Evaluation of satisfaction and the quality of life after bilateral breast reconstruction using the BREAST-Q questionnaire.

BACKGROUND: The demand of breast reconstruction is growing, the purpose of this study is to evaluate the satisfaction and quality of life of patients who underwent bilateral breast reconstruction. METHODS: In this cohort retrospective study, patients who underwent bilateral breast reconstruction in our department between September 2009 and December 2019 were asked to complete BREAST-Q questionnaire based on the timing of the reconstruction received following mastectomy, thus dividing them into three groups: (1) bilateral immediate breast reconstruction(BIBR), (2) immediate breast reconstruction in one side and delayed reconstruction on the other side (mixed group), (3) bilateral delayed breast reconstruction(BDBR). Surgical techniques were divided into prosthesthetic (permanent implant and expander), flaps (pedicle or free), mixed technique (associating flap and prosthesis). RESULTS: Seventy-one out of 94 patients responded to our BREAST-Q questionnaire, with a response rate of 84.5%. A high score is associated with a better result, except in physical well-being where a lower score indicates better outcome. The average score for psychosocial well-being is 63.0 (±17.2) achieving the lowest among the BDBR group. Physical well-being score is 26.0 (±18.6) scoring the highest in BIBR group. Sexual well-being score is 52.2 (±17.4) and seen highest among BDBR group. Satisfaction with breast score is 54.1 (±10.0) and was highest among mixed group. CONCLUSION: The therapeutic proposal was personalized based on patient profile and choice. The best reconstruction treatment enhancing the quality of life and patient satisfaction remains the option chosen by the patient and whose advantages and disadvantages are accepted by them.

[Buccinator muscle: A new target for botulinum toxin injections in the treatment of facial paralysis sequelae]. / Le muscle buccinateur : une nouvelle cible pour les injections de toxine botulique dans le traitement des séquelles de paralysie faciale.

AIM OF THE STUDY: Facial paralysis can cause aesthetic and functional sequelae such as spasms and synkinesis. Botulinum toxin injection is one of the key treatments for these sequelae. Its use is widely reported in the literature for many muscles of the face but little for the buccinator muscle. However, its hyperactivity can be disabling, generating chewing and smile disorders in particular. The aim of this prospective study is to report the effects of botulinum toxin using a questionnaire specifically for the buccinator muscle. PATIENTS AND METHODS: The study was conducted on 13 patients. The facial paralysis was of various origins. The questionnaire consisted of 10 questions each assessing a facial mimic involving the buccinator muscle. The rating scale ranged from -10 (major deterioration) to 10 (major improvement) for each question. The evaluation was done at 1 and 4 months after the injection. We found an improvement for all the mimics and gestures evaluated (0 to 7.38 at 1 month and 0.15 to 6.62 at 4 months). This improvement was greater at 1 month than at 4 months. Few side effects were reported. CONCLUSION: Botulinum toxin injections are an effective, safe therapeutic solution for the treatment of the facial paralysis sequelae of the buccinator muscle through a new specific questionnaire. Subsequently, it would be interesting to carry out an evaluation on a larger population and to compare it with other recognized scores in facial paralysis.

[Is it legitimate to propose surgery of the breast area before the end of puberty?] / Est-il légitime de proposer une chirurgie de la région mammaire avant la fin de la puberté ?

Breast surgery is usually recommended for women who have completed puberty. Indeed, during adolescence the breast is constantly changing, the patient's weight is often unstable, the risk of inflammatory scars (hypertrophic or keloid) is higher and disturbances of areolar sensitivity can affect the patient's quality of sexual life. In addition, the risk of infection is not negligible, especially during an acne outbreak. In case of early implant placement, iterative changes should be planned. Finally, the result obtained is not always stable but above all the lack of psychological maturity and the legal need to obtain the agreement of both parents are obstacles to early surgery. However, the authors argue for the possibility of surgical correction of the breast around puberty, in particular because of the very clear positive psychological impact. Other arguments are also detailed: to ensure a breast reconstruction in successive stages started early, to limit the repercussions of hypertrophy, to correct thoracic or skin anomalies. These indications are illustrated by numerous clinical cases demonstrating the need for customized surgery on a case-by-case basis.

[Gynécomastia. Management of diagnosis and therapy. Apropos of 148 cases]. / Gynécomastie : actualisation des données diagnostiques et thérapeutiques. À propos de 148 patients.

Gynecomastia is the most frequently breast lesion in males. 148 patients (mean age 24,7 years) operated in our department were reviewed with a mean follow-up of five years. Gynecomastia occurred most frequently during puberty (77,7 %), was bilateral (86,5%) and idiopathic (89,9%). The size of the enlargement was evaluated according to Simon's-classification based on breast-volume and skin-redundancy. 17 (11,5%) stage 1, 77 (52%) stage 2A, 32 (21,6%) stage 2B, 22 (14,9%) stage 3. Clinical examination and mammography determined the consistency of gynecomastia: adipose or firm. 4 different surgical managements were used: 17 (11,5%) subcutaneous mastectomies, 4 (2,7%) liposuctions, 110 (74,3%) liposuctions associated with subcutaneous mastectomy, 17 (11,5%) total mastectomy. All techniques gave good morphologic results. Nonetheless, the authors recommend the combination «liposuction and subcutaneous mastectomy¼, as this technique presents many advantages: small intraoperative blood loss, good skin redraping, short hospital stay, complete histologic examination of the material removed.

Free flap for lower limb salvage in infectious purpura fulminans.

BACKGROUND: Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life. METHODS: This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically. RESULTS: The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204±108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30±9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6±9.4 and mental component score was 44.6±13.2 (minimum 0, maximum 100). CONCLUSIONS: Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.

[New surgical strategy in breast reconstruction with implants for bilateral prophylactic mastectomies with BRCA gene mutation]. / Nouvelle stratégie chirurgicale dans les mastectomies bilatérales prophylactiques avec reconstruction par prothèses chez les patientes présentant une mutation du gène BRCA.

BACKGROUND: For the past decades, number of prophylactic bilateral mastectomies using reconstruction with implants increases. We describe a new surgical strategy and analyse its safety and feasability. METHOD: It is a retrospective, descriptive and monocentric study. The first step of surgery consisted in obteining a peri-prosthetic capsule with implants and if there was a mammary hypertrophy and/or ptosis, it was corrected at the same time. The second step of surgery was the nipple-sparing mastectomy with change of implants for bigger ones. Third step consisted in a lipofilling. RESULTS: Seven patients were included. 6 women had a BRCA1 gene mutation. Mean age was 35.6 year-old [29.6; 41.6], mean BMI was 23.8kg/m2 [20.6; 27], mean chest circumference was 93.7cm [87.4; 100], mean cup was C- [B-; D-]. 4 women had mammary hypertrophy and/or ptosis. Mean number of procedure per woman was 3.6 [2.5; 4.7]. Mean volume of implants used at the first step was 248.6ml [211.3; 285.9]. The second step was performed mean 33.9 weeks [22.3; 45.5] later. Mean increase of implants volume was 120ml [80.4; 159.6]. 4 patients had complications including 1 who had implant exposure. Six patients had lipofilling of mean volume per breast of 175ml [116; 234]. CONCLUSION: This new strategy could decrease complication rate, improve aesthetic outcome and decrease psychological impact of surgery.

The interest of "ortho-plastic" collaboration in management of complex limb injury.

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

[Gluteal flap harvest for breast reconstruction]. / Technique de prélèvement du lambeau fessier pour la reconstruction mammaire.

The lower gluteal flap is an autologous microsurgical breast reconstruction procedure using the soft tissue of the region of the gluteal sulcus. The perineal extension increases the volume of the sample. The pedicle with one artery and two large veins extends up the ischial notch and can reach 8 to 12cm. The two operative positions, the relative shortness of the pedicle and the firm tissues transferred are balanced by the discretion of the sequelae of the donor site and the volume which is always enough even in the slim woman. The best indication of this technique is two-sided breast reconstruction but it also provides a solution in case of contraindication of other autologous flaps, especially DIEP.

[Otoplasty]. / Cure d'oreilles décollées.

Prominent ears can have a significant psychological impact especially in children. It is often the subject of negative remarks among classmates. Prominent ears are the result of one or more congenital anomalies that may be associated together in various degrees. Absence of antihelical fold, opening the cephalo-conchal angle and conchal hypertrophy are the most common. The surgery aims to correct these anomalies, by reshaping the cartilage in order to obtain well-shaped ears that is normally positioned and oriented with natural size and appearance. It combines different steps that need to be simple and fast. Retro-auricular incision, and dissection posteriorly allows to expose and remove the post-auricular muscle. Modeling of antihelical fold aims to restore a natural relief by closing the scapha-conchal angle. The concha is then buried and is securely attached to the pre-mastoid periosteum, which by consequence closes cephalo-conchal angle. The result must be harmonious and sustainable. Each surgeon adopts a suitable technique for him to obtain best results, by avoiding complications mainly infection, which is fortunately exceptional.

Long-term sequelae treatment of peripheral facial paralysis with botulinum toxin type A: Repartition and kinetics of doses used.

STUDY OBJECTIVES: Botulinum toxin is a key therapeutic tool in the comprehensive treatment of peripheral facial paralysis. It fights spasms, synkinesis and overactivity of the different skin muscles responsible of facial expressions. Even though injection techniques as well as target muscles have been well identified, doses used remain quite imprecise and often not detailed muscle by muscle, further more dosage progression has not been monitored over time. Our retrospective study is the first one to refine the repartition of botulinum toxin doses on each of the relevant skin muscles and assess dosage kinetics. PATIENTS AND METHODS: Thirty patients were included since 2008 with a mean follow-up of 2.3years. Each patient had at least 3 injections, with a delay of 4 to 6months between each injection. RESULTS: Mean doses are indicated for each muscle injected on the paralyzed and healthy sides. Dose kinetics suggests an initial dosage increase after the first injection followed by a decrease over time. No treatment resistance was observed. CONCLUSION: Our study represents a didactic help in using botulinum toxin for sequelae of peripheral facial paralysis by providing more details on the effective mean doses for each muscle and their progression over time.

[Burn child specificity]. / Les spécificités de la brûlure chez l'enfant.

Burn is still a frequent accident in children and particularly occurs in young children under 4years. The majority were caused by hot liquids (scalds) with mixed-dermal burns and is commonly treated conservatively with surgery performed at 10-15 days post-injury after healing of superficial burn. Patients with burns greater than 10% need early fluid resuscitation and adequate nutritional support to avoid deepening with infection, improve healing and survival. Hypovolemic shock could be very abrupt in children. Prophylactic prevention of infection and optimization of healing before 21 days improve quality of scar. Management with rehabilitation team is more important in children than in adults because hypertrophic scar and retraction can restrain growth and function particularly for palmar hand burns occurring at the beginning of walking. Follow-up is essential during the growth to assess scar tension requiring secondary surgery. Better knowledge of injury mechanisms should facilitate education and prevention programs and decrease the incidence.

[The unsightly chest: Analysis and anomaly. Curative or palliative approach?] / Le thorax disgracieux : analyse et anomalie. Approche curative ou palliative ?

Anterior chest wall deformity are mostly represented by pectus excavatum, which is a depression of the chondrosternal plastron from the 3rd to the 7th pairs of the costal cartilages, then by pectus carinatum which conversely represents a protrusion of this plastron. The major esthetic and psychosocial impact is not to be demonstrated anymore whereas the cardiopulmonary functional impact remains still highly debated. Regarding the management, curative surgical techniques such as Wurtz's sub-perichondrial simplified sternochondroplasty or Nuss' minimaly invasive technique are opposed to palliative filling technique such as customized silicone implant, lipostructure and flaps. In addition to these there are non-surgical techniques like suction bells (Vacuum Bell®) for pectus excavatum or compressive orthotic bracing for pectus carinatum. The morbidity and the mortality related to some of the heavy surgeries must be weighed up with esthetic, functional or both surgical indications in order to choose the proper management. The other known deformities are much rarer. Pectus arcuatum is a combined type requiring the same management principles. Sternal cleft is caused by a fusion defect of the sternal bars, which must be treated mainly by neonatal surgery. Acquired restrictive thoracic dystrophy is a consequence of early curative surgery.

[Breast asymmetry of the teenager and the young adult. Stability of the result in time. About 144 patients]. / Asymétrie mammaire de l'adolescente et de la jeune adulte. Stabilité du résultat dans le temps. À propos de 144 patientes.

INTRODUCTION: Breast asymmetry is defined by a difference in breast shape and/or volume. The goal of this study was to assess the stability of the surgical results and to highlight predictive factors for deterioration in results. MATERIALS AND METHODS: This retrospective and monocentric study included all patients presenting constitutional isolated asymmetry, Poland's syndrome, asymmetric tuberous breast or pectus excavatum treated between 1980 and 2015. RESULTS: The statistical analysis included 144 patients and contained two parts. The first analysis compared patients with or without breast implant. Results were significant only for symmetry of shape, with better outcomes without breast implant (P=0.0170). The second analysis compared the subgroups of patients with breast asymmetry, according to the etiology. Patients with tuberous breasts and constitutional isolated asymmetry have been compared. We found a significant difference only regarding the long-term results (P=0.0091). Patients with tuberous breasts had deteriorating in results over time. Patients with Poland's syndrome, compared to patients with constitutional isolated asymmetry, had significantly less good results for symmetry of volume, of shape, of areola, and for early results (P<0.025). Concerning patients with pectus excavatum, the early and long-term results and the stability were good for most patients. CONCLUSION: Better results have been obtained with similar surgical procedures on both sides. Predictive factors for instability of results were the use of unilateral breast implant, weight variations, pregnancies and breast-feeding, the use of hormonal treatments, ageing and tuberous malformation.

[Tattooing of the nipple-areola complex in breast reconstruction: Technical note]. / Tatouage de la plaque aréolo-mammelonnaire en reconstruction mammaire : note technique.

The reconstruction of the nipple-areola complex is an essential step in breast reconstruction. It announces the end of the reconstruction process, which is often long and sometimes difficult to live for the patient and will significantly improve the perception of body image. Concerning the reconstruction of the areola, tattooing is one of the preferred techniques. It's a simple, quick and safe procedure with a high satisfaction rate. This technique is still perfectible in our opinion, because the random lifetime of pigmentation is a recognized disadvantage of this procedure. We propose a modification of the conventional technique for improving the quality of dermopigmentation while reducing its completion time. Our method is to perform a dermabrasion before starting the tattoo. Indeed, dermabrasion allows better penetration of the pigments inside the dermis and thus offers two advantages: a more durable result over time and reduced operation time by reducing the number of passing of the machine tattoo. Finally, our tattooing technique seems relevant and totally appropriate: its realization is simple, reproducible, does not increase the overall cost of reconstruction, provides timesavings and gives a better long-term result.

[Medaillon-like dermal dendrocyte hamartoma: A case report]. / Hamartome dendrocytaire dermique à type de médaillon: à propos d'un cas.

Medaillon-like dermal dendrocyte hamartomas are rare congenital cutaneous lesions. They are present at birth as asymptomatic, benign, round, erythematous, well-circumscribed, atrophic patches. Typically, they have characteristic pliable, wrinkled surface; subtle telangiectases may also be appreciated. They are localized on the upper trunk or the neck. They may be misdiagnosed as atrophoderma, cutis aplasia, or anetoderma. Characteristic histologic findings include epidermal atrophy and the presence of CD34-positive spindle cell proliferation in the dermis. Little is known about the pathophysiology of medaillon-like dermal dendrocyte hamartomas. The main diagnosis pitfall is atrophic congenital dermatofibrosarcoma protuberance due to clinical and histological similarities. We emphasize that molecular studies to eliminate the t(17;22)(q22;q13) translocation of dermatofibrosarcomas may provide determinant elements for diagnosis in order to avoid unnecessary mutilating surgery. We present a case of medaillon-like dermal dendrocyte hamartoma with a local recurrence.

[Management of purpura fulminans lesions in children]. / Prise en charge des lésions des parties molles du purpura fulminans chez l'enfant.

Purpura fulminans is a pediatric life-threatening emergency with a significant mortality, combining: septic shock, extensive purpuric lesions and disseminated intravascular coagulation. The most frequent bacterial pathogen is the meningococcus. The medical management includes antibiotics, corticoids, vascular filling and catecholamines. Purpura fulminans is characterized by the extent of hemorrhagic and mainly thrombotic lesions, attributed to the alteration in the vascular endothelium functions. Damage of soft tissues combines large necrotic areas and more or less extensive distal ischemic lesions. Necrotic lesions can be deep, reaching skin, subcutaneous tissue, fascia, muscle and sometimes even the bone. The importance of the aesthetic and functional sequelae as well as future quality of life, depend on the quality of surgical management for these wide and deep lesions. Fasciotomy is sometimes urgently needed in the case of a clinical compartment syndrome, confirmed by a high-pressure measurement in the muscle compartments. Debridement of necrotic lesions and amputations are only performed after a clear delineation of necrotic areas, between 10 days and 3 weeks of evolution. If an amputation is necessary, it must focus on the residual bone length, considering the child's growth potential. The coverage of tissue loss uses all the plastic surgery techniques, more or less complex, in order to reduce scars to minimum for these children. Rehabilitation follow-up includes physical and psychological care, which are essential until adulthood.

[Is cosmetic surgery proposal to children and adolescents well-founded?] / Est-il légitime de proposer de la chirurgie esthétique aux enfants et aux adolescents ?

Cosmetic surgery for children and adolescents experiencing an international increase. Their physical and psychological development is incomplete; establishment of an indication for cosmetic surgery requires several essential prerequisites. The motivations of surgery, often multiple and intricate, must be understood. There is a difference in motivation between adult, trying to be more "competitive" and the young patient, wishing to comply with a social group to integrate. We must identify who made the request to respond to requests from the child himself. The role of parents is crucial. Their presence, legal obligation, gives variable contribution: asset to a non-participating children, role of information relay delivered, organizational aspects of care but sometimes leads to difficulties if parent-child relationship is confrontational. According to the American Society of Plastic Surgery, 63,623 cosmetic surgery procedures occurred in 2013 in adolescents from 13 to 19 years old. Mainly rhinoplasties, otoplasties, breast surgery (breast augmentations, breast reductions, gynecomasties). From a purely technical viewpoint, cosmetic surgery is not riskier in young patients. However, surgery only targets "surgical problems"; we must make a distinction between "complex" and "depression", be able to identify a psychiatric underlying disease or understand that surgery is a hidden demand. If surgical art requires a real expertise, only a well-indication establishment will process to a successful result.

[Scar revision in children: Clinical situations and solutions]. / La reprise de cicatrice chez l'enfant : situations cliniques et solutions.

The scar of soft tissues is a permanent stigma of a trauma but it can sometimes be improved. It is more or less accepted by the patient and may be the source of a significant physical and psychosocial impact that leads to a request for a scar revision. Even if the child presents generally an excellent ability to heal, the quality of the scar depends on many factors such as the age, the type of scar or trauma and the affected body area. Thus, its aesthetic impact, functional but also on the growth of the child will be different. Moreover, these scars have a number of origins: neonatal surgery, natural history of congenital lesions or after a surgical management; surgeries for orthopedic, cardiac, craniofacial or hand birth defects and congenital malformations; or infectious or traumatic as in the case of burns and animal bites. We have many ways to try to correct or improve these scars, which use all the plastic surgery techniques. However, we need to establish for each case an appropriate management strategy with the objective of not inducing additional sequelae, respecting the growth of the child. Several techniques can be combined and the chronology of the surgical procedures must consider the school, social and family integration of the child.

[Aplasia cutis congenita: Update and management]. / Aplasia cutis congenita : mise au point et prise en charge.

Congenital skin aplasia, or aplasia cutis congenita (ACC) is a rare congenital disease. It is characterized by the absence of skin at birth, localized or widespread, of one or several areas. This condition commonly involve the scalp but can also involve more rarely the trunk or limbs. However it is most frequently an isolated disorder, it can be associated with other anomalies, such as the Adams-Oliver syndrome, the association with a fetus papyraceus or with an epidermolysis bullosa. Many hypothesis have been suggested: vascular, genetic, traumatic, pharmacological or an anomaly in the neural tube closure process, but the exact mechanism is still unknown. Morbidity and mortality of this malformation depends on the affected area and the size of the defect. The main risk is the infection, hemorrhage and thrombosis in the case of a scalp defect with an underlying bone defect, the exposure of the meninges and the superior sagittal sinus. The initial management of ACC will therefore involve several plastic surgery techniques, from more simple to more complex, using conservative wound care to flaps techniques. Other techniques can be performed later, in the management of ACC sequelae, such as skin expansion for scarring alopecia.