[Thoracic reassignment surgeries]

Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.

[Sociological aspects of transgenrism]

The surgery of trans people is not apprehended by most of plastic surgeons as a simple surgery for the purpose of morphological transformation. At the same time, the French trans population does not benefit from adequate surgical coverage. Over the past few years, French regulations have simplified the process of reassignment surgeries. In addition, we have witnessed a fairly rapid increase in requests for transition surgery with accelerated and sometimes atypical courses. In recent years, a number of specialists have warned the medical community about the risks of slippage due to a lack of psychological monitoring of certain people beginning a transition process. Quite recently, hybrid transition paths have also appeared which, from a surgical point of view, are no longer limited to ensuring that a native assigned female patient can take on the most masculine appearance possible or the reverse. In this manuscript, we expose the biological, historical and societal place of transidentity and then address the reasons for the warnings of a certain category of the medical population while reassuring the surgical community on the benefits of reassignment surgeries in a controlled context. We end by proposing a few ways to improve the care course of trans people applicable in France.

[The tube in tube thoracodorsal perforator flap phalloplasty]

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.

[State of affairs and optimization of plastic surgery training in France]

BACKGROUND

Concerns have been growing for several years among masters, as to the quality and quantity of training in plastic surgery in France. They are mainly based on the reduction in the working time of residents, the appearance of new residents from generation Z to be trained, and finally the multidisciplinarity of plastic surgery in the current context of overspecialization of training center.

METHODS

In order to objectify these concerns, a survey was carried out among French residents and young heads of plastic surgery to assess their training in the specialty since 2019. We then looked in the law for possibilities to alleviate these concerns.

RESULTS

All the respondents think that their training in the specialty is incomplete, and few of them have been able to supplement it with rotations outside the subdivision or visits from private practitioners. However, in the law, it is possible to carry out: three residents rotations outside the subdivision, clinics rotations and international exchanges.

DISCUSSION

At the end of this analysis, we propose three solutions to optimize training in plastic surgery in France: a system of exchange of residents, the opening of residents rotations in clinics, and finally, to facilitate the realization of operating aids with private practitioners.

CONCLUSION

With these solutions, the field of training for residents could extend from one region to the whole of France. These solutions could easily be applied to other specialties, surgical and medical.

Internal pudendal perforator artery flap harvesting without pre-operative imaging: Reliability and approach

Since its initial description in 1996 by Yii and Niranjan, the internal pudendal perforator flap (also known as the Singapore flap, the gluteal fold flap, and the lotus petal flap) has become a workhorse in perineal soft tissue reconstruction. In 2001, Hashimoto described the presence of three to five perforators in the perineal anogenital triangle. The ischial tuberosity has thus become a useful anatomic landmark for the safe boundary of medial dissection during flap elevation, in order to avoid damaging the perforator vessels. The objective of the present study was to evaluate the perforators' positions within the anogenital triangle by using color Doppler ultrasound. In a study of 15 subjects in the lithotomy position, we identified a total of 24 perforator vessels with a diameter greater than 5 mm. We noted the vessels' positions using orthonormal measurements, according to the distance from the midline and the distance on a straight line between the two ischial tuberosities (i.e. consistent bony anatomic landmarks that are independent of the patient's height and body mass index). The mean distance between the ischial tuberosity and the internal pudendal perforator was 27.3 mm. Based on our present results, we consider that routine ultrasound identification and dissection of the perforators is not always required before pudendal flap harvesting. This decreases the operating time and simplifies the flap harvesting procedure.

How to Save a Life From Macroscopic Fat Embolism: A Narrative Review of Treatment Options

Macroscopic fat embolism (MAFE) has grabbed the attention of the plastic surgery community in recent years because of its high mortality rate. Many articles on preventing MAFE during gluteal fat grafting are available in the literature. However, total prevention is difficult: a number of factors, both technical and human, mean that MAFE remains a potential complication. This review was written with the main goal of providing a treatment plan. MAFE shares many similar pathophysiologic and hemodynamic features with massive thrombotic pulmonary embolism (PE), especially the associated cardiopulmonary decompensation. Lessons learned from PE management were used to devise a management algorithm for MAFE. The use of extracorporeal membrane oxygenation and its potential application as a main modality of treatment for MAFE was explored. The lack of evidence in the literature for the treatment of MAFE, and its high mortality, lent urgency to the need to write an article on the management aspect in the form of a narrative review, to ensure that every plastic surgeon practicing gluteal fat grafting is knowledgeable about the treatment aspect of this deadly complication.

Breast reconstruction in France, observational study of 140,904 cases of mastectomy for breast cancer

OBJECTIVES

In France, there are few up-to-date epidemiological data on breast reconstruction after mastectomy for breast cancer. The objective of the present study was to measure immediate and delayed breast reconstruction (IBR and DBR, respectively) rates and thus the proportion of patients not benefiting from any reconstruction.

METHODS

We performed an observational study by assessing data from the French nationwide discharge summary database (Programme de Médicalisation des Systèmes d'Information) for the period 2008-2014. All women having undergone a total mastectomy for breast cancer during this period were included. We then searched for reconstructive surgery during the initial or subsequent hospital stays, and recorded the time interval between mastectomy and reconstruction.

RESULTS

Among the 140,904 mastectomies included, the IBR rate was 16.1% on average, and increased over the study period. The time interval between mastectomy and DBR was≤3 years in 92% of cases. For patients included in 2008 and 2009, the DBR rate was 17.8%, and the non-reconstruction rate was 66.4%.

CONCLUSION

The high proportion of women not undergoing breast reconstruction after mastectomy suggests that access to this procedure should be improved.

An Open, Prospective Study to Evaluate the Effectiveness and Safety of Hyaluronic Acid for Pectus Excavatum Treatment

Background

Pectus excavatum (PE) is sometimes associated with psychological and physiological difficulties influencing a patient’s quality of life. Treatment with a hyaluronic acid (HA)-based gel may benefit patients and be an alternative to other more invasive treatments.

Objectives

The authors sought to evaluate the effectiveness in terms of satisfaction, duration, and safety of HA gel treatment for PE including impact on quality of life.

Methods

Males ≥18 years having PE without functional problems received HA gel injections (50 – 150 mL) at the site of deformity and in some cases at the medial pectoralis muscle borders to optimize the aesthetic result. Follow-up visits were performed after 1, 3, 6, 12, and 24 months with optional retreatment at the 24-month visit including a 1-month follow-up. Evaluations included Pectus Excavatum Evaluation Questionnaire, patient satisfaction, magnetic resonance imaging, and safety assessments.

Results

The treatment significantly improved patients’ self-esteem (P < 0.001) and psychosocial function (P ≤ 0.038) throughout the study, as assessed by Pectus Excavatum Evaluation Questionnaire. Patients were satisfied with the aesthetic outcome and considered the treatment mild in terms of level of pain during injection. Treatment effects were maintained up to 24 months and 58% of the HA gel remained at this visit, shown by Magnetic Resonance Imaging measurements. The treatment was well tolerated.

Conclusions

Treatment of PE with HA gel improved patient quality of life related to self-esteem and psychosocial functioning including aesthetically pleasing results. The treatment may also offer benefits in terms of safety and tolerability compared with other treatments.

Level of Evidence: 4

Inverted Nipple Treatment and Poliglecaprone Spacer

INTRODUCTION

Nipple inversion is defined as a non-projectile nipple. It is a frequent pathologic condition, in which the whole nipple, or a portion of its, is buried inward towards the lactiferous duct and lies below the plane of the areola. Numerous strategies have been described to correct nipple inversion. All the procedures have the purpose to give a good shape to the nipple, preserving its function and sensitivity, when it is possible. To avoid recurrences and to obtain good aesthetic results, we present a modified percutaneous technique.

METHOD

We performed a retrospective study between 2011 and 2016 and included all the cases of inverted nipples treated in our department. Our modified percutaneous technique consists of a minimal incision supported by a percutaneous suture as a temporary spacer to fill the defect caused by releasing the fibro-ductal bands.

RESULTS

A total of 41 cases of inverted nipples were corrected in 32 patients. After 1 year of follow-up, no recurrence was observed and all nipples maintained complete eversion. There was only one case of partial unilateral necrosis in a patient who underwent tumorectomy and radiotherapy. All patients were satisfied with the aesthetic outcomes.

CONCLUSION

This is a simple, safe and cheap technique that should be considered as a reliable method for long-term correction of nipple inversion.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Anatomical basis for rejuvenation surgery]

The understanding of the face anatomy is mandatory before to be able to appreciate the different surgical techniques of face lifting. Despite numerous controversies and anatomical variations, we can find in the literature several keystone works that allows us to understand that the soft tissues of the face are not only a superposition of layers but also a tridimensionnal structure with a fibrous system that links the different layers. This structures creates a mix loose spaces, fat and retaining ligament that can be describe in a quite systematic manner. This systematisation can help the surgeon during the surgical procedure to search and find the area where there is no danger and alert him around the retaining for example, which is where we can often find a vessel or a branch of the facial nerve that we want to avoid. This article summarizes these anatomical knowledge.

[The third dimension of the face aging, improvement of its understanding]

OBJECTIVES

Over the past 30 years, surface imaging has made tremendous progress. Surgical management has also been subject of numerous technical and strategic developments. For a better understanding of the curative strategies of face aging, the authors have put into perspective the three-dimensional data acquired up to date.

METHOD

A review of the literature focused on the three-dimensional study of facial aging was carried out.

RESULTS

Thanks to the precision of new surface acquisition systems and larger patient cohorts, our understanding of surfaces and volumes is now much more accurate. 3D, particularly highlights the major impact of aging on the perioral area, which was up to now neglected compared to other facial areas.

CONCLUSION

A technical discussion is needed to identify the best techniques to correct the defects and provide a natural result for those anatomical areas that are heavily impacted by aging but not corrected in the final.

Dorsal median lipectomy (the arrow technique): A new approach for the treatment of the circumferential truncal skin and fatty tissue excess

The increase in the number of patients who undergo massive weight loss surgery has led to an increasing number of patients who complain of circumferential abdominal skin and soft tissue excess. Currently, the only surgical option to treat soft tissue excess is vertical median abdominal lipectomy (fleur-de-lys technique). However, many patients are reluctant to undergo this surgery because of the position of the scar. We presented a new surgical approach to manage circumferential excess - dorsal median lipectomy (arrow technique) - in which the dorsal scar is well-tolerated by patients.

[Superficial Circumflex Iliac Artery Perforator flap (SCIP flap): Revival of the inguinal donor site?]

The SCIP flap based on a superficial circumflex iliac perforator artery (SCIA) was described for the first time by Koshima in 2004 as a large and thin groin flap, with a low morbidity. The purpose of this study is to demonstrate the benefits of SCIP flap to cover cutaneous defects. We present a retrospective study from January 2007 to August 2016. Twelve patients had a SCIP flap reconstruction in the plastic surgery department of Amiens hospital. Thirteen flaps were performed. The average preoperative doppler mapping time was 8minutes. The average size of flaps was 62.5cm² [21; 180cm²]. The average time required for raising flaps was 61min [52; 82min]. It has not been observed any complication of the flap or donor site. The SCIP flap has a thin paddle and the donor site morbidity is minimal. The surgical technique is safe, accessible and precision is increased by preoperative color doppler mapping. The many strengths of the SCIP flap make it a must in the algorithm for defects management and come to revitalize the inguinal donor site.

[Extension of the thoracodorsal artery perforator flap's pedicle: Anatomical study]

PURPOSE

In recent years, the indications of latissimus dorsi myocutaneous flap decreased in favor of its version preserving muscle: the thoracodorsal artery perforator flap (TDAP). The intramuscular dissection reduce donor site morbidity but also allows an extension of the pedicle compared to conventional latissimus dorsi flap pedicle. The purpose of this study was to quantify objectively elongation of the pedicle when the perforator is dissected through the muscle.

METHOD

Sixteen TDAP flap were dissected in 9 cadavers. The pedicle was divided into 4 distinct parts: (1) hypodermis, (2) subcutaneous fat, (3) intramuscular, (4) conventional pedicle.

RESULTS

The length of the pedicle is significantly increased when the pedicle is dissected through the muscle. This extends the theoretical length from 5.25cm up to 9.19cm if the dissection is extended to the deep fat. Indeed, this results in a potentially exploitable TDAP pedicle length of 20.66cm.

CONCLUSION

The dissection of the perforator allows an extension of the pedicle of about 5 or 9cm if we continue the dissection in the subcutaneous fat. A long pedicle may be interesting in lower limb reconstructive surgery and facial reconstruction where microsurgery is not feasible.

Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps

Background The use of distally based neurocutaneous sural flaps (DBNCSF) is one of the most common methods of reconstructing the distal lower leg. However, they have developed a bad reputation because of their propensity for venous engorgement. Venous congestion that can lead to distal necrosis can be prevented by venous supercharging. Using a prospective comparative study, we thus explored the effect of venous supercharging on the reliability of these useful workhorse flaps.

Methods We prospectively included 38 patients who received a conventional DBNCSF and 38 patients who received a supercharged version of this flap (sDBNCSF) between January 2012 and July 2016.

Results No significant difference was identified between the groups in terms of age, sex, comorbidity, or defect origin. The main reconstruction etiology was traumatic (open fracture, scar disunion, and chronic osteitis). The flap size was noticeably larger in the sDBNCSF group, albeit without significance. The length-width ratio was significantly greater in the sDBNCSF group (6.08 vs. 5.53, p = 0.022). Venous congestion was significantly more common in the non-supercharged group (28.6 vs. 2.6%, p = 0.01), as was coverage failure (23.7 vs. 2.6%, p = 0.035).

Conclusion There are significant benefits to using venous supercharging of DBNCSF, when technically feasible. In our experience, venous supercharging increases reliability, allows the raise of larger skin paddles with much narrower pedicles limiting the morbidity of the procedure, and improves the functional and esthetic results.

Perforator-based propeller flaps reliability in upper extremity soft tissue reconstruction: a systematic review

Current data on upper extremity propeller flaps are poor and do not allow the assessment of the safety of this technique. A systematic literature review was conducted searching PubMed, EMBASE, and the Cochrane Library electronic databases, and the selection process was adapted from the preferred reporting items for systematic reviews and meta-analysis statement. The final analysis included ten relevant articles involving 117 flaps. The majority of flaps were used for the hand, distal wrist, and elbow. The radial artery perforator and ulnar artery perforator were the most frequently used flaps. The were 7% flaps with venous congestion and 3% with complete necrosis. No difference in complications rate was found for different flaps sites. Perforator-based propeller flaps appear to be an interesting procedure for covering soft tissue defects involving the upper extremities, even for large defects, but the procedure requires experience and close monitoring.

LEVEL OF EVIDENCE

II.

[Algorithm for surgical treatment of limb lymphedema]

Whether primary or secondary, limb lymphedema is a relatively common disease whose impact on the quality of life of patients is important. Although the microsurgical reconstruction techniques seem to be the techniques of choice in the treatment of limb lymphedema, no consensus about treatment of limb lymphedema has yet been defined. Considering the advantages and disadvantages of surgical techniques and their impact on the quality of life of patients, we propose a surgical treatment algorithm of limb lymphedema.

Leech therapy in flap salvage: Systematic review and practical recommendations

INTRODUCTION

Medicinal leeches have been part of the therapeutic armamenterium of plastic surgeons for more than 50 years. While their use in hand surgery is a matter of course, their use in salvage of flaps with venous congestion remains facultative depending on teams.

MATERIALS AND METHODS

We conducted a systematic review of leech therapy for flap salvage between 1960 and 2015, analyzing 121 articles and subsequently taking into consideration 41 studies. In parallel, we collected data from 43 patients for whom leach therapy had recently been applied in treatment of venous insufficiency in pedicled or free flaps after revision surgery had failed to improve flap vascularization, or in cases where flap revision was not appropriate. The data collected pertained to relevant indications, treatment procedure, efficacy, adjuvant therapies, side effects and complications.

RESULTS

For this indication, the success rate of leech therapy ranged from 65 to 85% (83.7% in our series) according to the situations encountered. Optimal frequency of application ranged from 2 to 8hours, while average overall duration ranged from 4 to 10 days. The number of leeches to be applied can be determined depending on volume of the flap. In 50% of the cases reported in the literature, the patients required transfusion. Antibiotic prophylaxis against Aeromonas is highly advisable. A ciprofloxacin and trimethoprim-sulfametoxazole combination currently appears as the most relevant prophylactic antibiotherapy.

CONCLUSION

Hirudotherapy is a reliable treatment in cases of patent venous insufficiency of pedicled or free flaps (or when revision surgery is not recommended). Even though the relevant literature is highly heterogeneous, we have attempted to put forward a specific protocol bringing together dosage, delivery route, frequency of administration and appropriate prophylactic antibiotherapy. An algorithm for treatment and management of venous congestion and a practical information sheet have been placed at the disposal of plastic surgery teams.

[Ring finger reconstruction by Colson's flap]

Surgical treatment of complete cutaneous ring finger avulsion is a challenge in hand surgery. When replantation of the avulsed fragment is not technically feasible, the surgeon must consider reconstruction of soft tissue. Many surgical techniques have been described. We report a case of complete avulsion of the cutaneous sheath and nail of the fourth finger with preservation of mobility and collateral nerves. The reconstruction of soft tissue was performed by a Colson flap-graft. This simple and reliable technique of reconstruction allowed to obtain a functional and sensitive finger with a satisfactory cosmetic result.

[Anatomical study of men's nipple areola complex]

The surgical approach of gynecomastia, sexual reassignment surgery in female-to-male transsexuals and the increase of number of obese wishing to turn to plastic surgery led us to deepen the anatomical knowledge of the nipple areola complex (NAC) in men, poorly retailed in the literature. By inspiring us of the methodology of a Japanese study, we studied 50 healthy volunteers male, from 18 to 55 years old, from July till August 2015. We measured various distances relative to the NAC to define its vertical and horizontal position, as well as the internipple distance according to the size, to the weight and to the body mass index (BMI). At the end of the analysis, we were able to underline a lower vertical thoracic position of the NAC in the tall category of person, a more side horizontal position to the subject presenting a high BMI and a linear relation between the BMI and the internipple (Em) defined by (Em)=8.96×BMI. The surgeon's judgment and the desires of the patient are essentials basis of therapeutics decisions that could be lean on this anatomical study, which allowed to establish an idea of the cartography of the NAC in man. It will be interesting and necessary to confront it with other studies with larger scale.

Change of paradigm in thoracic radionecrosis management

Classically, muscular or omental flaps are the gold standard in the management of thoracic defects following radionecrosis debridement. Their vascular supply and antibacterial property was supposed to enhance healing compared with cutaneous flaps. The evolution of reconstructive surgery allowed us to challenge this dogma. Therefore, we present five consecutive cases of thoracic radionecrosis reconstructed with cutaneous perforator flaps. In four patients, we performed a free deep inferior epigastric perforator (DIEP) flap and one patient had a thoracodorsal perforator (TDAP) flap. Median time healing was 22.6 days with satisfactory cutaneous covering and good aesthetic results. There were no flap necrosis, no donor site complications. We believe that perforator flaps are a new alternative, reliable and elegant option that questions the dogma of muscular flaps in the management of thoracic radionecrosis.

Capillary measurement of lactate and glucose for free flap monitoring

BACKGROUND

It is reported that the salvage rate of free flaps is inversely related to the time interval between the onset of pedicle impairments and their clinical recognition. Monitoring of free flaps is therefore of major importance and clinical monitoring remains the most used technique because of lack of low-cost and non-invasive techniques. The authors suggested an efficient, simple and cheap technique to detect early thrombotic events in monitoring free flaps with skin paddle.

METHODS

In this multicentre prospective study, measurements of capillary glucose and lactate in the flaps were done. These parameters were compared to standardized clinical monitoring during the first five days. Two sets of data (eventful versus uneventful postoperative period) were analyzed to define the thresholds of lactate and glucose values for diagnosis of pedicle complications, and to establish parameters for this screening test.

RESULTS

Over a period of 19 months, 37 patients were included. With 5 pedicle impairments, complication thresholds were defined as lactate ≥ 6.4 mmol L(-1) and glucose ≤ 3.85 mmol L(-1), in order to obtain a sensitivity of 98.5% and a specificity of 99.5% for the test. Modifications of capillary glucose and lactate measurements appeared in average 5.7 hours earlier than clinical symptoms in pedicle impairments. The mean cost of a five-day monitoring was about 90 USD.

CONCLUSION

This simple and cheap technique could be used as a routine technique in monitoring free flaps to improve safety of this reconstructive technique.

Management of the perineal wound after abdominoperineal resection

Although many options are available for the management of perineal wounds after abdominoperineal resection, ranging from direct closure to flap reconstruction, treatment remains challenging. A better understanding of the aims, drawbacks and progress in perineal wound management after abdominoperineal rectal resection can help the surgeon make better choices for each patient, but it is very difficult to propose a single, optimal, evidence-based procedure for the management of pelvic exenteration. Recent progress provided by the extralevator abdominoperineal resection technique and perforator flap concepts have changed our conception of reconstruction leading to the different technical options highlighted in this review.

"Body-lift"-like pattern for the simultaneous bilateral superior gluteal artery perforator flap in breast reconstruction

Prophylactic mastectomies have increased during the last 10 years. Breast reconstructions with free flaps are performed because they provide natural and long-lasting results. In bilateral mastectomy, a simultaneous bilateral superior gluteal artery perforator (SGAP) flap can provide good reconstruction with autologous tissue and low donor-site morbidity. This report describes the case of a "body-lift"-like pattern for a simultaneous bilateral SGAP flap procedure. This innovative pattern provides good aesthetic results for the abdomen and buttocks and preserves the option of using a deep inferior epigastric artery and vein perforator (DIEP) flap in case one SGAP flap fails. After 3 months, the patient was very satisfied with the results. The SGAP flap remains undeniably an alternative to the DIEP flap when the abdominal excess is insufficient for a bilateral reconstruction.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reduction of Skin Closure Time Without Loss of Healing Quality

The authors report the results of a multicenter prospective study evaluating a novel technology: dermal suture using absorbable staples composed of polylactic and polyglycolic acids. From January to June 2009, 59 dermal sutures were performed with Insorb absorbable staples and 41 with absorbable thread. All patients in the study underwent abdominal dermolipectomy (N = 65) or surgery for breast hypertrophy (N = 35). The purpose of the study was to compare the closure time and healing quality obtained with the 2 methods. Ninety-five patients were reexamined by the surgeon after 1 year of follow-up to assess scar width, suppleness, inflammation, and hypertrophy. The overall results were good and quite similar for the 2 groups. Thus, the use of Insorb staples reduced closure time while ensuring good healing quality.

Use of the thoracodorsal artery perforator flap for bronchial reinforcement in patients with previous posterolateral thoracotomy

The thoracodorsal artery perforator flap (TDAP flap) allows raising the same cutaneous island as in the classical latissimus dorsi musculocutaneous flap without its muscular part. All patients who underwent a completion pneumonectomy with reinforcement of bronchial stump with a TDAP flap from December 2009 to October 2010 were followed prospectively. The 30-day mortality and the procedure-related morbidity as well as bronchial fistula and TDAP flap were analyzed. The TDAP flap was used in 6 cases without failure or fistula formation. At 1 month, all patients were alive, and there was no morbidity (seroma, hematoma, fistula, or shoulder dysfunction). Computed tomography scans were performed at 1 month and 3 months postoperatively and showed viable nonatrophic flap. This type of flap has been described in the field of plastic surgery, and this is the first description of its use in the chest. Deepithelialized fasciocutaneous TDAP flap is safe and reliable. It is available even if the latissimus dorsi has been previously divided. It is now our first-line option to reinforce the bronchial stump.

Poland syndrome and breast tumor: a case report and review of the literature

Poland syndrome is a rare congenital malformation. Hypoplasia of the sternocostal portion of the pectoralis major muscle is the most significant feature and is most frequently associated with homolateral breast hypoplasia. In this article, the authors present a case of bilateral phyllodes tumors in a 28-year-old woman with Poland syndrome and discuss (1) the relationship between the condition and breast cancer, (2) the modes of surveillance in patients with Poland syndrome, and (3) its impact on breast reconstruction.

[Neonatal molding for minor deformities of auricular cartilage: a simple method]

Non-surgical correction of minor ear deformities by external splinting during neonatal age is a well-known, effective technique, but not frequently used in France. We would like to popularize an established, simple method that uses cheap, available means (a wire, adhesive strips and a silicone probe). It can be performed by parents, paediatricians and nurses. Spreading this method would allow early onset of treatment and better clinical results. On the long run, it would have a certain economic aftermath on national health insurance by reducing the number of surgical procedures for deformed ears.

[Reconstruction of hand dorsum soft tissue defect using anterolateral thigh perforator flap: description, case study and review of literature]

Reconstruction of hand dorsum soft tissue defect usually requires a flap. The dorsal skin is thin and the underlying structures require coverage by vascularised tissue. We have been using perforator flaps in these cases, especially the anterolateral thigh perforator flap. After a description of the technique, we present a case report in which this flap, in a free version, was used to reconstruct a dorsal hand defect after failure of a posterior interosseous flap. The fascia underlying the flap was used to create a sliding interface for extensor tendons. Postoperative care was without complications. The indications of this flap are numerous but after a review of international literature, we found that its use was seldom reported in France compared to other countries. However, we think that its trophic qualities and minor donor site morbidity make it ideal for coverage of hand dorsum soft tissue defects.

[Advantages of the superior areolar approach for tuberous breast II and III correction with implants]

Tuberous breast is a mammary malformation that remains difficult to treat in most cases. It results from an abnormal development of the mammary base, mainly at the lower pole of the breast. The superficialis fascia is adherent to the dermis and deep plane. For type II and III of Grolleau's classification, we were confronted by some difficulties with inferior areolar approach as in Puckett's or Ribeiro's techniques. We had frequently an insufficient glandular volume at the inferior part of the breast and an early look of a "double bubble" deformity. We propose a technical modification to these procedures using a superior hemiareolar approach to place the implant. Associated with an incision of the deep part of the superficialis fascia, it provides a good-shaped lower pole of the breast by preserving glandular volume at this part and reduces the apparition of "double bubble". We operated on 14 types II-III tuberous breasts on nine female patients and had no significant complication. The mean follow-up is 36 months and the results were very satisfying for the patient and her surgeon.