The accessory vascularization of the tensor fasciae latae muscle: towards a new classification?

PURPOSE: The tensor fasciae latae (TFL) muscle is supplied by the lateral femoral circumflex artery (LCFA), arising from the deep femoral artery. However, it has been noted that there is also a consistent vascular anastomotic network. The aim of this study was to describe the accessory vascularization of the TFL muscle through a descriptive anatomical study, in order to hypothesize the feasibility of harvesting a TFL flap in the event of an injury to the main pedicle. In addition, we illustrate this hypothesis with a successful clinical case of Scarpa freconstruction following ligature of the deep femoral artery. METHODS: The description of the accessory vascularization was obtained by injecting dye into seven lateral femoral circumflex arteries (LCFA), six superficial circumflex iliac arteries (SCIA), and three inferior gluteal arteries (IGA). RESULTS: The TFL muscle was vascularized primarily by the LCFA. A vascular anastomotic network with the SCIA and the IGA was observed. After selective injection to the SCIAs and IGAs, the subsequent injection to the LCFA showed a diffusion of the TFL skin paddle with a perforasome overlapping between the different vascular territories. CONCLUSION: The ascending branch of the lateral femoral circumflex plays a dominant role in the vascularization of the TFL muscle. As a result of a periarticular anastomotic network of the hip, this artery establishes several connections with the proximal arteries. Consequently, in cases where blood flow through the LCFA is interrupted, it should be equally possible to harvest the TFL flap through its accessory vascularization.

15-Lipoxygenase promotes resolution of inflammation in lymphedema by controlling Treg cell function through IFN-ß.

Lymphedema (LD) is characterized by the accumulation of interstitial fluid, lipids and inflammatory cell infiltrate in the limb. Here, we find that LD tissues from women who developed LD after breast cancer exhibit an inflamed gene expression profile. Lipidomic analysis reveals decrease in specialized pro-resolving mediators (SPM) generated by the 15-lipoxygenase (15-LO) in LD. In mice, the loss of SPM is associated with an increase in apoptotic regulatory T (Treg) cell number. In addition, the selective depletion of 15-LO in the lymphatic endothelium induces an aggravation of LD that can be rescued by Treg cell adoptive transfer or ALOX15-expressing lentivector injections. Mechanistically, exogenous injections of the pro-resolving cytokine IFN-ß restores both 15-LO expression and Treg cell number in a mouse model of LD. These results provide evidence that lymphatic 15-LO may represent a therapeutic target for LD by serving as a mediator of Treg cell populations to resolve inflammation.

Surgical management of slightly or non-displaced corporal scaphoid fractures by retrograde percutaneous screw fixation through the anterior trapezium horn: A single-center retrospective French study of 33 patients between January 2015 and January 2019.

INTRODUCTION: Percutaneous screw fixation has recently gained popularity as an alternative to conservative treatment to avoid prolonged immobilization. The placement of a screw in the central axis of the scaphoid has been shown to be biomechanically superior to its eccentricity. Still, it poses difficulties in performing percutaneous screw fixation via both palmar and dorsal approaches. OBJECTIVE: We describe a palmar percutaneous screwing of corporal fractures of the scaphoid by a simple palmar transtrapezial approach allowing an optimal centering of the screw. METHOD: We selected patients operated on by the same surgeon using the palmar transtrapezial approach between January 2015 and January 2019 based on the coding used for these fractures and the operative reports. In addition, pre- and postoperative data were collected from the patient's computer and paper records and by telephone contact with the patients. RESULTS: Thirty-three patients were included. Percutaneous screw fixation of the scaphoid was performed under locoregional anesthesia in the operating room with one arm in the supine position on the arm table. No hyper-extension of the wrist was performed. The Kirchner guidewire passed through the anterior horn of the trapezium and then into the trapezium-scaphoid joint. A screw replaced it after satisfactory centering in the axis of the scaphoid. Management took place on average within 12 days after the trauma. 75.8% were A2 fractures, according to Herbert's classification. The average operating time was 16.63minutes, and in 91% of the cases, the patient was hospitalized for one day. The variation of the scapholunate angle on the preoperative profile radiographs with the angle defined by the axis of the scaphoid screw and the lunate postoperatively was on average 2.94°. One patient presented nonunion, and four showed an undersized screw with a screw overhang requiring revision surgery. CONCLUSION: The transtrapezial approach to fixation of acute scaphoid fractures facilitates precise percutaneous screw placement in the central axis of the scaphoid. A study of long-term complications, including the degenerative impact on the scaphotrapezial joint, is needed to assess the safety of passage through the anterior horn of the trapezium.

[Place of 3D custom-made implants after failure of modeling steno-chondro-plasties]. / Place des implants sur mesure 3D après échec des sterno-chondro-plasties modelantes.

Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context.

[Breasts and congenital chest-wall deformities: Surgical strategy with 3D implants]. / Le sein et les malformations thoraciques : stratégie chirurgicale et implants.

Computer-aided design and manufacturing of custom-made elastomer implants leads from a CT scan to fill in with precision, a congenital chest wall congenital deformity, both bone (pectus excavatum) and muscle (Poland Syndrome), resulting in a natural repositioning of the breasts. We report our 25 years' experience in 301 women (234 Pectus+64 Poland). Parietal correction must always be done in first intention. It is common to have to carry out a second stage in women with an additional mammaplasty especially in the presence of insufficient glandular volume or a fairly frequently associated tuberous breast.

[Congenital thoracic deformities and 3D custom-made implants. New classification based on a series of 789 treated cases]. / Malformations thoraciques congénitales et implants sur mesure 3D. Nouvelle classification basée sur une série de 789 cas traités.

The authors present a new study on 789 cases of congenital thoracic malformations including 638 pectus excavatum and 151 Poland syndromes, according to a new classification which completes Chin's one. All these malformations were treated with silicone elastomer implants. The contribution of computer-aided design and manufacturing (CAD/CAM) since 2008 is essential. The one-stage surgical protocol is precisely described. The results are impressive, permanent, for life, and complications are rare. The authors evoke a common vascular etiopathogenesis theory at the embryonic stage and question the heavy techniques of invasive remodeling that are most often unjustified.

Innervation of digital joints: an anatomical overview.

INTRODUCTION: The innervation of the digital joints as well as the anatomical relationships of the articular branches is present in this anatomical work to determine the technical feasibility of a selective and efficient denervation of the digital joints. MATERIALS AND METHODS: A study of 40 distal interphalangeal (DIP), 40 proximal interphalangeal (PIP), 50 metacarpophalangeal (MCP), 10 interphalangeal (IP) of the thumb, and 10 trapezo-metacarpophalangeal (TMC) joints was performed on ten hands. Under magnification and a proper surgical approach, we collected the course, the source origin, the number of articular nerve branches, and their caliber. RESULTS: In total, 118 nerve branches arising from the proper palmar digital nerves were found on 10 DIP of each dissected long finger (n = 40). A total of 226 nerve branches were found on 10 PIPs of each long finger (n = 40), of which 204 branches (90.3%) had a palmar origin. Dorsal innervation was found for the ring and little finger, originating from the dorso-ulnar digital nerve. 212 branches were found on 10 MCP of long fingers (n = 40), including 87 branches of palmar origin (41.1%), 107 branches of dorsal origin (50.4%), and 18 branches of the motor branch of the ulnar nerve (8.5%). 42 articular branches directed to the TMC joint (n = 10) were found. 13 branches (31%) originated from the anterior sensory branch of the radial nerve, 13 branches (31%) originated from the lateral cutaneous nerve of the forearm, 5 branches (12%) originated from the palmar cutaneous branch of the median nerve, and 11 (26%) branches originated from the thenar branch of the median nerve. The involvement of the sensory anterior branch of the radial nerve was always present for the innervation of each TMC. DISCUSSION AND CONCLUSION: Our research shows that finger joints receive their primary innervation from small branches of the digital nerves with the exception of the MCP joint and the TMC joint. To obtain an efficient and a selective digital denervation for articular pain relief, it is necessary to plan the best surgical approach and it is crucial to recognize the articular nervous branch localization and source.

Innovative adaptation of the "spare tissues concept" applied for olecranon coverage of a severe burn patient: A case report.

BACKGROUND: The management of bone exposure in patients with extensive burns could be a challenge due to the lack of healthy tissue. In such cases, it could be interesting to use any still healthy tissue initially destined for amputation and use it to cover up another site. We present the case of a sever burn patient for whom we used the only healthy palmar hand skin to cover an olecranon exposure. CLINICAL CASE DESCRIPTION: A 38-year-old man has been admitted in burn victim unit with extensive deep burns on 60% of the total body surface. An exposure of the left olecranon was appeared occurring on a burned area, with absence of healthy local tissues available for coverage. Concomitantly a trans-radial amputation was indicated because of severe digits burns leading to an impossibility to preserve the function of the hand. A palmar skin area was healthy leading to harvested this palmar skin flap pedicled on ulnar vessels. Early post-operative healing was satisfactory and no vascular suffering of the flap has been observed with a total healing at three weeks. CONCLUSION: In any patient the spare tissues concept should be keep in mind when amputation is indicated simultaneously with a problematic of loss of substance coverage to a proximity area. In this case of severe burn patient, we used a palmar skin flap pedicled on the ulnar vessels to cover an olecranon exposure.

Lower limb perforator flaps: Current concept.

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

Nostril Surgery: Indications, Surgical Procedures and Outcomes-A Systematic Review of Published Cases.

INTRODUCTION: To achieve adequate nasal proportions, nostril surgery can be a complementary technique useful in facial surgery. To help surgeons with the decision to realize nostril surgery, we conducted a systematic review to summarize reported cases on surgical procedures with a specific interest on indications, surgical procedures and postoperative outcomes. A therapeutic algorithm is also proposed. METHOD: We carried out this review in accordance with the PRISMA criteria. Twenty-two eligible studies were identified using Medical databases, including 1599 patients. A qualitative and quantitative analysis was carried out. DISCUSSION: Excision techniques were realized on 728 patients (45.5%), followed by cinching sutures on 642 patients (40%) and combined techniques: excision techniques with flap advancement techniques in 189 cases (12%), excision techniques with flap advancement techniques and cinching suture in 40 patients (2.5%). When excessive alar flaring was present, alar wedge resection was preferred in the 92% of followed by alar and sill resection. Cinching sutures were realized when excessive alar flaring was associated with a vertical alar axis, in cases of wide alar base, of associated orthognathic surgery. When excessive alar flaring was associated with wide alar bases, indications changed basing on the associated deformities. In 795 patients, nostril surgery was conducted simultaneously with rhinoplasty. CONCLUSION: Nostril surgery through excision techniques, cinching sutures or flaps advancement techniques, reveals good outcomes and can be complementary to rhinoplasty or orthognathic surgery. Through this systematic review, we tried to orient surgeons to find the best treatment for nostril base surgery. LEVEL OF EVIDENCE III: 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 .

Thermal and chemical burns caused by e-cigarette battery explosions.

INTRODUCTION: E-cigarettes have become the main alternative to traditional cigarettes. An increasing number of explosive accidents with e-cigarettes have been described over the past years. Through our experience of sixteen consecutive cases, we wanted to acquire a better understanding of the origins and to specify the principles of management for these particular new burns. METHODS: A retrospective study was conducted to review all cases of burns related to e-cigarettes referred to our burn center from April 2014 through May 2019. Several key data were collected in relation to the patients, the circumstances and characteristics of the burns, their treatment and follow-up. RESULTS: In the past five years, sixteen patients were burned by e-cigarette explosions. They were all males with an average age of 41 years. They all had second or third degree burn injuries. The average burned area was 5% TBSA. The areas that were burned were the hands, buttocks, thorax, thighs and genital areas, and were always related to clothes pocket location. Eight patients described an increase in pain after cooling, suggesting significant contamination of the burn by lithium-ion deposits. Six required surgical management with excision and split-thickness skin graft. The others healed spontaneously in several weeks. CONCLUSIONS: Burns by e-cigarette lithium batteries explosion have a double mechanism (thermal and chemical). Carrying cigarettes in a pocket close to the body is a significant risk factor to which the male population is particularly exposed. Early debridement is recommended when possible while initial cooling does not seem helpful and is sometimes painful.

Upper body lift and breast reshaping with lateral chest wall perforator propeller flap following massive weight loss.

BACKGROUND: After massive weight loss (MWL), female patients often develop upper trunk laxity and severe breast deformities. Usually several procedures are required to address upper body contouring issues. OBJECTIVES: To achieve better breasts and improve upper body contour, the authors employed a combined approach, associating lateral chest wall perforator propeller flaps with an upper bodylift (UBL). METHODS: Between September 2015 and March 2017, nine post-bariatric patients underwent simultaneously an UBL and autologous augmentation breast reshaping with lateral chest wall perforator propeller flaps. The authors analyzed the clinical indications, results and complications of this procedure. RESULTS: Eighteen lateral perforator propeller flaps for autologous breast augmentation-mastopexy associated with an UBL were performed successfully. Mean pre-MWL body mass index (BMI) was 54.3±10.9kg/m2, with a mean preoperative pre-UBL BMI of 28.7±3.6kg/m2. The average weight loss before surgery was 67.7±22.4kg. The flaps were harvested on intercostal and/or lateral thoracic arteries. All donor sites had been closed primarily. Following the classification of Dindo and Clavien, four minor complications (I, II), and two major complications (IIIb), including two hematomas requiring reoperation, were reported. No flap necrosis occurred. Follow-up averaged 27.9±8.4months. The patients' satisfaction with their improved breast shapes and chest wall contours was "good", with an aesthetic outcome mean ranked 3.8±0.8 (out of 5). CONCLUSIONS: After MWL, upper body deformities can be treated safely and reliably by a combined approach, associating an UBL and autologous lateral chest wall perforator flaps to provide more natural and durable breast shapes, as well as an upper circumferential reshaping.

Use of Permacol™ to restore depression after temporal muscle flap: A case report.

The temporal muscle has been an essential tool in maxillo-facial reconstruction for more than a century. Despite many technical advances, depression in the temporal fossa after its use is a constant issue. There are several ways to fill this defect. However, their efficiency has not been proven. Currently, biomaterials (e.g. polymethylmethacrylate [PMMA] and polyethylene [PE]) are the alternative most frequently used and studied. This is the first case report of temporal depression filling with a porcine dermal matrix (Permacol™). A 58-year-old woman underwent limited maxillectomy for squamous cell carcinoma of the upper vestibular mucosa, after which a pure temporalis muscle flap was used for immediate reconstruction. A custom-shaped Permacol™ sheet was used with a PMMA spacer to fill the resulting depression at the temporal fossa. The procedure went smoothly without any complications. The surgeon and the patient are satisfied with the cosmetic result. Permacol™ is a safe and effective tool to fill defects after temporalis muscle flap and is an excellent alternative to other biomaterials currently on the market.

Complex abdominopelvic reconstruction by combined tensor fascia latae and superficial circumflex iliac artery perforator flaps.

BACKGROUND: Extensive full thickness abdominopelvic defects pose a difficult challenge to surgeons. Autologous tissues are versatile and can provide a satisfying reconstructive option for this type of defects. The tensor fascia latae (TFL) and superficial circumflex iliac perforator (SCIP) flaps provide a large area of vascularized tissue and their use in reconstructive surgery is well-known. In this report, the authors present the experience of using combined TFL and propeller SCIP flaps for covering large abdominal and pelvic defects. METHODS: Four patients underwent reconstruction of soft-tissue abdominopelvic defects by combined TFL and SCIP flaps. Three were men and one woman, aged from 52 to 76 years. The etiologies of the defects were tissue loss after tumor resection in 3 cases and necrotizing fasciitis in the fourth case. Defect dimensions ranged from 32 × 20 cm to 45 × 17 cm. An acoustic handheld Doppler was utilized to detect perforator vessels, then TFL and SCIP flaps were elevated at the same time by 2 surgical teams. Donor sites of the flaps were closed primary except for one TFL flap donor site. The latter one was treated with negative pressure therapy and finally with a split-thick skin graft. RESULTS: The size of the TFL flaps ranged from 25-38 × 10-14 cm. Concerning the SCIP flaps, the dimensions ranged from 18-32 × 12-18 cm. The average flap dimensions were 30.25 × 11.75 cm for the TFL and 26.75 × 14 cm for the SCIP. Two TFL flaps presented a necrosis of the distal tip. All the other flaps survived entirely. Complete healing was achieved in all patients. Patients were followed for an average of 4 months postoperatively (ranging between 2 and 8 months). CONCLUSIONS: Combined TFL and SCIP flaps may represent an alternative reconstructive procedure for large abdominopelvic defects in well-selected cases.

Indications, functional results and patient satisfaction after isolated second ray resection following traumatic injury: A retrospective review of 25 patients.

Amputation of the second ray is a surgical treatment option when reconstruction and/or reimplantation fail. The aim of our study was to review the outcomes after transmetacarpal resection of the second ray following a post-traumatic injury and to assess indications, functional outcomes, and patient satisfaction. Between January 2003 and December 2013, 25 patients (6 women and 19 men with a mean age of 51 years) underwent transmetacarpal resection of their second ray after a post-traumatic injury. Sixteen patients were right-handed and 9 were left-handed. Injuries involved the dominant hand in 14 cases (60%). In order to differentiate patients with preserved index finger length preoperatively from those with a shorter, amputated index finger stump, patients were divided into 2 groups. Group 1 included those with an "intact finger" and Group 2 included patients with an "amputated stump". Data collection, including patient satisfaction and functional outcomes, was performed at 83 months postoperative on average. Average length of follow-up was 7.0±1.0 years (range 5-12 years). Group 1 (intact finger) and 2 (amputated stump) included 15 and 10 patients, respectively. Six patients (24%) had primary ray amputation and 19 (76%) had secondary ray amputation. No surgical revision was necessary. In Group 1, the indications were purely functional in all but two cases, whereas aesthetic indications played a role in all patients in Group 2. The average total time off work was 3 months. There was no difference between Group 1 and 2 (P>0.05). However, patients with primary ray resection averaged 10 weeks of lost work compared to 17 weeks for secondary amputation. There was no functional difference between Groups 1 and 2. Scores for cosmetic appearance and patient satisfaction were higher in Group 2. In certain specific situations after complex hand trauma, transmetacarpal amputation of the second ray is indicated as soon as possible, in order to reduce the time off work. Patient satisfaction following this surgical procedure is high, especially in groups with amputated stumps. A 30% decrease in pinch and grip strength is the rule. No secondary surgery is normally required.

Reconstruction of a dorsal thoracic wall defect with a dorsal intercostal artery perforator flap after removal of a bulky cutaneous squamous cell carcinoma: a case report.

INTRODUCTION: Surgical reconstruction of large soft tissue defects of the upper back is challenging. Although the usefulness of free perforator flaps has been demonstrated, local options remain limited. The dorsal intercostal artery perforator flap was recently described but its use is still uncommon. CASE REPORT: An 88-year-old Causasian woman presented with a large, ulcerated, left prescapular cutaneous squamous cell carcinoma (T3N0M0). Complete excision was performed, and the resulting defect was reconstructed with a dorsal intercostal artery perforator flap based on two perforators. Postoperative recovery was uncomplicated and adjuvant radiotherapy commenced 10 weeks later. CONCLUSION: Compared to conventional muscle flaps, the dorsal intercostal artery perforator flap offers greater protection of muscle function, is less invasive, and lowers donor site morbidity. Based on these advantages, this flap should be considered a useful local option for reconstructing large cutaneous defects of the upper back.

[Complications of autologous breast reconstruction]. / Complication des lambeaux en reconstruction mammaire.

Flap reconstruction techniques are increasingly desired by French's patients and it represents almost half of breast reconstruction indications in 2017. The main reasons of this statistics are the growing concerns of the patients with breast implant of developing BIA-ALCL, as well as their desire of having a more natural reconstruction results without having any foreign bodies. The multiplication of autologous reconstruction techniques, especially microsurgical techniques which has been popularized in the recent years, makes possible to propose a reconstruction to the majority of patients without an implant. This type of reconstructions is associated with a significant number of complications; thus, a proper selection of patient should be done and a good knowledge of the surgical technique by the surgeon to reduce the complication. Our proposed study is divided into two main parts, the complications of the flap and the complications at the donor site. Based on the experience of our plastic surgery department in immediate and delayed breast reconstruction, the objective of this article is to describe and to analyze the possible complications of breast reconstruction by a flap and their surgical management in intra and post operatively. Our goal is to provide an algorithm for our young colleagues in order to obtain better understanding of this type of interventions difficulties and to provide an appropriate care in the event of complication, also to provide optimal care to the patients who wish to undergo autologous flap reconstructions.