The star approach, a surgical approach for skin sparing mastectomy and central lumpectomies.

When preservation of the nipple-areolar complex (NAC) is not possible in oncologic breast surgery, the traditional approaches are either a horizontal incision centered on the NAC resulting in visible scars and breast distortion, or a round block with risk of healing difficulties. To address these concerns, the authors propose a star approach technique for skin sparing mastectomies and lumpectomies of central breast tumors. During the oncologic surgery, the NAC is removed with four cutaneous extensions, which can be closed as a cross-shaped scar. The scarring is similar in size to the original NAC diameter and can easily be covered by the NAC reconstruction. This technique offers good exposure during surgery, a good aesthetic result with limited scarring, no breast deformity, correction of breast sagging, and high-quality healing.

Reconstruction of the anterior chest wall using the internal mammary artery perforator flap (IMAP): About a series of 23 cases.

BACKGROUND: The advent of propeller flaps has permitted new and less invasive coverage solutions for thoracic defects compared to conventional flaps. Through a retrospective analysis of our cases, we would like to show the advantages of the internal mammary artery perforator (IMAP) flap for anterior chest wall reconstruction. METHODS: We included patients who underwent anterior chest wall reconstruction with an IMAP propeller flap in the Toulouse University Hospital's plastic surgery department from January 2019 to December 2022. The data were collected on patient data, skin defects, and flap characteristics. RESULTS: Twenty-three IMAP flaps were realized to cover locoregional defects. The skin paddle size of the IMAP flap averaged 15.6cm long (12-20)×6.7cm wide (4-10). The average arc of rotation of the flap was 113.5° (range 70-140°). In 3 cases, the IMAP flap was performed with a superior epigastric artery perforator flap (SEAP). In 3 cases out of 23, the flap partially necrotized, requiring surgical revision. In 1 case, the flap was fully necrotized and had to be removed. DISCUSSION AND CONCLUSION: Our series of 23 IMAP flaps on thoracic reconstruction is one of the largest published to date. Our series shows that the IMAP flap offers a simple and reliable solution with minor donor site morbidity for reconstructing small to medium-sized defects in the medial and paramedian regions of the chest wall.

Feasibility of perforator flaps in Day surgery. A retrospective study through a two-years' experience.

BACKGROUND: Day surgery is developing and its popularity is increasing for a variety of reasons: economic constraints, changes in professional practices, a greater adhesion of the patient. In an era of progress in surgical procedures, pedicled-perforator flaps reducing donor site morbidity and avoiding micro-anastomosis could take their place in Day surgery if planned and managed by an experienced team. METHODS: In the period January 2019 to January 2021, we performed perforator flaps for soft tissue coverage in ambulatory setting. The patients were included retrospectively and data were collected by reviewing the medical records. Major and minor complications were recorded. RESULTS: The retrospective cohort included 32 surgical procedures in 32 patients. In all cases, perforator flaps were realized for resurfacing soft tissue defects consequent to oncodermatology surgery (84.3%), soft tissue sarcoma surgery (12.5%), invasive ductal breast carcinoma (3.1%). Major complications needing a surgical revision overcame 3/32 times (9.4%). In these cases, a failure requiring the drop off the flap overcame once. The average wound healing time was of 33 days (15-90) and the mean duration of follow-up was 9.6 months (1-22). CONCLUSION: The low complication rate in our series suggests that this first experience on perforator flaps in outpatient surgery is promising in terms of safety and feasibility. Day surgery could be a practical option for this type of surgical procedures avoiding the conventional department's saturation and allowing the delivery of proper surgical cares.

Trends of Neutron Skins and Radii of Mirror Nuclei from First Principles.

The neutron skin of atomic nuclei impacts the structure of neutron-rich nuclei, the equation of state of nucleonic matter, and the size of neutron stars. Here we predict the neutron skin of selected light- and medium-mass nuclei using coupled-cluster theory and the auxiliary field diffusion Monte Carlo method with two- and three-nucleon forces from chiral effective field theory. We find a linear correlation between the neutron skin and the isospin asymmetry in agreement with the liquid-drop model and compare with data. We also extract the linear relationship that describes the difference between neutron and proton radii of mirror nuclei and quantify the effect of charge symmetry breaking terms in the nuclear Hamiltonian. Our results for the mirror-difference charge radii and binding energies per nucleon agree with existing data.

Surgical management of slightly or non-displaced corporal scaphoid fractures by retrograde percutaneous screw fixation through the anterior trapezium horn: A single-center retrospective French study of 33 patients between January 2015 and January 2019.

INTRODUCTION: Percutaneous screw fixation has recently gained popularity as an alternative to conservative treatment to avoid prolonged immobilization. The placement of a screw in the central axis of the scaphoid has been shown to be biomechanically superior to its eccentricity. Still, it poses difficulties in performing percutaneous screw fixation via both palmar and dorsal approaches. OBJECTIVE: We describe a palmar percutaneous screwing of corporal fractures of the scaphoid by a simple palmar transtrapezial approach allowing an optimal centering of the screw. METHOD: We selected patients operated on by the same surgeon using the palmar transtrapezial approach between January 2015 and January 2019 based on the coding used for these fractures and the operative reports. In addition, pre- and postoperative data were collected from the patient's computer and paper records and by telephone contact with the patients. RESULTS: Thirty-three patients were included. Percutaneous screw fixation of the scaphoid was performed under locoregional anesthesia in the operating room with one arm in the supine position on the arm table. No hyper-extension of the wrist was performed. The Kirchner guidewire passed through the anterior horn of the trapezium and then into the trapezium-scaphoid joint. A screw replaced it after satisfactory centering in the axis of the scaphoid. Management took place on average within 12 days after the trauma. 75.8% were A2 fractures, according to Herbert's classification. The average operating time was 16.63minutes, and in 91% of the cases, the patient was hospitalized for one day. The variation of the scapholunate angle on the preoperative profile radiographs with the angle defined by the axis of the scaphoid screw and the lunate postoperatively was on average 2.94°. One patient presented nonunion, and four showed an undersized screw with a screw overhang requiring revision surgery. CONCLUSION: The transtrapezial approach to fixation of acute scaphoid fractures facilitates precise percutaneous screw placement in the central axis of the scaphoid. A study of long-term complications, including the degenerative impact on the scaphotrapezial joint, is needed to assess the safety of passage through the anterior horn of the trapezium.

[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.

[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.

Innervation of digital joints: an anatomical overview.

INTRODUCTION: The innervation of the digital joints as well as the anatomical relationships of the articular branches is present in this anatomical work to determine the technical feasibility of a selective and efficient denervation of the digital joints. MATERIALS AND METHODS: A study of 40 distal interphalangeal (DIP), 40 proximal interphalangeal (PIP), 50 metacarpophalangeal (MCP), 10 interphalangeal (IP) of the thumb, and 10 trapezo-metacarpophalangeal (TMC) joints was performed on ten hands. Under magnification and a proper surgical approach, we collected the course, the source origin, the number of articular nerve branches, and their caliber. RESULTS: In total, 118 nerve branches arising from the proper palmar digital nerves were found on 10 DIP of each dissected long finger (n = 40). A total of 226 nerve branches were found on 10 PIPs of each long finger (n = 40), of which 204 branches (90.3%) had a palmar origin. Dorsal innervation was found for the ring and little finger, originating from the dorso-ulnar digital nerve. 212 branches were found on 10 MCP of long fingers (n = 40), including 87 branches of palmar origin (41.1%), 107 branches of dorsal origin (50.4%), and 18 branches of the motor branch of the ulnar nerve (8.5%). 42 articular branches directed to the TMC joint (n = 10) were found. 13 branches (31%) originated from the anterior sensory branch of the radial nerve, 13 branches (31%) originated from the lateral cutaneous nerve of the forearm, 5 branches (12%) originated from the palmar cutaneous branch of the median nerve, and 11 (26%) branches originated from the thenar branch of the median nerve. The involvement of the sensory anterior branch of the radial nerve was always present for the innervation of each TMC. DISCUSSION AND CONCLUSION: Our research shows that finger joints receive their primary innervation from small branches of the digital nerves with the exception of the MCP joint and the TMC joint. To obtain an efficient and a selective digital denervation for articular pain relief, it is necessary to plan the best surgical approach and it is crucial to recognize the articular nervous branch localization and source.

Radiation-induced bullous pemphigoid after surgery for soft tissue sarcoma: About a rare case.

INTRODUCTION: Radiation therapy may cause a range of side effects of the skin within the irradiated area. Not of all the reactive effects of the skin induced by radiation therapy have to be related to some forms of radiodermatitis, and when non-standard clinical presentations overcome, it may be necessary to undertake appropriate diagnostic tools to not be in trap of wrong diagnosis. CLINICAL CASE DESCRIPTION: A 76 years-old man undertook resection surgery after a neoadjuvant radiation therapy for a soft tissue sarcoma of his groin region. After surgery, he developed an acute skin reaction comparable with a severe form of radiodermatitis. Despite cares, his clinical status got worse. Only skin biopsies guided us to the right diagnosis: it was a form of a bullous pemphigoid induced by radiation therapy. The consequent appropriate treatment was finally resolute. CONCLUSION: These forms have to be recognized in time, to undertake skin biopsies as soon as an evocative clinical presentation appears. The appropriate treatment, which consists in local or systemic corticotherapy, is resolute in most cases.

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 .

Vascularization of the superficial circumflex iliac perforator flap (SCIP flap): an anatomical study.

INTRODUCTION: The superficial circumflex iliac artery perforator flap (SCIP) has gained widespread popularity as local or free flap to cover soft tissue defects. However, there are numerous anatomical variations in terms of size, location and reliability of its perforators This cadaveric study aimed to focus on the anatomical bases of this flap. MATERIALS AND METHODS: A bilateral dissection of seven cadavers was performed to harvest 14 flaps. Superficial circumflex iliac artery parameters, number, length and diameters of perforators were measured. Correspondent perforasomes were highlighted through semi-selective injections. RESULTS: The major perforator of the superficial branch had a mean caliber of 2.0 mm, and a mean length of 1.8 mm. The major perforator of the deep branch had a mean caliber of 2.1 mm and a mean length of 1.43 mm. The mean area of the superficial pattern perforasome was 178.6 cm2 and the mean measured surface of the deep pattern perforasome was 156.2 cm2. The descending branches of the deep branch anastomosing with the ascending branch of the lateral circumflex femoral artery were found in three cases. CONCLUSION: Several anatomical variations were observed in this anatomical study, but major perforators supplying large perforasomes were always found.

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.

Thermal and chemical burns caused by e-cigarette battery explosions.

INTRODUCTION: E-cigarettes have become the main alternative to traditional cigarettes. An increasing number of explosive accidents with e-cigarettes have been described over the past years. Through our experience of sixteen consecutive cases, we wanted to acquire a better understanding of the origins and to specify the principles of management for these particular new burns. METHODS: A retrospective study was conducted to review all cases of burns related to e-cigarettes referred to our burn center from April 2014 through May 2019. Several key data were collected in relation to the patients, the circumstances and characteristics of the burns, their treatment and follow-up. RESULTS: In the past five years, sixteen patients were burned by e-cigarette explosions. They were all males with an average age of 41 years. They all had second or third degree burn injuries. The average burned area was 5% TBSA. The areas that were burned were the hands, buttocks, thorax, thighs and genital areas, and were always related to clothes pocket location. Eight patients described an increase in pain after cooling, suggesting significant contamination of the burn by lithium-ion deposits. Six required surgical management with excision and split-thickness skin graft. The others healed spontaneously in several weeks. CONCLUSIONS: Burns by e-cigarette lithium batteries explosion have a double mechanism (thermal and chemical). Carrying cigarettes in a pocket close to the body is a significant risk factor to which the male population is particularly exposed. Early debridement is recommended when possible while initial cooling does not seem helpful and is sometimes painful.

Properties of Nuclei up to A=16 using Local Chiral Interactions.

We report accurate quantum Monte Carlo calculations of nuclei up to A=16 based on local chiral two- and three-nucleon interactions up to next-to-next-to-leading order. We examine the theoretical uncertainties associated with the chiral expansion and the cutoff in the theory, as well as the associated operator choices in the three-nucleon interactions. While in light nuclei the cutoff variation and systematic uncertainties are rather small, in ^{16}O these can be significant for large coordinate-space cutoffs. Overall, we show that chiral interactions constructed to reproduce properties of very light systems and nucleon-nucleon scattering give an excellent description of binding energies, charge radii, and form factors for all these nuclei, including open-shell systems in A=6 and 12.

Ground-State Properties of Unitary Bosons: From Clusters to Matter.

The properties of cold Bose gases at unitarity have been extensively investigated in the last few years both theoretically and experimentally. In this Letter we use a family of interactions tuned to two-body unitarity and very weak three-body binding to demonstrate the universal properties of both clusters and matter. We determine the universal properties of finite clusters up to 60 particles and, for the first time, explicitly demonstrate the saturation of energy and density with particle number and compare with bulk properties. At saturation in the bulk we determine the energy, density, two- and three-body contacts, and the condensate fraction. We find that uniform matter is more bound than three-body clusters by nearly 2 orders of magnitude, the two-body contact is very large in absolute terms, and yet the condensate fraction is also very large, greater than 90%. Equilibrium properties of these systems may be experimentally accessible through rapid quenching of weakly interacting boson superfluids.

Is a Trineutron Resonance Lower in Energy than a Tetraneutron Resonance?

We present quantum Monte Carlo calculations of few-neutron systems confined in external potentials based on local chiral interactions at next-to-next-to-leading order in chiral effective field theory. The energy and radial densities for these systems are calculated in different external Woods-Saxon potentials. We assume that their extrapolation to zero external-potential depth provides a quantitative estimate of three- and four-neutron resonances. The validity of this assumption is demonstrated by benchmarking with an exact diagonalization in the two-body case. We find that the extrapolated trineutron resonance, as well as the energy for shallow well depths, is lower than the tetraneutron resonance energy. This suggests that a three-neutron resonance exists below a four-neutron resonance in nature and is potentially measurable. To confirm that the relative ordering of three- and four-neutron resonances is not an artifact of the external confinement, we test that the odd-even staggering in the helium isotopic chain is reproduced within this approach. Finally, we discuss similarities between our results and ultracold Fermi gases.

Electromagnetic Response of

The longitudinal and transverse electromagnetic response functions of ^{12}C are computed in a "first-principles" Green's function Monte Carlo calculation, based on realistic two- and three-nucleon interactions and associated one- and two-body currents. We find excellent agreement between theory and experiment and, in particular, no evidence for the quenching of the measured versus calculated longitudinal response. This is further corroborated by a reanalysis of the Coulomb sum rule, in which the contributions from the low-lying J^{π}=2^{+}, 0_{2}^{+} (Hoyle), and 4^{+} states in ^{12}C are accounted for explicitly in evaluating the total inelastic strength.

Chiral Three-Nucleon Interactions in Light Nuclei, Neutron-α Scattering, and Neutron Matter.

We present quantum Monte Carlo calculations of light nuclei, neutron-α scattering, and neutron matter using local two- and three-nucleon (3N) interactions derived from chiral effective field theory up to next-to-next-to-leading order (N(2)LO). The two undetermined 3N low-energy couplings are fit to the (4)He binding energy and, for the first time, to the spin-orbit splitting in the neutron-α P-wave phase shifts. Furthermore, we investigate different choices of local 3N-operator structures and find that chiral interactions at N(2)LO are able to simultaneously reproduce the properties of A=3,4,5 systems and of neutron matter, in contrast to commonly used phenomenological 3N interactions.

Neutral weak current two-body contributions in inclusive scattering from 12C.

An ab initio calculation of the sum rules of the neutral weak response functions in 12C is reported, based on a realistic Hamiltonian, including two- and three-nucleon potentials, and on realistic currents, consisting of one- and two-body terms. We find that the sum rules of the response functions associated with the longitudinal and transverse components of the (spacelike) neutral current are largest and that a significant portion (≃30%) of the calculated strength is due to two-body terms. This fact may have implications for the MiniBooNE and other neutrino quasielastic scattering data on nuclei.