Search

Summary Background Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. Methods This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. Results At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. Conclusion We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

Objective To assess the superiority of adipose tissue-derived stromal vascular fraction (AD-SVF) injection into the fingers vs placebo in reducing hand disability in systemic sclerosis (SSc) patients. Methods We performed a double-blind, multicentre, phase II trial from October 2015 to January 2018 in France. SSc patients with a Cochin Hand Function Scale (CHFS) ≥20/90 were randomized 1:1 to receive injection of AD-SVF or placebo. AD-SVF was obtained using the automated processing Celution 800/CRS system. The placebo was lactated Ringer’s solution. The primary efficacy end point was the change of the CHFS score from baseline to 3 months. Secondary efficacy endpoints included the CHFS score at 6 months, hand function, vasculopathy, hand pain, skin fibrosis, sensitivity of the finger pulps, Scleroderma Health Assessment Questionnaire, patients and physician satisfaction, and safety. Results Forty patients were randomized. The AD-SVF and placebo groups were comparable for age, sex ratio, disease duration, skin fibrosis of the hands and main cause of hand disability. After 3 months’ follow-up, hand function significantly improved in both groups with no between-group difference of CHFS (mean change of −9.2 [12.2] in the AD-SVF group vs −7.6 [13.2] in the placebo group). At 6 months, hand function improved in both groups. Conclusion This study showed an improvement of hand function in both groups over time, with no superiority of the AD-SVF. Considering the limits of this trial, studies on a larger population of patients with homogeneous phenotype and hand handicap should be encouraged to accurately assess the benefit of AD-SVF therapy. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov, NCT02558543. Registered on September 24, 2015.

ObjectiveThe autologous stromal vascular fraction (SVF) from adipose tissue is an alternative to cultured adipose-derived stem cells for use in regenerative medicine and represents a promising therapy for vasculopathy and hand disability in systemic sclerosis (SSc). However, the bioactivity of autologous SVF is not documented in this disease context. This study aimed to compare the molecular and functional profiles of the SVF-based medicinal product obtained from SSc and healthy subjects.MethodsGood manufacturing practice (GMP)-grade SVF from 24 patients with SSc and 12 healthy donors (HD) was analysed by flow cytometry to compare the distribution of the CD45− and CD45+ haematopoietic cell subsets. The ability of SVF to form a vascular network was assessed using Matrigel in vivo assay. The transcriptomic and secretory profiles of the SSc-SVF were assessed by RNA sequencing and multiplex analysis, respectively, and were compared with the HD-SVF.ResultsThe distribution of the leucocyte, endothelial, stromal, pericyte and transitional cell subsets was similar for SSc-SVF and HD-SVF. SSc-SVF retained its vasculogenic capacity, but the density of neovessels formed in SVF-loaded Matrigel implanted in nude mice was slightly decreased compared with HD-SVF. SSc-SVF displayed a differential molecular signature reflecting deregulation of angiogenesis, endothelial activation and fibrosis.ConclusionsOur study provides the first evidence that SSc does not compromise the vascular repair capacity of SVF, supporting its use as an innovative autologous biotherapy. The characterisation of the specific SSc-SVF molecular profile provides new perspectives for delineating markers of the potency of SVF and its targets for the treatment of SSc.

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.

Total lower lip defect is rare and its reconstruction difficult. The challenges are both aesthetic and functional. Suspension of the lower lip is essential for restoring oral competence. We report an original and simple technique of suspension by double nasolabial rigging.Two upper base orbitonasolabial flaps, extended over several centimeters below the lip commissures are raised. The epidermis is completely removed. Then, the flaps are tunneled under the skin and fixed to the reconstructed lower lip in order to provide it with effective suspension to the maxillary.In our experience, we used the nasolabial rigging associated with a total reconstruction of the lower lip for three patients. Lip continence is effective in the long term. The review of literature shows that the use of conventional locoregional flaps restores a good labial competence but is limited to subtotal lower lip defect. Distant pedicled flaps or free flaps made without suspension of the lower lip don't restore the labial competence. Several procedures to suspend the lower lip with strips of fascia lata or tendon of palmaris longus, associated or not with a free flap, seem to provide satisfactory oral competence. All these techniques are poorly standardized and technically difficult.The technique of the double nasolabial rigging that we describe seems to be an effective and interesting alternative by its simplicity, its reproducibility and its adaptability. It allows to obtain a perfectly fixed posterior plane, able to receive any reconstruction of the lower lip.

Summary 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 274 min for the first stage and 172 min 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 (

Summary 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 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.

Wrist osteoarthritis (OA) is one of the most common conditions encountered by hand surgeons with limited efficacy of non-surgical treatments. The purpose of this study is to describe the Platelet-Rich Plasma (PRP) mixed-microfat biological characteristics of an experimental Advanced Therapy Medicinal Product (ATMP) needed for clinical trial authorization and describe the clinical results obtained from our first three patients 12 months after treatment (NCT03164122). Biological characterization of microfat, PRP and mixture were analysed in vitro according to validated methods. Patients with stage four OA according to the Kellgren Lawrence classification, with failure to conservative treatment and a persistent daily painful condition &gt, 40 mm according to the visual analog scale (VAS) were treated. Microfat-PRP ATMP is a product with high platelet purity, conserved viability of stromal vascular fraction cells, chondrogenic differentiation capacity in vitro and high secretion of IL-1Ra anti-inflammatory cytokine. For patients, the only side effect was pain at the adipose tissue harvesting sites. Potential efficacy was observed with a pain decrease of over 50% (per VAS score) and the achievement of minimal clinically important differences for DASH and PRWE functional scores at one year in all three patients. Microfat-PRP ATMP presented a good safety profile after an injection in wrist OA. Efficacy trials are necessary to assess whether this innovative strategy could delay the necessity to perform non-conservative surgery.

BACKGROUND Free tissue transfer is occasionally necessary during reconstruction of large scalp and calvarial bone resections. A single-stage procedure is usually performed but if a flap becomes necrotic it exposes brain tissue or the meninges. Performing a two-stage procedure, the surgeon must preserve flap vitality and manage flap complications before resecting a tumor, and therefore before exposing the brain or meninges. We report here the first series of two-stage free-flap reconstruction during major neurosurgical resection. METHODS From 2012 to 2018, nine free-flaps were performed to eight patients (61 years-old, on average). Average skull resection was 10.1 cm × 15 cm (range 6-18 cm × 9-24 cm). It was performed in all cases due to large malignant tumors. Resection/reconstruction was performed in all case in a two-step procedure: during the first step, the free-flap was harvested and anastomosed to the cranial site; during the second step, resection was performed and the flap was positioned into the defect to assure coverage. RESULTS Average flap size was 11.3 cm × 17.7 cm (range: 7-20 cm × 11-30 cm). Two flap complications occurred after the first stage and one flap did not survive. One patient died before the second stage. Seven patients had the second procedure; no flap complication occurred. All procedures ended in complete wound healing. Follow-up period was 41.5 months on average (range: 10-83 months). Final outcome was total remission for two patients, recurrence for four patients, and two patients died. CONCLUSIONS Our data suggest that the two-stage free-flap reconstruction may be employed for major scalp and calvaria resection.

International audience; PRESENTATION An investigation into the patient's unusual dermatologic symptoms identified an underlying autoimmune disease. Fourteen days after breast-reduction surgery, the patient, a 25-year-old white woman, was completely recovered. But at 20 days after surgery, she had bilateral mammary ulcera-tive lesions and was admitted to another hospital. The lesions were painless, and she was afebrile. Negative pressure wound therapy failed to accomplish secondary intention healing. For 6 weeks, she was treated with oral prednisolone, 1 mg/kg/day, and hyperbaric oxygen therapy, but these had limited effect. She then underwent a biopsy of the right breast. The specimen showed perivascular inflammation of the superficial and deep dermis, as denoted by an infiltrate of numerous neutrophils, eosinophils, lymphocytes, and some giant cells. Areas of nonfibrinoid necrosis were evident in the superficial dermis. Bacterial cultures of the wound and blood were negative. A diagnosis of pyoderma gangreno-sum was suspected based on the necrotic ulceration and characteristic violaceous undermined borders of the patient's lesions, the high proportion of neutrophils in the biopsy specimen, and the appearance of lesions on the scar site after a complete recovery. Yet, though the biopsy findings suggested pyoderma gangrenosum, there was some atypia, such as the absence of a central necrotic zone. Treatment with prednisolone and hyperbaric oxygen was restarted 5 days after biopsy results returned. She was then referred to our internal medicine department for further work-up. ASSESSMENT On admission, the patient was afebrile. She had bilateral, painless , inframammary ulcerations with inflammatory borders (Figure 1A). These measured 5 cm in diameter and ran horizontally across the surgical scar line. She also had pain in the sinus region. She reported a 1-year history of rhinitis with crusting and bleeding in both nostrils. Treatment had consisted of several courses of corticosteroids and antibiotics, which offered transient relief from symptoms, and ultimately, she underwent nasal septum surgery. Interestingly, the patient's ear, nose, and throat symptoms improved while she was being treated with prednisolone for her mammary lesions. Laboratory tests revealed elevations in the plasma fibrin-ogen level (5.4 g/L) and the C-reactive protein levels Figure 1 On presentation, the patient had bilateral ulcera-tive mammary lesions.

Background When microsurgical transfers are required in posttraumatic lower limb reconstruction, surgeons must choose among many types of free flaps. Historically, surgeons have advocated muscular flaps for coverage of open lower extremity wounds, but fasciocutaneous free flaps are now often used with good results. This study aimed to compare the functional and aesthetic outcome of reconstruction by free muscular latissimus dorsi (LD) flap and free fasciocutaneous anterolateral thigh (ALT) flap used for soft tissue coverage of distal lower extremity open fractures. Methods We performed a single-center, retrospective study of subjects with distal lower limb open fractures treated with LD flaps or ALT flaps between 2008 and 2014. Patients with limited follow-up or incomplete data were excluded from the analysis. Donor and recipient sites, early complications and long-term outcomes (functional and aesthetic) were studied and compared according to the type of flap. Results A total of 47 patients were included: 27 patients in the LD flap group and 20 patients in the ALT flap group. No significant difference was found regarding early and late complications and long-term functional outcomes (bone healing, infectious bone complications, flap healing). As for aesthetic outcome and donor-site morbidity, reconstruction using the ALT free flap had significantly better results (p Conclusions In posttraumatic lower limb injury, either LD or ALT free flaps can be used for wound coverage with comparable long-term functional outcomes. The ALT flap provides better cosmetic results than LD.

Background Infection is a common complication of major lower limb-sparing surgery with massive total knee prosthesis (MTKP) reconstruction after extensive tumour resection. When free tissue transfer is required to cover the prosthesis, musculo-cutaneous flaps are usually preferred based on proven efficacy when used in both one-stage and two-stage procedures. The use of a free fascio-cutaneous antero-lateral thigh (FC-ALT) flap in 3 patients with infected knee reconstructions is reported here. Material and method A retrospective study was performed of 3 patients in whom a free FC-ALT flap was used during a two-stage procedure to treat MTKP infection after femoral sarcoma resection. Results Free FC-ALT flap transfer and exchange arthroplasty were successful in all 3 patients. Two years after the procedure, no patient had required amputation or experienced recurrent infection. Conclusion A free FC-ALT flap can provide adequate coverage of infected MTKP and deserves to be viewed as a valid alternative to free muscle flaps.

BackgroundIn patients with systemic sclerosis (scleroderma, SSc), impaired hand function greatly contributes to disability and reduced quality of life, and is insufficiently relieved by currently available therapies. Adipose tissue-derived stromal vascular fraction (SVF) is increasingly recognised as an easily accessible source of regenerative cells with therapeutic potential in ischaemic or autoimmune diseases. We aimed to measure for the first time the safety, tolerability and potential efficacy of autologous SVF cells local injections in patients with SSc with hand disability.MethodsWe did an open-label, single arm, at one study site with 6-month follow-up among 12 female SSc patients with Cochin Hand Function Scale score >20/90. Autologous SVF was obtained from lipoaspirates, using an automated processing system, and subsequently injected into the subcutaneous tissue of each finger in contact with neurovascular pedicles. Primary outcome was the number and the severity of adverse events related to SVF-based therapy. Secondary endpoints were changes in hand disability and fibrosis, vascular manifestations, pain and quality of life from baseline to 2 and 6 months after cell therapy.FindingsAll enrolled patients had surgery, and there were no dropouts or patients lost to follow-up. No severe adverse events occurred during the procedure and follow-up. Four minor adverse events were reported and resolved spontaneously. A significant improvement in hand disability and pain, Raynaud's phenomenon, finger oedema and quality of life was observed.InterpretationThis study outlines the safety of the autologous SVF cells injection in the hands of patients with SSc. Preliminary assessments at 6 months suggest potential efficacy needing confirmation in a randomised placebo-controlled trial on a larger population.FundingGFRS (Groupe Francophone de Recherche sur la Sclérodermie).Clinical Trials numberNCT01813279.

International audience; Free tissue transfers are sometimes required in the reconstruction of large full-thickness chest wall defects. To minimize the risk of viscera exposure in case of free flap complications, we describe a two-stage procedure using an anterolateral thigh flap.

Skull base and posterior fossa surgeries are sometimes complicated by cerebrospinal fluid (CSF) fistulae, which may be challenging to treat. They can lead to meningitis, increasing global morbidity and mortality. In case of failed medical treatment, revision surgery may be required. “Fat packing” (adipose tissue grafts) is usually used to close the communication between the intracranial contents and the cutaneous tissue, and to fill the dead space created by the skull base surgery. Vascularised flaps can also be used. They seem more efficient, especially in multi-operated patients or after radiotherapy, when cutaneous tissue is adhesive and fragile. Temporoparietal fascia (TPF) flap is a regional flap; it has reliable blood supply and can cover temporal and retroauricular defects. Folded into a ball, it can fill small dead spaces and can be skin grafted in case of cutaneous defect. We present a simple surgical solution to manage recurrent retroauricular CSF fistulae after posterior fossa surgery using a pedicled TPF flap folded into a ball.

International audience

International audience; Objective. Impaired hand function greatly contributes to disability and reduced quality of life in SSc patients. Autologous adipose-derived stromal vascular fraction (ADSVF) is recognized as an easily accessible source of regenerative cells. We reported positive 6-month safety and efficacy results from an open-label clinical trial assessing s.c. injection of autologous ADSVF into the fingers in SSc patients. The objective of this report is to describe the effects at 12 months. Methods. Twelve females, mean age 54.5 years (S.D. 10.3), were assessed 1 year after ADSVF injection. Patients were eligible if they had a Cochin Hand Function Scale score >20/90. ADSVF was obtained from lipoaspirate using an automated processing system and subsequently injected into the s.c. tissue of each finger in contact with neurovascular pedicles in a one-time procedure. Endpoints were changes in hand disability and skin fibrosis, vascular manifestations, pain and quality of life at the 12 month follow-up. During the visit, patients estimated the benefit of the procedure with a specific self-completed questionnaire. Results. A significant decrease from baseline of 51.3% (P< 0.001) for Cochin Hand Function Scale score, 63.2% (P< 0.001) for RP severity and 46.8% (P = 0.001) for quality of life (Scleroderma Health Assessment Questionnaire) was observed. A significant improvement of finger oedema, skin sclerosis, motion and strength of the hands and of the vascular suppression score was also noted. The reduction in hand pain approached statistical significance (P = 0.052). The questionnaire revealed a benefit in daily activities, housework and social activities. Conclusion. ADSVF injection is a promising therapy and appears to have benefits that extend for at least 1 year.

Summary 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.

Reconstruction after total amputation of the upper and lower eyelids with preserved globe is rare. The primary goal is immediate corneal protection. The second goal is to restore mobility, occlusion, and facial symmetry. Two women had full-thickness excision of both upper and lower eyelids to treat a melanoma. The reconstruction method required four steps over a period of 5 months. A buccal mucosal graft was used to recreate the conjunctival lining, and an oblique forehead flap was used to recreate the skin. Resection of the flap and replacement by a full-thickness skin graft made it possible to recreate a thin and mobile upper eyelid. Visual acuity remained unchanged, and the eyelids remained functional despite a degree of ptosis and lower eyelid retraction.Therapeutic, V.

A temperature increase can improve wound healing by activation of heat shock protein 70 and stimulation of fibroblasts. Since keloids are a dysfunction of collagen fiber synthesis and organization, this study aimed to evaluate if a 1,210 nm diode laser could have effects in a new animal model of keloid scars.A total of 39 nude mice were used for this study. Phototypes IV and V human keloids were grafted into their backs and after 1 month of healing, the mice were divided into four groups: Control, Laser, Resection, Resection/Laser. In the Laser group, the keloids were treated with a 1,210-nm diode-laser with the following parameters: 4 W; 10 seconds; fluence: 51 J/cm(2) ; spot: 18.9 × 3.7 mm(2) . In the Resection group, surgical intra-lesional excision was performed. In the Resection/Laser group, keloids were treated with the 1,210-nm laser-diode after surgical intra-lesional excision. Temperature measurements were made during the laser treatment. Clinical examination and histological study were performed on the day of treatment and 1 month, 2 months, and 3 months later.Mean temperature measurement was of 44.8°C (42-48°) in the Laser groups. No healing complications or keloid proliferation was observed in any group. Keloid histologic characters were confirmed in all grafts. No histologic particularity was observed in the laser groups in comparison with the Control and Resection groups.First, this keloid animal model appears to be adapted for laser study. Secondly, the 1,210-nm diode laser does not induce keloid thermal damage in vivo. Further studies with different 1,210-nm laser diode parameters should be performed in order to observe significant effects on keloids.

Background: Breast implant infections are usually caused by Staphylococcus aureus and coagulase-negative staphylococci. Gram-negative bacilli are rarely reported to be involved in breast implant infections. Methods: Thirty-seven cases of microbiologically confirmed breast implant infection managed from January 2008 to June 2012 in the study centre were reviewed, including 10 cases from the study centre itself and 27 cases from private clinics in the region. Results: The prevalence of breast implant infection in the study centre was 0.74% of breast implantation, i.e., 3.23% in breast reconstruction for breast cancer and 0.27% in aesthetic breast augmentation (p = 0.0002). Of the 37 cases, 30% had undergone radiotherapy and 11% had undergone a lymph node dissection. S. aureus was identified in 18 cases, Gram-negative bacilli in 10 cases, coagulase-negative staphylococci in eight cases, anaerobic bacteria in eight cases, and streptococci in three cases. Pseudomonas aeruginosa was the second most commonly identified pathogen. Staphylococcus epidermidis was the most frequent coagulase-negative Staphylococcus species. In addition to Propionibacterium acnes and Actinomyces neuii, other facultative and strict anaerobic bacteria have not been reported before, e.g., Bacteroides thetaiotaomicron, Corynebacterium simulans, Dermabacter hominis, Finegoldia magna, and Peptoniphilus harei. Seventy-percent of cases were treated by immediate implant removal. All cases treated only with antibiotics were treated with surgery at the second visit. Conclusions: The microbiological epidemiology was noted by an increasing the proportion of Gram-negative bacteria and anaerobic bacteria detected with the advent of MALDI-TOF MS and molecular identification for diagnosis.

Introduction Scleroderma is characterized by cutaneous manifestations that mainly affect the hands, arms and face. As of today, there is no treatment for fibrotic skin lesions of scleroderma. Previously we generated and validated a model of scleroderma-like skin sclerosis in nude mice, appropriate to inject human derived products. We showed that the subcutaneous injection of micro-fat (MF), purified and injected using small caliber cannulas, have anti-fibrotic and pro-angiogenic effects and appears more suitable for the treatment of skin lesions of scleroderma compared to the gold standard (Coleman’s technique or macro-fat). Here we compared the long-term efficacy of micro-fat “enriched” with other therapeutic products including the stromal vascular fraction (SVF) of fat and platelet-rich plasma (PRP) from blood in our murine model of scleroderma. Methods We used 72 nude mice in this study. We formed six experimental groups: Macro-fat, MF, SVF, PRP, MF + SVF, MF + PRP. This project has three phases: i) Induction of skin sclerosis by daily subcutaneous injections of bleomycin (BLM) for 4 weeks in nude mice; ii) Purification and injection of the different cell therapy products; iii) Histological analyses done 8 weeks post-injections. Results MF + SVF and MF + PRP significantly reversed dermal and epidermal sclerosis (P

Cutaneous tissue loss in patients with lesions on the arterial axes remains difficult to treat. Currently, combined surgery associating distal bypass and free flap seems to be the technique that yields the best results. The hemodynamic advantages of this technique, recently demonstrated, are the distal resistance and the increase in bypass flow. Nevertheless, it is complex and its indications limited. Two major drawbacks can be noted: The increasing risk of thrombosis due to the multiplication of anastomoses on the same arterial axis and the deterioration in venous autograft. To overcome these inconveniences we propose a new technique that we call bypass-flap (BF): the graft of an anatomical entity comprised of one artery and one flap. This graft secures the cover of tissue loss and the revascularization of the limb. Apart from its combined nature this technique presents three major advantages. The arterial autograft is superior to the venous graft, the gradually decreasing diameter of the artery secures the congruence of the anastaomoses, and the arterial flow of the graft is higher than a simple bypass due to the joint vascularization of the flap. The arterial graft includes the subscapular and the thoracodorsal arteries. The free flap is composed of serratus anterior muscle supplied by branches of the graft. This investigation studied the feasibility of the bypass flap and determined the length and diameter of the arterial graft and its muscular branch. Forty anatomical preparations were performed on 20 cadavers. The dissections were performed after injection of Rhodorsil. The anatomical feasibility of the bypass flap was confirmed in 37 cases. The total length of the arterial graft that preserved an external diameter above 2 mm was measured at 13 cm (8.5-15.5). This includes the subscapular artery and the thoracodorsal artery with its intramuscular part (if external diameter of that part always above 2 mm). The length of the pedicle of the serratus anterior flap was measured at 7.5 cm (3.0-12.5 cm).

Combined surgery for placement of a distal venous bypass and a free flap enables successful treatment of tissue loss caused by ischemia. This complex surgery has limited indications. The multiple anastomoses on the same arterial axis increase the risk of thrombosis and a certain number of venous grafts are likely to undergo mid-term deterioration. Because of these difficulties, we propose a new concept: the bypass flap (BF), which is based on the harvesting of an arterial axis to provide an arterial graft and a free flap supplied by a collateral branch of the graft. The aim of the anatomic part of this study was to evaluate the length and diameter of the arterial graft and its tissue branch and to study the feasibility of the BF. Thirty-two anatomic preparations were made by intraarterial injection of Rhodosil in 16 cadavers. The arterial graft included the subscapular artery and the thoracodorsal artery. The flap consisted of the anterior serrate muscle supplied by the branch of that graft. The distribution, length, and diameter of the arteries were examined. The mean length of the arterial graft line maintaining diameter above 2 mm was 12.5 cm (8.5-15.5). Three clinical applications of the BF based on the thoracodorsal artery axis were performed on three patients with tissue loss caused by severe ischemia of the lower limb. No occlusion of the BF occurred and healing of the tissue loss was achieved after 4, 7, and 10 months, respectively. This technique has the advantage of decreasing vascular distal resistance, which may contribute to improvement of vessel reconstruction patency. It is simpler because the anastomoses are fewer and it presents the advantage of requiring only autologous arterial material of an appropriate diameter.

L'aplasie cutanee congenitale est une malformation rare pouvant atteindre le scalp et parfois les tissus sous-jacents. Elle peut etre isolee ou associee a des malformations congenitales, souvent dans un contexte familial. La mortalite y est elevee, a l'occasion de complications vasculaires ou infectieuses. Les auteurs rapportent leur experience dans la prise en charge de 5 nouveaux-nes atteint d'ACC du vertex dans un contexte familial. Le traitement par cicatrisation dirigee semble etre la meilleure attitude, meme dans les formes severes. Apres la periode aigue, enquete familiale et expansion cutanee complete la prise en charge.

Early curettage of giant congenital naevi in new-born infants, if performed during the first few weeks after birth, can have a substantial effect on the pigmentation of the lesions, reducing the number of pigmented cells and leaving only moderate scars. We describe our experience in a series of nine congenital naevi treated by curettage between the first and seventh week after birth. Histological changes that occur in the naevus during the first few days after birth mean that early treatment is needed to obtain a cosmetic improvement. Curettage as an early treatment for giant congenital naevi in new-born infants provides cosmetic improvement and might decrease the risk of malignancy; however, the lesions are not cured. Naevus cells persist in the deep dermal layers and may come to the surface, such that close monitoring is needed long after curettage. The cosmetic improvement is likely to benefit the child's psychological development.

Summary Background Rhinoplasty sequelae can be difficult to treat, especially in patients with thin skin. Autologous fat grafting is already used in numerous applications in plastic surgery. However, its use in the nasal region remains relatively uncommon. Given its volumetric qualities and its action on cutaneous trophicity, adipose tissue can be considered the reference product for filling. Methods From 2006 to 2012, 20 patients were treated by autologous fat injections according to the Coleman technique in order to correct rhinoplasty sequelae. The procedures were performed under local or general anaesthesia. The quantity of adipose tissue injected ranged from 1 to 6 cc depending on the size of the deformation and the zone being injected: dorsum irregularities, inverted V deformations, visible lateral osteotomies and saddle nose deformity. Results Of the 20 patients followed up for 18–24 months, 18 had satisfactory aesthetic results after one procedure and two required a second session. Our experience gradually led us to design micro-cannulae for greater injection precision and enabled us to perform these procedures under local anaesthesia. The reduction in ecchymoses and postoperative oedema through the use of these cannulae has significantly reduced convalescence time. Conclusion In patients who undergo multiple procedures, lipofilling can be a simple and reliable alternative to correct imperfections following rhinoplasty.

Nevus spilus is clinically defined as a pigmented skin lesion composed of a light brown macule on which darker, circumscribed macular or papular lesions appear at a later stage. Histologically, nevus cells have been found both in pigmented spots and in the background stain. Cases of transformation into melanoma have been reported in the literature and the excision of these lesions is therefore justified. We discuss surgical techniques used in seven patients with nevus spilus and define their indications with respect to the characteristics of the lesion.

Necrotizing fasciitis (NF) is an uncommon infection caused by microorganisms called 'flesh eating bacteria'. It remains a life-threatening condition associated with high mortality rate. Its location to the chest wall is exceptional. Herein, we report the case of a 39-year-old female, without comorbidity, presenting a NF of the chest wall complicating an empyema. We describe the surgical management with a three-step procedure: antibiotherapy-debridement, vacuum-assisted closure and delayed surgical reconstruction.

Combined distal venous bypass grafting and free flap transfer can achieve successful treatment of soft tissue defects due to advanced leg ischemia. However, this combined approach is a complex technique involving multiple anastomoses on the same arterial axis with an increased risk of thrombosis. To reduce this risk, we have proposed a new bypass-flap (BF) reconstruction technique using an arterial graft and a free flap supplied by a collateral branch of the graft. The purpose of this report is to document the outcome in the first 10 patients treated using the BF reconstruction technique. From 2002 to 2004, a total of 10 patients with a mean age of 67 years (range 55-78) were treated using a BF. All patients presented critical ischemia with soft tissue defects resulting in exposure of tendons and muscles on the foot or ankle. Distal anastomosis was made between the distal branch of the BF and the pedal artery in five cases, the posterior tibial artery or plantar artery in four cases, and the peroneal artery in one case. In six cases proximal anastomosis was performed between the leg artery and arterial autograft. In the remaining four cases proximal anastomosis required extension of the bypass using a venous graft. The mean duration of hospitalization was 25 days. During the postoperative period, one patient died due to stercoral peritonitis and one patient required major amputation due to unrelenting sepsis. Bypass occlusion was not observed. Mean follow-up was 24 months (range 14-36). No patient was lost to follow-up and no patient died after the first 30 postoperative days. Follow-up examinations including clinical assessment and Doppler ultrasound imaging were performed at 3 months and every 6 months thereafter. Findings demonstrated bypass patency and healing of the covered defect in all cases. Outcome in this initial series demonstrates the clinical feasibility of the new BF reconstruction technique, which allows revascularization and coverage of tissue defects using a one-piece anatomic unit.

Objectives Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage. Methods Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally. Results One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg. Conclusion We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.

Backgrounds & Aims: Hepcidin is an acute-phase response peptide. We have investigated the possible involvement of hepcidin in massive obesity, a state of chronic low-grade inflammation. Three groups of severely obese patients with or without diabetes or nonalcoholic steatohepatitis were investigated. Methods: Hepcidin expression was studied in liver and adipose tissue of these patients. Hepcidin regulation was investigated in vitro by adipose tissue explant stimulation studies. Results: Hepcidin was expressed not only in the liver but also at the messenger RNA (mRNA) and the protein levels in adipose tissue. Moreover, mRNA expression was increased in adipose tissue of obese patients. The presence of diabetes or NASH did not modify the hepcidin expression levels in liver and adipose tissue. In adipose tissue, mRNA expression correlated with indexes of inflammation, interleukin-6, and C-reactive protein. Interleukin-6 also promoted in vitro hepcidin expression. A low transferrin saturation ratio was observed in 68% of the obese patients; moreover, 24% of these patients presented with anemia. The observed changes in iron status could be due to the role of hepcidin as a negative regulator of intestinal iron absorption and macrophage iron efflux. Interestingly, a feedback control mechanism on hepcidin expression related to low transferrin saturation occurred in the liver but not in the adipose tissue. Conclusions: Hepcidin is a proinflammatory adipokine and may play an important role in hypoferremia of inflammation in obese condition.

The lateral supramalleolar flap (LSMF) is frequently used for covering major tissue defects of the foot and ankle but usually, in case of arteriopathy of the lower limbs, this device is contra-indicated. Twenty-four specimens of amputated limbs of patients suffering from arteriopathy of the lower limbs allowed us to study the vascular anatomy of this flap after intra-arterial injection of colored latex. At the time of the amputation the average age of the patients was 68.5 years. The clinical signs of arteriopathy had been present for 3-16 years. In 10 cases the amputation was performed directly, in 14 cases after an unsuccessful attempt at revascularization. The dissection results revealed certain specificities in the vascularization of the LSMF with arteriopathy. The perforating branch of the peroneal artery was found in all cases. The descending branch of this perforating artery was found to be patent in 22 cases but slim in five cases. It was absent in two cases. The superficial peroneal nerve and its vascular network always participated in the vascularization of the flap. Thus, its preservation in the distal part of the flap offers a second vascular flow to the pedicle of the LSMF. This specificity increases the theoretical feasibility of the LSMF from 17 to 22 cases out of 24 in our dissections. The authors suggest a theory according to which the evolution of arteriopathy and the gradual concomitant development of a supply network, which effects the vascularization of the sensory nerves too, induces the "anticipation" of a flap. The preliminary distal revascularization by bypass grafts or by some kind of endovascular treatment should guarantee the good vascularization of a limb and the reliable use of this neurocutaneous arterial network.

International audience; Nonmelanoma skin cancers represent the most common malignant neoplasms in humans. UV-B play a major role in the etiology of these tumors, but exposure to environmental procarcinogens is also involved. CYP catalyzes numerous chemical carcinogen bio-activations and effects of UV-B on their expression are poorly understood. The aim of this study was to explore the molecular events involved in the induction of CYP1B1, a major cutaneous CYP, by UV-B. Our results demonstrated that unique UV-B exposure (20 mJ/cm 2) increases human CYP1B1 transcript in primary keratinocytes and HaCaT cell cultures. Among 20 human samples studied, we observed a large interindividual variability of CYP1B1 mRNA induction (1.1-to 4.5-fold). Pretreatment with an antioxidant, N-acetylcysteine, repressed CYP1B1 increase, suggesting the involvement of UV-B photoproducts.-Amanitin inhibition studies and CAT assays demonstrated that CYP1B1 mRNA induction is associated with a transcriptional activation of its expression.-Naphthoflavone inhibition studies and CAT assays performed after directed mutagenesis of xenobiotic responsive element sites showed the involvement of Ah receptor. Taken together, these data demonstrated that UV-B induces CYP1B1 gene expression after an activation of its transcription, which involves Ah receptor.

The manner in which leeches are maintained before they are used for therapy has not been studied as a factor contributing to nosocomial infections. A 5-year retrospective survey of Aeromonas hydrophila nosocomial infections at a hospital in Marseille, France, revealed infections in 5 (4.1%) of an estimated 122 patients treated with leeches in the Hand Surgery Unit and 2 (2.4%) of an estimated 85 patients treated with leeches in other hospital units. The retrospective survey showed that the Hand Surgery Unit was the only unit that had its own aquarium for maintaining leeches; this aquarium was filled with tap water contaminated with Aeromonas species and was not regularly disinfected or cleaned. Leeches used in other units were maintained in noncarbonated water in a transport device. Use of leeches kept in aquariums that are filled with tap water and not disinfected or cleaned regularly may be linked to A. hydrophila infections.

Over 10 years we performed 103 skin-expansion procedures and placed 207 prostheses on lower limbs, using the same surgical protocol. In 83 cases (80.6%) the expansion was achieved without complications. We recorded 20 complications in all (19.4%). Major complications included sepsis, damage due to undermining, exposure of the prosthesis and necrosis of the flap in 16 cases (15.5%), resulting in complete failure of the method in five cases (4.9%). In all, nine patients had septic complications (8.7% of the patients and 45% of the complications), five had exposure of the prosthesis and two had skin necrosis after expansion. Infection and skin necrosis, which are the main causes of failure of this method, can be prevented by a strict surgical protocol covering all stages of the procedure. Atraumatic undermining, remote and external valves, suction drains in the cavities, advancement flaps and plaster casts after surgery can help to prevent skin necrosis. A separate and remote approach for each prosthesis can prevent infection of all the prostheses and complete failure of the expansion procedure.

Skin damage after total knee arthroplasty may jeopardise the functional benefit of the prosthesis. In such cases standard treatment is aimed at avoiding arthrodesis, sometimes replacing the implant and, in exceptional cases, amputation. In most cases early and adequate coverage of the soft tissue defect may make it possible to salvage the prosthesis. Ten patients with skin damage after total knee arthroplasty were treated by debridement of the wound, which was then covered with a pedicled gastrocnemius muscle flap. This was supported by local irrigation and systemic antibiotics. Seven patients were reviewed after a mean follow-up of 28 months (range 14-59). Six patients kept their prostheses and one had a relapse caused by infection at 22 months, which required removal of the prosthesis and secondary arthrodesis. The gastrocnemius muscle flap provides good quality coverage, permits early mobilisation and fast rehabilitation, and reduces the rate of arthrodesis after failure of total knee arthroplasty.

It has been established that human skin grafted onto the nude mouse is able to regenerate after being subjected to a full-thickness wound. In the present work, we sought to determine the cells involved in the connective tissue repair process following superficial wounding. Two months after transplantation, superficial wounds were made at the center of the graft using mechanical dermabrasion. At various times thereafter, ranging from 2 days to 6 weeks, healing grafts were harvested and processed for immunohistological study with species-specific and cross-reacting antibodies directed against human or mouse antigens. The grafted human skin regenerated according to the following series of events. First, the human dermis underneath the scab became devoid of human fibroblasts while the surrounding human dermis preserved its own characteristics. The TUNEL reaction on earlyphase healing wounds indicated that apoptosis occurred steadily within this area and could be the mechanism by which cells disappeared. Moreover, cell death was reduced when the wound was covered with an occlusive dressing. The human dermis beneath the wound was then invaded by mouse cells which deposited type I collagen on the human extracellular matrix and produced mouse granulation tissue at the surface above it. Human keratinocytes migrated over the mouse granulation tissue to reconstruct the epidermis. Eventually, the mouse granulation tissue was progressively invaded by human fibroblasts, which formed a human neodermis. The overall process appeared to depend upon several successive epithelial-mesenchymal interactions, which were not species-specific. This suggests that myofibroblasts arise from a specific subpopulation of fibroblasts, probably located at the interface between the dermis and adipose tissue, and that the granulation tissue is eventually remodeled by another population of fibroblasts present in the human dermis.

International audience; Introduction: Hand involvement confers a substantial handicap in work and daily activities in patients with Systemic sclerosis (SSc). Autologous adipose-derived stromal vascular fraction is as an easily accessible source of cells with regenerative effects. We previously performed a phase I open-label clinical trial (NTC01813279) assessing the safety of subcutaneous injection of autologous adipose-derived stromal vascular fraction. Six and 12-month data have been reported. As patients were followed in our medical centre, we report their longer-term outcome beyond the end of the trial.Patients and method: Twelve females, mean age 54.5 ± 10.3 years, initially enrolled in the clinical trial were assessed during a scheduled medical care, which took place between 22 and 30 months after treatment.Results: Multiple patient-reported outcomes showed sustained improvement, in comparison with the assessment performed just before surgery: 62.5% in the Cochin Hand Function Scale, 51.1% in the Scleroderma Health Assessment Questionnaire, 33.1% in hand pain, and 88.3% in the Raynaud Condition Score. A decrease in the number of digital ulcers number was noted. Mobility, strength and fibrosis of the hand also showed improvement. None of the 8 patients who had previously received iloprost infusion required new infusion.Conclusion: Despite the limits of an open label study, the data are in favour of the long-term safety of the adipose-derived stromal vascular fraction injection. Two randomized double blind, placebo-controlled trials of this therapeutic agent are ongoing in the USA (NCT02396238) and in France (NCT02558543) and will help determine the place of this innovative therapy for SSc patients.