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Resume En six pages de dessins les auteurs resument l’histoire du traitement du cancer du sein, puis les etapes de la reconstruction. Ils mettent l’accent sur la variete des techniques qui ont ete employees et sur les debats autour des indications de la reconstruction apres cancer.

Resume Dans ce document, le Pr Guy Magalon presente une reflexion autour de la chirurgie plastique pediatrique tiree de 30 ans de pratique chirurgicale. Sa reflexion est etayee de plusieurs exemples de resultats d’operations de chirurgie plastique chez des enfants revus a l’âge adulte. Ces differents cas mettent en lumiere l’evolution des pratiques chirurgicales et la necessite de la formation permanente des praticiens pour s’adapter aux progres techniques. Le Pr Magalon rend hommage a ses maitres et rappelle sa vision personnelle des principes de la chirurgie plastique pediatrique.

The authors summarize in those six pages of drawings the history of breast cancer reconstruction treatment. The focus is on the variety of techniques available for breast reconstruction and on the debates around different indications.

Le consortium TOURNESOL, regroupant 11 equipes de chercheurs et de cliniciens de trois villes (Marseille, Montpellier et Rouen) et finance par la Fondation de l’Avenir, a pour mission de mener deux essais cliniques destines a reparer des nerfs peripheriques leses–nerfs facials et des membres – grâce a des greffes autologues de cellules souches nasales. Pourquoi la therapie cellulaire ? Environ 100 000 operations de reparation nerveuse sont realisees chaque annee aux Etats-Unis et en Europe. Elles representent 2,8 % des traumatismes et sont le plus souvent responsables d’une perte de fonction voire d’invalidite. Malgre des progres dans le delai de prise en charge et dans la qualite du geste technique chirurgical, il n’y a eu aucun progres majeur depuis une vingtaine d’annees. Une approche de therapie cellulaire pourrait limiter l’inflammation et ameliorer la croissance axonale. Pourquoi les cellules souches olfactives nasales ? Chez le mammifere adulte, y compris chez l’homme, la muqueuse olfactive est le seul tissu nerveux capable d’auto-renouvellement. La plasticite de ce tissu est en partie assuree par des cellules souches qui sont multipotentes. Comme demontre par plusieurs membres du consortium, elles peuvent donner naissance a des cellules neurales (neurones, astrocytes, oligodendrocytes, cellules de Schwann). Leur potentiel therapeutique a ete teste avec succes dans differents modeles animaux de paraplegie, de la maladie de Parkinson, de surdite et d’amnesie. Que disent les etudes menees chez le rat par le consortium. Deux etudes, menees en parallele sur le nerf facial et le nerf peronier ont permis de montrer que la greffe de cellules souches olfactives : ameliore la recuperation fonctionnelle de la mobilite faciale ; diminue les syncinesies œil-bouche ; accroit les capacites locomotrices ; ameliore le seuil tetanique, le temps de contraction et le taux de relaxation musculaire Les cellules souches olfactives, medicament de therapie innovante, agree par l’ANSM. Avant de mener les essais cliniques, il a ete necessaire de cultiver les cellules souches dans un laboratoire de therapie cellulaire, dans des conditions repondant aux normes europeennes. Les essais cliniques multicentriques porteront sur une premiere serie de 10 patients avec des lesions negligees des nerfs collateraux et de la branche sensitive du nerf radial avec une perte de substance. La periode d’evaluation post-greffe s’etalera sur 12 mois. La chirurgie regenerative va representer une revolution dans la reparation des membres. Et les nerfs peripheriques devraient en beneficier.

Background Achilles tendinopathy remains often chronic and rebel to a thorough conservative treatments. In this context, autologous platelet-rich plasma (PRP) could represent an interesting alternative. Methods This prospective, monocentric, descriptive study, conducted from January 2011 to May 2011, included 32 patients practicing sports at the competitive or amateur level and suffering from chronic Achilles tendinopathy diagnosed by ultrasound (US). The treatment consisted on a single injection of PRP directly into the Achilles tendon under US guidance. Hence, the cracks were gently filled without damaging the surrounding healthy tendon. PRP was systematically characterized before its administration. Tendon regeneration was followed using algofunctionnal testing and US examination at 1, 2, and 3 months post-injection. A satisfaction score was proposed at 6 and 12 months by phone call. Results Twenty-two patients (69%) at 1 month and 18 patients (88%) at 2 months were completely healed, associated with a widespread improvement of fibrillar echo-structure of the tendon and improvement reduction of the hypervascularity during power Doppler examination at 3 months. Of the 22 responses collected to the end of the protocol, 14 patients declared a complete improvement in term of satisfaction with a significant reduction of pain ( P P Conclusions A single autologous PRP injection was effective in the treatment of rebel Achilles tendinopathy. US guidance allows PRP injection directly into the degenerated part of the tendon with great accuracy.

In this document, Pr Guy Magalon presents a reflection on the plastic pediatric surgery drawn from 30 years of surgical practice. His thinking is supported by several examples of plastic surgery results from children reviewed in adulthood. These cases highlight the evolution of surgical practices and the need for continuing education for surgeons to adapt to technical progress. Professor Magalon honors his masters and shares his personal vision of the principles of pediatric plastic surgery.

L’espansione cutanea e una tecnica utilizzata in chirurgia plastica e riparativa da diverse decine di anni; essa consiste nel posizionamento di protesi di espansione vuote che saranno progressivamente riempite di soluzione fisiologica attraverso una valvola, permettendo, cosi, di ottenere un guadagno cutaneo e di trattare una perdita di sostanza. Il principio e sempre lo stesso, ma il materiale e progredito dalla prima protesi moderna descritta da Radovan nel 1976. Dopo una descrizione dettagliata della tecnica chirurgica, gli autori propongono una classificazione regione per regione delle principali indicazioni e delle specificita tecniche. Sono elencate le principali complicanze, cosi come la condotta da tenere. Un capitolo piu dettagliato e dedicato all’espansione nella ricostruzione mammaria. L’espansione cutanea resta una tecnica indispensabile nell’arsenale del chirurgo plastico; e una tecnica semplice ma che richiede un grande rigore chirurgico.

Resume Sujet Le traitement du sillon nasogenien (SNG) marque secondaire au vieillissement est une demande frequente en chirurgie plastique. De nombreuses solutions medicales et chirurgicales existent et se basent sur des notions anatomiques et physiologiques parfois tres differentes pour justifier de leur interet. Il n’existe a l’heure actuelle pas de reel consensus sur les indications precises de ces techniques qui presentent toutes des avantages et des inconvenients. Nous exposons notre experience d’une technique n’ayant fait l’objet d’aucune publication et utilisant un greffon de fascia temporalis superficialis (FTS) pour combler le SNG. Nous proposons une revue de la litterature sur la physiologie de la region du SNG et sur les solutions therapeutiques existantes. Patients et methodes Entre 1990 et 2010, nous avons ete amenes a pratiquer cette technique chez 24 patientes pour des SNG de moyenne a forte importance. Chez les patientes presentant un SNG de forte importance un comblement par lipostructure des sous-unites esthetiques de la joue et des levres etait pratique dans le meme temps, dans le but d’une recuperation des volumes perdus au cours du vieillissement. Resultats Les resultats objectifs et subjectifs etaient satisfaisants. Cette technique cumule selon nous plusieurs avantages qui concernent la rancon cicatricielle, le pouvoir « volumateur » et la duree de ses effets. La morbidite du site donneur est egalement faible. Conclusion Le comblement du SNG par greffon de FTS associe a une restauration des volumes des levres et de la joue est une technique simple, reproductible, et realisable sous anesthesie locale dans le cadre de la chirurgie ambulatoire. Dans la mesure ou le greffon tissulaire est « solide » elle permet selon nous un traitement efficace et harmonieux du SNG sur le long terme.

Resume Les sequelles retractiles sont frequentes dans les suites des brulures profondes des membres. Lorsque la reeducation ne permet pas le retablissement des amplitudes et de la fonction articulaires, le traitement chirurgical est indique. Il fait appel a toutes les techniques de la chirurgie plastique, des autoplasties aux greffes cutanees, dermes artificiels et lambeaux. Les sequelles esthetiques sont egalement source de demande de correction chirurgicale. Les differentes techniques utilisables, ainsi que leurs indications respectives, sont presentees.

Grace to the creativity of surgeons and the introduction of new technologies, second half of the XXth century opened the era of innovations and decisive progress. At the same time, however, is born the feeling of distrust and claiming which has come with the graving and threatening juridiciarisation. The evolution of complex structures of our society joined the ingenuity researchers unlimited makes formal law and the legal framework constantly to adapt oneself to circumstances. In the field of surgery, it's necessary to make work in integrity the innovation and protection at the patient's and their dignity. The legal framework that governs today innovation in surgery must still to go further and will precise. Dignity, compelling paradigm for all those who seek to better understand and better protect human starred as impassable limit any search and any experimentation. To make this chapter more alive, we have supplemented it and illustrated by the testimony some of the most fruitful French last years innovative in order to enrich our thinking of the fruit of their large and brilliant experience.

The cutaneous infectious pathology of the child is varied and frequent. Authors deal with surgical infections seen in current pediatrics, which often have to appeal to a plastic pediatric surgeon for their treatment. Superficial infections of skin and pilo-sebaceous follicles are common in big children. The folliculitis and the boil are the most frequent. Their treatment is medical and surgical and does not require an antibiotic treatment in most of the cases. The primitive abscesses or following an anterior lesion recover from a similar treatment. Some localizations or risky context need a particular follow-up. The whitlow is a particular example and needs to have a particular follow-up because of the risk of hand cellulitis. Nails embodied of the child require a specialized notice because of their numerous clinical forms, which must be distinguished according to the age. Finally the necrotizing cellulitis and fasciitis are surgical emergencies and have a well-codified treatment. These infections in children must benefit from an attentive care because when they are badly treated, they can involve the aesthetic, functional and vital forecast.

Children with severe congenital blepharoptosis are at risk of developing amblyopia. For this reason, ptosis repair is indicated as soon as the diagnosis is made. Frontalis suspension of the upper lid is an effective and simple method of treatment. This study reports on the long-term outcome of frontalis suspension surgery for congenital ptosis using autogenous sling material. Twelve children with severe congenital ptosis underwent frontalis suspension surgery using autologous fascia lata or temporal fascia. The results were assessed with a mean follow-up period of 8 years. Eleven children had good or excellent functional and aesthetic results. There were no cases of recurrence or overcorrection. Frontalis suspension using autologous material is a harmless procedure, which does not alter the upper eyelid structures. It is an effective procedure in the long term. In our opinion, it is the technique of choice to treat young children with severe congenital ptosis.

La expansion cutanea es una tecnica que se utiliza en cirugia plastica y reparadora desde hace varias decadas; consiste en colocar protesis de expansion vacias, que se rellenan progresivamente con suero fisiologico mediante una valvula, lo que permite obtener una ganancia cutanea y tratar una perdida de sustancia. El principio es siempre el mismo, pero el material ha evolucionado desde la primera protesis moderna, descrita por Radovan en 1976. En este articulo se describira con detalle la tecnica quirurgica, tras lo que se propondra una clasificacion regional de las principales indicaciones y especificidades tecnicas. Se enumeraran las principales complicaciones, asi como la conducta practica. Un apartado mas detallado se dedica a la expansion en la reconstruccion mamaria. La expansion cutanea sigue siendo una tecnica indispensable en el arsenal del cirujano plastico; es una tecnica simple, pero que requiere un gran rigor quirurgico.

Le deformazioni antiestetiche del padiglione auricolare associano, a gradi variabili, un valgismo, un difetto di curvatura dell’antelice e un’ipertrofia della conca. La loro correzione chirurgica, ancora detta «otoplastica», consiste in una combinazione di diverse tecniche che devono essere semplici, rapide e che hanno dato prova di raggiungere un risultato d’insieme armonico, elegante e duraturo. Oltre alle deformazioni il chirurgo, prima di proporre una tecnica chirurgica, deve sempre tener conto dello spessore della cartilagine, che condiziona la rigidita, l’elasticita del padiglione e il risultato nel tempo. La scelta delle tecniche richiede una valutazione preoperatoria precisa, che deve essere completata con una documentazione fotografica onde evitare ogni insufficienza, irregolarita e rottura in corrispondenza dell’antelice, all’origine di reinterventi chirurgici spesso complessi.

Las deformaciones antiesteticas del pabellon auricular asocian en grados variables un valgo, un defecto de pliegue del antihelix y una hipertrofia de la concha. Su correccion quirurgica, aun denominada otoplastia, combina distintas tecnicas que deben ser sencillas y rapidas, y que han demostrado lograr un resultado global armonioso, elegante y duradero. Ademas de las deformaciones, el cirujano siempre debe tener en cuenta, antes de proponer una tecnica quirurgica, el grosor del cartilago que condiciona la rigidez, la elasticidad del pabellon y el resultado en el tiempo. La eleccion de las tecnicas obliga a realizar un estudio preoperatorio preciso, que se completa mediante documentos fotograficos para evitar cualquier insuficiencia, irregularidad o discontinuidad frente al antihelix que den lugar a reintervenciones quirurgicas, que suelen ser complejas.

Resume Le syndrome des brides amniotiques (SBA) est une entite clinique desormais bien decrite, qui comprend diverses anomalies congenitales. Les malformations de la main sont les plus caracteristiques et les plus frequentes, associant avec une localisation tres variable, sillons de constriction, acrosyndactylies et amputations congenitales. De nombreuses associations malformatives sont possibles, le plus souvent letales. Les malformations crâniofaciales, viscerales ou de la paroi fœtale, sont alors regroupees sous le terme de limb body wall complex (LBWC). Il existe diverses denominations pour ce syndrome, du fait de la grande variabilite des anomalies morphologiques et des incertitudes concernant ses etiologies. En effet, plusieurs hypotheses pathogeniques se sont opposees au fil des annees, laissant une certaine confusion. De recents travaux experimentaux, de genetique notamment, pourraient aider a unifier ces diverses malformations congenitales. Le diagnostic, de plus en plus souvent pose avant la naissance, plonge la famille dans un grand desarroi. Un diagnostic antenatal precoce et precis est l’element clef de la prise en charge pre- et perinatale et pourrait rendre parfois possible un geste chirurgical in utero. Les traitements chirurgicaux ameliorent la morphologie, mais n’ameliorent la fonction que si les elements construits sont integres par l’enfant dans son schema corporel. Les interventions doivent etre entreprises tres tot : en urgence, a la naissance, en cas de trouble vasculaire, ou precocement en cas d’aggravation des deformations par une croissance rapide.

Resume La clinodactylie est un symptome dont la definition est l’angulation excessive d’un doigt dans le plan radio-ulnaire. Les auteurs presentent les differentes formes etiologiques se manifestant par une clinodactylie, en insistant plus particulierement sur la phalange delta et la deformation de Kirner. Les differents traitements sont detailles ainsi que leurs indications et l’âge ideal auquel les proposer.

Resume Sujet Malformation de la paroi thoracique anterieure la plus frequente, le thorax en entonnoir reste l’objet de nombreuses controverses. D’etiologie incertaine, son retentissement psychologique, cardiaque et pulmonaire est diversement apprecie. Plus discutee est sa prise en charge chirurgicale, avec des techniques plus ou moins radicales selon les equipes. Il n’existe ainsi aucun consensus etabli quant aux indications chirurgicales, la technique a utiliser ou l’âge d’intervention. Materiel et methodes Nous presentons ici notre etude, retrospective, interessant dix patients porteurs d’un thorax en entonnoir operes dans notre service entre 1989 et 2002. Neuf patients ont beneficie d’une correction par prothese thoracique sur mesure en silicone, et une patiente de la mise en place d’une seule prothese mammaire. Chaque patient a ete interroge et examine afin de completer une fiche de renseignements et d’evaluation. Le retentissement et d’eventuelles anomalies associees etaient objectives par des examens complementaires cardiopulmonaires, et la severite de l’entonnoir evaluee par l’index radiographique de Haller. Resultats Le recul moyen etait de plus de cinq ans. Le retentissement du thorax en entonnoir etait chez nos patients essentiellement psychologique, du fait de la disgrâce esthetique. Bien que deux tiers des entonnoirs soient juges severes, le retentissement cardiopulmonaire etait mineur chez nos patients. Tous etaient satisfaits du resultat, et ce independamment de l’appreciation chirurgicale. Les complications aigues relevees regroupaient cinq seromes et une desunion cicatricielle minime. Discussion Apres comparaison de nos resultats a ceux de la litterature, et au regard des differentes possibilites de traitement existantes (prothese, sternochondroplastie, transfert graisseux), les indications et les modalites de prise en charge chirurgicale du thorax en entonnoir sont discutees.

Summary Introduction Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high – from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. Patients and methods Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. Results The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72h in all cases. After good granulation was obtained, two patients required a thin skin graft. Discussion All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.

La extravasacion de un farmaco quimioterapico, una perfusion de metabolitos o producto de contraste para una exploracion radiografica puede provocar una necrosis cutanea en el sitio afectado. La lesion tisular dependera de la toxicidad del producto, y puede oscilar desde unas simples molestias en caso de inoculacion benigna (suero glucosado isotonico, Ringer lactato, etc.), a la necrosis cutanea en el caso de los antimitoticos. Los signos clinicos (con mas frecuencia en forma de dolor y de eritema local) deben permitir el diagnostico y el tratamiento precoz para evitar o limitar la evolucion hacia la necrosis y las posibles secuelas funcionales. Una vez identificada la gravedad, el tratamiento urgente del sitio de extravasacion mediante tecnicas de aspiracion-lavado supone una autentica «ducha» subcutanea y permite, en la mayoria de los casos, la eliminacion del toxico y la conservacion del revestimiento cutaneo. Si se produce una necrosis, las tecnicas clasicas de la cirugia plastica, como la cicatrizacion dirigida, los injertos y los colgajos, permiten la curacion.

Lo stravaso di un chemioterapico, di una perfusione di metaboliti o di prodotti di contrasto per esame radiografico puo essere all’origine di una necrosi cutanea a livello del sito raggiunto. L’interessamento tissutale dipende dalla tossicita del prodotto, andando dal semplice disagio per l’inoculazione benigna (glucosata isotonica, Ringer lattato ecc.) alla necrosi cutanea per gli antimitotici. I segni clinici, spesso a tipo dolore ed eritema locale, devono permettere la diagnosi e il trattamento precoce allo scopo di evitare o limitare l’evoluzione verso la necrosi e i possibili esiti funzionali. Una volta riconosciuta la gravita, il trattamento in urgenza del sito di stravaso con una tecnica di aspirazione-lavaggio realizza una vera «doccia» sottocutanea e consente spesso l’eliminazione della sostanza tossica e la preservazione del rivestimento cutaneo. Nei casi di necrosi installata, le tecniche classiche della chirurgia plastica quali la cicatrizzazione guidata, gli innesti e i lembi permettono il trattamento.

Apert’s syndrome is the most common of the acrocephalosyndactylies with complex malformations of the hands. Treatment of the Apert hand is complex, and numerous procedures are required. The aim of this study is to propose a strategy for hand management. Sixteen Apert’s syndrome hands were submitted to early surgery, which included opening of the first web, separation of the fingers, realigninment of the thumb, and correction of the clinodactylies. We performed an average of six operations per child. Treatment of the first web depended on the classification of Upton: For the severe stages, we used a dorsal hand flap. Radical clinodactyly was treated by osteotomy of the delta phalanx and Z-plasty. We treated nine hands with four fingers and seven hands with five fingers. There was always bilateral opposition and symphalangism excluding the fifth finger. All of the children have a rudimentary but functional pinch grip. Revision of the webs was necessary in 16% of the cases. The Apert hand requires early and specialized treatment that aims to provide a functional hand before 2 or 3 years, with the least surgical complications. The functional prognosis is adversely affected by symphalangism.

Advancing the posterior pharyngeal wall is a classic technique to treat velopharyngeal insufficiency. Injection of autologous fat behind the posterior pharyngeal mucosa according to the Coleman Lipostructure technique is a recent development. The authors report their experience in six cases using this modification. The preoperative work-up was performed by a speech therapist with a physical examination and measurement of the nasal air loss was performed using an aerophonometer. Fat was harvested either on the abdominal wall or on a buttock and then centrifuged. Fat injection was performed using a curved blunt cannula under the mucosa of the lateral and posterior pharyngeal walls. Injecting fat is an autologous graft of fat tissue: after a postoperative period of three months, the volume of fat becomes permanently stable. In five out of the six patients who presented moderate velopharyngeal insufficiency, speech improvement was significant. The single failure was a patient with bilateral cleft lip and palate sequels after previous pharyngoplasty using the Orticochea procedure. Treatment of moderate velopharyngeal insufficiency using fat injection is an efficient method. The advantages are its innocuousness and that scaring of the pharynx is avoided.

Resume Introduction Plus que les grossesses simples, les grossesses gemellaires engendrent des sequelles esthetiques et fonctionnelles majeures de la paroi abdominale. L'augmentation importante de la hauteur uterine a pour consequence une distension musculaire et cutanee de l'etage sous-ombilical et sus-ombilical. Cette etude a pour but de presenter la technique de lipectomie abdominale en T inverse traitant a la fois l'etage sus- et sous-ombilical. Materiel et methode Les auteurs presentent une serie de trente patientes d'âge moyen 35 ans, sans surpoids et non fumeuses. Le traitement chirurgical a consiste, dans 28 cas, en une resection cutaneograisseuse selon un trace en T inverse associee a une plastie musculaire des grands droits et suivi, dans six cas, d'un deuxieme temps operatoire a six mois pour retouches. Resultats Toutes les patientes ont eu une amelioration esthetique et fonctionnelle sans recidive du diastasis abdominal. Nous n'avons eu aucune complication ni probleme de cicatrisation sur ces peaux vergeturees. Conclusion Le point particulier de ces grossesses vient du fait que la distension abdominale se fasse autant dans le sens vertical qu'horizontal et que sa correction necessite parfois deux temps operatoires. Devant l'absence de complication et la qualite des resultats esthetiques et fonctionnels, la lipectomie en T inverse associee a une plastie musculaire des grands droits apparait etre la technique la plus adaptee.

The understanding of vascular anomalies (vascular tumours and vascular malformations) was obscured, for a long time, by confusion and uncertainties in nosology and terminology. The International Society for the Study of Vascular Anomalies (ISSVA) recently adopted a classification scheme, clearly separating vascular tumours (hemangiomas of different types) which result from active cell proliferation, from vascular malformations, which are inborn defects in vascular morphogenesis. These two types of lesions have different clinical behaviour and require different diagnostic and therapeutic strategies. The most frequent vascular tumour is infantile hemangioma. Its clinical aspects and evolution are well-known. New data have been recently obtained concerning the phenotype of tumour cells and its histogenesis. Of the numerous new vascular tumours, which have been recently described, only the congenital hemangiomas, the vascular tumours associated with the Maffucci syndrome and the tumours that may be complicated by a profound thrombocytopenia (Kasabach and Merritt phenomenon) will be considered. Vascular malformations can be classified according to the vessel(s) types they are composed of. A classification table is presented, separating the malformations of vascular trunks from tissular malformations which are more intimately embedded in the surrounding tissues. The different syndromes associated with vascular anomalies take also place in this table. The clinical, imaging and histological aspects of the most frequent malformations (capillary, venous, lymphatic and arteriovenous) are presented. This classification intend to clarify the nosology and terminology of the complex field of vascular tumours and malformation and to offer a common language to the different physicians and specialists contributing, preferably with a interdisciplinary approach, to the diagnosis and treatment of these difficult lesions.

INTRODUCTION: Nerve injury compromises sensory and motor functions. Techniques of peripheral nerve repair are based on our knowledge regarding regeneration. Microsurgical techniques introduced in the late 1950s and widely developed for the past 20 years have improved repairs. However, functional recovery following a peripheral mixed nerve injury is still incomplete. STATE OF ART: Good motor and sensory function after nerve injury depends on the reinnervation of the motor end plates and sensory receptors. Nerve regeneration does not begin if the cell body has not survived the initial injury or if it is unable to initiate regeneration. The regenerated axons must reach and reinnervate the appropriate target end-organs in a timely fashion. Recovery of motor function requires a critical number of motor axons reinnervating the muscle fibers. Sensory recovery is possible if the delay in reinnervation is short. Many additional factors influence the success of nerve repair or reconstruction. The timing of the repair, the level of injury, the extent of the zone of injury, the technical skill of the surgeon, and the method of repair and reconstruction contribute to the functional outcome after nerve injury. CONCLUSION: This review presents the recent advances in understanding of neural regeneration and their application to the management of primary repairs and nerve gaps.

Laboratories propose a large variety of mammary implants, in which the multiplicity makes it difficult for the surgeons to choose. The objective of this work was to analyze the various features of the implants proposed by manufacturers, in particular the characteristics of the shell, the specificities of the filling, and the morphology of the implants. Nine laboratories sell ten brands of mammary implants on the European market. The laboratories are: Arion, Eurosilicone, Inamed Aesthetics, Mentor, Nagor, Perouse Plastie, Poly Implants Protheses, Polytech Silimed and Sebbin. All laboratories propose smooth or textured surfaces on the shell. Only one laboratory uses a surface covered by micropolyurethane foam. The fillings consist of a saline solution or a silicone gel. One laboratory provides a filling with hydrogel containing carboxymethylcellulose. The forms suggested are round or anatomical. The various models propose a variation on the projection for the round implants and a variation on the height for the anatomical implants. Analysis of the different catalogues makes it possible to underline the lack of precision in the terms of usage, in particular for the description of the form and the texture. It is unfortunate to have very little technical information and no clinical or biological information imposed by the European standard EN 12180. This prevents the surgeon from making his choice according to the real quality of the implants.

In the wake of three consecutive cases of microscopical examination of resection specimens following breast reduction revealing an adenocarcinoma, we wanted to point out the interest of a complete preoperative senological examination including mammography and postoperative anatomopathological examination. A retrospective study concerning 837 patients over a three-year period was conducted. We found seven patients (0.83%) with malignant breast cancer diagnosed on anatomopathological examination, which is comparable to the incidence found in literature. Of these seven cases there were four ductal adenocarcinomas (0.47%), all of them in situ (DCIS), and three lobular adenocarcinomas (0.36%) of which one invasive (ILA), one in situ (LCIS) and one mixed. The majority was aggressive, multifocal and bilateral. Treatment consisted of mastectomy with or without adjuvant therapy with curative intent in five out of seven cases, and this within two months after a esthetic surgery. In our opinion this shows that breast reduction can help in tracking down breast cancer and underlines the need for systematic and meticulous microscopic examination of resection specimens after breast reduction.

Resume Objectifs Preciser l’aspect IRM des hemangiomes immatures. Discuter de l’interet de cette imagerie comparee a l’echographie-Doppler. Materiels et methodes Il s’agit d’une analyse retrospective des donnees cliniques, echo-Doppler et IRM de 12 hemangiomes immatures chez 11 enfants. L’âge moyen des enfants est de 6 mois et 21 jours. La surveillance clinique moyenne est de 22 mois et 7 jours. Resultats L’IRM est realisee en l’absence de diagnostic clinique (4 cas) ou dans le cadre du bilan d’extension (8 cas). Ces hemangiomes immatures sont developpes au niveau cervico-facial dans 8 cas et des membres dans 4 cas. En IRM, les 12 hemangiomes immatures sont des masses a limites nettes, homogenes, hyperintenses en ponderation T2 par rapport aux muscles. En ponderation T1, onze hemangiomes immatures sont isointenses par rapport aux muscles et se rehaussent uniformement et intensement apres injection de Gadolinium. Onze hemangiomes immatures contiennent des hyposignaux lineaires correspondant a des structures vasculaires circulant rapidement. Dix lesions sont de siege superficiel, cutane et/ou sous-cutane, alors que deux lesions sont de siege profond, intramusculaire. En echographie-Doppler, ces hemangiomes immatures sont des masses hypervascularisees, a limites nettes, souvent compressibles, homogenes isoechogenes ou heterogenes avec des plages nodulaires hypoechogenes, par rapport a la graisse sous-cutanee. Le diagnostic de certitude d’hemangiome immature est fourni par l’anatomopathologie (2 cas) ou par la surveillance clinique (10 cas). Conclusion Dans notre serie, la semiologie IRM des hemangiomes immatures apparait reproductible et superposable aux donnees de la litterature. L’IRM est un complement utile dans le bilan d’extension des hemangiomes immatures difficilement accessibles en echographie. La sensibilite et la specificite de l’IRM dans cette pathologie reste a demontrer.

The methods additional or substitution for the surgery of facial skin ageing are dramatically rising before 40 years. These methods are addressed more to the wrinkles and others signs of aging skin. They can constitute a door of entry in the aesthetic treatments and needs a professional approach. These noninvasive methods (within the meaning of the incision) can present complications this the more so as the tendency is with the vulgarizing and with under considerations of the initial diagnosis and the treatment itself. The devices of thermal effects consist of lasers, pulsed flashlamps and radiofrequency. The objective of this development is to consider the bonds, which link the initial diagnosis and the proposal for a treatment by considering side effects and complications of each method.

Resume Fond. – Le relissage laser constitue un des traitements du rajeunissement facial de pratique courante et peut dans certains cas etre une alternative aux techniques traditionnelles, chimiques et mecaniques. Cependant, des complications existent avec une frequence variable, qui tient compte toujours de la selection du patient au depart et des souhaits qu'ils expriment aux praticiens. Objectif. – Faire le point sur la frequence des complications observees au cours de nos huit premieres annees de relissage laser en tenant compte des possibilites preventives. L'experience de l'auteur sera discutee conjointement a une revue de la litterature. Methode. – Analyse retrospective de 749 patients ayant beneficie de relissage laser par un meme operateur avec les lasers CO2 et Erbium. Les effets secondaires et les complications post-operatoires precoces et tardives sont presentes sous forme de tableaux. Resultats. – L'erytheme post-operatoire est constant et regresse habituellement avant la sixieme semaine. L'hyperpigmentation a ete rencontree dans 32 % des cas et doit etre traitee precocement. La dermite irritative est la complication precoce la plus frequente (10,6 %). Des infections sont survenues dans moins 2 % des cas. L'hypopigmentation est rare ( Conclusion. – Le relissage laser par les lasers CO2 et/ou Erbium est une technique efficace et sure moyennant une bonne connaissance de l'interaction laser–tissu. Le plus souvent, des complications de faible importance peuvent survenir et sont rapidement traitees.

Resume La demande de prise en charge du vieillissement facial a evolue. Les patientes souhaitent de plus en plus un rajeunissement « naturel ». L’analyse des modes de vieillissement montre qu’il est important de restaurer les volumes mediofaciaux pour retrouver la plenitude de la jeunesse. De nombreuses techniques ont ete utilisees pour augmenter les volumes centraux. Apres avoir fait l’historique des differents procedes, les auteurs exposent les concepts actuels qui font une large place a la lipostructure ® decrite par Coleman. Cette technique peut etre utilisee seule ou en association a d’autres techniques (lifting, injections…). Les resultats sont encourageants, le procede est simple et rapide. Les suites operatoires sont souvent marquees, mais les complications sont exceptionnelles. Tous ces criteres correspondent aux exigences actuelles de la chirurgie esthetique compte tenu de la pression medicolegale. L’avenir repose sur une amelioration de la predictibilite des prises de greffes en definissant plus precisement les facteurs de resorption du tissu adipeux greffe.

Resume La cicatrisation de l'enfant est exceptionnelle. Lorsqu'il s'agit de cicatrisation par premiere intention, il faut utiliser des techniques chirurgicales qui laisseront le moins de rancon cicatricielle possible et favoriser les surjets intradermiques. En cas de cicatrisation de deuxieme intention, lors de pertes de substance importantes ou de brulures, il faut utiliser la cicatrisation dirigee. Les cicatrices de l'enfant peuvent evoluer suivant un mode hypertrophique ou retractile. Beaucoup plus rarement ces cicatrices peuvent devenir cheloidiennes. Il semble licite de mettre en place des la cicatrisation obtenue tous les moyens qui peuvent prevenir une evolution defavorable. Il faut utiliser les pansements et les vetements compressifs pour eviter l'hypertrophie et les attelles de posture pour la retraction. Si une reintervention chirurgicale doit etre envisagee, en l'absence de problemes fonctionnels, il est preferable d'attendre deux ans apres la lesion initiale, en cas de cicatrices cheloides, il est imperatif de ne realiser que des resections intracheloidiennes.

Split skin graft is frequently needed in the treatment of burned patients. Scalp is often free of burns. Due to its good skin quality and important surface, scalp is a very interesting skin donor site, specially in case of children. A controlled, randomised clinical trial was carried out in 10 French Plastic Surgery or Burns Units. It assessed the efficacy and the acceptability of calcium alginate dressing (Algosteril) versus paraffin gauze dressing (Jelonet) in the treatment of scalp donor sites in children. 67 children (mean age 54 months) entered the study, 34 in the alginate group and 33 in the control group. Follow-up visits were on day 2/d3, d5/d6, Day complete healing, d30 and d60 after surgery. The two groups were comparable on inclusion (demographic characteristics, burn nature and surface, donor site surface and thickness of split skin graft). The mean healing time was 10 and 11 days for Algosteril and Jelonet group respectively (ns). The quality of the newly formed tissue was estimated to permit a sooner skin reharvesting in the Algosteril group than in the control group (p = 0.003). Bleeding through dressing was significantly less important in the Algosteril group (p = 0.02). Changes were considered by investigators less painful with Algosteril on day complete healing (p = 0.0096). Hair growth is homogenous in both groups on day 30 and day 60 (ns). These results showed that scalp is a very interesting skin donor site and that Algosteril is of a real interest in donor site treatment.

Revision rhinoplasty can be very challenging especially in cases of thin skin. Autologous fat graft is utilized in numerous applications in plastic surgery; however, its use relative to the nasal region remains uncommon. Adipose tissue, by virtue of its volumetric qualities and its action on skin trophicity, can be considered to be a gold standard implant. From 2006 until 2012, we have treated patients by lipofilling in order to correct sequelae of rhinoplasty. The mean quantity of adipose tissue injected was 2.1cm(3) depending on the importance of the deformity and the area of injection: irregularity of the nasal dorsum, visible lateral osteotomies, saddle nose. Following the course of our practice, we conceived micro-cannulas that allow a much greater accuracy in the placement of the graft and enable to perform interventions under local anesthesia. These non-traumatic micro-cannulas do not cause post-operative ecchymosis and swelling which shorten the recovery time for the patient. On patients who have undergone multiple operations, lipofilling can be a simple and reliable alternative to correct imperfections that may take place after a rhinoplasty.

Purpose The aim of this study was to report our experience in embolization of high flow peripheral arteriovenous malformations (AVMs) with Onyx. Material and methods Nineteen patients (10 men, 9 women) with peripheral high-flow AVMs who were treated with arteruial embolization using Onyx were retrospectively included. AVMs were located in the head and neck (6), extremities (5), chest (2), kidney (2), uterus (2), pelvis (1) and parietal (1). In 13 patients, embolization was done using Onyx only. One patient underwent embolization by direct puncture, the others by transarterial approach. Embolization was performed in one or multiple sessions (up to 5). A total of 28 sessions were performed. Follow-up was performed with a delay between 10 and 34 months. Results Technical success was achieved in all patients. Complete devascularization was obtained in 12 patients. Surgical excision was performed in 9 patients. Non-target Onyx embolization was not observed. One patient developed stroke. In 1 patient microcatheter fracture occured. One patient presented severe pain and bradycardia during the procedure that disappeared shortly after. One patient had persistent but less frequent epistaxis after embolization. Another patient had persistent pain without improvement. One patient was lost to follow-up. Other patients were free of symptoms on follow-up. Conclusions Embolization with Onyx ® is an interesting option for management of peripheral high-flow AVMs either preoperatively or as a single treatment.

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

Resume La principale critique faite aux techniques de reinjection de graisse porte sur la possibilite ou non de greffer des adipocytes. La solution ideale consisterait a realiser des biopsies quelques mois apres l'intervention afin de connaitre l'evolution du tissu greffe. Cette attitude serait difficile a faire admettre a nos patients. Pour pallier cette difficulte, les auteurs ont rassemble un faisceau d'arguments qui plaident en faveur de la greffe adipocytaire lorsqu'on utilise la technique de Coleman. Les travaux chez l'animal effectues par Peer ont montre qu'il etait possible de realiser une greffe de tissu adipeux et que la resorption etait plus importante lorsque les fragments greffes etaient de grande taille. Les analyses histologiques ont montre que les differentes etapes de la technique de Coleman n'alterent pas la viabilite des adipocytes. Une simple desorganisation de l'architecture lobulaire est observee, ce qui ne va pas a l'encontre de la theorie de greffe adipocytaire. Une etude realisee par imagerie par resonance magnetique sur dix patients a montre une persistance de la graisse reinjectee plusieurs mois apres l'intervention. La graisse presente alors les memes caracteristiques en imagerie que la graisse native juxtaposee. Cette impression a ete confirmee par l'analyse histologique de tissu graisseux reinjecte avec un recul de 18 mois. Enfin, les resultats cliniques obtenus sur plus de 200 patients traites dans des indications variees en chirurgie plastique et esthetique nous permettent de penser qu'il est possible de realiser une greffe de tissu adipeux.

We describe two cases of giant-cell fibroblastoma (GCF) with dermato fibro sarcoma protuberans (DFSP) component, occurring in two children in a chest wall localization. One case recurred 1 year later. The two patients were tumor-free 12 and 8 years later. GCF is a rare mesenchymal cutaneous and subcutaneous tumor reported mostly in the first two decades of life. Dermato fibro sarcoma protuberans, occurring preferentially in adults, is a rare skin tumor with a pronounced tendency to local recurrence. Some cases of association of recurrence of GFC under the form of DFSP have been reported, raising the question of a continuum between the two tumors. The treatment of choice of the two tumors is a wide local excision.

In birth palsy of the brachial plexus, the mixed interference pattern recorded for the brachial biceps on the electromyogram often conflicts with the muscle's inability to flex the elbow. We report our observations of a six-month-old infant who presented paralysis of the upper and medial elements of the brachial plexus, in whom we demonstrated early biceps-triceps co-contractions, which may explain this discrepancy and 'pseudo-paralysis' of the biceps. We analyse and discuss the practical consequences of these findings, and notably the possible therapeutic use of triceps-to-biceps surgical transposition.

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

To evaluate the efficacy of full-field optical coherence tomography to differentiate hypertrophic and keloid scars on ex-vivo tissues.All patients who underwent resection of pathological scar from November 2012 to September 2013 were analyzed. The scars were fixed in formalin and analyzed by conventional histology and full-field optical coherence tomography. The criteria for evaluation were: presence of dermal nodules, presence of cells and hyalinization of collagen.Nineteen pathological scars were analyzed. Histology found 7 keloid scars, 7 mixed and 3 hypertrophic scars. The sensitivity of optical coherence tomography for the detection of dermal nodules was 100%. This technology was not helpful for detection of cells and hyalinized collagen.In the present state of technology, optical coherence tomography did not identify the presence of cells, which makes the differential diagnosis difficult in the case of hypertrophic and keloid scars.

Systemic sclerosis is a disorder involving the connective tissue, arterioles and microvessels. It is characterized by skin and visceral fibrosis and ischemic phenomena. Currently, therapy is limited and no antifibrotic treatment has proven its efficacy. Beyond some severe organ lesions (pulmonary arterial hypertension, pulmonary fibrosis, scleroderma renal crisis), which only concern a minority of patients, the skin sclerosis of hands and face and the vasculopathy lead to physical and psychological disability in most patients. Thus, functional improvement of hand motion and face represents a priority for patient therapy. Due to its easy obtention by fat lipopaspirate and adipocytes survival, re injection of adipose tissue is a common therapy used in plastic surgery for its voluming effect. Identification and characterization of the adipose tissue-derived stroma vascular fraction, mainly including mesenchymal stem cells, have revolutionized the science showing that adipose tissue is a valuable source of multipotent stem cells, able to migrate to site of injury and to differentiate according to the receiver tissue's needs. Due to easy harvest by liposuction, its abundance in mesenchymal cells far higher that the bone marrow, and stroma vascular fraction's ability to differentiate and secrete growth angiogenic and antiapoptotic factors, the use of adipose tissue is becoming more attractive in regenerative medicine. We here present the interest of adipose tissue use in the treatment of the hands and face in scleroderma.

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