Clitoral reduction: Technical note

Clitoral hypertrophy is a rare genital malformation that can be congenital or acquired. In congenital forms, the most common cause is adrenal hyperplasia. The acquired forms are caused by endocrinological diseases, benign tumours or cysts. Idiopathic clitoral hypertrophies can be detected after the elimination of secondary causes. A complete assessment is needed to treat the origin of clitoridomegaly. The hypertrophy is often increased or unmasked during sexual arousal with the appearance of a true vulvar appendage in erection. It is often accompanied by a hypertrophy of the clitoral hood and can cause psychological suffering with an impact on the quality of sexual life. When the cause of clitoral hypertrophy is diagnosed, treated or stabilized, the plastic surgeon may be called upon for surgical correction. Reconstructive surgery in this area has evolved considerably since the historical clitoral amputations which led to the current technique of partial resection with sparing the dorsal neurovascular pedicle of the clitoris as described by Professor Paniel. We propose a modified conservative technique to treat clitoral hypertrophy and the clitoral hood and present two clinical cases: ventral reduction clitoridoplasty with preservation of the neurovascular pedicle associated with a chevron plasty of the clitoral hood and a lipofilling of the labia majora. The postoperative follow-up is simple with reports of great satisfaction from patients regarding their quality of life.

Skin-reducing oncoplasty: A new concept and classification in breast cancer surgery

BACKGROUND AND OBJECTIVES

Breast-conserving surgery and skin-sparing mastectomy are nowadays widely accepted as the standard of care in selected patients with early breast cancer. After an accurate review of the literature, it appeared that no ordered list of the numerous techniques described for conservative breast surgery has been established so far. The aim of this study was to develop a simple classification of the different skin incision patterns that may be used in breast surgery.

METHODS

A systematic review of the English literature was conducted using the PubMed database to identify all the articles reporting breast-conserving surgery and skin-sparring mastectomy techniques up to the 31st of December 2016.

RESULTS

Among the 1426 titles identified, 230 were selected for review. Based on the reviewed papers, the skin-reducing oncoplasty incision pattern (SROIP) classification was elaborated.

CONCLUSIONS

Breast cancer surgery should nowadays optimise aesthetic outcomes by improving the final breast shape, volume and scar location. This may be achieved using different procedures that we grouped together under the term skin-reducing oncoplasty (SRO). Depending on the breast cancer location, the SROIP classification helps in the choice of the best technique to be used.

Using virtual reality to control preoperative anxiety in ambulatory surgery patients: A pilot study in maxillofacial and plastic surgery

INTRODUCTION

Preoperative anxiety may lead to medical and surgical complications, behavioral problems and emotional distress. The most common means of prevention are based on using medication and, more recently, hypnosis. The aim of our study was to determine whether a virtual reality (VR) program presenting natural scenes could be part of a new therapy to reduce patients' preoperative anxiety.

MATERIALS AND METHODS

Our prospective pilot study consisted of a single-blind trial in skin cancer surgery at the Henri-Mondor teaching hospital in France. In the outpatient surgery department, 20 patients with a score of >11 on the Amsterdam preoperative anxiety and information scale (APAIS) were virtually immersed into a natural universe for 5minutes. Their stress levels were assessed before and after this experience by making use of a visual analog scale (VAS), by measuring salivary cortisol levels, and by determining physiological stress based on heart coherence scores.

RESULTS

The VAS score was significantly reduced after the simulation (P<0.009) as was the level of salivary cortisol (P<0.04). Heart coherence scores remained unchanged (P=0.056).

DISCUSSION

VR allows patients to be immersed in a relaxing, peaceful environment. It represents a non-invasive way to reduce preoperative stress levels with no side effects and no need for additional medical or paramedical staff. Our results indicate that VR may provide an effective complementary technique to manage stress in surgery patients. Randomized trials are necessary to determine precise methods and benefits.

Wound healing of cutaneous substance losses based on infectious, inflammatory and traumatic skin disorders: The experience of a center

INTRODUCTION

There is no reference available concerning the standard healing time based on dermatological diseases responsible for cutaneous substance losses. The aim of our study was to assess the healing time after surgical debridement of necrotizing fasciitis (NF), hidradenitis suppurativa (HS) and skin necrosis due to trauma (SNT) based on multiples existing co-morbidities among these patients to provide surgeons with accurate scientific data in order to inform and educate patients and nurses who are practicing care under the supervision of the surgeon.

MATERIALS AND METHODS

This was a retrospective study. The primary endpoint was the time for complete wound healing, which was calculated from the time of the last surgical procedure to the complete wound healing corresponding to the time of complete reepithelialization, when daily dressings were no longer needed.

RESULTS

A total of 107 patients were included. The mean time for complete wound healing was 64.94±31.55 days in patients with NF, 45.70±21.40 days in patients with SNT and 75.02±26.41 days in patients with HS (SNT versus NF, P=0.004** and SNT versus HS, P<0.0001**).

CONCLUSION

The mean time for complete wound healing was 64.94 days in patients with NF, 45.70 days in patients with SNT, 75.02 days in patients with HS. This study can be considered as a referential based on the experience of a reference centre for these 3 pathologies (NF, HS, and SNT) whose aim is to inform plastic surgeons in order to anticipate the management or educate the patient.

Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting

OBJECTIVE

The aim of this study was to describe a technique for midface rejuvenation combining lower blepharoplasty, midcheek lift and autologous fat transfer.

METHODS

All patients who underwent a midface rejuvenation procedure performed by the same surgeon and using a classic subciliary blepharoplasty surgical approach were identified. The technique combined three distinct procedures: lower blepharoplasty with use of a transposition flap of orbital adipose tissue in the medial and central compartment to reduce the subpalpebral bags and attenuate the palpebrojugual sulcus; midcheek lift in the preperiosteal plane with trans-osseous fixation exerting traction on the soft tissues of the cheek along several vectors; autologous fat transfer to offset the loss of volume in the target area.

RESULTS

Between January 2011 and December 2015, 14 patients were operated with the described technique. Long-term results were good and stable over time. Two complications in the form of ectropion were observed in the series but resolved with daily massages.

CONCLUSIONS

The combination of lower blepharoplasty, midcheek lift and autologous fat transfer appear to enable treatment of midface ageing. The results were satisfactory and durable, and the procedure was well tolerated. The procedures could be combined with others for the treatment of the upper and lower face during the same surgical procedure.

Use of platelet-rich plasma (PRP) in microsurgery

Platelet-rich plasma (PRP) is currently used for its property to improve tissue regeneration and wound healing. Platelet derived growth factors are involved in tissue regeneration and new vessels formation that could improve a free flap survival. Nevertheless to validate the use of regenerative medicine in microsurgery further large and robust human clinical trials are needed.

Use of the 3D surgical modelling technique with open-source software for mandibular fibula free flap reconstruction and its surgical guides

INTRODUCTION

Tridimensional (3D) surgical modelling is a necessary step to create 3D-printed surgical tools, and expensive professional software is generally needed. Open-source software are functional, reliable, updated, may be downloaded for free and used to produce 3D models. Few surgical teams have used free solutions for mastering 3D surgical modelling for reconstructive surgery with osseous free flaps. We described an Open-source software 3D surgical modelling protocol to perform a fast and nearly free mandibular reconstruction with microvascular fibula free flap and its surgical guides, with no need for engineering support.

PROCEDURE

Four successive specialised Open-source software were used to perform our 3D modelling: OsiriX^®, Meshlab^®, Netfabb^® and Blender^®. Digital Imaging and Communications in Medicine (DICOM) data on patient skull and fibula, obtained with a computerised tomography (CT) scan, were needed. The 3D modelling of the reconstructed mandible and its surgical guides were created.

CONCLUSIONS

This new strategy may improve surgical management in Oral and Craniomaxillofacial surgery. Further clinical studies are needed to demonstrate the feasibility, reproducibility, transfer of know how and benefits of this technique.

[Hyaluronic acid rheology: Basics and clinical applications in facial rejuvenation]

Hyaluronic acid (HA) is the most widely used dermal filler to treat facial volume deficits and winkles specially for facial rejuvenation. Depending on various areas of the face, filler is exposed to two different forces (shear deformation and compression/stretching forces) resulting from intrinsec and external mechanical stress. The purpose of this technical note is to explain how rheology, which is the study of the flow and deformation of matter under strains, can be used in our clinical practice of facial volumization with fillers. Indeed, comprehension of the rheological properties of HA has become essential in selection of dermal filler targeted to the area of the face. Viscosity, elasticity and cohesivity are the main three properties to be taken into consideration in this selection. Aesthetic physicians and surgeons have to familiarize with those basics in order to select the HA with the right rheological properties to achieve a natural-looking and long-lasting outcome.

Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon's perspective

Objective aesthetic criteria are important for patient evaluation and analysis during aesthetic surgeries, while successful aesthetic surgeries must take into account the underlying ethnic differences. The aim of this study is to help surgeons and scientists better plan facial aesthetic surgeries and understand the aesthetic needs according to different patients by reviewing and comparing the current aesthetic principles and preferences in Caucasian and East Asian populations. PubMed and The Cochrane Library were searched using keywords regarding anthropometric measurements. Only original clinical studies and reviews written in English and Chinese and those that focused on the objective assessment of facial aesthetics in Caucasian and East Asian female populations were retained for review. Reference lists of the selected articles were also reviewed for eligible studies. Sixty-five articles that described objective aesthetic criteria in Caucasian and East Asian female populations were found through PubMed, among which 47 included Caucasian populations and 18 included East Asian populations. Compared with White women, East Asian women prefer a small, delicate, and less robust face, lower position of double eyelid, more obtuse nasofrontal angle, rounder nose tip, smaller tip projection, and slightly more retruded mandibular profile. Various differences exist between objective facial aesthetic criteria in Caucasian and East Asian populations. Further studies that focus on the objective aesthetic criteria of facial attractiveness in different ethnicities need to be conducted, especially in Asian countries. Level V: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Factors That May Enhance Longevity: A Literature Review and a Comprehensive Update for Aesthetic Surgeons

INTRODUCTION

After surgery, the plastic surgeon is very often questioned about how to maintain the result and more frequently how to slow down the aging process. However, this type of knowledge is not commonly delivered during medical education or at least needs an update. This review could be used as a guide to help plastic surgeons to manage these frequent postoperative consultations. The aim of this literature review was to focus discussion on specific positive factors, identified to have a significant impact on human longevity.

MATERIALS AND METHODS

A literature review was performed using the automated computerized PubMed search, with the keywords "human longevity." Only papers written in the English language were included. References were screened to identify further relevant articles. Experimental studies based on microorganisms and animals, works published in non-indexed journals, case reports, letters, and viewpoints were excluded.

RESULTS

One hundred and twenty-four articles reporting factors influencing human longevity were analyzed for data extraction. A total of 59 articles reporting only positive factors were included. Fourteen factors seemed to have a positive impact on longevity: caloric restriction, active effort and sports, happiness, vitamins, vegetarian or Mediterranean diet, oriental practices, socioeconomic status, genetics, sexual activity, sleep, moderate wine consumption, religion, and education.

CONCLUSION

While some factors with a positive impact on longevity are clearly identified and should be integrated in the postoperative process, further studies are still needed to be able to slow down the aging process.

NO LEVEL ASSIGNED

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 www.springer.com/00266 .

Assessment Tools for Facial Rejuvenation Treatment: A Review

BACKGROUND

In the field of cosmetic medicine, patient satisfaction is an important and common indicator used to measure the efficacy of the treatment. However, it is insufficient to prove objectively that the benefit of the specific factors involved in the cosmetic outcomes. The practitioner should be aware of these assessment tools, in particular in case of demanding or litigious patients.

OBJECTIVE

The aim of this review was to establish a list and discuss the subjective and objective methods used to assess facial aesthetic rejuvenation treatments.

METHODS

A systematic literature search was performed using the Pubmed search engine. Studies published over the last 5 years, i.e. between January 2010 and January 2015 were considered for review. The following keywords were used: "aesthetic treatment", "facial rejuvenation", and "subjective evaluation" or "objective evaluation".

RESULTS

Of the 446 articles identified by the search strategy, 47 articles focused specifically on facial rejuvenation and on the efficacy of aesthetic medical treatments were retrieved for review. Thirty-seven articles used quantitative methods to assess aesthetic treatment outcomes and only 12 used subjective methods. The different assessment methods were listed according to the tools used and treatment indications.

CONCLUSION

This review will help in choosing adequate methods to assess facial rejuvenation medical treatment. It is important to combine these tools adequately to improve the assessment. There is no current consensus on assess facial rejuvenation treatments but we noted that objective assessment methods seem helpful.

NO LEVEL ASSIGNED

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 www.springer.com/00266 .

[Use of hyaluronidase to correct hyaluronic acid injections in aesthetic medicine]

Hyaluronic acid (HA) is the most commonly used filler in aesthetic medicine. However, overcorrections are frequent even with experienced practitioner. Hyaluronidase is an enzyme that hydrolyzes HA. Hyaluronidase has been recently proposed to correct unsatisfactory results of HA injections in aesthetic medicine (overcorrection, asymmetry, Tyndall effect) and to treat immediate complications such as arterial or venous thrombosis. The objective of this technical note was to summarize the literature data regarding the efficacy, safety and technique of use of hyaluronidase. Hyaluronidase may be responsible for allergies. The practitioner should take this risk and the possible drug interactions into account before using this antidote in order to weigh up the risk/benefit ratio.

Nasal basal cell carcinomas. Can we reduce surgical margins to 3mm with complete excision?

BACKGROUND

The purpose of this study was to evaluate the incomplete excision rate of nasal basal cell carcinomas (BCC) resected with different margins to demonstrate that 3-mm surgical margins could be used as safety margins to reduce esthetic consequences with a low risk of incomplete excision.

METHODS

All patients with BCC of the nose excised from January 1st 2008 to December 31st 2011 were included. Data were analyzed and reviewed retrospectively. Tumors were treated with different surgical margins of excision: 3mm, 4mm, and 5mm. The primary outcome variable was the rate of incomplete excision. Other study variables were the histologic subtype, size, and recurrent lesions.

RESULTS

Of the 132 patients, 115 were included corresponding on with 127 BCC. Median age was 75.5 (64-83) and sex ratio M:F=1.05. Of the 127 BCC, 80 were aggressive histologic subtype (63%), and 11 were recurrent (8.7%). The overall rate of incomplete excision was 17.3% (n=22). Of these 22, 17 (77.3%) were of an aggressive subtype. The incomplete excision rates within the groups were 12.5% (n=4), 22.2% (n=10), and 16% (n=8), respectively within the group with 3-, 4- and 5-mm surgical margins. No significant difference was observed between the groups (P=.519). The incomplete excision rate was not independently associated with the surgical margins, histologic subtype and recurrent type (P>.05).

CONCLUSION

Three-millimeters margins could possibly be used to treat nasal BCC in chosen cases. Regarding the high rate of incomplete excision, reconstruction should be performed after receiving the pathologic report.

Soft tissue expansion and cranioplasty: For which indications?

PURPOSE

The aim of this study was to better define indications for scalp tissue expansion before cranioplasty, and to describe our methodology for calculate the surface of tissue needed, by combining a preoperative analysis of both the size of the defect and the quality of skin above.

MATERIAL AND METHODS

A retrospective analysis of patients who underwent expansion before cranioplasty between 2009 and 2015 was conducted. Information was collected on the etiology, size and location of the defect, and reasons of skin contracture. Data concerning expansion and cranioplasty were reviewed.

RESULTS

Among 47 patients who underwent operation for cranioplasty, five (10.6%) required previous scalp tissue expansion. The etiology of the bone defect was tumoral in three cases, posttraumatic in one case, and a decompressive craniectomy in one case. The mean surface of the bone defect was 69.6 ± 18.7 cm(2). The locations of the defects were fronto-temporo-parietal, frontal, temporo-frontal, on the vertex, and occipital. The cause associated with the skin contracture was an infection in four cases and a delayed cranioplasty in one case. A round-profile expander and a custom-made porous hydroxyapatite implant were used for all patients.

CONCLUSIONS

The accurate assessment of tissue needed before cranioplasty is as essential as the choice of the material used for bone reconstruction. After previous infected cranioplasty or delayed reconstruction of large defects, scalp tissue expansion should be proposed.

Dermatosurgery: total quality management in a dermatology department

BACKGROUND

Dermatosurgery (DS) is a growing sector in dermatology. Performance measurement is organized worldwide to improve the quality of health care. Clinical audit relies on self-assessment, comparison with guidelines, frames of references and implementation of improvement actions.

OBJECTIVE

To assess the efficiency of our DS department.

METHODS

A clinical audit focusing on the organization of the DS unit, patient routing, continuing medical education and training for students was conducted by two external auditors. After an initial evaluation, improvements were implemented and reassessed 1 year later by the same auditors.

RESULTS

The audit resulted in the implementation of preoperative consultation, improved pre- and postoperative information leaflets for patients, standardizing of surgery reports, earmarking of funds for materials, and patient satisfaction survey. The training of residents was organized.

CONCLUSION

This audit was a driving force for communication among the medical and paramedical teams and helped improve patient care and training of residents in DS. It also highlighted areas needing further improvement.

Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes

Composite tissue allotransplantations can be indicated when autologous transfers fail to restore human appearance. We report the reproducibility, difficulties, serious adverse events and outcomes of our patients. Five patients were included in a registered clinical research protocol after thorough screenings assessed by an independent expert committee systematically discussing the alternative options. One patient suffered from plexiform neurofibromas, two from third degree burns and two from gunshot injuries. They were included on a national waiting list with a dedicated face procurement procedure. Transplants were harvested from heart beating brain-dead donors before other tissues and organs. Induction immunosuppressive therapy included antithymocyte globulins, steroids, mycophenolate mophetil and tacrolimus. Maintenance therapy included the last three ones associated with extracorporeal-photopheresis. Four patients were transplanted with 7- to 38-month follow-up. One could not due to multiple panel reactive antibodies after 18 months on waiting list. Acute cellular rejections were controlled by conventional treatment. Opportunistic infections affected all patients and lead one patient to die two month after the transplantation. Voluntary facial activity appeared from 3 to 5 month. Face transplantation has been reproducible under conventional immunosuppression. Major improvements in facial aesthetic and function allowed patients to recover social relations and improved their quality of life.

Traitement de l’ulcère de Buruli par excision-greffe : à propos de 118 observations

INTRODUCTION

Buruli ulcer is the most common mycobacteria disease after leprosy and tuberculosis. The purpose of our study is to make our contribution to the surgical treatment of Buruli ulcer and to asses our results.

METHOD

One hundred eighteen patients presenting progressive Buruli ulcers were operated on. The surgical procedure included excisions for necrotic lesions and grafts for clean wounds. The results were estimated on the time of hospitalization and appearance of complications.

RESULTS

Seventy-three patients (62%) were subjected to excision followed by thin skin grafts and 35 patients (30%) were subjected to grafts only. The number of excision times varies from 1 to 7 per patient and from 1 to 4 for the skin grafts. All our patients heal within a period of 120 days with extremes going from 14 to 265 days. We deplored 26 complications (22%): eight new focus, seven infectious complications, six recurrences, five stiffnesses and ankyloses.

CONCLUSION

The treatment of Buruli ulcer by excision and grafts is efficient but does not prevent recurrences and new focus from happening and for their prevention, it is necessary to discover pharmaceutical molecules that are efficient on Mycobacterium ulcerans.

[Quality of scientific publications about cosmetic surgery]

OBJECTIVE

Ethical and methodological quality of scientific papers on cosmetic surgery is often criticised. This is why we have proposed to create and validate an ethical and a methodological grid in the field of cosmetic surgery.

METHODS

A questionnaire had been mailed to 40 cosmetic surgeons. The questionnaire was voluntary and simple and included two open questions and the possibility of giving one's opinion on this subject. The first question was: "Please mention, without describing your first ten methodological criteria, when you decide to evaluate a scientific publication concerning cosmetic surgery". The second question was written exactly in the same way, except that the word "methodological" was replaced by the word "ethical".

RESULTS

In the methodological field, our results are the same as the classical criteria that permit answers the following questions: what did you do?, why did you do?, how did you do?, what did you find?, what is the meaning of this finding?, what is the future of this finding? Finally, except for the importance of comparing before and after photography, our criteria are not so different from the methodological criteria of all scientific studies. In the ethical field, in a decreasing order, we found the balance of benefits and risks, the probity of the author, the respect for the a priori equivalence clause, the disclosure of conflicts interest, the quality of the iconography, the respect for legislation, the transparency on the effective work of each author, the existence of rules for early stopping of the study and the transparency on preliminary animal studies if necessary.

CONCLUSION

Similar to the existing practice, a study could be refused for publication because of its methodological insufficiencies; in the future, more and more studies would be refused because of their ethical insufficiencies.

[Plastic surgery treatment of Buruli ulcer sequelaes. A retrospective study of 16 patients]

INTRODUCTION

Thirteen percents of the patients suffering from Buruli ulcer in Ivory Coast show sequels at a result of their spontaneous healing. The purpose of our study is to report and estimate the first series of the sequel treatment of Buruli ulcer, with standard reconstructive procedures used in plastic surgery.

METHOD

Sixteen patients totalizing 18 sequels were classified into 2 groups:13 patients showed functional sequels in connection with cicaticial retractions about level with joints;3 patients showed aesthetic sequels with no repercussion on the functional aspect. The surgical treatment included for the functional sequels, the excision of the retractile scar, the restoration of the underlying structures followed by the coverage of the defect with skin grafts or muscle or musculo cutaneous flaps and for aesthetic sequels, the excision of the scar tissues and the coverage with full-thickness skin grafts.

RESULTS

The results were considered good because the patients found an acceptable physical activity again that enable some of them to resume a professional activity and others a school activity. Motherless, a certain number of complications are to be deplored:1 case of distal necrosis of a skin flap autonomized which required excision and conducted healing but without repercussions on the functional result;1 residual edema about level with the fingers at the time of the covering of a hand with a groin flap;1 haematoma at the donar site of a full-thickness skin graft.

CONCLUSION

Distance flaps are more advisable for hand sequels in Buruli ulcer considering the regional character of the disease and the necessity to preserve the main vascular axes about level with the hand. On the lower limb, autonomized skin flaps enable provide important tissue and preserve the major vascular axes of the lower limb.

[Multifocal forms of Buruli ulcer: clinical aspects and management difficulties in 11 cases]

OBJECTIVE

A certain number of authors have in literature pointed out multifocal forms of Buruli ulcer but no study was ever dedicated to them. The purpose of this study is to be more specific about the clinical aspects and to show how difficult it is for those multifocal forms of Buruli ulcer to be operated on.

METHOD

The 11 patients who were accepted for the study were subjected to an interrogation, a thorough clinical examination, research of BAAR in ulcers and operative pieces with a direct examination after Ziehl-Neelsen colouring. Each of these patients underwent a surgical treatment under general anaesthesia or spinal anaesthesia depending on the seat of the lesions under cover of pre and post operative therapy by antibiotics.

RESULTS

Initial lesions preferentially were located at limbs level; new foci appeared within an average period of 3 months, ranging from 1 to 15 months in some cases. All body parts could be the seats of secondary foci. Depending on the patients, the number of foci varied from 3 to 7. Furthermore, amputation has been necessary for the complete healing of four patients. The average operation was 2.4 by patient ranged from 2 to 5. We observed the healing of all the patients within an average hospitalisation time of 6.3 months running sometimes from 4 to 13 months. In addition to amputations, 4 patients presented after-effects as articular stiffness, retractions of the hand's dorsal face and knee's retraction.

CONCLUSION

Those multifocal forms can, with good reason, be considered as malignant form of Buruli ulcer.

[Proposing surgical management to a patient with low-grade glioma: controversies and ethical consequences]

The therapeutic controversies surrounding low-grade glioma result mainly from the lack of certainty about their histological definition, and, from our imperfect knowledge of the natural history of the disease. Heterogeneous surgical management is the consequence of this situation, which renders difficult to propose the best attitude to each individual patient, thus raising ethical questions, because the absence of a consensus. Performing prospective studies able to analyse these different modalities is mandatory whenever we want to be enable to give to our patients the best answer in their precise case, and furthermore to justify back our acts too.

Aetiology and incidence of facial fractures sustained during sports: a prospective study of 140 patients

A prospective study was carried out involving patients presenting with facial fractures sustained during sports. One hundred and forty patients were admitted to the Pitié-Salpêtrière University Hospital of Paris between March 1998 and March 2000, accounting for 13.3% of all patients with facial bone fractures. The ratio of males to females was 7.2:1 and the mean age was 28.5 years. The majority of accidents occurred during soccer (25.0%), followed by rugby (15.0%), and as a consequence of collisions between players (50.7%). The majority of the injuries involved the mandible (34.4%), the zygomatic bone (23.4%) and the nasal bone (15.6%). The sporting activities were classified as either contact or non-contact sports. Frontal sinus, central midface and LeFort fractures were seen more often in vehicular sports such as mountainbiking and skiing. The authors stress the importance of preventive measures, including the use of protective equipment, periodic sports medical check-ups and personal discipline.

Depression, anxiety and quality of life among scheduled cosmetic surgery patients: multicentre prospective study

OBJECTIVE

To measure cosmetic surgery patients' state of psychological vulnerability.

METHOD

A multicentre prospective study was carried out in three hospital departments. One hundred and three patients scheduled for cosmetic surgery were examined using a structured interview and using three assessment scales: the MADRS (Montgomery and Asberg Depression Rating Scale), the SISST (Social Interaction Self Statement Test) and the EQ-5D (EuroQol) which measures quality of life.

RESULTS

The MADRS index was higher than that of the control group (p<0.01) with 20% depressive patients. SISST: the social anxiety was greater than that of the control group (p<0.001). The EQ-5D visual analogue scale average was 77.39% indicating that there was no significant difference when compared with the control group, but the descriptive EQ-5D revealed an overrepresentation of the anxiety/depression category (p<0.01); 50% had already taken psychotropic treatment of which 27% were an antidepressant.

CONCLUSION

The cosmetic surgery population presents a significant state of psychological vulnerability.

Dynamic study about metal release from titanium miniplates in maxillofacial surgery

It has been shown that titanium (Ti) has had dramatic success in many surgical procedures as a result of its excellent mechanical properties and resistance to corrosion. There is still concern, however, about the release of metal and controversy surrounding whether or not the plates should be removed after bone healing. This study has been conducted to investigate whether or not there is a relationship between duration of plating and metal release from Ti miniplates in maxillofacial surgery. A prospective cohort study design was used. The concentration of Ti, in the soft tissues covering the plates, was examined in all patients who underwent removal of Ti miniplates from January 1998 to April 1999 (51 cases). Inductively Coupled Plasma-Optical Emission Spectrometry was used to measure Ti. Total ti and soluble Ti levels were compared to duration of plating (ranged from 15 days to 3 years, mean = 8 months). Correlation coefficients and two-way ANOVA were data processed. The average amount of total Ti in the soft tissues surrounding the plates was 1306 micrograms/g dry tissue. The mean of soluble Ti was 0.53 microgram/g dry tissue. The results of this study do not support the existence of a relationship between duration of plating and total Ti (correlation coefficient = 0.093 (P > 0.1) nor soluble Ti (correlation coefficient = 0.009 (P > 0.1) in the soft tissue surrounding the plates. Moreover, the only independent factor of Ti release found was associated with mechanical constraints during surgery. Almost 100% of Ti is released during the osteosynthesis. Then Ti levels remain constant in the surrounding tissues. Most of the time, Ti seems to be clinically inert. Compared to the possible risks of a second operation, removal of Ti miniplates should not be a routine procedure except in the case of complaints from patients, particularly in the case of infection, hypersensitivity, dehiscence or screw loosening.

[Knowledge of flap complications in finger pulp surgery and patient education--ethical implications]

INTRODUCTION

The two highest French courts have recently decided that not to fully inform a patient constitutes negligence, and that doctors should be able to prove that the information has been given. The medical community is now debating as to how to protect physicians without harming the doctor-patient relationship. Following this study we put forward the hypothesis that although information might not be available to surgeons nevertheless this should not prevent them taking the ethical steps necessary to redress the situation.

METHODS

We conducted a telephone interview to discover what surgeons knew about the complications of finger flaps used for the reconstruction of pulp defects. Four flaps were studied: the VY flap described by Atasoy, the island finger flap known as Ventataswami's, the reverse island flap and the thenar flap. Surgeons were asked to give the percentage of necrosis, infection, sensory disturbances, digital stiffness and exclusion, as well as the time off work, the time of healing and the sensory discrimination of the flap. The results obtained were compared to those obtained by a literature review.

RESULTS

Twenty one qualified hand surgeons answered the questionnaire. Many answers were absent or only fragmentary when sought in the literature. Where complication rates were available, there was a huge variation among series. A large variety of answers was also found in our study. The direct island flap was the best known flap. Complications of the reverse island flap and the thenar flap were overestimated in the group interviewed.

DISCUSSION

There is no true answer, either in the literature or from the study group. There is a gulf between the jurists' demand and the possibilities of knowledge by surgeons. We are still waiting for clinical studies that will answer the questions asked by patients regarding the complications of surgery. However, even if absolute knowledge is not available, it is the ethical duty of surgeons to give the patient information that is as close as possible as the "truth", and that will be helpful to them.

Ethical acceptability, health policy and foods biotechnology based foods: is there a third way between the precaution principle and an overly enthusiastic dissemination of GMO?

The demand for consumer safety with regard to the food-processing industry is becoming, legitimately, more and more urgent. If ingested drugs can carry deleterious effects that exceed the beneficial effect that the research was initially undertaken for, then the same can only be the case for foods that stem from the same new biotechnologies, zero risk being non existent. There are two conflicting viewpoints about the possible risks linked to genetically modified organisms: a posteriori protection (based on vigilance once the product is on the market) and an a priori protection (at present usually supported by the precaution principle). We suggest a third way, which ensures consumer safety, but doesn't hinder scientific progress. Just as there are regulations for the protection of human subjects in biomedical research and regulations for the use of drugs after they are marketed, so should such regulations be introduced in the domains of food production that use biotechnologies. We therefore suggest that the scientific community and the food-processing industry develop evaluation protocols for new foods like the ones that exist for drugs. We thus offer thirteen regulations, based on the Helsinki declaration, in order to establish these protocols. These proposals, applied to food-processing research, would enable the industry to return confidence to consumers and thus avoid the random blocking of scientific progress, which is a source of health for the greater population.

Ethical assessment of clinical research publications

The ethical quality of research could be improved in four ways: increasing the expertise of research committees, encouraging the popularization of research in ethics, delivering medical training in ethics, and improving the a posteriori control of editorial committees. With regard to the last point, we propose ethical guidelines that may be used as a screening device for publication. Scientific publications have a duty to contribute to the diffusion and application of ethical principles. But too often pieces of research published in these journals do not adequately demonstrate their ethical reflections and chosen ethical procedures. Only scientific procedures are extensively discussed. We think it is essential to develop an assessment of the ethical value of research that is featured in journals, in the same way that the methodological value is assessed. This paper reports what motivated our group to create an ethical scheme, how we developed this scheme and what was our process of validation. In the same way that today a study can be refused publication for methodological inadequacies, in the future publication could more likely be refused for ethical shortcomings.

Bio-libraries and DNA storage: assessment of patient perception of information

BACKGROUND

Since the creation of places where DNA is stored, a number of questions appear about protecting the individual, confidentiality and the validity of the proposed consent to storage. This study, originating in France, analyzes and assesses the impact of the information given by the clinician to the patient regarding having his DNA stored. How does the patient receive the information? What is left of it? Is he informed enough to sign a "well-informed" consent?

METHODS

A questionnaire issued to 170 patients in the same department was used to assess: (1) their knowledge of genetics, (2) their knowledge of DNA storage, (3) their perception of the consent.

FINDINGS

A third of the patients answered, 20% of whom understood the objectives of a genetic test. None of the patients contacted was aware that he had samples stored in a DNA bank, that genetic analyses had been undertaken or remembered that he had signed a consent (which indeed exists).

INTERPRETATION

The idea of a "well-informed" consent belongs to the criteria defining the validity of a cure and research agreement. Yet, its validity is doubted as soon as the information it implies is not understandable by the patients. Indeed, can the individual be considered autonomous, in the philosophical sense, in a well-informed decision making if the information given to the patient has not been well understood?

[Controversies over the surgical placebo: legal issues and the ethical debate]

The debate on controlled surgery trials has had some rather "sensational" repercussions, enlivening the placebo issue. In France, there is a consensus on the ethical conditions necessary for proper protection of individual persons. This consensus has taken on a legal form with the promulgation of the Huriet law. For this reason, all studies and research protocols in medicine and surgery are examined by ethics committees (CCPPRB) who assess the inclusion conditions within the framework of biomedical research and in compliance with the concept that individual participants must be give proper protection. These committees are faced with increasingly complex situations, particularly concerning the pertinence of information give to the participant and the modalities of consent. In France, standard measures were established after a parliamentary debate issuing from a wider public debate. The issue has become a social transaction between biomedical research professionals and the society in general. The international debate over the surgery placebo is an interesting illustration of how mediation institutions, working along the principles of ethical committees, play a key role in social awareness of the ethical issues involved before an innovating practice is initiated. But how legitimate are sensational pieces published in the media, which as is clearly demonstrated with the debate over the surgical placebo, are almost always individual points of view? Shouldn't the debate take into account the contributions of ethical committees which integrate representatives of the social community as well as the importance of a legal framework for individual protection as proposed by the French law? Shouldn't personal points of view be counterbalanced by regularly expressed ethical committee opinions formed after appropriate ethics-oriented discussion going beyond the simple question of "should we do it", a question often dismissed by extreme theoretical arguments that leave unanswered the practical question of "how should we do it"?

[Piercing: health education or medicalization?]

In Europe, the piercing mode has naturally been associated with specific complications raising an important public health problem. The debate on the role physicians should play requires a careful analysis of the ethical issues involved. Specifically, should the piercing be done in a medical setting? This question is raised because, when performed under ideal conditions, the act of piercing requires a certain degree of medical competency: history taking, asepsia, technical procedure (hemostasis), anesthesia.... However, mandatory medicalization would not, in our opinion, appear to be desirable since we are dealing with a social rite which lies outside the domain of specific medical care. Nevertheless, although we do not advocate systematic medicalization, we do believe that medicine should play a role, in terms of public health, in this emerging practice. We discuss the modalities of a health education dialogue which could be established with professional practicing piercing.

Ethics and aims of cosmetic surgery: a contribution from an analysis of claims after minor damage

MAIN OBJECTIVES

Cosmetic surgery raises the ethical problem of the balance of risks and benefits of an operation the benefit of which is psychological and difficult to evaluate. The aim of this study is to improve the understanding of the factors that influence an unsatisfactory outcome. In this context, we have analyzed complaints from patients the alleged damage to whom proved to be ultimately non-existent or minimal.

METHODS

Review of the case notes of 20 patients who had sought damages through the French judicial system for minimal or non-existent alleged damage. Data were collected in 1999.

FINDINGS

We found fifteen complaints of insufficient results, two for cause and effect relations with pathologies without any connection, and three for lack of information. 5 patients received compensation, the rest having been ruled out of court. The gender ratio (17 F/3 M), the average age (38 years old), the distribution of the operations and the socio-professional categories reflect the characteristics of a standard cosmetic surgery population. The average period of time between an operation and a complaint was 4.3 years (SD = 4.2). Among the medical histories we found two cases of depression, one treatment "for the nerves", one suicide attempt, and two cases of alcoholism without possible interpretation in the framework of this study. In six cases, the surgeon's qualification was not appropriate to the type of operation. The unprofessional conduct of colleagues had an influence on the effect of the procedure as an independent factor.

CONCLUSION

These results call for more responsibility from professionals and encourage the undertaking of prospective complementary studies in order to evaluate more precisely the balance of risks and benefits.

Biotechnology-based foods: is there a third way between the precaution principle and an overly enthusiastic dissemination of GMO?

The demand for consumer safety with regard to the food-processing industry is becoming, legitimately, more and more urgent. If ingested drugs can carry deleterious effects that exceed the beneficial effect that the research was initially undertaken for, then the same can only be the case for foods that stem from the same new biotechnologies, zero risk being non existent.

Sex reassignment surgery in France: analysis of the legal framework and current procedures and its consequences for transsexuals

MAIN OBJECTIVES

In France there is no specific law that recognizes either sex reassignment surgery (SRS) or changes in civil status. This practice is based on a set of rules that have been devised by those practitioners in the disciplines involved. This study has been directed to evaluate the perceptions of French surgeons regarding their own activity in the area of the SRS with the implications that these perceptions may have on the management of patients and to contribute to a useful international collection of material on this difficult topic in terms both of report and interpretation.

METHODS

Personal interviews with 10 surgeons representing almost all of teams involved in transsexualism in France. The data were collected during 1998.

FINDINGS

Surgeons alone cannot evaluate the motivation of each patient's request. Their decision whether or not to operate is made in consultation with both a psychiatrist and an endocrinologist. They never urge patients to undergo SRS. An assessment lasting at least two years before making a recommendation for surgery is routine. The rate of postoperative suicides is very low. Among surgeons, postoperative regrets are minimal (postoperative regrets by patients were not directly evaluated in the framework of this study). The diagnosis seems to be made with satisfactory reliability, but at the cost of a tedious process for the patient. As a consequence some decide to be operated on abroad. However not all are true transsexuals.

CONCLUSION

SRS represents a good example of the collaboration of certain disciplines as surgery, medicine, psychiatry and law to reaffirm the meaning that society gives to the status of the individual while protecting the respect of some unusual situations.

[Halitosis in 1999]

Bad breath is a major concern to the general population and a source of an important profit industry world wide. Between 50 and 60 per cent of the population suffer from chronic halitosis. This can have consequences for private or professional life. Reasons can imply many specialities: ENT, gastro-enterology, pneumology, hepatology, genetics and psychiatry (a high percentage of the patients who come to the clinic with a primary complaint of halitosis do not have a detectable problem). Nevertheless, 85% are stomatological and are explained by the release of volatile sulfur compounds. These substances have a very offensive odor in very low concentrations. A specialized device called a halimeter is available to measure the volatile sulphur compounds in mouth air but in practice the objective assessment of malodor is still best performed by the organoleptic method. A careful examination can determine the patient's problem in most cases. Initial treatment strategy should focus on the exact cause and on oral hygiene. In addition to the usual recommendations, the daily use of tongue cleaners is very beneficial. Other than etiologic therapy, masking can be achieved by oral care products (mouth rinses, toothpastes, chewing gums) which contain metal ions, especially zinc, that inhibit odor formation because of its affinity to sulphur compounds.

[Eckelt's technic: an evaluation of the access route used at Salpêtrière Hospital]

AIM

We report a prospective study undertaken to investigate the morbidity connected with the approach of lag screw osteosynthesis for the treatment of subcondylar fractures in the department of Maxillo-Facial Surgery at the Salpêtrière University Hospital.

METHOD

24 patients have been operated between November 1997 and December 1998. We estimated the accessibility, the size and quality of scars the satisfaction index, and the complication rate.

RESULTS

The average size of scars was 3 cm (2.5-4). Their quality was satisfactory, except for an hypertrophic and an invaginated one. The satisfaction index was always excellent and often superior to the surgeon one.

COMPLICATIONS

three paresis in the mental territory of the facial nerve regressive in three months, a salivary fistula regressive in three weeks, an hematoma and a subcutaneous infection. These different criteria improved during the study.

CONCLUSION

The approach is not free of risks but these ones seem to decrease with surgeon's experience.

Cinegammography and 3-D emission tomoscintigraphy for evaluation of revascularized mandibular bone grafts: a preliminary report

The following reports a study conducted to investigate a scintigraphic monitoring procedure for bone free flap in mandibular reconstruction. This procedure is based on the one hand, on vascular and bone cinegammography, and on the other hand, on vascular and bone 3-D tomoscintigraphy. We used a prospective cohort study design. All patients who underwent free flap mandibular reconstruction from April 1993 to April 1998 in the Salpêtrière University Hospital, France (20 cases) have been evaluated in relation to this scintigraphic procedure. Vascular and bone scintigraphy were performed within the second week after surgery during 2 consecutive days. All images were read by one author (J.- Y. B.), who did not know the skin status of the flap. The results were compared with the viability of revascularized bone grafts as evaluated by the skin status and Greenberg classification based on bone radiographs three months after reconstruction. Vascular cinegammography seems to be closely related to anastomosis patency. Bone cinegammography gives appreciable information on bone viability. 3-D vascular tomoscintigraphy remains difficult to interpret. 3-D bone tomoscintigraphy gives precise information on the viability of the different segments of the bone flap. These results suggest that vascular and bone 3-D tomoscintigraphy coupled with cinegammography have an excellent prognostic value. In the event of partial failure it can give information on the location of the impaired patency and on the osseous fragment which has lost any viability.

[Osteosynthesis of subcondylar fractures using compression screws with the Eckelt technic. Experiences and difficulties with the technic over 5 years]

With creation of new fixation material, the surgical treatment of displaced subcondylar fractures is most frequently used in adults. The Eckelt compression osteosynthesis is described as an easy procedure in the current literature, but, in our experience, several problems require our attention. We report the treatment of 57 patients with displaced subcondylar fractures where compression osteosynthesis was indicated. The difficulty of this technique is presented on the basis of a 5-years experience.

[Gunshot wounds and injuries of the face in civilian practice]

Firearm wounds are relatively frequent in civilian practice. Due to the variable power of the weapons involved, a wide range of maxillofacial lesions are encountered and classification is a difficult task. In order to predict the gravity of the lesions, we have drawn a classification scheme from our experience with maxillofacial injuries. The scheme was based on the kind of ammunition which gives a better classification than the type of weapon. Three main categories have been identified.

Do temperature and atmospheric pressure affect the incidence of serious odontogenic infection?

OBJECTIVE

The purpose of this study was to investigate the popular belief that the incidence of odontogenic cellulitis is weather-related. Two meteorologic parameters were examined: temperature and atmospheric pressure.

STUDY DESIGN

To test the hypothesis being studied, a retrospective cohort study design was used. Medical reports of all patients with serious odontogenic cellulitis who were treated at the Salpêtrière University Hospital between January 1, 1995, and December 31, 1995, (a total of 301 cases) were evaluated in relation to the weather. Hypothesizing that the incidence of odontogenic cellulitis was constant over a period of 1 year, the authors calculated the probability of observed incidence for each month over a 12-month period. The mean number of cases of odontogenic cellulitis (+/- standard error of the mean) for days on which (1) the temperature was within the same 2 degrees -C (3.6 degrees -F) interval and (2) the atmospheric pressure was within the same 3-hPa (2.25-mmHg) interval was also calculated.

RESULTS

When the monthly incidence of odontogenic cellulitis and either the average temperature or the average atmospheric pressure for each month were examined together, fluctuation in the former seemed to be independent of the latter. Similarly, when we calculated the mean number of cases of odontogenic cellulitis for several intervals of temperature and atmospheric pressure without taking the calendar into account, no direct relationship could be observed.

CONCLUSION

The results of the study suggest that the occurrence of odontogenic cellulitis is not influenced by the weather, at least insofar as weather is measured by temperature and atmospheric pressure.