[Surgical approaches in rhinoplasty]. / Voies d'abord en rhinoplastie.

In the first step of rhinoplasty, the surgical approach will expose through different types of incisions and dissection planes the osteocartilaginous framework of the nasal pyramid prior to performing actions to reduce or increase the latter. This exposure can be performed by a closed approach or by an external approach--the choice depends on the type of nose and the habits of the surgeon. Far from being opposites, closed and external approaches are complementary and should be known and mastered by surgeons performing rhinoplasty.

[The short nose]. / Le nez court.

Short noses are not only depending on the length of the dorsum, but also if there is a saddle deformity, or a too lower situation of the fronto-nasal angle, or an open naso-labial angle or a rim retraction. All the cases are treated, often with the help of cartilage grafts and with a closed approach.

[Over projected tip]. / Pointe du nez hyper-projetée.

Overprojected tip is a pretty usual request not easy to manage. Preop analysis is crucial in order to evaluate tip support and skin thickness and ability to retract. For example, if the skin is very thick and has poor chance to retract, the surgeon should be very careful in the tip projection decreasing to avoid a skin pollybeak deformity. In such cases, he has to analyze the facial proportions, especially other areas projection (radix, dorsum and chin) and think about augmenting them to balance the profile rather than decreasing tip projection. Correction should always be conducted incrementally, starting with weakening the tip support mechanisms and, only if necessary, continue with alar cartilage interruption. This can be performed on many areas (lateral cruras, domes, medial cruras) and with several techniques (resection or interruption+overlapping).

[Preoperative analysis in rhinoplasty]. / Analyse préopératoire en rhinoplastie.

Preoperative analysis in rhinoplasty consists in analyzing individual anatomical and functional characteristics without losing sight of the initial requirements of the patient to which priority should be given. The examination is primarily clinical but it also uses preoperative photographs taken at specific accurate angles. Detecting functional disorders or associated general pathologies, which will reduce the risk of complications. All of these factors taken into account, the surgeon can work out a rhinoplasty plan which he or she will subsequently explain to the patient and obtain his or her approbation.

[The correction of one cause of the short nose: how to bring the retracted alar rim downwards?]. / Corriger une des causes de nez trop court : note technique sur l'abaissement du rebord narinaire.

The author reports a genuine procedure called the "sliding flap" used to correct the retraction of the rim of the nostril upward. The new position of the rim is stabilized by a simple resorbable thread through the skin fixing the rim in the new situation. This technique is efficient in both primary and secondary cases.

[Posterior pedicle: anatomoclinical concept of mammaplasty]. / Le pédicule postérieur: un concept anatomo-chirurgical de plastie mammaire.

The classical inferior pedicle is actually a posterior pedicle. It is vascularized by means of the pectoral muscle and fascia, as has been demonstrated by injection studies of the thoracoacromial artery in fresh cadavers. The resulting mammary dissection as an anatomo surgical concept is nowadays employed in numerous mammary techniques and particularly in the majority of the peri areolar techniques as well as in reduction techniques with vertical scars.

The pure posterior pedicle procedure for breast reduction.

The inferior pedicle technique, which has already become classic, employs a glandular areola-bearing pedicle whose source of vascularization is primarily posterior. In fact, the inferior pedicle is a posterior pedicle with an inferior border. After systematically and progressively reducing this inferior border, I have completely eliminated it. The pure posterior pedicle that results is independent of the inframammary fold. It is vascularized by means of the pectoral muscle and fascia, as has been demonstrated by injection studies of the thoracoacromial artery in fresh cadavers. The resulting mammary reduction technique retains the advantages of the inferior pedicle technique while avoiding its major inconveniences: dependence on the inframammary fold, bulging at the inferior base of the pedicle, and the necessity of low positioning for the breast.

[Use of polytetrafluoroethylene (Gore-Tex E-PTFE Soft Tissue Patch) for suspension of former facial paralysis and as reconstructive tissue]. / Utilisation du polytétrafluoroéthylène (Gore-Tex E-PTFE Soft Tissue Patch) dans les suspensions de paralysies faciales anciennes et en tissu de comblement.

The insertion of autogenous fascia lata to suspend the paralyzed cheek and lips remains one of the most widely practiced procedures in correction of long term paralysis of the lower facial muscles. For 34 months we used thin layers (1 mm) of expanded polytetrafluoroethylene (E-PTFE Gore-Tex Soft Tissue Patch) to replace autogenous fascia lata, in 20 patients, with satisfactory results. 13 patients were treated by classical techniques of insertion-suspensions of the paralyzed side with a perioral loop and slings of PTFE suspended to the zygomatic arch and the infraorbital rim, by way of nasolabial angle or rhytidectomy incisions. In 7 patients, an eyelid suspension was performed with PTFE by Arion's technique, but by replacing the classical silicon thread by E-PTFE and transposing the medial part of the temporalis muscle on the external canthus, and fixing the lateral end of the sling to the muscle. This technique assures a good corneal coverage with healing of the previous ulceration and allows a voluntary occlusion of the eyelids. The PTFE soft tissue is notably successful as an implant. This biocompatible material shows excellent tissue tolerance, the porous microstructure encouraging tissue attachment and infiltration. E-PTFE holds its shape, resists to infection, and permits a notably reduction of the hospitalization because it avoids a second surgical site. We have experience of the material as a reconstructive substance in 6 cases of either bone or subcutaneous deficits, where no other satisfactory solution was available. Is these cases our follow-up is 18 months.

Subfascial lifting.

The authors demonstrate by anatomical dissection that inaccuracies made by classical anatomists have worried plastic surgeons for many years. They demonstrate that continuity between the parotid fascia and the fibrous platysma has not been recognized. In addition, anatomists in the past have not been aware that the platysma is a unique type of fasciomuscular layer because in contrast to conventional anatomical opinions, the platysma has no bony attachment to the mandible.

Comparative anatomy of cutaneous muscles of the face.

Comparative anatomical studies of monkeys, apes, and humans have clarified essential factors involved in the structure of the cutaneous muscles of the face. Among the findings are that the platysma muscle is a very important entity because it is the only muscle without any bony attachments. In addition, the platysma is a fan-shaped structure that has been divided artificially by classical anatomists into five elements. The parotid fascia forms part of this fan-shaped fibromuscular structure and is not of the deep fascia. As such, these findings require a revision of the classical anatomical concepts of the parotid space.

[Nasal reconstruction using the Converse frontal flap or a Washio retroauricular flap. Technical notes]. / Les reconstructions nasales par lambeau frontal de Converse ou par lambeau rétro-auriculaire de Washio. Notes techniques.

14 cases of nasal reconstruction by the Converse Scalping Flap or the Washio Temporo-auricular flap technique, over three years, led us to point out details necessary to insure the quality of the results. In particular, the Converse Flap must be thin; it never needs bone neither cartilage reinforcement when used in reconstructions of the two inferior third of the nose. The pedicle weaning method described allows the replacement of the scalp on thirteenth day. New data for the Washio technique are as following: --The mastoidian skin and not the retro-auricular skin must be used; --The back-cut of the scalp follows the AC line dating from three fixed points: A = helix root B = end of incision on the frontal hairline vertically to the fronto-orbital suture, and AB = AC = BC. This new data seem to warrant the fiability of the Washio flap, however the latter cannot dethrone the Converse flap, king flap of medio-facial reconstructions.