Interest of a 3D custom-made implant in the reconstruction of bone defects of the cranial vault.

The authors report a case of a patient managed for severe cranial vault depression following combined neurosurgery and radiotherapy. This situation caused major aesthetic discomfort and was potentially dangerous due to the mechanical weakness of the bone flap. The authors had a CAD (computer aided design) silicone elastomer custom-made implant made to fill perfectly the depression. Beforehand, an expansion was performed to cover the implant after removal of the radiated skin. The surgery and post-operative course raised no concerns. After one year of follow-up, the result is very good and the patient very satisfied, proving that this technique certainly has its place in the therapeutic arsenal when faced with a tissue defect of the cranial vault.

["Junior Doctor" in Plastic Surgery, a new status. Evaluation of the practices after one semester of application of the reform]. / Docteur Junior en chirurgie plastique, un nouveau statut. Évaluation des pratiques après un semestre d'application de la réforme.

INTRODUCTION: The reform of the third cycle of medical studies in 2017 led to the creation of the status of "Junior Doctor", corresponding to the consolidation phase and allowing increasing autonomy and supervision from the intern. In plastic surgery, this status appeared for the first time in November 2021 in French hospitals; it lasts two years and succeeds the first four years of internship. MATERIAL AND METHODS: We sent a self-questionnaire by email in May 2022 to the 21 French Junior Doctors. This was interested in their training ground, formation program, consultation activity, operating program, integration into the on-call list, the existence of half-days of availability, and their general opinion on this reform and its implementation. RESULTS: We collected 20 questionnaires with a sex ratio of twelve men for eight women. The majority of respondents worked in a university hospital (85 %). 45 % had their consultations, 60 % had their own operating sessions under general anesthesia, and 35 % under local anesthesia. Only 25 % of them considered this reform to be a step forward in terms of training. CONCLUSION: The introduction of the status of Junior Doctor is contrasted within the various hospitals. Despite the progressive and supervised autonomy provided by this reform, it is generally perceived neutrally or negatively by Junior Doctors. The establishment of own consultations and operating sessions stands out as a key positive element allowing better application of the reform.

[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.

[Reanimation de l'extension du pouce par transfert de l'extensor indici proprius chez les enfants atteints de pouce flexus adductus congenital]. / Réanimation de l'extension du pouce par transfert de l'extensor indici proprius chez les enfants atteints de pouce flexus adductus congénital.

Congenital clasped thumb is a rare congenital deformity characterized by a permanent contracture of the thumb metacarpo-phalangeal joint. Surgical option often raise in case of failure of the orthopaedic method. We wanted to evaluate the use of the extensor proprius indici (EPI) tendon to reanimate thumb extension in children affected by congenital clasped thumb. We made a retrospective review of children operated in our center between 2005 and 2019. We operated eight children (twelve hands) over this period: nine were grade I, two grade II and one case grade III (arthrogryposis). Medium age at surgery was 18 months (10 to 23 months). In each case, EPI tendon transfer was realized and sutured to the extensor pollici longus. Children were seen in consultation at six weeks postoperative and then mean follow-up was nineteen months. Seven children (87.5%) had a physiologic thumb extension at six weeks. One case of partial loss of extension on the index was noted. One second time of surgery was necessary to change the course of EPI transfer. At six months postoperative, all children could use their thumb with an extension similar to the opposite thumb. Surgery must be proposed in congenital clasped thumb persistent after at least four months of orthopaedic treatment or in cases of severe deformity. Tendon transfer using EPI must be proposed first given the good functionnal results and low morbidity.

Impact of the 2020 French lockdown due to the SARS-CoV-2 pandemic on emergency consultations for pediatric burns in a regional referral hospital.

INTRODUCTION: SARS-CoV-2 pandemic required the establishment of total lockdown in France from March 17 to May 11, 2020. We analyzed the impact of this lockdown on the pediatric burn population consulting in our burn unit during this period compared to data from previous years in order to analyze our model of emergency care for children burned during this unprecedented situation. MATERIAL AND METHODS: We carried out a retrospective single-center study by reviewing files concerning emergency consultations for children burns during the total lockdown in France in 2020 (COVID group) compared to the same weeks of 2018 and 2019 (no-COVID group). RESULTS: We find a significant decrease in the number of consultations (P=0.02) during the confinement period. In the "COVID" group, we found a significant increase in burn to the hand (P=0.03) and lower limbs (P=0.03). The other criteria evaluated did not find any difference between the groups. Assessment of a possible rebound effect within 2 weeks of total lockdown found an increased incidence of the children burn consultation, an increased number of older children and mainly male. CONCLUSION: The decrease in the number of consultations alerts us to a potential increase in the functional sequelae of burns in these patients at risk. Longer-term follow-up will allow us to assess the consequences of this lockdown on this particularly at-risk population.

[The de-epidermized sural flap: An original technique to increase the reliability of the neurocutaneous sural flap]. / Le lambeau sural désépidermisé : technique originale de fiabilisation du lambeau neurocutané sural.

BACKGROUND: The neurocutaneous sural flap is useful to cover defects of the distal quarter of the lower limb. Nevertheless, severe complications occur in 14% of the cases, and venous congestion is reported in 75% of these cases. This congestion can lead to total necrosis of the flap and a failure of the procedure. We describe a new surgical method aiming to reduce the risk of venous congestion occurrence and failure of the defect coverage. PATIENTS AND METHODS: We realized a retrospective study of patients who undergone a de-epidermized distally based neurocutaneous sural flap in our surgery department from 2015 to 2020. The following data were collected: sex, age, vascular risk factors, size of the wound, defect area, etiology, delay between the surgery of the flap and the split-thickness skin graft and complications. RESULTS: The cohort is composed of 5 cases. We reported no failure of the coverage of the defect. There were no cases of venous congestion. CONCLUSION: The de-epidermized distally based neurocutaneous sural flap could increase the reliability of these flaps by reducing the risk of venous congestion. A larger study comparing the classic technique to the de-epidermized sural flap could confirm these data on a greater number of cases and position this technique in the therapeutic arsenal.

[Median nerve compression in the carpal tunnel in children - a delayed diagnosis. About 20 clinical cases]. / La compression du nerf médian dans le canal carpien chez l'enfant ­ un diagnostic retardé. À propos de 20 cas.

OBJECTIVES: The carpal tunnel syndrome is rare in children. We performed a retrospective study of 10 children. The aim is to show that the diagnosis of carpal tunnel syndrome is difficult in children. PATIENTS AND METHODS: We identified all children with median nerve compression in the carpal tunnel between 2010 at 2020, managed in our service. RESULTS: Ten children with 20 hands included. There was different etiologies of carpal tunnel syndrome: 5 lysosomal storage diseases, 4 idiopathic carpal tunnel syndrome, 1 genodermatose, 1 Byler syndrome and 1 VACTERL syndrome. Common presenting symptoms were pain (five patients) and under use of fingers (five patients). Two children had opposition deficit of the thumb. We operated 19 hands. Median age at diagnosis was 4 years and 7 months. One children or 2 hands had a reanimation of opposition by tendinous transfer of flexor digitorum superficialis tendon of the ring finger. All children had a complete regression of the painful symptoms, a use improvement of fingers and recovery of the opposition of the thumb. CONCLUSION: The diagnosis of carpal tunnel syndrome is difficult in children. It is common to be confronted with an advanced clinical symptoms. The atypical symptoms may cause diagnostic delay. Due to the quality of the clinical results obtained, we recommend open carpal tunnel release even when the diagnosis seems delayed. LEVEL OF EVIDENCE: IV.

Negative Pressure Wound Therapy in children: A 25 cases series.

Negative Pressure Wound Therapy is a device applied to a wound that causes local depression. There are a few series showing the effectiveness of this treatment in Pediatric. The objective of this work is to try to clarify the indications in children. This is a retrospective series of 25 children between 2004 and 2019. The inclusion criteria were all children with a wound treated with Negative Pressure Wound Therapy. The characteristics retained were their age, the context of occurrence, the treatment time, the depression applied, the technique of skin covering wound and the average healing time. We included 25 patients. The average age was 8.8 years. The context of the wound occurrence was mainly a road (44%) or a domestic (36%) accident. Substance losses were mainly located in the lower limb (84%). The depression applied was -90mmHg. The healing time was 18.4 days. Thin skin grafting was the main method chosen (88%). No complications related to Negative Pressure Wound Therapy equipment have been identified. Despite the weakness of the literature and the lack of consensus regarding its use, Negative Pressure Wound Therapy is an essential therapy in pediatric. It is a simple and effective technique in children. It can reduce the need for flaps coverage, even in the event of exposure of noble elements. The flaps should not, however, be excluded from the decision-making algorithm, on pain of complications or sequelae.

Evaluation of satisfaction and well being with Breast-Q© of aesthetic breast augmentations by implants using the "Dual Plane" technique: A serie of 191 cases.

INTRODUCTION: Dual Plane allows, according to J.B Tebbetts, to combine the advantages while reducing the drawbacks of the other implantation pockets. We assessed patient satisfaction using the Breast-Q © questionnaire after breast augmentation using the Dual Plane technique. MATERIAL AND METHODS: Our study involved evaluating data from the Breast-Q © questionnaire from 191 patients retrospectively. Other secondary criteria were studied such as postoperative complications, the correlation between satisfaction and implant volume, satisfaction and operating time, satisfaction and age of the patient. RESULTS: The Breast-Q © questionnaire allows us to assess the satisfaction of the patients in our series about their breasts, their implants, the information received and the outcome of the intervention. Physical, sexual and psychosocial well-being is also assessed. CONCLUSION: Breast augmentation using a Dual Plane pocket according to Tebbetts achieves significant levels of satisfaction and well-being in patients. To our knowledge, this is the most important series devoted to the evaluation of these criteria after the use of the Dual Plane.

Management of loss of tissue substance in children's limbs. What are the salient peculiarities? A proposed algorithm.

Loss of tissue substance in children's limbs has the same etiologies and in many cases, the same severity as in adults' limbs, and the means placed at the disposal of a surgeon are likewise comparable. It may nonetheless prove difficult to strategically position the different treatment methods in a decision-making tree. After all, a child presents numerous peculiarities: high quality of vascularization (both microcirculation and macrocirculation), better ability to achieve nerve regeneration and durable bone consolidation and, last but not least, a pronouncedly superior overall functional prognosis. Moreover, a child's future needs to be taken into account ; it is not only cicatrization per se, but also the quality of healing that should dictate therapeutic choices, which will consequently be determined in view of avoiding functional disorders during the growth process. On the basis of their experience and following a review of the literature, the authors have assessed the interest of each relevant technique and drawn up a decision-making tree.

Long-term behavior of the vascularized fibular free flap for reconstruction of bony defects in children.

OBJECTIVE: Bony resection in children presents a unique reconstructive challenge because of future growth potential. To achieve limb salvage and provide the patient with a functional extremity, vascularized free fibula transfer has become the workhorse for bony reconstruction. The authors present their reconstructive experience using vascularized fibula flaps in a group of pediatric patients. PATIENTS AND METHOD: This is a monocentric, retrospective study of 25 pediatric patients who underwent reconstruction of bony defects with a vascularized fibula flap from 2004 to 2017. Perioperative and long-term complications were noted. Functional outcomes were analyzed. RESULTS: Twenty-five patients with a mean age of 10 years were included. The etiology was tumor for 21 of them and 4 had neurofibromatosis. Median follow-up was 86 months. Overall, survival was 92 percent and flap survival was 100 percent. Perioperative surgical complication rate was 32 percent. The overall union rate was 87 percent following supplemental bone grafting. 67 percent of the lower limb fibula presented hypertrophy, with a mean hypertrophy of 154 percent. Median time to union was 15 months. Leg-length discrepancy was present in 5 patients. Mean Musculoskeletal Tumor Score was 23. CONCLUSION: Vascularized fibula free flap is the ideal material for long bone reconstruction with a definitive result. It allows children with early ambulation, provides good functional outcomes and improve their quality of life.

[Use of methoxyflurane on acute pain during burn dressing in adult consultation]. / Utilisation du méthoxyflurane sur la douleur aiguë lors du pansement en consultation des brûlés adultes.

INTRODUCTION: The objective was to compare the short-term efficacy of methoxyflurane vs. MEOPA on acute pain during burn dressing in consultation, the secondary outcome was to assess the patient's comfort and the quality of the dressing performed. MATERIALS AND METHODS: Monocentric, prospective study from April 2018 to January 2019. Men and women>18 years presenting acute burn on<10% SCT were included. A pain≥4 on the numerical scale (from 0 to 10) at the beginning of the treatment established the indication of methoxyflurane or MEOPA, with randomization done by a nurse. The following data were collected: burn description, performed debridement, pain assessment by numerical scale: on arrival, at the beginning of care, after 6 to 10 inhalations for methoxyflurane or 3 to 4minutes of inhalation for MEOPA and at the end of care. RESULTS: Sixty patients were included, 30 in each group. There was a decrease of -2.47 points of numerical scale when initiating methoxyflurane against -1.53 points for MEOPA (P=0.08). Patients were significantly less painful when stopping treatment in the methoxyflurane group -4 points vs -2 points (P=0.001). Methoxyflurane significantly improved the debridement of the burn (P=0.018). CONCLUSION: Methoxyflurane is more effective than MEOPA in acute pain in burn dressing, improved patient comfort, and improved dressing quality.

[Pollicization in the management of congenital hypoplasias and aplasias of the thumb, functional results, about 13 cases]. / Pollicisation dans la prise en charge des hypoplasies et aplasies congénitales du pouce, résultats fonctionnels, à propos de 13 cas.

INTRODUCTION: Pollicization of the index finger as a treatment for aplasia and severe congenital thumb hypoplasia remains a demanding surgical procedure. In aplasias, it is generally well-accepted, less in hypoplasias. However, it is often the only solution to give back to the child the possibilities of a pollici-digital grip, guaranteeing an excellent function of the hand. We decided to evaluate the long-term results of this intervention. MATERIAL AND METHODS: We reviewed all children operated of index pollicization for a congenital aplasia or hypoplasia of the thumb between 2006 and 2018. The evaluation was performed with a specialized reeducator. The analytical and functional characteristics of the neo-thumbs were evaluated, as well as the consequences on the daily life of the child. RESULTS: Thirteen pollicisations were performed on 10 patients. The mean age at surgery was 21 months (10; 43). It was a Blauth stage IIIB in 1 case, IV in 5 cases, and V in 7 cases. Seven children, and eight hands, could be evaluated. The average postoperative follow-up was 6.5 years. The mean age at the examination was 7.7 years (3.3, 12.1). The mean Percival score was 18 out of 22. The adapted video-assisted scoring system had an average score of 11 out of 14. Children described a momentary psychosocial discomfort for 5 of them, and still present in 3 of them. CONCLUSION: The pollicization of the index finger in congenital aplasia or severe hypoplasia (stage IIIB and IV) of the thumb remains for us the only way to create a sensitive thumb, mobile, with satisfactory strength and appearance, and to bring a normal function of the hand. The evaluation of our functional results are good to very good in the majority of patients, and show the benefits give by this intervention.

[Brachioplasty and its complications]. / Brachioplastie et complications.

Due to an increasing number of major weight loss after bariatic surgery, the demand for body-coutouring surgery increase in paralell. Among all the technics which can be realized, brachioplastyis one of them. The goal is to reach a functionnal but an aesthetic improvement too. The literature show that the rate of major complication is very low (or not reported in the majority of the series). Minor complication is more common : hypertrophic scar, large scar, paresthesia, and wound dehiscence. Re-operation can be asked by the patient in order to improve the result. With the help of clinical cases and literature review the authors try to analyse the balance between benefice and risk to realize a second operation.

Utilisation précoce de l'irm pour l'évaluation du niveau d'amputation des membres dans la prise en charge des brûlures électriques à haute tension.

High-voltage electrical burns are rare, but the functional prognosis is often disastrous. Electrical currents are responsible for a wide range of injuries and their clinical assessment is difficult. For a case of severe electrical burn, and based on the literature, the authors performed an early MRI to elaborate their surgical strategy and avoid multiple surgeries by determining the level of amputation. Analysis of the different MRI signals and the per-operative study of the tissues led the team to take an early surgical approach and we were able to determine the level of limb amputation. Early analysis of lesions by MRI imaging allows us to consider a more aggressive surgical approach and thus reduce the number of interventions and the duration of stay in the intensive care unit.

[Free flaps use in chronic wounds: Retrospective study about 91 cases]. / Utilisation des lambeaux libres dans la prise en charge des plaies chroniques.

INTRODUCTION: Chronic wounds represent a major health challenge with no current standardized surgical treatment. The use of free flaps is little discussed in the literature, with a supposed propensity to failure given unfavorable local conditions and land often debility. We present here the analysis of our monocentric experience of the use of free flaps in the curative treatment of chronic wounds. PATIENTS ET METHODS: We performed a retrospective monocentric study over 18 years of all free flaps used for the treatment of a chronic wound between January 2001 and September 2016. Several criteria were evaluated on patients, wounds, free flaps used and immediate to late outcomes. RESULTS: Ninety-one patients were included (sex ratio M/F: 3.55) with an average age of 41.6±16 years. Wounds were localized to the leg in 92.3% of cases and 58% of patients had initial osteomyelitis. The flaps used were predominantly muscle flaps (61.6%). The flaps survival rate was 92.3%. With a mean follow-up of 50 months, the reconstructive failure rate was 20.9%. The presence of a chronic osteomyelitis is the only statistically significant factor of reconstruction failure (P=0.0169) with a risk of failure multiplied by 5. CONCLUSION: Our study demonstrates that the reliability of free flaps in the treatment of chronic wounds is comparable, regardless of the time since the initial cutaneous lesion, to that existing in the treatment of acute wounds or in the reconstruction after oncological excision. The presence of a chronic osteomyelitis, however, represents a major risk of reconstruction failure by increasing 5 times the risk of failure. Recent changes in the integumentary reconstruction paradigm of the lower limb will undoubtedly allow in the next few years to establish more rationally the place of muscle free flaps in the therapeutic armamentarium of chronic wounds.

Extradigital glomic tumor of the forearm. About a case and review of literature.

We report the clinical case of a 72-year-old man followed for 10years by a specialized pain center, for neuropathic pain poorly systematized, triggered by the contact of the anteromedial face of the right forearm. After surgical excision, histological analysis indicated a well-circumscribed nodule in the subcutaneous region, confirming that the mass was a glomus tumor. In this clinical case, surgical excision allowed an immediate disappearance of the pains without recurrence to this day.

[Contribution of computer-aided design for the conception of custom-made implants in Pectus Excavatum surgical treatment. Experience of the Nantes plastic surgery unit]. / Apport de la conception assistée par ordinateur (CAO) à la réalisation des implants thoraciques sur mesure pour correction des pectus excavatum. Expérience du CHU de Nantes.

INTRODUCTION: Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method. PATIENTS AND METHODS: We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded. RESULTS: Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications. CONCLUSION: The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.