[The transverse musculocutaneous gracilis free flap: Innovative autologous breast reconstruction]. / Le lambeau de gracilis à palette transversale : une nouvelle technique de reconstruction mammaire autologue.

INTRODUCTION: The transverse musculocutaneous gracilis free flap allows a wider range of indications in autologous breast reconstruction. They extend far beyond traditional dorsal, abdominal and gluteal flaps. The authors present their experience in using this innovative procedure. PATIENTS AND METHODS: The cutaneous and adipose part of the flap consists in a horizontal ellipse centered on the gracilis muscle in the upper thigh. The distal part of the muscle is released without neither visual control nor additional incision. The flap vascular pedicle is microanastomosed to the recipient internal thoracic vessels in the third intercostal space. Eleven patients, with a mean age of 44 years (29-62) and a BMI of 24 (19-32) underwent this procedure. Surgery was performed on either one side (n=6) or two (n=5), in indications of immediate (n=5) or delayed reconstruction (n=6). The main operative parameters (time, vessel diameter, pedicle length, flap volume) as well as postoperative follow-up were studied. RESULTS: Mean time of surgery was 4h33 (3-6 hours). Pedicle measured 6.2 cm (5-7.5) and diameter of the artery was 19 mm (15-30). Average weight of the flap was 344g (270-498). Two cases of partial necrosis occurred in the posterior cutaneous part of the flap (1cm(3) and 3 cm(3)). They were treated using controlled wound healing. Sequelae in the donor site proved minimal as the scar was placed in the crural crease and the gluteal fold. No major functional defect was noted after mean follow-up of six months. CONCLUSIONS: The transverse musculocutaneous gracilis free flap allows natural and durable reconstruction while reducing cosmetic and functional sequelae in the donor site. It proves to be particularly useful in bilateral immediate reconstructions following skin-sparing mastectomy. This surgical option offers new opportunities to long-limbed women without abdominal excess wishing autologous breast reconstruction.

[A trick to improve the technique of the IntraVascular Stent (IVaS): "Clip Stent"]. / Une astuce pour améliorer la technique du stent intravasculaire (IVaS) : le "Clip Stent".

The infra-millimetre vessels are difficult to suture, because the placement of forceps in the lumen is delicate and threads often cross the walls. The technique of the IntraVascular Stent (IVaS), developed to remedy it, did not make the proof of its superiority. The purpose of this study was to analyze the results of a variant, the Clip Stent. Our series included two groups of 10 rats. In group I, the artery of the tail was anastomosed by threads of nylon 10/0. In group II, the artery was anastomosed according to the technique of Clip Stent including three stages: introduction of a monothread of polypropylene 6/0, anastomosis by threads of nylon 10/0, ablation of the Clip Stent and the closure of possible leaks. The assessment consisted in measuring the time of anastomosis, in counting the number of separate threads and leaks, and in testing the permeability. The time of anastomosis was longer 12 minutes in the group II. The number of points by anastomosis was 6.5 in the group I and of 5.5 in the group II. The permeability was 90% in two groups. The Clip Stent is faster than the IVaS. It is useless to realize vascular threads of the lumen before the introduction of the stent. Once the stent in position, it cannot traumatize the intima and its migration is impossible. Contrary to the IVaS, the Clip Stent allows to realize the last threads stent in position, by releasing the tourniquet. The ablation is safe. Its superiority to the conventional methods remains to demonstrate by improving its introduction in the lumen.

Pull out stent: a trick to improve the intravascular stenting technique.

The intravascular stent technique (IVaS) was developed to simplify the anastomosis of submillimeter blood vessels. One variation of the IVaS called the "clip stent", improved the patency of anastomosed vessels. The goal of this study was to analyze a subsequent technical variation called the "pull out stent", which aims to reduce trauma to the vessel. Our experimental study comprised 4 groups of 10 rats. Anastomosis of the tail artery was performed with 10-0 nylon suture using either interrupted sutures (group I), IVaS (group II), "clip stent" (group III), or "pull out stent" (group IV). The "pull out stent" technique consisted of 3 steps: introduction of the stent (intraluminal and then transluminal introduction of a 4-0 nylon monofilament followed by introduction of the other end into the opposite lumen), anastomosis, and then removal of the stent. The anastomosis procedure time was longer in group III than in group IV. The number of stitches and the patency were similar in all groups. There were more leaks in group I. The "pull out stent" was faster, less traumatic to the vessel wall, allowed for more regular sutures and caused fewer leaks than the other stenting techniques. One possible clinical application is the anastomosis of digital veins as part of replantation or toe transfers, especially in children.