Primary management of the inframammary fold in breast reconstruction using the thoracoabdominal advancement flap: Surgical technique.

Our experience in breast reconstruction confirms the significant importance of reconstructing the inframammary fold in achieving overall aesthetic satisfaction. We describe our technique for primary fixation of the inframammary fold in breast reconstruction using a thoracoabdominal advancement flap. This technique is suitable for patients with a vertical skin laxity of at least 5cm in the future inframammary fold. Prior to the procedure, it requires preparation through physiotherapy, the use of adhesive external breast prosthesis, and skin expansion using an inflatable prosthesis in extreme cases. The surgical approach follows the existing mastectomy scar. After subfascial dissection of the thoracoabdominal advancement flap, the surgeon proceeds to create two separate rows of sutures. The first row mimics the deep attachment of the inframammary fold, fixing the superficial fascia of the flap to the rib periosteum. The second row mimics the superficial attachment of the inframammary fold, fixing the dermis of the flap to the rib periosteum. The main advantage of this technique is its applicability to all breast reconstruction programs.

[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.

[Juvenile and tuberous breast hypertrophy]. / Hypertrophie mammaire et seins tubéreux hypertrophiques de l'adolescent.

Adolescence is defined as the period extending from puberty to adulthood, the limit of which is difficult to determine. It is a delicate period, in which the distancing from one's own body image can have deleterious consequences on psychological development and social-emotional life. Breast hypertrophy and the correction of hypertrophic tuberous breasts in adolescents raise some questions that we will attempt to answer in this article. There are specificities to manage, in relation to surgical indications, resection volume, postoperative follow-up and cutaneous healing.

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 .

Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: Retrospective single-center 24-case series.

Isolated scaphotrapeziotrapezoid (STT) osteoarthritis has functional consequences on the wrist. The main objective of our study was to evaluate the functional outcomes of patients managed surgically during the last 12 years at the Toulouse University Hospital, regardless of the surgical technique used, for isolated STT osteoarthritis. We performed a single-center retrospective observational study using the CCAM database. The inclusion criteria were patients treated surgically for isolated STT osteoarthritis who did not respond to conservative treatment, with at least 6 months of clinical and radiological follow-up. Twenty-four patients were treated between 2006 and 2018. Partial arthroplasty of the distal pole of the scaphoid with or without interposition and total trapeziectomy had been performed on these patients. The mean follow-up was 79±46.8 months. The wrist range of motion (ROM) and the Kapandji score were not significantly reduced postoperatively. The mean postoperative QuickDASH score was 29.15±8.46. The mean pain assessed using a visual analog scale was 6.6±1.17 preoperatively versus 1.25±1.51 postoperatively (P=0.003). Statistical subgroup analysis found no predictive factor for a better postoperative QuickDASH score, and no surgical technique was superior at halting the progression of intracarpal misalignment and postoperative ROM. Surgical treatment of isolated STT osteoarthritis resistant to conservative treatment leads to significant functional improvement, particularly in terms of pain, without altering the wrist's overall mobility.

[Medical residents and wound healing: A French national survey]. / Internes en médecine et cicatrisation des plaies : une étude descriptive multicentrique entre février et avril 2018.

OBJECTIVES: Around 2.5 million wounds are recorded in France, representing, in terms of cost and quality of life, a real problem of public health issue. In France, residents are among the first line personnel having to manage wounds and their complications: this study is carried out to identify the view and feelings of residents concerning their preparation and training in this field. MATERIALS AND METHODS: A questionnaire was distributed to residents throughout France. Residents' characteristics, interests and training in wound healing, training courses and opinions concerning their training were recorded. RESULTS: Seven hundred and eleven French residents answered the questionnaire, the majority of whom (79 %) had not experienced training in wound healing. The majority of residents (69 %) believe that all physicians are concerned. Training in wound management and wound healing is considered insufficient (94 %) and most (79 %) had never received any training in wound management and wound healing. Ninety-eight percent stated they needed additional training courses in wound management. CONCLUSIONS: Wound management and healing is a topic of interest to residents. Residents need more training in wound management in their curriculum to improve their practice.

[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.

[The pectus excavatum: Secondary surgery with implants]. / Le pectus excavatum : chirurgie secondaire par implants.

The pectus excavatum affects about one in 500 people. It is the most common malformation of the thorax. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results. Secondary surgery with a deep customized 3D implant, may be an elegant and effective solution; it allows to obtain a good aesthetic result expected by patients in the absence of any respiratory or cardiovascular functional context.

Assessment of quality-of-life in patients with face-and-neck burns: The Burn-Specific Health Scale for Face and Neck (BSHS-FN).

INTRODUCTION: Burns to the cephalic extremities are particularly implicated in problems of self-image and alterations to personal social relations. The aim of this study was to objectively assess the quality-of-life (QoL) of patients suffering from face-and-neck burns through our newly created scale: The Burn-Specific Health Scale for Face and Neck (BSHS-FN). METHODS: After constructing the BSHS-FN, we compared QoL of patients with or without face-and-neck burns. SF-36, the French version of the BSHS-B (Burn Specific Health Scale-Brief), and the BSHS-FN were administrated to 53 patients divided into two groups: GB group (general burns, 26 patients) and FN group (face-neck burns, 27 patients). RESULTS: QoL evaluated using the SF-36 had a higher average total score in GB patients compared to FN patients, but there were no significant difference between the two groups (54.3±18.5 vs. 47.0±17.3, respectively, p=0.11). In contrast, in BSHS-B the total score was significantly different between the two groups with a higher score recorded for the GB group (71.9±13.4 [median: 72.8] in the GB group vs. 62.2±14.4 [median: 64.4] in the FN group). In percentage terms, total score of BSHS-FN for GB group was 79.1±10.1, while total score for FN group was 53.6±13.1 (p<0.001), with the highest score for the Face and Neck domain in GB group (99.7±1.1, p<0.001) CONCLUSION: The BSHS-FN seemed to be more appropriate to assess QoL for FN burn patients. This study supports its application in routine clinical practice and in international studies.

3D imaging of cleared human skin biopsies using light-sheet microscopy: A new way to visualize in-depth skin structure.

BACKGROUND: Human skin is composed of the superimposition of tissue layers of various thicknesses and components. Histological staining of skin sections is the benchmark approach to analyse the organization and integrity of human skin biopsies; however, this approach does not allow 3D tissue visualization. Alternatively, confocal or two-photon microscopy is an effective approach to perform fluorescent-based 3D imaging. However, owing to light scattering, these methods display limited light penetration in depth. The objectives of this study were therefore to combine optical clearing and light-sheet fluorescence microscopy (LSFM) to perform in-depth optical sectioning of 5 mm-thick human skin biopsies and generate 3D images of entire human skin biopsies. MATERIALS AND METHODS: A benzyl alcohol and benzyl benzoate solution was used to successfully optically clear entire formalin fixed human skin biopsies, making them transparent. In-depth optical sectioning was performed with LSFM on the basis of tissue-autofluorescence observations. 3D image analysis of optical sections generated with LSFM was performed by using the Amira® software. RESULTS: This new approach allowed us to observe in situ the different layers and compartments of human skin, such as the stratum corneum, the dermis and epidermal appendages. With this approach, we easily performed 3D reconstruction to visualise an entire human skin biopsy. Finally, we demonstrated that this method is useful to visualise and quantify histological anomalies, such as epidermal hyperplasia. CONCLUSION: The combination of optical clearing and LSFM has new applications in dermatology and dermatological research by allowing 3D visualization and analysis of whole human skin biopsies.

Cell-assisted lipotransfer: Friend or foe in fat grafting? Systematic review and meta-analysis.

Autologous fat grafting is a common procedure for soft-tissue reconstruction but is associated with a graft resorption rate ranging from 20% to 80%. To improve the fat graft survival rate, a new technique, called cell-assisted lipotransfer (CAL), was developed. With CAL, fat is injected along with adipose-derived stromal cells that are assumed to improve fat survival rate. We conducted an evidence-based meta-analysis to evaluate the efficacy and safety of CAL as compared with conventional autologous fat grafting (non-CAL). The databases MEDLINE (via PubMed), Cochrane Library, EBSCO, Web of Science, and EMBASE were searched for reports of clinical trials, case series, and cohorts available from 2008 to 2016. We conducted a meta-analysis of the efficacy of CAL with data analysis concerning fat survival rate. The incidence of complications and the need for multiple procedures were evaluated to determine the safety of CAL. We identified 25 studies (696 patients) that were included in the systematic review; 16 studies were included in the meta-analysis to evaluate the efficacy of CAL. The fat survival rate was significantly higher with CAL than non-CAL (64% vs. 44%, p < .0001) independent of injection site (breast and face). This benefit of CAL was significant for only injection volumes <100 ml (p = .03). The two groups did not differ in frequency of multiple procedures after fat grafting, but the incidence of complications was greater with CAL than non-CAL (8.4% vs. 1.5%, p = .0019). The CAL method is associated with better fat survival rate than with conventional fat grafting but only for small volumes of fat grafting (<100 ml). Nonetheless, the new technique is associated with more complications and did not reduce the number of surgical procedures needed after the first fat grafting. More prospective studies are required to draw clinical conclusions and to demonstrate the real benefit of CAL as compared with common autologous fat grafting.

Non-surgical treatments for hidradenitis suppurativa: A systematic review.

INTRODUCTION: The management of hidradenitis suppurativa is multidisciplinary, involving general measures, medical treatment and surgery. Non-surgical treatments, often first-line procedures, mainly concern forms of low-to-moderate severity or, conversely, very severe forms in non-operable patients or those refusing surgery. While many treatments have been attempted, few randomized controlled trials have been conducted, so the choice of treatments is most often based on the personal experience of the clinicians. The objective of this systematic review is to propose a synthetic analysis of the currently available non-surgical procedures. METHODS: This systematic review of the literature was conducted in accordance with the PRISMA criteria. We searched for articles in the Medline®, PubMed Central, Embase and Cochrane databases published between January 2005 and September 2015. RESULTS: Sixty-four articles were included. They generally had a low level of evidence; indeed, the majority of them were retrospective observational studies. They involved biotherapy (44%), dynamic phototherapy (16%), antibiotics (11%), Laser (8%), retinoids (6%) and immunosuppressive therapies, anti-inflammatory drugs, zinc, metformin, gammaglobulins and fumarates. CONCLUSIONS: None of the non-surgical treatments can treat all stages of the disease and offer long-term remission. Antibiotics and biotherapy seem to have real effectiveness but their effect remains suspensive and the disease is almost certain to reappear once they are stopped. As regards antibiotics, no association has shown their superiority in a study with a high level of evidence. And while some biotherapies seem quite effective, due to their side effects they should be reserved for moderate-to-severe, resistant or inoperable forms of the disease. Randomized controlled studies are needed before valid conclusions can be drawn. In the resistant or disabling forms, it is consequently advisable to orientate to the greatest possible extent towards radical surgery, which is the only treatment allowing hope for cure.

Cell-assisted lipotransfer: Current concepts.

Autologous fat transfer, or lipofilling, is a common technique used for soft tissue reconstruction. It has been used for many years, but the technique is associated with a significant graft resorption rate (20% to 80%). To improve the fat graft survival rate, several methods have been tested, and one has appeared more promising: cell-assisted lipotransfer (CAL). In the CAL method, fat is enriched with adipose-derived stromal cells (ASC), contained in the stromal vascular fraction (SVF) obtained after enzymatic digestion of fat or after cell culture to improve the fat survival rate. In this concise review, we present the clinical indications, and the technical principles of CAL, as well as a presentation of ASC. To conclude, we present the main results (efficacy, complications and safety) obtained from different studies of this technique.

[Tuberous breast: Current concept]. / Seins tubéreux.

Tuberous breast deformity is a congenital breast anomaly with different clinical signs. The most consistent sign is the constricting ring at the base of the breast. There is deficiency in the horizontal and/or vertical dimensions of the breast and often herniation of breast parenchyma toward the nipple-areola complex with areola enlargement. Breast asymmetry is frequently associated. This anomaly occurs only in females, during breast development at puberty. The incidence is unknown because of minor forms more difficult to diagnose. This deformity produces psychological morbidity and encourages the patients to consult. In 1999, Grolleau publishes a classification with three types of tuberous breast deformity. The goals of the surgical treatment are the expansion of the constricted base, the redistribution of volume, the correction of areolar size and of herniated subareolar breast tissue. In type II and III, the simple use of breast implant involves the "memory" of the previous inframammary fold line. To avoid this complication, it is necessary to make a glandular rearrangement with parenchymal flaps like Puckett and Ribeiro. It is a real challenge for the plastic surgeon who must reshape the breast and obtain a symmetry of volume. It would be delusive to think all types of tuberous breast can be corrected with the same one-step technique. It is often necessary to plan several surgeries and patient must always be informed about the strategy.

[Morbidity of bodylift. Evaluation of 111 patients over 5 years]. / Morbidité de la dermolipectomie abdominale circulaire. Série rétrospective de 111 patients sur 5 ans.

INTRODUCTION: The management of patients with weight loss sequelae, sometimes major, is increasingly well standardized. However, this surgery is not without risk. Complications of bodylift are more frequent than those of conventional abdominoplasties. The objective of this study was to evaluate the morbidity associated with this surgery through a retrospective, single-center study. MATERIALS AND METHODS: One hundred and eleven circular abdominaloplasties were conducted between June 2011 and September 2015 in the plastic surgery department of the university hospital of Toulouse. Minor and major complications were identified and analyzed. RESULTS: Frequency of postoperative complications was 44.1% in our series. Major complications have involved 15.3% of patients. Blood transfusions (9%) and hematoma requiring reoperation (7.2%) were the most frequent major complications. We found significantly more major complications in patients with important fat resection with a cut off at 3200 g (P=0.02). Men experienced significantly more major complications than women (P=0.005). The average delta-BMI (before and after weight loss) was significantly higher in the group of patients with the highest percentage of minor complications (P=0.045). Indeed, a high delta-BMI (greater than 19.5) was associated with an excess risk of minor complications in our population. CONCLUSION: Democratization and progress in the field of bodylift should not obscure the fact that it is, in reality, a procedure at risk. While we manage increasingly better cosmetic results and thromboembolic complications, it still persists many complications.

Validation of the French version of the Burn Specific Health Scale-Brief (BSHS-B) questionnaire.

INTRODUCTION: The Burn Specific Health Scale-Brief questionnaire is a widely validated tool for estimating the health related quality of life and for assessing the best multidisciplinary management of burn patients. The aim of this study was to translate the BSHS-B into French and to investigate its reliability and validity. METHODS: According to the procedure proposed by the Scientific Advisory Committee of the Medical Outcomes Trust, the Burn Specific Health Scale-Brief (BSHS-B) was translated from the English version into French. In order to test the reliability of the French version of the BSHS-B, 53 burn patients French speakers completed the BSHS-B and SF-36 questionnaires from two to four years after burn. Ten of them have been re-tested at 6 months after the first evaluation. To evaluate clinical utility of the BSHS-F, internal consistency, construct validity (using SF-36) and stability in time were assessed using Cronbach's alpha statistic, Spearman rank test, and intra-class correlation coefficient respectively. RESULTS: The French version of the BSHS-B Cronbach's alpha coefficient was 0.93 and was >0.80 for all the sub-domains. French version of the BSHS-B and the SF-36 were positively correlated, all the associations were statistically significant (p<0.01). Intra-class correlation coefficients for test-retest ranged between 0.95 and 0.99 for the sub-domains. The intra-class correlation coefficient (ICC) for the total score was 0.98. CONCLUSION: The French version of the BSHS-B shows a robust rate of internal consistency, construct validity and stability in time, supporting its application in routine clinical practice as well as in international studies.

[Correction of congenital malformations by custom-made silicone implants: Contribution of computer-aided design. Experience of 611 cases]. / Chirurgie des malformations congénitales par implants sur mesure en silicone. Apport de la conception assistée par ordinateur (CAO). À propos d'une expérience de 611 cas opérés.

INTRODUCTION: Modern techniques of computer-aided design and tridimensional prototyping for manufacturing silicone elastomer custom implants are growing. They have widely modified the surgical indications in our unit. MATERIALS AND METHODS: By presenting their experience of 611 cases managed between 1993 and 2016, the authors describe the method of conception from CT-scans, the virtual image of the body and the manufacture of the custom-made implant perfectly adapted to the anatomy of each one. The operative techniques are described for the three main indications: the funnel chest or pectus excavatum (474 cases) according to a modified CHIN classification is corrected simply and very satisfactorily. This approach may render thoracic surgery techniques obsolete. Indeed, these operations remain risky and of doubtful functional utility; Poland syndrome (116 cases), where the use of a custom-made implant for compensation of muscle volume is frequently used, but can be improved by a transfer of adipose tissue or a classic breast implant; the leg atrophies (21 cases) receive custom elastomer implants introduced in a sub-fascial plane. RESULTS: The results are excellent for pectus excavatum but more difficult to optimize for the other two indications, requiring sometimes complementary techniques. Complications are rare and often benign, implants endure for life. Quality of life, psychological comfort and self-esteem have been improved with low morbidity and without having undergone a painful surgical experience. CONCLUSION: Reconstructive procedures of congenital malformations by custom-made silicone implants open a new field of activity for our surgical specialty with vast opportunities.