[Paramedian frontal clefts or superior orbital clefts]. / Les fentes frontales paramédianes ou orbitaires supérieures.

Superior orbital frontal clefts are one of the rare craniofacial clefts described by Tessier in 1976, and occur most often sporadically. They are numbered 9, 10 and 11 in this classification, and are located respectively laterally, in the middle and medially to the upper part of the orbit. Their clinical expression is variable on soft tissue and bone, with possible dissociation of involvement. They range from a simple aesthetic defect to an eyes functional prognosis. CT scans are systematically required in this context. Their management must be adapted to the polymorphism of the damage, and is based on multidisciplinary approach. In case of ocular risk, the eyelid reconstruction is an emergency. In all other cases, treatment is deferred, but must be carried out at an early stage to ensure the child's healthy development.

Emissary veins and pericerebral cerebrospinal fluid in trigonocephaly: do they define a specific subtype?

INTRODUCTION: The premature fusion of the metopic suture may be associated with the presence of emissary veins (EV) and abnormally large pericerebral cerebrospinal fluid (CSF) spaces which suggest an associated focal disturbance in CSF dynamics. The incidence of such findings and their potential significance in terms of management of the disease have not been fully elucidated. The aim of this study is to investigate whether these phenomena identify specific subtypes of trigonocephaly. In such a direction, we evaluated the volume of the pericerebral CSF spaces and their relationship to the morphology ("Ω," "V," or flat type) of the prematurely fused metopic suture and to the value of the interfrontal angle value on the grounds of computed tomographic (CT) scan examinations. METHOD: The preoperative brain CT scans of 74 children (52 boys, 22 girls) with trigonocephaly who had undergone fronto-orbital remodeling were evaluated. The volume of the pericerebral CSF spaces and the value of the interfrontal angle were calculated. The type of intracranial notch was studied and classified according to its shape on the preoperative CT scan: a groove "Ω," a ridge/"V" ridge or absent when flat and evidence of emissary veins related to the abnormally fused suture. RESULTS: Preoperatively, an endocranial metopic groove or ridge was seen in 70% of the children. Emissary veins were identified in 34 of 74 patients (45%), at a mean distance of 2.04 cm (1.18-2.94 cm) from the nasion. The presence of large pericerebral CSF spaces significantly correlated with the presence of EV (p < 0.05), with the "Ω" type (p < 0.05) and with interfrontal angles under 134° (p < 0.005). CONCLUSIONS: Metopic suture early fusion shows an association between EV, pericerebral CSF spaces, and the "Ω" groove appearance of the suture. This association identifies a specific subgroup in which the presence of emissary veins and large pericerebral CSF spaces is an indicator of local venous hypertension due to the sagittal sinus constriction within an osseous groove created by the abnormal suture fusion process. The implications for the surgical management and long-term results as compared to trigonocephalic children with small or absent normal peripheral spaces and EV are still to be determined.

[Use of the autologous dorsal dermis in reconstruction of the posterior palpebral lamella in blepharopoiesis]. / Utilisation du derme dorsal autologue en reconstruction lamellaire palpébrale postérieure en blépharopoïèse.

OBJECTIVES: Blepharopoiesis represents a double aesthetic and functional challenge. If anterior lamellar reconstruction is less discussed, the variety of posterior lamellar substitutes testifies that none is ideal. We report here our experience of the use of autologous dermal dermis as posterior lamellar substitutes in bilamellar blepharopoiesis. PATIENTS AND METHOD: We performed a single-center retrospective observational study of seven patients undergoing blepharopoiesis using dorsal dermal autograft as posterior lamellar substitute. RESULTS: Between September 2011 and January 2017, seven patients aged of 80.9 years on average were cared for. The defect, affecting in 6 cases on 7 the lower eyelid, concerned almost three-quarter of the length of the eyelid. These defects followed the excision of basal cell carcinomas. Procedures performed under local anesthesia have simple follow-up without complications of the donor site. The superficial surface of the graft in contact with eyeball was covered in 2.4 months with a non-keratinized squamous epithelium like the conjunctiva. Two patients presented ocular functional signs during 2 months without keratitis. Two patients required a second correction procedure. CONCLUSION: The use of the dorsal dermis seems reliable, simple, fast, possible under local anesthesia and sedation, achievable in one operative time, outpatient, without temporary tarsorraphy. The graft is available in large quantities and its removal is not morbid. The good functional and esthetic results suggest that the autologous dermal dermis could represent the main alternative to palatal fibromucosa as a posterior lamellar substitute in old population.

[Paracommissural cleft of the lower lip: Therapeutic strategy]. / Fente labiale inférieure para-commissurale : stratégie thérapeutique.

We report the first case described in the literature of lateral, paracommissural cleft of the lower lip in a 2-year-old child. This anomaly caused labial incompetence requiring surgical correction. Different surgical techniques have been described for the treatment of the cleft of the upper lip. We studied each of them, analyzed the advantages and disadvantages of these techniques by inverting them and adapting them for the lower lip. We opted for the double "Z" plasty of Malek because the difference in height between the cleft side and the healthy side was important. In addition, this plasty hides part of the scar in the labiomental groove. The functional and aesthetic result at 6 months after surgery is satisfactory.

[Facial feminization surgery - middle and inferior thirds]. / Chirurgie de féminisation du visage ­ tiers moyen et inférieur.

The authors present the surgical techniques of facial feminization of the middle third and the inferior third in the context of sexual reassignment surgery. These techniques adapted to patients 'male to female' are proposed to strong masculine facial features of patients and are based in the middle third of the remodeling of the malar region by fat grafting, reduction and/or deprojection techniques in rhinoseptoplasty and upper lip surgery. Concerning the inferior third, remodeling of the mandibular angles, genioplasty and chondrolaryngoplasty are adapted.

[Facial feminization surgery - upper third]. / Chirurgie de féminisation du visage ­ tiers supérieur.

The authors present the upper third of the facial feminization techniques in the context of transgender surgery. These techniques adapted to patients "male to female" are proposed to strong masculine facial features of the patients and for the upper third of the face, based on transfer of adipose tissue, fronto-orbital remodeling and correction of the hairline by scalp advance.

Cricothyroidotomy in extreme emergency: A case report of a real-life experience in three steps and less than 30 s using a single blade.

INTRODUCTION AND IMPORTANCE: Cricothyroidotomy is often the last resort when conventional ventilation devices prove ineffective. The conventional procedure that involves several steps and requires the completion of a preoperative checklist. This report describes a novel approach to cricothyroidotomy, allowing quick access to the cricothyroid membrane in fewer steps. CASE PRESENTATION: We present the case of a 26-year-old male with Schimmelpenning syndrome, exhibiting significant anatomical deformity. Following surgery for temporomandibular joint replacement, the patient developed a hematoma requiring urgent intervention. During nasotracheal intubation, the patient experienced a significant drop in oxygen saturation, which required prompt cricothyroidotomy. The procedure was performed in less than 30 s using a single blade for incising the tissues and the surgeon's hands for dissection and retraction. The procedure resulted in immediate recovery of the patient's oxygen saturation. CLINICAL DISCUSSION: In contrast to previously reported multi-step procedures, this study reports a simpler three-step cricothyroidotomy. The technique involves a vertical skin incision, blunt dissection using the surgeon's fingers, and a horizontal incision on the cricothyroid membrane. The procedure was executed with the patient in a semi-reclined position, optimizing time efficiency. CONCLUSION: This case highlights the efficacy of a rapid cricothyroidotomy technique in extreme emergencies. The presented technique requires minimal instrumentation and can be completed quickly in an emergency situation, even in the presence of anatomical variations.

[Inflammatory granuloma of iliac bone harvest site: a rare complication of Horsley bone wax]. / Granulome inflammatoire du site de prélèvement osseux iliaque : une complication rare de la cire à os d'Horsley.

Bone wax or Horsley wax, which is used very frequently in bone surgery, is a non-absorbable mixture of beeswax (70%) and Vaseline. It permits the haemostasis of bone gaps by mechanical obstruction of bone pores containing blood capillaries. Complications due to this product are rare but sometimes quoted in literature. We report the case of a 17-year-old patient who, 10 months after surgery and after an asymptomatic period, presented an inflammatory granuloma at the scar of iliac bone harvest, which had been used as a maxillary graft. This complication necessitated a first exploratory and cleansing surgery, as well as a second surgery, which clarified the origin of the inflammation and made it possible to eliminate the wax remains. We think that bone wax should be used sparingly and with caution, firmly applied to the bleeding site without leaving any free particles.

[Zygomatic bone repositioning osteotomies]. / Ostéotomies de repositionnement de l'os zygomatique.

INTRODUCTION: The main morphological sequels of zygomatic bone fractures are lack of zygomatic projection and enopthalmia. They may be corrected by zygomatic osteotomy which is a difficult operation because of modified anatomic landmarks. Onlay bone or alloplastic grafts are preferred. TECHNICAL NOTE: Zygomatic osteotomies are performed through three surgical approaches: superior palpebral, sub-ciliary, and upper vestibular, followed by repositioning with osteosynthesis micro-plates. They allow reconstruction with an adequate projection in three dimensions. Surgery is usually associated with a bone graft of the orbital floor. DISCUSSION: Zygomatic osteotomy is a simple, reproducible technique, but it requires a good bone exposure. The esthetic results are satisfactory with an uneventful outcome. This surgical procedure is a good alternative to isolated techniques of autologous bone grafting or alloplastic material reconstruction which have sometimes disappointing and short lasting results due to graft resorption.

Posterior auricular artery helix root free flap-part I: radio-anatomical study.

Full-thickness defects of the distal nose are an ongoing surgical challenge. Among the available techniques, pre-auricular chondrocutaneous free flaps based on the superficial temporal artery (STA) have good aesthetic and functional outcomes. However they often require autologous venous grafts. The aim of this radio-anatomical study was to evaluate the feasibility of the helix root free flap based on the posterior auricular artery (PAA). Vascular lengths, diameters, and networks were investigated in flaps harvested from cadavers. The perfusion of the flaps was studied by injecting patent blue. Some flaps were also injected with contrast agent and studied by angiography and computed tomography. Ten flaps from seven fresh cadavers were dissected and analysed. The mean length of the PAA was 114.2 mm and the mean diameter was 2.2 mm. Perfusion was investigated in six flaps and considered good in three of these. The study results demonstrate the feasibility of PAA-based helix root free flaps. This alternative technique provides an 11 cm pedicle with vessels of appropriate calibre, facilitating any potential microsurgery. The scar is mostly hidden behind the ear. This PAA-based helix root free flap could be a reliable and promising single-stage procedure to repair complex defects of the alae nasi.

A new approach of crenellated fronto-orbital advancement for the management of trigonocephaly: Technical note.

Trigonocephaly is a craniosynostosis characterized by a premature fusion of the metopic suture associating a characteristic triangular head shape, with a frontal medial crest and hypotelorism. Various techniques have been described for its surgical treatment which is usually performed during the first year of life. However, there might be cases with a late referral, after the age of one year. One of the technical issues with a fronto-orbital advancement surgery in a child over one year of age is that there is a significant risk of persistent residual bone defects. This article describes a surgical technique of crenellated fronto-orbital advancement for correcting trigonocephaly in children over one year of age, allowing to reduce residual bone defects.

Optimized enrichment for the detection of Escherichia coli O26 in French raw milk cheeses.

AIMS: Our main objective was to optimize the enrichment of Escherichia coli O26 in raw milk cheeses for their subsequent detection with a new automated immunological method. METHODS AND RESULTS: Ten enrichment broths were tested for the detection of E. coli O26. Two categories of experimentally inoculated raw milk cheeses, semi-hard uncooked cheese and 'Camembert' type cheese, were initially used to investigate the relative efficacy of the different enrichments. The enrichments that were considered optimal for the growth of E. coli O26 in these cheeses were then challenged with other types of raw milk cheeses. Buffered peptone water supplemented with cefixim-tellurite and acriflavin was shown to optimize the growth of E. coli O26 artificially inoculated in the cheeses tested. Despite the low inoculum level (1-10 CFU per 25 g) in the cheeses, E. coli O26 counts reached at least 5.10(4) CFU ml(-1) after 24-h incubation at 41.5 °C in this medium. CONCLUSIONS: All the experimentally inoculated cheeses were found positive by the immunological method in the enrichment broth selected. SIGNIFICANCE AND IMPACT OF THE STUDY: Optimized E. coli O26 enrichment and rapid detection constitute the first steps of a complete procedure that could be used in routine to detect E. coli O26 in raw milk cheeses.

[Contribution of low-intensity pulsed ultrasounds to bone regeneration]. / Intérêt des ultrasons pulsés de faible intensité dans la stimulation de la régénération osseuse.

A maxillo-facial surgeon manages patients with bone defects due to trauma, malformations or of iatrogenic origin. The surgical management has potentially deleterious effects and its cost for society is increasing. Hence, it is crucial to develop techniques stimulating bone growth, stimulating the regeneration of a fracture or filling bone deficit. Ultrasounds (US), vibrations of the same nature as sound but with frequencies above the highest audible frequency for men (above 20 kHz), are used in many fields, particularly in medicine, usually at frequencies of around 0.5 to 5 MHz (million cycles per second). Their biological effects are not fully understood yet, but it is well known that US have effects on organic tissues when their mechanical energy is converted into thermic energy. These effects induce vasodilation and modification of membrane permeability. Several publications present the benefit of US for the stimulation of bone regeneration after a fracture. We present an overview of current knowledge on the effect of pulsed ultrasound on craniofacial bone regeneration, with study results conducted within Inserm unit U1032 in Lyon, the current reference lab on this issue.

Superficial temporal artery perforator flap for reconstruction of periorbital and eyelid defects, a variant of the classic flaps dissected in perforator flap.

INTRODUCTION: The eyelids reconstruction presents an aesthetic, but above all, a functional challenge. It must allow the good protection of the cornea. The development of perforator flaps is major in recent years and is gradually spreading to the face, which has pushed us to apply it to palpebral surgery. MATERIAL AND METHOD: Since 2014, in the maxillofacial surgery department of St Etienne, four patients have benefited from a palpebral reconstruction. A temporal perforator flap, dissected on a perforator of the superficial temporal artery was performed for the anterior lamella and a palatal mucosa graft for the tarsal reconstruction. RESULTS: The results were satisfying. Functionally, this technique allowed good occlusion of the eyelid and prevented the occurrence of ocular complications. On the aesthetic view, the position of the neo-eyelids is satisfying. No patient need retouching. The perforator flap allowed a significant mobilization without distortion of neighboring tissues, and maintaining frontal contractility. DISCUSSION: This contemporary approach to flap dissection provides a good functional result, reduces the sequelae of the donor site and does not impose a secondary aesthetic gesture. However, despite these advantages, this type of dissection has the disadvantage of being technically more delicate and requires a trained operator.

Survival and spread of Shiga toxin-producing Escherichia coli in alpine pasture grasslands.

AIMS: To determine the fate of Shiga toxin-producing Escherichia coli (STEC) strains defecated onto alpine grassland soils. METHODS AND RESULTS: During the summers of 2005 and 2006, the field survival of STEC was monitored in cowpats and underlying soils in four different alpine pasture units. A most probable number (MPN)-PCR stx assay was used to enumerate STEC populations. STEC levels ranged between 3.9 and 5.4 log(10) CFU g(-1) in fresh cowpats and slowly decreased until their complete decay (inactivation rates k < 0.04 day(-1)). PFGE typing of STEC strains isolated from faecal and soil samples assessed the persistence of various clonal types for at least 2 months in cowpats and their vertical dispersal down through the soil at a depth up to at least 20 cm. STEC cells counts in soil were always below 2 log(10) CFU g(-1), regardless of the pasture unit investigated. The soil became rapidly free of detectable STEC once the cowpat had decomposed. The eight STEC strains isolated during this study belonged to six distinct serotypes and tested positive for the gene(s) stx2, including the stx2g and stx2 NV206 variants. CONCLUSIONS: STEC were able to persist in cowpats and disseminate down through the soil but were unable to establish. SIGNIFICANCE AND IMPACT OF THE STUDY: This study provides useful information concerning the ecology of STEC in alpine pasture grasslands and may have implications for land and cattle management.

[The impact of low intensity pulsed ultrasound on mouse skull bone osteoblast cultures]. / Ultrasons pulsés de faible intensité (LIPUS): effets sur des cultures d'ostéoblastes crâniens de souris.

INTRODUCTION: Low intensity pulsed ultrasound (LIPUS) is one of the methods used to stimulate bone regeneration. This technique is still not well known or explained. The expression of several proteins (VEGF, IL-8, FGF-ß, IL-1 ß) or genes (ALP and OP) was increased after being exposed to weak ultrasounds, whereas IL-6 and TNF-α were not affected. The purpose of this study was to verify and understand the mechanisms involved in this stimulation, and more specifically to understand if the stimulation concerned only cellular differentiation factors or if it also affected transcription of stem cells into osteoblasts. MATERIALS AND METHODS: Cultures of mouse skull bone osteoblasts were exposed to pulsed ultrasounds of varying intensities during three consecutive days. The effect of this stimulation was assessed by counting cells and determining the number of bone nodules formed. We studied various genes participating in osteoblast proliferation or in the differentiation and transcription of osteoblasts, using reverse transcriptase PCR. RESULTS: The cellular proliferation of osteoblasts was increased after stimulation by low intensity pulsed ultrasound. The expression of various genes involved in differentiation and transcription of stem cells into osteoblasts was increased, especially after stimulating at 100 mW/cm(2). DISCUSSION: Low intensity pulsed ultrasound allows stimulation of bone proliferation in vitro by stimulating osteoblastic differentiation and transcription.

[Treatment by fat tissue transfer for radiation injury in childhood facial cancer]. / Traitement par transfert graisseux des séquelles postradiques de tumeur faciale maligne de l'enfance.

The radiation treatment of malignant facial tumors in children may induce major functional and cosmetic sequelae, mainly due to uneven growth of the bones and soft tissues, resulting in facial asymmetry and hemihypotrophy at adult age. Although fat transfer has proven effective for facial cosmetic treatment, few studies have demonstrated the benefit of the technique in heavily irradiated tissues. The techniques generally used for the treatment of facial asymmetry or hypotrophy are ill-adapted to irradiated patients. Indeed, procedures such as skin detachment, osteotomy and vascular suture are risky because of radiation-induced damage. The aim of the present study was to investigate the potential benefits of fat transfer for the correction of sequelae of facial irradiation. Four patients (two males and two females) aged 27, 25, 16 and 13 years underwent fat grafting for the correction of facial asymmetry or hypotrophy induced by cancer radiation treatment during childhood (radiation dose of more than 50Gy). One to three grafting sessions were required, depending on the cases. After a median follow-up of 3.9 years, cosmetic results were considered satisfactory by both the patient and the surgeon in all four cases. Fat transfer remarkably improved the cosmetic appearance of the patients, without deleterious consequences for the vitality of tissues. In addition, a restoration of skin trophicity was observed, thus confirming the benefit of grafting adipocytes into the irradiated integument. In conclusion, fat grafting appears to be a simple and easily reusable technique which makes it possible to obtain the best morphological and cosmetic results in irradiated patients, whereas avoiding complex and potentially hazardous procedures.

[Justification for the mandibular-maxillary order in bimaxillary osteotomy]. / Justification de l'ordre mandibule-maxillaire dans l'ostéotomie maxillomandibulaire.

INTRODUCTION: Our aim was to study the reliability of sagittal split osteotomy and Le Fort I osteotomy respectively, and to try to judge objectively the impact of their order for the final result of bimaxillary osteotomy. PATIENTS AND METHOD: Fifty patients were included. For each we calculated the errors generated by sagittal split osteotomies on one hand and Le Fort I osteotomy on the other hand, by performing a peroperative splint after each osteotomy. RESULTS: After sagittal split osteotomies changes in the anteroposterior direction were present in 74% of cases with an average amplitude of 0.32mm. They were less frequent in the transversal direction, 54% of cases, with a smaller amplitude (0.19mm). After Le Fort I osteotomy, there was no difference in 92% of cases with an average error of 0.02mm in the anteroposterior direction. No errors were observed in the transverse direction. DISCUSSION AND CONCLUSION: Le Fort I positioning is remarkably accurate contrary to the sagittal split. Using Le Fort I osteotomy first and mandibular sagittal split second has for drawback to perpetuate the errors of the sagittal split. The reverse order, beginning with the mandible, allows correction of sagittal split mistakes with the Le Fort I osteotomy. So it seems that the latter order is more logical and preferable.

[Intermaxillary fixation: technique and benefit for piezosurgical sagittal split osteotomy]. / Blocage maxillomandibulaire: technique et intérêt dans le clivage sagittal piézoélectrique.

INTRODUCTION: The aim of this study was to assess piezosurgical sagittal split osteotomy with peroperative inter maxillary fixation. MATERIAL AND METHOD: We studied 25 bimaxillary osteotomies, 50 sagittal split osteotomies performed with this technique. It included both maxillomandibular fixation during all the split osteotomy and performing split osteotomy in five steps. For each case, we noted the type of dysmorphia, the size of split osteotomy and the time required for surgery, along with common data such as sex, age, etc. The data was compared to results of a previous series of patients also operated with Piezosurgery but without peroperative maxillomandibular fixation. RESULTS: Using peroperative maxillomandibular fixation during piezosurgical bilateral sagittal osteotomy decreases the length of surgery by 33%, allows 9 times out of 10 for complete splitting, including the basilar edge, has no adverse effect especially on orthodontic material. DISCUSSION: Piezosurgery is a great progress for orthognatic surgery because of its precision and ability to preserve soft tissues. But it requires modification of the usual technique for mechanical section. Using peroperative inter maxillary fixation during ultrasonic splitting is a remarkably effective and easy technical modification.

Sagittal suture craniosynostosis or craniosynostoses? The heterogeneity of the most common premature fusion of the cranial sutures.

BACKGROUND: Scaphocephaly is usually defined as the deformation of the skull resulting from the premature fusion of the sagittal suture. It is the most common type of craniosynostosis, and can be easily recognized on simple clinical examination. Its pathophysiology is easy to understand and to confirm on neuroradiological examination. In contrast, surgical indications are still somewhat controversial, the dispute mainly concerning therapeutic versus esthetic objectives. In recent years, however, several studies have challenged these basic and relatively simplistic interpretations of the pathophysiology of the condition. MATERIALS AND METHODS: To assess the heterogeneity of scaphocephaly, we reviewed cases of scaphocephaly operated on at the Hôpital Femme-Mère-Enfant, Lyon University Hospital, France during a 10-year period (2008-2017) and performed a review of the literature on scaphocephaly and sagittal suture closure. RESULTS: During the 10-year period, 401 children were operated on for a scaphocephaly at the Hôpital Femme Mère Enfant, Lyon University Hospital. Mean age at surgery was 1.14 years, for a median 0.7 years (range, 4 months to 8. 5 years). Several subtypes could be distinguished according to morphology, intracranial findings on imaging, patient age, and etiology associated to the sagittal synostosis. Two main surgical techniques were used to correct the malformation, depending on patient age, type of deformation and the surgeon's preference: cranial vault remodeling with occipital pole widening, with the patient in a prone position, and parietal enlargement with or without forehead remodeling, in dorsal decubitus. CONCLUSIONS: The complexity and heterogeneous nature of sagittal synostoses depend on different pathogenic mechanisms leading to and interfering with the skull abnormalities: abnormalities of CSF dynamics, possibly associated with systemic alterations, accounting for the varied postoperative morphological and functional course, in terms of cognitive impairment and late complications (notably intra-cranial pressure elevation). However, the real impact of such heterogeneous clinical presentations on surgical indications and surgical results remains to be elucidated.