Covering of wound infection in hip arthroplasty with local cutaneous flaps.

Total hip arthroplasty is a very common procedure to treat osteoarthritis. One of the complication is the infection which occurs in about 1% of the cases. The manifestation of infection can be poor wound healing with dehiscence and exposition of bone or prosthetic components. Hip arthroplasty infections are difficult to treat. It required an associated multidisciplinary approach with infectiology, orthopedic and plastic surgeries. The study included five patients with hip wound dehiscence after total hip arthroplasty. Coverage after orthopedic surgery was provided by local cutaneous flap. These cutaneous flaps were either a deep inferior epigastric perforator flap (DIEP) or a transposition flap. The orthopedic and the plastic treatment were done at the same time. Two deep inferior epigastric flaps were performed for patients with a deep defect with bone or prosthesis exposure. Four transposition flaps were done in three patients with wound dehiscence but without direct contact with the prosthesis. Three transposition flaps were done from the abdominal wall and one from the posterior thigh. The mean follow up was 18 months, ranging from 10 to 24months. After healing, there was no recurrence of the infection. In all cases, the coverage was obtained. The prosthesis was salvage and the gait was possible. Cutaneous flaps are easy and safe to cover the hip. They are reliable flaps even in patients with multiple co-morbidities. They do not cause sequelae on the recipient site. This study is the first about cutaneous flap for covering hip defects in hip arthroplasty infections.

Satisfaction survey of secondary rhinoplasty among unilateral cleft lip and palate patients.

Secondary rhinoplasty on patients with cleft is a challenging procedure, and the most important criterion for evaluating the surgery success is patient satisfaction even if it's subjective. OBJECTIVES: To evaluate patient satisfaction following secondary cleft rhinoplasty with a specific assessment for patients with Unilateral Cleft Lip and Palate (UCLP). PATIENTS AND METHODS: Our retrospective cross-sectional study is composed of 29 patients with UCLP with a mean age of 23years old, who underwent secondary rhinoplasty between 2010 and 2021 in our department. The survey was conducted postoperatively using a cleft-nose specific custom designed questionnaire based on the Byrne questionnaire, over the phone. This satisfaction questionnaire comprises six questions about physical appearance and one question about functional aspect. Patients were asked to answer "yes" or "no" or to rate from 0 (no improvement) to 10 (perfect result) depending on the question. RESULTS: Twenty out of 29 people responded to the questionnaire, representing an answer rate of 69%. The average score given by the patient for nasolabial scar improvement was 7.2/10, and the one concerning global improvement was 8.2/10. All patients would be ready to undergo the same procedure again, knowing the final result. A functional improvement concerning breathing or snoring was reported in 45% of cases. All dorsum or tip issues were improved after surgery (P=0,07). CONCLUSIONS: Our results demonstrate high patient satisfaction after cleft rhinoplasty, which encourages the continuation of this surgery. We would recommend the use of this simple questionnaire to allow a more accurate evaluation of patient outcomes.

Unilateral cleft nose deformities at adulthood.

Secondary rhinoplasty is a challenging procedure, requiring a precise preoperative diagnosis of nasal deformities before correcting them. As there is currently no accepted outcome measurement tool available to assess unilateral cleft lip and palate (UCLP) nose sequelae before secondary rhinoplasty. The goal of this retrospective study is to identify the nose deformities and rate them in an evaluation scale that allows collecting and analyzing cleft nose data. Our retrospective cohort is composed of 29 patients with UCLP, who underwent secondary rhinoplasty between 2010 and 2021 in a cleft center, with a mean age of 23years old. Evaluation of deformities is made from preoperative two-dimensional photography. The assessment photographic tool is a custom-designed scale of 16 items. A binary scoring system is used by two experts to assess nasolabial deformities. The most encountered sequelaes are the alar foot displacement (93%), the enlarged tip (90%) and the nostril horizontalization (86%). The inter-examiner ICC for total rating was calculated at 0.911 and indicated a strong level of reliability that was highly significant (P<0.05). The simplicity, reliability and reproducibility of the proposed assessment system could be interesting for clinicians, in order to diagnose the nasal deformities before surgery, but also to assess postoperative success of a secondary rhinoplasty and thus to compare several surgical techniques.

[Deep inferior epigastric pedicle for microsurgical free flap transfer for contralateral thigh root coverage]. / Utilité du pédicule épigastrique inférieur profond pour le branchement microchirurgical de lambeau libre pour la couverture de la racine de la cuisse controlatéral.

Thigh loss cover after carcinologic resection of sarcomas can be complex and compromise the vascular tree of the lower limb. We report a case of a patient with recurrent sarcoma of the right thigh. After multiple resections, the femur and hip joint are exposed. The superficial and deep femoral vessels are taken in the excisional piece. The reconstruction is performed by a free musculocutaneous latissimus dorsi flap, anastomosed to the deep inferior controlateral epigastric vessels. The deep inferior epigastric vessels are of sufficient length to join the contralateral hemiabdomen after dissection with a gauge allowing microsurgical anastomoses. They can serve as recipient vessels for a flap covering the contralateral thigh.

[A pedicled deep inferior epigastric flap to cover a hip arthroplasty infection]. / Couverture d'une prothèse de hanche infectée par un lambeau perforant épigastique inférieur profond pédiculé.

The deep inferior epigastric perforator (DIEP) flap is a reliable flap mostly used in skin resurfacing after signifiant resection for sarcoma or correction contour deformities. This case is about a pedicled DIEP flap covering the trochanteric region after a total hip arthroplasty infection. A 62years old woman with a BMI at 42kg/m2 presents an infected total hip arthroplasty with a cutaneous defect. The hip prosthesis is changed and covered with a pedicled DIEP flap. This original case reports the used of pedicled DIEP flap in hip coverage. This local fasciocutaneous flap covered the hip osteoarticular infection. The limb is salved and the patient can walked again. The success of this surgery is the collaboration between infectious disease specialist, orthopedic surgeon and plastic surgeon.

[Reverse abdominoplasty in the presence of bi-subcostal scar: Technical note]. / Abdominoplastie inversée en présence d'une cicatrice bi-sous-costale : note technique.

INTRODUCTION: The presence of horizontal supraumbilical scars increases the risk of vascular complications after a large abdominoplasty. We present here a technique of abdominal dermolipectomy with umbilical transposition called « reverse ¼, in the presence of a bi-subcostal scar. TECHNICAL NOTE: The reverse abdominoplasty technique consists in uninserting the umbilicus, detaching the supra-umbilical and sub-umbilical soft tissues by assessing the existing bi-subcostal scar in order to pull the skin upwards, and to remove the supra-umbilical excess skin, before bringing the umbilicus back to its proper position. DISCUSSION: This technique is a good alternative to perform an abdominal dermolipectomy in a patient with a history of bi-subcostal scarring without increasing the risk of abdominal skin necrosis, and without complicating or lengthening the conventional surgical procedure, provided that the upper redraping is achievable with sufficient upper excess skin and laxity.

[Medical photographs: Time saving and data security thanks to a dedicated application]. / Photographies médicales : gain de temps et sécurité des données grâce à une application smartphone dédiée.

INTRODUCTION: Medical photography, ubiquitous in plastic surgery, provides essential information to the medical record. Smartphones have become the preferred tool for acquiring these photographs, but cause a data security issue. Furthermore, the management of photographs is frequently manual and time-consuming. The Pixacare software suite has been designed to meet this need in complete security. It includes a mobile application, a web application and a HADS server. The objective of the study was to calculate the time saved by the Pixacare application at the time of data acquisition. PATIENTS AND METHODS: This prospective and monocentric study was carried out in two steps in order to time the acquisition times with the usual method and with the Pixacare mobile application. Each phase included 89 patients recruited in plastic and maxillofacial surgery consultation with four surgeons. The number of patients and the average number of photographs per patient were comparable for each practitioner in both phases. RESULTS: The acquisition time of the photographic data was divided by 3.77 (P<0.001). With the usual method, the average acquisition time was 259seconds, compared to 69seconds with the Pixacare application, saving 3minutes and 10seconds per patient. CONCLUSION: The Pixacare software suite saves the surgeon significant time while ensuring appropriate data security. This study does not take into account the additional time saved by organising medical meetings, the benefits of sharing photographs between healthcare professionals and the efficiency of secure messaging.

[Shape and aesthetic outcome evaluation of transposed umbilicus according to four surgical procedures]. / Évaluation de la forme et du résultat esthétique d'ombilics transposés selon quatre techniques chirurgicales.

INTRODUCTION: In abdominal plastic surgery, umbilicus is frequently transposed, generating scars and shapes variating with the techniques used. Various umbilical transposition techniques have been described, all of them attempt to reproduce the "ideal" umbilicus. This study aimed to define the shape and the aesthetic results obtained with four different surgical procedures, in order to choose an "ideal" umbilical transposition technique. PATIENTS AND METHODS: This retrospective study analyzed the characteristics of transposed umbilicus, in 50 patients who had undergone abdominal dermolipectomy for aesthetic reason, after a loss of weight or in breast reconstruction by Deep-Inferior-Epigastric-Perforator. Four surgical procedures were chosen, which differed by their counter-incision shape in the abdominal flap (Y, inverted Y, de-epidermized round with horizontal incision or U), and the deep points position of umbilical docking (along a horizontal or vertical axis). Shape and depth were evaluated by a panel of experts. The global assessment was based on a double evaluation, by the surgical jury and the patients themselves. RESULTS: The counter-incision type determined the umbilicus shape: triangular for the Y (60%) or inverted-Y (41%), round for the U (52%) and vertical oval (67%) or round (32%) for the de-epidermized circle. The deep points position influenced the umbilicus axis. Regarding the appreciation, the de-epidermized circle had the best results for surgeons in a significant way, and for patients (respectively 72% and 100% satisfied), followed by the inverted-Y (57% and 92%) and Y techniques (55% and 89%) and at last the U (50 and 75%). CONCLUSION: Horizontal counter incision in a de-epidermized round, with two anchoring points on a vertical axis, generates vertical oval or round shaped umbilicus, considered attractive in the literature, and giving the highest aesthetic satisfaction for both surgeons and patients.

Accuracy of mammography, sonography and magnetic resonance imaging for detecting silicone breast implant ruptures: A retrospective observational study of 367 cases.

INTRODUCTION: The purpose of this study was to assess the efficacy of magnetic resonance imaging, ultrasound and mammography in detecting breast implant rupture. METHODS: This retrospective study included all cases of breast implant revision. Implant integrity was determined preoperatively by magnetic resonance imaging, ultrasound and mammography. The primary study endpoint was the surgical finding. The sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratio of the tests were evaluated. RESULTS: Two hundred and thirty-four (234) patients were included; 213 mammographies, 295 ultrasounds and 160 magnetic resonance imagings were carried out. While 114 clinical ruptures were confirmed, 253 implants remained intact. Magnetic resonance imaging was the most sensitive (99%); outperforming mammography (sensitivity: 70%). Mammography was the most accurate in diagnosis of intact implant (specificity: 93%), and magnetic resonance imaging was second (specificity: 78%). Ultrasound was rated intermediately. Positive mammography signifies a rupture in 84% of cases, whereas magnetic resonance imaging (positive predictive value: 78%) can be mistaken in 20% of cases. Negative ultrasound and magnetic resonance imaging rule out a rupture (negative predictive value of 93% and 99% respectively). Mammography and ultrasound are more accurate than magnetic resonance imaging in diagnosing implant rupture (positive likelihood ratios of 9.78, 8.24 and 4.44 respectively). Magnetic resonance imaging provides convincing affirmation of implant integrity (negative likelihood ratio: 0.02). CONCLUSION: Ultrasound seems to be the most reliable imaging method for patients younger than 50 years. In cases where doubt exists, mammography ensures supplementary assessment. In patients over 50 years of age, mammography and ultrasound should be carried out immediately. If necessary, magnetic resonance imaging rules out a hypothesized rupture.

[Concomitant breast surgery with a vertical latero-thoracic incision in continuity with a brachioplasty incision: About twelve (12) cases after massive weight loss]. / Plastie brachio-thoraco-mammaire : à propos de 12 cas après amaigrissement massif.

INTRODUCTION: The need of iterative surgeries, the proximity of two anatomical areas, the combination of an aesthetic surgery with a surgery covered by health insurance are the reasons which motivated the authors to provide a simultaneous procedure on arms and breast in patients achieving massive weight loss. We propose a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision to treat the excess skin and subcutaneous tissue of the lateral chest wall, either by resection, or by increasing the breast with the patients own autologous tissue. METHODS: Between 2010 and 2017, twelve patients aged between 31 and 56 years, with 42 being the average, have undergone a technique that utilises a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision: transverse skin incisions and free nipple transplantation for correction of extreme gynaecomastia (2 cases), mastopexy with resection of the excess tissue of the lateral chest wall (8 cases), autologous breast augmentation by the use of intercostal artery perforator flaps (2 cases). Mean body mass index (BMI) was 24kg/m2 [23; 32] after average weight loss of 56kg [14; 112] following diet (3 cases) or bariatric surgery (9 cases). RESULTS: Mean operative time was 4hours [3: 6], mean length of hospital stay was 4 days [2; 9]. We observed one major complication (hematoma) and one minor complication (wound dehiscence). At a mean follow-up of 21 months (ranged from 15 days to 84 months), the lateral flank scarring was well tolerated, with the additional benefit of reducing flank fullness. CONCLUSION: The extended lateral flank scar allows reducing the excess skin and subcutaneous tissue of the lateral chest wall, while being easily concealable. This technique offers an elegant solution to this excess that used to persist after multistage surgeries.

The palatal mucosal graft: The adequate posterior lamellar reconstruction in extensive full-thickness eyelid reconstruction.

INTRODUCTION: Full-thickness eyelid defects exceeding 25% of the eyelid width should benefit from a skillful, immediate and simultaneous reconstruction of two layers; anterior and posterior lamella. In this article, we recall, through an original series of cases, the possibility of using a palatal fibromucosal graft during the reconstruction of the posterior lamella as well as the modalities of its optimal use. PATIENTS AND METHODS: Retrospective study, including 8 patients with an extensive full-thickness eyelid defect affecting more than half of the upper and/or lower eyelid, after tumor excisions. 4 cases were involved in lower eyelid reconstruction, 2 in upper one and 2 in both. Posterior lamella was reconstructed using a palatal mucosal graft. Anterior lamella was reconstructed using different flaps: Esser-Mustardé flap, medially and laterally based orbicularis oculi myocutaneous flap, Tripier and orbitonasolabial flaps. Mean follow-up was 12.75 months. RESULTS: The survival rate of grafts and flaps was excellent with only one flap border necrosis. The donor site healed in an average time of 3 weeks. Functional recovery, complete eye closure and opening, was obtained in all cases. Lining, texture and color was considered satisfactory in all cases. CONCLUSION: The palatal mucosal graft provides a good and lasting structural support to the eyelid, which is essential for the inferior eyelid, especially when combined with a flap. Slight overcorrection is recommended.

[Thirty-six (36) French cases of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): What do we know about their prosthetic histories, and what conclusions may be drawn?] / Trente-six cas français de lymphomes anaplasiques à grandes cellules associés aux implants mammaires. Que savons-nous sur leur histoire prothétique ?

INTRODUCTION: Breast implant-associated anaplastic large cell lymphoma is a recent pathology; the one known risk factor is breast implantation. METHODS: A retrospective study was conducted on the French BIA-ALCL cases diagnosed by the Lymphopath network and reported to the National Medical Safety Agency (ANSM). Wishing to obtain supplementary data on the prosthetic history of implants, we sent the referent surgeons a questionnaire. RESULTS: By combining the relevant ANSM data and questionnaire data, we studied the histories of 32 unilateral cases of BIA-ALCL and 2 bilateral cases of BIA-ALCL. Mean patient age on diagnosis was 59 (29; 83). Twelve BIA-ALCL cases occurred after breast augmentation for esthetic purposes, 22 following mastectomy for neoplasia and 2 after symmetrization of the contralateral breast in reconstruction. Fifteen BIA-ALCL cases were diagnosed on single prostheses, all of them macrotextured with macrotexturing obtained by projection of biocell salt crystals, also known as the biocell "salt loss" technique. The other 21 BIA-ALCL cases were diagnosed on multiple prostheses (2 to 5), and all of them had had at least one contact with a biocell implant. Mean duration of exposure to implants was 11 years (4; 31). Mean duration of exposure to the macrotextured shell surfaces obtained by the salt loss technique was 9 years (2; 23). Six patients were exposed to a temporary macrotextured Expander implant obtained with the aforementioned salt loss technique. No patient was exposed to the macrotextured Expander implant alone. CONCLUSION: Salt loss macrotextured implants, particularly those of the biocell-type, were found in the prosthetic history of all 36 BIA-ALCL cases in this series.

[Secondary surgery of abdominal dermolipectomies]. / La chirurgie secondaire des dermolipectomies abdominales.

The abdominoplasty (AP) is a common type of plastic surgery procedure that removes unsightly and uncomfortable cutaneous and fatty excess from the anterior abdominal wall. In 30% of the cases, the results prove to be insufficient and motivate a request for reintervention which goes from the simple cicatricial revision under local anesthesia to the complete recovery of the procedure. The defects at the origin of the secondary abominoplasty are persistent skin excess, residual fat deposits, scarring malpositions or abnormalities of the umbilicus. The respect of certain technical rules during the primary AP are likely to limit the postoperative defects at the origin of these surgical revisions. When an imperfection of result is found postoperatively, the methodical clinical analysis of the defect will allow in determining the cause and to choose the most adapted corrective solution in order to obtain finally the satisfaction of the patient.

[Oncoplastic breast surgery]. / Chirurgie oncoplastique du sein.

Oncoplastic surgery is to treat breast tumors with the help of plastic surgery. Efficiency of breast-conserving treatments (BCT) compared to mastectomies is equivalent. BCT is better accepted but can cause breast deformity, thus further operations. Oncoplastic surgery aims at conserving an acceptable shape to the breast. It ranges from simple remodeling to more complex techniques modifying the width of the breast. According to the quadrant to treat (inner upper, outer upper, inner lower, outer lower, union of quadrants, tumors of the nipple-areola complex, tumors of the inframammary fold), according to the proximity of the tumor to the nipple, and to the size of the breast and tumor, various techniques are displayed. Few touch ups are necessary. Symmetry is managed during the initial operation or after.

[Breast reconstruction with free flap of gracilis]. / La reconstruction du sein avec le lambeau libre de gracilis à palette cutanée transversale (TMG flap).

Breast reconstruction with free flap of gracilis has been described since 2004. The procedure consists in harvesting a flap made of the gracilis muscle and a transverse cutaneous paddle originating from the internal root of the thigh. The pedicle of the flap is the main pedicle of the gracilis muscle. After weaning, the vessels are anastomosed to the internal thoracic artery and vein. The modeling of the breast is done by folding the cut points in front of the muscle to obtain the shape of a cone. This surgical technique allows the realization of autologous breast reconstructions of small to medium size, immediate or delayed, unilateral or bilateral.

[The reconstruction of the nipple-areolar]. / La reconstruction de l'aréole et du mamelon.

The reconstruction of the nipple-areolar complex is the final stage of breast reconstruction that restores the visual identity of the breast. The most common options for reshaping the areola are tattooing, total skin grafting of the inner thigh and the total skin graft taken from the contralateral areola. Nipple reconstruction solutions include duplication of contralateral nipple, local flap, total skin graft and tattoo in three-dimension. Duplication of the nipple is the technique of choice because it immediately offers optimal color, texture and projection. The areolar tattoo is the most common procedure for its simplicity and reproducibility.

[Breast reconstruction by latissimus dorsi myocutaneous flap and implant: The dorsal bra technique]. / Reconstruction mammaire par lambeau musculo-cutané de grand dorsal avec prothèse : la technique du soutien-gorge dorsal.

Despite the development of microsurgical techniques, latissimus dorsi myocutaneous pedicle flap remains mainly used in breast reconstruction surgery. It is reliable and could be performed on almost all the patients, even if they smoke. It is also a good indication in case of irradiation. The technical alternative, which combines latissimus dorsi myocutaneous flap and an implant, allows the reconstruction of the expected volume and enables controlateral implant augmentation if the patient desires. The dorsal skin paddle increases the cutaneous pocket. The muscle in-depth enhances the irradiated skin and protects the implant. Positioning the skin paddle on the breast area is essential: it should be based on the mastectomy scar or on an added contraincision barring it. Thus it allows the muscle to embrace the implant as a bra. The precise reference points helping the placement of the flap could be reproduced and ensure pleasant and stable results over time.

[Results album]. / L'album des résultats.

This document is meant to be a practical guide for the surgeon, to assist him in informing the patient more easily. Different clinical results with different reconstructive techniques and different morphologies are presented. This document is not meant to be a catalogue, or to guarantee any result to the patient, but truly to assist as best as it can the surgeon and the patient in choosing together the most appropriate techniques on a visual basis.

[Clinical and morphological indications for delayed breast reconstruction]. / Les indications cliniques et morphologiques des reconstructions mammaires différées.

A full range of breast reconstructions procedures exists and had to be proposed within a surgical team, from the simplest to the most complex. The choice of the technique is simply based on the discussion between the surgeon and the patient during a consultation. A computed tomographic angiography might be required in the case of DIEP flap reconstruction. The surgeon bases his decision on a clinical exam of the breast area, the quality of the tissues and looks for potential flaps or fat donor sites. The patient expresses her expectations in terms of breast volume, form and is clearly informed about potential risks and follow-up. Thus the surgeon could propose the most adequate procedure in the case of the patient, who will take the final decision. The surgeon should ensure to find the most adapted procedure to each individual. A well-determined indication will lead to a truly satisfied patient, which is the main goal of breast reconstruction. We decided to present this dialogue and the path towards the final choice in a fun and original format.

[Back loss cover in orthopedic surgery by helical lumbar perforator flaps: About 6 cases]. / Couverture des pertes de substance du rachis en chirurgie orthopédique par des lambeaux perforants lombaires en hélice : à propos de 6 cas.

INTRODUCTION: The existence of voluminous paralumbar perforators allows a simplification of the coverage of the lumbar region. MATERIALS AND METHODS: The authors present a series about lumbar loss substance following orthopedic surgery, from 2012 to 2017. Coverage was provided by a fascio-cutaneous lumbar perforator flap. RESULTS: Six patients were operated with mean age of 62.3 years, with an average follow-up of 16 months (up 6 to 41 months). Substance losses were secondary to a carcinologic excision, to a radiodermitis excision and to four debridements after infection of the operative site. In five cases, the reconstruction was performed by one lumbar perforator flap, and in one case by two lumbar perforator flaps. The average size of the substance losses was 171.91 cm2 (up 78 to 250 cm2). The average size of the flaps taken was 161 cm2 (up 50 to 250 cm2). The donor site was self-closing without sequelae. The postoperative sequences were simple and marked by a single partial necrosis of a flap, with a favorable evolution after directed healing. The quality of the cover was good with excellent trophicity. CONCLUSION: Lumbar perforator helical fascio-cutaneous flaps are a reliable means of covering the loss of substances in the lumbar region. The use of these flaps makes it possible to avoid the taking of complex myo-cutaneous flaps, causing sequelae of the donor site in a location difficult to cover.