Fat grafting of hairy areas of head and neck - comparison between lipofilling and nanofat grafting procedures in a cadaveric study.

AIM: Fat grafting has well-recognized effects in terms of volume gain, skin trophicity, relieving of post-wound nevralgia. Recent publications suggest a regenerative action on hair follicles. The objective of our study was to compare lipofilling and nanofat grafting in hairy areas of head and neck so as to determine a convenient fat injection technique for those areas in the prospect of treating alopecia. MATERIAL AND METHODS: Our study compared lipofilling and nanofat grafting, in a cadaveric study involving one body. RESULTS: Lipofilling was found easy to perform in the face, avoiding classical pitfalls, but was more difficult in the scalp areas. Nanofat grafting seemed particularly convenient to inject into the scalp, especially in Merkel's space, and hairy areas that required high precision injections. CONCLUSION: After having compared lipofilling and nanofat grafting in hairy areas of the head and neck, we propose a combination of lipofilling (in hairy areas where a durable gain of volume is acceptable, in case of burn or scar) and nanofat grafting (in all hairy areas and in Merkel's space in scalp areas). This technique may be used either as a complement of hair follicle grafting or as a regenerative treatment of alopecia.

[Outline surgery after massive weight lossing or gastroplasty]. / Chirurgie de la silhouette et gastroplastie.

The silhouette surgery in case of obesity or after gastroplasty and massive weight loss is near the usual outline surgery. However, many differences shall be well-known: more and more cases appear and demand is rapidly growing. The main demand for surgery is aesthetical improvement. The development of gastroplasty has greatly increased the demand of this outline surgery. At the beginning of gastroplasty, plastic surgeons sent pathological obeses to the first "gastroplastician" visceral surgeons. Now, after massive weight loss (over 60 kg), general health is improved, but aesthetical aspect is often worsened; so the patients turn back to the plastic surgeons. The therapeutical program associated combined surgeries, for example: breast plasty and abdominoplasty performed during the same procedure or important and multilocular lipoaspirations. Large skin excess and persisting over weight influence surgical procedure. A strict preoperative planning is mandatory to obtain safe, quick and satisfying result. Preoperative informations concerning results and postoperative evolution (like, for example, the possibility of blood transfusion, infection and scars em leader ) are very important. Usually, five procedures will be necessary over a 3 or 4-years period of time: abdominoplasty, body-lifting, arm and thigh-lifting, breast surgery for ptosis, hyper- or hypotrophia of the chest, lipoaspirations and, in a few cases, face lifting em leader. We describe this so particular outline surgery, its techniques and usual evolution.

Thumb reconstruction for aesthetic reasons using an exteriorised microvascular pedicle.

Thumb reconstruction following amputation is usually performed in order to restore function. Nevertheless, the reconstruction should be cosmetically acceptable in order to be fully functional, and, in some cases, reconstructive surgery may be justified for purely aesthetic reasons. The most satisfying aesthetic results in adults are obtained with microsurgical partial great-toe transfer. The technique that we use for thumb reconstruction is illustrated by two case reports: that of a 26-year-old female patient and that of a 35-year-old male patient. Both patients had a distal thumb amputation with destroyed nail apparatus, and both sought thumb reconstruction for cosmetic reasons. Aesthetic reconstruction was performed in both cases with a partial ipsilateral great-toe transfer, composed of nail apparatus, underlying bone and custom-made pulp tissue. The vascular anastomosis was done at the snuff-box, through a small incision, with an exteriorised pedicle. The result was satisfactory in both cases, with minimal donor-site sequelae. Partial toe transfer has proven to be a reliable technique for thumb reconstruction. It is an evolving technique. Many modifications have been introduced to optimise the aesthetic result and to reduce donor-site morbidity. Our technique allows us to restore thumb length, replace the missing nail and reconstruct the pulp, with acceptable sequelae at the donor toe. The exteriorised-pedicle technique prevents pedicle compression and twisting and reduces scarring and stiffness. It does, however, require delicate postoperative care and a second procedure for pedicle division.

[Vascular leiomyoma of the hand. Report of a case and review of literature concerning a rare pathology]. / Léiomyome vasculaire de la main. Présentation d'un cas clinique et revue de la littérature à propos d'une pathologie rare.

Vascular leiomyoma is a benign painful tumour that occurs most frequently in the lower extremity. We report an uncommon case in the hand. Only surgical removal of the tumour allows establishing the diagnosis histologically. A review of the literature confirms the rarity of the tumour in the hand. The purpose of this case report is furthermore to consider the differential diagnosis in painful masses of the hand.

[Intraluminal absorbable device to assist in vascular microanastomosis. Experimental study on 20 rat aortas]. / Dispositif résorbable endoluminal d'aide à la micro-anastomose vasculaire. Etude expérimentale sur vingt aortes de rats.

The subject of this experimental study is a cylindrical device, with a gauge adjusted to the vessel lumen, which disintegrates in a few minutes. The goal of this device is to increase the reliability of vascular microanastomosis. This study was designed to assess the efficacy and drawbacks of the device. The device is a cylindrical sugar stick, 5 mm long and with a gauge of 1 mm. Ten Wistar rats underwent a standard end-to-end aortic anastomosis with interrupted sutures and ten underwent the same anastomosis with the device placed in the lumen of the proximal and distal vessel. The same surgeon performed all anastomoses. Clamp application time was recorded and anastomotic patency was tested in each case; the vessels were also examined histologically. The clamp application time was significantly lower (p < 0.01), and the patency rate significantly higher (p < 0.01) in the group in which the device was used. There was no histologic sign of intima injury in either group. This very simple device facilitates microanastomosis. It reduces the ischemia time and increases the reliability of the anastomosis, avoiding transfixing sutures. These results suggest that clinical trials are warranted.

[Late infection of breast implant, complication of colonic perforation. Review of the literature. Role of preventive treatment]. / Infection tardive d'implant mammaire, complication de perforation colique. Revue de la littérature. Place d'un traitement préventif.

The authors report a cases of breast implant infection, 40 years after augmentation mammoplasty. The infection developed 6 weeks after colonoscopy complicated by acute peritonitis due to colonic perforation. Bacteroides fragilis, a usual organism of the gastrointestinal tract flora, was identified in the two septic sites (peritoneal and periprosthetic). Contamination of the implant was haematogenous in a context of bacteraemia. Other authors have already suspected this route of contamination without any bacteriological proof. The risk of infection of breast implants is known, but the late infection rate is poorly documented. It is probably very low in view of the rare cases reported in the literature. Breast implants are not at high risk of sepsis, in contrast with prosthetic heart valves. The authors therefore do not recommend any particular preventive treatment in the case of distant infection or dental treatment. Women with breast implants must be informed and reassured: late infection of their implant is possible, but very unlikely. Recognition and prevention of this risk could be based on better long-term follow-up of breast implants.

Is it necessary to suture the platysma muscles on the midline to improve the cervical profile? An anatomic study using 20 cadavers.

To ameliorate the cervicomental angle, most surgeons suggest different techniques of platysmaplasty. The aim of this anatomic study is to find a simple answer to the following question: Is suturing of the anterior edges of the platysma muscles during platysmaplasty the best procedure to use to obtain the best concave anterior neck angle? Three different surgical techniques using platysma muscle flaps were used on 20 cadavers prepared for anatomic dissection. Each piece of dissection was controlled by a radiograph of the profile of the cervical region before and after the application of these different techniques. Cephalometric measures were made and statistically analyzed. The analysis of the results demonstrates that the best concave anterior neck angle to perform platysmaplasty is one in which the platysma muscle flap is shifted posterosuperiorly but without suturing the medial borders of the platysma muscles. Suturing the midline does not deepen the concavity in the front of the neck.

[Results of biplane face lifts with maximal skin underlining and vertical SMAS flap]. / Résultats des liftings biplans avec décollement cutané étendu et lambeau de smas vertical.

It is difficult to evaluate the medium and long-term results of facelift due to loss to follow-up of a large number of patients. The authors developed a questionnaire which they sent to their patients. 148 patients (143 women and 5 men) answers this questionnaire and 54 patients returned for review. This subjective evaluation of the results nevertheless had the advantage of identifying three target organs specifically treated by the surgical techniques used: the nasolabial folds, the jowls and the neck. Improvement or deterioration of the results was therefore evaluated and reported on a series of tables. The results are analysed in this paper. 70.3% of patients studied reported a satisfactory objective result with a mean follow-up of 26.8 months. The least favourable results were observed in the neck, due to the small number of technical procedures performed on the platysma, which would appear to justify greater surgical attention. Among the complications reported, 9.2% of cases indicated inadequate results, especially concerning the "lion's wrinkle", which emphasizes the value of a complementary endoscopic procedure at this site. Perioral wrinkles were a source of dissatisfaction in 14.8% of cases, and can be treated by dermabrasion. Lastly, a number of minor complications such as malposition of the ear lobe, facial redness or scar abnormalities were also mentioned and are easily accessible to an ambulatory secondary improvement procedure. This study therefore validated the operative technique of biplane facelift with a satisfactory stability of the results over time. Objective review of dissatisfied patients, who generally returned for review after receiving the questionnaire, led to a number of reoperations, which appear to be useful in the case of early deteriorations occurring during the first postoperative year and which concern about 5% of patients. The ultimate objective of this paper was to try to establish a methodology for the analysis of the long-term results of facelift, without directly involving the examiner or operator, who may ignore what the patient really feels.

[In situ thrombolysis. Correlation between creatine phosphokinase increase and local thrombolysis. An experimental study in the rat]. / Thrombolyse in situ. Corrélation entre l'augmentation de la créatine-phosphokinase et la thrombolyse locale. Etude expérimentale chez le rat.

This study proposes intraarterial in situ thrombolysis for the treatment of microthrombi occurring after tissue crushing. In order to assess the efficacy of the thrombolytic, the authors assayed the serum creatine phosphokinase (CPK) level in the crushed muscle capillary bed. The action of thrombolytics has now been clearly established. In contrast, the correlation between local thrombolysis and the serum CPK variation in crush injuries of striated muscle constitutes the originality of this paper. This experiment was conducted in twenty Wistar rats in which striated muscle crushing was performed. The serum CPK level assayed in venous blood, obtained from the capillary bed concerned, before and after local thrombolysis. The increased CPK level provided an objective indication of the efficacy of intra-arterial thrombolysis after crush injury. The authors now apply local thrombolysis according to a prospective clinical protocol for hand emergencies associated with a crush mechanism.

[Value of scaphal graft in secondary rhinoplasties]. / Intérêt du prélèvement du scapha au cours des rhinoplasties secondaires.

The scaphal cartilaginous area is a most suitable anatomic site for cartilaginous graft harvesting. These grafts allow reconstruction of a flat dorsum, or a rounded dome, or alar cartilages or can be used for an extended tip graft. In some cases, both scaphes may be harvested. Raising of the grafts does not leave any sequelae when performed correctly. We have an experience of 20 cases. The main advantage of this graft is its flatness, which makes it ideal for the nasal dorsum. It has to be tailored, moderately crushed and included in a collagen "surgicel" in order to break the shape memory, slightly curved at its borders. We have used scaphal autografts in 15 cases of secondary rhinoplasties, 2 cases of cleft lip repair and in 3 cases of tertiary rhinoplasties. They solved most problems of missing cartilage, when minor defects had to be treated. These grafts will not solve major tissue defects which must be repaired by bone autografts, mostly iliac bone harvesting in our experience. The results of scaphal autografts are stable after 5 years. Resorption is moderate when the graft is correctly inserted, in an extramucosal pocket. The aesthetic result is maintained with a mean follow up of 2 years for 15 cases. The scaphal area of the ear therefore appears to be a favorable donor site for secondary, nose repair; it is easy to harvest, with inconspicuous morbidity and allows the raising of a good, flat and sculpturable material for cartilaginous nose replacement. Achieves the objectives of ore informed patients asking for artistic perfection.

[Reconstruction of digital pulp by pulp tissue transfer of the toe. Apropos of 15 cases]. / Reconstruction de la pulpe des doigts par transfert d'hémipulpe de gros orteil. A propos de 15 cas.

PURPOSE OF THE STUDY: The authors report their experience of digital pulp reconstruction by free toe pulp transfer. Fifteen patients were treated with the lateral great toe hemipulp. MATERIAL AND METHODS: 15 cases of post-traumatic finger tip reconstruction were reviewed including 9 thumbs, 5 index, 2 medius, and one ring finger. There were 6 emergency cases and 9 secondary reconstructions (7 after inconvenient spontaneous healing and 2 after groin flap coverage). RESULTS: We noted 2 partial necrosis, and 4 patients suffered from cold intolerance. The flap sensibility, according to the American Society for Hand Surgery criteria, was excellent in 1 case good in 6 cases, fair in 7 cases and bad in 1 case. The value of the mean two point discrimination test was 10 mm, the mean moving two points discrimination test equalled 9 mm. We had 1 excellent functional result, 6 good, 6 fair and 2 bad. The subjective evaluation found 12 patients satisfied and 3 disappointed. DISCUSSION: A wide range of procedures from spontaneous healing to thenar flap, neuro vascular flap or toe pulp transfer can be proposed to treat digital pulp loss. In the case of moderate thumb pulp avulsion and homodigital volar flap can be proposed; if microsurgery is contra-indicated, an hetero-digital flap from the index can be performed. When the other fingers are concerned, a homodigital flap can be proposed for moderate defects. For more important trauma, the thenar flap is convenient to cover the index and the medius pulp. Ring and little fingers can be treated by a reverse digital artery flap or by a cross finger flap. When a toe pulp transfer is indicated we recommend the lateral great toe hemipulp for the thumb and a second or third toe pulp transfer for the other fingers when digital vascular anastomosis are possible. The great toe hemipulp transfer represented a good indication for complete digital pulp loss reconstruction where the thumb is concerned. Performing this reconstruction during the acute phase may improve the management of those trauma by reducing the time needed for cicatrisation and the length of work inability.

Secondary expansion of a totally replanted scalp for aesthetic adjustment.

Total scalp avulsion is an uncommon and dramatic accident. Replantation is the only way for acceptable aesthetic final results. However, partial loss of tissue can result, and secondary procedures can be required. A total avulsion of a scalp involving the upper part of the right ear and both eyebrows was replanted after a long delay in our department. As a result, loss of a third of the hair-bearing area occurred. Secondary expansion of the replanted scalp achieved complete reconstruction.

[Cutaneous repairs of the hand]. / Les recouvrements cutanés de la main.

Immediate post traumatic skin defects can complicate osteo-articular, tendinous or neurovascular lesions of the hand. Aesthetic and functional repairs permit early rehabilitation. Having to choose between spontaneous heal and microvascular tissue transfer, many pediculated flaps are possible; the size of the wound and an exposure of bone or tendon are the determining factors. Spontaneous healing or skin grafting can be adequate in cases of a superficial wound. Deep wounds with a large exposure shall be covered with flap. A large range of flaps exists: the optimal flap permits adequate coverage with minimal sequellae.

[Severe injuries of the elbow: emergency coverage and transient revascularization. Apropos of 13 cases over a 3-year period]. / Les traumatismes délabrants du coude: couverture en urgence et revascularisation transitoire. A propos de 13 cas sur 3 ans.

Large open elbow fractures with extensive soft-tissue loss must be treated as an emergency. Vessels and nerves are often alvulsed. One stage reconstruction is very challenging. Ischemia of the distal part of the upper extremity is limited by a synthetic arterial shunt (SAS). After debridement, the authors install the SAS, then the complex procedure can begin. The authors purpose a new four-stage classification and prognostic factors. Debridement concerns crushed, devitalised soft and osteo-articular tissues. If it appears possible to salvage the hand and forearm with necessity of complex reconstructions (vessels, nerves, osteosynthesis, soft tissues) SAS is used. SAS was used 3 times on the group of large avulsions with ischemia (5 cases); it was quickly installed between the humeral and a distal artery and allowed section of the best distal artery for revascularisation. Seven external fixation devices allowed intra operative and post operative management of the wound. The coverage of these large, complex wounds was performed by the latissimus dorsi transposition flap (2 muscular and 5 musculo-cutaneous flaps). It should be considered the flap of choice. Local flaps, which include local skin transposition, muscle transposition or vascular axis, would be contra indicated in a wide zone of injury (the base of these local flaps are damaged by high energy trauma) or when distal ischemia is present because of arterial axis sacrifice. The dorsal decubitus position, the specific dissection of neurovascular pedicle proximally as far as the axillary artery, the muscular and cutaneous design can be used to cover anterior, posterior, internal and external parts of the elbow. Restoration of elbow function uses an innervated latissimus dorsi muscle (3 cases). If only coverage is wanted, this flap has significant advantages over local flaps and free transfer procedures when the recipient vessels are within the area of injury. Between the donor site and the recipient site, the muscular part of the latissimus dorsi flap is placed in an arm counterincision. It ensures closure of the elbow joint. Early progressive range of movement exercises can be performed.

[Scalp reconstruction after avulsion: emergency microsurgery and secondary tissue expansion. Apropos of 3 cases caused by farming machines]. / Reconstruction du cuir chevelu après avulsion: microchirurgie en urgence et expansion tissulaire secondaire. A propos de trois cas survenus par machine agricole.

Total scalp avulsion is an uncommon accident. Three recent cases illustrate our surgical procedure. Small and central hair-bearing avulsed scalps can be treated by secondary scalp expansion (1 case). Large hair-bearing scalp (> 400 cm2) or including aesthetic relief should be treated by microsurgical reimplantation. Venous grafts allow vascular anastomoses beyond the intimal trauma area. Secondary expansion of reimplanted tissue (2 cases) eliminates scalp defects after initial necrosis. Thus, in the cases of total scalp avulsion even with high risk of failure (long time elapsed since injury, significant crush, part being in bad condition, two levels avulsion...), reimplantation has to be performed according to localization and size of avulsion. A secondary procedure with using expansion of the remaining replanted scalp is possible.

[Abrikossoff's tumor of the hand. Apropos of a case. Review of the literature]. / Tumeur d'Abrikossoff de la main. A propos d'un cas. Revue de la littérature.

This mucous tumor (tongue) is uncommon. The cutaneous site is even rare. We report a recurrent granular cell tumor of the thumb and the clinical, diagnostic and prognostic aspects of this usually non malignant tumor.

[Foot replantation followed by tibial lengthening. Apropos of a case]. / Réimplantation d'un pied suivie d'un allongement tibial. A propos d'un cas.

The authors present a foot replantation case at the ankle level followed six months later by a tibial lengthening using the Ilizarov procedure. Performing the aforementioned lengthening following a replantation enables good nervous and vascular sutures, tension-free and ensures a satisfactory result.