Management after fibula free flap necrosis in maxillofacial reconstruction

INTRODUCTION

Few articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction.

MATERIAL & METHODS

Between 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy.

RESULTS

In Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days.

DISCUSSION

Based on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.

Interest of frozen section procedure in skin tumors other than melanoma

BACKGROUND

Skin tumors are common. Recommended treatment in most cases is surgery, with margins adapted. Except in the case of simple resection and suture, it is necessary to know the status of the margins before reconstructing the defect. A one-stage technique is possible with frozen section analysis, which gives the surgeon an intraoperative assessment of resection quality. The aim of our work is to study the reliability of the frozen section procedure.

METHOD

A retrospective study included 689 patients who underwent surgery for skin tumor (excluding melanoma) between January 2011 and December 2019 at the University Hospital of Caen, France.

RESULTS

In 639 patients (92.75%), the frozen section analysis found healthy margins. There were 21 cases of discrepancy between the frozen section analysis and final histology. Infiltrating and scleroderma-like basal cell carcinomas showed a significantly higher frequency of affected margins on frozen section analysis (p < 0.001). The tumor size and location played a significant role in the margin status.

CONCLUSION

In our department, the frozen section procedure is the reference examination indicating immediate flap reconstruction. The present study demonstrated its interest and overall reliability. However, it is to be used according to histologic type, size, and location.

Retrospective study of long-term hard and soft tissue stability after advancement genioplasty with the use of rigid osteosynthesis

The main objective of this study was to evaluate long-term stability of rigid osteosynthesis in the context of advancement genioplasty. Bone stability was defined as a long-term bone loss of less than 2 mm. Measurements were performed on lateral cephalograms, in the sagittal and vertical planes, at three times: preoperative (T0, less than one month before surgery), early postoperative (T1, at least one month post-operatively) and late postoperative (T2, at least one year after surgery). 25 patients were included in the study, with a mean follow-up of 3.47 years (range 1-9.42 years). The mean sagittal bone advancement at T1 was 4.06 mm ± 1.34, with a bone loss of 0.65 mm at T2 (p = 0.001). The mean vertical bone movement was 1.25 mm ± 0.47 at T1, with a relapse at T2 of 0.34 mm (p = 0.27). The soft-to-hard tissue ratio was 78% in the sagittal plane. Rigid osteosynthesis offers long-term stability, with very little change in clinical outcome, in advanced genioplasty.

Correction of lip and nasal deformities in bilateral cleft operated with Le Mesurier procedure

INTRODUCTION

Bilateral cleft lip surgery recently evolved with the generalization of cheilorhinoplasty replacing cheiloplasty alone. The aim of this study was to analyze lip and nasal deformities of bilateral cleft lip operated on with the Le Mesurier procedure, and then to evaluate possible secondary surgical solutions used in our Cleft Center.

PATIENTS AND METHODS

We retrospectively reviewed a total of 39 patients born between 1991 and 2009 with a bilateral cleft all type included (isolated lip, lip and alveolar, associated or not with a cleft palate), all treated at the Caen University Hospital with a Le Mesurier procedure for the primary cleft lip closure. We studied population characteristics, the number of secondary surgical procedures for lip and nasal deformities. We analysed therapeutic approaches of the different secondary surgical procedures used and their morphological results.

RESULTS

85% of patients needed at least one secondary surgical procedure, 28% two procedures, 15% three procedures and 8% four or more procedures. Median age at secondary surgery was 6,8. 79% had a "scar repositioning", 33% managed the vermilion, 18% a restoration of the volume of the lip, 12% a philtral tissue sacrifice, 9% a procedure on Cupid's bow, 24% a surgery for nasal tip projection, 45% a columella lengthening and 58% a reposition of the alar base.

DISCUSSION

Le Mesurier procedure for bilateral clefts leads to deformities that require secondary surgical procedures. We propose an algorithm to manage loop scar in this procedure.

Significant decrease of facial cellulitis admissions during COVID-19 lockdown in France: A multicentric comparative study

During the 2020 coronavirus pandemic, a lockdown was imposed in France during the first wave. An apparent decrease in incidence of cellulitis of odontogenic origin was noticed then. This study aimed to compare the incidence of cellulitis during this extraordinary period with the same period in 2018 and 2019, based on retrospective multicentric data. All maxillofacial surgery departments in French public hospitals were contacted. Responders were asked to include all patients admitted for the surgical drainage of a head and neck abscess of odontogenic origin during the first 2020 lockdown period, and in a similar time frame in 2018 and 2019 (control group), based on screening the French diagnostic and therapeutic classification of medical acts. We report a 44% significant nationwide decrease in the incidence of admissions for cellulitis. There were 187 patients in 2020 for 334 and 333 patients in 2018/2019 respectively. The reasons to explain this finding are hypothetical (organizational reasons leading to earlier management, patients' fear to seek for medical management, usual excess in surgical indications or concomitant decrease of non-steroidal anti-inflammatory drugs delivery). Whatever the explanation, it would be of great interest to find it out in order to improve the prevention of cellulitis.

Alveolar distraction osteogenesis of a fibula free flap in maxillary reconstruction

In maxillary reconstruction, it is challenging to obtain satisfactory maxillary projection and to optimizate the dental implant-prosthetic rehabilitation. We report a case of sagittal distraction of a fibula free flap used to reconstruct maxilla after a ballistic trauma. Distraction began seven days after implantation of the device. The distraction protocol was 0.9mm per day during a total period of 2 months. Cone beam computed tomography acquisitions were performed at 3 months after the end of the distraction. The distractor device was removed 5 months after the end of the distraction protocol to allow bone consolidation. A satisfactory total distraction of 7mm was obtained with an esthetic variation of the projection of the upper lip and closure of the nasolabial angle.

[Palato velar fistulae in cleft palate]

Palatal fistulas after primary closure of a cleft palate are extremely variable ranging from 15 to 35%. When they are symptomatic, these fistulas affect feeding (nasal regurgitation to liquids, discharge, bad smells) and phonation (hypernasality that can hinder the precise assessment of velar incompetence). First of all, it is important to analyze the cause of the fistula, it helps to avoid early recurrences. The correction must apply to respect the 2 mucosal planes (nasal mucosa and oral mucosa), the only guarantee of surgical success. Different techniques are usually described: lingual flap, lifting of all palatal mucosa, flap hinge, blaster, FAMM. In all cases, postoperative care plays a key role in the success of the surgical correction.

Management of nasopharyngeal teratomas associated with cleft palate

Nasopharyngeal teratomas are rare tumours, responsible for a high birth mortality rate from acute respiratory distress. Palatine localization can lead to an embryopathogenic mechanical obstacle responsible for a cleft palate. The aim of this study was to update current knowledge concerning the management of this rare pathological association. We conducted a multicentre, retrospective study by case analysis. The inclusion criteria were patients of any age under care for a nasopharyngeal teratoma associated with a velopalatine cleft. The diagnosis of the teratoma was confirmed by histological analysis. Seven cases were included in the study: three cases from the University Hospital of Lille, one from the University Hospital of Caen, one from of the University Hospital of Toulouse, and two from of the University Hospital of Amiens. Approximately 30% of patients experienced acute respiratory distress at birth, necessitating oro- or nasotracheal intubation. The surgical excision was performed in the first 5 months of life for all patients and in a single operative time for 70%. There was no recurrence. Therapeutic management of nasopharyngeal teratomas associated with cleft palate at birth is multidisciplinary and is based on surgical excision. In the absence of other associated pathologies, the prognosis is favourable.

Impact of early intravelar veloplasty at six months on mandibular growth in patients with Pierre Robin Sequence

Pierre Robin Sequence (PRS) combines mandible microretrognathia, asynchronism of the pharynx and tongue, glossoptosis and, in some cases, cleft palate. Its principal functional consequences are respiratory and feeding problems during the neonatal period. In this study, we focused on the impact of early closure of the cleft at six months on mandibular growth in patients with PRS. We performed a retrospective study of 15 patients followed for PRS and undergoing surgery performed by the same senior surgeon (HB) at our cleft center between 2005 and 2012. These patients underwent early closure of the cleft (at a mean age of 5.87 months) by intravelar veloplasty, as described by Sommerlad. Only one article with exploitable data analyzing facial and mandibular growth in a cephalometric study of children with PRS has been published. The children in this series, constituting the control group for our study, underwent veloplasty between the ages of 12 and 18 months, often accompanied by labioglossoplasty, and the cephalometric study was carried out between the ages of four and seven years. We compared this control group in which surgery was performed at 12-18 months with our series of children undergoing surgery at six months, in a cephalometric study based on teleradiographic profile measurements performed between the ages of four and seven years. We found that early closure of the cleft soft palate yielded results identical to those for the control group in terms of mandibular growth, without the need for labioglossopexy. Finally, early intravelar veloplasty led to early functional improvement in terms of speech and phonation.

Tessier number 4 bilateral craniofacial cleft associated with amniotic band syndrome: 22 years of follow-up

Tessier clefts are a very rare entity. Number 4 Tessier cleft is describe like an orbito-facial cleft with trajectory between the lower eyelid and the lip. We report management of a bilateral number 4 Tessier cleft with amniotic band syndrome with 22 years of follow-up. After reviewing literature, we talk about difficulty to manage these kinds of rare Tessier clefts.

Congenital Midline Upper Lip Sinuses

Congenital sinuses of the upper lip are rare congenital malformations. There have been only 40 cases described in the literature. We report 3 cases of congenital midline upper lip sinus in Caucasian children. Two of those lesions were associated with other anomalies (complete cleft palate and hemifacial macrosomia or submucous cleft palate with bifid uvula). The pathophysiology remains unexplained yet. Congenital upper lip sinuses can be considered as possible microforms of cleft-lips. Associated anomalies are frequent and must be sought. The treatment is a full excision of the sinus tract and of the skin around the punctum in order to avoid risks of recurrence.

Study of the mechanical reliability of an S-shaped adjustable osteosynthesis plate for bilateral sagittal split osteotomies. Study on 15 consecutive cases

INTRODUCTION

The main challenge during the osteosynthesis of a bilateral sagittal split osteotomy (BSSO) is to take into account the correct position of the condyle. Adjustable plates can be used to fine-tune the final occlusion without changing the osteosynthesis. A new type of adjustable plate is presented in this article. The aim is to assess the mechanical reliability of this system during the surgery and during the healing period, thanks to a preliminary prospective on 15 consecutive cases.

MATERIAL AND METHODS

The bridge of the plate studied here has an "S"-shape and can be bent in two different planes. Fifteen patients presenting a maxilla-mandibular disharmony have been operated on with this device. Clinical results were evaluated three months postoperatively and the mechanical reliability of the device was studied prospectively from teleradiographies of 15 patients operated on in our department.

RESULTS

This study shows good results, with respect to the mechanical reliability of this S-shaped adjustable plate, three months postoperatively corresponding to the bone-healing period. Radiographic observations did not show any significant displacement at the osteosynthesis site.

DISCUSSION

This preliminary study shows the mechanical reliability of this new S-shaped adjustable plate. Its semi-rigid character may allow for certain condyle position adaptability. No plate fracture was reported for this 15 patient series. These encouraging results have to be confirmed on a larger series.

Autologous Adipose Tissue Graft to Treat Hypertensive Leg Ulcer: A Pilot Study

BACKGROUND

Adipose tissue is an abundant source of mesenchymal stem cells, called adipose-derived stem cells, which have anti-inflammatory and trophic effects to enhance overall tissue repair.

OBJECTIVE

To determine the healing effects of autologous adipose tissue graft on hypertensive leg ulcers.

METHODS

Prospective pilot study in 1 French dermatology department. Ten patients with a hypertensive leg ulcer were enrolled from April 2013 to June 2015. The primary end point was the wound closure rate at each follow-up visit. The secondary end points were wound characteristics, pain assessment and adverse events.

RESULTS

One patient, the only smoker, was lost to follow-up at month 5 (M5). For the 9 non-smokers, wound surfaces constantly and significantly decreased: the median wound closure rate was 73.2% at M3 and 93.1% at M6, p < 0.001. The median wound closure rate of the 10 patients was 63.2% at M3, p < 0.001. Percentages of fibrin and necrosis decreased, granulation tissue increased significantly. Pain rapidly and significantly decreased. No recurrence or adverse event was observed.

CONCLUSION

Our data suggest that autologous adipose tissue grafting induces pain relief and promotes wound healing with a good skin quality. Large prospective controlled randomized studies are required to confirm these results.

Cheiloplasty associated to a palatal obturator in a preterm infant with a cleft lip and palate

INTRODUCTION

Preterm infants are commonly treated by non-invasive ventilation (NIV) and nasal continuous positive airway pressure (CPAP), which are associated with fewer complications than nasotracheal intubation. In preterm infants with a cleft lip and palate, this method of respiratory management is difficult or impossible to perform because of air leakage through the cleft defect.

CASE

We report a male infant who was born at 29 weeks of gestation with a left complete unilateral cleft lip and palate. Birth weight was 900 grammes. Because of the cleft, we have any problems to ventile this infant. We decide to close the cleft prematurely on day 17 after multidisciplinary discussion.

DISCUSSION

NIV cannot be performed with the usual equipment in very premature infants with a cleft lip and palate because of air leakage through the cleft defect. Very few studies report pre term infant with cleft lip and palate and his difficulties of ventilation. This is the first case reported to perform cheiloplasty on a 900g preterm infant.

[Information quality in general public French-speaking websites dedicated to oral cancer detection]

INTRODUCTION

The goal set by the French highest national authorities in the 2014-2019 Cancer Plan is to "heal more sick persons by promoting early diagnosis through screening". Screening requires information. Nowadays, Internet allows for access to information "in one click". The aim of our study was to evaluate the quality of information found on the Internet.

MATERIALS AND METHODS

Several sites dedicated to oral cavity cancer screening were selected on Google. The quality of health information found in these sites was evaluated by the DISCERN questionnaire. The quality of decision support provided by the sites was evaluated by the IPDAS checklist.

RESULTS

Twenty-seven sites were selected. The average DISCERN score was 25.1/75 (15/75 to 40/75). Eighteen sites (66.6%) had very poor, 8 sites (29.6%) had poor and 1 site had average information quality. IPDAS scores ranged from 11.1 to 38.1. Eight sites (29.6%) had less than 20%, 14 sites (51.9%) had between 20 and 30% and 5 sites (18.5%) had 30% or more validated criteria. No site achieved the pass mark.

DISCUSSION

The quality of general public French-speaking website dedicated to oral cancer detection is very bad. The role of health professionals such as general practitioners and head and neck surgeons, remains essential.

Cleft palate caused by congenital teratoma

A cleft palate results from incomplete fusion of the lateral palatine processes, the median nasal septum and the median palatine process. This case report describes a rare case of congenital teratoma originating from the nasal septum that may have interfered with the fusion of the palatal shelves during embryonic development, resulting in a cleft palate. An infant girl was born at 40 weeks of gestation weighing 3020 g with a complete cleft palate associated with a large central nasopharyngeal tumour. Computed tomography (CT) of the head showed a well defined mass of mixed density. The tumour was attached to the nasal septum in direct contact with the cleft palate. A biopsy confirmed the teratoma. Tumour resection was performed at 5 months, soft palate reconstruction at 7 months and hard palate closure at 14 months. There was no sign of local recurrence 1 year later. Most teratomas are benign and the prognosis is usually good. However, recurrence is not rare if germ cell carcinomatous foci are present within the teratoma. For these reasons, we advocate the use of a two-stage procedure in which closure of the cleft palate is postponed until histological examination confirms complete excision of the teratoma.

[Temporomandibular disorders and Ehlers-Danlos syndrome, hypermobility type: A case-control study]

INTRODUCTION

The Ehlers-Danlos syndrome, hypermobility type (EDS-HT) is a rare genetic disease. Diagnosis is based on a combination of clinical criteria described in the classification of Villefranche. Diagnosis is difficult to make because of the lack of specific clinical signs and the absence of genetic testing. The EDS-TH manifests itself manly by musculoskeletal pain and joint hypermobility. Temporomandibular disorders (TMD) are also reported. Our aim was to objectify the presence and to qualify the type of TMD associated with the EDS-HT in order to propose an additional diagnostic argument.

MATERIAL AND METHODS

A prospective, monocenter case-control study, comparing a cohort of patients suffering from EDS-HT to a paired control group of healthy volunteers has been conducted. Clinical examination was standardized, including a general questioning, an oral examination and a temporomandibular joint examination following the TMD/RDC (temporomandibular disorders/research diagnostic criteria).

RESULTS

Fourteen EDS-HT patients and 58 control patients were examined. The prevalence of TMDs (n=13; 92.9% vs. n=4; 6.9%; P=10(-11)) was significantly higher in the EDS-HT group. TMDs occurring in the EDS-HT group were complex, combining several mechanisms in contrast to the control group, where only one mechanism was found in all the patients (n=13; 92.9% vs. n=0; 0.0%).

DISCUSSION

TMDs are strongly associated with RDS-HT. TMDs could therefore be used in the diagnosis of this disease.

[Temporo-mandibular ankylosis]

Ankylosis of the temporomandibular joint is defined as a permanent constriction of the jaws with less than 30mm mouth opening measured between the incisors, occurring because of bony, fibrous or fibro-osseous fusion. Resulting complications such as speech, chewing, swallowing impediment and deficient oral hygiene may occur. The overall incidence is decreasing but remains significant in some developing countries. The most frequent etiology in developed countries is the post-traumatic ankylosis occurring after condylar fracture. Other causes may be found: infection (decreasing since the advent of antibiotics), inflammation (rheumatoid arthritis and ankylosing spondylitis mainly) and congenital diseases (very rare). Management relies on surgery: resection of the ankylosis block in combination with bilateral coronoidectomy… The block resection may be offset by the interposition temporal fascia flap, a costochondral graft or a TMJ prosthesis according to the loss of height and to the impact on dental occlusion. Postoperative rehabilitation is essential and has to be started early, to be intense and prolonged. Poor rehabilitation is the main cause of ankylosis recurrence.

Facial features in Harlequin ichthyosis: Clinical findings about 4 cases

We report 4 cases of Harlequin ichthyosis, which is a rare and severe congenital ichthyosis involving the face. Facial appearance consists in severe ectropion, conjonctival edema, eclabium, flattened ears, broadened nose and large, thick, plate-like skin scales. Recent advances in neonatal care have been made, such as retinoid therapy, and have led to an increased survival rate. Early surgical correction of ectropion may be required because of ocular complications.

[Diagnosis and management of ankyloglossia in young children]

Ankyloglossia is a common condition. Its prevalence is between 3.2% and 4.8% depending on the series and is largely underestimated given the fact of non-diagnosis when the symptoms are limited. It is defined as a short lingual frenulum resulting in a limitation of the lingual mobility. It is due to a defect in cellular apoptosis embryogenesis between the floor of the mouth and tongue. The result is a fibrous and short lingual frenulum. Several classifications were used to make the diagnosis. However, these are the clinical implications, particularly on food and primarily breastfeeding in the baby and phonation in older children that will motivate the management. This is surgical and different techniques are available: infants before the age of 6 months and when the lingual frenulum is still a fine cellular membrane, frenotomy is recommended. Frenectomy with or without frenoplasty is indicated for the older child. The surgery is simple, the results are good and rapidly improving grievances. Complications are rare. Finally, speech therapy is important when there are implications for phonation.

[Child care management in maxillofacial humanitarian mission]

Our practice in a humanitarian (or crisis) context differs from what we experience in daily practice. There are several reasons for this. First, the diseases encountered are sometimes unfamiliar, such as sequelae of noma, or the presentation of familiar diseases may be unusual, such as facial malformations seen at a late stage. Secondly, these missions take place in developing countries, and consequently, evaluation and anticipation of possible malnutrition should be considered, especially because facial diseases themselves may be responsible for nutritional problems. Lastly, conditions are often difficult, occurring in an unusual environment, and we sometimes have to face communication and equipment problems. The goal of our work, based on a 15-year experience (in Bamako and Mopti with the Association "Santé et Développement", and in Ouagadougou with the organization "Les enfants du noma") and the analysis of literature, is to point out these features and maybe to be helpful to others.

Treatment of the nasal abnormalities of Hallermann-Streiff syndrome by lipofilling

Hallermann-Streiff syndrome (HSS) is a rare congenital abnormality affecting mostly the head and face area. Craniofacial deformities, which are present in 98-99% of cases, are the principal abnormalities detected. We focus here on a particular subset of these deformities: atrophy of the skin of the centre of the face and nose. Two patients diagnosed with HSS were treated in our department. Both patients underwent nasal lipofilling to treat the atrophy of the nasal skin, as described by Nguyen et al. In both cases, a satisfactory improvement in nasal skin colour and texture was observed. A functional gain was also reported by the parents and observed during follow-up consultations. Lipofilling thus appears to be an excellent option for treating craniofacial deformities in children.

Spinal cord metastasis of squamous cell carcinoma of the maxillary sinus

INTRODUCTION

Squamous cell carcinomas arising from the maxillary sinus have been rarely reported. The authors report the original case of a patient with squamous cell carcinoma of this site with an unusual clinical course.

CASE REPORT

A woman presented with squamous cell carcinoma of the maxillary sinus that was only diagnosed 6 months after onset of symptoms. At the time of diagnosis, the tumour had spread to the brain via the maxillary nerve and to the skin. The patient was treated by chemotherapy and radiotherapy. Four months after stopping treatment, the patient presented Brown-Sequard syndrome, for which imaging examinations were performed, demonstrating a spinal cord metastasis from her squamous cell carcinoma.

DISCUSSION

This case of squamous cell carcinoma presents several unusual features: the maxillary sinus is a rare site of squamous cell carcinoma and progression and distant metastasis have been only exceptionally described in the literature.

Intralesional cryosurgery to treat keloid scars: results from a retrospective study

BACKGROUND

A variety of treatment modalities have been proposed to treat keloid scars, but outcomes are often disappointing. Intralesional cryosurgery may significantly reduce these scars.

OBJECTIVE

To evaluate the clinical safety and efficacy of intralesional cryosurgery to treat keloid scars. Feedback from patients on pain, pruritus and aesthetic discomfort was recorded before and after treatment.

METHODS

A total of 10 patients with 14 keloid scars resistant to conventional treatments were enrolled in a retrospective study between October 2007 and October 2013. The efficacy of this treatment was evaluated by measuring the reduction in scar surface.

RESULTS

Scar surface was reduced by an average of 58.5% after intralesional cryosurgery treatment for all scars (average pre-operative keloid scar surface: 874.6 ± 954.1 mm2; average post-operative keloid scar surface: 505.8 ± 1,024.7 mm2; p = 0.002). Pain and aesthetic discomfort were significantly decreased after treatment in all patients (p = 0.008 and p = 0.012, respectively).

CONCLUSION

Our data suggest that intralesional cryosurgery is an effective treatment for keloids.

[Bicortical reconstruction of a large calvarial bone defect with Hydroset® osteoconductive cement and titanium mesh. A preliminary study]

INTRODUCTION

Bi-cortical calvarial bone loss is a very frequent issue for neurosurgery and craniofacial surgery. Several techniques can be used to reconstruct the skull, with variable difficulty and costs. The purpose of our study was to assess the use of Hydroset® osteoconductive cement for large size bicortical cranioplasties.

MATERIALS AND METHODS

Three patients presented with extensive loss of calvarial bone bi-cortical substance (>25 cm(2)), between 2010 and 2012. The 3 patients underwent cranioplasty with Hydroset® osteoconductive cement and titanium mesh.

RESULTS

The esthetic results were very satisfactory, especially for the skull dome, with a completely invisible and non-palpable cement/native skull junction. Scalp adherence to the cement was natural with maintenance of skin mobility.

DISCUSSION

Bicortical calvarial bone reconstruction with Hydroset® cement is technically easy to perform, gives very good results, with an uneventful outcome, and induces lower costs.

[Condylar positioning during mandibular orthognatic surgery]

Sagittal split osteotomy of the mandible is the most frequently used method in orthognatic surgery. Osteosynthesis was performed with wires in the 1970s. The instability of fixation allowed condyle movements and there was no problem of condylar positioning. The drawback of this technique was that it required a strict intermaxillary fixation for 6 weeks. Osteosynthesis evolved in the 1980s to a rigid and semi-rigid fixation, with no longer any need for an intermaxillary fixation. But accurately determining the condyle position in the fossa is essential when using a rigid fixation, because no spontaneous adaptation is possible. Moreover, an improper condyle positioning is known to increase short term skeletal relapse, inadequate corrections, and a high incidence of temporomandibular joint dysfunctions. Many solutions have been proposed to solve the problem of condylar positioning: manual positioning technique at osteosynthesis, and mechanical or computer assisted devices to control condylar positioning. The repositionable and adjustable miniplates have also been designed to improve condyle positioning, with the possibility of peroperative adjustment.

Molecular mechanism of hypoxia-induced chondrogenesis and its application in in vivo cartilage tissue engineering

Cartilage engineering is one of the most challenging issue in regenerative medicine, due to its limited self-ability to repair. Here, we assessed engineering of cartilage tissue starting from human bone marrow (hBM) stem cells under hypoxic environment and delineated the mechanism whereby chondrogenesis could be conducted without addition of exogenous growth factors. hBM stem cells were cultured in alginate beads and chondrogenesis was monitored by chondrocyte phenotypic markers. Activities and roles of Sox and HIF-1α transcription factors were investigated with complementary approaches of gain and loss of function and provided evidences that HIF-1α is essential for hypoxic induction of chondrogenesis. Thereafter, hBM cells and human articular chondrocytes (HAC) underwent chondrogenesis by 3D and hypoxic culture for 7 days or by ectopic expression of HIF-1α. After subcutaneous implantation of 3 weeks into athymic mice, tissue analysis showed that hypoxia or HIF-1α overexpression is effective and sufficient to induce chondrocyte phenotype in hBM cells, without use of exogenous growth factors. Therefore, this study brings interesting data for a simple and affordable system in biotechnology of cartilage engineering.

Prosthetic reconstruction of the auricle: indications, techniques, and results

Extensive defects of the ear require satisfactory cosmetic reconstruction to enable the patient to achieve full social integration. Although surgical procedures are the gold standard for reconstruction of the ear, in some cases they cannot be performed because of extended scars, threatening tumor, or congenital tissue abnormalities. Prosthetic reconstruction of the auricle is an established and reliable alternative technique to autologous surgical reconstructions. Since studies performed by Brånemark, osseointegrated implants have been widely used to provide a reliable and stable anchorage for a prosthesis (prosthesis anchored to bone). To allow good osseointegration of the titanium screw implants, two stages are necessary. After careful preparation for the surgical procedure (local and general examination, computed tomography scan, skin preparation), screws are implanted into bone, which are then covered by a skin flap. During the second stage, the skin is incised, and penetrating fixtures are attached to the screw implants, which allow fixation of the prosthesis. This procedure is reliable and reproducible, with good to excellent results and stability over time.

["Double barrel" free fibula flap and vascular risk. A national investigation in France]

INTRODUCTION

The free fibula flap is the most commonly used flap for mandibular reconstruction thanks to its multiple advantages. Its main drawback is the thin width of the bone section. The "double barrel" fibula flap is a solution to this problem allowing reconstruction of both basilar and alveolar ridges for a stable prosthetic dental rehabilitation. The authors wanted to assess its use, in France, to evaluate its reliability, and to determine its indications.

PATIENTS AND METHODS

The authors sent a questionnaire to the 25 French Maxillo-Facial University Hospital Departments. Questions concerned the surgical technique, its indications, and the operative results, between January 2002 and December 2007.

RESULTS

Out of the 18 teams who answered, 16 used a free fibula flap for mandibular reconstruction but only seven used the double barrel technique, for a total of 24 double barrel reconstructions. Only one total necrosis was reported. The indications for double barrel fibula flap were nearly all for corpus reconstruction and the operating overtime was less than one hour.

DISCUSSION

The international literature review analysis gives results which compare to French ones, with a weak rate of necrosis despite the intermediate rectangular ostectomy. This technique may be recommended especially since it does not increase the operative time much and it improves dental restoration.

[Repair of palatal fistulae in cleft patients]

OBJECTIVES

Treatment of oronasal fistulae in cleft patients remains a surgical challenge because of its high failure rate. The authors report the results of an aggressive surgical technique using the total elevation of palatal mucoperiosteum, even for small fistulae.

METHODS

This approach was used on twelve consecutive patients, from five to 33 years of age, presenting with a Pittsburgh classification type IV palatal fistulae. The surgical procedure was total elevation of the hard palate mucoperiosteum starting from the dental sulcus combined with sealed double layer sutures. Clinical and photographical control was made at least 6 months after to detect a possible relapse.

RESULTS

The success rate was 100%. No relapsing fistula was observed with follow-up ranging from 6 to 36 months.

DISCUSSION

This technique allows wide exposure and safe closure of the nasal layer. It is simple and leaves no raw bone surface exposed and no additional scar. The authors think it can be used in all type IV fistulae less than 1cm wide. Several other surgical techniques have been described to close palatal fistulae: local turnover flaps, pedicled flaps from adjacent oral tissue, tongue flaps, tissue expansion, and even free flaps. Obturator prostheses have also been used. The technique we report, even if more aggressive, seems to be more reliable with fewer relapse and sequelae.

[Benign bone forming tumors]

Benign bone forming tumors typically produce dense bone (osteoma, enostosis) or osteoid tissue (osteoid osteoma, osteoblastoma). Even though these four lesions have distinct characteristics, it is sometimes difficult to tell them apart and to rule out malignant bone forming lesions such as osteosarcoma. The first line treatment is surgical exeresis.

[Management of whole-scalp tumour: the Poncet-Spiegler cylindroma or turban tumour]

INTRODUCTION

The Poncet-Spiegler cylindroma (PSC) is a benign annexal cutaneous tumor which preferentially develops on the scalp, neck, or forehead. Localizations may be isolated or multiple and often affect the young adult. The lesions grow progressively. When the scalp is completely involved, it presents as a "turban tumor". Treatment is surgery and may be difficult when the tumor is extended. We report the management of turban tumor.

OBSERVATION

A 25 year-old female patient was first treated by partial scalp nodule exeresis and histology documented a PSC. She was lost to follow-up. But 9 years later, she was managed for a turban like PSC. The treatment was a complete scalp exeresis and secondary reconstruction with a skin graft. Follow-up was uneventful with a progressive functional and cosmetic improvement and after 2 years, there was no relapse.

DISCUSSION

As for most tumors, management depends on the size of the PSC. An aggressive surgical treatment must be considered if the PSC is extended. In case of turban tumor, total scalp exeresis and secondary reconstruction with a skin graft is recommended.

[The Antia-Buch flap technique in reconstruction of marginal ear defects]

INTRODUCTION

The aim of this study was to evaluate the results of ear defect reconstruction using the Antia-Buch flap technique and to compare it to other techniques described in international literature.

MATERIALS AND METHODS

We performed 19 Antia-Buch flaps between November 1998 and November 2002: 15 cases after neoplastic treatment and four post-traumatic cases. Defect ranged between 15 and 40 mm. Between 30 and 40 mm, we used Fata's modification. The final assessment took into account patient satisfaction, cosmetic aspect of reconstruction assessed by the medical team, the presence of a notch at the helical rim and the degree of microtia.

RESULTS

All ear reconstructions were successful. No complications were reported. Fata's modification was used for eight patients. All the patients were satisfied with the result in spite of a systematic microtia. The cosmetic aspect was considered as good for 16 patients, average for three. Nine patients presented with a notch at the helical rim.

DISCUSSION

Reconstruction using the Antia-Buch flap is a simple and fast operative technique performed in a single operation under local anesthesia. It allows for a harmonious reconstruction of the helix and auricle with a tissue of same nature, and only a tiny cicatricial ransom, systematic microtia and frequent notch on the helical rim.

Test prédictif de Manktelow appliqué à l'utilisation de la toxine botulique

We are reporting the use of a xylocain test before the injection of botulinal toxin within the "facial paralysis and botulinal toxin" multidisciplinary consultation of the Caen regional hospital. Our assessment is about 16 patients tested. This test is based on a digital film and a questionnaire. It is often proposed when toxin is first used. It influences the patient's choice. It permits a better understanding of the toxin action by the patient, it reassures. It is reliable for the practitioner even though we do not have a mathematical correlation between the xylocain volume and the botulinal toxin volume. Simple and far, it is a help for the patient and the practitioner before a delicate injection of botulinal toxin.

Les séquelles maxillaires dans les fentes labioalvéolopalatovélaires. Place de la distraction ostéogénique

A high rate of cleft patients present with maxillary hypoplasia. Most of the growth defects concern the anteroposterior axis of the maxilla. Before bone lengthening by distraction osteogenesis, orthognathic surgery was the only alternative treatment for maxillary hypoplasia. Several studies showed the lack of stability after conventional surgery. In this article reviewing the literature concerning all bone lengthening procedures, the authors discuss published data on maxillary distraction osteogenesis by external and internal devices. Indications of distraction in growing children as an interceptive step are discussed.

Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Véloplasties et pharyngoplasties par lambeau pharyngé à pédicule supérieur ou inférieur

Velopharyngeal insufficiency remains a sequel of labial-alveolar-velopalatine clefts. It may occur despite a good quality primary repair. A surgical management must be considered as soon as speech therapy is no longer efficient or before any irreversible compensatory speech pattern appears. Thus, surgery should be decided on after consultation between the surgeon and the speech pathologist or speech therapist, when considering that speech therapy has failed. Several surgical techniques are discussed: intravelar veloplasty, Furlow double-opposing Z-plasty, pharyngoplasty using an inferior or superior pedicle flap. Superior pedicle flap surgery is currently the most commonly used technique. For the past twenty years we have used this technique as described by Petit and modified by Malek, because of the excellent speech results. The drawbacks are known and can be contained by a preventive management.

[Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention]

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. In this article the authors analyze the impact of primary surgery on the maxillary growth failure and discuss on how to prevent this complication.

[Salivary nitrates. New perspectives concerning the physiological function of saliva]

For many years, nitrate ions have been thought to be "toxic agents", but scientific reality seems very different. The source of nitrate ions is double: exogenous and endogenous, and the metabolism of nitrates is partly salivary. The strong concentration of nitrate ions in saliva has many beneficial physiological effects. Salivary nitrate has anti-infectious effects on the oral cavity and all along the digestive tract. They give cardiovascular protection, are instrumental in the adaptive relaxation of the stomach by acting on smooth stomach muscles and have a protective action on the gastric mucosa.

[Mandibular chloroma]

CASE REPORT

A 23 year-old girl was admitted for a facial tumefaction, fixed to the mandible. The X-rays showed a fuzzy osteolytic lesion of the mandibular angle. The CT-scan confirmed the rupture of the cortical bone and the extension to the soft tissue. Biopsy provided the diagnosis of granulocytic monoblastic sarcoma (chloroma). Chemotherapy was efficient.

DISCUSSION

Mandibular localizations of chloroma are rare. Granulocytic monoblastic sarcoma is a localized tumor made of extramedullar immature granulocytes, in general associated (or more rarely preceded by) with leukemia. Early diagnosis is important because high dose chemotherapy induction may completely cure leukemia.

Place de la chirurgie dans les hémangiomes au stade des séquelles

The cure without after-effect of an hemangioma is classic but sometimes the spontaneous involution, a premature surgical treatment or an evolutionary complication can be at the origin of a definitive after-effect. In these cases, the treatment of the hemangioma, often multidisciplinary, will be begun in a late way during the late childhood or the adolescence. Surgical excision of an excess tissue or of a wide scar, lipoaspiration of a fat remainder, lasertherapy and fat tissue reinjection are simple and mostly sufficient procedures. In the most complex cases, notably at the facial site, a surgery heavier as a rhinoplasty, a resection of lip, a local flap or orthognatic surgery can be necessary.

Gunshot wounds: reconstruction of the lower face by osteogenic distraction

BACKGROUND

Although osteogenic distraction is a well-established technique, the distraction device still needs to be improved, miniaturized, and made lighter, more flexible, and more adaptable for mandibular reconstruction in adults with gunshot wounds. The authors successively used unidirectional and bidirectional devices, followed by a bone transporter with a horseshoe-shaped trammel. The trammel system was then replaced by an endless screw, and finally by a customized endless screw.

METHODS

Eleven adult patients with gunshot injuries underwent mandibular reconstruction using osteogenic distraction with an external device.

RESULTS

An average bone gain of 79 mm was achieved. No infectious complications were observed. The authors encountered equipment problems during the study, requiring a change of material. The mean duration of mandibular distraction was 3.5 months.

CONCLUSIONS

Distraction of bone fragments facilitates the simultaneous expansion of soft tissues, avoiding free or pedicled myocutaneous flaps, for soft-tissue reconstruction. The alveolar ridge with the attached gum is also recreated by distraction, allowing dental reconstruction by osseointegrated implants.