[Evaluation of the result of 50 face-lifts with monobloc suspension]. / Evaluation de 50 liftings cervicofaciaux monobloc avec suspension.

PURPOSE OF STUDY: To evaluate the efficacy, while performing a face-lift, of a monobloc suspension, by a wide loop of Prolene 2/0, of the deep tissues of the face and the neck. PATIENTS AND METHOD: Fifty patients have been operated, 48 women and two men, mostly thin patients and often, it was a secondary face-lift. In favorable cases, a limited undermining has been performed followed by a strong pull on the deep layers by the loop of 2/0 Prolene. RESULTS: An acceptable social appearance at eight days post operatory has been obtained in over 50% of the cases. A slight recurrence of ptosis is observed between 1 and 6 months, but at 1 year, the results were very satisfactory for 36 patients out of 50. CONCLUSION: This simple and fast technique is mostly suitable for moderate ptosis in thin patients and especially for secondary face-lifts.

Syndromal and nonsyndromal primary trigonocephaly: analysis of a series of 237 patients.

From a series of 1,713 patients with craniosynostosis hospitalized between 1976 and 1996, 237 propositi with metopic synostosis were analyzed. The prevalence of metopic synostosis was estimated in the order of 1 in 15,000 children. Family information was obtained from 184 propositi from 179 families. The male-to-female ratio was 3.3:1. There was no maternal or paternal age effect. A family history was obtained in 10 of the 179 families, giving a 5.6% figure of familial cases. The frequency of twinning was 7.8% with two concordances for metopic synostosis in two monozygotic twin pairs. The male-to-female ratio, the twinning frequency, and the proportion of familial cases in trigonocephaly are very similar to those observed in scaphocephaly, which also involves the longitudinal sutural system. Fetal exposure to valproic acid was noticed in eight cases. The series was divided into two groups: nonsyndromal trigonocephaly (n = 184) and trigonocephaly associated with other malformations (n = 53). The second group included 13 cases of well-delineated syndromes and 40 cases of trigonocephaly associated with one or more malformations, but without any known syndrome, that could be undelineated syndromes. These groups differed significantly in their mental prognosis.

Genetic study of nonsyndromic coronal craniosynostosis.

From a series of 1265 individuals with different craniosynostoses hospitalized between 1976 and 1993, 260 probands with nonsyndromic unilateral (181) or bilateral (79) coronal synostosis were analysed. The prevalence of craniosynostoses was estimated as 1 in 2100 children. In the group of coronal synostosis, family history was obtained on 192 probands in 180 pedigrees. The male:female ratio was 1:2. The average paternal age was 32.7 +/- 6.4 years, which is significantly higher than normal. In 26 of the 180 pedigrees, a high degree of familial aggregation was observed, giving a 14.4% figure of familial cases. The bicoronal synostoses were significantly more often familial than the unicoronal synostoses. Segregation analysis of these families leads to the conclusion that coronal synostosis is transmitted as a dominant disorder with 0.60 penetrance and 61% of sporadic cases.

Genetic study of scaphocephaly.

From a series of 1,408 patients with craniosynostosis hospitalized between 1976 and 1994, 561 probands with non-syndromal isolated sagittal synostosis were analyzed. The prevalence of sagittal synostosis was estimated in the order of 1 in 5,000 children. Family information was obtained from 373 probands distributed among 366 families. The male:female ratio was 3.5:1. There was no maternal or paternal age effect. In 22 of the 366 pedigrees, a high degree of familial aggregation was observed, giving a 6% figure of familial cases. Segregation analysis of 253 families indicates that sagittal synostosis is transmitted as a dominant disorder with 38% penetrance and 72% of sporadic cases. The frequency of twinning was 4.8% with only 1 concordance for sagittal synostosis in a monozygotic twin pair. The possibility of a mechanical pathogenesis in sporadic cases is discussed.

Prognosis for mental function in scaphocephaly.

Three hundred ninety-six children with scaphocephalies were prospectively studied to analyze the correlation between age, intracranial pressure (ICP), and mental function outcome. The ICP measurements and the early and late psychometric assessments were compared. The influence of surgery, when performed, was analyzed. In most cases, the mental function outcome of the patients was good whether or not they had undergone surgery. The mental level and the frequency of increased ICP both correlated with patient age. A correlation was found between the early and late psychometric assessments in all patients. Thus, the main predictive factor of mental function outcome appears to be the initial developmental level.

Classification of previously unclassified cases of craniosynostosis.

Cases of craniosynostosis usually fall into well-demarcated categories: those related to a syndrome or those identified by a combination of suture involvement and morphological appearance. Between 1976 and 1995, 53 (3.6%) of 1474 cases in the craniofacial databank were assessed and designated as nonsyndromic but unclassifiable. The records and radiological studies obtained in these patients were retrospectively analyzed and comparisons were made with patients classified in the databank as having simple craniosynostoses. It proved possible to divide the formerly unclassifiable cases into two groups: those with "two-suture disease" (Group A) and a "complex" group (Group B) in which more than two sutures were affected. Group A consisted of 36 cases (68%) of patients presenting with clear evidence of simultaneous involvement of two sutures but with no progression over time to suggest a more diffuse pansynostosis. Suture involvement was as follows: 17 of 36 sagittal plus one coronal; seven of 36 sagittal and metopic; six of 36 sagittal plus one lambdoid; and six of 36 metopic plus one coronal. The only significant difference between the Group A cases and the cases of simple craniosynostoses was in the percentage requiring a second operation (24% vs. 5%, p < 0.0001). Group B consisted of 17 cases in which the patients presented at a slightly earlier age (mean 1 year) with severe morphological changes and multiple suture involvement. At the time of surgery, six of 17 patients showed large areas of lacunae within the cranial vault, making craniectomy the only option. In Group B, 10 of 17 patients displayed bilateral lambdoid plus sagittal suture involvement resulting in marked occipital recession posteriorly, whereas anteriorly in six of these 10 patients there was a massive frontal bone associated with posteriorly located coronal sutures. In contrast, there were also four patients in Group B with bilateral coronal plus metopic involvement resulting in a small frontal bone. There was a trend toward a lower intelligence quotient and a worse morphological outcome in the patients in Group B, but again the only result attaining statistical significance when compared to the databank was the rate of second operation (37.5 vs. 5%, p < 0.0001). "Two-suture synostosis" is a relatively straightforward condition and is treatable with standard craniosynostosis techniques. However, possibly as a result of surgical compromise when two sutures are involved, the rate of reoperation is far higher than in simple suture cases. In contrast, patients in the "complex" group presenting with severe multisuture involvement require a more tailor-made approach to their management that often entails a second procedure.

Intracranial pressure in craniostenosis.

In this study, intracranial pressure (ICP) was recorded with an epidural sensor for periods of 12 to 24 hours in 92 cases of craniosynostosis. Pre- and postoperative recordings were performed in 23 patients, and 55 children underwent preoperative psychometric testing. The ICP was found to be normal in one-third of the cases, was obviously elevated in one-third, and was borderline in one-third. Waves of increased ICP were recorded during rapid eye movement (REM) sleep. After surgery, ICP decreased progressively and returned to normal in several weeks. A significant statistical relationship was found between the patients' ICP and their mental level: the higher the ICP the lower the mental level. The regression curve of ICP as a function of age shows that ICP is maximal at the age of 6 years and decreases later. The significance of these results is discussed. The authors recommend that ICP be recorded in cases of craniosynostosis since it is of some help in deciding whether patients should undergo surgery.

Prognosis for mental function in Apert's syndrome.

The factors involved in the mental development of patients with Apert's syndrome were studied by the authors, focusing on the age of the patient at operation, associated brain malformations, and the quality of the family environment. Overall, 32% of patients with significant follow-up review had an intelligence quotient (IQ) greater than 70. Age at operation appeared to be the main factor associated with changes in mental development: final IQ was greater than 70 in 50% of patients operated on before 1 year of age versus only 7.1% in patients operated on later in life (p = 0.01). Malformations of the corpus callosum and size of the ventricles played no role in the final IQ, whereas anomalies of the septum pellucidum had a significant effect, with the proportion of patients with an IQ over 70 increasing more than twofold in patients with a normal septum compared with patients with septal anomalies (p < 0.04). Quality of the family environment was the third factor involved in intellectual achievement: only 12.5% of institutionalized children reached a normal IQ level compared to 39.3% of children from a normal family background.

Hydrocephalus and craniosynostosis.

OBJECT: A retrospective study of 1727 cases of craniosynostosis was undertaken to determine the interrelationship between abnormal cerebrospinal fluid (CSF) hydrodynamics and craniosynostosis. METHODS: The patients were divided into two groups: nonsyndromic craniosynostosis and syndromic craniosynostosis. Cases of occipital plagiocephaly without suture synostosis and cases of shunt-induced craniosynostosis were excluded from the study. The majority of patients (1297) were treated surgically for their cranial deformity; 95% of these patients had a postoperative follow-up review period lasting 5 years. Clinical and radiographic charts covering the time from presentation through the follow-up period were reviewed. CONCLUSIONS: Abnormal intracranial CSF hydrodynamics was found in 8.1% of the patients (3.4% of whom had received shunts and 4.5% of whom had not). Three types of CSF hydrodynamic disturbance were observed: progressive hydrocephalus with ventricular dilation, nonprogressive ventriculomegaly, and dilation of the subarachnoid spaces. Hydrocephalus occurred much more frequently in patients with syndromic craniosynostosis (12.1%) than in those with isolated craniosynostosis (0.3%). In fact, patients with kleeblattschädel exhibited hydrocephalus as a constant feature and patients with Crouzon's syndrome were far more likely to have hydrocephalus than those with other syndromes. In Apert's syndrome, ventricular dilation occurred very frequently, but it was almost always nonprogressive in nature. In most cases of syndromic craniosynostosis, venous sinus obstruction and/or chronic tonsillar herniation were found. Their role in the pathophysiology of hydrocephalus in craniosynostosis is discussed.

Treatment of craniosynostosis in infancy.

Craniosynotosis affects approximately one infant out of 1000. The increase of intracranial pressure and the risks of functional problems are more frequent than usually estimated, especially in monosutural synostosis. Frontocranial remodeling will correct both functional and aesthetic consequences of craniosynostosis. The best operative period is the first year of life, 2 to 3 months of age for the brachycephalies, and 6 to 9 months of age for the other craniosynostoses. Not only does growth not adversely affect the results of the forehead remodeling, but the adjacent orbitonasal areas improve with time. In Crouzon's disease and Apert's syndrome, early frontal advancement does not prevent the midface retrusion, and a radical frontofacial advancement may be indicated in very severe cases.

Mammaplasty with a short horizontal scar. Evaluation and results after 9 years.

To obtain a shorter horizontal branch of the inverted T used in mammaplasties, the senior author has developed a technique based on a vertical skin resection stopping above the inframammary line. An evaluation of the results after 9 years of experience has been carried out in 176 patients. Results were satisfactory overall because the shape obtained was pleasing and stable in most cases; the horizontal scar remained hidden beneath the breast in the standing position. Modifications and refinements of the technique since its first publication in 1980 are discussed.

Case report: Reconstruction of the mid-face in an adult, after gangrenous destruction in infancy.

We report a case of an adult mid-face reconstruction for a deformity occurring in infancy, using a Le Fort III advancement first to restore the contour of the skeleton. This was followed by a scalping forehead flap for the nasal reconstruction, and a fleur-de-lis Abbe flap for reconstruction of the lip and nasal vestibule.

Radical forehead remodeling for craniostenosis.

A normal forehead has two parts, shaped differently: (1) the lower part (corresponding to the supraorbital rim and glabellar area) set at a steep angle to the nose; (2) the upper part, sloping gently backward. To reproduce this normal anatomy in cases of cranostenosis affecting the frontal area, we found it essential to mobilize and reshape a supraorbital bar of bone and to transfer a suitable piece of the cranial vault in one piece to make a new upper forehead. By this method we have treated 18 patients with oxycephaly since 1973, with good results. We have also operated on babies with craniostenosis to try to solve simultaneously the functional and the cosmetic problems. In faciocraniostenosis, there are dominant malformations at the base of the skull, but an isolated frontal advancement of two cm has produced gratifying early results.

Intracranial enlargement of the orbital cavity and palpebral remodeling for orbitopalpebral neurofibromatosis.

Exophthalmos with lowering of the globe, eyelid enlargement, and canthal displacement are the usual consequences of orbitopalpebral neurofibromatosis. A cerebral hernia into the orbit may be seen on CT scan. An intracranial approach allows for pushing back the brain with a bone graft to create an enlarged orbital cavity, lifting the globe with a graft on the orbital floor, and fixing the canthi in proper position. An eyelid radical resection is performed in the same stage or later. This approach is discussed in the treatment of 17 cases of orbitopalpebral neurofibromatosis.

Repair of large midline abdominal-wall hernias by a running strip of abdominal skin.

Our experience with a full-thickness running strip of abdominal skin for the treatment of large midline abdominal hernias has been very positive. The mechanical properties of the skin strip allow one to reestablish a normal anatomy by bringing the rectus muscle in contact. Clinical and histologic studies have shown that the full-thickness skin rapidly loses its epidermal components and appears to transform itself into a dense connective tissue very similar to normal aponeurosis.

Giant breast implant for unilateral aplasia. Case report.

The authors present a patient who had aplasia of the right breast associated with absence of the pectoralis muscles and a chest wall deformity. The insertion of combined breast-chest wall implants improved her appearance markedly.

Abdominoplasty in infants for removal of giant congenital nevi: a report of three cases.

The abdominal wall of the infant presents a significant skin excess. Applying techniques of aesthetic abdominoplasty, it is possible to excise extensive abdominal wall lesions, as often seen in children with congenital hairy nevi. Three cases of congenital nevi were handled in this manner and are presented. One case involved the upper abdomen, while the other two involved the lower abdomen.

The axial frontonasal flap revisited.

After 15 years of experience and 50 cases, we think that the axial frontonasal flap is of great value for the repair of large skin defects of the nose. This flap mobilizes all the skin cover of the nose located above the defect and the adjacent frontal skin and rotates it on a vascular pedicle existing at the level of the inner canthi. The excess of skin of the glabella is then transferred to the nose, and this large flap allows coverage of the defect without tension or distortion. The long-term results are very good, with a hardly visible repair in 26 of 50 patients, the long scar being very well hidden at the periphery of the nose.

Evaluation of the effect of early mobilization of the supraorbital bar on the frontal sinus and frontal growth.

Consequences of early frontocranial remodeling are controversial. It has been said that secondary operations are more difficult and that the frontal sinus does not develop well, with an adverse effect on forehead aesthetics. Some illustrative cases are presented, among 820 operated craniosynostoses, to demonstrate that (1) an early, well-performed frontal advancement and/or remodeling is followed by satisfactory reossification and permits easy secondary surgery, (2) frontal sinus development, which is always impaired in anterior craniosynostosis, is only moderately diminished by early supraorbital bar remodeling (when the frontal bar is repositioned after remodeling, as with trigonocephaly, the frontal sinus develops in 83 percent of cases, whereas when the advancement is significant, as with brachycephaly, the development of the frontal sinus is observed in only 50 percent of the cases), and (3) forehead aesthetics are not linked closely to the development of the frontal sinus. After a significant advancement, even if the sinus does not develop, the frontal bar projection can remain satisfactory.

Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases.

The endoscopic approach has totally replaced the bicoronal approach for the treatment of forehead aging in our practice since November of 1993. The fixation in proper position is obtained with fibrin glue. Results of a series of 206 procedures performed in 196 patients are presented. Eyebrow positioning and muscle weakening were rated on a scale of 1 to 4. The evaluation has been made at a minimal follow-up time of 6 months. The comparison of the results between the first series of 28 patients during the first 6 months of our experience and the second series of 69 patients during the following period showed a significant increase in the number of excellent results (from 47 to 78 percent). Altogether, the satisfactory results (rated excellent or good) increased from 71 to 86 percent. Fibrin glue provides a stable fixation with the possibility of displacement in several directions, including transversal expansion. Complications have been minimal. Secondary procedures and association with other facial operations have been analyzed.