[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]. / Cytostéatonécrose après reconstruction mammaire par lambeau graisseux avec ou sans préconditionnement ischémique.

INTRODUCTION: Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM. MATERIAL AND METHODS: All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded. RESULTS: Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM. CONCLUSION: PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

[Frontal sinus anatomical scanographic study of transgender patients for feminization frontoorbitoplasty surgery]. / Étude anatomique scanographique du sinus frontal des patients transgenres en vue d'une chirurgie de frontoorbitoplastie de féminisation.

INTRODUCTION: Little is known about the anatomical elements that allow safe and predictable performance of fronto orbital surgery for facial feminization. The primary objective of this study was to analyze the characteristics (dimensions, pneumatization rate, and anterior wall thickness) of the frontal sinus in MtF transgender patients. The secondary objective was to establish reproducible criteria for CT measurements that could guide preoperative planning of frontal impaction in feminization frontoplasty (FF). MATERIALS: Fifty preoperative facial mass scans of FF surgery patients were included. The mean age of the operated patients was 34 years. The F line represented the ideal forehead tilt in the absence of a frontal hump. RESULTS: The height, width, depth, and thickness of the anterior sinus wall were 26.6mm (±5.7), 49.5mm (±11.3), 10.9mm (±3.3), and 3mm (±0.7), respectively. The mean sinus width to skull width ratio was 0.73 (±0.12). Six percent of patients had bilateral frontal sinus agenesis. An osteotomy of the anterior wall of the frontal sinus was performed in the 64% of patients with frontal sinus projection anterior to the F-line. The emergence of the supraorbital nerves from the frontal bone was through a bony notch in 73.8% of cases. CONCLUSIONS: Knowledge of the anatomy of the frontal sinus and preoperative study of the scans of the facial mass is essential for planning the FF. These characteristics guide the surgical technique of bone remodeling as well as the procedure for releasing the supraorbital nerves.

[Reconstruction by thoracodorsal perforator flap after petrosectomy]. / Comblement de cavité d'évidement après pétrectomie.

Petrosectomy is a debilitating intervention, consisting of a resection of the bone forming the external auditory canal, the middle ear and sometimes the internal ear as well. The cavity formed after this surgery can lead to infectious complications. Reconstruction is an essential element for patients' rehabilitation. Most cases require local rotation flaps such as temporal muscle flap. However, when the remaining defect is too large or when the structures have been altered by radiotherapy, free flaps are the most adequate solution for repair. Upon review of the literature, there are very few articles providing options regarding reconstruction possibilities post-petrosectomy. Plastic surgeons are often unfamiliar with this indication, therefore, it is essential to call their attention in order to provide the best options of care in these difficult and complicated cases where possibilities are limited. That is why, it is important for us to share our experience in this domain through the example of our patient presenting with a large osteoradionecroses of the petrous bone, requiring resection and immediate reconstruction using a free flap.

Coverage of radial forearm flap donor site with full thickness skin graft and Matriderm®: An alternative reliable solution?

PURPOSE: After harvesting a radial forearm flap (RFF) an optimal aesthetic and functional restitution of the donor site is required. In order to cover the secondary defect of the donor site, several solutions are currently available, but there is still no real evidence of the most reliable option. A retrospective study was conducted in order to evaluate a new technique of forearm coverage with artificial dermis: the association of full thickness skin graft (FTSG) with Matriderm®. METHODS: Our study included all RFF performed during a 34-month period. Forty-three forearm secondary defects after harvesting a RFF (16 men, 27 female) were included. Forearm donor site was covered using three techniques: a simple FTSG, split thickness skin graft (STSG) with Matriderm® or FTSG with Matriderm®. Clinical evaluations based on residual functionality, skin quality and aesthetic result were assessed using respectively the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Vancouver Scar Scale (VSS) score and a blind panel questionnaire. RESULTS: FTSG with Matriderm® showed an improved DASH (10.6/100) and VSS score (5.5/13) if compared to the other techniques, mean surgeon satisfaction score was 3/5, mean patient satisfaction score was 3/5 in the FTSG with Matriderm® group. CONCLUSION: The results of this study revealed that the new association of FTSG with Matriderm® improves the DASH score and the aesthetic outcomes resulting to be a reliable solution in treating full thickness forearm skin defects after RFF harvesting.

[Bilateral breast reduction and obesity: What is the ideal resection enabling significant improvement in back pain according to the body mass index?] / Mastoplastie bilatérale de réduction et obésité : quel est le poids de résection idéal pour obtenir une amélioration significative des douleurs rachidiennes en fonction de l'indice de masse corporelle ?

INTRODUCTION: Dorsal pain is the first symptoms about which patients with macromasty complain. Health insurance reimbursement takes place if the resection weight is at least 300grams per breast. However, this weight is not correlated with the body mass index (BMI). In this context, we sought to determine the ideal resection weight leading to significant BMI-based improvement. MATERIALS AND METHODS: This is a multicentre prospective study of patients operated between November 2016 and July 2017. In the year following the surgical procedure, we studied overall improvement using the INDIC questionnaire. Any INDIC improvement of at least 50% was considered positive. These data were then compared to tissue resection weights and BMI. In order to refine our results, age, bra size, comorbidities and complications were also identified. RESULTS: Forty-one patients were included in our study. Average age was 41.5±11.4years. Average BMI was 27.9±4.1kg/m2. The bra cap chosen after the procedure were C. Average resection weight was 663±352g per breast. The preoperative and postoperative INDIC scores were 734.9±226.6 points and 225.3±319.1 points, respectively (P=0.001). Significant improvement was achieved at 12months in 71.8% of patients. A correlation of 38.7g/kg/m2 was found between breast resection weight and BMI. CONCLUSION: This study clarifies the correlation between the breast resection weight required to relieve optimal back pain and BMI. It defines three categories of patients: patients with standard weights (1830). Overweight and obese patients require greater tissue excretion to be relieved optimally. These findings underline a need to adjust the health insurance threshold for these types of patients.

[Tongue reconstruction by thoracodorsal perforator flap: A new harvesting technique to reduce morbidity]. / Reconstruction d'hémilangue par lambeau perforant thoracodorsal : nouveau prélèvement à morbidité réduite.

The thoracodorsal artery perforator flap is increasingly used in head and neck reconstructions. One of its multiple advantages is the low donor site morbidity compared to the other free flaps usually used for this type of surgery, such as the radial forearm free flap and the anterolateral flap of the thigh. However, the current harvesting technique of the thoracodorsal artery free perforator flap needs a vertical incision rising high in the axillary hollow for the dissection of the pedicle, thus impeding optimal discretion of the donor site, especially for women. We describe an original technique to harvest a pure transversal skin paddle on its own perforator, leaving a horizontal scar thoroughly hidden in the bra and preserving the thoracodorsal pedicle. We detail the requirements for this new type of harvesting.

[A giant sacral chordoma resection and reconstruction with a gluteal perforator flap, a case report and literature review]. / Chordome géant du sacrum et reconstruction par lambeau perforant glutéal supérieur, à propos d'un cas clinique et revue de la littérature.

BACKGROUND: Sacral chordomas are rare primary bone tumors and represent more than half of all primary malignant sacral tumors. Surgical resection is the only treatment with close to 50% of remission at 10 years, with or without radiotherapy. This tissue removal can be very extensive and morbid, particularly for evolved tumors. The reconstruction mostly uses myocutaneous flaps, notably the gluteus maximus flap and the latissimus dorsi flap, increasing morbidity of the surgical procedure. To avoid a muscular sacrifice and reduce the post-surgical morbidity, we describe the case of a patient who underwent a giant sacral chordoma resection and a reconstruction with a superior gluteal artery perforator flap. CASE REPORT: A 57-y.o. patient with a voluminous sacral chordoma had undergone a partial sacrectomy and abdomino-perineal resection. Firstly, a laparoscopy was realized to create a colostomy, to dissect an omental flap and to prepare the monobloc resection. In a prone position, the resection of the tumor was achieved and a de-epithelialized superior gluteal artery perforator flap was performed to fill the space and to support pelvic organs. CONCLUSION: For resections of sacral chordomas, coelioscopy has considerably reduced the surgical morbidity. However, the majority of reconstructions use myocutaneous flaps, specifically gluteus maximus and latissimus dorsi, which their postural function is considerable. Muscular sacrifice can lead to functional impotence with difficulty walking and standing up and run contrary to the diminution morbidity initiated by oncologic surgeons.

[Radical treatment of hidradenitis suppurativa: Comparison of the use of the artificial dermis and pedicled perforator flaps]. / Traitement radical de la maladie de Verneuil : comparaison de l'utilisation du derme artificiel et des lambeaux perforants pédiculés.

OBJECTIVES: The objective of this study was to compare the use of artificial dermal and perforator flap after radical surgery of severe axillary and perineal hidradenitis suppurativa disease. PATIENTS AND METHODS: The data on postoperative outcomes, scar assessment (POSAS) and quality of life (DLQI, SF-36) were collected during consultation or by phone call. Forty-seven patients were included in our study between January 2015 and September 2017, including 27 patients in the artificial dermal group and 20 patients in the perforator flap group. RESULTS: The quality of life assessment by the SF-36 questionnaire showed a significant increase in quality of life in both groups (P<0.05), higher in the perforating flap group (P<0.001). The DLQI questionnaire showed a decrease in the impact of MV on quality of life in both groups, which was greater in the perforator flap group (P<0.05). The scarring assessment by the POSAS patient and observer questionnaire showed a better overall opinion in the perforator flap group (P<0.001). In the perforator flap group, the total hospital stay and healing time was shorter (P<0.001) and the return to work was faster (P<0.001). CONCLUSION: The artificial dermis and the perforator flaps are very useful coverage solutions after radical surgery of hidradenitis suppurativa. The use of perforator flaps, however, seems more interesting while simplifying the post-operative course.

Evaluation of the mobility of the shoulder and quality of life after perforator flaps for recalcitrant axillary hidradenitis.

BACKGROUND: Hidradenitis suppurativa is a very debilitating disease, treated by antibiotics and excision. The reconstruction is usually done by secondary wound healing and/or split-thichness skin graft. The aim of this study was to evaluate the reconstruction of the axilla with local perforator flaps as a single stage surgical treatment. METHODS: This was a monocentric retrospective study conducted between November 2013 and June 2015. We included the patients with a severe axillary localization of the disease. Between 6 months and 1 year postoperatively, we noted length of complete healing, complications, patients satisfaction score about the surgery, DASH functional score, maximum abduction angle of the arm, and recurrence of the disease. RESULTS: Thirteen patients were included, for a total of seventeen affected axillae. We performed seven thoracodorsal artery perforator flaps, seven lateral intercostal artery perforator flaps and three serratus anterior artery perforator flaps. The mean duration of follow-up was 279.1±84.1 days (180-365). The average complete healing time was 20.5±13.5 days (10-60). Six axillae were compounded (35%). The average recurrence rate of HS was 0%. The average score in the DASH questionnaire was 68.6±35.3 points (39-152) and the average maximum abduction angle of the arm was 160.6±18.5 degrees. The average score on the satisfaction questionnaire was 36.5±5.6 points (25-43). CONCLUSION: This is a single stage, reliable and effective surgical procedure. The results are very encouraging, with a good quality of life, a low functional disability and a shorter healing time.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study.

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Interleukin-32 promotes detachment and activation of human Langerhans cells in a human skin explant model.

BACKGROUND: Cross-talk between skin keratinocytes (KCs) and Langerhans cells (LCs) plays a fundamental role in the body's first line of immunological defences. However, the mechanism behind the interaction between these two major epidermal cells is unknown. Interleukin (IL)-32 is produced in inflammatory skin disorders. We questioned the role of IL-32 in the epidermis. OBJECTIVES: We aimed to determine the role of IL-32 produced by KCs on surrounding LCs. METHODS: We used an ex vivo human explant model from healthy donors and investigated the role of IL-32 on LC activation using imaging, flow cytometry, reverse transcriptase quantitative polymerase chain reaction and small interfering (si)RNA treatment. RESULTS: Modified vaccinia virus ankara (MVA) infection induced KC death alongside the early production of the proinflammatory cytokine IL-32. We demonstrated that IL-32 produced by MVA-infected KCs induced modest but significant morphological changes in LCs and downregulation of adhesion molecules, such as epithelial cell adhesion molecule and very late antigen-4, and CXCL10 production. The treatment of KCs with IL-32-specific siRNA, and anti-IL-32 blocking antibody significantly inhibited LC activation, demonstrating the role of IL-32 in LC activation. We also found that some Toll-like receptor ligands induced a very high level of IL-32 production by KCs, which initiated LC activation. CONCLUSIONS: We propose, for the first time, that IL-32 is a molecular link between KCs and LCs in healthy skin, provoking LC migration from the epidermis to the dermis prior to their migration to the draining lymph nodes.

Surgical treatment of trans-sphincteric anal fistulas with the Fat GRAFT technique: a minimally invasive procedure.

AIM: Anal fistulas are common pathologies with a significant social impact; however, their treatment is often complex and the recurrence rate can be significant. Some surgical treatments for fistula are also associated with the risk of sphincter injury. In this technical note, we aim to evaluate the feasibility and efficacy of the Fat GRAFT technique (Fat Grafting in Anal Fistula Treatment) in the treatment of recurrent anal fistulas. METHOD: All patients presenting with recurrent trans-sphincteric anal fistulas over an 18-month period were included. After abdominal fat harvesting and fat preparation, fat grafting was performed in the track and peripheral area of the fistula. The internal and external openings of the fistula were closed to maximally preserve the retention of the adipocyte graft in the fistula. RESULTS: Eleven patients underwent the Fat GRAFT procedure (seven men, four women). The average re-injected volume for each fistula was 21 ml (range 10-30 ml). The postoperative course was uneventful. At 6 months three patients developed recurrence (73% healed). There were no postoperative complications. CONCLUSION: The Fat GRAFT technique appears to be a promising technique with a low risk of anal incontinence, in contrast to other techniques. This method was effective in > 70% of patients in a single session.

[Earlobe reconstruction in one step by the Gavello's procedure: Surgical technique and a case report]. / Reconstruction du lobe d'oreille en un temps par la méthode de Gavello : technique opératoire et à propos d'un cas clinique.

The earlobe because of its anatomical position is subject of defects secondary to multiple and varied etiologies. Although its functional role appears negligible, its aesthetic and social importance makes its reconstruction a delicate surgery because it must be discreet but also the simplest possible. Many methods have been described but some require several operating times. The aim of this article is to present a simple procedure with a bilobed flap based on a reliable vascularization and which requires only one operative time. We describe the technique through a clinical case and review the literature to discuss the other methods described.

High speed optical holography of retinal blood flow.

We performed noninvasive video imaging of retinal blood flow in a pigmented rat by holographic interferometry of near-infrared laser light backscattered by retinal tissue, beating against an off-axis reference beam sampled at a frame rate of 39 kHz with a high throughput camera. Local Doppler contrasts emerged from the envelopes of short-time Fourier transforms and the phase of autocorrelation functions of holograms rendered by Fresnel transformation. This approach permitted imaging of blood flow in large retinal vessels (∼30 microns diameter) over 400×400 pixels with a spatial resolution of ∼8 microns and a temporal resolution of ∼6.5 ms.

[Patient counseling in case of postoperative complication leading to emergency reintervention in plastic surgery. What is the current situation? How to improve? Retrospective study of counseling modalities and traceability in a series of 16 patients who needed emergency reintervention within a cohort of 402 patients]. / Information du patient dans le cadre d'une complication postopératoire nécessitant une reprise chirurgicale en urgence en chirurgie plastique. Quel est l'état des lieux? Comment améliorer notre pratique? Étude rétrospective des modalités et de la traçabilité de l'information sur une série de 16 patients réopérés en urgence issus d'une cohorte de 402 patients.

AIM: Preoperative counseling is structured and well defined. Nevertheless, in the event of a complication leading to a new emergency surgical procedure, counseling is not well defined. We conducted a retrospective study of information delivered in this situation at our institution. PATIENTS AND METHODS: We included all the patients who underwent emergency reintervention because of hematoma or operative site infection between November 2013 and October 2014. Sixteen patients were included over the 402 patients operated during this period. RESULTS: Information before initial surgery: all patients had at least two preoperative consultations, and all preoperative informed consents were obtained. Complications leading to reintervention were mentioned in the consultation record in 31% of cases, and in a letter to another practitioner in 19% of cases. SofCPRE information card was delivered in 63% of cases. Information before reintervention: reintervention indication was mentioned in the hospitalization report in 81% of cases, and in the operative report in 88% of cases. Blood count results were mentioned in 55% of cases when it had been done. Patients were orally informed of reintervention in 100% of cases, and this new information was mentioned in 50% of cases. A new informed consent was signed in 31% of cases and postoperative letter was written in 25% of cases. CONCLUSION: Information delivery traceability is mandatory. In case of complication leading to emergency reintervention, traceability should be done in the same way as prior to initial surgery.

[Poly Implant Prothèse (PIP®) incidence of complications in breast reconstructive surgery: A retrospective comparative analysis]. / Poly Implant Prothèse (PIP®) et incidence des complications en reconstruction mammaire: une étude rétrospective contrôlée.

INTRODUCTION: On 29 March 2010, the Poly Implant Prothèse (PIP(®)) breast prosthesis was withdrawn from the market by the ANSM. In this study we review our experience with PIP(®) implants in breast reconstruction. We compare our complications with other types of breast implants used during the same period at our institution. PATIENTS AND METHOD: This is a retrospective study conducted at the Hospital René Huguenin of the Institut Curie (Paris, France). It includes 327 prostheses, from 268 patients who underwent surgery for breast reconstruction between February 2008 and February 2012: 69 PIP(®) (Group 1), 82 Mentor(®) (Group 2) and 179 Allergan(®) (Group 3). The objective of the study was to compare the rates of early and late complications for each prosthesis. Our results are compared with the current literature. RESULTS: With regard to the rate of early complications (hematoma, infection, seroma, wound dehiscence), no difference was observed between the three groups (P not significant). However, the study found that 100% of the 13 PIP(®) implants with early complications required surgical revision. There were too few late complications (capsular contracture, prosthetic rupture) in our cohort to allow statistical comparison between the three groups (P not significant). We compare our results with the current literature. CONCLUSION: This study highlights the lack of significant difference in the occurrence of early adverse events between the three groups of implants. This may explain the time taken for surgeons to become aware there was a problem with the PIP(®) implants. The low rate of late complications in our series does not allow statistical analysis between the three groups of implants.

Holographic laser Doppler imaging of microvascular blood flow.

We report on local superficial blood flow monitoring in biological tissue from laser Doppler holographic imaging. In time-averaging recording conditions, holography acts as a narrowband bandpass filter, which, combined with a frequency-shifted reference beam, permits frequency-selective imaging in the radio frequency range. These Doppler images are acquired with an off-axis Mach-Zehnder interferometer. Microvascular hemodynamic components mapping is performed in the cerebral cortex of the mouse and the eye fundus of the rat with near-infrared laser light without any exogenous marker. These measures are made from a basic inverse-method analysis of local first-order optical fluctuation spectra at low radio frequencies, from 0 Hz to 100 kHz. Local quadratic velocity is derived from Doppler broadenings induced by fluid flows, with elementary diffusing wave spectroscopy formalism in backscattering configuration. We demonstrate quadratic mean velocity assessment in the 0.1-10 mm/s range in vitro and imaging of superficial blood perfusion with a spatial resolution of about 10 micrometers in rodent models of cortical and retinal blood flow.