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Summary Background The three-stage folded forehead flap (FFF) proved to be a simple and readily available method of lining replacement. To date, no clinical trial has evaluated the outcomes of the FFF on the nose shape and function. Methods Patients undergoing a full-thickness unilateral alar reconstruction with a forehead flap between January of 2010 and December of 2015 were included for analysis. Patients were divided into two groups: The FFF group included patients that had a unilateral alar reconstruction using a three-stage FFF; the standard forehead flap (SFF) group included patients that had a reconstruction using a two-stage forehead flap in combination with another method for lining reconstruction. The following objective measurements were performed: the alar thickness, nostril and hemi-nose areas, and nostril height. Subjective evaluation of the results was performed using the NAFEQ score. Independent raters also evaluated the appearance of the nose. Results Thirty-one patients were included: 15 in the FFF group and 16 in the SFF group. In both groups, the reconstructed ala was thicker than that on the normal side, the reconstructed nostril was smaller than the normal nostril, and the reconstructed hemi-nose was bigger than the normal side. Moreover, 84% of the patients were satisfied with their total nasal functioning. All the patients were satisfied with their total nasal appearance. Conclusion The FFF showed objective, subjective, aesthetic, and functional results comparable to other lining reconstruction techniques.

Summary Background Surgical approaches in neck dissection: comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul Andre’s approach. Methods This single-center retrospective study compares a new transverse incision for cervicotomy to the classical approach described by Paul Andre in neck dissections. The evaluation criteria were: number of lymph nodes analyzed, operative time, complications, patient satisfaction and aesthetic aspects of the scar. Results A total of 34 patients were included in this study, from September 2009 until January 2015. The number of lymph nodes analyzed is not affected by this new approach compared to the classical one (P = 0.9). The scar has a significantly more discreet appearance in the transverse cervicotomy group (P = 0.023) likewise; patient satisfaction is higher in this group (P = 0.006). Conclusions Aesthetic and functional impairment can be reduced using this new transverse cervical approach hidden in the natural creases of the neck described by Langer.

Defects involving several aesthetic subunits (ASUs) or lying at the junction of an ASU are challenging and require a complex reconstruction. This study aimed to describe the hemi-tip as a new ASU.We conducted a retrospective study including patients who underwent a nasal reconstruction for lower nasal pyramid defects according to our modified ASU principle. Patients who suffered from a subtotal alar defect, which also involved50% of the tip, were reconstructed after excising the remaining tissue of the hemi-tip subunit. An aesthetic evaluation was performed using a patient satisfaction scale and by independent raters.From 2010 to 2014, 21 patients underwent a lower hemi-nose reconstruction. All patients had a full-thickness defect and underwent a reconstruction of the three layers of the nose. Sixty-four percent of our patients were very satisfied, 26% were satisfied, and only 10% were unsatisfied with their nasal tip appearance, with a mean score of 4.4/5. The nasal tip was also rated by independent raters with a mean score of 4.1/5.Our results and experience showed that a midline scar between the two hemi-tips is inconspicuous. The majority of the defects involving only one side of the tip would benefit from the hemi-tip ASU reconstruction.We have modified the number of ASUs by considering the hemi-tip as a proper subunit.

Resume Introduction La detection du ganglion sentinelle (GS) axillaire utilisant la fluorescence du vert d’indocyanine (ICG) dans le cancer du sein est une technique recemment developpee mais sa validite, comparee a la technique de reference utilisant le Technetium 99 (Tc), a peu ete evaluee. Materiels et methodes Entre decembre 2013 et janvier 2014, 40 patientes presentant un cancer du sein sans adenopathie palpable ont eu une detection du GS axillaire par injection peri-areolaire de Tc en preoperatoire, et une injection peri-areolaire d’ICG en peroperatoire. Les GS etaient initialement identifies et reseques par utilisation du vert d’indocyanine (ICG) couple a une camera infrarouge. Apres exerese du GS fluorescent, nous verifiions la radioactivite de celui-ci a la sonde gamma de detection (methode isotopique). En presence d’un marquage radioactif residuel au sein du creux axillaire, nous procedions a l’exerese des GS restants. Nous avons retrospectivement etudie le taux de concordance de detection des ganglions sentinelles axillaires entre ces 2 methodes. Resultats Au total nous avons reseque 53 GS. Parmi ceux-ci 48 (90,6 %) etaient positifs a l’ICG et 53 (100 %) etaient positifs au Tc. Les 5 GS discordants (9,4 %) etaient tous negatifs a l’ICG et positifs au Tc. Il n’y a eu aucune complication liee a l’utilisation de l’ICG. Conclusion La detection du GS dans le cancer du sein par fluorescence de l’ICG, est une technique sure, fiable et prometteuse mais neanmoins necessite une certaine expertise avant d’obtenir des resultats comparables au Tc.

Children have specific characteristics of wound healing. The aim of this study was to describe the specific clinical characteristics of wounds healing in children and to present the current knowledge on the specific mechanisms with regard to infant age. The tissue insult or injury in fetus can heal without scar, mainly due to reduced granulation tissue associated to diminished or even no inflammatory phase, modified extracellular matrix such as the concentration of hyaluronic acid in amniotic liquid, expression and arrangement of collagen and tenascin. Thickness of children skin is a serious negative factor in case of trauma, whereas poor co-morbidities and efficient growth tissue mechanisms are beneficial to good evolution, even in cases of extensive damage and loss of tissue. The subsequent tissue mechanical forces, wound healing during childhood, spanning from the age of 2 until the end of puberty, is associated with more hypertrophic scars, both in duration and in intensity. Consequently, unnecessary surgery has to be avoided during this period when possible, and children with abnormal or pathologic wound healing should benefit from complementary treatments (hydration, massage, brace, silicone, hydrotherapy…), which represent efficient factors to minimize tissue scarring. After wound healing, the growth body rate can be responsible for specific complications, such as contractures, alopecia, and scar intussusceptions. Its evolutionary character implies the need of an attentive follow-up until adult age. Psychologic repercussions, as a consequence of pathologic scars, must be prevented and investigated by the surgeon.

Introduction Bilateral reduction mammaplasty (BRM) is a common procedure in plastic surgery. Our study aims to determine whether single-shot infiltration with ropivacaine during surgery reduces postoperative pain and decreases analgesic consumption. Methods In a prospective and monocentric study, all women operated by a single senior plastic surgeon, for whom BRM had been performed were included. The same surgical technique was performed for all patients (a superior pedicle, wise-pattern BRM with a closed-suction drainage). During the first half first part of the study period, none of the patients received ropivacaine infiltration (control group) and during the second half, all the patients received this infiltration (ropivacaine group). Infiltration was performed with a 20 mL solution of ropivacaine per side. Analgesic consumption and pain intensity were recorded during hospitalization and following discharge. Results Forty-nine patients were divided into two groups (29 in the ropivacaine group and 20 in the control group). The ropivacaine group had a significantly lower consumption than the control group on all analgesics (paracetamol, tramadol, nefopam and morphin) (P

Free-floating thrombi in the right heart chambers is a rare phenomenon. Nearly 99% of detected cases are associated with the presence of proven pulmonary embolism. Its presence is associated with a poor outcome with a mortality between 27 to 44% according to studies. Despite the emergency of treatment, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 84-year-old man hospitalised for acute decompensated heart failure. After an initial favourable evolution, a degradation of respiratory occurred with dyspnea and desaturation. A bedside transthoracic echocardiography showed a mobile serpiginous thrombus, 7cm size, moving to and across the tricuspid valve. A computed tomography of the chest demonstrated massive bilateral pulmonary embolism. After persistence of the thrombus and seven days of heparinotherapy, thrombolysis therapy was initiated. The thrombus disappeared 24h after thrombolysis. Without contra-indication, thrombolysis is a faster, readily available treatment for the management of floating thrombus in the right heart chambers associated with pulmonary embolism.

The performance of a heat-driven vapor absorption chiller with various alkane mixtures as working pairs was studied. A Thermodynamic analysis showed that under specified operating conditions and with a generator temperature below 130 °C, temperature achievable with a simple flat plate collector when solar energy is expected as the driving heat source, the application of some of the proposed alkane mixtures is not feasible. Simulations using ASPEN Plus flow sheeting program are then done with the selected working pairs. All simulations were done specifying the Peng-Robinson equation of state as the property method. A parametric study was carried out allowing the investigation of the generator temperature effect on the system performance and the comparison between performances released with each working pair. Results revealed that a water-cooled absorption machine using the C3H8/n-C9H20 pair as working fluid releases the best performances from a heat driving temperature level of about 100 °C.

The middle and distal part of the nose has multiple well-defined cosmetic units with a distinct outline, color, consistency, sebaceous content, texture and function. Crossing these units with surgical incisions can lead to a more visible scar. Here we will deal with the case of an 84-year-old patient with basal cell carcinoma of the junction between the dorsum and the alar of the nose and the management of the resulting loss of surgical substance with the Marchac flap. This frontal flap described by Marchac is an axial flap based on a vascular pedicle emerging near the inner palpebral ligament, allowing coverage of the loss of substance while respecting the nasal subunits and less thickness difference is present.

Hyaluronic acid (HA) is the most used dermal filler. Some complications associated with its use have been described, but most of them are rare and benign. We report an exceptional case of skin necrosis of the tip of the nose, in a 22-year-old patient, after HA injection. The initial appearance may occurred subsequent aesthetic sequels. After necrotic tissue excision, patient was followed in rapid succession. Daily local care has led to wound healing, without any important sequel. This rare complication reminds us that HA injections are not without risk, despite their apparent simplicity of use. Moreover, the case presented confirms the potential healing of the nasal tip, allowing treatment with wound healing, rather than other early invasive procedure.

Summary Introduction After implant-based breast reconstruction, the nipple reconstruction technique must be carefully chosen, especially in patients with a history of radiotherapy. When the contralateral nipple is not available, using a classical dermal-fat local flap may lead to the implant exposure, and consequently, removal. We describe here a simple nipple reconstruction technique, using a strictly dermal local flap and evaluate its complication rate. Patients and methods All patients who underwent our technique for nipple reconstruction between January 2012 and April 2015 were included in this retrospective study. We described our surgical technique and noted the occurrence of postoperative complications. Results Forty-nine nipples, in 47 patients with a history of radiotherapy, were reconstructed with our technique. The mean age was 53 years old (range 27–78 years old). The average time between radiotherapy and nipple reconstruction was 42.5 months (range from 4.6 to 274.8 months). The mean follow-up was 30.9 months (range from 6 to 47 months). No implant exposure occurred. Regarding the nipple flap, two partial flap loss and one infection occurred, the whole complication rate was 6.1%. Regarding nipple projection, it was quite low (between 2 and 5 mm) after 6 months, but remained stable. Conclusion Our strictly dermal local flap technique for nipple reconstruction is a safe procedure and represents a good alternative to composite contralateral nipple graft in irradiated patients with an implant-based reconstructed breast.

Recent studies have demonstrated that cardiac resynchronization therapy diminish morbidity and mortality of patients with heart failure, who remain symptomatic despite an optimal medical treatment and who have a wide QRS. However, 30% of patients are non-responders. Hence, echocardiography constitutes an interesting tool for the diagnosis of asynchrony. Different echocardiographic indices predict response to cardiac resynchronization therapy. In this article, a practical approach is proposed for these patients.

We conducted surveys in 1997 and 2002 to determine the rate, underlying sources and outcome of nosocomial bacteraemia. Blood culture results were reviewed daily. All patients with positive cultures drawnor=48 h after hospitalization were included in the study and their charts were reviewed. The underlying source of infection was determined by pre-defined clinical and/or microbiological criteria. Patients were followed until discharge or death. In 1997 and 2002, 851 and 857 patient-unique cases of bacteraemia were diagnosed, respectively, excluding contaminants; of these, 228 (27%) and 277 (32%) cases, respectively, were hospital acquired (P0.05). The overall rate decreased from 7.5 to 7.0 per 1,000 admissions (P0.001). The sources of bacteraemia in 1997 and 2002, respectively, were: intravascular catheters (36% and 27%, P0.05), urinary tract (8% and 15%, P0.05), respiratory tract (5% and 13%, P0.01) and surgical sites (14% and 4%, P0.001). In one-third of patients, the source of bacteraemia could not be determined. Only 52% and 54%, respectively, of these patients were discharged alive (difference was not significant). In 1997, Staphylococcus aureus was the most frequent isolate (26%), followed by coagulase-negative Staphylococcus (13%) and Klebsiella pneumoniae (11%). By 2002, the incidence of S. aureus had fallen to 11% (P0.001), acinetobacter was the single most frequently isolated organism (increased from 6% to 17%) (P0.001). In-hospital mortality associated with acinetobacter bacteraemia (57%) was significantly higher than that for other organisms (31-43%) (P0.05). In conclusion, prospective surveys of nosocomial bacteraemias provide valuable information, facilitating the pursuit of successful interventions.

Objective To evaluate digoxin pharmacokinetic parameters using Bayesian estimation in 60 patients, and to identify factors that appeared to affect the risk of digoxin toxicity. Patients and methods 60 patients with serum digoxin concentrations were evaluated retrospectively. We collected demographic, clinical and laboratory data, and information on concurrent medications and clinical and electrocardiographic features of digoxin toxicity. The incidence of digoxin toxicity was evaluated in 50 patients. Serum digoxin concentrations were measured with fluorescence polarisation immunoassay Individual pharmacokinetic parameters were estimated by Bayesian method using Abbottbase Pharmacokinetic Systems. Results Signs of digoxin toxicity were present in 23 patients (46%). Patients without signs of digoxin toxicity had a significantly lower mean serum digoxin concentration than patients with signs, 1.99 ± 0.9 μg/L vs 2.7 ± 1.5 μ.g/L, respectively (p = 0.047). Patients with serum digoxin concentrations >2.2 μg/L differed significantly from those with values ≤2.2 μg/L, respectively, for the following parameters: age (82.0 ± 8.0 vs 72.0 ± 16.0 years; p = 0.005), serum creatinine levels (133.0 ± 55.0 vs 106.0 ± 26.0 μmo1/L; p = 0.012), bodyweight (57.4 ± 12.8 vs 69.2 ± 17.8kg; p = 0.01), volume of distribution (208.5 ± 89.5 vs 315.7 ± 91.2L; p = 0.0001), total clearance (1.60 ± 0.65 vs 3.4 ± 1.5 L/h; p = 0.0001), and elimination half-life (94.2 ± 28.6 vs 72.4 ± 16.7h; p = 0.001). Estimation of optimal dose showed that the doses recommended in intoxicated patients should be 3.5 times lower to reach the therapeutic range. Conclusion Digoxin concentrations were higher in patients with toxicity. Older age enhanced the risk of digoxin toxicity. Monitoring digoxin concentrations may help to confirm suspected digitalis toxicity.

Liposarcoma is the most common malignant deep soft-tissue tumor in adults. however, primitive cutaneous liposarcoma is very rare. We report the observation of a patient who presents a liposarcoma of the thumb.

The reconstruction of severe defects of the ankle and foot is a challenge. The ideal solution should combine a thin skin flap on the dorsum to allow shoe fitting and a muscle flap with a split-thickness skin graft on the weight-bearing area. Perforator-based thoracodorsal chimaeric flaps allow us to achieve these two goals with minimal donor-site morbidity. We present a reconstruction of an extended circumferential defect of the ankle with an exposed heel using a chimaeric thoracodorsal perforator flap with a serratus muscle flap. The skin flap was transferred on the dorsal foot, whereas the serratus anterior muscle was transferred on the exposed heel. Postoperative recovery was uneventful and the patient began full weight bearing after 3 months. Twelve months after reconstruction, natural shape and walking function were successfully achieved.

Aims So far, a total of five patients with eclipsed mitral regurgitation (MR) have been reported in the literature by three different teams. The aim of this article was to detail clinical and echocardiographic characteristics, and outcome of patients presenting eclipsed MR. Methods and results We defined eclipsed MR as spontaneous appearance, at rest, from 1 min to the next of an acute restriction in the motion of mitral leaflets preventing coaptation and leading to massive MR in patients with normal left ventricular end-diastolic diameter, left ventricular ejection fraction >45%, and baseline MR ≤2. Spontaneous regression occurred within 30 min, and no obvious trigger such as acute hypertension, new-onset arrhythmia, or myocardial ischaemia is present. Clinical data, ECG, echocardiographic data, surgery report, and follow-up status of six patients with eclipsed MR are reported: all were post-menopausal women with median age of 74 [57–80] years presenting hypertension (4/6), chronic kidney disease (5/6), or chronic anaemia (4/6). Five out of six patients experienced acute pulmonary oedema requiring hospitalization and underwent mitral valve replacement because of heart failure recurrence. Two patients died in the first days after surgery while the three others are free of symptoms at, respectively, 56, 18, and 10 months follow-up. Conclusion Eclipsed MR is a clinical and echocardiographic syndrome responsible for heart failure with preserved EF. It is presently underdiagnosed and should be evoked in cases of recurrent acute pulmonary oedema without obvious trigger, in particular in patients presenting discordant evaluation of MR severity over time.