Necrotizing fasciitis: A highly fatal infection.

BACKGROUNDS: Necrotizing fasciitis is a severe bacterial infection characterized by involvement of all skin's layers, including the superficial fascia. Diagnosis and treatment must be as quick as possible. Once suspected, extensive surgical debridement is required. METHODS: All necrotizing fasciitis, managed in our hospital in Dijon, during the period from January 2011 to May 2021, were retrospectively analyzed. Demographics characteristics of patients, biological parameters, and type of bacteria were collected. Statistical analysis was performed on the cost of hospitalization, as well as on the death rate between type I and II NF and the speed of management. Student's t-test and Chi2 test were performed with a significant level P<0.05. FINDINGS: A total of 65 patients were included over the period. The mean age was 68.8 years. The average length of stay was 32.4 days, with an average cost of 79,305 €. The main locations were the lower limbs (57%) and the perineum (35%). Cost of hospitalization did not differ between type I and II (P=0.21), unlike mortality rate (P=0.003). Furthermore, the mortality rate according to the speed of management did not vary in our series (P=0.45). CONCLUSION: Necrotizing fasciitis is quickly fatal if left untreated. Early diagnosis, combined with surgical debridement and probabilistic antibiotic therapy are required. Our study shows the impact of necrotizing fasciitis in terms of cost to society and the importance of prevention of certain risk factors. A global management of the patient is necessary to increase the survival rate.

[Complications and quality of life after bodylift: About 143 patients]. / Complications et qualité de vie après bodylift inférieur : à propos de 143 patients.

INTRODUCTION: The rise of bariatric surgery has led to a considerable increase in the demand for weight loss surgery. The lower body lift consists of removing the residual abdominal fat and skin excess and re-tensioning the surfaces. The objective of our study was to evaluate the associated complications, as well as the consequences of this surgery on the quality of life of the patients. MATERIALS AND METHODS: A retrospective monocentric study was conducted in patients operated on for lower body lift between 2010 and 2019 at the University Hospital of Besançon. We collected postoperative complications and studied the satisfaction and quality of life of the operated patients using the Body-QoL and SF-36 questionnaires. RESULTS: One hundred forty-three patients were included with a mean age of 41.2 years. The mean body mass index was 26.6kg/m2 with a mean weight of 73.8kg and a mean weight loss of 54.4kg. Forty-one patients (29.7%) had at least one complication. Most complications were minor, with 16.8% of scar disunions, and 7% of complications were major, requiring revision surgery. Ninety-three patients (65%) responded to the satisfaction questionnaires with improvement mostly in physical symptoms and social life. CONCLUSION: The lower body lift is an effective, safe procedure with mostly minor complications that do not influence quality of life. Patient satisfaction is high, and it is therefore justified to continue offering this procedure to correct the sequelae of massive weight loss.

Contributions of the Thiel's Method in teaching and researching anatomy.

INTRODUCTION: Knowledge of the human body is based on teaching and research. Anatomy remains an essential prerequisite for medical personnel to know the human body. The idea of Thiel's technique is to preserve the natural texture, volume, color and shape of the body. The objective of this study was to analyze a literature review of this technique from the perspective of anatomy teaching and biomechanical research. METHOD: We have taken up the process of Thiel's method from the original publication, stating the known applications of this technique in teaching and research. We have integrated into our study the specific advantages of using bodies preserved by this method in intertropical countries with a warm climate: the example of Gabon. DISCUSSION: Biomechanical research and teaching of medical and surgical sciences are regularly performed on human cadavers. Anatomical dissection therefore represents one of the main activities of anatomy laboratories. We have limited our analysis to aspects of anatomy teaching, research, and clinical and surgical practice. CONCLUSION: We have sought to popularize the Thiel body preservation technique. It offers many advantages. Teaching and research on human cadavers preserved by this method is an educational alternative. The simulation centre creates the conditions of a surgical block for the learners. We recommend this technique to anatomists and clinicians. This technique seems to be very interesting for structures with a limited number of bodies.

The infragluteal fold: An appraisal by MRI combined with an anatomic study.

PURPOSE: The gluteal region is a key element of beauty balance and sexual appearance. However, there is no clear anatomical description of the infragluteal fold, nor any classification exists allowing standardizing treatment of this area in case of jeopardisation. The purpose of this study was to perform an anatomical description of the infragluteal fold (IGF) matching radiological and anatomical findings in describing specifically raise of the fibrous component at the bone level. METHODS: Six volunteers (three males and three females) underwent an MRI scan (Siemens Aera® 1.5 T) of the pelvic region. T1 Vibe Morpho T2, Sag Space 3D, and Millimetric slices were performed in order to obtain a more detailed selection of the gluteal landmark. Trabecular connective tissue of the region was analyzed using Horos® ROI (region of interest) segmentation function. Four fresh cadavers (two males, two females, accounting for 8 hemipelvis) were dissected in order to compare the radiological findings. RESULTS: The infragluteal fold is a connectival fibrous band extending from the ramus of the ischium (but not involving the ischial tuberosity, for a length of 21 mm ± 2 and 21 mm ± 3), the apex of the sacrum (for a length of 13 ± 2 and 11 mm ± 2), and the coccyx (for a length of 19 mm ± 2 and 20 mm ± 2, all measures referring to volunteers and cadavers, respectively) reaching superficially the dermis of the medial one-third of the cutaneous fold. No significant difference was found between volunteer and cadaver group in MRI measurement of bony origins, or between MRI and cadaveric dissection measurements. CONCLUSION: Knowledge of this structure will define novel surgical techniques in infragluteal fold restoration.

[Evaluation of the risk of postoperative bleeding complications in hand surgery without interruption of anticoagulant Vitamin K Antagonist (VKA), a retrospective study]. / Évaluation du risque de saignement postopératoire en chirurgie de la main sans interruption des anticoagulants de type AntiVitamines K (AVK), étude rétrospective.

OBJECTIVE: The management of patients on Vitamine K Antagonist (VKA) anticoagulation is a public health issue with surgery being the primary cause of VKA interruption. The aim of this study was to evaluate the bleeding risk in patients operated on hand surgery without interruption of VKA treatment. PATIENTS AND METHODS: This retrospective, monocentric study was conducted between 2013 and 2015. The inclusion criteria were, as follows: patients on VKA over 18 years of age who had emergency or scheduled surgery without interruption of VKA treatment; INR inferior to 3 analyzed less than 24h before surgery. Exclusion criteria were, as follows: INR superior to 3; interruption of VKA treatment with or without switch to heparin treatment. The primary evaluation parameter was any form of bleeding that occurred during the first 7 post-operative days. The secondary criteria were other surgical complications. RESULTS: There were 93 patients and 104 procedures. The mean age was 74.36 years (from 27 to 90) with a sex ratio male-to-female of 2.47. The scheduled surgeries were 61.5% against 36.5% for the emergency cases. The mean INR was 2.29 (from 1.07 to 3). One patient presented a postoperative hematoma on the 4th postoperative day, which did not require any revision surgery. There were no other complications reported. CONCLUSION: The results of this series suggest a small bleeding risk in hand surgery without interruption of VKA treatment provided that IRN is inferior to 3 less than 24hours before the procedure.

Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap.

OBJECTIVE: The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. MATERIALS AND METHODS: This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion. RESULTS: Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. CONCLUSION: In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1hour and 45minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.

Improving free-flap survival using intra-operative heparin: Ritualistic practice or evidence-base medicine? A systematic review.

INTRODUCTION: The failure rate of free flaps is approximately 5%, mostly due to thrombosis of microvascular anastomosis. A number of pharmacological agents have been tested in order to enhance the patency of microvascular anastomosis and so to as extend the survival of free flaps. One of them is heparin, a very commonly used anticoagulant. However, there exists no consensus on its use in microsurgery as concerns time of introduction (pre-, intra- or post-operative), recommended dosage, or duration of utilization. The aim of this study was to determine whether or not the use of intra-operative heparin, in its systemic or topical forms, can bring about improved survival of free flaps, and if and when it should be recommended in microsurgery. MATERIAL AND METHODS: A systematic review on the PUBMED database enabled us to identify articles evaluating the benefits of intra-operative heparin with regard to free-flap survival. All in all, fifteen articles in animal and human research were selected. RESULTS: As far as animal research is concerned, 9 studies out of 11 showed the superiority of topical intra-operative heparin compared to saline in improving free-flap survival rates through improved patency of the anastomosis. As regards systemic intra-operative heparin, on the other hand, only two trials out of four yielded favorable results. In clinical research in humans, there has been no prospective randomized trial studying the action of topical intra-operative heparin in vessel irrigation of ex-vivo free flaps before vascular repermeabilisation. However, the preliminary results of four trials seem to provide positive arguments for this practice. CONCLUSION: The use of systemic per-operative heparin (intravenous injection) does not improve the survival of free flaps in either animal models or humans. In animal models, however, the use of topical intra-operative heparin (vessel irrigation) has been shown to improve the free-flap survival rate by avoiding thrombosis of microvascular anastomosis. Finally, in clinical studies concerning humans, as of now no prospective randomized trial has proven that use of topical intra-operative heparin to ensure vessel irrigation in ex-vivo flaps is likely to increase free-flap survival. Studies should be conducted to decide whether or not to validate a rather ritualistic practice that consists in irrigating the relevant vessels before anastomosis; does it or does it not improve the patency rate?

Surgical approaches in neck dissection: Comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach.

BACKGROUND: Surgical approaches in neck dissection: comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach. METHODS: This single-center retrospective study compares a new transverse incision for cervicotomy to the classical approach described by Paul André in neck dissections. The evaluation criteria were: number of lymph nodes analyzed, operative time, complications, patient satisfaction and aesthetic aspects of the scar. RESULTS: A total of 34 patients were included in this study, from September 2009 until January 2015. The number of lymph nodes analyzed is not affected by this new approach compared to the classical one (P=0.9). The scar has a significantly more discreet appearance in the transverse cervicotomy group (P=0.023) likewise; patient satisfaction is higher in this group (P=0.006). CONCLUSIONS: Aesthetic and functional impairment can be reduced using this new transverse cervical approach hidden in the natural creases of the neck described by Langer.

[Nipple projection augmentation in breast reconstruction by artificial derm injection]. / Augmentation de la projection du mamelon dans les reconstructions mammaires par injection de derme artificiel.

INTRODUCTION: The reconstruction of the Nipple-Areola Complex (NAC) is the last step and a key part in breast reconstruction. The technique to be used should be chosen as to avoid any complications on previous reconstruction steps. The use of local flaps for NAC reconstruction could be associated with implant exposure especially in the presence of a history of radiation therapy. The pure dermal flap could be indicated for the nipple reconstruction after breast reconstruction by implant after radiotherapy. The limit stay in the nipple hypoprojection. We suggest to assess the increase of the nipple projection, reconstructed by pure dermal flap, by injection of Integra® Flowable Wound Matrix (Integra LifeSciences®, Plainsboro, New jersey). PATIENTS AND METHOD: Nipple projection has been measured among patients enclosed from february to March 2016 reconstructed by pure dermal flap: before, after and also at a 6months term from the injection of Integra® Flowable Wound Matrix. Patient satisfaction and complications have been measured retrospectively. RESULTS: Ten patients with an average of 55years have been enclosed, with an average limit of time of 19months (7 to 33months) between the breast nipple reconstruction by dermal flap and the injection. A volume of 1 to 1.6cc has been injected. A significative increase projection of 2mm at a 6months term has been measured (1.5 to 2.5mm, P<0.01), without complication and a satisfaction rate of 4.5/5. CONCLUSION: The injection of an artificial derm-like Integra® Flowable Wound Matrix seems to be efficient to increase the nipple projection reconstructed by pure dermal flap after a breast reconstruction and moreover, without complications.

[Postoperative complications of labia minora reduction. Comparative study between wedge and edge resection]. / Complications postopératoires des nymphoplasties de réduction. Étude comparative rétrospective entre résections longitudinale et cunéiforme.

BACKGROUND: Labia minora reduction interventions rise in Europe and in North America. Several techniques are described. The objective of this study was to compare postoperative complications of the two most practiced interventions: wedge resection and edge resection. METHODS: Primary labia minora reductions realized in our unit between October 2009 and July 2016 have been retrospectively identified. Two techniques were used by two surgeons: edge resection technique and wedge resection technique. The main evaluation criterion was the occurrence and the quantity of wound dehiscence: superior to 50% (total or subtotal) and inferior to 50% (partial). Patients were systematically examined at 1 week, 1 month and 6 months postoperatively. Data analysis between both groups was made with an exact Fisher test. RESULTS: Mean follow-up was 5.3 months after intervention. Sixty-four patients have been included, 42 wedge resections (group C) and 22 edge resections (group L). Global complication rate at 1 month was 13% (n=8). Among wedge resections 14% (n=6) developed complication and 2% (n=9) among edge resection. Seven surgical revisions were necessary: 5 for wound dehiscence (4 in the group C and 1 in the group L) and 2 for hematoma, one in each group. Three (5%) partial wound dehiscence (inferior to 50%) have been identified and let in secondary intention healing: 2 (19%) in the group C and 1 (27%) in the group L. Complication rates between both techniques were not significantly different. CONCLUSIONS: Postoperative wound dehiscence is the main labia minora reduction complication. Our global complication rate, 13%, matches with the current literature. A tendency can be shown where wedge resection is more likely to develop wound dehiscence than edge resection.

[Pathomimia and plastic surgery, a case report]. / Pathomimie en chirurgie esthétique, à propos d'un cas.

Pathomimia is defined as a dummy pathology self-induced deliberately and is neither associated with mental confusion nor disturbance of consciousness. This article reports a case of pathomimia in plastic surgery. One of our patients had intentionally injected physiological saline solution into her breast implants in order to increase their volume. Implants removal was necessary because of severe local inflammatory signs. Psychiatric assessment revealed body dysmorphic disorder (BDD) developed on an hysterical personality, which explained the self-induced injuries. This nosologic entity must be promptly identified because it's diagnosis remains problematic and a multidisciplinary medical management is essential.

Surgical treatment of symmastia: A systematic review of techniques, outcomes and complications.

BACKGROUND: The term "symmastia" defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care. OBJECTIVE: This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications. RESULTS: In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases. CONCLUSION: Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Lower limb reconstruction involving osteosynthesis material: A retrospective study on propeller flaps outcomes.

INTRODUCTION: Reconstruction of soft tissue defects in lower limb fractures requiring internal fixation remains a challenging scenario with the optimal surgical treatment still debated. This study aims to recommend, and eventually redefine, surgical indications for propeller flaps reconstruction in the distal lower limb, with a particular focus on the presence or not of metalwork. METHODS: A retrospective study of lower limb soft tissue reconstructions performed between January 2015 and July 2018 was carried out including all patients treated with a propeller perforator flap (PPF) with at least 6-month follow-up. Patients were further divided in 2 groups depending on the presence of metalwork fixation beneath the flap (F group, propeller on Framework; NF group, propeller with No-Framework). RESULTS: 21 patients were retained (F group, 11 patients; NF group, 10 patients). There were no significant differences between the two groups in age, BMI, ASA scores, comorbidities or defect size. There was a statistically significant difference between the groups (p<0.05) in the cumulative hospital stay with a mean cumulative hospital stay of 22 ± 9 days in the F group and 12 ± 8 days in NF group. Failures were higher where PPF were used to cover hardware material, with 3 patients requiring a major secondary procedure in F group versus 1 patient in NF group. CONCLUSION: The presence of underlying metalwork significantly reduced the margin for small, day-case revision procedures such as flap readvancement or STSG. This study emphasizes clinical intuition that whilst PPF are a useful and elegant tool in lower limb reconstruction, their use should be limited when underlying metalwork is present.

Systematic reappraisal of the reverse-flow medial plantar flap: From vascular anatomical concepts to surgical applications.

INTRODUCTION: The medial plantar artery (MPA) flap in its anterograde form is considered the gold standard for heel reconstruction. This flap can be also raised distally for the reconstruction of the weight-bearing forefoot. However, terminal branches of the MPA, together with their connection with distal and dorsal systems, can be variable. Our objective was to provide a comprehensive anatomic description that could match all technical possibilities in raising the distally based MPA flap. A systematic review of indication outcomes and complications of the distally based MPA flap is provided. METHODS: According to PRISMA criteria, we systematically reviewed previous literature using the MEDLINE database concerning the MPA flap from 1977 to November 2018 using the keywords « Medial plantar flap ¼ OR « Medial Plantar Artery ¼. Anatomic variations, techniques, indications, outcomes, and complications were analyzed. RESULTS: All different vascular pedicles that may be used for the vascularization of the MPA flap were classified. Apart from the flap with a proximal flow, there may be five anastomotic connections from the superficial MPA to the plantar arterial network. Four dorso-plantar links supply the plantar network thanks to dorsal vascularization. Literature analysis of outcomes showed how the retrograde MPA flap may be unreliable with 14% of venous congestion rate and 9.3% of average flap loss, for a total average flap complication of 18.6%. CONCLUSION: This review provides the ultimate, clear picture of the complex anastomosis of the forefoot, with direct referral to surgical flap raising techniques, guiding surgeons during challenging reconstructions.

Traumatic atlanto-axial rotatory subluxation after surgical correction of prominent ears: Case report and review of the literature.

Corrective surgery of prominent ears may be justified for social or aesthetic reasons during childhood or adulthood. Post-operative complications occur in approximately 0 to 8.4% of cases. This case describes a rare atlanto-axoid rotatory subluxation after bilateral surgical correction of prominent ears under general anesthesia. Orthopedic treatment was done after two months of medical roaming outside of our center. The one-year post-operative clinic consultation and radiological exam were normal. Only the psychological impact of the episode remained. Traumatic atlanto-axial rotatory subluxation is a rare complication but should be considered after post-operative torticollis in order to aid with diagnosis and allow doctors to implement the appropriate course of treatment.

Are prostaglandins or calcium channel blockers efficient for free flap salvage? A review of the literature.

The free flap failure rate is less than 5%. The responsible mechanisms of postoperative secondary ischemia are mostly vascular. The main postoperative complication leading to flap failure is thrombosis. Different strategies have been reported to improve the reliability of flaps and decrease the risk of partial or total necrosis: thus, pharmacologic agents have been studied to reduce the risk of microvascular thrombosis. The aim of this review was to evaluate the effect of calcium channel blockers and prostaglandins on free skin flap survival. A systematic review of the literature was performed to identify articles studying the efficacy of calcium channel blockers and prostaglandins on free flap survival. After full text reading, eleven articles were finally included. Eight articles investigated the role of prostaglandins in free tissue transfers, two in rats subjects, one in rabbits, five in humans. Two articles studied the effect of calcium channel blockers on free flaps, one in rats subjects, one in rabbits. One article studied in different groups the effect of calcium channel blockers and prostaglandins on free flaps in rabbits. Literature regarding the efficacy of calcium channel blockers and prostaglandins to salvage free flap is poor and mainly based on animal models. Nevertheless, studies on prostaglandins showed a slight efficiency of these molecules for free flap salvage. Results are less reliable for calcium channel blockers and dependent on the molecule used. In conclusion, there is a lack of evidence to use them in clinical practice.

Classification proposed of malignant intraosseous odontogenic tumors (MIOT).

Malignant intraosseous odontogenic tumors (MIOT) of the jaws are very rare. The diagnosis is difficult. Clinical, paraclinical and histological diagnostic criteria, strict are well established. But the International Union Against Cancer (UICC) does not provide TNM classification that will allow harmonization of the treatment. Indeed, despite their location, they cannot be classified as primary tumors of the oral cavity because of their localization in the bone marrow, making them systematically classified as T4. We propose a classification taking into account the clinical and radiological data.

[Custom-made implant for complex facial reconstruction: A case of total replacement of temporo-mandibular joint, zygomatic arch and malar bone]. / Reconstruction faciale complexe sur mesure : un cas de remplacement total de l'articulation temporo-mandibulaire, de l'arcade zygomatique et du zygoma.

INTRODUCTION: Total prosthetic replacement of the temporo-mandibular joint (TMJ) has become a common procedure, but it is usually limited to the TMJ itself. We report about one case of complex prosthetic joint reconstruction extending to the neighbouring bony structures. CASE: A 57-year-old patient, operated several times for a cranio-facial fibrous dysplasia, presented with a recurring TMJ ankylosis and a complexe latero-facial bone loss on the right side. We performed a reconstruction procedure including the TMJ, the zygomatic arch and the malar bone by mean of custom made composite prosthesis (chrome-cobalt-molybdenum-titanium and polyethylene). Five years postoperatively, mouth opening, nutrition, pain and oral hygiene were significantly improved. DISCUSSION: Nowadays technical possibilities allow for complex facial alloplastic reconstructions with good medium term results.