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The reform of the third cycle of medical studies in 2017 led to the creation of the status of "Junior Doctor", corresponding to the consolidation phase and allowing increasing autonomy and supervision from the intern. In plastic surgery, this status appeared for the first time in November 2021 in French hospitals; it lasts two years and succeeds the first four years of internship.We sent a self-questionnaire by email in May 2022 to the 21 French Junior Doctors. This was interested in their training ground, formation program, consultation activity, operating program, integration into the on-call list, the existence of half-days of availability, and their general opinion on this reform and its implementation.We collected 20 questionnaires with a sex ratio of twelve men for eight women. The majority of respondents worked in a university hospital (85 %). 45 % had their consultations, 60 % had their own operating sessions under general anesthesia, and 35 % under local anesthesia. Only 25 % of them considered this reform to be a step forward in terms of training.The introduction of the status of Junior Doctor is contrasted within the various hospitals. Despite the progressive and supervised autonomy provided by this reform, it is generally perceived neutrally or negatively by Junior Doctors. The establishment of own consultations and operating sessions stands out as a key positive element allowing better application of the reform.

The neurocutaneous sural flap is useful to cover defects of the distal quarter of the lower limb. Nevertheless, severe complications occur in 14% of the cases, and venous congestion is reported in 75% of these cases. This congestion can lead to total necrosis of the flap and a failure of the procedure. We describe a new surgical method aiming to reduce the risk of venous congestion occurrence and failure of the defect coverage.We realized a retrospective study of patients who undergone a de-epidermized distally based neurocutaneous sural flap in our surgery department from 2015 to 2020. The following data were collected: sex, age, vascular risk factors, size of the wound, defect area, etiology, delay between the surgery of the flap and the split-thickness skin graft and complications.The cohort is composed of 5 cases. We reported no failure of the coverage of the defect. There were no cases of venous congestion.The de-epidermized distally based neurocutaneous sural flap could increase the reliability of these flaps by reducing the risk of venous congestion. A larger study comparing the classic technique to the de-epidermized sural flap could confirm these data on a greater number of cases and position this technique in the therapeutic arsenal.

The carpal tunnel syndrome is rare in children. We performed a retrospective study of 10 children. The aim is to show that the diagnosis of carpal tunnel syndrome is difficult in children.We identified all children with median nerve compression in the carpal tunnel between 2010 at 2020, managed in our service.Ten children with 20 hands included. There was different etiologies of carpal tunnel syndrome: 5 lysosomal storage diseases, 4 idiopathic carpal tunnel syndrome, 1 genodermatose, 1 Byler syndrome and 1 VACTERL syndrome. Common presenting symptoms were pain (five patients) and under use of fingers (five patients). Two children had opposition deficit of the thumb. We operated 19 hands. Median age at diagnosis was 4 years and 7 months. One children or 2 hands had a reanimation of opposition by tendinous transfer of flexor digitorum superficialis tendon of the ring finger. All children had a complete regression of the painful symptoms, a use improvement of fingers and recovery of the opposition of the thumb.The diagnosis of carpal tunnel syndrome is difficult in children. It is common to be confronted with an advanced clinical symptoms. The atypical symptoms may cause diagnostic delay. Due to the quality of the clinical results obtained, we recommend open carpal tunnel release even when the diagnosis seems delayed.IV.

Resume Introduction En chirurgie plastique, les recommandations sur l’antibioprophylaxie sont imprecises et incompletes, du fait d’une quasi-absence d’etude de haut niveau de preuve sur le sujet. L’objectif principal est de proposer des recommandations nationales detaillees consensuelles concernant l’antibioprophylaxie en chirurgie plastique. Materiel et methode Une analyse multicentrique des pratiques au sein de trois Centres Hospitaliers et Universitaires, comparee a une analyse interdisciplinaire des recommandations de la Societe Francaise d’Anesthesie et de Reanimation et de la litterature scientifique a ete proposee pour discussion et validation a un groupe de travail compose de chirurgiens plasticiens membres du chapitre de plastique generale de la Societe francaise de Chirurgie plastique reconstructrice et esthetique, d’infectiologues et d’anesthesistes afin de definir des protocoles d’antibioprophylaxie preoperatoire clairs et precis. Resultats Une antibioprophylaxie par cefazoline (ou clindamycine ± gentamicine en cas d’allergie), est recommandee pour les interventions de chirurgie generale avec lambeau ou prothese, la chirurgie mammaire avec ou sans prothese, la lipostructure, les dermolipectomies de membres, les chirurgies abdominales et les rhinoplasties/septorhinoplasties. Aucune antibioprophylaxie n’est recommandee lors des autres interventions de chirurgie plastique, hors lambeau ou implant, ou de la face, hors rhinoplastie. Conclusion Nous avons etabli un protocole detaille qui constitue une premiere etape vers l’actualisation des recommandations concernant l’antibioprophylaxie en chirurgie plastique. Celui-ci pourra etre evalue en situation clinique afin de permettre sa possible validation.

In plastic surgery, guidelines about antibiotic prophylaxis are inaccurate and incomplete, due to result the absence of high-level studies on this subject. The main aim is to establish national common recommendations for plastic surgery antibiotic prophylaxis.A working group will discuss and validate a multi-center analysis of practices in three University Hospital Centers compared to an interdisciplinary analysis of recommendations to the French Society of Anaesthesia and Intensive Care Medicine and scientific literature. This working group is composed of plastic surgeon members of the French Society of Aesthetic Reconstructive Plastic Surgery, infectious disease physicians, and anaesthesiologists to define clear and precise antibiotic prophylaxis recommendations.Antibiotic prophylaxis with cefazoline (or clindamycine±gentamicine in case of allergy), has been recommended for general surgery with flap or implants, for breast surgery, lipofilling, and rhinoplasty. In other plastic surgery, no antibiotic prophylaxis has been recommended.We established common recommendations for plastic surgery antibiotic prophylaxis that is the first step to update these recommendations. Now, they can be evaluated in clinical situation to validate them.

Pollicization of the index finger as a treatment for aplasia and severe congenital thumb hypoplasia remains a demanding surgical procedure. In aplasias, it is generally well-accepted, less in hypoplasias. However, it is often the only solution to give back to the child the possibilities of a pollici-digital grip, guaranteeing an excellent function of the hand. We decided to evaluate the long-term results of this intervention.We reviewed all children operated of index pollicization for a congenital aplasia or hypoplasia of the thumb between 2006 and 2018. The evaluation was performed with a specialized reeducator. The analytical and functional characteristics of the neo-thumbs were evaluated, as well as the consequences on the daily life of the child.Thirteen pollicisations were performed on 10 patients. The mean age at surgery was 21 months (10; 43). It was a Blauth stage IIIB in 1 case, IV in 5 cases, and V in 7 cases. Seven children, and eight hands, could be evaluated. The average postoperative follow-up was 6.5 years. The mean age at the examination was 7.7 years (3.3, 12.1). The mean Percival score was 18 out of 22. The adapted video-assisted scoring system had an average score of 11 out of 14. Children described a momentary psychosocial discomfort for 5 of them, and still present in 3 of them.The pollicization of the index finger in congenital aplasia or severe hypoplasia (stage IIIB and IV) of the thumb remains for us the only way to create a sensitive thumb, mobile, with satisfactory strength and appearance, and to bring a normal function of the hand. The evaluation of our functional results are good to very good in the majority of patients, and show the benefits give by this intervention.

Due to an increasing number of major weight loss after bariatic surgery, the demand for body-coutouring surgery increase in paralell. Among all the technics which can be realized, brachioplastyis one of them. The goal is to reach a functionnal but an aesthetic improvement too. The literature show that the rate of major complication is very low (or not reported in the majority of the series). Minor complication is more common : hypertrophic scar, large scar, paresthesia, and wound dehiscence. Re-operation can be asked by the patient in order to improve the result. With the help of clinical cases and literature review the authors try to analyse the balance between benefice and risk to realize a second operation.

The objective was to compare the short-term efficacy of methoxyflurane vs. MEOPA on acute pain during burn dressing in consultation, the secondary outcome was to assess the patient's comfort and the quality of the dressing performed.Monocentric, prospective study from April 2018 to January 2019. Men and women18 years presenting acute burn on10% SCT were included. A pain≥4 on the numerical scale (from 0 to 10) at the beginning of the treatment established the indication of methoxyflurane or MEOPA, with randomization done by a nurse. The following data were collected: burn description, performed debridement, pain assessment by numerical scale: on arrival, at the beginning of care, after 6 to 10 inhalations for methoxyflurane or 3 to 4minutes of inhalation for MEOPA and at the end of care.Sixty patients were included, 30 in each group. There was a decrease of -2.47 points of numerical scale when initiating methoxyflurane against -1.53 points for MEOPA (P=0.08). Patients were significantly less painful when stopping treatment in the methoxyflurane group -4 points vs -2 points (P=0.001). Methoxyflurane significantly improved the debridement of the burn (P=0.018).Methoxyflurane is more effective than MEOPA in acute pain in burn dressing, improved patient comfort, and improved dressing quality.

Chronic wounds represent a major health challenge with no current standardized surgical treatment. The use of free flaps is little discussed in the literature, with a supposed propensity to failure given unfavorable local conditions and land often debility. We present here the analysis of our monocentric experience of the use of free flaps in the curative treatment of chronic wounds.We performed a retrospective monocentric study over 18 years of all free flaps used for the treatment of a chronic wound between January 2001 and September 2016. Several criteria were evaluated on patients, wounds, free flaps used and immediate to late outcomes.Ninety-one patients were included (sex ratio M/F: 3.55) with an average age of 41.6±16 years. Wounds were localized to the leg in 92.3% of cases and 58% of patients had initial osteomyelitis. The flaps used were predominantly muscle flaps (61.6%). The flaps survival rate was 92.3%. With a mean follow-up of 50 months, the reconstructive failure rate was 20.9%. The presence of a chronic osteomyelitis is the only statistically significant factor of reconstruction failure (P=0.0169) with a risk of failure multiplied by 5.Our study demonstrates that the reliability of free flaps in the treatment of chronic wounds is comparable, regardless of the time since the initial cutaneous lesion, to that existing in the treatment of acute wounds or in the reconstruction after oncological excision. The presence of a chronic osteomyelitis, however, represents a major risk of reconstruction failure by increasing 5 times the risk of failure. Recent changes in the integumentary reconstruction paradigm of the lower limb will undoubtedly allow in the next few years to establish more rationally the place of muscle free flaps in the therapeutic armamentarium of chronic wounds.

Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method.We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded.Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications.The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.

Describes the contrasting structures of negation in French and in Hungarian. (AM)

Proposes description of Latin syntactic structures through an analysis of their communicative functions. (AM)

Congenital deformities of the hand and upper limb include a significant number of clinical situations. Their expression is, as in all congenital diseases, variable. Therefore, we can almost consider that each clinical situation is a bit unique. The difficulty, as any congenital disease, is the fact that the clinical cases are extremely diverse and difficult to classify. So what to do and surgical strategies are often matter of "School". This is even more true that the evaluation of results is very difficult due to low series (poor statistical value) and functional assessment to be partly due to the growth of the child. It is impossible in a few pages to describe all malformations of the hand and upper limb, summarize the indications and evaluate the results. Also, this chapter is not exhaustive and we will focus primarily on the most frequent pathologies.

In our team, free flap and especially serratus anterior muscle is the first option for the coverage of lower limb post-traumatic defects. For complex tissue loss, it may be advantageous to harvest the free serratus anterior with rib myo-osseous composite flap. We performed 20 osteomuscular serratus anterior composite flap between 2008 and 2010.We retrospectively studied the records of 20 patients, by separately analyzing the characteristics of the bone defect and the soft tissue loss. Patients have been recently reviewed by an independent operator. We compared our results to other reconstruction techniques and other similar series reported in the literature.The average age of our patients was 43 years and 11 months. In all cases, defect was traumatic. The average follow-up was 5 years (4.5 to 5.8). The average flap area was 135cm(2) and the average rib length was 9.21cm. Our microsurgical success rate is 95%. Our global consolidation rate is 82%.Use of vascularized rib in the treatment of lower limb traumatic defects is rare. The bone quality of rib is lower than fibula, but the coverage provided is better, due to serratus anterior muscle. The length and diameter of the vascular pedicle is very useful too. Our results are comparable to other series using this flap. Its coverage properties and the possibility of simultaneous bone reconstruction is useful. It allows one stage procedure for complex tissue losses with satisfactory results in the short and long term. The further realization of a free fibular transfer in cases of persistent non union remains possible.

We report the case of a 57-year-old patient who presented radiological images similar to ruptured breast implants one year after the supposed withdrawal of the latter. This woman had benefited for the first time from cosmetic PIP breast implants in 2000. Early in 2014, she requested the removal of the implants without renewal because she was feeling pain and functional discomfort. A few months after the operation, she consulted for breast swelling in the upper pole of the breast. Radiological assessment showed liquid formations compatible with the presence of implants. At our request, the rereading of the MRI by the radiologist definitively concluded on a bilateral seroma within the persistent fibrous capsule. In the absence of symptoms, clinical monitoring had been decided. But at the recrudescence of anaplastic large cell lymphoma cases associated with breast implants, a cytological sampling was intended. In case of cytological abnormality or recurrence of the seroma, a surgical procedure should be performed. In conclusion, the removal of a breast implant without capsulectomy may result in the formation of a seroma whose images resemble those of an implant. It is always worthwhile to provide precise clinical data to the radiologist in order to help him to make informed interpretations. Every serous effusion in a breast lodge having contained a silicone implant must evoke the diagnosis of anaplastic large cell lymphoma.

Among all complications that affect patients with neurofibromatosis, type I (NF1) are very aggressive malignant nerve sheath tumors (MPNSTs). Surgery is their first line therapy.We report the case of a non metastatic neurofibrosarcoma of the axillary area in a 22-year-old male with NF1. An interscapulothoracic resection was performed to resect the tumor and had sacrificed the homolateral latissimus dorsi pedicled myocutaneous flap. In this extreme and not codified situation, the coverage of the tissue loss was possible in the same time using a free flap harvested on the amputated limb (fillet flap). The free flap based on the humeral pedicle was composed of the entire skin and muscles of the amputated forearm. It was anastomosed on the subclavian vessels. Only a free flap was suitable in this tissue loss. The use of a fillet flap allows a wide and reliable coverage without donor site morbidity.

The spare-parts concept is well described in traumatology of the hand. Tissues of a scarified ray are used to reconstruct another damaged finger. We will detail an application in pediatric hand through a clinical case.We describe a patient presenting a bilateral complete and non-complex syndactyly of the third web space associated with a bilateral hexadactyly classified as type B according to the Temtamy and Mc Kusick's classification. The treatment of the syndactyly was performed with a dorsal flap for the web space and with longitudinal zigzag incisions in mirror. Skin loss of the lateral sides of the fingers was covered by the full-thickness graft taken on the supernumerary finger which was treated in the same surgical time.This application of the spare-parts concept allows only one surgical site with absence of scar on the donor site and a skin graft close to the skin loss on the finger.The spare-parts concept can be applied in some cases of pediatric hand and must be a tool for the surgeon.

Surgical treatment of congenital syndactylies is based on the creation of a new commissure - with a commissural flap - and on the management of fingers lateral faces - with mirror zigzag incisions. Lateral skin defects are covered by full-thickness skin graft. Since their discover 30 years ago, dermal substitutes applications have been enlarged. We have wandered if these technique could be interesting for the treatment of these lateral skin defects.We have launched a monocentric and retrospective study with only one surgeon. The assessor and the operator were different. Included patients have a simple or complex congenital syndactyly, complete or not, associated with a syndrome or not. Children with a first web space syndactyly were excluded. Surgical treatment was performed with a dorsal commissural flap, with mirror incisions and with a lateral skin defects coverage by dermal substitute (Matriderm(©)) and split-thickness skin graft taken from the scalp. The initial assessment criterion was the quality of the scare measured by the OSAS score. Web creep (Whitney's scale) and time of surgery were two minor criteria.Twenty commissures (11 children) have been included between 2008 and 2013. Fourteen complex syndactylies were noted. The average aftercare was equal to 2.7 years (0.5-5.5 years). Interventions were performed at the age of 1.8 years (0.5-4 years). Surgical time was equal to 44.6 min (22-95 min). Patients OSAS score was 11.9 (6-18). It was 12.2 (60-20) for complex forms and 11.9 (10-16) for simple forms. Graft weren't hairy. There was no complication on the donor site. Whitney's score was 1.2 (0-3) and three web spaces were reoperated.We think that the use of dermal substitute Matriderm(©) is a new and serious alternative to treat congenital syndactylies. Results have to be confirmed by a new study which would compare this material to full-thickness skin graft, gold standard technique for these skin defects.

Management of scalps defect is a common subject for reconstructive surgery. The use of local flap is better because of the hairy skin.The auricular posterior artery is often described as an accessory blood supply for the scalp.We present an original case of 16×6 cm scalp flap harvested almost in "vascular island" on the right retro-auricular pedicle to cover an occipital wound.We have obtained an effective healing in 20 days. Despite its considerable length, no distal necrosis has occurred.Rarely reported in the surgical literature, the posterior auricular vessels are a good blood supply to harvest scalp flap. This procedure adds to overall techniques of reconstructive surgery for scalps defects that plastic surgeons can use.

Occlusive dressings for second-degree hand burns in children must prevent infection and promote healing. For good management of analgesia, these treatments often require children to be hospitalized. Our goal was to find an alternative to conventional care protocol that would reduce the number of dressings and therefore the length of hospitalization. We report our experience with the use of Aquacel(®) Burn.Non-randomized monocentric prospective study was conducted from 2012 to 2014. The glove was used in the operating room within 72hours after the burn in children younger than 15 years old with isolated superficial to deep 2nd degree hand burns. Once the glove was perfectly stuck to the burn, the children could go back home. We saw them 10 to 12 days after the accident to be sure there was no indication of skin graft.Twenty gloves were used in 16 children aged from 16 months to 13 years. The average length of stay (ALOS) was five days to put the glove on and one day to remove it. Four hands were grafted.Once we get used to the product, Aquacel(®) Burn gloves have reduced the ALOS before skin graft in cases of isolated hand burns in children.

During breast augmentation, surgical drainage remains a source of debate. The objective of the study was to determine the interest of the drainage after pre-pectoral breast implants pre, analyzing the risk of hematoma and capsular contracture.We retrospectively analyzed a cohort of 400 patients who underwent a first aesthetic breast augmentation by pre-pectoral silicone gel implants. Patients were followed with a maximum of nine years and a minimum of one year.The mean age of patients was 37 years (18-64). Ninety-two percent (368 cases) had no drainage (patients "low risk of bleeding") and 8% (32 cases) underwent a bilateral drainage (patients "high risk of bleeding"). We recorded 1.75% hematoma (7 cases) and 2% of capsular contracture (8 cases).We believe that the drainage should not be systematic for pre-pectoral breast implants. In patients at high risk of bleeding that we drained, it does not prevent the occurrence of a possible hematoma. In patients at low risk of bleeding that we have not drained, we do not observed more hematoma or capsular contracture than data published for drained patients.

The carpal tunnel syndrome is a common peripheral neuropathy in adults but is rare in children. We report a series of 10 carpal tunnel syndromes in children.We have supported five children, two males and three females, with a bilateral carpal tunnel syndrome. We studied the clinical history (history, symptoms, stage of disease), therapeutic management and remote development. Three children were diagnosed with a mucopolysaccharidosis, the fourth with VATER association. For the last child, it was a form considered idiopathic. Two children were referred for night pains, the others for under-utilization of their first three fingers, two of which had a thenar atrophy. Four children underwent an electromyogram for diagnostic confirmation. We realized open surgical treatment at one time, by section of the carpal ligament.The average age of our patients was 4years. The average decline in the surgical study was 19 months. Postoperatively, we noted, in all patients, complete regression of the painful symptoms, a sensory improvement and recovery of the opposition of the thumb.The scarcity of carpal tunnel syndrome in children and the atypical symptoms may cause diagnostic delay, with serious consequences. We keep vigilant and ready to access to additional tests (electromyogram). For our team, the therapeutic approach is a systematic open surgical treatment.

Intraneural perineurioma is a rare benign peripheral sheath tumor, which is most prevalent in adolescents and young adults. It is characterized by focal perineural cell proliferation infiltrating the endoneurium leading to the macroscopic aspect of hypertrophic nerve. It typically presents a loss of motor function in the involved nerve. We report the case of a 3-year-old boy presented with painless, subcutaneous mass on the palmar aspect of his right hand without loss of motor function. Imaging studies showed a large mass within the median nerve suggesting schwannoma. Surgical exploration was undertaken. The tumor could not be removed without leading to motor and sensitive loss. Neurolysis of the hypertrophic fascicles was performed. Microbiopsies ruled out malignant tumor and could make the diagnosis of intraneural perineurioma of the median nerve. An annual clinical follow-up has been decided in order to detect any functional trouble such as loss of motor function.

During pregnancy, the Haute Autorité de santé (HAS) recommends to realize three ultrasonographic evaluations, notably for the early detection of congenital malformations. Yet, in our experience, ultrasonographic antenatal diagnoses of hand malformations are rare. This is both a retrospective (years 2003-2008) and a prospective study (2009-2012). It quantifies the sensibility of hand malformations ultrasonographic diagnosis. Questionnaires have been sent or given during consultations to parents of children with upper limb malformation. The parents' acceptance of diagnosis and their anxiety have been evaluated. Eighty-eight malformations have been recruited for our series. Only 11 antenatal diagnoses have been made. Thus, sonographic diagnosis sensibility is 12.5% in our series. Thirty-nine percent of the parents have been shocked by the absence of diagnosis at birth. The sensibility of hand malformation ultrasonographic diagnosis is rarely documented in literature. It is generally low. This diagnosis may raise concerns about eugenism and legal issues. However, congenital malformations, even in the absence of a diagnosis, must be taken care of by a clearly determined network. Our results highlight difficulties of prenatal diagnosis of upper limb malformations. A lot of questions arise: what information should be delivered to the parents? Should antenatal ultrasonographic diagnosis be legislated? "Minor" malformations are often well managed by the parents, but "major" malformations ignored often raise legal issues.