RESUMO
PURPOSE: The deep inferior epigastric perforator (DIEP) flap provides excellent results when performed by a trained surgical team. However, the beginning of the procedure is often complicated. To date, few authors have published their initial experiences. This study presents our team's experience using a DIEP flap in breast reconstruction. METHODS: From June 2008 until December 2013, the same leading operator performed 132 consecutive DIEP flaps. Breast reconstructions were immediate (n=18) or delayed (n=114), unilateral (n=110) or bilateral (n=11). The learning curve was assessed using the operating time, ischemic time, postoperative hospital stay, and complications. For statistical comparisons, unilateral reconstructions were divided into five chronologic groups of 22 consecutive DIEP flaps and two chronologic groups of 55 flaps. RESULTS: The average time of surgery was 291 min (range, 185-645) for unilateral breast reconstruction and 513 min (range, 400-790) for bilateral breast reconstruction. The global complication rate was 24.5%. In the unilateral series, the time of surgery decreased progressively from 415 min to 233 min (P=4.8×10(-8)). The mean postoperative hospital stay was reduced from 7.14 days to 6.32 days (P=0.042). The complications and flap failure rates had regular time distributions. Initially, the revision rate reached 50% for the first ten unilateral cases but decreased rapidly and remained steady at 6% for the following cases (P=0.0012). CONCLUSIONS: Our initial experience of DIEP flap breast reconstruction showed a significant improvement of surgical performances exceeding 50 cases, with a critical ten first case period.
Assuntos
Mamoplastia , Retalho Perfurante , Adulto , Idoso , Feminino , Hospitais Universitários , Humanos , Curva de Aprendizado , Mastectomia , Pessoa de Meia-Idade , Duração da Cirurgia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto JovemRESUMO
INTRODUCTION: Squamous cell carcinomas (SCC) of the ear are known for their aggressiveness. The aim of this study was to investigate factors of gravity while freeing the therapeutic requirements. PATIENTS AND METHODS: This is a retrospective study of 28 patients (30 ears) operated for SCC. The characteristics of the lesion, the presence of metastasis, treatment modalities and histologic findings were collected. Local recurrences and metastasis are identified with a mean follow-up time of 37months (17-110months). RESULTS: The lesion size was less than 2cm in 19 cases (63.3%) and greater than or equal to 2cm in 11 cases (36.7%). Macroscopic resection margins were 5, 7 or 10mm. The resections were histologically incomplete in 4 cases (13%) requiring further surgery. Six cases had local recurrence (20%): three with pulmonary or lymph node metastases (10%) and one death (3.3%). In these 6 cases of recurrence, the surgical margins were 6.3mm on average, the initial lesion measured always greater than 2cm (100%). Three quarters of incomplete resections have recurrent despite a surgical revision in healthy margin. CONCLUSION: Our study confirms the data of literature, namely the pejorative character of a lesion greater than 2cm and incomplete resection. The HAS recommendations seem minimal regarding the ear. In case of injury by more than 2cm and with a proximal location on the ear pinna, only amputation of the ear allows satisfactory cancer control.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Neoplasias da Orelha/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
INTRODUCTION: The transverse musculocutaneous gracilis free flap allows a wider range of indications in autologous breast reconstruction. They extend far beyond traditional dorsal, abdominal and gluteal flaps. The authors present their experience in using this innovative procedure. PATIENTS AND METHODS: The cutaneous and adipose part of the flap consists in a horizontal ellipse centered on the gracilis muscle in the upper thigh. The distal part of the muscle is released without neither visual control nor additional incision. The flap vascular pedicle is microanastomosed to the recipient internal thoracic vessels in the third intercostal space. Eleven patients, with a mean age of 44 years (29-62) and a BMI of 24 (19-32) underwent this procedure. Surgery was performed on either one side (n=6) or two (n=5), in indications of immediate (n=5) or delayed reconstruction (n=6). The main operative parameters (time, vessel diameter, pedicle length, flap volume) as well as postoperative follow-up were studied. RESULTS: Mean time of surgery was 4h33 (3-6 hours). Pedicle measured 6.2 cm (5-7.5) and diameter of the artery was 19 mm (15-30). Average weight of the flap was 344g (270-498). Two cases of partial necrosis occurred in the posterior cutaneous part of the flap (1cm(3) and 3 cm(3)). They were treated using controlled wound healing. Sequelae in the donor site proved minimal as the scar was placed in the crural crease and the gluteal fold. No major functional defect was noted after mean follow-up of six months. CONCLUSIONS: The transverse musculocutaneous gracilis free flap allows natural and durable reconstruction while reducing cosmetic and functional sequelae in the donor site. It proves to be particularly useful in bilateral immediate reconstructions following skin-sparing mastectomy. This surgical option offers new opportunities to long-limbed women without abdominal excess wishing autologous breast reconstruction.
Assuntos
Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/cirurgia , Mamoplastia/métodos , Retalho Miocutâneo/cirurgia , Adulto , Anastomose Cirúrgica/métodos , Artérias/cirurgia , Neoplasias da Mama/radioterapia , Terapia Combinada , Feminino , Seguimentos , Retalhos de Tecido Biológico/irrigação sanguínea , Humanos , Pessoa de Meia-Idade , Retalho Miocutâneo/irrigação sanguínea , Radioterapia Adjuvante , Coleta de Tecidos e Órgãos/métodos , Cicatrização/fisiologiaRESUMO
INTRODUCTION: The Risdon modified approach, for mandibular surgery, is well adapted to treatment of low subcondylar fractures. According to our experience, this approach with a low rate of complications should also be considered for non-traumatic ramus surgery. MATERIAL AND METHODS: Twenty Risdon modified approaches were used in 11 patients for non-traumatic indications (seven bilateral osteotomies, four unilateral osteotomies, one biopsy, one bone graft). One patient was operated twice with the same approach. RESULTS: In all cases, the planned surgery could be performed using this approach. The only complication was a case of temporary paresis of the facial nerve's mandibular branch. The scar was always considered as quite acceptable. DISCUSSION: As for traumatology, the Risdon modified approach is an improvement for ramus non-traumatic surgery. It has a very low rate of complications, especially for the facial nerve. The intraoral approach avoids scarring, but the resulting exposure is insufficient and requires using a transcutaneous device or endoscopy. In orthognathic surgery, the wide exposure of the lateral aspect of the ramus, the corpus, and the basilar edge, facilitates important mandibular advancement.
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Mandíbula/cirurgia , Cirurgia Ortognática/métodos , Osteotomia/métodos , Adulto , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Fraturas Mandibulares/patologia , Fraturas Mandibulares/cirurgia , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Osteotomia/reabilitação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Adulto JovemRESUMO
UNLABELLED: The quality of microsurgical sutures is a key to success in free flaps. Automatic devices are meant to improve safety and simplify microvascular anastomoses. We present the assessment of our clinical experience using automatic suture based on double ring eversion system. MATERIAL AND METHODS: This system has been tested during an eighteen months period, in 72 consecutive venous end to end anastomoses. This technical innovation was used in 58 free flaps on a total of 52 patients. Indication for free flap was breast reconstruction (n=40), facial reconstruction (n=14), abdominal and limb reconstruction (n=4). Assessment was based on efficiency, anastomosis time, and thrombosis ratio in venous sutures. RESULTS: The mechanical system made microsurgical procedure easier. It notably decreased coupling time compared to manual sutures. At the beginning, coupling time averaged eight minutes. It decreased to five minutes for the last ten cases. In our series, we noticed two venous thromboses (2.7%). In every case, emergency revision surgery allowed saving the flap. Thrombosis did not seem specifically due to the mechanical system. CONCLUSION: Our positive experience together with good outcome published throughout literature lead us to routinely use double ring-based automatic suture. We chose this system in first line for every venous end to end anastomoses regardless of indication.
Assuntos
Microcirurgia/instrumentação , Técnicas de Sutura/instrumentação , Procedimentos Cirúrgicos Vasculares/instrumentação , Veias/cirurgia , Anastomose Cirúrgica/instrumentação , Desenho de Equipamento , HumanosRESUMO
During the 2020 coronavirus pandemic, a lockdown was imposed in France during the first wave. An apparent decrease in incidence of cellulitis of odontogenic origin was noticed then. This study aimed to compare the incidence of cellulitis during this extraordinary period with the same period in 2018 and 2019, based on retrospective multicentric data. All maxillofacial surgery departments in French public hospitals were contacted. Responders were asked to include all patients admitted for the surgical drainage of a head and neck abscess of odontogenic origin during the first 2020 lockdown period, and in a similar time frame in 2018 and 2019 (control group), based on screening the French diagnostic and therapeutic classification of medical acts. We report a 44% significant nationwide decrease in the incidence of admissions for cellulitis. There were 187 patients in 2020 for 334 and 333 patients in 2018/2019 respectively. The reasons to explain this finding are hypothetical (organizational reasons leading to earlier management, patients' fear to seek for medical management, usual excess in surgical indications or concomitant decrease of non-steroidal anti-inflammatory drugs delivery). Whatever the explanation, it would be of great interest to find it out in order to improve the prevention of cellulitis.
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COVID-19 , Celulite (Flegmão) , Celulite (Flegmão)/diagnóstico , Celulite (Flegmão)/epidemiologia , Celulite (Flegmão)/etiologia , Controle de Doenças Transmissíveis , Humanos , Estudos Retrospectivos , SARS-CoV-2RESUMO
The coronavirus disease 2019 (COVID-19) outbreak has had a major impact on medical and surgical activities. A decline in facial trauma incidence was noticed during the lockdown period. The aim of this study was to evaluate the decline in maxillofacial trauma in France during this particular period. A retrospective multicentre comparative study was initiated in 13 major French public hospital centres. The incidence of facial trauma requiring surgery during the first month of lockdown was compared to that during equivalent periods in 2018 and 2019. Differences in the types of trauma were also analysed. Thirteen maxillofacial departments participated in the study. A significant decline in maxillofacial trauma volumes was observed when compared to equivalent periods in 2018 and 2019 (106 patients compared to 318 and 296 patients, respectively), with an average reduction of 65.5% (P=0.00087). The proportion of trauma due to sports and leisure was reduced when compared to reports in the literature. As a consequence, in the context of a pandemic, the material and human resources related to this activity could be reallocated to the management of other pathologies that cannot be postponed.
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COVID-19 , Traumatismos Maxilofaciais , Controle de Doenças Transmissíveis , França/epidemiologia , Humanos , Traumatismos Maxilofaciais/epidemiologia , Estudos Retrospectivos , SARS-CoV-2RESUMO
AIM: To describe the anatomy and topography of the laryngeal fat body and of the space it lies within. MATERIALS AND METHODS: The study is carried out on series of histological sections of head and neck blocks from six foetuses and three newborns. Three adult necks were dissected, a fourth one analysed through sagittal median section. CT-Scan and MRI imaging complete the description. RESULTS: The laryngeal fat body (LFB) lies within the pre-epiglottic (PE) space that stands in the median anterior part of the upper infrahyoid region, located just below the level of the hyoid bone. The walls of the PE space are: superior (base), anterior lateral right and left, posterior, inferior (apex). This space is divided into two compartments by a median septum. The LFB consists in a rather pure fat, structured in large polyhedral lobules. It shows no limiting capsule. DISCUSSION: Dissection-based description of the PE space made in literature matches ours conducted on series of histological sections. All authors agree on the fat content of the space but some of them find a capsule around the LFB that we did not observe on our histological sections. CT-Scan and MRI imaging are accurate for analysis of these structures and of similar efficiency. The study of the LFB should be considered regarding the one of other fat bodies in the human body. CONCLUSION: Anatomical knowledge of the PE space and its content, the LFB, is important, as alteration of their morphology is the early witness of neighbouring carcinological extension.
Assuntos
Tecido Adiposo/patologia , Corpo Adiposo/patologia , Laringe/patologia , Adulto , Animais , Dissecação , Epiglote/anatomia & histologia , Feto , Humanos , Osso Hioide/anatomia & histologia , Recém-Nascido , Laringe/embriologia , Imageamento por Ressonância Magnética , Glândula Tireoide/anatomia & histologia , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: Patient satisfaction is a good indicator to evaluate the success of breast reconstruction. The aim of this study was to compare the long-term satisfaction in patients who underwent four breast reconstruction techniques. PATIENT AND METHODS: Self-evaluation was achieved by patients in 147 breast reconstructions using a four-point score: very disappointed, disappointed, satisfied and very satisfied. The mean follow-up was 5.3 year (1 to 21.5 year). The surgical procedures used were: transverse rectus abdominis myocutaneous flap (TRAM) 15%, autologous latissimus dorsi flap (ALD) 14%, latissimus dorsi flap with implant (LDI) 32% and implant alone 39%. Patients' satisfaction was compared regarding the type of surgical procedure, the postoperative follow-up time; the immediate or delayed breast reconstruction and the radiation history. RESULTS: Thirty-five percent of the patients were very satisfied with their operation, 54% were satisfied, 7% were disappointed and 4% very disappointed. After a 5-year follow-up, autologous flaps showed better results (P<0.001). Patients were more satisfied with TRAM flaps than with surgical techniques using latissimus dorsi flaps (ALD and LDI). Patients treated with implants alone were statistically less satisfied. Only in the implant series, patient satisfaction decreased significantly with time (P<0.001) and preoperative radiation (P=0.005). CONCLUSIONS: Flap-based breast reconstructions show consistent long-term satisfaction although the surgery is initially more demanding. Our study matches the latest trends in the use of free perforator flaps for breast reconstruction. Indeed, these procedures combine good satisfaction and minor sequelae at the donor site.
Assuntos
Mamoplastia/métodos , Satisfação do Paciente , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoRESUMO
The advent of customized three-dimensional (3D) printing allows the affordable manufacturing of sophisticated medical devices, thereby providing swift and simple solutions to specific needs in modern healthcare. Meanwhile, certain devices such as industrial mandibular external fixators (EFs) have become less and less available from medical device companies because of decreased indications. What is more, their handling is often complex. The authors report, step by step, the original design and uneventful clinical use of a 3D-printed, customized mandibular EF. This device was designed together with a positioning and drilling guide for the fixation of a septic mandibular pseudarthrosis. It provided an adequate and satisfactory balance between lightness and rigidity. A simple, accurate and safe placement of the EF was achieved thanks to the skin-supported positioner and drilling guide, thereby making the procedure minimally invasive and time-efficient. To our knowledge, this is the first reported clinical use of a 3D-printed, customized mandibular EF to date. Because such 3D technology is becoming increasingly available to a large number of surgeons, the authors believe that the present innovation could become an alternative to reusable standard EFs.
Assuntos
Impressão Tridimensional , Cirurgia Assistida por Computador , Fixadores Externos , Mandíbula/cirurgiaRESUMO
Defects affecting the anterior wall of the tympanal bone can result from trauma, infection, neoplasm or previous local surgery. An anatomic variation, namely the persistence of the foramen tympanicum, can also be encountered. When symptomatic, surgical reconstruction may be indicated. The aim of this study was to identify the surgical treatments of symptomatic foramen tympanicum found in the literature and detail our innovative reconstruction technique. A bibliographic research was conducted in PubMed database in March 2020, without time limitation. Papers dealing with surgical management of a foramen tympanicum were included. Data collected were the publication date, the number of patients, their age and gender, the symptoms and the surgical treatment performed. We report, in addition, the case of a symptomatic persistent foramen tympanicum in a 30-year-old man with a follow-up of 18-months. A total of 17 studies (n=23 patients) were included for analysis. The main reconstruction techniques were, in equal proportion, cartilage graft (30%) and insertion of a titanium mesh (30%). We carried out an iliac crest bone graft using a preauricular approach on a patient suffering from chronic tinnitus and fullness in the left ear resulting from a persistent foramen tympanicum, confirmed by clinical and radiological examinations. It allowed the complete resolution of symptoms and no complication such as temporomandibular ankylosis occurred. Based on the review of the literature, we believe this technique has the advantage of providing durable reconstruction thanks to osseointegration.
Assuntos
Transtornos da Articulação Temporomandibular , Tomografia Computadorizada por Raios X , Adulto , Humanos , Masculino , Osseointegração , SíndromeRESUMO
Mandibular reconstruction using computer-aided design/computer-aided manufacturing cutting guides is currently a common procedure. However, inaccurate positioning of the cutting guide onto the fibular bone may result in osteosynthesis difficulties or imprecision in the reconstruction. A novel way to improve the stability of the cutting guides may be to add pillars in order for them to be suspended from the fibula, avoiding soft tissues interactions. We present the case of a 39-year-old male who needed mandibular reconstruction after a self-inflicted ballistic injury. We designed a customized cutting guide which included a set of 8 pillars allowing a suspension of the cutting guide 8 millimeters above the bone level. The pillars were perpendicular to one another, and allowed the operator to screw the cutting guide to the bone. The orthogonal position of the pillars enabled real stability during the osteotomies. In the operator experience, the length of the pillars was too important, and led to incomplete osteotomies, and the whole device was too bulky. However, with adaptations in the size of the pillars and the size of the whole device, this solution could be useful in cutting guide design to avoid impairments due to the soft tissues surrounding the fibula.
Assuntos
Retalhos de Tecido Biológico , Reconstrução Mandibular , Cirurgia Assistida por Computador , Adulto , Desenho Assistido por Computador , Fíbula , Humanos , MasculinoRESUMO
INTRODUCTION: Three-dimensional imaging of facial surfaces is a useful tool in different fields of cranio-facial, maxillo-facial and facial aesthetic surgery. Many devices that use several stereoscopic cameras are available but require a dedicated room. In contrast, the Vectra H-1 is a handheld device that can be used regardless of location but requires three consecutive acquisition and might therefore provide less accuracy. The aim of this study was to assess the accuracy, repeatability and reproducibility of the Vectra H1 device to validate its use in daily medical practice. MATERIAL AND METHODS: A comparative analysis of the Vectra H1 device and a digital calliper was performed based on 23 distances measured among 11 facial landmarks. One operator repeated the procedure six times on a 24-year-old male volunteer to assess repeatability, and six operators performed the measurement procedure on a 22-year-old female volunteer to assess reproducibility. Repeatability, reproducibility and accuracy versus the distances measured were successively assessed by testing the correlations between the distances measured versus the coefficient of variation (CV) calculated for repeatability, reproducibility and accuracy. RESULTS: The CVs for all distances ranged from 0.34% to 1.53% and decreased linearly when distances measured increased, and this correlation was significant (P = 0.0026) for repeatability. The CVs for all distances ranged from 0.23% to 2.90% and decreased linearly as distances measured increased; there was a significant correlation (P = 0.00045) for reproducibility. CONCLUSIONS: This study shows that the Vectra H1 provides an accurate linear assessment of clinical parameters and allows the accurate analysis of craniofacial morphology. Furthermore, this device costs less and requires less space than other multi-pod devices.
Assuntos
Face , Imageamento Tridimensional , Fotogrametria , Adulto , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Adulto JovemRESUMO
This study was performed to present the authors' experience with botulinum toxin therapy for salivary stenosis and salivary fistula in terms of the procedure, dosage, effectiveness, and complications. A retrospective study of all patients treated in the maxillofacial surgery department for salivary stenosis or fistula from January 2014 to September 2018 was performed. Intraglandular injections of incobotulinumtoxinA (Xeomin) were utilized. The frequency of relapse and the pain recorded before injection and at 3 months after each injection or fistula resolution were assessed. Swallowing dysfunction or any diffusion of toxin into the facial muscles was recorded. This study included 22 patients (mean age 53 years). Botulinum therapy was indicated for parotid duct stenosis in 14 patients, submandibular duct stenosis in four patients, and parotid fistula in four patients. The frequency of relapse (P = 0.0001) and pain level (P = 0.0001) decreased after botulinum therapy. The average duration of the botulinum effect was 4.50±2.00 months after the first injection. No complication was observed. Botulinum therapy with 100 IU of Xeomin proved effective at resolving salivary fistula. Botulinum therapy is an effective treatment for symptoms of salivary duct stenosis in patients for whom minimally invasive procedures have failed. Botulinum therapy can also be used for the treatment of salivary fistulas.
Assuntos
Toxinas Botulínicas Tipo A , Fístula , Doenças Parotídeas , Sialorreia , Constrição Patológica , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fístula das Glândulas SalivaresRESUMO
PURPOSE: The aim of this study was the long-term evaluation of different techniques concerning the reconstruction of a nipple-areola complex. PATIENTS AND METHODS: We included 135 women who had undergone nipple-areola reconstruction between 1983 and 2004. A clinical examination was performed after a mean delay of 5 years and 3 month (1-24). All of the patients were asked to evaluate their level of satisfaction based on a grading scale displaying four scores. The most important parameters (texture, shape, size, color, position, nipple projection) and the complication-rate were investigated. The different techniques were compared with each other to determine the one giving the best results. RESULTS: Eighty-nine percent of the patients were satisfied or even very satisfied with their nipple-areolar reconstruction. Eleven percent were disappointed or very disappointed. The factors patients disliked the most were, in descending order, dys-chromia (45%), hypo-sensibility (37%) and lack of projection (36%). When the opposite areola is used as donor site, results seem to be more satisfactory than using a full-thickness skin graft from the upper inner thigh (P=0.054). Concerning the rebuilding of the nipple, the graft from the opposite nipple leads to a mean projection of 3.4 mm where the local flap leads to 2.4 mm and the earlobe composite graft to 1.5 mm (P<0.001). CONCLUSION: Removing a part of contralateral nipple and areola when possible, reveals itself to be the most effective technique showing the most stable long-term results.
Assuntos
Mamoplastia/métodos , Mamilos/cirurgia , Retalhos Cirúrgicos , Feminino , Seguimentos , Humanos , Mamoplastia/efeitos adversos , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND: The reconstitution of a nasal alar rim and lobule defect represent a difficult challenge in consideration of his situation, anatomy and function. This article describes the technique and the interest of the nasolabial flap when used to cover the entire alar subunit. METHODS: We present 7 cases of alar rim and lobule defect after skin cancer excision. In the series, there are two full-thickness with lining defect. The patients were reconstructed with a superiorly based nasolabial flap, according to the subunit principle as introduced by Burget. A free cartilage graft was used to restore structural support with marginal skin flaps were turned over for intranasal lining when necessary. RESULTS: The cosmetic and functional outcomes of each repair were judged from good to excellent by patients and surgeons. No case of flap infection or necrosis occurred. CONCLUSION: The superiorly based nasolabial flap, describe by Burget, provides an excellent choice for cosmetic and functional reconstruction of the nasal alar defect.
Assuntos
Nariz/patologia , Nariz/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos , Idoso , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade , Neoplasias Nasais/complicações , Neoplasias Nasais/cirurgia , Satisfação do Paciente , Neoplasias Cutâneas/complicações , Neoplasias Cutâneas/cirurgia , Resultado do TratamentoRESUMO
Ossifying fibroma (OF) is a benign fibro-osseous lesion mainly occurring in young adults and seems to originate from the periodontal ligament. Aneurysmal bone cyst (ABC) is a benign intraosseous lesion characterized by blood-filled spaces of various sizes. These two lesions can specifically affect the jaws and are commonly described in the literature. However, few cases describing an association of OF and ABC have been reported in the literature, especially in the maxillary sinus. We report the case of a 40-year-old male patient affected with an asymptomatic lesion with a dual component of OF and ABC laying in the maxillary sinus. Our aim is to discuss its clinical and morphological features as well as treatment results.