Orbital in juries in wartime: Historical study from Paul Tessier's work in Iran.

INTRODUCTION: Paul Tessier was a leading French oculoplastic surgeon who took part in several surgical missions in Iran to manage victims of the Iraq-Iran conflict in the late 1980's and early 1990's. METHODS: We collected the records of 322 patients who underwent surgical procedures for the management of wartime injuries by Paul Tessier's team in Iran from 1990 to 1993. We also report one of the most representative cases of orbital reconstruction performed by Tessier. RESULTS: Mean age at the time of trauma was 20.65±7.04 years (range: 2--62). Craniofacial CT-scans were available for 54 patients. The bones of the upper third of the face and the orbital contents were affected in 124/322 patients (38.50%). Soft-tissue lesions of the upper third included 13 frontal lacerations (4.04%), 60 orbital injuries (18.63%) and 95 uni- or bilateral enucleations (29.50%). Thirty-nine uni- or bilateral lid injuries (12.11%) and 8 tear duct injuries (2.48%) were reported. A specific case of orbital reconstruction using antero-internal and posterior iliac bone grafts was reported as a representative example of Tessier's techniques. CONCLUSION: This study highlights the challenges of orbital reconstruction in wartime injuries and provides insights on the work of one of the most renowned surgeons in this field.

[Lessons from a master in tissue transfer: A study of the surgical notebooks of General Gustave Ginestet during the Foch years]. / Leçons d'un maître en déplacement de tissus : études des carnets opératoires du médecin général Gustave Ginestet dans ses années Foch (1945­1959).

The surgical notebooks (1945-1959) of General Gustave Ginestet are the last direct testimony of the quintessential period in which autoplastic techniques were used, before their twilight, favored by the advent of axial pedicle flaps, musculocutaneous flaps and later free flaps. They summarize all the refinements of the experience accumulated at the National Center for Reconstructive Surgery (Centre Médico-Chirurgical Foch-Suresnes). They appear to be more informative than the various books of the time, which were intended for an experienced public or for those benefiting from a companionship, thus eluding a certain number of precautionary advice, which are undoubtedly tacit but essential to obtain a successful operation in the hypothesis of their current use. This paper aims to establish the principles of historical surgical techniques and to integrate them into the management of patients in therapeutic impasse. One hundred and seven clinical situations requiring tissue displacement were analyzed by reconstructed region and by type of flap used. This technical view of the past, as close as possible to the daily practice of a famous reconstructive surgery center, does not offer absolute methodological or technical precepts. From the surgical notebooks studied, the only thing that emerges is a rigorous approach that allows us to contain a permanent doubt and an experimental process. This notion of constant evolution of the autoplastic practice, guided by its errors, intuitions and beliefs, highlights the importance of a surgical culture, which, with a humanistic approach, must be nourished by the paths of the past.

[Odyssey of the iliac. "Mandibular reconstruction by bone free flaps"]. / L'Odyssée de l'iliaque. « De la reconstruction mandibulaire par autotransplantation ¼.

The authors proposed here a retrospective analysis of a surgical procedure they performed for long time. It allows to put into questions some established principles, to find some unkwown datas which could be important to predict complications. It is also interesting to discuss about the use of indication and choice of the flaps along years of reconstructive surgery history in the way to improve protocoles and management of those large reconstruction. During ten years in one maxillofacial surgery departement, more than 200 bone free flaps (essentially fibula and iliac crest) have been used for mandibular reconstruction and analyse with a three years follow-up. The global failure rate is estimated as 28 % included all various complications from fistulas to infections. Five different points are discussed from the ambiguity of the reported studies to the way of doing of such surgery. It is also pointed out the importance of the biological dimension of all surgical procedures and the place of clinical figures regarding of the technical processes which usually forget the main clinical purpose.

Reverse blood flow in cervicofacial veins after venous ligations: Potential implications in microsurgery.

INTRODUCTION: The consequences on the cervicofacial venous circulation of major cervicofacial vein ligations are poorly known. We aimed to highlight by using Doppler Ultrasound flow differences in the cervicofacial venous network in the case of unilateral or bilateral ligation of main venous collector trunks (external jugular vein [EJV] and internal jugular vein [IJV]) METHODS: A Doppler ultrasound was performed on 10 healthy volunteers, 8 patients with previous bilateral ligation of the EJV, 8 with a unilateral ligation of the EJV, and 8 with a unilateral ligation of the EJV and IJV, after modified radical neck dissection. The diameter, the flow direction and the peak systolic velocity (PSV) of the superficial temporal vein, the facial vein (FV) and the IJV were measured. RESULTS: Healthy patients had a similar right and left PSV for all the veins studied, with always antegrade flows. Patients with previous ligations had some significant right/left differences and retrograde flows. CONCLUSION: A redistribution of venous blood flow on the contralateral side of the face and neck seems to take place in the case of unilateral ligation of the EJV and/or IJV. Retrograde flows are sometimes observed in the case of previous ligation of the EJV and/or IJV and might compromise the success of venous microanastomoses.

[Anatomical characteristics of the superficial temporal venous system and implications in microsurgery]. / Caractéristiques anatomiques du système veineux temporal superficiel et implications en microchirurgie.

INTRODUCTION: The superficial temporal vessels remain underused in microsurgery, the superficial temporal vein (STV) being reported as inconstant. The aim of this study was to precise the anatomical characteristics of the superficial temporal venous system by means of a cadaveric anatomical study and a doppler-ultrasound study on healthy subjects. MATERIALS AND METHODS: In order to study the anatomical variations of the STV and its different branches in the temporo-parietal area, 10 hemifaces of bodies donated to science were injected with latex and dissected. A doppler-ultrasound study of the superficial temporal venous system was also performed on 10 healthy subjects in order to assess the median diameter of the STV. RESULTS: A common temporo-parietal trunk was found on all the bodies dissected, with a mean number of 1,6 [1-3] venous affluents. The STV preceded systematically the superficial temporal artery (STA) in the pre-auricular area. The arterio-venous relationships were in contrast highly variable above that area. The diameter of the STV presented major interindividual variations, with a median diameter of 1,3mm [0,5-2]. CONCLUSION: The superficial temporal vessels can be easily identified in the pre-auricular area. With a mean harvestable length of 6,5cm and a mean diameter of 1,3mm, the parietal branch of the STV presents a caliber sufficient for the realization of the anastomoses.

Second metatarsal free transfer in total temporomandibular joint reconstruction for ankylosis in a child: 10-year follow-up.

The management of temporomandibular joint (TMJ) ankylosis requires complete removal of the ankylosed block and the prevention of recurrence. For this purpose, the ramus-condyle unit can be reconstructed with a second metatarsal free flap. This article reports the use of this flap in a young patient treated for left TMJ ankylosis, post costochondral graft for the treatment of hemifacial microsomia. Data from the 10-year follow-up are reported. The glenoid fossa was reconstructed with a graft of the second metatarsal base, enabling the juxtaposition of two cartilaginous joint surfaces, with the aim of optimizing the functional result and preventing the recurrence of ankylosis. At the 10-year follow-up after this surgery, there was no recurrence of the ankylosis and no articular disorder, and the morphological result was satisfactory. Bone fixation was stable over the 10-year period and the metatarsal head was still in place. Quantitative measurements obtained by computed tomography scan did not show any growth of the second metatarsal free flap compared to the right unaffected condylar process.

[CDAGS syndrome (craniostenosis, deafness, anal abnormalities and genitourinary malformations with skin rash)]. / Syndrome CDAGS (craniosténose, surdité, anomalie anale et génito-urinaire avec éruption cutanée).

INTRODUCTION: CDAGS syndrome (craniosynostosis, deafness, anal and genitourinary abnormality with rash) has been reported in 8 families of different geographical origins since 1981. No genes have been identified to date. PATIENTS AND METHODS: The patient is a girl born at 40 weeks of amenorrhea after a normal pregnancy. She was born to non-consanguineous parents and there was no significant family history. At birth, she presented craniosynostosis with a form of premature coronal suture. When she was 3 months old, she presented an eczematous facial rash. At 11 months, a skin biopsy showed lichenoid dermatosis with epidermal atrophy associated with ortho- and para-keratotic hyperkeratosis. She had sparse hair, eyelashes and eyebrows. Her initial psychomotor development was normal. No other malformations were observed. At 6 years, she presented pale pink, reticulated, erythematous plaques around healthy bands of skin on her throat and chin. Lesions on the elbows, knees and buttocks were linear and keratotic with no atrophy or telangiectasia. At 7 years, she had learning difficulties and delayed speech. Genetic assessment revealed no abnormalities. DISCUSSION: The specific dermatologic aspect combined with craniosynostosis suggested a possible diagnosis of CDAGS syndrome, even in the absence of urogenital or anal lesions. This syndrome may take numerous different forms. The appearance of porokeratosis previously noted was not found here. The underlying genetic substratum of this syndrome is not known as yet and additional genetic studies should be considered.

Fraser syndrome: review of the literature illustrated by a historical adult case.

Fraser syndrome (cryptophthalmos-syndactyly syndrome) is a rare autosomal recessive malformation disorder. The first description of the syndrome was reported by George Fraser in 1962. Diagnosis is based on the major and minor criteria established by van Haelst et al. in 2007. Unilateral or bilateral cryptophthalmos, syndactyly, unilateral renal agenesis, and genital anomalies are the most frequent anomalies. Several maxillofacial, oro-dental, ear-nose-throat, hormonal, and anorectal disorders are reported. Cardiac malformations and musculoskeletal anomalies are uncommon. The syndrome is related to mutations in three different genes (FRAS1, FREM2, and GRIP1) resulting in failure of the apoptosis program and disruption of the epithelial-mesenchymal interactions during embryonic development. Prenatal diagnosis is based on the detection of renal agenesis and laryngeal atresia, together with a family history. Most foetuses with severe anomalies are terminated or are stillborn. All patients or pregnancies with a diagnosis of Fraser syndrome should be referred to expert centres. A collaborative approach including anaesthetists, ENT specialists, maxillofacial surgeons, and geneticists is necessary for the management of this syndrome. In vivo and in vitro research models are available to better understand the underlying aetiology.

Reduction of morbidity of the revascularization surgery in the management of mandibular osteoradionecrosis by basilar edge preservation.

INTRODUCTION: The chronic complications of bone free-flap revascularization surgery are mainly characterized by skin fistulization of the osteosynthesis material, which sometimes leads to reactivation of the osteoradionecrotic phenomenon. The objective of the study is to evaluate the benefit of mandibular basilar edge preservation in bone reconstructive surgery in irradiated areas performed for the treatment of advanced mandibular osteoradionecrosis. MATERIALS AND METHODS: A retrospective monocentric study conducted between 2003 and 2018 including all patients undergoing revascularization surgery for the treatment of advanced osteoradionecrotic lesion with respect to the basilar margin was conducted. RESULTS: Eight patients (7 males and 1 female, aged 50 to 63 years) who had a marginal mandibulectomy with reconstruction by bone free flap or composite free flap were included. The stability of the reconstruction (junction native mandible/bone free flap) was achieved on average by using 1.75 [range 0-4] mini plates (Medartis® Modus 2.0, Medartis AG, Basel, Switzerland). During the follow-up (30±13 months) no chronic complication related to a dissociation of the osteosynthesis material or a reactivation of the osteoradionecrotic phenomenon were identified. CONCLUSIONS: Despite the limited number of patients, it seems that the increase in the friction surface between the free flap and the native mandibular bone, linked to the preservation of the basilar edge, improves the primary stability of the reconstruction. This reduction in mechanical stress on osteosynthesis materials limits its use and reduces the rate of chronic complications of bone flap revascularization surgery in irradiated areas.

Role of flow magnetic resonance imaging in the monitoring of facial allotransplantations: preliminary results on graft vasculopathy.

Chronic vascular rejection characterized by the myointimal proliferation of smooth muscle cells that progressively obstruct the arterial graft lumen may become the main cause of long-term graft loss in vascularized composite allotransplantation (VCA), as observed in solid organ transplantation. As such, new diagnostic tools are required. The objective of this study was to evaluate the usefulness of flow magnetic resonance imaging (MRI) in the qualitative and quantitative monitoring of VCA in three patients transplanted between 2005 and 2012. Seven flow MRI acquisitions were performed concurrently with standardized clinical and histological monitoring between 2015 and 2017. A progressive reduction in the average flow rate and intraluminal diameter of the arterial pedicle of the grafts was demonstrated. During follow-up, two patients developed chronic vascular rejection requiring partial resection of the graft. For these patients, flow MRI acquisitions were characterized by a significant reduction in vascular signal, with a reduction in intravascular flow prior to anatomical injury. The results of this study confirm the feasibility of reproducible, non-invasive, and non-operator-dependent morphometric and haemodynamic radiological analysis, providing clinicians with new information on the vascular status of VCA over time and offering the prospect of an imaging technique specific to vascular outflow.

The value of reconstructive surgery in the management of refractory jaw osteoradionecrosis: a single-center 10-year experience.

Mandibular osteoradionecrosis (mORN) is a severe complication of head and neck irradiation. International consensus on the management of mORN is currently lacking. The present study sought to evaluate the effectiveness and benefits of early reconstructive surgery (resection of the diseased bone and immediate reconstruction with a free flap) in treatment-refractory mORN. A single-center retrospective study was carried out of operations performed in a French university medical center between 2003 and 2013 inclusive. For each patient, the surgical modalities and postoperative outcomes were recorded. A total of 55 operations (19 marginal resections and 36 segmental resections) were performed, and the overall success rate was 92.3%. Relative to marginal resections, segmental resections were associated with longer operating times (440±62min vs. 531±72min, respectively; P<0.05 in Student's t-test), a longer length of hospital stay (16.5±6.5 days vs. 25.6±11.3 days, respectively; P<0.05), and a higher complication rate (26.3% vs. 63.9%, respectively; P<0.05 in Fisher's test). Given the unpredictable progression of treatment-refractory mORN and the risk-benefit ratio observed here, the value of early reconstructive surgery with curative intent should be reassessed.

Treatment of mandibular osteoradionecrosis by periosteal free flaps.

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

Technical note on the harvest of periosteal forearm composite free flaps in the treatment of early mandibular osteoradionecrotic injury.

Periosteal radial forearm free flaps allow functional and curative treatment of osteoradionecrotic jaw lesions. The flap responds physiologically to hypoxia, hypocellularity, and hypovascularity, which are characteristic results of osteoradionecrotic injury. Here, we propose a reproducible, simple, and safe method for harvesting a forearm free flap, allowing us to obtain a periosteal composite free flap. Our technique offers potential early management of osteoradionecrotic lesions resistant to medical treatment. Furthermore, the forearm periosteal composite free flap offers the advantage of a long vascular pedicle which is ideally suited for necks which have been submitted to irradiation or multiple operations. Thusly, vascular anastomosis can be performed at a distance from the irradiated areas. Compared to other periosteal free flaps, such as those harvested from the iliac crest or the internal femoral condyle, the presence of a skin paddle facilitates clinical flap monitoring, optimizes the restoration of bone sealing, and facilitates the treatment of scarring.

[Feminism and cosmetic surgery: Suzanne Gros-Noël (1878-1954)]. / Féminisme et chirurgie esthétique : Suzanne Gros-Noël (1878­1954).

Born at the late 19th century, Suzanne Noël achieved, despite prejudices, to become at the same time the first female cosmetic surgeon and an influential feminist activist. Trained as a dermatologist by Professor Brocq, she first became fascinated by rejuvenation surgery during her studies by meeting Sarah Bernardh, who had undergone a facelift in the United States. As a surgeon, she mainly performed procedures under local anaesthesia in her salon, where she maintains worldly relations with her women clients. As an activist, she founded feminist clubs all over the world since 1923, under the aegis of a still flourishing organization: "Soroptimist International", which provided assistance in the field to women in need. She successively lost her first husband, then her single daughter and her second husband to be 46 years old, widowed, indebted and without any medical license. Their personal difficulties are not foreign to what she advocates: the women's emancipation by achieving economic independence. Suzanne Noel's journey is a singular paradox on the relationship between the earliest days of cosmetic surgery and feminist ideology. She structured the controversy within the various thinking movements at that time: does embellishing a woman serve her cause? Provocative but necessary question for thinking the surgical act. Suzanne Noël, as a liberal feminist, however, supported the idea that cosmetic surgery could be a transitional solution to integrate a working environment in which there was significant discrimination in women's employment.