Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report.

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

Reconstruction of a septic femoral triangle fistula with a pedicled DIEP flap: A case report and mini-review.

Flap-based reconstruction techniques have shown promise in preventing scar contractures and enhancing healing in fold areas by providing vascularized and thick tissue. We report a septic rupture of the superficial femoral artery treated with an arterial allograft and covered with a contralateral pedicled Deep Inferior Epigastric Artery Perforator (DIEP) flap. The patient presented favorable outcomes, including optimal healing at 8 months, with no functional limitation. A literature review also discusses alternative pedicled perforator flaps. These modern techniques present several advantages, including reliability, and can be of great interest in complex vascular surgery cases.

[Outcome, quality of life and functional assessment after perineal and external genitalia gangrene]. / Prise en charge de la gangrène des organes génitaux externes et du périnée : résultats, qualité de vie et évaluation fonctionnelle.

INTRODUCTION: External genitalia gangrene is a well-known uncommon disease; however, mortality remains important. Recent literature focuses on early management. The object of this study was to assess quality of life and disease-specific function, in the medium- and long-term. METHOD: We evaluated retrospectively adult inpatients with external genitalia gangrene who had a surgical debridement between 2010 and 2020 at CHU de Poitiers. Preoperatory FGSI Score was calculated for patients included. In a second phase, surviving patients at 2020 who had agreed to take part in the follow-up were assessed by clinical examination, and asked to complete Short-Form 36 test and two additional disease-specific questionnaire (USP, IIEF5). RESULTS: The patients consisted of 33 men. Mean age was 61.18. Eleven patients (33%) died primarily from external genitalia gangrene. Median FGSI score was 6 (1-13). We were able to reach 11 patients (33%) for secondary clinical revaluation. Time before revaluation was 3months to 8years. All parts of SF-36 were significantly low. Mean USP score was 1.27±2.68/4.54±4.43/0.72±1.84. Nine patients (81%) suffered erectile dysfunction without any sexual intercourse possible. CONCLUSION: Patients with external genitalia gangrene experience severe deterioration of their quality of life. Multidisciplinary healthcare process should systematically be carried out, as so as early screening of vulnerability risks factors, to improve functional outcomes and quality of life.

[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.

[Flap harvest training on a new ultrarealistic simulation model: In-training operator feedback about a pulsating reperfused and reventilated cadaver Simlife®]. / Prélèvement des lambeaux sur sujet anatomique et nouveau modèle de simulation ultra-réaliste : retour d'expérience d'un opérateur en formation sur corps reperfusé pulsatile et reventilé Simlife®.

INTRODUCTION: The anatomical subject is still a key element to learn complex procedures in plastic surgery. We present here the evaluation of an in-training operator on a SIMLIFE® model, hyper realistic model consisting in human bodies donated to science equipped with pulsating recirculation and reventilation device. MATERIAL AND METHODS: From February 2019 to October 2019, 8 forearm flaps with radial proximal pedicle were harvested by the learner on a SIMLIFE® model. Conditions were as close as possible to the operating room : asepsy, sterile draping, assistant and instrumentation including electrocoagulation. RESULTS: The procedure was decomposed in 13 distinct steps. Mean total surgery time was 90,5±11,62minutes. There was only one case of arterial pedicle lesion resulting in major blood leak. Bleeding was measured by fake blood loss from the SIMLIFE® console. Mean intraoperatoy bleeding was 171±108 milliliters. We review pros and cons of this new technology particulary suited for complex plastic and reconstructive surgery training. CONCLUSION: Using SIMLIFE® technology we have a new mean to train for complex procedures in plastic and reconstructive surgery. This new technology could be applied to numerous other surgical procedures. Broader applications are still limited by cost and cadaver use legislation.

Use of a skin perforator flap pedicled by the intercostal muscle for reconstruction of a posterior cervical defect.

A posterior cervical defect featuring exposed spinal and occipital bone can be covered in various ways. The "ideal" flap should be a low-morbidity, pedicled locoregional flap that can reach the occiput. Cervical adjuvant radiation therapy may limit the coverage options, because many pedicles are located in areas that are often irradiated. Here, we describe a new surgical technique; we used a skin perforator flap pedicled by the intercostal muscle to cover a posterior cervical defect in a patient with metastatic squamous cell lung carcinoma. This technique is a valuable option; the flap originated from outside the irradiated area and reached the occiput. It adds to the options for cervical coverage in patients who require head-and-neck reconstruction. EVIDENCE-BASED MEDICINE: Level V: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Nostril Surgery: Indications, Surgical Procedures and Outcomes-A Systematic Review of Published Cases.

INTRODUCTION: To achieve adequate nasal proportions, nostril surgery can be a complementary technique useful in facial surgery. To help surgeons with the decision to realize nostril surgery, we conducted a systematic review to summarize reported cases on surgical procedures with a specific interest on indications, surgical procedures and postoperative outcomes. A therapeutic algorithm is also proposed. METHOD: We carried out this review in accordance with the PRISMA criteria. Twenty-two eligible studies were identified using Medical databases, including 1599 patients. A qualitative and quantitative analysis was carried out. DISCUSSION: Excision techniques were realized on 728 patients (45.5%), followed by cinching sutures on 642 patients (40%) and combined techniques: excision techniques with flap advancement techniques in 189 cases (12%), excision techniques with flap advancement techniques and cinching suture in 40 patients (2.5%). When excessive alar flaring was present, alar wedge resection was preferred in the 92% of followed by alar and sill resection. Cinching sutures were realized when excessive alar flaring was associated with a vertical alar axis, in cases of wide alar base, of associated orthognathic surgery. When excessive alar flaring was associated with wide alar bases, indications changed basing on the associated deformities. In 795 patients, nostril surgery was conducted simultaneously with rhinoplasty. CONCLUSION: Nostril surgery through excision techniques, cinching sutures or flaps advancement techniques, reveals good outcomes and can be complementary to rhinoplasty or orthognathic surgery. Through this systematic review, we tried to orient surgeons to find the best treatment for nostril base surgery. LEVEL OF EVIDENCE III: 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 .

[Male to female sex reassignment surgery with a new surgical simulation device using a human perfused cadaver SIMLIFE®: New paradigm in transsexual surgery education ?] / Aïdoïopoïèse sur modèle cadavérique humain revascularisé pulsatile et ventilé SIMLIFE® : cas isolé ou futur changement de paradigme en chirurgie de réassignation génitale ?

INTRODUCTION: In 2015, we reported our experience with the learning curve in genital reassignment surgery and highlighted a four-step learning concept. CLINICAL CASE: In this article, we present our first vaginoplasty performed on a humanoid model SIMLIFE®, a human body associated with a pulsating circulation device and a ventilation device. RESULTS: The surgical technique included 14 steps. The total surgical time was 182minutes. There was no intraoperative complication, and there was no damage to the urethra or rectum. The intraoperative bleeding measured by the loss of operative fluid was 280mL. We discuss the advantages of this technology perfectly adapted to transsexual surgery. CONCLUSION: We demonstrated the feasibility of vaginoplasty performed on a humanoid model SIMLIFE® and highlighted improvement of the surgical skills with this model. This technology could find many other surgical applications. However, it faces cost constraints and legislation on corpses.

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.

Indications, functional results and patient satisfaction after isolated second ray resection following traumatic injury: A retrospective review of 25 patients.

Amputation of the second ray is a surgical treatment option when reconstruction and/or reimplantation fail. The aim of our study was to review the outcomes after transmetacarpal resection of the second ray following a post-traumatic injury and to assess indications, functional outcomes, and patient satisfaction. Between January 2003 and December 2013, 25 patients (6 women and 19 men with a mean age of 51 years) underwent transmetacarpal resection of their second ray after a post-traumatic injury. Sixteen patients were right-handed and 9 were left-handed. Injuries involved the dominant hand in 14 cases (60%). In order to differentiate patients with preserved index finger length preoperatively from those with a shorter, amputated index finger stump, patients were divided into 2 groups. Group 1 included those with an "intact finger" and Group 2 included patients with an "amputated stump". Data collection, including patient satisfaction and functional outcomes, was performed at 83 months postoperative on average. Average length of follow-up was 7.0±1.0 years (range 5-12 years). Group 1 (intact finger) and 2 (amputated stump) included 15 and 10 patients, respectively. Six patients (24%) had primary ray amputation and 19 (76%) had secondary ray amputation. No surgical revision was necessary. In Group 1, the indications were purely functional in all but two cases, whereas aesthetic indications played a role in all patients in Group 2. The average total time off work was 3 months. There was no difference between Group 1 and 2 (P>0.05). However, patients with primary ray resection averaged 10 weeks of lost work compared to 17 weeks for secondary amputation. There was no functional difference between Groups 1 and 2. Scores for cosmetic appearance and patient satisfaction were higher in Group 2. In certain specific situations after complex hand trauma, transmetacarpal amputation of the second ray is indicated as soon as possible, in order to reduce the time off work. Patient satisfaction following this surgical procedure is high, especially in groups with amputated stumps. A 30% decrease in pinch and grip strength is the rule. No secondary surgery is normally required.

Thoracotomy and esophageal surgery: Key points to preserve the possibilities of flaps.

Anastomotic leakage frequently complicates esophagectomy and can trigger a rare life- threatening complication, a tracheoesophageal fistula. No guideline has yet addressed this complication. Plastic surgeons play a crucial role for salvage surgery. When a re-operation is chosen the possibilities of flap interposition depend on how the thoracotomy was initially performed. This study tried to identify key techniques in order help thoracic or general surgeons to preserve all the local flaps available for TEF if it occurs. These techniques improve flap conservation, helping plastic surgeons when a later transposition flap is required.

The trapezius perforator flap: Versatility for locoregional reconstruction.

Only a few surgical choices are available for cervical and thoracic spine coverage. The trapezius perforator flap is relatively unknown and only a few authors have published on this subject. In this article, we report on four clinical cases where a trapezius perforator flap was used either as a propeller flap, as a tunnelized island flap, or as a supercharged flap for cervical spine, thoracic spine and anterior cervical defects. Harvesting this flap is quite simple and enables high quality reconstruction with low donor-site morbidity in complex situations.

Adipose mesenchymal stromal cells: Definition, immunomodulatory properties, mechanical isolation and interest for plastic surgery.

Ever since their discovery in 2001, adipose mesenchymal stromal cells (ASC) have profoundly modified clinical indications and our practice of plastic surgery, thereby placing our discipline at the forefront of regenerative medicine. These cells act through paracrine signaling by synthesizing immunosuppressive and pro-angiogenic factors. They are of key importance with regard to the regenerative properties of autologously grafted adipose tissue (AT). Taken together, they make up the stromal vascular fraction (SVF) comprising all AT cells except for adipocytes. As our knowledge evolves, we are moving from fat grafting towards SVF grafting, of which the essential sought-after effect is tissue regeneration. The objective of the present review is to synthesize present-day information on ASCs and their immunomodulatory properties and, from a practical standpoint, to indicate present-day and future steps towards establishment of clinical routine, particularly through application of techniques favoring mechanical digestion of adipose tissue.

Assessment of quality-of-life in patients with face-and-neck burns: The Burn-Specific Health Scale for Face and Neck (BSHS-FN).

INTRODUCTION: Burns to the cephalic extremities are particularly implicated in problems of self-image and alterations to personal social relations. The aim of this study was to objectively assess the quality-of-life (QoL) of patients suffering from face-and-neck burns through our newly created scale: The Burn-Specific Health Scale for Face and Neck (BSHS-FN). METHODS: After constructing the BSHS-FN, we compared QoL of patients with or without face-and-neck burns. SF-36, the French version of the BSHS-B (Burn Specific Health Scale-Brief), and the BSHS-FN were administrated to 53 patients divided into two groups: GB group (general burns, 26 patients) and FN group (face-neck burns, 27 patients). RESULTS: QoL evaluated using the SF-36 had a higher average total score in GB patients compared to FN patients, but there were no significant difference between the two groups (54.3±18.5 vs. 47.0±17.3, respectively, p=0.11). In contrast, in BSHS-B the total score was significantly different between the two groups with a higher score recorded for the GB group (71.9±13.4 [median: 72.8] in the GB group vs. 62.2±14.4 [median: 64.4] in the FN group). In percentage terms, total score of BSHS-FN for GB group was 79.1±10.1, while total score for FN group was 53.6±13.1 (p<0.001), with the highest score for the Face and Neck domain in GB group (99.7±1.1, p<0.001) CONCLUSION: The BSHS-FN seemed to be more appropriate to assess QoL for FN burn patients. This study supports its application in routine clinical practice and in international studies.

Three-dimensional imaging, an important factor of decision in breast augmentation.

INTRODUCTION: Since the beginning of the 21st century, three-dimensional imaging systems have been used more often in plastic surgery, especially during preoperative planning for breast surgery and to simulate the postoperative appearance of the implant in the patient's body. The main objective of this study is to assess the patients' attitudes regarding 3D simulation for breast augmentation. METHOD: A study was conducted, which included women who were operated on for primary breast augmentation. During the consultation, a three-dimensional simulation with Crisalix was done and different sized implants were fitted in the bra. RESULTS: Thirty-eight women were included. The median age was 29.4, and the median prosthesis volume was 310mL. The median rank given regarding the final result was 9 (IQR: 8-9). Ninety percent of patients agreed (66% absolutely agreed, and 24% partially agreed) that the final product after breast augmentations was similar to the Crisalix simulation. Ninety-three percent of the patients believed that the three-dimensional simulation helped them choose their prosthesis (61% a lot and 32% a little). After envisaging a breast enlargement, patients estimated that the Crisalix system was absolutely necessary (21%), very useful (32%), useful (45%), or unnecessary (3%). Regarding prosthesis choice, an equal number of women preferred the 3D simulation (19 patients) as preferred using different sizes of implants in the bra (19 patients). CONCLUSION: The present study demonstrated that 3D simulation is actually useful for patients in order to envisage a breast augmentation. But it should be used as a complement to the classic method of trying different sized breast implants in the bra.

Cell-assisted lipotransfer: Friend or foe in fat grafting? Systematic review and meta-analysis.

Autologous fat grafting is a common procedure for soft-tissue reconstruction but is associated with a graft resorption rate ranging from 20% to 80%. To improve the fat graft survival rate, a new technique, called cell-assisted lipotransfer (CAL), was developed. With CAL, fat is injected along with adipose-derived stromal cells that are assumed to improve fat survival rate. We conducted an evidence-based meta-analysis to evaluate the efficacy and safety of CAL as compared with conventional autologous fat grafting (non-CAL). The databases MEDLINE (via PubMed), Cochrane Library, EBSCO, Web of Science, and EMBASE were searched for reports of clinical trials, case series, and cohorts available from 2008 to 2016. We conducted a meta-analysis of the efficacy of CAL with data analysis concerning fat survival rate. The incidence of complications and the need for multiple procedures were evaluated to determine the safety of CAL. We identified 25 studies (696 patients) that were included in the systematic review; 16 studies were included in the meta-analysis to evaluate the efficacy of CAL. The fat survival rate was significantly higher with CAL than non-CAL (64% vs. 44%, p < .0001) independent of injection site (breast and face). This benefit of CAL was significant for only injection volumes <100 ml (p = .03). The two groups did not differ in frequency of multiple procedures after fat grafting, but the incidence of complications was greater with CAL than non-CAL (8.4% vs. 1.5%, p = .0019). The CAL method is associated with better fat survival rate than with conventional fat grafting but only for small volumes of fat grafting (<100 ml). Nonetheless, the new technique is associated with more complications and did not reduce the number of surgical procedures needed after the first fat grafting. More prospective studies are required to draw clinical conclusions and to demonstrate the real benefit of CAL as compared with common autologous fat grafting.

Cell-assisted lipotransfer: Current concepts.

Autologous fat transfer, or lipofilling, is a common technique used for soft tissue reconstruction. It has been used for many years, but the technique is associated with a significant graft resorption rate (20% to 80%). To improve the fat graft survival rate, several methods have been tested, and one has appeared more promising: cell-assisted lipotransfer (CAL). In the CAL method, fat is enriched with adipose-derived stromal cells (ASC), contained in the stromal vascular fraction (SVF) obtained after enzymatic digestion of fat or after cell culture to improve the fat survival rate. In this concise review, we present the clinical indications, and the technical principles of CAL, as well as a presentation of ASC. To conclude, we present the main results (efficacy, complications and safety) obtained from different studies of this technique.

[Light sources usable by the plastic surgeon in the absence of photographic studio]. / Sources lumineuses utilisables par le chirurgien plasticien en l'absence de studio photographique.

Medical photography is an important part of the medical file and is widely used in medical communication, especially in our discipline. His practice has to be the most standardized and reproducible as possible, which distinguishes it from artistic photography. Photography fix the light reflecting from a subject, so surgeon have to control of the light source in any environment. In the absence of dedicated studio, using external cobra or ring flashes with special diffusers allow the surgeon to have light sources adapted to the different conditions encountered in daily practice.