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BACKGROUND: The risk to benefit ratio of face transplantation with a composite tissue allograft remains debatable, although this procedure is technically feasible. We report here a 1-year follow-up of a patient who underwent face transplantation with a composite tissue allograft. METHODS: On Jan 21, 2007, a 29-year-old man with neurofibromatosis type 1 underwent resection of a massive plexiform neurofibroma diffusely infiltrating the middle and lower part of his face. The main goal was to restore both the cutaneous appearance and function of the face, including, in particular, control of orbicularis oculi and oris muscle contraction. The issues of immunosuppressive therapy, psychological outcome, and social reintergration were addressed, together with the monitoring of graft rejection by biopsies of the skin and mucosa. FINDINGS: The initial postoperative course was uncomplicated. Two episodes of clinical rejection occurred on days 28 and 64. The second episode was associated with cytomegalovirus infection. Both episodes resolved favourably, with no further clinical signs of rejection, making the reduction of immunosuppressive treatment possible. A year after surgery, the functional outcome was very good, with successful sensory and motor reinnervation in the transplanted territory. Psychological recovery was excellent, with complete social reintegration. INTERPRETATION: This case demonstrates the feasibility of surgically removing a large part of the face and replacing it with a composite tissue allograft. This facial repair procedure, which seems to have a satisfactory risk to benefit ratio, could be offered in rare and selected cases. [ABSTRACT FROM AUTHOR]

Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background:  The volume of the profunda femoris artery perforator (PAP) flap limits its indications to small- and medium-sized breast reconstructions after modified radical mastectomy for cancer. We report a modified PAP flap design, including not only a vertical extension that increases its volume but also the skin surface, which suits larger breasts requiring immediate or delayed breast reconstructions and compare the results with our horizontal skin paddle PAP flap experience., Patients and Methods:  In our center between November 2014 and November 2016, 51 consecutive patients underwent a PAP flap breast reconstruction following breast cancer. A retrospective analysis on the collected data was performed to compare 34 patients with a bra cup smaller than C who underwent 41 horizontal PAP flap procedures, with those ( n  = 17) of a bra cup greater than or equal to C who underwent 21 fleur-de-lys PAP flap procedures. Demographic, anthropometric, flap and surgical characteristics, postoperative complication rates, and hospital stay were compared between the two groups., Results:  The average flap weight was 480 g (range: 340-735 g) for the fleur-de-lys PAP flap group compared with 222 g (range: 187-325 g) for the horizontal PAP flap procedure ( p  < 0.001). The mean flap dimensions were 25 × 18 cm for the fleur-de-lys PAP flap group compared with 25 × 7 cm in the horizontal PAP flap group. No flap failure was observed in the fleur-de-lys PAP flap group compared with two flap failures secondary to venous thrombosis in the horizontal PAP flap group ( NS ). Three patients (14%) experienced delayed healing at the donor site compared with four patients (10%) in the horizontal PAP flap group ( NS )., Conclusion:  The fleur-de-lys skin paddle design not only allows an increase of the horizontal PAP flap volume, but also increases the skin surface, with an acceptable donor site morbidity. For medium- or large-sized breasts, the fleur-de-lys PAP flap seems to be ideal when a DIEP flap-based reconstruction is contraindicated., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Unlabelled: The authors conducted a retrospective study of breast reconstruction with DIEP free flap between 1994 and 2014 by a single team., Material and Method: A retrospective analysis of all operative charts and hospitalization was conducted for the period from 1994 to 2014. The number of cases per year, the complication rate of the donor site and recipient site, and surgery time were recorded. Sequence analysis was conducted to determine the elements that have enabled to implement this technique reliably and effects of the learning curve. The series was split into two periods (1994/2011 and 2012/2014) corresponding to two different hospitals with the same team., Results: The total number of shreds of 1138 between November 1994 and December 2014 respectively with 477 and 661 the period 1994/2011 to 2012/2014 period. The failure rate increased from 8% to 2.2%., Conclusion: The establishment of units mainly dedicated to microsurgical reconstruction can offer the DIEP technique reliably and reproducibly., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Treatment options for congenital hypoplastic breast anomalies are often open, including radial scoring, parenchymal flaps, and insertion of expanders and implants. Drawbacks of open techniques involve scarring, the use of drains, and inpatient stays. The use of lipofilling to treat breast deformities is increasing, as more research is completed in this area., Patients and Methods: We report a retrospective study of 10 patients below the age of 20 following autologous fat transfer between January 1, 2003 and January 1, 2004. (2 Poland syndrome, 3 bilateral tuberous breast, and 5 unilateral micromastia). Age, cup size, the number of sessions, time interval between each session, volumes injected, and complications were recorded. Postoperative mammography, ultrasonography, and MRI were assessed by a specialized radiologist. Patients answered a questionnaire 1 year after the procedure., Results: Mean follow-up was 68 months (60-77 months) and mean age was 17.5 years (15-20 years). Mean number of fat injection sessions was 2 (1-4) and mean volume injected 285 mL per breast (200-500 mL). The time interval between each session was 5 months (3-6 months). Cup size remained unchanged after at least 5 years of follow-up. One case underwent a contralateral breast reduction. The cosmetic results considered satisfactory in almost all the patients after 1 year of follow-up. None of our patients complained of scars or defects at the donor site. All breasts imaging were normal except 1 patient with oil cysts., Conclusion: Our preliminary results using lipofilling to treat young patients with breast hypoplasia with lipofilling are very encouraging. The authors believe it is an alternative of choice for the correction of the young woman's breast deformities if the avoidance of scarring is preferred.

Unlabelled: The performance of simultaneous vascularized composite allotransplantation procedures on patients requiring both the face and bilateral hands remains controversial. The authors present their separate institutional experiences with this challenging procedure in the interests of dispelling misconceptions regarding this intervention and forwarding their understanding of the issues related to concomitant vascularized composite allotransplantation., Clinical Question/level of Evidence: Therapeutic, V.

Background: Among 18 face transplantations (FTs) performed worldwide, seven were performed at the Henri Mondor Hospital, Paris, France. Their feasibility and risk-benefit ratios have been reported, whereas this study analyzed the costs of FT for our first five patients., Materials and Methods: The first five FT patients transplanted at the Henri Mondor Hospital presented disfigurements due to neurofibromatosis, severe burns, or ballistic trauma and had no relevant comorbidity. All were socially isolated and unemployed. We analyzed the costs of preoperative investigations, operative procedures, and hospitalization for each patient. A public research program (PHRC) financed the procedures, and the clinical research department refunded each FT's cost. To allow comparisons between health care systems, the cost of FT was compared with the mean costs of heart, liver, and kidney transplantations performed at the same institution., Results: If all the five patients survived the FT procedure, one patient died during subsequent revisions procedures for sepsis. The overall costs for the operation and its subsequent hospitalization for each patient ranged from (20AC)103,108 to (20AC)170,071, depending on the transplant required, the technical pitfalls, the outcomes, and mainly postoperative intensive cares., Conclusions: In our institution, the transplantation of a face led to higher costs than heart or any other solid organ and represented twice the costs faced for a liver transplantation. FT is currently performed in a research setting, and cost might decrease with teams' experiences, which may shorten postoperative intensive care and overall hospital stays.

Background: After organ retrieval, restoration of the donor is a legal and ethical necessity; this is particularly true in facial transplantation. However, very few data are available regarding this procedure., Methods: This article reviews the seven facial masks produced during seven consecutive face transplants carried out at Henri Mondor Hospital in Paris, France. The time of production, morphologic outcome, and donor family feedback were recorded. Technical tips and pitfalls are also discussed., Results: Recording an impression of the donor's face with alginate required less than 25 minutes and, in all cases, the production of a resin mask was completed before the surgical harvesting was finished. Although all morphologic results were satisfactory or very satisfactory, the best outcomes were achieved using a total face mask, avoiding color discrepancies. Family feedback was positive, and none of the funeral ceremonies was disturbed by the procedure., Conclusions: The production of a full-face resin mask is a reliable and reproducible technique. This procedure restores donor integrity and gives a very satisfactory morphologic and aesthetic outcome., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Venous thrombosis is the main cause of radial forearm flap failure, especially when recipient vessels are compromised by prior radiation therapy or neck dissection. In such conditions, semi-free radial forearm flap (SF-RFF) can be performed to reduce this risk., Patients and Method: We reviewed all SF-RFF procedures performed in our institution for head and neck reconstruction. The flap was harvested as a conventional radial forearm flap but the cephalic vein was dissected along the arm up to the deltopectoral crease and used as the sole drainage vein., Result: Seven SF-RFFs were harvested for head and neck reconstructions. The dissection of the cephalic vein lasted less than 25 min in all cases. No flap loss or thrombosis was observed., Conclusion: The SF-RFF is a reliable and versatile procedure for facial, oral, or larynx reconstruction. This hybrid version of the radial forearm free flap is particularly appropriate when no suitable recipient veins are available as a result of radiation or prior surgery., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: To review our experience of facial reconstruction with split-thickness skin grafts (STSGs) harvested from the scalp., Methods: We included all patients undergoing STSG harvested from the scalp for the reconstruction of extensive forehead or temple defects after cancer resection. We recorded the size of resection before surgery and after healing, and we calculated the resulting contraction rate. Time of healing and occurrence of complication were also recorded., Results: Forty patients were included. Their mean age was 87 years, and the mean size of resection was 26 cm(2). The duration of healing at the donor site was shorter than 12 days, and pain levels were low. The rate of contraction at the recipient site was 11% after healing. Good morphologic outcomes were reported by both patients and surgeon., Conclusion: Extensive forehead and temple defects can be covered in this way with a low morbidity; rapid, painless healing; and a high success rate, making this procedure particularly suitable for elderly patients.

Aim: In this study, we report our experience on immediate reconstruction after resection of primary or metastatic chest wall tumors, to restore protective function and elasticity of chest or sternum., Methods: Between 2005 and 2009, 22 patients underwent reconstruction using a free or pedicled flap combined, or not, to alloplastic materials (Goretex®) in order to cover full-thickness defects of the chest wall after cancer surgery. Reconstruction was immediate in all cases., Results: Mean follow-up was 27 months. Of these, 18 patients were alive at the end of the study (81.5%). Eighteen patients had malignant tumors (82%); within these patients, 12 were alive without recurrence at the end of the study (67%). The average size of the chest wall defect was 255 cm². Goretex® Mesh was used in 8 patients. All patients benefited from reconstruction with a flap: pedicled or free latissimus dorsi flap (n = 15), pedicled great omentum (n=3), deep inferior epigastric perforator free flap (n = 3), and parascapular pedicled flap (n=1)., Conclusion: In this series, we were able to achieve long-term palliation and even cure in some patients by resecting full-thickness chest wall in local primary or recurrence of breast cancer without increasing morbidity. The same process was used successfully in association with adjuvant treatment in other tumors like skin sarcoma. We have followed a surgical algorithm according to the tumor localization and etiology.

Background: We postulate that the absence of a CPT code for DIEP (deep inferior epigastric perforator) free flap in breast reconstruction is in part responsible for the delayed adoption of this modern technique in France. In order to provide data to our regulating health agency, we determined the cost of this technique compared to a gold standard. We performed a cost-identification study, comparing costs of DIEP free flap versus latissimus dorsi pedicled flap with implant (LD+I) in secondary breast reconstruction following irradiation., Methods: Over a 12-month period, direct medical and non-medical costs as well as indirect costs were recorded in both groups (DIEP and LD+I)., Results: In an academic department funded by the national health system, total cost of a secondary breast reconstruction by DIEP free flap was 10,671 ± 3005€ (n=57) versus 8218 ± 2049€ (n=18) for the LD+I group (P<0.05). Mean OR occupation time was 390 ± 64minutes for DIEP versus 283 ± 44minutes for LD+I (P<0.05). Mean hospital stay was 6 ± 2 days for DIEP versus 5 ± 2 days for LD+I (P>0.05)., Conclusion: DIEP free flap technique offers a long lasting breast reconstruction at an reasonable expense compared to the LD+I (+22%). Furthermore, in an academic department, collaboration of two microsurgeons during DIEP flaps allows OR times to drop significantly and become competitive with LD+I., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Maxillofacial trauma caused by severe ballistic injuries requires many steps of reconstruction and is often associated with disappointing results. The authors report on two clinical cases of facial allografting., Methods: After a preclinical anatomical study of 10 fresh cadavers, the authors performed allotransplantation of the lower two-thirds of the face in two patients in March and August of 2009. The grafts included all perioral muscles, facial nerves, parotid glands, the anterior region of the maxilla, and part of the mandible. The mandibular osteotomy included only the chin in one case, and the mandibular arch from one angle to the other in the second case., Results: The cadaveric study confirmed that relying only on the anastomoses between the facial and the maxillary artery for vascularization of the posterior part of the maxilla was unsafe. Periosteal vascularization seemed essential. The clinical results confirmed that complete revascularization from a single facial pedicle was possible: the first end-to-end arterial anastomosis to the left external carotid artery was sufficient for full perioperative revascularization of the flap and immediate reestablishment of bilateral venous flow. The facial appearance of both recipients improved gradually, with the development of changes in expression and the appearance of nasolabial folds. Preoperatively placed gastrostomies and tracheostomies were able to be removed in both patients within 6 weeks postoperatively. The procurement part of the operation was performed in 7 hours., Conclusion: Partial facial composite tissue allotransplantation of the lower two-thirds of the face along with parts of the maxilla and mandible (chin or entire-toothed mandible) is technically feasible, with a good cosmetic and functional outcome in typical cases of attempted suicide with rifles.

Composite tissue allotransplantations can be indicated when autologous transfers fail to restore human appearance. We report the reproducibility, difficulties, serious adverse events and outcomes of our patients. Five patients were included in a registered clinical research protocol after thorough screenings assessed by an independent expert committee systematically discussing the alternative options. One patient suffered from plexiform neurofibromas, two from third degree burns and two from gunshot injuries. They were included on a national waiting list with a dedicated face procurement procedure. Transplants were harvested from heart beating brain-dead donors before other tissues and organs. Induction immunosuppressive therapy included antithymocyte globulins, steroids, mycophenolate mophetil and tacrolimus. Maintenance therapy included the last three ones associated with extracorporeal-photopheresis. Four patients were transplanted with 7- to 38-month follow-up. One could not due to multiple panel reactive antibodies after 18 months on waiting list. Acute cellular rejections were controlled by conventional treatment. Opportunistic infections affected all patients and lead one patient to die two month after the transplantation. Voluntary facial activity appeared from 3 to 5 month. Face transplantation has been reproducible under conventional immunosuppression. Major improvements in facial aesthetic and function allowed patients to recover social relations and improved their quality of life., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Introduction: The superior gluteal artery perforator flap (SGAP) typically requires a peroperative change of the patient's position that increase the duration time of the procedure and the hospitalization. The aim of this study is to present our serie of eight consecutive SGAP flaps without setup change, and to precise the surgical technique we used., Patients and Methods: This is a retrospective series of eight consecutive SGAP flaps performed between September 2001 and March 2010. All these flaps were performed without peroperative setup change. We studied the number of perforators used and their origins, the type of recipient vessels, the duration time of the procedure and the hospitalization. We also analyzed the morphological and functional outcomes for the donor site., Results: All eight flaps were raised on a single septo-cutaneous perforator located between the gluteus maximus and gluteus medius muscles. The internal mammary vessels were chosen as recipients in all cases. The average duration time of the operation was 6 hours and 5 minutes. We report one flap loss. No functional or morphological complications were reported on the donor site. The morphological results on the reconstructed breast were satisfactory or very satisfactory in most cases., Conclusion: A satisfying breast reconstruction can be achieved with the SGAP flap without changing setup. The use of the septo-cutaneous branch between the gluteus maximus and gluteus medius muscles lengthens the pedicle and reduces the surgery time by facilitating the dissection. SGAP is therefore another autologous technique for breast reconstruction with low morbidity, when a DIEP flap cannot be harvested., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Background: The authors report the technical difficulties involved in the procurement of a total human face graft for allotransplantation., Methods: After completing a preclinical study that involved 13 fresh cadavers, the authors harvested a total face graft for allotransplantation onto a patient in April of 2009. The harvested tissue specimen included the entire face along with the scalp and the auricles. The authors then removed the unnecessary parts, specifically, the lips and the skin overlying the chin., Results: The preclinical study and clinical results confirmed that complete revascularization of a total face graft, complete with the scalp and auricles, from a single external carotid vascular pedicle was possible. All dissections were completed in less than 6 hours during the preclinical study. Graft procurement for the clinical case took 11 hours. Facial soft tissues were harvested en bloc to decrease graft harvest time and prevent tissue injury. A resin mask that covered the entire face of the donor provided excellent cosmetic results. All nerves and eyelid structures were easily reattached. One month after transplantation, skin necrosis necessitated several stages of excision. Biopsy specimens from the transplanted tissue were negative for immune-mediated rejection. Unfortunately, the patient experienced a cardiac arrest during follow-up surgery and died 2 months after the transplant procedure., Conclusions: A composite tissue allotransplantation of the total face along with the scalp and the auricles is technically feasible. The authors' flap provided reliable vascularization and was obtained in a standardized fashion in less than 11 hours. The graft contained all of the perioral muscles, branches of the facial nerve, eyelid structures, and major salivary glands.

Our experience of the deep inferior epigastric artery perforator flap has led us to perform systematically an abdominal CT-scan for the pretherapeutic checking. This exam gives us a precise vascular mapping of musculocutaneous and septocutaneous perforators artery of the flap, may enable a better orientation in the dissection and reduce the surgery time. We have enlarged the indication of this exam to the members flaps who needs the dissection of a musculocutaneous or a septocutaneous perforators vessels: Nakajima's et al. classification [1]. The mapping of perforating vessels on 3D reconstruction pictures helps us to planify the vascular cutaneous autologous grafts., (2009 Elsevier Masson SAS. All rights reserved.)

Liposuction represents the standard surgical treatment of localized fat excess. Some non-plastic-surgery-board-certified practitioners are likely to offer non-invasive alternatives treatments. We report the clinical case of a 14-year-old female patient who followed a Lipectomy treatment. The Lipectomy technique consists in a hypodermic injection of hypotonic solutions in order to obtain an adipocytes lysis by osmotic shock. No PubMed referenced scientific publication is related to the efficacy or the tolerance of this technique. Postoperative evolution was marked by a polymicrobial subcutaneous abscess that needed two surgical evacuations and 10 days of overnight stay in our department. Through this clinical case, we evoke the possible dangers linked to the application of a non-evaluated medical technique and the necessity of establishing an official validation agency related to innovative techniques in aesthetic medicine and surgery.