[3D printing in plastic surgery, an accessible tool: Technical note around a case of otopoiesis assisted by 3D model]

3D printing has been used in the medical field since the beginning of the 21st century. Over the years, it has been democratized and has become an accessible tool at almost no cost, provided that a 3D printer is available. The surgeon can thus easily integrate it into his practice and techniques in the operating room, provided that he learns to use 3D image processing software. In order to illustrate the whole process, from the genesis and processing of the 3D image to its application in the operating room, we describe the case of a patient with a left auricle amputation, whose reconstruction was guided by a 3D model printed from his right ear.

[Ethical issues of gender reassignment surgery]

Gender reassignment raises complex ethical issues. It questions gender identity and the right to self-determination. Some highlight the right to access the medical care necessary to live according to one's perceived gender. Others worry about the potential rush into major medical decisions, especially among minors. The need for a medical diagnosis of gender dysphoria can be seen as pathologizing. The requirement for surgery for marital status change, while not mandatory in many places, remains controversial. The balance between informed consent and access to treatment, as well as stigma and discrimination, contribute to the complexity of ethical issues. Finally, the issues surrounding the competence of health professionals, the quality of care and the integration of individual needs make these decisions particularly sensitive from an ethical point of view.

Immediate vaginal reconstruction following pelvic exenteration using the pedicled vertical Deep Inferior Epigastric Perforator (DIEP) flap: A technical note

Immediate vaginal reconstruction is usually offered following pelvic exenteration for recurrent cervical cancer in women previously treated with radiotherapy or with severe radiation-induced fistulae. Introduction of muscle-sparing flaps, such as the pedicled vertical deep inferior epigastric perforator (DIEP) flap, provides viable tissues for vaginal reconstruction and is associated with reduced donor-site morbidity. This report describes the surgical technique, which is one of the procedures of choice for vaginal reconstruction. It is safe and beneficial, especially for women with gynecologic cancer who have undergone pelvic exenteration after failed radiation therapy.

Immediate vaginal reconstruction following pelvic exenteration using the pedicled vertical Deep Inferior Epigastric Perforator (DIEP) flap: A technical note

Immediate vaginal reconstruction is usually offered following pelvic exenteration for recurrent cervical cancer in women previously treated with radiotherapy or with severe radiation-induced fistulae. Introduction of muscle-sparing flaps, such as the pedicled vertical deep inferior epigastric perforator (DIEP) flap, provides viable tissues for vaginal reconstruction and is associated with reduced donor-site morbidity. This report describes the surgical technique, which is one of the procedures of choice for vaginal reconstruction. It is safe and beneficial, especially for women with gynecologic cancer who have undergone pelvic exenteration after failed radiation therapy.

Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: Preliminary results of the feasibility EPIONE trial

BACKGROUND AND OBJECTIVE

Quality of life preservation after anti-cancer therapy is a major challenge for breast cancer survivors. Approximately 42-70% of patients who receive systemic therapy for breast cancer, including endocrine therapy, will develop vulvovaginal atrophy (VVA). For these patients, the commonly proposed gel-based treatments for topical applications are restrictive. Recently, innovative, non-hormonal therapeutic approaches, such as laser therapy, have emerged. The purpose of this feasibility study is to investigate the safety and efficacy of CO₂ laser therapy in women with a history of breast cancer.

MATERIAL AND METHODS

This prospective monocentric study included 20 patients with vulvovaginal atrophy who were treated at Henri Mondor University Hospital between 2017 and 2018. We included patients with a vaginal health index (VHI) score<15 and a contraindication for hormone administration due to a history of breast cancer. Two carbon dioxide laser sessions were used. The treatment was delivered using the following settings: vaginal tightening, FinePulse (pulse width 0.9ms), and energy density of 11.5J/cm² that allows coverage of 70% of the targeted vaginal area to be treated. All patients had their follow-up visit at one (M1), three (M3), and six (M6) months after the first treatment to evaluate efficacy of the treatment on vulvovaginal atrophy. Vaginal health index score and female sexual distress (FSD) score were used to assess treatment efficacy and its impact on sexual quality of life. A score≥11 was associated with sexual dysfunction. The vaginal health index and female sexual distress scores were evaluated at baseline, M1, M3, and M6 of follow-up.

RESULTS

The mean age of the patients was 56.1±8.8 years (range, 27-69 years). Seventeen of the 20 patients had experienced menopause (mean menopausal age, 51.25±1.5 years). At inclusion, the mean vaginal health index and the female sexual distress scores were 10.58±1.71 and 21.36±15.10, respectively. Fourteen out of 20 patients (70%) had FSD scores≥11 at the baseline. At M1, the mean vaginal health index score increased significantly to 13.42±2.3 (P=0.03), which represented an improvement of 21% from the baseline. A persistent and significant improvement in the vaginal health index score was observed at M6, with the score increasing to 16.75±4.23 post-treatment (P<0.0001), representing a 34% improvement from the mean baseline score. The mean female sexual distress at M1 was 19.83±13.57, representing a 7% decrease compared to the baseline scores (P<0.01). At M3, the female sexual distress significantly decreased to 13.88±15.58, representing an improvement of 35% (P=0.006). It increased to 10.35±14.7 at M6, representing an improvement of 52% (P=0.001). At M3, 35% of the patients had a female sexual distress score>11, and at M6, only 15% had a female sexual distress score>11. No side effects were reported during follow-up.

CONCLUSION

This pilot feasibility study showed that carbon dioxide laser treatment appears to be an effective and safe method to improve the trophicity and decrease vaginal mucosal dryness in women with vulvovaginal atrophy that developed after systemic breast cancer therapy.

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.

Implementation of a digital chain for the design and manufacture of implant-based surgical guides in a hospital setting

The digital revolution has led to many recent developments in implantology that have considerably facilitated implant planning and the creation of surgical guides. The purpose of this article is to explain how we set up a digital workflow in a large city hospital and how we met the requirements of the European regulations on the production of custom-made devices in a medical establishment. The internal manufacture of a surgical guide complied with European regulation EU/2017/45 concerning medical devices. This regulation allowed the hospital to create these medical devices locally without CE marking. However, the hospital must be declared as a manufacturer of medical devices and comply with the general requirements in terms of safety and performance related to the manufacture and use of medical devices. In addition, hospitals are large structures involving many different actors. Each step of the digital workflow, which included both the patient course and the creation of the surgical guide, was thus adapted to European regulations by considering local constraints.

[Peculiarities of botulinum toxin injections for the aesthetic treatment of men's face. A review of the literature]

INTRODUCTION

Botulinum toxin injections in aesthetic medicine are the most widely used products, ahead of hyaluronic acid, and aesthetic medicine is constantly increasing, including in the male population. The objective of this development was to show the specificities described in the literature concerning botulinum toxin injections in men.

MATERIAL AND METHOD

A systematic literature search was carried out using the Pubmed search engine. Data were then collected to determine the specificities of botulinum toxin injections in men according to the morphology of the male face and the wishes of these patients.

RESULTS

The studies conducted show that it is necessary to inject higher doses in men than in women to obtain a satisfactory result, due to a higher muscle mass. This adjustment gives the number of points to be performed per injection site, as well as the number of points to be performed, compared to the female population.

CONCLUSION

Botulinum toxin injections for aesthetic purposes in men are different from those in women. Taking these particularities into account is essential to patient satisfaction.

Facial surgery for cosmetic purposes: Practice guidelines

OBJECTIVES

Facial surgery for cosmetic purposes aims to improve the physical appearance and self-image of normal individuals. The aim of the guidelines is to answer questions related to legislation, patient evaluation and motivations, relevance and risk assessment, patient information and patient follow-up.

METHODOLOGY

Analysis and synthesis of the medical literature through research of bibliographic databases in French and English from 2000 to 2017. Research and use of guidelines from evaluation agencies and academic societies. Drafting of guidelines with indications on levels of evidence.

RESULTS

24 guidelines with levels of evidence B (scientific presumption), C (low level of evidence) or EO (expert opinion) were selected to answer the questions. Cosmetic facial surgery must be performed by certified, qualified professionals in authorized structures. It must follow certain specific rules as well as a charter and code of ethics so as to enforce the rules of practice.

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.

Platelet-rich plasma-enriched autologous fat graft in regenerative and aesthetic facial surgery: Technical note

The goal of adding platelet-rich plasma (PRP) to autologous fat graft is to increase the survival rate of the graft. After their activation, platelets release some important growth factors. As a result, PRP may increase the proliferation and differentiation of Adipose-derived stem cells (ASCs) into adipocytes, improve fat graft vascularisation, and may block the apoptosis of grafted adipocytes. The other benefit expected from the addition of PRP to fat graft is the improvement of cutaneous trophicity above the grafted areas. An exhaustive review of the literature retrieved 11 clinical studies on humans and 7 on animals. A statistically significant increase of the survival rate of fat grafts has been found in 9 comparative studies. Our synthesis allowed us to set up the following protocol: addition of 20% of PRP activated with calcium hydrochloride to fat grafts. It may enhance the results of autologous facial fat graft in regenerative and aesthetic facial surgery.

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.

Oral surgery in the European Union: challenges of diversity in training and practice

INTRODUCTION

At the crossroads of medicine and dentistry, oral surgery with orthodontics are the only recognised dental specialties by the European Union. The goal of our study is to evaluate the current state of oral surgery in Europe from its teaching to its practice, the hypothesis being that a notable diversity persists despite European Union harmonisation process.

MATERIALS AND METHODS

To understand the impact of this diversity applied to European Union freedom of movement and its ethical implications for the practice of oral surgery, English and French questionnaires were sent by email to universities and organisations delivering authorisation to practise in France, Germany, Spain, Sweden and United Kingdom chosen based upon inclusion and exclusion criteria. An analysis of documents on these organisations' official websites was also conducted. Demographic information was obtained from the aforementioned organisations.

RESULTS

The profile of practising oral surgeons is different dependent on the country. The university and hospital trainings conform to European recommendations and span 3-4 years. European Board certification is not required. Continuing education is mandatory only in France, Germany and United Kingdom. As for curricula and scope of practice, no consensus can be derived.

DISCUSSION

There is potential conflict of interest between European Union principles of freedom of movement and protection of all citizens, as member countries do not uniformly apply Directives and recommendations. A new survey of all European Union oral surgery programmes as well as organisations delivering authorisation to practise is necessary to implement across the board harmonisation of training and practice to insure patient safety in light of the migration of European Union practitioners.

[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.

Mandibular reconstruction after cancer: an in-house approach to manufacturing cutting guides

The restoration of mandibular bone defects after cancer can be facilitated by computer-assisted preoperative planning. The aim of this study was to assess an in-house manufacturing approach to customized cutting guides for use in the reconstruction of the mandible with osteocutaneous free flaps. A retrospective cohort study was performed, involving 18 patients who underwent mandibular reconstruction with a fibula free flap at three institutions during the period July 2012 to March 2015. A single surgeon designed and manufactured fibula and mandible cutting guides using a computer-aided design process and three-dimensional (3D) printing technology. The oncological outcomes, production parameters, and quality of the reconstructions performed for each patient were recorded. Computed tomography scans were acquired after surgery, and these were compared with the preoperative 3D models. Eighteen consecutive patients with squamous cell carcinoma underwent surgery and then reconstruction using this customized in-house surgical approach. The lengths of the fibula bone segments and the angle measurements in the simulations were similar to those of the postoperative volume rendering (P=0.61). The ease of access to 3D printing technology has enabled the computer-aided design and manufacturing of customized cutting guides for oral cancer treatment without the need for input from external laboratories.

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 .

Surgical management of necrotizing cellulitis: Results of a survey conducted in French plastic surgery departments

OBJECTIVE

Necrotizing cellulitis (NC) is a severe infection of the skin and soft tissues, requiring an urgent multidisciplinary approach. We aimed to clarify the surgical management of NC in French plastic surgery departments.

PATIENTS AND METHOD

Thirty-two French plastic surgery departments were invited to complete a survey sent by email. Questions focused on diagnostic and therapeutic management of NC in France.

RESULTS

Twenty-five plastic surgery departments completed the survey (78%) and each center had a lead plastic surgeon. Overall, 88% of surgeons declared to have managed at least five NC patients within the year. The plastic surgeon was the lead surgical specialist for NC in 80% of cases. Conversely, 76% of interviewed facilities reported not to have any lead medical specialist. Time between surgical indication and surgical management was less than six hours in 92% of cases. Overall, 24% of responding facilities declared that access to the operating room never delayed management. Finally, 80% of facilities declared to be in favor of dedicated care pathways to improve the management of necrotizing cellulitis patients.

CONCLUSION

Our study results highlight the heterogeneity of necrotizing cellulitis management in France. The lack of a dedicated care pathway may lead to diagnostic and treatment delays.

[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.

[One-staged surgical technique for scrotal calcinosis]

INTRODUCTION

Idiopathic calcinosis cutis is a rare condition involving the development of scrotal nodules in the skin and subcutaneous tissue. Although it is a benign disease, patient's quality of life can be importantly impaired.

OBJECTIVE

We report herein our experience and surgical management of diffuse scrotal calcinosis.

MATERIAL AND METHODS

From 2012 and 2015, 7 patients who suffered of diffuse scrotal calcinosis cutis were included in this study. We performed a one-staged resection of the lesions by an elliptic resection centered on the scrotal median raphe as a scrotal lift shape. Outcomes including sexual quality of life and patient's satisfaction were assessed with a questionnaire.

RESULTS

No postoperative complication occurred. Aesthetic result was high and sexual quality of life was importantly improved. No recurrence was observed in a 2-year follow-up.

DISCUSSION

This disease is a pathological condition of unknown origin and hence is idiopathic. Multi-staged resection of the nodules are often performed despite being a time-consuming and expensive approach. Our one-staged treatment increased the patient's quality of life and self-esteem.

CONCLUSION

We present a one-staged treatment of scrotal calcinosis cutis that is simple and effective. Aesthetic and functional results were achieved.

LEVEL OF EVIDENCE

5.

[Delayed endoscopic reconstruction of the anterior wall of the frontal sinus: Technical note]

INTRODUCTION

Reconstruction of the anterior wall of the frontal sinus usually requires a coronal incision. This extended approach may lead to paresthesia, unsightly scars, bruises and cicatricial alopecia. These complications encouraged several authors to endoscopic management of this kind of fractures. We present a delayed technique of reconstruction of the anterior wall of the frontal sinus by means of endoscopic hydroxyapatite filling.

TECHNICAL NOTE

Two incisions were performed behind the hair line. Subperiosteal dissection using a periosteal elevator was performed. A 30° angled endoscope was used to visualize the depression. The latter was filled by Hydroset® (Stryker, USA) as a bone substitute.

DISCUSSION

In the absence of contra-indication, the reconstruction of the anterior wall of the frontal sinus by means of endoscopic hydroxyapatite filling has many advantages including uneventful outcome, reduction of the hospital stay and a fast learning curve.

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.

[Benefits of using the cutometer to evaluate the effectiveness of skin treatments in plastic and maxillofacial surgery]

INTRODUCTION

Evaluating skin properties is often too subjective. Using the cutometer allows one to take objective measures of certain mechanic properties of the skin such as visco-elasticity. The aim of this article is to evaluate through a review of existing literature the advantages and the limits of the cutometer and to propose an improvement.

MATERIAL AND METHODS

The selection of articles has been conducted with the PubMed database in order to identify all publications concerning the cutometer up until September 2013. The analysis criteria were: (1) quantitative distribution of articles from the first publication until today; (2) qualitative distribution over the various medical fields. The articles have been organized in 3 groups: medical, surgical and burns; (3) list of biases in the interpretation of results and limits of this measuring tool.

RESULTS

One hundred and twenty-nine publications have been included. The first article regarding the cutometer was published in 1994. We observe an increase in the number of publications after 2005. Most of the articles were published in medical journals of dermatology or cosmetology (83%), only 9% of articles have been published in burn study journals and 8% in surgical journals. The pressure applied by the experimenter constitutes the main measure bias.

DISCUSSION

The use of an external device maintaining the probe with an invariable pressure corresponding to its own weight enables more reliable results all the while limiting the inter- and intra-individual variability.

[Low level laser therapy in inflammatory and infectious oral diseases]

PURPOSE

Low Level Laser Therapy (LLLT) is an increasingly studied technique. The authors of a meta-analysis published in 2012 had already confirmed the effectiveness of LLLT for radio-induced mucitis. Our purpose was to check its indication for similar pathologies.

MATERIAL AND METHODS

The articles were selected with the PubMed engine. The selected terms were "Low Level Laser Therapy", "oral surgery", "oral infection", "oral inflammation", "oral mucosal lesions", "oral mucosal disease", "stomatitis", "aphtous", "Herpes", "oral lichen planus", and "oral ulceration". The analysis was made on the following criteria: assessment criteria, methodological quality, and bias. We estimated the level of proof according to Sackett's modified score.

RESULTS

Six articles were selected. Two focused on the effectiveness of LLLT for Herpes simplex virus 1 oral symptoms. Two focused on the effectiveness of LLLT for oral lichen planus. One focused on the effectiveness of LLLT for recurrent aphthous stomatitis. The last one focused on the usefulness of LLLT to control stomatitis pain in the hand-foot-and-mouth disease.

CONCLUSION

All the selected studies were assessed with a Sackett's score of IV. No study presented the required quality standards to recommend the treatment of LLLT for the selected indications.

[Infectious cellulitis of the face complicating injection for esthetic nasolabial sulcus by hyaluronic acid: report of seven cases]

We report a case series of seven patients with bacterial cellulitis of the face complicating a filler injection for cosmetic reason, treated in a university hospital from 2005 to 2012. There were seven women aged 34 to 57 years. Two patients had a deep collection requiring surgical excision combined with antibiotics. Five patients were treated with antibiotics only. In two cases the bacteria was found streptococcus A and in one case Staphylococcus aureus. One patient required hospitalization in an intensive care unit. Only patients who needed surgical treatment showed moderate aesthetic sequelae.

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.

[After titanium, peek ?]

The PEEK-Optima(®), composite mixture of polyetheretherketon and inert materials, is used in orthopedics, spinal surgery and cranio-facial surgery. It could be used in dental implantology because of its biological and mechanical properties. The results of an experimental and finite element study made on basal implant prototypes, on basal implantology show that PEEK, contrary to titanium, has a compound structure that allows to optimize the distribution of masticatory forces around the implant. These results should be confirmed by a clinical study according to research regulation.

[From the first face replants operations to the first total face transplant: the history of surgical prowess]

Composite tissue allografts of the face were considered as science-fiction just a decade ago. They have become wonderful realities in our hospitals. Face transplantation is one of the great scientific adventures of the 21(th) century that history will remember. Physicians dreamed to give a new face to disfigured patients. Allografts of the face have become a reality thanks to breakthroughs in anatomy and plastic surgery, HLA system research, microsurgery, neurology, and immunosuppressive molecules. In 2010, two teams performed the first total face transplants in the world. They represent technical milestones in the history of transplantation. These face transplants, which have raised a lot of controversy and ethical questions, open the way for other surgical perspectives, allowing medicine to write new history, and show that progress is also made through transgression.

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.

[Endoscopic-assisted retrocaruncular approach for management of medial orbital wall lesions: a review of 6 cases]

BACKGROUND

Medial wall orbital fractures can result from external trauma (midfacial trauma, blow out) or from endonasal trauma (functional endoscopic sinus surgery). Entrapment of the medial rectus muscle can lead to optical complications if not treated (restriction of ocular mobility, diplopia). Enophtalmos can also be the result of extrusion of orbital fat into the ethmoïdal cavities. Surgical repair entails treatment and prevention of these complications.

OBJECTIVE

Define the contribution of endoscopy and retrocaruncular incision, particularly in terms of accessibility and visibility of the posterior third of the medial wall of the orbit.

MATERIAL AND METHODS

Six patients with medial orbital wall fractures were treated between May 2006 and May 2007 using a retrocaruncular approach assisted peroperatively by endoscopy. No complications occurred during the postoperative follow up. The authors describe the surgical techniques used.

CONCLUSIONS

Retrocaruncular approach is a safe and effective technique that presents the particular advantage of not leaving a dysesthetic scar. Peroperative endoscopy allows then a better accessibility and visibility of the posterior third of the medial orbital wall.

[Treatment of HIV facial lipoatrophy with a submalar porous polyethylene implant (Medpor)]

Human immunodeficiency virus associated facial lipoatrophy is becoming epidemic and is a distressing sign for patients. Non permanent fillers provide only temporary results and cannot be the solution for severe cases. Lipodystrophy makes the lipofilling difficult to perform with a fibrous low quality fat difficult to harvest. We propose another solution using porous polyethylene implants (Medpor). Eight patients underwent submalar augmentation through an upper gingivobuccal sulcus incision that allows a subperiosteal dissection. The implants are carved to provide the desired augmentation. Overall, eight patients had good or very good aesthetic postoperative outcomes as determined by the patient and the surgeon. No complications occurred and results remain natural. Porous polyethylene implant (Medpor) is our treatment of choice for mild to severe facial lipoatrophy. Besides these implants could be removed easily later if needed.

[Treatment of cutaneous infections due to Mycobacterium fortuitum: two cases]

INTRODUCTION

Cutaneous infections due to Mycobacterium fortuitum, a rapidly growing environmental mycobacteria, are often iatrogenic, resulting from surgery or injection. We report two cases following plastic surgery and describe the outcome after surgery and antibiotics.

CASE REPORTS

Two immunocompetent women underwent abdominal plastic surgery and liposuction, which were complicated with recurrent abscesses one and 13 months later respectively. Cultures of bacteriologic samples isolated M. fortuitum in the two patients. The two strains exhibited different antibiotic sensibility profiles. The initial antibiotic therapy consisted of combined amikacin and moxifloxacin in both patients plus imipenem in one, followed by oral doxycycline and clarithromycin in one and moxifloxacin in the other for a total duration of nine and five months, respectively. In both cases, surgical treatment was also given before, during and after antibiotic therapy. No new lesions had appeared six months after the end of antibiotic therapy.

DISCUSSION

Cutaneous infections due to M. fortuitum are rare and secondary to iatrogenic skin wounds. The clinical appearance is not specific, accounting for delayed diagnosis. Treatment is difficult and there is no consensus. According to our experience, surgical treatment is essential whereas the efficacy of antibiotics, even involving multiple agents, seems more doubtful.

Le contexte éthique et juridique de l'allotransplantation de face

Every french medical research, notably the ones regarding the facial allotransplant, is supposed to respect the code of professional conduct. Nevertheless, these researches have to be conducted in a specific ethical and juridical environment that is important to know. The French national ethics advisory committee for life sciences and health (CCNE) has the duty to give advices on the ethical problems raised by the progress of knowledge in the fields of biology, medicine and health and to publish guidelines on these subjects. The Biomedicine Agency (Agence de la biomédecine) is a state health agency that has replaced the French agency for transplants (EFG) for all the duties of this state agency. Its authorization is mandatory. The French agency for sanitary safety in health products (Afssaps) warrants, through its missions of sanitary protection, the efficacy, the quality and the good use of all human health products, notably the organs and the tissues from human origin. From now on, the CPPs (Ethics committees enforced by the bioethical law in 2004) replace the former CCPPRBs (Ethics committees enforced by the Huriet-Sérusclat law in 1988). They are the protagonists of the new biomedical research framework. All human research on allotransplantation undertaken is from now on, subject to the prior and jointly favorable opinion of a CPP and authorization by Afssaps. The Clinical research hospital program (PHRC) allows the monetary support of these researches providing they respect the ethical guidelines and the law.

Allotransplantation de face: étude anatomique, techniques de prélèvement partiel ou total de face, indications potentielles en clinique humaine

The authors evaluated the technical aspects of harvesting facial tissues in order to perform a facial allotransplantation by conducting dissections in 15 fresh cadavers. They developped anatomical models of harvesting the inferior two thirds and the totality of the face. The approach consisted in harvesting the totality of the facial soft tissues including the muscles and their innervation, in that way harvesting is fast and associated to minimal tissular trauma. The vessels were dissected at their origin at the level of the external carotid artery and the internal jugular vein. The vascular anatomy within the facial flaps was evaluated by transillumination and radiographic (Rx) studies and the authors concluded that the vascular network is rich and sufficient in both partial and full size face transplants. Another important aspect of that study was the restauration of the donor's face. This was achieved in a fast and aesthetically satisfying way with the use of a resin mask. After switching the facial soft tissues on the bony structures of the different subjects, the facial appearence that they observed was rather mixed. In conclusion, that study showed that a face allotransplantation is sound from a technical point of view and could achieve good results in selected cases which are discussed.

Endoscopic excision of forehead lipomas

Endoscopic surgery is a significant addition in the maxillofacial surgeon's armamentarium. Authors' experience of endoscopically assisted removal of forehead lipomas has been presented. The endoscopic technique permits to hide minimal scars in the hair. The magnification allows a good identification of anatomical structures and thus decreases the risk of numbness. The main disadvantages of this technique are the more expensive equipment and the steep learning curve. But with the expansion of endoscopic techniques, prices should decline and the duration of operations always lessens with experience. This technique might possibly appear to offer a new standard procedure for removal of forehead lipomas, notably in patients with keloid history or high aesthetic concerns.

[Endoscopically assisted retro-caroncular approach for medial wall fracture of the orbit: preliminary study]

PURPOSE

The purpose of this study was to present our experience of endoscopically assisted retro-caruncular approach of medial wall fracture of orbital bone, notably concerning the accessibility and visibility.

METHODS

Five consecutive patients (4 men and 1 woman) with recent fracture (1 to 3 days), underwent medial wall reconstruction with a polydioxanone plate, endoscopically assisted via a retro-caruncular approach. The surgical technique and its results are described. Helpful hints are discussed.

RESULTS

The plate did not have to be bent for introduction. Operative time was less than an hour for all patients. All patients were discharged the day after surgery. All experienced a mild degree of postoperative edema-related diplopia. None had persistent or secondary diplopia or enophthalmos at the one and six-month follow-up visits, respectively. Other postoperative complications, such as hematoma, nerve injury, or infection were not observed. All patients were satisfied with the outcome and especially the cosmetic result.

DISCUSSION

The retro-caruncular approach with adjunctive endoscopic surgery should be the gold standard for posttraumatic isolated medial wall reconstruction of the orbit.

[Current data and perspectives in minimally invasive video-assisted head and neck surgery: example of endoscopic exploration of the submandibular region]

The purpose of this study was to review the current status of research in this field and to describe the endoscopic technique for resection of the submandibular gland: a 15-mm incision is sufficient for the endoscopic material and gland resection without insufflation. The wound is minimal and the dissection is not traumatic. This innovating technique enables a magnified view of the structures providing an excellent teaching method.

[Kikuchi-Fujimoto disease: histiocytic necrotising lymphadenitis]

BACKGROUND

Kikuchi-Fujimoto disease or necrotizing histiocyte lymphadenitis is a disease of unknown cause whose main clinical feature is adenopathy, generally in a cervical location. The disease was described for the first time in Japan in 1972 and the first case in France was reported in 1986. Clinicians should be aware of this uncommon disease in order to differentiate it from infectious adenitis, lymphoma and collagenosis.

CASE REPORT

A 21-year-old woman consulted the emergency physician in January 2002 for a right cervical mass which had developed rapidly with no associated symptom. Other smaller masses developed within the following days. Laboratory results demonstrated discrete inflammation. All serologies tested were normal. Diagnostic cervicotomy was performed. The histological diagnosis was necrotizing adenitis.

DISCUSSION

Necrotizing histiocyte lymphadenitis is generally observed in young women in their twenties. There has been no predominant ethnic background. Laboratory tests are normal excepting for discrete signs of inflammation. Diagnosis is provided by pathology and immunohistochemistry. The clinical course is generally spontaneously favorable in six months. Relapse is uncommon.