[Pregnancy-induced post-lipofilling inflammatory mastitis]. / Mastite inflammatoire post-lipomodelage («lipofilling¼) induite par la grossesse.

The autologous fat injection technique, called lipofilling or lipomodeling, is used in both aesthetic and reconstruction procedures. Lipofilling is rarely accompanied by complications. We report the case of a young female patient who had undergone breast lipofilling before and who developed significant recurrent but self-limiting inflammatory mastitis in the previously injected breast during two successive pregnancies. To our knowledge, no case of post-lipofilling inflammatory mastitis induced by pregnancy has been described to date. This case suggests an interaction between autologous fat injected into the breast and hormonal impregnation linked to pregnancy. This interaction would create a local environment conducive to the occurrence of an inflammatory reaction, according to a pathophysiological mechanism yet to be defined.

La technique d'injection de graisse autologue, appelée lipofilling ou lipomodelage, est utilisée aussi bien lors de procédures esthétiques que de reconstruction. Le lipofilling s'accompagne rarement de complications. Nous rapportons le cas d'une jeune patiente ayant bénéficié d'un lipofilling mammaire et qui a développé, au cours de deux grossesses successives, une importante mastite inflammatoire récidivante, mais chaque fois spontanément résolutive, au niveau du sein précédemment injecté. à notre connaissance, aucun cas de mastite inflammatoire post-lipofilling induite par la grossesse n'a été décrit à ce jour. L'histoire clinique de notre patiente suggère une interaction entre la graisse autologue injectée au niveau mammaire et l'imprégnation hormonale liée à la grossesse. Cette inter-action créerait un environnement local propice à la survenue d'une réaction inflammatoire, selon un mécanisme physiopathologique encore à définir.

[Pathergic postsurgical-induced Pyoderma gangrenosum]. / Le cas clinique du mois. Pyoderma gangrenosum pathergique post-chirurgical.

Pyoderma gangrenosum (PG) is a rare pustular and ulcerative inflammatory disease belonging to the group of neutrophilic dermatoses. It is frequently associated with systemic immune diseases. In this context the PG can be exceptionally triggered by tissue trauma such as surgery (pathergy). We report the case of a patient with stabilized rheumatoid arthritis who developed aggressive and disseminated PG at all surgical wounds following an abdominal dermolipectomy associated with breast pexy. Systemic corticosteroid methylprednisolone allowed a rapid control of skin ulcerations. In the aftermath of an intervention, PG is often confused with a bacterial skin-necrotizing panniculitis. The recognition of the inflammatory nature of cutaneous symptoms is crucial to quickly start an immunosuppressive treatment and limit scarring sequelae. Our case also illustrates the need to consider any history of dysimmune inflammatory or oncohematological disease as a risk factor before surgery, even if the latter are stabilized.

Le Pyoderma gangrenosum (PG) est une pathologie inflammatoire pustuleuse et ulcérative rare appartenant au groupe des dermatoses neutrophiliques. Elle est fréquemment associée à une maladie systémique dysimmunitaire. Dans ce contexte, le PG peut être exceptionnellement déclenché par un traumatisme tissulaire tel qu'une intervention chirurgicale (pathergie). Nous rapportons le cas d'une patiente atteinte de polyarthrite rhumatoïde peu active, mais ayant développé un PG agressif et disséminé au niveau de toutes les plaies opératoires à la suite d'une dermolipectomie abdominale associée à une pexie mammaire. Une corticothérapie systémique à base de méthylprednisolone a permis un contrôle rapide des ulcérations cutanées. En post-opératoire, le PG est très souvent confondu avec une dermo-hypodermite bactérienne nécrosante. La reconnaissance du caractère inflammatoire de la symptomatologie cutanée est cruciale afin d'entamer rapidement un traitement immunosupresseur et de limiter les séquelles cicatricielles. Notre cas clinique illustre aussi la nécessité de prendre en compte les antécédents de pathologies dysimmunitaires inflammatoires ou onco-hématologiques comme facteurs de risque avant toute intervention chirurgicale, même si ces dernières sont stabilisées et peu actives.

[How I treat a funnel chest with Computer Aided Design (CAD)]. / Comment je traite un pectus excavatum par un implant de conception assistée par ordinateur.

The contribution of computing in the management of patients with pectus excavatum has greatly improved the aesthetic result of the reconstruction endoprosthesis. Computer aided design (CAD) enables the design of implants perfectly suited to the deformation of the patient and avoids approximations of the traditional technique of plaster mold. Although this technique is applicable in many areas, this article will only deal with pectus excavatum.

L'apport de l'informatique dans la prise en charge des patients porteurs d'un pectus excavatum a permis d'améliorer considérablement le résultat esthétique de la reconstruction par endoprothèse. La Conception Assistée par Ordinateur (CAO) permet de concevoir des implants parfaitement adaptés à la déformation propre du patient et évite ainsi les approximations de la technique traditionnelle du moulage plâtré. Bien que cette technique soit applicable dans de nombreux domaines, cet article ne traitera que du pectus excavatum.

[About an extreme case of giant lymphoedema of the upper limb: ligasure may be useful and a multidisciplinary approach is mandatory]. / À propos d'un cas de lymphœdème géant du membre supérieur : intérêt du Ligasure(®) et importance du traitement multidisciplinaire.

Treatment of giant lymphoedema remains very difficult. The main problem is not only the obtention of early postoperative favorable results but to keep them long-lasting. The available treatment options are numerous and often combined. The indications have to be adapted to the clinical stage of the lesion. Ligasure(®) give us many advantages in the achievement of the surgical resection due to the quality of the lymphostasis that can be obtained and to the very limited thermic lesions caused to tissues. Long lasting postoperative physiotherapy is of first importance. We here describe a case of a giant lymphoedema of the upper limb after axillary lymph node dissection for breast cancer. The first physiotherapy failed, causing a lymphatic decompensation resulting in a lymphoedematous mass of nearly 7kg. The surgical resection with Ligasure(®) associated to drainage and compressive physiotherapy in the long run allows to obtain good results. The late follow-up after 4 years still shows stable results.

[Advantages of the superior areolar approach for tuberous breast II and III correction with implants]. / Avantages de la voie hémi-aréolaire supérieure pour la correction par implants des seins tubéreux de types II et III.

Tuberous breast is a mammary malformation that remains difficult to treat in most cases. It results from an abnormal development of the mammary base, mainly at the lower pole of the breast. The superficialis fascia is adherent to the dermis and deep plane. For type II and III of Grolleau's classification, we were confronted by some difficulties with inferior areolar approach as in Puckett's or Ribeiro's techniques. We had frequently an insufficient glandular volume at the inferior part of the breast and an early look of a "double bubble" deformity. We propose a technical modification to these procedures using a superior hemiareolar approach to place the implant. Associated with an incision of the deep part of the superficialis fascia, it provides a good-shaped lower pole of the breast by preserving glandular volume at this part and reduces the apparition of "double bubble". We operated on 14 types II-III tuberous breasts on nine female patients and had no significant complication. The mean follow-up is 36 months and the results were very satisfying for the patient and her surgeon.

Two cases of isolated unilateral paralysis of hypoglossal nerve after uncomplicated orotracheal intubation.

We report two cases of postoperative unilateral hypoglossal nerve palsy following uncomplicated orotracheal intubation for plastic surgery. Both patients underwent a long procedure and were installed in a non physiological position. These two factors might have played an important role in the mechanism of nerve damage. Furthermore, other etiologies of neurological injury like a difficult airway or anatomical anomalies were not present. The aim of these two case reports is to sensitize the anesthetists to hypoglossal nerve palsy and to highlight a potential clinical problem of positioning during plastic surgery.

Idiopathic scoliosis and breast asymmetry.

The aim of this study is to describe the semiology for the assessment of breast asymmetry in the presence of scoliosis. Twenty-four women with right idiopathic scoliosis treated with bracing alone (23 out of 24) or with bracing and spine surgery (1 out of 24) were evaluated by physical and morphological examinations and three-dimensional (3D) surface scan. Physical examination revealed a smaller right breast in 20 women. A left costal protrusion was observed in 18 patients. Anthropomorphic analysis revealed that the right breast was higher in 19 cases, and smaller in 18 cases. The calculations from 3D scan showed the right breast to be smaller in 19 women. A strong correlation is found between clinical parameters, anthropomorphic measurements and 3D scan analysis, suggesting that a meticulous clinical examination is sufficient to evaluate breast asymmetry in patients with idiopathic scoliosis. A patient who is properly diagnosed and informed of her skeletal deformity and breast asymmetry is more likely to have realistic expectations from breast surgery.

[About an uncommon case of post-irradiation sarcoma of the chest wall]. / A propos d'un cas rare de sarcome radio-induit du sein.

A case of postirradiation leiyomyosarcoma of the chest wall is presented. The tumor occurred after 4 episodes of radiotherapy over a period of 12 years. Criterious to define the radiation-induced sarcoma are discussed. The location of the leiomyosarcoma in comparison with the different irradiated fields shows that the tumor occurred in the border line of the differents fields called "zone of penumbra".

[The tuberous breast: a review]. / Les seins tubéreux: une mise au point.

The tuberous breast is one of the most challenging problem in breast surgery. Pediatricians, gynaecologists and plastic surgeons are particularly concerned with the treatment of these young patients. A good assessment of the pathology and a precise knowledge of the surgical procedures are keypoints for a successful treatment. A case report will precede a literature overview of this very complex problem.

[Skin necrosis after prophylactic treatment with heparin]. / Nécrose cutanée après traitement prophylactique par héparine.

The authors present a case of cutaneous necrosis following local injection of heparin. The physiopathology and the clinical aspect are discussed.

Isolated adenomatous polyposis of the appendix: report of a case.

This case study describes a 61-year-old patient who had previously undergone sigmoid polypectomy. A follow-up colonoscopy revealed a polyp prolapsing into the colonic lumen through the base of the appendix. A laparoscopic-assisted appendectomy was performed, in which the cecum was exteriorized through the trocar hole so that a wide excision of the base could be performed. Fifty-eight polyps were observed in the appendix, but the base was free of polyps. Histologic studies reveal well-differentiated villous adenomatous polyposes. The patient was symptom free four years after surgery.

Lesser curvature Roux-en-Y gastric bypass as an alternative procedure to failed vertical banded gastroplasty: surgical technique and short-term results.

PURPOSE: The incidence of revisional surgery for failed vertical banded gastroplasty has increased markedly over the last years. Conversion to gastric bypass is considered as a good alternative with satisfactory long term weight loss without further revisional surgery. Nevertheless, significant morbidity and mortality is still associated with this procedure. New technical aspects make it safer and more effective. The aim of the work is to expose a surgical bypass technique to attempt to reduce morbidity. PATIENTS AND METHODS: Thirty patients have undergone conversions from failed vertical banded gastroplasty to a lesser curvature Roux-en-Y Gastric Bypass. Surgical technique is described in detail and early complications and initial weight loss were analyzed (mean follow-up: 12 months). RESULTS: The key points of the operation were the small vertical pouch, the complete transection of the distal bypassed stomach, the interposition of a jejunal limb between the two gastric shares and the latero-lateral gastrojejunal anastomosis without proximal ring interposition. For the entire series, we noticed one major complication, an acute pancreatitis causing anastomotic fistula and four mild complications, one bleeding on the excluded stomach, one bronchopneumonia, one pleural effusion and one wound dehiscence. The percentage of excess weight loss attained 56.1% at one year follow-up. CONCLUSIONS: There have been tremendous improvements in the safety of gastric bypass over the years. One year follow-up indicates that our surgical bypass procedure is secure with a low complication rate.

[Hypothenar hammer syndrome]. / Le syndrome du marteau.

The hypothenar hammer syndrome is an uncommon but underestimated lesion of the cubital artery caused by repetitive trauma at the level of the hamate bone. It characteristically occurs in patients with a history of manual work as metal workers, carpenters and motor mechanics. We present a case of a patient who developed this syndrome following intensive use of a dig. Clinical finding, diagnosis and treatment are discussed.

Isolation and long-term cultivation of human tonsil follicular dendritic cells.

Highly purified follicular dendritic cells (FDC) were isolated from human tonsils and cultivated for up to 150 days. The cell separation method employed produced pure aggregates (FDC-clusters) composed of FDC and germinal center lymphoid cells, useful for the analysis of the relationship between these two cell types and of the behavior of FDC in culture. During the first few days of culture, lymphoid cells located between FDC extensions survived better than those which were free or partly covered by FDC. After 6 days, the lymphoid population degenerated and only the FDC survived. The unique antigenic pattern of FDC (positive for HLA-DR. DRC-1, CD14b, CD21, CD23, CD35) disappeared within a few days of culture. Recombinant interferon-gamma exerted a positive effect either on retaining HLA-DR expression or on the reexpression of these antigens by FDC. HLA-ABC antigens were traced until the 10th day and desmosomal junctions until the 14th day. Subsequently, FDC presented peculiar features, including oval and rhomboid shapes, one to ten nuclei, fine amoeboid extensions, stress fibers and a radical dense zone in their cytoplasm. FDC possessed actin, tubulin and vimentin, but neither desmin nor cytokeratin. After 40 days of culture, FDC enlarged and were covered with abundant membrane extensions. Even when kept as long as 150 days in vitro. FDC did not proliferate in any of the culture conditions employed.

Localization of interleukin 6 mRNA in human tonsils by in situ hybridization.

We have investigated which areas produce interleukin 6 (IL 6) in human tonsils. This growth factor is required for the terminal differentiation of B lymphocytes into plasmocytes. Using 35S-labeled IL 6 cDNA we demonstrated IL 6 gene expression over various areas of the tonsils, with consistent exception of the follicles, by in situ hybridization. It is, therefore, proposed that B cells are stimulated during their migration out of the follicles.

Cytokines produced in lymph follicles.

The events occurring inside lymph follicles during a germinal center reaction are poorly understood. Using B and T lymphoid cell populations prepared from human tonsillar lymph follicles, and enriched or not in macrophages or in follicular dendritic cells, we examined the production of cytokines by these cells in vitro. Interleukin 6 (IL-6) and tumor necrosis factor (TNF) were found in the supernatants of cultures stimulated with phytohemagglutinin or pokeweed mitogen. IL-1 beta was occasionally detected; its secretion apparently depends on the origin of the tonsils, the stimulation, and the cell populations. IFN-gamma and IL-2 were not produced in significant amounts by these lymph follicle cells. IL-4 was only found in very low concentrations in the supernatant of the different cell cultures. The cell populations containing follicular dendritic cells produced more IL-6 and TNF than the others, especially than those composed of only B and T cells.