Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap.

OBJECTIVE: The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. MATERIALS AND METHODS: This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion. RESULTS: Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. CONCLUSION: In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1hour and 45minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study.

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

A new cost-effective and fast method of autologous fat grafting.

Due to the increasing number of fat grafting procedures, several laboratories have developed their own fat processing system (Puregraft(®), LipiVage(®), Viafill(®), etc.), such as closed harvesting systems, centrifugation or washing and filtration devices, or even simple decantation techniques. However, all these tissue-engineering systems are expensive. Our team has developed a simple and fast autologous fat grafting system, useable even for a large volume of lipofilling, and based on low-pressure suction and a sterile closed-system for processing the harvested fat tissue. It is a cost-effective system, as it only costs 9.28Eur (10.52USD) for a 500milliliters autologous fat graft procedure.

[Ainhum and "African acral keratoderma": three cases]. / Aïnhum et « kératodermies acrales africaines ¼ : trois cas.

BACKGROUND: Ainhum, or spontaneous dactylitis, involves the formation of a gradual constriction in the digital-plantar fold of the fifth toe that leads, after several years, to autoamputation of the digit. This condition is classically distinguished from "true" ainhum, of unknown aetiology and affecting only subjects of African origin, from "pseudo-ainhum", resulting from different causes such as inflammatory constriction or constriction by a foreign body, and finally from ainhumoid palmoplantar keratoderma, which is of genetic origin and occurs for instance in Vohwinkel syndrome. Herein, we report three cases of ainhum in women of sub-Saharan African origin; in addition, all three subjects were also presenting various forms of hyperkeratosis of the hands and feet known to primarily affect subjects of African origin. PATIENTS AND METHODS: The three patients, aged 30, 48 and 44 years, were respectively from Mali, Guinea and Senegal. They had consulted a dermatologist for violent pain in the fifth toe, which frequently prevented sleep and was inexplicable despite several consultations, and even in one case in spite of surgical investigation. Once the diagnosis had been made, relief was promptly provided for all three patients through Z-plasty to remove the circular constriction around the toe in question. In addition to ainhum, the first patient was also presenting diffuse palmoplantar keratoderma, together with an aspect of acrokeratoelastoidosis on the edges of her hands and feet, and knuckle pads, while the second was presenting diffuse palmoplantar keratoderma and an aspect of marginal acrokeratoelastoidosis, and the third was presenting small knuckle pads. DISCUSSION: A recent study has confirmed the high incidence of several forms of palmoplantar keratoderma of African origin, as well as frequent association of these different varieties with one another. These consist of diffuse keratoderma having a relatively non-specific aspect, keratoderma punctata of the palmar creases, marginal keratoderma known also as focal acral hyperkeratosis, and acrokeratoelastoidosis, despite the absence of histological evidence, and finally, inverted keratoderma, i.e. affecting the dorsal aspects of the extremities, such as knuckle pads. In the three cases presented here, ainhum was associated with these different forms of acral keratoderma seen chiefly in subjects of African origin. CONCLUSION: So-called "true" ainhum may be included in a broader group of African acral keratoderma, further reinforcing the unity of this group. Genetic studies are required to enable validation and refinement of these clinical findings.

Urinary cotinine testing as pre-operative assessment of patients undergoing free flap surgery.

BACKGROUND: The identified risks of smoking with regard to operated tissues are so elevated that it is clearly dangerous to operate a smoker when the proposed intervention is neither vital nor urgent. MATERIALS AND METHODS: The aim of this prospective study was to evaluate a simple method of screening patients who smoke, with the evaluation carried out before agreeing to carry out free tissue transfer. The purpose of the testing was to hold the patient responsible for his actions and minimize smoking-related complications by cancelling or postponing the planned operation if the patient continued to smoke. Screening included use of a standardized questionnaire at the first consultation and detection of cotinine using a urine test strip 7 days before the scheduled surgery. Patients were informed that in the event of positive results, the operation would not take place. A six-week preoperative smoking cessation period was mandatory. RESULTS: Seventy-six patients were included in this study. Among them, 25 (32.9%) reported being former smokers and 11 (14.5%) admitted in the initial questionnaire to being active smokers. Six patients (7.9%), including one self-reported non-smoker, tested positive for cotinine, and their operations were cancelled. CONCLUSION: Screening using a questionnaire and cotinine detection appeared to constitute a simple, inexpensive, rapid and reliable test. It allowed us to refuse to operate 6 non-compliant patients and was thereby likely to diminish morbidity in the free tissue transfers carried out in our ward.

[Clitoral epidermoid cyst causing clitoromegaly. A rare case report]. / Clitoridomégalie dans le cadre un kyste épidermoïde géant: à propos d'un cas.

Clitoromegaly is uncommon. It is mostly congenital, hormonal or tumoral. Epidermoid cyst is rare. It can be the consequence of trauma, but in some situations the cyst can be non-traumatic. We report the case of a 53-year-old woman who presented a misdiagnosis of clitoromegaly due to hormonal condition. Surgical exploration has highlighted an epidermoid cyst. This observation underlines the importance to evoke a cystic origin for clitoral hypertrophy and encourages us to propose imaging (ultrasound, MRI) in case of etiological doubt. The preoperative diagnosis must be made to preserve vascularization and innervation of the clitoris.

[Intraoperative verification of a perforator flap vascularization by indocyanine green angiography]. / Vérification peropératoire de la vascularisation d'un lambeau perforant par angiographie au vert d'indocyanine.

After Koshima and Soeda first described perforator flaps in 1988, Wei has improved the technique by describing the "free style perforator flap". These flaps have the advantage of being performed on all skin perforators and in reducing donor site morbidity. The disadvantage, however is that the size of their angiosome is not defined and the evaluation of their relay on the experience of the surgeon. An evaluation of the size of an angiosome by conducting intraoperative angiography is proposed. Intraoperative angiography is performed after injection of indocyanine green. Stimulation of the indocyanine green by infrared causes the emission of fluorescent radiation. This fluorescence is then detected by a specific camera that displays real-time visualization of the skin's perfusion. We present the case of a 39-year-old patient who had an open tibial pilon fracture, for which we performed a pedicled propeller flap based on a posterior tibial perforator. Angiography was used to determine accurately the optimal skin perfusion of the propeller flap, which was based on a perforator from the posterior tibial artery. Angiography identified several levels of skin perfusion with a high fluorescence, intermediate and absent. The non-vascularized part of the skin paddle was resected. Given the unreliability of this technique, hypoperfused area was retained. Debridment of this area, however was necessary at day 5 postoperative with repositionning of the flap. Indocyanine green angiography may be a useful decision-making tool for intraoperative surgeon. It allows to adjust the size of the propeller flap's skin paddle to it angiosome. However, this evaluation method needs to be improved with the introduction of a quantitative threshold.

[Reduction mammaplasty in ambulatory: A prospective study of feasibility]. / Plasties mammaires de réduction en ambulatoire : étude prospective de faisabilité

OBJECTIVE: The French Ministry of Health and its regional agencies decided on December 27th, 2010 to develop the ambulatory surgery in the purpose to eliminate 48,000 beds of surgery in France. This evolution, which results from Anglo-Saxon countries, is inevitable in front of the financial deficit of our health insurance. Like the Canadian plastic surgeons, who were forced to it for 7 years, we wanted to study the feasibility of an ambulatory care of the reduction mammaplasties in a hospitalo-university department. METHODS: Between January and June, 2012, 25 patients, of less than 65 years old, were operated for a reduction mammaplasty scheduled in ambulatory. None presented particular anesthetic risk. All lived unless 1h of the hospital, went out accompanied, were revised the day after the intervention, then in a usual way. Our criterias of evaluation were the following ones: global satisfaction of the care in ambulatory, weight of glandular resection, postoperative complications, rate of readmission. RESULTS: The average age of the patients was 32 years (19-56 years). The average weight of resection was 400g by breast (140-1000g). Twenty patients went out on evening (80%). Among them, 19 (95%) expressed their satisfaction and would accept again this intervention in ambulatory. No major complication arose in this series. Five other patients saw their release repelled by the anaesthetists for the following motives: score of Aldrete lower than 9, pain not relieved by the analgesic (I or II), nausea and uncontrollable vomitings. CONCLUSION: This first clinical study realized in France, confirms that when certain conditions are filled, the reduction mammaplasty can be realized in ambulatory with complete safety. The rate of satisfaction shows a very strong support of the patients for the ambulatory care.

[A case of nasal tip necrosis after hyaluronic acid injection]. / Nécrose de la pointe du nez secondaire à une injection d'acide hyaluronique.

Hyaluronic acid (HA) is the most used dermal filler. Some complications associated with its use have been described, but most of them are rare and benign. We report an exceptional case of skin necrosis of the tip of the nose, in a 22-year-old patient, after HA injection. The initial appearance may occurred subsequent aesthetic sequels. After necrotic tissue excision, patient was followed in rapid succession. Daily local care has led to wound healing, without any important sequel. This rare complication reminds us that HA injections are not without risk, despite their apparent simplicity of use. Moreover, the case presented confirms the potential healing of the nasal tip, allowing treatment with wound healing, rather than other early invasive procedure.

[In search of the ideal surgical treatment for lymphedema. Report of 2nd European Conference on supermicrosurgery (Barcelona - March 2012)]. / À la recherche d'un traitement idéal du lymphœdème. Compte-rendu de la 2(e) Conférence européenne de supermicrochirurgie (Barcelone - Mars 2012).

Since more than 50 years, many surgeons all around the world try to find the perfect surgical technique to treat limb lymphedemas. Decongestive physiotherapy associated with the use of a compressive garment has been the primary choice for lymphedema treatment. Many different surgical techniques have been developed, however, to date, there is no consensus on surgical procedure. Most surgical experts of lymphedema met in the second European Conference on supermicrosurgery, organized on March 1st and 2nd 2012, in San Pau Hospital, Barcelona. Together they tried to clarify these different options and ideally a strategy for using these techniques.

Latissimus dorsi breast reconstruction with or without implants: A comparison between outcome and patient satisfaction.

BACKGROUND: The latissimus dorsi (LD) flap is largely used in breast reconstruction. The aim of this study is to evaluate and compare the advantage of the LD flap in association with an implant to that of LD flap in association with lipofilling to add additional volume following breast reconstruction by assessing the number of revision procedures, length of hospitalization, complication rate, and patient satisfaction. METHODS: A retrospective cohort study was performed to evaluate complication rate, number and type of revision procedures required, hospitalization time, and overall duration of the reconstructive process in patients undergoing LD breast reconstruction in our department between January 2012 and March 2015. Patient satisfaction was assessed using BREAST-Q®. RESULTS: Ninety-five breast reconstructions performed on 90 patients were included. In 38 patients, 42 breasts were reconstructed using LD flap in association with lipofilling (Group 1). In the remaining 52 patients, 53 breast reconstructions were performed using LD flap in association with an implant (Group 2). Findings concerning total hospitalization time, overall duration of the reconstructive process, and the distribution of supplementary surgical procedures demonstrated no statistically significant differences between the two groups. However, the surgical complication rate was higher in Group 2 than in Group 1 (14.2% vs. 18.8%, respectively). Regarding BREAST-Q, a detailed analysis of the "satisfaction with breasts" domain showed a higher score for Group 1 than for Group 2. CONCLUSIONS: The association of a breast implant with LD reconstruction does not decrease breast reconstruction time in terms of the number of revision procedures and hospitalization time, exposes patients to a higher complication rate, and does not improve patient satisfaction.

[Gigantomastia complicating pregnancy. A case report]. / Gigantomastie gestationnelle. À propos d'un cas exceptionnel.

The authors report a very rare case of gestational gigantomastia and the pregnancy could be carried out in term. The repetition being inescapable, the mastectomy is the advised intervention if there is a later desire of pregnancy, in other cases a post-partum mammoplasty can be discussed.