Two-stage surgery for large sacrococcygeal chordomas: How I do it.

Sacrococcygeal chordoma is a malignant, slow-growing, and locally aggressive bone tumor. A wide surgical margin is recommended to prevent local recurrence and metastasis. This disease tends to cause massive defects when rectal resection and sacrectomy are required. Therefore, soft tissue reconstruction is required and a pedicled vertical rectus abdominis muscle flap (VRAM) is a viable option. Important anatomical landmarks, advantages and limitations are discussed and the procedure is described step by step. This case report presents a two-stage operation with an anterior rectal resection and VRAM flap harvest followed by a complementary posterior approach with sacrectomy and soft tissue reconstruction: approach and results. The wound completely healed in six weeks. Three years after surgery, no local recurrence or distal metastasis was detected. This two-stage strategy presents a viable and safe option for large sacrococcygeal chordomas.

Locking of the metacarpophalangeal joint: A comprehensive review of the literature.

Locked metacarpophalangeal joint is an uncommon phenomenon with many possible etiologies. Diagnosis can be difficult because of the many more common pathologies (trigger finger, sagittal band lesion, etc.) that can lead to a clinical picture that may resemble the locked metacarpophalangeal joint. Once the differential diagnoses have been eliminated, the etiology of this blockage must be determined and the surgical procedure must be oriented. The origin of the problem is often difficult to determine, especially since standard imaging tests are often not very informative. Several clinical forms are possible, with blockages in extension or flexion, but which will have a disabling functional impact on the overall function of the hand. Currently, there is no gold standard for the management of this condition. In this study, we performed a review of the literature in order to better understand the different possible etiologies but also to analyze the different diagnostic and therapeutic management. LEVEL OF EVIDENCE: IV.

[Is the internet a reliable source of information for patients eligible for breast reconstruction by DIEP flap?] / Internet : source fiable d'information pour des patientes éligibles à la reconstruction mammaire par lambeau de DIEP ?

INTRODUCTION: Informing breast reconstruction patients is a major factor in shared medical decision-making. In the light of the development of multimedia, patients face a paradoxical duality: the possibility of consulting various sources while having impression of a lacking the needed information. The objective of this study is to assess the quality of the available information around MR by DIEP on Youtube. METHODS: For this descriptive study, we reviewed 531 videos resulted from the terms "DIEP breast reconstruction". 39 videos were analyzed in detail. The evaluation criteria established from the SOFCPRE sheet were listed in 43 items divided into 4 themes. A score representing the percentage of correct information is then calculated. RESULTS: The average length of the videos is 40'05″±46'45″. The average total score is 42.52%. Concerning the subgroups, the themes generalities and physiopathology have the highest result (66.10% of the correct items). This is followed by technique and perioperative preparation (51.65%), postoperative (27.35%) and finally complications (22.76%). Only 2 videos have an excellent total score (>80%). CONCLUSION: The information on breast reconstruction by DIEP flap on Youtube seems insufficient and lacks quality. The surgeon should strive to provide the highest quality of information and refer patients to reliable sources.

Open palmar metacarpophalangeal joint dislocation: Case report, pathogenesis and literature review.

We report the case of a 58-year-old man who sustained an open palmar dislocation of the fifth metacarpophalangeal joint of the little finger secondary to a bicycle accident with an uncommon presentation. These open dislocations have only been reported once in the literature. A palmar and dorsal approach had to be used to completely free the joint from incarcerations and allow complete reduction and repair of the damaged anatomical structures. We then discuss this particular type of dislocation, its pathophysiology and management.

Assessing the effect of PRP addition to facial micro-lipofilling for patients suffering from Scleroderma: A prospective routine care analysis.

BACKGROUND: Combining fat graft with platelet derived products is now common practice in regenerative surgery. We proposed to assess the safety and efficacy of Platelet-Rich Plasma (PRP) addition to a micro-lipofilling protocol for facial treatment of patients suffering from Systemic Sclerosis (SSc). OBJECTIVE: Main objective was to evaluate the improvement of the Mouth Handicap In Systemic Sclerosis (MHISS) scale score at 6 months post-therapy. METHOD: Included SSc patients had a MHISS score equal or up to 20. Surgery was performed under general anesthesia. Micro-fat and PRP (CCA-NA from DEPA Classification) were mixed in a 70/30 ratio, before injection in peri-oral sites according to a specific protocol. Efficacy criteria were recorded at baseline, 3 and 6 months. Moreover, we compared this cohort (current study) to a former (2015) non-enriched micro-lipofilling cohort in the same indication, using the same protocol. RESULTS: Thirteen women patients with mean age of 53.2 years (±14.3) have been included. At baseline, mean MHISS score was 29.5 (±8.7) and significantly decreased to 22.5 (±7.8) at 6 months (P=0.016), corresponding to a 22.0% of improvement from baseline, with a mean decrease of 6.5 points (±7.5) at 6 months. Patients received a mean volume of 30.8ml PRP-micro-fat (±8.1ml). CONCLUSION: PRP addition appeared beneficial, however, controlled studies are required to determine its superiority to facial micro-lipofilling.

Restoration of the first dorsal interosseous muscle.

Motor dysfunction of the 1st dorsal interosseous (DIO) muscle is typically observed in low and high ulnar nerve palsy. This causes weak thumb-index pinch, which can be disabling for the patient. Various reconstructive techniques have been described; however, the choice often depends on the surgeon's experience, the presence of associated neurovascular and musculotendinous injuries, as well as the requirements of the palliative surgery schedule. Nerve transfers can be proposed when patients present early in the course of the disease. Tendon transfers are often a last resort when late presentation occurs. Tendon transfers must follow general principles: the insertion is made on the 1st DIO terminal tendon; the tension must be adjusted in a neutral position to avoid excessive tension, and immobilization is maintained for 4 weeks. Although many transfers are possible, the extensor pollicis brevis transfer is our preferred option. This donor does not require additional tendon grafting, has a direct line of pull close to that of the 1st DIO and is not often used for other reconstructive purposes.

Revision of trapeziectomy failures in thumb base osteoarthritis: retrospective analysis of ten cases and review of the literature.

Controversy persists around trapeziectomy as standard of care in thumb base osteoarthritis. The difficulty of management of failure requires the utmost caution in choice of the initial technique. We here report a retrospective series of 10 revision procedures following trapeziectomy, supported by a review of literature. The main cause of revision was collapse of the thumb column resulting in arthrogenic contact of the first metacarpal with the scaphoid. At a mean 73.3 months' follow-up, 5 patients had to undergo additional surgery. Mean VAS pain score was 2.9; 5 patients were pain-free. Strength was more severely impaired than joint motion, resulting in disappointing functional results. The present outcomes are consistent with the literature, which mostly comprises heterogeneous series, making it impossible draw conclusions to guide practice. The most common option seems to be to perform a new ligament procedure, with or without tendon or pyrocarbon interposition, and was the one that provided the only good result in the present series. Other techniques (composite graft, non-autogenic interposition, scaphometacarpal prosthesis) seem promising, and deserve large-scale evaluation. Thus, the gold-standard status of trapeziectomy should be weighed against the observation of these multi-operated patients in situations of therapeutic impasse. Should indications for first-line trapeziectomy be restricted, especially in patients with a revision risk factor? LEVEL OF EVIDENCE: 4.

Unusual rupture of the middle finger flexor digitorum superficialis tendon in a climber: Biomechanical analysis.

Sport climbing is increasingly popular and consultations by climbers in hand surgery departments are on the increase. The pathologies related to this sport concern essentially the pulley system, tendons being rarely affected. We report the case of a male climber who presented an atypical rupture of the flexor superficialis tendon in his left middle finger sustained when using an atypical climbing grip technique: the "hook grip". This consists in extension of the metacarpophalangeal joints and maximal flexion of the proximal interphalangeal joints with force exerted only on middle phalanx of the middle finger. A biomechanical analysis using finger musculoskeletal modeling was performed to compare the hook grip to other grips, and the patient's recovery performance was assessed. Adapted functional treatment with physiotherapy seems to have been a good option for the treatment of this atypical lesion since the patient recovered normal use of his finger in daily life. He recovered maximal force in climbing holds. The biomechanical analysis confirmed that the atypical "hook grip" was likely at the origin of the rupture, since flexor digitorum superficialis tendon force for this grip is greater than in other climbing grip techniques. The "hook grip" seems to be dangerous and should be used cautiously by climbers to prevent similar pathology. Additionally, the patient should henceforth be careful when climbing, since the biomechanical model showed that the remaining flexor digitorum profundus tendon was overused.

Vascularization of the lateral and medial antebrachial cutaneous nerves by cutaneous perforator arteries: An anatomical study.

The forearm is an interesting donor site for non-vascularized nerve grafts, especially hand surgeons. Very few studies have described the use of the lateral and medial antebrachial cutaneous nerves (LABCN and MABCN, respectively) as vascularized nerve grafts (VNGs). The aim of this anatomical study was to analyze the characteristics and vascularization of these nerves to describe new potential donor sites for VNGs. Twelve forearms were dissected from fresh cadavers injected with red latex. The number of terminal branches, lengths, and proximal and distal diameters of both the LABCN and MABCN were studied. An anatomical description of the cutaneous perforator arteries from the radial and ulnar arteries that vascularized the nerve was also recorded: number of perforators, length, type of perforator (septo- or musculocutaneous), and location within the forearm (proximal, middle, and distal third). In over 80% of the specimens, the cutaneous perforator arteries from the radial and ulnar artery vascularized the LABCN and the MABCN, respectively. These arteries, found mostly in the proximal third of the forearm, had diameters >0.5mm. Most of them came from the radial and ulnar arteries (for LABCN and MABCN vascularization, respectively). In over 75% of the specimens, the nutrient arteries of both nerves also vascularized the superficial veins and the skin. We found that these nerves are vascularized by perforators arteries, which also participate in vein and skin vascularization. Altogether, this anatomical study shows that reconstructive surgeons could use new VNGs based on the perforator artery of the forearm.

The two-stage free flap strategy: An alternative to reconstruct major oncological surgical defects with noble organ exposure.

BACKGROUND: To minimize the risk of viscera exposure for parietal or calverial reconstruction after tumor removal, we used the two-stage free flap strategy. The flap was transferred a few days before tumor resection and left in a standby position until the second stage. PATIENTS AND METHOD: We conducted a retrospective monocentric study. All patients who underwent reconstruction with the two-stage free flap strategy after tumor resection since 2000 were included. RESULTS: We performed 14 two-stage flaps (8 for calvaria, 3 for abdomen, and 3 for thorax) on 12 patients. The average skin paddle surface was 318 cm2. The mean operative time was 274min for the first stage and 172min for the second stage. The average time between the two stages was 8.8 days (2 to 24 days). One flap necrosis, one venous thrombosis, and one hematoma were observed after the first stage. Partial skin paddle necrosis (2 flaps) and infections (3 flaps) occurred after the second stage. The mean follow-up was 20 months (6 to 61 months), and two patients had tumor recurrence. CONCLUSIONS: The two-stage free flap strategy is another option for major oncological reconstructions, to be safe and reliable some rules must be followed. The flap must contain a large skin paddle to ensure flap autonomization and to allow for complete tight plication of the flap between the two stages, which limits germ colonization. A short delay between the two stages (<12 days) decreases the risk of infection. The presence of a plastic surgeon during the second stage decreases the risk of pedicle trauma.

Arm reconstruction.

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

[Surgical treatment of recurrent pressure ulcers in spinal cord injured patients]. / La chirurgie secondaire des escarres chez le blessé médullaire.

Not to burn one's bridges. This is the basic principle that comes immediately to the mind of the plastic surgeon when one brings up the secondary surgery of pressure ulcers, which is a common pathology in the spinal cord injured patients. Which ones are good candidates for surgical treatment? When? What preoperative, infectious, rehabilitative management is most likely to minimize the number of failures and recurrences? Which operative technique to prefer in first intention? And in case of secondary surgery, how to choose the best strategy? We will see that some cases can be treated by primarily closing or flap remobilization but, in case of greater loss of substance the realization of a flap from another anatomical region will be essential.

[To harvest a SIEA flap instead of a DIEP flap in breast reconstruction: A technical note]. / Prélever un SIEP à la place d'un DIEP en reconstruction mammaire : note technique.

Breast reconstruction by abdominal flap has evolved to ensure minimal donor-site morbidity with the description of Deep Inferior Epigastric artery Perforator flap (DIEP flap). Being of the same thickness and the same surface, the Superficial Inferior Epigastric Artery flap (SIEA flap) does not require, for it harvesting, to open the abdominal fascia or to dissect through the muscles minimizing again donor-site sequelae. However, it is little used because of the variability of its vascularization and a higher failure rate than the DIEP in the literature. We believe that it is reasonable, in some cases, to harvest a SIEA flap instead of DIEP flap in mammary reconstruction. We present a technical note explaining our operative strategy for reliably taking a SIEA when the caliber of the vessels allows.

Rice-body formation without rheumatic disease or tuberculosis in a "sausage" ring finger.

Rice bodies are very unusual lesions, generally encountered in chronic synovitis due to rheumatoid diseases or tuberculosis. A 31-year-old right-handed man presented with a 15-year history of progressively growing "sausage-like" swelling of the 4th finger and palm of his right hand. There was an immovable, painless mass with restriction of the finger's ROM without local or general associated signs. Imaging showed a large non-aggressive mass within the tendon sheath. Complete excision of the mass was performed. Histopathological examination showed synovial villi with rice bodies and central necrosis suggestive of tuberculous synovitis or rheumatoid arthritis (RA). Tests for mycobacterial infections were all negative and there was no argument in favor of a rheumatoid pathology. There is no established standard treatment in a case like ours, which has no origin in tuberculosis or RA. Prolonged follow-up will be needed to confirm absence of recurrence after complete excision.

A thoracic parasternal granular cell tumor in a child: About one case and review of the literature, discussion about treatment guidelines, is complete resection compulsory?

Granular cell tumor is a well known soft tissue tumor, very rare in children; we describe here the first case of GCT in this particular location in a child. The diagnostic is easily done with histopathology. The treatment is based on the complete resection, no other validated treatment exists. We reviewed the literature to find out if it would be safe to consider a simple follow-up after partial resection of the tumor.

[Keloid scars (part II): Treatment and prevention]. / Les cicatrices chéloïdes (deuxième partie) : arsenal et stratégie thérapeutique.

Keloids scars are a dysregulated response to cutaneous wound healing and can be associated with substantial physical and psychological distress. Unfortunately, they occur when surgical excision is performed. While the pathogenesis of keloids continues to be investigated, numerous treatment options exist. But there is still no ideal treatment. Their management needs association of treatment and long-term follow-up to observe and manage recurrence. In this second part, we propose a strategy for management of keloids scars.

[Palpebral malformations in children]. / La paupière malformative chez l'enfant.

Palpebral malformations can be isolated or associated with a craniofacial disorder. Their assessment is based on clinical examination; additional investigations are mainly done to characterize craniofacial syndromes. In case of extrapalpebral lesions or complex craniofacial pathology, genetic testing must be performed. Some isolated malformations will only need a simple follow-up; others must have specific treatment, undertaken following a precise timing, taking into account child and anatomical structures' growth and the possible consequences of the malformation on the eye and child's sight (degree of urgency). When dealing with these malformations, there are two main risks to be taken into consideration: corneal irritation due to lagophtalmos and amblyopia owing to visual axis obstruction, anisometropia or strabismus.

[Skin tumors in children]. / Les tumeurs cutanées de l'enfant.

The presence of a congenital or acquired cutaneous lesion is a frequent reason for consultation in pediatric plastic surgery unit. The management of these lesions requires a good knowledge of specific diagnoses in children. This step is sometimes difficult because of the multiplicity of possible diagnosis. Some skin tumors may be the external sign of a general disease or an underlying malformation; those can change the overall prognosis and management and require to be properly identified. The decision of surgical excision depends on various criteria, including diagnosis but also the reconstruction possibilities. The timing of surgical treatment depends on the medical emergency of the tumor resection (benign tumor, spontaneously regressive tumor, risk of degeneration into malignancy), on the cosmetic and psychological impact but also on the growth or learning steps in child life. This article first provides an aid in the diagnosis of the most common or more characteristic skin tumors. The algorithm is principally based on the pigmentation aspect of the tumor. The age and conditions of the surgical management are specified for each type of tumor. Cutaneous hemangiomas and vascular malformations, and congenital cysts and fistulas are not reported in this article.