The scalp as a donor site for split-thickness skin graft: a rare complication case report.

The scalp is a useful and reliable donor site for the paediatric burn population that can be harvested several times with minimal morbidity. However, the scalp cannot be used as skin graft donor site with impunity. Scalp alopecia and chronic folliculitis can be observed among the complications. In these cases, the reconstruction phase offers different surgical procedures such as primary closure, staged excision or tissue expansion. We report the case of a patient (29-years-old), treated 20 years ago for second-degree burns covering up to 20% total body surface area (TBSA) by using thin split-thickness skin grafts of his scalp. As a teenager, he developed multiple episodes of folliculitis at the donor site of the scalp and then of recurrent abscesses, resistant to all existing medical treatments. Surgical treatment consisted in the skin excision of his scalp donor site which was immediately covered by a thin split-thickness skin graft. Four months after surgery, the patient was satisfied with the functional and aesthetic result.

Nostril alar rim threshold flap for columellar reconstruction.

The reconstruction of the columella poses a significant challenge to the plastic surgeon. A multitude of techniques have been developed to address this issue; however, the end result is often unsatisfactory or comes at too high a morbid cost. Gillies described an alar margin flap in 1949 that never gained significant popularity. This technique had been refined by Servant over the past two decades in his work on Noma noses in Africa. We describe a two-stage columella reconstruction technique with a nostril alar rim threshold flap and provide the results of our case series. Under local anaesthesia, a full-thickness alar flap is raised by placing an incision along the alar-facial groove and carrying it around the lateral crus. This flap is then rotated on its medial pedicle and inserted into the nasal tip. Three weeks after the first stage, the flap is divided to the desired columellar length and the remaining ala relocated to the alar-facial groove. At the same time, the contralateral ala can be adjusted to match the donor side. We performed a retrospective study of all our columellar reconstructions using this local flap. Our case series consisted of seven patients, and satisfactory cosmetic results were obtained in all cases. The nostril alar rim threshold flap is a useful technique for columellar reconstruction, producing near-anatomic results that can be performed as a two-stage outpatient procedure under local anaesthesia. This technique is particularly well suited for columellar reconstruction in patients of African descent.

Pyoderma gangrenosum of the breast: a diagnosis not to be missed.

Pyoderma gangrenosum (PG) is a non-infectious purulent ulcerative disease triggered mainly by chronic inflammatory bowel disease, monoclonal gammapathy, polyarthritis and haematological malignancies; exceptionally, it can be triggered by surgery alone. When PG is associated with fever, it can mimic infectious cellulitis. When it is located on the breast, unnecessary and deleterious surgical debridement may be performed. We present two cases of PG of the breast. The first is a postoperative PG and the second was associated with acute myeloid leukaemia - both led to unnecessary surgery. Several elements may have helped to make the diagnosis: nipples little affected by PG, symmetrical lesions on both breasts, other similar lesions elsewhere on the body, resistance to wide spectrum antibiotherapy, complete blood count abnormalities and negativity of bacterial culture. We propose an index to help the surgeon in his decision to realise a surgical debridement or to postpone it and consider the diagnosis of PG.

[Repair of fingertip amputations using composite grafts: nine clinical cases]. / Traitement par greffe composée des amputations distales des doigts : à propos d'une étude clinique de neuf cas.

PURPOSE: Even if a digital replantation is not possible, we present a series of nine cases of fingertip amputations treated with clinical efficacy by using a composite graft from the amputated finger part. PATIENTS AND METHOD: All of our eight patients (four children and four adults) were traumatically amputated. The level of amputation passed by the bunch of P3 and carried partially or completely the ungula. The reposition was always performed under local anaesthesia. Our evaluation related on the survival of the composite grafts, the functional and the aesthetic result. RESULTS: The composite grafts were revascularised in eight amputations out of nine, with a satisfactory remote result on the function as well as aesthetic level. CONCLUSION: After a short recall of the alternative surgical methods of the treatment of the fingertip amputations, we will insist on the simplicity and the reliability of the repositioning of a composite graft, recommended for us from the start and depending on the traumatic level. In the event of a failure, surgeons still have the possibility of realising the other alternative surgical methods.

[Anthropometric study of cutaneous projection perceived by the previous edge of the latissimus dorsi muscle. Clinical study including 50 women]. / Analyse anthropométrique de la projection cutanée palpée du bord antérieur du grand dorsal chez la femme. Etude clinique. A propos de 50 cas.

The purpose of this anthropometric forward-looking study was to estimate the projection perceived by the previous edge of the latissimus dorsi muscle according to the morphology of the patients. Fifty women were included in this study. We performed thoracic measurements: chest (sub-mammary groove), waist and the middle-hip circumference measurement as well as the anterior rim projection, of the latissimus dorsi, felt at three levels: sub-mammary groove, waist as well as the middle-hip area. We then conducted studies on the variation of these measurements according to the morphology of the patients represented by the variation of the ratio circumference of waist/circumference of chest (TT/TP). By this, we concluded there exists in fact a correlation between the decrease of the ratio TT/TP and the recession of the perceived anterior rim of the latissimus dorsi. The more the report TT/TP decreases, the more the anterior rim of the latissimus dorsi is posterior. In conclusion, because the anterior rim of the latissimus dorsi is the main anatomical mark for the drawing of the musculocutaneous flap, it is therefore necessary to take extra care when assessing slim-waisted women: the drawing must be done in a posterior position.

Biguanides and thiazolidinediones inhibit stimulated lipolysis in human adipocytes through activation of AMP-activated protein kinase.

AIMS/HYPOTHESIS: In rodent adipocytes, activated AMP-activated protein kinase reduces the lipolytic rate. As the hypoglycaemic drugs metformin and thiazolidinediones activate this enzyme in rodents, we tested the hypothesis that in addition to their known actions they could have an anti-lipolytic effect in human adipocytes. METHODS: Adipose tissue was obtained from individuals undergoing plastic surgery. Adipocytes were isolated and incubated with lipolytic agents (isoprenaline, atrial natriuretic peptide) and biguanides or thiazolidinediones. Lipolysis was quantified by the glycerol released in the medium. AMP-activated protein kinase activity and phosphorylation state were determined using standard procedures. RESULTS: In human adipocytes, isoprenaline and atrial natriuretic peptide stimulated the lipolytic rate three- to fourfold. Biguanides and thiazolidinediones activated AMP-activated protein kinase and inhibited lipolysis by 30-40%, at least in part by inhibiting hormone-sensitive lipase translocation to the lipid droplet. Inhibition of AMP-activated protein kinase by compound C precluded this inhibitory effect on lipolysis. Stimulation of lipolysis also induced an activation of AMP-activated protein kinase concomitant with a drop in ATP concentration. CONCLUSIONS/INTERPRETATION: We show for the first time in human adipocytes that biguanides and thiazolidinediones activate AMP-activated protein kinase, thus counteracting lipolysis induced by lipolytic agents. In addition, beta-agonist- or ANP-stimulated lipolysis increases AMP-activated protein kinase activity. This is because of an increase in the AMP/ATP ratio, linked to activation of some of the released fatty acids into acyl-CoA. AMP-activated protein kinase activation could represent a physiological means of avoiding a deleterious drain of energy during lipolysis but could be used to restrain pharmacological release of fatty acids.

Calcium polyuronate dressing supplemented with zinc and manganese (trionic®) in necrotizing dermohypodermitis of the extremities: a randomized multicentre study.

Background. For the burn surgeon, the treatment of necrotizing soft tissue infections is one of the most demanding surgical emergencies, requiring "radical excisions" of the infected tissue and reconstruction. During the infection period, the excised sites are treated with application of gauzes soaked in saline solution. When the septic period is over, the excision sites are usually covered by sterile paraffin gauze dressing. Our aim was to evaluate a new calcium polyuronate dressing enriched with zinc and manganese ions (test group) versus the reference therapeutic combination (control group) from the septic period to the grafting of skin. Materials and methods. A multicentre, prospective, controlled, randomized clinical trial was conducted from November 2003 to July 2005. The primary endpoint was the waiting period for carrying out the skin graft and the percentage of grafted patients at 28 days after the last excision. The secondary endpoints were blood loss, exudates amounts, and pain during dressing changes. Results. Twenty-five patients were included, 14 with the new dressing and 11 with the reference therapeutic combination. The average waiting period for skin graft was 18 days in the test group versus 27.1 days in the control group (p = 0.128). All the patients in the test group received their grafts within 28 days after the last excision, compared with 60% (p = 0.043) in the control group. Bleeding during dressing change was statistically lower in the test group: 45.5% of the patients did not bleed compared with 0% in the control group (p = 0.045). Treatments were well tolerated. Conclusion. The properties of this new calcium polyuronate enriched with zinc and manganese ions seem to accelerate granulation tissue development, allowing skin grafting earlier in favourable conditions with less bleeding and less pain during dressing renewal.

[Tenodesis in hand surgery]. / Les ténodèses en chirurgie de la main.

Joining tendon's inextensibility with joint's mobility, a tenodesis fixes on the bones the two ends of a tendon on both sides of one or several joints. A "simple" tenodesis overrides only one joint, whereas a "dynamic" tenodesis crosses two or more joints. A "crossed" dynamic tenodesis crosses the line which joins rotation axes. A "direct" dynamic tenodesis is located on the same side of this line. The "tenodesis effect" is normally produced by the movements of the joint on the neighbouring tendons. Anatomical examples are given by the oblique retinacular ligaments (crossed dynamic tenodesis), and by the tenodesis effects linked to the flexion-extension of the wrist on the extrinsic tendons of the fingers (direct tenodesis effect), or to the flexion-extension of the PIP joints on the intrinsic tendons of the fingers (crossed tenodesis effect). Main tenodesis techniques are used for palliative surgery in paralysis of EDC, intrinsic muscles of the fingers, or extrinsic muscles of the thumb (EPL, FPL, APL and EPB).

Early management, with a minimal initial hospitalization length, of major self-inflicted rifle wounds to the face by a single latissimus dorsi free musculocutaneous flap: a 10-year experience.

OBJECTIVE: Severe ballistic injuries to the face create complex, composite defects of 2 facial subunits. These injuries have an extremely high economic impact for the Medicare system. The surgical goal with these patients is to restore basic functions of the face with a rapid morphological improvement. Our hypothesis is as follows: Early restoration of facial segments with a single free multiple island latissimus dorsi flap without primary bone reconstruction can significantly reduce hospitalization time and allow earlier psychiatric therapy with good morphological results. SURGICAL METHOD: (1) Large debridement, bony stabilization with external fixation, and tracheotomy. (2) Definitive early reconstruction of soft tissue with composite free latissimus dorsi-scapular musculocutaneous flap. (3) Several refinements will optimize the results. STUDY DESIGN: Retrospective case series of lower- and middle-face composite facial close-range high-energy gunshot wound patients were evaluated. Age, gender, mechanism of injury, anatomic subsites involved, surgical procedures, flaps utilized, complications, functional outcomes, time of tracheotomy closure, hospitalization duration, and beginning of psychiatric treatment were analyzed. RESULTS: Twelve defects were gunshot wounds, 12 free latissimus dorsi flaps, and no flap losses. Patients received psychiatric treatment after 22 days (7-29); the tracheotomy was removed in 10 patients with normal alimentation in all cases. Mean hospitalization duration was 21 days. CONCLUSIONS: Free tissue transfer techniques allow early reconstruction of the soft tissue framework of the face with a single multiple-island flap. Rapid restitution of facial compartments at a soft tissue level can dramatically reduce duration of hospitalization.

[Late results in breast reconstruction by latissimus dorsi flap and prothesis implantation]. / Résultats à long terme des reconstructions mammaires par lambeau de grand dorsal et prothèse.

Breast reconstruction by latissimus dorsi myocutaneous flap in combination with prosthesis has been used for 30 years. Short- and medium-term evaluation after this procedure is well described in the literature, but there have been few evaluations of the late course published until now. In our retrospective study, we included 47 patients who had a breast reconstruction according to this technique, with a minimal follow-up of five years and a maximal follow-up of 11 years. We found that one third of the patients complained about the subjective donor-site morbidity of the latissimus dorsi myocutaneous flap and 37% of the patients needed a late reoperation for prosthesis exchange. Evolution of the reconstructed breast is different compared to the healthy side and getting a long-term symmetry seems difficult.

[Z-plasty low tension]. / Plasties en Z basse tension.

Performing a conventional Z-plasty on postburn scar tissue frequently leads to varying degrees of necrosis of the tips of the transposed flaps. In the conventional technique, the flaps are transposed first by anchoring the tips and then by performing the other sutures. In this order, the tips are subjected to a high degree of tension. Again, according to the conventional technique, perpendicular incisions are performed along the tips, which do not ensure the effective vascularisation of the tips in this context of postburn scarring tissue with loss of dermal blood flow. Two technical modifications are proposed: a different approach to the tension by first of all anchoring the base of the flaps and not by classical first suturing of the tips and the performance of oblique incisions away from the tips to ensure a maximum vascularisation of the subdermal fatty tissue. These two elements have allowed us to improve the results of our plasties.

[Merkel cell carcinoma: study of 24 cases and review of the literature]. / Carcinome à cellules de Merkel : à propos de 24 cas et revue de la littérature.

UNLABELLED: Merkel cell carcinoma is a cutaneous-neuroendocrine tumor, which may be difficult to diagnose and to treat. OBJECTIVE: The objective of this study was to analyse the treatment and the recurrences of Merkel cell carcinoma. PATIENTS AND METHODS: A retrospective study was performed on the patients operated of a Merkel cell carcinoma between 1994 and 2004. Clinical data of the patients and the tumor, treatment (surgery and radiotherapy) and recurrences were entered in a database. RESULTS: Twenty-four patients were operated (8 men and 16 women). The mean age at diagnosis was 71.5 years. The average follow-up was 30.8 months. The treatment was a large surgical removal of the tumor with immediate closure, systematically followed by radiotherapy. There were five recurrences and no death. CONCLUSION: Merkel cell carcinoma is an aggressive tumor. Immediate closure after large surgical removal allows radiotherapy.

A Franco-British patients' and partners' satisfaction audit of breast reconstruction.

AIMS: To compare French and British patients' and partners' satisfaction with breast reconstruction after mastectomy and determine what factors affect it. METHODOLOGY: The study analysed validated questionnaires from 182 pairs (the woman and her partner), split equally between France and the UK. The patients underwent breast surgery at the Norfolk and Norwich University Hospital (NNUH) and at the Hôpital Saint-Louis in Paris, France. All main surgical procedures were considered. RESULTS: Participants were satisfied with the outcome but satisfaction levels differed between France and the UK, British patients reporting higher satisfaction (P=0.029) because of a closer match between their expectation and the outcome. There were also statistically significant differences in: There was no difference in satisfaction levels between patients and partners who accurately reported on patients' views and whose own views matched patients'. Satisfaction was correlated to the level of information, pain management, recovery time, technique used, cosmetic results, intervention timing, but not to the independent assessment of the outcome.

Functional and aesthetic outcome of a complex upper-limb reconstruction after criminal caustic injection.

Extensive upper-limb injuries are usually secondary to accidental partial or complete avulsions or massive burns. Caustic injections are an exceptional etiology, with terrible lesions that present therapeutic challenges and major aftereffects. We report the case of a 41-year-old patient presenting with a large and deep anterior necrosis of the upper-limb anterior tissues, after a criminal intravenous injection of caustic soda on the inner side of his left elbow. Reconstruction methods consisted of a homolateral latissimus dorsi pediculated flap, a humeroulnar vascular bypass, a medial nerve autograft, and a secondary palliative Brand 1 procedure. Final functional and aesthetic results, obtained after long-term physiotherapy, were unexpectedly good. In conclusion, reconstructive surgery of such major lesions cannot be considered without a multidisciplinary approach. Moreover, patients have to be well informed about the necessity of multiple surgical interventions, the risk of major handicap, and the unpredictable nature of the final outcome.

[Surgical treatment of keratosis palmaris in Mal de Meleda]. / Peut-on traiter chirurgicalement le Mal de Meleda (kératodermie palmoplantaire diffuse de Siemens) ?

BACKGROUND: Mal de Meleda (MDM, OMIM #248300) is a rare congenital palmoplantar keratosis. Deep fissures cause pain and limit extension of the metacarpo-phalangeal joints. We report the case of a patient operated on both hands with a 29-year interval between each hand. OBSERVATIONS: A 53-year-old patient with MDM demonstrated severe keratosis of the left hand. The same surgeon operated on the right hand. Both hands were operated using the same technique. Skin of the palm, the palmar side of the index, and the first phalangeal of third, fourth and fifth fingers were excised with a sharp rugine. The hand was immediately covered by a full thickness-skin graft (FTSG) harvested on groin. CONCLUSIONS: The excision of all keratosis on the palm can lead to complete cure of MDM symptoms. FTSG is essential, especially on the fingers, in order to minimize secondary retraction. At the palm, FTSG offers better mechanical resistance then a split-thickness skin graft. A large groin graft, with closure of the donor site in a Y fashion, can cover the entire hand. Long term follow-up (29 years) demonstrates no recurrence of keratosis on surgically treated areas.

Upper limb surgery for tetraplegia: assessment of a 10-point strategy.

PURPOSE: Palliative motor surgery of the tetraplegic upper limb is well-defined, with relatively precise indications that however vary somewhat from team to team. Our personal indications originated mainly from Zancolli, and were applied by the same surgeon in two independent rehabilitation centers. The goals of this study were to assess the application of these indications with time. METHODS: Our retrospective study included three parts: summarization of our initial indications into a 10-point reference strategy; gathering the medical records related to all of the tetraplegic upper limb operations from 1989 to 2006, except for those related to complications and/or salvage procedures. For each patient, collected data corresponded to the 10 strategic points (SP); comparison of the collected data with the reference strategy, upper limb by upper limb, point by point, in order to identify and document any deviations. RESULTS: We assessed the use of the reference strategy in 272 consecutive operations (139 upper limbs, 96 patients). Overall nonconformity rate with the use of the 10-point strategy was 27% (38/139). Except for one very atypical case, all of the exceptions from the reference strategy were due to specific anatomical or physiological conditions. CONCLUSIONS: Our reference strategy has remained noticeably stable over time. However, three important evolutionary modifications occurred: systematic choice of biceps instead of deltoid to restore elbow extension; addition of the split distal flexor pollicis longus tenodesis procedure; and removal of extensor carpi radialis brevis from the list of potential flexor pollicis longus motors. Two issues, dealing with the systematic use of lassos and with brachio radialis to extensor digitorum communis transfer, are likely to be revisited in the future.

[Paralysis of the intrinsic muscles of the hand]. / Paralysie des muscles intrinsèques des doigts longs.

Intrinsic muscles of the fingers are the interosseous, lumbricals and hypothenar muscles. Their main action is metacarpophalangeal (MP) flexion and interphalangeal (IP) extension. If extrinsic muscles remain active, intrinsic paralysis results in a claw deformity: MP hyperextension and IP flexion. Bouvier's test is positive if IP extension is actively possible when MP hyperextension is passively prevented. Surgical operations to correct claw deformity are divided into passive and active palliative procedures. Passive palliative procedures are tenodeses and capsuloplasties. Active palliative procedures have either a proximal action (MP flexion only): lasso and direct interosseous activation, or a distal action (MP flexion and IP extension). When Bouvier's maneuver is positive, a simple claw deformity may be treated by a passive procedure and/or an active palliative with proximal action procedure. This last procedure should be preferably indicated on index and middle finger if a few muscular motors are available. When claw deformity is complicated by MP stiffness in extension, a capsulectomy-capsuloplasty is indicated. When Bouvier's test is negative, and passive IP extension is possible, an active palliative with distal action procedure is indicated. Even when there is no claw deformity, intrinsic paralysis may be treated by an active palliative with proximal action procedure, in order to stabilize pinch and grasp. Capsuloplasties, lassos and interosseous activation procedures were all invented by Eduardo Zancolli.

[Chest wall reconstruction for recurrent breast cancer]. / Reconstruction des pariétectomies thoraciques effectuées pour récidive de cancer du sein.

Some recurrences of breast cancer require wide chest wall resection as curative or palliative therapy. We report a retrospective review of 14 chest wall resections and reconstructions. The width of the anterior chest wall excision was 150 cm(2) (80 to 360 cm(2)). Two defects were full-thickness ones, with sternal or costal resection. The reconstruction required synthetic mesh covered by a latissimus dorsi musculocutaneous flap. The 12 other resections were superficial ones, and have been covered by a skin graft in 5 patients, and by a regional flap in 7 patients (5 latissimus dorsi, 1 DIEP, and 1 bilobed flap). Two patients had a chest wall irradiation after the surgical procedure. We have analysed the factors, which had influenced our choice of the type of reconstruction. The reconstruction is performed by a regional flap, most commonly a latissimus dorsi pedicled flap, in case of full-thickness defect, of nodular isolated recurrence, or when a radiation therapy is provided after the surgical procedure. The coverage is made by a skin graft in case of palliative excision, or of multiple nodular chest wall recurrence (which have a high risk of recurrence in the same form).

[Breast reconstruction by DIEP free flap: a 30 cases experience]. / Reconstruction mammaire par lambeau libre DIEP : à propos de 30 cas.

PURPOSE: The purpose of this study was to analyse the surgical procedure and the complications in case of breast reconstruction by deep inferior epigastric perforator flap (DIEP). MATERIALS AND METHODS: This retrospective study concerns 30 cases performed between 2001 and 2005. The reconstruction was delayed (73%), immediate (3%) or realised after failed attempt to reconstruct the breast with implant or flap (27%). We studied perforator selection, operative time, total flap loss, partial flap loss, and postoperative complications. RESULTS: Flap was raised with one pedicle in 22 cases and with two pedicles in eight cases. The recipient vessels were the axillary vessels (70%), circumflex scapular vessels (27%), and the thoracodorsal vessels (1%). Mean operating time was 6h 17min for the one-pedicle flaps and 8h 43min for the double-pedicle flaps. We noted two total flap necrosis, four partial flap necrosis, one deep venous thrombosis and one pulmonary embolism. Postoperative abdominal hernia or bulge never occurred. CONCLUSION: Although the use of DIEP flap reduces morbidity of the harvest, long operative time and thrombosis complications cause significant morbidity. Therefore we only use the DIEP flap when other procedures cannot be performed.

[Excision skin margin and recurrence rate of skin cancer: a prospective study of 844 cases]. / Marges d'exérèse chirurgicale et taux de récidive des carcinomes cutanés: etude prospective de 844 cas.

OBJECTIVES: In order to evaluate recurrence rates after a mean follow-up period of five years, the aim of this unicentric prospective study was to collect data of the surgical procedure concerning both skin basal cell carcinomas (BCC) and squamous cell carcinomas (SCC). PATIENTS AND METHOD: Eight hundred and fourty-four patients were included and data were retrospectively analyzed. During the surgical procedure, the peripheral clinical clearance margin was, respectively, 4mm for the skin basal cell carcinomas, 8 mm for the sclerodermiform type and 10mm for the squamous cell carcinomas. RESULTS: Basal cell carcinomas (BCC) were represented in 80% and the most frequent locations were the nasal area (30%). On average, the BCC measured 13.2mm. The peripheral histological clearance margin average was 4.1mm. The rate of recurrence was 3.8% after follow-up at an average of 36 months. Squamous cell carcinomas were represented in 20% cases and their locations were mainly located on the lips, the cheeks, the genital region and the extremities. On average, the SCC measured 22.45 mm. The peripheral histological clearance margin average was 10.26 mm. The rate of recurrence was 5% after follow-up at an average of 33 months. CONCLUSION: In our study, the rate of recurrence was less than 5% after follow-up of five years. To avoid repetitive operations and the risk of recurrence in anatomically sensitive areas, these tumors should be treated with standard wide margins chosen between 4 and 10 mm, function of the histological type.