E. Lebreton

Efficacy of leukocyte- and platelet-rich fibrin in wound healing: a randomized controlled clinical trial.

Background: Application of platelet concentrates to wounds could speed healing. Leukocyte- and platelet-rich fibrin, a relatively recent development, stands out from the other preparations. This prospective, randomized, controlled clinical trial studied the rate of healing of postoperative hand wounds after a single application of leukocyte- and platelet-rich fibrin. Methods: Eligible patients were healthy individuals older than 18 years who had been scheduled for elective McCash (open palm) surgery for Dupuytren disease at the Plastic and Hand Surgery Department of Nices University Hospital between August of 2007 and February of 2010. The control group received the reference care of petroleum jelly mesh (Vaselitulle), and test patients had leukocyte- and platelet-rich fibrin applied. The primary endpoint was healing delay measured in postoperative days. Secondary endpoints included pain, bleeding, and wound exudate. The trial was carried out as a single-blind trial. Results: Among the 68 randomized patients, 33 patients in the leukocyte- and platelet-rich fibrin group and 31 in the Vaselitulle group were analyzed. Primary endpoint analysis showed a median healing delay of 24 days (interquartile range, 18 to 28 days) for the fibrin group and 29 days (interquartile range, 26 to 35 days) for the Vaselitulle group (p = 0.014, log-rank test). Postoperative pain assessment, bleeding, and exudate were always lower for the fibrin group, but not significantly so. Conclusion: The authors trial demonstrates that a single leukocyte- and platelet-rich fibrin application on fresh postoperative hand wounds shows a median improvement of 5 days in comparison with the standard treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Histological staging and Dupuytren's disease recurrence or extension after surgical treatment: a retrospective study of 124 patients.

Dupuytren’s disease has a high rate of recurrence after treatment. In this study we have assessed the usefulness of histological staging in the prediction of recurrence. We have also verified whether there is a correlation between histological staging and features of Dupuytren’s diathesis. We studied 139 hands in 124 Caucasian patients treated between 1997 and 2004. There was a significant difference in the recurrence rate between the three histological types (P = 0.04). Histological staging was independent of features of Dupuytren’s diathesis. This study confirms that histological staging is a reliable method for predicting recurrence. However, it should be used in association with clinical data to determine precisely the prognosis of patients suffering from Dupuytren’s contracture.

Les asymétries constitutionnelles en chirurgie d’augmentation mammaire esthétique : incidence, satisfaction et applications chirurgicales

INTRODUCTION The clinically observable, constitutional breast asymmetries are frequent and physiological in the general population. Although there has been a preponderance of literature concerning breast augmentation, a conspicuous lack of data exists regarding the preoperative breast and chest wall asymmetries seen in the patient seeking consultation for aesthetic breast augmentation. These asymmetries can lead to postoperative dissatisfaction in patients. MATERIALS AND METHODS An independent plastic surgeon analysed the data of 200 patients who had a primary aesthetic breast augmentation. The mean follow-up was 36 months. All patients had pre- and postoperative standardized pictures of the anterior chest wall. The clinical examination was achieved using an original evaluation form. Patients were also asked to fill an exhaustive satisfaction form. Breasts and chest wall asymmetries were diagnosed by clinical examination and photographic analysis. Mastopexy-augmentations, breast reconstructions, breast malformations (tuberous breasts and Poland syndrome) and patients with incomplete data were excluded from the study. Stastical analysis was done using SPSS software version 15. RESULTS There were 77% of chest wall and breast asymmetries and 69,5% of breasts asymmetries (26,5% of breast mound volume asymmetry and 62,5% of shape asymmetry). An isolated chest wall asymmetry was found in 17% of patients. Scoliosis was the main cause of asymmetry (52,9% of chest wall asymmetries) as it is often associated with chest wall rotation, chest wall depression, submammary depression or rib asymmetry. Patients often noticed an asymmetry postoperatively (28%). Among the patients complaining from a postoperative asymmetry, 83,3% had a constitutional breast or chest wall asymmetry. Asymmetry was the third cause of dissatisfaction and the third argument for revision surgery (after volume dissatisfaction and ptosis). Thirty per cent of patients asking for a surgical revision and 35.3% of unsatisfied patients complained about asymmetry, which was preoperative in 83.3% of cases. CONCLUSION The asymmetry rate of our study is compared with the others studies found in the literature. In the daily practice, asymmetry can be diagnosed by a complete clinical examination and standardized chest wall pictures. Patients with constitutional asymmetry should be educated, helping to increase postoperative satisfaction. The authors propose and discuss a surgical pattern for the handling of the different types of asymmetries in breast augmentation.

Double breast contour in primary aesthetic breast augmentation: incidence, prevention and treatment.

The goal of this study was to define the incidence of double breast contour in primary aesthetic breast augmentation and to analyze its risk factors. An independent plastic surgeon analyzed the data of 200 patients who had a primary aesthetic breast augmentation with silicone gel implant and with a minimum 12-month follow-up. All patients had pre and postoperative standardized photography. Mastopexy-augmentations, breast reconstructions, breast malformations (tuberous breasts and Poland syndrome), and patients with incomplete data were excluded from the study. Assessment was achieved using an original standardized evaluation form (preoperative breast morphology, surgical options, postoperative aesthetic results). Patients were also asked to complete an exhaustive satisfaction form. A double breast contour was assessed clinically using Massihas classification. The mean follow-up was 36 months. The double breast contour incidence was 7%. All of them were type I (the so called waterfall deformity). There was no type II (double inframammary crease). They were minor for 6.5% and major for 0.5%. They were related to a preoperative breast ptosis, subpectoral placement, and implant upper malposition. The rate of the type I was 10.5% of submuscular augmentation and 15% of preoperative breast ptosis. A double breast contour was primitive for 6% and secondary for 1% (pregnancy and breast-feeding postaugmentation). It was bilateral for 4.5% (3 cases of upper malposition, 1 case of medial malposition, 2 cases of pregnancy with breast-feeding postaugmentation and 1 patient refused a mastopexy-augmentation). It was unilateral for 2.5% related to a preoperative breast asymmetry with ptosis asymmetry and skin quality asymmetry. The satisfaction rate in the group “double contour” (14 patients) was 85.7% (vs. 91.9%). One patient had revision surgery (upper malposition). These types of deformities are fundamentally different with consideration on their clinical aspects, physiopathogeny, prevention and treatment. Type I major risk factor is subpectoral augmentation of ptotic breasts (with medium to bad skin quality and loses muscle to gland attachments). The muscle at the inferior pole of the breast is a “brake” preventing implant to fill the envelope. This risk is increased with implant malposition, constitutional ptosis asymmetry with symmetrical implant placement and selection of an insufficient implant projection or dimensions. This deformity can be avoided with selection of a subglandular or dual plane (type II or III) placement, a sufficient implant volume or projection and anatomic prosthesis. Type II is related to a lowering of a well-defined submammary fold more commonly in constricted and dens glandular breasts. This deformity can be avoided with respecting the inframammary fold, radial incisions on the glands posterior surface, and selection of anatomic implants.

Prise en charge des amputations traumatiques de l’oreille : revue de la littérature

Traumatic ear amputation (TEA) is a complete avulsion of a part or of the total auricular tissue. TEA are rare (only 74 cases have been described in the literature) and their handling is complex. The surgeons objective is to obtain the best cosmetic result without demolishing the auricular area in order to allow future ear reconstruction in case of replantation failure. Many techniques of ear replantation have been described in the literature during the last 30 years: microsurgical replantation, pocket techniques and reattachment techniques. Microsurgical replantation should be achieved every time it is possible. When it is not possible, the surgeon can choose between ear reattachment and a pocket technique according to two clinical features: the size of the amputated part and the involvement of the ear lobe. Ear reattachment can be achieved when the amputated part is smaller than 15 mm or when amputation involves the earlobe. Pocket techniques, which are appropriate for the replantation of the auricular cartilage, can be used when the amputated part is bigger than 15 mm and does not comprise the earlobe.

Transfer of Pectoral Nerves to Suprascapular and Axillary Nerves: An Anatomic Feasibility Study

PURPOSE We conducted an anatomic study to provide detailed information on the pectoral nerves and anatomic data on the transfer of the pectoral nerves to the axillary nerve. Moreover, we experimentally determined the feasibility of transferring the pectoral nerves to the suprascapular nerve in upper brachial plexus injury. METHODS We dissected 26 brachial plexus from 15 fresh cadavers. The origin, location, course, and branching of the pectoral nerves were recorded. The length and the diameter of the pectoral nerves were measured. The diameter of the suprascapular and axillary nerves was recorded. In all dissections, we assessed the feasibility of directly transferring the pectoral nerves to the suprascapular and axillary nerves. RESULTS We found 3 constant branches of pectoral nerves arising from 3 distinct origins in 20 cases, and 3 constant branches arising from 2 distinct origins in 6 cases. The C7 sent nerve fibers to all 3 branches. The average length and diameter of the superior, middle, and inferior branches of the pectoral nerves were 65 mm, 110 mm, and 105 mm, and 2.0 mm, 2.3 mm, ad 2.4 mm, respectively. The average diameter of the suprascapular and axillary were 2.8 mm and 3.6 mm, respectively. The superior branch reached the suprascapular and axillary nerves in 17 and 8 cases. The middle and inferior branches reached the suprascapular and axillary nerve in all dissections. CONCLUSIONS With an adequate length, diameter, and nerve composition, the middle and inferior branches of the pectoral nerves are suitable donor nerves to the axillary nerve and a potential source of reinnervation of the suprascapular nerve in upper brachial plexus injury.

Cutis verticis gyrata primitif essentiel : cas clinique et revue de la littérature

INTRODUCTION Cutis verticis gyrata (CVG) is a rare and slowly progressive deformity of the scalp with thick gyrated skin folds and ridges which are similar to gyri of the brain cortex. Those folds can lead to local skin infections, to a social and cosmetic complain. CVG can be classified into two forms: primary (essential and non-essential) and secondary. To date, fifteen operated cases of primary essential CVG have been reported in the medical literature. CASE REPORT We report the case of an 18 year-old male patient with a primary essential CVG. There were several large skin folds in the sagittal axis on the vertex region, and in the coronal axis on the occipital region. He did not present any cutaneous complication. His main complains was the unaesthetic aspect of his scalp with a psychological complex. The disease had occurred during puberty. We present the excision pattern and the results with a six months follow-up. CONCLUSION CVG can be treated surgically with resection of the thickened excess skin in coronal and sagittal axis. Scalp lift must be effective all over the different areas of the scalp. The scalp flaps must have a reliable vascularisation. Combined incisions of the galea help to treat the residual folds. The excision pattern must be reproductible, as this disease is progressive.

Étude de la rétraction cutanée appliquée à la prise en charge des tumeurs cutanées. Cartographie du corps humain

SUBJECT Skin, the main organ of the human body, is equipped with own biomechanical characteristics, highly variable depending on intra-individual factors (location, weight status, dermatological diseases…) and interindividual (age, sex…). Despite some recent cutometric studies, our review of the literature shows that there is no currently reliable analytical model representing the biomechanical behavior of the skin. Yet, this is a central issue in dermatology surgery, especially in the treatment of skin tumors, for the proper observance of surgical margins. PATIENTS AND METHODS We studied prospectively on 75 resection specimens (about 71 patient(s)), for the treatment of skin lesions tumor suspicious or known malignant or benign. Room dimensions were measured before and 5 minutes after excision, leading us to calculate a ratio of retraction of the skin surface. This retraction was correlated with age, gender, tumor type, and anatomic location of the site of excision. RESULTS The power of retraction of the skin varies significantly by region of the body. It is maximum in the upper limb (hand excluded) and in the cervical region. At the cephalic region, skin of the ear and periorbital skin have capacities of important early retraction. Unlike the lower limb (foot excluded), the back skin of the nose and face appear to be a minimum of shrinkage. Age also seems to change on that capacity shrinkage, sex would have no influence. CONCLUSION Our study confirms the variations in the ability of skin retraction based on a number of factors. In dermato-oncology, that power retraction could cause significant differences between clinical surgical margins and final pathologist margins. We believe it must be taken into account by the couple surgeon-pathologist, especially in the context of invasive and/or recurrent tumors.

Article originalÉtude de la rétraction cutanée appliquée à la prise en charge des tumeurs cutanées. Cartographie du corps humainStudy of skin retraction applied to the treatment of skin tumors. Mapping of the human body

SUBJECT Skin, the main organ of the human body, is equipped with own biomechanical characteristics, highly variable depending on intra-individual factors (location, weight status, dermatological diseases…) and interindividual (age, sex…). Despite some recent cutometric studies, our review of the literature shows that there is no currently reliable analytical model representing the biomechanical behavior of the skin. Yet, this is a central issue in dermatology surgery, especially in the treatment of skin tumors, for the proper observance of surgical margins. PATIENTS AND METHODS We studied prospectively on 75 resection specimens (about 71 patient(s)), for the treatment of skin lesions tumor suspicious or known malignant or benign. Room dimensions were measured before and 5 minutes after excision, leading us to calculate a ratio of retraction of the skin surface. This retraction was correlated with age, gender, tumor type, and anatomic location of the site of excision. RESULTS The power of retraction of the skin varies significantly by region of the body. It is maximum in the upper limb (hand excluded) and in the cervical region. At the cephalic region, skin of the ear and periorbital skin have capacities of important early retraction. Unlike the lower limb (foot excluded), the back skin of the nose and face appear to be a minimum of shrinkage. Age also seems to change on that capacity shrinkage, sex would have no influence. CONCLUSION Our study confirms the variations in the ability of skin retraction based on a number of factors. In dermato-oncology, that power retraction could cause significant differences between clinical surgical margins and final pathologist margins. We believe it must be taken into account by the couple surgeon-pathologist, especially in the context of invasive and/or recurrent tumors.

Merkel cell carcinoma of the hand

could be idiopathic in nature (Toru et al., 2000) and may be visible on plain radiographs. Ossification in the carpal tunnel is reported in association with lipofibromatous hamartoma of the median nerve (Louis and Dick, 1973). This case highlights the need to investigate selected cases of carpal tunnel syndrome. When patients are in the younger age group, or there is a clinical suspicion of a space-occupying lesion, imaging is recommended.