Prise en charge d'une mucormycose disséminée chez un patient polytraumatisé et brûlé: intérêt des instillations locales, rapport de cas et revue de la littérature.

Mucormycosis are infrequent filamentous fungal infections, but severe and with high mortality (20 to 50%). Symptoms are very common, like necrosis, and burn/polytrauma patients have a higher risk of mucormycosis than the general population. We report here the history of a 38-year-old man, polytraumatized and burned because of a tractor incident. During the first two weeks two haemorrhagic shock episodes occurred because of necrosis of the humeral artery. Analysis of vascular fragment identified Lichteimia spp. The diagnosis of invasive infection was established after identifying Lichteimia spp. in blood cultures also. We treated the patient with intravenous liposomal amphotericin, oral posaconazole and surgical debridement according to the gold standard. The wound mucormycosis was also treated with a humeral bypass with vascular allograft and a latissimus dorsi pedicled flap. Furthermore, mucormycosis was treated with local instillations of amphotericin B in the dressings twice a day with 1% (1 mg/100mL) solution of non-liposomal amphotericin. Early diagnosis and treatment is very important for mucormycosis healing and to minimize morbimortality. With burn and polytrauma patients necrosis and bad local evolution have to be carefully screened and analyzed.

[Tissue expansion in child's burn reconstruction. Management principles and eleven years retrospective study of 42 patients]. / Expansion cutanée pour séquelles de brûlure de l'enfant. Principes de prise en charge et étude rétrospective de 42 patients sur 11 ans.

PURPOSE: With constraints and a risk of complication, tissue expansion in child's burn sequelae need a controlled surgical procedure, and a therapeutic plan appropriate to the specific pediatric healing, growth, and development. MATERIAL AND METHODS: Our principles of management and technical points are described. A retrospective study of tissue expansion in child's burn sequelae between 2005 and 2016 is submitted. RESULTS: There are 185 expanders, 98 protocols in 41 children, over half of sequelae concerning scalp, neck and chest. Mean age at the first expansion was 10.3 years old (5.8 years after burn). There are in average 2,4 (1-8) protocols by patient, with 1.9 (1-4) expanders by procedure. Surgical repair was a flap (78.8%), a full-thickness skin graft (13.3%) or both. Fifteen patients (30 expanders (14.6%) and 22 protocols (22.4%)), had expansion's complications, mostly infections and expositions. Eight patients (14 expanders (7.6%) and 10 protocols (10.2%)) had reconstructive's complications. An increase of burn area was a risk factor of complication (significant). Complicated expanders rate by location was 7.9% (scalp), 12.5% (neck), 9.8% (supraclavicular), 10.5% (chest), 19.4% (abdomen), 30% (buttock), 29.4% (lower limb), 1/2 (face). CONCLUSION: Tissue expansion in child's burn sequelae is ideal in scalp, good in neck, chest and proximal upper limb, and to do carefully in lower limb and face.

An anatomic study of deep inferior epigastric artery diameters at the origin from external iliac and at the lateral border of rectus abdominis muscle by computed tomographic angiography from autologous breast reconstruction patients.

BACKGROUND: Autologous breast reconstruction by means of microsurgical abdominal flaps is an very well described technique. The flap harvest dissection under inguinal ligament would cause the risk of parietal weakening in this zone and postoperative bulging. The goal of our study is to investigate whether the deep inferior epigastric artery diameter remains constant from its exit of the external iliac artery to its entrance in the rectus muscle sheath. PATIENTS AND METHOD: One hundred arteries were studied on fifty preoperative computed tomographic angiographies made before a DIEAP flap for breast reconstruction. We measured the caliber of the left and right deep inferior epigastric arteries at these two landmarks. The length of this artery between these was also calculated. This data were collected with specific angiography reconstruction. RESULTS: At the caudal landmark, the mean DIEA diameter was 2.1±0.27mm on the left side and 2.1±0.31mm on the right side. At the cephalic landmark, the mean DIEA diameter was 2.0±0.28mm on the left and 2.0±0.27mm on the right side (P=0.00035 at left side; P=0.0089 at right side). The mean pedicle length between the two landmarks was 22.3±2.85mm on the left side and 22.2±2.98mm on the right side. CONCLUSION: This computed tomographic angiography study showed that the diameter of DIEA is equivalent at its origin and at the lateral border of muscle. Flap harvest without dissection under inguinal ligament provides sufficient pedicle length and caliber to allow for comfortable and reliable sutures.

[Profunda femoral artery perforator flap: Anatomical study]. / Le lambeau perforant de l'artère fémorale profonde : une étude anatomique morphométrique.

BACKGROUND: Within the framework of mammary reconstruction, since 2012 when Allen first described it, the profunda femoral artery perforator flap (PAP) takes an important place in the current therapeutic options. OBJECTIVE: This anatomical study aims to analyze the anatomy and morphologic consideration of the PAP : position of the perforating artery; length of the pedicle, area and volume of vascularization. METHODS: Sixteen flaps were harvested on fresh subjects at the University Department of Anatomy of Rockfeller, Lyon. The first direct cutaneous branch from the deep femoral vessels was located between or through the adductor magnus and gracilis muscles. Pedicle location, diameter, length and position regard to the great saphenous vein were recorded. A flap based on this vessel was designed. Height, width, and surface of the skin paddle were recorded. Three-dimensional computed tomographic angiography was used to analyze the area and volume of cutaneous territory supplied by the studied perforator. RESULTS: On the 16 analyzed flaps, localization of the perforating artery is on average to 8.2cm of the pubic tuber and 3.7cm behind a line connecting the pubic tuber to the internal femoral condyle. The length of the pedicle is on average of 11.7cm and the average area of skin perfused was 94,68cm2. The way of this perforating arterty is primarily through the adductor magnus. On the radiological images of the 8 flaps, the analysis shows an average surface of 111,25cm2 and a mean volume of 325.3cm3. DISCUSSION: PAP is an interesting therapeutic choice within the framework of a mammary reconstruction. Its surface and its volume associated with a discrete scar make a valid indication within the framework of this surgery.

[Evaluation of the risk of postoperative bleeding complications in hand surgery without interruption of anticoagulant Vitamin K Antagonist (VKA), a retrospective study]. / Évaluation du risque de saignement postopératoire en chirurgie de la main sans interruption des anticoagulants de type AntiVitamines K (AVK), étude rétrospective.

OBJECTIVE: The management of patients on Vitamine K Antagonist (VKA) anticoagulation is a public health issue with surgery being the primary cause of VKA interruption. The aim of this study was to evaluate the bleeding risk in patients operated on hand surgery without interruption of VKA treatment. PATIENTS AND METHODS: This retrospective, monocentric study was conducted between 2013 and 2015. The inclusion criteria were, as follows: patients on VKA over 18 years of age who had emergency or scheduled surgery without interruption of VKA treatment; INR inferior to 3 analyzed less than 24h before surgery. Exclusion criteria were, as follows: INR superior to 3; interruption of VKA treatment with or without switch to heparin treatment. The primary evaluation parameter was any form of bleeding that occurred during the first 7 post-operative days. The secondary criteria were other surgical complications. RESULTS: There were 93 patients and 104 procedures. The mean age was 74.36 years (from 27 to 90) with a sex ratio male-to-female of 2.47. The scheduled surgeries were 61.5% against 36.5% for the emergency cases. The mean INR was 2.29 (from 1.07 to 3). One patient presented a postoperative hematoma on the 4th postoperative day, which did not require any revision surgery. There were no other complications reported. CONCLUSION: The results of this series suggest a small bleeding risk in hand surgery without interruption of VKA treatment provided that IRN is inferior to 3 less than 24hours before the procedure.

Abdominoplasty with simultaneous laparoscopic umbilical hernia repair: A practical approach to preserve the umbilical vascularization.

BACKGROUND: Umbilical necrosis is a well-known complication of abdominoplasty, the risk of this complication can be increased when an associated umbilical hernia requires further dissection in peri-umbilical region, potentially leading to umbilical devascularisation. Multiple minimally invasive open techniques were described to avoid this problem. The combined approach of abdominoplasty with laparoscopic umbilical hernia repair is one promising solution to avoid devascularising the umbilicus. METHODS: A retrospective evaluation of patients who underwent concomitant abdominoplasty with laparoscopic umbilical hernia repair from 2007 to 2017 was carried out. All patients were followed up and evaluated for complications, including the incidence of umbilical skin necrosis. RESULTS: A total of 47 patients were included in this study. The average operative duration was 3.3hours with an average hospital stay of 2.5 days. No cases of postoperative umbilical necrosis were encountered. A mean follow-up period was 2.4 years showed no cases of hernia or rectus abdominis diastasis recurrence. Minor complications included 4 cases of dehiscence, one hematoma. There was no major complications. CONCLUSION: The concomitant use of laparoscopic umbilical hernia repair and abdominoplasty is a feasible approach to reduce the risks of umbilical devascularization. Especially in larger hernias and in patients with higher risk of recurrence.

[Surgical approaches of tumors of the posterior cone of the orbit]. / Voies d'abords des tumeurs du cône postérieur de l'orbite.

The surgical management of posterior orbital tumors is complex because it is an anatomical area located at the borders between the face and the skull base. The goal of the procedures carried-out in this area is to resect the tumor while preserving vision by using the safest possible approach. The aim of our work was to determine, in the light of our experience and of a review of the literature, the advantages and drawbacks of the numerous approaches described.

[Anatomical study of muscular latissimus dorsi surface vascularized by the transverse branch of thoraco-dorsal artery]. / Étude anatomique du territoire musculaire du latissimus dorsi vascularisé par la branche transverse de l'artère thoraco-dorsale.

INTRODUCTION: The latissimus dorsi muscle flap is a type V according to Mathes and Nahai. It is vascularized by a proximal main pedicle represented by the thoraco-dorsal pedicle and pedicle distal accessory represented by the dorsal branches of the posterior intercostal arteries. The main thoraco-dorsal pedicle has a descending branch and a transverse branch. This anatomical study clarifies the muscular territory vascularized by the transverse branch of thoraco-dorsal artery for a secondary use after harvesting a thoraco-dorsal artery perforator flap or a muscle-sparing latissimus dorsi flap. MATERIAL AND METHODS: Our study focused on ten dissections latissimus dorsi muscle taken from five fresh cadavers chest, carried out within the University Department of Anatomy. The descending branch of thoraco-dorsal artery was ligated, the transverse branch was cannulated and injected with a mixture of barium sulfate/gelatin. After freezing, a static angiotomodensitometry (3D) of each flap was performed. RESULTS: The average muscular surface vascularized by the transverse branch is measured at 80% (77% minimum value, maximum value 83%) of the complete latissimus dorsi muscle. Intermuscular connections between the two branches of thoraco-dorsal pedicle were shown. CONCLUSION: The use of a ipsilateral latissimus dorsi muscle is a therapeutic option after harvesting a thoraco-dorsal artery perforator flap (TAP) or a muscle-sparing latissimus dorsi flap (MSLD-flap).

[Sequelae after harvesting latissimus dorsi flap and derivates--review]. / Séquelles du prélèvement du lambeau de grand dorsal et ses dérivés--Revue de la littérature.

INTRODUCTION: The latissimus dorsi (LD) appears as a therapeutic option in many cases of reconstruction. Its large surface and reliability make it an ideal therapeutic choice. Since its initial description in 1896 by Tansini, many publications have been reported on its clinical application and the low donor site morbidity. However, harvesting of LD can be a source of functionnal and aesthetic sequelae. The purpose of this study is to provide a state of the science regarding the potential functional, aesthetic and pain sequelae related to harvesting of LD flap in its original description, but also in its modifications (muscle-sparing LD flap [MSLD-flap] and thoracodorsal artery perforator flap [TAP-flap]). MATERIAL AND METHODS: A review of the literature was realized, the database PubMed was chosen. Keywords used for the research were: LD flap; LD flap morbidity; donor site sequelae of LD flap; TAP-flap AND donor site morbidity; MSLD-flap AND donor site morbidity. RESULTS: Literature report suggests that harvesting of the whole LD muscle flap can provoke pain and functional deficit which diminish and even tend to disappear over time due to functional replacement by the other muscle groups. The partial (MSLD) or total (TAP-flap) preservation of the muscle leads to less pain, functional and aesthetic sequelae. These results are supported by objective, reliable and reproducible studies. CONCLUSION: Well-targeted and well-designed studies could allow for better evaluation of the advantages and disadvantages of each technique. This would lead to better selection of candidates for each technique.

[Optimization of primary aesthetic breast augmentation using implants: an evidence-based level approach]. / Optimisation de l'augmentation mammaire primaire par implants: approche basée sur le niveau de preuve.

The primary aesthetic breast augmentation has been the most performed cosmetic surgery procedure in the world for over 40 years. The current literature focuses on the new concept of "process of breast augmentation" and the importance of non-surgical part (patient selection, preoperative planning and personalized management of postoperative care) in potentiating the cosmetic results and reducing the rate of complications and reoperations. This review of literature discusses, through an analysis of scientific evidence levels, every step of the whole process of breast augmentation in order to determine the current best practices tailored to each patient to optimize satisfactory and durable cosmetic outcomes.

[Vascularloops in reconstructive microsurgery: A review of the literature]. / Les boucles vasculaires en microchirurgie réparatrice : revue de la littérature.

The success of free tissue transfer depends on the quality of vascular micro-anastomosis and recipient vessels. Adequate recipient vessels are sometimes not available near the recipient site for they can be either destroyed or of poor quality (radiotherapy, traumatism). In such cases, good quality recipient vessels are at a distance from the reconstructed site. If this distance is important flap pedicle lengthening implies - for the artery, for the vein or for both flap artery and vein. This lengthening can be carried out in two manners - by interpositional vein grafts (VG) or by a vascular loop (VL) in one or two stages. The aim of this study was to review the utilisation of VL and their type since their introduction in the clinical practice of reconstructive microsurgery. Two main types of VL are used - BV by VG and VL "in situ". Both of them can be carried out in one or two stages. Each of these techniques has its advantages and disadvantages. The overall data from the literature shows that VL are indicated in cases where both artery and vein are damaged or destroyed. There is not enough evidence concerning the VL in one or two stages but there are some tendencies in favour of the VL in one stage. The technique of VL seems to be more avantageous over the interpositional VG but with a smaller success rate compared to free-flaps with direct anastomosis to recipient vessels. Further studies are necessary to investigate these controversial questions.

One-stage reconstruction of the eye socket with vascularized temporalis muscle flap in orbital exenteration.

AIM: Two cases of one-stage reconstruction of exenterated orbit with vascularized temporalis muscle flap in oncological patients are presented. The anatomical characteristics of the temporalis muscle flap and the choice of one-stage or delayed reconstruction of the exenterated orbit are discussed. METHODS: Two patients were operated for malignancy recurrence during the period May-November 2000. One patient suffered recurrent squamous cell carcinoma in the left nasolabial region that infiltrated the lower eyelid and periorbit. The other patient had recurrence of previously operated primary rhabdomyosarcoma of the orbit. Both patients underwent orbital exenteration. In the first patient it supplemented the tumor excision and partial maxillary excision resulting in large orbitomaxillary defect communicating with the nasal meatuses. RESULTS: In both patients good filling effect and isolation of the orbit from the neighbouring nasal meatuses and cranial cavity were obtained using vascularized temporalis muscle flap. CONCLUSION: The vascularized muscle flap appears a reliable technique and method of choice in one-stage as well as in delayed reconstruction in orbital exenteration.

Pleural effusions in acute pancreatitis.

BACKGROUND: Acute pancreatitis ranks third among the inflammatory diseases causing acute abdomen; it accounts for about 2% of all cases of acute surgical abdomen. The clinical course of the disease is characterised by a number of local and systemic complications, the most frequent being respiratory disorders. METHODS: In the present study we review our experience with the management of acute pancreatitis in 75 patients complicated by pleural effusions in some of them. The patients were allocated into two groups depending on the severity of the disease: group I included patients with mild pancreatitis and group II--with severe acute pancreatitis. RESULTS: Pleural effusions were found in 4.7% of the patients in group I and in 24.2% in group II. They were given conservative treatment; it included puncture in three patients. CONCLUSIONS: Pleural effusions, which are indicators of poor prognosis, are observed most often in severe acute pancreatitis.