Head and neck reconstruction in vessel-depleted necks: Case report of a labio-mental and mandibular reconstruction using an arteriovenous loop.

Major defects of the facial structures cause severe functional and esthetic impairment. Difficulty in head and neck reconstruction lies in cases of secondary, tertiary, or further reconstruction. This is not a rare situation for patients who had cancer of the upper airways, since the rate of recurrence, second location, or osteoradionecrosis is high. Multiple surgeries and radiation therapy cause significant fibrosis and scar tissues, making any further reconstruction a major challenge for the surgeon when operating patients with vessel- depleted neck. We report our experience with a clinical case of a patient to whom we performed a double free flap reconstruction anastomosed on a vascular loop in a context of vascular cervical desert. In our case, the use of an arteriovenous loop proved to be a reliable approach for a vessel-depleted free tissue reconstruction. This technique has received insufficient attention, yet it provides a means to establish dependable vascular alternatives.

Management of intra-osseous arteriovenous malformations of the mandible.

Intra-mandibular arteriovenous malformations (IM-AVM) are rare congenital lesions sadly known by the appearance of cataclysmic haemorrhages. It represents a therapeutic challenge which requires a multidisciplinary approach. This paper aims to evaluate the characteristics and management of IM-AVM through the illustration of six case reports, the largest serie in the literature to our knowledge. This retrospective study included all patients with IM-AVM treated in the hospital of Lyon and Saint-Etienne between 1982 and 2021, in France. The management of mandibular AVMs should be individualized and permanently adjusted according to their stage of development, which makes their management difficult. Furthermore, long-term follow-up is essential to detect and manage the subclinical progression of the lesion. Based on these results and a systematic review of the literature, an algorithm has been developed to guide the treatment strategy for this are pathology.

Overlapping Phenotypes Associated With CYP24A1, SLC34A1, and SLC34A3 Mutations: A Cohort Study of Patients With Hypersensitivity to Vitamin D.

Mutations in CYP24A1 (vitamin D 24-hydroxylase) and SLC34A1 (renal phosphate transporter NPT2a) cause autosomal recessive Infantile Hypercalcemia type 1 and 2, illustrating links between vitamin D and phosphate metabolism. Patients may present with hypercalciuria and alternate between chronic phases with normal serum calcium but inappropriately high 1,25-(OH)2D and appropriately low PTH, and acute phases with hypercalcemia with suppressed PTH. Mutations in SLC34A3 and SLC9A3R1 have been associated with phosphate wasting without hypercalcemia. The aims of this study were to evaluate the frequency of mutations in these genes in patients with a medical history suggestive of CYP24A1 mutation to search for a specific pattern. Using next generation sequencing, we screened for mutations in 185 patients with PTH levels < 20 pg/mL, hypercalcemia and/or hypercalciuria, and relatives. Twenty-eight (15%) patients harbored biallelic mutations in CYP24A1 (25) and SLC34A3 (3), mostly associated with renal disease (lithiasis, nephrocalcinosis) (86%). Hypophosphatemia was found in 7 patients with biallelic mutations in CYP24A1 and a normal phosphatemia was reported in 2 patients with biallelic mutations in SLC34A3. Rare variations in SLC34A1 and SLC34A3 were mostly of uncertain significance. Fifteen patients (8%) carried only one heterozygous mutation. Heterozygous relatives carrying SLC34A1 or SLC34A3 variation may present with biochemical changes in mineral metabolism. Two patients' genotype may suggest digenism (heterozygous variations in different genes). No variation was found in SLC9A3R1. As no specific pattern can be found, patients with medical history suggestive of CYP24A1 mutation should benefit from SLC34A1 and SLC34A3 analysis.

Healthcare associated coronavirus disease 2019 among health care workers in Normandy, France: a multi-center study.

INTRODUCTION: In the early phase of the coronavirus disease (COVID-19) epidemic in France, knowledge of SARS-COV-2 characteristics was limited, and personal protective equipment (PPE) was lacking. Thus, health care workers (HCWs) were exposed to nosocomial transmission. METHODS: A multicenter regional descriptive study of fifty-two heath care facilities covering 30,533 HCWs in western Normandy, France, from March 3 to March 27, 2020, before the incidence threshold of 10/100,000 inhabitants was crossed in the study area. The incidence rate of COVID-19 in HCWs, the attack rates and the serial interval distribution of nosocomial transmission were computed. Demographic characteristics of HCWs, contacts with index cases, and the use of personal protective equipment were collected by a structured questionnaire. RESULTS: The incidence rate of COVID-19 in HCWs was 2.7‰. Among 19 situations (13 clusters >2 cases), 10 were HCW-HCW and 9 patient-HCW transmission, the global attack rate was 13.7% (95% confidence interval, 10.6%-17.3%), and 68 HCWs were involved (10 index cases, with 58 secondary cases). Exposure of secondary cases was only in the presymptomatic phase of the index case in 29% of cases, 48% for HCW-HCW and 10% for patient-HCW transmission (P<0.001). The mean serial interval was 5.1 days (95% CI, 4.2-5.9 days). Preventative measures were not optimal. CONCLUSIONS: Our investigation demonstrated that HCWs who were not assigned to the care of COVID-19 patients were not prepared for the arrival of this particularly insidious new virus, which spread rapidly from an often asymptomatic colleague or patient.

Efficacy of Surgical Excision and Brachytherapy in the Treatment of Keloids: A Retrospective Cohort Study.

OBJECTIVE: To demonstrate the efficacy of a protocol combining surgical excision and high-dose-rate brachytherapy for treatment of keloids. METHODS: The authors performed a unicentric retrospective cohort study between 2013 and 2018. The minimum follow-up was 12 months. All patients treated for keloids at the authors' institution were included. Extralesional excision was performed with placement of a brachytherapy sheath under the skin. The total dose of irradiation was 18 Gy. The postoperative results were evaluated for aesthetic and functional outcomes with a validated scale, as well as the presence or absence of recurrence. RESULTS: Fifteen patients were lost to follow-up. Thirty-eight patients with 67 keloids were included. The control rate was 94%. The aesthetic and functional outcomes were considered good in 62% of cases. The main limitation of the study was the small patient population. CONCLUSIONS: Extralesional excision combined with postoperative high-dose-rate brachytherapy seems to be one of the most effective invasive protocols to treat and prevent keloids.

Difficultés d'apprentissage et mise en place des plans d'accompagnement personnalisé dans l'Académie de Caen.

INTRODUCTION: Learning disorders concern between 10 and 15% of students in France. Since 2015, the National Education has set up the "Plan d'Accompagnement Personnalisé" (PAP) to offer these students adapted facilities. However, we note that this answer does not seem sufficiently solicited in view of the need. We therefore seek to improve the care of these students by analyzing the difficulties of setting up the appropriate response. METHOD: This is a unique departmental cross-sectional cluster sampling study. We met and distributed a questionnaire to the principals of 19 schools. This questionnaire was addressed to elementary school teachers. This questionnaire included quantitative and qualitative questions on the identification of pupils in difficulty, the procedures for setting up the facilities and the difficulties encountered. RESULTS: 51 teachers answered the questionnaire, corresponding to 2155 students. 11.5% of these students had difficulty learning, and of these only 5.5% had a PAP. The "Plan Personnel de Réussite Educative" was proposed as the first solution by 1 professor out of 3. The doctors of the National Education are under-solicited, 2% of the teachers advise the families to approach them at first. CONCLUSION: We can highlight a mismatch between the number of students with learning difficulties and the number of students benefiting from development under a PAP. In addition, a misunderstanding of the objectives and indications of the PAP appears among the teachers. Finally, the latter seem to need a redefinition of the role of actors involved in the PAP.

[Temporomandibular joint prostheses]. / Prothèses d'articulation temporo-mandibulaire.

Temporomandibular joint prosthesis. The temporomandibular joint can be affected by end-stage pathology such as arthritic disease, trauma, ankylosis. The main debilitating symptoms results in limited mouth opening and pain. TMJ prosthesis is recommended for disease resulting in an anatomical modification and aims at restoring joint function with pain relief. Despite its initial history of health scandals, prosthetic replacement for end-stage TMJ disease is gradually becoming a common procedure because of good functional results and low morbidity. Significant advances have been made in the design of the temporomandibular joint prostheses during the last decades, specially thanks to the use of 3D printing. The indications should be further clarified and extended.

Prothèses d'articulation temporo-mandibulaire. L'articulation temporo-mandibulaire peut être le siège de pathologies telles que l'arthrose, les séquelles de trau¬matisme ou l'ankylose. Les principaux symptômes inva¬lidants sont la limitation de l'ouverture buccale et la douleur. La prothèse d'articulation temporo-mandibulaire s'adresse aux pathologies entraînant une modification anatomique. Son but premier est de restaurer la fonction de l'articulation en soulageant la douleur. Malgré son histoire initialement émaillée de scandales sanitaires, le remplacement prothétique pour les pathologies avancées de l'articulation temporo-mandibulaire est progressive¬ment devenu une intervention courante, grâce à de bons résultats fonctionnels et une morbidité faible. D'impor¬tantes avancées ont été réalisées dans la conception des prothèses durant les dernières décennies, notamment grâce à l'apport de l'impression 3D. Ses indications doivent encore être précisées et étendues.

Transverse Facial Artery Perforators: Anatomical, Two- and Three-Dimensional Radiographic Study.

BACKGROUND: Increased anatomical knowledge of skin vascularization, such as the recent description of angiosome and perforasome concepts, has led to important innovations in flap surgery. In this sense, few studies have been performed on face vascularization especially for facial artery perforasomes. The aim of this study was to analyze the number, size, and localization of transverse facial artery perforators and their perfusion area. METHODS: Fourteen hemifaces of fresh adult cadavers from the Department of Anatomy of Lyon University were harvested. Transverse facial artery perforators were identified, dissected, cannulated, and selectively injected with 1 ml of patent blue or contrast solution. Photography, microangiography, and computed tomography were performed. Perforator diameter and localization from the lateral canthus were measured. Exact topography and size of the perforasome were analyzed. RESULTS: Twenty-three transverse facial artery perforators were identified. Mean perforator diameter was 1.01 ± 0.3 mm. Mean perforating site was 31.0 ± 8.0 mm lateral to and 38.7 ± 8.8 mm below the lateral canthus. Mean single perforasome surface area was 25.3 ± 18.34 cm and mean transverse facial artery skin territory was 40.5 ± 9.78 cm. CONCLUSIONS: The transverse facial artery provides at least one perforator that can be accurately localized using a Doppler probe. Clinical applications related to the improved knowledge of transverse facial artery perforators could be as follows: (1) performing a lateral facial skin flap; (2) facial composite allotransplants; (3) face-lift procedures to improve skin perfusion; and (4) prevention of vessel injury in aesthetic procedures such as dermal filler injection or thread-lift techniques.

[Learning disorders and "PAP" services in the Academy of Caen]. / Difficultés d'apprentissage et mise en place des plans d'accompagnement personnalisé dans l'Académie de Caen.

INTRODUCTION: Learning disorders concern between 10 and 15% of students in France. Since 2015, the National Education has set up the "Plan d'Accompagnement Personnalisé" (PAP) to offer these students adapted facilities. However, we note that this answer does not seem sufficiently solicited in view of the need. We therefore seek to improve the care of these students by analyzing the difficulties of setting up the appropriate response. METHOD: This is a unique departmental cross-sectional cluster sampling study. We met and distributed a questionnaire to the principals of 19 schools. This questionnaire was addressed to elementary school teachers. This questionnaire included quantitative and qualitative questions on the identification of pupils in difficulty, the procedures for setting up the facilities and the difficulties encountered. RESULTS: 51 teachers answered the questionnaire, corresponding to 2155 students. 11.5% of these students had difficulty learning, and of these only 5.5% had a PAP. The "Plan Personnel de Réussite Educative" was proposed as the first solution by 1 professor out of 3. The doctors of the National Education are under-solicited, 2% of the teachers advise the families to approach them at first. CONCLUSION: We can highlight a mismatch between the number of students with learning difficulties and the number of students benefiting from development under a PAP. In addition, a misunderstanding of the objectives and indications of the PAP appears among the teachers. Finally, the latter seem to need a redefinition of the role of actors involved in the PAP.

[Smoking and alcohol cessation programs in patients with head and neck cancer]. / Accompagnement des dépendances à l'alcool et au tabac des patients atteints d'un cancer des voies aérodigestives supérieures.

Most head and neck cancers are associated with smoking and alcohol exposure. Smoking and alcohol cessation (ASC) is associated with improved quality of life, cancer therapy efficacy, decreased treatment-related and cardiovascular risks, and is expected to decrease the risk of second primary tumor. It is therefore a high priority in the plan of care. However, results of current ASC programs are disappointing and understanding the reasons of this is critical. We started a qualitative study in 6 academic centers including 3 university hospitals, one regional hospital and one comprehensive cancer center. We first interviewed surgeons and care givers involved in the management of head and neck cancers. Poor communication between stakeholders, absence of alignment of care goals between patients, surgeons and other caregivers, and low level of understanding by patients of the benefits of ASC were felt to represent frequent obstacles to successful outcome. More work is ongoing within the context of our IHNPACT umbrella protocol to identify hurdles associated with successful ASC.

Mandibular Advancement Means Lower Facial Enlargement: A 2-Dimensional and 3-Dimensional Analysis.

PURPOSE: Bilateral sagittal split osteotomy (BSSO) is frequently used to treat Class II malocclusion for functional and esthetic purposes, with expected changes in the profile. The goal of this study was to assess transversal changes in mandibular advancement by comparing 3-dimensional (3D) photogrammetric modifications and 2-dimensional (2D) radiographic enlargement. MATERIALS AND METHODS: A cohort study was conducted of patients who underwent an isolated advancement BSSO (Obwegeser-Dal Pont II type) for a Class II malocclusion. All patients had 3D photogrammetric and 2D radiographic evaluations before and after surgery. Frontal cephalograms were used to measure the evolution of bigonial distance (BGD) and 3D photographs were used to measure the evolution of cutaneous BGD (CBGD). RESULTS: Fourteen patients were included. Mean mandibular advancement was 6 mm. BGD (+6.1 mm; P < 10-3) and CBGD (+4.2 mm; P = .0017) were significantly increased. The mean ratio of soft tissue response to transversal skeletal changes was 0.81. CONCLUSION: This 2D and 3D analysis of transversal modifications shows that advancement with the BSSO is responsible for marked lower third facial enlargement. This parameter must be taken into account during the preoperative esthetic assessment to ensure the provision of pertinent information to the patient and the consideration of complementary surgical correction.

Periorbital Necrotizing Fasciitis Induced by Streptococcus pyogenes: A Case Report and Clarification.

Periorbital necrotizing fasciitis (PONF) is a rare condition of the face. PONF can lead to blindness, functional and esthetic sequelae, multiple-organ failure, and death. The aim of this report is to raise the awareness of this severe condition in maxillofacial surgeons. This report describes the case of a 30-year-old woman who presented with a bilateral palpebral edema and pain 3 days after a jugal wound was sutured. Necrosis of the skin of the left palpebral unit was extending rapidly. The patient had signs of sepsis. Surgical debridement was performed promptly and intravenous broad-spectrum empiric antibiotics were administered. The patient recovered slowly with no complication other than a residual skin defect of the 2 eyelids that was later corrected by full-thickness skin grafting. Special attention should be paid to signs of preseptal cellulitis because it can, in some cases, rapidly develop into PONF. Early diagnosis and treatment are the keys to a favorable outcome.

Multicenter prospective micro-costing study evaluating mandibular free-flap reconstruction.

Free-flap mandibular reconstruction is a highly specialized procedure associated with severe complications necessitating re-interventions and re-hospitalizations. This surgery is expensive in terms of health workers' time, equipment, medical devices and drugs. Our main objective was to assess the direct hospital cost generated by osseocutaneous free-flap surgery in a multicentric prospective micro-costing study. Direct medical costs evaluated from a hospital perspective were assessed using a micro-costing method from the first consultation with the surgeon until the patient returns home, thus confirming the success or failure of the free-flap procedure. The mean total cost for free-flap intervention was 34,009€ (5151-119,604€), the most expensive item being the duration of hospital bed occupation, representing 30-90% of the total cost. In the event of complications, the mean cost increased by 77.3%, due primarily to hospitalization in ICU and the conventional unit. This surgery is effective and provides good results but remains highly complex and costly.

Teaching Surgical Procedures with Movies: Tips for High-quality Video Clips.

Video must now be considered as a precious tool for learning surgery. However, the medium does present production challenges, and currently, quality movies are not always accessible. We developed a series of 7 surgical videos and made them available on a publicly accessible internet website. Our videos have been viewed by thousands of people worldwide. High-quality educational movies must respect strategic and technical points to be reliable.

Management of dentoskeletal deformity due to condylar resorption: literature review.

OBJECTIVES: The aim of this review was to examine all publicly available literature on the current treatments of the dentoskeletal deformity due to condylar resorption and their outcomes and to suggest management guidelines. STUDY DESIGN: A systematic review was performed of all literature located on the electronic PubMed database from 1970 to 2012. RESULTS: The search resulted in 21 papers and 210 cases treated from 1991 to 2012. Orthognathic surgery was the most commonly used option (42%) and was sometimes combined with open joint surgery (19%). Stability was observed, respectively, in 57% and 100% of the orthognathic surgery and open joint surgery cases. Condylectomy and reconstruction with chondrocostal graft or temporomandibular joint total joint prosthesis were used in 19% and 10% of all cases of orthognathic surgery and open joint surgery with good results (95% and 100%, respectively). Osteogenic distraction was anecdotic (1%). Nine percent of all cases received conservative treatment. CONCLUSIONS: Larger comparative studies are necessary to obtain evidence-based recommendations.

Actinomycosis: etiology, clinical features, diagnosis, treatment, and management.

Actinomycosis is a rare chronic disease caused by Actinomyces spp., anaerobic Gram-positive bacteria that normally colonize the human mouth and digestive and genital tracts. Physicians must be aware of typical clinical presentations (such as cervicofacial actinomycosis following dental focus of infection, pelvic actinomycosis in women with an intrauterine device, and pulmonary actinomycosis in smokers with poor dental hygiene), but also that actinomycosis may mimic the malignancy process in various anatomical sites. Bacterial cultures and pathology are the cornerstone of diagnosis, but particular conditions are required in order to get the correct diagnosis. Prolonged bacterial cultures in anaerobic conditions are necessary to identify the bacterium and typical microscopic findings include necrosis with yellowish sulfur granules and filamentous Gram-positive fungal-like pathogens. Patients with actinomycosis require prolonged (6- to 12-month) high doses (to facilitate the drug penetration in abscess and in infected tissues) of penicillin G or amoxicillin, but the duration of antimicrobial therapy could probably be shortened to 3 months in patients in whom optimal surgical resection of infected tissues has been performed. Preventive measures, such as reduction of alcohol abuse and improvement of dental hygiene, may limit occurrence of pulmonary, cervicofacial, and central nervous system actinomycosis. In women, intrauterine devices must be changed every 5 years in order to limit the occurrence of pelvic actinomycosis.

Feasibility of a porcine oral mucosa equivalent: a preclinical study.

Oral tissue engineering aims to treat and fill tissue deficits caused by congenital defects, facial trauma, or malignant lesion surgery, as well as to study the biology of oral mucosa. The Food and Drug Administration (FDA) and the European Medicines Agency (EMA) require a large animal model to evaluate cell-based devices, including tissue-engineered oral mucosa, prior to initiating human clinical studies. Porcine oral mucosa is non-keratinized and resembles that of humans more closely than any other animal in terms of structure and composition; however, there have not been any reports on the reconstruction of a porcine oral mucosa equivalent, probably due to the difficulty to culture porcine fibroblasts. In this study, we demonstrate the feasibility of a 3D porcine oral mucosa equivalent based on a collagen-GAG-chitosan scaffold, as well as reconstructed porcine epithelium by using an amniotic membrane as support, or without any support in form of epithelial cell sheets by using thermoresponsive culture plates. Explants technique was used for the isolation of the porcine fibroblasts and a modified fibroblast medium containing 20% fetal calf serum was used for their culture. The histological and transmission electron microscopic analyses of the resulting porcine oral mucosa models showed the presence of non-keratinized epithelia expressing keratin 13, the major differentiation marker of non-keratinized oral mucosa, in all models, and the presence of newly synthesized collagen fibers in the lamina propria equivalent of the full-thickness model, indicating the functionality of porcine fibroblasts.

Distally based adipofascial sural flap for foot and ankle reconstruction.

BACKGROUND: this retrospective study of a case series analyzed the results from the application of a distally based adipofascial sural flap for nonweightbearing defects of the foot and ankle. METHODS: twenty-eight patients with post-traumatic ankle and foot defects (ten women and 18 men; age range, 17-63 years) underwent surgery between November 1, 2003, and November 30, 2008. Distally based adipofascial sural flaps were used in ten open fractures, 14 soft-tissue post-traumatic defects, and four deep burns. Defects were on the dorsal side of the foot (eight cases), the lateral malleolus (four cases), the medial malleolus and inframalleolar region (four cases), the Achilles tendon region (eight cases), and the anterior surface of the ankle (four cases). Surgical procedures were performed by a single surgeon (A.M.). RESULTS: all of the flaps healed uneventfully. There was no partial or total flap loss. All 28 patients walked normally at the time of follow-up. Three delayed healings occurred at the donor site. CONCLUSIONS: this is a homogeneous series of lower-limb reconstructions with the distally based adipofascial sural flap, which permits better analysis of the results. This flap has a constant and reliable blood supply. It can be used for the reconstruction of nonweightbearing foot and ankle regions to avoid the bulky volume of the fasciocutaneous flap in this area and to minimize the donor site scar.