[The biplane microlift. Principles, technic, results]. / Le microlift biplan. Principes, technique, résultats.

There has been a growing number of patients asking for a lighter face lift than the classical biplane procedure with wide undermining; This explains the popularity of medical threads lifts. A surgical approach is nevertheless possible by performing a new technique, derived from minilfts, but with a dissection elevating skin and SMAS layers together, preserving as much retaining ligaments as possible, and allowing a predesigned skin excision. Thirty-two patients have been operated this way since 2014; 3 asked and sustained for a redo because of skin relapse at one year postoperatively. Few complications have occurred, mostly limited hematomas, or skin problems because of suture threads rejection. The best indications seemed to be young patients presenting a jowl ptosis or cervical skin laxity, and patients who require a secondary facelift as a lighter procedure.

[Vascular leiomyoma of the hand. Report of a case and review of literature concerning a rare pathology]. / Léiomyome vasculaire de la main. Présentation d'un cas clinique et revue de la littérature à propos d'une pathologie rare.

Vascular leiomyoma is a benign painful tumour that occurs most frequently in the lower extremity. We report an uncommon case in the hand. Only surgical removal of the tumour allows establishing the diagnosis histologically. A review of the literature confirms the rarity of the tumour in the hand. The purpose of this case report is furthermore to consider the differential diagnosis in painful masses of the hand.

[Morbid obesity: laparoscopic gastroplasty prior to plastic surgery]. / Obésité massive: gastroplastie coelioscopique avant la chirurgie de la silhouette.

OBJECTIVES: Reduction of the weight in obese patients is a pre-condition for the aesthetic improvement of obesity or its after effects by plastic surgery. The aim of this study was to evaluate the effectiveness and advantages of gastric banding, using a ring positioned under laparoscopic guidance. PATIENTS AND METHODS: Thirty-nine patients with morbid obesity were operated on. For the first nine patients, gastric restriction was obtained by Mason's traditional technique. In the remaining thirty, a Kuzmak ring was positioned a few centimeters under the cardia, under laparoscopic guidance. The study concerned the evolution of weight, associated pathologies, and complications. RESULTS: Three months after surgery, all patients had lost weight (mean loss: 15 kg). At six months, a mean weight loss of 26 kg was observed. At one year, the mean weight loss was 35 kg. Two patients experienced postprandial vomiting that justified widening of the ring; one ring was poorly tolerated and was removed 10 days after surgery. CONCLUSION: This new surgical technique is effective for reducing the weight of obese patients. The laparoscopic approach to the stomach reduces parietal complications and enables subsequent abdominal plastic surgery to be performed.

Computerized morphometric quantitation of elastin and collagen in SMAS and facial skin and the possible role of fat cells in SMAS viscoelastic properties.

Recently, the superficial musculoaponeurotic system (SMAS) was found to be a composite tissue comprising collagen, elastic fibers, and fat cells in an extracellular viscous matrix. Both SMAS and facial skin tissues exhibit viscoelastic properties, but SMAS tissue has delayed stress relaxation. As a consequence, SMAS is viewed as a firmer elastic foundation for the more viscous facial skin. In some patients, a slackening effect of SMAS tissue takes place over a period ranging from weeks to months after tightening. To determine the relative quantity of viscoelastic components and better understand their biomechanical behavior, a quantitative morphometric study of the elastic and collagen fibers in the SMAS and facial skin was conducted. Thirty-four SMAS preparations were taken from 17 patients during either primary face lift operations (12 women) or reoperative face lift procedures (4 women, 1 man), which were performed 4 to 9 months after the original surgery, to examine the elastin and collagen content. For comparison, preauricular skin was also gathered from these patients. The specimens were stained with Weigert's staining to identify elastin and collagen fibers. Using a computerized morphometric analysis, 100 fields of each SMAS and skin specimen were examined. According to our findings, the average percentage of elastin and collagen fibers in SMAS and facial skin was as follows: (1) the percentage of elastin fibers in the SMAS was 4.71 +/- 1.2 (standard error of mean +/- 0.0291); (2) the percentage of elastin fibers in the skin was 6.1 +/- 1.8 (standard error of mean +/- 0.0436); (3) The percentage of collagen fibers in the SMAS was 38.7 +/- 5.9 (standard error of mean +/- 0.1430); and (4) the percentage of collagen fibers in the skin was 48.47 +/- 6.96 (standard error of mean +/- 0.1688). A statistical significance of p < 0.0001 was demonstrated between the collagen and elastin groups. A different percentage of elastin and collagen fibers was found among the 17 patients and within each of them separately. Neither gender nor age differences were found regarding elastin and collagen fiber content. No statistical differences were demonstrated between specimen sources, i.e., whether the operations were primary or reoperative face lift procedures. Findings from previous studies indicate that the cheek has two viscoelastic layers, the skin and the SMAS. The proportional similarity in average percentages of elastin and collagen in SMAS and facial skin cannot explain the relatively delayed stress relaxation effect of the SMAS. Therefore, the fat cells that are found exclusively in the SMAS probably lend a certain degree of firmness to this layer and play a significant role in the long-term efficacy of SMAS surgery.

[Intraluminal absorbable device to assist in vascular microanastomosis. Experimental study on 20 rat aortas]. / Dispositif résorbable endoluminal d'aide à la micro-anastomose vasculaire. Etude expérimentale sur vingt aortes de rats.

The subject of this experimental study is a cylindrical device, with a gauge adjusted to the vessel lumen, which disintegrates in a few minutes. The goal of this device is to increase the reliability of vascular microanastomosis. This study was designed to assess the efficacy and drawbacks of the device. The device is a cylindrical sugar stick, 5 mm long and with a gauge of 1 mm. Ten Wistar rats underwent a standard end-to-end aortic anastomosis with interrupted sutures and ten underwent the same anastomosis with the device placed in the lumen of the proximal and distal vessel. The same surgeon performed all anastomoses. Clamp application time was recorded and anastomotic patency was tested in each case; the vessels were also examined histologically. The clamp application time was significantly lower (p < 0.01), and the patency rate significantly higher (p < 0.01) in the group in which the device was used. There was no histologic sign of intima injury in either group. This very simple device facilitates microanastomosis. It reduces the ischemia time and increases the reliability of the anastomosis, avoiding transfixing sutures. These results suggest that clinical trials are warranted.

[Late infection of breast implant, complication of colonic perforation. Review of the literature. Role of preventive treatment]. / Infection tardive d'implant mammaire, complication de perforation colique. Revue de la littérature. Place d'un traitement préventif.

The authors report a cases of breast implant infection, 40 years after augmentation mammoplasty. The infection developed 6 weeks after colonoscopy complicated by acute peritonitis due to colonic perforation. Bacteroides fragilis, a usual organism of the gastrointestinal tract flora, was identified in the two septic sites (peritoneal and periprosthetic). Contamination of the implant was haematogenous in a context of bacteraemia. Other authors have already suspected this route of contamination without any bacteriological proof. The risk of infection of breast implants is known, but the late infection rate is poorly documented. It is probably very low in view of the rare cases reported in the literature. Breast implants are not at high risk of sepsis, in contrast with prosthetic heart valves. The authors therefore do not recommend any particular preventive treatment in the case of distant infection or dental treatment. Women with breast implants must be informed and reassured: late infection of their implant is possible, but very unlikely. Recognition and prevention of this risk could be based on better long-term follow-up of breast implants.

Viscoelastic properties of the superficial musculoaponeurotic system (SMAS): a microscopic and mechanical study.

A study was undertaken to determine the physical properties and microscopic structure of the superficial musculoaponeurotic system (SMAS) tissue. Forty virginal specimens and eight reoperated specimens were examined. The following findings were discovered. 1) Microscopic appearance shows the SMAS to consist of collagen fibers, a relatively high concentration of elastic fibers interspersed with fat cells. 2) On scanning electron microscopy, the virginal SMAS shows the collagen fibers to have a similar convoluted appearance as in the dermis. There is some evidence of parallelization of the collagen fibers in the reexcised SMAS specimens. 3) Mechanical testing (Instron) demonstrates that both the SMAS and preauricular skin were subjected to a series of loading/ unloading tests at various rates, amplitudes, and stress relaxation tests. Both sets of specimens indicated definite viscoelastic properties. Although the mechanical behavior of both tissues was somewhat similar, the viscoelastic effect of the SMAS was less pronounced. A slackening effect of the SMAS indicated a gradual expansion of the SMAS postoperatively. These results could provide some indication of the long-term effects of SMAS surgery.

[Indications and results of breast implant replacement with implants pre-filled with silicone gel]. / Indications et résultats de l'opération déprothèse-prothèse avec implants préremplis de gel de silicone.

Based on a series of 74 patients, the authors report their experience of reoperation on unsatisfactory breast implants by the implant replacement technique using silicone prefilled implants. In 92 (57.8%) of the 160 cases, the implant was modified because of a peri-implant capsule, with a satisfactory aesthetic result after only a single operation. However, this leaves the problem of repeated surgical operations, especially in the context of Baker stage IV capsules, which are only partially improved after two to three surgical operations. A particular surgical revision technique is required in the cases, while the role of in situ cortivazol is under investigation. This series comprises two patients with auto-immune disease and dysimmune profiles, not exarcerbate by secondary surgery. Analysis of this series clearly argues in favour of reoperation for unsatisfactory breasts implants. Squeezing manoeuvres appear to be dangerous and useless. Textured implants filled with very cohesive silicone gel should be maintened in view of the absence of any reported serious complications.

[Fasciitis following face lift]. / Les fascéites rétractiles de la face après lifting.

Facial fasciitis or non infectious facial retractions are rare and surprising events after a facelift performed at any age. The signs are firm retraction located on one or both sides of the face or neck. They differ from salivary fistula, localised oedema, and limited hematoma, which may be the initial factor responsible for this curious outcome. We found a particular psychological status in these patients, who are often fragile and depressed and who obtain a secondary gain from this impaired status. The treatment of facial retraction (facial fasciitis is non surgical: we recommend local massage, patience and psychological help for quite a long time (6 months-one year). The outcome is spontaneously favorable, unless the patient automanipulates. A psychosomatic link must be considered. This transient facial retraction may correspond to some forms of hand retraction (such as Dupuytren's disease with spontaneous healing) or some thoracic retractions after insertion of mammary prosthesis. Facial fasciitis is a rare complication in our practice (1.4% of all patients) but must be recognized.

Is it necessary to suture the platysma muscles on the midline to improve the cervical profile? An anatomic study using 20 cadavers.

To ameliorate the cervicomental angle, most surgeons suggest different techniques of platysmaplasty. The aim of this anatomic study is to find a simple answer to the following question: Is suturing of the anterior edges of the platysma muscles during platysmaplasty the best procedure to use to obtain the best concave anterior neck angle? Three different surgical techniques using platysma muscle flaps were used on 20 cadavers prepared for anatomic dissection. Each piece of dissection was controlled by a radiograph of the profile of the cervical region before and after the application of these different techniques. Cephalometric measures were made and statistically analyzed. The analysis of the results demonstrates that the best concave anterior neck angle to perform platysmaplasty is one in which the platysma muscle flap is shifted posterosuperiorly but without suturing the medial borders of the platysma muscles. Suturing the midline does not deepen the concavity in the front of the neck.

[Results of biplane face lifts with maximal skin underlining and vertical SMAS flap]. / Résultats des liftings biplans avec décollement cutané étendu et lambeau de smas vertical.

It is difficult to evaluate the medium and long-term results of facelift due to loss to follow-up of a large number of patients. The authors developed a questionnaire which they sent to their patients. 148 patients (143 women and 5 men) answers this questionnaire and 54 patients returned for review. This subjective evaluation of the results nevertheless had the advantage of identifying three target organs specifically treated by the surgical techniques used: the nasolabial folds, the jowls and the neck. Improvement or deterioration of the results was therefore evaluated and reported on a series of tables. The results are analysed in this paper. 70.3% of patients studied reported a satisfactory objective result with a mean follow-up of 26.8 months. The least favourable results were observed in the neck, due to the small number of technical procedures performed on the platysma, which would appear to justify greater surgical attention. Among the complications reported, 9.2% of cases indicated inadequate results, especially concerning the "lion's wrinkle", which emphasizes the value of a complementary endoscopic procedure at this site. Perioral wrinkles were a source of dissatisfaction in 14.8% of cases, and can be treated by dermabrasion. Lastly, a number of minor complications such as malposition of the ear lobe, facial redness or scar abnormalities were also mentioned and are easily accessible to an ambulatory secondary improvement procedure. This study therefore validated the operative technique of biplane facelift with a satisfactory stability of the results over time. Objective review of dissatisfied patients, who generally returned for review after receiving the questionnaire, led to a number of reoperations, which appear to be useful in the case of early deteriorations occurring during the first postoperative year and which concern about 5% of patients. The ultimate objective of this paper was to try to establish a methodology for the analysis of the long-term results of facelift, without directly involving the examiner or operator, who may ignore what the patient really feels.

Thenar flap rehabilitated: a review of 20 cases.

The thenar flap is a satisfactory reconstruction technique for the treatment of extensive loss of the distal phalanx of the index and middle fingers. As we observed in this series of 20 patients, this flap is reliable and provides tissue that closely matches the missing finger pulp. Flap sensibility is good (average Weber of 6.5 mm). Transferring a distally based flap prevents proximal interphalangeal joint contracture and allows the surgeon to better reconstruct the outlines of the distal phalanx, thereby reducing the risk of a clawed nail. Finally, we did not observe major postoperative complications at the donor site.

[In situ thrombolysis. Correlation between creatine phosphokinase increase and local thrombolysis. An experimental study in the rat]. / Thrombolyse in situ. Corrélation entre l'augmentation de la créatine-phosphokinase et la thrombolyse locale. Etude expérimentale chez le rat.

This study proposes intraarterial in situ thrombolysis for the treatment of microthrombi occurring after tissue crushing. In order to assess the efficacy of the thrombolytic, the authors assayed the serum creatine phosphokinase (CPK) level in the crushed muscle capillary bed. The action of thrombolytics has now been clearly established. In contrast, the correlation between local thrombolysis and the serum CPK variation in crush injuries of striated muscle constitutes the originality of this paper. This experiment was conducted in twenty Wistar rats in which striated muscle crushing was performed. The serum CPK level assayed in venous blood, obtained from the capillary bed concerned, before and after local thrombolysis. The increased CPK level provided an objective indication of the efficacy of intra-arterial thrombolysis after crush injury. The authors now apply local thrombolysis according to a prospective clinical protocol for hand emergencies associated with a crush mechanism.

Mechanical properties and microstructure of the superficial musculoaponeurotic system.

Because of the widespread reliance on SMAS tightening procedures in present-day face lift surgery, a study was undertaken to examine the physical properties and microscopic structure of both virginal (40 specimens) and reoperated (8 specimens) SMAS tissue. The findings could be of practical value to the surgeon and are reported herewith: First, the SMAS is a composite fibrofatty layer comprising collagen and elastic fibers interspersed with fat cells. Second, microscopic appearance shows a considerable amount of elastic fibers in close relationship to the collagen fibers. Third, on scanning electron microscopy, the collagen fibers in the virginal SMAS show a convoluted appearance similar to that found in the dermis. In the reexcised SMAS tissue, there is some evidence of parallelization of the collagen fibers as seen in the stretched dermis. Fourth, mechanical testing (Instron), i.e., a series of loading/unloading tests at various rates and amplitudes, and stress relaxation tests were performed on samples of preauricular skin and SMAS. These indicated definite viscoelastic properties for both sets of specimens, with the tendency of an increased stiffness and a reduction in viscoelastic effects on repeated working of the samples. Overall, the mechanical behavior of both tissues was somewhat similar, the viscoelastic effects in SMAS being less pronounced. A nonlinear viscoelastic model is under development to represent the behavior of both tissues. The implications of these results may help to explain the slackening effect observed in some postoperative patients.

[Experimental cervicoplasty: correction of the cervicomental angle by postero-superior suspension of the hyoid bone. A study of 20 anatomical dissections]. / Cervicoplastie expérimentale: correction de l'angle cervico-mentonnier par la suspension postéro-supérieure de l'os hyoïde. Etude sur vingt pièces de dissection anatomique.

The elegance of the cervical region is due to a certain balance between concave and convex surfaces, and is based on the presence of a well-defined cervicomental angle, generally between 90 degrees to 110 degrees. An excessively wide-open cervicomental angle makes the cervical profile inelegant. Numerous surgical techniques can improve this angle. There is however a certain limit to this correction: an excessively caudal and anterior hyoid bone. In this case the last proposal is a modification of the hyoid bone position in order to replace it in a backward and upper location. To achieve this goal we studied postero-superior suspension of the hyoid bone by plication of the tendon of the digastric muscle in 20 anatomic dissection. Each an dissection was controlled by x-ray of the profile of the cervical region before and after application of this technique. Cephalometric measures were performed and statistically analysed using the "Paired t-test" on Statview II. Analysis of the results after the plication of the tendon of the digastric muscle, demonstrated an average closing of the cervicomental angle of 25.6 degrees with an average ascent of the hyoid bone of 13.27 millimeters and an average posterior transposition of 3.75 millimeters. This experimental cervicoplasty appears to be feasible. A precise surgical technique has been developed with an easy approach to the digastric tendon during standart faced lift procedures. The effect of the compression generated on the pharyngo-oesophageal complex by posterior transposition of the hyoid bone is unknown. This problem is now under investigation.

[Value of scaphal graft in secondary rhinoplasties]. / Intérêt du prélèvement du scapha au cours des rhinoplasties secondaires.

The scaphal cartilaginous area is a most suitable anatomic site for cartilaginous graft harvesting. These grafts allow reconstruction of a flat dorsum, or a rounded dome, or alar cartilages or can be used for an extended tip graft. In some cases, both scaphes may be harvested. Raising of the grafts does not leave any sequelae when performed correctly. We have an experience of 20 cases. The main advantage of this graft is its flatness, which makes it ideal for the nasal dorsum. It has to be tailored, moderately crushed and included in a collagen "surgicel" in order to break the shape memory, slightly curved at its borders. We have used scaphal autografts in 15 cases of secondary rhinoplasties, 2 cases of cleft lip repair and in 3 cases of tertiary rhinoplasties. They solved most problems of missing cartilage, when minor defects had to be treated. These grafts will not solve major tissue defects which must be repaired by bone autografts, mostly iliac bone harvesting in our experience. The results of scaphal autografts are stable after 5 years. Resorption is moderate when the graft is correctly inserted, in an extramucosal pocket. The aesthetic result is maintained with a mean follow up of 2 years for 15 cases. The scaphal area of the ear therefore appears to be a favorable donor site for secondary, nose repair; it is easy to harvest, with inconspicuous morbidity and allows the raising of a good, flat and sculpturable material for cartilaginous nose replacement. Achieves the objectives of ore informed patients asking for artistic perfection.

[Reconstruction of digital pulp by pulp tissue transfer of the toe. Apropos of 15 cases]. / Reconstruction de la pulpe des doigts par transfert d'hémipulpe de gros orteil. A propos de 15 cas.

PURPOSE OF THE STUDY: The authors report their experience of digital pulp reconstruction by free toe pulp transfer. Fifteen patients were treated with the lateral great toe hemipulp. MATERIAL AND METHODS: 15 cases of post-traumatic finger tip reconstruction were reviewed including 9 thumbs, 5 index, 2 medius, and one ring finger. There were 6 emergency cases and 9 secondary reconstructions (7 after inconvenient spontaneous healing and 2 after groin flap coverage). RESULTS: We noted 2 partial necrosis, and 4 patients suffered from cold intolerance. The flap sensibility, according to the American Society for Hand Surgery criteria, was excellent in 1 case good in 6 cases, fair in 7 cases and bad in 1 case. The value of the mean two point discrimination test was 10 mm, the mean moving two points discrimination test equalled 9 mm. We had 1 excellent functional result, 6 good, 6 fair and 2 bad. The subjective evaluation found 12 patients satisfied and 3 disappointed. DISCUSSION: A wide range of procedures from spontaneous healing to thenar flap, neuro vascular flap or toe pulp transfer can be proposed to treat digital pulp loss. In the case of moderate thumb pulp avulsion and homodigital volar flap can be proposed; if microsurgery is contra-indicated, an hetero-digital flap from the index can be performed. When the other fingers are concerned, a homodigital flap can be proposed for moderate defects. For more important trauma, the thenar flap is convenient to cover the index and the medius pulp. Ring and little fingers can be treated by a reverse digital artery flap or by a cross finger flap. When a toe pulp transfer is indicated we recommend the lateral great toe hemipulp for the thumb and a second or third toe pulp transfer for the other fingers when digital vascular anastomosis are possible. The great toe hemipulp transfer represented a good indication for complete digital pulp loss reconstruction where the thumb is concerned. Performing this reconstruction during the acute phase may improve the management of those trauma by reducing the time needed for cicatrisation and the length of work inability.

Association of latissimus dorsi muscle expansion with electrostimulation before cardiomyoplasty.

BACKGROUND: The principle of cardiomyoplasty is chronic electrostimulation of the latissimus dorsi muscle (LDM) flap wrapped around the heart to obtain a phasic activity that can be integrated to ventricular kinetics. In clinical cardiomyoplasty procedures, a complete wrap of both ventricles by the LDM cannot always be obtained in cases of extremely dilated hearts. This is due to the limited LDM length available for wrapping. In most of these cases, benefits of cardiomyoplasty are very limited. We have investigated the feasibility of progressive LDM expansion associated with electrostimulation. The aim was to increase the muscle area before cardiomyoplasty, while preserving the electrophysiologic characteristics of muscle fibers. METHODS: In 5 goats, a silicone LDM expander with two incorporated muscular pacing electrodes was inserted deep into the LDM through a paravertebral incision along the posterior edge of the muscle. The pacing leads were connected to a myostimulator implanted in a subcutaneous pocket. The expander was progressively inflated over 8 weeks, up to 500 mL. Simultaneously the LDM was electrostimulated. RESULTS: At 2 months planimetric studies demonstrated an increase of the LDM surface from 175 +/- 12 to 229 +/- 17 cm2 (+31% +/- 4%; p < 0.05). The expanded LDM showed preserved electrophysiologic characteristics. The analysis of biopsy samples revealed histologic integrity of muscle fibers and preservation of their mean diameter. CONCLUSIONS: Potential benefits of this procedure are (1) increase of muscle surface, (2) training of muscular fibers and preservation of muscular tone, and (3) division of the distal vascular supply at implantation, which may potentiate vascularization from the LDM main pedicle. An LDM expansion could be considered before cardiomyoplasty in cases of significant heart dilatation. This device was successfully implanted in 2 patients, 2 months before cardiomyoplasty. Cardiomyoplasties were performed without difficulty, and a complete biventricular wrap was obtained in both patients in spite of massive cardiomegaly.

Secondary expansion of a totally replanted scalp for aesthetic adjustment.

Total scalp avulsion is an uncommon and dramatic accident. Replantation is the only way for acceptable aesthetic final results. However, partial loss of tissue can result, and secondary procedures can be required. A total avulsion of a scalp involving the upper part of the right ear and both eyebrows was replanted after a long delay in our department. As a result, loss of a third of the hair-bearing area occurred. Secondary expansion of the replanted scalp achieved complete reconstruction.

[Replantation of the ring finger]. / Réimplantation des doigts d'alliance ou ring finger.

Tearing of a finger caught by a ring or by another similar mechanism is a rare but spectacular accident. The lesions vary from simple cutaneous erosion to complete separation of the extremity, which is the most spectacular and most difficult to treat. Reimplantation techniques are now well developed and involve very long vascular by pass to perform sutures in healthy zones. The operation is thus technically difficult, it can have a favourable course in some cases whereas in others, despite the use of meticulous technique, it can lead to thrombosis and failure of reimplantation. Alternatives to reimplantation can nevertheless obtain an esthetic hand, by regularisation or by intracarpal osteotomy. However, it appears of interest in young, motivated patients to propose reimplantation using microsurgery.