A preoperative cotininury test for abdominoplasty reduces peri-operative complications.

BACKGROUND: Smoking induces complications in plastic surgery, in particular wound healing delays. Despite a 4-weeks' abstinence asking before and after surgery, some patients denied or hid their consumption. The aim of this study was to evaluate the effectiveness of a cotininury detection test in terms of improvement in outcomes after an abdominoplasty. MATERIAL AND METHODS: This retrospective cohort study included patients who underwent an abdominoplasty with umbilical transposition and lipoaspiration. Current smokers were asked to stop smoking 4 weeks before and after surgery. After 2013, we performed a preoperative cotininury test for patients having abdominoplasty, with a cancellation of surgery in case of positive result. We analyzed the test's effectiveness on delayed healing and on other complications. RESULTS: Two hundred and thirty-five patients were included; 80 were tested and 21,3% had a positive test. There was significantly less delayed healing in the "screening" group than in the "no screening": 20,3% versus 41,5% (P=0,002). Alike, complications were significantly less frequent in the "screening" group than in the "no screening": 18,1% versus 42,3% (P<0,001). CONCLUSION: The routine use of the cotininury test in preoperative abdominoplasties significantly reduces risk of delayed healing and other serious complications. It is an objective test, which is simple, quick and non-invasive. Smoking cessation must be at least 4 weeks before and after the surgery. Following medical advice to cease smoking by the surgeon and anesthetist, referral to an appropriate tobacco-addiction specialist clinic may be helpful for the patient who has difficulty stopping smoking.

[Abdominoplasty complications: particularities of the post-bariatric patients within a 238 patients series]. / Complications des abdominoplasties: particularités des patients post-bariatriques au sein d'une série de 238 patients.

BACKGROUND: Obesity is one of the health issues that is recently worldwide increasing, as well as in France. Variety of procedures of bariatric surgery have been developed over the past decade and are performed for morbid obesity hence. The demand of plastic surgery increased for body contouring and reshaping after dramatic weight loss, in which the abdominoplasty is considered as one of the most common procedures. The purpose of this study is to clarify the differences between the post-bariatric patients and others, and their influence on the occurrence of complications following abdominoplasty. PATIENTS AND METHODS: Retrospective study involving a group of post-abdominoplasty patients collected from the same center between January 2000 and December 2010. RESULTS: Among 238 reviewed patients' files; 114 of them are post-bariatric patients, and 124 are non-bariatric patients. Several differences were found between these two groups of patients including the maximum BMI, BMI at the time of surgery, the rates of cardiovascular risk factors, and a longer operative time in the post-bariatric group. The complication rate in these patients was significantly higher (55.3% against 26.6%) with mainly healing problems. Major maximum weight, obesity at the time of surgery, long operative time and postoperative drainage system are all considered as risk factors, which carry high rate of complications. CONCLUSION: It appears that abdominoplasty in post-bariatric patients requires specific care because of particularities inherent in this population.

[Coverage of a hand palmar defect by a synovial flap of the flexor digitorum superficialis]. / Couverture d'une perte de substance palmaire par un lambeau synovial des fléchisseurs superficiels des doigts.

Post-traumatic palmar soft tissue defects are a difficult problem in plastic surgery and many techniques have been described. We report the case of a 41-year-old patient with a large palmar soft tissue defect of the right hand due to a work accident. The classical flaps used in this indication were not usable. So, we chose the synovial flap of the Flexor digitorum superficialis to cover this palmar defect. We discuss the coverage possibilities for a hand palmar defect in emergency, and the use of the synovial flap in this indication. This case report shows that the synovial flap could be an option for the coverage of palmar soft tissue defects.

[Razemon's lateral digital rotation flap in severe Dupuytren contracture of the fifth finger]. / Le lambeau de rotation latéro-digital de Razemon dans les formes graves de la maladie de Dupuytren du cinquième rayon.

In Dupuytren's disease, correction of severe contracture deformities and excision of dermal lesions are often responsible for palmar skin defects. This study aimed to assess the results of the lateral digital flap described by Razemon. Thirty-seven patients were analysed retrospectively for functional and trophic results. Twelve months of follow-up were at least required. The lack of extension was appreciated through Thomine's coefficient. Subjective patient's opinion was noted about function of fifth finger and hand. The flap trophicity was evaluated through softness, coverage quality and esthetic aspect. In the preoperative period, the average lack of extension was 105°; 89% of the patients were ranked as stages 3 or 4 of Tubiana's classification. At the 12th month, the average Thomine's coefficient was 0.74; 70% of the patients were very satisfied. Two patients exhibited some lack of suppleness and seven a dyschromic scars. The lateral digital rotation flap is a quite simple surgical procedure. It allows satisfactory results corresponding to functional and trophic coverage in severe Dupuytren's contracture involving the fifth finger.

[Complication of radical lymph node dissection following sentinel lymph node biopsy in patients with melanoma]. / Complications du curage ganglionnaire réalisé après exérèse du ganglion sentinelle dans le mélanome.

OBJECTIVE: To assess the rate of complications of radical lymph node dissection following sentinel lymph node biopsy in patients with malignant melanoma. PATIENTS AND METHODS: A single-centre retrospective study was performed between 2001 and 2009. All melanoma patients who first had a sentinel node biopsy followed by a radical lymph node dissection were included. RESULTS: Seventy-four patients had radical lymph node dissection after confirmation of metastasis in a sentinel node. The sites of the lymphadenectomy were axillary in 51% of patients, groin in 43%, neck in 5% and popliteal in 1%. A nodal metastasis was observed in 12 of 74 lymph node dissections. Median follow-up time was 41.5 months (3-135 months). At least one complication was seen in 47 patients (64%). Early complications were: postoperative infection (n=9; 12%), lymphocele (n=22; 30%), chronic seroma (n=9; 12%), postoperative haematoma (n=6; 8%), and wound separation (n=7; 9%). Late complications were: lymphoedema (n=30; 41%), joint complications (n=10; 14%), fibrous scar (n=11; 15%), chronic pain (n=6; 8%) and hyposensitivity (n=6; 8%). Two patients were rehospitalised for a complication. The complication rate was 53% for axillary location and 81% for inguinal location (P=0.02). CONCLUSION: Radical lymph node dissection performed after positive sentinel node biopsy in melanoma patients is associated with significant morbidity.

[Necrotizing dermohypodermitis of the abdominal wall in obesity. Two cases indicative of abdominopelvic deep infection]. / Dermo-hypodermites nécrosantes du tablier abdominal chez l'obèse. À propos de deux cas cliniques révélateurs d'infections profondes abdomino-pelviennes.

Necrotizing dermohypodermitis of abdominal wall in obese is a rare disease with high mortality. We report two cases of 50 and 62years old patients whose intra-abdominal infectious pathology (appendicular abscess for one and pyosalpinx for the other) was revealed by a necrotizing dermohypodermitis of the abdominal wall. The diagnosis has been established on the basis of converging clinical arguments (abdominal pain, crackles and necrotic appearance of abdominal wall in a septic shock context), linked with a CT-scan. The treatment consisted of a large excision of the abdominal wall necrosis and surgical eradication of deep infection source, with an intensive care and a broad spectrum antibiotic therapy. Both these patients present morbid obesity (BMI>40) whose implication must be taken into consideration in the way the disease appears. Indeed, the necrotizing dermohypodermitis of abdominal wall in these patients must lead first in looking for a deep infection with few symptoms. It must be identified quickly to propose an early and multidisciplinary surgical treatment.

[Breast augmentation by Poly Implant Prothèses silicone implants: retrospective study about 99 patients. Rupture analysis and management]. / Augmentation mammaire par prothèses en gel de silicone de la marque Poly Implant Prothèses (PIP) : étude rétrospective de 99 patientes. Analyse des ruptures et prise en charge.

BACKGROUND: Breast augmentation is one of the most frequent intervention in plastic surgery. In March 2010, the Afssaps has withdrawn from the market all the Poly Implant Prothèses (PIP) silicone implants, the authors report a retrospective study of 99 patients who had breast augmentation by PIP implants. The aims of this work are to evaluate the ruptures observed with these implants and to propose a management. METHODS: We included in the study 99 patients and 192 silicone gel implants. The interventions were performed between 2005 and 2010. On 192 implants, 184 had a textured surface and eight a smooth one. According to the latest recommendations from the Afssaps, all patients had a clinical examination and an ultrasonography looking for rupture signs. MRI was performed in case of doubt. RESULTS: We found 23 ruptured implants: 18 intracapsular and five extracapsular ruptures, involving 17 patients. We also found 28 patients with axillary lymphadenopathy and eight patients with locoregional silicone spread. Finally, we found that 35 patients had chronic breast pains. CONCLUSION: Given our results, it seems reasonable to withdraw all the PIP silicone breast implants.

[Biometric and morphometric analyse of the umbilicus: about 70 cases]. / Analyse biométrique et morphométrique de l'ombilic. À propos de 70 cas.

PURPOSE OF THE STUDY: More than the first scar present from the birth, the umbilicus is the original and fundamental element, which characterizes the abdomen. It can be analyzed under various aspects: symbolic, artistic, anatomical and morphometric. Its place takes on all its importance in frame of the abdominal plastic surgery. We tried to measure how the position of the umbilicus varies with the age, the weight or the sex… to optimize our abdominoplasties. PATIENTS AND METHOD: We realized a study on the umbilicus from 70 persons to determine its abdominal position in the general population. Some objective measurements between bones projections and umbilicus were realized and analyzed with various parameters (weight, age especially…). Depth of the umbilicus, its situation compared the median line, its dimensions, were noted for each patient. RESULTS: Population was composed of 39 women and 31 men, 35.4 years on average. The umbilicus was measured one centimeter under the line joining the top of the iliac crest. In the group of men, its situated lower. We noted a positive correlation between body mass index (BMI) and height of the umbilicus. More the BMI increases, lower is the umbilicus (R=0,72, P<10(-5)). Similarly, the umbilicus is lower when the age increases (R=0,36, P=0,0022). Its average depth was 15 mm, correlated to BMI (R=0,60, P<10(-7)). Some data about dimensions and form were precised. CONCLUSION: This anatomical and morphometric study could allow a more precise determination of the position, dimensions and form of the umbilicus during abdominoplasty.

[Dupuytren's disease: state of knowledge and research in physiopathology]. / Maladie de Dupuytren: état des connaissances et de la recherche en physiopathologie.

From Baron Dupuytren's historical description up to the advent of molecular biology, many hypotheses about the etiology of Dupuytren's disease have been proposed. This bibliography of the last ten years' publications describes tissue anomalies from the macroscopic down to the ultrastructural level of pathology. The myofibroblast, which is the principal cell of the disease, is the seat of genetics anomalies involving proto-oncogenes (c-myc and MafB). Similarly, glycoproteins implicated in cellular adhesion like fibronectins and catenins are modified and overexpressed in the disease. Extracellular proteins of the metalloproteinase family exhibit many dysfunctions responsible for collagenic proliferation. Finally, growth factors like Transforming Growth Factor (TGF) and Epidermal Growth Factor (EGF) receptor maintain and worsen the disease and could be therapeutic targets in the future.

Direct neurectomy of the motor branches of the tibial nerve in hemiplegic adults: an assessment with a mean follow-up period of 11 years.

INTRODUCTION: Neurectomy of the tibial nerve plays a major role in the relief of disabling spasticity, which is refractory to drug treatment and physiotherapy. Although the immediate postoperative results are generally satisfactory, few evaluations of the procedure's long-term efficacy have been published. OBJECTIVE: To estimate the long-term efficacy of total or partial neurectomy of the motor branches of the tibial nerve (combined with additional orthopaedic surgery in some cases). METHOD: A descriptive, retrospective study of 25 brain-damaged patients having undergone neurectomy at least 4 years ago. RESULTS: The mean post-neurectomy follow-up period was 11 years. Twenty patients became less dependent on the use of walking aids. Of the 18 patients unable to walk barefoot before surgery, 11 could do so after surgery. Of the 12 patients unable to walk on uneven ground before surgery, seven could do so afterwards. The walking distance increased for 20 patients. In 22 cases, the spasticity disappeared immediately after the operation and did not reappear in the long-term. In three other cases, spasticity persisted postoperatively and, in the long-term, affected the soleus (the denervation of which had been incomplete or not performed). Eighty-three percent of the patients were satisfied with the operation's outcome. CONCLUSIONS: The observed maintenance of the benefits of total or partial neurectomy after an average follow-up period of 11 years confirms the value of this procedure. The few mediocre outcomes (observed in cases of partial neurectomy of the soleus) are in agreement with literature reports and emphasize the role of the soleus in this pathology.

[Mondor's disease and breast plastic surgery]. / Maladie de Mondor et chirurgie plastique du sein.

AIM: Mondor's disease is a rare complication following breast plastic surgery. CASE REPORT: We report the case of a 40-year-old woman with breast shape and volume asymmetry. She was treated by left breast submuscular prothesis augmentation followed by right breast mastopexy 6 months later. Following this surgery, she presented with subcutaneous painful abdominal cords on the right side or Mondor's disease. DISCUSSION: We discuss the diagnosis, physiopathology and treatment of this disease in the light of scientific literature. The physiopathology is based on fascial origin in a context of local vascularitis. CONCLUSION: Mondor's disease is a rare but benign pathology following breast plastic surgery. The treatment is symptomatic and the surgeon must reassure the patient on the benignity and the lack of consequence on the final cosmetic result.

Abdominoplasty after major weight loss: improvement of quality of life and psychological status.

Abdominoplasty provides a reconstructive but rarely aesthetic cosmetic solution after major weight loss. Few articles document quality of life (QOL) issues and the psychological impact of abdominoplasty on obese patients. We report a retrospective study of 41 abdominoplasties performed after an average weight loss of 40.2 kg. Data were obtained through review of patient medical files, double-blind surgical and psychological examinations, and two specifically designated questionnaires used to assess pre-abdominoplasty body perception and QOL, post-body contouring perception of improvement, and psychological status. To date, 14 patients have regained >10 kg; 84.6% have improved QOL; 86.5% have improved psychological status; 74% have better sexual relations; 53.9% admit liking their body; 76.9% are satisfied with the results of abdominoplasty; and 96.1% would be willing to undergo abdominoplasty again. Anterior dermolipectomy improves both QOL and psychological status. Provision of patient education, multidisciplinary management, and long-term follow up are necessary to obtain satisfactory results.

[Abrikossoff's tumor: about one case of inter-mammary cutaneous localization and review of literature]. / Tumeur d'Abrikossoff : à propos d'une localisation cutanée du sillon intermammaire et revue de la littérature.

SUBJECT: Our report concerns a large inter-mammary cutaneous Abrikossoff tumor on a 41-year-old female patient, which has prompted us to review the literature. CASE: It was a low pre-sternal skin tumor; CT-Scanning showed a homogeneous mass 5 cm high, 4 cm wide and 4 cm deep. Total tumoral included the right pectoralis major muscle aponeurosis. The skin defect was closed using a V-Y local plasty. Histologic examination revealed no sign of malignity. DISCUSSION: Abrikossoff tumors (or granular cell tumors) are rare ubiquity tumors locating preferably in ENT and oral cavity mucosa. They develop between 20 and 60 and more often concern women. They are overwhelmingly single and benign but on occasion multifocal or malignant. Immunohistochemistry points to a schwannian origin. Treatment is exclusively surgical. Skin closure is by direct suture, skin grafting or local plasty. The use of flaps is not advised as it may delay local recidivation diagnosis. The literature reports one single other case of chest wall location. CONCLUSION: Abrikossoff tumors require complete exeresis and mandatory histological examination into possible signs of malignity. The risk of recidivation warrants long-term surveillance.

[Non vascularized toe phalangeal transfers for symbrachydactyly. Active range of motion without joint reconstruction]. / Transferts non vascularisés de phalanges d'orteils pour symbrachydactylie. Mobilités articulaires actives sans reconstruction articulaire.

Symbrachydactyly is a rare congenital malformation of the hand and its treatment is controversial. Non vascularized toe phalangeal transfers have been used for management of short digits for three children. Six phalanges have been harvested complete with their periosteum. No joint reconstruction has been performed and all children have undergone surgery at a young age. Four of six digits involved have an active range of motion (range 30 to 105 degrees ). All authors who have reported active range of motion of toe phalangeal transfers have performed joint reconstruction. Here, we report obtaining active range of motion of phalangeal transfers without necessity of joint reconstruction.

[Complications after sentinel lymph node excision in patients with malignant melanoma]. / Complications liées à l'exérèse du ganglion sentinelle dans le mélanome.

INTRODUCTION: Side-effects occurring after sentinel lymph node excision in malignant melanoma patients have been poorly evaluated to date. The aim of the present study was to assess the side-effects of sentinel lymph node excision in this population. PATIENTS AND METHODS: All consecutive malignant melanoma patients undergoing sentinel lymph node excision between March 2000 and December 2002 were included in this retrospective study. Patients with a metastatic sentinel node subsequently undergoing lymph node dissection were excluded. Median follow-up of patients was 12.6 +/- 8.8 months. Complications were classified as "early" (i.e. occurring the month following surgery), or "late" (after this time). RESULTS: Forty malignant melanoma patients (17 males, 23 females) with a normal histologic examination of their sentinel lymph node were included. They belonged to a series of sixty-one melanoma patients undergoing lymph node excision. Fourteen complications were observed in ten patients. Two early complications were seen: hematoma (n=1) and deep venous thrombosis with pulmonary embolism (n=1). Twelve late complications were observed: mild lymphoedema (n=5), hypertrophic scars (n=2), painful scars (n=4), and one chronic seroma (n=1). Many complications (33%) were observed after excision in the inguinal area. DISCUSSION: The complications of sentinel lymph node excision must be considered in determining the benefit/risk ratio of this technique.

[Hereditary neuropathy with liability to pressure palsies (HNPP) in hand surgery: reminds and warn against a usually unrecognised disease]. / Les neuropathies tomaculaires et la chirurgie de la main : rappels et mise en garde sur une pathologie souvent méconnue.

Tomacula is a rare hereditary disease due to a deletion on chromosome 17. Clinical presentation varies but patients usually complain of recurrent paraesthesiaes and palsies related to compression or trauma of a peripheral nerve. Diagnosis is based on electrophysiological studies, nerve biopsies and genetic tests. Implications for the patient and family members are a genetic counselling and some simple preventive measures. Although there is no curative treatment for this neuropathy, surgery can be useful for decompression of nerves and neurolysis. However, the surgical act increases the risk of nerve damage. Knowing about the diagnosis can help the patient and the surgical team avoid causing lesions.

Anatomical comparative study of two vascularized bone grafts for the wrist.

Atrophic scaphoid non-union and lunate necrosis can be treated with vascularized bone grafting; through a posterior approach as described by Zaidemberg, based on a supraretinacular artery, or through an anterior approach, based on the volar carpal artery, according to Kuhlmann's procedure. The aim of our study was to determine the area covered by each of these two grafts and their respective future applications. Fifteen hands from eight adult human cadavers, free of any scar, were dissected after injection of colored fluid latex, through dorso-radial approach for Zaidemberg's graft and through volar approach for Kuhlmann's. We observed the morphological parameters of the pedicles and the arc of rotation of each flap. The volar vascularized graft had a constant origin and it could be transferred to the scaphoid, the lunate and the scapholunate joint. The posterior graft of Zaidemberg was technically more difficult to harvest because of the anatomical variations. It made it possible to reach the scaphoid, the trapezium and the scaphotrapeziotrapezoid joint line. Both these two vascularized bone grafts represent interesting procedures for treatment of scaphoid non-union or lunate necrosis, or intracarpal bones arthrodesis. They bring various possibilities of bone covering, related to specific area of mobilization and are not opposite procedures, but have different targeted indications. One must better define the respective places of the vascularized bone grafts, compared with the traditional free (non-vascularized) graft.

[Influence of the size and the localization of metastases in melanoma sentinel lymph nodes on the results of lymphadenectomy]. / Influence de la taille et de la localisation des métastases dans les ganglions sentinelles de mélanome sur le résultat du curage, à propos de 35 cas.

AIM: Thirty-five cases of lymphadenectomy carried out in the context of positive sentinel lymph node for malignant melanoma have been reviewed to assess the prognostic value of certain metastatic charachteristics. We have checked wether the type (macro or micrometastasis) and localisation (subcapsular or intraparenchymal) in the sentinel lymph node had predictive value for the lymphadenectomy outcome and evolution of the case. MATERIAL AND METHODS: The retrospective study relates to 35 cases (with an average 2 years history) taken from a total of 87 sentinel lymph node protocols; average age 46.5 years, Breslow 2.5 mm with an history of 25 months. RESULTS: Among the 35 positive sentinel lymph nodes we have 19 cases (54.2%) of micrometastasis. Among the 35 lymphadenectomy 5 cases (14.28%) turned out positive, 3 of which concerned micrometastatic sentinel lymph nodes. In our cohort the micrometastatic nature of sentinel lymph nodes did not have statistically significant impact upon the lymphadenectomy result but showed more favourable short-term evolution with 68.42% metastatic free evolution as against 43.75% in case of initial macrometastasis. The subcapsular localisation of micrometastasis equally represents a factor of improved prognosis (69.2% of metastatic free evolution against of 30.8% in the case of intraparenchymal localistion). CONCLUSION: Unfortunately, none of the studied criteria justifies a modification of our present clinical attitude whereby a systematic lymphadenectomy in cases of positive sentinel lymph nodes is performed, whatever the type or localisation of the relevant metastases.

[Recurrence of a basal cell carcinoma in a skin graft in spite of total excision. A case report]. / Apparente récidive d'un carcinome basocellulaire de la face au sein d'une greffe de peau totale malgré une exérèse complète. A propos d'un cas.

The authors report an original case of a recurrence of basal cell carcinoma in a skin graft recipient site. The skin graft was used to resurface the defect following complete excision of basal cell carcinoma in the mandibular angle area. Three answers can be given to the question of the origin of that new carcinoma: recurrence of the primary carcinoma, metastasis to a lymph node or a transfer of a basal cell carcinoma located into the skin graft which grew further. This last hypothesis remains the most probable because the histology of the two carcinomas was different and that the patient presented many others locations of basal cell carcinomas. Skin grafted areas must be checked for recurrence of basal cell carcinoma in such patients because invisible basal cell carcinoma can be transferred within the graft where they can grow for their own.

[The total thigh flap in reconstructive surgery]. / La place du lambeau total de cuisse en chirurgie reconstructrice.

Plastic surgeons have sometimes to face large pelvic tissue defects, particularly in paraplegic patients with recurrent pressure sores. This is frequently a reconstructive challenge and different locoregional flaps may be useful to manage those wounds when medical solutions were unsuccessful. However, in cases when other reconstructive options have been exhausted the total thigh flap represents the last acceptable solution to cover the defects by providing a large volume of healthy tissue. We remind here the operative technique and its interest in reconstructive surgery by reporting our experience in two patients for which this flap was successfully used.