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Background:  Unfractionated heparin has anticoagulant properties by catalyzing antithrombin III, which inactivates coagulation enzymes. Used in microsurgery, it would prevent the occurrence of thrombosis during microsurgical anastomoses. The objective of this study was to evaluate the role of intraoperative irrigation of the vascular lumen with pure sodium heparin to prevent vascular thrombosis after end-to-end microsurgical anastomoses., Methods:  End-to-end anastomoses were performed on rats by 21 operators. Three surgical sites were studied (cervical, femoral, and rat tail). The first vessel was irrigated with physiological salt solution (0.9%) before, during, and before the end of the anastomosis. Whenever possible, the contralateral vessel was irrigated with pure unfractionated heparin 5,000 UI/mL. The primary endpoint was the occurrence of thrombosis 60 minutes after anastomosis., Results:  From November 2015 to April 2018, 247 anastomoses were performed on 229 arteries and 18 veins. One hundred twenty-five anastomoses were irrigated with physiological salt solution, 122 with pure unfractionated heparin. A 60-minute thrombosis was found on 31 anastomoses (25%) irrigated with physiological salt solution compared with 16 anastomoses (13%) irrigated with heparin, that is, a decrease in the thrombosis rate of 2.6 ( p  = 0.01)., Conclusion:  The use of pure unfractionated heparin in intraoperative lumen irrigation during microsurgical end-to-end anastomoses reduces the rate of vascular 60-minute thrombosis compared with physiological salt solution irrigation. It is an effective intraoperative procedure for the prevention of microsurgical thrombosis., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The abdominoplasty (AP) is a common type of plastic surgery procedure that removes unsightly and uncomfortable cutaneous and fatty excess from the anterior abdominal wall. In 30% of the cases, the results prove to be insufficient and motivate a request for reintervention which goes from the simple cicatricial revision under local anesthesia to the complete recovery of the procedure. The defects at the origin of the secondary abominoplasty are persistent skin excess, residual fat deposits, scarring malpositions or abnormalities of the umbilicus. The respect of certain technical rules during the primary AP are likely to limit the postoperative defects at the origin of these surgical revisions. When an imperfection of result is found postoperatively, the methodical clinical analysis of the defect will allow in determining the cause and to choose the most adapted corrective solution in order to obtain finally the satisfaction of the patient., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: Immediate or delayed breast reconstruction by deep inferior epigastric perforant flap (DIEP) is a frequent and widespread autologous breast reconstruction technique that presents a risk of failure inherent in its microsurgical nature. The main objective was to evaluate the interest of surgical revision in case of DIEP failure, the secondary objective was to evaluate the consequences of surgical revision on the subsequent management., Materials and Methods: This is a retrospective monocentric and single-operator analytical study of 167 unilateral DIEPs carried out from 2008 to 2016. Two groups were compared: success of DIEP without revision versus DIEP requiring a revision that resulted in success or failure. After analyzing the failure and recovery rates of DIEP, we compared the transfusion rate, total operating time, hospitalization time, and final breast reconstruction in the two groups., Results: One hundred and sixty-seven DIEPs were performed from 2008 to 2016 in 167 women, 18 revisions were reported (10.7%), 12 revisions were successfully reported (7.2%) 6 failures were reported after revision (3.6%). Surgical revision allows the flap to be rescued in 67% of cases. Revision increases the risk of blood transfusion by a factor of 12 (OR=12.24 [95% CI=3.74-43.17] P<0.05). Revision or failure doubles the total operating time (281.8min [170-570] vs. 577.8min [285-860] P<0.05) and increases hospitalization time by 2.5days compared to DIEP's initial success (5.74days [4-9] vs. 8.33days [5-17] P<0.05). Fifty percent of patients choose another type of breast reconstruction after DIEP failure., Conclusion: DIEP is a reliable microsurgical breast reconstruction technique, failure can be prevented in two thirds of cases by monitoring and early reoperation., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: The purpose of this study is to evaluate patients' satisfaction after immediate breast reconstruction (IBR) according to the surgical technique., Methods: Included patients had an IBR between 2012 and 2017 and finished their reconstruction since a year. Patients were contacted by phone and their satisfaction was evaluated with the Breast Q questionnaire. According to the surgical technique, patients were divided into 5 groups: DIEP, gracilis, Latissimus Dorsi flap, definitive implant and expander implant. Techniques were grouped into two categories: free flaps and prothesis. Nipple reconstruction techniques were also evaluated: toe pulp grafting, nipple sharing and local flap., Results: Nighty-five patients on the 103 who were eligible accepted to answer the questionnaire. Satisfaction with breasts was stastistically higher in the free flap group (72.6/100) than in the prothesis group (62.7/100) (P<0.01). Physical well-being (chest) was better for the free flap group than for the prothesis group (92.2/100 vs. 85.2/100, P=0.02). Nipple reconstructions with nipple sharing and free flap give a better satisfaction for patients than toe pulp grafting (75.3/100 and 73.5/100 vs. 47.8/100, P<0.01)., Conclusion: IBR with free flap give, in a short time, a statistically higher satisfaction for breast than prothesis. Nipple reconstructions with free flap and nipple sharing give a better satisfaction too., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: This study analyzes postoperative course of different immediate breast reconstruction techniques: deep inferior epigastric perforator flap (DIEP), gracilis, latissimus dorsi flap, expander implants and definitive implants., Methods: All women operated on IBR between 2012 and 2017 in the CHU Strasbourg were included in this retrospective study. The main data collected were healing time, complications, surgical revisions and failure rates. These data were compared between the five IBR techniques to find a significant difference. Two groups were distinguished according to the surgical techniques: free flaps and implants. Data of those groups were compared too., Results: One hundred and ninety three patients have had a breast surgical treatment between 2012 and 2017. Among them, 44 had a bilateral IBR (23%). Early and unserious complications, were less frequent in the implants group than in the free flaps group: 8.6% vs. 33.3% (P<0.01) for unilateral reconstructions and 10.9% vs. 38.9% (P<0.01) for bilateral reconstructions. No surgical failures were found in the free flaps group versus 6.2% for definitive implants and 3.6% for expander implants. Healing time was longer for the free flaps group than for the prothesis group: 5.6 weeks vs. 4.2weeks, (P<0.01)., Conclusion: IBR with free flaps is associated with a higher risk for early and unserious complications as healing disorders, which extend the dressings time. However the failure rate is not higher with free flaps., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Breast reconstruction is an integral part of breast cancer treatment. It must be systematically mentioned when the disease is announced and proposed at an optimal time during cancer management. In case of ductal carcinoma in situ, reconstruction should be proposed at the same time as mastectomy, which generally preserves the skin. The conservation of the nipple-areolar complex should be further evaluated. In the case of invasive breast carcinoma, breast reconstruction is generally proposed at a distance from the oncological time, except for patients requiring neither chemotherapy nor postoperative radiotherapy for whom reconstruction can be immediate. Finally, in the case of prophylactic synchronous contralateral mastectomy, reconstruction should never delay the overall management of breast cancer., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

The reconstruction of the nipple-areolar complex is the final stage of breast reconstruction that restores the visual identity of the breast. The most common options for reshaping the areola are tattooing, total skin grafting of the inner thigh and the total skin graft taken from the contralateral areola. Nipple reconstruction solutions include duplication of contralateral nipple, local flap, total skin graft and tattoo in three-dimension. Duplication of the nipple is the technique of choice because it immediately offers optimal color, texture and projection. The areolar tattoo is the most common procedure for its simplicity and reproducibility., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Breast reconstruction with free flap of gracilis has been described since 2004. The procedure consists in harvesting a flap made of the gracilis muscle and a transverse cutaneous paddle originating from the internal root of the thigh. The pedicle of the flap is the main pedicle of the gracilis muscle. After weaning, the vessels are anastomosed to the internal thoracic artery and vein. The modeling of the breast is done by folding the cut points in front of the muscle to obtain the shape of a cone. This surgical technique allows the realization of autologous breast reconstructions of small to medium size, immediate or delayed, unilateral or bilateral., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

This document is meant to be a practical guide for the surgeon, to assist him in informing the patient more easily. Different clinical results with different reconstructive techniques and different morphologies are presented. This document is not meant to be a catalogue, or to guarantee any result to the patient, but truly to assist as best as it can the surgeon and the patient in choosing together the most appropriate techniques on a visual basis., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Despite the development of microsurgical techniques, latissimus dorsi myocutaneous pedicle flap remains mainly used in breast reconstruction surgery. It is reliable and could be performed on almost all the patients, even if they smoke. It is also a good indication in case of irradiation. The technical alternative, which combines latissimus dorsi myocutaneous flap and an implant, allows the reconstruction of the expected volume and enables controlateral implant augmentation if the patient desires. The dorsal skin paddle increases the cutaneous pocket. The muscle in-depth enhances the irradiated skin and protects the implant. Positioning the skin paddle on the breast area is essential: it should be based on the mastectomy scar or on an added contraincision barring it. Thus it allows the muscle to embrace the implant as a bra. The precise reference points helping the placement of the flap could be reproduced and ensure pleasant and stable results over time., (Copyright © 2018. Published by Elsevier Masson SAS.)

A full range of breast reconstructions procedures exists and had to be proposed within a surgical team, from the simplest to the most complex. The choice of the technique is simply based on the discussion between the surgeon and the patient during a consultation. A computed tomographic angiography might be required in the case of DIEP flap reconstruction. The surgeon bases his decision on a clinical exam of the breast area, the quality of the tissues and looks for potential flaps or fat donor sites. The patient expresses her expectations in terms of breast volume, form and is clearly informed about potential risks and follow-up. Thus the surgeon could propose the most adequate procedure in the case of the patient, who will take the final decision. The surgeon should ensure to find the most adapted procedure to each individual. A well-determined indication will lead to a truly satisfied patient, which is the main goal of breast reconstruction. We decided to present this dialogue and the path towards the final choice in a fun and original format., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Oncoplastic surgery is to treat breast tumors with the help of plastic surgery. Efficiency of breast-conserving treatments (BCT) compared to mastectomies is equivalent. BCT is better accepted but can cause breast deformity, thus further operations. Oncoplastic surgery aims at conserving an acceptable shape to the breast. It ranges from simple remodeling to more complex techniques modifying the width of the breast. According to the quadrant to treat (inner upper, outer upper, inner lower, outer lower, union of quadrants, tumors of the nipple-areola complex, tumors of the inframammary fold), according to the proximity of the tumor to the nipple, and to the size of the breast and tumor, various techniques are displayed. Few touch ups are necessary. Symmetry is managed during the initial operation or after., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: Ingenol mebutate is an actinic keratosis treatment, which has a dual action mechanism. It allows a rapid cellular death and a severe inflammation., Observation: We report the case of a 75 years old patient with a rapidly growing tumor 5 weeks after application of ingenol mebutate on typical actinic keratosis. Histological analysis after surgical excision showed an invasive squamous cell carcinoma (SCC); with aggressiveness signs: perineural infiltration and vascular permeation., Discussion: Ingenol mebutate's common side effects are benign and regressive within 2 to 4 weeks. There are erythema, edema, crusts, and ulcerations/erosions. Squamous cell carcinoma development was rarely reported. We have tried to collect other cases in the literature and in pharmacovigilance centres: three similar cases were recently published in the literature, 21 cases were notified to the European Medicines Agency and we asked French pharmacovigilance centres and found 5 cases of SCC after ingenol mebutate application. The role of the molecule in SCC development is currently unknown. Induced inflammation could take part in the development of these tumors. We compare this case with other situations of inflammation, such skin graft donor site or surgical incision, complicated of rapidly growing SCC. Our case, literature's and pharmacovigilance's cases encourage us to follow ingenol mebutate's side effects. Careful follow-up and registration of such cases are important to gain further insight on this topic., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Following the tremendous development of hydrogels for cell therapy, there is now a growing need for surgical techniques to validate in vivo scaffold benefits for islet transplantation. Therefore, we propose a newly designed surgical procedure involving the injection of hydrogel-embedded pancreatic islets in the omentum, which is considered a favorable environment for cell survival and function. Our technique, called h-Omental Matrix Islet filliNG (hOMING) was designed to test the benefits of hydrogel on islet survival and function in vivo. Islets were implanted in the omentum of diabetic rats using the hOMING technique and alginate as an islet carrier. Blood glucose and C-peptide levels were recorded to assess graft function. After 2 months, grafts were explanted and studied using insulin and vessel staining. All rats that underwent hOMING exhibited graft function characterized by a glycemia decrease and a C-peptidemia increase ( P < 0.001 compared with preoperative levels). Furthermore, hOMING appeared to preserve islet morphology and insulin content and allowed the proper revascularization of grafted islets. The results suggest that hOMING is a viable and promising approach to test in vivo the benefits of hydrogel administration for islet transplantation into the omental tissue.

Introduction: The existence of voluminous paralumbar perforators allows a simplification of the coverage of the lumbar region., Materials and Methods: The authors present a series about lumbar loss substance following orthopedic surgery, from 2012 to 2017. Coverage was provided by a fascio-cutaneous lumbar perforator flap., Results: Six patients were operated with mean age of 62.3 years, with an average follow-up of 16 months (up 6 to 41 months). Substance losses were secondary to a carcinologic excision, to a radiodermitis excision and to four debridements after infection of the operative site. In five cases, the reconstruction was performed by one lumbar perforator flap, and in one case by two lumbar perforator flaps. The average size of the substance losses was 171.91 cm 2 (up 78 to 250 cm 2 ). The average size of the flaps taken was 161 cm 2 (up 50 to 250 cm 2 ). The donor site was self-closing without sequelae. The postoperative sequences were simple and marked by a single partial necrosis of a flap, with a favorable evolution after directed healing. The quality of the cover was good with excellent trophicity., Conclusion: Lumbar perforator helical fascio-cutaneous flaps are a reliable means of covering the loss of substances in the lumbar region. The use of these flaps makes it possible to avoid the taking of complex myo-cutaneous flaps, causing sequelae of the donor site in a location difficult to cover., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction: There is a growing demand for weight loss sequelae. Some women have a particular morphology with a major trochanteric excess that warrants specific treatment., Materials and Methods: On the basis of the technique published in 1964 by Pitanguy, the authors suggest a lift of the external face of the thigh with the scar redrawing the lower part of the buttock, from the gluteal fold to the inguinal region by crossing the trochanteric region. Eleven cases of major trochanteric excess after slimming are presented. In 4 cases, the trochanteric excess is solely treated by trochanteric under gluteus lift. In 7 cases, it is associated with abdominoplasty to perform a trochanteric under gluteus bodylifting., Results: Complications and results are presented. The trochanterian excess is reduced, the buttock is harmonious and the patients satisfied., Discussion: Modifications are made to the much criticized technique of Pitanguy. The lipectomy replaces the monobloc resection, the scar is verticalized on the trochanter to join the abdominoplasty scar. This technique is an alternative to the vertical trochanteric resection associated with classic bodylift., Conclusion: The trochanteric under gluteus lift is an elegant solution for treating large trochanteric excess. It is adaptable. It can become bodylifting TSF in the cases of great slimming., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

The position of the skin paddle on the breast area is a fundamental element for the breast reconstructions by latissimus dorsi flap and prosthesis implantation. Should, as Millard advocated, to recreate the initial defect and include it in the mastectomy scar or is it better in an additional incision as have others authors. This study compares the long-term morphological results of these two attitudes, with or without additional incision., Patients and Methods: Eighty-two breast reconstructions by latissimus dorsi flap and prosthesis implantation, with a mean follow-up of 9.5 years were scored from 1 to 5 by a panel of expert and non-expert. The patients scored also their own reconstruction. Various parameters of the reconstructed breast were thus evaluated. We compared the results, according to the positioning of the skin paddle: with additional incision (50 cases); without additional incision (32 cases). The characteristics of the mastectomy scar on the breast area, high or low, horizontal or oblique, defined 6 groups where the results of the 2 surgical options were compared., Results: Only the reconstructions with additional incision get significantly higher results than those without additional incision (P<0.05). This involves the two panels, in the case of high mastectomy scars. In the others cases the additional incision is not essential., Conclusions: If the realization of an additional incision can be perceived like misfit on an area already "mutilated", we plead for this solution in selected cases. This provides a benefit stable in time, in terms of overall results, shape and even rendering scar., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Trichoblastic carcinoma is a rare epithelial malignant epithelial tumor, its diagnosis is difficult and the therapeutic management is non-consensual. This retrospective study, carried out between 2009 and 2015, covered 21 cases and analyzed the diagnostic and therapeutic characteristics of trichoblastic carcinomas. Sex ratio is 2. Trichoblastic carcinoma predominated in the face (65% of cases), particularly in perinasal (30% of cases). Its clinical presentation is in 95% of cases as basal cell carcinoma, which is the first clinical diagnosis evoked. The average size of the tumors was 2.3cm in diameter (from 0.7cm to 15cm). The treatment of these tumors is surgical: the margins retained were on average 0.7cm (0.5cm to 1cm). The first excision was mostly performed under local anesthesia, healthy borders were found in less than 40% of cases, requiring another intervention under general anesthesia with reconstruction by flap or skin graft in nearly 80% of cases. The lymph node metastasis rate was 5%. Three cases of recurrence (17%) occurred between 18 months and 6 years follow-up, despite complete resection. One case recurred three times. These results highlight the difficulty of diagnosing trichoblastic carcinomas, often confused with basal cell carcinomas. Though larger, poorly limited and infiltrating, trichoblastic carcinomas are not really distinguished from basal cell carcinomas. Only the anatomopathological examination of the excision piece make it possible to conclude, the biopsy being most often insufficient. Their local aggressiveness requires a greater margin of excision. The micrographic analysis of Mohs, for the periorificial lesions of the face, would reduce margins, increase their reliability and limit the number of surgical revisions. Finally, the literature reports a high rate of ganglion and visceral metastases (between 9.5 and 11%). Initial search for distal lymph node or metastatic involvement is essential, as well as regular clinical follow-up., (Copyright © 2017. Published by Elsevier Masson SAS.)

Purpose: Extended and full-thickness abdominal wall defects are commonly reconstructed using free flaps. Published surgical outcomes involving the latissimus dorsi (LD) free flap procedure are limited and are less numerous than those with free flaps involving the thigh. The aim of this report was to describe the immediate and long-term evaluation of complex abdominal wall reconstruction using a LD free flap with mesh., Patients and Methods: Between 2005 and 2013, nine patients with extended malignant tumors of the abdominal wall underwent surgeries. After the surgical resection, the mean defect size was 385 cm 2 (range: 190-650 cm 2 ). Full-thickness abdominal wall reconstruction was performed with a combination of LD free flaps and meshes. The immediate and long-term outcomes were assessed regarding the complications, sustainable strength of the abdominal wall and cancer recurrence., Results: The meshes measured 927 cm 2 in average (range: 500-1036 cm 2 ). Eight Parietex Composite® and 1 Bard Collamend Implant® were used. No donor site complications occurred, and complete LD flap survival was achieved without partial necrosis or thrombosis. One obese patient who received a porcine dermis mesh developed an eventration four days postoperatively and exhibited a limited amount of abdominal skin necrosis around the flap. Two patients died from cancer evolution. After a mean follow-up of 60.4 months (range: 29-94 months), clinical evaluation of the abdomen revealed 2 patients without anomalies, 4 cases of abdominal bulging without functional discomfort and 1 case of major abdominal distension., Conclusions: Complex abdominal reconstruction with LD free flap and mesh allows extended satisfactory coverage with a low incidence of flap and donor site complications. However, patients should be advised of the significant risk of abdominal bulging. © 2014 Wiley Periodicals, Inc. Microsurgery 37:38-43, 2017., (© 2015 Wiley Periodicals, Inc.)

Background & Objective: The majority of studies assessing the rupture rate of breast implants were performed by the breast implant manufacturing industry with questionable independence. After repetitive removals of ruptured implants from the same model, our team decided to assess the rupture rate and the estimated risk thereof for most of the silicone gel-filled implants we have used since they regained market approval in France in 2001., Methods: Our study is a retrospective cohort of 809 patients operated in our University Hospital from 2001 to 2013 for cosmetic or reconstructive goals. We could track 1561 implants, 90% of them from the same manufacturer, Allergan (Irvine, CA, USA). For each of those, we gathered their exact reference, date of implantation, surgical approach, status, last follow-up visit or the eventual date, and cause of removal., Results: Of 225 explanted devices, only 27 were ruptured, all from the Allergan brand. Risks of removal for rupture were estimated: 0.5% at 1000 days, 6% at 2000 days, and 14% at 3000 days. Risks were significantly different between the models from this same manufacturer. One of the range of macro-textured round implants showed risks of removal for rupture of 33% at 3000 days compared to 6% for the anatomically shaped range., Conclusions: These results suggest a qualitative discrepancy among the different ranges of breast implants of a single manufacturer within the same timeframe of implantation. To determine the in vivo lifespan of the implants that we use more precisely and sooner, we suggest that each removed implant should be analyzed for wear and tear, independently from the industry., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

During adolescence, psychological and physical changes occur and breast takes a major place in the young woman body image. Except rare malign tumors, breast pathologies at this age are mainly benign or malformative. Malformative issues are revealed during breast growth, as isolated asymmetry or associated to other regional anomalies, with abnormal shape or volume of the breast, or even supernumerary breast. Therapeutic solutions will not differ from the ones used for adults. Breast lipofilling, recently admitted by plastic surgery community is an interesting tool that can be used on young women. Choosing the right technic depends on the initial problem. It comes at an early stage to offset hypoplasia resulting in a problem of asymmetry. It waits for breast stability in case of hypertrophy and for legal majority in case of breast augmentation using implants. Psychological impairment stays however a central issue and forces the surgeon to adapt to the individual and to his body change over time., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The latissimus dorsi myocutaneous flap combined with an implant is an effective breast reconstruction solution especially in irradiated patients. The authors describe the specific technical aspects that allow them to optimize the results of this intervention. In the back, the skin paddle is drawn in the shape of a horizontal spindle so as to conceal the residual scar under the bra. In breast area, a J-shaped contraincision barring the mastectomy scar ensures a harmonious positioning of the skin paddle to the inferolateral part of the breast. After a 180° rotation, the latissimus dorsi muscle envelops the implant like a bra. Its upper edge is attached at the bottom to define the new submammary fold. Under the pectoralis major muscle, its distal end comes to fill the décolleté above the implant., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background and Purpose: Cleft surgery is marked by all the controversies and the multiplication of protocols, as it has been shown by the Eurocleft study. The objective of this pilot study is to start a comparison and analyzing procedure between primary surgical protocols in French centers., Methods: Four French centers with different primary surgical protocols for cleft lip and palate repair, have accepted to be involved in this retrospective study. In each center, 20 consecutive patients with complete cleft lip and palate (10 UCLP, 10 BCLP per center), non syndromic, have been evaluated at a mean age of 5 [range, 4-6]. In this second part, maxillary growth and palatine morphology were assessed on clinical examination and on dental casts (Goslon score). Speech was also evaluated clinically (Borel-maisonny classification) and by Aerophonoscope., Results: Veau-Wardill-Killner palatoplasty involves a higher rate of transversal maxillary deficiency and retromaxillary. The fistula rate is statistically lower with tibial periosteum graft hard palate closure but this technique seems to give retromaxillary. Malek and Talmant two-stage-palatoplasty techniques reach Goslon scores of 1 or 2. Considering speech, Sommerlad intravelar veloplasty got higher outcomes., Conclusions: Primary results. Extension to other centers required. The two-stage palatoplasty, including a Sommerlad intravelar veloplasty seems to have the less negative impact on maxillary growth, and to give good speech outcomes., Level of Evidence: Therapeutic study. Level III/retrospective multicenter comparative study., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: Although alveolar cleft bone grafting is the most widely accepted approach, controversies remain on the operative timing., Methods: A consecutive retrospective series of 28 patients who received alveolar bone grafting was examined and divided into 2 groups depending on the age at the time of bone graft. Group A (14 patients) was operated at a mean age of 5.2 years [range, 4-7] and Group B (14 patients) at a mean age of 10 years [range, 8.5-13]. All the children were assessed clinically and by Cone Beam Computed Tomography (CBCT) before bone grafting and 6 months post-operatively. Cleft and bone graft dimensions, volumes were assessed using Osirix v.3.9.2. Residual bone graft coefficient (Bone Graft Volume on 6-months Postoperative CBCT/Alveolar Cleft Volume) was calculated. Complications, tooth movement or dental agenesis were also reported., Results: The sample was uniform within both groups, considering cleft forms, pre-surgical fistula rate and cleft volume. Residual bone graft coefficient reached 63.3% in Group A and 46.2% in Group B (p = 0.012). Results of residual bone graft are also influenced by tooth eruption through the graft (p = 0.007 in Group A and p = 0.02 in Group B)., Conclusions: This 3D analysis highlighted higher success of alveolar bone grafts when children are operated earlier around 5 years., Level of Evidence: Therapeutic study. Level III/retrospective comparative study., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The transverse musculocutaneous gracilis (TMG) flap has become a common solution for breast reconstruction. However, the safe skin paddle limits are not yet understood. In this study, we attempted to address this issue based on our experiences with inferior and posterior skin paddle extension., Methods: Forty-four breast reconstructions with TMG flaps performed between November 2010 and January 2014 were analyzed retrospectively. For the first 20 cases, the flap skin paddle was extended 3 cm posteriorly to the middle thigh (group 1). For the next 20 flaps (group 2), the posterior tip was limited to this line, whereas more fat was recruited inferiorly. In the four cases of group 3, the skin flap was extended posteriorly with a second vascular pedicle from the profunda artery perforator (PAP) flap. The weights and the dimensions of the flaps, operating durations, and postoperative complications of the entire series were analyzed. Groups 1 and 2 were statistically compared., Results: Flap complications were statistically more frequent in group 1 compared with group 2 (45 vs. 0%, P = 0.0012); 40% posterior flap tip necrosis was observed in group 1. Conversely, donor site complications were statistically more frequent in group 2 than in group 1 (40 vs. 5%, P = 0.019) with 35% inner thigh dehiscence. In the TMG with extended PAP flap group, the operating duration was 77 min longer compared with the rest of the series with no donor site complications. In one case, limited necrosis occurred at the anterior skin tip., Conclusions: Harvesting the posterior portion of the TMG up to the middle of the posterior thigh may lead to partial flap necrosis. Extending subcutaneous fat removal under the inferior skin incision may increase the risk of donor site complications. Adding a second vascular pedicle from the PAP flap may improve posterior TMG tip perfusion at the expense of a longer operation., (© 2015 Wiley Periodicals, Inc.)

Background and Purpose: Cleft surgery is marked by all the controversies and the multiplication of protocols, as it has been shown by the Eurocleft study. The objective of this pilot study is to start a comparison and analyzing procedure between primary surgical protocols in French centers., Methods: Four French centers with different primary surgical protocols for cleft lip and palate repair, have accepted to be involved in this retrospective study. In each center, 20 consecutive patients with complete cleft lip and palate (10 UCLP and 10 BCLP per center), non syndromic, have been evaluated at a mean age of 5 [4,6]. In this first part, the aesthetic results of nose and lip repair were assessed based on the scale established by Mortier et al. (1997)., Results: Considering nose outcome, primary cleft repair surgery including a nasal dissection gives a statistically significant benefit in terms of septum deviation. Considering lip result, muscular dehiscence rate is significantly higher in BCLP patients with a two-stage lip closure. The centers using Millard one-stage lip closure do not have uniform results. For UCLP patients, the quality of scar is not statistically different between Skoog and Millard techniques., Conclusions: Primary results based on a simple, reproducible evaluation protocol. Extension to other centers required., Level of Evidence: Therapeutic study. Level III/retrospective multicenter comparative study., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

We report the case of a 57-year-old patient who presented radiological images similar to ruptured breast implants one year after the supposed withdrawal of the latter. This woman had benefited for the first time from cosmetic PIP breast implants in 2000. Early in 2014, she requested the removal of the implants without renewal because she was feeling pain and functional discomfort. A few months after the operation, she consulted for breast swelling in the upper pole of the breast. Radiological assessment showed liquid formations compatible with the presence of implants. At our request, the rereading of the MRI by the radiologist definitively concluded on a bilateral seroma within the persistent fibrous capsule. In the absence of symptoms, clinical monitoring had been decided. But at the recrudescence of anaplastic large cell lymphoma cases associated with breast implants, a cytological sampling was intended. In case of cytological abnormality or recurrence of the seroma, a surgical procedure should be performed. In conclusion, the removal of a breast implant without capsulectomy may result in the formation of a seroma whose images resemble those of an implant. It is always worthwhile to provide precise clinical data to the radiologist in order to help him to make informed interpretations. Every serous effusion in a breast lodge having contained a silicone implant must evoke the diagnosis of anaplastic large cell lymphoma., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Appropriate positioning of the maxilla is critical in orthognathic surgery. As opposed to splint-based positioning, navigation systems are versatile and appropriate in assessing the vertical dimension. Bulk and disruption to the line of sight are drawbacks of optical navigation systems. Our aim was to develop and assess a novel navigation system based on electromagnetic tracking of the maxilla, including real-time registration of head movements. Since the software interface has proved to greatly influence the accuracy of the procedure, we purposely designed and evaluated an original, user-friendly interface. A sample of 12 surgeons had to navigate the phantom osteotomized maxilla to eight given target positions using the software we have developed. Time and accuracy (translational error and angular error) were compared between a conventional and a navigated session. A questionnaire provided qualitative evaluation. Our system definitely allows a reduction in variability of time and accuracy among different operators. Accuracy was improved in all surgeons (mean terror difference = 1.11 mm, mean aerror difference = 1.32°). Operative time was decreased in trainees. Therefore, they would benefit from such a system that could also serve for educational purposes. The majority of surgeons who strongly agreed that such a navigation system would prove very helpful in complex deformities, also stated that it would be helpful in everyday orthognathic procedures., (Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Free-flap breast reconstruction is a challenging surgical procedure with a steep learning curve. A reproducible large animal model could be relevant for free-flap harvesting and microsurgical anastomosis training. The aim of this study was to assess the feasibility of a porcine model for free-flap breast reconstruction., Methods: Three female pigs were placed under general anesthesia in order to study feasibility and estimate relevance for training. The deep inferior epigastric perforator (DIEP) flap, the transverse musculocutaneous gracilis (TMG) flap, and the superior gluteal artery perforator (SGAP) flap were harvested and anastomosed to the internal thoracic vessels. Differences were noted between pig and human anatomy, and the surgical procedure was adapted to build training models., Results: Under a more prominent anterior thoracic wall, the internal thoracic vessels were slightly deeper and larger than in human anatomy. The DIEP flap was never feasible in the porcine model. However, the superior epigastric artery perforator (SEAP) flap showed anatomical similarity with the human DIEP flap, and it proved to be suitable for an inverted training model. The porcine TMG flap harvesting was close to the human one, reproducing specific dissection and anastomotic difficulties. The SGAP flap was not a muscular perforator flap in pigs but a septocutaneous flap. Because of the thinness of the hypodermal fat, porcine flaps were not considered adequate training models for breast-mound shaping., Conclusions: Despite any anatomical variations, the pig has proven to be a suitable training model for free-flap harvesting and transfer in the field of breast reconstruction., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The skin between the mastectomy scar and the future infra-mammary fold may be managed in different ways in delayed breast reconstruction using a DIEP (deep inferior epigastric perforator). Conserving this skin and positioning the flap skin paddle in the middle of the breast usually highlights skin color disparity because of two visible transition zones. Resection of the entire skin under the scar may be more aesthetic but limits direct closure possibility in case of flap failure. In order to benefit from both aesthetic result and safe surgical method, we propose the abdominal drop flap. The inferior thoracic skin flap is detached from the thoracic wall beyond the future infra-mammary fold, preserved and pushed under the breast., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Purpose: The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast reconstruction with the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap., Methods: Over a three-year period, 95 patients suffering from breast cancer were treated with mastectomy and breast reconstruction using free flaps. We performed 121 mechanical venous anastomoses for 105 flap procedures (80 DIEP and 25 TMG). The coupler size, anastomotic duration, number of anastomoses and postoperative complications were assessed for the entire series., Results: The coupling device was perfectly suitable for all end-to-end anastomoses between the vein(s) of the flap and the internal mammary vein(s). No venous thrombosis occurred. The mean anastomotic time did not significantly differ between the DIEP (330 seconds) and TMG flap procedures (352 seconds) (P = 0.069). Additionally, there were no differences in coupling time observed following a comparison of seven coupler sizes (P = 0.066). The mean coupler size used during the TMG flap procedure was smaller than that used with the DIEP (2.4 mm versus 2.8 mm) (P < 0.001). The mean size was also smaller when double venous anastomoses were required compared to single anastomosis (2.4 mm versus 2.9 mm) (P < 0.001). The double branching was more frequent with the TMG flap (28%) than with the DIEP flap (11%)., Conclusions: The coupler size used was smaller for the TMG procedure and when double venous anastomosis was performed. Additionally, anastomotic time was not affected by the flap type or coupler size used or by anastomosis number., (© 2014 Wiley Periodicals, Inc.)

Background: A transverse musculocutaneous gracilis flap provides good autologous reconstruction for small- and medium-sized breasts. Although the procedure is well adapted for bilateral breast reconstruction, no publication has specifically addressed simultaneous bilateral cases., Methods: From 2010 to 2014, the authors performed seven simultaneous bilateral breast reconstructions using transverse musculocutaneous gracilis flaps. The results with respect to operative data, immediate complications, second-stage reconstruction, and patient satisfaction after >1 year of follow-up were studied retrospectively., Results: The mean operative time was 7 h and 48 min (range, 6-9 h). Three minor complications occurred: two cases of limited flap necrosis and one case of donor-site wound dehiscence. Surgical revision was not required, and there was no flap failure. A second-stage operation was performed in 71% of the patients to improve the aesthetic results and flap volume. On average, 167 cm(3) of fat was injected per breast. After a mean follow-up of 27 months, the satisfaction rate was 86% without significant functional deficits., Conclusions: A transverse musculocutaneous gracilis flap is an effective and safe option for simultaneous bilateral reconstruction. The operating time is shorter than that for other autologous procedures with similar complication rates and high patient satisfaction levels., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The lotus petal flap procedure is widely used for vulvovaginal reconstructions after gynecologic resections, but its effectiveness for posterior perineal coverage and filling is not yet well defined., Methods: We conducted a retrospective evaluation of 10 lotus petal flap procedures performed between 2010 and 2014. Six patients were operated upon with posterior transpositions of unilateral (n = 2) or bilateral (n = 4) supra-fascial flaps. The patient demographics, comorbidities, and previous surgical treatments were surveyed. The postoperative outcomes, including length of stay, time of healing, and complications, were analyzed., Results: Lotus petal flaps were indicated for filling of the chronic perineal cavity (n = 4) and for skin resurfacing (n = 2). The mean patient age was 61.5 years, and four patients previously underwent radiotherapy. The total operative time was 2.2 h on average. No wound complications or flap necrosis instances occurred during the follow-up consultations, which occurred at a mean of 20.5 months. The hospital stay duration was 11.3 days, and the duration of healing was 35.2 days, on average. Each flap transposition achieved the sustainable perineal reconstruction goal., Conclusions: The supra-fascial lotus petal flap is an easy and safe procedure for posterior perineal reconstructions. Whether for an immediate or a delayed operation, unilateral or bilateral flap harvestings allow for effective coverage and filling. Furthermore, the donor-site morbidity remained low because the scars were hidden in the gluteal fold., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Squamous cell carcinomas (SCC) of the ear are known for their aggressiveness. The aim of this study was to investigate factors of gravity while freeing the therapeutic requirements., Patients and Methods: This is a retrospective study of 28 patients (30 ears) operated for SCC. The characteristics of the lesion, the presence of metastasis, treatment modalities and histologic findings were collected. Local recurrences and metastasis are identified with a mean follow-up time of 37months (17-110months)., Results: The lesion size was less than 2cm in 19 cases (63.3%) and greater than or equal to 2cm in 11 cases (36.7%). Macroscopic resection margins were 5, 7 or 10mm. The resections were histologically incomplete in 4 cases (13%) requiring further surgery. Six cases had local recurrence (20%): three with pulmonary or lymph node metastases (10%) and one death (3.3%). In these 6 cases of recurrence, the surgical margins were 6.3mm on average, the initial lesion measured always greater than 2cm (100%). Three quarters of incomplete resections have recurrent despite a surgical revision in healthy margin., Conclusion: Our study confirms the data of literature, namely the pejorative character of a lesion greater than 2cm and incomplete resection. The HAS recommendations seem minimal regarding the ear. In case of injury by more than 2cm and with a proximal location on the ear pinna, only amputation of the ear allows satisfactory cancer control., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Introduction: Following the upsurge in cases of morbid obesity and bariatric surgery, there is after massive weight loss effects of the thorax in man such as pseudogynecomastia extremely poorly tolerated by patients. Treatment aims to correct the excess skin while optimizing the location and quality of scars. Turning our back on techniques derived from mammoplasty, we go into these major forms for mastectomy with grafting the areolo-mammelonar plate and resulting scar in L extended if needed until the axilla., Materials and Methods: From 2005 to 2011, we performed 12 mastectomies after massive weight loss (45 kg on average). Patients aged 19 to 64 had an average BMI of 29.2. In five patients, we had started the move by liposuction (190 cc average per side). The mastectomy was performed by placing the scar at the lower edge of the pectoralis major. The areolas previously harvested were placed on the axis of the graft within two to three centimeters above the scar. All patients were reviewed and evaluated in consultation questionnaire with an average follow up of 2 years (6 months-5 years)., Results: The average volume of resection was 560 g per side (55 g-2500 g), operative time 155 minutes. Complications consisted of hematoma requiring surgical revision and delayed wound healing in three over 1 month with partial areola necrosis. The overall patient satisfaction was excellent with no secondary correction request., Conclusion: In the major pseudogynecomastia, the option is taken immediately for a mastectomy technique which scar is located at the basis of the thorax and may include an axillary extension in L. It effectively corrects the large cutaneous and fat surplus and restores in one time a flat male chest. Satisfaction is high and patients are no more ashamed to expose their chest., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Introduction: Hidradenitis suppurativa is a chronic inflammatory disease, particularly incapacitating. Wide surgical excision of the whole affected skin is the only radical and successful treatment that can be offered. Coverage of the defect is then generally obtained with a split-thickness skin graft after a period of granulation. We expose a single-stage procedure which reduces the number of surgical times and the period of recovery., Patients and Methods: We have documented a series of five patients who underwent uni- (three cases) or bilateral (two cases) axillary hidradenitis suppurativa, between December 2008 and December 2009. Surgical procedure included excision of the lesions and coverage with a split-thickness skin graft. The graft was meshed in a ratio of 1.5:1, and secured with a negative-pressure dressing. This dressing, which provided a continuous subatmospheric pressure of -75 mmHg, was removed after five days. Then, complete healing was obtained with conventional vaseline gauze dressings., Results: After removal of the negative-pressure dressings, the graft take was 90% on average (80-100%). Complete healing was obtained within an average of 34 days (20-43 days), with a good quality of scar tissue, no retraction and no limitation of arm's abduction., Conclusion: This technique, enabled by negative-pressure dressings, provides a quick and good quality healing, with only one surgical stage. It has many advantages: reduced morbidity, faster healing, higher level of patient's comfort, and lower costs., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: The transverse musculocutaneous gracilis free flap allows a wider range of indications in autologous breast reconstruction. They extend far beyond traditional dorsal, abdominal and gluteal flaps. The authors present their experience in using this innovative procedure., Patients and Methods: The cutaneous and adipose part of the flap consists in a horizontal ellipse centered on the gracilis muscle in the upper thigh. The distal part of the muscle is released without neither visual control nor additional incision. The flap vascular pedicle is microanastomosed to the recipient internal thoracic vessels in the third intercostal space. Eleven patients, with a mean age of 44 years (29-62) and a BMI of 24 (19-32) underwent this procedure. Surgery was performed on either one side (n=6) or two (n=5), in indications of immediate (n=5) or delayed reconstruction (n=6). The main operative parameters (time, vessel diameter, pedicle length, flap volume) as well as postoperative follow-up were studied., Results: Mean time of surgery was 4h33 (3-6 hours). Pedicle measured 6.2 cm (5-7.5) and diameter of the artery was 19 mm (15-30). Average weight of the flap was 344g (270-498). Two cases of partial necrosis occurred in the posterior cutaneous part of the flap (1cm(3) and 3 cm(3)). They were treated using controlled wound healing. Sequelae in the donor site proved minimal as the scar was placed in the crural crease and the gluteal fold. No major functional defect was noted after mean follow-up of six months., Conclusions: The transverse musculocutaneous gracilis free flap allows natural and durable reconstruction while reducing cosmetic and functional sequelae in the donor site. It proves to be particularly useful in bilateral immediate reconstructions following skin-sparing mastectomy. This surgical option offers new opportunities to long-limbed women without abdominal excess wishing autologous breast reconstruction., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Introduction: Since the 1980s, leeches have been ingeniously used in the management of venous flap congestion. The presence of anticoagulative substances in their saliva improves the blood drainage. Their digestive tract contains several bacterial species, the main ones being Aeromonas hydrophila and Aeromonas veronii biovar sobria, which contribute to the digestion of ingested blood. These bacteria can be the cause of infections., Case Presentation: We report two cases of septicemia related to Aeromonas veronii biovar sobria that presented after leeches had been applied to congested transverse rectus abdominis myocutaneous flaps for delayed mammary reconstructions.Patient number 1 was a 55-year-old Caucasian woman who underwent a delayed breast reconstruction procedure. On the sixth postoperative day she showed a clinical presentation of septicemia. Aeromonas veronii biovar sobria was identified in the patient's skin and blood bacteriological samples. Her fever ceased after 4 days of antibiotic treatment.Patient number 2 was a 56-year-old Caucasian woman who underwent a delayed breast reconstruction procedure. On the seventh postoperative day we noticed that she showed a clinical presentation of septicemia. Aeromonas veronii biovar sobria was identified in the patient's blood cultures and local bacteriological samples. An antibiogram showed resistance to amoxicillin/clavulanic acid. Her fever ceased on the eleventh postoperative day after 4 days of antibiotic treatment., Conclusion: The rate of infection after application of leeches is not negligible. The concentration of Aeromonas inside the digestive tracts of leeches largely decreases when the patient is under antibiotic therapy. These germs are sensitive to third-generation cephalosporins and fluoroquinolones and resistant to amoxicillin/clavulanic acid. We recommend preventive treatment based on classical measures of asepsis and on oral antibioprophylaxy with a fluoroquinolone during the whole period of treatment by leeches.

Background: The birth of a child with a cleft lip, whether or not in association with a cleft palate, is a traumatic event for parents. This prospective, multidisciplinary and multi-centre study aims to explore the perceptions and feelings of parents in the year following the birth of their child, and to analyse parent-child relationships. Four inclusion centres have been selected, differing as to the date of the first surgical intervention, between birth and six months. The aim is to compare results, also distinguishing the subgroups of parents who were given the diagnosis in utero and those who were not., Methods/design: The main hypothesis is that the longer the time-lapse before the first surgical intervention, the more likely are the psychological perceptions of the parents to affect the harmonious development of their child. Parents and children are seen twice, when the child is 4 months (T0) and when the child is one year old (T1). At these two times, the psychological state of the child and his/her relational abilities are assessed by a specially trained professional, and self-administered questionnaires measuring factors liable to affect child-parent relationships are issued to the parents. The Alarme Détresse BéBé score for the child and the Parenting Stress Index score for the parents, measured when the child reaches one year, will be used as the main criteria to compare children with early surgery to children with late surgery, and those where the diagnosis was obtained prior to birth with those receiving it at birth., Discussion: The mental and psychological dimensions relating to the abnormality and its correction will be analysed for the parents (the importance of prenatal diagnosis, relational development with the child, self-image, quality of life) and also, for the first time, for the child (distress, withdrawal). In an ethical perspective, the different time lapses until surgery in the different protocols and their effects will be analysed, so as to serve as a reference for improving the quality of information during the waiting period, and the quality of support provided for parents and children by the healthcare team before the first surgical intervention., Trial Registration: ClinicalTrials.gov Identifier: NCT00993993.

Introduction: Patient satisfaction is a good indicator to evaluate the success of breast reconstruction. The aim of this study was to compare the long-term satisfaction in patients who underwent four breast reconstruction techniques., Patient and Methods: Self-evaluation was achieved by patients in 147 breast reconstructions using a four-point score: very disappointed, disappointed, satisfied and very satisfied. The mean follow-up was 5.3 year (1 to 21.5 year). The surgical procedures used were: transverse rectus abdominis myocutaneous flap (TRAM) 15%, autologous latissimus dorsi flap (ALD) 14%, latissimus dorsi flap with implant (LDI) 32% and implant alone 39%. Patients' satisfaction was compared regarding the type of surgical procedure, the postoperative follow-up time; the immediate or delayed breast reconstruction and the radiation history., Results: Thirty-five percent of the patients were very satisfied with their operation, 54% were satisfied, 7% were disappointed and 4% very disappointed. After a 5-year follow-up, autologous flaps showed better results (P<0.001). Patients were more satisfied with TRAM flaps than with surgical techniques using latissimus dorsi flaps (ALD and LDI). Patients treated with implants alone were statistically less satisfied. Only in the implant series, patient satisfaction decreased significantly with time (P<0.001) and preoperative radiation (P=0.005)., Conclusions: Flap-based breast reconstructions show consistent long-term satisfaction although the surgery is initially more demanding. Our study matches the latest trends in the use of free perforator flaps for breast reconstruction. Indeed, these procedures combine good satisfaction and minor sequelae at the donor site., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Use of an autologous latissimus flap in breast reconstruction accounts for a supple and natural look of reconstructed breast. Most common postoperative complication, seroma, became more of a rule then an exception when it comes to postoperative evaluation of the patients who underwent this reconstructive procedure. A retrospective study analysing and evaluating different complication rates in 20 patients who underwent breast reconstruction by autologous latissimus flap, was conducted. All patients included in the study were operated at the Department of plastic surgery of Hôpital Civil in Strasbourg, France, between 1996 and 2008. The complication rates were noted as follows: seroma in 19 of our 20 patients (95%), late hypertrophic scarring in 3 patients (15%), postoperative surgical site hematoma in 3 patients (15%), and 2 patients (10%) presented postoperative chronic back pain. Different options used in seroma treatment and prevention (subcutaneous-fascia anchor sutures of donor site, application of corticosteroids by injection into donor site postoperatively, passive drainage) can reduce seroma formation and thus overall complication rates, leading to much faster patient's recovery time and return to normal daily activities.

Introduction: Various clinical situations may require an important increase of the size of the nose. The aim of our work was to analyze long-term results of calvarial bone grafts used in rhinoplasties., Material and Method: We retrospectively studied the files of 20 patients having undergone a calvarial bone graft. Photogrammetry was used to determine morphological modifications and the stability of results., Results: The average follow-up was 8 years. The parietal donor site morbidity was low. All nose sizes were dramatically augmented and the stability of results ranged between 74.5 and 95%., Discussion: The calvarial bone graft can be used for important nose augmentation with a good stability. There are few alternative techniques. This method is only limited by available skin and endonasal lining. Calvarial bone graft in rhinoplasty is not frequent but it is our first choice for the correction of important hypoplasia or saddling of the nose.

Purpose: To assess the characteristics, the diagnosis and the treatment of intrathyroid metastasis., Method: The authors report a case of a locally advanced intrathyroid metastasis of a bronchial cancer., Results: A 60-year-old woman, treated seven years before for a well-differentiated bronchial adenocarcinoma, developed enlargement of the thyroid gland. Metastatic disease was confirmed by a surgical biopsy. Following incomplete radiochemotherapy, a palliative surgical debulking was performed, associating an isthmolobectomy with a large skin excision and closure with a pectoralis major myocutaneous flap., Conclusion: Intrathyroid metastases are rare and usually treated by surgery. Surgical management is decided taking into account the type and the kinetics of the primary tumor, the location of the thyroid metastasis, and the extension of the metastatic disease. Except for isolated intrathyroid metastasis of kidney cancer, prognosis remains poor.

Purpose: The aim of this study was the long-term evaluation of different techniques concerning the reconstruction of a nipple-areola complex., Patients and Methods: We included 135 women who had undergone nipple-areola reconstruction between 1983 and 2004. A clinical examination was performed after a mean delay of 5 years and 3 month (1-24). All of the patients were asked to evaluate their level of satisfaction based on a grading scale displaying four scores. The most important parameters (texture, shape, size, color, position, nipple projection) and the complication-rate were investigated. The different techniques were compared with each other to determine the one giving the best results., Results: Eighty-nine percent of the patients were satisfied or even very satisfied with their nipple-areolar reconstruction. Eleven percent were disappointed or very disappointed. The factors patients disliked the most were, in descending order, dys-chromia (45%), hypo-sensibility (37%) and lack of projection (36%). When the opposite areola is used as donor site, results seem to be more satisfactory than using a full-thickness skin graft from the upper inner thigh (P=0.054). Concerning the rebuilding of the nipple, the graft from the opposite nipple leads to a mean projection of 3.4 mm where the local flap leads to 2.4 mm and the earlobe composite graft to 1.5 mm (P<0.001)., Conclusion: Removing a part of contralateral nipple and areola when possible, reveals itself to be the most effective technique showing the most stable long-term results.

The aim of this study is to evaluate fat tissue graft as a treatment of sequelae of breast cancer conservative surgery., Means and Methods: This prospective study during a nine-month period concerned 15 patients with breast cancer conservative treatment sequelae. Fat tissue has been injected at the site where the tumorectomie and subsequent radiotherapy had been performed. A mammographic and photographic checkup along with the patients' subjective evaluation were done before the operation and after the operation with a one-month, three-month, and nine-month follow-up. An objective analysis of the results was done by a panel from the pictures of the ninth month's follow-up. Preoperative and postoperative mammary volumes were calculated by a CT scan using a 3D program., Results: Mean fat tissue injected was 63.3cc. Mean patients' satisfaction grade was 8.1/10 at one month and 6.7/10 at nine months. The estimation of the resorption at nine months was 52.6% according to the patients while announced at 47.5% with the CT scan. Eighty percent of patients estimated the operation as "light" and 60% would be ready to have another injection. Skin tissue quality was enhanced and only one infection has been stated. Two-thirds of postoperative mammographies are still ACR 2 and one-third of the patients have had cytosteatonecrosis., Conclusion: This fat tissue graft technique on irradiated skin for the correction of tumorectomy sequelae brings a simple and efficient solution, which is radiologically reliable and satisfying for the patients.

Verneuil's disease (hidradenitis suppurativa) is a chronic inflammatory, suppurating, fistulizing and scar-producing disease of apocrine gland-bearing skin. Its transformation into epidermoid carcimona has been reported 38 times in literature. We describe two new cases - two males aged 67 and 68-years-old. The first one is still alive with no recurrence after one year and the second patient died 2 months after surgery, showing generalised scattering. This rare complication is interesting for two reasons. It only concerns perianal location and it targets mainly men. Surgical treatment consists of wide excision. However, it is often too late. The outcomes are critical for it has been reported a 50% rate of deaths within 2 years after surgery. It is therefore imperative that both general practitioners and dermatologists follow patients with Verneuil's disease so that they can propose a preventive excision at the right time.

A latissimus dorsi myocutaneous flap now appears to be the best solution to closing large carcinological exeresis of the breast. After an analysis of a series of 14 cases of advanced cancer (T3 or T4) or of progressive cancers (PeV3) of the breast treated by inductive chemotherapy and which underwent surgery at the Strasbourg CRLCC (France), the authors stress the simplicity and reliability of the method, which can make it possible to carry out an extensive and complete exeresis, which is of primordial importance in the control of the local tumor. Its excellent trophic quality made it possible to start radiochemotherapeutic adjuvant treatments rapidly. The other methods (myocutaneous flap of the rectus abdominis, Kiricuta's epiploic flap, neighboring autoplasties) now persist only in cases of advanced breast tumor in which the greater dorsal flap is contraindicated.