[Fat grafting in facial burns sequelae]. / La lipostructure dans les séquelles de brûlures faciales.

INTRODUCTION: Fat graft is now part of the armamentarium in face plastic surgery. It is successfully used in burn scars. The aim of our study is the discussion of the value of this technique in optimizing cosmetic result of burns face sequelae. PATIENTS AND METHOD: Fifteen adult patients (10 females and five males) with scars resulting from severe burns 2 to 9 years previously were selected. The patients were treated by injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. Two to three injections were administered at the dermohypodermal junction. Ages, sexes, aetiology of burn, facial burn sequelae, recipient sites, quantity of fat injected, aesthetic results are discussed. RESULTS: Patient age ranged from 21 to 55 years (average: 38). The mean follow-up of the study was 66 months (23-118). Patients received 7.5 (5-11) facial restorative surgeries before fat graft. Patients underwent two sessions of fat transfer, 33cc average per session. We did not report any complications. The clinical appearance, discussed by three surgeons and subjective patient feelings, after a 6-month follow-up period, suggests considerable improvement in the mimic features, skin texture, and thickness. The result is good in 86% of cases and acceptable in the other cases. DISCUSSION: Burns sequelae offer local conditions which justify special cannula can cross fibrosis and explaining the value of multiplying the sessions. Indications for lipostructure include four distinct nosological situations, sometimes combined. Lipostructure can restore a missing relief, filling a localized depression, reshape a lack of face volume or smooth a scarring skin. CONCLUSION: Fat graft seems to complete and improve the results of the standard surgical approach in burned face.

Comparison of foam dressings with silver versus foam dressings without silver in the care of malodorous malignant fungating wounds.

PURPOSE: To investigate the effectiveness of foam dressings with silver vs. foam dressings without silver to reduce malodorous and septic phenomena in malignant fungating wounds (MFWs). METHODS: The study included 26 patients with malodorous MFWs at home care. Thirteen patients formed the intervention group A (foam dressings with silver), and another 13 patients formed the control group B (foam dressings without silver). The patients' selection was random. The dressing changes were carried out according to the needs of the ulcer and depending on the exudates' level. The evaluation of the odor was 4 weeks after the start of the study. The patients' evaluation was excluded due to familiarization with the odor. RESULTS: In group A 10/13 (76.9%) patients showed a significant reduction of the odor compared with 4/13 (30.8%) patients in group B (p = 0.049). CONCLUSION: Microbial activity and septic phenomena in the ulcerated surface of MFWs are the causes of unpleasant odor. This study provided evidence that the antimicrobial property of silver dressings is very useful in the treatment of microbial activity and can reduce malodorous and septic phenomena.

[Face rehabilitation for post-burn deformities]. / Traitement chirurgical des séquelles de brûlures de la face.

Severe post-burn sequelae of the face can result from deep initial burns or inappropriate (initial or secondary) treatment. They still remain a surgical challenge, leading to both aesthetic and functional diseases. The acute treatment is preventive, and usually consists in early split thickness skin grafts from the scalp, while full thickness skin grafts and local flaps are employed for the sequels. Our surgical treatment consists in scar replacement using expanded supraclavicular skin. Depending on the location of the scars and depending on available skin, surgical procedure can use expanded full thickness skin graft or expanded advancement flaps. Some "aesthetic" procedures like lipofilling, rhinoplasty or botulinum toxin can be performed in order to improve the final aspect. Good aesthetic and functional results are usually obtained if fundamental rules are respected: preservation of aesthetic units of the face, good management of skin availability. In any case, whatever techniques are employed, numerous surgical procedures and months of rehabilitation are necessary to achieve good cosmetic and functional results.

[Surgery of burn sequelae on the scalp]. / Chirurgie des séquelles de brûlure du cuir chevelu.

Surgical treatment of scalp burn sequelae has achieved a decisive step with the use of tissue expansion. First, authors propose a brief recap on anatomy, physiopathology and usual surgical processes. Then they describe in details the tissue expansion and present some experimental results. As a conclusion, they discuss the learning curve associated with such a process.

[Is there a relation between mammaplasties incisions and the final shape of the breast?]. / Existe-t-il un rapport entre les incisions et la forme finale d'un sein ?

GOAL: The results of reduction mammoplasty and mastopexy demonstrate a great variety of shapes derived from the particularities inherent to each technique. More precisely, it has become apparent to us that the usage of an abnormally long vertical scar leads to a suboptimal final shape of the breast due to the excessive projection compared to its height. Although our clientele continually asks to minimize scars, we have noticed a resurgence in the literature of vertical incision mammoplasty techniques albeit with a scar of an excessive length. The multitude of publications leads to an evident and consistent conclusion: breasts reconstructed with an overly long vertical incision all suffer the same deformity characterized by a banana or squash-shaped breast. METHODS: We studied the totality of publications on vertical incision technique mammoplasty from the last 15 years and realised they all presented the same problem: an abnormally low height/projection ratio. These numbers have been confronted by the golden ratio established by the first author (2005) [1]. RESULTS: The breast's golden ratio developed by Moufarrège is optimal at a number close to, or superior to 2. Results between 2 and 1.5 are acceptable. All height/projection ratios inferior to 1.5 correspond to suboptimal breast shapes. Furthermore, the totality of results in the vertical scar mammoplasty technique which displayed unsatisfying results had a height/projection ratio inferior to 1.5. CONCLUSION: Those who promote the vertical incision have the greatest drive to encourage other plastic surgeons to abandon the traditional mutilating boat anchor scar. Nevertheless, they should always remember the deforming effect caused by exaggerated vertical incisions which may be avoided by transforming it into an inverted T with short horizontal branches, a small price to pay to obtain a superior aesthetic result.

Imiquimod 5% cream: a new treatment for Bowen's disease.

Bowen's disease (BD) is a squamous cell carcinoma in situ. Recent studies suggest that human papilloma virus plays an important role in the development of BD. We investigated whether imiquimod 5%, a topical immune response modifier, is an effective treatment for BD in five immunocompetent patients. The lesions were one genital and four extragenital. The frequency of application varied from three times weekly up to twice daily, and treatment duration ranged from 8-24 weeks. Four patients achieved clinical and histological cure. The patient with the genital lesion gained an important reduction in size and infiltration, which enabled surgical removal of the remaining lesion with good functional and cosmetic result. Our results suggest that topical imiquimod 5% is an effective treatment for BD through its viral and antitumor effects.

Topical use of Rectogesic® and Emla® to improve cutaneous blood perfusion following thermal injury. A comparative experimental study.

Early post-burn ischemic necrosis of the skin is of particular interest in modern burn research. The purpose of this study was to test the hypothesis that blood perfusion could be improved by the topical application of vasoactive substances. A sample of 55 wistar rats was used to investigate the effect of 0,4% nitroglycerin ointment (Rectogesic(®)) comparatively to no application and placebo. The beneficiary action of 5% prilocaine/lidocaine cream (EMLA(®)) in burn blood perfusion was also tested comparatively to Rectogesic(®). Both preparations were tested respectively to non burned controls. Laser Doppler assessment of blood flow at 15, 30, 45, 60, 120 and 180 minutes after preparation application, demonstrated that the use of Rectogesic(®) improved perfusion at all measurements compared to placebo and to no preparation application (p&0,05). There was no statistical significant difference in the effect of the two preparations.

La nécrose ischémique précoce de la peau brûlée est d'un grand intérêt dans la recherche actuelle en brûlologie. Le but de cette étude était de vérifier l'hypothèse que la vascularisation peut être améliorée par l'application topique de substances vaso-actives. Un échantillon de 55 rats Wistar a été utilisé pour étudier l'effet de 0,4% onguent à la nitroglycérine (Rectogesic®) comparativement à aucune application d'onguent et un placebo. L'action bénéfique de la crème lidocaïne (EMLA®)( 5% prilocaïne) sur la vascularisation cutanée a également été testé comparativement àvec le Rectogesic®. Les deux préparations ont été testées respectivement sur des témoins non brûlés. Une évaluation Laser Doppler du flux sanguin à 15, 30, 45, 60, 120 et 180 minutes après l'application de la préparation, a démontré que l'utilisation de Rectogesic® améliore la circulation à chaque mesure par rapport au placebo et par rapport à la non application d'onguent (p&0,05). Il n'y avait aucune différence statistiquement significative dans l'incidence des deux préparations.

[Malakoplakia of the submandibular gland in a renal transplant patient]. / Malakoplakie de la glande sous-mandibulaire chez un patient transplanté rénal.

INTRODUCTION: Malakoplakia (MP) is a rare granulomatous disease, usually occurring in immunocompromised patients, linked to Escherichia coli infection. The lesions are usually located in the genitourinary tract, but there is a great variability in the topography and the clinical presentation. CASE REPORT: A 70-year-old diabetic kidney transplant patient under immunosuppressive treatment presented with a voluminous submandibular chronic lesion, involving the skin, associated with a burgeoning lesion of the oral mucosa. Histological examination of biopsies concluded to MP and bacteriological samples were positive for E. coli. Antibiotic treatment allowed for the regression of the lesion before surgical removal. Histological examination of resected material confirmed the diagnosis of invasive MP of the submandibular gland. DISCUSSION: The diagnosis of MP relies on histological examination, showing the presence of von Hansemann's cells and Michaelis- Gutmann bodies. The treatment is based on active antibiotics targeted against intracellular bacteria, possibly associated with surgery. We report the first case of MP involving the submandibular gland.

Expression of proteoglycans and glycosaminoglycans in angiofibroma and fibrous plaque skin lesions from patients with tuberous sclerosis.

Tuberous sclerosis complex (TSC) is a disorder of cell lineage, migration, proliferation and differentiation, characterized by the development of widespread benign hamartomas, which are particularly evident in hamartomatous lesions of the skin. The aim of this study was to investigate differences in gene expression of certain proteoglycans (PGs) and to characterize glycosaminoglycans (GAGs) in tissue specimens of normal skin, fibrous plaques and angiofibromas from patients with TSC. The expression of PG mRNA was determined by semiquantitative RT-PCR analysis. Total GAGs were isolated from tissue specimens after lipid extraction and extensive digestion with Pronase and DNase and characterized by treatment with GAG-degrading enzymes followed by electrophoresis on polyacrylamide gradient gels and cellulose acetate membranes. Normal skin specimens express versican, decorin and aggrecan and contain hyaluronic acid and dermatan sulphate. In angiofibroma specimens aggrecan is not expressed while versican splice variant with two EGF-like domains and decorin are downregulated. Furthermore, angiofibromas differ from normal skin in that they additionally contain keratan, heparan and chondroitin sulphates and do not contain dermatan sulphate. In fibrous plaque specimens gene expression of PGs was similar to that in normal skin, but with respect to GAGs, they contained a single acidic glycan population that did not share common structural features with known GAGs. The variations of the above ECM molecules between normal and TSC skin may be attributed to TSC-related mutations and, overall, support the TSC-associated pathological manifestations of cell migration, proliferation and differentiation.

[The non-perfect results of breast implants]. / Imperfections de résultats des implants mammaires.

The non-perfect results of breast implants (i.e. preexisting asymmetries, skin wrinkling, implant displacement, anatomical implant rotation), sometimes temporary in nature, can induce some aesthetic doubts into the patients that might have implications for the patient-plastic surgeon relationship. Preexisting asymmetries (i.e. chest wall, nipple-areola complex and breast mound) considerably influence the final aesthetic result of breast augmentation. Thus, such asymmetries along with their related, even more pronounced, potential postoperative ones should be discussed with patients during the preoperative period. Skin wrinkling is closely related with filler material and implant texture. We believe that the recent, cohesive silicone gel-filled implants, which are of rough texture, might be associated with fewer incidences of skin wrinkling than other implants. Implant displacement, either upwards or downwards, could occur even many years after the operation. Capsular contracture, initial malposition and/or erroneous incision are the main causes of displacement. Anatomical implant rotation seems to be related to the mechanical and geometric features of the implant and to a reduction in adhesion factors. In these cases, implants should be replaced. We must understand that some properties of the implants are not well-known as is also the case of the implant long-run comportment inside the human body. These facts are probably responsible for the appearance of non-perfect, undesirable results. Plastic surgeons should be aware of such "inconveniences" and advise their patients.

Proboscis lateralis: treatment of two atypical cases.

Proboscis lateralis (PL) is a rare congenital malformation of the nose. We describe two atypical cases of proboscis we treated to obtain symmetrical nostrils. We used the PL as a donor tissue. Due to the variable aspects of this malformation, achieving an aesthetical goal remains a surgical challenge.

[The significance and role of speech therapy in rehabilitation after lip surgery]. / Intérêt et place de l'orthophonie dans la rééducation après chirurgie labiale.

Post-operative functional rehabilitation of the orofacial region has greatly benefited from progress in orthophony. Technical know-how in pediatric patients can be adapted to the specific requirements of postoperative rehabilitation in children.