[Secondary surgery of the external ear]. / Chirurgie secondaire du pavillon de l'oreille.

Secondary surgeries of the external ear can be divided into two categories: secondary otoplasties and secondary ear reconstructions. The most frequent causes of secondary otoplasties are a recurrence, an over-corrected ear, an off-center ear, a prominent lobule, and finally chronic ear pain. Recurrence of the prominence can be treated by a new posterior stitch otoplasty, an Earfold clip, or a frame stitch. The over-corrected ear can be projected either by costal cartilage grafts or by hyaluronic acids. Patients who are unsatisfied of the aesthetic result of their prominent ear correction usually complain about an off-centered ear, because the ideal ear axis is parallel to the cheek. A prominent lobule can be corrected with a posterior stitch and a VY flap. Chronic ear pain can be significantly reduced by a protocol of physiotherapy with positive sensory feedback. In ear reconstruction, it is important preserve the retroauricular skin and the superficial temporal fascia, which are the workhorses of ear reconstruction. Secondary ear reconstructions are usually very complex procedures, which should be performed by specialists.

[Forehead rejuvenation]. / Le rajeunissement du front.

The goal of this article is to provide a systemic approach to forehead rejuvenation. Fillers, botulinic toxin injections, transpalpebral, endoscopic or bicoronal brow lift must be usual techniques for every plastic surgeon in overall facial rejuvenation. Achieving a long lasting and aesthetically pleasing forehead is possible only with surgical techniques when aging is obvious.

[Auricular malformations]. / Malformations de l'oreille.

Reconstruction of complex auricular malformations is one of the longest surgical technique to master, because it requires an extremely detailed analysis of the anomaly and of the skin potential, as well as a to learn how to carve a complex 3D structure in costal cartilage. Small anomalies can be taken care of by any plastic surgeon, providing that he/she is aware of all the refinements of ear surgery. In this chapter, we analyze retrospectively 30 years of auricular reconstruction, ranging from small anomalies to microtia (2500 cases), excluding aesthetics variants such as prominent ears.

A new strategy for prophylactic surgery in BRCA women: Combined mastectomy and laparoscopic salpingo-oophorectomy with immediate reconstruction by double DIEP flap.

BACKGROUND: Prophylactic surgery remains the most effective modality for reducing both breast and ovarian cancer rate in woman at high risk, such as BRCA1 or BRCA2. Autologous breast reconstruction with bilateral deep inferior epigastric perforator (DIEP) flap allows predictable and durable results. However, existing two-step approach separating salpingo-oophorectomy and reconstruction could even make DIEP flap impossible, or make insufflation more difficult during laparoscopy. Other authors described one-step procedure but with open laparotomy. The goal of this study was to verify the feasibility of a simultaneous procedure, including laparoscopic salpingo-oophorectomy. METHODS: We included BRCA mutation careers scheduled for simultaneous laparoscopic salpingo-oophorectomy, and bilateral breast reconstruction with DIEP flaps. The first step of the procedure was laparoscopic salpingo-oophorectomy and ports had to be strategically placed to avoid interference with the following procedure. The second step was bilateral breast reconstruction with DIEP flaps. We reviewed medical charts. Surgical procedure was analyzed for duration, revisions and surgical complications. RESULTS: During 1-year period, eight patients agreed to a simultaneous procedure. All of them were BRCA positive, mean age was 38.3years (range, 39-50), and mean BMI was 28.3kg/m(2) (range, 21-33). The mean duration of the entire procedure was 524minutes (range, 405-630) and the mean hospital stay 9.2 days (range, 8-14). There was 100% flap survival. No abdominal wall dehiscence occurred. CONCLUSION: One-step procedure for prophylactic surgery of ovarian and breast hereditary malignancies is feasible. First salpingo-oophorectomy with open laparoscopy then bilateral immediate or delayed breast reconstruction with DIEP flaps can be performed.

[Setting of a breast autologous microsurgical reconstructive surgery evolution in 20 years and review of 1138 cases]. / Mise en place d'une activité de reconstruction microchirurgicale du sein par tissus autologues. Évolution sur 20 ans et revue de 1138 cas.

UNLABELLED: The authors conducted a retrospective study of breast reconstruction with DIEP free flap between 1994 and 2014 by a single team. MATERIAL AND METHOD: A retrospective analysis of all operative charts and hospitalization was conducted for the period from 1994 to 2014. The number of cases per year, the complication rate of the donor site and recipient site, and surgery time were recorded. Sequence analysis was conducted to determine the elements that have enabled to implement this technique reliably and effects of the learning curve. The series was split into two periods (1994/2011 and 2012/2014) corresponding to two different hospitals with the same team. RESULTS: The total number of shreds of 1138 between November 1994 and December 2014 respectively with 477 and 661 the period 1994/2011 to 2012/2014 period. The failure rate increased from 8% to 2.2%. CONCLUSION: The establishment of units mainly dedicated to microsurgical reconstruction can offer the DIEP technique reliably and reproducibly.

Percutaneous gene therapy heals cranial defects.

Nonhealing bone defects are difficult to treat. As the bone morphogenic protein and transforming growth factor beta pathways have been implicated in bone healing, we hypothesized that percutaneous Smad7 silencing would enhance signaling through both pathways and improve bone formation. Critical sized parietal trephine defects were created and animals received percutaneous injection of: agarose alone or agarose containing nonsense or Smad7 small interfering RNA (siRNA). At 12 weeks, SMADs1, 2, 3, 5, 7 and 8 levels were assessed. Smad1/5/8 osteogenic target, Dlx5, and SMAD2/3 angiogenic target, plasminogen activator inhibitor-1 (Pai1), transcription levels were measured. Noncanonical signaling through TGFß activated kinase-1 (Tak1) and target, runt-related transcription factor 2 (Runx2) and collagen1α1 (Col1α1), transcription were also measured. Micro-computed tomography and Gomori trichome staining were used to assess healing. Percutaneous injection of Smad7 siRNA significantly knocked down Smad7 mRNA (86.3 ± 2.5%) and protein levels (46.3 ± 3.1%). The SMAD7 knockdown resulted in a significant increase in receptor-regulated SMADs (R-SMAD) (Smad 1/5/8 and Smad2/3) nuclear translocation. R-SMAD nuclear translocation increased Dlx5 and Pai1 transcription. Additionally, noncanonical signaling through Tak1 increased Runx2 and Col1α1 target transcription. Compared with animals treated with agarose alone (33.9 ± 2.8% healing) and nonsense siRNA (31.5 ± 11.8% healing), animals treated Smad7 siRNA had significantly great (91.2 ± 3.8%) healing. Percutaneous Smad7 silencing increases signal transduction through canonical and noncanonical pathways resulting in significant bone formation. Minimally invasive gene therapies may prove effective in the treatment of nonhealing bone defects.

[Neglected skin tumors. Three cases]. / Tumeurs "historiques": tumeurs négligées. Trois observations.

BACKGROUND: Giant skin tumours are defined as greater than 10 cm in size and are frequently a consequence of neglect. We report three cases of giant skin tumours and discuss possible factors associated with delayed diagnosis and treatment. OBSERVATIONS: Two men and one woman, aged 52, 62 and 78 years, presented with giant skin tumours. One was mentally retarded, one had a borderline personality and another was presenting a major depressive disorder. Pain, smell, bleeding and/or loss of function forced the patients to seek medical care. Tumour sizes were 11 to 30 cm and were present for between six months and 20 years. All patients had hidden their lesion from their doctor and families. In one case, a sebaceous carcinoma of the right shoulder required amputation of the right upper limb. In a second, palliative surgery and medical care was given for a metastatic porocarcinoma. The last patient received neoadjuvant chemotherapy for an undifferentiated carcinoma. DISCUSSION: Neglected skin tumours continue to be encountered even in 2011. Consultation was delayed due to fear of the diagnosis and/or lack of corresponding physicians, resulting in worsening of the prognosis. A larger scale study could help us to identify the factors associated with neglected giant tumours and to improve their management.

[Reconstruction of the burned ear]. / La reconstruction auriculaire en cas de destruction par brûlures.

BACKGROUND: The external ear is a complex, delicate structure and treatment of burned ears should not be neglected. We will detail the different scenarios a surgeon can encounter and present a therapeutic algorithm. PATIENTS AND METHODS: From 1984 to 2011, we operated 134 patients for ear deformities secondary to burns, of which 90 cases were unilateral (67%) and 44 cases bilateral (32%), accounting for 178 ear in total. Our two-stage technique is based on an autologous cartilage framework, covered by mastoid skin, superficial temporal fascia (STF) or indirect skin expansion, and later by elevation of the construct. RESULTS: Costal cartilage is the ideal support when loss of substance is greater than one quarter of the ear pavilion and/or two plans. Mastoid skin integrity is the best factor of prognosis when planning an ear reconstruction. If injured, the STF can be used. If the STF has been injured as well, indirect expansion represents the last option before placement of prosthesis. Free contralateral STF is rarely an option in these patients, although it should be considered. CONCLUSION: Reconstruction of one or both ears is often the last step in a rehabilitation process after burns. It is ideally performed after wound healing has been achieved, and by a team well trained in microtia treatment and post-traumatic reconstruction.

[A cost analysis of DIEP flap in breast reconstruction]. / Analyse médico-économique du lambeau libre de DIEP en reconstruction mammaire.

BACKGROUND: We postulate that the absence of a CPT code for DIEP (deep inferior epigastric perforator) free flap in breast reconstruction is in part responsible for the delayed adoption of this modern technique in France. In order to provide data to our regulating health agency, we determined the cost of this technique compared to a gold standard. We performed a cost-identification study, comparing costs of DIEP free flap versus latissimus dorsi pedicled flap with implant (LD+I) in secondary breast reconstruction following irradiation. METHODS: Over a 12-month period, direct medical and non-medical costs as well as indirect costs were recorded in both groups (DIEP and LD+I). RESULTS: In an academic department funded by the national health system, total cost of a secondary breast reconstruction by DIEP free flap was 10,671 ± 3005€ (n=57) versus 8218 ± 2049€ (n=18) for the LD+I group (P<0.05). Mean OR occupation time was 390 ± 64minutes for DIEP versus 283 ± 44minutes for LD+I (P<0.05). Mean hospital stay was 6 ± 2 days for DIEP versus 5 ± 2 days for LD+I (P>0.05). CONCLUSION: DIEP free flap technique offers a long lasting breast reconstruction at an reasonable expense compared to the LD+I (+22%). Furthermore, in an academic department, collaboration of two microsurgeons during DIEP flaps allows OR times to drop significantly and become competitive with LD+I.

[Surgical treatment of keratosis palmaris in Mal de Meleda]. / Peut-on traiter chirurgicalement le Mal de Meleda (kératodermie palmoplantaire diffuse de Siemens) ?

BACKGROUND: Mal de Meleda (MDM, OMIM #248300) is a rare congenital palmoplantar keratosis. Deep fissures cause pain and limit extension of the metacarpo-phalangeal joints. We report the case of a patient operated on both hands with a 29-year interval between each hand. OBSERVATIONS: A 53-year-old patient with MDM demonstrated severe keratosis of the left hand. The same surgeon operated on the right hand. Both hands were operated using the same technique. Skin of the palm, the palmar side of the index, and the first phalangeal of third, fourth and fifth fingers were excised with a sharp rugine. The hand was immediately covered by a full thickness-skin graft (FTSG) harvested on groin. CONCLUSIONS: The excision of all keratosis on the palm can lead to complete cure of MDM symptoms. FTSG is essential, especially on the fingers, in order to minimize secondary retraction. At the palm, FTSG offers better mechanical resistance then a split-thickness skin graft. A large groin graft, with closure of the donor site in a Y fashion, can cover the entire hand. Long term follow-up (29 years) demonstrates no recurrence of keratosis on surgically treated areas.

[A pediatric case of Alveolar Soft Part Sarcoma]. / Sarcome alvéolaire de la langue: un cas pédiatrique.

INTRODUCTION: Alveolar Soft Part Sarcoma (ASPS) is a rare malignant tumor arising from skeletal muscles and occurring usually in young adults. It is a solid chemo resistant tumor. At time of diagnosis the disease is usually advanced and lung metastasis are present in 65% of the cases. The translocation (X; 17), producing an ASPL-TFE3 transcript fusion which is detected on tumoral cells wall, is specific of ASPS. The curative treatment is surgical. CLINICAL REPORT: We report the case of a child with an ASPS of the tongue and lung metastasis. DISCUSSION: This report presents two particularities. Firstly this type of sarcoma is very exceptional in a 2-year-old child. Secondly ASPS is not usually susceptible to chemotherapy.