[Post-traumatic enophthalmos. Pathogenic, diagnostic and therapeutic approaches]. / Enophtalmie post-traumatique. Approches pathogénique, diagnostique et thérapeutique.

Post-traumatic enophthalmos has a complex pathogenesis, resulting from injuries to the bony walls of the orbit or to the intraorbital contents. Computed tomography allows specifying this pathogenesis by locating displaced bone, fat leakage or muscle incarceration, as well as calculating the volumes of the orbit and of the soft tissues. This assessment guides surgery (most often bone grafts), but correction remains limited by scar retraction, especially around the orbit. The prognosis of enophthalmos mainly depends on a general initial treatment after the trauma.

[Enophthalmos of the enucleated eye]. / Enophtalmie de l'énucléé.

Even when it is corrected by an ocular prosthesis, enucleation often causes enophthalmos. After studying the integrality of the walls of the orbits with CT, the presence and position of the intraorbital implant must be controlled and the enophthalmos treated by compensating for the residual volume loss of the orbital content (bone or biomaterials) and, sometimes, filling up the upper palpebral space (dermal graft, galea flaps or biomaterials). The retraction of palpebral scars limits the possibilities of correction.

[Fractures of the condylar region]. / Fractures de la région condylienne.

Condylar fracture are responsible for: homolateral TMJ disorders following discal apparatus lesions such as: disc displacement, discal lesion, osteoarthrosis of articular surfaces (condylar and temporal), contralateral TMJ disorders, more frequent, with destabilisation of the masticatory apparatus and decrease of ramus height or compensatory hypermobility. Functional treatment can prevent articular and muscular ankylosis. It is often indicated: non-displaced low undercondylar fractures or after surgery. Surgical reduction is indicated in two cases: displaced-low undercondylar fracture. The discal apparatus is intact and function usually excellent, displaced-high undercondylar fractures with 90 degrees head luxation. The bone reduction and contention must be associated to discal apparatus control. If dislocated or displaced, the apparatus should be replaced and sutured. Four factors are implicated in articular function: the fracture position, bone displacement (condylar head in or out of the glenoid fossa), discal apparatus integrity (the lower layer of the retrodiscal tissue is involved in bone regeneration especially in infants), and the quality of occlusion.

[Use of a posterior temporal muscle flap in surgery of the temporomandibular joint]. / Utilisation du lambeau postérieur de muscle temporal dans la chirurgie de l'articulation temporomandibulaire (A.T.M.).

The anatomical and physiological relation between temporal muscle and temporomandibular joint are well-knowed. The versatility of the temporo muscle-fascia flap must be stressed. The posterior temporal flap is a simply, reliable procedure, with low morbidity. This technique is probably the procedure of choice in discal replacement and in interposition arthroplasty for ankylosis.

[Repair of enlarged orbital exenteration cavities]. / Réparation des cavités d'exentération orbitaire élargie.

An empty orbital cavity is always unesthetic-looking, but several plastic surgery procedures exist to attenuate the cosmetic damage. In case of exenteration affecting periorbital tissues and cavities, spontaneous epithelialization is preferable than a split skin graft. Except for rare cases, where it is indicated to preserve the conjunctivae and eyelids, covering up may be realized with minimal scarring using two flaps, one superficial jugotemporal, and the other deep mid-frontal.

[Post-traumatic ptosis]. / Ptosis post-traumatique.

Traumatic ptosis is most often secondary to a fasciomuscular lesion of the levator system. Less frequently, it results from the paralysis of the levator muscle due to an injury to the third pair of cranial nerves. This ptosis is observed in comminuted orbital fractures or fractures of the base of the skull involving the orbital apex, and it is then associated with oculomotor paralysis. In favorable cases seen early, repairing surgery of the levator system produces excellent results. When associated with ophthalmoplegia or corneal anesthesia, neurogenic ptosis requires a watch and wait policy.

[The aging eyelid]. / Paupière sénile.

Eyelid involution affects all the tissues of the lid, including the tarsotendinous band and the levator muscle. Dermatochalasis can be complicated by ptosis, entropion or ectropion, which must be taken into account during assessment and treatment.

[Synovial chondromatosis of the temporomandibular joint. Apropos of 3 cases]. / La chondromatose synoviale de l'articulation temporo-mandibulaire. A propos de trois observations.

Synovial chondromatosis of the temporo-mandibular joint is a rare and mild disorder. Three cases are reported, one with an histological aspect of chondrosarcoma. The evolution is favourable after removing the loose particles and the synovial tissues.

[Repair of mutilations of the lacrimal apparatus]. / Réparation des mutilations des voies lacrymales.

Repair of mutilated lacrimal passages should be adapted to the anatomy and physiology. Whenever possible, this should be performed as an emergent operation and come in as part of an overall therapeutic strategy. Repair methods used are simple end-to-end approximation of permeable segments, in case of limited lesions, and use of arterial grafts or of adjacent, nasal or saccular mucous flaps, in case of extended lesions. When reconstruction is not feasible owing to the extent of the lesions or to failure of the repair methods, tear derivation is carried out directly via the lacrimal sac or nasal fossa, by means of intermediate flaps (primarily nasal mucosa) or indwelling drains. Objectively, the functional outcome of repair is hard to assess, as tearing can, by no means, be considered a clinical criterion of obstruction, in the same way as lack of tearing is not a criterion of permeability. Only dacryography or, when possible, postoperative scintigraphy of the lacrimal passages allow for an objective evaluation of the results. Thus, although satisfactory results are the rule, long-term objective observation often leads to mitigating feelings.

[Conservative rhinoseptoplasty of the nasal roof]. / Rhinoseptoplastie conservatrice de l'auvent nasal.

Rhinoseptoplasty is proposed to preserve the integrity of the ridge of the nose and its natural appearance. It is patterned on Maurel's procedure (1940). After mobilization of the bony root of the nose, the resection of a strip of the nasal septum just under the "keystone" allows pushing the nose back into the facial structures. Besides its simplicity, the advantages of this method include: the integral preservation of the ridge of the nose, the controlled reduction of the profile. and the relative autonomy of the tip of the nose. The indications for this type of rhinoplasty are mainly restricted to straight noses with a mild, harmonious osteocartilaginous hump.

[Entropion: therapeutic indications]. / Entropion: indications thérapeutiques.

The severity of entropion depends on trichiasis which is perpetuated by orbicularis spasm, creating a vicious cycle. The therapeutic approaches are based on the aetiopathogenesis. Congenital entropion is essentially treated by infraciliary cutaneomuscular resection. The various components of involutional (senile) entropion, horizontal and vertical retraction, orbicularis dyskinesia, are treated respectively by tissue reduction, reinforcement of retractore and myoplasties. In cicatricial entropion, chondro-mucosal or fibromuscular graft is the technique of choice for correcting insufficiency of the tarsoconjunctival plane or its curvature. It is also the best solution for the correction of trichiasis or distichiasis.

[Repair of orbital exenteration cavities]. / La réparation des cavités d'exentération orbitaire.

Several plastic surgical procedures can attenuate the unsightly effects of a disinhabited empty orbit. Only the imperatives of follow-up or very poor general status can still justify spontaneous epithelialisation, which we prefer to split skin graft. In other cases, apart from the exceptional indications of preservation of the eyelids and conjunctival sac, closure by flap is the technique of choice: temporo-frontal flap in cases of simple exenteration and temporo-jugal for the superficial plane and medio-frontal for the deep plane in radical exenterations. In young adults, when the resection is limited to the orbit, after flap closure, conjunctival reconstruction by means of a mucosal graft can be attempted without preliminary temporalis muscle transposition, as the orbital cavity is filled spontaneously and sufficiently by fibrous tissue.

[Conservative rhinoplasty of the nasal canopy]. / Rhinoplastie conservatrice de l'auvent nasal.

A rhinoplasty technique is proposed to maintain the integrity of the nasal ridge and to retain the natural appearance of the nose. It is derived from Maurel's technique (1940). After global mobilisation of the bony canopy, the resection of a band of nasal septum immediately under the keystone allows displacement of the nose deeper within the face. The advantages of this method, apart from its simplicity, are: preservation of the entire bony ridge, controlled reduction of the profile, relative autonomy of the nasal tip. The indications for this rhinoplasty are essentially confined to straight noses with moderate and harmonious osteocartilaginous kyphosis.

[Grafts in esthetic and functional corrective rhinoplasty]. / Les greffons en rhinoplastie correctrice esthétique et fonctionnelle.

Results of the use of grafts in primary and secondary rhinoplasty are reported, the grafts being either of cartilage (concha auriculae, nasal septum, alar cartilage), bone (mastoid, ilium) or connective tissue (temporal aponeurosis). The distinction is made between modelling grafts of softened cartilage, supporting grafts of non-softened cartilage and mastoid bone, of bone reconstruction and of cartilaginous filling grafts.