels: 1 million (low-dose), 500 million (medium-dose), and 1000 million (high-dose) platelets/ml, and fat alone (control). The authors grafted 0.4 ml of the 70/30 platelet-rich plasma-enriched microfat mixtures (0.4 million, 200 million, and 400 million platelets per 0.12 ml for the low-dose, medium-dose, and high-dose mixtures, respectively) or 0.4 ml of microfat alone into 22 nude mice and monitored surviving graft volumes every month for 3 months. Then, the authors histologically analyzed all grafts to assess neoangiogenesis status and fat integrity. RESULTS: Three-dimensional magnetic resonance imaging showed that the median surviving graft volumes at 3 months were 9.5 percent (interquartile range, 0 to 25 percent; p = 0.003) (high-dose), 4.1 percent (interquartile range, 0 to 18 percent; p = 0.001) (medium-dose), and 18 percent (interquartile range, 8 to 38 percent; p = 0.41) (low-dose) compared to 36 percent (interquartile range, 28 to 53 percent) for the control value. The histologic integrity of microfat-alone grafts was significantly better than those of the other grafts, although the high-dose and low-dose grafts exhibited higher levels of neoangiogenesis. CONCLUSION: Higher platelet levels in microfat grafts were associated with poor graft survival in nude mice; a clinical review would be appropriate.

Two-stage free flap reconstruction of the scalp and calvaria for large neurosurgical resections.

BACKGROUND: Free tissue transfer is occasionally necessary during reconstruction of large scalp and calvarial bone resections. A single-stage procedure is usually performed but if a flap becomes necrotic it exposes brain tissue or the meninges. Performing a two-stage procedure, the surgeon must preserve flap vitality and manage flap complications before resecting a tumor, and therefore before exposing the brain or meninges. We report here the first series of two-stage free-flap reconstruction during major neurosurgical resection. METHODS: From 2012 to 2018, nine free-flaps were performed to eight patients (61 years-old, on average). Average skull resection was 10.1 cm × 15 cm (range 6-18 cm × 9-24 cm). It was performed in all cases due to large malignant tumors. Resection/reconstruction was performed in all case in a two-step procedure: during the first step, the free-flap was harvested and anastomosed to the cranial site; during the second step, resection was performed and the flap was positioned into the defect to assure coverage. RESULTS: Average flap size was 11.3 cm × 17.7 cm (range: 7-20 cm × 11-30 cm). Two flap complications occurred after the first stage and one flap did not survive. One patient died before the second stage. Seven patients had the second procedure; no flap complication occurred. All procedures ended in complete wound healing. Follow-up period was 41.5 months on average (range: 10-83 months). Final outcome was total remission for two patients, recurrence for four patients, and two patients died. CONCLUSIONS: Our data suggest that the two-stage free-flap reconstruction may be employed for major scalp and calvaria resection.

Development of Autologous Platelet-Rich Plasma Mixed-Microfat as an Advanced Therapy Medicinal Product for Intra-Articular Injection of Radio-Carpal Osteoarthritis: From Validation Data to Preliminary Clinical Results.

Wrist osteoarthritis (OA) is one of the most common conditions encountered by hand surgeons with limited efficacy of non-surgical treatments. The purpose of this study is to describe the Platelet-Rich Plasma (PRP) mixed-microfat biological characteristics of an experimental Advanced Therapy Medicinal Product (ATMP) needed for clinical trial authorization and describe the clinical results obtained from our first three patients 12 months after treatment (NCT03164122). Biological characterization of microfat, PRP and mixture were analysed in vitro according to validated methods. Patients with stage four OA according to the Kellgren Lawrence classification, with failure to conservative treatment and a persistent daily painful condition >40 mm according to the visual analog scale (VAS) were treated. Microfat-PRP ATMP is a product with high platelet purity, conserved viability of stromal vascular fraction cells, chondrogenic differentiation capacity in vitro and high secretion of IL-1Ra anti-inflammatory cytokine. For patients, the only side effect was pain at the adipose tissue harvesting sites. Potential efficacy was observed with a pain decrease of over 50% (per VAS score) and the achievement of minimal clinically important differences for DASH and PRWE functional scores at one year in all three patients. Microfat-PRP ATMP presented a good safety profile after an injection in wrist OA. Efficacy trials are necessary to assess whether this innovative strategy could delay the necessity to perform non-conservative surgery.

Molecular profile and proangiogenic activity of the adipose-derived stromal vascular fraction used as an autologous innovative medicinal product in patients with systemic sclerosis.

OBJECTIVE: The autologous stromal vascular fraction (SVF) from adipose tissue is an alternative to cultured adipose-derived stem cells for use in regenerative medicine and represents a promising therapy for vasculopathy and hand disability in systemic sclerosis (SSc). However, the bioactivity of autologous SVF is not documented in this disease context. This study aimed to compare the molecular and functional profiles of the SVF-based medicinal product obtained from SSc and healthy subjects. METHODS: Good manufacturing practice (GMP)-grade SVF from 24 patients with SSc and 12 healthy donors (HD) was analysed by flow cytometry to compare the distribution of the CD45- and CD45+ haematopoietic cell subsets. The ability of SVF to form a vascular network was assessed using Matrigel in vivo assay. The transcriptomic and secretory profiles of the SSc-SVF were assessed by RNA sequencing and multiplex analysis, respectively, and were compared with the HD-SVF. RESULTS: The distribution of the leucocyte, endothelial, stromal, pericyte and transitional cell subsets was similar for SSc-SVF and HD-SVF. SSc-SVF retained its vasculogenic capacity, but the density of neovessels formed in SVF-loaded Matrigel implanted in nude mice was slightly decreased compared with HD-SVF. SSc-SVF displayed a differential molecular signature reflecting deregulation of angiogenesis, endothelial activation and fibrosis. CONCLUSIONS: Our study provides the first evidence that SSc does not compromise the vascular repair capacity of SVF, supporting its use as an innovative autologous biotherapy. The characterisation of the specific SSc-SVF molecular profile provides new perspectives for delineating markers of the potency of SVF and its targets for the treatment of SSc.

Reconstruction of columellar defects: Which surgical technique to choose? A retrospective study of 18 patients.

The reconstruction of the columella is challenging and poorly evaluated in the literature. Our study aimed to evaluate retrospectively the different techniques used in our center and to propose an algorithm of reconstruction adapted to each patient. We report a retrospective cohort study included 18 patients (9 men and 9 women; 53 years-old in average) with columellar reconstruction treated from 1999 through 2014. Six different techniques were used: chondrocutaneous graft, nasolabial flap, paramedian forehead flap and scalping flap according to the Converse technique or the Raulo technique. Four independent plastic surgeons evaluated the aesthetic result on a 10 cm visual analogue scale comparing the patients' photographs before and after the reconstruction. Furthermore, we asked the patients to perform the same evaluation, and to evaluate their level of satisfaction. The mean follow-up was 4 years. Three chondrocutaneous grafts were performed to reconstruct partial defects (Surgical Evaluation (SE): 7.9, Patient Evaluation (PE): 8.3).Three bilateral nasolabial flaps (SE: 6.1, PE: 6.7), 5 paramedian forehead flap (SE: 6.9, PE: 7.3) 6 Converse scalping flap (SE: 4.9, PE: 5.4) and 1 Raulo scalping flap (SE: 6,1, PE: 6,3) were performed to reconstruct total defects exceeding the columella. The use of composite graft was the most satisfactory procedure for partial defects. Paramedian forehead flaps and Raulo scalping flap were the most satisfactory procedures for extended defects. Nasolabial flap was the most adapted procedure for patients with general anesthesia contraindication or for defects extended to the lip.

Free antero-lateral thigh flap for total knee prosthesis coverage after infection complicating malignant tumour resection.

BACKGROUND: Infection is a common complication of major lower limb-sparing surgery with massive total knee prosthesis (MTKP) reconstruction after extensive tumour resection. When free tissue transfer is required to cover the prosthesis, musculo-cutaneous flaps are usually preferred based on proven efficacy when used in both one-stage and two-stage procedures. The use of a free fascio-cutaneous antero-lateral thigh (FC-ALT) flap in 3 patients with infected knee reconstructions is reported here. MATERIAL AND METHOD: A retrospective study was performed of 3 patients in whom a free FC-ALT flap was used during a two-stage procedure to treat MTKP infection after femoral sarcoma resection. RESULTS: Free FC-ALT flap transfer and exchange arthroplasty were successful in all 3 patients. Two years after the procedure, no patient had required amputation or experienced recurrent infection. CONCLUSION: A free FC-ALT flap can provide adequate coverage of infected MTKP and deserves to be viewed as a valid alternative to free muscle flaps.