Latissimus dorsi seroma prevention with running quilting suture using barbed suture.

Dorsal seroma is a common complication of autologous latissimus dorsi flap (ALDF) in breast reconstruction, and has limited the use of this technique, despite its aesthetic success. It is important to find a right technique to limit the incidence of seroma formation after ALDF. The aim of this study was to evaluate the effectiveness and tolerance of a dorsal quilting technique called "running quilting" using barbed resorbable suture in seroma prevention. Three hundred patients who underwent ALDF breast reconstruction in the period between 2004 and 2014 were included in this study. The population was divided in 3 groups; without quilting, with simple quilting suture, and with running quilting using barbed suture. The incidence of small seromas (requiring 1 or 2 aspirations during routine postoperative visits without adding additional appointments to the follow-up routine) was not significantly decreased: it was 54% in the non-quilted group, 47% in group 2 Quilting, and 34% in group 3 running quilting. However, quilting reduced the duration of drainage, and the rate of late seromas (from 8% to 0%), and chronic sero-hematomas completely disappeared in our experience. Running quilting using barbed suture is highly effective in preventing late and refractory donor-site seromas. Its effectiveness is expected to increase the use of ALDF in breast reconstruction, which we consider currently as one of the best autologous reconstruction techniques.

[Breast restoration by the lipomodeling technique after breast sequelae following complications of reduction mammoplasty]. / Rattrapage des séquelles esthétiques de réduction mammaire par la technique du lipomodelage.

BACKGROUND: Complications of reduction mammoplasty can lead to aesthetic sequelae, which are known to be difficult and delicate to treat, and only a few articles deal with this subject. PURPOSE: The objective of this article is to present and analyze our experience of lipomodeling for the secondary management of aesthetic sequelae occurring after a complication of reduction mammoplasty. MATERIAL AND METHODS: An uniform and consecutive series of 22 female patients, operated with the lipomodeling technique from December 2003 to March 2019 by the last author, to correct aesthetic sequelae after secondary complications of reduction mammoplasty was studied analyzing the efficiency and the tolerance of this technique. RESULTS: The results showed 86.4% of very good results and 13.6% of good results. Seventeen patients (77.3%) were highly satisfied with the postoperative outcome, and 5 patients were satisfied (22.7%). The number of procedures varied from 1 to 3: 15 patients (68.2%) underwent only one session of lipomodeling, 5 patients (22.7%) underwent two sessions, and 2 patients (9.1%) underwent three sessions. The mean time between two interventions was 4 months (3-12). No patient of this series initiates any medico-legal proceeding towards the first surgeon. CONCLUSION: After this study, lipomodeling, in association with ancillary procedures, seems to be an effective and safe solution to correct aesthetic sequelae following secondary complications of reduction mammoplasty. It should have a key role for the correction of these sequelae. An effective and appropriate care of these patients leads to good results and patients' final satisfaction, and manages to avoid any medico-legal proceeding, always badly lived as much for the patient as for the first surgeon.

Primary management of the inframammary fold in breast reconstruction using the thoracoabdominal advancement flap: Surgical technique.

Our experience in breast reconstruction confirms the significant importance of reconstructing the inframammary fold in achieving overall aesthetic satisfaction. We describe our technique for primary fixation of the inframammary fold in breast reconstruction using a thoracoabdominal advancement flap. This technique is suitable for patients with a vertical skin laxity of at least 5cm in the future inframammary fold. Prior to the procedure, it requires preparation through physiotherapy, the use of adhesive external breast prosthesis, and skin expansion using an inflatable prosthesis in extreme cases. The surgical approach follows the existing mastectomy scar. After subfascial dissection of the thoracoabdominal advancement flap, the surgeon proceeds to create two separate rows of sutures. The first row mimics the deep attachment of the inframammary fold, fixing the superficial fascia of the flap to the rib periosteum. The second row mimics the superficial attachment of the inframammary fold, fixing the dermis of the flap to the rib periosteum. The main advantage of this technique is its applicability to all breast reconstruction programs.

Titanium plates salvage in irradiated facial areas with the lipomodeling technique.

Major defects of the facial structures cause severe functional and aesthetic impairment. For composite defects with bone loss, the use of a titanium plate bridging the bony defect, associated or not to a soft tissue pedicled flap is to be considered in complex cases, or for patients with high comorbidities. The principal limit of this technique is the risk of plate exposure, especially for patients who had adjuvant radiation therapy. We present two clinical cases of patients who had a facial reconstruction using a titanium plate associated with a locoregional soft tissue flap, and who presented a near-exposed plate a few years after the first surgery and adjuvant radiation therapy. In order to prevent plate exposure, we performed several lipomodeling sessions between skin and plate. Our results are very encouraging, with no plate exposure and thickening of the soft tissues which cover the plate at 10-years follow-up. The knowledge of the possibility to use fat grafting transfer could therefore lead to a strong return to the use of titanium plates in facial reconstruction.

[How to manage late periprosthetic fluid collections (seromas) in patients with breast implants?] / Conduite à tenir devant un sérome tardif péri-prothétique.

The widespread use of silicone implants in reconstructive and aesthetic breast surgery led to an increase in the incidence of breast implant associated anaplastic large cell lymphoma, BIA-ALCL, mainly associated with the use of macro-textured breast implants. BIA-ALCL is a serious complication presenting clinically as a late onset periprosthetic seroma. Thus, its occurrence became an alarming sign feared by most plastic surgeons. Therefore, a good knowledge with respect to early diagnosis, subsequent workup, and treatment is crucial in the management of periprosthetic seroma. The diagnosis of late onset seroma is clinically evident. Although idiopathic seroma is the most common cause, BIA-ALCL should be always eliminated. A complete workup is usually necessary. An ultrasound performed by a radiologist specialized in breast imaging followed by an ultrasound guided puncture is imperative. Consequently, the cytological and the bacteriological analysis will orient us toward the etiology (infectious, neoplastic or mechanical). A standardized management of late periprosthetic seroma does not exist, with various factors are to be taken into consideration. These include the surgeon's experience, the diagnosis, and the medical institution facilities. Although idiopathic seroma is managed by a simple puncture and drainage, other causes may require a surgical procedure with implant removal, capsulotomies, and/or total capsulectomies.

[Lipomodeling for congenital breast deformities: Technique, results and indications]. / Place des transferts graisseux dans les malformations des seins et du thorax.

Congenital breast deformities usually occur during adolescence and can disturb the self-development and affect the identity during this crucial stage. Several surgical techniques are now available to correct these different anomalies. The objective is to clarify the place of lipomodeling in thoraco-mammary malformations, resuming the different indications, the results, as well as the limits and potential complications. The adipose tissue was harvested by soft aspiration as to reduce adipocyte trauma and using a syringe fitted with a 3.5mm cannula. After centrifugation, fat was reinjected retrogradely and by making thin cylinders of fat similar to "spaghetti". Moderate to severe asymmetry is one of the best indications for lipomodeling using one or two sessions. Thus, a perfect and lasting symmetry is achieved, without the need of an implant, which would inevitably leads to asymmetry because of a dissimilar evolution of the breast all over the time. In Becker's nevus syndrome, lipomodeling has also been performant in bluring the hyperpigmentation of the nevus. The role of lipomodeling in pectus excavatum deformity (antero-posterior sternocostal depression) is also crucial. Lipomodeling can be used alone, or in combination with a rigid customed silicone implant. Tuberous breasts include various anomalies. Lipomodeling is currently used especially when the anomaly is unilateral (2 fat graft sessions are usually needed). Fasciotomies are frequently performed too. Lipomodeling is a real revolution in the management of Poland syndrome (anomaly characterized by the unilateral lack of the pectoralis major muscle, more or less associated with other ipsilateral anomalies). On average, 3 to 5 sessions are necessary to obtain a suitable symmetry. Lipomodeling is very unlikely to cause major surgical complications. Cytosteatonecrosis nodules mainly occur with novice practitioner and decrease as they become more experienced. However, the principle of the three-dimensional network, and the phenomenon of tissue saturation of the recipient site should be respected. The main limitation of lipomodeling is directly related to the amount of fat available. That's why it is very important to evaluate it during the first clinical consultation, and to carefully select the patients eligible in order to limit the risk of failure. Lipomodeling of congenital breast anomalies is a technique well established, with a precise algorithm to follow, and is a procedure with low surgical risk, less scarring, cosmetic and lasting results. This technique is to be suggested as a first line treatment in all indications of congenital breast deformities, alone or combined to an implant. Therefore, it seems essential that a plastic surgeon fully master the indications and the use of fat tissue transfer procedure, in order to obtain natural and harmonious results.

[Poland's syndrome]. / Syndrome de Poland.

Breast and thoracic deformities of Poland syndrome is a rare malformation known to be difficult to treat. Numerous descriptions of surgical corrections have been published but none achieved to correct severe cases before description of lipomodeling technique. The aim of this article is to present thoraco-mammary deformity of Poland syndrome, corrections techniques already available and therapeutical indications in primary and secondary cases. Constant anomaly of Poland syndrome is agenesis of sterno-costal part of pectoralis major muscle but other muscular anomalies can be associated. Skin and glandular anomalies present with a fine skin and an absent or hypoplasic subcutaneous fat with a glandular hypoplasia of various degree. Osteo-cartilaginous anomalies can be associated in very severe cases. Clinical sign of Poland syndrome is forced adduction manoeuvre highlighting pectoralis major agenesis. Functional impact of the deformity is low but psychological and psychosocial implications can be very important, supporting an early surgical correction. Therapeutic means are various and accurate descriptions are given in this article: thoracic bony reconstruction, thoracic implant made of silicone elastomer, breast implant, skin expansion, latissimus dorsi pedicled flap, free flaps, breast lipomodeling, Breast-pectoralis flap. Principles of each technique are described and balanced with their actual use in this malformation. Indications have been completely modified these last years due to lipomodeling contribution which represented a huge step in this deformity treatment. In our practice, if autologous reconstruction with lipomodeling is possible, we choose this solution at first. In case of severe thoracic deformity, a silicone elastomer implant made with the help of computed assisted conception can be an important adjunct, mainly by thin young man. In secondary cases, if implant is well tolerated, we found logical to stay in the same reconstruction path and do one or two sessions of lipomodeling in order to improve reconstruction. If implant tolerance is low and skin very thin at risk of exposure, we do recommend a conversion of implant reconstruction to autologous reconstruction. In conclusion, thoraco-mammary deformities of Poland syndrome are rare and hard to treat and should be managed by well trained and experimented surgeons. Breast lipomodeling is a huge step in the treatment of these deformities and should be regarded, in our opinion, as first line treatment if fat deposits are sufficient. In case of low fat provisions or in the thin young man, composite techniques should be used with silicone elastomer implant.

The role of reconstructive surgery after soft tissue sarcoma resection.

Soft tissue sarcomas are rare malignant tumors with pejorative prognosis. They require a multidisciplinary approach in a specialized hospital belonging to the NetSarc network in France. In all cases treated with curative intent, the objective of excision surgery is to achieve wide, microscopically negative margins (R0 according to the UICC classification). When growing on a limb, sarcomas may threaten functionally relevant structures and even lead to amputation. Nowadays, when combined with radiation therapy, wide exeresis limb-sparing surgery is achievable in 90 to 95% of the cases, of which 25% will nevertheless require reconstructive surgery to preserve the limb, to limit postoperative complications and to manage possible sequelae. Progress in reparative surgery, particularly in microsurgery, has helped not only to improve limb salvage rates but also to create wider margins without altering oncologic goals of curative resection. After determining the range of resection, reconstructive surgery should be tailored to address the tissue defect. The converse is to be strongly discouraged. The extent of resection must not be compromised or reduced in order to facilitate reconstructive surgery. A plastic surgeon must master all the flap techniques, including microsurgery, while taking into account the impact of preoperative and postoperative radiation therapy on previously irradiated tissues or on wounds requiring adjuvant therapy. Recent developments, especially as regards perforator flaps, have helped to enhanced the quality of reconstruction procedure while reducing donor site morbidity. In our experience, perforator flaps are a workhorse in reconstructive surgeries subsequent to soft tissue sarcoma of the extremities. On a parallel track, lipofilling (otherwise known as fat grafting or fat transfer) has become the first-line treatment for patients with post-surgical functional or cosmetic sequalae. It is performed after long-term follow-up during disease-free survival. Strict clinical examination and MRI are mandatory prior to programming any local procedure. Usually, three to four sessions of fat grafting are needed to enhance local trophicity or the cosmetic aspect. Sequalae treatments are of great interest in terms of psychological as well as functional outcome.

[Breast reconstruction with the autologous latissimus dorsi flap]. / Reconstruction mammaire par lambeau de grand dorsal autologue.

Amongst various techniques of breast reconstruction, Autologous Latissimus Dorsi (ALD) flap without breast implant is the newest technique that took advantage of recent improvement during the last decade. Surgical procedure is well standardized, and allows to harvest various fat areas attached to the muscle, to obtain an autologous reconstruction. Thoracodorsal pedicle is steady and makes ALD the most reliable flap that can be used in several indications, especially when DIEP or TRAM flap are inappropriate. Lipomodeling of the cleavage is performed during the first surgery. Additionnal lipomodeling is performed in the whole reconstructed breast area at 2 months to get the expected volume. In some cases, two lipomodelings may be required. Advantages of ALD flap are numerous such as its reliability, its trophicity, and a very low complications rate. After a learning curve, drawbacks are well controlled, since quilting suture of the donor site helped to reduce drastically seroma rate. Finally, ALD flap became the best technique, and the most used in our team for autologous breast reconstruction, and surpassed abdominal flaps such as TRAM flap or DIEP flap.

[Results album]. / L'album des résultats.

This document is meant to be a practical guide for the surgeon, to assist him in informing the patient more easily. Different clinical results with different reconstructive techniques and different morphologies are presented. This document is not meant to be a catalogue, or to guarantee any result to the patient, but truly to assist as best as it can the surgeon and the patient in choosing together the most appropriate techniques on a visual basis.

[Lipomodeling in breast reconstruction]. / Lipomodelage en reconstruction mammaire.

Breast Lipomodeling, or Breast Lipofilling, consists in performing a graft of fatty tissue, from an area of the lower body, and moving it to the breast. This method, initially decried, has progressively taken a major place in breast reconstruction. Preoperative information is important: information must be given verbally and also by information forms from the French for French Society of Plastic, Reconstructive and Aesthetic Surgery (SOFCPRE) that can be downloaded from www.plasticiens.org. After the infiltration of adrenalized serum (1mg of adrenaline in 500mL of physiological serum), taking the fatty tissue requires a fine canula, and, non traumatically, applying a light vacuum to the syringe. The tissue is then prepared by a short centrifugation (15s at 3200rotations/s). The transfer has to be done by gently placing fine "fatty spaghettis" in the entire reconstructed breast (3D network). On the end of the fat transfer, fasciotomies are realized to free the fibrous tracts, and 30 to 50mL of tissue are added. The indications of this technique are many. Lipomodeling has progressively taken the center stage in breast reconstruction, and can be applied in addition to all reconstruction techniques. The indication of exclusive lipomodeling are much rarer: patient with very small breast and important steatomery. Ultimately, breast lipomodeling has provided a remarkable solution for the approach of the sequelae of conservative treatment in breast cancer. Finally, lipomodeling of the breast is a major advance in breast reconstruction. It has significantly improved the quality of breast reconstructions, whether autologous, or in combination with a prosthesis.

Tolerance of latissimus dorsi in immediate breast reconstruction without implant to radiotherapy.

INTRODUCTION: Immediate breast reconstruction (IBR) improves the quality of life of patients who undergo mastectomy. The latissimus dorsi flap (LDF) method provides particularly good aesthetic results, but its tolerance to subsequent radiotherapy remains unclear. We thus sought to assess tolerance and esthetic results and satisfaction, as reported by patients who underwent IBR by LDF with or without subsequent radiotherapy. MATERIALS AND METHODS: We performed a retrospective case-control study in a population of women who were diagnosed with breast cancer between January 1999 and January 2014 and who had mastectomies with IBR by LDF without prostheses. We paired 29 patients who needed postoperative radiotherapy to 58 control patients who did not. These patients responded to a questionnaire to evaluate tolerance and their satisfaction with the aesthetic results of the reconstruction. RESULTS: In total, 86.2% of all patients reported "very good" or "good" overall aesthetic satisfaction. Consistency was judged as "very good" or "good" by 82.7% of control patients and by 93.1% of case patients. No statistically significant differences were identified between the two groups with regard to reconstruction results. The number of surgical procedures needed did not differ significantly between the two groups. CONCLUSION: In our study, IBR by LDF appeared to have excellent tolerance to subsequent radiotherapy, the latter having no impact on patient aesthetic satisfaction. Our results suggest that the possibility of postoperative radiotherapy should not prevent physicians from proposing this method to women who are candidates for it.

[Anatomical basis for rejuvenation surgery]. / Bases anatomiques du tégument facial appliquées à la chirurgie du rajeunissement facial.

The understanding of the face anatomy is mandatory before to be able to appreciate the different surgical techniques of face lifting. Despite numerous controversies and anatomical variations, we can find in the literature several keystone works that allows us to understand that the soft tissues of the face are not only a superposition of layers but also a tridimensionnal structure with a fibrous system that links the different layers. This structures creates a mix loose spaces, fat and retaining ligament that can be describe in a quite systematic manner. This systematisation can help the surgeon during the surgical procedure to search and find the area where there is no danger and alert him around the retaining for example, which is where we can often find a vessel or a branch of the facial nerve that we want to avoid. This article summarizes these anatomical knowledge.

[Incisions and baseline operative technique of cervicofacial lifting]. / Incisions et technique opératoire de base du lifting cervicofacial.

Cervicofacial lifting is one of the most iconic procedure of plastic surgery and is about hundred years old. In the following chapters of this report, numerous technical points will be specify. A baseline reliable and reproducible technique, appealing to the largest possible audience is presented in order to begin this surgery in optimum conditions. Pre- and postoperative management is also exposed. The aim of this chapter is to precise incisions and baseline operative technique of cervicofacial lifting, with description of SMAS and platysma suspensions as well as complementary procedures like liposuccion and lipofilling. This chapter will lay the foundation of more complex elements that will be described in the various following chapters.

[Care and optimal management of the face- and neck-lift patients]. / Prise en charge et gestion des patients demandeurs d'un lifting cervico-facial.

Surgical and case management for patients demanding a face- and neck-lift are very important. The purpose of this paper is to help the plastic surgeons with information and recommendations useful for the best medical care of patients requiring a face- and neck-lift. The first consultation is the most important contact with the patient. The preoperative discussion helps to define patient demands and to evaluate eventual contraindications for surgery. The clinical exam and patient requirements are useful in the construction of the therapeutic proposition. This proposition is then confronted with patients' expectations and demands. The confrontation between the surgical proposition and patients' expectations allows to evaluate if it is appropriate, or not, to operate. At the end of the first consultation, the patient receives the information sheets of the French Plastic Surgery Society (SOFCPRE) according to the proposed surgical treatment. The second consultation makes it possible to verify the pertinence of the surgical act, to reiterate the preoperative recommendations, to confirm that the information given to the patient was well understood and to obtain the written consent from the patient. The written consent should include the fact that the patient received the information sheets of the SOFCPRE, that they were read and understood, and that the surgeon has transmitted the necessary information in order for the patient to take an informed and free decision to pursue with the surgery. The follow-up after surgery is as important as the surgery itself. In some cases, cosmetic gestures can be performed in the following months to obtain the best results possible and the highest satisfaction. The face- and neck-lift is an "adventure" for the patients and the postoperative difficulties should not be underestimated. However, the caring and professional support of the plastic surgeon and the support of someone of the patients' entourage can help the patient overcome this stage, and obtain a maximum benefit after this operation.

Quality of life after mastectomy with or without immediate breast reconstruction.

BACKGROUND: Mastectomy with immediate breast reconstruction (IBR) is a surgical strategy in breast cancer when breast-conserving surgery is not an option. There is a lack of evidence showing an advantage of mastectomy plus IBR over mastectomy alone on health-related quality of life (QoL). METHODS: A large prospective multicentre survey, STIC-RMI (support of innovative and expensive techniques - immediate breast reconstruction), was undertaken to study the changes in QoL in patients treated by mastectomy with or without IBR. Patients were recruited between 2007 and 2009. European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 instruments were used to assess QoL before operation, and at 6 and 12 months after surgery. A propensity score was used to compare QoL between mastectomy alone and mastectomy plus IBR, with limited bias. RESULTS: A total of 595 patients were included from 22 French academic hospitals, of whom 407 (68·4 per cent) underwent IBR. One-year data were available for 71·1 per cent of patients. Factors associated with IBR were age, histological tumour type, palpable nodes and an attempt at breast-conserving surgery. At inclusion, QoL was significantly better in the IBR group (P < 0·001) and there was no significant change in either group during 1 year compared with baseline. Results for the QLQ-BR23 functional dimension varied according to propensity score quartiles; IBR had no influence in the lowest quartile. In the upper quartiles, QoL increased slightly over the year among patients who had IBR, whereas it decreased among those who had mastectomy alone (P = 0·037). Satisfaction with the cosmetic outcome strongly influenced QoL, especially in upper quartiles (P < 0·001). However, an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy. CONCLUSION: The QoL benefit provided by IBR depends on patients' life status at inclusion; young active women with an in situ tumour are more likely to preserve their QoL after IBR.

[Patient with homozygous sickle cell disease and free flap surgery: Ensuring the success of the procedure]. / Drépanocytose homozygote et nécessité d'une réparation par lambeau libre : comment assurer la réussite du projet thérapeutique.

Sickle cell anaemia is rare in France but frequent in Africa, leading to rigid, sickle-like shape red blood cells which bind together blocking microcirculation under certain circumstances. The vaso-occlusive crisis is the most frequent clinical manifestation especially in case of homozygous disease. Sickle cells disease is therefore usually considerated as a contraindication to microsurgery, however sometimes, a free flap procedure is mandatory. We here report the case of a 47-year-old man suffering with homozygous sickle cell anaemia and needing an antebrachial free flap procedure for a tongue reconstruction. The postoperative course was unremarkable apart from a delayed healing which is common in this particular localization. A review of the litterature allows to list the precautions to be taken to ensure a microsurgical procedure with this medical background. The preoperative examination has to assess usual sickle cell disease comorbidities such as kidney failure, heart failure or pulmonary hypertension. All the events leading to either low output syndrome, hypoxia, hypothermia, or a stress caused by uncontrolled pain should be avoided per- and postoperatively. With an optimum medical care, microsurgery is possible even in patients suffering with sickle cells anaemia. This case is rare in France but will become frequent in Africa with the improvement of the healthcare system, allowing to give all patients the best medical care.

[Reconstruction of proximal nasal defect after deep carcinological resection. Interest to combine titane mesh with fat grafting]. / Reconstruction de la racine du nez après exérèse carcinologique profonde. Intérêt de combiner implants de titane et greffe de tissu graisseux.

INTRODUCTION: The mucosal cylindroma or adenoid cystic carcinoma is the second sinonasal non-epithelial malignant tumor frequency argument. Due to the achievement of the nasal mucosa and a late diagnosis reconstructions are often complex. We report the case of a mucous cylindroma recurrence of nasal septum requiring a wide and deep excision of the root of the nose with nasal reconstruction. CASE REPORT: A patient aged 66 years whose history resection two years ago with a mucous adenoid cystic carcinoma of the right side of the nasal septum, had a local recurrence T2NOM0 imposing a wide excision with amputation nasal septum own bones of nose, the anterior portion of the triangular cartilages. The reconstruction was carried out in three areas: a musculocutaneous forehead flap to the mucosal level, a titanium plate to the bone plane, nasal native skin to skin level. Histological examination confirmed the existence of a recurrence cylindroma infiltrating the bone. The surgical margins were however in sano. Adjuvant radiotherapy to 60Gy dose of the surgical area was indicated after surgery. The consequences of surgery and radiotherapy were simple. However local changes to show a progressive refinement of the nasal skin due to irradiation leading to a small titanium plate exposure revision surgery with coverage by a glabellar flap associated with a time of lipomodeling unexposed areas have improved and trophism of soft tissue. Two further lipomodeling sessions have yielded a good quality and stable skin. From an oncological point of view, no recurrence was detected with a decline of 10 years. Aesthetic and functional point of view the results were highly satisfactory. DISCUSSION: Oncologic resections subtotal nasal pyramid are complex, we will see the benefits and disadvantages of the different techniques used in the different stages. CONCLUSION: This case report illustrates the difficulties of reconstruction after wide excision of mucosal lesions root of the nose carrying the mucous plan and nasal bones. It stresses the importance of bone reconstruction titanium plate and innovative element, the efficiency of fat transfer to restore the quality and trophicity soft tissue. Fat transfer in addition to reconstructions by titanium plates and splints may thus expand the indications of these types of techniques in complex facial and cranial reconstructions.