[Electrical flash burns, about 33 cases. A 10-year retrospective study. Epidemiology, treatment and prevention]. / Brûlures par flash électrique, à propos de 33 cas. Une étude rétrospective sur 10ans. Épidémiologie, traitement et prévention.

BACKGROUND: The electric flash burns are a common cause of accident at workplace, especially among electricians. The aim of this study is to determine the parts of the body most often burned by the flash, to define the usual course and finally to give some simple rules of care and prevention. MATERIALS AND METHODS: This is a retrospective, observational and descriptive study including all patients treated at the University Hospital of Tours for electrical flash burns between 1 January 2003 and 01 January 2013. A collection of medical and socio-economic data was achieved. We present 3 cases of patients hospitalized in our department. RESULTS: Thirty-three patients were included. In our series, all hospitalized patients were men. The average age was 43.2years (range 18 to 82years). In 81% of cases, the burn was due to a low voltage source, in 19% of cases to a high voltage source. It was an accident at workplace for 71% of patients, of whom 67% were electricians. The average total burned area was 9,52% (from 1.5% to 24%). The main locations included the face (86%), upper limbs (86%) and hands (86%). Medical treatment has healed 95% of patients. A surgical procedure was required in 5% of cases. A post-traumatic stress was found in 41% of patients. Outpatient treatment was performed in 36% of cases. CONCLUSION: Flash burns remain a common cause of hospitalization. Screening for hearing and eye disorders, a post-traumatic stress, as well as the prescription of early physiotherapy for burned hands are important components of their management. Following simple rules of prevention would limit their morbidity.

[The role of skin substitutes in the surgical treatment of extensive burns covering more than 60 % of total body surface area. A review of patients over a 10-year period at the Tours University Hospital]. / Place des substituts cutanés dans le traitement chirurgical des grands brûlés sur plus de 60 % de la Surface corporelle. Revue de patients sur 11ans dans le centre des brûlés adultes du CHRU de Tours.

INTRODUCTION: Progress in intensive care and surgery has made it possible to significantly improve the survival of victims with burns over 60% of total body surface area (TBSA). Coverage of the excised areas of these patients can be difficult when there is a shortage of skin donor sites; then the role of skin substitutes can be important. MATERIALS AND METHODS: This retrospective study included patients with burns covering more than 60% TBSA and treated at the Tours University Hospital over a period of 10 years. Patients who died during the first week or who presented superficial burns were excluded. The various substitutions means to temporarily or permanently replace the cutaneous barrier are presented. The biological dressings associated with grafts expanded by six according to the sandwich technique, allografts and xenografts, widely expanded postage stamp skin grafts using a modified Meek technique (Humeca(®)), temporary cutaneous substitutes such as Biobrane(®) and skin substitutes colonized by autologous cells (Integra(®)) are presented. RESULTS: Forty-four patients were admitted. Self-immolations represented 52% of the cases. Twenty-one patients were treated with Integra(®), 5 with Biobrane(®), 17 with sandwich grafts and 4 with postage stamp skin grafts. Integra(®) was widely used when donor sites were insufficient. The mean number of surgical procedures per patient was 8.4. The mean duration of hospitalization was 155 days. Twenty-four patients survived until the end of treatment. Eighteen patients died during the first week before any surgery could be performed. Two patients died at the end of treatment. The overall survival rate was 55%. It was 92% for patients who survived the first week. The principal sequel were functional (hand, cervical, thoracic and axillary contractures) and aesthetic (face and hands). Associated treatments were pressotherapy, physical therapy, ergotherapy and thermal water therapy. CONCLUSION: By temporarily replacing the cutaneous barrier in the absence of sufficient donor sites, skin substitutes make it possible to increase the survival of patients with very extensive burns and to optimize their treatment.

[Thigh root reconstruction with a pedicled DIEP flap]. / Reconstruction d'une perte de substance de racine de cuisse sur membre lymphœdèmateux par un lambeau DIEP pédiculé

Root thigh extensive loss of substance requires surgical coverage. The presence of chronic lymphedema (LC) makes random with the postoperative healing time longer. We report an original case of reconstruction of extensive loss of substance from the root of the thigh using a pedicled deep inferior epigastric flap perforator (DIEP) flap. A 22-year-old woman with angiosarcoma occurring in hemi-body lymphedema. The defect generated by the oncologic resection was 16×24cm. She was reconstructed by a pedicled DIEP flap. Skin wound healing was obtained within 30 days. Donor site healing was obtained within 15 days. The pedicled DIEP flap seems to be effective for root thigh reconstruction.

[Occult primary MALT lymphoma of the breast diagnosed and treated by reduction mammaplasty. An exceptional case report and review of the literature]. / Lymphome du MALT primitif du sein découvert fortuitement et traité par la réduction mammaire. À propos d'un cas exceptionnel et revue de la littérature.

Primary Mucosa-associated Lymphoid Tissue (MALT) lymphoma of the breast is a very rare disease. We report here a case of occult primary MALT lymphoma of the breast diagnosed from a mammaplasty specimen. Primary tumor resection during the mammaplasty surgery was the only treatment of this lymphoma, and there was no recurrence at five years. The clinical and radiologic presentation of primary MALT lymphoma of the breast is similar to epithelial breast carcinoma, and the main diagnostic criteria are microscopic examination and immunohistochemistry. The prognosis of breast primary MALT lymphomas is good after local treatment by surgery and/or radiotherapy, and surgery shouldn't be too aggressive. In this case, no other treatment was indicated after the first surgical procedure. To our knowledge, this is the first case report in the literature of occult primary MALT lymphoma of the breast diagnosed from a mammaplasty specimen. This allows us to highlight the need for systematic microscopic examination of mammaplasty specimens conducted by an experienced pathologist, especially as preoperative examinations are not able to detect all occult breast carcinomas.

[Use of Matriderm® 1mm in reconstructive surgery. Series of 31 cases]. / Utilisation de Matriderm® 1mm en chirurgie reconstructrice. Série de 31 cas.

INTRODUCTION: Dermal substitute are used for soft-tissue defect for their functional and aesthetic advantages. Matriderm® 1mm, single layer dermal matrix, composed of collagen and elastin covered by a split thickness skin graft simultaneously to its application, has been used most often in burned surgery. This prospective series evaluates the interest of this recent dermal matrix in reconstructive surgery. PATIENTS AND METHOD: Twenty-eight patients have been treated with the substitute in our department for reconstructive surgery indication between November 2008 and May 2012. Indications were tissue losses treatment after limb or trunk sarcoma resection, melanoma, extended baso- or spinocellular carcinoma, palmoplantar keratodermy, burn sequels, or traumatic tissue losses. Indications were preferentially deep tissue losses, functional areas and the face. RESULTS: Mean treated area has been 82.4 cm(2) (10 to 600 cm(2)). Mean taken rate has been 87±19% of the area and mean day of discharge has been 4.8 days and the mean cost per patient 906.5 euros. Negative wound therapy, until D3, was used 6 times. Three patients treated for limb sarcoma had radiotherapy performed on the grafted area. Aesthetic and functional results have been encouraging. CONCLUSIONS: Matriderm® 1mm, dermal substitute commonly used in acute burn treatment can be indicated in reconstructive surgery. This series show that it permits to obtain a good graft taken rate, a quick healing with a satisfying aesthetic and functional results and permit an early discharge. However, its indications are limited by its cost.

[Donor site preserved skin grafts. A clinical study of 10 cases]. / La greffe de peau en nourrice. Étude clinique à propos de dix cas.

INTRODUCTION: In spite of a rigorous technique, a graft will not necessarily completely take on a burned area. We propose to preserve on the donor site the excess skin graft harvested during the excision-graft procedure. PATIENTS AND METHODS: A clinical study was carried out in nine patients who had their excess skin graft preserved at the time of excision-graft for deep burn. The unused fragments of skin graft were preserved on the donor site. In the event of a small skin graft failure, the preserved skin graft was separated from its donor site and used as a new skin graft during wound dressing. RESULTS: Nine patients required the use of 10 preserved skin grafts. The average age was 54years and the average burned third degree surface was 17% total body surface area. In seven procedures for six patients, the preserved skin graft was taken off without pain and was used with a complete take. In three cases, the preserved skin graft was not used because in two cases, the take of the initial skin graft was complete and in one case, a definitely insufficient take required reoperation. CONCLUSION: The preservation and use of the skin graft as a complement was simple and useful and made it possible to easily complete a skin graft when the initial take was incomplete. It would appear to be efficient in burn surgery since it accelerates cicatrisation and avoids the need for a new graft harvesting procedure.

[Indication of sclerotherapy in the treatment of ischiatic pressure sore: about 13 cases]. / Indication de la sclérothérapie dans le traitement de l'escarre ischiatique. À propos de 13 cas.

INTRODUCTION: Ischiatic pressure sore is a common pathology of the paraplegic patient. Usually treated after medical therapy, with fasciocutaneous or musculocutaneous local flaps, despite this treatment the recurrence rate is high. Sclerotherapy, injection of pure ethanol in the cavity of the pressure sore could be an interesting solution in the armentarium of the plastic surgeon in some indications. PATIENTS AND METHODS: Sclerotherapy was used for 13 patients in the plastic surgery department to treat ischiatic pressure sores with a cavity, beneath the defect. RESULTS: The mean length of stay was 24 days. The ischiatic pressure sore was completely healed with no skin defect or cavity for nine patients (65%). For two patients, there was a delay of healing of the skin defect but no cavity beneath. There were two early recurrences of the pressure sore. They were treated by sclerotherapy with a complete recovery in 2 months with simple hydrocolloid dressings. The mean post op follow-up was 14,6 months (4 to 24). Only one recurrence was observed after 12 months. CONCLUSION: The injection of pure ethanol in the cavity of specifics ischiatics pressure sores is a simple, fast and effective technique with a good and stable long term wound healing. The mean length of stay is shorter and the recurrence rate is equivalent to other techniques.

[Original treatment of constitutional painful callosities by surgical excision, collagen/elastin matrix (MatriDerm(®)) and split thickness skin graft secured by negative wound therapy]. / Traitement original des callosités plantaires douloureuses constitutionnelles par exérèse, matrice de collagène et d'élastine (MatriDerm(®)) et greffe de peau mince en un temps, associée à une thérapie par pression négative.

Constitutional painful callosities is an unusual pathology, integrated in the frame of "palmoplantar keratodermia" (PPK). Lesions are located at areas of support of the sole. These lesions are painful and disable the normal walking. Treatments are suspensive and painkillers. We report our experience of a single surgical treatment: surgical excision, split thickness skin graft applied on a dermal substitute and secured by negative wound therapy. A 28-year-old patient, affected by this disease, has a desire of pregnancy but her treatment is highly teratogen. A year post-op, wounds were healed. The walk was possible with a relief of the pain, without any ulcerations. The surgical treatment by excision and graft or flaps was previously reported for PPK. The use of dermal substitute was never described for this indication. Dermal substitute compensate the thickness of the soft tissue defect and give an accurate quality of elasticity in this localisation .The negative wound therapy enhances the quality and shortens the length of graft taking, and the adhesion of the dermal substitute on his bed.

[Principles of the local treatment: Surgical processing]. / Principes de la prise en charge locale : traitements chirurgicaux.

The deep burns require a surgical treatment. The third degree circular burns require escharotomies and sometimes fasciotomies to avoid vascular compression. Early burn wound excision permits to remove the necrotic tissue that produce toxins and encourage infection. Wound coverage by an autologous split-thickness skin grafting, meshed or not, usually leads to a correct scar quality. In severe burns, when donor's sites are limited, the homografts permit to pass a critical stage even though they are rejected secondarily. The keratinocytes culture remains a difficult and exceptional technique for very severe burns permitting to save their life but with poor cosmetic results. Artificial dermal substitute could sometimes permit to replace the homograft and to improve the cosmetic results of the grafts by a better reconstitution of skin. If early burn wound excision with autologous split-thickness skin grafting remains the gold standard, the tissue-engineering will be a future way for the surgical treatment of the burns.

[Basement of matrix therapy in regenerative medicine by RGTA(®): From fundamental to plastic surgery]. / Les bases de la thérapie matricielle en médecine régénérative par les RGTA(®) : du fondamental à la chirurgie plastique.

Cells present continuous renewal, permitting permanent regeneration which is called tissue homeostasis. The signaling protein, known as growth factors, cytokines, interleukins and chemokines, but also the extracellular matrix play a key role in the cellular communication. All processes are deregulated after tissue injury, inducing scars. By reconstituting the extracellular matrix, it is possible to avoid the development of scar and to favorize the regeneration of the injured tissue. Glycosaminoglycans, and particularly heparan sulfates, by participating to the extracellular matrix structure, are implicated in cellular communication. This article describes how, by creating heparan sulfate mimetic or Regenerating Agent (RGTA), a French academic team has demonstrated that mammals have the ability to regenerate, by restoring the proper cellular micro-environment. After a first clinical development in two severe and chronic pathologies (corneal and skin ulcers), we show now the potential of these agents in plastic and reconstructive surgery, to regulate fibrosis and to enhance speed and quality of tissue healing.

[First applications of matrix therapy in plastic and aesthetic surgery]. / Premières applications de la thérapie matricielle en chirurgie plastique et esthétique.

INTRODUCTION: A new medical device based on a concept of the reconstruction of the extracellular matrix by a molecule belonging to the family of the ReGeneraTing Agents (RGTA(®)) has just been available to treat skin lesions. RGTA(®) are biodegradable polymers engineered to mimic heparan-sulfate in the extracellular matrix of damaged tissue. RGTA(®) improves tissue healing in several animal models, by stabilizing and protecting heparin-binding growth factors (HBGFs) and matrix proteins. We have evaluated the effects of this device containing RGTA(®) on cutaneous cicatrisation in a group of patients treated by reduction mammoplasty and in a group operated by a centrofacial lifting. PATIENTS AND METHODS: Seventeen patients who underwent mammoplasty for breast hypertrophy received cutaneous application of the device at D1, D4, D8 and D11 on one breast. Quality, color, inflammation of the scar and eventual complications have been evaluated by photography and at the third postoperative month by the Vancouver Scar Scale. Another group of 50 patients that underwent a centrofacial lifting received a bilateral deposition of drops of RGTA(®) in the operating plane at the end of the surgical procedure. Discomfort, oedema, ecchymosis and inflammation of the scars have been evaluated at 1-month postoperative and compared with an identical group of 50 other patients, operated by the same surgeon without RGTA(®). RESULTS: In the group of mammoplasties, inflammation, prurit and hypertrophic scars were less frequent for the breast treated by RGTA(®). The mean Vancouver Scar Scale has been lower in the treated group than in the control group. In some patients the pain, related probably to the local inflammation, has been less important for the treated breast. In the sequence of centrofacial lift at 1-month postoperative, scar inflammation, oedema and bruises were much less frequent in the treated group (10 %) than in the non-treated group (90 %). CONCLUSION: Topical application of RGTA(®) seems to improve cutaneous healing in a group of patients operated for breast reduction and to reduce discomfort, ecchymosis and oedema in the group of centrofacial lifting. These results are concordant to the experimental results obtained and pilot studies results.

High-resolution cutaneous ultrasonography to differentiate lipoedema from lymphoedema.

BACKGROUND: Lipoedema is an accumulation of fat abnormally distributed in the lower limbs, and lymphoedema is oedema caused by a deficiency of the lymphatic system. High-resolution ultrasound operating at 20 MHz makes it possible to characterize dermal oedema. OBJECTIVES: The purpose of our study was to demonstrate that high-resolution ultrasound imaging of the skin can differentiate lipoedema from lymphoedema. METHODS: Sixteen patients with lymphoedema (22 legs), eight patients with lipoedema (16 legs) and eight controls (16 legs) were included. Patients with lipolymphoedema were excluded. Ultrasound examinations were carried out with a real-time high-resolution ultrasound device on three different sites for each lower limb. The images were then anonymized and examined by an independent dermatologist who was blind to the clinical diagnosis. A new series of images was examined by three dermatologists to check interobserver agreement. RESULTS: A significant difference in dermal thickness was observed between patients with lymphoedema and those with lipoedema and between patients with lymphoedema and controls. No significant difference in dermal thickness was shown between patients with lipoedema and controls at the thigh or ankle. Dermal hypo-echogenicity was found in at least one of the three sites in 100% of patients with lymphoedema, 12.5% of cases with lipoedema and 6.25% of the controls. Hypoechogenicity affected the entire dermis in all cases of lymphoedema except one. In cases of lipoedema and controls, hypoechogenicity was localized at the ankle and prevailed in the upper dermis. The expert correctly diagnosed all lower limbs with lymphoedema. No cases of lipoedema were diagnosed as lymphoedema. Exact interobserver agreement was excellent (0.98). CONCLUSIONS: High-resolution cutaneous ultrasonography makes it possible to differentiate lymphoedema from lipoedema. Obtaining a reliable diagnosis through high-resolution cutaneous ultrasonography might be valuable for improving the treatment of lipoedema and lymphoedema.

[Metaplasia of aortic tissue into tracheal tissue. Surgical perspectives]. / Métaplasie de tissu aortique en tissu trachéal. Perspectives chirurgicales.

Tracheal reconstruction after extensive resection remains an unsolved surgical problem. Numerous attempts have been made using tracheal grafts or prosthetic conduits with disappointing results. In this study, we propose a new alternative using an aortic autograft as tracheal substitute. In a first series of experiments, a half circumference of two rings was replaced with an autologous carotid artery patch. In a second series, a complete segment of trachea was replaced with an autologous aortic graft supported by an endoluminal tracheal stent. No dehiscence or stenosis was observed. Microscopic examinations at 3 and 6 months showed the replacement of the aortic tissue by tracheal tissue comprising neoformation of cartilage and mucociliary or non-keratinizing metaplastic polystratified squamous epithelium. Although these results need to be confirmed by a larger series of experiments, they showed that a vascular tissue placed in a different environment with a different function can be submitted to a metaplastic transformation which tends to restore a normal structure adapted to its new function. These remarkable findings offer new perspectives in tracheal reconstruction in human.