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

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

[Evaluation of a short incision double eyelidplasty for Asian patients]. / Technique chirurgicale de création d'un double pli palpébral supérieur par voie semi-ouverte dans la paupière asiatique.

BACKGROUND: Creation of a double upper eyelid is a popular procedure in Asian countries. Many incisional and non-incisional approaches have been described to create a new suprapalpebral fold. OBJECTIVE: The authors recommended a short incision technique to create a double eyelid and evaluated the results. METHODS: The location of the partial incision was determined pre-operatively with the patient. A one-centimeter partial incision was made on the middle one-third of the upper eyelid, and the orbicularis oculi muscle was dissected. Three anchoring stitches were placed for the creation of the permanent suprapalpebral fold. Those stitches were inverted single knots which linked the tarsal plate to the lower margin's dermis or dermomuscular junction of the incised skin. Intra-operative adjustment of position and curvature of the new fold was done by the active opening of the upper eyelid. Global results, symmetry and design were evaluated by the patient and one independent surgeon. RESULTS: Between January 2012 and January 2013, a total of 10patients were operated using this technique. All patients were satisfied, with 8results graded excellent and 2results graded good. The average operation time was 20minutes. There were no serious complications, the only unfavorable outcome was one persistent bruise. The follow-up period was one year. Recovery time varied from 2weeks to a month. No correction procedure was needed. CONCLUSIONS: The short central incisional technique for creation of a double eyelid described here provides excellent permanent and natural results, with no visible scar nor serious complications.

Urinary cotinine testing as pre-operative assessment of patients undergoing free flap surgery.

BACKGROUND: The identified risks of smoking with regard to operated tissues are so elevated that it is clearly dangerous to operate a smoker when the proposed intervention is neither vital nor urgent. MATERIALS AND METHODS: The aim of this prospective study was to evaluate a simple method of screening patients who smoke, with the evaluation carried out before agreeing to carry out free tissue transfer. The purpose of the testing was to hold the patient responsible for his actions and minimize smoking-related complications by cancelling or postponing the planned operation if the patient continued to smoke. Screening included use of a standardized questionnaire at the first consultation and detection of cotinine using a urine test strip 7 days before the scheduled surgery. Patients were informed that in the event of positive results, the operation would not take place. A six-week preoperative smoking cessation period was mandatory. RESULTS: Seventy-six patients were included in this study. Among them, 25 (32.9%) reported being former smokers and 11 (14.5%) admitted in the initial questionnaire to being active smokers. Six patients (7.9%), including one self-reported non-smoker, tested positive for cotinine, and their operations were cancelled. CONCLUSION: Screening using a questionnaire and cotinine detection appeared to constitute a simple, inexpensive, rapid and reliable test. It allowed us to refuse to operate 6 non-compliant patients and was thereby likely to diminish morbidity in the free tissue transfers carried out in our ward.

[Intraoperative verification of a perforator flap vascularization by indocyanine green angiography]. / Vérification peropératoire de la vascularisation d'un lambeau perforant par angiographie au vert d'indocyanine.

After Koshima and Soeda first described perforator flaps in 1988, Wei has improved the technique by describing the "free style perforator flap". These flaps have the advantage of being performed on all skin perforators and in reducing donor site morbidity. The disadvantage, however is that the size of their angiosome is not defined and the evaluation of their relay on the experience of the surgeon. An evaluation of the size of an angiosome by conducting intraoperative angiography is proposed. Intraoperative angiography is performed after injection of indocyanine green. Stimulation of the indocyanine green by infrared causes the emission of fluorescent radiation. This fluorescence is then detected by a specific camera that displays real-time visualization of the skin's perfusion. We present the case of a 39-year-old patient who had an open tibial pilon fracture, for which we performed a pedicled propeller flap based on a posterior tibial perforator. Angiography was used to determine accurately the optimal skin perfusion of the propeller flap, which was based on a perforator from the posterior tibial artery. Angiography identified several levels of skin perfusion with a high fluorescence, intermediate and absent. The non-vascularized part of the skin paddle was resected. Given the unreliability of this technique, hypoperfused area was retained. Debridment of this area, however was necessary at day 5 postoperative with repositionning of the flap. Indocyanine green angiography may be a useful decision-making tool for intraoperative surgeon. It allows to adjust the size of the propeller flap's skin paddle to it angiosome. However, this evaluation method needs to be improved with the introduction of a quantitative threshold.

[In search of the ideal surgical treatment for lymphedema. Report of 2nd European Conference on supermicrosurgery (Barcelona - March 2012)]. / À la recherche d'un traitement idéal du lymphœdème. Compte-rendu de la 2(e) Conférence européenne de supermicrochirurgie (Barcelone - Mars 2012).

Since more than 50 years, many surgeons all around the world try to find the perfect surgical technique to treat limb lymphedemas. Decongestive physiotherapy associated with the use of a compressive garment has been the primary choice for lymphedema treatment. Many different surgical techniques have been developed, however, to date, there is no consensus on surgical procedure. Most surgical experts of lymphedema met in the second European Conference on supermicrosurgery, organized on March 1st and 2nd 2012, in San Pau Hospital, Barcelona. Together they tried to clarify these different options and ideally a strategy for using these techniques.

The scalp as a donor site for split-thickness skin graft: a rare complication case report.

The scalp is a useful and reliable donor site for the paediatric burn population that can be harvested several times with minimal morbidity. However, the scalp cannot be used as skin graft donor site with impunity. Scalp alopecia and chronic folliculitis can be observed among the complications. In these cases, the reconstruction phase offers different surgical procedures such as primary closure, staged excision or tissue expansion. We report the case of a patient (29-years-old), treated 20 years ago for second-degree burns covering up to 20% total body surface area (TBSA) by using thin split-thickness skin grafts of his scalp. As a teenager, he developed multiple episodes of folliculitis at the donor site of the scalp and then of recurrent abscesses, resistant to all existing medical treatments. Surgical treatment consisted in the skin excision of his scalp donor site which was immediately covered by a thin split-thickness skin graft. Four months after surgery, the patient was satisfied with the functional and aesthetic result.

[Microsurgery]. / Microchirurgie.

This article traces some of the developments in the innovation of microsurgery since the first free flaps in the 1970s. French reconstructive surgeons contribution to microsurgery and composite tissue allotransplantation was particularly important. Robotic assisted microsurgery and microgravity represent some of the latest innovations.

[Anthropometric study of cutaneous projection perceived by the previous edge of the latissimus dorsi muscle. Clinical study including 50 women]. / Analyse anthropométrique de la projection cutanée palpée du bord antérieur du grand dorsal chez la femme. Etude clinique. A propos de 50 cas.

The purpose of this anthropometric forward-looking study was to estimate the projection perceived by the previous edge of the latissimus dorsi muscle according to the morphology of the patients. Fifty women were included in this study. We performed thoracic measurements: chest (sub-mammary groove), waist and the middle-hip circumference measurement as well as the anterior rim projection, of the latissimus dorsi, felt at three levels: sub-mammary groove, waist as well as the middle-hip area. We then conducted studies on the variation of these measurements according to the morphology of the patients represented by the variation of the ratio circumference of waist/circumference of chest (TT/TP). By this, we concluded there exists in fact a correlation between the decrease of the ratio TT/TP and the recession of the perceived anterior rim of the latissimus dorsi. The more the report TT/TP decreases, the more the anterior rim of the latissimus dorsi is posterior. In conclusion, because the anterior rim of the latissimus dorsi is the main anatomical mark for the drawing of the musculocutaneous flap, it is therefore necessary to take extra care when assessing slim-waisted women: the drawing must be done in a posterior position.

[Merkel cell carcinoma: study of 24 cases and review of the literature]. / Carcinome à cellules de Merkel : à propos de 24 cas et revue de la littérature.

UNLABELLED: Merkel cell carcinoma is a cutaneous-neuroendocrine tumor, which may be difficult to diagnose and to treat. OBJECTIVE: The objective of this study was to analyse the treatment and the recurrences of Merkel cell carcinoma. PATIENTS AND METHODS: A retrospective study was performed on the patients operated of a Merkel cell carcinoma between 1994 and 2004. Clinical data of the patients and the tumor, treatment (surgery and radiotherapy) and recurrences were entered in a database. RESULTS: Twenty-four patients were operated (8 men and 16 women). The mean age at diagnosis was 71.5 years. The average follow-up was 30.8 months. The treatment was a large surgical removal of the tumor with immediate closure, systematically followed by radiotherapy. There were five recurrences and no death. CONCLUSION: Merkel cell carcinoma is an aggressive tumor. Immediate closure after large surgical removal allows radiotherapy.

[Chest wall reconstruction for recurrent breast cancer]. / Reconstruction des pariétectomies thoraciques effectuées pour récidive de cancer du sein.

Some recurrences of breast cancer require wide chest wall resection as curative or palliative therapy. We report a retrospective review of 14 chest wall resections and reconstructions. The width of the anterior chest wall excision was 150 cm(2) (80 to 360 cm(2)). Two defects were full-thickness ones, with sternal or costal resection. The reconstruction required synthetic mesh covered by a latissimus dorsi musculocutaneous flap. The 12 other resections were superficial ones, and have been covered by a skin graft in 5 patients, and by a regional flap in 7 patients (5 latissimus dorsi, 1 DIEP, and 1 bilobed flap). Two patients had a chest wall irradiation after the surgical procedure. We have analysed the factors, which had influenced our choice of the type of reconstruction. The reconstruction is performed by a regional flap, most commonly a latissimus dorsi pedicled flap, in case of full-thickness defect, of nodular isolated recurrence, or when a radiation therapy is provided after the surgical procedure. The coverage is made by a skin graft in case of palliative excision, or of multiple nodular chest wall recurrence (which have a high risk of recurrence in the same form).

[Breast reconstruction by DIEP free flap: a 30 cases experience]. / Reconstruction mammaire par lambeau libre DIEP : à propos de 30 cas.

PURPOSE: The purpose of this study was to analyse the surgical procedure and the complications in case of breast reconstruction by deep inferior epigastric perforator flap (DIEP). MATERIALS AND METHODS: This retrospective study concerns 30 cases performed between 2001 and 2005. The reconstruction was delayed (73%), immediate (3%) or realised after failed attempt to reconstruct the breast with implant or flap (27%). We studied perforator selection, operative time, total flap loss, partial flap loss, and postoperative complications. RESULTS: Flap was raised with one pedicle in 22 cases and with two pedicles in eight cases. The recipient vessels were the axillary vessels (70%), circumflex scapular vessels (27%), and the thoracodorsal vessels (1%). Mean operating time was 6h 17min for the one-pedicle flaps and 8h 43min for the double-pedicle flaps. We noted two total flap necrosis, four partial flap necrosis, one deep venous thrombosis and one pulmonary embolism. Postoperative abdominal hernia or bulge never occurred. CONCLUSION: Although the use of DIEP flap reduces morbidity of the harvest, long operative time and thrombosis complications cause significant morbidity. Therefore we only use the DIEP flap when other procedures cannot be performed.

[Vaginal reconstruction after anterior pelvectomy by deep inferior epigastric perforator flap (DIEP)]. / Reconstruction vaginale par lambeau perforant basé sur le pédicule epigastrique inférieur après pelvectomie antérieure.

Muscle sparing technique is one of the latest improvements of rectus abdominis flaps harvesting. It minimizes donor site morbidity by preserving the abdominal wall. The deep inferior epigastric perforator flap (DIEP) provides reliable tissues for vaginal reconstruction with local low morbidity. We describe the surgical technique and flap-related specific complications. This technique is safe and useful in the vaginal reconstruction especially following a radiotherapy.

[Direct excision of the deep nasolabial fold: a logical and easy surgical management]. / Traitement du sillon nasogénien marqué par exérèse-suture: série préliminaire de neuf cas.

OBJECTIVE: Surgical management of the deep nasolabial fold, due to age, genetic diseases or facial lipoatrophy, is difficult and often short-lived. Direct excision seems to improve the long-term results. Clinical illustration and review of literature about the anatomy and physiology of the nasolabial fold are proposed to explain this fact. MATERIALS AND METHODS: Direct excision of the nasolabial fold has been performed on nine patients, three females and six males. The problem was aging midface in two cases, facial lipoatrophy in five cases, cutis laxa in one case and pachydermoperiostosis in one case. The excision was sitting astride the nasolabial fold and the suture preserved a dog-ear at the upper extremity to restore the projection of the cheek. Evaluation items were quality of the scar, durability of the result and personal improvement. RESULTS: Scars were always unnoticeable within six months, projection of the cheek was restored, and results were durable with an average follow-up of eighteen months. All patients were satisfied with the aesthetic or social improvement. CONCLUSION: Direct excision of the nasolabial fold is a simple, reliable and durable method, respecting the physiology of this area of the face. Then, it should be indicated in deepened nasolabial fold, whatever the etiology.

[Role of cutaneous pinch grafts in the healing of patients with dystrophic epidermolysis bullosa wounds: report of four cases]. / Intérêt des greffes de peau en pastilles dans les épidermolyses bulleuses dystrophiques. A propos de quatre cas.

Epidermolysis bullosa (EB) is a heterogeneous group of genetically determined skin fragility disorders in which minor trauma leads to blister formation on the skin. One of the most severe forms is Hallopeau-Siemens recessive dystrophic EB which main cause of mortality is squamous cell carcinoma (SCC). Exeresis of SCC leads to a difficult problem about treating the surgical wound. Most of the time, achieving a split-thickness skin graft on these severely affected EB patients is either too difficult or gives poor quality results. In some cases, flaps could be performed but they represent a too aggressive solution. However cutaneous pinch grafting is really adapted to the healing of these wounds. We have reported 4 cases of patients with recessive dystrophic EB complicated with SCC from 30 mm to 270 mm. After surgical excision of these SCC, dressings have been applied until obtaining a good enough floor for achieving a skin graft. The four patients have been treated by cutaneous pinch grafting. Airway management and monitoring have required particular precautions for avoiding anaesthetic related morbidity. We have noticed no adverse effect. A complete healing of good quality has been obtained in all cases (3 to 16 months of follow-up). No recurrence of SCC has been noticed and donors sites have had got a good healing. Relating to the healing of wounds after exeresis of SCC in case of dystrophic EB, cutaneous pinch grafting represents the most reliable solution with a minimum of physical traumatism.

[Analysis of lymph mode recurrence in patients with melanoma and negative sentinel lymph node negative. Retrospective study at the Hospital Saint-Louis, Paris]. / Evaluation du taux de récidive ganglionnaire après ganglion sentinelle négatif chez les patients porteurs de mélanome, et analyse des résultats. L'expérience de l'hôpital Saint-Louis, Paris.

Melanoma is a malignant tumor, with dominant lymphatic extension. Sentinel lymph node is the first lymph node touched by melanoma. Our retrospective and monocentric study is about 87 patients, between July 1999 and July 2003. The inclusion criteria were malignant melanoma with Breslow level superior or equal 1.5 mm, and/or Clark level superior or equal IV, and/or ulcerated, and/or in regression. Sentinel lymph node has been negative on histological analysis in 75 patients (86.2%). About these 75 patients, we found five metastatic lymph node recurrence (6.66%) in a short notice (median 10.2 months). For the five patients with recurrence, the original slides and tissue blocks were available for reexamination. Then, we found micrometastasis in two patients (40% of occult metastasis). Our rate of lymph node recurrence in patients with sentinel lymph node negative is about 6.66%. Our analysis make us believe that early recurrence are essentially linked to histological analysis limits, and maybe to skip metastasis existence.

[Congenital quintus varus supraductus: surgical procedure]. / Quintus varus supraductus congénital : technique chirurgicale.

Quintus varus supraductus is a congenital malformation that associates a hyperextension, a varus and an external rotation of the fifth toe coming over the fourth. The goal of this study is to explain an easy, reproducible and efficient surgical procedure to correct that malformation. Our procedure is only about soft tissues. It comprises a fifth toe extensor tenolysis, a circular capsulotomy and lateral ligament section of the fifth metacarpophalangeal articulation. The glenoid plaque is desinserted only if the peroperative reduction did not seem sufficient. The stabilization is achieved through a cutaneous plasty of modified BUTLER, with a cutaneous lengthening VY plasty. Exceptionally, an axial broaching of the articulation has been done. On about 20 children, aged 4-17 years, operated with this procedure, we have noticed a complete and definitive correction in 19 patients. Only one patient showed an incomplete resurgence, but without any functional disturbance. We did not notice any failure. This procedure seems efficient, and all the more interesting that it is technically easy to perform.

[Oblique latissimus dorsi myocutaneous flap in breast reconstruction]. / Le lambeau de grand dorsal à palette oblique en bas et en avant en chirurgie reconstructrice mammaire.

Breast reconstruction with latissimus dorsi myocutaneous flap is a reliable technique. Its width is limited to between 10 and 12 cm if direct closure of the donor site defect is required. We report a study with assessment of the dorsal skin laxity in 25 women, simulating vertical, horizontal and reverse oblique flap. The average width was 12.5 cm (11.6 to 14 cm) for reverse oblique flap, 9.4 cm (8 to 11 cm) for vertical and 9.2 cm (8 to 10.6 cm) for horizontal flap. Our study suggests that the reverse-oblique flap provides a wider flap and reduces the donor site morbidity.

[Extensor tenodesis to the retinaculum extensorum: anatomic and biomechanical study]. / Ténodèse des extenseurs sur le retinaculum extensorum: étude anatomique et biomécanique.

INTRODUCTION: The extensor tenodesis is a direct dynamic tenodesis which is activated by wrist flexion due either to hand weight or flexor carpi radialis. This tenodesis is usually performed to the distal radius, but it is possible to fix EDC (extensor digitorum communis) to the retinaculum extensorum. MATERIAL AND METHODS: Biomechanical study concerned 12 anatomical subjects (24 wrists). The biometric and radiological analysis of retinaculum displacement distalwards was made under low (1 kg) and moderate (6 kg) pulling. Surgical clips were placed on the proximal and distal limits of the retinaculum in order to study their positions on roentgenograms. RESULTS: Average width of the retinaculum was 19 mm. Average movement under 1 kg drive was 6 mm and 8.6 mm under 6 kg drive. X-rays showed that the proximal border of the retinaculum was always located proximally to the wrist rotate centre, whatever the traction. DISCUSSION: We found the same anatomical features described by different authors, except for the width of the retinaculum. Our study suggests that the retinaculum is strong enough to support a surgical tenodesis.