A thoracic parasternal granular cell tumor in a child: About one case and review of the literature, discussion about treatment guidelines, is complete resection compulsory?

Granular cell tumor is a well known soft tissue tumor, very rare in children; we describe here the first case of GCT in this particular location in a child. The diagnostic is easily done with histopathology. The treatment is based on the complete resection, no other validated treatment exists. We reviewed the literature to find out if it would be safe to consider a simple follow-up after partial resection of the tumor.

[The complications of skin expansion in paediatrics: Diagnostic, taking over and prevention]

Skin expansion is a difficult and long process in which can occur more or less serious complications. Overall complications rates describe in the literature vary between 13 and 37%. We can categorize them in major complications, which can lead to a failure maybe even an aggravation of the anterior status, and in minor complications that do not compromise the expansion process but can alter it. The main major complications are infection, skin suffering and necrosis which can lead to prosthesis exposition, leaks and technical problems with equipment dysfunctions that may cause difficulties or a failure of the inflations. The main minor complications are hematomas, seromas, valve or tube exposition, pains with paraesthesias caused by neighbouring organs compression, pathologic and unsightly scares and can lead to an important psychological impact. These complications can be due to a precarious skin's state, a material dysfunction or unpredictable technical problems but also by an inappropriate preoperative indication or planning. The emerging of a complication, however, is not synonymous to a failure of the procedure; a satisfactory reconstruction may still be obtained in 75% of all cases. The purpose of this article is to help to identify the situations at risk of complications in order to prevent, detect and treat them early.

[Autologous fat grafting in children]

Lipofilling or fat grafting transfer is defined as a technique of filling soft tissue by autologous fat grafting. The basic principle of lipofilling is based on a harvest of adipose tissue, followed by a reinjection after treatment. Lipofilling main objective is a volume defect filling, but also improving cutaneous trophicity. Lipofilling specificities among children is mainly based on these indications. Complications of autologous fat grafting among children are the same as those in adults: we distinguish short-term complications (intraoperative and perioperative) and the medium and long-term complications. The harvesting of fat tissue is the main limiting factor of the technique, due to low percentage of body fat of children. Indications of lipofilling among children may be specific or similar to those in adults. There are two types of indications: cosmetic, in which the aim of lipofilling is correcting a defect density, acquired (iatrogenic, post-traumatic scar) or malformation (otomandibular dysplasia, craniosynostosis, Parry Romberg syndrom, Poland syndrom, pectus excavatum…). The aim of functional indications is correcting a velar insufficiency or lagophthalmos. In the paediatric sector, lipofilling has become an alternative to the conventional techniques, by its reliability, safety, reproducibility, and good results.

[Forearm osteomusculocutaneous free filet flap for arm reconstruction after amputation as an alternative to shoulder disarticulation]

We report the case of a 55-year-old woman suffering from a type I neurofibromatosis (also known as Von Recklinghausen neurofibromatosis) who was diagnosed with a high-grade schwannosarcoma of the median nerve, between the upper third and the medium third of the arm, upon contact with the humerus, invading the humeral vessels. The oncologic treatment of this tumour consisted in the amputation of the arm through the surgical neck of the humerus. In order to create a laterothoracic claw, to bring a partial function of the upper limb back, we decided to realize a free fillet forearm flap. This composite flap was composed of the radius and the ulna, all the forearm muscles and the skin of the anterior side of the forearm. A humeroradial plate osteosynthesis was done and the flap was then harvested with the radial pedicle, and anastomosed to the axillar artery. This procedure gave our patient a functional stump, giving back the arm functionality, especially the claw movement.

[Technical note: iliac crest bone graft harvesting in children]

Harvesting iliac crest bone in children is special because of the presence of a thick cartilage. Constant pressure on the internal iliac fossa, ascends the skin, and moves the abdominal muscles away from the iliac crest. A single incision is then used for cutaneous and subcutaneous dissection. An internal piece of cartilage is then removed and the iliac muscle retracted in order to harvest cortical and spongy bone from the internal side of the iliac crest. That pièce of cartilage is then sutured at its initial place. During the harvesting, the surgeon needs to be careful to preserve the lateral femoral cutaneous nerve.

[Resurfacing of an ischial and trochanteric recurrent pressure sore by a pedicled fasciocutaneous anterolateral thigh flap]

Ischial pressure sores, common in paraplegic patient, are the most difficult to treat, and poor prognosis associated with a high rate of postoperative recurrence. Many surgical techniques by muscular or myocutaneous flap coverage have been described. We report an original use of a fasciocutaneous pedicled anterolateral thigh (ALTp) flap for coverage of an ischial pressure sore combined with a trochanteric pressure sore, exceeded beyond any conventional therapeutic solution. A 45-year-old paraplegic patient suffered from a trochanteric and ischial pressure sore, which had already received coverage by a muscular flap of biceps femoris and gluteus maximus. At 1 year, the result is satisfactory, with good coverage without recurrence. The fasciocutaneous ALTp flap can be a solution to cover recurrent ischial pressure sores beyond conventional methods.

Inadvertent subcutaneous injection of hypertonic saline solution during lipofilling

Subcutaneous infiltration with a mixture of plain saline and adrenaline is a useful option in lipoharvesting for autologous fat grafting. This report presents the case of 34-year-old woman who experienced inadvertent subcutaneous injection of hypertonic saline solution during body fat harvesting. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

[Two cases of lymphoma in an implant capsule: A difficult diagnosis, an unknown pathology]

The anaplastic large cell lymphoma (ALCL) is a rare disease, its incidence in the United States is one case per 500,000 women and three for 100 million patients for breast single location. Forty-six cases have been reported in the literature. They can grow on any type of implant: expander prosthesis silicone and saline, smooth or textured envelope. Currently, the consensus process includes capsulectomy, removal of the implant, chemotherapy and radiotherapy. However, some authors classify under indolent disease, but we believe that some cases may escape any therapeutic and become very aggressive forms. It is therefore important to make an early diagnosis and start treatment urgently. Severity and suspicion of iatrogenic nature of ALCL have an obligation to inform future with implants.

[Current place of curettage in the management of giant congenital nevi: report of 29 patients]

SUBJECT

The management of giant nevi remains discussed to date. Curettage, early superficial technique, allows a lightening of the lesions. We wanted to define the current interest in its use, from results obtained after 20 years of experience.

PATIENTS AND METHODS

Twenty-nine patients were treated by curettage between 1991 and 2011. Surgery consisting of excision of the superficial dermis was performed between the 1st and 7th week of life in an average of 1.8 procedures. The cosmetic result was judged subjectively.

RESULTS

Healing was achieved in 7 days. We noted a few local complications but no general complications. The aesthetic results, with initial variable lightening, induced an overall parental satisfaction in 100 % of cases. A secondary heterogeneous and varying pigmentation was observed in all cases.

CONCLUSION

To date, we believe that curettage is indicated for the treatment of giant nevi in some localization difficult to treat by conventional techniques (eyebrow, those associated with many satellite nevi) or those with a psychological impact too important to support a therapeutic delay.

[Hypogastric abdominal wall reconstruction with a pedicled anterolateral thigh flap]

Looking at a full-thickness abdominal wall defect, it is necessary to use reconstructive surgery techniques. The authors present an original case of reconstruction of the abdominal wall, using an anterolateral thigh flap (ALT) harvested with vascularised fascia lata. We describe the advantages of this technique, which has rarely been used for this indication. An 80-year-old woman presenting a full-thickness abdominal wall defect of 15×18cm was reconstructed by a pedicled ALT flap. Skin wound healing was obtained within 15 days, with no complication. There was no donor site sequela. The pedicled ALT flap appears to be a good solution for hypogastric abdominal wall defect in a one step procedure. Vacularised fascia lata bring with the cutaneous flap is useful to reconstruct the abdominal fascia.

[Dorsi elastofibroma. About 14 cases, and review of the literature]

Elastofibroma dorsi is a benign tumor which usually occurs at the inferior angle of the scapula. We retrospectively reviewed 14 cases of elastofibroma dorsi, in nine patients. The patients were hospitalized in the departments of plastic surgery, orthopedic surgery or visceral surgery. Mean age was 67 years. The location of the lesions (bilateral in five patients) was typical, in the thoracoscapular region. Nine lesions were removed surgically, six shoulders were asymptomatic after surgery. Elastofibroma is a rare, slow-growing lesion. It occurs in connective tissue of the infrascapular region of elderly patients. The pathogenesis of the lesion still remains unclear. MRI and computed tomography are useful for assessment of elastofibroma dorsi, and can potentially help avoid the need for unnecessary biopsy and surgery, especially in the asymptomatic patient. It should be surgically removed only in symptomatic patients.

The V-Y latissimus dorsi musculocutaneous flap in the reconstruction of large posterior chest wall defects

Posterior chest wall defects are frequently encountered after excision of tumors as a result of trauma or in the setting of wound dehiscence after spine surgery. Various pedicled fasciocutaneous and musculocutaneous flaps have been described for the coverage of these wounds. The advent of perforator flaps has allowed the preservation of muscle function but their bulk is limited. Musculocutaneous flaps remain widely employed. The trapezius and the latissimus dorsi (LD) flaps have been used extensively for upper and middle posterior chest wounds, respectively. Their bulk allows for obliteration of the dead space in deep wounds. The average width of the LD skin paddle is limited to 10-12 cm if closure of the donor site is expected without skin grafting. In 2001 a modification of the skin paddle design was introduced in order to allow large flaps to be raised without requiring grafts or flaps for donor site closure. This V-Y pattern allows coverage of large anterior chest defects after mastectomy. We have modified this flap to allow its use for posterior chest wall defects. We describe the flap design, its indications, and its limitations with three clinical cases.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Influence network effectiveness in promoting couples' HIV voluntary counseling and testing in Kigali, Rwanda

OBJECTIVE

To identify predictors of promotion of couples' HIV voluntary counseling and testing (CVCT) in Kigali, Rwanda.

DESIGN

Analysis of CVCT promotional agent [influential network leaders (INLs), influential network agents (INAs)], and couple/invitation-level predictors of CVCT uptake.

METHODS

Number of invitations and couples tested were evaluated by INL, INA, and couple/contextual factors. Multivariable logistic regression accounting for two-level clustering analyzed factors predictive of couples' testing.

RESULTS

Twenty-six INLs recruited and mentored 118 INAs who delivered 24 991 invitations. 4513 couples sought CVCT services after invitation. INAs distributed an average of 212 invitations resulting in an average of 38 couples tested/agent. Characteristics predictive of CVCT in multivariate analyses included the invitee and INA being socially acquainted [adjusted odds ratio (aOR) = 1.4; 95% confidence interval (CI) 1.2-1.6]; invitations delivered after public endorsement (aOR = 1.3; 95% CI 1.1-1.5); and presence of a mobile testing unit (aOR = 1.4; 95% CI 1.0-2.0). In stratified analyses, predictors significant among cohabiting couples included invitation delivery to the couple (aOR = 1.2; 95% CI 1.0-1.4) and in the home (aOR = 1.3; 95% CI 1.1-1.4), whereas among noncohabiting couples, predictors included invitations given by unemployed INAs (aOR = 1.7; 95% CI 1.1-2.7). Cohabiting couples with older men were more likely to test, whereas younger age was associated with testing among men in noncohabiting unions.

CONCLUSIONS

Invitations distributed by influential people were successful in prompting couples to seek joint HIV testing, particularly if the invitation was given in the home to someone known to the INA and accompanied by a public endorsement of CVCT. Mobile units also increased the number of couples tested. Country-specific strategies to promote CVCT programs are needed to reduce HIV transmission among those at highest risk for HIV in sub-Saharan Africa.