Combined genioplasty, chondrolaryngoplasty, and glottoplasty: A novel scarless procedure in facial feminization surgery.

Facial feminization is a long process with multiple surgical steps that is known to improve quality of life in transgender patients. Visible scars are a frequent complaint by this community as it adds to the stigmatization in this population. Combined procedures have been shown to be effective, by reducing the number of hospitalizations and the total length of recovery periods. In this context, we propose a novel scarless procedure combining a chondrolaryngoplasty, a glottoplasty, and a genioplasty using solely a transoral approach. First, we perform a glottoplasty according to the technique described by Wendler et al. and then a contraction genioplasty. Finally, the thyroid cartilage is approached by a subplatysmal dissection, between the mandibular osteotomy fragments. For now, 15 patients have benefited from this procedure in our department. Preliminary results demonstrate that this is an easy and safe procedure with good esthetic results and good patient satisfaction.

Contactless surface registration of featureless anatomy using structured light camera: application to fibula navigation in mandible reconstruction.

PURPOSE: Mandibular reconstruction using fibula free flap is a challenging surgical procedure. To assist osteotomies, computer-assisted surgery (CAS) can be used. Nevertheless, precise registration is required and often necessitates anchored markers that disturb the patient and clinical flow. This work proposes a new contactless surface-based method adapted to featureless anatomies such as fibula to achieve a fast, precise, and reproducible registration. METHODS: Preoperatively, a CT-scan of the patient is realized and osteotomies are virtually planned. During surgery, a structured light camera digitizes the fibula. The obtained intraoperative point cloud is coarsely registered with the preoperative model using 3 points defined in the CT-scan and located on the patient's bone with a laser beam. Then, a fine registration is performed using an ICP algorithm. The registration accuracy was evaluated comparing the position of points engraved in a 3D-printed fibula with their position in the registered model and evaluating resulting osteotomies. Accuracy and execution time were compared to a conventional stylus-based registration method. The work was validated in vivo. RESULTS: The experiment performed on a 3D-printed model showed that execution time is equivalent to surface-based registration using a stylus, with a better accuracy (mean TRE of 0.9 mm vs 1.3 mm using stylus) and guarantee good osteotomies. The preliminary in vivo study proved the feasibility of the method. CONCLUSION: The proposed contactless surface-based registration method using structured light camera gave promising results in terms of accuracy and execution speed and should be useful to implement CAS for mandibular reconstruction.

Stensen's Duct Stenosis Balloon Dilatation: Long-term Evaluation of Clinical Outcomes and Quality of Life Impacts.

OBJECTIVE: To conduct a long-term retrospective evaluation of the safety and effectiveness of sialographic balloon dilatation in Stensen's duct stenosis (SDS). STUDY DESIGN: Retrospective cohort. SETTING: Single-institution academic tertiary referral center. METHODS: All SDS balloon dilatations (SSBDs) performed from 2011 to 2017 were monitored. Pain relief was evaluated by a numeric rating scale at 3-year follow-up at least. Long-term glandular swelling frequency patterns, quality of life (QoL), and drug consumption were retrospectively assessed. Procedure-related complications were recorded. RESULTS: Twenty-one SSBD procedures were recorded (mean ± SD age, 55 ± 12 years), all performed under local anesthesia. SSBD led to complete dilatation in 7 patients (33%), residual stenosis in 8 (38%), and no dilatation (failure) in 6 (29%). Retrospective analysis of clinical outcomes was possible for 17 patients, 71% of whom presented with long-term pain relief, at a mean relief of 3.2 points on the numeric rating scale (P < .001). Long after SSBD, patients presented with a mean decrease of 15.4 glandular swellings per month (P < .001). Medical consumption was reduced to 18% of patients taking some drugs because of SDS after SSBD vs 71% before. SSBD showed an impact on QoL in >80% of patients, with mean improvements of 26% and 25% in the percentage point reduction of physical and mental QoL, respectively (P < .001). No complications were noted except temporary discomfort due to the procedure. CONCLUSION: Despite the advent of sialendoscopy-guided techniques, SSBD should be considered for SDS treatment, as it is a safe procedure and provides sustained pain relief.

Sutureless socket technique after removal of third molars: a multicentric, open, randomized controlled trial.

BACKGROUND: Although wisdom-tooth extraction is a routine intervention, the postoperative period remains marked by local inflammation classically manifesting as pain, edema and trismus. Furthermore, there is no consensus on the best operative techniques, particularly for the mucosal closure stage on impacted mandibular wisdom teeth. METHODS: This parallel, randomized, non-blinded study compared pain following removal of impacted third molars, with and without sutures. Patients were electronically allocated 1:1 to extraction with versus without sutures. Patients ≥ 14 years' old scheduled for extraction of four impacted wisdom teeth under general anesthesia at three French hospitals were eligible for inclusion. Exclusion criteria included taking antiplatelet agents or anticoagulants, coagulation disorders or immunosuppression, and planned orofacial surgical procedures or emergency pain/infection. The primary objective was pain evaluated by Visual Analogue Scale on Day 3. Secondary outcomes were edema, trismus, healing, complications, painkiller consumption and quality of life on Day 3 and 31. RESULTS: Between June 2016 and November 2018, 100 patients were randomized. Finally, 44 patients in the Suture group and 50 patients in the Without Suture group were analyzed. Mean age was 16.5 years and 66.6% of patients were female. After adjustment on center, age and smoking, no statistical difference was seen between groups for pain on Day 3 (p = 0.904). No differences were seen for swelling, trismus, consumption of painkillers, healing, complications or quality of life. Smokers had a 3.65 times higher complications rate (p = 0.0244). CONCLUSIONS: Sutureless removal of third molars is thus a reliable technique without negative consequence on outcomes, and allows shorter operating time. Smoking is a risk factor for postoperative complications. Trial registration www. CLINICALTRIALS: gov (NCT02583997), registered 22/10/2015.

Nanofat and Platelet-Rich Plasma injections used in a case of severe acne scars.

BACKGROUND: Acne is a common chronic inflammatory disease, which can result in permanent scarring. Different types of treatments have been used in order to treat acne scars. However, esthetic results have proved variable. Furthermore, none of these treatments has had an impact on the underlying inflammatory process. OBJECTIVE: The main purpose of this case-report is to suggest a new potential therapy for acne scar management combining esthetic filling with an anti-inflammatory and a regenerative action. METHODS: A Platelet rich plasma (PRP) and Nanofat mixture was injected into the pathological dermis in order to treat and fill severe acne scars. RESULTS: After a one- year follow-up, skin elasticity had improved, scar reduction and a reversal of the inflammation process had been observed. CONCLUSIONS: PRP and Nanofat could represent a new and promising therapeutic approach in the treatment of the inflammatory scarring process in severe acne.

Autologous Gluteal Augmentation with Parasacral Perforator-Pedicled Propeller Flaps.

BACKGROUND: De-epithelialized flaps have been used in gluteal contouring over the last three decades, but most improve the projection rather than the upper quadrants. The authors provide a detailed description of their method of gluteal augmentation using parasacral perforator-pedicled propeller flaps. This technique achieves a volumetric increase and maximal buttock projection at the midlevel and in the medial half of the buttocks. METHODS: Between January and December of 2019, a series of 18 patients on whom a lower body lift with a parasacral perforator-pedicled propeller flap had been performed by the senior author (F.B.) were prospectively evaluated. Postoperatively, the satisfaction rate was assessed using a 10-point analog scale (1 = unsatisfied, 10 = very satisfied) by the patient and by two independent surgeons based on photographs taken 1 year after surgery. RESULTS: Eighteen patients underwent this procedure. Their mean age was 32.2 ± 5.6 years (range, 24 to 40 years). The mean flap length was 20.3 cm, their mean width was 10.4 cm, and the mean thickness was 3.4 cm. The authors noted only two minor complications, one seroma and two skin dehiscences that healed without surgery. The rate of satisfaction as assessed by the patients was 8.3 out of 10 (±1.1), and by surgeons, 7.9 and 8.1. CONCLUSION: This article describes a gluteal autoaugmentation flap technique using parasacral perforator-pedicled propeller flaps to increase projection and volume in the inferomedial gluteal region after lower body lift. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fibular registration using surface matching in navigation-guided osteotomies: a proof of concept study on 3D-printed models.

PURPOSE: Fibula free flap is currently used in mandibular reconstruction. The main difficulties involved in this surgery concern mandible shaping and therefore, osteotomy positioning on the fibula. The use of navigation could help in osteotomy positioning, but accurate registration is required. We assess a surface-matching method for fibula registration that relies on an iterative closest point (ICP) algorithm. Since the fibula shape is landmark free, a robust registration initialization approach is used to avoid non-optimal local minimums in the ICP. METHODS: Bone surface-matching registration was evaluated on a 3D printed fibula and compared to its virtual reference model. The registration initialization relied on 3 initialization points placed on the surgically exposed area, geometrically remote from the fibular distal extremity. The bone surface was digitized, and the obtained point clouds were registered to the virtual reference model. The position of 3 assessment points engraved on the 3D printed fibula was then compared to that of the equivalent points on the virtual model. RESULTS: The registration procedure was performed 24 times by an expert surgeon. Seventy-two target registration errors (TRE) were computed, corresponding to the distance between the paired assessment points. Most TRE (86.1%) were less than 1 mm, with a maximum of 1.552 mm. The overall mean value was 0.759 ± 0.302 mm. CONCLUSION: This study illustrates a surface-matching approach for fibula registration, with an initialization method based on points remote from the fibula distal extremity. This registration technique gave promising results and should be considered as a valid registration method for straight bones like the fibula. These findings indicate that navigation can be used for fibula flap shaping for mandibular reconstruction, with a noninvasive and accurate registration method.

Bilateral mandibular block improves pain relief and morphine consumption in mandibular osteotomies: a prospective, randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: The sensory innervation of the lower jaw mainly depends on the third root of the trigeminal nerve, the mandibular nerve (V3). The aim of this single-center, prospective, randomized, double-blind, placebo-controlled study was to evaluate the effectiveness of bilateral V3 block for postoperative analgesia management in mandibular osteotomies. METHODS: 107 patients undergoing mandibular surgery (75 scheduled osteotomies and 32 mandible fractures) were randomized in two groups. A bilateral V3 block was performed in each group, either with ropivacaine 0.75% (block group, n=50) or with a placebo (placebo group, n=57). A postoperative multimodal analgesia was equally provided to both groups. The primary outcome was the cumulative morphine consumption at 24 hours. Secondary outcomes were the occurrence of severe pain and the incidence of postoperative nausea and vomiting (PONV) in the first 24 hours. Data were analyzed on an intention-to-treat basis. RESULTS: The cumulative morphine consumption at 24 hours was significantly lower in the block group (median 8.0 mg (IQR 2.0-21.3) vs 12.0 mg (IQR 8.0-22.0), p=0.03), as well as the incidence of severe pain during the 24 hours of follow-up (4.0% vs 22.8%, p<0.01). The mandibular block had no impact on the incidence of PONV. CONCLUSION: Bilateral V3 block for mandibular osteotomies is an effective opioid-sparing procedure. It provided better postoperative analgesia in the first 24 hours, and it did not affect PONV incidence. TRIAL REGISTRATION NUMBER: NCT02618993.

Equivalence Randomized Trial to Compare Treatment on the Basis of Sentinel Node Biopsy Versus Neck Node Dissection in Operable T1-T2N0 Oral and Oropharyngeal Cancer.

PURPOSE: Sentinel node (SN) biopsy is accurate in operable oral and oropharyngeal cT1-T2N0 cancer (OC), but, to our knowledge, the oncologic equivalence of SN biopsy and neck lymph node dissection (ND; standard treatment) has never been evaluated. METHODS: In this phase III multicenter trial, 307 patients with OC were randomly assigned to (1) the ND arm or (2) the SN arm (experimental arm: biopsy alone if negative, or followed by ND if positive, during primary tumor surgery). The primary outcome was neck node recurrence-free survival (RFS) at 2 years. Secondary outcomes were 5-year neck node RFS, 2- and 5-year disease-specific survival (DSS), and overall survival (OS). Other outcomes were hospital stay length, neck and shoulder morbidity, and number of physiotherapy prescriptions during the 2 years after surgery. RESULTS: Data on 279 patients (139 ND and 140 SN) could be analyzed. Neck node RFS was 89.6% (95% CI, 0.83% to 0.94%) at 2 years in the ND arm and 90.7% (95% CI, 0.84% to 0.95%) in the SN arm, confirming the equivalence with P < .01. The 5-year RFS and the 2- and 5-year DSS and OS were not significantly different between arms. The median hospital stay length was 8 days in the ND arm and 7 days in the SN arm (P < .01). The functional outcomes were significantly worse in the ND arm until 6 months after surgery. CONCLUSION: This study demonstrated the oncologic equivalence of the SN and ND approaches, with lower morbidity in the SN arm during the first 6 months after surgery, thus establishing SN as the standard of care in OC.

Oral and oropharyngeal cancer surgery with free-flap reconstruction in the elderly: Factors associated with long-term quality of life, patient needs and concerns. A GETTEC cross-sectional study.

OBJECTIVES: To assess the factors associated with long-term quality of life (QoL) and patient concerns in elderly oral or oropharyngeal cancer (OOPC) patients after oncologic surgery and free-flap reconstruction. METHODS: Patients aged over 70 years who were still alive and disease-free at least 1 year after surgery were enrolled in this cross-sectional multicentric study. Patients completed the EORTC QLQ-C30, -H&N35 and -ELD14 QoL questionnaires, and the Hospital Anxiety and Depression Scale (HADS). Patient needs were evaluated using the Patient Concerns Inventory (PCI). Factors associated with these clinical outcomes were determined in univariate and multivariate analysis. RESULTS: Sixty-four patients were included in this study. Long-term QoL, functioning scales and patient autonomy were well-preserved. Main persistent symptoms were fatigue, constipation and oral function-related disorders. Salivary and mastication/swallowing problems were the main patient concerns. The mean number of patient concerns increased with the deterioration of their QoL. Psychological distress (HADS score ≥ 15) and patient frailty (G8 score < 15) were significantly associated with poor QoL outcomes. CONCLUSIONS: We found a negative correlation between the number of patient concerns and QoL. Dental rehabilitation and psychological and nutritional supportive measures are of critical importance in the multidisciplinary management of elderly OOPC patients.

Delayed diagnosis and inappropriate clinical management of nicorandil-induced oral lesions: A case report.

Oral ulcers have a number of causes, and as a result, their etiology can be difficult to determine. Clinical management can range from simple treatment of the symptoms to extensive surgical excision, as in the case of malignant ulcers. Nicorandil, an antiangina drug, has been identified as a potential trigger for cutaneomucosal ulcers. This article reviews the importance of taking a full medical history when seeking to identify the side effects of treatments. We present the case of a 70-year-old patient with chronic ulceration of the oral mucosa. Determining the cause of ulceration as a side effect of taking nicorandil was delayed because the team that initially managed the patient hypothesized a malignant etiology. As a result, a partial glossectomy was performed for diagnostic and therapeutic purposes. After extensive examination of the patient's medical history and current treatments, nicorandil was identified as the potential trigger. The patient finally recovered after discontinuation of nicorandil.

Exclusive Functional Treatment for Mandibular Condylar Fractures.

PURPOSE: Despite the frequency of condylar fractures, no consensus has been reached regarding treatment alternatives (ie, operative vs nonoperative). The purpose of the present study was to describe functional treatment without intermaxillary fixation of condylar fractures and summarize the treatment outcomes. PATIENTS AND METHODS: We designed a retrospective case series and enrolled patients with condylar fractures with malocclusion. The primary outcome was treatment success, assessed at the end of 6 weeks. We recorded 5 parameters to assess treatment success, including a stable return to the initial occlusion, lateral excursion of more than 7 mm, centered protrusion of more than 4 mm, centered mouth opening of more than 35 mm, and painless mandibular mobilization. If all 5 parameters were met, treatment was deemed a success. Treatment failure was defined as meeting less than all 5 parameters. We used numbers and percentages for these nominal qualitative variables (healing criterion absent or present). Two prognostic variables (ie, fracture type and age range), stratified by treatment success, were compared using the Fisher exact test for patients presenting with all healing criteria. RESULTS: We included 30 patients with a median age of 33 years. Of the 30 patients (34 fractures), 15 had low subcondylar fractures (44.1%), 12 had high subcondylar fractures (35.3%), and 7 had head condylar fractures (20.5%). At the last consultation, 21 patients (70%) had exhibited all the criteria defining treatment success. A significant difference was found in the success rate when stratified by age (P = .002) in favor of the younger patients. Also, high subcondylar and head fractures were associated with a better success rate. CONCLUSIONS: Exclusive functional treatment showed promising results and should be considered for cooperative patients, avoiding the risks of surgery and the discomfort with intermaxillary fixation.

Osteomyelitis of the jaw: time to rethink the bone sampling strategy?

This work aims at describing the diversity of osteomyelitis of the jaw (OJ) and at assessing the relevance of a new method designed to avoid salivary contamination during bone sampling in order to improve microbiological analysis and clinical decision-making. We reviewed medical and microbiological data of patients with a suspected OJ based on clinical and/or CT-scan signs and at least one bone sample made for microbiological analysis. During the study period, a new procedure for intraoral bone sampling was elaborated by surgeons and infectious diseases specialists authoring this article (based on stratified samples, cleaning of the surgical site and change of instruments between each sample). A comparison of the microbiological analyses between the two procedures was performed. From 2012 to 2017, 56 patients were included. Median age was 58 years (11-90), sex ratio: 1.24. Main risk factors were having a dental disease (n = 24) or cancer (n = 21). Nineteen patients with the new sample procedure were compared to 37 patients with standard procedure, especially non-cancer patients (n = 16 and 19, respectively). With the new procedure, a median of 3 (1-7) microorganisms per sample was recovered, vs. 7 (1-14) with the former (p < 0.001), a significant decrease of the microbial density was observed for all types of microbes, especially in deeper samples and cultures were more frequently sterile. The way sampling is managed deeply influences microbiological analysis. This strategy facilitates the distinction between pathogens and contaminants and should constitute the first step toward an evidence-based antimicrobial strategy for OJ.

A novel Eulerian approach for modelling cyanobacteria movement: Thin layer formation and recurrent risk to drinking water intakes.

Toxic cyanobacteria (CB) blooms are being reported in an increasing number of water bodies worldwide. As drinking water (DW) treatment can be disrupted by CB, in addition to long term management plans, short term operational decision-making tools are needed that enable an understanding of the temporal variability of CB movement in relation to drinking water intakes. In this paper, we propose a novel conservative model based on a Eulerian framework and compare results with data from CB blooms in Missisquoi Bay (Québec, Canada). The hydrodynamic model considered the effects of wind and light intensity, demonstrated that current understanding of cell buoyancy in relation to light intensity in full-scale systems is incomplete and some factors are yet to be fully characterized. Factors affecting CB buoyancy play a major role in the formation of a thin surface layer that could be of ecological importance with regards to cell concentrations and toxin production. Depending on velocities, wind contributes either to the accumulation or to the dispersion of CB. Lake recirculation effects have a tendency to create zones of low CB concentrations in a water body. Monitoring efforts and future research should focus on short-term variations of CB throughout the water column and the characterization of factors other than light intensity that affect cell buoyancy. These factors are critical for understanding the risk of breakthrough into treatment plants as well as the formation of surface scums and subsequent toxin production.

Breakthrough of cyanobacteria in bank filtration.

The removal of cyanobacteria cells in well water following bank filtration was investigated from a source water consisting of two artificial lakes (A and B). Phycocyanin probes used to monitor cyanobacteria in the source and in filtered well water showed an increase of fluorescence values demonstrating a progressive seasonal growth of cyanobacteria in the source water that were correlated with cyanobacterial biovolumes from taxonomic counts (r = 0.59, p < 0.00001). A strong correlation was observed between the cyanobacterial concentrations in the lake water and in the well water as measured by the phycocyanin probe (p < 0.001, 0.73 ≤ r(2) ≤ 0.94). Log removals from bank filtration estimated from taxonomic counts ranged from 0.96 ± (0.5) and varied according to the species of cyanobacteria. Of cyanobacteria that passed through bank filtration, smaller cells were significantly more frequent in well water samples (p < 0.05) than larger cells. Travel times from the lakes to the wells were estimated as 2 days for Lake B and 10 days for Lake A. Cyanobacterial species in the wells were most closely related to species found in Lake B. Thus, a travel time of less than 1 week permitted the breakthrough of cyanobacteria to wells. Winter samples demonstrated that cyanobacteria accumulate within bank filters, leading to continued passage of cells beyond the bloom season. Although no concentrations of total microcystin-LR were above detection limits in filtered well water, there is concern that cyanobacterial cells that reach the wells have the potential to contain intracellular toxins.

Median cleft of the upper lip: A new classification to guide treatment decisions.

Median cleft of the upper lip (MCL) is a specific and rare entity on the spectrum of facial clefts. MCL have different clinical expressions and can be either isolated or part of multiple malformations. Confusion still exists regarding the explanation and classification of MCL; some cases have been reported in the literature, but no studies carried out a complete review of the literature. This study reviewed cases of MCL in 2 French units and conducted a systematic review of the literature, in order to derive a new classification. Fourteen patients with MCL in the 2 units and 195 cases in the literature were reviewed. They involved complete (42%), incomplete (49%), and minor forms (9%). Epidemiological and clinical data were collected, from which a classification was derived, based on the type of cleft and its belonging to other syndrome(s). Three main groups were distinguished, namely, isolated MCL, MCL within craniofacial malformations, and MCL with extrafacial malformations. Each group and subgroup was associated with a prognosis and led to specific management. This study reviewed all of the various forms of MCL and their associated anomalies, in order to have a global view of MCL and to derive a useful classification scheme to guide management of care.

Estimating the risk of cyanobacterial occurrence using an index integrating meteorological factors: application to drinking water production.

The sudden appearance of toxic cyanobacteria (CB) blooms is still largely unpredictable in waters worldwide. Many post-hoc explanations for CB bloom occurrence relating to physical and biochemical conditions in lakes have been developed. As potentially toxic CB can accumulate in drinking water treatment plants and disrupt water treatment, there is a need for water treatment operators to determine whether conditions are favourable for the proliferation and accumulation of CB in source waters in order to adjust drinking water treatment accordingly. Thus, a new methodology with locally adaptable variables is proposed in order to have a single index, f(p), related to various environmental factors such as temperature, wind speed and direction. The index is used in conjunction with real time monitoring data to determine the probability of CB occurrence in relation to meteorological factors, and was tested at a drinking water intake in Missisquoi Bay, a shallow transboundary bay in Lake Champlain, Québec, Canada. These environmental factors alone were able to explain a maximum probability of 68% that a CB bloom would occur at the drinking water treatment plant. Nutrient limitation also influences CB blooms and intense blooms only occurred when the dissolved inorganic nitrogen (DIN) to total phosphorus (TP) mass ratio was below 3. Additional monitoring of DIN and TP could be considered for these source waters prone to cyanobacterial blooms to determine periods of favourable growth. Real time monitoring and the use of the index could permit an adequate and timely response to CB blooms in drinking water sources.

Reconstruction of anterior scalp defect with V-Y advancement flap pedicled on the temporal fascia superficialis.

Reconstruction of scalp defect can call upon several surgical techniques. Direct joining is used whenever possible, but because of the low laxity of the scalp, other approaches are often required. Several types of autoclosing flaps of the scalp have been described in the literature. In this article, we report the advantages of the island flap pedicled on the superficial temporal fascia, as described by Onishi (2005) in a case report for the reconstruction of an anterior scalp defect.