Axillary Hidradenitis Suppurativa: A Comparison between Two Perforator Flap Reconstructive Approaches after Radical Surgical Management.

Background: Axillary hidradenitis suppurativa (HS) can result in significant functional impairment in both personal and professional lives. Stage 3 HS requires radical surgical treatment. Flap reconstruction allows for faster healing and better functional and aesthetic outcomes. We compared the results of thoracodorsal artery perforator (TDAP) and propeller inner arm artery perforator (IAAP) flap reconstructions after radical surgical treatment of axillary HS. Methods: We conducted a retrospective study that included 13 consecutive patients who underwent stage 3 axillary HS treatment between August 2015 and January 2023. Seven patients underwent reconstruction by islanded TDAP flaps, whereas six patients underwent reconstruction by propeller IAAP flaps, with one patient undergoing bilateral reconstruction. The data collected from the patient records included age, gender, smoking status, body mass index, comorbidities, operative time, defect size, flap size, hospital stay, and complications. Results: Although not statistically significant (P = 0.1923), a higher rate of flap complications is reported here with propeller IAAP flaps (42.86 %), whereas islanded TDAP flaps had no flap complications (0%). We found a statistically significant difference in operative time (P = 0.0006), defect size (P = 0.0064), and flap size (P = 0.0012) between the two groups. All patients exhibited satisfactory functional and aesthetic outcomes. Fourteen flaps were performed in total; only one case exhibited recurrence (7.14%). Conclusion: After radical surgical management, both islanded TDAP and propeller IAAP flap reconstructions offer excellent outcomes for stage 3 axillary HS. We strongly encourage our peers to consider performing perforator flaps over secondary healing for these patients with a major functional impairment.

Phenol-soluble modulins α are major virulence factors of Staphylococcus aureus secretome promoting inflammatory response in human epidermis.

Staphylococcus aureus is a skin commensal microorganism commonly colonizing healthy humans. Nevertheless, S. aureus can also be responsible for cutaneous infections and contribute to flare-up of inflammatory skin diseases such as atopic dermatitis (AD), which is characterized by dysbiosis of the skin microbiota with S. aureus as the predominant species. However, the role of major virulence factors of this pathogen such as phenol-soluble modulin (PSM) toxins in epidermal inflammation remains poorly understood. Stimulation of primary human keratinocytes with sublytic concentrations of synthetic and purified PSM α3 resulted in upregulation of a large panel of pro-inflammatory chemokine and cytokine gene expression, including CXCL1, CXCL2, CXCL3, CXCL5, CXCL8, CCL20, IL-1α, IL-1ß, IL-6, IL-36γ and TNF-α, while inducing the release of CXCL8, CCL20, TNF-α and IL-6. In addition, using S. aureus culture supernatant from mutants deleted from genes encoding either α-type PSMs or all PSM production, PSMs were shown to be the main factors of S. aureus secretome responsible for pro-inflammatory mediator induction in human keratinocytes. On the other hand, α-type PSM-containing supernatant triggered an intense induction of pro-inflammatory mediator expression and secretion during both topical and basal layer stimulation of an ex vivo model of human skin explants, a physiologically relevant model of pluristratified epidermis. Taken together, the results of this study show that PSMs and more specifically α-type PSMs are major virulence factors of S. aureus inducing a potent inflammatory response during infection of the human epidermis and could thereby contribute to AD flare-up through exacerbation of skin inflammation.

Superior epigastric artery perforator flap for reconstruction of deep sternal wound infection.

BACKGROUND: The treatment of deep wound sternal infection requires loco-regional pedicled flaps, usually with muscular flaps. Perforator propeller flaps represent the ultimate progress in the history of reconstructive surgery. We report here our experience with the superior epigastric artery perforator (SEAP) flaps to repair sternal defect. PATIENTS AND METHODS: Six patients presenting deep sternal wounds infection were treated with SEAP propeller flap, between March 2015 and June 2017. The mean age was 71.5 (range 53-83) years. The mean length and width of the defect were 16.2 × 7 cm (ranging 8-20 × 4-10). An elliptical skin flap pedicled on the SEAP was harvested in the inframammary fold and rotated up to 90° to cover the defect. RESULTS: All SEAP flaps achieved a successful entire coverage of the defect. The mean size of the skin paddle of the flap was 20.2 × 7.3 cm (ranging 14-27 × 6-9). All flaps were able to provide a complete sternal wound cover. Venous congestion was present in five cases and adequately treated by leech therapy; necrosis was distal in one case, and interesting the entire superficial flap in two cases but with deep tissues remaining viable and able to cover the mediastinum: an infected flap required revision. Satisfyingly, at 2-years postoperative follow-up all-patients were alive with a successful mediastinal cover. CONCLUSIONS: The SEAP Perforator propeller flap is an alternative to muscle flaps to achieve treatment of deep and large sternal wound infection.

Septic shock caused by Gardnerella vaginalis and Atopobium vaginae.

Although bacterial vaginosis is the most common and benign vaginal infection worldwide, some cases of severe acute infections have been described in the literature. We report the case of a 57-year-old French female who developed a life-threatening postoperative peritonitis after a total hysterectomy with adnexectomy in the context of the removal of leiomyosarcoma. The microbiological analysis of the peritoneal fluid identified Gardnerella vaginalis and Atobopium vaginae. The final diagnosis was a septic shock induced by an early onset peritonitis caused by Gardnerella vaginalis and Atobopium vaginae. The normal flora of the genital area could lead to a serious life threatening postoperative infection and should always be in the differential diagnosis.

Acellular dermal matrix: New applications for free flap pedicle coverage - A prospective study in 10 patients.

INTRODUCTION: The goal of lower extremity reconstruction after trauma is the coverage of defects to give patients a healed wound and to let them resume their life, ambulate and return to work, while preventing amputation. In this article, we describe an innovative use of Integra® for free flap pedicle coverage in lower extremity reconstruction. MATERIALS AND METHODS: Between January 2011 and December 2015, ten patients, four women and six men, underwent a lower limb reconstruction with an association of free flap and Integra® to cover the flap pedicle. The mean age of the patients was 38.8±15.6 years at the time of surgery (range of 14-59 years). The mean defect size was 102±54 cm2 (range of 40-160 cm2). The bone and/or tendons were exposed at the level of the middle third of the leg in 2 cases, at the level of the distal leg in 5 cases and at the level of the foot in 3 cases. RESULTS: There were no intra-operative complications. Mean size of Integra® needed for flap pedicle coverage was 12.8±2.3 cm2 (range 10-15 cm2). The mean follow-up was 41±19 months (range 21-70 months). Revision surgery was necessary in three cases due to haematoma of the pedicle. In these cases, the dermal substitute was easily removed while awaiting revision. This allowed flap survival in all cases. A skin graft was performed after a mean time of 3.4±0.8 weeks post-operatively. Complications at the donor site level included one seroma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. CONCLUSIONS: The combination of free flap and Integra® appears to be a useful option in covering complex defects in the lower limb. The dermal substitute avoids skin tension and compression of the pedicle. Haematomas of the pedicle, if they occur, are highly visible and thus easy to manage. We hypothesize that the use of dermal substitute for this specific indication of pedicle coverage will expand in the near future.

Perilunate fracture-dislocations: clinical and radiological results of 21 cases.

BACKGROUND: Perilunate dislocations and fracture-dislocations are a subcategory of the carpal instability complex. Herein, we report our university hospital experience with this complex injury. The goal of our study was to find predictive factors and quantify the development of arthritis and lunate necrosis. We tried to measure the impact of arthritis on hand function. METHODS: Between January 2000 and December 2014, 21 patients underwent surgery for perilunate dislocations and perilunate fracture-dislocations of the wrist in our tertiary university center. Mean patient age was 29.3 ± 10.0 years (range 18-49 years). All displacements were posterior. They were reviewed both clinically and radiologically. RESULTS: Complications included misdiagnosed Essex-Lopresti-like lesion in one case, insufficient reposition of the carpus in two cases (LT in one case, SL in one case), and iatrogenic injury to the radial artery immediately sutured in one case. All 3 cases underwent a second procedure with satisfactory outcome. After a mean follow-up of 112 ± 60 months (range 12-210 months), the average Cooney score was 80 ± 19 (range 50-125). The mean PRWE score was 10 ± 8 (range 0-25). The mean DASH score was 40 ± 13 (range 30-75 months). Mean pain on load, measured with VAS was 1.1 ± 1.6; Clinical examination assessed a mean wrist extension/flexion of 42.4° ± 17.2°/48.4° ± 15.2°. Mean wrist ulnar/radial deviation was, respectively, 22.9° ± 11.3°/15.3° ± 7.0°. Mean pro/supination was, respectively, 75.2° ± 11.5°/76.3° ± 8.1°. Mean pinch strength was 9.4 ± 2.2 kg (87.4 ± 17.7% of the contralateral side). Mean power strength was 41.9 ± 9.9 kg (76.2 ± 19.2% of the contralateral side). Two patients had a scaphoid non-union identified on their most recent imaging. The mean carpal height ratio was 0.53 ± 0.05 (range 0.44-0.65). All except one patient developed arthritis: Grade 1 in 11 patients, Grade 2 in 3 patients, and Grade 3 in the remaining 6 patients. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis (p < 0.001). Lunate avascular necrosis assessed by magnetic resonance imaging was present in 6 patients: Stage 2 in 4 patients, Stage 3a in 1 patient, and Stage 3b in the remaining patient. All these patients' intraoperative findings showed lesion of the cartilage of the radial side of the lunate. However, the small number of patients who developed lunate necrosis did not allow satisfactory statistical analysis. CONCLUSIONS: This retrospective study demonstrates good functional results despite the high rate of radiological wrist arthritis. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis in our series.

The Role of Dynamic Ultrasound in the Immediate Conservative Treatment of Volar Plate Injuries of the PIP Joint: A Series of 78 Patients.

INTRODUCTION: The management of volar plate avulsion fractures in the context of a stable joint and a bony fragment of less than 30% has traditionally been conservative. This study was performed to assess volar plate healing with high-resolution ultrasound in order to provide early full mobilization. MATERIAL AND METHODS: Between January 2012 and December 2013, 78 patients with volar plate injuries of the proximal interphalangeal (PIP) joints (42 distortions and 36 dislocations) were treated conservatively in our department for volar plate avulsion fracture associated with stable joint and bony fragment inferior to 30% of the intra-articular surface assessed both by radiography and ultrasound. Conservative treatment included extension stop splinting for the first 2 weeks and Coban bandage until 6 weeks postinjury. However, it may be possible to modify the duration of extension stop splinting based on clinical and ultrasound findings (with no additional X-ray) performed every 2 weeks for the first 3 months and then at 4 months postinjury. Only patients with residual contracture at the 4-month assessment had prolonged follow-up in order to ensure adequate dynamic splint therapy. RESULTS: The amount of soft tissue oedema and the mobility of the volar plate were factors used to determine return to full mobilization. Mean extension-stop-splint wear was 16 ± 2 days. During the first 2 follow-up assessments, 4 patients were excluded from the study because of the instability of the PIP joint. One patient required refixation of a large fragment of 30%, 2 patients required superficial flexor tendon (FDS) tenodesis of the unstable volar plate in hyperextension and 1 other patient required arthrodesis of the PIP joint. In 51 patients, the postoperative follow-up was free of complications at 4 months. In 18 patients, flexion contracture of 20° (range 11°-40°) and oedema during follow-up required dynamic extension splints for 3 to 5 months. After this time, 5 patients had a residual contracture of 10° to 15°. CONCLUSION: Avulsion fractures of the volar plate at the PIP joint are common. In general, they have a good outcome using the conservative treatment with extension block splints. Flexion contracture is a common complication and may be reduced by immediate splints in full extension at night and Coban bandage during the day. High-resolution sonography is a convenient tool to evaluate palmar plate stability, to assess reduction of oedema, and thus to guide safe return to full range of movement.

INTRODUCTION: La prise en charge des avulsions de la plaque palmaire lorsque l'articulation est stable et que le fragment osseux est inférieur à 30 % est habituellement conservative. Cette étude visait à évaluer la cicatrisation de la plaque palmaire à l'aide de l'échographie à haute resolution afin de favoriser un retour rapide à une mobilisation complète. MATÉRIEL ET MÉTHODES: Entre janvier 2012 et décembre 2013, 78 patients ayant des lésions de la plaque palmaire des articulations interphalangiennes proximales (IPP) (42 distorsions, 36 dislocations) associées à une articulation stable et à un fragment osseux inferieur à 30 % de la surface articulaire à la radiographie ont été traité de manière conservative et suivi par échographie. Le traitement incluait une attelle extension-stop pendant les deux premières semaines, puis un bandage CobanMD pendant les quatre semaines suivantes. Il était cependant possible d'adapter la durée du port de l'attelle en fonction des données cliniques et de l'échographie (sans radiographie) réalisée toutes les 2 semaines jusqu'à 3 mois, puis le quatrième mois suivant la lésion. Seuls les patients présentant une contracture résiduelle au bout de quatre mois étaient soumis à un suivi prolongé incluant une attelle dynamique. RÉSULTATS: L'ampleur de l'œdème des tissus mous et la mobilité de la plaque palmaire faisaient partie des facteurs utilisés pour déterminer le retour à une mobilisation complète. Le port moyen de l'attelle extension-stop était de 16±2 jours. Lors des deux premières évaluations de suivi, quatre patients furent exclus de l'étude en raison de l'instabilité de l'articulation IPP : Pour un patient, un fragment de 30% a nécessité une refixation, pour deux patients, une ténodèse du tendon fléchisseur superficiel (TFS) a permis de stabiliser l'articulation instable en hyperextension et pour le dernier patient, une arthrodèse de l'IPP fut réalisée. Chez 51 patients, la guérison était complète après 4 mois. Chez 18 patients, une contracture résiduelle de 20° de flexion (11° à 40°) a exigé le port d'une attelle dynamique d'extension pendant une durée complémentaire de 3 à 5 mois. Après cette periode, cinq patients présentaient une contracture residuelle de 10° à 15°. CONCLUSION: Les avulsions de la plaque palmaire de l'articulation IPP sont des lésions courantes. Habituellement, un traitement conservateur à l'aide d'une attelle extension-stop permet leur guérison rapide. L'echographie à haute résolution quantifie la réduction de l'œdème et la guérision de la plaque palmaire, et par là permet de limiter le port de cette attelle extension-stop. La contracture résiduelle en flexion est une complication courante qui peut être traitée par attelle dynamique.

Use of bioartificial dermal regeneration template for skin restoration in combat casualty injuries.

A letter in response to: Seavey JG, Masters ZA, Balazs GC, Tintle SM, Sabino J, Fleming ME & Valerio IL. Use of bioartificial dermal regeneration template for skin restoration in combat casualty injuries. Regen. Med. 11(1), 81-90 (2016).

Cuttlefish Ink Melanin Encapsulated in Nanolipid Bubbles and Applied Through a Micro-Needling Procedure Easily Stains White Hair Facilitating Photoepilation.

BACKGROUND: Photothermolysis of unwanted hair depends on the presence of melanin in the hair follicle as the chromophore, but is not effective in patients with non-pigmented, melanin-sparse hair shafts and follicles. This split-scalp, double-blind study was to monitor the efficacy of melanin bound in nanosomes to inject exogenous melanin into the hair follicles thus potentiating successful photothermolysis.
MATERIAL AND METHODS: Twelve patients, phototypes II-III, with white or very fair hair, were treated with a compound containing melanin encapsulated in nanosomes (Melaser®) together with a fluorescent marker. Two equal 6 cm² areas were marked on each side of the occiput of the subjects. The compound was applied to a randomly selected experimental side on each patient (area A), and a saline solution applied in the same manner to the contralateral control side (area B). Penetration of the melanin into the hair follicle was assessed using optical and fluorescence microscopy. Also, condition of hair structure was checked in vivo after standard laser settings used for epilation.
RESULTS: A slight transient erythema was observed in those areas where the compound was applied with some perifollicular edema. No such effects were noticed in those areas where saline solution was applied. No persistent complications such as scarring, hypo- or hyperpigmentation were observed in any of the experimental or control areas. Under fluorescence microscopy, the hair structures in the areas to which the compound had been applied showed a clear melanin deposit confirmed by the immunofluorescence intensity, which was highest at 2 hours after application. By optical microscopy, external melanin was deposited in hair follicles. Tests with standard settings for epilation were efficacious in damaging melanin-marked white hair.
CONCLUSION: This study strongly suggests the safety and efficacy of the application of nanosomes encapsulating melanin for the introduction of melanin into hair follicles. Changes noticed in the hair structure compromising its viability indicated potential application of this external melanin marker for white hair photoepilation.

J Drugs Dermatol. 2016;15(5):615-625.

Laser-assisted lipolysis for arm contouring in Teimourian grades III and IV: A prospective study involving 22 patients.

BACKGROUND: Upper arm deformities secondary to weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures. OBJECTIVE: To objectively assess whether, in Teimourian high-grade upper arm remodelling, laser-assisted lypolysis (LAL) alone could result in patient satisfaction. METHODS: Between 2012 and 2013, 22 patients were treated for excessive upper arm fat (Teimourian grade III and IV) solely with LAL. The laser used in the present study was a 1470 nm diode laser (Alma Lasers, Israel) with the following parameters: continuous mode, 15 W power and transmission through a 600 µm optical fibre. Previous mathematical modelling suggested that 0.1 kJ was required to destroy 1 mL of fat. Patients were asked to complete a satisfaction questionnaire. The arm circumference was measured pre- and postoperatively. Treatment parameters, adverse effects and outcomes were recorded. RESULTS: Pain during the anesthesia and discomfort after the procedure were minimal. Complications included ecchymoses and prolonged edema. The mean (± SD) arm circumference decreased 5.5±1.0 cm in the right arm (P<0.01) and 5.2±1.1 cm in the left arm (P<0.01) in grade III patients and 4.9±1.1 cm in the right arm (P<0.01) and 4.9±1.1 cm in the left arm (P<0.01) in grade IV patients. Although the circumference of both arms significantly decreased in grade III and grade IV patients, the skin tightening remained incomplete. Overall, the average opinion of treatment was poor for both patients and investigators. Of the 22 patients, only nine (41%) would recommend this treatment. CONCLUSION: LAL for upper arm remodelling is not sufficient to ensure full skin tightening for patients with Teimourian grades III and IV upper arm deformities. A complementary surgery is mandatory for grades III and IV.

ETAT DE L'ART: Les déformations des bras attribuables à une perte de poids ou à l'élastose sénile ont suscité l'augmentation des demandes d'interventions de redrapage esthétique. OBJECTIF: Evaluer objectivement si la lipolyse laser (LL) seule, utilisée pour le redrapage des bras de grades Teimourian III et IV, permet la satisfaction des patients. MATÉRIEL ET MÉTHODES: Entre 2012 et 2013, 22 patients ont été traités par LL seule pour le redrapage des bras de grades Teimourian III et IV. Le laser diode 1470 nm (Alma Lasers, Israël) était utilisé avec les paramètres suivants : mode continu, puissance de 15W, et transmission par fibre optique de 600µm. Selon notre modélisation antérieure, 0,1 kJ était nécessaire pour détruire 1 mL de tissus adipeux. Les patients ont été invités à remplir un questionnaire de satisfaction. La circonférence des bras étaient consignée avant et après intervention. Les paramètres laser requis, les complications, et les résultats étaient enregistrés de manière prospective. RÉSULTATS: La douleur pendant l'anesthésie et l'inconfort après l'intervention étaient minimes avec cette technique. Les complications incluaient des ecchymoses et un oedème prolongé. La circonférence moyenne des bras a diminué de 5,5±1,0 cm au bras droit (p<0,01) et 5,2±1,1 cm au bras gauche (p<0,01) chez les patients de grade Teimourian III, et de 4,9±1,1 cm au bras droit (p<0,01) et 4,9±1,1 cm au bras gauche (p<0,01) chez les patients de grade IV. Même si la circonférence des deux bras a diminué considérablement pour les grades Teimourian III et IV, le redrapage cutané est demeuré incomplet. En moyenne, le résultat est jugé insatisfaisant tant pour les patients que pour les investigateurs. Sur les 22 patients, seuls neuf (41%) recommanderaient le traitement. CONCLUSION: La lipolyse laser est insuffisante pour assurer un redrapage complet des déformations des bras de grades Teimourian III et IV. Une chirurgie complémentaire reste nécessaire dans ces cas-là.

Current laser applications in reconstructive microsurgery: A review of the literature.

BACKGROUND: Microvascular surgery has become an important method for reconstructing surgical defects following trauma, tumor resection, or burns. Laser-assisted microanastomoses (LAMA) were introduced by Jain in 1979 in order to help the microsurgeon reduce both operating time and complications. This article reviews the literature on clinical applications of LAMA. METHODS: A Medline literature search was performed and cross-referenced. Articles between 1979 and 2014 were included. Keywords used were laser, laser microanastomoses, laser microanastomosis, LAMA, and microsurgery. RESULTS: Only seven clinical studies using three different wavelengths were found in the literature: 1,064 nm (Nd: YAG), 10,600 nm (CO2), 514 nm (Argon), and 1,950 nm (Diode). Clinical outcomes, type of procedures, laser wavelength and parameters, and possible wider applications in the operating room are discussed in each case. CONCLUSIONS: The success rate for reconstructive free flap surgery and hand surgery achieved with LAMA appears promising. In particular, use of the 1950-nm diode laser for microsurgery is likely to increase in the near future.

Stroke from an External Carotid: Lesion Pattern and Mechanisms.

Traditionally, patients with symptomatic external carotid stenosis present with neck or face pain, retinal ischemic symptoms or jaw claudication and rarely as ipsilateral cerebrovascular events. In this present case, our patient suffered a stroke from a paradoxical embolism from the external carotid, without involvement of the internal carotid artery. A plaque ulceration of the external carotid's origin was the cause of this cerebral emboli. Duplex ultrasound showed a pathologic left external carotid, with a floating thrombus in the internal carotid. The diagnostic was confirmed by a computerized tomography scan. An external carotid thromboendarterectomy was performed 6 days after symptom onset, and intraoperative findings confirmed the plaque rupture with an extensive clot in the carotid bifurcation.

Vaginoplasty in Male-to-Female Transsexual Surgery: A Training Concept Incorporating Dissection Room Experience to Optimize Functional and Cosmetic Results.

INTRODUCTION: Learning a new technique, even for an established surgeon, requires a learning curve; however, in transsexual surgery especially, there is a lack of professional and public tolerance for suboptimal aesthetic and functional results due to a learning curve. AIMS: In this context, we have tried to build a learning concept for vaginoplasty that includes four steps: (i) formal identification of the surgical steps in order to provide both measure of surgical process and measures of outcomes; (ii) training on cadavers with expert assistance; (iii) performing the live surgery with assistance from expert; and (iv) performing the surgery alone. Herein, we emphasize the second step of our learning concept. MATERIAL AND METHODS: Between September 2013 and December 2013, 15 cadavers were operated on by an established surgeon learning vaginoplasty under assistance from two expert practitioners. Mean global time and mean time necessary to perform each step of the operation were recorded by the experts. Intraoperative complications were systematically registered. The final depth and diameter of the neaovaginal cavity were precisely measured. For each cadaver, the aesthetic results were assessed by one of the experts. RESULTS: Mean total operating time was 179 ± 34 minutes and decreased from 262 minutes for the first training attempt to 141 minutes for the last one. Intraoperative expert correction included modification of the scrotal triangular flap design and change of position of the urethra: This happened during the first training. No lesion of the urethra or of the anus occurred. The two experts judged the outcomes as excellent in seven cases, very good in four cases, good in two cases, and fair in two cases. CONCLUSION: Despite the numerous reports on vaginoplasty in the literature, there is a real lack of published information on the learning curve of this operation. We make the hypothesis that introducing a learning concept with assistance from expert practitioners at the beginning of the surgeon's experience can optimize both the duration of his learning curve and reduce the risk of major complications.

Description of the Baudet Surgical Technique and Introduction of a Systematic Method for Training Surgeons to Perform Male-to-Female Sex Reassignment Surgery.

INTRODUCTION: Male-to-female sex reassignment surgery involves three main procedures, namely, clitoroplasty, new urethral meatoplasty and vaginopoiesis. Herein we describe the key steps of our surgical technique. METHODS: Male-to-female sex reassignment surgery includes the following 14 key steps which are documented in this article: (1) patient installation and draping, (2) urethral catheter placement, (3) scrotal incision and vaginal cavity formation, (4) bilateral orchidectomy, (5) penile skin inversion, (6) dismembering of the urethra from the corpora, (7) neoclitoris formation, (8) neoclitoris refinement, (9) neovaginalphallic cylinder formation, (10) fixation of the neoclitoris, (11) neovaginalphallic cylinder insertion, (12) contouring of the labia majora and positioning the neoclitoris and urethra, (13) tie-over dressing and (14) compression dressing. RESULTS: The size and position of the neoclitoris, position of the urethra, adequacy of the neovaginal cavity, position and tension on the triangular flap, size of the neo labia minora, size of the labia majora, symmetry and ease of intromission are important factors when considering the immediate results of the surgery. We present our learning process of graduated responsibility for optimisation of these results. We describe our postoperative care and the possible complications. CONCLUSION: Herein, we have described the 14 steps of the Baudet technique for male-to-female sex reassignment surgery which include clitoroplasty, new urethral meatoplasty and vaginopoiesis. The review of each key stage of the procedure represents the first step of our global teaching process. LEVEL OF EVIDENCE V: 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.

Nerve Transfers for Persistent Traumatic Peroneal Nerve Palsy: The Inselspital Bern Experience.

BACKGROUND: Patients in whom conventional peroneal nerve repair surgery failed to reconstitute useful foot lift need to be evaluated for their suitability to undergo a concomitant tendon transfer procedure or nerve transfers. OBJECTIVE: To report our first clinical experience with nerve transfers for persistent traumatic peroneal nerve palsy. METHODS: Between 2007 and 2013, 8 patients were operated on for foot drop after unsuccessful nerve surgery. Six patients without fatty degeneration of the anterior tibial muscle and proximal lesion of the peroneal nerve were oriented for tibial to peroneal nerve transfer. In the other 2 cases where the anterior and lateral compartments were destructed, the anterior tibial muscle function was reconstructed with a neurotized lateral gastrocnemius transfer. For each patient, we graded postoperative results using the British Medical Research Council scheme and the Ninkovic assessment scale. RESULTS: Of the 6 patients who underwent nerve transfer of the anterior tibial muscle, 2 patients had excellent results, 1 patient had good results, 1 patient had fair results, and 2 patients had poor results. Of the 2 patients that underwent neurotized lateral gastrocnemius transfer, 1 patient achieved excellent results after tenolysis, whereas 1 patient achieved poor results. After the nerve transfer, 5 patients did not wear an ankle-foot orthosis. Four patients did not limp. Four patients were able to walk barefoot, navigate stairs, and participate in activities. CONCLUSION: Early clinical results after tibial to peroneal nerve transfer and neurotized lateral gastrocnemius transfer appear mixed. The results of nerve transfer seem, on the whole, less reliable than the literature reports on tendon transfer.