The authors report a case of a patient managed for severe cranial vault depression following combined neurosurgery and radiotherapy. This situation caused major aesthetic discomfort and was potentially dangerous due to the mechanical weakness of the bone flap. The authors had a CAD (computer aided design) silicone elastomer custom-made implant made to fill perfectly the depression. Beforehand, an expansion was performed to cover the implant after removal of the radiated skin. The surgery and post-operative course raised no concerns. After one year of follow-up, the result is very good and the patient very satisfied, proving that this technique certainly has its place in the therapeutic arsenal when faced with a tissue defect of the cranial vault.

Background. - Pectus excavatum (PE) is the most common congenital chest wall deformity, whose cardiopulmonary consequences are controversial. PE surgery is in our experience usually performed for aesthetic reasons. Objectives. - The aim of this study was to evaluate the impact of PE on respiratory function and exercise capacity in patients with PE before patient -specific silicone implant correction. Methods. - This monocentric prospective study conducted at Toulouse University Hospital included sixty patients scheduled for custom-made silicone implants correction. Respiratory function (pulmonary function tests (FPTs)) and exercise capacity (VO2 max) were measured before surgery. Results. - Before surgery, no (0/60) restrictive lung disease was detected, with a mean total lung capacity (TLC) of 98.5% of predicted value (IC 95%; 80.4-137). Median VO2 max (n = 56) was normal (89% predicted), with no cardiac limitation. Conclusion. - In this cohort, PE had no impact on respiratory function nor exercise capacity. In patients without cardiac or respiratory effects of PE, silicone implants should be considered the preferred approach as it adequately addressed patients' main complaint of low self-esteem. (c) 2023 Elsevier Masson SAS. All rights reserved.

La sindrome di Poland è una malformazione rara (1 caso su 30 000 nascite) che associa, a vari gradi, delle anomalie toraciche e delle anomalie dell’arto superiore omolaterale. L’anomalia costante è l’agenesia dei fasci sternocostali e sternoclavicolari del grande pettorale. Frequente esiste un’asimmetria mammaria, con ipoplasia di una mammella e del complesso capezzolo-areola omolaterale. Le deformità della mano, presenti in circa il 20% dei casi, sono multiple e di importanza variabile, ma la più costante è la brachimesofalangia. Questo quadro clinico si riscontra più frequentemente negli uomini (rapporto tra i sessi 3/2) e più spesso nell’emitorace destro. L’eziopatogenesi è a favore di un’anomalia vascolare succlavia embrionaria (6a settimana). Non vi è mai alcuna conseguenza funzionale nella compromissione toracica e nemmeno della mano, ma esiste solo un disagio estetico. Una classificazione recente, basata su un’esperienza di 151 casi operati, permette di orientare le scelte terapeutiche. Negli ultimi anni, la ricostruzione ha beneficiato del contributo della tecnologia digitale, con protesi toraciche in elastomero di silicone realizzate su misura mediante progettazione e fabbricazione assistita da computer, a partire da una TC. Le altre tecniche che associano, a seconda dei casi, degli impianti mammari e un trapianto di grasso possono essere utilizzate in aggiunta. Il classico lembo muscolare del latissimus dorsi è raramente utilizzato. A seconda dell’età, del sesso e della gravità delle anomalie toraciche, può essere proposta una strategia terapeutica adattata a ciascun caso di sindrome di Poland.

Mammalian p21-activated kinase 1 (Pak1) is a highly conserved effector for the small GTPases Cdc42 and Rac1 [1]. In lower eukaryotes, Pak1 homologs are regulated during the cell cycle by phosphorylation. Here, we show that Pak1 is phosphorylated during mitosis in mammalian fibroblasts. This phosphorylation occurs at a single site, Thr 212, within a domain that is unique to Pak1. Cdc2 phosphorylates Pak1 at the identical site in vitro, and inhibition of Cdc2 abolishes Pak1 mitotic phosphorylation in vivo, indicating that Cdc2 is the kinase responsible for phosphorylating Pak1 in mitotic cells. Expression of a Pak1 mutant in which Thr 212 is replaced with a phosphomimic (aspartic acid) has marked effects on the rate and extent of postmitotic spreading of fibroblasts. The mitotic phosphorylation of Pak1 does not alter the basal or Rac-stimulated activity of this kinase, but it does affect the coimmunoprecipitation of at least three proteins with Pak1. These findings are the first to implicate a mammalian Pak in cell cycle regulation and suggest that Pakl, as a result of phosphorylation by Cdc2, alters its association with binding partners and/or substrates that are relevant to the morphologic changes associated with cell division.

The authors present a new study on 789 cases of congenital thoracic malformations including 638 pectus excavatum and 151 Poland syndromes, according to a new classification which completes Chin's one. All these malformations were treated with silicone elastomer implants. The contribution of computer-aided design and manufacturing (CAD/CAM) since 2008 is essential. The one-stage surgical protocol is precisely described. The results are impressive, permanent, for life, and complications are rare. The authors evoke a common vascular etiopathogenesis theory at the embryonic stage and question the heavy techniques of invasive remodeling that are most often unjustified.

La technique des implants sur mesure 3D en élastomère de silicone, permet à partir d’un scanner de combler avec précision, une malformation thoracique congénitale, qu’elle soit osseuse (pectus excavatum) ou musculaire (Syndrome de Poland) avec pour conséquence un repositionnement naturel des seins. Nous rapportons notre expérience de 25 ans chez 301 femmes (234 Pectus et 64 Poland). La correction pariétale doit être faite en première intention. Il est fréquent de devoir réaliser dans un second temps chez la femme, une plastie mammaire complémentaire notamment en présence d’une insuffisance de volume glandulaire ou d’un sein tubéreux assez fréquemment associé.

Il pectus excavatum è la malformazione toracica congenita più frequente. Sono state descritte diverse tecniche chirurgiche, ma, a causa della mancanza di impatto funzionale del pectus excavatum, nella nostra esperienza, la sua correzione mediante il posizionamento di una protesi in posizione profonda è l’opzione chirurgica privilegiata. Il prototipo in resina della protesi è ottenuto attraverso immagini virtuali di sintesi tratte da sezioni TC (progettazione assistita da computer). Tramite una via d’accesso mediana presternale, di 5-7 cm di lunghezza, la loggia protesica viene portata dall’area prossimale in posizione retropettorale, piazzando l’impianto sotto le fibre caudali del muscolo grande pettorale e tra la guaina anteriore e il muscolo retto addominale distalmente. A differenza delle tecniche aggressive di chirurgia toracica e pediatrica, si tratta di una tecnica semplice, molto precisa, indipendentemente dalla profondità e dall’asimmetria, con una mortalità nulla e una bassa morbilità. Il tasso di soddisfazione dei pazienti è quasi del 90%. La complicanza più frequente è il sieroma, la cui gestione è semplice e ben codificata. La tecnica di ricostruzione con impianto su misura può essere considerata come una tecnica di riferimento, che permette di soddisfare le reali esigenze morfologiche dei pazienti in assenza di disturbi funzionali.

The pectus excavatum affects about one in 500 people. It is the most common malformation of the thorax. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results. Secondary surgery with a deep customized 3D implant, may be an elegant and effective solution; it allows to obtain a good aesthetic result expected by patients in the absence of any respiratory or cardiovascular functional context.

El pectus excavatum es la malformación torácica congénita más frecuente. Se han descrito diferentes técnicas quirúrgicas, pero debido a la ausencia de repercusión funcional del pectus excavatum, en la experiencia de los autores de este artículo, la opción quirúrgica de elección es la corrección mediante la colocación de una prótesis en posición profunda. Se obtiene un prototipo en resina de la prótesis a partir de imágenes virtuales de síntesis procedentes de cortes tomográficos (diseño asistido por ordenador). A través de una vía de acceso preesternal media, de 5-7 cm de longitud, se diseca la celda para la prótesis en proximal, en posición retropectoral, colocando el implante por debajo de las fibras caudales del pectoral mayor y entre la vaina anterior y el músculo recto abdominal en distal. Al contrario que las técnicas agresivas de cirugía torácica y pediátrica, se trata de una técnica simple, muy precisa, independientemente de la profundidad y de la asimetría, con una mortalidad nula y una baja morbilidad. La tasa de satisfacción de los pacientes es casi del 90%. La complicación más frecuente es el seroma, cuyo tratamiento es sencillo y está bien codificado. La técnica de reconstrucción mediante implante a medida se puede considerar como una técnica de referencia, que permite responder a la demanda morfológica real de los pacientes cuando no existen problemas funcionales.

Le retentissement cardiorespiratoire du pectus excavatum (PE) est débattu, mais il peut exister une souffrance psychosociale liée à ses conséquences esthétiques. Les chirurgies corrigeant la déformation entraînent des douleurs postopératoires intenses et des complications fréquentes, parfois graves, tandis que le motif de recours est principalement esthétique. Ainsi, leur rapport bénéfice/risque peut être remis en question, notamment depuis l’apparition des techniques chirurgicales plastiques, moins invasives. L’objectif de l’étude était de décrire la fonction respiratoire, les capacités à l’effort et la qualité de vie avant, puis, à 1 an d’une chirurgie plastique par prothèse de comblement sur mesure. Les patients avec un PE consultant au CHU de Toulouse pour une chirurgie plastique étaient recrutés. Ils réalisaient une EFR (pléthysmographie, CO, Psnif, Pi et Pe max), une épreuve d’effort (EFX) et une étude de la qualité de vie (QDV). Une réévaluation était réalisée à 1 an de la chirurgie (SF–36, satisfaction, EFR, EFX). Le PE était décrit par l’indice de Haller et le volume de l’implant. Soixante patients ont bénéficié du bilan préopératoire et 93 % étaient asymptomatiques. Le volume de l’implant était corrélé négativement à la CV (r : −0,252 ; p : 0,04), la CPT (r : −0,34 ; p < 0,007) et au VEMS (r : −0,31 ; p = 0,009) mais, leurs valeurs moyennes étaient normales. Il n’y avait aucun trouble ventilatoire restrictif, 4 troubles obstructifs, dont 3 liés à des co-morbidités. Le VO2 max moyen était de 87 ± 13 0 % de la théorique. Le Vo2 max était < 84 % chez 38 % des patients, mais associé à une limitation musculaire. Une limitation ventilatoire liée au PE ne pouvait être exclue chez 2 patients. Le score physique moyen n’était pas abaissé. Les moins de 24 ans avaient un score mental abaissé. Chez les 41 patients réévalués à 1 an, la chirurgie répondait en moyenne à 8,7/10 à leurs attentes, l’amélioration était de 3,4/4 pour l’image du corps, de 2,9/4 pour la confiance en soi, et de 2,4/4 pour la QDV (0 = pas du tout, 4 = énormément). Il existait une tendance non significative à l’amélioration des scores de fonctionnement social (82 ± 21 vs 87 ± 13 ; p : 0,16) et de santé psychique (73 ± 17 vs 77 ± 15 ; p : 0,22). Il n’y avait pas de modification postopératoire des EFR et EFX (n = 16). Le préjudice esthétique est le principal élément altérant la QDV des patients jeunes, le retentissement fonctionnel étant absent ou minime. Une correction esthétique seule semble répondre à leurs attentes.

Introduction. - Modern techniques of computer-aided design and tridimensional prototyping for manufacturing silicone elastomer custom implants are growing. They have widely modified the surgical indications in our unit.Materials and methods. - By presenting their experience of 611 cases managed between 1993 and 2016, the authors describe the method of conception from CT-scans, the virtual image of the body and the manufacture of the custom-made implant perfectly adapted to the anatomy of each one. The operative techniques are described for the three main indications: the funnel chest or pectus excavatum (474 cases) according to a modified CHIN classification is corrected simply and very satisfactorily. This approach may render thoracic surgery techniques obsolete. Indeed, these operations remain risky and of doubtful functional utility; Poland syndrome (116 cases), where the use of a custom-made implant for compensation of muscle volume is frequently used, but can be improved by a transfer of adipose tissue or a classic breast implant; the leg atrophies (21 cases) receive custom elastomer implants introduced in a sub-fascial plane.Results. - The results are excellent for pectus excavatum but more difficult to optimize for the other two indications, requiring sometimes complementary techniques. Complications are rare and often benign, implants endure for life. Quality of life, psychological comfort and self-esteem have been improved with low morbidity and without having undergone a painful surgical experience.Conclusion. - Reconstructive procedures of congenital malformations by custom-made silicone implants open a new field of activity for our surgical specialty with vast opportunities. (C) 2016 Elsevier Masson SAS. All rights reserved.

The contribution of computing in the management of patients with pectus excavatum has greatly improved the aesthetic result of the reconstruction endoprosthesis. Computer aided design (CAD) enables the design of implants perfectly suited to the deformation of the patient and avoids approximations of the traditional technique of plaster mold. Although this technique is applicable in many areas, this article will only deal with pectus excavatum.

Objectives. - Tobacco addiction is a risk factor for complication in plastic surgery. The authors have assembled concrete arguments detailing the risks of perioperative and postoperative complication that are incurred by a patient with continued tobacco intoxication who wishes to undergo a surgical intervention.Research strategy. - Through application of the PRISMA criteria, we have carried out a systematic review of the literature, in which we explored five databases while using predefined keywords. We selected randomized, controlled observational studies on the perioperative and postoperative complications related to tobacco use in actively smoking, abstinent and nonsmoking patients.Data collection and analysis. - The levels of evidence for each article were evaluated. Risk of bias was assessed using the Newcastle-Ottawa Scale. Incidence parameters including the Odds Ratio and relative risk were calculated for each complication of which the number of occurrences had been indicated. Meta-analysis of the results was carried out.Results. - We included 60 observational studies. In the cosmetic surgery group, we calculated a combined Odds Ratio of 2.3 [1.51-3.54] P < 0.001 for surgical site infections and 2.5 [1.49-4.08] P < 0.001 for delayed wound healing. In the bariatric surgery sequelae group, we found a combined Odds Ratio of 3.3 [1.90-5.64] P < 0.001 with regard to delayed wound healing and 3.1 [1.39-7.13] P = 0.006 for cutaneous necrosis. No proof was provided as to the possible influence of tobacco on the success rate of free flap microsurgery, but it is difficult to extrapolate results on the latter to digital reimplantation.Conclusions. - The review underlines the fact that patients with smoking habits run a significantly heightened risk of cutaneous necrosis, particularly in the event of major detachment (cervico-facial lift, skin-sparing mastectomy, abdominoplasty), of additionally delayed wound healing and of addition surgical site infections. Rigorous preoperative evaluation of smokers could help to diminish these risks. (C) 2014 Elsevier Masson SAS. All rights reserved.

Introduction. - Hyaluronic acid has come to represent the most widely used injectable cosmetic product in the world. Brought into being by the Swedish company Q-Med, in 2007 Macrolane (TM) was authorized for use in France, and the year after, it received official European approval as a means of breast augmentation. Since then, however, numerous controversies pertaining to its side effects have led to its withdrawal from the worldwide breast augmentation market. The objective of this article is to carry out a review of the literature providing updated information on Macrolane (TM) and its recent indications.Materials and methods. - We carried out a review of the literature on the PubMed and PubMed Central data bases through use of the keywords "Macrolane (TM)'', "NASHA'', "hyaluronic acid'' and "soft filler'', and subsequently analyzed the levels of evidence and possible biases of the different publications. The official sites of the French, English, Spanish and American scholarly organizations of plastic surgery were likewise consulted. Perusal of the notifications and recommendations for use brought out by the Q-Med company completed our study.Results. - A large majority of the available clinical series on Macrolane (TM) with regard to not only breast augmentation, but also its other indications, offer an insufficient level of evidence and present a number of conflicts of interest. Since April 2012 Macrolane (TM) has been temporarily withdrawn by its distributors from the worldwide breast augmentation market. In point of fact, Macrolane (TM) injections have been found to interfere with breast imaging and screening for breast cancer. As regards the latest indications for this controversial product, it is not yet possible to step back and take stock.Conclusions. - Present-day scientific data fail to justify the market reappearance of Macrolane (TM) breast augmentation products. Q-Med has shown full awareness of the problem by imposing worldwide restrictions on products aimed at penis as well as breast enlargement. Larger cohorts of female patients are more necessary than ever, as is an approach based on stepping back and taking stock. (C) 2014 Elsevier Masson SAS. All rights reserved.

Los progresos recientes en cirugía plástica del abdomen permiten en la actualidad tratar de forma satisfactoria a los pacientes que consultan por secuelas de adelgazamiento o de la gestación. La cirugía de la pared abdominal, tanto estética como posbariátrica, forma parte integrante de la especialidad de cirugía plástica y responde a una fuerte demanda de los pacientes, no sólo estética, sino sobre todo funcional. El adelgazamiento, en ocasiones muy marcado, permite en determinadas condiciones realizar un tratamiento quirúrgico dirigido a rehabilitar las alteraciones corporales debidas a los excedentes cutáneos que quedan como secuela. Aunque esta cirugía está perfectamente estandarizada, conviene no olvidar que no está desprovista de riesgos. El conocimiento y el tratamiento de las posibles complicaciones son tan importantes como la propia cirugía. El objetivo de este artículo es exponer las técnicas modernas de las dermolipectomías abdominal anterior y total circular, describiendo las distintas modalidades en cada tiempo quirúrgico.