Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report.

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

[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.

[Superficial circumflex iliac artery perforator free flap in pediatric reconstruction: A case report]. / Lambeau libre SCIP en reconstruction pédiatrique : à propos d'un cas.

The dorsalis pedis reconstruction requires to bring a thin tissue to recover every noble structure of the foot including tendons, nerves and vessels while resisting the stress induced on these structures when walking or wearing shoes. We report the case of a thirteen year-old child who presented a third-degree burn sequelae on the dorsalis pedis with scar retraction and chronic ulceration on the fifth metatarsal despite multiple skin grafts. He couldn't put on his shoes because of the pain and walking was difficult. We performed a SCIP flap (Superficial Circumflex Iliac Artery Perforator) to reconstruct this defect. The flap measuring 12×7cm has been harvested on the right groin and anastomosed with the pedicle of the first intermetatarsal space. At 3 months postoperatively, the child can put on his shoes again and walk without pain. The donor site is discrete in the inguinal crease, hidden in the underwear. The SCIP flap is a thin and pliable flap with a discrete donor site. It is suitable for reconstructions of distal extremities of limbs, both in adults and children.

[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.

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.

[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.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction]. / Le lambeau médial sural perforant : bases anatomiques, technique chirurgicale et indications en reconstruction cervicofaciale.

INTRODUCTION: The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery. MATERIAL AND METHODS: We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap. RESULTS: A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application. DISCUSSION: This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.

The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction.

Today's customary techniques for pharyngo-esophageal reconstruction are jejunum and radial forearm free flaps. In this type of reconstruction, the jejunum flap is considered as the reference, but when its harvesting is not possible, the radial forearm flap is used. Since perforator flaps have begun to be developed, the anterolateral thigh flap (ATF) has become increasingly prominent in pharyngo-esophageal reconstruction. The aim of our study was to describe the use of the anterolateral perforator flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks as regards oral feeding and esophageal speech.

[Use of indocyanine green angiography in oncological and reconstructive breast surgery]. / Utilisation du vert d'indocyanine en chirurgie sénologique et reconstruction mammaire.

The Indocyanine green (ICG) is a soluble dye that is eliminated by the liver and excreted in bile. When illuminated by an near-infrared light, the ICG emits fluorescence in the near-infrared spectrum, which can be captured by a near-infrared camera-handled device. In case of intravenous injection, ICG may be used as a marker of skin perfusion. In case of interstitial injection, it may be useful for lymphatic network mapping. In oncological and reconstructive breast surgery, ICG is used for sentinel lymph node identification, to predict mastectomy skin flap necrosis, to assess the perfusion of free flaps in autologous reconstruction and for diagnosis and treatment of upper limb secondary lymphedema. Intraoperative indocyanine green fluorescence might also be used to guide the excision of nonpalpable breast cancer.

The ongoing emergence of robotics in plastic and reconstructive surgery.

Robot-assisted surgery is more and more widely used in urology, general surgery and gynecological surgery. The interest of robotics in plastic and reconstructive surgery, a discipline that operates primarily on surfaces, has yet to be conclusively proved. However, the initial applications of robotic surgery in plastic and reconstructive surgery have been emerging in a number of fields including transoral reconstruction of posterior oropharyngeal defects, nipple-sparing mastectomy with immediate breast reconstruction, microsurgery, muscle harvesting for pelvic reconstruction and coverage of the scalp or the extremities.

[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.

[The thin ALT perforator flap for oropharyngeal robotic-assisted reconstruction]. / Le lambeau libre perforant antérolatéral de cuisse fin dans les reconstructions oropharyngées robot-assistées.

Since a few years, the transoral robotic surgery reduced the morbidity of oropharyngeal tumors excision. Large posterior tumors can now be removed without any scar visible on the face. In this context and to respect the thinness required for reconstructions at the junction of the upper aerodigestive tract, the free radial forearm flap still remains the solution of choice. However, if the transoral robotic surgery respects the anatomy and the aesthetics of patients at the visible and social area that represents the face, the forearm flap provides visible scars on the other region of social interaction that represents the upper limb. The aim of our work was to prove the feasibility and the benefits in terms of reducing sequelae when using a thin anterolateral perforator flap harvested above the plane of the superficial fascia. We present this new original method in detail and the advantages it offers to patients after surgery.

[Complex carcinological head and neck reconstruction in pediatric surgery]. / Reconstructions complexes par lambeaux libres en cancérologie cervicofaciale pédiatrique.

Head and neck reconstruction in pediatric oncology, even if it is based on adult experience, presents important characteristics including age-related growth, the type of tumor and donor sites features. Indications of free flaps are rare but required care that should be codified, taking into account the details specific to context, and not giving place for improvisation as it is important that surgical outcomes must be as simple as possible. The objective of this article is not to present the technical details of free flaps harvesting in children because it is what is certainly the least different with adults. The aim is to share our experience of the specificities and singularities of pediatric head and neck reconstruction in order to focus attention to everything that makes this surgery demanding. We present the most common indications, the types of free flaps used for reconstruction, facial location modalities of reconstruction and the perioperative management.

[Harvesting technique of chimeric multiple paddles fibular flap for wide oromandibular defects]. / Technique de prélèvement du lambeau de fibula chimérique multipalettes pour la reconstruction des larges defects oromandibulaires.

Carcinological head and neck reconstruction still remains a challenge due to the volume and varied tissues needed. Large and wide oromandibular defects require, not just the bone but also soft tissues for the pelvilingual reconstruction and therefore, a second free flap may become necessary in addition to a fibular flap. The option of an unique chimeric flap based on the fibular artery and its branches is less known whereas it offers the advantage of a unique flap with bone, muscle and multiple skin paddles, independent of each other. The aim of this technical note is to present step by step the surgical procedure of this chimeric flap and share this method that avoids a second free flap.

A new method of sutureless microvascular anastomoses using a thermosensitive poloxamer and cyanoacrylate: an experimental study.

INTRODUCTION: Recently, a new method of sutureless micro-anastomosis based on the injection of a termosensitive poloxamer into the vessel lumen and application of cyanoacrylate, was described. The long-term results in animals are attractive but its use requires a specific heated poloxamer gel and an external heating lamp to maintain the surgical site above the transition temperature. The aim of our study was to prove the feasibility of this method of sutureless anastomosis with a poxolamer gel, which could be used at ambient temperature. MATERIALS AND METHODS: Twenty male Sprague-Dawley rats were used. Right common iliac arteries anastomoses (RCIA) were performed with the sutureless method (poloxamer gel and cyanoacrylate) (SG group) and were compared to left common iliac arteries (LCIA) sutured with conventional sutures (CG group). Diameters, duration of microvascular anastomosis (DMA) and patency rates were reported. RESULTS: The mean diameter of RCIA and LCIA was about 1 mm. The mean DMA for the SG group was 9.25 ± 1.45 min and 21.65 ± 2.96 min in the CG group. Patency rates didn't differ between the both groups, either 15 min after anastomosis (CG group 95% vs.SG group 100%, P = 0.23) or 15 days after surgery (CG group 90% vs.SG group: 95%, P = 0.55). Histological analysis showed lower foreign body reaction in sutureless group. CONCLUSION: This sutureless method of micro-anastomosis seems to be easy to learn and require lower time than conventional sutures. However, this technique needs further investigations over the coming years to prove long-term reliability.

[Thin perforator flaps elevated in the plane of the superficial fascia: Principle and surgical procedure]. / Lambeaux perforants fins prélevés dans le plan du fascia superficialis : principe et technique opératoire.

Perforator flaps have an ever growing place in reconstructive surgery and classical surgical procedures describe sub or supra-fascial plane elevation. In some indications, defatting of perforator flaps may be necessary and different methods have been described, primary or secondary, but may expose to partial loss of the flap or to another operation. Recently, a new method of perforator flap elevation in the plane of the superficial fascia has been described. This method permits to obtain a thin and reliable flap in the same procedure without the need of debulking and while decreasing donor site morbidity. We present the principle and the surgical procedure of this new method. Advantages and drawbacks are discussed with the help of clinical cases.

Supermicrosurgery and hyaluronic acid: experimental feasability study of a new method.

INTRODUCTION: As a technique of anastomosis for vessels of less than 0.8mm in diameter, supermicrosurgery has aroused renewed interest on account of its potential clinical applications. The technical difficulty of surgery at such a small scale necessitates exploration of new methods likely to render the anastomoses accessible and reliable. The aim of this article is to present the results of an experimental study on the feasibility of anastomoses (arterial diameter ≤0.5mm), assisted by the injection of hyaluronic acid (HA). MATERIALS AND METHODS: Ten end-to-end arterial anastomoses of the inferior epigastric artery (diameter ≤0.5mm) were performed in 5 rats. An injection of HA had previously been carried out in the vessel lumen and the sutures were made with 12-0 nylon. Immediate and 3-day permeability were controlled and anastomosis times were measured. RESULTS: Average diameter of the arteries was 0.42 mm (range 0.29-0.48 mm). Mean anastomosis duration was 19.5 min (range 15-23 min). The average number of stitches was 6. Immediate patency was 100% with a success rate of 80% at 3 days. CONCLUSIONS: The properties of HA seem to effectively facilitate anastomoses of arteries with a diameter ≤0.5mm. HA provides comfort and promotes safety in performance of exceedingly small-scale surgery. While the results appear promising, but further studies are needed in order to determine the potential toxicity of this method on tissues.

Super-microdissected local flaps for the coverage of temporal defects.

INTRODUCTION: Skin graft is still a method of choice for the coverage of temporal defects. But there are some disadvantages like a "patch" appearance, the need of dressing or longer healing time. Numbers of local flaps have been described for closing skin defects on temporal region. Yet, they may cause distortion of the surrounding tissues, especially in the temporal hairline and eyebrow. We present a series of seven local flaps based on small branches (SB) of the superficial temporal artery (STA) for the coverage of temporal defects, and discuss their advantages. PATIENTS AND METHODS: Supermicrodissection of SB of the STA was performed to obtain local flaps for reconstruction of temporal defects after skin cancer excisions in seven patients. Patient's age ranged from 70 to 88 years old and the diameter of defects ranged from 4 to 6 cm. All procedures were performed under local anesthesia except one. In all cases, defects were obtained after skin cancer excisions. RESULTS: The operative time ranged from 55 to 75 min. All flaps survived with an average follow-up of 8 months, reconstructions have maintained a cosmetically pleasing result. CONCLUSION: We believe that SB flaps may be a new option for reconstruction of temporal defects with the advantages of local flaps, without the inconvenience of a skin pedicle. Moreover, these flaps raise the question of the use of SB based flaps for the coverage of moderate-sized skin defects anywhere in the body, and open new fields in reconstructive surgery.