[Flap harvest training on a new ultrarealistic simulation model: In-training operator feedback about a pulsating reperfused and reventilated cadaver Simlife®]

INTRODUCTION

The anatomical subject is still a key element to learn complex procedures in plastic surgery. We present here the evaluation of an in-training operator on a SIMLIFE® model, hyper realistic model consisting in human bodies donated to science equipped with pulsating recirculation and reventilation device.

MATERIAL AND METHODS

From February 2019 to October 2019, 8 forearm flaps with radial proximal pedicle were harvested by the learner on a SIMLIFE® model. Conditions were as close as possible to the operating room : asepsy, sterile draping, assistant and instrumentation including electrocoagulation.

RESULTS

The procedure was decomposed in 13 distinct steps. Mean total surgery time was 90,5±11,62minutes. There was only one case of arterial pedicle lesion resulting in major blood leak. Bleeding was measured by fake blood loss from the SIMLIFE® console. Mean intraoperatoy bleeding was 171±108 milliliters. We review pros and cons of this new technology particulary suited for complex plastic and reconstructive surgery training.

CONCLUSION

Using SIMLIFE® technology we have a new mean to train for complex procedures in plastic and reconstructive surgery. This new technology could be applied to numerous other surgical procedures. Broader applications are still limited by cost and cadaver use legislation.

Use of a skin perforator flap pedicled by the intercostal muscle for reconstruction of a posterior cervical defect

A posterior cervical defect featuring exposed spinal and occipital bone can be covered in various ways. The "ideal" flap should be a low-morbidity, pedicled locoregional flap that can reach the occiput. Cervical adjuvant radiation therapy may limit the coverage options, because many pedicles are located in areas that are often irradiated. Here, we describe a new surgical technique; we used a skin perforator flap pedicled by the intercostal muscle to cover a posterior cervical defect in a patient with metastatic squamous cell lung carcinoma. This technique is a valuable option; the flap originated from outside the irradiated area and reached the occiput. It adds to the options for cervical coverage in patients who require head-and-neck reconstruction. EVIDENCE-BASED MEDICINE: Level V: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

[Male to female sex reassignment surgery with a new surgical simulation device using a human perfused cadaver SIMLIFE®: New paradigm in transsexual surgery education ?]

INTRODUCTION

In 2015, we reported our experience with the learning curve in genital reassignment surgery and highlighted a four-step learning concept.

CLINICAL CASE

In this article, we present our first vaginoplasty performed on a humanoid model SIMLIFE®, a human body associated with a pulsating circulation device and a ventilation device.

RESULTS

The surgical technique included 14 steps. The total surgical time was 182minutes. There was no intraoperative complication, and there was no damage to the urethra or rectum. The intraoperative bleeding measured by the loss of operative fluid was 280mL. We discuss the advantages of this technology perfectly adapted to transsexual surgery.

CONCLUSION

We demonstrated the feasibility of vaginoplasty performed on a humanoid model SIMLIFE® and highlighted improvement of the surgical skills with this model. This technology could find many other surgical applications. However, it faces cost constraints and legislation on corpses.

Indications, functional results and patient satisfaction after isolated second ray resection following traumatic injury: A retrospective review of 25 patients

Amputation of the second ray is a surgical treatment option when reconstruction and/or reimplantation fail. The aim of our study was to review the outcomes after transmetacarpal resection of the second ray following a post-traumatic injury and to assess indications, functional outcomes, and patient satisfaction. Between January 2003 and December 2013, 25 patients (6 women and 19 men with a mean age of 51 years) underwent transmetacarpal resection of their second ray after a post-traumatic injury. Sixteen patients were right-handed and 9 were left-handed. Injuries involved the dominant hand in 14 cases (60%). In order to differentiate patients with preserved index finger length preoperatively from those with a shorter, amputated index finger stump, patients were divided into 2 groups. Group 1 included those with an "intact finger" and Group 2 included patients with an "amputated stump". Data collection, including patient satisfaction and functional outcomes, was performed at 83 months postoperative on average. Average length of follow-up was 7.0±1.0 years (range 5-12 years). Group 1 (intact finger) and 2 (amputated stump) included 15 and 10 patients, respectively. Six patients (24%) had primary ray amputation and 19 (76%) had secondary ray amputation. No surgical revision was necessary. In Group 1, the indications were purely functional in all but two cases, whereas aesthetic indications played a role in all patients in Group 2. The average total time off work was 3 months. There was no difference between Group 1 and 2 (P>0.05). However, patients with primary ray resection averaged 10 weeks of lost work compared to 17 weeks for secondary amputation. There was no functional difference between Groups 1 and 2. Scores for cosmetic appearance and patient satisfaction were higher in Group 2. In certain specific situations after complex hand trauma, transmetacarpal amputation of the second ray is indicated as soon as possible, in order to reduce the time off work. Patient satisfaction following this surgical procedure is high, especially in groups with amputated stumps. A 30% decrease in pinch and grip strength is the rule. No secondary surgery is normally required.

[Bilateral breast reduction and obesity: What is the ideal resection enabling significant improvement in back pain according to the body mass index?]

INTRODUCTION

Dorsal pain is the first symptoms about which patients with macromasty complain. Health insurance reimbursement takes place if the resection weight is at least 300grams per breast. However, this weight is not correlated with the body mass index (BMI). In this context, we sought to determine the ideal resection weight leading to significant BMI-based improvement.

MATERIALS AND METHODS

This is a multicentre prospective study of patients operated between November 2016 and July 2017. In the year following the surgical procedure, we studied overall improvement using the INDIC questionnaire. Any INDIC improvement of at least 50% was considered positive. These data were then compared to tissue resection weights and BMI. In order to refine our results, age, bra size, comorbidities and complications were also identified.

RESULTS

Forty-one patients were included in our study. Average age was 41.5±11.4years. Average BMI was 27.9±4.1kg/m². The bra cap chosen after the procedure were C. Average resection weight was 663±352g per breast. The preoperative and postoperative INDIC scores were 734.9±226.6 points and 225.3±319.1 points, respectively (P=0.001). Significant improvement was achieved at 12months in 71.8% of patients. A correlation of 38.7g/kg/m² was found between breast resection weight and BMI.

CONCLUSION

This study clarifies the correlation between the breast resection weight required to relieve optimal back pain and BMI. It defines three categories of patients: patients with standard weights (18<BMI<25), overweight (25<BMI<30) and obese (BMI>30). Overweight and obese patients require greater tissue excretion to be relieved optimally. These findings underline a need to adjust the health insurance threshold for these types of patients.

Composite neuromusculo-fasciocutaneous triceps brachii free flap for complex foot reconstructive surgery

Since it was first described by Song in 1982, then by Katsaros in 1984, the lateral arm flap has become a workhorse technique for upper limb reconstruction. Herein we describe a clinical case of complex foot defect and bring up the possibility of using a composite neuromusculo-fasciocutaneous lateral arm/triceps free flap for its reconstruction. A 19-year-old male nonsmoker suffered ballistic trauma to his right foot with open multifragment Gustilo-IIIb fractures of the first to fifth metatarsal bones. Two weeks after debridement and V.A.C.™ therapy performed in another hospital, we decided to reconstruct the remaining defect with a neuromusculo-fasciocutaneous medial triceps/lateral arm free flap anastomosed with the anterior tibial pedicle. The posterior brachial cutaneous nerve was sutured to a sensory branch of the superficial fibular nerve. The advantages and drawbacks of this technique are discussed and other options for this type of complex foot reconstruction are reviewed. After 3 years' follow-up, the metatarsal bones were consolidated without residual defect or chronic infection. The foot had sensation with full mobility and no pain. At the donor site, there was no complaint of scarring. Elbow extension/flexion was 0-0-130. Wrist extension/flexion was 60-0-60 and there was no extension deficit of the metacarpophalangeal joints. The composite neuromusculo-fasciocutaneous triceps brachii free flap was an excellent option for this complex foot defect. The choice of this reconstructive procedure among other options was made during our reconstruction board meeting while taking the patient's specific condition and our own experiences into account.

[Poly Implant Prothèse (PIP®) incidence of complications in breast reconstructive surgery: A retrospective comparative analysis]

INTRODUCTION

On 29 March 2010, the Poly Implant Prothèse (PIP(®)) breast prosthesis was withdrawn from the market by the ANSM. In this study we review our experience with PIP(®) implants in breast reconstruction. We compare our complications with other types of breast implants used during the same period at our institution.

PATIENTS AND METHOD

This is a retrospective study conducted at the Hospital René Huguenin of the Institut Curie (Paris, France). It includes 327 prostheses, from 268 patients who underwent surgery for breast reconstruction between February 2008 and February 2012: 69 PIP(®) (Group 1), 82 Mentor(®) (Group 2) and 179 Allergan(®) (Group 3). The objective of the study was to compare the rates of early and late complications for each prosthesis. Our results are compared with the current literature.

RESULTS

With regard to the rate of early complications (hematoma, infection, seroma, wound dehiscence), no difference was observed between the three groups (P not significant). However, the study found that 100% of the 13 PIP(®) implants with early complications required surgical revision. There were too few late complications (capsular contracture, prosthetic rupture) in our cohort to allow statistical comparison between the three groups (P not significant). We compare our results with the current literature.

CONCLUSION

This study highlights the lack of significant difference in the occurrence of early adverse events between the three groups of implants. This may explain the time taken for surgeons to become aware there was a problem with the PIP(®) implants. The low rate of late complications in our series does not allow statistical analysis between the three groups of implants.

Double crush syndrome of the median nerve revealing a primary non-Hodgkin's lymphoma of the flexor digitorum superficialis muscle

Extranodal manifestations of lymphoma are well described in the literature and occur in 20 to 30% of patients. Skeletal muscle involvement is rare. We describe the case of a patient with non-Hodgkin's lymphoma in a forearm muscle. At the age of 86, the featured patient started experiencing continuous, progressive and high intensity pain that was more frequent at night and localized in the right dominant hand. It was associated with paresthesia and hypoesthesia, primarily in the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to the diagnosis of carpal tunnel syndrome. The patient underwent carpal tunnel release at a private hand center. The progression was unfavorable. Additional clinical examination and electrodiagnosis showed compression of the anterior interosseous nerve (double crush syndrome). The patient was referred to our university hand center for further management. Magnetic resonance imaging showed a large mass of about 20cm occupying the entire anterior compartment of the forearm and enclosing the median nerve. Biopsies were performed and revealed a diffuse large B-cell primary non-Hodgkin's lymphoma. The patient underwent chemotherapy and radiotherapy. Six months later, the patient was in complete remission. Muscular involvement during lymphoma is rare. Biopsy is mandatory; needless radical surgery can be avoided because lymphoma is primarily a non-surgical disease. The key points of the treatment process are reviewed.

[The Linburg-Comstock phenomenon: a review]

Simultaneous flexion of thumb and fingers is described as the Linburg-Comstock phenomenon. Congenital and acquired coupling of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) tendons is the reason for this clinical entity. Additionally, coupling of the FPL and the flexor digitorum superficialis II or III has been described. The coupling can be between the muscles, the tendon sheaths or the tendons themselves. Asymptomatic and symptomatic coupling should be differentiated. In general symptomatic congenital or acquired coupling demands surgical intervention. We report about a 35-year-old patient with a congenital asymptomatic coupling of FPL and FDP-II who suffered a distorsion of the thumb. Afterwards she complained of pain and strength loss. An accessory tendon of 3 mm in diameter and 3.5 cm length between FPL and FDP-II was identified during surgery. The patient recovered completely after resection of this coupling.

[Symptomatic carpal coalition of scaphoid, trapezium and trapezoid with coexisting ipsilateral hypoplasia of the thumb]

We present the case of a 54-year-old woman with symptomatic coalition of scaphoid, trapezium and trapezoid as well as a coexisting ipsilateral hypoplasia of the thumb.

Does preoperative subscapularis fatty muscle infiltration really matter in anterosuperior rotator cuff tears repair outcomes? A prospective multicentric study

INTRODUCTION

Anterosuperior (AS) rotator cuff tear describes a combined tear of the subscapularis and the supraspinatus tendons. We hypothesized that results after AS tendon repairs might be influenced by the size of the subscapularis rupture and the preoperative subscapularis muscle fatty infiltration.

METHODS

A prospective multicentric study of 53 AS rotator cuff tears from five centers was performed (January 2008-January 2009). Subscapularis tendon retraction and fatty infiltration were assessed preoperatively. An ultrasonographic healing control was performed 1 year after surgery.

RESULTS

Patients were on average 60 years (range, 43-75 years) and were operated on average 16 months (range, 2-72 months) after the beginning of their symptoms. The incidence of AS tears was found to be 18%. Average follow-up was 15 months (range, 12-24). The Constant-Murley (CM) score for the patients with AS ruptures improved significantly from 49 points (range, 35-51 points) preoperatively to 73 points postoperatively (range, 50-95 points)(P=0.0205). CM score gains were 26 for Lafosse group 1 ruptures and 29 for Lafosse group 2 & 3 with pre- and postoperative P values at P<0.0000001 and P<0.000001, respectively. The last follow-up CM score according to the subscapularis fatty infiltration was 70 (range, 48-95) for groups 0-1, 70 (range, 56-87) for group 2, and 56 (range, 53-88) for groups 3-4 with pre- and postoperative P values at P<0.001, P<0.001, and P<0.004, respectively. The global retear rate was 6%.

DISCUSSION

Our study showed that the CM score after repairs of AS rotator cuff tears was lower in advanced subscapularis fatty infiltration. However, gains in CM scores were similar whatever the initial subscapularis fatty infiltration. The rate of tendon healing was correlated with subscapularis fatty infiltration. Subscapularis tendon rupture size was not significantly correlated with outcomes.

LEVEL OF EVIDENCE

Level III.

[A 15-year-old adolescent presenting both Madelung deformity with Vickers' ligament and additional palmaris profundus muscle]

The palmaris profundus muscle is a rare entity which has been mentioned in association with nerve compressions. Madelung deformity is based both on an osteochondral lesion of the distal radial physis and often on the Vickers' ligament which originates around the lunate and inserts proximally in the radial physis. A 15-year-old right-handed female adolescent suffered from symptomatic left-sided Madelung deformity with Vickers' ligament and additional palmaris profundus muscle.

[Distal reconstruction of the finger with a partial toe transfer in the child]

Distal reconstruction of the finger or the thumb with a "custom-made" arterialized toe transfer in the child is a sophisticated operation. This operation can restore an excellent hand function and good cosmetic result with reduced morbidity at the donor site. Characteristics of these microsurgical toe transfers in the child are the potential of nerve regeneration and the conservation of a growth potential of the phalanx. We report 10 cases of reconstruction of a part of the distal finger in children (nail, pulp, bone) with a high degree of parents' satisfaction.

Microsurgery in liver research: end-to-side portocaval microanastomoses in dogfish

BACKGROUND

The use of an operating microscope in animal liver surgery has made it possible to obtain new experimental models. The goal of this prospective animal study is to present our experience with dogfish portocaval microanastomoses.

METHODS

Nineteen portocaval microanastomoses were performed in dogfish. The end-to-side anastomoses were accomplished using continuous 11-0 sutures. The diameter of the vessels and time required for the anastomoses were measured. A patency test and its outcome were also prospectively evaluated at the time of anastomoses and then 3 and 6 months after.

RESULTS

The mean vessel diameter was 2.5 ± 0.2mm. The mean anastomosis time was 14 ± 1.5 min. The anastomoses patency rate was 100% at the time of surgery. A postoperative control performed after 3 and 6 months showed a partial stenosis in three animals.

CONCLUSION

The dogfish appears to be a reliable experimental model in liver research. Moreover, this technique could be used for microsurgical training.

[Thirty years of laser-assisted microvascular anastomosis (LAMA): what are the clinical perspectives?]

INTRODUCTION

Since the first studies by Jain and Gorisch (1979), laser-assisted anastomoses have been steadily developed to a stage where clinical use is within reach. The laser-assisted vascular microanastomosis (LAMA) procedure is performed more quickly than conventional anastomosis, the surgically induced vessel damage is limited, and reduced bleeding after unclamping is observed.

MATERIAL AND METHODS

A Medline literature search, for the January 1979 to February 2010 period, was performed to review articles focusing on the LAMA technique.

RESULTS

The search yielded a total of 354 publications, of which 87 were relevant: 82 were animal series and five clinical studies. Microsurgical techniques and principal characteristics of LAMA in patients are the focus of the analysis. This study discusses the technological innovations and new orientations in laser welding.

CONCLUSION

The first two clinical series using the 1.9-μm diode laser appear promising. Technical innovation will most likely lead to greater ease of use of the laser handpiece in the operating room.

[Double dislocation of the interphalangeal joints of the little finger, a report of two cases]

Two cases of simultaneous traumatic dorsal dislocation of the interphalangeal joints of the little finger are described. In both cases the patients were managed by closed reduction and neighbour strapping followed by immediate mobilisation. At review, no complications were noted. The range of movements of all the affected joints was normal.