[Satisfaction and quality of life after DIEP-flap breast reconstruction]. / Satisfaction et qualité de vie après reconstruction mammaire par lambeau de DIEP.

Satisfaction and quality of life of patients who have undergone DIEP-flap breast reconstruction have been assessed by many authors in many countries using standardized tools. However, some simple and practical information is often not found in these studies. The aim of our work was to carry out a practical satisfaction survey of patients reconstructed by DIEP flap in our center. Our cohort was made up of 207 patients who underwent DIEP-flap breast reconstruction in Marseille between January 2014 and December 2020. A letter containing our original satisfaction survey was sent to all the patients in our sample. We received 104 responses, which were statistically analyzed using the flat sorting method. Nine-two percent of patients were globally satisfied with the result of their breast reconstruction. A large majority of patients are in favor of the idea of performing their reconstruction again using a DIEP flap. Fifty-five percent of participants were "not bothered at all" by their abdomen after their surgery. The DIEP flap is a versatile technique that allows surgeons to offer it in multiple breast reconstruction situations and to obtain a high degree of patient satisfaction.

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.

[Classification of mammary asymmetries and principles of treatment]. / Classifications des asymétries mammaires et indications chirurgicales.

Constitutional breast asymmetries are responsible not only for esthetic unsightliness, but also, at times, for psychological disorders, and medical management is necessitated. While surgical treatment is the only viable therapeutic option, given the wide variety of morphological presentations of mammary asymmetries, the surgeon is called upon to be well versed in breast surgery techniques. The authors have put forward a classification of mammary asymmetries and principles of treatment.

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.

A new surgical approach in the treatment of tracheostomy scars.

The tracheostomy procedure presents some long term complications such as the depressed scar. It can be responsible for a tracheal tug, invaginated scar, inaesthetic scar or all of them. No consensus has emerged in the treatment of this type of pathological scarring. We want to propose a new surgical approach to correct all these three pathological scarring mechanism by a subcutaneous flap in single operation.

[Secondary surgery of breast reconstructions by breast implant. Assessment of patient satisfaction based on surgical technique implant conservation vs. autologous conversion]. / Chirurgie secondaire des reconstructions mammaires par prothèses. Évaluation de la satisfaction des patientes selon la technique chirurgicale : conservation d'implant vs conversion autologue.

INTRODUCTION: Breast reconstruction with implants has long-term disadvantages and is leading an increasing number of patients to request secondary corrective surgery. Two surgical strategies are possible: implant replacement (associated with capsulectomy/capsulotomy and/or lipofilling procedures) and implant removal associated with the provision of autologous tissue (flap and/or lipofilling). METHOD: Between 2010 and 2018, 54 patients underwent secondary surgery for correction of a first implant breast reconstruction. The reasons for dissatisfaction with the initial reconstruction, the procedures performed, and postoperative complications were analysed. Patient well-being and satisfaction were evaluated using the BREAST-Q questionnaire. RESULTS: Thirty-four patients benefited from a prosthesis change and 20 patients benefited from a permanent removal of their prosthesis combined with the addition of autologous tissue. The presence of a periprosthetic shell, pain, fixed appearance of the breast and breast asymmetry were the most frequent reasons for dissatisfaction. With a mean follow-up of 2.6 years, autologous conversion patients were generally more satisfied with the appearance of their breasts than patients who retained a breast implant (P<0.0001). CONCLUSION: In cases of poor esthetic or functional outcomes of implant-based breast reconstruction, removal of the prosthesis in combination with autologous reconstruction provides better results in terms of well-being and satisfaction than implant replacement.

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.

Production of platelet-rich plasma gel from elderly patients under antithrombotic drugs: Perspectives in chronic wounds care.

Platelet-Rich Plasma (PRP) is an autologous biological therapy obtained by centrifuging the patient's own blood to concentrate platelets. The addition of autologous thrombin and calcium chloride to PRP allows the production of a semi-solid form called PRP gel. PRP gel is increasingly used in a variety of tissue defects and predominantly in the management of non-healing chronic wounds. The topical application of PRP gel seems promising due to the capability of platelets to store and secrete growth factors (GF), fibrin and cytokines, which are essentials for wound healing. Most patients who suffered from chronic wounds are elderly patients with co-morbidities and polypharmacy including antithrombotic drugs such as antiplatelet agents (AP) or anticoagulants (AC), which could hamper the feasibility of this autologous platelet-derived therapy. To date, no study has investigated PRP gel formation in patients with AP or AC. The aim of this study was to evaluate the influence of AP or AC drugs on the production of PRP gel formation from elderly patients. Different biological characteristics were determined to qualify the production of PRP gel from such patients (Interquartile range (IQR) = 75-92 years) compared to healthy volunteers (IQR = 23-37 years). No significant difference was observed in the volume, composition (quantity of platelets, leukocytes and red blood cells) and functionality of platelets from PRP except a higher ADP-induced P-selectin expression in healthy donors compared with elderly patients. Autologous thrombin characteristics were similar in the two groups. Gel time formation (IQR: 120-195 seconds for controls and 135-210 seconds for elderly patients) and final composition of PRP gel were not significantly modified. Concentrations of theoretical thrombin generated in the serum and in the gel were inversely correlated with the time of formation of PRP gel (r2 = 0.57, p = 0.012). Altogether these data indicate that PRP gel preparation is not impacted by the use of antithrombotic drugs. Such results support the feasibility of using this innovative autologous biotherapy in the management of elderly patients with non-healing chronic wounds.

Cell therapy and vocal fold scarring.

Vocal fold microstructure is complex and can be affected by laryngeal microsurgery, inducing scarring that prevents mechanical uncoupling of epithelium and muscle, leading to vibration disorder and disabling dysphonia. Treatment options presently are few, and often without efficacy for vibration, having only an impact on volume to reduce glottal closure defect. The present review of the literature had two aims: (i) to report the current state of the literature on cell therapy in vocal fold scarring; and (ii) to analyze the therapeutic interest of the adipose-derived stromal vascular fraction in the existing therapeutic armamentarium. A PubMed® search conducted in September 2016 retrieved English or French-language original articles on the use of stem cells to treat vocal fold scarring. Twenty-seven articles published between 2003 and 2016 met the study selection criteria. Mesenchymal stem cells were most widely used, mainly derived from bone marrow or adipose tissue. Four studies were performed in vitro on fibroblasts, and 18 in vivo on animals. End-points comprised: (i) scar analysis (macro- and micro-scopic morphology, viscoelastic properties, extracellular matrix, fibroblasts); and (ii) assessment of stem cell survival and differentiation. The studies testified to the benefit of mesenchymal stem cells, and especially those of adipose derivation. The stromal vascular fraction exhibits properties that might improve results by facilitating production logistics.

What About the Rheological Properties of PRP/Microfat Mixtures in Fat Grafting Procedure?

BACKGROUND: Fat grafting has emerged as a reference procedure in daily plastic surgery practice. Unpredictable fat resorption is the main clinical problem. For this purpose, the addition of PRP to enhance fat revascularization is now an easy and popular procedure. However, no consensus exists regarding the respective volume of fat and PRP used to obtain the ideal mixture. This study investigated the rheological properties of microfat mixed with different proportions of PRP. Results obtained were compared with commercialized hyaluronic acid fillers. METHODS: Microfat and PRP preparations were performed using standardized techniques. Lipoaspirate residue and blood were obtained from six patients undergoing aesthetic facial microlipofilling. Elastic modulus G' and tan δ (proportion of elasticity versus fluidity) were obtained for the following conditions: microfat alone and microfat mixed with 10, 30 or 50% of PRP. RESULTS: An expected decrease in elastic modulus was observed by adding increase volumes of PRP. Two groups of products with different rheological properties were considered based on statistical differences highlighted regarding the value of G'. Mean tan δ varied from 0.20 ± 0.04 (microfat alone) to 0.28 ± 0.08 (50% microfat/50% PRP). Microfat mixed with 10% of PRP presents consistency comparable to stiffer fillers, whereas microfat mixed with 30 or 50% corresponds to softer fillers. CONCLUSION: Rheological differences were highlighted given the proportion of PRP added to the microfat. Further studies assessing the impact of increased doses of platelets in microfat/PRP mixtures on clinical outcomes should also be investigated. Our findings will help clinicians to choose a mixture that meets their specific needs for a given indication. NO LEVEL ASSIGNED: 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.

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.

[Palsy of the upper limb: Obstetrical brachial plexus palsy, arthrogryposis, cerebral palsy]. / Les paralysies du membre supérieur : plexus brachial obstétrical, arthrogrypose, paralysie cérébrale.

"Palsy of the upper limb" in children includes various diseases which leads to hypomobility of the member: cerebral palsy, arthrogryposis and obstetrical brachial plexus palsy. These pathologies which differ on brain damage or not, have the same consequences due to the early achievement: negligence, stiffness and deformities. Regular entire clinical examination of the member, an assessment of needs in daily life, knowledge of the social and family environment, are key points for management. In these pathologies, the rehabilitation is an emergency, which began at birth and intensively. Splints and physiotherapy are part of the treatment. Surgery may have a functional goal, hygienic or aesthetic in different situations. The main goals of surgery are to treat: joints stiffness, bones deformities, muscles contractures and spasticity, paresis, ligamentous laxity.

[Congenital malformations of the forefoot]. / Les malformations congénitales de l'avant-pied.

Malformations and deformations of the forefoot are a frequent reason for consultation. The most frequent malformations viewed at birth are syndactylies (second web space), clinodactylies (quintus varus, halllux), polydactylies (hallux, fifth toe). The macrodactylies, hypoplasia, amniotic bands are rare. The management of these defects requires knowledge of surgery adult foot, plastic surgery and especially collaboration with physiotherapists, podiatrists and orthotists. The fast growth of the foot the first year and the development of walking at one year require to start early the treatment of deformations and to anticipate the evolution of malformations.

[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.

[The complications of skin expansion in paediatrics: Diagnostic, taking over and prevention]. / Les complications de l'expansion cutanée en pédiatrie : diagnostic, prise en charge et prévention.

Skin expansion is a difficult and long process in which can occur more or less serious complications. Overall complications rates describe in the literature vary between 13 and 37%. We can categorize them in major complications, which can lead to a failure maybe even an aggravation of the anterior status, and in minor complications that do not compromise the expansion process but can alter it. The main major complications are infection, skin suffering and necrosis which can lead to prosthesis exposition, leaks and technical problems with equipment dysfunctions that may cause difficulties or a failure of the inflations. The main minor complications are hematomas, seromas, valve or tube exposition, pains with paraesthesias caused by neighbouring organs compression, pathologic and unsightly scares and can lead to an important psychological impact. These complications can be due to a precarious skin's state, a material dysfunction or unpredictable technical problems but also by an inappropriate preoperative indication or planning. The emerging of a complication, however, is not synonymous to a failure of the procedure; a satisfactory reconstruction may still be obtained in 75% of all cases. The purpose of this article is to help to identify the situations at risk of complications in order to prevent, detect and treat them early.