International consensus (ICON) on functional and aesthetic rhinoplasty.

During the 2017 IFOS international congress in Paris, a roundtable discussion on the topic of functional and aesthetic rhinoplasty was organised. Five experts, from the five continents and renown in the field of rhinoplasty, were brought together to discuss the issue from an international perspective and to put forward a consensus or on the contrary practical differences. Five questions were put to the experts beforehand to guarantee independent answers, which were then discussed during the roundtable. The questions were the following: - What are the age limits for achieving a rhinoplasty? - Do you use objective measurements before, during and after surgery? (facial landmarks, airflow, peroperative measurements) - How do you manage the preoperative general information and computer imaging of the patient? - What are the indications in your practice to perform a CT-scan or endoscopic examination before doing a rhinoplasty? - What kind of graft or prosthesis do you use for an augmentation rhinoplasty? This paper offers a synthesis of the roundtable based on the experts' answers to the different questions.

Reconstruction of lateral defects of the tip and supratip less than 1.5 cm in diameter.

The authors describe the surgical technique as well as the indications and limitations of the East-West flap for repair of lateral defects of the tip/supratip of the nose less than 1.5 cm in diameter. This easy and reliable technique is based on the use of skin from the lower third of the nose to repair the defect. This tissue presents the same thickness and colour characteristics, which limits excessive thickness, distortion and dyschromia phenomena.

Guidelines of the French Society of Otorhinolaryngology (SFORL), short version. Extension assessment and principles of resection in cutaneous head and neck tumors.

Cutaneous head and neck tumors mainly comprise malignant melanoma, squamous cell carcinoma, trichoblastic carcinoma, Merkel cell carcinoma, adnexal carcinoma, dermatofibrosarcoma protuberans, sclerodermiform basalioma and angiosarcoma. Adapted management requires an experienced team with good knowledge of the various parameters relating to health status, histology, location and extension: risk factors for aggression, extension assessment, resection margin requirements, indications for specific procedures, such as lateral temporal bone resection, orbital exenteration, resection of the calvarium and meningeal envelopes, neck dissection and muscle resection.

[Reconstruction of nasal cartilage defects using a tissue engineering technique based on combination of high-density polyethylene and hydrogel]. / Reconstruction du cartilage nasal par ingénierie tissulaire à base de polyéthylène de haute densité et d'un hydrogel.

AIM OF THE STUDY: Nasal reconstruction remains a challenge for any surgeon. The surgical indications for nasal reconstruction after oncologic resection, trauma or as part of cosmetic rhinoplasty, are steadily increasing. The current attitude for reconstruction is the use of autologous cartilage grafts of various origins (septal, ear or rib) trying to restore a physiological anatomy but their quantity is limited. Thus, in order to produce an implantable cartilaginous model, we developed a study protocol involving human nasal chondrocytes, growth factors and a composite biomaterial and studied at the molecular, cellular and tissue level the phenotype of the chondrocytes cultured in this model. MATERIALS AND METHODS: After extraction of chondrocytes and their amplification on plastic, the cells were cultured for 15 days either in monolayer or within an agarose hydrogel or a composite biomaterial (agarose/high density polyethylene: Medpor(®)) in the presence or not of a cocktail of soluble factors (BIT): bone morphogenetic protein-2 (BMP-2), insulin and triiodothyronine (T3). The quality of the chondrocyte phenotype was analyzed by PCR, western blotting and immunohistochemistry. RESULTS: During their amplification in monolayer, chondrocytes dedifferentiate. However, our results show that the BIT cocktail induces redifferentiation of chondrocytes cultured in agarose/Medpor with synthesis of mature chondrogenic markers. Thereby, chondrocytes associated with the agarose hydrogel will colonize Medpor and synthesize an extracellular matrix characteristic of nasal cartilage. CONCLUSION: This nasal cartilage tissue engineering protocol provides the first interesting results for nasal reconstruction.

Saddle nose: classification and therapeutic management.

INTRODUCTION: The understanding and treatment of saddle nose have always been a surgical challenge. The authors propose a three-stage classification of this deformity as well as a treatment strategy adapted to each case. MATERIALS AND METHODS: A retrospective study was carried out on 25 patients with saddle nose. After defining the three stages of saddle nose: minimal, moderate and major, the authors describe the treatment protocol adopted for each stage. RESULTS: This series comprised 3 cases of minimal saddle nose, 17 cases of moderate saddle nose and 5 cases of major saddle nose. Minimal saddle nose was treated by extracorporeal rhinoplasty, an inverted U-shaped conchal graft was used to treat moderate saddle nose, and costal cartilage was used to reconstruct major saddle nose. Surgical approaches varied according to the technique adopted. Surgical revision was never required. CONCLUSION: Saddle nose is a classical condition in facial reconstructive surgery. The proposed treatment strategy is based on detailed analysis of the clinical signs, resulting in a graduated solution adapted to each clinical case according to the severity of the deformity.

[Post-operative evaluation of 63 cases of rhinoseptoplastie by nasal frameworks]. / Evaluation post-opératoire de 63 cas de rhinoseptoplastie par maquette de cartilage septale.

INTRODUCTION: The rhinoplasty is a difficult operation in plastic surgery of the face. The principles of the extracorporeal septoplasty were launched in the 50's, consisting of the treatment of the septal framework outside the nose. The most recent evolution, which is the creation of nasal frameworks required a precise evaluation of the results. PATIENTS AND METHODS: The patients having benefited from a rhinoseptoplasty by nasal frameworks are included. Eleven criteria are studied. Every patient is rated before and after rhinoplasty procedure, one point if improvement of the criterion, zero if no modification and -1 if degradation of the criterion. RESULTS: Sixty three patients were operated, 54 women and 9 men. The postoperative average follow-up is of 5 months. CONCLUSIONS: The cartilaginous nasal frameworks, allows on complex noses (diverted, traumatic), an improvement of the righteousness of the dorsum (88%), of the projection of the tip (82.5%), of the naso-labial angle (84%), lines of Sheen (63%). An extension of the middle nose is observed in 28% of the patients, counterparty of a functional and inhaling nose.

[Smile "forced" smile versus "spontaneous": comparison of 3 techniques of reconstructive surgery of the face. Myoplasty temporal muscle, hypoglossal facial anastomosis and gracilis muscle free flap]. / Sourire "contraint" versus sourire "spontané": comparaison entre 3 techniques de chirurgie réparatrice de la face. Myoplastie du muscle temporal, anastomose hypoglosso faciale et lambeau libre de muscle Gracilis.

The facial palsy cause serious consequences for patients. Studies have also shown that in these patients, the inability to produce an appropriate and spontaneous smile would be a key factor of depression. When facial palsy is considered complete and the nerve cannot be repaired, the patient can benefit from palliative surgery to regain a better quality of life in the aesthetic, functional, and psychological aspects. The hypoglossal-facial anastomosis (AHF), temporal myoplasty (MAT) and gracilis transposition (TG) are the major surgeries currently used for this purpose. The aim of our study is to assess quantitatively and qualitatively the effects of each of these surgeries on the lip mobility and production of smile. From this perspective, we proposed a protocol of an evaluation of facial motricity, of quality of life, and more particularly on the quality and the analysis of the smile. The results underline that there is no significant difference in the recovery of the facial motricity according to the surgery. Only the slower, deferred deadline of recovery at the patients AHF and TG who have to wait several months, it is for the same levels as that of the patients' MAT. A premature and intensive rehabilitation such as the patients of our protocol benefited from it what is nevertheless essential to a good recovery whatever is the surgery.

Thulium-YAG laser sialendoscopy for parotid and submandibular sialolithiasis.

OBJECTIVE: To evaluate the efficacy and safety of thulium-YAG laser in sialendoscopic fragmentation of salivary lithiasis. DESIGN: Retrospective, interventional case series. MATERIAL: Sixty-three patients treated by interventional sialendoscopy with thulium-Yag laser fragmentation between 2003 and 2010 at Edouard Herriot Hospital were included in the study. The laser was used for non-floating or large lithiasis (>4 mm). METHODS: The sialendoscopic thulium fiber laser was used in a pulsed mode with an average power output of 2-8 W to fragment and facilitate extraction of salivary stones. Several variables were studied: success rate, total number of procedures, total energy per procedure, size and number of salivary stones removed, and complications. RESULTS: Our series of 63 cases includes 40 cases of parotid lithiasis and 23 cases of submandibular lithiasis. In nine cases, two sessions of laser were performed. Stone size was evaluated pre-operatively by ultrasound and varied between 2 and 18 mm. Laser fragmentation was possible in every case. Complete extraction of the lithiasis was possible in 51 cases (73.9%) and partial extraction in eight cases (12.6%). Extraction failed in four cases (6.3%). Mean stone size was 5.4 mm (5.7 mm for parotid glands and 5.0 mm for sub-mandibular glands) and mean energy per procedure was 1,450 J (range: 1,400-1,800 J). Ductal perforations were observed in 12.7% of the cases. 65.1% of patients were free of symptoms with a mean follow-up of 18 months. CONCLUSION: Thulium-YAG laser appears to be an effective and safe technique in the treatment of salivary lithiasis.

[Management of labial incompetence and gummy smile using profiloplasty]. / Apport de la profiloplastie dans le traitement du sourire gingival et de l'incompétence labiale.

INTRODUCTION: Gummy smile and labial incompetence are frequent for consultation in plastic surgery. We wanted to show that rhinoplasty and genioplasty should correct these anomalies. PATIENTS AND METHODS: Profiloplasty was performed on 20 patients. Aesthetic and functional items were evaluated. RESULTS: There is a correlation between aesthetic and functional results. Results seem to be better for patients having an important labial incompetence without gummy smile. CONCLUSION: Those results are based on anatomical and surgical considerations. Some non surgical procedures do exist to treat this problem. It should be a challenge to find the place for each procedure.

[Importance of a molding nasolabial flap in the reconstruction of mobile nose defects, a review of 25 cases]. / Intérêt du lambeau nasogénien (LNG) modelant dans la reconstruction des pertes de substances du nez mobile à propos de 25 cas.

INTRODUCTION: Mobile nose reconstruction, because of its location, its anatomy and its functional role is a surgical challenge. We describe throughout this article the surgical technique and the importance of the nasolabial flap in a single-step procedure for repairing mobile nose defects. MATERIALS AND METHODS: We present 25 cases of mobile nose defects secondary to an oncologic etiology, affecting the supratip, the alar margin and the columella. Patients benefited from a superiorly pedicled molding nasolabial flap harvested in a one-step procedure under local anesthesia. RESULT: Aesthetic result of each repair was evaluated according to 5 criteria and was considered as very satisfactory by the surgeons. No complication such as necrosis or infection was recorded. DISCUSSION: A molding nasolabial flap allows optimum repair of the mobile nose. It represents reliability, elasticity at the price of minimal scarring. We find it an important tool in the therapeutic armamentarium in patients with tissue loss in mobile nose.

[The nasal framework in rhinoplasty and its dimensions: the importance of a third element]. / La maquette du nez dans la rhinoplastie et ses dimensions: l'importance d'un troisième élément.

INTRODUCTION: Reconstructing a crooked nose has been a challenge. Reshaping a nose reducing or improving its profile may be followed by irregularities and functional troubles. The principles of the extracorporeal septoplasty were launched in the 50's, consisting of the treatment of the septal framework outside the nose. Thus, it is replaced and fixed inside the nose. Dorsal irregularity or low projection may be overcome with a dorsal onlay graft. OBJECTIVE: To describe an evolution of extracorporeal rhinoseptoplasty based on a three-dimensional reshaping of the nasal framework, and its average dimensions. PATIENTS AND METHODS: Data of patients presenting nasal obstruction related to septal deviation and operated by the proposed technique were collected prospectively. The dimensions of the framework were measured during the surgery. RESULTS: 25 patients were operated from February to September 2010. Fifteen (60%) cases were related to previous trauma or surgery. The other 40% (N=10) were primary, claiming mainly a reduction rhinoplasty. A closed approach was used for all but one (4%). In 12% (N=3) of the patients no lateral osteotomies were performed after opening the bony roof. Tip surgery was performed in 32% (N=8). CONCLUSIONS: The principles of the "three-dimensional framework technique" are globally reproducible independently of the amount of residual septal cartilage. We believe that our technique assures more stability to the framework and offers a better regularity of the nasal dorsum, eliminating the need of an open approach if other manoeuvres requiring it are not associated.

[Partial allotransplantation of the face including the mandible: a feasibility study]. / Allotransplantation partielle de face incluant l'os mandibulaire: étude de faisabilité.

OBJECTIVE: Facial grafts are useful in that they allow the repair of severe facial defects in one step in contrast to the actual available techniques which require staged procedures with limited cosmetic and functional results. The aim of our study was to determine whether it would be possible to include part of the mandible in a partial allotransplant of the face. MATERIAL AND METHODS: An anatomical study on the arterial and venous vascularisation of the face and the mandible was performed on 7 heads. Then nine heads were used to describe an anatomical model of harvesting two-thirds of the lower face. RESULTS: The study determined that a graft could be viable with a facial artery, inferior dental artery and two veins facial. Thus, a reliable method for harvesting hemi-mandible and total mandible is developed. The average sampling time was 4 hours and thirty minutes. Harvesting a total mandibular graft was more tedious because of the loss of joint laxity caused by the absence of mandibular osteotomy. CONCLUSION: Partial allotransplant of the face including the mandible is feasible. In such transplantations, functional difficulties related to the temporo-mandibular joint and orthognathic problems need to be overcome.

[Evaluation of 3D imaging software to study computed tomography images of middle ear defects]. / Evaluation d'un logiciel de reconstruction 3D à l'étude TDM des malformations de l'oreille moyenne.

OBJECTIVE: Evaluate the contribution of original 3D reconstruction software based on the principle of region growing segmentation of CT images to diagnosis of ossicular malformations of the middle ear. METHOD: Prospective study on a population of ten patients presenting uni- or bilateral transmission deafness. Twenty ears were studied using multislice CT. All the data were treated using original software segmentation based on the principle of region growing segmentation. The 3D images were compared with the original CT slices to judge the software's potential contribution to the management of these patients. RESULTS: All the images obtained were deemed of sufficient diagnostic quality. The two normal ears on the CT slices were also found to be normal on the 3D images. Typical CT images of otospongiosis found in two patients were not visible on the 3D images. The 18 ossicular malformations were well analyzed on the images obtained, which also provided better visualization of the abnormalities and associated lesions (particularly the anomalies in facial nerve position), thus providing quality surgical planning as judged by the surgeon. CONCLUSION: The image reconstruction method studied, using region growing segmentation seems to be, in this limited sample, a useful complement to classical CT images in the study of constitutional abnormalities of the middle ear.

Three-dimensional modeling system for unilateral mandibular bone distraction: a clinical case.

Facial hemiatrophies are anomalies of the first branchial arch and affect one in 4000-5000 newborns. Bone distraction is the technique of choice for the treatment of these dysmorphoses. Mandibular osteodistraction requires prior determination of the characteristics of the distraction vector whose three components will serve to activate the distractor. The patient, aged 5 years, presented with a right facial hemiatrophy, Grade IB according to the classification of Pruzansky. Tomodensitometric acquisition was obtained with a CT scanner. Software specifically designed for this application allows segmentation of the anatomical elements by a region-growing algorithm. The 3D representation of each element is added to a 3D scene, in which are placed the built-up landmarks necessary for the surgical simulation after 3D cephalometric analysis. The surgical cleavage plane is oriented according to the surgeon's requirements while preserving the predominant anatomical elements. The software allows performance of rotations and translations of the bone segments rendered independently from the cleavage plane. The distances and angles covered during the virtual movement are measured at its conclusion. The aim of moving the bone segments is to render the mandibular occlusion plane parallel to the reference occlusion plane. The vertical growth of the maxilla is realized by secondary recuperation. The distractor used was of an external multidirectional type allowing elongation of the mandibular ramus and mandibular corpus, closure of the goniac angle, and lateralization or medialization of the ramus. On the 15th day, the mandibular angle was reduced by 10 degrees, which allowed closure of the anterior gap and recentering of the incisive areas by a half-cuspid. The patient presented with a complex bone deficit in the three spatial directions, which allowed the development of software for modeling the distraction. Other clinical cases will be necessary to validate this 3D imaging-based technique.

[Analysis of the projection of the nasal tip]. / Analyse de la projection de la pointe nasale.

The success of a rhinoplasty is conditioned by a detailed preoperative analysis of the morphology of the nose and face of the patient. A good knowledge of the characteristic reference marks and nasal proportions authorize a detailed description of the nose. The position of the nasal tip is one of the principal characteristics of the nose. It is expressed by the combination of its projection and its height. A reflexion on the position of the tip and its ideal position post-operatively enabled us to work out a conceptual approach aiming at guiding the surgical project. The drawing of two circles centered on the nasal pyramid is the expression of this concept. Thus, a detailed analysis of the nasal pyramid and a biomechanical approach are the key to a relevant surgical plan.

[Apology for the biplane cervico-facial face lift]. / Apologie du lifting cervico-facial biplan.

After a description of the physiopathology of facial ageing, the author specifies the interest of the biplane cervico-facial face lift to correct the tegumentary ptose of the lower third of the face. The various technical stages are described while insisting on the complementarity of the handing-over in tension of the SMAS (Superficial Musculo Aponevrotic System) and the redrap of the SACS (Superficial Adipo-Cutaneous System).

Decreased expression of keratinocyte beta1 integrins in chronically sun-exposed skin in vivo.

BACKGROUND: Chronic exposure to ultraviolet (UV) radiation induces changes in the skin structure which are mostly found in the superficial dermis and at the dermal-epidermal junction. Keratinocytes and fibroblasts contribute both to the synthesis and to the degradation of the molecules important for the integrity of this skin site. While several studies have reported on alterations of dermal components and of the functions of fibroblasts in vivo and in vitro after UV exposure, recent data suggested that keratinocytes could be the main skin cell type involved in the photoageing process. OBJECTIVES: In this study, we analysed the expression of two keratinocyte molecules namely, beta1 integrin (a proliferation marker) and involucrin (a differentiation marker) in sun-exposed and sun-protected facial skin of 16 healthy patients undergoing facial lifting. METHODS: Methods included histology, immunohistochemistry and quantitative reverse transcriptase-polymerase chain reaction analysis. RESULTS: Sun-exposed skin displayed the characteristic morphological and molecular features of dermal photoageing, compared with sun-protected skin, including dermal elastosis, diminished fibrillin and type VII collagen expression. Analysis of the epidermis in sun-exposed vs. sun-protected skin showed no histological differences, but dramatic changes in the expression of beta1 integrin and involucrin. In sun-exposed skin, expression of beta1 integrin protein by epidermal basal cells was reduced, paralleling a downregulation of beta1 integrin mRNA, whereas involucrin protein expression was greatly enhanced in the superficial epidermal cell layers. Interestingly, the ratio between involucrin and beta1 integrin protein expression was consistently increased in sun-exposed skin sites. CONCLUSIONS: Collectively these results demonstrate that epidermal homeostasis is impaired by chronic UV exposure, and define beta1 integrin expression as a molecular marker of the epidermal photoageing process.

[Three-dimensional modeling of mandibular distraction]. / Modélisation tridimensionnelle de la distraction mandibulaire.

Facial hemi-atrophy affects 1 in 4000 or 5000 children. We propose treating this deformation of the 1st branchial arch with the "bone distraction" lengthening technique first described by Ilizarov in the 1950s, which has already been employed with the mandible. We have modelled mandibular distraction in facial hemi-atrophy patients and discuss the benefits of such pre-surgical planning encompassing the assistance of pre- and post-operative as well as surgically coordinated orthodontic therapy. Using X scanner views of a 5 year-old girl patient, we have developed a distraction-simulation software, which makes the pathological side harmonious with the healthy side along the medial sagittal plane. In order to obtain facial symmetry, put bones in balance, and orient the occlusal plane horizontally, essential requisites of occlusal stability, it is necessary: to employ a 2 or 3-dimensional distractor, to pre-plan the distraction and screw positioning, to set up a fixed orthodontic treatment plan prior to beginning distraction therapy.