Superior epigastric artery perforator flap for reconstruction of deep sternal wound infection.

BACKGROUND: The treatment of deep wound sternal infection requires loco-regional pedicled flaps, usually with muscular flaps. Perforator propeller flaps represent the ultimate progress in the history of reconstructive surgery. We report here our experience with the superior epigastric artery perforator (SEAP) flaps to repair sternal defect. PATIENTS AND METHODS: Six patients presenting deep sternal wounds infection were treated with SEAP propeller flap, between March 2015 and June 2017. The mean age was 71.5 (range 53-83) years. The mean length and width of the defect were 16.2 × 7 cm (ranging 8-20 × 4-10). An elliptical skin flap pedicled on the SEAP was harvested in the inframammary fold and rotated up to 90° to cover the defect. RESULTS: All SEAP flaps achieved a successful entire coverage of the defect. The mean size of the skin paddle of the flap was 20.2 × 7.3 cm (ranging 14-27 × 6-9). All flaps were able to provide a complete sternal wound cover. Venous congestion was present in five cases and adequately treated by leech therapy; necrosis was distal in one case, and interesting the entire superficial flap in two cases but with deep tissues remaining viable and able to cover the mediastinum: an infected flap required revision. Satisfyingly, at 2-years postoperative follow-up all-patients were alive with a successful mediastinal cover. CONCLUSIONS: The SEAP Perforator propeller flap is an alternative to muscle flaps to achieve treatment of deep and large sternal wound infection.

Acellular dermal matrix: New applications for free flap pedicle coverage - A prospective study in 10 patients.

INTRODUCTION: The goal of lower extremity reconstruction after trauma is the coverage of defects to give patients a healed wound and to let them resume their life, ambulate and return to work, while preventing amputation. In this article, we describe an innovative use of Integra® for free flap pedicle coverage in lower extremity reconstruction. MATERIALS AND METHODS: Between January 2011 and December 2015, ten patients, four women and six men, underwent a lower limb reconstruction with an association of free flap and Integra® to cover the flap pedicle. The mean age of the patients was 38.8±15.6 years at the time of surgery (range of 14-59 years). The mean defect size was 102±54 cm2 (range of 40-160 cm2). The bone and/or tendons were exposed at the level of the middle third of the leg in 2 cases, at the level of the distal leg in 5 cases and at the level of the foot in 3 cases. RESULTS: There were no intra-operative complications. Mean size of Integra® needed for flap pedicle coverage was 12.8±2.3 cm2 (range 10-15 cm2). The mean follow-up was 41±19 months (range 21-70 months). Revision surgery was necessary in three cases due to haematoma of the pedicle. In these cases, the dermal substitute was easily removed while awaiting revision. This allowed flap survival in all cases. A skin graft was performed after a mean time of 3.4±0.8 weeks post-operatively. Complications at the donor site level included one seroma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. CONCLUSIONS: The combination of free flap and Integra® appears to be a useful option in covering complex defects in the lower limb. The dermal substitute avoids skin tension and compression of the pedicle. Haematomas of the pedicle, if they occur, are highly visible and thus easy to manage. We hypothesize that the use of dermal substitute for this specific indication of pedicle coverage will expand in the near future.

Perilunate fracture-dislocations: clinical and radiological results of 21 cases.

BACKGROUND: Perilunate dislocations and fracture-dislocations are a subcategory of the carpal instability complex. Herein, we report our university hospital experience with this complex injury. The goal of our study was to find predictive factors and quantify the development of arthritis and lunate necrosis. We tried to measure the impact of arthritis on hand function. METHODS: Between January 2000 and December 2014, 21 patients underwent surgery for perilunate dislocations and perilunate fracture-dislocations of the wrist in our tertiary university center. Mean patient age was 29.3 ± 10.0 years (range 18-49 years). All displacements were posterior. They were reviewed both clinically and radiologically. RESULTS: Complications included misdiagnosed Essex-Lopresti-like lesion in one case, insufficient reposition of the carpus in two cases (LT in one case, SL in one case), and iatrogenic injury to the radial artery immediately sutured in one case. All 3 cases underwent a second procedure with satisfactory outcome. After a mean follow-up of 112 ± 60 months (range 12-210 months), the average Cooney score was 80 ± 19 (range 50-125). The mean PRWE score was 10 ± 8 (range 0-25). The mean DASH score was 40 ± 13 (range 30-75 months). Mean pain on load, measured with VAS was 1.1 ± 1.6; Clinical examination assessed a mean wrist extension/flexion of 42.4° ± 17.2°/48.4° ± 15.2°. Mean wrist ulnar/radial deviation was, respectively, 22.9° ± 11.3°/15.3° ± 7.0°. Mean pro/supination was, respectively, 75.2° ± 11.5°/76.3° ± 8.1°. Mean pinch strength was 9.4 ± 2.2 kg (87.4 ± 17.7% of the contralateral side). Mean power strength was 41.9 ± 9.9 kg (76.2 ± 19.2% of the contralateral side). Two patients had a scaphoid non-union identified on their most recent imaging. The mean carpal height ratio was 0.53 ± 0.05 (range 0.44-0.65). All except one patient developed arthritis: Grade 1 in 11 patients, Grade 2 in 3 patients, and Grade 3 in the remaining 6 patients. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis (p < 0.001). Lunate avascular necrosis assessed by magnetic resonance imaging was present in 6 patients: Stage 2 in 4 patients, Stage 3a in 1 patient, and Stage 3b in the remaining patient. All these patients' intraoperative findings showed lesion of the cartilage of the radial side of the lunate. However, the small number of patients who developed lunate necrosis did not allow satisfactory statistical analysis. CONCLUSIONS: This retrospective study demonstrates good functional results despite the high rate of radiological wrist arthritis. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis in our series.

Stroke from an External Carotid: Lesion Pattern and Mechanisms.

Traditionally, patients with symptomatic external carotid stenosis present with neck or face pain, retinal ischemic symptoms or jaw claudication and rarely as ipsilateral cerebrovascular events. In this present case, our patient suffered a stroke from a paradoxical embolism from the external carotid, without involvement of the internal carotid artery. A plaque ulceration of the external carotid's origin was the cause of this cerebral emboli. Duplex ultrasound showed a pathologic left external carotid, with a floating thrombus in the internal carotid. The diagnostic was confirmed by a computerized tomography scan. An external carotid thromboendarterectomy was performed 6 days after symptom onset, and intraoperative findings confirmed the plaque rupture with an extensive clot in the carotid bifurcation.

Current laser applications in reconstructive microsurgery: A review of the literature.

BACKGROUND: Microvascular surgery has become an important method for reconstructing surgical defects following trauma, tumor resection, or burns. Laser-assisted microanastomoses (LAMA) were introduced by Jain in 1979 in order to help the microsurgeon reduce both operating time and complications. This article reviews the literature on clinical applications of LAMA. METHODS: A Medline literature search was performed and cross-referenced. Articles between 1979 and 2014 were included. Keywords used were laser, laser microanastomoses, laser microanastomosis, LAMA, and microsurgery. RESULTS: Only seven clinical studies using three different wavelengths were found in the literature: 1,064 nm (Nd: YAG), 10,600 nm (CO2), 514 nm (Argon), and 1,950 nm (Diode). Clinical outcomes, type of procedures, laser wavelength and parameters, and possible wider applications in the operating room are discussed in each case. CONCLUSIONS: The success rate for reconstructive free flap surgery and hand surgery achieved with LAMA appears promising. In particular, use of the 1950-nm diode laser for microsurgery is likely to increase in the near future.

Cuttlefish Ink Melanin Encapsulated in Nanolipid Bubbles and Applied Through a Micro-Needling Procedure Easily Stains White Hair Facilitating Photoepilation.

BACKGROUND: Photothermolysis of unwanted hair depends on the presence of melanin in the hair follicle as the chromophore, but is not effective in patients with non-pigmented, melanin-sparse hair shafts and follicles. This split-scalp, double-blind study was to monitor the efficacy of melanin bound in nanosomes to inject exogenous melanin into the hair follicles thus potentiating successful photothermolysis.
MATERIAL AND METHODS: Twelve patients, phototypes II-III, with white or very fair hair, were treated with a compound containing melanin encapsulated in nanosomes (Melaser®) together with a fluorescent marker. Two equal 6 cm² areas were marked on each side of the occiput of the subjects. The compound was applied to a randomly selected experimental side on each patient (area A), and a saline solution applied in the same manner to the contralateral control side (area B). Penetration of the melanin into the hair follicle was assessed using optical and fluorescence microscopy. Also, condition of hair structure was checked in vivo after standard laser settings used for epilation.
RESULTS: A slight transient erythema was observed in those areas where the compound was applied with some perifollicular edema. No such effects were noticed in those areas where saline solution was applied. No persistent complications such as scarring, hypo- or hyperpigmentation were observed in any of the experimental or control areas. Under fluorescence microscopy, the hair structures in the areas to which the compound had been applied showed a clear melanin deposit confirmed by the immunofluorescence intensity, which was highest at 2 hours after application. By optical microscopy, external melanin was deposited in hair follicles. Tests with standard settings for epilation were efficacious in damaging melanin-marked white hair.
CONCLUSION: This study strongly suggests the safety and efficacy of the application of nanosomes encapsulating melanin for the introduction of melanin into hair follicles. Changes noticed in the hair structure compromising its viability indicated potential application of this external melanin marker for white hair photoepilation.

J Drugs Dermatol. 2016;15(5):615-625.

Vaginoplasty in Male-to-Female Transsexual Surgery: A Training Concept Incorporating Dissection Room Experience to Optimize Functional and Cosmetic Results.

INTRODUCTION: Learning a new technique, even for an established surgeon, requires a learning curve; however, in transsexual surgery especially, there is a lack of professional and public tolerance for suboptimal aesthetic and functional results due to a learning curve. AIMS: In this context, we have tried to build a learning concept for vaginoplasty that includes four steps: (i) formal identification of the surgical steps in order to provide both measure of surgical process and measures of outcomes; (ii) training on cadavers with expert assistance; (iii) performing the live surgery with assistance from expert; and (iv) performing the surgery alone. Herein, we emphasize the second step of our learning concept. MATERIAL AND METHODS: Between September 2013 and December 2013, 15 cadavers were operated on by an established surgeon learning vaginoplasty under assistance from two expert practitioners. Mean global time and mean time necessary to perform each step of the operation were recorded by the experts. Intraoperative complications were systematically registered. The final depth and diameter of the neaovaginal cavity were precisely measured. For each cadaver, the aesthetic results were assessed by one of the experts. RESULTS: Mean total operating time was 179 ± 34 minutes and decreased from 262 minutes for the first training attempt to 141 minutes for the last one. Intraoperative expert correction included modification of the scrotal triangular flap design and change of position of the urethra: This happened during the first training. No lesion of the urethra or of the anus occurred. The two experts judged the outcomes as excellent in seven cases, very good in four cases, good in two cases, and fair in two cases. CONCLUSION: Despite the numerous reports on vaginoplasty in the literature, there is a real lack of published information on the learning curve of this operation. We make the hypothesis that introducing a learning concept with assistance from expert practitioners at the beginning of the surgeon's experience can optimize both the duration of his learning curve and reduce the risk of major complications.

Efficacy and safety of laser therapy on axillary hyperhidrosis after one year follow-up: a randomized blinded controlled trial.

INTRODUCTION: Hyperhidrosis is a debilitating problem that is not only uncomfortable and inconvenient, but also embarrassing in work and social situations. In spite of the availability of several options for the treatment of axillary hyperhidrosis, recently, there has been an increasing interest in the use of laser therapy. This study aims to evaluate the efficacy of a laser diode device emitting at wavelengths of 924 and 975 nm and classical curettage either alone, simultaneously or in combination. MATERIAL AND METHODS: A randomized prospective controlled trial was carried out on 100 patients divided into four groups, each with a different protocol: Laser alone at 975 nm (group 1), laser alone at 924/975 nm simultaneously (group 2), curettage alone (group 3), and finally laser at 924/975 nm followed by curettage (group 4). HDSS, starch test and GAIS were used to assess treatment efficacy. The follow-up extended to one year. Statistical analysis (SPSS) was used to determine the accuracy of the results. RESULT: Two patients of group 1 experienced burns during treatment, which took over a month to heal. This group of patients achieved the worst results: The starch test scale results after treatment were 2.48 ± 0.51 and 2.76 ± 0.44 (at 1 and 12 months). The GAIS results were 1.04 ± 0.35 and 0.92 ± 0.28 (1 and 12 months). In group 2 the starch test scale results after treatment were 1.36 ± 0.49 and 1.48 ± 0.51 (at 1 and 12 months). The GAIS results were 2.36 ± 0.49 and 2.72 ± 0.46 (at 1 and 12 months). In group 3, the starch test scale results after treatment were 1.56 ± 0.51 and 1.76 ± 0.60 (at 1 and 12 months), which corresponds to small to substantially smaller dark areas. The GAIS results were 2.28 ± 0.46 and 2.64 ± 0.49 (at 1 and 12 months). The best results were obtained in group 4: HDSS scores were reduced from 3.88 ± 0.33 before treatment to 1.24 ± 0.44 and 0.48 ± 0.51 at the 1 and 12 months controls. The starch test scale results after treatment were 0.40 ± 0.50 and 0.44 ± 0.51 (at 1 and 12 months). The GAIS results were 3.72 ± 0.54 and 3.76 ± 0.44 (at 1 and 12 months). CONCLUSION: In this study, the laser at 924/975 nm combined with curettage was determined to be the optimal treatment option of those tested for axillary hyperhidrosis. This treatment was safe, with few side effects and improvement that persisted to one year follow-up.

Reconstruction of a traumatic plantar foot defect with a novel free flap: The medial triceps brachii free flap.

INTRODUCTION: Lower extremity defects may account for 14.6% of the approximately 117 million visits to emergency departments in the U. S. in 2007. In this article, we present a reconstruction of a traumatic plantar foot defect with a medial triceps brachii (MTB) free flap. CLINICAL CASE: A 53-year-old man sustained an accidental gunshot wound to the right foot. The patient was admitted after the failure of a sural flap procedure performed in another hospital. He presented with a soft-tissue defect with calcaneal exposition and osteomyelitis. The defect was reconstructed with a MTB free flap anastomosed to his dorsalis pedis vessels. RESULTS: Flap raising time was 52 min. There were no intraoperative complications. The total flap surface was 38.5 cm². The pedicle length was 3 cm. The diameters of the artery and vein of the flap pedicle were 1.1 mm and 1.4 mm, respectively. Ischemia time was 28 min. His donor site healed uneventfully without any morbidity, and the scar was well concealed. The flaps survived and there was no partial flap necrosis. A split-thickness skin graft was performed 12 days postoperatively. Two months later, he had a completely healed wound with no contour abnormality. The total follow-up was 24 months. The patient was able to walk normally. CONCLUSION: MTB free flap appears to be an excellent option for plantar foot defects in patients with preserved vascularization of the foot. Due to the anatomical shape of the flap, the position of its pedicle, and the moldability of the muscle, we predict that the use of the MTB free flap will grow and develop rapidly for reconstruction of ankle and foot defects.

Long-term patient-reported functional and cosmetic outcomes following severe traumatic foot and ankle wound reconstruction with acellular dermal matrix.

BACKGROUND: The prevalence of acellular dermal matrices in reconstructive surgery has increased through the last decade with satisfying outcomes. Long-term follow-up and effectiveness studies could enable appropriate use of these devices and challenge the current gold-standard treatments. This paper presents functional and cosmetic long-term outcomes on the Integra(®) Dermal Regeneration Template (IDRT) for treating traumatic soft-tissue defects of the foot and ankle. METHODS: All adult patients who underwent severe traumatic foot and ankle reconstruction with Integra(®) since 2004 were retrospectively included. Results were evaluated using standardized outcome instruments. RESULTS: Twenty-one reconstructions were evaluated 4.5 ± 2.5 years after foot and ankle injury. Major complications inducing a second application included 1 hematoma and 1 infection. Seven patients (35%) had good or excellent Foot and Ankle Ability Measures. Subjectively, when asked to compare current function with pre-injury status, the mean response was 66 ± 23%. The Observer Scar Assessment Scale scored 17 ± 5 points (possible range, 5-50), while the Patient Scar Assessment Scale scored 30 ± 11 points (possible range, 6-60). CONCLUSIONS: Long-term functional and cosmetic outcomes 4.5 years after severe traumatic foot and ankle wounds treated with IDRTs were rated fair in the great majority of patients. Nevertheless, because complications and surgical revisions were few, potential benefits might be underestimated because of the initial combined injuries and their sequelae. In this way, for appropriately selected patients with severe traumatic foot and ankle soft-tissue defects, including subacute coverage, it appears that this treatment may be a viable first option.

Laser-assisted lipolysis for neck and submental remodeling in Rohrich type IV patients: fact or fiction?

BACKGROUND: Since the first studies by Apfelberg in 1994 and the mathematical model of Mordon introduced in 2004, laser-assisted lipolysis (LAL) has been on the rise. In a previous study, we presented our results in patients treated with LAL for Rohrich type I to III aging neck. The average cervicomental angle decreased from 152.6 ± 5.9 to 123.6 ± 8.8 degrees after LAL. This demonstrated a systematic decrease in fat thickness, and improved skin tightening. OBJECTIVE: This new protocol focuses solely on LAL in the Rohrich type IV aging neck. METHODS: Between June 2012 and February 2013, a prospective study was performed on 10 patients treated with LAL for Rohrich type IV aging neck. The laser used in this study was a 1470 nm diode laser (Alma Lasers, Caesarea, Israel). Laser energy was transmitted through a 600 µm optical fiber and delivered in a continuous mode, at 15 W power. Previous mathematical modeling suggested that 0.1 kJ was required in order to destroy 1 ml of fat. Patients were asked to fill out a satisfaction questionnaire. The cervicomental angle was measured 6 months postoperatively, and compared with the preoperative values. RESULTS: No seromas were observed, but prolonged edema was observed in two patients. Pain during anesthesia and discomfort after the procedure were minimal. The average cervicomental angle decreased from 191.5 ± 5.7 to 164.9 ± 14.2 degrees (p < 0.01). This demonstrated a systematic decrease in fat thickness and improved skin tightening. Even though the cervicomental angle was higher than 140° in each case, the investigators, in agreement with the patients, decided to perform a complementary surgery with platysma muscle advancement and plication six months after LAL, in only two of the ten patients. This complementary surgery led to a mean cervicomental angle of 140.2 ± 11.4, and fair satisfaction of both patients and investigators. CONCLUSION: LAL alone appears insufficient for complete remodeling in Rohrich type IV aging neck. While LAL alone is sufficient for Grade I to III, a complementary surgery must be added for Grade IV.

Comparison of functional gains after arthroscopic rotator cuff repair in patients over 70 years of age versus patients under 50 years of age: a prospective multicenter study.

PURPOSE: To assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic repair in patients older than 70 years versus patients younger than 50 years. METHODS: We conducted a multicenter, prospective, comparative study of 40 patients younger than 50 years (group A) and 40 patients older than 70 years (group B) treated with arthroscopic rotator cuff repair. Patients older than 70 years were operated on only if symptoms persisted after 6 months of conservative treatment, whereas patients younger than 50 years were operated on regardless of any persistent symptoms. Imaging consisted of preoperative magnetic resonance imaging and postoperative ultrasound. Preoperative and postoperative function was evaluated with Constant and modified Constant scores. Patient satisfaction was also assessed. The evaluations were performed at least 1 year postoperatively. RESULTS: No patient was lost to follow-up. The incidence of both supraspinatus and infraspinatus tears was greater in group B. Greater retraction in the frontal plane and greater fatty infiltration were observed in group B. The Constant score was significantly improved in both groups (51 ± 12.32 preoperatively v 77.18 ± 11.02 postoperatively in group A and 48.8 ± 10.97 preoperatively v 74.6 ± 12.02 postoperatively in group B, P < .05). The improvement was similar in both groups. The modified Constant score was also significantly improved in both groups (57.48 ± 18.23 preoperatively v 81.35 ± 19.75 postoperatively in group A and 63.09 ± 14.96 preoperatively v 95.62 ± 17.61 postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). Partial rerupture of the rotator cuff occurred in 2 cases in group A and 5 cases in group B. Complete rerupture was observed in 2 patients in group B. In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. CONCLUSIONS: Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

1950-nm diode laser-assisted microanastomoses (LAMA): an innovative surgical tool for hand surgery emergencies.

Based on previous observations, the 1950-nm diode laser seems to be an ideal wavelength for laser microvascular anastomoses. The data presented here, part of a larger ongoing study, assess its use in emergency hand surgery. Between 2011 and 2014, 11 patients were operated on for hand trauma with laser-assisted microanastomoses (LAMA) and prospectively analysed. LAMA was performed with a 1950-nm diode laser after placement of equidistant stitches. For vessel size <1.5 mm, the following laser parameters were used: spot size 400 µm, five spots for each wall, power 125 mW, and arterial/venous fluence 100/90 J/cm(2) (spot duration 1/0.9 s). Mean operating time for arterial and venous microanastomoses was 7.3 ± 1.4 and 8.7 ± 1.0 min, respectively. Three anastomoses required a secondary laser application. Arterial and venous patency rates were 100 % at the time of surgery. The success rate for the 11 procedures assessed clinically and with the Doppler was 100 %. The technique is compared to the current literature. The 1950-nm LAMA is a reliable tool with excellent results in emergency hand surgery. The system is very compact and transportable for utilization in the emergency operating room.

Laser-assisted lipolysis for arm contouring in Teimourian grades I and II: a prospective study of 45 patients.

Upper arm deformities secondary to weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures. We conducted this study to objectively assess if, in Teimourian low-grade upper arm remodelling, one session of laser-assisted lypolisis (LAL) could result in full patient satisfaction. Between 2011 and 2013, 45 patients were treated for unsightly fat arm Teimourian grade I (15 patients), grade IIa (15 patients) and grade IIb (15 patients) with one session of LAL. The laser used in this study was a 1470-nm diode laser (Alma Lasers, Cesarea, Israel) with the following parameters: continuous mode, 15 W power and transmission through a 600-µm optical fibre. Previous mathematical modelling suggested that 0.1 kJ was required in order to destroy 1 ml of fat. Treatment parameters and adverse effects were recorded.The arm circumference and skin pinch measurements were assessed pre and postoperatively. Patients were asked to file a satisfaction questionnaire. Pain during the anaesthesia and discomfort after the procedure were minimal. Complications included prolonged oedema in 11 patients. The average arm circumference decreased by 4.9 ± 0.4 cm in the right arm (p < 0.01) and 4.7 ± 0.5 cm in the left arm (p < 0.01) in grade I patients, 5.5 ± 0.6 cm in the right arm (p < 0.01) and 5.2 ± 0.5 cm in the left arm (p < 0.01) in grade IIa patients and 5.4 ± 0.5 cm in the right arm (p < 0.01) and 5.3 ± 0.5 cm in the left arm (p < 0.01) in grade IIB patients. The skin tightening effect was confirmed by the reduction of the skin calliper measurements in all three groups. Overall mean opinion of treatment was high for both patients and investigators. Of the 45 patients, all but one would recommend this treatment. A single session of LAL in upper arm remodelling for Teimourian grades I to IIb is a safe and reproducible technique. The procedure allows reduction in the amount of adipose deposits while providing full skin tightening.

Description of the Baudet Surgical Technique and Introduction of a Systematic Method for Training Surgeons to Perform Male-to-Female Sex Reassignment Surgery.

INTRODUCTION: Male-to-female sex reassignment surgery involves three main procedures, namely, clitoroplasty, new urethral meatoplasty and vaginopoiesis. Herein we describe the key steps of our surgical technique. METHODS: Male-to-female sex reassignment surgery includes the following 14 key steps which are documented in this article: (1) patient installation and draping, (2) urethral catheter placement, (3) scrotal incision and vaginal cavity formation, (4) bilateral orchidectomy, (5) penile skin inversion, (6) dismembering of the urethra from the corpora, (7) neoclitoris formation, (8) neoclitoris refinement, (9) neovaginalphallic cylinder formation, (10) fixation of the neoclitoris, (11) neovaginalphallic cylinder insertion, (12) contouring of the labia majora and positioning the neoclitoris and urethra, (13) tie-over dressing and (14) compression dressing. RESULTS: The size and position of the neoclitoris, position of the urethra, adequacy of the neovaginal cavity, position and tension on the triangular flap, size of the neo labia minora, size of the labia majora, symmetry and ease of intromission are important factors when considering the immediate results of the surgery. We present our learning process of graduated responsibility for optimisation of these results. We describe our postoperative care and the possible complications. CONCLUSION: Herein, we have described the 14 steps of the Baudet technique for male-to-female sex reassignment surgery which include clitoroplasty, new urethral meatoplasty and vaginopoiesis. The review of each key stage of the procedure represents the first step of our global teaching process. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Medial triceps brachii free flap in reconstructive surgery: a prospective study in eight patients.

INTRODUCTION: In this study, we present a prospective series of medial triceps free flaps for ankle and foot complex defects coverage and discuss its numerous advantages. MATERIALS AND METHODS: Between January 2011 and December 2012, eight patients, two women and six men underwent medial triceps brachii (MTB) free flap procedure to cover defects localized at the ankle and foot in our department. Patient mean age was 37.3 ± 15.2 years at the time of surgery (range of 13-53 years). Mean defect size to be covered was 21.8 ± 9.9 cm(2). The bone was exposed at the level of the calcaneum in six cases, at the level of the forefoot in one case, and at the level of the lateral malleolus in one case. Special attention was accorded to intra-operative findings. Flap survival and complications on both the donor and recipient site were prospectively evaluated. RESULTS: Mean MTB flap raising time was 51.3 ± 6.0 min. All the flaps survived and there was no partial flap necrosis. A skin graft was performed after a mean time of 11.8 ± 2.1 days post-operative. The mean follow-up was 18.1 ± 3.8 months. Complications at the donor site level included one hematoma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. CONCLUSIONS: MTB free flap appears to be a useful option for covering small to medium defects in lower limb extremities. Due to the constant anatomy of the MTB nerve, we suggest that the flap could also be used as an innervated free flap for small or medium muscular reanimation such as sequelae of forearm and hand muscle impairment, or facial palsy.

Suspected adipose tumours of the hand and the potential risk for malignant transformation to sarcoma: a series of 14 patients.

INTRODUCTION: Lipomas are associated with a variety of symptoms including neuropathies, local compression of the surrounding tissues, aesthetic complaints and may be graded as liposarcomas histologically. This study was performed to review our surgical management at the level of the hand. MATERIALS AND METHODS: Between 2008 and 2013, 14 patients were referred to our department for suspected adipose tumour of the hand. Preoperative MRI was used to assess tumour and surrounding tissue to plan the surgical therapy. We reviewed the clinical history, MRI findings, surgical approach, and outcomes. RESULTS: Complaints leading to consultation were pain in 11 cases, compression neuropathy in 7 cases, aesthetic concern in 8 cases, and limited wrist range of motion in 2 cases. Magnetic resonance imaging was performed in 13 cases, confirming the diagnosis of adipose tumour in all but two cases. These two cases were diagnosed in one case as a ganglion and the other as an epithelioid sarcoma. An amputation of the fifth digit was performed regarding the latter case and the patient received additional radiotherapy. The mean follow-up period was 32 ± 20 months. There was no recurrence of lipoma or sarcoma. CONCLUSION: MRI is useful for diagnosing and planning of the surgical intervention performed in the latter case adipose tumours. Rapidly evolving tumours with subfascial localization are absolute surgical indications. Incision biopsy is mandatory for entities of unknown dignity and for malignant tumours. Interdisciplinary tumour board meetings should discuss each patient before surgery is performed. LEVEL OF EVIDENCE AND STUDY TYPE: IV.

Results of 45 arthroscopic Bankart procedures: Does the ISIS remain a reliable prognostic assessment after 5 years?

PURPOSE: The Instability Severity Index Score (ISIS) includes preoperative clinical and radiological risk factors to select patients who can benefit from an arthroscopic Bankart procedure with a low rate of recurrence. Patients who underwent an arthroscopic Bankart for anterior shoulder instability with an ISIS lower than or equal to four were assessed after a minimum of 5-year follow-up. METHODS: Forty-five shoulders were assessed at a mean of 79 months (range 60-118 months). Average age was 29.4 years (range 17-58 years) at the time of surgery. Postoperative functions were assessed by the Walch and Duplay and the Rowe scores for 26 patients; an adapted telephonic interview was performed for the 19 remaining patients who could not be reassessed clinically. A failure was defined by the recurrence of an anterior dislocation or subluxation. Patients were asked whether they were finally very satisfied, satisfied or unhappy. RESULTS: The mean Walch and Duplay score at last follow-up was 84.3 (range 35-100). The final result for these patients was excellent in 14 patients (53.8 %), good in seven cases (26.9 %), poor in three patients (11.5 %) and bad in two patients (7.7 %). The mean Rowe score was 82.6 (range 35-100). Thirty-nine patients (86.7 %) were subjectively very satisfied or satisfied, and six (13.3 %) were unhappy. Four patients (8.9 %) had a recurrence of frank dislocation with a mean delay of 34 months (range 12-72 months). Three of them had a Hill-Sachs lesion preoperatively. Two patients had a preoperative ISIS at 4 points and two patients at 3 points. CONCLUSION: The selection based on the ISIS allows a low rate of failure after an average term of 5 years. Lowering the limit for indication to 3 points allows to avoid the association between two major risk factors for recurrence, which are valued at 2 points. The existence of a Hill-Sachs lesion is a stronger indicator for the outcome of instability repair. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series, Treatment Study.

New treatment techniques for axillary hyperhidrosis.

Hyperhidrosis is a medical problem defined as perspiration in excess of what is normally needed to cool the body. The excessive production of sweat by the sudoriferous glands is independent of the process of thermoregulation. Techniques have recently appeared that make use of energy sources, in particular microwave devices and light (pulsed flashlamp or laser). The aim is to obtain very long-lasting efficacy without notable side effects. Thermal Nd:YAG lasers used with an interstitial fiber, microwave devices, and photodynamic therapy appear to offer new treatment options for axillary hyperhidrosis. However, insertion of a laser fiber into tissue by means of a cannula may lead to complications if the procedure is not well mastered, as has been shown by numerous studies on laser lipolysis. The only microwave device available on the market is certainly interesting. Photodynamic therapy using eosin gel is an attractive technique. The energy source is a pulsed flashlamp, which many physicians have. Eosin gel is relatively easy to produce and these gels are already marketed in several countries. However, further clinical studies of larger series of patients and with longer follow-up are still needed to reach a definitive conclusion as to the value of this approach.

New treatment options for onychomycosis.

Onychomycosis is the most common nail disorder. The causative pathogens are not only dermatophytes in the majority of cases (Trichophyton rubrum and T. mentagrophytes), but also yeasts of the genus Candida and molds. A wide variety of topical antifungal agents are proposed for first-line treatment of superficial onychomycosis, when the matrix is not involved. New treatment options using light were recently introduced, such as thermal lasers, non-thermal lasers, and photodynamic therapy. For thermal lasers, a temperature increase in the nail of around 50 °C seems to be a prerequisite for success. For non-thermal lasers, the clinical data are very debatable and their mechanism of action still remains mysterious. For photodynamic therapy, 5-aminolevulinic acid is used. The therapy consists of exciting protoporphyrin IX with red light that penetrates relatively deeply. Further clinical studies of larger series of patients and with longer follow-up are still needed to reach a definitive conclusion on the value of these devices.