Zygomatic implant placement using a robot-assisted flapless protocol: proof of concept.

Robotic assistance can help in physically guiding the drilling trajectory during zygomatic implant positioning. A new robot-assisted strategy for a flapless zygomatic implant placement protocol is reported here. In this protocol, a preoperative computed tomography scan is used to plan the surgical path. After surface registration, the ROSA robot (Zimmer Biomet Robotics) guides several steps, which are performed with shared control. The surgeon performs the drilling and tapping, guided by the robotic arm, which is positioned according to the planned trajectory. Placement of the zygomatic implant is done manually. Immediate intraoperative 3D verification is performed by cone beam computed tomography (flat-panel detector, Medtronic O-arm II). Four zygomatic implants were placed in the case patient according to the flapless protocol, with a mean vector error of 1.78 mm (range 0.52-4.70 mm). A screw-retained temporary prosthesis was placed on the same day. No significant complications were observed. The application of this robot-assisted surgical protocol, which guarantees a very high degree of precision, may reduce inaccuracies in the positioning of zygomatic implants that could deviate from the surgeon's plan. This appears to be a potentially safe flapless surgery technique. Drill slipping on the crest or on the maxillary wall is the main source of error in this procedure, emphasizing the usefulness of the assisted surgical guidance with haptic feedback.

Orbital in juries in wartime: Historical study from Paul Tessier's work in Iran.

INTRODUCTION: Paul Tessier was a leading French oculoplastic surgeon who took part in several surgical missions in Iran to manage victims of the Iraq-Iran conflict in the late 1980's and early 1990's. METHODS: We collected the records of 322 patients who underwent surgical procedures for the management of wartime injuries by Paul Tessier's team in Iran from 1990 to 1993. We also report one of the most representative cases of orbital reconstruction performed by Tessier. RESULTS: Mean age at the time of trauma was 20.65±7.04 years (range: 2--62). Craniofacial CT-scans were available for 54 patients. The bones of the upper third of the face and the orbital contents were affected in 124/322 patients (38.50%). Soft-tissue lesions of the upper third included 13 frontal lacerations (4.04%), 60 orbital injuries (18.63%) and 95 uni- or bilateral enucleations (29.50%). Thirty-nine uni- or bilateral lid injuries (12.11%) and 8 tear duct injuries (2.48%) were reported. A specific case of orbital reconstruction using antero-internal and posterior iliac bone grafts was reported as a representative example of Tessier's techniques. CONCLUSION: This study highlights the challenges of orbital reconstruction in wartime injuries and provides insights on the work of one of the most renowned surgeons in this field.

[Lessons from a master in tissue transfer: A study of the surgical notebooks of General Gustave Ginestet during the Foch years]. / Leçons d'un maître en déplacement de tissus : études des carnets opératoires du médecin général Gustave Ginestet dans ses années Foch (1945­1959).

The surgical notebooks (1945-1959) of General Gustave Ginestet are the last direct testimony of the quintessential period in which autoplastic techniques were used, before their twilight, favored by the advent of axial pedicle flaps, musculocutaneous flaps and later free flaps. They summarize all the refinements of the experience accumulated at the National Center for Reconstructive Surgery (Centre Médico-Chirurgical Foch-Suresnes). They appear to be more informative than the various books of the time, which were intended for an experienced public or for those benefiting from a companionship, thus eluding a certain number of precautionary advice, which are undoubtedly tacit but essential to obtain a successful operation in the hypothesis of their current use. This paper aims to establish the principles of historical surgical techniques and to integrate them into the management of patients in therapeutic impasse. One hundred and seven clinical situations requiring tissue displacement were analyzed by reconstructed region and by type of flap used. This technical view of the past, as close as possible to the daily practice of a famous reconstructive surgery center, does not offer absolute methodological or technical precepts. From the surgical notebooks studied, the only thing that emerges is a rigorous approach that allows us to contain a permanent doubt and an experimental process. This notion of constant evolution of the autoplastic practice, guided by its errors, intuitions and beliefs, highlights the importance of a surgical culture, which, with a humanistic approach, must be nourished by the paths of the past.

[Odyssey of the iliac. "Mandibular reconstruction by bone free flaps"]. / L'Odyssée de l'iliaque. « De la reconstruction mandibulaire par autotransplantation ¼.

The authors proposed here a retrospective analysis of a surgical procedure they performed for long time. It allows to put into questions some established principles, to find some unkwown datas which could be important to predict complications. It is also interesting to discuss about the use of indication and choice of the flaps along years of reconstructive surgery history in the way to improve protocoles and management of those large reconstruction. During ten years in one maxillofacial surgery departement, more than 200 bone free flaps (essentially fibula and iliac crest) have been used for mandibular reconstruction and analyse with a three years follow-up. The global failure rate is estimated as 28 % included all various complications from fistulas to infections. Five different points are discussed from the ambiguity of the reported studies to the way of doing of such surgery. It is also pointed out the importance of the biological dimension of all surgical procedures and the place of clinical figures regarding of the technical processes which usually forget the main clinical purpose.

Second metatarsal free transfer in total temporomandibular joint reconstruction for ankylosis in a child: 10-year follow-up.

The management of temporomandibular joint (TMJ) ankylosis requires complete removal of the ankylosed block and the prevention of recurrence. For this purpose, the ramus-condyle unit can be reconstructed with a second metatarsal free flap. This article reports the use of this flap in a young patient treated for left TMJ ankylosis, post costochondral graft for the treatment of hemifacial microsomia. Data from the 10-year follow-up are reported. The glenoid fossa was reconstructed with a graft of the second metatarsal base, enabling the juxtaposition of two cartilaginous joint surfaces, with the aim of optimizing the functional result and preventing the recurrence of ankylosis. At the 10-year follow-up after this surgery, there was no recurrence of the ankylosis and no articular disorder, and the morphological result was satisfactory. Bone fixation was stable over the 10-year period and the metatarsal head was still in place. Quantitative measurements obtained by computed tomography scan did not show any growth of the second metatarsal free flap compared to the right unaffected condylar process.

Fraser syndrome: review of the literature illustrated by a historical adult case.

Fraser syndrome (cryptophthalmos-syndactyly syndrome) is a rare autosomal recessive malformation disorder. The first description of the syndrome was reported by George Fraser in 1962. Diagnosis is based on the major and minor criteria established by van Haelst et al. in 2007. Unilateral or bilateral cryptophthalmos, syndactyly, unilateral renal agenesis, and genital anomalies are the most frequent anomalies. Several maxillofacial, oro-dental, ear-nose-throat, hormonal, and anorectal disorders are reported. Cardiac malformations and musculoskeletal anomalies are uncommon. The syndrome is related to mutations in three different genes (FRAS1, FREM2, and GRIP1) resulting in failure of the apoptosis program and disruption of the epithelial-mesenchymal interactions during embryonic development. Prenatal diagnosis is based on the detection of renal agenesis and laryngeal atresia, together with a family history. Most foetuses with severe anomalies are terminated or are stillborn. All patients or pregnancies with a diagnosis of Fraser syndrome should be referred to expert centres. A collaborative approach including anaesthetists, ENT specialists, maxillofacial surgeons, and geneticists is necessary for the management of this syndrome. In vivo and in vitro research models are available to better understand the underlying aetiology.

The value of reconstructive surgery in the management of refractory jaw osteoradionecrosis: a single-center 10-year experience.

Mandibular osteoradionecrosis (mORN) is a severe complication of head and neck irradiation. International consensus on the management of mORN is currently lacking. The present study sought to evaluate the effectiveness and benefits of early reconstructive surgery (resection of the diseased bone and immediate reconstruction with a free flap) in treatment-refractory mORN. A single-center retrospective study was carried out of operations performed in a French university medical center between 2003 and 2013 inclusive. For each patient, the surgical modalities and postoperative outcomes were recorded. A total of 55 operations (19 marginal resections and 36 segmental resections) were performed, and the overall success rate was 92.3%. Relative to marginal resections, segmental resections were associated with longer operating times (440±62min vs. 531±72min, respectively; P<0.05 in Student's t-test), a longer length of hospital stay (16.5±6.5 days vs. 25.6±11.3 days, respectively; P<0.05), and a higher complication rate (26.3% vs. 63.9%, respectively; P<0.05 in Fisher's test). Given the unpredictable progression of treatment-refractory mORN and the risk-benefit ratio observed here, the value of early reconstructive surgery with curative intent should be reassessed.

Treatment of mandibular osteoradionecrosis by periosteal free flaps.

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

[Feminism and cosmetic surgery: Suzanne Gros-Noël (1878-1954)]. / Féminisme et chirurgie esthétique : Suzanne Gros-Noël (1878­1954).

Born at the late 19th century, Suzanne Noël achieved, despite prejudices, to become at the same time the first female cosmetic surgeon and an influential feminist activist. Trained as a dermatologist by Professor Brocq, she first became fascinated by rejuvenation surgery during her studies by meeting Sarah Bernardh, who had undergone a facelift in the United States. As a surgeon, she mainly performed procedures under local anaesthesia in her salon, where she maintains worldly relations with her women clients. As an activist, she founded feminist clubs all over the world since 1923, under the aegis of a still flourishing organization: "Soroptimist International", which provided assistance in the field to women in need. She successively lost her first husband, then her single daughter and her second husband to be 46 years old, widowed, indebted and without any medical license. Their personal difficulties are not foreign to what she advocates: the women's emancipation by achieving economic independence. Suzanne Noel's journey is a singular paradox on the relationship between the earliest days of cosmetic surgery and feminist ideology. She structured the controversy within the various thinking movements at that time: does embellishing a woman serve her cause? Provocative but necessary question for thinking the surgical act. Suzanne Noël, as a liberal feminist, however, supported the idea that cosmetic surgery could be a transitional solution to integrate a working environment in which there was significant discrimination in women's employment.

Small cell carcinoma of the floor of mouth: Difficulties of a therapeutic choice.

INTRODUCTION: With only 14 cases and as many different therapeutic strategies reported in the literature, small cell carcinoma of the oral cavity remains a real challenge with diagnostic and therapeutic pitfalls. CLINICAL CASE SUMMARY: A 65-year-old patient with an active smoking habit consulted for a painful oral pelvic mass. The staging confirmed the diagnosis of small cell carcinoma of the anterior floor of mouth, classified as cT3N0M0. By analogy with pulmonary locations, medical management combining chemotherapy specific for small bronchial cell carcinoma (carboplatin-etoposide) and radiotherapy (tumor bed and cervical lymph nodes) was preferred. We found no recurrence of the disease 12 months after treatment. DISCUSSION: Local invasiveness and metastatic potential of small cell carcinoma of the oral cavity require harmonization of therapeutic strategies. We suggest initiating chemotherapy associated with radiotherapy as quickly as possible, a treatment to which these tumors are known to have histological sensitivity.

Contribution of flow MRI in the therapeutic management of middle face high flow arteriovenous malformation: A case report.

BACKROUND: The radiosurgical management of high flow arteriovenous malformations (HFAVM) in the "destructive" stage requires a precise hemodynamic and anatomical assessment. PATIENT AND METHODS/CASE REPORT: We report the case of a 32 years-old patient with a large ulcerated face HFAVM, on which Doppler ultrasound was impossible to perform. We show that, by combining 3D PCA and 2D CINE PC-MRI sequences, magnetic resonance imaging is capable to provide a complete morphometric and velocimetric mapping of the nidus and feeding arteries of the HFAVM. CONCLUSION: Although Doppler ultrasound is the reference examination in the HFAVM, Flow MRI without contrast agent provides an advantageous alternative to assess vascular pathologies and choose the therapeutic strategy.

Face Transplantation: Partial Graft Loss of the First Case 10 Years Later.

Ten years after the first face transplantation, we report the partial loss of this graft. After two episodes of acute rejection (AR) occurred and completely reversed in the first posttransplantation year, at 90 months posttransplantation the patient developed de novo class II donor-specific antibodies, without clinical signs of AR. Some months later, she developed several skin rejection episodes treated with steroid pulses. Despite rapid clinical improvement, some months later the sentinel skin graft underwent necrosis. Microscopic examination showed intimal thickening, thrombosis of the pedicle vessel, and C4d deposits on the endothelium of some dermal vessels of the facial graft. Flow magnetic resonance imaging of the facial graft showed a decrease of the distal right facial artery flow. Three steroid pulses of 500 mg each, followed by intravenous immunoglobulins (2 g/kg), five sessions of plasmapheresis, and three cycles of bortezomib 1.3 mg/m2 , were administered. Despite rescue therapy with eculizumab, necrosis of the lips and the perioral area occurred, which led to surgical removal of the lower lip, labial commissures, and part of the right cheek in May 2015. In January 2016, the patient underwent conventional facial reconstruction because during the retransplantation evaluation a small-cell lung carcinoma was discovered, causing the patient's death in April 2016.

[Feasability study of screening for malignant lesions in the oral cavity targeting tobacco users]. / Faisabilité d'une stratégie de dépistage des lésions malignes de la cavité buccale chez les fumeurs.

INTRODUCTION: Oral cavity cancer is frequent. Prognosis of this cancer is closely linked to the development. Although the oral cavity is a potentially accessible site for examination, up to 50% of oral cancers are not detected until the disease is well advanced. PATIENTS AND METHOD: In a region where incidence rate is particularly high, local teams involved in screening, in epidemiological survey, in diagnosis and treatment of oral cancer performed a pilot feasibility study to improve strategy of early detection of oral cancer and premalignant lesion. Tobacco venders were solicited to distribute a flyer, which invite smokers to a free examination by general practitioner. General practitioners were invited to examine smokers, and to fill a predeterminate systematic oral cavity examination record during 3 months. They were asked to refer to a specialist if there was a potentially malignant disorder. RESULTS: The involvement of tobacco venders was rated as 67.3%. Ninety-three patients were included in 3 months. General practitioners referred 27% of the examinated patients. Among them, only 63.6% really saw a specialist, and a premalignant lesion was confirmed in 15.3%; further exams were carried out in 28.6%; a benign lesion was diagnosed in 57.1%. DISCUSSION/CONCLUSION: Original incentives for oral cavity screening were performed, based on multidisciplinary network. Nevertheless, it remains hardship to reach the targeted population and to maintain the patients in health system.

Management of somatic pain induced by treatment of head and neck cancer: Postoperative pain. Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL).

OBJECTIVE: To present the guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL) concerning the management of somatic pain induced by the treatment of head and neck cancer, and in particular the management of early and late post-surgical pain. METHODS: A multidisciplinary work group conducted a review of the scientific literature on the study topic. An editorial group subsequently read the resulting guidelines before validation. RESULTS: It is recommended to prevent onset of pain caused by malpositioning on the operating table, as well as pain related to postoperative care. During surgery, it is recommended to spare nerve and muscle structures as far as possible to limit painful sequelae. Management of early postoperative pain upon tumor resection and flap harvesting sites requires patient-controlled analgesia by morphine pump. Physical therapy is recommended after flap harvesting to minimize painful sequelae. CONCLUSION: Preventive and curative measures should be undertaken for appropriate management of post-surgical pain in the treatment of head and neck cancers.

Management of somatic pain induced by head-and-neck cancer treatment: definition and assessment. Guidelines of the French Oto-Rhino-Laryngology- Head and Neck Surgery Society (SFORL).

OBJECTIVES: The authors present the guidelines of the French Oto-Rhino-Laryngology- Head and Neck Surgery Society (Société Française d'Oto-rhino-Laryngologie et de Chirurgie de la Face et du Cou [SFORL]) for the management of somatic pain induced by head-and-neck cancer treatment, and in particular the instruments needed for the definition and initial assessment of the various types of pain. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: The priority is to eliminate tumoral recurrence when pain reappears or changes following head-and-neck cancer treatment. Neuropathic pain screening instruments and pain assessment scales should be used to assess pain intensity and treatment efficacy. Functional rehabilitation sessions should be prescribed to reduce musculoskeletal pain and prevent ankylosis and postural disorder. Psychotherapy and mind-body therapy, when available, should be provided in case of chronic pain. In case of recalcitrant complex pain, referral should be made to a multidisciplinary pain structure. CONCLUSION: The management of somatic pain induced by head-and-neck cancer treatment above all requires identifying and assessing the intensity of the various types of pain involved, their functional impact and their emotional component.

Management of somatic pain induced by head and neck cancer treatment: pain following radiation therapy and chemotherapy. Guidelines of the French Otorhinolaryngology Head and Neck Surgery Society (SFORL).

OBJECTIVES: The authors present the section of the guidelines of the French Otorhinolaryngology Head and Neck Surgery Society (SFORL) for the management of somatic pain induced by head and neck cancer treatment concerning management of pain following radiation therapy and chemotherapy. METHODS: A multidisciplinary work group was entrusted with a literature review. Guidelines were drawn up based on the articles retrieved and the group members' experience. They were read over by an editorial group independent of the work group. A coordination meeting drew up the final version. Guidelines were graded A, B or C or as expert opinion in decreasing order of level of evidence. RESULTS: Particular care should be given to detection and early adapted treatment of pain induced by radiation therapy and/or chemotherapy, to improve quality of life in head and neck cancer patients.