[The therapeutic purpose of plastic surgery]. / La finalité thérapeutique en chirurgie plastique.

The acts of plastic surgery consist in providing care to patients and pursue a therapeutic purpose. They benefit from VAT exemption in accordance with European legislation. They appear in the Common Classification of Medical Acts as therapeutic acts, whether or not they are covered by health insurance. To assist the plastic surgeon during the consultation in his role as a medico-surgical expert, we propose a global assessment scale for physical disgraces. This scale specifies the importance of disharmony, its etiology, and considers the patient in his entirety, both biologically and psychosocially. All repercussions are analyzed: physiopathological impact, pain, functional impact on daily life activities, pleasure and sexual activities, psychological, social, and professional impact. Each item is independently rated. Depending on the overall score obtained, the therapeutic nature of the act can be confirmed. The proposed scale is a simple tool that easily and seriously supports the therapeutic nature of our acts. It ensures argued expertise, a reliable and indisputable synthesis. We are, above all, doctors, caregivers, contributing to health as defined by the WHO: "a state of complete physical, mental, and social well-being." We alone are able to judge the therapeutic nature of a service, in agreement with our patients.

Filler-induced blindness "seen" by ophthalmologists: Case presentation and treatment algorithm.

PURPOSE: Filler-induced blindness (FIB) is the most threatening complication following periocular injection. To date, no standard of care has been established. The goal of this study is to report a new case of FIB with partial visual recovery and present our personalized algorithm for treatment based on fluorescein angiography findings. MATERIALS AND METHODS: Case report with 24 months follow-up and treatment algorithm. RESULTS: Our patient experienced complete vision loss to no light perception following forehead lipofilling. Retinal angiography identified a posterior ciliary artery occlusion. Antiplatelet medication, steroids and intraocular pressure lowering medications were administrated, followed by hyperbaric oxygen treatment (HBOT). Visual acuity improved to +0.8 logMar. The HBOT treatment was monitored by fluorescein angiogram. Based on this case and on the ophthalmic literature on retinal and ciliary artery occlusion, we established a personalized FIB protocol guided by fluorescein angiography. CONCLUSION: Although prevention remains the best treatment, all physicians should be prepared to manage FIB. Prompt management at the office guided by written protocols, as well as emergency kits, are essential. In referral centers, personalized treatment should be undertaken based on fluorescein angiography findings.

The infraorbital artery: Clinical relevance in esthetic medicine and identification of danger zones of the midface.

BACKGROUND: Over the past decade, cosmetic injections of dermal fillers or fat have become a popular procedure in facial rejuvenation in an overconsuming society. However, complications such as arterial embolism and occlusion can occur even with experienced injectors, especially in high-risks zones namely the glabella, the nasal dorsum or the nasolabial fold. The aim of this study was to define the vascular danger zones of the infraorbital area in order to provide guidelines helping avoid them. MATERIALS AND METHODS: The infraorbital artery, its main branches and their anastomoses with neighbouring vessels were studied in 18 fresh cadavers. Mimetic injections of inked hyaluronic acid were performed in the infraorbital area in the interest of analyzing its distribution and to determine potential vascular risks towards the infraorbital artery and its branches. RESULTS: The infraorbital artery and its branches were located in common injection regions and anastomosed to the supratrochlear artery, the dorsal nasal artery and the angular artery through the nasal branch of the infraorbital artery. Two danger zones could be depicted: injections can be risky when performed too superficially in the midcheek area, and likewise risky when performed in a periosteal layer in infraorbital hollow or tear-trough correction, because of an obvious possibility of retrograde embolism. CONCLUSION: The infraorbital artery can be involved in anatomic mechanism of arterial occlusion, further blindness and stroke, among the related neighbouring arteries. Based on the findings of this study, injections to the periosteum layer in tear-trough correction and above the periosteum on the zygomatic arch is not advised.

[The eyelid-cheek junction]. / La jonction palpébro-jugale.

The eyelid-cheek junction is a key area which generates many comments: from looking tired to looking good or rested, without forgetting charm, beauty, and a youthful appearance. In spite of many interesting medical and surgical procedures, treating this area is sometimes difficult and results are not always up to our expectations. Standardized blepharoplasty, which has often been improperly used, has shown its limits. Since the latest refinements, lipostructure has revolutionised blepharoplasty and serving as a reference, it has become an established technique. Subperiostal mediofacial lift allows outstanding results at the cost of a certain technical aggressiveness. Aesthetic medicine proposes worthy alternative and/or appropriate complementary solutions. Different procedures we dispose of have been reviewed together with their assets and their limits. A codification of therapeutic indications is proposed. The positioning of the eyelid-cheek clinical junction in relation with the low orbital bone rim influences our strategy in choosing the appropriate technique.

Glomus tumors of the upper limb: Single-center retrospective study of clinical and functional outcomes.

Glomus tumors are rare and benign hamartomas, arising from neuro-myo-arterial proliferation and deriving from mesenchymal origin. As they have a long-term impact on the individual's quality of life, the primary complaint is unbearable pain. The aim of this study was to assess the clinical and functional outcomes of their surgical treatment, and to review their clinical, radiological and therapeutic features. We performed a retrospective study over a 16-year period including 31 patients with an upper limb glomus tumor. Epidemiologic, diagnostic, therapeutic and follow-up data were collected and a functional outcome questionnaire was filled out postoperatively. Thirty-one patients underwent surgery with safe macroscopic resection margins. The glomus tumor was located on the fingers in 77.4% of cases, with predominance in the ring finger (41.9% of the cases). Patient age at surgery ranged from 22 to 80 years old (mean: 54.6) with a sex ratio of 0.48. Upon clinical suspicion, magnetic resonance imaging and ultrasound were done in most cases. Immediate pain relief was obtained in 18 cases. Only one patient underwent a second surgery for incomplete removal and persistent pain. The QuickDASH questionnaire was completed by 24 patients, resulting in a mean score of 1.61, with a mean follow-up time of 88.8 months (range: 3-171 months). Seven patients were lost to follow-up. These subcutaneous, mostly subungual, nodules, with predominance on the ring finger, have a disproportionate negative impact despite their small size. The long-term outcomes after microscope-assisted surgery indicate obvious improvement in the quality of life and the patient's satisfaction, with a very low rate of recurrence.

[Treatment of neurotrophic ulceration following alcohol injection of the gasserian ganglion in trigeminal neuralgia: Case report and review of the literature]. / Traitement de l'ulcération neurotrophique après alcoolisation du ganglion de Gasser dans l'atteinte du nerf trijumeau : cas clinique et revue de la littérature.

INTRODUCTION: Trigeminal trophic syndrome (TTS) can occur after any injury on the fifth cranial nerve. The etiology is dominated by iatrogenic causes, especially after gasserian ganglion ablation. Middle-aged women are mostly involved and the differential diagnosis is vast. PRESENTATION OF CASE: A 88-year old woman presented with TTS and destruction of the right nasal ala 25 years after retrogasserian alcohol injection for trigeminal neuralgia. Facing iterative failure of medical treatment, topics and neurostimulation, we performed lipofilling for the lesion. In the third month, we found a 50 % decrease in size of the lesion, as well as a complete disappearance of pruritus, thus allowing to consider reconstructive surgery. DISCUSSION: Our literature review reports 28 cases of TTS subsequent to alcohol injection of the gasserian ganglion. Age of presentation ranges from 49 to 88 years, with a time of onset between trigeminal injury and TTS ranging from 2 weeks to 17 years. Recurrences are frequent. The management varies a lot according to the authors (topics, antibiotics, flaps), however the efficiency of lipofilling has not been reported yet. CONCLUSION: The pathophysiology of TTS remains unknown, nevertheless the therapeutical care has to be multidisciplinary. Even though not described yet, lipofilling seems to be an interesting treatment of TTS following alcohol injection in the trigeminal ganglion.

[Breast lesions of a metastatic melanoma on a radiotherapy territory: Treatment by vemurafenib and carcinologic surgery]. / Métastases cutanées d'un mélanome sur un territoire de radiothérapie au niveau du sein: traitement par vémurafénib et chirurgie d'exérèse large.

INTRODUCTION: This article describes the unique case of a female patient who presented distant melanoma metastasis on the breast while having irradiation therapy for breast cancer. This happened eight months after the initial treatment for a melanoma of the back (under the right scapula). Furthermore, this case report demonstrates the efficiency of Vemurafenib® as a treatment for late stage melanomas. CASE REPORT: The patient was a 47-year-old female that had a superficial spreading melanoma under the right scapula (Breslow 1.02mm) that was treated with 2cm skin excision and sentinel lymph node sampling that was negative. The melanoma was positive for the BRAF600E mutation. One month after this incident, the patient developed breast cancer that was treated with conservative surgery and radiotherapy. Three months after the end of the irradiation treatment, she developed multiple melanoma metastasis on the skin of the breast. Our multidisciplinary team decided to initiate a treatment with vemurafenib. The patient showed an excellent response, so the surgical team completed the treatment with a radical mastectomy and immediate reconstruction with a pedicled latissimus dorsi flap. The histologic report of the mastectomy specimen showed no sign of melanocytic proliferation, that demonstrates the efficacy of vemurafenib. The patient showed no relapse after two years of follow-up. DISCUSSION: The speed of development and location of cutaneous metastases in this case brought us to think about the effects of radiation therapy on the skin. Radiation therapy causes acute complications (radiodermatitis) by cellular and molecular mechanisms. Moreover, depressed immunity is found after irradiation. Association of these mecanisms could explain the appearance of these metastases in irradiation field. The efficiency of vemurafenib found in our case is consistent with what is described in literature, especially with the improvement in median overall survival. CONCLUSION: This case demonstrates a unique case of distant melanoma metastasis on the irradiation field of a breast cancer. It also demonstrates the efficacy of vemurafenib as well as the efficacy of a radical complementary surgical treatment in these patients.

[Axillary hyperhidrosis, botulinium A toxin treatment: Review]. / Hyperhidrose axillaire, traitement par injection de toxine botulique de type A: revue de la littérature.

Injection of type A botulinum toxin in the armpits is a temporary treatment for axillary hyperhidrosis. This technique described in 1996 by Bushara et al., is known to be efficient and safe. The purpose of this article was to review the data concerning the treatment of axillary hyperhidrosis with botulinum toxin type A, and discuss the other treatment modalities for this socially disabling entity.

[New cutaneous strategy in sural flap surgery and possibility to adapt this technique to other pedicled flaps]. / Stratégie cutanée dans la chirurgie du lambeau sural et possibilité d'adaptation de cette technique aux autres lambeaux pédiculés.

INTRODUCTION: Therapeutic managements in losses of substance of the lower limb using sural flap give an important scar and, sometimes, an impossibility to close the flap donor site. That led us to think about an operative procedure that can reduce those scars without increasing the risk of necrosis of the cutaneous paddle. PATIENTS AND METHOD: We present this operative procedure which underwent in the plastic and reconstructive surgery service in our hospital. Classical flap procedure with two cutaneous parts was used. The cutaneous laxity was evaluated so as to close with one cutaneous part; the other cutaneous part was taken and used like a skin graft after the suture of the calf and the formation of a bursa on the donor site. The leg was closed with only one cutaneous flap. RESULTS: This technique is illustrated by a case report. Results at the 4th month are very interesting with an acceptable scar and a good result of the skin graft. However, with this technique, we don't decrease the venous risk of this flap. We used this technique for an antebrachial flap. CONCLUSION: This technique is an easy and reliable technique based on cutaneous laxity and that decreases scarring of this very useful flap: the neurocutaneous sural flap. We can have a diminution of the number of surgery, a diminution of the scar and good aesthetics results.

Interest of including trauma photography in the picture archiving and communication system of a teaching hospital.

Digital imaging is a daily practice in traumatology. Such photographs should remain confidential. However, there is a need for objectivity concerning the circumstances and clinical follow-up for trauma patients. This paper describes how to conserve these photographs within the picture archiving and communication system (PACS) safely as regards identity and confidentiality. A computer converts the photographs into DICOM files. The DICOM image is associated to a reconciliation layer, validated by the physician in charge, and then included in the hospital PACS. This improves transmission from one medical team to another, both initially and after the accident if an expert medical opinion is required. The literature has demonstrated the value of photographs in modern medicine, but the technical and legal challenges are many. They enhance the computerized medical records. Identification, confidentiality and integration in the PACS are obstacles that we have now overcome.

[Face and neck lift using a superficial musculo-aponeuro­t­ic system (SMAS) plication: Radiological analysis of tissu displacement, a case report].

Objectives: Face and neck lift (FNL) using SMAS plication is a simple and well-known surgical technique. The principle of smas plication from two fixed points allows an important tissue ascension. Our purpose was to objectively evaluate the SMAS plication results, although a common critic may be due to its early deep tissular displacement. Materials and methods: We present the case of a 65 y.o. female patient who received a FNL. Miniature metal pins were placed on the external surface of the SMAS in order to ensure radiological monitoring. A cephalo­metric and photographic monitoring were performed pre­operatively and on day 1, months 2, 6 and 16 postoperatively . We performed a computed numerised analysis of the movement of the markers in an orthogonal axis. Results: All our bearings kept a constant position in the radiographic follow-up , demons­tra­ting the fixity of SMAS kinked 16 months postoperatively. Clinically the correction remained a good appearance with a very slight relaxation of the superficial tissues (skin and subcutaneous fat). Conclusion: In the case of our patient, the tensioning of the deep facial plan (the SMAS) objectively appeared to be efficient over time, with an overall delay of 16 months. Our protocole appeared to be coherent without any specific complication. It permits to objectively differentiate the relaxation of the deep or superfial tissues after a facial lift procedure.

["V" axillary incision for the management of tumors of upper outer quadrant and axillary tail of the breast: retrospective study and technical description]. / Incision en "V" axillaire dans la prise en charge des tumeurs du quadrant supéro-externe et du prolongement axillaire du sein: étude rétrospective et description technique.

INTRODUCTION: Tumors of the upper outer quadrant of the breast represent the most common location of breast malignant tumors. Although the choice of surgical approach should be dictated primarily by an imperative of oncological safety, esthetic and practical considerations of the surgeon as well as the esthetic demands of patients have become increasingly important with the development of breast conservative surgery. MATERIALS AND METHODS: In this retrospective study, we reviewed 30 patients (mean age: 62.3 years) who were operated for a tumor of the upper outer quadrant (50 %) or the axillary tail (50 %) of the breast and who received a "V" axillary incision between 2008 and 2012. The incision draws a "V" that comprises a horizontal incision in an axilla fold associated with a vertical arcuate incision in a Langer line of the breast. The number and type of postoperative complications were collected. Patients were asked about the quality of their scar, position of the areola and breast shape was notified during consultations control. RESULTS: The mean follow-up of patients was 32.7 months. No postoperative complications were observed. A percentage of 86.6 % of patients rated their scar result as excellent. We found no areolar malposition and no morphological deformation of the breast. The surgeons who performed this technique were very pleased with the wide exposure and the uniqueness of this incision fully respecting the architecture of the breast. CONCLUSION: "V" axillary incision is a useful and easily reproducible technical option for the management of tumors of the upper outer quadrant and the axillary tail of the breast.

Severe granulomatous reaction associated with hypercalcemia occurring after silicone soft tissue augmentation of the buttocks: a case report.

UNLABELLED: Liquid silicone is a permanent filler. Its use to augment soft tissues for aesthetic purposes was widespread worldwide in the 1960s. Although initially considered to be biologically inert, this substance may cause, after its injection, an inflammatory granulomatous effect of variable severity and, in very rare cases, a severe hypercalcemia, which can be life threatening. The reported case highlights the well-known physiopathology of hypercalcemia, and the various therapeutic options are discussed. 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 .

[Treatment of Dupuytren's contracture by collagenase injection]. / Traitement des brides de la maladie de Dupuytren par la collagénase injectable.

Dupuytren's disease is a disorder of the palmar aponeurosis responsible for apparition of pathological collagen cords that will gradually lead to a digital retraction. These cords cause functional disability to the hand with a real handicap for the patient. No curative treatment exists currently in this disease. Injections of collagenase from Clostridium histolyticum cause lysis of the collagen present in the cords and cause an interruption of the palmar cord. It is a new treatment in the management of Dupuytren's disease. The use of collagenase injection in the treatment of palmar form of Dupuytren's disease gives good results in the short and medium terms. It is a simple, minimally invasive treatment, several studies have proven its effectiveness and it approximates percutaneous needle fasciotomy in its easy use and its indications. Patients should be well informed about local reactions and transient pain with the injection of C. histolyticum collagenase. Diffusion of this technique is still limited by: the assessment of its cost compared to that of other methods of treatment and particularly the needle fasciotomy, and the evaluation of results over the long-term.

[Intra-osseous ganglion cyst of the carpal bones. A review of the literature underlining the importance of systematic computed tomography]. / Kystes synoviaux intraosseux du carpe : intérêt de la tomodensitométrie systématique pour l'évaluation du risque fracturaire.

The intraosseous ganglion cyst (IOGC) is a benign and lytic bone tumor affecting mostly the metaphyseal and epiphyseal regions of long bones. Its location on the short bones, including the carpal bones has been little reported in the literature. Our review of the literature shows consensus about the surgical techniques to use, but there is currently no real consensus about its pathophysiology, and its diagnostic work-up. Complications related to this lesion (mainly the risk of pathologic fracture) are potentially serious, and can cause irreversible damage. They therefore require accurate assessment to guide the choice of medical or surgical treatment, including a CT scan, which - we believe - is essential.

Modern lipostructure: the use of platelet rich fibrin (PRF).

OBJECTIVES: To evaluate the interest of growth factors adjonction during lipostructure. MATERIALS AND METHODS: Between May 2005 and June 2012, 232 patients benefited from this modern approach of lipostructure with concentrate of platelets. The technique evolves on the simplification way. RESULTS: All the patients were satisfied with the result with minimal associated resorptions. No massive resorption requiring a resumption of lipostructure was noted. CONCLUSION: By offering a matricial support to angiogenesis and by stimulating the proliferation of pre-adipocytes, the PRF could have a beneficial role on the cicatrization and the consolidation of an adipocyte graft.

[Mastectomy and immediate breast reconstruction using a prosthesis and lower dermal flap: description of five cases]. / Mastectomie avec reconstruction immédiate par prothèse et lambeau inférieur dermique : à propos de cinq cas.

INTRODUCTION: When performing mastectomy involving immediate reconstruction with prosthesis, it is required to obtain a complete cover of the implant. However, this is hardly ever possible for patients having a significant breast volume, despite the use of the skin-reducing technique. Using the lower dermal flap makes it possible to fully cover the implant for these patients. PATIENTS AND METHODS: We will describe five cases of patients on whom skin-reducing mastectomy and immediate reconstruction with prosthesis and lower dermal flap were performed. Preoperative drawings were made following the so-called "Saint-Louis" pattern. During surgery, the future skin flap representing the skin cover of lower breast quadrants was de-epidermised. Mastectomy was then performed via an incision at the upper limit of the future flap. Then, a retro-pectoral pocket was created by lifting the pectoralis major muscle. The implant was introduced into this pocket and covered up at its lower part by the dermal flap, the upper edge of which was sutured to the lower edge of the pectoralis major muscle. The implant was thereby fully covered. Finally, the skin was closed with inverted T-scars. RESULTS: Postoperative effects were minor. Two patients suffered from skin pain at the junction between the vertical and horizontal scars of the inverted T. These injuries were treated via healing by secondary intention. We have not observed any infection. Cosmetic results assessed by the patients and surgical team were considered as satisfactory. CONCLUSION: Mastectomy with immediate reconstruction using a prosthesis and lower dermal flap makes it possible to fully cover the implant in patients who require the skin-reducing technique. This technique seems to minimise the risk of major complications and generates satisfactory cosmetic results.

[Functional impairment and its impact on sporting activities after latissimus dorsi flap breast reconstruction]. / Séquelles fonctionnelles et impact sur la pratique sportive de la reconstruction mammaire par lambeau de grand dorsal.

AIM OF THE STUDY: The latissimus dorsi flap is commonly used for breast reconstruction. Donor site morbidity is the major side effect of this surgery. However, if the impact of the latissimus dorsi muscle removal on daily living activities has already been studied, few data are available about its consequences on sporting activities. MATERIAL AND METHOD: Our retrospective monocentric study reviewed 75 consecutive female patients who underwent latissimus dorsi muscle transfer for breast reconstruction with a mean follow-up of 32.4 months. Patients had to answer a questionnaire per phone about their sporting, daily living and working activities before and after surgery. If they felt any changes after surgery, the type of limitation was detailed (pain, strength, endurance). RESULTS: We showed a reduction in sporting activities for 43% patients practising a sport using the upper limb compared to 19% for them using the lower limb (P<0.05%). Eighty-three percent of the patients felt restricted for at less one activity of daily living. 5.2% had to adapt their working conditions after surgery. CONCLUSION: The reduction in sporting activities using the upper limb after surgery suggests a negative impact of the surgery. However, other factors than the latissimus dorsi muscle removal might contribute to this reduction.

[Interest and reliability of frozen section biopsy in the treatment of skin tumors]. / Intérêt et fiabilité de l'examen extemporané dans la prise en charge des tumeurs cutanées.

INTRODUCTION: Association of surgical treatment combined to frozen section biopsies appears to be one of the most appropriate therapeutic solution for the treatment of skin carcinomas. We report our experience on 269 tumors assessed with frozen sections. Our goal was to first study the benefit of a one-time surgical approach, then to better target the tumors eligible for this examination and finally to number the difference between frozen section and final histology studies. MATERIALS AND METHODS: This is a retrospective analysis of 269 tumors, operated on an outpatient basis with frozen section followed later by a final histology study. All being performed by the same team of surgeons and pathologist. Only previously biopsied and diagnosed basal cell or squamous cell tumors were included. The recorded data were: location of tumor; histological type; involved margins; number of cuts; differences between frozen section and final histological studies, which conduct to a two-time surgical approach; number of tumors for which frozen section was impossible during surgery and that lead to a two-time surgical approach; type of reconstruction; number of recurrence. RESULTS: The follow up was 48 months (26.6 to 78.1). Histogical analyses were carried on basal cell carcinoma (92%), squamous cell carcinoma (8%) with a topographic distribution mainly in face and neck (72%). Of the 269 tumors excised, 207 representing 77% had a sufficient safety margin, 62 representing 23% had at least one invaded bank that required further surgical resection. We found seven cases of two-time surgical approach. In three cases, it was secondary to medical decision because of a technical difficulty of histologists. In one case, histological diagnosis can't be obtained by frozen section study. In three cases, we found a difference between frozen section and final study. CONCLUSION: The benefit provided by the frozen section takes its value in the treatment of face and neck tumors, whose optimal margins are sometimes difficult to obtain and minimal scar ransom necessary. A one-time surgery was made possible to us thanks to this fast examination. The low rate of second surgery and recurrence allows us to demonstrate the reliability of this technique.

[Study of skin retraction applied to the treatment of skin tumors. Mapping of the human body]. / Étude de la rétraction cutanée appliquée à la prise en charge des tumeurs cutanées. Cartographie du corps humain.

SUBJECT: Skin, the main organ of the human body, is equipped with own biomechanical characteristics, highly variable depending on intra-individual factors (location, weight status, dermatological diseases…) and interindividual (age, sex…). Despite some recent cutometric studies, our review of the literature shows that there is no currently reliable analytical model representing the biomechanical behavior of the skin. Yet, this is a central issue in dermatology surgery, especially in the treatment of skin tumors, for the proper observance of surgical margins. PATIENTS AND METHODS: We studied prospectively on 75 resection specimens (about 71 patient(s)), for the treatment of skin lesions tumor suspicious or known malignant or benign. Room dimensions were measured before and 5 minutes after excision, leading us to calculate a ratio of retraction of the skin surface. This retraction was correlated with age, gender, tumor type, and anatomic location of the site of excision. RESULTS: The power of retraction of the skin varies significantly by region of the body. It is maximum in the upper limb (hand excluded) and in the cervical region. At the cephalic region, skin of the ear and periorbital skin have capacities of important early retraction. Unlike the lower limb (foot excluded), the back skin of the nose and face appear to be a minimum of shrinkage. Age also seems to change on that capacity shrinkage, sex would have no influence. CONCLUSION: Our study confirms the variations in the ability of skin retraction based on a number of factors. In dermato-oncology, that power retraction could cause significant differences between clinical surgical margins and final pathologist margins. We believe it must be taken into account by the couple surgeon-pathologist, especially in the context of invasive and/or recurrent tumors.