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.

[French innovations in plastic and reconstructive surgery of hand and limbs. Interview by Michel Schoofs]. / La créativité et les innovations françaises en chirurgie plastique reconstructrice et esthétique de la main et des membres.

This unique manuscript reports the interviews of Pr Michel Merle and Jacques Baudet, two figures of the French plastic reconstructive and microsurgical surgery of the limbs. Their testimony shed lights into our past, explains our present and helps foresee our future. The lesson to take away from their story is that no mountain can be overcome in one day, but rather requires countless efforts, dedication and persistence.

Intramuscular innervation of upper-limb skeletal muscles.

We studied 150 skeletal muscles from 8 upper limbs using the modified Sihler's staining technique. Based on the pattern of the intramuscular innervation and shape, the muscles were grouped into trapezoidal-shaped (Class I), spindle-shaped (Class II), and muscles that were combinations of these two classes (Class III). Such distinctions are clinically important for limb reconstruction procedures. Bipennate, spindle-shaped muscles with the aponeurosis of the tendons of insertion extending proximally into the muscle belly and Class III muscles with multiple tendons of origin may be split for separate independent functional transfers.

Angiosomes of the brachial plexus: an anatomical study.

This anatomical study analyzed the neurovascular relationships of the brachial plexus. Ten fresh cadaveric brachial plexuses were examined after injection of the arterial system. The vascular anatomical features of the brachial plexus were documented with microdissection after lead oxide/gelatin injection. The specimens were analyzed by using radiography (including digital subtraction techniques) and light-microscopic, macroscopic, and digital photography. Four angiosomes, based on the subclavian, axillary, vertebral, and dorsal scapular arteries, were observed. As noted in previous angiosome studies, connections between angiosome territories lay within tissues, in this case, nerve trunks. Nutrient vessels penetrated nerve trunks at points of branching within the brachial plexus, with a Y-shaped mode of division on entry. The vascular supply was markedly rich, often with true anastomotic connections occurring within the nerves. There was much variation in supply, depending on the vascular anatomical features of the subclavian artery.

Bone reconstruction of the lower extremity: complications and outcomes.

A study was performed to analyze the results and final outcomes of bone reconstruction of the lower extremity. Twenty-six patients presented with type IIIB open fractures, nine with type IIIC open fractures, and 15 with chronic osteomyelitis. Seven patients underwent primary amputation, and reconstruction was attempted for 43 patients. The mean bone defect size was 7.7 cm (range, 3 to 20 cm). Bone reconstruction was achieved with conventional bone grafts in 16 cases, in association with either local (13 cases) or free (three cases) flaps. Vascularized bone transfer was performed in 24 cases, with either osteocutaneous groin flaps (10 cases), soleus-fibula flaps (12 cases), or osteocutaneous lateral arm flaps (two cases). For three patients, bone reconstruction was performed with a technique that combines the induction of a membrane around a cement spacer with the use of an autologous cancellous bone graft. Infections were observed to be responsible for prolonged hospital stays and treatment failures. The cumulative rates of sepsis were 4.6 percent at 1 week after injury and 62.8 percent at 2 months. Vascular complications were also related to infections and were responsible for four secondary amputations. One patient asked for secondary amputation because of a painful nonfunctional lower limb. Bone healing occurred in 37 of 43 cases, and the average time to union was 9.5 months, with an average of 8.7 procedures. The mean lengths of stay were 49 days for conventional bone grafts and 62 days for vascularized bone grafts. All of the 50 patients were able to walk, with an average time of 14 months. All of the patients with amputations underwent prosthetic rehabilitation. Patients mostly complained about the reconstructed limb (62.8 percent). Joint stiffness was present in 40 percent of the cases. Other long-term complications were pain (nine cases), lack of sensation (five cases), infection (five cases), and pseudarthrosis (one case). However, all of the patients with successful reconstructions preferred their salvaged leg to an amputation. Of 41 patients who were working before the injury, 26 returned to work.

Reconstruction of short lower leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap.

To avoid a more proximal amputation at the distal part of the thigh, and when the knee joint is preserved, it is possible to lengthen short lower leg stumps. The authors report five cases in which the latissimus dorsi-rib flap was used to achieve a satisfactory functional prosthetic result. The bone segment is long enough to both lengthen the stump and allow its extremities to be firmly fixed to the tibia. Depending on the remaining tibia length, one or two ribs were included in the flap. The procedure allowed achievement of a 5-cm to 9-cm lengthening of the tibia. Bone healing time was 5 to 6 months and allowed prosthetic rehabilitation and ambulating 5 to 7 months after surgery. Final range of motion of the knee joint is compatible with normal ambulating, and the prosthesis is well tolerated. This procedure, which provides a large amount of skin, muscle, and bone, is very effective for reconstruction of short lower leg stumps.