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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.

Resume Objectif La perte de substance totale de la levre inferieure est rare et sa reconstruction difficile. Les enjeux sont aussi bien esthetiques que fonctionnels. La suspension de la levre inferieure est essentielle pour restaurer la continence labiale. Nous rapportons une technique originale et simple de suspension par double haubanage nasogenien. Methode Deux lambeaux orbitonasogeniens a base superieure, etendus sur plusieurs centimetres sous les commissures labiales sont leves et completement desepidermises. Ils sont ensuite tunnelises et fixes a la levre inferieure reconstruite afin de lui assurer une suspension efficace aux maxillaires. Resultats Dans notre experience, nous avons utilise le haubanage nasogenien associe a une reconstruction totale de la levre inferieure pour trois patients avec une continence labiale assuree a long terme. L’etude de la litterature montre que l’utilisation des lambeaux locoregionaux conventionnels retablit une bonne continence labiale mais reste limitee a des pertes de substance subtotales. Les lambeaux pedicules a distance ou libres realises sans suspension ne restaurent pas la continence labiale. Plusieurs techniques d’haubanage de la levre inferieure par bandelettes de fascia lata ou tendon du long palmaire, associees ou non a un lambeau libre, semblent apporter une continence labiale de la levre inferieure satisfaisante. Tous ces procedes sont peu standardises et techniquement difficiles a realiser. Conclusion La technique du double haubanage nasogenien que nous decrivons semble etre une alternative efficace et interessante par sa simplicite, sa reproductibilite et son adaptabilite. Elle permet d’obtenir un plan posterieur parfaitement fixe, capable de recevoir n’importe quel moyen de couverture externe.

Resume Introduction La reconstruction mammaire par implant presente des inconvenients a long terme et conduit un nombre croissant de patientes a demander une chirurgie secondaire de correction. Deux strategies chirurgicales sont possibles : le changement d’implant (associe a des gestes de capsulectomie/capsulotomie et/ou lipofilling) et le retrait d’implant associe a l’apport d’un tissu autologue (lambeau et/ou lipofilling). Methode Entre 2010 et 2018, 54 patientes ont beneficie d’une chirurgie secondaire de correction d’une premiere reconstruction mammaire par implant. Les motifs d’insatisfaction de la reconstruction initiale, les interventions realisees et les complications postoperatoires ont ete analyses. Le bien-etre et la satisfaction des patientes ont ete evalues au moyen du questionnaire BREAST-Q. Resultats Trente-quatre patientes ont beneficie d’un changement de prothese et 20 patientes d’un retrait definitif de leur prothese associe a l’apport d’un tissu autologue. La presence d’une coque periprothetique, la douleur, l’aspect fige du sein et l’asymetrie mammaire etaient les motifs d’insatisfaction les plus frequents. Avec un recul moyen de 2,6 ans, les patientes ayant beneficie d’une conversion autologue etaient globalement plus satisfaites de l’aspect de leurs seins que les patientes ayant conserve un implant mammaire (p Conclusion En cas de mauvais resultat esthetique ou fonctionnel d’une reconstruction mammaire par implant, le retrait de la prothese associe a une reconstruction autologue donne de meilleurs resultats en termes de bien-etre et de satisfaction que le changement d’implant.

Resume Introduction Le pansement d’alginate de calcium pur (l’ALGINATE) et le traitement par pression negative (TPN) sont frequemment utilises pour la preparation d’une exerese a la greffe de peau mince. Cette etude a compare l’efficacite cicatrisante de ces deux produits, leur securite et le cout de prise en charge des patients. Patients et methodes Cent treize patients avec une exerese chirurgicale traitee par l’ALGINATE ou le TPN ont ete inclus dans cette etude randomisee de non-inferiorite. Le critere principal etait le delai d’obtention d’un tissu de bourgeonnement permettant une greffe de peau mince. Les criteres secondaires etaient la survenue d’evenements indesirables (EI) et l’impact de l’utilisation des deux produits sur le budget de l’Assurance Maladie. Resultats L’ALGINATE et le TPN ont permis l’obtention d’un bourgeonnement optimal dans un delai similaire : environ 20 jours. Aucun patient ALGINATE n’a presente d’EI alors que 24 % de patients TPN ont presente un EI. Apres l’hospitalisation, 94 % des patients ALGINATE etaient pris en charge a domicile par un infirmier liberal alors que 90 % des patients TPN etaient suivis en SSR ou en HAD. Par consequent, le cout de prise en charge, par patient, pour l’Assurance Maladie, etait de 498 € avec l’ALGINATE vs 2104 € avec le TPN. Conclusion Cette etude a demontre que l’ALGINATE a une efficacite cicatrisante similaire a celle du TPN, est mieux tolere et permet une economie financiere considerable. L’ALGINATE devrait etre privilegie dans cette indication.

Background Even though the manufacturing processes of the stromal vascular fraction for clinical use are performed in compliance with the good manufacturing practices applying to advanced therapy medicinal products, specifications related to stromal vascular fraction quality remain poorly defined. We analyzed stromal vascular fraction clinical batches from two independent good manufacturing practices-compliant manufacturing facilities, the Swiss Stem Cell Foundation (SSCF) and Marseille University Hospitals (AP-HM), with the goal of defining appropriate and harmonized release acceptance criteria. Methods This retrospective analysis reviewed the biological characteristics of 364 batches of clinical-grade stromal vascular fraction. Collected data included cell viability, recovery yield, cell subset distribution of stromal vascular fraction, and microbiological quality. Results Stromal vascular fraction from SSCF cohort demonstrated a higher viability (89.33% ± 4.30%) and recovery yield (2.54 × 105 ± 1.22 × 105 viable nucleated cells (VNCs) per mL of adipose tissue) than stromal vascular fraction from AP-HM (84.20% ± 5.96% and 2.25 × 105 ± 1.11 × 105 VNCs per mL). AP-HM batches were significantly less contaminated (95.71% of sterile batches versus 74.15% for SSCF batches). The cell subset distribution was significantly different (higher proportion of endothelial cells and lower proportion of leukocytes and pericytes in SSCF cohort). Conclusions Both centers agreed that a good manufacturing practices-compliant stromal vascular fraction batch should exert a viability equal or superior to 80%, a minimum recovery yield of 1.50 × 105 VNCs per mL of adipose tissue, a proportion of adipose-derived stromal cells at least equal to 20%, and a proportion of leukocytes under 50%. In addition, a multiparameter gating strategy for stromal vascular fraction analysis is proposed.

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.

Breast reconstruction by abdominal flap has evolved to ensure minimal donor-site morbidity with the description of Deep Inferior Epigastric artery Perforator flap (DIEP flap). Being of the same thickness and the same surface, the Superficial Inferior Epigastric Artery flap (SIEA flap) does not require, for it harvesting, to open the abdominal fascia or to dissect through the muscles minimizing again donor-site sequelae. However, it is little used because of the variability of its vascularization and a higher failure rate than the DIEP in the literature. We believe that it is reasonable, in some cases, to harvest a SIEA flap instead of DIEP flap in mammary reconstruction. We present a technical note explaining our operative strategy for reliably taking a SIEA when the caliber of the vessels allows.

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 reconstruction of the columella is challenging and poorly evaluated in the literature. Our study aimed to evaluate retrospectively the different techniques used in our center and to propose an algorithm of reconstruction adapted to each patient. We report a retrospective cohort study included 18 patients (9 men and 9 women; 53 years-old in average) with columellar reconstruction treated from 1999 through 2014. Six different techniques were used: chondrocutaneous graft, nasolabial flap, paramedian forehead flap and scalping flap according to the Converse technique or the Raulo technique. Four independent plastic surgeons evaluated the aesthetic result on a 10 cm visual analogue scale comparing the patients' photographs before and after the reconstruction. Furthermore, we asked the patients to perform the same evaluation, and to evaluate their level of satisfaction. The mean follow-up was 4 years. Three chondrocutaneous grafts were performed to reconstruct partial defects (Surgical Evaluation (SE): 7.9, Patient Evaluation (PE): 8.3).Three bilateral nasolabial flaps (SE: 6.1, PE: 6.7), 5 paramedian forehead flap (SE: 6.9, PE: 7.3) 6 Converse scalping flap (SE: 4.9, PE: 5.4) and 1 Raulo scalping flap (SE: 6,1, PE: 6,3) were performed to reconstruct total defects exceeding the columella. The use of composite graft was the most satisfactory procedure for partial defects. Paramedian forehead flaps and Raulo scalping flap were the most satisfactory procedures for extended defects. Nasolabial flap was the most adapted procedure for patients with general anesthesia contraindication or for defects extended to the lip.

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.

International audience; Background External radiotherapy has become indispensable in oncological therapies. Unfortunately, radiation is responsible for serious side effects, such as radiodermatitis. The skin is weakened and ulcerated. Our study aimed to evaluate the subcutaneous transfer of microfat (MF) alone and two mixes: MF + Platelet-rich plasma (PRP) and MF + stromal vascular fraction (SVF) to treat radiation-induced skin lesions.Method We defined randomly five experimental groups of nine mice: 1 healthy control group and 4 irradiated (60 Grey) and treated groups. The skin lesions were treated 3 months after irradiation by MF, MF + PRP (50%–50%), MF + SVF (90%–10%) or Ringer-lactate subcutaneous injections. Wound healing was evaluated at 1, 2 and 3 months post-injection and histological wound analysis at 3 months, after euthanasia.Results All the irradiated mice presented with wounds. After sham-injection, the wound area increased by 91.1 ± 71.1% versus a decrease of 15.9 ± 23.1% after MF alone (NS), 27.3 ± 23.8% after MF + SVF (NS) and 76.4 ± 7.7% after MF + PRP (P = 0.032). A significative reduction of skin thickness in wound periphery was measured for the three treated groups compared to sham-injection (P < 0.05) but not in the healed wounds (NS). The most important subcutaneous neo-vessel density was shown after MF + SVF injection.Conclusion The MF + PRP mix was the most efficient product to increase healing. The MF + SVF mix showed the highest rate of neo-angiogenesis but was disappointing in terms of healing.

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 (

Supplemental Digital Content is available in the text., Background: A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments. Methods: This randomized, non-inferiority trial enrolled patients who underwent skin excision (>30 cm2), which was left open to heal by secondary intention. They received ALGINATE or NPWT by a centralized randomization. Follow-up was performed weekly until optimal granulation tissue was obtained. The primary outcome was time to obtain optimal granulation tissue for a split thickness skin graft take (non-inferiority margin: 4 days). Secondary outcomes were occurrence of adverse events (AEs) and impact of the treatments on the patient’s daily life. Results: ALGINATE and NPWT were applied to 47 and 48 patients, respectively. The mean time to optimal granulation was 19.98 days (95% CI, 17.7–22.3) with ALGINATE and 20.54 (95% CI, 17.6–23.5) with NPWT. Between group difference was −0.56 days (95% CI −4.22 to 3.10). The non-inferiority of ALGINATE versus NPWT was demonstrated. No AE related to the treatment occurred with ALGINATE versus 14 AEs with NPWT. There was no difference in the impact of the treatments on the patient’s daily life. Conclusion: This trial demonstrates that ALGINATE has a similar healing efficacy to that of NPWT and that is markedly better with regard to patient safety.

Resume Introduction Les infections sont une complication frequente lors des reconstructions par prothese totale massive du genou (PTMG) apres resection tumorale large. En cas d’indication de couverture par lambeaux libre, les lambeaux musculaires sont le plus souvent preferes. Nous presentons ici une technique de sauvetage du membre par lambeau libre fasciocutane antero-lateral de cuisse (ALC). Methode Trois patients ayant une infection de PTMG apres exerese de sarcome du femur ont beneficie d’un lambeau ALC libre. Le prelevement du lambeau et la reimplantation de la prothese ont ete realises en deux temps operatoires. Resultats Le transfert du lambeau et le remplacement de la prothese ont ete realises sans complication. Apres deux ans, les membres ont pu etre conserves sans recidive infectieuse. Conclusion Le lambeau libre ALC represente une solution efficace de couverture en cas d’infection de PTMG et peut-etre considere comme une alternative valable aux lambeaux musculaires libres.

Introduction The gastrocnemius muscular flap has already proven its efficiency for soft tissue coverage in cases of knee joint exposure. However, it may be too small to cover large defects and has not the same aesthetic and mechanical properties as normal skin. Perforator fasciocutaneous flaps have recently been described in knee joint coverage with good results as they replace skin by skin, but they can be hard to harvest. Gastrocnemius flaps can be easily harvested with a planned skin paddle designed over the chosen muscle. This simple technique combines the advantages of muscular and fasciocutaneous flaps for knee joint area coverage. Perforator fasciocutaneous flap take a growing place in coverage of this localization in recent literature, but very few articles report the results of gastrocnemius myocutaneous flaps (MCFs). Methods All patients who underwent knee joint coverage with the use of a lateral or medial gastrocnemius MCFs between January 2012 and February 2017 in our university institution were included in this retrospective study. Results Sixteen gastrocnemius MCFs (10 medial and 6 lateral) were performed. The indication was posttraumatic in 5 cases, posttumoral in 5 cases, and after total knee prosthesis exposure in 6 cases. Skin paddles up to 15 cm in width and 18 cm in length were harvested. Complete healing was achieved in 15 days in all cases without suffering or nonunion. Three flaps were secondarily raised to allow total knee prosthesis reimplantation or arthrodesis, and 4 patients were treated with postoperative radiotherapy without complication. Conclusions In addition to its reliability and very easy harvesting, the gastrocnemius MCF allows a robust joint coverage and good skin resurfacing that makes eventual revision easier and allows early radiotherapy. Furthermore, skin paddle also increases the effective area of the flap. This technique should always be considered with the other classic alternatives.

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.

Resume Introduction La mastectomie bilaterale de reassignation sexuelle vers l’homme est la premiere et souvent l’unique intervention chirurgicale permettant au patient transsexuel d’acceder physiquement au sexe masculin. C’est une chirurgie specialisee necessitant un accompagnement psychologique particulier. L’objectif de notre etude etait d’evaluer la satisfaction des patients operes de mastectomie bilaterale de reassignation vers le sexe masculin et l’impact sur leur vie sociale et personnelle. Materiel et methode L’ensemble des 22 patients operes entre janvier 2012 et mars 2013 pour mastectomie bilaterale de reassignation ont ete contacte par courrier pour etre inclus dans l’etude. La satisfaction apres intervention etait mesuree par auto-questionnaire adapte du questionnaire de reconstruction mammaire du Q-Breast modifie pour la chirurgie de reassignation sexuelle. Un score global superieur a 320/378 etait considere comme « tout a fait satisfaisant ». Resultats Seize patients sur 22 (73 %) ont repondu au questionnaire. Le score moyen etait de 332/378, correspondant a un resultat « tout a fait satisfaisant ». Le score d’evaluation du bien-etre psychologique etait de 54,5/60. Conclusion Notre etude a confirme le benefice reel de la chirurgie de mastectomie bilaterale dans le processus de reassignation sexuelle vers l’homme, a la fois en termes de qualite de vie et de confiance en soi. Les patients ont rapporte une importante satisfaction quelle que soit la technique utilisee et une amelioration de l’integration sociale apres chirurgie. Cependant, cette chirurgie ne doit s’envisager que dans le cadre d’une prise en charge globale par une equipe multidisciplinaire experimentee.

Les évaluateurs constituent un maillon essentiel des dispositifs d’évaluation des compétences langagières et doivent bénéficier d’un accompagnement continu pour maintenir la qualité des évaluations à un niveau satisfaisant. Cet article compare deux méthodes pour la détermination des profils de sévérité d’évaluateurs d’une épreuve d’expression écrite en français langue étrangère, à partir de leurs données de production. La première méthode s’inscrit dans le cadre de la théorie classique des tests et la seconde s’appuie sur la théorie de réponse aux items, par la mise en oeuvre d’un modèle multifacettes de Rasch. Les résultats concordants des deux méthodes montrent l’utilité de tenir compte de la sévérité des correcteurs aux différents points de césure pour améliorer la fidélité du test, même si cette dernière n’explique qu’une part limitée de la variance d’erreur. Ces informations permettent également de dresser des profils d’évaluation individuels des correcteurs, qui peuvent être exploités dans le cadre de leur suivi pour la mise en oeuvre d’actions de remédiation ciblées., Raters are a key element of language proficiency assessment systems. They ought to be monitored closely to keep the quality of assessments at a high level. This article compares two methods in order to determine the raters’ severity profiles using real rating data, for a writing test of French as a foreign language. The first method makes use of the Classical Test Theory while the second is based on the Item Response Theory using the multifaceted Rasch Model (MFRM). The concurring results of both methods show that in order to improve the reliability of a test, it is important to take into account a rater’s severity at each cut-off score, even if this consideration only explains a moderate portion of the error variance. This information also allows for drawing up the raters’ individual evaluation profiles, which could prove useful for more focused training activities., Os avaliadores são um elemento chave dos dispositivos de avaliação de competências linguísticas e devem receber apoio contínuo para manter a qualidade das avaliações a um nível satisfatório. Este artigo compara dois métodos para a determinação de perfis de avaliadores de um teste de expressão escrita em francês como língua estrangeira, a partir dos seus dados de produção. O primeiro método inscreve-se no quadro da teoria clássica dos testes e o segundo apoia-se na teoria de resposta aos itens para a implementação de um modelo multifacetado de Rasch. Os resultados concordantes dos dois métodos mostram a utilidade de considerar a severidade dos corretores em cada nota mínima para melhorar a fiabilidade do teste, mesmo se esta última explique apenas uma pequena parte da variância do erro. Estas informações também ajudam a desenvolver os perfis de avaliação individuais dos corretores, que podem ser úteis para atividades de formação mais focadas.

Resume But de l’etude Cinq cas d’une meme malformation congenitale du nez sont presentes, dont il ne semble pas exister d’equivalent dans la litterature. Cette malformation touche l’arete nasale et le supra-tip. Nous souhaitions presenter cette pathologie. Patients et methodes Cinq patients presentant une malformation nasale congenitale similaire non decrite dans la litterature ont ete pris en charge entre 1994 et 2014. Ces patients ont ete examines afin de decrire finement la malformation. Des analyses genetiques et histologiques ont ete realisees. Leur prise en charge diagnostique et therapeutique a ete discutee. Resultats La malformation decrite presente 4 composantes : une masse de tissu mou situee au niveau du tiers moyen de l’arrete nasale, les domes des cartilages alaires qui sont refoules et deformes vers le bas et en dehors par la masse, un defaut de soutien de la pointe et une atrophie cutanee mediane. Ils ne presentent pas d’autres anomalies de la ligne mediane. L’analyse histologique n’a pas apporte d’element diagnostique, ni l’analyse caryotypique bien que deux patients soient freres. Trois patients ont ete operes dont un jusqu’a l’âge adulte avec un resultat satisfaisant. Conclusion Les recherches bibliographiques n’ont pas permis de poser un diagnostic precis sur cette malformation qui semble etre non syndromique et a caractere familial. Notre attitude therapeutique est en faveur d’une exerese precoce de la masse adipeuse pour prevenir les deformations alaires, a associer avec un greffon cortico-spongieux, qui dans notre experience croit avec l’âge, pour soutenir la pointe.

Since the first description of Kasabach-Merritt syndrome (KMS) in 1940, many treatments have been proposed combining pharmacologic and non-pharmacologic approaches, which can be effective on the pathology but can have adverse and unpredictable side-effects with long-term use. Herein we describe the solely surgical treatment of Kasabach-Merritt syndrome in a neonate with a severe and rapidly progressive thrombocytopenia. The patient's condition normalized at 7 days postoperatively, with rapid increase in platelet count and normalization of d-dimer concentration.

Background Platelet-rich plasma improves engraftment after fat transfer. However, the effects of platelet dose have never been investigated. The authors used magnetic resonance imaging to compare surviving graft volumes in mice after administration of four different formulations (microfat alone, and three platelet-rich plasma-enriched microfat mixes). Methods The authors used a random, double-blinded, fat transfer protocol using three different platelet levels: 1 million (low-dose), 500 million (medium-dose), and 1000 million (high-dose) platelets/ml, and fat alone (control). The authors grafted 0.4 ml of the 70/30 platelet-rich plasma-enriched microfat mixtures (0.4 million, 200 million, and 400 million platelets per 0.12 ml for the low-dose, medium-dose, and high-dose mixtures, respectively) or 0.4 ml of microfat alone into 22 nude mice and monitored surviving graft volumes every month for 3 months. Then, the authors histologically analyzed all grafts to assess neoangiogenesis status and fat integrity. Results Three-dimensional magnetic resonance imaging showed that the median surviving graft volumes at 3 months were 9.5 percent (interquartile range, 0 to 25 percent; p = 0.003) (high-dose), 4.1 percent (interquartile range, 0 to 18 percent; p = 0.001) (medium-dose), and 18 percent (interquartile range, 8 to 38 percent; p = 0.41) (low-dose) compared to 36 percent (interquartile range, 28 to 53 percent) for the control value. The histologic integrity of microfat-alone grafts was significantly better than those of the other grafts, although the high-dose and low-dose grafts exhibited higher levels of neoangiogenesis. Conclusion Higher platelet levels in microfat grafts were associated with poor graft survival in nude mice; a clinical review would be appropriate.

Lipofilling or fat grafting transfer is defined as a technique of filling soft tissue by autologous fat grafting. The basic principle of lipofilling is based on a harvest of adipose tissue, followed by a reinjection after treatment. Lipofilling main objective is a volume defect filling, but also improving cutaneous trophicity. Lipofilling specificities among children is mainly based on these indications. Complications of autologous fat grafting among children are the same as those in adults: we distinguish short-term complications (intraoperative and perioperative) and the medium and long-term complications. The harvesting of fat tissue is the main limiting factor of the technique, due to low percentage of body fat of children. Indications of lipofilling among children may be specific or similar to those in adults. There are two types of indications: cosmetic, in which the aim of lipofilling is correcting a defect density, acquired (iatrogenic, post-traumatic scar) or malformation (otomandibular dysplasia, craniosynostosis, Parry Romberg syndrom, Poland syndrom, pectus excavatum…). The aim of functional indications is correcting a velar insufficiency or lagophthalmos. In the paediatric sector, lipofilling has become an alternative to the conventional techniques, by its reliability, safety, reproducibility, and good results.

Resume Les malformations palpebrales de l’enfant peuvent etre isolees ou associees a des syndromes malformatifs craniofaciaux. Leur evaluation est surtout clinique, les examens complementaires sont realises pour faire le bilan des malformations craniofaciales associees. Un bilan genetique doit etre demande systematiquement en cas de lesions extrapalpebrales associees ou de malformations palpebrales complexes. Tandis que certaines malformations isolees ne necessitent qu’une simple surveillance, d’autres ont besoin d’un traitement adapte. Celui-ci devra etre realise a un âge precis. Il prend en compte la croissance de l’enfant, des structures anatomiques et les consequences de la malformation sur l’œil et la vision (degre d’urgence). Ces anomalies s’accompagnent de deux risques principaux : l’irritation corneenne par inocclusion palpebrale et l’amblyopie par obstruction de l’axe visuel, par anisometropie ou par strabisme.

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.

Resume But de l’etude Nous presentons le cas d’une patiente presentant un syndrome de Goldenhar associe a une fistule congenitale situee au milieu du philtrum au niveau de la levre superieure. Patients et methode La patiente a ete prise en charge des sa naissance pour un syndrome de Goldenhar. Plusieurs interventions ont ete realisees dans l’enfance afin de corriger une macrostomie droite et une hypoplasie mandibulaire droite. A l’âge de 14 ans, elle beneficie d’une rhinoplastie pour corriger une malformation nasale complexe. En peroperatoire un orifice situe dans l’espace inter-incisif median superieur est decouvert. Il se prolonge par une fistule qui se dirige a travers la voute palatine anterieure en direction du rail vomerien, a la base de la cloison. Cette fistule est borgne en arriere du vomer et peut etre resequee en totalite. L’examen anatomopathologique de la piece revele un revetement malpighien. Resultats Les fistules medianes de la levre superieure sont extremement rares : moins de 30 cas reportes dans la litterature. Le trajet inhabituel de la fistule et l’apparition recente d’un syndrome hypophysaire chez cette patiente nous a fait rechercher une continuite entre celle-ci et la poche de Rathke par une imagerie de type tomodensitometrie. Conclusion L’association d’un syndrome de Goldenhar et d’une fistule congenitale mediane de la levre superieure n’a jamais encore ete decrite dans la litterature. L’association a un hypopituitarisme a fait suspecter un prolongement posterieur de la malformation, non confirme par le scanner, mais fortement presume conjointement par l’equipe de neurochirurgie et de chirurgie plastique.

Background and Objective 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. Study Design/Materials and Methods 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/cm2; spot: 18.9 × 3.7 mm2. 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. Results 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. Conclusion 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. Lasers Surg. Med. © 2015 Wiley Periodicals, Inc.

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.

La chirurgia ricostruttiva delle palpebre conosce uno sviluppo importante a causa della frequenza elevata dei carcinomi cutanei nella nostra popolazione anziana. Le tecniche di ricostruzione sono numerose e il chirurgo deve attuare quella che padroneggia meglio ottenendo, al tempo stesso, dei risultati oncologici, funzionali ed estetici soddisfacenti. La protezione del bulbo oculare, il ripristino del campo visivo e la discrezione del procedimento di ricostruzione sono gli obiettivi principali. La conoscenza dell’anatomia palpebrale e indispensabile. Le palpebre devono essere ricostruite piano per piano, a partire da tessuti vicini, morbidi e sottili ogni volta che sia possibile. La regola dei quarti di Mustarde e una guida fondamentale per la scelta della ricostruzione.

Resume Nous rapportons le cas d’une patiente de 55 ans atteinte d’une neurofibromatose de type I ou maladie de Recklinghausen. Elle presentait un schwannosarcome du nerf median, de haut grade de malignite, a l’union des tiers superieur et moyen du bras, au contact de l’humerus. Le traitement carcinologique de cette tumeur imposait une amputation du bras au niveau du col chirurgical de l’humerus, et donc une desarticulation d’epaule. Dans le but d’ameliorer la fonction residuelle du membre superieur, et afin de creer une pince latero-thoracique, nous avons decide de realiser un lambeau libre total d’avant-bras banque. Ce lambeau composite a ete compose du radius, de la totalite des muscles de l’avant-bras, ainsi que de la peau de la face anterieure de l’avant-bras, prelevee avec le pedicule radial proximal. Il a ete anastomose en proximal a l’artere axillaire apres osteosynthese humero-radiale par plaque. Le lambeau a permis a cette patiente active d’obtenir un moignon fonctionnel, retablissant la fonction du bras et permettant une action de pince.