The star approach, a surgical approach for skin sparing mastectomy and central lumpectomies.

When preservation of the nipple-areolar complex (NAC) is not possible in oncologic breast surgery, the traditional approaches are either a horizontal incision centered on the NAC resulting in visible scars and breast distortion, or a round block with risk of healing difficulties. To address these concerns, the authors propose a star approach technique for skin sparing mastectomies and lumpectomies of central breast tumors. During the oncologic surgery, the NAC is removed with four cutaneous extensions, which can be closed as a cross-shaped scar. The scarring is similar in size to the original NAC diameter and can easily be covered by the NAC reconstruction. This technique offers good exposure during surgery, a good aesthetic result with limited scarring, no breast deformity, correction of breast sagging, and high-quality healing.

Genitocrural Island Perforator Flap (GIP-Flap): An ideal surgical technique for covering uni- or bilateral vulvar loss tissue.

Vulvar loss of soft tissue leads to urinary, sexual and morphological dysfunctions. Most patients affected are comorbid making it difficult to perform a flap, which is the most appropriate way to reconstruct. Our multidisciplinary plastic and gynecologic surgery team has developed a new technique using a pedicled internal pudendal island flap. Reconstruction is reliable, quick and applicable to all patients, with a highly satisfactory final appearance.

Cephalic vein transposition in head-and-neck reconstruction.

The advent of free flaps has made it possible to undertake increasingly complex reconstructive surgeries. Many of the patients have already undergone extensive prior surgery, primary free flap reconstruction and/or cervical irradiation. These treatments strongly impact anatomy and tissue quality. The reconstructive surgeon may be faced with a situation where the choice of recipient vessels is limited; in 7% of cases, no cervical vessels are available at all. For venous anastomosis, branches of the internal and external jugular vein are preferentially used, but may have been ligated or be unusable. Venous congestion is one of the most common causes of failure in these situations. The cephalic vein has been described as an alternative for second anastomosis in first line, but is rarely used for early free-flap salvage. Based on a case study, the technique of cephalic vein transposition is illustrated for early salvage of a double free flap for head-and-neck reconstruction. This technique is simple, reliable and rapid. It should be part of the armamentarium of the head and neck reconstructive surgeon.

Muscle sparing latissimus dorsi flap for reconstruction of a large chemo-necrosis of the chest wall: A case report.

BACKGROUND: Extravasation of chemotherapeutic agents is a common complication in cancer centers. In severe cases involving large tissue necrosis, surgery may be needed to resect necrotic tissues and to cover the exposed areas. CLINICAL CASE DESCRIPTION: A 71 years old women was referred to our unit two month after extravasation of epirubicin from an implanted port-a-cath with a large chemonecrosis of the anterior chest wall. She presented an evolutive tissue necrosis extending from the upper anterior thoracic region to the right breast. Surgical debridements and negative wound pressure therapy were necessary in order to obtain clean areas. The final chest wall defect was covered using a Muscle Sparing Latissimus Dorsi pedicled flap. This surgical management have permitted a satisfying wound healing and functional recovery without any complication. CONCLUSION: Chemotherapeutics' extravasations can be a severe complication of oncologic treatment and have to be discussed between oncologists and plastic surgeons to find the most effective and suitable solution with consideration of the specificities of cancer therapy. In chest wall skin defect, the use of muscle sparing latissimus dorsi pedicled flap is a robust solution with low morbidity of the donor site.

Radiation-induced bullous pemphigoid after surgery for soft tissue sarcoma: About a rare case.

INTRODUCTION: Radiation therapy may cause a range of side effects of the skin within the irradiated area. Not of all the reactive effects of the skin induced by radiation therapy have to be related to some forms of radiodermatitis, and when non-standard clinical presentations overcome, it may be necessary to undertake appropriate diagnostic tools to not be in trap of wrong diagnosis. CLINICAL CASE DESCRIPTION: A 76 years-old man undertook resection surgery after a neoadjuvant radiation therapy for a soft tissue sarcoma of his groin region. After surgery, he developed an acute skin reaction comparable with a severe form of radiodermatitis. Despite cares, his clinical status got worse. Only skin biopsies guided us to the right diagnosis: it was a form of a bullous pemphigoid induced by radiation therapy. The consequent appropriate treatment was finally resolute. CONCLUSION: These forms have to be recognized in time, to undertake skin biopsies as soon as an evocative clinical presentation appears. The appropriate treatment, which consists in local or systemic corticotherapy, is resolute in most cases.

Innovative adaptation of the "spare tissues concept" applied for olecranon coverage of a severe burn patient: A case report.

BACKGROUND: The management of bone exposure in patients with extensive burns could be a challenge due to the lack of healthy tissue. In such cases, it could be interesting to use any still healthy tissue initially destined for amputation and use it to cover up another site. We present the case of a sever burn patient for whom we used the only healthy palmar hand skin to cover an olecranon exposure. CLINICAL CASE DESCRIPTION: A 38-year-old man has been admitted in burn victim unit with extensive deep burns on 60% of the total body surface. An exposure of the left olecranon was appeared occurring on a burned area, with absence of healthy local tissues available for coverage. Concomitantly a trans-radial amputation was indicated because of severe digits burns leading to an impossibility to preserve the function of the hand. A palmar skin area was healthy leading to harvested this palmar skin flap pedicled on ulnar vessels. Early post-operative healing was satisfactory and no vascular suffering of the flap has been observed with a total healing at three weeks. CONCLUSION: In any patient the spare tissues concept should be keep in mind when amputation is indicated simultaneously with a problematic of loss of substance coverage to a proximity area. In this case of severe burn patient, we used a palmar skin flap pedicled on the ulnar vessels to cover an olecranon exposure.

Lower limb perforator flaps: Current concept.

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

Vascularized lymph node transfer with submental free flap.

Limb lymphoedema is common in patients who have undergone inguinal or axillary lymph node dissection. Lymphoedema seriously impacts the patient's quality of life by inducing adipogenesis, fibrosis and repeated episodes of lymphangitis and cellulitis. Following failure of compression therapies, several curative or symptomatic surgical options have been proposed over recent decades, such as liposuction or lymphovenous anastomosis. Vascularized lymph node transfer techniques have recently been described, with promising results. Vascularized lymph node transfer with submental free flap appears to be the most reliable of these technique, associated with the lowest morbidity. The flap harvesting technique presents several specific differences compared to conventional submental free flap. A good knowledge of neck anatomy is essential and multimodal and multidisciplinary management is often required. In the light of a case report, we describe the basic submental free flap technique for vascularized lymph node transfer for the treatment of lower limb lymphoedema. This technique may be used by head and neck surgeons performing flap harvest, as well as plastic surgeon surgeons or gynaecologists ensuring long-term management of these patients.

[Complications of autologous breast reconstruction]. / Complication des lambeaux en reconstruction mammaire.

Flap reconstruction techniques are increasingly desired by French's patients and it represents almost half of breast reconstruction indications in 2017. The main reasons of this statistics are the growing concerns of the patients with breast implant of developing BIA-ALCL, as well as their desire of having a more natural reconstruction results without having any foreign bodies. The multiplication of autologous reconstruction techniques, especially microsurgical techniques which has been popularized in the recent years, makes possible to propose a reconstruction to the majority of patients without an implant. This type of reconstructions is associated with a significant number of complications; thus, a proper selection of patient should be done and a good knowledge of the surgical technique by the surgeon to reduce the complication. Our proposed study is divided into two main parts, the complications of the flap and the complications at the donor site. Based on the experience of our plastic surgery department in immediate and delayed breast reconstruction, the objective of this article is to describe and to analyze the possible complications of breast reconstruction by a flap and their surgical management in intra and post operatively. Our goal is to provide an algorithm for our young colleagues in order to obtain better understanding of this type of interventions difficulties and to provide an appropriate care in the event of complication, also to provide optimal care to the patients who wish to undergo autologous flap reconstructions.

Contribution of 3D printing to mandibular reconstruction after cancer.

Three-dimensional (3D) printing is booming in the medical field. This technology increases the possibilities of personalized treatment for patients, while lowering manufacturing costs. To facilitate mandibular reconstruction with fibula free flap, some companies propose cutting guides obtained by CT-guided moulding. However, these guides are prohibitively expensive (€2,000 to €6,000). Based on a partnership with the CNRS, engineering students and a biomedical company, the authors have developed cutting guides and 3D-printed mandible templates, deliverable in 7days and at a lower cost. The novelty of this project is the speed of product development at a significantly lower price. In this technical note, the authors describe the logistic chain of production of mandible templates and cutting guides, as well as the results obtained. The goal is to allow access to this technology to all patients in the near future.

[Morbidity of bodylift. Evaluation of 111 patients over 5 years]. / Morbidité de la dermolipectomie abdominale circulaire. Série rétrospective de 111 patients sur 5 ans.

INTRODUCTION: The management of patients with weight loss sequelae, sometimes major, is increasingly well standardized. However, this surgery is not without risk. Complications of bodylift are more frequent than those of conventional abdominoplasties. The objective of this study was to evaluate the morbidity associated with this surgery through a retrospective, single-center study. MATERIALS AND METHODS: One hundred and eleven circular abdominaloplasties were conducted between June 2011 and September 2015 in the plastic surgery department of the university hospital of Toulouse. Minor and major complications were identified and analyzed. RESULTS: Frequency of postoperative complications was 44.1% in our series. Major complications have involved 15.3% of patients. Blood transfusions (9%) and hematoma requiring reoperation (7.2%) were the most frequent major complications. We found significantly more major complications in patients with important fat resection with a cut off at 3200 g (P=0.02). Men experienced significantly more major complications than women (P=0.005). The average delta-BMI (before and after weight loss) was significantly higher in the group of patients with the highest percentage of minor complications (P=0.045). Indeed, a high delta-BMI (greater than 19.5) was associated with an excess risk of minor complications in our population. CONCLUSION: Democratization and progress in the field of bodylift should not obscure the fact that it is, in reality, a procedure at risk. While we manage increasingly better cosmetic results and thromboembolic complications, it still persists many complications.

The latest information on Macrolane™: its indications and restrictions.

INTRODUCTION: Hyaluronic acid has come to represent the most widely used injectable cosmetic product in the world. Brought into being by the Swedish company Q-Med, in 2007 Macrolane™ was authorized for use in France, and the year after, it received official European approval as a means of breast augmentation. Since then, however, numerous controversies pertaining to its side effects have led to its withdrawal from the worldwide breast augmentation market. The objective of this article is to carry out a review of the literature providing updated information on Macrolane™ and its recent indications. MATERIALS AND METHODS: We carried out a review of the literature on the PubMed and PubMed Central data bases through use of the keywords "Macrolane™", "NASHA", "hyaluronic acid" and "soft filler", and subsequently analyzed the levels of evidence and possible biases of the different publications. The official sites of the French, English, Spanish and American scholarly organizations of plastic surgery were likewise consulted. Perusal of the notifications and recommendations for use brought out by the Q-Med company completed our study. RESULTS: A large majority of the available clinical series on Macrolane™ with regard to not only breast augmentation, but also its other indications, offer an insufficient level of evidence and present a number of conflicts of interest. Since April 2012 Macrolane™ has been temporarily withdrawn by its distributors from the worldwide breast augmentation market. In point of fact, Macrolane™ injections have been found to interfere with breast imaging and screening for breast cancer. As regards the latest indications for this controversial product, it is not yet possible to step back and take stock. CONCLUSIONS: Present-day scientific data fail to justify the market reappearance of Macrolane™ breast augmentation products. Q-Med has shown full awareness of the problem by imposing worldwide restrictions on products aimed at penis as well as breast enlargement. Larger cohorts of female patients are more necessary than ever, as is an approach based on stepping back and taking stock.

Dermatofibrosarcoma protuberans: margins reduction using slow-Mohs micrographic surgery. Experience with 35 patients.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a potentially malignant dermal mesenchymal tumour with a high risk of local recurrence. DFSP presents a sprawling appearance whose complete excision requires important margins. DFSP was initially resected with a 5cm excision margins, and more recently 3cm then 2cm margins were recommended. Mohs micrographic surgery (MMS) helps reduce these margins thanks to a 3-dimensional excision around the tumour, which is analysed in its entirety. We used the modified MMS called slow-MMS and tried every time it was possible to perform direct closure. METHODS: Thirty-five patients presenting a DFSP between 2004 and 2013 within the Plastic Surgery unit at Claudius Regaud Institute were included in this retrospective study. The patients were treated with slow-MMS using paraffin-embedded sections. RESULTS: One surgery was necessary for 72% of patients. For 17%, we had to perform a second surgery, and for 11% a third one. Our median clinical excision margins was 17mm (range 9.0:30.0). After a median follow-up of 46 months (range 35.2:60.2), we didn't observe any recurrence. Only one case required a local flap; for the others, the loss of substance was resolved with a direct closure. CONCLUSION: Slow-MMS enabled a local control of the margins without recurrence at 46 months in our series. Besides, it helps performing smaller margins than wide excision and thus preserving the tissues. In our opinion, this is the treatment of choice regarding DFSP for which tissue sparing is essential. It seems particularly appropriate near functional areas or on the face.

[Histological techniques in oncodermatology]. / L'apport des techniques anatomopathologiques en oncodermatologie.

The skin oncology or "oncodermatology" requires a surgical treatment in most cases. For some surgeons, the oncodermatology takes a very important part of their practice. In the course of diagnostic and therapeutic of skin lesions, the pathologist plays now an essential role. He will guide our surgery. The techniques used by this specialist are numerous. Therefore, the objective of this paper is to review the different histological methods used to improve our management of skin tumors.

[Giant abdomino-pubic melanoma. A case report]. / Mélanome géant abdomino-pubien. À propos d'une observation clinique.

Cutaneous melanoma patients are usually young adults. The evolution into a nodular form darkens the prognosis because it increases the risk of metastasis occurrence. The only curative treatment is wide surgical excision when extension check is negative. We report a case of abdomino-pubic melanoma original by its amazing size, its spreading, both superficial and nodular, without metastasis, and its late occurrence to a senior patient. Curative management was performed with a plastic surgery technique: the abdominal plasty. The melanoma was removed with free margins and the patient was free of disease at six month. This report illustrates the interest of plastic surgery techniques in oncology. It also confirms that plastic surgeon forms an integral part of a multidisciplinary team managing patients with cutaneous melanoma.

[About a simple method to prevent accidents caused by changes in positioning in surgery: The transparent head drape]. / Le champ de tête transparent. Un moyen simple de prévention des accidents liés au changement d'installation en chirurgie plastique.

Surgical drapes are a physical barrier between the surgical team's sterile working space (the operating field) and the non-sterile environment of the anaesthesia team and the nursing team within the operating theatre. Once the patient's position has been checked and the skin preparation has been done, they are put in place. They are usually opaque, leaving visible just the areas where the surgical and anaesthesia teams will be working. When the patient's position is changed perioperatively, malpositions may be unnoticed and cause complications. Using a transparent head drape allows one to check the position of the head and upper limbs at all times, thus reducing the risk of complications. It is a simple, easy, economic, non-restrictive method which will produce an improvement in the quality of patient care.

[Addition of antithrombosis in situ in the case of digital replantation: preliminary prospective study of 13 cases]. / Adjonction d'antithrombotiques in situ en cas de replantation digitale: étude prospective préliminaire de 13 cas.

Antithrombotic agents are not routinely used in microsurgery for finger replantation. A prospective monocentric study of 13 cases of replantation at hand level is reported with local irrigation of anastomosis with urokinase and low-molecular-weight heparin. Thirteen consecutive patients have been included and treated in the first six hours by three senior surgeons in microsurgery. The injuries consisted in one devascularisation of hand, two complete amputations of hand, four ring fingers and six complete amputations of finger. Crush injury was always pointed in case of amputation. During anastomoses, the arterial lumina were topically irrigated with 50,000 UI of urokinase and the venous lumina by 1.2 ml of Lovenox®. Bleeding was encouraged in case of digit replantation. In all cases, patients received Aspegic® 10mg/day and Fonzylane® three times per day for three weeks. Three failures have been reported and blood transfusion was necessary in one patient. The results showed that topical irrigation with urokinase and low-molecular-weight heparin or enoxaparin solution significantly reduced the thrombosis rate at the anastomosis site of the crushed arteries in clinical practice without uncontrolled adverse effect.