[The use of implants in ptosis, hypertrophic and breast deformities]

Breast precise analysis, due to a partial or global diformity, total or minor tuberous breast allows an interesting appreciation of the skin and gland importance in breast modifications. This same analysis enables us to consider the ptosis and hypertrophies under a different angle. Thus, the relative proportions in between the various segments, their evolution in the time and especially the glandular distribution mode, sometimes leads to a different technical approach. To ensure a better glandular distribution, an important factor of the breast stability, the use of a mastopexy, which everyone knows the limits, appears under a new light and, more often than one thought, the use of a breast implant ensures homogeneity of consistency and a more long term result. Concerning the various skin modifications, their specific analysis permit to establish the type of incision used for a better-adapted scar result. The approach we suggest, (detailed analytic study of the breast, glandular distribution, relative proportion of the different breast levels and a more frequent use of an implant) which in any case should not be systematic, can obviously in certain situation optimize the quality of the result (long term projection and a better stability of the mammary shape).

Lipo-aspiration et liposculpture

Liposuction set a watershed in the evolution of plastic and cosmetic surgery, by allowing permanent removal of excess fat localized underneath the skin. Many body areas, once considered as untouchable, are now accessible since liposuction grew superficial and circular. Liposuction, generating skin retraction, made shorter scars feasible in most cosmetic surgery procedures, and opened up the way to liposculpture of the face and the body. Constantly improving therapeutic means have been succeeding one another: use of sharp followed by blunt cannula, laser/ultrasound-assisted liposuction, as well as rotary and vibrating cannula: what will remain in a few years em leader ? It is today taken for granted, that liposuction, now becoming sculptured, cannot be ignored anymore, and numerous ongoing research studies ensure that it still has a long life ahead.

["Vertical, triangular mammaplasty technique". Description, indications, six year retrospective study]

The authors present a new mammaplasty technique with a vertical scar: the vertical triangular technique (VTT). A retrospective study was carried out on 82 patients, for six years, with a minimal hindsight of one year, an average glandular resection of 190 g and average liposuction of 60 mL. The technical principles are based on mammary liposuction of the basis, the inferior pole and the axillary extension, the glandular cavity of the inferior pole of the breast, the conical shape of the breast and the lower scar cutaneous bursa. The pitfalls and traps to avoid are described: the liposuction must be large enough except concerning segment IV, the cutaneous pinch must be hyper-corrected, the lower subcutaneous mastectomy must be complete, while a perfect suture of the glandular pillars conditions the shape of the future mammary cone. Short-term complications (7.5%) are the slackening of the bursa and seroma. Medium-term complications (< 10%) are the residual distortion of the bursa, an insufficiently tightened pinch, and a glandular resection defect. Analysis of the results of the VTT makes it possible to determine the long-term stability of the shape of the breasts, and to notice that the scar gain does not affect the morphological quality.

["Modern" combined abdominoplasty]

Cosmetic abdominoplasties have been the subject of many criticisms because of their frequent disadvantages and complications. Although the length of the scar depends on anatomical conditions, diffuse adipose infiltration of the abdominal wall, the often excessively low umbilicus (surrounded by a circular scar characteristic of the operation), and the postoperative risks, severely limited the aesthetic quality of the final result. A new therapeutic approach, based on recent technical progress and old, but neglected surgical techniques, provides results which appear to be satisfactory. Liposuction, particularly performed at the beginning of the operation, regularly thins the abdominal wall and constitutes a useful complement to the so-called superficial method and especially the more extensive use of ultrasound, which has become almost essential in certain regions. Neo-umbilicoplasty according to an original hourglass plan and an abdominoplasty using four skin flaps provide a natural result, with no visible scar, and allow harmonious positioning of the umbilicus. This technique constitutes an interesting alternative to the limited possibilities of classical repositioning. Liposuction of the pubic region and lowering of the pubic hair line also improve the aesthetic possibilities. Although not all of the various disadvantages of aesthetic abdominoplasty have yet been resolved, their frequency has been markedly decreased and this therapeutic approach, which also constitutes a line of research, allows a more optimistic view of this operation, for which the indications must remain selective and rigorous. Various classifications are described to guide the choice of treatment based on analysis of clinical signs.

[Complications of plastic surgery of the abdomen]

Plastic surgery of the abdomen remains difficult and is therefore associated with a number of complications of varying severity, but whose global incidence appears to justify a separate chapter. The most serious complications of abdominoplasty are thromboembolic complications, which may be life-threatening. The incidence of these complications must be minimized by rigorous preventive measures. Prevention is based on early mobilization of the patient, perioperative treatment with low molecular weight heparin and wearing of anti-thrombosis stockings. Skin necrosis is generally associated with one or several aetiological factors: excessive tension at the end of the operation, development of a haematoma, excessive or too superficial detachment. The so-called "Morel-Lavallée" fluid collection is best prevented by well performed postoperative compression applied continuously for three weeks after the operation. Complications of isolated abdominal liposuction are exceptional, or at least they should be, when the indication and technique are rigorously respected. The combination of liposuction and abdominoplasty does not add any complication not already described in the case of abdominoplasties and does not increase the incidence of these complications. Liposuction appears to decrease the number of abdominoplasties, but also their extent, which is beneficial in terms of the quality and safety of the postoperative course. A better definition of indications and improvement of techniques have therefore markedly decreased the severity and incidence of complications of plastic surgery of the abdomen. Truly effective preventive measures are available for each of these complications.

[Circumscribed mandibular osteitis in children due to hematogenous dissemination. Apropos of 5 clinical cases]

In children, mandibular swelling associated with an X-ray bone osteolysis may correspond to tumoral or infection diseases. Circumscribed osteitis of a child's mandibula, with no dental etiology occurs around 7-years of age, adjacent to a healthy first molar. Five cases reports were analyzed. Clinically, it is a bone swelling of the mandibula's lateral cortical associated with a soft tissue swelling. X-ray signs were not specific but all cases showed a bone lacuna with sharp outlines. Such clinical and X-ray signs strongly suggest diagnosis of osteitis which has a higher incidence than malignant tumors. The lack of dental pathology suggests bloodstream dissemination from another localized sepsis. Surgical removal of pathologic bone in addition to antibiotics (6 or 8 weeks) appears to be an effective treatment.

Distal bypass for limb salvage: comparative study in patients below and above 80 years of age

Revascularization for chronic lower extremity ischemia in patients of 80 years and older is controversial. To better define operative risk and outcome after peripheral vascular procedures in the elderly, our experience from January 1990 to December 1992 was reviewed. We compared two groups of patients: group I with 26 patients (28 revascularizations) 80 years of age and older (84 +/- 3 years) and group II with 29 patients (32 revascularizations) younger than 80 years (70 +/- 8 year). The two groups were similar with regard to risk factors, surgical indication (rest pain and/or gangrene) and type of graft (in situ vein: 35, reversed vein: 12, PTFE: 13). Fourteen femoro-popliteal bypasses, 17 femoro-tibial bypasses (8 to the anterior tibial artery and 9 to the posterior tibial artery) and 29 femoro-peroneal bypasses were performed. The operative mortality rate was 11.5% in group I and 6.9% in group II. The cumulative life-table survival rate at 24 months was 39.5% in group I and 55% in group II. Primary patency rate at 24 months was 64% in group I and 67% in group II. Secondary patency rate at 24 months was 74.5% in group I and 73% in group II. Limb salvage at 24 months was 80% in group I and 83% in group II. Comparison of the older and younger groups showed no statistically significant difference in mortality rate, graft patency and limb salvage. Operative mortality and graft patency were not different with regard to age of patients.