[Self-assessment of healthcare workers regarding the management of trans people in a university hospital]. / Auto-évaluation de professionnels de santé concernant la prise en charge des personnes trans dans un hôpital universitaire.

INTRODUCTION: Trans people face more barriers when seeking healthcare than the cisgender population probably due to a lack of knowledge, education and comfort of healthcare workers. The purpose of this study was to assess the knowledge and comfort felt by healthcare professionals in managing trans people in a French university hospital. METHODS: A self-questionnaire was emailed to healthcare professionals working in departments usually involved in the care of trans people in a French university hospital "not specialized" in medical and surgical gender transition. The questionnaire included demographic questions and Likert scales regarding their knowledge and comfort in taking care of trans people. Responses on the 7-point Likert scales were categorized into "low", "medium" and "high" groups, and responses on the 5-point Likert scales were categorized into "in favour", "neutral" and "against" groups. RESULTS: One hundred and two (29%) healthcare professionals answered the questionnaire. Half worked in surgical departments (urology, plastic surgery, gynecology), 24% worked in medical departments (endocrinology, reproductive medicine, cytogenetics) and 26% worked in psychiatry. The majority (60.3%) rated their level of knowledge as "low" and 39.7% as "medium". Sixteen percent rated their level of comfort in managing trans people as "low", 72.5% as "medium" and 11.5% as "high". A majority (77.5%) were in favor of having the costs of gender transition care covered by the national health insurance system, 16.4% were neutral and 6% were against this idea. Feelings about surgical and hormonal gender transition were overwhelmingly (96.4%) in favour or neutral and 91% were willing to get more training and education to manage trans people. CONCLUSION: The lack of comfort felt by healthcare professionals in university hospital in managing trans people seems to be related to a lack of knowledge and training in that field and not to a disagreement with the need of transgender healthcare. LEVEL OF EVIDENCE: 3.

Upper body lift and breast reshaping with lateral chest wall perforator propeller flap following massive weight loss.

BACKGROUND: After massive weight loss (MWL), female patients often develop upper trunk laxity and severe breast deformities. Usually several procedures are required to address upper body contouring issues. OBJECTIVES: To achieve better breasts and improve upper body contour, the authors employed a combined approach, associating lateral chest wall perforator propeller flaps with an upper bodylift (UBL). METHODS: Between September 2015 and March 2017, nine post-bariatric patients underwent simultaneously an UBL and autologous augmentation breast reshaping with lateral chest wall perforator propeller flaps. The authors analyzed the clinical indications, results and complications of this procedure. RESULTS: Eighteen lateral perforator propeller flaps for autologous breast augmentation-mastopexy associated with an UBL were performed successfully. Mean pre-MWL body mass index (BMI) was 54.3±10.9kg/m2, with a mean preoperative pre-UBL BMI of 28.7±3.6kg/m2. The average weight loss before surgery was 67.7±22.4kg. The flaps were harvested on intercostal and/or lateral thoracic arteries. All donor sites had been closed primarily. Following the classification of Dindo and Clavien, four minor complications (I, II), and two major complications (IIIb), including two hematomas requiring reoperation, were reported. No flap necrosis occurred. Follow-up averaged 27.9±8.4months. The patients' satisfaction with their improved breast shapes and chest wall contours was "good", with an aesthetic outcome mean ranked 3.8±0.8 (out of 5). CONCLUSIONS: After MWL, upper body deformities can be treated safely and reliably by a combined approach, associating an UBL and autologous lateral chest wall perforator flaps to provide more natural and durable breast shapes, as well as an upper circumferential reshaping.

Recent advances in trigonocephaly.

INTRODUCTION: The aim of this review was to report on recent advances in trigonocephaly since the last report on craniosynostosis published in 2006. MATERIAL AND METHODS: The review was conducted in accordance with the PRISMA guidelines. Research focused on four main topics: epidemiology, neurodevelopmental disorders, genetics and surgical techniques. RESULTS: Forty reports were included. The prevalence of trigonocephaly increased during the last two decades both in Europe and in the United States, but no clear contributing factors have yet been identified. Neurodevelopmental disorders are frequent in syndromic trigonocephaly and not particularly rare in non-syndromic cases (up to 34%). Developmental retardation (speech, motor or global) was almost always present in children exposed to valproic acid. Chromosomal abnormalities described in metopic synostosis comprised deletion of chromosome 11q24, deletion or trisomy of 9p and deletion of 7p, deletions of 3q, 13q, 12pter, 22q11, and duplication of 15q25. SMAD6 mutations should be systematically screened for in familial cases. Recent advances in surgical techniques have mainly concerned endoscopic-assisted procedures, as they significantly reduce perioperative morbidity. CONCLUSIONS: Neurosurgeons, maxillofacial and plastic surgeons will be increasingly concerned with trigonocephaly because of the increase in prevalence observed over the last two decades. Cytogenetic alterations are probably underestimated in this craniosynostosis, considering the high rate of neurodevelopmental retardation compared to other single-suture synostoses. Genetic counselling is therefore more and more effective in this pathology. An objective method to evaluate the cosmetic results of both endoscopic and open surgeries is necessary, as some under-corrections have been reported with minimally invasive surgery.

Surgical management of subcutaneous fat necrosis of the newborn required due to a lack of improvement: a very rare case.

Subcutaneous fat necrosis of the newborn (ScFN) is an uncommon and transient disease characterized by defined areas of fat necrosis and overlying cutaneous nodule lesions. It usually becomes apparent within the first 6 weeks of life in full-term or post-term infants. It is caused by generalized and/or local tissue hypoperfusion. The skin lesions of ScFN tend generally to improve spontaneously in a few weeks. We present a full-term newborn with birth distress. After therapeutic hypothermia, she presented voluminous and numerous subcutaneous fat necrosis with extensive calcifications. Surgical management was decided at her ninth month because of a total lack of regression. Hypercalcaemia, the most threatening complication, appeared only after this delayed surgery.

Knee dermolipectomy: a simple operation with significant functional improvement.

BACKGROUND: Obesity is a major public health problem in Western societies. It may lead to difficulties in daily life that have an impact on quality of life and create psychological disorders. After failure of diet and exercise, patients can undergo bariatric surgery, but some obese patients are not motivated to undergo a bariatric procedure. For such patients, plastic surgeons can correct some excess fat to improve their quality of life. This report describes an original technique for correcting the excess fat at the medial part of the knees to regain a normal walking perimeter. METHODS: A 68-year-old woman was admitted to the authors' center for correction of a functional walking disorder. Indeed, her clinical examination found a static disorder, with a valgus knee morphotype related to a major excess of skin and fat in the medial part of the knees. She underwent a knee dermolipectomy to obtain a solely functional result. RESULTS: No complications were observed in the woman's postoperative course. At this writing, the result is stable 18 months after the surgical procedure, with a minimal visible scar hidden in the internal face of the knees. The woman has experienced a loss of her genu valgum and regained a walking distance longer than 1 km. She also has lost 10 kg of weight. CONCLUSIONS: Knee dermolipectomy is a simple procedure with good results and few complications that improves the quality of life for obese patients. 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 .

Large necrosis: a rare complication of medial thighplasty.

Obesity is a major public health problem in Western societies. After failure of diet and exercise, patients can have bariatric surgery. Weight loss causes excess skin on the body, including the thighs. This leads to difficulty walking and psychological disorders such as devalued self-image. Medial thighplasty is an intervention to reduce excess skin and fat in the thighs. The main complications are scar migration, scar infection, hematoma, lymphedema, gaping vulva, and, rarely, skin necrosis. We describe a case of flap necrosis after a reoperation of medial thighplasty. Treatment included debridement of necrotic tissue and healing of the wound by secondary intention (vacuum-assisted closure and dressings with calcium alginate). Complete healing was achieved in 4 months. As the patient refused any new procedure, skin grafting was not performed. The aesthetic results of plastic surgery procedures are often imperfect. Patients should be clearly prepared and informed about the results expected from the operation. Surgeons should know contraindications for reoperation.

[Surgical excision of giant congenital naevi: how far can we go with surgery?]. / Exérèse des nævus congénitaux géants : jusqu'où aller avec la chirurgie ?

Surgical excision of giant congenital nevi is recommended by principle for dermatological reasons. Malignant potential is real but its incidence remains widely discussed. Their excision represents a surgical challenge but is also a real assault course for the child and his family. The sequelae and the psychological effects can be important. Can an incomplete excision to limit these aesthetic after-effects and relieve the surgical treatment be acceptable? We present the case of a child affected by a giant congenital nevi of the cephalic extremity where the excision was partial. A review of the literature on the degenerative risk of the giant congenital nevi allowed us of noticed that this one tends to be overestimated. The advantages and the disadvantages to practise a preventive, premature excision and complete of the giant congenital nevi are approached. We discuss the possibility to resort to a partial excision in certain cases delicate of reconstruction under the cover of a strict and moved closer dermatological surveillance.

[Leech-borne infection on a TRAM flap: a case report]. / Complication infectieuse d'un lambeau de TRAM liée aux sangsues: à propos d'un cas.

Leeches are used worldwide to treat venous congestion of flaps. Aeromonas hydrophila infections are recognized complications of leech use. We report a new case of delayed leech-borne infection in mammary reconstruction by a Transverse Rectus Abdominis Myocutaneous flap (TRAM), which caused the flap loss. The use of prophylactic antibiotics is a way to prevent A.hydrophila infection (third generation cephalosporin, ciprofloxacin). This antibioprophylaxy must be followed until wound closure of the venous congested tissue.

[Refinements in the labia minor reduction procedures]. / Mise au point sur les techniques de nymphoplastie de réduction.

AIM: The aim of this study is to appreciate the hypertrophy of labia minor, its psychological and functional effects and the different techniques of reduction available. PATIENTS AND METHODS: From August 2004 to June 2007, 14 patients have been operated with a posterior wedge resection technique associated with a Z plasty. A questionnaire has been sent to each patient in order to make a retrospective study of the different reasons of consultation and their degree of satisfaction after surgery. RESULTS: Among the 12 patients who answered the questionnaire, main part of them was satisfied or very satisfied of the morphologic and functional results. All of them were satisfied to have decided on this surgery. DISCUSSION: We can notice an increase of the requests concerning the vulvar morphologic changing, either due to aesthetics preoccupations or functional disorders. Technically, the wedge resection brings the most satisfactory results. The addition of a Z plasty and the posterior location of the scar should prevent dyspareunia and per-partum tears. CONCLUSION: This preliminary clinical study focuses on the different techniques, enables a better knowledge of these women expectations and confirms our technique.

[Pyoderma gangrenosum and breast cancer: a case report]. / Pyoderma gangrenosum et cancer du sein : à propos d'un cas.

The authors report a case of pyoderma gangrenosum (PG) following a breast lumpectomy for a relapse of a breast cancer. The treatment has associated a systemic corticosteroid therapy and local wound care with vacuum assisted closure Vacuum-Assisted Closure and skin graft.

[Contribution to the detection of Melan-A/Mart-1 specific CD8+ T cells in surgery of melanoma. Preliminary study]. / Apport de la détection de l'activité des lymphocytes T cytotoxiques dirigés contre l'antigène Mélan-A/Mart-1 dans la chirurgie du mélanome malin cutané. Etude préliminaire.

Melanoma treatment is based on surgery. In metastatic cases, vaccine therapy has been recently developed to overcome T cell or dendritic cell dysfunction. HLA tetramerbased assays are useful for immunologic monitoring of this trial and to quantitate CD8+ specific lymphocytes. In the present work, we used tetrameric technology to detect expanded populations of tumor specific CD8+ Tcells specific of Melan-A/Mart-1 Antigen have been quantified using flow cytometry. The feasibility of routinely detection of 0,1% +/- 0,03 of CD8 T cells has been demonstrated, without any difference the levels observed before and after (day 30) surgery. The value of experimentation of these cells should be determined in clinic and particularly to analyze surgical practice.

Breast feeding after reduction mammaplasty performed during adolescence.

UNLABELLED: Reduction mammaplasty (RM) can be performed during adolescence if the functional capacity of the breast is preserved. Future breast feeding must be carefully considered in the therapeutic decision making process. PURPOSE OF THE STUDY: Breast feeding after reduction mammaplasty performed during adolescence was assessed to determine surgical factors influencing outcome and patient reception of information concerning breast feeding. METHODS: A questionnaire was sent to 109 women who had undergone reduction mammaplasty between 1981 and 1997 when they were 15-17 years old to ascertain their reasons for having surgery, their satisfaction, and their attitude towards breast feeding. RESULTS: Sixty-five questionnaires (60%) could be analyzed. Mean delay since surgery was 8.1 years. Seventeen women (26%) had delivered 25 infants (mean 1.5). Mean delay after surgery to first delivery was 7.68 years. Five women (29%) nursed their first infant for a mean 11.3 days. None of the women interrupted breast feeding for a reason related to a nipple anomaly or difficult sucking. Twelve women (71%) did not nurse their first infant, because of the prior breast surgery for six of them. Among the 48 nulliparous women, 24 (50%) stated they would nurse their future infant. Although information on breast feeding was systematically delivered, 41 women (63%) stated they had not been informed. There was no statistical relationship between breast feeding and degree of satisfaction, patient-assessed scar quality, or nipple disorders. CONCLUSION: Adolescents who undergo reduction mammaplasty can nurse their future infants with a complication rate similar to that in the general population. Special attention must be given to delivery of information on breast feeding.

[Endarteriectomy of the femoral tripod: long-term results and analysis of failure factors]. / Endartériectomie du trépied fémoral: résultats à long terme et analyse des facteurs d'échec.

STUDY AIM: The aim of this retrospective study was to report immediate and long term results of endarteriectomies of the common femoral artery (CFA) and/or femoral tripod and to analyse predictive factors of failure. PATIENTS AND METHODS: Between 1982 and 1995, 110 endarteriectomies were performed in 101 patients, 52% of them in limb salvage situation. The arteriogram showed a thrombosis or stenosis of the common femoral artery in 100% of cases. There was a stenosis of the deep femoral artery (DFA) in 79% of cases. The superficial femoral artery (SFA) was thrombosed in 40% of cases. One artery only of the lower leg was permeable in 43.3% of cases. Run off was judged bad in 38% of patients. RESULTS: The endarteriectomy could be realised in 93 patients (84.5%). It concerned the only common femoral artery in 20% of cases (patch angioplasty in 55% of cases), common and deep femoral arteries in 50.5% of cases (82% of patch), CFA, DFA and SFA at its origin in 29.1% of cases (93% of patch). Perioperative mortality rate was 1%. Local morbidity rate was 21.6% with 18% of minor complications and 3.6% of complications requiring a second operation. There were 2% of vascular complications (1 thrombosis and 1 false-aneurysm). Mean follow-up was 43 months in 90 patients. There were restenosis or thrombosis (5.5%), false-aneurysms (2.2%) and amputations (6.6%). Femoro-popliteal (10%) and iliac complementary bypasses (6.6%) were necessary. Permeability was 94.9% at 3 years and 88.8% at 5 years. Clinical results were considered good in 80.7% of the cases at 3 years and in 71.7% at 5 years. With univariate analysis, the predictive factors for failure were: limb salvage (P < 0.01), altered popliteal run off (P < 0.03) and extended distortion of the deep femoral artery (P < 0.05). CONCLUSION: Isolated endarteriectomy of the femoral tripod is a low risk and effective technique. A femoropopliteal revascularisation should be associated in case of a major alteration of the deep femoral artery.

Pseudo-aneurysm of the popliteal artery by femoral exostosis in a young child.

Exostosis is a solitary benign bone tumor frequently observed in children. It may be totally quiescent or provoke complications. We report a case of pseudo-aneurysm of the popliteal artery caused by an exostosis on the lower metaphysis of the femur in a 12-year-old boy. This unusual complication mostly reported in young males (mean age 19 years) occurs in the context of an initial trauma in half the cases. Surgical treatment is a semi-emergency requiring both bone and arterial repair. Preventive surgery should be discussed for all cases of exostosis with a risk of arterial damage due to the gravity of the potential vascular complications.

[Juvenile breast hypertrophy: analysis of long-term results of reductive mammoplasty]. / Hypertrophie mammaire juvénile: analyse des résultats à long terme des plasties mammaires de réduction.

UNLABELLED: Reduction mammaplasty has now become routine surgery with good results in middle-aged women. However the scars it leaves, its psychological and functional (breastfeeding) impact could limited its indications in teenage girls. AIM: The purpose of our study was to report the long-term results of reduction mammaplasty in teenage girls and to assess their consequences. MATERIAL AND METHODS: We conducted a retrospective study of 65 reduction mammaplasty carried out between 1981 and 1997 in 15 to 17 years old girls. The study was based on data in their medical records and answers to a questionnaire which was sent to each patient. RESULTS: Average followup was 8.1 years. The reduction technique with superior pedicle were mainly used. Average breast tissue excised was 1050 g. Minor complications occurred in three cases. Eleven revisions had to be carried out with 1.6 years on average after primary surgery. The psychological and functional complaints observed preoperatively disappeared in more than 90% of the cases. In over 80% of the cases the patients were pleased or very pleased with the shape, the volume kept and the symmetry. Scars were well accepted in 83% of the cases. Seventeen women were given birth to 25 children. Five of whom breast-fed their babies, while six refused because of their breast surgery history. Although information about breast-feeding after such surgery is systematically given, 41 women claimed they had not received it. CONCLUSION: Reduction mammaplasty is reliable in teenage girls. Patients are generally satisfied and the remaining scar is well accepted. Breast-feeding is possible after this surgery and information on that point ought to be better developed.

Sealing of polyester prostheses with autologous fibrin glue and bone marrow.

The purpose of this study was to develop a sealing technique for polyester prosthetic grafts able to promote healing and reduce intimal hyperplasia. The porcine experimental model was aortoiliac bypass with a 6-mm diameter knitted polyester prosthetic graft implanted for 14 and 90 days. Animals were divided into three groups according to sealing technique as follows: pre-clotting with blood (group I, n = 12), sealing with autologous fibrin glue (group II, n = 14), and sealing with autologous fibrin glue and bone marrow cells (group III, n = 16). Feasibility and quality of sealing were evaluated by scanning electron microscopy prior to implantation and by assessment of blood loss. After removal, prostheses were cut into three segments comprising the proximal anastomosis, midsection, and distal anastomosis. Pieces were fixed, embedded in paraffin, and serially sectioned for histologic study. Histological study focused on the degree of stenosis and hyperplasia of the neointima of each prosthesis. The results of this short-term study indicate that sealing of polyester vascular prosthetic grafts with autologous fibrin glue and bone marrow cells is effective in reducing intimal hyperplasia. However further study will be needed to assess long-term healing.

[Isolated popliteal arteries: results of surgical treatment and causes of failure]. / Artères poplitées suspendues: résultats du traitement chirurgical et causes des échecs.

UNLABELLED: Isolated popliteal artery is defined as an obstruction of a superficial femoral artery with a patent popliteal segment followed by an obstructed distal popliteal artery or a patent leg artery less than 5 cm long. PURPOSE: The aim of this retrospective study was to report the results of surgical treatment and the causes of failures. PATIENTS AND METHODS: From 1988 to 1996, 31 patients with isolated popliteal artery were operated on with femoropopliteal bypass. The age of the patients ranged from 45 to 92 years, (mean: 79 years); all had critical ischemia that threatened limb viability. All underwent preoperative arteriography and diagnosis was confirmed by intraoperative arteriography. RESULTS: In the postoperative course, there were 22 patent bypasses (68%) with minor amputation in five patients, and nine thromboses that required a major amputation in seven patients, a trans-metatarsal amputation in one, and a medical treatment in one. With a mean 37-month follow-up, seven thromboses required a major amputation in five patients, a new bypass in one and a medical treatment in one. The death rate was 34% at two years. The actuarial patency rates of the bypasses were 51% at one year, 38% at two years and 25% at five years. The limb salvage rate was identical. The patency rates were 65% at one, two and five years for venous bypasses and 38%, 13% and 0% respectively for PTFE bypasses. Statistical analysis showed two causes of failure: the absence of a run-off branch and the use of PTFE prostheses. No other statistically significant cause of failure was demonstrated among those analysed. Favourable anatomic conditions for a bypass to a leg artery were not predictive of failure of a femoro-popliteal bypass on the isolated arterial segment. CONCLUSION: Bypass to isolated popliteal artery is indicated in patients whose limb viability is jeopardized. Results may be considered as satisfactory especially if there is a run-off branch and if a venous graft is available for the bypass.

[Biomechanical study of the vasomotor system of the arterial smooth muscle after long-term cryopreservation of a human arterial graft at two different temperatures -80 and -150C]. / Etude biomécanique et de la vasomotricité du muscle lisse artériel après cryocongélation de longue durée de greffon artériel humain à deux températures différentes -80 degrees et -150 degrees C.

We conducted two parallel studies on cryopreserved arterial homografts: a biomechanical study based on traction tests and a functional study coupled with a histology examination. Twenty-four arterial segments from 6 donors (2 iliac and 2 superficial femoral segments per donor) were cryopreserved at -150 degrees C and -80 degrees C. Cryopreservation lasted at least 6 months. Lengthening at rupture, the Young elasticity module, and rupture stress were calculated from the traction test. Results were significantly different depending on the preservation temperature. The functional properties of the cryopreserved arterial grafts were evaluated by studying the vasomotricity capacity of the vascular smooth muscle (VSM) and the endothelium. The expected results (direct contracture of VSM induced by PHE and endothelial dependent relaxation of VSM induced by ACH) were measured on fresh arteries. Cryopreserved arteries showed no response to physiological doses of PHE and ACH, whatever the preservation temperature. In one-third of the cases, a lower amplitude vasoconstriction was obtained using nonphysiological doses of PHE; there was no relaxation with ACH.