[State of affairs and optimization of plastic surgery training in France]. / État des lieux et optimisation de la formation à la chirurgie plastique en France.

BACKGROUND: Concerns have been growing for several years among masters, as to the quality and quantity of training in plastic surgery in France. They are mainly based on the reduction in the working time of residents, the appearance of new residents from generation Z to be trained, and finally the multidisciplinarity of plastic surgery in the current context of overspecialization of training center. METHODS: In order to objectify these concerns, a survey was carried out among French residents and young heads of plastic surgery to assess their training in the specialty since 2019. We then looked in the law for possibilities to alleviate these concerns. RESULTS: All the respondents think that their training in the specialty is incomplete, and few of them have been able to supplement it with rotations outside the subdivision or visits from private practitioners. However, in the law, it is possible to carry out: three residents rotations outside the subdivision, clinics rotations and international exchanges. DISCUSSION: At the end of this analysis, we propose three solutions to optimize training in plastic surgery in France: a system of exchange of residents, the opening of residents rotations in clinics, and finally, to facilitate the realization of operating aids with private practitioners. CONCLUSION: With these solutions, the field of training for residents could extend from one region to the whole of France. These solutions could easily be applied to other specialties, surgical and medical.

[The tube in tube thoracodorsal perforator flap phalloplasty]. / Phalloplastie par Lambeau perforant thoracodorsal « tube in tube ¼.

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.

The contribution of the late Dr. Musa Mateev to the field of upper limb surgery with the shape-modified radial forearm flap.

The shape modified radial forearm flap was developed by the late Dr. Musa Mateev. This type of propeller flap has many benefits, especially for donor site morbidity. However, it is not currently widely used for the coverage of hand defects. Therefore, we will describe the Dr. Mateev technique including a demonstrative video of our experience in remembrance of Dr. Mateev and his brilliant work with upper limb reconstruction.

Placental Swab in Supporting Diagnosis of Vertical Transmission in SARS-CoV-2 Positive Mothers.

Aims To review the evidence regarding the possibility of fetal vertical transmission in COVID-19 positive pregnant mothers by diagnosing through placental swabs. Methods The search terms 'pregnant COVID-19 positive mothers', 'fetal vertical transmission' and 'placental swabs' were used. 20 papers were selected. Results 183 COVID-19 positive pregnant women were identified whose 184 placentas and 185 neonates were also analysed by RT-PCR or immunohistochemistry and/or in situ hybridization for the presence of SARS-CoV-2 (one case of monochorionic diamniotic twins and one case of dichorionic diamniotic twins). 183 liveborn neonates were successfully delivered primarily via caesarean section (99%). 2 mothers did not deliver liveborn infants due to severe preeclampsia resulting in a termination of pregnancy and a miscarriage, both occurring in the second trimester. 9 neonates tested positive for SARS-CoV-2 (5%). We report no neonatal mortality after live birth and no maternal mortality. 17 placentas tested positive for SARS-CoV-2 out of a total of 184 tested (9%). Of these 17, 7 cases of SARS-CoV-2 were identified in the maternal, neonatal and placental tissue. Conclusion There is no concrete evidence of vertical transmission occurring between mother and infant. We propose further research investigating the effects of COVID-19 on pregnant women by using RT-PCR to test the mother, placenta, vaginal fluid, breast milk and infant for SARS-CoV-2 at various stages of transmission.

[The surgical portfolio: A new educational tool for the French plastic surgery residents?] / Le portfolio de l'interne de chirurgie plastique : un outil d'aide à la formation des internes de chirurgie plastique en France ?

A recent reform of the French government has shortened the plastic surgery residency from 5 to 4 years. Until today, the evaluation and validation of the residency was shared between the local coordinator for practical skills and, after the residency, by the French College of Plastic Surgery for theorical knowledges. The new reform suggests to add a portfolio that will follow the resident during his surgical training. Based on the French reform and syllabus of others medical specialities, we designed a surgical portfolio that will help the resident both with his practical progression and his knowledges acquisition. The aim of the portfolio is to get a national unity of the plastic surgery training. As a first step we will describe the actual plastic surgery residency. Then, we will detail what the reform is going to change. At last, we will introduce the surgical portfolio, its content, its use and its goals.

Triple flap technique for vulvar reconstruction.

OBJECTIVE: Perineal defects are encountered ever more frequently, in the treatment of vulvar cancers or abdominoperineal resection. The surgical treatment of vulvar cancer leads to significant skin defect. The aim of the reconstruction is not to provide volume but rather to resurface perineum. We propose a new solution to cover the extensive skin defect remaining after excision. METHODS: We report 3 patients who underwent large excision for vulvar cancer, with lymph node dissection. For reconstruction, we performed 3 advancement flaps. Two V-Y flaps cantered on the infra-gluteal folds and based on pudendal perforator arteries were used to cover the postero-lateral parts of the defect. The third advancement flap from the superior aspect of the defect was a Y-V Mons pubis flap. RESULTS: The defects were successfully covered by the 3 flap technique. The first patient suffered a non-union that slowly healed by secondary intention. For the other cases, we used the same technique, but applied negative pressure wound therapy on the sutures, with excellent results. CONCLUSION: The 3 flap technique is a simple and reliable method and the donor site morbidity is minimal. It can be realised without changing the position of the patient after tumour excision, and does not require delicate perforator dissection. This surgical option can be easily applied, allowing better management of these cases.

[Ring finger reconstruction by Colson's flap]. / Reconstruction d'un arrachement digital par lambeau-greffe de Colson.

Surgical treatment of complete cutaneous ring finger avulsion is a challenge in hand surgery. When replantation of the avulsed fragment is not technically feasible, the surgeon must consider reconstruction of soft tissue. Many surgical techniques have been described. We report a case of complete avulsion of the cutaneous sheath and nail of the fourth finger with preservation of mobility and collateral nerves. The reconstruction of soft tissue was performed by a Colson flap-graft. This simple and reliable technique of reconstruction allowed to obtain a functional and sensitive finger with a satisfactory cosmetic result.

[Thin flaps in the management of hand and upper limb defects]. / Les lambeaux cutanés minces dans la prise en charge des pertes de substance cutanée de la main et du membre supérieur.

Cutaneous defect of the hand and the upper limb expose the underlying anatomical structures. The reconstruction therefore often resorts to flaps. The ideal flap must be thin and flexible, allowing a good resurfacing and a satisfactory functional result. The objective of this study is to analyze the various thinned flaps, to reveal their advantages and to underline their limits. We presented a literature review on the various techniques of thin skin flaps developed over the last 20 years, bringing together 18 articles, and including 225 patients. For 3 articles, the skin flaps were thinned down by preliminary expansion and for the 15 others they were surgically thinned during the harvesting of the flap. Thinning the flap seems to be an interesting surgical alternative in the management of cutaneous defect of the hand and the upper limb, but it would be interesting to be able to compare the results of these thin flaps to those of the conventional ones. This study also led us to propose a classification of thin flaps according to their thickness in order to clarify the terminology.

[Superficial Circumflex Iliac Artery Perforator flap (SCIP flap): Revival of the inguinal donor site?] / Lambeau de SCIP : renouveau du site donneur inguinal ?

The SCIP flap based on a superficial circumflex iliac perforator artery (SCIA) was described for the first time by Koshima in 2004 as a large and thin groin flap, with a low morbidity. The purpose of this study is to demonstrate the benefits of SCIP flap to cover cutaneous defects. We present a retrospective study from January 2007 to August 2016. Twelve patients had a SCIP flap reconstruction in the plastic surgery department of Amiens hospital. Thirteen flaps were performed. The average preoperative doppler mapping time was 8minutes. The average size of flaps was 62.5cm2 [21; 180cm2]. The average time required for raising flaps was 61min [52; 82min]. It has not been observed any complication of the flap or donor site. The SCIP flap has a thin paddle and the donor site morbidity is minimal. The surgical technique is safe, accessible and precision is increased by preoperative color doppler mapping. The many strengths of the SCIP flap make it a must in the algorithm for defects management and come to revitalize the inguinal donor site.

Dorsal median lipectomy (the arrow technique): A new approach for the treatment of the circumferential truncal skin and fatty tissue excess.

The increase in the number of patients who undergo massive weight loss surgery has led to an increasing number of patients who complain of circumferential abdominal skin and soft tissue excess. Currently, the only surgical option to treat soft tissue excess is vertical median abdominal lipectomy (fleur-de-lys technique). However, many patients are reluctant to undergo this surgery because of the position of the scar. We presented a new surgical approach to manage circumferential excess - dorsal median lipectomy (arrow technique) - in which the dorsal scar is well-tolerated by patients.

[Anatomical study of men's nipple areola complex]. / Étude anatomique du complexe aérolo-mamelonnaire (CAM) chez l'homme.

The surgical approach of gynecomastia, sexual reassignment surgery in female-to-male transsexuals and the increase of number of obese wishing to turn to plastic surgery led us to deepen the anatomical knowledge of the nipple areola complex (NAC) in men, poorly retailed in the literature. By inspiring us of the methodology of a Japanese study, we studied 50 healthy volunteers male, from 18 to 55 years old, from July till August 2015. We measured various distances relative to the NAC to define its vertical and horizontal position, as well as the internipple distance according to the size, to the weight and to the body mass index (BMI). At the end of the analysis, we were able to underline a lower vertical thoracic position of the NAC in the tall category of person, a more side horizontal position to the subject presenting a high BMI and a linear relation between the BMI and the internipple (Em) defined by (Em)=8.96×BMI. The surgeon's judgment and the desires of the patient are essentials basis of therapeutics decisions that could be lean on this anatomical study, which allowed to establish an idea of the cartography of the NAC in man. It will be interesting and necessary to confront it with other studies with larger scale.

Change of paradigm in thoracic radionecrosis management.

Classically, muscular or omental flaps are the gold standard in the management of thoracic defects following radionecrosis debridement. Their vascular supply and antibacterial property was supposed to enhance healing compared with cutaneous flaps. The evolution of reconstructive surgery allowed us to challenge this dogma. Therefore, we present five consecutive cases of thoracic radionecrosis reconstructed with cutaneous perforator flaps. In four patients, we performed a free deep inferior epigastric perforator (DIEP) flap and one patient had a thoracodorsal perforator (TDAP) flap. Median time healing was 22.6 days with satisfactory cutaneous covering and good aesthetic results. There were no flap necrosis, no donor site complications. We believe that perforator flaps are a new alternative, reliable and elegant option that questions the dogma of muscular flaps in the management of thoracic radionecrosis.

[Dynamic reconstruction of Achilles tendon by free composite perforator flap with functional assessment]. / Reconstruction dynamique de tendon d'Achille par lambeau perforant composite avec évaluation fonctionnelle.

INTRODUCTION, DEFECTS: Achilles tendon are common in patients after immobilization, therefore the reconstruction of a ruptured Achilles tendon with defects remains a surgical challenge. The ideal characteristics are a thin layer of skin, a strong tendon component, combined with a reliable blood supply and minimal morbidity at the donor site. We present a reconstructive technique using a composite anterolateral thigh perforator free flap, meeting these criteria, for the treatment of rupture of Achilles tendon with cutaneous and tendon defect. METHODS: A 34-year-old patient presenting a third rupture of his left Achilles tendon with 4cm composite defect was reconstructed with a contralateral anterolateral thigh perforator flap with part of the fasciae latae. The latter was raised by dissecting one intramuscular perforating artery from a descending branch of the lateral circumflex femoral artery. The postoperative observation period was one year. The functional outcome was determined by clinical scores (IKDC, OAK and Lysholm-Tegner). RESULTS: The healing time was 21 days. At six months, the aesthetic and functional result was satisfactory without delayed healing or secondary rupture. The aesthetic discomfort at the donor site was considered negligible by the patient. At one year, there is a continuing stability with no recurrence. The functional result was considered good with a clinical score of 75/100. CONCLUSION: Therefore, this method seems to be a good option for complex reconstruction of Achilles meeting the requirements of reconstruction with good stability at a distance.

The national incidence and outcomes of gastroschisis repairs.

The birth prevalence of gastroschisis worldwide has increased over the past decades. We aim to determine the Irish national incidence of gastroschisis repairs (NIGR) over a 5 year period (2007- 2011) and clinical outcomes by a retrospective cohort review of cases admitted to all Irish paediatric surgical units. Seventy patients were identified. The NIGR per 10,000 live births was 1.96 (SD 0.51) per year. Fifty eight (82%) were antenatally detected. Twenty eight (40%) had primary repair day 1 with the remaining repaired in a median of 3(2-5.75) days. Thirty three (47%) experienced a central catheter related infection. Duration of stay was significantly correlated with decreasing gestational age (p = 0.016), decreasing birthweight (p = 0.005), increasing numbers of blood transfusions (p < 0.001) and co-morbidity or complication (p < 0.001). This study provides individual centres with patient outcomes and national data that can be provided to parents and clinical staff regarding the clinical course of gastroschisis.

Using lateral radiographs to determine umbilical venous catheter tip position in neonates.

We aimed to assess the difference in measurement of the distance of the UVC tip from the diaphragm between (Anteroposterior) AP and lateral radiographs and to determine the reliability of the measurement of UVC tip distance from the diaphragm between the two views. A retrospective review of paired AP and lateral radiographs taken to assess UVC tip position was carried out in 25 infants was conducted and reliability analysis was carried out. There was a significant difference in the mean (SD) distance of the UVC catheter above the diaphragm between the AP and lateral radiographs: 8.7 (7.8) mm versus 11.6 (7.3) mm (p = 0.003) respectively. Measurements using lateral radiographs were more reliable (Intraclass correlation coefficient: 0.99 vs. 0.93). Inter-observer reliability analysis yielded similar results. Lateral radiographs are more reliable in measurement of UVC tip position and should be performed in conjunction with AP films to aid in determining UVC position.

Application of the inner arm perforator flap in the management of axillary hidradenitis suppurativa.

Axillary hidradenitis suppurativa is a chronic and debilitating disease that primarily affects the axillae, perineum, and inframammary areas. Surgical removal of all the diseased skin constitutes the only efficient treatment. Covering an axillary fossa defect is challenging, due to the range of shoulder movement required. Indeed, shoulder movement may be compromised by scar contraction after inadequate surgery. The present study is the first to apply an inner arm perforator flap to the treatment of twelve axillary skin defects in 10 patients. The defect originated from extensive excision of recurrent hidradenitis suppurativa in the axilla. The technique used to cover the defect is a V-Y advancement flap or a propeller flap from the inner arm based on one to three perforators arising from the brachial artery or the superior ulnar collateral artery. The flap provides a tensionless wound closure and a generally unremarkable postoperative course in a short hospital stay. No major complications occurred. Two patients had minor delayed wound healing. Outcomes (including donor site morbidity, function and the cosmetic outcome) were very satisfactory in all cases. We consider that the inner arm perforator flap is a valuable new option for the reconstruction of axillary defects.

Evaluation of predictive algorithms used for estimating potential postapplication, nondietary ingestion exposures to pesticides associated with children's hand-to-mouth behavior.

Postapplication exposure assessment related to indoor residential application of pesticide products requires consideration of product use information, application methods, chemical-specific deposition, time-dependent availability and transferability of surface residues, reentry time, and temporal location and macro- and microactivity/behavior patterns ( Baker et al., 2000 ). Children's mouthing behavior results in potential postapplication exposure to available pesticides in treated microenvironments through the nondietary ingestion route, in addition to the dermal or inhalation routes. Children's activities and associated behaviors may result in multiple or repeat contact of dermal areas (clothed and unclothed body areas and hands) with treated surfaces, or surfaces that may have indirect sources of residues. Further, some surfaces contacted may have transferable pesticide residues and others may not. Transfer of residues from the indoor residential environment to the dermal surface (e.g., hands) of an individual has been assumed to be linear as a function of time and number of contacts. However, studies suggest that this transfer process to the hands and other body areas may be rapidly saturable. In the most recent U.S. Environmental Protection Agency (EPA), Office of Pesticide Programs (OPP) "Residential Exposure Assessment Standard Operating Procedures" (U.S. EPA, 2012), the input variable for the number of dermal contacts (with treated surfaces) is an exponent, making the relationship nonlinear. Further, removal processes such as hand washing and transfer to untreated surfaces are important to consider. Predictive algorithms for estimating children's hand-to-mouth-related incidental ingestion exposures post pesticide application have been developed by the EPA/OPP and incorporated into probabilistic models. A review of literature addressing variables used to estimate potential incidental ingestion exposure is presented. Data relevant to input variables for predictive algorithms are discussed, including the results of a multiyear, pesticide transferable residue measurement program conducted by the Non-Dietary Exposure Task Force (NDETF) and the associated distributional characterization for this key variable. Sources of conservative bias in current hand-to-mouth, incidental ingestion exposure estimation and the role of biomonitoring to evaluate predicted exposures are discussed.

Paediatric HIV: the experience in Ireland 2004-2011.

Despite effective prevention strategies paediatric HIV infection remains an important condition in Ireland. To characterise presentation and identify barriers to optimal management a retrospective chart review of HIV-infected children presenting in Ireland, 2004-2011 was undertaken. Forty-two HIV-infected children were identified; (25 male). Median age at presentation was 6 years (range 0-16 years). 38 children (90%) were born to African mothers. Eleven (26%) were born in Ireland. Twenty-five (59%) were late diagnoses; 11 were symptomatic. Ten of 12 foreign born HIV-infected children had antiretroviral exposure with frequent resistance associated mutations. Seven of 8 children with stage C disease had previously been admitted to hospital in Ireland before diagnosis. Maternal non-adherence to recommendations and seroconversion in pregnancy challenge the goal of paediatric HIV eradication. Targeted strategies for women at risk of infection in pregnancy are required. Late HIV diagnosis remains common, highlighting the need for a more proactive approach to HIV testing.

[Freestyle free perforator flaps for heel reconstruction]. / Couverture du talon par lambeaux libres perforants de type "freestyle".

INTRODUCTION: Heel coverage requires the surgeon to considerate of multiple parameters: the type of defect, the exposed tissues, the weight-bearing requirements, the donor site morbidity, and the shape of the reconstructed heel allowing at best normal footwear. Although many methods of coverage exist, they are often chosen at the cost of a compromise between all the parameters described. In recent years, perforator freestyle free flaps offer plastic surgeons an unparalleled freedom that can adapt the constraints of the reconstruction while minimizing the functional and scar donor site morbidity. PATIENTS AND METHODS: We present four cases of heel defect of different origins treated by three types of tailored perforator freestyle free flaps (ALT, TAP and SCIP Flaps). End-to-side anastomosis to the posterior tibial vessels was used in three flaps while one flap was anastomosed to the internal plantar artery in an end-to-end fashion. RESULTS: No postoperative complication occurred. This approach allowed, in all patients, a reconstruction of excellent quality with minimal cicatricial morbidity. All patients were walking effectively at 21 days postoperatively. CONCLUSION: Perforator freestyle free flaps offer a solution of first choice for heel reconstruction. At the price of a linear hidden scar, they offer a functional, aesthetic and durable coverage.

Pleiotropic effects of rimonabant and simvastatin on obesity associated multiple metabolic risk factors in rats.

BACKGROUND: Obesity, a worldwide health problem, is a metabolic disease currently associated with a cluster and progressive pathologies presenting several features of metabolic syndrome. OBJECTIVES: The present study was undertaken to investigate the effect of rimonabant, simvastatin and their combination on obesity associated metabolic disorder mediators in adult male rats. MATERIALS AND METHODS: Fifty adult male Wistar rats weighing (120 +/- 10 g) were divided into five groups: Group 1 was kept on standard rodent chow and served as normal diet control. Group 2 was given high fat diet (HFD) for twenty weeks and served as HFD control. Groups 3, 4 and 5 administered HFD for ten weeks and then orally received rimonabant (2 mg/kg/day), simvastatin (10 mg/kg/day), combination of both drugs, respectively for another ten weeks with continuing feeding HFD. RESULTS: The current results showed that the treatment of HFD rats with either rimonabant or simvastatin significantly reduced body mass index, total cholesterol, triacylglycerides, low density lipoproteins, tumor necrosis factor alpha and monocyte chemoattractant protein-1, while increased adiponectin serum levels. Rimonabant showed to be more effective than simvastatin. Moreover, concomitant administration of rimonabant and simvastatin achieved the highest effect which nearly normalized most of the studied parameters as compared to singular therapy. CONCLUSION: Rimonabant is the drug of primary choice as singular therapy for obesity. The adjunct therapy of rimonabant with simvastatin may be a novel and a promising therapeutic approach as it has a beneficial effect on the pathophysiological processes of obesity and its associated metabolic disorders.