Dr LUPON Élise

1. •Secondary intention healing remains an option for nail apparatus melanoma.
2. •Healing time is long and cosmetic results can be unpredictable.
3. •Local flaps or dermal substitutes allow faster healing and better outcomes.
4. •Perforator flaps can improve comfort and long-term functional results.

Background/Objectives: Soft-tissue defects surrounding the big toe can be a challenging problem for reconstructive surgeons. The first dorsal metatarsal artery (FDMtA) arises from the dorsalis pedis artery, which itself arises in front of the ankle joint from the anterior tibial artery. This study aimed to characterize the FDMtA cutaneous perforators (FDMtAPs) and evaluate the potential of a local pedicled perforator flap to cover a hallux soft-tissue defect. Methods: Nine feet from fresh cadavers were dissected to describe the FDMtAP anatomy. For each artery, we recorded the origin’s position from the FDMtA, the proximal and distal diameters, and the artery’s course, length, number, and type. We described the FDMtA perforator flap harvest and its application through a clinical case. Results: A mean of 3.67 ± 1.23 FDMtAPs were found from the nine dissected feet, with at least 2 perforators per foot. Around 88% were located between 0 and 4 cm along the axis at their origin from the FDMtA, with an area of around 8 cm² and a mean of 2.35 ± 0.36 cm long. The proximal diameter had a mean of 0.178 ± 0.037 mm and 0.110 ± 0.008 mm at the distal diameter. A pedicled flap was readily feasible for all dissections. The case described had satisfactory healing, correct functional, and aesthetic recovery at two months. Conclusions: The first dorsal metatarsal artery perforator flap seems to be a reliable and valuable solution for the hallux soft-tissue reconstruction, notably after the excision of acral melanoma.

Full facial vascularized composite allotransplantation (VCA) offers a reconstructive option for patients with severe facial disfigurement who cannot be treated with conventional methods. This article details a surgical protocol for donor procurement of a full facial allograft, focusing on soft tissue with limited bony harvest restricted to the nasal framework, and emphasizes key anatomical landmarks and technical considerations for safe and efficient harvest. The procedure involves dissection of the entire facial soft tissues while preserving the external carotid artery, internal jugular veins and subsequent thyro-linguofacial, and branches of the facial and maxillary nerves to maximize pedicle length for later neurorrhaphy. The protocol describes systematic exposure of the vascular pedicles at their origin in the neck, subperiosteal elevation of the scalp, identification and division of the supraorbital and infraorbital nerves, and preparation of the facial nerve at its root to achieve optimal length. Strategies to minimize ischemia time and ensure allograft integrity are highlighted. This article provides a comprehensive visual guide to the procurement phase of a full soft tissue face allograft and aims to standardize the technique for research application and surgical training in advanced vascularized composite allotransplantation.

In vascularized composite allograft (VCA) for upper limb reconstruction, upper arm-level or transhumeral transplantations are performed less frequently than forearm and hand transplantations. Transplantation is technically more feasible at this proximal level, largely owing to the use of macrovascular anastomoses. Despite these challenges, the outlook for arm allotransplantation remains encouraging, and this protocol provides a standardized technique for harvesting a vascularized upper arm composite allograft, ensuring both optimal outcomes and minimal tissue trauma. In the case of upper arm transplant, the technique varies according to the level of transplantation: supracondylar, transhumeral at a proximal arm level, or through the shoulder with the donor humeral head. A circumferential skin incision at mid-arm, or depending on the level at the origin of the upper limb, is made. A skin flap, such as a deltoid flap, can be harvested from the donor for skin closure at proximal levels. Dissection of the cephalic vein and deeper the brachial or axillary artery and veins is required. Then, the surgeon must identify the nerves depending on the level (terminal branches of brachial plexus or anteromedial and anterolateral cords for proximal transplantation) and transect the biceps, brachialis, and triceps muscles. The coracobrachialis and the deltoid muscles may also be dissected depending on the amputation level. Finally, the surgeon must make a transhumeral osteotomy or, if needed, harvest the donor humeral head for shoulder reconstruction. In this case, a peroneus longus graft for the suspension ligamentoplasty can also be harvested. The goal of this protocol is to standardize the procedure of harvesting and preparing an upper arm allotransplant.

Vascularized composite allografts (VCA) face ischemic challenges due to their limited availability. Reperfusion following ischemia triggers oxidative stress and immune reactions, and scavenger molecules could mitigate ischemia-reperfusion injuries and, therefore, immune rejection. We compared two scavengers in a myocutaneous flap VCA model. In total, 18 myocutaneous flap transplants were performed in Major histocompatibility complex (MHC)-defined miniature swine. In the MATCH group (n = 9), donors and recipients had minor antigen mismatch, while the animals were fully mismatched in the MISMATCH group (n = 9). Grafts were pretreated with saline, sodium iodide (NaI), or hydrogen sulfide (H₂S), stored at 4 °C for 3 h, and then transplanted. Flaps were monitored until clinical rejection without immunosuppression. In the MATCH group, flap survival did not significantly differ between the saline and hydrogen sulfide treatments (p = 0.483) but was reduced with the sodium iodide treatment (p = 0.007). In the MISMATCH group, survival was similar between the saline and hydrogen sulfide treatments (p = 0.483) but decreased with the sodium iodide treatment (p = 0.007). Rhabdomyolysis markers showed lower but non-significant levels in the experimental subgroups for both the MATCH and MISMATCH animals. This study provides insightful data for the field of antioxidant-based approaches in VCA and transplantation.

Reconstructive techniques to repair severe tissue defects include the use of autologous fasciocutaneous flaps, which may be limited due to donor site availability or lead to complications such as donor site morbidity. A number of synthetic or natural dermal substitutes are in use clinically, but none have the architectural complexity needed to reconstruct deep tissue defects. The perfusion decellularization of fasciocutaneous flaps is an emerging technique that yields a scaffold with the necessary composition and vascular microarchitecture and serves as an alternative to autologous flaps. In this study, we show the perfusion decellularization of porcine fasciocutaneous flaps using sodium dodecyl sulfate (SDS) at three different concentrations, and identify that 0.2% SDS results in a decellularized flap that is efficiently cleared of its cellular material at 86%, has maintained its collagen and glycosaminoglycan content, and preserved its microvasculature architecture. We further demonstrate that the decellularized graft has the porous structure and growth factors that would facilitate repopulation with cells. Finally, we show the biocompatibility of the decellularized flap using human dermal fibroblasts, with cells migrating as deep as 150 µm into the tissue over a 7-day culture period. Overall, our results demonstrate the promise of decellularized porcine flaps as an interesting alternative for reconstructing complex soft tissue defects, circumventing the limitations of autologous skin flaps.

The treatment of postburn hypopigmentation was primarily surgical before the advent of new technologies. Medical devices and therapies are emerging to manage scar sequelae that can be disfiguring and associated with severe psychosocial impact. These innovations have been poorly investigated for hypopigmentation, but they represent a real hope. We reviewed all articles published on Pubmed up to June 2022. Included studies had to specifically focus on treating postburn hypopigmented scars. All articles evaluating transient solutions such as make-up, and articles describing inflammation-linked hypopigmentation with no etiological details or no burn injury history were excluded. Through this review, we have highlighted 6 different types of nonsurgical treatments reported in postburn leukoderma potentially allowing definitive results. Electrophoto-biomodulation or E light (combining intensive pulsed light, radiofrequency, and cooling), topical daylight psoralen UVA therapy, and lasers (fractional lasers using pulse energies or CO2FL devices, lasers-assisted drug delivery as local bimatoprost and tretinoin or pimecrolimus) have been explored with encouraging results in hypopigmented burns. Finally, other promising medical strategies include using FK506, a nonsteroidal anti-inflammatory drug, to induce melanogenesis or using melanocyte-stimulating hormones with fractional laser-assisted drug deliveries, which are expected to emerge soon.

Les allotransplantations de tissus composites (ATC) concernent les transplantations de face, de membre supérieur, de trachée, de pénis, de paroi abdominale et, plus récemment, d’utérus. Ces greffons ont la particularité de comporter de nombreux tissus spécialisés dérivant de plusieurs feuillets embryonnaires, chacun présentant des contraintes spécifiques. Là où la composante cutanée, en tant que barrière immunologique, est un véritable challenge sur le plan de la tolérance immunitaire, le muscle est très sensible à l’ischémie, et les lésions d’ischémiereperfusion peuvent mener à un relargage antigénique favorisant les épisodes de rejet. Si le gold standard de la préservation de ces greffons demeure la préservation froide statique (4 °C), l’émergence des techniques dynamiques de perfusion en transplantation d’organes solides permet d’envisager leur adaptation aux ATC. Par cette revue, nous exposons les défis posés par l’allotransplantation de tissus composites, et discutons les dernières avancées en matière de préservation d’ATC basées sur machine de perfusion mais également sur les techniques statiques à températures négatives. Une attention particulière est portée à la préservation par perfusion subnormothermique et aux techniques de supercooling (surfusion), développées par notre équipe, tentant d’importer ces techniques optimisées en préservation d’organes solides. © 2024 l’Academie nationale de médecine. Publié par Elsevier Masson SAS. Tous droits réservés, y compris ceux relatifs à la fouille de textes et de données, à l’entraînement de l’intelligence artificielle et aux technologies similaires.