Dermal substitute: a safe and effective way in surgical management of adults post-burn dorsal foot contractures

OBJECTIVE

Neglected dorsal foοt burns may result in typical fοrefοοt defοrmities characterised by cοntractures leading tο hyperextensiοn οf the tοes and gait disturbance. These defοrmities usually cause a significant impairment in daily activities and difficulty in wearing shοes. This article presents a recοnstructiοn series οf severe fοrefοοt defοrmities by means of dermal regeneratiοn templates (also known as dermal substitutes) and split thickness skin grafts.

PATIENTS AND METHODS

We retrοspectively reviewed οur institutiοnal burn database from 2010 to 2020 focusing on all those dοrsal fοοt cοntractures treated with the use οf a dermal regeneratiοn template. The patients' demοgraphics, burn injury mechanisms, depth, lοcalizatiοn, surface, treatments and fοllοw-up were described.

RESULTS

Twelve patients underwent this prοcedure and the mean affected area was 75 cm2. The mean time between the dermal regeneratiοn template applicatiοn and the split thickness skin graft was 19.6 days. Just fοr one patient, an additiοnal skin grafting prοcedure was required. The mean fοllοw-up was 4.6 years. We did not register specific cοmplicatiοns at bοth the recipient (forefoot) and dοnοr sites (scalp). All patients were able tο wear shοes and walk after the procedure. Nο recurrence οf cοntractures were οbserved. All patients were satisfied with cοsmetic results, and they did not request any additiοnal prοcedure οf cοsmetic imprοvement.

CONCLUSIONS

The use οf the dermal regeneratiοn template can be cοnsidered as an extremely safe and efficient treatment οf severe post-burn fοrefοοt defοrmities.

[Buried chipped skin grafts for patients in failure of treatment]

Local conditions can lead to a failure of traditional skin grafts. We propose here our technique about the realization of autologous skin graft using it buried chipped grafts, for wounds in failure of treatments or at risk of failure. The protocol includes cutting the skin graft within little squared pieces of a few millimeters of length, that are then buried directly deep into the wound. We can then obtain little islands of epidermisation on the random places of the wound that will heal by confluence of those epidermal islands.

Brûlures Profondes Des Membres Inférieurs Chez Les Patients Diabétiques: À Propos De 30 Cas

We checked the files of 30 inpatients with diabetes and deep burns to the lower limbs. We looked for a diabetes-related neuropathy (60% had one), the context of the accident, the topography of burns, any delays before the first and possible subsequent surgeries, the length of stay, and return to walking, if achieved. Burns mostly involved distal parts of the lower limbs, were thermal in 90% with an intentional action in 43%, and frequently occurred in a bathing room (48%) during a footbath (54%). Mean time to the first surgery was day 3,35 and, when needed, the second one was performed 6,54 days later. Mean LOS was 14,6 days, eleven patients were walking again by this time. We found a significant (p<0.001) association between the time to the 1st surgery and time elapsed between the burn and hospitalization. The existence of a diabetes-related neuropathy is a risk factor of lower limb burns, provided it suppresses the alarm of pain. Early surgery seems to reduce the LOS.

Dunnigan lipodystrophy syndrome: French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins)

Dunnigan syndrome, or Familial Partial Lipodystrophy type 2 (FPLD2; ORPHA 2348), is a rare autosomal dominant disorder due to pathogenic variants of the LMNA gene. The objective of the French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins), is to provide health professionals with a guide to optimal management and care of patients with FPLD2, based on a critical literature review and multidisciplinary expert consensus. The PNDS, written by members of the French National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity (PRISIS), is available on the French Health Authority website (in French). Dunnigan syndrome is characterized by a partial atrophy of the subcutaneous adipose tissue and by an insulin resistance syndrome, associated with a risk of metabolic, cardiovascular and muscular complications. Its prevalence, assessed at 1/100.000 in Europe, is probably considerably underestimated. Thorough clinical examination is key to diagnosis. Biochemical testing frequently shows hyperinsulinemia, abnormal glucose tolerance and hypertriglyceridemia. Elevated hepatic transaminases (hepatic steatosis) and creatine phosphokinase, and hyperandrogenism in women, are common. Molecular analysis of the LMNA gene confirms diagnosis and allows for family investigations. Regular screening and multidisciplinary monitoring of the associated complications are necessary. Diabetes frequently develops from puberty onwards. Hypertriglyceridemia may lead to acute pancreatitis. Early atherosclerosis and cardiomyopathy should be monitored. In women, polycystic ovary syndrome is common. Overall, the management of patients with Dunnigan syndrome requires the collaboration of several health care providers. The attending physician, in conjunction with the national care network, will ensure that the patient receives optimal care through regular follow-up and screening. The various elements of this PNDS are described to provide such a support.

Repair Of Palm Burns Of The Hand: A Contralateral Inner Arm Bag-Shaped Flap

Hands are one of the most often burnt parts of the body. Deep palmar burns are often the result of an electrical burn or a thermal burn from grasping a hot item. With a deep burn, joints, vasculo-nervous pedicles, tendons or bones can become exposed and lead to amputation. Different surgical repair methods are used depending on the area of the hand that is burnt. Most of the publications to date have described surgical techniques for dorsal hand burns. The abdominal bag-shaped flap is one of the main surgical techniques to cover dorsal deep tissue exposure. Bag-shaped flaps need time to achieve the vascular autonomy of the flap without any movement. Abdominal bagshaped flaps are particularly suitable for dorsal soft-tissue defects, while for palmar defects, it is an uncomfortable position to maintain for three weeks. A contralateral arm bag-shaped flap for palmar burns allows a comfortable position to be achieved as the upper burnt limb is positioned as if the patient has their arms crossed. Furthermore, as stated above, the contralateral arm bag-shaped flap has the advantage of allowing a flap to be used that is thinner than an abdominal bag-shaped flap. At the Saint Louis Burns Center, we recently treated two patients with deep palmar burns and deep tissue exposure. We performed a contralateral arm bag-shaped flap for both of these patients. In our experience, the use of the contralateral arm bag-shaped flap technique to cover palmar lesions resulted in favorable postoperative progression, with complete closure of the lesions, good functional outcomes, as well as other advantages such as a hidden scar at the donor site. This technique allows amputation of fingers to be avoided when pedicles, joints, or tendons are exposed and when the burnt area of the palm is extensive and no other flaps can be used.

Head and neck skin expansion: assessment of efficiency for the treatment of lesions in the lower half of the face

The treatment of sequelae for burns or other loss of perioral tissues is complex due to the site where they occur, its functional importance, and social and esthetic aspects. Functional consequences of burns to this area are cutaneous retraction and a lack of skin that can lead to an inability to close the oral aperture, compromising the provision of dental hygiene and intubation procedures. The aim of the present publication was to evaluate the efficacy of chin, labial and jugal cutaneous expansions for the treatment of perioral lesions and lesions of the lower half of the face in our retrospective series of patients. We collected data and photography from digital files for each patient. Proportion of scarred skin that could be treated by one or several expansion procedures was evaluated. The main outcome was the resection of 50% or more initial lesions. Side effects were assessed. Out of a total of 33 expanders, 28 were at the jugal level, 5 were chin expanders, and none were labial expanders. This equated to the inclusion of fourteen patients. The average percentage of the lesion that was removed after the perioral expansion protocol was 68.9% (40%-100%). 85% of patients had a positive outcome. 12% of procedures were complicated by hematoma, infection or prosthesis exposure. Each time that the lesional area could be fully (i.e. 100%) treated, only a single expansion was used. Head and neck expansion is the technique of choice for reconstruction of the lower half of the face and the horizontal part of the neck in terms of efficiency and safety.

[Quick screening for Body Dysmorphic Disorder in a plastic surgery population in France]

INTRODUCTION

All plastic surgeons are frequently faced with patients with Body Dysmorphic Disorder (BDD). However, no screening test exists in French to help the plastic surgeons to diagnose this disease. The Body Dysmorphic Disorder Questionnaire (BDDQ) is the Gold Standard to easily detect BDD in consultation with any non-psychiatric physician. The aim of this study was to translate and validate the BDDQ into French to help plastic surgeons to detect BDD before the surgery. This way, plastic surgeons will be able to provide an optimal medical care and to reduce the risk of psychiatric collapse.

METHODS

We asked Katherine Philipps for her approval to use her BDDQ for our study, and thereafter we translated it respecting the criteria of the World Health Organization. We first evaluated the psychometric qualities of the BDDQ in French and then its reproducibility and its sensitivity to change.

RESULTS

A French version of the BDDQ appeared to be reliable and comprehensible. The questionnaire has been tested on a sample of patients in plastic surgery consultation, at a T moment and a T plus one month to certify its reproducibility and its sensitivity to change.

CONCLUSION

These results permit to claim that the French version of the BDDQ is now validated to detect patients with a BDD in a plastic surgery consultation.

Reconstruction Of The Burnt Nose Using A Carved Flap In Four Cases

Techniques for reconstructing nasal defects in burns are very limited because the surrounding scar tissue makes it difficult to use local flaps. The authors report their experience using the Converse scalping flap harvested from scarred skin, placed as a mass on the nasal area, then secondarily carved to shape the nose and covered by a skin graft. This is a retrospective study of 4 patients, 3 men and 1 woman, with an average age of 45 years, who were operated on between 1994 and 2013 using this technique for postburn nasal reconstruction. Patients had 45% burns on average. The flap was weaned from its donor site at the third week and the frontalis donor area grafted. Several months later, the flap was sculpted from the outside to the inside in the three dimensions, removing the scarred epidermal areas to restore the aesthetic units of the nose, which were grafted using a full thickness skin graft. The final aesthetic result of the nasal reconstruction was evaluated by the patient and the surgical team. The four nasal reconstructions were carried out to completion. Three were rated as 'very good' (75%) and one was rated as 'good' (25%). The Converse flap modification, referred to as the "carved flap", to reconstruct the burned nose is a reliable technique, possible on a scarred forehead with no additional donor site morbidity.

Electrical Burns and Late Spontaneous Artery Ruptures: About Three Cases

Electrical burns are responsible for arterial and venous thrombosis, as well as weakening of the arteries. Immediate or delayed arterial occlusions, secondary to the aggression of the intima, or aneurysms, secondary to the aggression of the media, sometimes lead to artery ruptures without any warning signs. Such ruptures may trigger a hemorrhagic shock whose period of onset is variable and unpredictable. We are presenting here three cases treated in our department for electrical burns, whose complications were marked by hemorrhagic shock, secondary to late artery ruptures, sometimes occurring several months following the event. These case reports required performance of emergency hemostasis in order to control sudden bleeding, with first approach being placement of a tourniquet at the base of the limb and/or a compression point. Through these cases, we thought it is crucial to closely monitor for a few weeks all patients who were victims of electrical injury, even more so if it was associated with a compartment syndrome of one or more limbs and high rhabdomyolysis, which seem to be predictive factors of late artery ruptures in our case reports.

[Complications with surgical treatment of basal cell carcinomas in individuals over 75 years of age: A retrospective study of prognostic factors in 158 cases]

INTRODUCTION

Basal cell carcinoma (BCC) is a pathology that evolves locally and it is common in elderly subjects whose frailty could restrict the indications for the reference treatment, which is based on surgery. The aim of this study was to investigate the morbidity and the mortality associated with surgical treatment of BCC in patients over 75 years of age, so as to identify possible prognostic factors for postoperative complications.

MATERIALS AND METHODS

This was a retrospective study carried out with patients over 75 years of age who were treated surgically for one or several BCC between 2010 and 2015 in the reconstructive and cosmetic plastic surgery unit of the Saint-Louis Hospital in Paris (France). We collated the demographic characteristics, the characteristics of the treatment, as well as the rate of major postoperative complications. We performed a univariate and then a multivariate analysis of the various risk factors that were identified.

RESULTS

A total of 158 patients were analyzed and they exhibited a rate of major complications of 12%. The statistical analysis identified five significant risk factors: being over 85 years of age (P=0.006), long-term use of anticoagulant treatment (P=0.02), the presence of at least one comorbidity (P=0.018), a conventional hospitalization (P=0.002), and the use of general anesthesia (P=1.2e^-10).

CONCLUSION

Five risk factors for major postoperative complications with the surgical treatment of BCC in patients over 75 years of age were identified. These factors may provide direction to medico-surgical teams in regard to the optimal treatment of BCC in elderly patients.

Design, characterization and in vivo performance of synthetic 2 mm-diameter vessel grafts made of PVA-gelatin blends

Since the development of the first vascular grafts, fabrication of vessel replacements with diameters smaller than 6 mm remains a challenge. The present work aimed to develop PVA (poly (vinyl alcohol))-gelatin hybrids as tubes suitable for replacement of very small vessels and to evaluate their performance using a rat abdominal aorta interposition model. PVA-gelatin hybrid tubes with internal and external diameters of 1.4 mm and 1.8 mm, respectively, composed of 4 different gelatin ratios were prepared using a one-step strategy with both chemical and physical crosslinking. By 3D Time of Flight MRI, Doppler-Ultrasound, Computed Tomography angiography and histology, we demonstrated good patency rates with the 1% gelatin composition until the end of the study at 3 months (50% compared to 0% of PVA control grafts). A reduction of the patency rate during the time of implantation suggested some loss of properties of the hybrid material in vivo, further confirmed by mechanical evaluation until one year. In particular, stiffening and reduction of compliance of the PVA-gelatin grafts was demonstrated, which might explain the observed long-term changes in patency rate. These encouraging results confirm the potential of PVA-gelatin hybrids as ready-to-use vascular grafts for very small vessel replacement.

[Not Available]

Chemical burns raise diagnostic and treatment issues because they have specific appearances and evolution. Our objective was to study the characteristics of chemical burns and to assess the quality of our treatment. This retrospective observational study examined the records of all patients admitted for chemical burns to the burn treatment center of Saint Louis Hospital in Paris from January 1, 1990, through December 31, 2015. During this period, 162 patients came to our center for chemical burn treatment. Most of them were men (67%). The majority of the burns were caused by alkalis (27%) and resulted from workplace accidents (29%). The average time before consultation was 5.36 days. The areas mainly damaged were the hands (36%) and the burn areas averaged 1.2% of the total body surface area (TBSA). Forty-eight patients had at least one deep patch. In total, 59 patients (36.4%) were hospitalized for an average duration of 4.18 days. Thirty-eight of them underwent surgery. Lastly, 92% of the operations had been anticipated from the first consultation. In our center, the population affected, the circumstances and the topography of our patients' burns were similar to the data from the literature. It appears that the principal specificity of our series is a very low body surface burned. This can be attributed to the prevention measures we have in France and underlines their importance. Only 8% of the patients who had surgery were underestimated or their burns became deeper secondarily. This number is lower than the data from other series.

Our 35 years' experience on postburn heterotopic ossification: A three-step treatment

Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment - excision surgery, early rehabilitation, and antalgia - seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

[Not Available]

The hands are the most commonly affected area in burn injuries and are involved approximately 80% of the time. Because of the thinness of the skin and superficial location of critical structures, the dorsum of the hand needs an optimal coverage to preserve maximum articular mobility and range of motion. The aim of this article is to detail the therapeutic alternatives to skin graft in cases of very deep burns on the dorsum of the hand, and to specify the indications. We reviewed all articles referenced on PubMed, and included all the original articles related to the management of acute burned hands and their different coverage techniques (dermal substitutes and flaps). We excluded articles that dealt only with skin grafting techniques, as well as articles about secondary management (sequelae and reconstruction). One hundred and sixteen articles were found and twenty of these were selected. Alternatives to full-thickness skin grafting are dermal substitutes (Alloderm®, Matriderm®, Integra®) and flaps. In cases of immediately usable autologous donor sites, the combination Matriderm® with a thin skin graft is preferred. Otherwise, we use Integra®. In cases of deep exposure of critical structures and doubtful vascularization quality on the wound, flaps can be discussed (cross-arm, abdominal wall flap…).

[Study of satisfaction concerning the navel after abdominal dermolipectomy with transposition: A report of 96 cases]

GOAL OF THE STUDY

The umbilicus has a major role in the aesthetics of the anterior abdominal wall. Many publications deal with abdominal dermolipectomies but few focus on umbilicoplasty. However, these are essential in assessing the aesthetic result. Umbilicoplasty in "aile de mouette" used in our service is reliable and easily reproducible. In this article, we evaluate the satisfaction of patients with abdominal dermolipectomy with this technique of transposition.

MATERIALS AND METHOD

In the plastic surgery department of the Saint-Louis Hospital in Paris, we carried out a retrospective study of patients undergoing abdominal dermolipectomy with transposition of the umbilicus, between 1 January 2012 and 31 December 2012. All patients were operated according to our technique of umbilicoplasty: disinsertion of the umbilicus in V, reinsertion of the umbilic in "aile de mouette", a degreasing periumbilical associated with a plication of the umbilical stem. The complications identified in patients medical records and satisfaction were assessed by a telephone questionnaire.

RESULTS

Ninety-six patients were included. No patient presented umbilical necrosis. The overall result of umbilical transposition was considered good to excellent for 92.7% of patients.

CONCLUSION

Umbilicoplasty in gull wing has many advantages: it is a simple, easily reproducible, reliable technique, the patients of which are for the most part very satisfied.

[Reconstruction of abdo-perineal resection by Taylor flap: About 68 patients]

PURPOSES

Healing after abdomino-perineal resection is often difficult, especially in patients who have undergone radiation therapy. Vaginal reconstruction is also an important issue for the women who undergo this surgery. We describe and analyze here our series of perineal reconstructions with modified Taylor flaps. Between 2010 and 2016, 68 patients (52 women, 16 men) with cancer of the anal canal (53), adenocarcinoma of the lower rectum (9), or other malignant neoplasms of the perineum underwent reconstruction with a rectus abdominis myocutaneous (RAM) flap with an inferior pedicle and an oblique skin paddle.

RESULTS

This review of records showed that all patients healed, with a median of 30 days. The reoperation rate was 11.7% including 1 for eventration. The principal causes for delayed healing were scar dehiscence, abscess, and partial necrosis. No flap required removal, however. The mean duration of hospitalization was 23.7 days.

CONCLUSION

Modified Taylor flaps substantially improved the reconstruction of defects resulting from abdomino-perineal resection. They enabled complete and rapid healing with low comorbidity.

Burns caused by electronic vaping devices (e-cigarettes): A new classification proposal based on mechanisms

Introduction With more than 10 million of daily users, e-cigarettes encountered a great success. But in the past few years, the number of medical reports of injuries caused by the explosion of e-cigarettes has significantly increased. This article aims at reporting our series and reviewing the literature to propose a new classification based on the mechanisms of injuries related to e-cigarettes that can guide non-specialists and specialists in the management of these patients. Method We performed a retrospective review of our institutional burn database from June 2016 to July 2017 for injuries caused by or in the context of using an e-cigarette. The patients' demographics (age, gender), burn injury mechanisms, depth, localization, surface and interventions were described. Results Ten patients suffered from burns related to the use of e-cigarettes. The burns were located at the thigh (80%) and the hand (50%) with a mean surface of 3% of TBSA. Four different mechanisms could be described: Type A: thermal burns with flames due to the phenomenon of "thermal runaway", Type B: blasts lesions secondary to the explosion, Type C: chemical alkali burns caused by spreading of the electrolyte solution and Type D: thermal burns without flames due to overheating. These different mechanisms suggest specific surgical and non-surgical management. Conclusion Management of injuries sustained from e-cigarettes' explosions should be approached from the standpoint of mechanisms. Different mechanisms could be associated and should be considered in specific management.

Intraoperative instillation of ropivacaine during the placement of sub-muscular cosmetic breast implants: Is there a clinical benefit?

INTRODUCTION

The sub-muscular placement of cosmetic breast implants leads to substantial pain due to the muscular distention. The aim of this study was to assess the efficiency of intraoperative ropivacaine instillation to reduce postoperative pain the day after surgery.

MATERIAL AND METHODS

We conducted a prospective, controlled, single-blinded study comparing the intraoperative instillation of 7.5mg of ropivacaine through Redon drains with the standard procedure in 72 patients undergoing sub-muscular cosmetic breast augmentation for the first time.

RESULTS

Pain at the awakening on postoperative day 1 was 4.8 on a simple numeric pain scale in the treatment group and 5.1 in the control group (P>0.05). On postoperative day 3, pain at awakening was 3.7 in both groups (P>0.05), and on postoperative day 5, pain was 2.8 in the treatment group and 2.7 in the control group (P>0.05).

CONCLUSION

Local instillation of ropivacaine in the implant pocket during surgery did not decrease postoperative pain on day 1, day 3 and day 5. From now on, we are able to tell to patients that the postoperative pain after sub-muscular cosmetic breast implants surgery is about 5/10 on postoperative day 1, 4/10 at day 3 and 3/10 at day 5.

LEVEL OF EVIDENCE

Level II.

Pressure guided surgery of compartment syndrome of the limbs in burn patients

Compartment syndrome is a serious complication of high voltage electrical burns, limb carbonization and deep circular burns with delayed escharotomy. Without treatment, ischemic tissue damage leads to irreversible necrosis. Treatment is emergency surgical decompression. The burned patient is usually not searchable and cannot always be readily examined because of bulky dressings; diagnosis of compartment syndrome is always hard to make. The pressure transducer used in central arterial catheters is easy available. We used it to measure pressure in muscular compartments. We measured compartment pressure three times at different depths in all cases of electrical burn, carbonization and deep circumferential burns with delayed escharotomy. We also took the pressure in the uninjured limb. The pressure assessment device was composed of a blood pressure transducer commonly used in arterial catheters for arterial pressure monitoring with three connecting branches. The first branch was connected to the 'arterial pressure exit' in the monitoring device. The second, an IV tube, was connected to one litre of physiological serum in a pressure bag inflated to 200 mmHg. The third, also an IV tube with a sterile extension cable, was directly connected to an 18G standard straight needle to be inserted in the tissues for which interstitial pressure had to be measured. In patients with thermal burns, we measured pressure before and after escharotomy. Threshold intracompartmental pressure was 35 mmHg. We carried out pressure assessment of all muscular compartments during and at the end of surgery. The pressure transducer provides a pressure value in all muscular compartments with a time of installation and measuring of less than 5 minutes. Sensitivity is measured at +/- 1 mmHg. Operation is simple, non-operator dependent, and accessible to medical and paramedic teams. The pressure transducer allows accurate diagnosis of early or established compartment syndrome. It requires no additional equipment and its application does not delay therapeutic management. Its use helps with fasciotomy decision, especially after escharotomy, guides the surgeon in the exploration of different compartments and verifies the effectiveness of surgery.

[Not Available]

Split-thickness meshed skin graft is frequently used in the treatment of acute burns. We studied the effect of the type of basement preparation on graft intake and healing time. We retrospectively analysed 1,129 meshed grafts used in the treatment of acute burns between 1995 and 2005. Intake was significantly better after avulsion (82%) than after tangential excision (75%). Intake was better if avulsion was performed before day 7 (83% vs. 73%). A trend for better intake after tangential excision was seen when performed between day 7 and 21. Healing time was significantly shorter after tangential excision. These results show the paradox that avulsion favours graft intake but delays healing time, contrary to tangential excision.

[Major chest wall resection for the treatment of invasive breast carcinoma: A series of 33 patients]

INTRODUCTION

Breast cancer can spread to the chest wall. It is an aggressive stage of poor prognosis. We have developed a technique of major chest wall resection extended beyond the breast area in order to reduce the recurrence.

PATIENTS AND METHODS

This is a retrospective single-center series of 33 patients with breast cancer spread to the chest wall without metastasis (13 patients present with primary breast cancer and 20 patients present with recurrent breast cancer) treated by major chest wall resection between January 1993 and January 2013, by the same surgeon. Analysis of the results was made by another surgeon.

RESULTS

Patients aged between 27-83years with an average of 55years. The removed parts measured 350cm(2) to 1200cm(2), and the average duration of complete healing was 7.9months. The mean follow-up time was 122months (6months-240months). The 1 year survival was 84.4%, at 2years 72.6%, at 3years 69.5% and at 5 years of 66.4%.

CONCLUSION

The technique of major chest wall resection is simple and reproducible. Breast cancer with chest wall extension has a poor prognosis. At the end of the study, 20 of 33 patients who benefit from this technique are still alive.

[T plasty for the treatment of skin forehead defects]

INTRODUCTION

The closure of the skin defect of the forehead area with local flap must prevent the distortions of the eyebrow and hairlines and must limit the visibility of the scars. The H plasty is the most common procedure to treat this kind of defect but the scars are extensive and numerous. The H cutaneous flap presents necrosis risks if the skin is thin and the defect important. The H musculocutaneous flap presents sensitive and motors lesions risks. The T cutaneous flap is a good choice because of its excellent cosmetic result and minimized risks.

MATERIALS AND METHODS

Twenty-six patients have been treated by the same surgeon between 2006 and 2012 with T cutaneous flap in order to treat forehead and temples' skin defects (the surface goes from 1.5 to 15cm).

RESULTS

Excisions were completed in the every 26 cases. We had excellent cosmetic result and no complications such as necrosis, infection, sensitive and motor troubles after the surgery.

DISCUSSION

The T plasty is easy for treating skin forehead defects. The scars are 25% less extensive than with a H plasty. The T flap permits to treat important defects without distortion or risks.

CONCLUSION

The T cutaneous flap can easily substitute the H plasty for the forehead and temples reconstruction with no risks but good cosmetics results.

[Reconstruction of transfixing loss of substance from the wing of the nose by composite graft of the controlateral nostril: about three cases]

INTRODUCTION

Reconstruction of the loss of transfixing substance from the nose wing is one of the most difficult procedures in facial plastic surgery. We propose a new technique consisting of a composite graft of the controlateral nostril among patients having an asymmetry of the nostrils.

PATIENTS AND METHODS

A clinical study was carried out on three patients who had undergone a composite nasal graft. The graft was harvested from the nostril controlateral to the nasal defect then placed at the level of the previously prepared affected nostril.

RESULTS

Three patients aged 27, 37 and 39years respectively received a controlateral nasal composite graft for the treatment of transfixing substance loss of the nose wing of less than 1cm. In all three cases, the result was judged to be very satisfactory by the surgeon and by all the patients.

CONCLUSION

The controlateral nasal composite graft is a straightforward, quick and reliable technique to treat small losses of transfixing substance from the nose wing. However, because of an uncertain cicatricial ransom of the donor site, this technique must be compared to the auricular composite graft that is the technique of reference.

Female sexual function after abdominoperineal resection for squamous cell carcinoma of the anus and the specific influence of colpectomy and vertical rectus abdominis myocutaneous flap

AIM

Abdominoperineal resection (APR) is the only curative treatment for recurrent or persisting squamous cell carcinoma of the anus after radiochemotherapy. A vertical rectus abdominis myocutaneous (VRAM) flap reduces perineal morbidity. The sexual life (SL) of women after APR is unknown. Aims of this study were to evaluate SF of women after APR.

METHOD

47 women alive after APR performed between 1996 and 2007 were included. SL was evaluated using the female sexual function index (FSFI) score.

RESULTS

29 (62%) women answered the questionnaire: 15 (52%) had a VRAM and 16 (55%) a colpectomy. Among the 21 patients with SL before surgery, 16 (76%) still had intercourse with a mean FSFI score of 19.5 ± 10.9 [4.8-36]. Main difficulties reported were troubles of lubrication, orgasm, and dyspareunia. Confection of a VRAM did not influence the recovery of SL (P = 0.717). Colpectomy reduced return of SL (P = 0.026).

CONCLUSION

Among women who had SL before APR, 76% still had sexual intercourse after. Colpectomy seems to reduce SL.

[Principles of the local treatment: Surgical processing]

The deep burns require a surgical treatment. The third degree circular burns require escharotomies and sometimes fasciotomies to avoid vascular compression. Early burn wound excision permits to remove the necrotic tissue that produce toxins and encourage infection. Wound coverage by an autologous split-thickness skin grafting, meshed or not, usually leads to a correct scar quality. In severe burns, when donor's sites are limited, the homografts permit to pass a critical stage even though they are rejected secondarily. The keratinocytes culture remains a difficult and exceptional technique for very severe burns permitting to save their life but with poor cosmetic results. Artificial dermal substitute could sometimes permit to replace the homograft and to improve the cosmetic results of the grafts by a better reconstitution of skin. If early burn wound excision with autologous split-thickness skin grafting remains the gold standard, the tissue-engineering will be a future way for the surgical treatment of the burns.

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection

BACKGROUND

Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection.

METHODS

Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy.

RESULTS

Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months).

CONCLUSION

The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

Steroidal hormones and proliferation, differentiation and apoptosis in breast cells

The impact of estrogens (E) and progestins (P) on the breast is crucial. Recent epidemiological studies raised a great concern concerning breast cancer risk and hormone replacement therapy (HRT). However, the effects of HRT in breast tissue remain unclear. Biological data predominantly show that P are antiproliferative and proapoptotic at least for normal breast cells. These antiproliferative effects of P are well described at the cellular level. Whereas E2 increases the level of the various cyclins involved in the cell cycle progression and decreases the cyclin kinase inhibitors, p21 and p27, progestins act in an opposite manner. In addition, they both modulate the phosphorylated rate of Rb involved into the S phase progression. Various proteins of the apoptotic cascade are also targets for E2 and P. We showed that bcl-2, p53 and caspase 3 are oppositely modulated by E2 and P in normal and breast cancer cell cultures. It is very possible that in vivo the balance between E2/P, the type of P, specific phenotypes could explain increasing risk during HRT, which appears to be mainly a promoter effect on preexisting transformed cells.

[Plastic surgery and obesity: why, when, how?]

In this review, we describe the main surgical procedures used in the plastic surgery of obesity: lipectomies and removal of excess fat tissues after weight loss, liposuction of localised fat deposits, surgery of breast hypertrophies. The main surgical procedures, their indications, their techniques and their long-term results are described. Such surgery should be part of a coherent and structured therapeutic project, defined together with the patient. The management and follow-up should be maintained on the long term after the initial weight loss and the surgical procedure, in order to reinforce the benefit and to prevent a weight regain.

[Skin, wrinkles and botulinum toxin]

OBJECTIVE

To present an up-to-date analysis about the use of botulinum toxin for treating facial lines and wrinkles.Method. - A systematic search of the literature was conducted to select the most recent or relevant publications on this topic, through Medline.

RESULTS

Out of the 583 articles retrieved, 90 were finally selected for the study.

DISCUSSION

Validity of using botulinum toxin for cosmetic use is demonstrated, together with contra-indications and different methods to objectivate the results. The different available types of toxin are presented and compared. Modalities of preparation, conservation, and waste disposal are detailed. Anatomical bases of muscular facial balance are reviewed, with techniques of injection presented for each site, and also with adjunctive procedures. Complications and side effects are described and analysed. Most complications can be prevented through: perfect knowledge of local anatomy;use of small volumes;orientation of the needle bevel towards the muscle body, injection within the muscle body if thick, more superficial if thin;application of ice on the skin pre- and post-injecting. Adding epinephrin or diluting with xylocaïne and epinephrin is not commonly used.

CONCLUSION

Botulinum toxin has found its way as a major component of the therapeutic armamentarium. Its efficacy for facial rejuvenation has made it extremely popular, but its use does follow strict rules, and should be restricted to soundly trained practitioners.

How long can cryopreserved skin be stored to maintain adequate graft performance?

Skin graft preservation for the purpose of delayed application is still a basic tool in burn treatment and plastic and reconstructive surgery. As the demand for skin allografts has increased the responsibility for processing, storage and evaluation of graft performance of preserved skin has become an important issue of banking organizations. The present experiments were undertaken to determine how long can cryopreserved cadaveric skin be stored to maintain adequate graft performance? We applied a mouse recipient model, developed by us: Human cadaveric skin cryopreserved and stored for 5,6 or 7 years was grafted on Balb/c mice, and primary take was evaluated by gross observation and predetermined histologic criteria after 7 days. The results demonstrate that graft performance of cryopreserved skin decreased with time, as reflected in the lower percent of samples with high score of separate histologic criteria after prolonged storage. Nevertheless, paired comparison analysis between cryopreserved and fresh skin indicated that this decrease was not significant for storage of 5 years; whereas it was highly significant for 6 years of storage. Linear regression analysis indicated that there was no correlation between the score of the histologic criteria and storage period for upto 65 months. These results are in line with the paired comparison analysis. We feel that our in vivo model and analysis may be used as an evaluation procedure for transplantation performance of banked skin.

Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results

A retrospective study was done on a population of 258 women who had undergone surgery for abdominal dermolipectomy between January of 1991 and May of 1996. The postoperative complications and flaws seen at long-term follow-up are discussed. The surgical techniques used, with or without lipoaspiration, were the infraumbilical plasty and full plasties with horizontal or inverted T scars. Six types of postoperative complications were noted: hemorrhage in 1.2 percent, lymphorrhea in 10.9 percent, infection in 7 percent, skin necrosis in 6.6 percent, secondary dehiscence of the scar in 2.3 percent, and thromboembolic accidents in 1.2 percent. No significant difference was found in the rate of necrosis development between patients who did and did not undergo lipoaspiration. However, a statistically significant difference was seen in the rate of skin necrosis between the T-type plasty (35.5 percent) and the other two procedures (1.43 percent for infraumbilical plasties and 4.60 percent for full plasties with horizontal scar). With regard to the flaws found at long-term follow-up, the rate of above-scar fat folds and/or dog-ears was 27.9 percent, and the rate of defective scars was 26 percent. No significant difference was found with regard to the rate of flaws. The rate of all secondary surgical procedures was 29.1 percent, but performance of secondary procedures depended on the willingness of the patient and on the surgeon's judgment. Abdominoplasty procedures involve a high risk of early complications. The rate of skin necrosis is clearly augmented in cases of T-type plasty. The need for secondary surgical correction is frequent, and the patient should be reminded of this possibility during preoperative consultation.

Hormonal regulation of apoptosis in breast cells and tissues

Few studies have referred to the implication of apoptotic processes following hormonal treatment. No data are available on the effects of progesterone in breast cells. In order to gain insights on the effects of the gonadal steroids and antiestrogens in breast cells, we have carried out studies on apoptosis in different breast materials. We have developed a model of normal breast cells in cultures that remain hormone-dependent. On these cells and in some hormone-dependent breast cancer cell lines (T-47-D, ZR75-1, MCF-7) we have observed an antiapoptotic effect of estradiol (E(2)) and a potent proapoptotic effect of some antiestrogens. Progestins were also proapoptotic in normal as well as in hormone-dependent breast cancer cells. In order to understand the mechanisms of these hormones on apoptosis, we studied the bcl-2 family proteins. We demonstrated that E(2) increased the antiapoptotic proteins, bcl-2 and bclx(L), whereas, the progestins drastically decreased bcl-2 expression and weakly bclx(L) levels. We investigated the mechanisms by which E(2) increased bcl-2 expression. Our results using quantitative RT-PCR showed that E(2) increased bcl-2 mRNA levels at 48 h of treatment via a transcriptional mechanism. None of the hormone treatments altered the proapoptotic protein levels, bax and bak. We also studied the in vivo expression of bcl-2 and other members of its family in biopsies of normal breast tissues according to the menstrual cycle. Bcl-2 displayed a strong cyclical variation and seemed to be the most hormone-dependent member of the family.

The Israel National Skin Bank: Quality Assurance and Graft Performance of Stored Tissues

The Israel National Skin Bank (INSB) was founded jointly by the Israel Defense Forces (IDF) Medical Corps and the Ministry of Health in 1986. The prime purpose of the Skin Bank is to treat burn victims incurred at war or during mass casualty incidences. The INSB Protocol is comprised of international skin bank protocols and our previous and present research results. They provide the framework for selecting optimal guidelines for procurement, processing, preservation, storage and evaluation of transplantation performance of viable skin grafts. For evaluation and direct comparison of graft performance of glycerolized or cryopreserved skin stored for long periods, we have applied a mouse recipient model developed by us. This model assesses graft performance before the rejection process takes place. The in vivo design has inherent clinical relevance, which is especially appealing. Cryopreserved skin performed better than glycerolized skin (p > 0.027), but fresh skin performed significantly better than cryopreserved skin (p > 0.003), as analyzed by the Mann-Whitney non-parametric test. Then graft performance of skin specimens were cryopreserved by programmed or stepwise freezing and stored at -80 degrees C or in liquid nitrogen for 1 and 6-10 months was evaluated. The average score of skin preserved by programmed freezing and stored in liquid nitrogen is the highest for both storage periods. This method has a highly significant advantage (p < 0.007) over the others for 6-10 months storage, evaluated by graft adherence. Several interaction factors determine the quality of cryopreserved skin. Highly significant is the interaction factor/'combined effect' of sample variability with the method of cryopreservation or with the storage period. Finally, the results of paired comparison of selected histology criteria of cryopreserved to fresh skin indicated that storage of skin for up to 5 years did not impair significantly its performance compared to fresh skin, whereas, after six years of storage, there was a highly significant (p < 0.001) impairment in skin quality. We offer a simplified in vivo model and analysis for cryopreserved skin graft performance, suggesting that the evaluation procedures, which are issues of great interest in skin banking, may help future skin banks to make informed choices and decisions regarding quality issues.

Growth inhibition of psoriatic keratinocytes by quinazoline tyrosine kinase inhibitors

Psoriasis is characterized by hyperproliferation of keratinocytes associated with an inflammatory infiltrate in the epidermis. Among factors which may be related to hyperplasia of psoriatic keratinocytes is the persistent autocrine stimulation of the epidermal growth factor receptor (EGFR) by transforming growth factor-alpha. Owing to the pivotal role of the EGFR in driving the growth of human psoriatic keratinocytes, we examined two selective inhibitors of EGFR kinase activity: 4-(3-bromophenylamino)-6, 7-dimethoxyquinazoline (AG1517/SU5271) and 4-(3-chlorophenylamino)-6, 7-dimethoxyquinazoline (AG1478) on psoriatic keratinocytes. SU5271 potently inhibits ligand-induced autophosphorylation of EGFR, and downstream signal transduction events, including DNA replication and cell cycle progression. SU5271, at micromolar concentrations, inhibited the proliferation of keratinocytes isolated from psoriatic lesions in excellent correlation with its EGFR kinase inhibitory activity in these cells. Biologically active concentrations of SU5271 penetrated human cadaver skin, suggesting that this compound is a strong candidate as an antipsoriatic agent.