Accuracy of mammography, sonography and magnetic resonance imaging for detecting silicone breast implant ruptures: A retrospective observational study of 367 cases.

INTRODUCTION: The purpose of this study was to assess the efficacy of magnetic resonance imaging, ultrasound and mammography in detecting breast implant rupture. METHODS: This retrospective study included all cases of breast implant revision. Implant integrity was determined preoperatively by magnetic resonance imaging, ultrasound and mammography. The primary study endpoint was the surgical finding. The sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratio of the tests were evaluated. RESULTS: Two hundred and thirty-four (234) patients were included; 213 mammographies, 295 ultrasounds and 160 magnetic resonance imagings were carried out. While 114 clinical ruptures were confirmed, 253 implants remained intact. Magnetic resonance imaging was the most sensitive (99%); outperforming mammography (sensitivity: 70%). Mammography was the most accurate in diagnosis of intact implant (specificity: 93%), and magnetic resonance imaging was second (specificity: 78%). Ultrasound was rated intermediately. Positive mammography signifies a rupture in 84% of cases, whereas magnetic resonance imaging (positive predictive value: 78%) can be mistaken in 20% of cases. Negative ultrasound and magnetic resonance imaging rule out a rupture (negative predictive value of 93% and 99% respectively). Mammography and ultrasound are more accurate than magnetic resonance imaging in diagnosing implant rupture (positive likelihood ratios of 9.78, 8.24 and 4.44 respectively). Magnetic resonance imaging provides convincing affirmation of implant integrity (negative likelihood ratio: 0.02). CONCLUSION: Ultrasound seems to be the most reliable imaging method for patients younger than 50 years. In cases where doubt exists, mammography ensures supplementary assessment. In patients over 50 years of age, mammography and ultrasound should be carried out immediately. If necessary, magnetic resonance imaging rules out a hypothesized rupture.

Vascularization of the superficial circumflex iliac perforator flap (SCIP flap): an anatomical study.

INTRODUCTION: The superficial circumflex iliac artery perforator flap (SCIP) has gained widespread popularity as local or free flap to cover soft tissue defects. However, there are numerous anatomical variations in terms of size, location and reliability of its perforators This cadaveric study aimed to focus on the anatomical bases of this flap. MATERIALS AND METHODS: A bilateral dissection of seven cadavers was performed to harvest 14 flaps. Superficial circumflex iliac artery parameters, number, length and diameters of perforators were measured. Correspondent perforasomes were highlighted through semi-selective injections. RESULTS: The major perforator of the superficial branch had a mean caliber of 2.0 mm, and a mean length of 1.8 mm. The major perforator of the deep branch had a mean caliber of 2.1 mm and a mean length of 1.43 mm. The mean area of the superficial pattern perforasome was 178.6 cm2 and the mean measured surface of the deep pattern perforasome was 156.2 cm2. The descending branches of the deep branch anastomosing with the ascending branch of the lateral circumflex femoral artery were found in three cases. CONCLUSION: Several anatomical variations were observed in this anatomical study, but major perforators supplying large perforasomes were always found.

The esthetic outcome of lower limb reconstruction.

BACKGROUND: In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. OBJECTIVES: This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. DATA SOURCES: A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. STUDY ELIGIBILITY CRITERIA: All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. PARTICIPANTS, AND INTERVENTIONS: One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. RESULTS: We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. LIMITATIONS: The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. CONCLUSIONS: Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

[Unfavorable results of reduction mammoplasty: Causes, preventions and treatments]. / Résultats défavorables des plasties mammaires de réduction. Causes, préventions et traitements.

Reduction mammoplasty is known to be a highly satisfactory surgery but complications and unfavorable results can occur. The objective was to describe the main unfavorable results, to specify their causes, preventions and treatments. We have analyzed articles from the last ten years regarding reduction mammoplasty complications as well as their main unfavorable results. The most common complications were wound dehiscence, hypertrophic scars, infections, fat necrosis, hematomas, and partial or total nipple-areolar complex necrosis. The most frequently reported unfavorable results were unaesthetic and retracted scars, asymmetry in breast size, abnormalities in shape, and malposition of the nipple-areolar complex. For each type of unfavorable outcomes, the possible causes, preventions and treatments were detailed.

Morbidity in combined-procedure associating abdominoplasty and breast surgery: A systematic review.

OBJECTIVES: Combined aesthetic procedures are an increasing procedure and demands of the patients. The authors have assembled concrete arguments detailing the risks of combined-surgery associating abdominoplasty and mammoplasty relative to abdominoplasty alone. The purpose of this study was to compare abdominoplasty alone versus abdominoplasty combined with breast surgery in terms of short-term complications, in support of surgical choices. RESEARCH STRATEGY: Through application of the PRISMA criteria, we have realized a systematic review of the literature from 1969 to April 2015 in English and French languages by searching in MEDLINE®, PubMed central, Embase and Cochrane Library databases. DATA COLLECTION AND ANALYSIS: The levels of evidence for each article were evaluated. Statistical analysis of the results was carried out through association parameters including statistical tests and Odds ratios were calculated for each complication when data was available. RESULTS: We included 32 observational studies that met the inclusion criteria but only four with usable data. We highlighted a combined Odds ratio of respectively 5.35 and 14.71 for major complications in these studies for combined-surgery compared with abdominoplasty alone. CONCLUSIONS: The results of this systematic review appears in favor of an increase in major complications related to abdominoplasty combined with breast surgery compared to abdominoplasty alone but the level of evidence of included studies is low or moderate. Prospective cohort comparative studies are necessary to provide strong evidence. However, we recommend to avoid this procedure in massive weight loss patients or patients with thromboembolism history.

[Long-term functional evaluation of complex traumatic heel defects reconstructed by flap in children]. / Évaluation fonctionnelle à long terme des reconstructions complexes du talon par lambeau chez l'enfant.

INTRODUCTION: Complex heel injuries in children are rare and their management requires coverage combining resistance and thinness, to allow walking and footwear. The objective of this study was to create a decision-making algorithm for heel defect in children. MATERIALS: Children received for heel defect, reconstructed with flap in our plastic surgery unit of Bordeaux with a follow-up greater than 10 years were investigated. Three children operated between 1999 and 2003 were included. A free contralateral reinnervated medial plantar flap, a free latissimus dorsi flap and a lateral supramalleolar flap were performed. Patients were reviewed in consultation to assess quality of reconstruction and functional outcomes. Three scores were used, the Foot Function Index (FFI), the AOFAS Ankle and Hindfoot Scale and the Maryland Foot Score. RESULTS: No growth disorder has been found. Scores greater than 80 for the Maryland Foot Score and AOFAS Ankle and Hindfoot Scale and less than 10 for the FFI were very satisfactory in cases 1 and 3. We found pain and greater functional impairment in the second case. CONCLUSIONS: "Like-with-like" reconstruction remains the gold standard, whether in loco-regional or free flap. The fasciocutaneous flaps allow custom reliable coverage with little donor site morbidity. Loco-regional flaps remain easily accessible but donor site sequelae are not negligible.

[Complications of breast reduction about 715 breasts]. / Complications des réductions mammaires à propos de 715 seins.

BACKGROUND: Breast reduction is one of the most frequent operations in elective plastic surgery. The main objective of this study was to describe complications due to breast reduction, and to determine the risk factors. METHODS: Our comparative retrospective study reviewed the medical files of 715 operated breasts between 2004 and 2009. Statistical analyses were performed with bivariate analyses and multivariable analysis. RESULTS: Smoking, resected mammary gland mass and stretch marks were the three risk factors associated with complications after breast reduction. Smoking was also associated with a high risk of hypertrophics carring. Body-mass index was not associated with a risk of general complications but with a risk of wound dehiscence. The superior pedicle and free nipple graft surgical techniques presented a higher complication rate than the postero-superior and postero-inferior pedicle techniques. CONCLUSIONS: These results incite us to postpone and even contraindicate breast reduction surgery in obese and smoking patients. These results also incite us to prefer surgical techniques with optimum security in terms of vascular supply. Complications of breast reduction about 715 breasts.

[Reconstruction of an abdominal wall defect with a superior epigastric perforator propeller flap: case report]. / Reconstruction de la paroi abdominale par un lambeau propeller issu de l'artère épigastrique supérieure: cas clinique.

Perforators flaps take a special place in reconstructive surgery. These flaps can be dissected and turned as a propeller blade on its pedicule axis. We report the case of a 54-year-old man presenting a recurrence of a dermatofibrosarcoma in the right hypochondrium. Tumor resection caused a large abdominal wall defect taking the anterior aponeurosis of the rectus abdominis. An angioscanner was realized in preoperative to locate the perforators of the deep superior epigastric artery. We realized a propeller flap based on a perforator of the left superior epigastric artery who allowed to cover the wall defect. We set up a patch of Vicryl® to reconstruct the aponeurosis plan at the same operative time. We didn't note any necrosis and complete healing occurred in 2 weeks. The margins were healthy. The cosmetic result and the low morbidity make this flap a good therapeutic option. This flap seems reliable, arteries perforators are constant with good diameter.

[Six cases of facial adnexial carcinomas with reconstruction]. / Six cas de carcinomes annexiels de la face avec reconstruction.

INTRODUCTION: Adnexial carcinomas are a group of rare and aggressive malignant skin tumors. Management of these tumors is not well codified. PATIENTS AND METHOD: The authors present a retrospective and single-center study of six cases. Surgery was performed between November 2005 and February 2008. RESULT: Pathological study revealed two syringoideccrine carcinomas, one microcystic adnexal carcinoma, two tricholemmal carcinomas, and one extra-ocular sebaceous neoplasm. In five cases, complete excision was guided by extemporaneous examination. In five cases, reconstructive surgery involved loco-regional skin flaps: two Abbé flaps, one Webster flap, one lifting lip flap, one submental flap, and one LLL flap. One case of relapse occurred, at 40months. Several particular characteristics of these tumors are shown in this study. They often follow a non-specific and discrete clinical course, are deeply infiltrated with a perineural tropism in some forms, and are preferentially located in the mid-face. Risks of incomplete excision and relapse are high. CONCLUSION: Complete excision is absolutely necessary in the management of these tumors, especially if reconstructive surgery is performed. Extemporaneous examination was in our experience a good option, particularly in the case of large labial or eyelid excisions.

[Management of patients with squamous cell carcinoma of the skin]. / Prise en charge chirurgicale des carcinomes spinocellulaires.

Recurrence, metastasis and mortality due to squamous cell carcinoma are all most often linked to late or inappropriate management and/or aggressive histological types. In consequence, clear guidelines for management are necessary. The aim of this article is to detail clinical management of squamous cell carcinomas based on the official guidelines.

Retrospective evaluation of WALANT in emergency hand surgery in the Bordeaux university hospital.

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique uses local anesthesia based on lidocaine and adrenaline, enabling surgery without the tourniquet normally used in hand surgery. Only a few studies have been conducted on the use of WALANT for emergency hand surgery in teaching hospitals. We therefore set up the WALANT procedure in our emergency department in the university hospital of Bordeaux, France, to evaluate its feasibility and the satisfaction of patients and operators. Between April and June 2020, we included 58 patients undergoing surgery for acute trauma of the hand/wrist. WALANT was performed following a specific protocol. A tourniquet was systematically available on standby. After the procedure, patients and operators were asked to complete a questionnaire. Patients rated pain on a 0-10 numerical analog scale. Surgeons reported their feelings about bleeding and patient cooperation. All patients underwent a nearly painless operation, with a mean pain score of 0.36/10. The mean pain score during injection was 2.57, and postoperatively 5.2. Bleeding complications were reported to be absent or slight by 43% of operators, moderate but acceptable by 47%, and significant by 10%. Bipolar forceps were used in 76% of cases. No digital necrosis or prolonged ischemia requiring the use of phentolamine was reported. WALANT offers a simple, safe, and effective alternative to traditional anesthesia techniques in an emergency setting. Patients and surgeons reported overall satisfaction, with no increase in the complications rate.

Intra-articular injection of autologous bone marrow aspirate concentrate in the treatment of osteoarthritis of the thumb first carpometacarpal joint: A pilot study.

This study aimed to evaluate the effect of bone marrow aspirate concentrate (BMAC) in the treatment of osteoarthritis of the thumb first carpometacarpal joint. Injections were carried out in 27 thumbs. According to the Dell classification, there were 2 stage I, 11 stage II, 13 stage III and 1 stage IV cases. The bone marrow was aspirated from the iliac crest, concentrated by centrifugation, and injected under fluoroscopic control into the pathological thumb. Results were assessed at a mean 16 months' follow-up (range, 8-26). Clinical evaluation comprised QuickDASH and PRWE scores, pain at rest on a numerical analog scale (NAS), and thumb column abduction on goniometry. QuickDASH and PRWE scores were 59 (range, 27-82) and 88 range, 37-125) preoperatively and 29 (range, 0-64) and 50 (range, 1-99) postoperatively, respectively. Mean pain at rest on NAS improved from 7 (range, 1-10) to 4 (range, 0-9). Thumb abduction improved by a mean 18° over preoperative data. No postoperative complications were found. Two patients had to be operated on for inefficacy of injection. This is the first article presenting the effect of an intra-articular injection of BMAC in the thumb first carpometacarpal joint and the results were encouraging. Many patients showed improved quality of life and pain relief. These injections appear to be an effective means of postponing surgery.

[Perforator propeller flap for cutaneous coverage of the knee]. / Le Lambeau perforant en hélice pour la couverture cutanée du genou.

Previous pedicled techniques for coverage of the knee use muscular flaps and/or local fascio-cutaneous flaps limited to rotate until 90° on their cutaneous base. Freestyle perforator flaps match the patient's anatomy to fill a defect. Propeller perforator flaps have been used to treat three patients presenting with a skin loss over the knee. The surgery is based on the Echo-Doppler tracing the good perforator vessels around the wound. We performed two supero-medial flaps with a self-closing donor site and one supero-lateral flap where a graft was needed. All the patients healed in less than six weeks, with satisfying functional and esthetical results. We think freestyle perforator flaps are a reliable and predictable technique with a low morbidity rate and they are well adapted to cover skin defects over the knee.

Indications, functional results and patient satisfaction after isolated second ray resection following traumatic injury: A retrospective review of 25 patients.

Amputation of the second ray is a surgical treatment option when reconstruction and/or reimplantation fail. The aim of our study was to review the outcomes after transmetacarpal resection of the second ray following a post-traumatic injury and to assess indications, functional outcomes, and patient satisfaction. Between January 2003 and December 2013, 25 patients (6 women and 19 men with a mean age of 51 years) underwent transmetacarpal resection of their second ray after a post-traumatic injury. Sixteen patients were right-handed and 9 were left-handed. Injuries involved the dominant hand in 14 cases (60%). In order to differentiate patients with preserved index finger length preoperatively from those with a shorter, amputated index finger stump, patients were divided into 2 groups. Group 1 included those with an "intact finger" and Group 2 included patients with an "amputated stump". Data collection, including patient satisfaction and functional outcomes, was performed at 83 months postoperative on average. Average length of follow-up was 7.0±1.0 years (range 5-12 years). Group 1 (intact finger) and 2 (amputated stump) included 15 and 10 patients, respectively. Six patients (24%) had primary ray amputation and 19 (76%) had secondary ray amputation. No surgical revision was necessary. In Group 1, the indications were purely functional in all but two cases, whereas aesthetic indications played a role in all patients in Group 2. The average total time off work was 3 months. There was no difference between Group 1 and 2 (P>0.05). However, patients with primary ray resection averaged 10 weeks of lost work compared to 17 weeks for secondary amputation. There was no functional difference between Groups 1 and 2. Scores for cosmetic appearance and patient satisfaction were higher in Group 2. In certain specific situations after complex hand trauma, transmetacarpal amputation of the second ray is indicated as soon as possible, in order to reduce the time off work. Patient satisfaction following this surgical procedure is high, especially in groups with amputated stumps. A 30% decrease in pinch and grip strength is the rule. No secondary surgery is normally required.

A randomized controlled double-blind study of rotigotine on neuropsychiatric symptoms in de novo PD.

Management of apathy, depression and anxiety in Parkinson's disease (PD) represents a challenge. Dopamine agonists have been suggested to be effective. This multicenter, randomized (1:1), double-blind study assessed the 6-month effect of rotigotine versus placebo on apathy, depression and anxiety in de novo PD. The primary outcome was the change of apathy, measured with the LARS. The secondary outcomes were the change in depression and anxiety, measured with BDI-2 and STAI-trait and state. Forty-eight drug-naive PD patients were included. The primary outcome was not reached, with a surprisingly high placebo effect on apathy (60%). There was no significant difference in the change of depression at 6 months between rotigotine and placebo. Trait-anxiety was significantly improved by rotigotine compared to placebo (p = 0.04). Compared to placebo, low dose rotigotine significantly improved trait anxiety, but not apathy and depression. The major placebo effect on apathy points towards the importance of a multidisciplinary and tight follow-up in the management of neuropsychiatric symptoms.

[Influences of induced membranes on heterotopic bone formation within an osteo-inductive complex. Experimental study in rabbits]. / Influence des membranes induites sur l'ostéogenèse hétérotopique au sein d'un complexe ostéo-inducteur. Etude expérimentale chez le lapin.

UNLABELLED: Based on a new concept, a procedure combining induced membranes and cancellous autografts allows the reconstruction of wide diaphyseal defects. To date, this procedure is limited by the amount of cancellous bone available from the patient and by the related morbidity at the donor site. The aim of this study was to evaluate the biological effect of induced membranes on a cylindrical-shaped ceramic implants loaded with OP-1 in heterotopic site. MATERIALS AND METHODS: Sixty hydroxyapatite tricalcium phosphate (HA-TCP) implants, 20 of which being loaded with a bone growth factor (rhOP-1) were inserted either in a subcutaneous tunnel or within a previously induced membrane on the back of rabbits. There were two time-points at four and 16 weeks. Implants were investigated at three different levels (extremities and middle). RESULTS: None of the untreated implants showed any evidence of bone formation. Implants inserted in an induced membrane presented with less resorption. Bone ingrowth within the pores of the materials was significantly higher when the implants were inserted into the induced membrane whatever the time-point considered. CONCLUSION: The membrane seems to play the role it was assigned, i.e. to protect and revascularize the implant, thus favouring osteogenesis that occurs in 80% of the implants after four months.

[Postoperative analgesia with continuous intra-articular infusion of ropivacaine following trapeziectomy]. / Analgésie post-trapézectomie par diffusion intra-articulaire continue de ropivacaïne.

OBJECTIVES: A pilot study was implemented to evaluate the efficacy of patient controlled analgesia (PCA) with continuous intra-articular infusion of ropivacaine following trapeziectomy with ligament reconstruction and tendon interposition. METHODS: Twelve patients were prospectively included. A catheter was placed into the trapezium void and connected to a PCA pump set on a continuous intra-articular infusion rate of ropivacaine: 2mg/ml. Patients were allowed to deliver additional boluses when analgesia was incomplete. RESULTS: Pain was evaluated less than 3/10 (Numeric Scale Evaluation) by 92% of the patients during the first 48 h. No toxicity of the local anaesthetic nor catheter-related complication were reported. CONCLUSION: This preliminary study showed continuous basal and bolus infusion of ropivacaine through a single catheter placed into the trapezium void to provide an excellent postoperative pain control and to be related to a high patient's satisfaction level.

Treatment of defects in the tip and palmar surface of the fingers.

Defects on the palmar surface of the fingers are an important part of hand emergencies, especially fingertip wounds. Luckily, many coverage methods are available. We will review the anatomy of this area and the thought process for treating these defects. We will also propose an algorithm that can be used to select the best technique based on the type of injury present.

NCA2, a second nuclear gene required for the control of mitochondrial synthesis of subunits 6 and 8 of ATP synthase in Saccharomyces cerevisiae.

Respiratory-competent nuclear mutants have been isolated which presented a cryosensitive phenotype on a non-fermentable carbon source, due to a dysfunction of the mitochondrial F1-Fo ATP synthase. This defect results from an alteration of the mtDNA-encoded protein synthesis level of subunits 6 and 8 of the Fo sector, due to the simultaneous presence of a mutation in two unlinked nuclear genes. These mutations promote a modification of the expression of the cotranscript ATP8-ATP6 (formerly denoted AAP1-OL12): this mRNA undergoes a maturation at a unique site reaching to two cotranscripts of 5.2 and 4.6 kb in length: in the mutant, the relative amount of 5.2 kb cotranscript was greatly lowered. NCA2 was isolated from a wild-type yeast genomic library by genetic complementation. The relative level of the 5.2 kb transcript, as the synthesis of subunits 6 and 8, was partly restored in the transformed strain. A 1848 nucleotide open reading frame was depicted that encoded an amphiphilic protein of 70,816 Da. Disruption of chromosomal DNA within the reading frame promoted a dramatic decrease of the 5.2 kb mRNA but did not abolish the respiratory competence of a wild-type strain. Hybridization analyses indicated that NCA2 is located on chromosome XVI and produces a single 2750 base transcript.

[Adrenal hypoplasia congenita: four new cases in children]. / Hypoplasie congénitale des surrénales : à propos de quatre observations.

Adrenal hypoplasia congenita (AHC) is an extremely uncommon disease of early onset. This condition can be lethal in the absence of adapted treatment. Some of these diseases are related to changes in the gene DAX1 that encodes a member of the superfamily of hormone nuclear receptors. It is a transcriptional repressor that is central in the morphogenesis of the adrenals and the gonadic differentiation. Here we report on four cases of X- linked AHC. In the first two familial cases, mutations were identified and mothers were heterozygotes. Abnormally low levels of estriol were evidenced during the pregnancy leading to an early diagnosis and adapted care of the affected male neonates. These children are doing well with a 21-and 20 months follow-up with hormone replacement at the present time. The two last cases corresponded to a contiguous gene syndrome associating AHC to glycerol-kinase deficiency that was revealed respectively at six days and seven years of age by acute adrenal insufficiency.