Franck Marie Leclère

Efficacy and safety of laser therapy on axillary hyperhidrosis after one year follow‐up: A randomized blinded controlled trial

Hyperhidrosis is a debilitating problem that is not only uncomfortable and inconvenient, but also embarrassing in work and social situations. In spite of the availability of several options for the treatment of axillary hyperhidrosis, recently, there has been an increasing interest in the use of laser therapy. This study aims to evaluate the efficacy of a laser diode device emitting at wavelengths of 924 and 975 nm and classical curettage either alone, simultaneously or in combination.

Laser‐assisted cartilage reshaping for protruding ears: A review of the clinical applications

In 2006, our institute reported the first clinical use of laser‐assisted cartilage reshaping (LACR) for protruding ears. Since then, the technique has been developed and refined. This article reviews the literature on the clinical application of LACR.

Description of the Baudet Surgical Technique and Introduction of a Systematic Method for Training Surgeons to Perform Male-to-Female Sex Reassignment Surgery

IntroductionMale-to-female sex reassignment surgery involves three main procedures, namely, clitoroplasty, new urethral meatoplasty and vaginopoiesis. Herein we describe the key steps of our surgical technique.MethodsMale-to-female sex reassignment surgery includes the following 14 key steps which are documented in this article: (1) patient installation and draping, (2) urethral catheter placement, (3) scrotal incision and vaginal cavity formation, (4) bilateral orchidectomy, (5) penile skin inversion, (6) dismembering of the urethra from the corpora, (7) neoclitoris formation, (8) neoclitoris refinement, (9) neovaginalphallic cylinder formation, (10) fixation of the neoclitoris, (11) neovaginalphallic cylinder insertion, (12) contouring of the labia majora and positioning the neoclitoris and urethra, (13) tie-over dressing and (14) compression dressing.ResultsThe size and position of the neoclitoris, position of the urethra, adequacy of the neovaginal cavity, position and tension on the triangular flap, size of the neo labia minora, size of the labia majora, symmetry and ease of intromission are important factors when considering the immediate results of the surgery. We present our learning process of graduated responsibility for optimisation of these results. We describe our postoperative care and the possible complications.ConclusionHerein, we have described the 14 steps of the Baudet technique for male-to-female sex reassignment surgery which include clitoroplasty, new urethral meatoplasty and vaginopoiesis. The review of each key stage of the procedure represents the first step of our global teaching process.Level of Evidence VThis 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.

Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques

Rosemary Basson, MD, FRCP(UK),* Allan Young, MD, PhD, FRCPsyche, FRCP(C),† Lori A. Brotto, PhD,‡ Miriam Driscoll, MD, FRCP(C),* Shauna Correia, MD, FRCP(C)*, and Fernand Labrie, MD, PhD§ *Psychiatry, University of British Columbia, Vancouver, BC, Canada; †Psychological Medicine, King’s College, London, UK; ‡Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; §Laval University Hospital, Research Center in Molecular Endocrinology, Oncology, and Human Genomics, Laval University, Laval, QC, Canada

Acellular Dermal Matrix: New Applications For Free Flap Pedicle Coverage A Prospective Study in 10 Patients

ABSTRACT Introduction: The goal of lower extremity reconstruction after trauma is the coverage of defects to give patients a healed wound and to let them resume their life, ambulate and return to work, while preventing amputation. In this article, we describe an innovative use of Integra® for free flap pedicle coverage in lower extremity reconstruction. Materials and methods: Between January 2011 and December 2015, ten patients, four women and six men, underwent a lower limb reconstruction with an association of free flap and Integra® to cover the flap pedicle. The mean age of the patients was 38.8±15.6 years at the time of surgery (range of 14-59 years). The mean defect size was 102±54 cm2 (range of 40-160 cm2). The bone and/or tendons were exposed at the level of the middle third of the leg in 2 cases, at the level of the distal leg in 5 cases and at the level of the foot in 3 cases. Results: There were no intra-operative complications. Mean size of Integra® needed for flap pedicle coverage was 12.8±2.3 cm2 (range 10–15 cm2). The mean follow-up was 41±19 months (range 21–70 months). Revision surgery was necessary in three cases due to haematoma of the pedicle. In these cases, the dermal substitute was easily removed while awaiting revision. This allowed flap survival in all cases. A skin graft was performed after a mean time of 3.4±0.8 weeks post-operatively. Complications at the donor site level included one seroma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. Conclusions: The combination of free flap and Integra® appears to be a useful option in covering complex defects in the lower limb. The dermal substitute avoids skin tension and compression of the pedicle. Haematomas of the pedicle, if they occur, are highly visible and thus easy to manage. We hypothesize that the use of dermal substitute for this specific indication of pedicle coverage will expand in the near future.

Laser-assisted lipolysis for arm contouring in Teimourian grades III and IV: A prospective study involving 22 patients.

Background Upper arm deformities secondary to weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures. Objective To objectively assess whether, in Teimourian high-grade upper arm remodelling, laser-assisted lypolysis (LAL) alone could result in patient satisfaction. Methods Between 2012 and 2013, 22 patients were treated for excessive upper arm fat (Teimourian grade III and IV) solely with LAL. The laser used in the present study was a 1470 nm diode laser (Alma Lasers, Israel) with the following parameters: continuous mode, 15 W power and transmission through a 600 μm optical fibre. Previous mathematical modelling suggested that 0.1 kJ was required to destroy 1 mL of fat. Patients were asked to complete a satisfaction questionnaire. The arm circumference was measured pre- and postoperatively. Treatment parameters, adverse effects and outcomes were recorded. Results Pain during the anesthesia and discomfort after the procedure were minimal. Complications included ecchymoses and prolonged edema. The mean (± SD) arm circumference decreased 5.5±1.0 cm in the right arm (P<0.01) and 5.2±1.1 cm in the left arm (P<0.01) in grade III patients and 4.9±1.1 cm in the right arm (P<0.01) and 4.9±1.1 cm in the left arm (P<0.01) in grade IV patients. Although the circumference of both arms significantly decreased in grade III and grade IV patients, the skin tightening remained incomplete. Overall, the average opinion of treatment was poor for both patients and investigators. Of the 22 patients, only nine (41%) would recommend this treatment. Conclusion LAL for upper arm remodelling is not sufficient to ensure full skin tightening for patients with Teimourian grades III and IV upper arm deformities. A complementary surgery is mandatory for grades III and IV.

Stroke from an External Carotid: Lesion Pattern and Mechanisms

Traditionally, patients with symptomatic external carotid stenosis present with neck or face pain, retinal ischemic symptoms or jaw claudication and rarely as ipsilateral cerebrovascular events. In this present case, our patient suffered a stroke from a paradoxical embolism from the external carotid, without involvement of the internal carotid artery. A plaque ulceration of the external carotids origin was the cause of this cerebral emboli. Duplex ultrasound showed a pathologic left external carotid, with a floating thrombus in the internal carotid. The diagnostic was confirmed by a computerized tomography scan. An external carotid thromboendarterectomy was performed 6 days after symptom onset, and intraoperative findings confirmed the plaque rupture with an extensive clot in the carotid bifurcation.

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-Hodgkins 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-Hodgkins 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.

Should a Preoperative Testicular Exam Be Mandatory for Abdominal Body Contouring Patients

The “bodylift/belt dermolipectomy” surgery can be thought of as a circumferential wedge excision of the lower trunk. Simplified by Lockwood,1 it has become a common surgery in massive weight loss (MWL) patients. An often neglected part of the preoperative evaluation is the testicular exam. The majority of MWL patients present with an obvious excess of the abdominal and pubic skin, resulting sometimes in a massive hanging panniculus. This deformity may incite the surgeon to focus on the skin laxity, overlooking an important step in the physical examination: the testicular exam. We report a surgical incident that have changed our routine preoperative physical examination in abdominal body contouring surgeries. In October 2013, a previously healthy 28-year-old male presented to our clinic after a MWL of 163 pounds. He had a gastric banding surgery performed four years ago by a general surgeon. He weighed 190 pounds at presentation. On physical examination he had a circumferential skin laxity, a hanging abdominal panniculus and a ptotic mons pubis. The testis were not examined at this time as this was not part of our preoperative examination routine. He was scheduled for a circumferential lower body lift procedure. Intraoperatively, after the posterior resection, the patient was turned into a supine position. The inferior abdominal incision was done and the dissection was taken down to the abdominal aponeurosis. At this time, we found two sub-scarpal, sus-aponeurotic inguinal masses (Figure 1). An intraoperative testicular examination revealed an empty scrotum. These masses were identified as extra-scrotal testicles. They were easily manually mobilized to their original position. The diagnosis of a retractile testis was done and a bilateral orchiopexy was performed. Postoperatively, the patient was followed for 1 year. No adverse events were noted during the follow-up period. A retractile testis is typically asymptomatic. The notion that the retractility will most likely resolve following puberty may not always be true. Previous reports about the ascent of the testis in adults have been described.2 Another explanation would be a congenital or acquired cryptorchidism, but the testicles were easily mobilized from the inguinal region to their original position making these diagnosis less likely.3 Furthermore, the patient did not recall any abnormal testicular palpation preoperatively and this was also found in his previous medical records. Treatment is generally not required for retractile testis and orchiopexy is not usually performed. In our case, in the absence of a preoperative testicular exam we were not able to determine

The Use of Integra® Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost–Benefit Analysis

It was with great interest that we read the article by Dr. Schiavon et al. [1]. The use of Integra dermal regeneration template versus flaps for reconstruction of full-thickness scalp defects involving the calvaria: A cost–benefit analysis. We congratulate the author on this important study, its outcome and conclusion where the point is made that in cases of patients with scalp defects larger than 100 cm for whom major surgery is needed, the treatment with Integra seemed to be less expensive than the treatment with free flaps or pedicle flaps. Besides the lower cost of treatment, we found three advantages to the uses of dermal substitute in full-thickness scalp reconstructive surgery [2]: (1) Reconstruction with Integra is a relatively simple and short procedure when compared to alternative approaches; the patient’s state (shock, infection and instability), the treatments initiated (vasopressins) and the local conditions of the recipient site (local inflammation) might contraindicate certain extensive and difficult operative procedures, such as free flaps [2–4]. (2) The method uses an off-the-shelf tissue substitute. In other words, if an initial application of Integra fails or needs to be revised, no native tissue is lost. This technique avoids donor-site functional morbidity and scars [3, 4]. (3) The technique allows for a significant degree of contour restoration after extensive tissue loss. In the case of insufficient resurfacing or insufficient bulk, two or three layers of Integra can be added to the first layer using the same procedure. The major disadvantage of tissue flaps is the persistent bulky aspect at the end of the procedure. Conversely, skin grafting is an inherently two-dimensional technique and can result in a hollow at the reconstructed side when compared to the contralateral non-operated side [2]. We have one question: Do you have any experience with the use of Integra as a complementary tool for free flap pedicle coverage in full-thickness scalp reconstruction? Indeed, in addition to the advantages of dermal matrix for complex reconstruction described in the literature, we have found supplementary benefits for the specific indication of free flap pedicle coverage. It avoids skin tension and compression at the level of the pedicle. A compression of the free flap pedicle would result in a thrombosis of the vessels and flap necrosis. Furthermore, a hematoma at the level of the pedicle will be highly visible due to the change of color of the Integra . This renders this complication easy to identify permitting rapid intervention: The Integra can be removed easily while awaiting surgical revision. This avoids compression of the pedicle and thrombosis of the vessels. Recently, Leclère et al. [5] published a series of 10 reconstructive procedures including free flaps with Integra, where Integra was used to cover the free flap pedicle. This & Franck Marie Leclère franckleclere@yahoo.fr; franck.leclere@inserm.fr