Use of perfusion device for free flap salvage after ischemia in swine.

INTRODUCTION: In free flap reconstruction, improving flap tolerance to warm ischemia (WI) is fundamental. WI is the result of a venous or arterial thrombosis, which can only be addressed through surgical revision. No additional treatments have shown superior efficacy at salvaging free flaps after or during WI. Custom perfusion machines (PM), used to reduce the intensity of lesions of the flap stored in cold ischemia, have not been evaluated for WI flap salvage. This proof-of-concept study assessed whether the Lifeport® perfusion machine could improve the salvage procedure's success rates after one hour of venous WI. METHODS: Five different groups were evaluated with four porcine latissimus dorsi free flaps included in each group. Depending on the group, the flaps were subjected to one hour of WI followed by revascularization, static hypothermic submersion, or dynamic Lifeport® perfusion. Additionally, two flap perfusion liquids were evaluated: KPS-1® and IGL-1®. Biopsies were performed before in vivo warm ischemia of the flap, after in vivo warm ischemia of the flap, and after one and two hours of preservation. Interstitial edema, muscular cell size and muscular diffuse necrosis were quantified by histological assessment. RESULTS: Static submersion did not demonstrate any efficacy for venous flap salvage. Dynamic perfusion on Lifeport® machine showed a significant improvement in tissue parameters. Thrombi and fibrine, present during the WI period, were no longer visible inside vessels and the perfusion machine flow evacuated the inflammatory cells and their substrates from the flap. The flap weights did not increase during perfusion time, confirming the benefits of the Lifeport® perfusion machine. CONCLUSION: Evaluating Lifeport® advantages on human free flap salvage is necessary to confirm the benefits for the tissue and to increase post-operative results after congestive free flap revision surgery.

Novel role of fluorescent in situ hybridization technique (FISH) in recommended surgical margins of dermatofibrosarcoma protuberans: A preliminary study.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare skin tumor. There is no standard recommendation for its surgical management. The currently used histological analysis are HES (hematoxylin eosin saffron) staining and immunohistochemistry for CD34 expression in particular cases. Fluorescent in situ hybridization (FISH) technique is only used to qualify the DFSP as translocated or non-translocated and is not used as a diagnostic method. The aim of our study was to determine by FISH (as a diagnostic method) whether cancerous cells that could not be identified through HES staining±immunohistochemistry were present at the two-centimeter margins that were found to be tumor-free. METHODS: Samples from patients who underwent surgery between 2010 and 2018 were collected. Intralesional and peripheral (at 2cm margins) paraffin slides were included. An average of 7.4 slides per specimen was analyzed. Firstly, the preselected slides were reread by a senior pathologist to confirm the absence of microscopic findings of DFSP at 2cm margins. Secondly a FISH analysis was used as a quantitative diagnostic approach, in order to find the t(17;22) translocation. RESULTS: Among the seven specimens that included 2cm margins, two samples presented one or more translocations, which were not visible in standard morphology assessments at two centimeters tumor-free margins. CONCLUSIONS: FISH analysis can have a new role in defining tumor-free margins. This would reduce the incidence of disease recurrence after resection and improve the post-operative complementary care.

[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]. / Cytostéatonécrose après reconstruction mammaire par lambeau graisseux avec ou sans préconditionnement ischémique.

INTRODUCTION: Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM. MATERIAL AND METHODS: All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded. RESULTS: Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM. CONCLUSION: PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

[Transition, fertility and options for preservation of fertility]. / Transition, fertilité et options de préservation de fertilité.

Oftentimes ignored or infrequently expressed, some transgender persons harbor a desire for parenthood. Given the evolution of medical techniques and the enacting of legislative reforms, it is henceforth possible to propose fertility preservation strategies in the overall context of gender transidentity. During the "female to male" (FtM) transition pathway, androgen therapy has an impact on gonadic function, generally inducing blockage of the ovarian function, with amenorrhea. Even though these events may be reversed on cessation of treatment, the possible long-term effects on future fertility and on the health of children yet to be born are little known. Moreover, transition surgeries definitively compromise the possibility of pregnancy insofar as they involve bilateral adnexectomy and/or hysterectomy. Options for fertility preservation in the framework of FtM transition are premised on cryopreservation of oocytes and/or ovarian tissue. In a comparable manner, even though relevant documentation is lacking, hormonal treatments for persons transitioning from male to female (MtF) can have an impact on future fertility. In the event of surgery involving bilateral orchidectomy in which spermatozoid cryopreservation has not been carried out, fertility is definitively impossible. In both cases and under present-day legislation, numerous legal and regulatory barriers render highly problematic the reutilization of cryopreserved gametes. Given these different constraints, it is indispensable to closely supervise these types of treatment by proposing psychological support.

[Eye feminization]. / Féminisation du regard.

Eye feminization embraces surgical and non-surgical aesthetic procedures used in order to feminize upper third of the face. Eye feminization is indicated for transwomen during facial gender affirming surgery, and also for aging women. During aging, volume of facial osseous and soft tissues is decreasing, the orbit is squeletonizing, with skin sagging, evolving in a more masculine appearance of the orbital area. Upper eye area analyze (forehead, temple, eyebrow, eyelid, external canthus) as lower eye area analyze (zygoma, dark circle, palpebral bags, eyelid skin) must be assessed in preferential order in order to maximize good post-therapeutic results. Procedures include bony surgery (frontoplasty, orbitoplasty), browlift, external canthoplasty, fat grafting, and also classic eyelid surgery or aesthetic medicine injections.

Effect of ischemic preconditioning on skeletal tissue tolerance after warm venous ischemia.

PURPOSE: Free muscular flaps are commonly used in plastic surgery. The main reason of failure is thrombosis induced by a phenomenon called ischemia reperfusion. Preconditioning showed an interest to prevent ischemia reperfusion injury in transplantation surgery. The aim of the study is to evaluate the effect of ischemic preconditioning on skeletal tissue tolerance after warm venous ischemia. MATERIALS AND METHODS: We realized an experimental study with latissimus dorsi flaps of 12 pigs, divided in 6 groups in function of their time of preconditioning and duration of warm venous ischemia. A morphologic analysis was performed measuring cell's diameter and interstitial tissue area and notifying the presence or absence of neutrophils, necrosis or intravascular thrombosis. To detect inflammation, necrosis or hypoxia, immunohistochemistry was effectuated using the follow primary antibodies, AIF, HIF1 alpha, caspase 3, SOD 1 and PKC epsilon. TUNEL assay showed apoptosis cells, were realized. One way Anova test was performed to compare the quantitative evolution over time of histological parameters and rate of apoptosis. RESULTS: Preconditioning of 40min or 1hour allowed to reduced ischemia reperfusion lesions: no cellular or interstitial oedema, reduction of neutrophils infiltrate and intravascular thrombus. TUNEL assay showed a higher rate of apoptosis nucleus for the control group E compared to preconditioning group C and D. Immunohistochemistry results were no relevant. CONCLUSION: We showed a diminution of lesions of ischemia reperfusion for experimental groups with preconditioning: diminution of interstitial oedema, of cellular oedema, diminution of neutrophils infiltrated and level of apoptosis cells. Preconditioning of 40minutes were as efficient as one hour.

[Frontal sinus anatomical scanographic study of transgender patients for feminization frontoorbitoplasty surgery]. / Étude anatomique scanographique du sinus frontal des patients transgenres en vue d'une chirurgie de frontoorbitoplastie de féminisation.

INTRODUCTION: Little is known about the anatomical elements that allow safe and predictable performance of fronto orbital surgery for facial feminization. The primary objective of this study was to analyze the characteristics (dimensions, pneumatization rate, and anterior wall thickness) of the frontal sinus in MtF transgender patients. The secondary objective was to establish reproducible criteria for CT measurements that could guide preoperative planning of frontal impaction in feminization frontoplasty (FF). MATERIALS: Fifty preoperative facial mass scans of FF surgery patients were included. The mean age of the operated patients was 34 years. The F line represented the ideal forehead tilt in the absence of a frontal hump. RESULTS: The height, width, depth, and thickness of the anterior sinus wall were 26.6mm (±5.7), 49.5mm (±11.3), 10.9mm (±3.3), and 3mm (±0.7), respectively. The mean sinus width to skull width ratio was 0.73 (±0.12). Six percent of patients had bilateral frontal sinus agenesis. An osteotomy of the anterior wall of the frontal sinus was performed in the 64% of patients with frontal sinus projection anterior to the F-line. The emergence of the supraorbital nerves from the frontal bone was through a bony notch in 73.8% of cases. CONCLUSIONS: Knowledge of the anatomy of the frontal sinus and preoperative study of the scans of the facial mass is essential for planning the FF. These characteristics guide the surgical technique of bone remodeling as well as the procedure for releasing the supraorbital nerves.

FACE-Q satisfaction following upper third facial gender-affirming surgery using custom bone-section guides.

Postoperative satisfaction after facial gender-affirming surgery (FGAS) has not yet been assessed using a validated questionnaire. There is currently no postoperative satisfaction questionnaire specific to transgender patients concerning facial surgery. The contributions of three-dimensional planning in fronto-orbital surgery in trans women and the use of bone cutting guides for facial feminization surgery have been demonstrated. The primary objective of this study was to evaluate postoperative satisfaction with the upper third of the face in trans women using a validated questionnaire - FACE-Q - after fronto-orbital surgery using custom-made bone cutting guides. The secondary objective was to determine predictive factors of satisfaction. Forty-two patients who underwent frontoplasty with frontal sinus impaction osteotomies using custom bone cutting guides between May 2018 and September 2020 were included. Three-dimensional preoperative computed tomography planning was performed for each patient. Evaluations were performed preoperatively and at 1 year postoperative using FACE-Q items relating to the upper third of the face (fronto-orbital area) and general questionnaire items. At 1 year, the following FACE-Q scales had improved significantly in comparison to the preoperative evaluation: overall facial appearance (33.6 ± 19.4 vs 70.1 ± 21.1; P < 0.001), forehead and eyebrow appearance (38.3 ± 19.7 vs 80.1 ± 15.9; P < 0.001), wrinkles between the eyebrows (54.1 ± 26.7 vs 82.6 ± 19.9; P = 0.001), appearance-related psychological distress (58.1 ± 18.1 vs 24.6 ± 24.5; P < 0.001). No factors predictive of postoperative satisfaction were found for the included frontal FGAS. In the absence of a validated questionnaire specific to facial feminization surgery in transgender patients, the FACE-Q questionnaire showed an improvement in patient satisfaction after FGAS of the upper third using custom-made cutting guides.

[Modalities of gynecological follow-up of transgender patients - Literature review]. / Modalités du suivi gynécologique chez les patients transgenres ­ Revue de littérature.

Transgender patients are at increased risk of cancer, sexually transmitted diseases, short- and long-term postoperative complications in patients with vaginoplasty, but also unwanted pregnancy in non-hysterectomized trans men. However, access to care is often difficult for these patients, who often do not benefit from appropriate gynecological monitoring, especially for fear of judgment or discrimination. In view of the health risks of these patients, it is essential to be able to offer them specific and adapted gynecological follow-up. To date, there are no clear recommendations regarding the gynecological follow-up of transgender patients. We relied on the recommendations of the World Professional Association of Transgender Health (W-PATH) and the Endocrine Society Guideline and performed a literature review. We carried out several searches via pubmed in order to explore one by one the different aspects of gynecological follow-up, in particular of non-hysterectomized transgender men and transgender women with a vaginoplasty. It emerges from this a lack of follow-up of transgender people, with a reluctance to consult a gynecologist, associated with the lack of knowledge and experience of health professionals. Due to the risks identical to those of the general population, added to those specific to transgender people, it is important to be able to offer these patients specialized and personalized gynecological follow-up, and to raise awareness and train health professionals on the importance of and the specificities of the gynecological follow-up of these patients.

[Scapular flap, an alternative to the radial forearm flap in phalloplasty: Advantages and limitations]. / Lambeau scapulaire, une alternative au lambeau antébrachial en phallopoièse : avantages et inconvénients.

INTRODUCTION: Antebrachial phalloplasty is considered as the standard technique in total penile reconstruction. This technique allows the creation of a phallus and a neourethra in one step at the cost of significant sequelae of the donor site. Thus, this technique has been replaced in some centers by other techniques such as the MSLD flap or the ALT flap. However, in Western populations, these techniques require the addition of a technique dedicated to the urethroplasty. The scapular flap is a technique that is not widely described in the literature and, like the antebrachial flap, allows the creation of a phallus and a urethra in one step according to the "tube within tube" technique. AIM: The aim of the study was to detail this technique, to study its vascularization and to adapt the measurements of the flap to a western population. PATIENTS AND METHODS: Six cadaveric dissections were performed in the laboratory. Intravascular injection of colored latex allowed easier identification of the vessels of interest and study of the subcutaneous vascular tree. Scapular flaps of variable size were raised to adapt the size to a Western population. RESULTS: Six dissections were performed in Caucasian subjects. The scapular circumflex artery was constant and had a mean diameter of 3.5mm (3.3mm-3.8mm). The mean pedicle length was 7.3cm (6.8cm-8.1cm). The size of the flaps was adapted to the subcutaneous tissue and flaps of at least 14×16cm allowed the "tube within tube" technique to be performed. CONCLUSION: The scapular flap has the advantage of allowing phalloplasty with urethroplasty to be performed at the same time. The pedicle is constant and of good diameter. In addition, the sequelae of the donor site are minimal. On the other hand, the pedicle used is short and the flap cannot be surgically reinnervated. Nevertheless, the restoration of a protective sensitivity allows the implantation of a penile prosthesis.

[Fertility preservation for transwomen]. / Place de la préservation de la fertilité dans le parcours de transition des femmes transgenres.

The evolution of medical care for transgender people currently makes it possible to propose fertility preservation. Fertility preservation should be initiated before the start of hormonal treatments and/or surgical procedures. The "reproductive" aspect and the desire for parenthood among transgender people have long been ignored. However, these aspects are important to consider and fertility preservation should be discussed before the start of the physical transition. The aim of this review is to assess the literature on fertility preservation for transgender women ("male to female"). Many uncertainties remain regarding the impact of hormonal treatments on the reproductive functions of transgender women and their reversibility. However, the significant increase in the number of recently published articles is evidence of the improvement in the conditions of access to these procedures for women starting a transition process. Nevertheless, there are still a number of barriers that can prevent or delay this process.

Coverage of radial forearm flap donor site with full thickness skin graft and Matriderm®: An alternative reliable solution?

PURPOSE: After harvesting a radial forearm flap (RFF) an optimal aesthetic and functional restitution of the donor site is required. In order to cover the secondary defect of the donor site, several solutions are currently available, but there is still no real evidence of the most reliable option. A retrospective study was conducted in order to evaluate a new technique of forearm coverage with artificial dermis: the association of full thickness skin graft (FTSG) with Matriderm®. METHODS: Our study included all RFF performed during a 34-month period. Forty-three forearm secondary defects after harvesting a RFF (16 men, 27 female) were included. Forearm donor site was covered using three techniques: a simple FTSG, split thickness skin graft (STSG) with Matriderm® or FTSG with Matriderm®. Clinical evaluations based on residual functionality, skin quality and aesthetic result were assessed using respectively the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Vancouver Scar Scale (VSS) score and a blind panel questionnaire. RESULTS: FTSG with Matriderm® showed an improved DASH (10.6/100) and VSS score (5.5/13) if compared to the other techniques, mean surgeon satisfaction score was 3/5, mean patient satisfaction score was 3/5 in the FTSG with Matriderm® group. CONCLUSION: The results of this study revealed that the new association of FTSG with Matriderm® improves the DASH score and the aesthetic outcomes resulting to be a reliable solution in treating full thickness forearm skin defects after RFF harvesting.

[Postoperative complications after genital gender confirming surgery in transgender women]. / Complications postopératoires après transformation génitale homme-femme (aidoiopoiëse).

Genital gender affirmation surgery in transgender women is usually performed by single-stage penile inversion vaginoplasty, with creation of vagina, perineal urethral meatus, majora and minora labia, and clitoris. Postoperative functional or aesthetic complications are common, affecting every reconstructed part of the neovulva. Patients should be preoperatively informed of those possible complications. Postoperative close follow-up must be conducted, beginning with therapeutic learning of the self-dilation regimen, detecting and treating any complication, and ending up when complete healing is obtained among satisfied patient.

Fluorescent indocyanine green angiography: Preliminary results in microsurgery monitoring.

INTRODUCTION: Pedicled flaps and free-tissue transfer flaps are used routinely to reconstruct hard and soft tissue defects in head and neck, limb, hand, thoracic and abdominopelvic reconstructive surgery. But failure remains a constant concern, particularly in free-tissue transfers. Usually failure is due to blood supply compromise. Indocyanine green (ICG), a fluorescent dye is a suitable tracer for vessel perfusion. The objective of this study is to evaluate the fluorescent indocyanine green angiography (FA ICG) in free flaps procedures. MATERIEL AND METHODS: Patients who had microsurgical flap reconstruction were included during the study period in a single center. The FA ICG was used at specific times. Intra-veinous injections of 0.1mg/kg of INFRACYANINE® (concentration 2.5mg/mL) were done intraoperatively. The Fluobeam® device programmed on sensitivity and mapping to interpret the data, was used. These different injections allowed to checked skin paddle perforators vessels, osseous perforators vessels, arterial and venous patency after anastomosis and the cutaneous, muscular and osseous perfusion. RESULTS: A total of 12 patients enrolled were 10 males and 1 female. Their mean age was 54.5 years (range 25-75 years). Of the 12 flaps, 8 were free flaps with 4 fibular flaps (3 for mandibular reconstruction and one for femur reconstruction); 2 radial forearm flaps for maxillary reconstruction; one latissimus free flap for tibia skin coverage and one retroauricular fasciocutaneous free flap for thumb skin coverage. We got to modify specific steps during surgery with 8 patients by using the FA ICG to anticipate potential complications: modifying the draw of the skin paddle, recut of this paddle, modifying the osteotomies, re-doing the anastomosis or modifying the position of the pivot point. DISCUSSION: Evaluation of microvascular flap perfusion is still based on subjective clinical features. Clinical monitoring is observer-dependent and does not allow information sharing, test reproducibility, and consistent postoperative follow-up. The successful of salvage rate is linked to the delay between the onset of ischemia and its clinical assessment. FA ICG could be a reliable method for monitoring free-tissue transfers. This technique is objective, non invasive and facilitate a complex reconstructive procedure to augment is liability. This technique may be used such a pedagogical tool for young practitioners in their first microsurgery procedures.

Latissimus dorsi breast reconstruction with or without implants: A comparison between outcome and patient satisfaction.

BACKGROUND: The latissimus dorsi (LD) flap is largely used in breast reconstruction. The aim of this study is to evaluate and compare the advantage of the LD flap in association with an implant to that of LD flap in association with lipofilling to add additional volume following breast reconstruction by assessing the number of revision procedures, length of hospitalization, complication rate, and patient satisfaction. METHODS: A retrospective cohort study was performed to evaluate complication rate, number and type of revision procedures required, hospitalization time, and overall duration of the reconstructive process in patients undergoing LD breast reconstruction in our department between January 2012 and March 2015. Patient satisfaction was assessed using BREAST-Q®. RESULTS: Ninety-five breast reconstructions performed on 90 patients were included. In 38 patients, 42 breasts were reconstructed using LD flap in association with lipofilling (Group 1). In the remaining 52 patients, 53 breast reconstructions were performed using LD flap in association with an implant (Group 2). Findings concerning total hospitalization time, overall duration of the reconstructive process, and the distribution of supplementary surgical procedures demonstrated no statistically significant differences between the two groups. However, the surgical complication rate was higher in Group 2 than in Group 1 (14.2% vs. 18.8%, respectively). Regarding BREAST-Q, a detailed analysis of the "satisfaction with breasts" domain showed a higher score for Group 1 than for Group 2. CONCLUSIONS: The association of a breast implant with LD reconstruction does not decrease breast reconstruction time in terms of the number of revision procedures and hospitalization time, exposes patients to a higher complication rate, and does not improve patient satisfaction.

[Evolution of surgical indications in upper limb functional surgery for tetraplegic patients: Retrospective study of 428 procedures]. / Évolution des indications chirurgicales dans la chirurgie fonctionnelle du membre supérieur chez le patient tétraplégique : étude rétrospective à propos de 428 interventions.

INTRODUCTION: Regarding surgical strategy for upper limb functional rehabilitation in patients with traumatic tetraplegia, there are few publications and the case series are quite small. PATIENTS AND METHOD: We reviewed all traumatic quadriplegic patients, operated one by one surgeon, professor Marc Revol, for functional surgery of the upper limb in the same department from 1989 to 2018. For each patient, we recorded their gender, their group according to the international classification, their age at the time of the first surgical procedure, the length of time between the accident and the first surgery and between two procedures, the average duration of the whole surgical program, and the surgical technique used for the elbow, the wrist, the long fingers and the thumb. RESULTS: We reviewed 158 cases, representing 428 surgical procedures. Some surgical principles have remained unchanged through the years: the hand opening stage comes before the closing one, and systematically includes intrinsic active palliative procedures using lassos; and restoration of long fingers grasping is consistently associated with restoration of thumb gripping and with flexor tendons tenolysis in the lassos region. Other strategic points have evolved over time: restoration of active elbow extension now systematically uses the biceps over the deltoid transfer; brachio radialis (BR) to extensor digitorum communis (EDC) and to extensor pollicis longus (EPL) transfer has been replaced by tenodesis; in groups 2, 3, 4 and 5, the hand opening stage has been consistently associated with the biceps transfer, thus shortening the surgical program to two procedures instead of three for each upper limb; split distal flexor pollicis longus (FPL) tenodesis has replaced thumb arthrodesis; and, whenever it was possible, BR has been spared from group 3 and beyond. CONCLUSION: In groups 2 to 5, the indications have evolved towards the following strategy. The first surgical step includes restoration of elbow extension using biceps transfer and hand opening reinforcement through four lassos, one split distal FPL tenodesis for the thumb, and EDC and EPL tenodesis to the retinaculum. The second surgical procedure consists of restoration of long fingers and thumb flexion using one unique motor (BR or extensor carpi radialis longus), and closed tenolysis of the flexor tendons in case of adhesions in the lassos area.

Traumatic atlanto-axial rotatory subluxation after surgical correction of prominent ears: Case report and review of the literature.

Corrective surgery of prominent ears may be justified for social or aesthetic reasons during childhood or adulthood. Post-operative complications occur in approximately 0 to 8.4% of cases. This case describes a rare atlanto-axoid rotatory subluxation after bilateral surgical correction of prominent ears under general anesthesia. Orthopedic treatment was done after two months of medical roaming outside of our center. The one-year post-operative clinic consultation and radiological exam were normal. Only the psychological impact of the episode remained. Traumatic atlanto-axial rotatory subluxation is a rare complication but should be considered after post-operative torticollis in order to aid with diagnosis and allow doctors to implement the appropriate course of treatment.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study.

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap.

OBJECTIVE: The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. MATERIALS AND METHODS: This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion. RESULTS: Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. CONCLUSION: In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1hour and 45minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.

Are prostaglandins or calcium channel blockers efficient for free flap salvage? A review of the literature.

The free flap failure rate is less than 5%. The responsible mechanisms of postoperative secondary ischemia are mostly vascular. The main postoperative complication leading to flap failure is thrombosis. Different strategies have been reported to improve the reliability of flaps and decrease the risk of partial or total necrosis: thus, pharmacologic agents have been studied to reduce the risk of microvascular thrombosis. The aim of this review was to evaluate the effect of calcium channel blockers and prostaglandins on free skin flap survival. A systematic review of the literature was performed to identify articles studying the efficacy of calcium channel blockers and prostaglandins on free flap survival. After full text reading, eleven articles were finally included. Eight articles investigated the role of prostaglandins in free tissue transfers, two in rats subjects, one in rabbits, five in humans. Two articles studied the effect of calcium channel blockers on free flaps, one in rats subjects, one in rabbits. One article studied in different groups the effect of calcium channel blockers and prostaglandins on free flaps in rabbits. Literature regarding the efficacy of calcium channel blockers and prostaglandins to salvage free flap is poor and mainly based on animal models. Nevertheless, studies on prostaglandins showed a slight efficiency of these molecules for free flap salvage. Results are less reliable for calcium channel blockers and dependent on the molecule used. In conclusion, there is a lack of evidence to use them in clinical practice.