J. Pauchot

Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery

Breast reconstruction with adipocutaneous free flap from the abdominal wall combines the benefits of abdominoplasty to those of a prosthesis-free breast reconstruction. The deep inferior epigastric artery perforator (DIEP) flap is supplied by intramuscular perforators from the deep inferior epigastric artery (DIEA). It consists of the dissection of perforating branches of the DIEA within the rectus abdominis muscle, thus sparing both muscle and fascia. Preoperative imaging in the planning of DIEP flap surgery has been shown to facilitate faster and safer surgery. This review article aims to discuss advantages and drawbacks of current imaging modalities for mapping the course of perforating vessels in the planning of DIEP flap surgery, and to present state-of-the-art imaging techniques.

Post-traumatic reconstruction of digital joints by costal cartilage grafting: A preliminary prospective study

In digital joint defects, reconstruction is meant to obtain a stable, mobile and pain-free finger. Six patients aged 29 years in average (15-46) and who were prospectively followed-up presented with digital joint defects that affected at least half of either the proximal interphalangeal (PIP) joint or the metacarpophalangeal (MCP) joint. These defects were treated in emergency (four cases) or scheduled for an autograft of costal cartilage harvested from the ninth rib. Four digits showed lesions of the extensor system which were repaired. One digit grafted after complete amputation was no more vascularized. All patients were reviewed and prospectively followed-up by the surgeons and were also reviewed by an independent operator 16.1 months post-surgery in average (9-25). No infection occurred. None of the grafted fingers had to undergo arthrodesis or secondary amputation. One case of type 1 complex regional pain syndrome occurred. No functional or aesthetic complaint was reported, and no complication was observed at the donor site. The mean arc of motion was 33° (20-50) for the PIP joint and 37° (30-40) for the MCP joint. Mean total active motion (TAM) was 191° (160-250°), whichever the injured finger, i.e. 79.1% compared with the contralateral finger. The Buck-Gramko score averaged 11/15 (8-15). The Strickland score (interphalangeal TAM) was 57.8%, which corresponds to a medium result. The quick DASH assessment averaged 17.42 (0-47.72). Even if arthrodesis or amputation remain the conventional option in case of joint defect, prosthesis or cartilage grafting constitute solutions that allow the preservation of a functional painless finger.

Reconstruction des pertes de substance de membres inférieurs par lambeau libre en urgence. À propos de 35 ans d’expérience

Authors analyzed 89 cases (86 patients) of lower limb extensive soft tissue defects reconstruction during 1978 to 2013. The mean age is 37 years and 2 months old (range: 5-84 years old). A total of 71 males and 15 female were included. Free flaps were used in emergency in 23 cases for principally covering Gustilo 3B open lower limb fracture and in a later stage for 66 cases all referred from their center for coverage of exposed bone, with frequently osteomyelitis. About the selection of free flaps, in 47 cases we used a latissimus dorsi flaps, 12 cases of epiploon free transfer (in septic area), 10 cases of gracilis transfer and 10 serratus anterior flaps. There are one medial gastrocnemius flap, 2 composite soleus and fibular free flap, 2 antebrachial flap, one inguinal myoosteocutaneous flap, 1 transferred from the other lower limb and one inguinal cutaneous flap. There are 18 free flap losses: one in emergency and 17 after delayed reconstruction. Authors retrospectively analyzed the results (complications, osteomyelitis) according to the timing for lower extremity reconstruction. They found a low infection and flap failure rates (4%) when the coverage is made in the same operating time than initial fracture fixation, they increase to 60% for osteomyelitis and to 23% for flap failure when the reconstruction is delayed.

Évaluation rétrospective monocentrique comparative par tamisage des greffes veineuses et des greffes nerveuses dans les pertes de substance des nerfs collatéraux digitaux palmaires. À propos de 32 cas

AIM Palmar digital nerves defects can be treated by conventional nerve grafts or by means of a conduit, such as a vein. We compared a vein graft technique to a nerve graft technique in a retrospective monocentric study. MATERIAL AND METHOD A surgeon who was not involved in the treatment reviewed blind 15 nerve grafts and 17 vein grafts. The evaluation concerned sensitivity, pain, donor site morbidity, social integration and autoassessment of the benefits by the patient. Data were compacted by a sifting method eliminating bad results. The classical functional scores (British Medical Research Council, Möberg, Chanson, Alnot, Dumontier) were also used. RESULTS The evaluation was carried out at least 11 months after treatment. Defect was never greater than 30 mm. After sifting, vein grafts appeared less efficient than nerve grafts (41% good results against 73%), except in emergencies (86% good results). CONCLUSION For defect loss of no more than 30 mm in emergencies, the authors propose to use vein grafting. In other situations, the surgeon must take into account the patients profile and the hemi-pulp concerned, dominant or non-dominant, before opting for a nerve or a vein graft.

Dermal Equivalents in Oncology: Benefit of One-Stage Procedure

BACKGROUND In oncology, dermal equivalent may be indicated to cover losses of substance related to skin tumors or after the removal of skin flaps. OBJECTIVE To report our experience of two dermal equivalents, Matriderm 1 mm with a one‐stage graft (DE1) and Integra DL with a two‐stage graft (DE2) in oncology. PATIENTS AND METHOD Retrospective, single‐center study involving 16 patients. RESULTS Sixteen patients received dermal equivalents as an alternative to flaps (7 cases), over tendinous areas (7 cases), and for cosmetic purposes (2 cases). Twelve patients received DE1 and four DE2. Wound healing times with DE1 were 4 weeks less than those with DE2. Three cases of infection were noted with DE2. The use of dermal equivalents as an alternative to skin flaps was effective, and no adhesions were found over the tendinous areas. CONCLUSION The learning curve, the two‐stage graft required with DE2, and not using a vacuum‐assisted closure system can explain the high infection rate. The use of dermal equivalents is particularly indicated in the treatment of skin defect in oncology. The possibility of a one‐stage graft with DE1 and combination with negative pressure therapy is beneficial.

Geometrical analysis of the V–Y advancement flap applied to a keystone flap

BACKGROUND The V-Y advancement flap and, more recently, the keystone flap are commonly used to cover skin defects. Both flaps allow for primary closure after advancement by substituting the initial defect for a narrower defect distributed over a greater length. The first objective of this study was to develop a geometrical analysis of the V-Y advancement flap. The second objective was to explain the benefit of using the keystone flap compared to a single V-Y advancement flap. MATERIAL AND METHOD A geometrical analysis is proposed using a two-dimensional analysis in which the flaps are assumed to have a rigid-body behaviour. First, in the case of the V-Y advancement flap, a trigonometric relationship is defined between the distance of closure before and after advancement, thus implying the value of the flaps apex angle. Second, by considering the keystone flap as the association of three V-Y advancement flaps, the trigonometric relationship is applied to the keystone flap. RESULTS In the case of the V-Y advancement flap, the optimal apex angles are between 20° and 60°. At less than 20°, the length of the flap increases in an exaggerated manner. At greater than 60°, the distance of closure, particularly at the apex of the flap where a corner stitch is performed, is greater than the distance of closure of the initial defect. In the case of the keystone flap, the width of the final defect around the flap is clearly smaller and more regular compared to the final defect around a single V-Y advancement flap. CONCLUSION The geometrical analysis of the V-Y advancement flap in our description illustrates the major benefit of the keystone flap over a single V-Y advancement flap.

Couverture d’une perte de substance dorsale médiane par deux lambeaux musculocutanés de rotation de latissimus dorsi avec palette cutanée en V-Y. Bases géométriques et intérêt. À propos d’un cas

Reconstruction of a large dorsal radionecrosis with bilateral latissimus dorsi V-Y musculocutaneous flaps is reported. This procedure provides a reliable, well-vascularized soft-tissue coverage. Geometric analysis and differences between V-Y advancement flap and V-Y rotation flap are discussed.

Leap Motion Gesture Control With Carestream Software in the Operating Room to Control Imaging: Installation Guide and Discussion

Nowadays, routine cross-sectional imaging viewing during a surgical procedure requires physical contact with an interface (mouse or touch-sensitive screen). Such contact risks exposure to aseptic conditions and causes loss of time. Devices such as the recently introduced Leap Motion (Leap Motion Society, San Francisco, CA), which enables interaction with the computer without any physical contact, are of wide interest in the field of surgery, but configuration and ergonomics are key challenges for the practitioner, imaging software, and surgical environment. This article aims to suggest an easy configuration of Leap Motion on a PC for optimized use with Carestream Vue PACS v11.3.4 (Carestream Health, Inc, Rochester, NY) using a plug-in (to download at https://drive.google.com/open?id=0B_F4eBeBQc3yNENvTXlnY09qS00&authuser=0) and a video tutorial (https://www.youtube.com/watch?v=yVPTgxg-SIk). Videos of surgical procedure and discussion about innovative gesture control technology and its various configurations are provided in this article.

Le lambeau perforant abdominal (DIEP) et grand dorsal autologue en reconstruction mammaire. Étude rétrospective comparative à propos des 60 premières patientes d’un même opérateur

INTRODUCTION Autologous techniques for breast reconstruction get the best cosmetic results. Aesthetic satisfaction with breast reconstruction is an important evaluation criterion. The indication is based on technical criteria (morphological, medical history) and the wishes of the patient. A rigorous evaluation of the results is necessary to assist the patients in their choice of reconstruction. METHODS Thirty-three DIEP and 27 latissimus dorsi were involved. A satisfaction questionnaire was sent to patients to collect the aesthetic evaluation of their reconstructed breast, sequelae at the donor site of the flap as well as their overall satisfaction. Post-operative photographs of the patients were subject to aesthetical evaluation by two groups of observers. Complications were analyzed. RESULTS The DIEP tends to get higher aesthetic satisfaction regarding the symmetry of the breasts and the volume of the reconstructed breast (P=0.05), and a better overall satisfaction (P=0.02). The uniformity of the colour of the reconstructed breast was considered superior by observers in the latissimus dorsi group (P=0.005). Donor site scar of DIEP was considered more unsightly while the latissimus dorsi was considered more painful (P=0.04) and uncomfortable, with more frequently contour abnormalities (P=0.03). We noted two total flap necrosis and three partial necrosis in the group DIEP, and two partial flap necrosis in the group latissimus dorsi. CONCLUSION This study provides evidence that can guide the patient and the surgeon in the complex process of therapeutic decision, without exempting the latter from a careful selection of indications.

Adjonction d’antithrombotiques in situ en cas de replantation digitale : étude prospective préliminaire de 13 cas

Antithrombotic agents are not routinely used in microsurgery for finger replantation. A prospective monocentric study of 13 cases of replantation at hand level is reported with local irrigation of anastomosis with urokinase and low-molecular-weight heparin. Thirteen consecutive patients have been included and treated in the first six hours by three senior surgeons in microsurgery. The injuries consisted in one devascularisation of hand, two complete amputations of hand, four ring fingers and six complete amputations of finger. Crush injury was always pointed in case of amputation. During anastomoses, the arterial lumina were topically irrigated with 50,000 UI of urokinase and the venous lumina by 1.2 ml of Lovenox®. Bleeding was encouraged in case of digit replantation. In all cases, patients received Aspegic® 10mg/day and Fonzylane® three times per day for three weeks. Three failures have been reported and blood transfusion was necessary in one patient. The results showed that topical irrigation with urokinase and low-molecular-weight heparin or enoxaparin solution significantly reduced the thrombosis rate at the anastomosis site of the crushed arteries in clinical practice without uncontrolled adverse effect.