Nomadic plastic surgery: from healthcare huts to war-zones. Our experience over 30 years.

We present 30 years' experience of "nomadic" plastic surgery missions carried out by a small non-governmental organization, specialized in reconstructive surgery in challenging conditions in developing countries. Here, we provide a record of missions carried out between 1993 and 2023. The study shows how surgical missions are conducted and the methodology used. We carried out 70 missions, with more than 8,000 consultations, and operated on 3,780 patients. A quarter of operations concerned clefts, a quarter tumors, a quarter burns and a quarter various diseases such as Noma and, recently, traumatic lesions secondary to armed conflict. We show some adaptations such as autonomy during missions, adjustment of indications to this new environment and the integration of local traditions in our therapeutic action. We offer practical ideas about surgery and some reflections on the social concerns.

Revue De La Littérature Sur Les Brûlures Au Phosphore.

Armenia and Azerbaijan fought between September and November 2020 in Nagorno-Karabagh. Several surgical missions were scheduled by Assistance Publique- Hôpitaux de Paris to help care for the warinjured Armenians. These missions included the evaluation of Armenian soldiers suspected of having been injured by phosphorus. Facing, during these missions, such infrequent burns, we were interested in their pathophysiology, care and complications. Repeated up-to-date information is necessary in order to better take care of phosphorus burns. Therefore, we conducted a literature review, using PubMed and the Mesh Terms "phosphorus" and "burns", without setting any date limit. The review acknowledges that phosphorus burns are deep, tend to spread and may be the cause of systemic toxicity including hypocalcaemia, which can lead to heart rate disturbance and even death. In the acute phase, burns should be extensively washed with normal saline or water before a mechanical decontamination. One should not use oily dressings, given the liposolubility of phosphorus. Subsequently, one or many debridements are necessary before starting wound coverage, for which any kind of plastic surgery may be used. Phosphorus burns are infrequent but serious. They mainly occur in warfare and should be known by any caregiver acting in this context.

[Plastic surgery and fighting: Our experience during Nagorno-Karabakh war in 2020]. / Chirurgie plastique et conflit armé : notre expérience lors du conflit au Haut-Karabakh en 2020.

INTRODUCTION: This work relates the experience of three French surgical missions in the care of the war wounded during the armed conflict in Nagorno Karabakh which took place from September 27 to November 10, 2020. MATERIALS AND METHODS: Three surgical missions were carried out in Armenia between October 2020 and January 2021. Surgeons intervened in different hospitals, at different times of the conflict and on various war wounds. RESULTS: The presence of a plastic surgeon proved to be essential in the care of war wounded, especially in delayed emergency and secondary care. The ortho-plastic treatment offered during these missions has proven to be effective in the reconstruction of limbs. These missions made it possible to introduce the induced membrane technique of Masquelet AC in Armenia. During our visit to the Yerevan burn center, we mentioned the very probable use of white phosphorus as an etiology in several of the cases analyzed. CONCLUSION: We relate the particular experience of civilian surgeons in the context of a modern armed conflict. The presence of a plastic surgeon proved to be indispensable in the care of war wounded and especially in their secondary reconstructions.

[Nomadic plastic surgery: 1 NGO, 10 years, 30 missions]. / Chirurgie plastique nomade: 1 ONG, 10 années, 30 missions.

This publication presents the results of 10 years of nomadic plastic surgery missions by a small French non-governmental organization: Interplast-France/surgery without borders (www.Interplast-France.net). This NGO is specialized in reconstructive surgery in challenging conditions and works in developing countries. We present a view of 10 years of missions carried out between 2003 and 2013. This experience covers a uniform period both by the objectives proposed and the regularity of missions observed. This work shows the way surgical missions take place and the methodology used. We carried out 30 missions. We made more than 4000 consultations and we operated 1500 patients. Interventions are divided into one quarter cleft, one quarter tumors, one quarter burn injuries and one quarter of various diseases such as noma and Buruli ulcer. We show some adaptations such as autonomy during missions, the adjustment guidance in relation to this new environment and the integration of local traditions in our therapeutic action. We offer practical notions on the surgical procedures and some reflections on the societal level. This work aims primarily to pay tribute to all the invisible actors in this long chain of humanity, and thanks to the simple intervention of men, a patient can have the same medical treatment whether he is in an industrial country or in some isolated place on this earth.

Renal impairment after liver transplantation - a pilot trial of calcineurin inhibitor-free vs. calcineurin inhibitor sparing immunosuppression in patients with mildly impaired renal function after liver transplantation.

OBJECTIVES: Chronic kidney disease is frequent in patients after orthotopic liver transplantation (OLT) and has impact on survival. Patients receiving calcineurin inhibitors (CNI) are at increased risk to develop impaired renal function. Early CNI reduction and concomitant use of mycophenolat mofetil (MMF) has been shown to improve renal function. METHODS: The aim of this trial was to compare dose-reduced CNI/MMF versus CNI-free MMF/prednisone-based treatment in stable patients after OLT with respect to glomerular filtration rate (GFR). 21 patients (GFR 44.9 ' 9.9 mL/min/1.73m2 measured by 99m-Tc-DTPA-clearance, serum creatinine (SCr) 1.5 ' 0.42 mg/dL) were randomized either to exchange CNI for 10 mg prednisone (group 1; n = 8) or to receive CNI at 25% of the initial dose (group 2; n = 13) each in combination with 1000 mg MMF b.i.d. RESULTS: At month 12 mean SCr (-0.3 ' 0.4 mg/dL, p = 0.031) and GFR improved (8.6 ' 13.1 mL/min/ 1.73m superset2, p = 0.015) in group 2 but remained unchanged in group 1. Main side effects were gastroinstestinal symptoms (14.3%) and infections (4.8%). Two biopsy proven, steroid-responsive rejections occurred. In group 1 mean diastolic blood pressure (BP) increased by 11 ' 22 mmHg (p = 0.03). CONCLUSIONS: Reduced dose CNI in combination with MMF but not CNI-free-immunosuppression leads to improvement of GFR in patients with moderately elevated SCr levels after OLT. Addition of steroids resulted in increased diastolic blood pressure presumably counterbalancing the benefits of CNI withdrawal on renal function.

[Buruli disease and plastic surgery]. / Ulcère de Buruli et chirurgie plastique, au dispensaire.

The Buruli ulcer is a skin infection with Mycobacterium ulcerans which progresses silently. This infection affects mostly women and children who live near stagnant waters. Buruli ulcer is disease that has terrible consequences if not promptly diagnosed and treated. It destroys progressively skin tissues and consequently leaves very important scars. There is no efficient medical treatment. This presentation proposes to take care efficiently of the Buruli ulcer by simple plastic surgery techniques. We relate our experience of a mission in Benin, in the context of the national programme of struggle against the Buruli ulcer.

[Plastic surgery under challenging conditions: the concept of the five F's]. / Chirurgie plastique en situation précaire: concept cinq F.

This work was done essentially for the benefit of the surgeon who wishes to practice plastic surgery under challenging conditions. The questions he asks himself are most often aimed at what type of pathology he will encounter during his mission, on the operating techniques he will have to adopt and the surgical principles he will have to observe in this type of environment. This presentation tries to come up with an answer, among others, by offering a concept which could be adapted to surgical techniques under challenging conditions. The study, retrospectively, of 100 patients operated during a mission led us to suggest six techniques of reconstructive surgery. We have observed the conditions in which we can apply these different techniques and we have paid a lot of attention and reflection on the environment of our therapy. Before going on a plastic surgery mission we strongly advise the surgeon to bear in mind, in his choice of a surgical technique, the following concepts: the ultimate goal to be reached, the feasibility of the surgical practice, the safety of the technique, the familiarity of the surgical procedure and the easiness to teach of the method.

[Humanitarian aesthetic surgery]. / Chirurgie esthétique humanitaire.

Must a face be disfigured by a terrible tropical disease, in order to make us realise that the well being of our gesture is aesthetically acceptable? Must our reparative motivation remain the only trace of our skill and our humanity? During a plastic surgery mission, so-called humanitarian mission, can this surgery be aesthetic? Can aesthetic surgery be humanitarian? We learnt from aesthetic surgery on humanitarian missions, that aesthetic is only a technic to assist the reparation aspect. There is no need to justify aesthetic by reconstruction, because aesthetic belongs, in its entirety, to reparation. There is no need either to feel guilty, when our technical gesture is aesthetic, since what really motivates our intervention is not for us to decide. Is the reparation of the cleft lip of a little Asian girl, a reparation gesture or only an aesthetic approach? You may think that this will be a reparation gesture, because it will be more "popular" or because you will reconstruct the muscular belt. This child will most probably look for a more beautiful or aesthetic lip (in any case, she ignores the intricacies of facial growth principles). Therefore, it will be an aesthetic intervention. Never mind the motivation, since your technic will be the same, and you will try to do your very best and the most aesthetically you can. Only the very intention behind an intervention will decide whether it is an aesthetic or a plastic intervention, whereas your technical gesture will remain the same. All this illustrates that our definitions are of a minor importance, compared with the mere satisfaction of our little Asian girl, which, hopefully, will be a "beautiful" satisfaction. In fact, we have learnt not to do aesthetic surgery, but to give an aesthetic approach to our surgery, even during our humanitarian missions. The form aesthetic surgery will take is very subjective and only the final result will have the last say. Hopefully this surgical result will be aesthetically and humanly acceptable.

[Aesthetic snapshot: study about cosmetic surgical procedures and complications]. / Instantané esthétique : le questionnaire sur les interventions et leurs complications.

A questionnaire was addressed to 600 members of the French Society of Plastic Reconstructive and Aesthetic Surgery. Out of 19,000 interventions, thanks to the analysis of 112 answers, we were able to get a good picture of the activity in aesthetic surgery, showing the number and type of complications experienced during each intervention. Cosmetic surgical procedure represents 35% of global surgical activity of the French plastic surgeon. The most frequent interventions are liposuction (19%), breast augmentation (16%), eye-lid surgery (14%), abdominoplasty (12%), mammaplasty (10%), facelift (10%) and rhinoplasty (8%). The techniques for which we register more than 10% of problems are: abdominoplasty and mammaplasty. The techniques for which we register between 5% and 10% of problems are: rhinoplasty, facelift and breast augmentation. The techniques for which we register less than 5% of problems are: liposuction and eye-lid surgery. On average, the most frequent cosmetic surgical procedures give rise to 7% of complications.

[The face lifting]. / Le << lifting >> cervicofacial.

The authors wanted to evoke the main steps of the "star" operation that is the face lifting. They also wanted to recall what had been done, what is being done and what has passed off. They also wanted to toss out some ideas concerning the future, knowing of course that it is unpredictable.

Is it necessary to suture the platysma muscles on the midline to improve the cervical profile? An anatomic study using 20 cadavers.

To ameliorate the cervicomental angle, most surgeons suggest different techniques of platysmaplasty. The aim of this anatomic study is to find a simple answer to the following question: Is suturing of the anterior edges of the platysma muscles during platysmaplasty the best procedure to use to obtain the best concave anterior neck angle? Three different surgical techniques using platysma muscle flaps were used on 20 cadavers prepared for anatomic dissection. Each piece of dissection was controlled by a radiograph of the profile of the cervical region before and after the application of these different techniques. Cephalometric measures were made and statistically analyzed. The analysis of the results demonstrates that the best concave anterior neck angle to perform platysmaplasty is one in which the platysma muscle flap is shifted posterosuperiorly but without suturing the medial borders of the platysma muscles. Suturing the midline does not deepen the concavity in the front of the neck.

[In situ thrombolysis. Correlation between creatine phosphokinase increase and local thrombolysis. An experimental study in the rat]. / Thrombolyse in situ. Corrélation entre l'augmentation de la créatine-phosphokinase et la thrombolyse locale. Etude expérimentale chez le rat.

This study proposes intraarterial in situ thrombolysis for the treatment of microthrombi occurring after tissue crushing. In order to assess the efficacy of the thrombolytic, the authors assayed the serum creatine phosphokinase (CPK) level in the crushed muscle capillary bed. The action of thrombolytics has now been clearly established. In contrast, the correlation between local thrombolysis and the serum CPK variation in crush injuries of striated muscle constitutes the originality of this paper. This experiment was conducted in twenty Wistar rats in which striated muscle crushing was performed. The serum CPK level assayed in venous blood, obtained from the capillary bed concerned, before and after local thrombolysis. The increased CPK level provided an objective indication of the efficacy of intra-arterial thrombolysis after crush injury. The authors now apply local thrombolysis according to a prospective clinical protocol for hand emergencies associated with a crush mechanism.

[Experimental cervicoplasty: correction of the cervicomental angle by postero-superior suspension of the hyoid bone. A study of 20 anatomical dissections]. / Cervicoplastie expérimentale: correction de l'angle cervico-mentonnier par la suspension postéro-supérieure de l'os hyoïde. Etude sur vingt pièces de dissection anatomique.

The elegance of the cervical region is due to a certain balance between concave and convex surfaces, and is based on the presence of a well-defined cervicomental angle, generally between 90 degrees to 110 degrees. An excessively wide-open cervicomental angle makes the cervical profile inelegant. Numerous surgical techniques can improve this angle. There is however a certain limit to this correction: an excessively caudal and anterior hyoid bone. In this case the last proposal is a modification of the hyoid bone position in order to replace it in a backward and upper location. To achieve this goal we studied postero-superior suspension of the hyoid bone by plication of the tendon of the digastric muscle in 20 anatomic dissection. Each an dissection was controlled by x-ray of the profile of the cervical region before and after application of this technique. Cephalometric measures were performed and statistically analysed using the "Paired t-test" on Statview II. Analysis of the results after the plication of the tendon of the digastric muscle, demonstrated an average closing of the cervicomental angle of 25.6 degrees with an average ascent of the hyoid bone of 13.27 millimeters and an average posterior transposition of 3.75 millimeters. This experimental cervicoplasty appears to be feasible. A precise surgical technique has been developed with an easy approach to the digastric tendon during standart faced lift procedures. The effect of the compression generated on the pharyngo-oesophageal complex by posterior transposition of the hyoid bone is unknown. This problem is now under investigation.