[Patient-reported outcome of their breast reconstruction after mastectomy]. / Évaluation de la satisfaction des patientes de leur reconstruction mammaire après mammectomie.

BACKGROUND: The overall care of patients with breast cancer is a major public health issue. Breast reconstruction is a part of it, and could be modulated by factors related to their personal life or surgical management. The aim of our study was to investigate a statistical link between these factors of variability, and overall satisfaction after breast reconstruction. PATIENTS AND METHODS: We evaluated in a retrospective study patients' satisfaction in Plastic, Reconstructive and Aesthetic Surgery Department of the University Hospital, Poitiers, after breast reconstruction using different sources of variability: elements of life at the moment of reconstruction decision, reconstruction management and the feeling of involvement in decisions related to reconstruction. Satisfaction was quantified by modified BREAST-Q pre- and postoperative questionnaires ("reconstruction" module) complemented by an open question to address patients experience. RESULTS: From January 2005 to May 2011, 148 patients underwent surgery, 60.1% accepted to complete the survey (89 patients). Postoperative overall satisfaction was 89.1 out of 100. Satisfaction gradually decreased (P=0.022), postoperative overall satisfaction was non-significantly higher with autologous reconstruction, regardless of the variability factor studied. Secondary reconstruction with autologous reconstruction enhanced physical well-being (P<0.001). Patients expressed a high request for information about the different kinds of reconstruction, postoperative, as well as support groups. CONCLUSION: This study shows that patients are generally very satisfied, but do not explain the causes of dissatisfaction. It paves the way for development of satisfaction with breast reconstruction databases.

[Cheek reconstruction]. / Reconstruction jugale.

We describe the different cheek reconstruction techniques with primary emphasis on the superficial layers. In addition to the clinical context, location and size of the lesion will be taken into account to choose the best method that will optimize the functional and aesthetic results while minimizing potential sequelae. Main evaluation criteria include absence of natural orifice deformation, scar location, skin cover quality and respect of volumes.

[Post-traumatic reconstruction of the lower lip after total or subtotal amputation using the Webster's modification of the Bernard cheiloplasty -- advantages, disadvantages and limitations: three cases]. / Reconstruction post-traumatique de la lèvre inférieure après amputation totale ou subtotale selon la technique de Camille-Bernard modifiée Webster - avantages, inconvénients, limites : à propos de trois cas.

Webster's modification of the Bernard cheiloplasty is a well-known technique, usually applied to the reconstruction of total or subtotal amputations of the lower lip following oncological resection. We present three cases of post-traumatic reconstructions with interesting results.

[Eyelid, medial canthus and medial orbital wall reconstruction using a combination of Hübner and conchal grafts with two illustrative cases]. / Reconstruction par greffons de Hübner et conque après exérèse étendue palpébro-cantho-orbitaire médiale - Présentation de deux cas.

Post-ablative medial canthus and medial orbital wall reconstruction may involve various materials. Few articles present such reconstructions using cartilage homografts, and very few opt for conchal cartilage. In some cases of medial orbital wall excision, at least half of the eyelid must also be removed. We present two cases where we decided to use conchal cartilage to reconstruct the medial orbital wall and tarsomarginal Hübner grafts to reconstruct the eyelid. This combination offers several advantages: a very limited resorption, only one operative field and a reduced infection risk.

[Importance of thorough removal of all affected tissues before grafting epidermolysis bullosa lesions: ten-year follow-up of one patient with multiple grafts]. / Nécessité d'une exérèse complète des tissus lésés dans les épidermolyses bulleuses : suivi sur dix ans d'une patiente multigreffée.

We present the case of a patient suffering from dominantly inherited dystrophic epidermolysis bullosa and followed over a period of ten years. Skin lesions of this patient have been treated with multiple thin skin grafts applied over Integra®. The experience proved that, in order to have a perfect graft take, it was necessary to remove all the affected tissues, which includes an abnormally thickened dermis, and also a portion of the subcutaneous tissue.

Simplified scaphoid reconstruction technique with Zaidemberg's vascularized radial graft.

For more than 10 years, we have been using a simplified reconstruction technique for scaphoid non-unions that involves the use of a graft first described by Zaidemberg et al. [1]. This approach requires that an island bone graft harvested from the radial styloid and pedicled on the 1,2-intercompartmental supraretinacular artery be embedded into the site of the non-union. The objective of our technical modifications was to simplify the harvesting and handling of the graft and the internal fixation. This technique is only used for cases of scaphoid non-union with avascular changes in the proximal fragment, repeated non-union after bone grafting and internal fixation, chronic non-union with osteophyte formation in the dorso-radial aspect and fracture secondary to Preiser disease.

[Gorlin syndrome: photodynamic therapy, as a useful adjunct to surgery]. / Syndrome de Gorlin : la photothérapie dynamique, technique complémentaire du traitement chirurgical.

Gorlin syndrome, also called nevoid basal cell carcinoma syndrome, is well known by dermatologists. Since its onset, 10 years ago, photodynamic therapy has found new applications and is now currently used to cure single or multiple basal cell carcinomas, with good results and without residual scars. We recall some of the basic principles of this technique, as well as its indications in Gorlin syndrome, which we illustrate with one case. Plastic surgeons must consider this relatively new technique, developed by dermatologists, as a useful adjunct to surgery in the management of Gorlin syndrome.

[Laparoscopy coupled with classical abdominoplasty in 10 cases of large rectus diastasis]. / Couplage cœlioscopie-abdominoplastie dans dix cas d'important diastasis des grands droits.

UNLABELLED: In 10 cases of abdominoplasty where an important rectus diastasis had to be corrected, we completed the plication of the rectus sheath included in a classical abdominoplasty with the laparoscopic positioning of an intraperitoneal prosthesis. PURPOSE: To assess the middle-term results of this technique and present its advantages and drawbacks. PATIENTS AND METHOD: Fifteen patients have been operated from 2007 to 2011 by two surgeon teams. Ten of them have accepted to be included in our survey. RESULTS: All the patients said they were satisfied with their surgery. Four of them reported mild pain during the first postoperative weeks, and two of them mentioned very moderate pain at the time of the survey. The surgeons were not satisfied with the results obtained in two cases. Only one of these two patients accepted revision abdominoplasty with a good result. CONCLUSION: Laparoscopic positioning of an intraperitoneal prosthesis, coupled with a classical plication of the rectus sheath, gives excellent results in difficult cases of rectus diastasis.

[Eyelid reconstruction according to Hübner's technique: About the use of 12 tarsomarginal grafts]. / Reconstruction palpébrale selon la technique de Hübner : à propos de l'utilisation de 12 greffons tarsomarginaux.

PURPOSE: The repair of full-thickness eyelid defect must fulfill multiple surgical requirements that are determined by the anatomical and functional features of the eyelids. Many reconstructive procedures are available, each and anyone of them presenting their own peculiar goals and constraints. Among them, we have tried to determine the place and the reliability of Hübner's tarsomarginal grafts. PATIENTS AND METHOD: Through a retrospective study of 11 patients treated with 12 grafts, over a period of 3 years, we evaluated our indications, technical principles and results of this procedure. RESULTS: The full-thickness eyelid defects represented between one quarter and three quarter of the marginal border length. They principally resulted from malignant tumors resection. In most of the cases, their management required a single graft, harvested on the contralateral homologous eyelid. Complications were minor and rare. Functional and aesthetical results were satisfactory. There was no functional sequel on the donor site. CONCLUSION: Tarsomarginal grafts in eyelid reconstruction provide multiple advantages. With this simple and versatile technique, wide and complex eyelid repairs can be managed in a one-step surgery. This procedure is very reliable; it gives good functional and aesthetical results. Hübner's technique is a major tool in eyelid reconstructive surgery.

A role for T cell-derived interleukin 22 in psoriatic skin inflammation.

Interleukin (IL)-22 is a T cell-derived cytokine that has been reported recently to induce cutaneous inflammation in an experimental murine model of psoriasis, and to induce in vitro an inflammatory-like phenotype. In the present study, we assessed the presence of IL-22 and the IL-22 receptor 1 (IL-22R1) in skin lesions, skin-derived T cells, as well as IL-22 levels in sera from patients with psoriasis. IL-22R1 and IL-10R2 transcripts are expressed at a similar level in psoriatic and healthy skin. In contrast, IL-22 mRNA expression was up-regulated in psoriatic skin lesions compared to normal skin, whereas IL-22 mRNA levels in peripheral blood mononuclear cells from psoriatic patients and normal subjects were similar. Circulating IL-22 levels were significantly higher in psoriatic patients than in normal subjects. T cells isolated from psoriatic skin produced higher levels of IL-22 in comparison to peripheral T cells isolated from the same patients. IL-10 was expressed at similar levels in skin biopsies and peripheral blood mononuclear cells of psoriatic patients and normal subjects. Finally, we show here that supernatants of lesional psoriatic skin-infiltrating T cells induce an inflammatory response by normal human epidermal keratinocytes, resembling that observed in psoriatic lesions. Taken together, the results reported in this study indicate that IL-22 is a cytokine produced by skin-infiltrating lymphocytes that is potentially involved in initiation and/or maintenance of the pathogenesis of psoriasis.

[The reversed dermis flap soon to be forgotten as a major filler?]. / Le "reversed dermis flap" bientôt détrôné comme lambeau de comblement?

In his paper entitled "The reversed dermis flap" published in 1978, Pakiam explained the advantages of de-epithelialising local flaps and applying them dermis-side down. We present a ten-year series of 107-reversed dermis flaps used to raise depressed scars. There have been no significant complications in this series except two cases of infection and six cases of postoperative haematoma. All patients were satisfied with the cosmetic outcome. We do not use this flap as much as we used to since Coleman demonstrated how efficient lipostructure could be especially when applied to thin depressed scars. The reversed dermis flap remains invaluable in cases of widespread scars or when lipostructure is dangerous or impossible.

A retrospective review of 20 hypertensive leg ulcers treated with mesh skin grafts.

BACKGROUND: Few articles have been published about hypertensive leg ulcers and their surgical treatment. Since mid of the year 2000, it has been our policy to treat all hypertensive leg ulcers very early with mesh split-thickness skin grafts. The present series consists of 15 patients whose hypertensive leg ulcers, including five bilateral cases, were treated with 20 mesh grafts from 2000 to 2002. SUBJECTS AND METHODS: All patients, nine women and six men, had a long history of hypertension. The same surgical procedure was applied to all 15 patients: a complete mechanical debridement of all necrotic tissues, immediately followed by mesh skin grafting. RESULTS: Patients were discharged from the hospital after an average post-operative period of 16 days. Upon leaving the hospital, the patients had lesions completely healed in 14 of 20 cases. The graft take had been complete after an average period of 14 days. In six cases, one or two very small patches of skin graft had necrosed and complete healing required an additional period of 1 to 3 months. In all 20 cases, pain had disappeared within 1 week from surgery. DISCUSSION: All patients were on opioid therapy before surgery. With medical treatment only, hypertensive leg ulcers used to heal after a mean period of 15 months. After surgery, the average healing period was 2 weeks and opioids were stopped within 1 month after surgery. CONCLUSION: The review of the present series shows that early mesh grafting of hypertensive leg ulcers is beneficial, because healing is very quick and the pain will disappear quasi-instantly.

[Four-layer laryngotracheoplasty to repair an anterior tracheal wall defect induced by a Montgomery T-tube]. / Réparation par laryngotrachéoplastie cutanéochondromyocutanée d'une perte de substance trachéale antérieure induite par un tube de Montgomery.

A 37-year old patient was referred in 2000 for reconstruction of the anterior tracheal wall eroded by a Montgomery T-tube. A four-layer laryngotracheoplasty was proposed to the patient. The endotracheal plane was reconstructed by a bilateral random pattern quadrangular skin hinge flap raised from both sides of the defect. The chondral plane was realized with conchal cartilage. This cartilage graft was covered with an inferiorly based sternocleidomastoid flap. The fourth layer was a mesh split-thickness skin graft. Satisfactory and lasting results were observed during a three-year follow-up. Few articles deal specifically with tracheal reconstruction after anterior wall erosion induced by a Montgomery-T tube. We found no mention of the described four-layer flap in the literature.

Seven reconstructions of the orbital and periorbital region with a contralateral orbitonasolabial flap.

Blasius designed the first orbitonasolabial flap in 1842, which has since, been reshaped by many other surgeons. Three years ago, we were confronted with a difficult reconstructive case where ipsilateral local flaps were insufficient to cover a huge defect of the periorbital region. We performed 11 cadaver dissections to determine the type of vascularisation of the orbitonasolabial flap and to define its arc of rotation prior to contralateral use. This contralateral orbitonasolabial flap was subsequently applied to seven cases with satisfactory results.

Post-ablative reconstruction of the medial canthus and medial orbital wall using conchal cartilage graft with three illustrative cases.

When the medial third of the upper or lower eyelid has to be reconstructed after full-thickness tumour excision, we usually use Hübner tarsomarginal grafts, but when medial canthal lesions spread to the medial orbital wall without invading the orbital margin, conchal graft becomes our first surgical option. Previously reported solutions to this difficult problem are few and concern more directly medial orbital wall fractures. We found no article dealing specifically with the use of conchal graft in post-ablative reconstruction of the medial orbital wall. Nevertheless the concha presents great advantages over bone grafting or rib cartilage, because it is more flexible and malleable. And it is less prone to extrusion or infection as may be allografts implants. It is a very effective way to repair medial orbital defects, but graft reorientation must be perfect to match exactly the medial orbital wall concavity.

Allergic contact dermatitis from natural rubber latex in atopic dermatitis and the risk of later Type I allergy.

The aims of the study were to assess whether contact dermatitis in children could be due to a delayed hypersensitivity reaction to natural rubber latex (NRL) and to define risk factors for later occurrence of Type I hypersensitivity to this allergen. Among 1800 children investigated for contact dermatitis, 55 were referred on suspicion of rubber allergy and had patch tests to NRL, as well as prick tests and blood tests for specific immunoglobulin E (IgE). A 2-year follow-up was then carried out. Delayed hypersensitivity to NRL was confirmed in 32 children. Patch testing with NRL proved to be positive, and clinical improvement confirmed the diagnosis and relevance of patch tests. 30 of these 32 patients had associated atopic dermatitis (AD). Prick tests and blood tests for specific IgE to latex were negative at the time of diagnosis. A 2-year follow-up showed that 10 of 27 patients presenting initially with a positive patch test without associated Type I sensitization later developed immediate hypersensitivity. Children with AD are at high risk for allergy to NRL protein. Exclusion of this allergen should be strongly advised in atopics because of the dual risk of dermatitis and later evolution into severe Type I hypersensitivity.

[A tailor-made flap for an extremely severe case of hidradenitis suppurativa in the genital area]. / Un lambeau sur mesure dans un cas évolué de maladie de Verneuil s'étendant à la région génitale.

Hidradenitis suppurativa is a chronic, suppurative and scarring disease characterized by painful, inflamed lesions in the axillae, perineum, groin, scrotum and other parts of the body with apocrine-bearing skin including genital skin. Appropriate medical treatment alone appears to be insufficient for managing most patients with severe lesions. In the vast majority of cases, surgery consists in complete excision of the lesions with primary closure or healing by secondary intention. In severe cases, radical excision of all diseased apocrine-bearing skin is mandatory and the resulting defects are generally repaired by mesh skin grafts. In the most severe cases it may be necessary to realize loco-regional flaps. Generally we reconstruct the perineal region with bilateral fasciocutaneous thigh flaps. We report a case of hidradenitis suppurativa where the lesions were so extensive from penis to anus we had to imagine a tailor-made flap based on the abdominoplasty techniques.

Aesthetic surgery techniques after excision of dermatofibrosarcoma protuberans: a case report.

Dermatofibrosarcomata protuberans are rare locally aggressive tumours that have a very high recurrence rate in the absence of wide resection. Normally, when the area to be covered is exceptionally large or when skin grafting is not possible because of the location, pedicle or free flaps are used. We report one case of wide excision where the opportunity arose to apply aesthetic surgery techniques combining bilateral superiorly based mammaplasty and reverse abdominoplasty.

[Reorientation of the distal radial articular surface in Madelung's deformity by a reversed cuneiform osteotomy]. / Réorientation de la glène radiale dans la déformation de Madelung par ostéotomie cunéiforme avec retournement.

A technique of cuneiform osteotomy of the distal end of the radius is presented. It was used in three female patients with Madelung's deformity (two bilateral cases and one unilateral case). A wedge of bone was harvested in situ from the metaphysis, then returned and replaced in situ. This technique, performed through the Henry's approach, combines closing wedge osteotomy on the longer radial cortices with opening wedge osteotomy on the shorter radial cortices. The biplane osteotomy, which provides the bony wedge, involves the entire width of the metaphysis and is performed with an oscillating saw. Once the wedge is reversed and replaced, stabilization is obtained with an anterior plate. In all five cases the forward subluxation of the carpus was reduced as well as the distal radioulnar dislocation through the backward projection of the epiphysis. The reversed cuneiform osteotomy brings new possibilities of reorienting the radial articular surface and its technical mastery allows for accurate correction of severe deformities.