Description and variability of temporal venous vascularization: clinical relevance in temporoparietal free flap technique.

The few studies on the venous vascularization of the temporal area indicate a high variability among individuals. The preoperative knowledge of the venous vascularization of the temporal area is critical for microsurgical reconstruction, such as temporoparietal fascia free flap, and especially in understanding the anatomy of the veins for flap survival. Therefore, we conducted an anatomic study to confirm the classification of Legre et al. and a radiologic study to examine the venous network of the temporal area. We found three frequent patterns of the temporal venous network: (1) Type I (the most common), with a predominant temporal vein; (2) Type II, with a predominant posterior auricular vein; (3) Type III, when both veins were equally important. Because of this great variability, the use of a temporal flap for reconstruction of the head and neck should be restricted, and the examination of venous vascularization appears to be necessary before surgery. Here, we report a three-dimensional description of the venous temporal vascularization by computer tomography, which is particularly useful before temporoparietal flaps.

[Oral appliances or maxillomandibular advancement osteotomy for severe obstructive sleep apnoea in patients refusing CPAP]. / Orthèse d'avancée mandibulaire ou ostéotomie maxillo-mandibulaire pour le traitement des syndromes d'apnées obstructives du sommeil sévères refusant la PPC.

OBJECTIVES: The management of patients with severe obstructive sleep apnea syndrome (OSAS) refusing or not tolerating continuous positive pressure ventilation (CPAP) remains problematic. We evaluated the effectiveness of oral appliances and of maxillomandibular advancement osteotomy. METHODS: One hundred and two patients with severe OSAS were included between 2001 and 2006. Maxillo-mandibular advancement osteotomy was proposed to patients less than 60 years of age, non obese and without comorbidities. The other patients were treated with oral appliances. All patients underwent polysomnography at 3 months. RESULTS: Group A: 25 patients with mean apnea-hypopnea index (AHI) at 45/h were treated by maxillo-mandibular advancement. Three months after the surgery, AHI had decreased from 45 to 7. The success rate was 89% when AHI was less than 15/h and 74% when AHI was less than 10/h. Sixteen patients performed a polysomnography one year after surgery with similar results. There were no major postoperative complications. Group B: 77 patients with a mean AHI at 41/h were treated with oral appliances. Only 23 patients underwent polysomnography at 3 months. The mean AHI had decreased from 41/h to 22/h. The success rate was 56% when AHI was less than 15/h and 30% when AHI was less than 10/h. DISCUSSION: We are confronted with an increasing number of severe OSAS patients with CPAP failure or intolerance. Surgery for maxillo-mandibular advancement is an effective alternative. However, it is not always indicated or accepted by the patient. So an oral appliance remains a useful therapeutic option despite its moderate success rate.

[Advanced skin tumors (incurables?) of the cephalic extremity: surgical considerations]. / Tumeurs cutanées évoluées (dépassées ?) de l'extrémité céphalique : réflexions chirurgicales.

Suggest a surgical thinking for a multidisciplinary problem is inevitably difficult. Nevertheless, through targeted clinical examples, we tried to prioritize our clinical and intellectual approach for advanced tumors of the cephalic extremity. In these cases, decisions can only be collegial, and respect for the patient and his choices remain essential. Ultimately, we would argue this problematic, discussing successively the histological type, ethical concern with regard to clinic, operability and reconstruction opportunities.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

Mechanical properties of fused sagittal sutures in scaphocephaly.

BACKGROUND: Craniosynostosis in newborns is caused by the premature closure of the cranial sutures leading to cranial vault deformity. It results in aesthetic imbalance and developmental disabilities and surgery is frequent during the first months of growth. Our study focused on scaphocephaly defined as the premature closure of the sagittal suture. We hypothesised that the effective mechanical properties of sutures were altered as compared to those of the parietal adjacent tissue considered as control. METHODS: The population consisted of seven males and four females (mean age 4.9 months). Sixteen suture samples and thirty-four parietal tissue samples were harvested during corrective surgery and investigated by using three-point bending tests to obtain the structure-stiffness of specimens. An energy model was used to derive the effective Young's modulus. A histological study complemented the experimental protocol. FINDINGS: Fused sutures were thicker than adjacent bone and the natural curvature of sutures did not influence the static mechanical response. The stiffness of stenotic sutures was significantly higher than that of the parietal bone. The effective Young's modulus of stenotic sutures was significantly lower than that of the parietal adjacent tissue. The parietal tissue showed a parallel bone architecture whereas the central stenotic tissue was disorganised with more vascularisation. INTERPRETATION: The stenotic suture differed in structural and mechanical terms from the adjacent bone during calvarial growth in the first year of life. Our study emphasised the alteration of effective tissue properties in craniosynostosis.

[A novel miniplate model for maxillary osteotomies]. / Nouveau modèle de miniplaques pour les ostéotomies maxillaires.

INTRODUCTION: The use of miniplates in orthognatic surgery, and especially for Le Fort I osteotomies, has brought great improvement in technical aspects, postoperative evolution, and long-term stability. Nevertheless, accurate modelling of theses plates remains problematic because the right balance between malleability and rigidity is hard to determine. This is why we designed an original new miniplate model. The aim of this study was to assess our new model in clinical settings. MATERIAL AND METHOD: This novel plate was made of two lateral sockets with two holes on each side, linked by a central bar, 1mm thick like the plate. Three lengths were available. A mechanical study proved that this plate was stronger than a 0.6 millimeter thick plate and that its adaptability was much superior to that of a common 1-mm thick plate. We retrospectively studied 180 patients having undergone a Le Fort I osteotomy with or without mandibular osteotomy. Follow-up ranged from 6 to 12 months. Congenital abnormalities were excluded. RESULTS: Bone healing was achieved without any complication in due time for all but two patients. In one case, a plate fracture was observed. In the other case, a slight mobility of the upper jaw appeared after removal of the device. No intolerance was observed. DISCUSSION: This novel miniplate seems to be improved when compared to other available devices. Rigid osteosynthesis of a Le Fort I osteotomy can be problematic because of the repositioning gap and the variable anatomy of the maxilla. The device must be rigid enough, inconspicuous, and well tolerated. Only three plate lengths are necessary to treat all cases, which reduces cost and storage. The only requirement is to mandatorily insert four plates every time. Removal of the plates does not seem necessary.

One-step primary reconstruction for complex craniofacial resection with PEEK custom-made implants.

PURPOSE: Reconstruction of large craniofacial defects has largely improved since custom-made implants have been developed in the past decade. For large lesions in fronto-orbital region (such as osteomeningioma), we applied a simple and reliable protocol to perform optimal primary reconstruction with PEEK (polyetheretherketone) specific implant at the same time of the resection. MATERIAL AND METHODS: Our protocol is based on virtual preoperative surgery with a planned bone resection that allows engineering of a specific implant to accurately fit to the defect during the surgery. Thus tumour removal and optimal immediate reconstruction are performed easily in a single-step procedure. The use of navigation is required to perform accurate resection according to the planning. We report our experience in five patients requiring complex orbito-frontal reconstruction. RESULTS: Planned resection was always achieved with accurate placement of the implant. Optimal orbital reconstruction is allowed and permits exophthalmos correction and orbital contour symmetry. No major complication was observed. CONCLUSION: We provide a simple one-step technique to reconstruct the orbit while achieving symmetric cosmetic and functional results, reducing operative time and avoiding donor site morbidity.

[Custom-made implants for craniofacial reconstruction]. / Les implants sur mesure en reconstruction craniofaciale.

The development of computer-aided design (CAD) technologies applied to biomaterials has allowed designing patient-specific implants perfectly adapted to the area to rebuild, and ensuring an easier, less invasive, and optimal reconstruction of the craniofacial skeleton. Custom-made implants, originally developed for the reconstruction of large cranial vault defects, were used to optimize cosmetic results, avoiding the morbidity related to donor site bone harvesting, or preventing frequent asymmetrical result due to peroperative biomaterial design. These implants thus proved very useful for facial skeleton reconstruction including for the orbital region. The preoperative computerized simulation made in collaboration with manufacturers allows optimizing reconstructions specifically for each patient.

[Septic pseudarthrosis of the mandible and endodontic treatment]. / Pseudarthrose septique mandibulaire et traitement endodontique.

INTRODUCTION: Septic pseudarthrosis of the mandible is an uncommon complication with several etiologies. The presence of a tooth next to a fracture site is one of the etiological factors. Conservative management of a tooth in or near the mandibular fracture site is often the issue when treating fracture of a toothed part. OBSERVATION: A 49 year-old male patient was hospitalized in our department for a bifocal fracture of the mandible (right parasymphysis and left sub-condylar). An open reduction internal fixation with plates and screws was performed. The immediate postoperative period was uneventful except for persistent tooth pain in the parasymphyseal fracture site. At 1 postoperative month, the fracture site was stable and signs of consolidation were documented by the panoramic view. A dentist performed root canal treatment on tooth 42, 8 weeks after surgery, because of recurrent complaint by the patient. At 6 months, clinical and radiological examinations revealed mandibular pseudarthrosis. DISCUSSION: This type of pseudarthrosis case is relatively infrequent. It occurs after endodontic treatment of a healthy tooth close to the fracture site (performed after the physiological delay before bone healing). The bacterial colonization of the fracture site could be related to this endodontic treatment. This case raises questions on the need for endodontic treatment of a tooth near a mandibular fracture site.

[Osirix: free and open-source software for medical imagery]. / Osirix: logiciel libre d'imagerie médicale.

Osirix is a tool for diagnostic imagery, teaching and research tasks, which presents many possible applications in maxillofacial and oral surgery. It is a free and open-source software developed on Mac OS X (Apple) by Dr Antoine Rosset and Dr Osman Ratib, in the department of radiology and medical computing of Geneva (Switzerland).