[Legal aspects of teenager aesthetic surgery]. / Aspects médicojuridiques de la chirurgie esthétique chez l'adolescent(e).

The teenager is more and more in search of cosmetic surgery. The current societal mode favors this evolution. There are, however, a variety of demands, from disabling major disgrace, through the desire for aesthetic consumption, to unjustified demand in the patient with dysmorphophobia. Information and consent of the patient and parents are mandatory. Cosmetic surgery is legally possible in minors but while it is possible for other therapeutic decisions, there is no anticipated medical majority for cosmetic surgery. Parental consent remains mandatory. The surgeon must also agree to perform this act, but he must take into account the maturity of the minor patient before giving his consent to the requested surgical act.

[Brachioplasty and its complications]. / Brachioplastie et complications.

Due to an increasing number of major weight loss after bariatic surgery, the demand for body-coutouring surgery increase in paralell. Among all the technics which can be realized, brachioplastyis one of them. The goal is to reach a functionnal but an aesthetic improvement too. The literature show that the rate of major complication is very low (or not reported in the majority of the series). Minor complication is more common : hypertrophic scar, large scar, paresthesia, and wound dehiscence. Re-operation can be asked by the patient in order to improve the result. With the help of clinical cases and literature review the authors try to analyse the balance between benefice and risk to realize a second operation.

[Medical liability for secondary surgery]. / Responsabilité médicale en chirurgie secondaire.

Taking care of a patient for secondary surgery is an important moral, ethical and legal responsibility. The patient is expecting a lot of this recovery. A new failure is hardly not acceptable to him. Before agreeing to operate, the new surgeon must well evaluate the possibilities of success and the operational risks, as well as the psychological aspects of this recovery. He must also inform the patient extensively. In front of the technical difficulty of these secondary surgeries, a new failure is always possible. It can lead to a judicial questioning of the last surgeon. The latter is responsible only for his own actions, however the reality of the prior state at the origin of this secondary surgery will have to be investigated and demonstrated, as it will not be borne by the last surgeon in terms of compensation.

[Septoplasty during primary unilateral cleft lip repair]. / La septoplastie lors de la chéilorhinoplastie primaire dans les fentes labio-palatines unilatérales.

Primary repair of cleft lip and palate has become a nasal and lip repair. In the aim to improve our nasal results on symmetry we perform an extensive septoplasty to put the nose in a good shape and a median axis. This septoplasty without resection of cartilage does not cause growth disorders to the nose and it promotes maxillary growth by improving early nasal breathing. It can prevent secondary rhinoplasty, source of new scars (externally, fork). But rhinoplasty will increase the incidence of scar contraction, thus shaping with a nasal conformer is essential.

[Neonatal treatment of stage 3 Pierre Robin sequence by mean of a naso-pharyngeal tube]. / Traitement néonatal par tube nasopharyngé dans les séquences de Pierre-Robin stade 3.

INTRODUCTION: In the stage 3 Pierre Robin sequence, glossoptosis is responsible for pharyngeal obstruction and for respiratory and eating disorders. An alternative to labioglossopexie, tracheotomy or mandibular distraction is the placing of a nasal pharyngeal tube in order to lift the lingual obstacle. MATERIAL AND METHOD: In our series of 15 new born with a stage 3 Pierre-Robin sequence, the nasal pharyngeal tube was positioned a few days after birth. RESULT: Ventilation and oxygen saturation were satisfactory. A lowering of hypercapnia and a rise of the weight curve were observed. The tube had to be maintained 64 days on average. No specific complication was noticed. DISCUSSION: The nasal pharyngeal tube lifts the lingual obstacle, improves hypercapnia and allows for a weight gain. In case of glossoptosis, hypercapnia may be ignored or underestimated. Normal oxygen saturation may be falsely reassuring while severe hypercapnia is occurring. Attentive care and parental involvement are needed.

Plastic reconstructive and esthetic surgery and tobacco, a legal approach.

Tobacco is a supplementary surgical risk factor to which some of our patients expose themselves. A patient who smokes incurs a heightened risk of medical accident. This is now accepted scientific knowledge, and no currently practicing plastic surgeon can be unaware of the close connection between smoking and postoperative cutaneous healing complications. On this subject, surgeons are invested with a duty to advise. And when a patient continues to smoke, a physician can refuse to operate, except in the event of an emergency. In some cases, however, he can go ahead with the operation, provided that his analysis of the risk/benefit highlights the interest of the surgery for the patient, whatever may be the tobacco-related complications. It is nonetheless necessary that the latter be preliminary informed and that he or she knowingly accept the risk.

Smoking and plastic surgery, part I. Pathophysiological aspects: update and proposed recommendations.

OBJECTIVES: Smoking patients undergoing a plastic surgery intervention are exposed to increased risk of perioperative and postoperative complications. It seemed useful to us to establish an update about the negative impact of smoking, especially on wound healing, and also about the indisputable benefits of quitting. We wish to propose a minimum time lapse of withdrawal in the preoperative and postoperative period in order to reduce the risks and maximize the results of the intervention. METHODS: A literature review of documents from 1972 to 2014 was carried out by searching five different databases (Medline, PubMed Central, Cochrane library, Pascal and Web of Science). RESULTS: Cigarette smoke has a diffuse and multifactorial impact in the body. Hypoxia, tissue ischemia and immune disorders induced by tobacco consumption cause alterations of the healing process. Some of these effects are reversible by quitting. Data from the literature recommend a preoperative smoking cessation period lasting between 3 and 8 weeks and up until 4 weeks postoperatively. Use of nicotine replacement therapies doubles the abstinence rate in the short term. When a patient is heavily dependent, the surgeon should be helped by a tobacco specialist. CONCLUSIONS: Total smoking cessation of 4 weeks preoperatively and lasting until primary healing of the operative site (2 weeks) appears to optimize surgical conditions without heightening anesthetic risk. Tobacco withdrawal assistance, both human and drug-based, is highly recommended.

Smoking and plastic surgery, part II. Clinical implications: a systematic review with meta-analysis.

OBJECTIVES: Tobacco addiction is a risk factor for complication in plastic surgery. The authors have assembled concrete arguments detailing the risks of perioperative and postoperative complication that are incurred by a patient with continued tobacco intoxication who wishes to undergo a surgical intervention. RESEARCH STRATEGY: Through application of the PRISMA criteria, we have carried out a systematic review of the literature, in which we explored five databases while using predefined keywords. We selected randomized, controlled observational studies on the perioperative and postoperative complications related to tobacco use in actively smoking, abstinent and non-smoking patients. DATA COLLECTION AND ANALYSIS: The levels of evidence for each article were evaluated. Risk of bias was assessed using the Newcastle-Ottawa Scale. Incidence parameters including the Odds Ratio and relative risk were calculated for each complication of which the number of occurrences had been indicated. Meta-analysis of the results was carried out. RESULTS: We included 60 observational studies. In the cosmetic surgery group, we calculated a combined Odds Ratio of 2.3 [1.51-3.54] P<0.001 for surgical site infections and 2.5 [1.49-4.08] P<0.001 for delayed wound healing. In the bariatric surgery sequelae group, we found a combined Odds Ratio of 3.3 [1.90-5.64] P<0.001 with regard to delayed wound healing and 3.1 [1.39-7.13] P=0.006 for cutaneous necrosis. No proof was provided as to the possible influence of tobacco on the success rate of free flap microsurgery, but it is difficult to extrapolate results on the latter to digital reimplantation. CONCLUSIONS: The review underlines the fact that patients with smoking habits run a significantly heightened risk of cutaneous necrosis, particularly in the event of major detachment (cervico-facial lift, skin-sparing mastectomy, abdominoplasty), of additionally delayed wound healing and of addition surgical site infections. Rigorous preoperative evaluation of smokers could help to diminish these risks.

[Nose surgical anatomy in six aesthetic subunits]. / L'anatomie chirurgicale du nez en six sous-unités esthétiques.

The nose is a complex entity, combining aesthetic and functional roles. Descriptive anatomy is a fundamental science that it can be difficult to relate directly to our daily surgical activity. Reasoning in terms of aesthetic subunits to decide on his actions appeared to us so obvious. The aim of this paper is to resume the anatomical bases relevant to our daily practice in order to fully apprehend the restorative or cosmetic procedures. We discuss the limits of the systematization of these principles in nasal oncology.

[The therapeutic function of cosmetic surgery]. / De la fonction thérapeutique de la chirurgie esthétique.

The therapeutic purpose or not of cosmetic surgery is the criterion chosen by the tax authorities to secure acts for aesthetic purposes to VAT. Purpose and necessity of medical therapy are often confused. Yet there are two distinct concepts. In the case of cosmetic surgery, its therapeutic purpose is recognized by physicians and judges. This is the psychological improvement after surgery, well be secondary to surgery, although be desired by the WHO, which demonstrates the therapeutic purpose of cosmetic surgery.

[From information to the right to advice, the responsibility increase in aesthetic surgery]. / De l'obligation d'information au devoir de conseil, une étape de plus dans la responsabilité en chirurgie esthétique ?

The law stipulates that the patient should be informed by the surgeon. For plastic surgery the right to advice has also become jurisprudence. This right obliges the surgeon to take an active part in his patient's decision. The medical contract is obsolete since the law of 4th march 2002. Thus medical staffs are only responsible if they are in fault. On the other hand the legal obligation to establish an estimate before operating and to give a withdrawal date constitutes a real consumer's contract between the surgeon and his patient. Maybe this is the reason why the right to advice, which is common practice in commercial or service contracts, is now also important for the plastic surgeon.

[Treatment indications for hand agenesis or acquired loss: Standard technics versus allotransplantation (CTA)]. / Une main vous manque et... Indications thérapeutiques des agénésies et amputations de mains : plasties et prothèses versus allogreffes.

The new surgery thinking, in matter of hand loss, is made of two ways: without hand, there is no more functional abilities; homograft or allograft of hand is the best actual treatment. This is not true and we are able to get new functional abilities by other ways: without any treatment, we are able of spontaneous functional recovery. There are other treatments: the old operation of Krukenberg or new bionic prosthesis. This work is a recall of obvious or forgotten facts.

[Substantiated scientific facts, current scientific facts. What are the consequences in esthetic surgery?]. / Données acquises, données actuelles de la science. Quelles implications en droit médical et en chirurgie esthétique en particulier ?

"Substantiated scientific facts" is reported in 1936 Mercier decree. This expression is often confused with current scientific facts. But, for jurists, they have different senses with consequences in aesthetic surgery, particularly when using new procedures or when new indications are founded for substantiated techniques. Fat autograft in breast aesthetic surgery is a current event example.

[Sequels of labial-alveolar-velopalatine clefts observed in charity missions. Analysis and management]. / Séquelles des fentes labioalvéolopalatovélaires en mission humanitaire. Analyse et prise en charge.

A lot of children with cleft lip and palate are not operated in the developing world, due to a lack of surgeons, hospitals, or simply because the condition is not considered as a priority. Charity missions give the opportunity to repair these malformations. Non-operated cleft lip and palate are the first problem, but our surgery may cause growth disturbances and sometimes a second operation is needed, more difficult than the first one in mission conditions. Repairing a cleft palate needs to be adapted to the type of cleft but also to the age of the child, a velopalatine pharyngoplasty can be performed in some cases.

[Neonatal surgery of cleft lip and palate: juridical aspects]. / Chirurgie néonatale des fentes labiopalatines: aspects juridiques.

Neonatal surgery of cleft lip and palate is a common practice fro many surgical teams. The modifications of the French Law in 2002 on patient's rights, the way judges decide how the law should be applied, and the modifications of the rules for health centres need an analysis of the juridical aspects of this surgery. First the bases of the Law are presented, then how the surgeon responsibility can be engaged is learned.

[Palatovelopharyngoplasty at the same time. Our experience in Philippines]. / Palatovélopharyngoplastie en un temps. Notre expérience aux Philippines.

After many surgical charity missions in the same hospital in the Philippines, we have evaluated the child's phonation being operated of cleft palate. We had bad results so we decided to do in the same time an Orticochéa pharyngoplasty and the closure of the palate. These patients were evaluated too, the results were improved.

[The treatment of cleft lip, cleft palate and other dysmorphisms: the ideal technic and therapeutic reality]. / A propos du traitement des fentes labio-palatines et autres dysmorphies: idéal technique et réalisme thérapeutique.

Good results in any surgical or orthodontic procedure require expert technique, well adapted to the problem and scrupulously executed. A technique that would achieve the best results can be described as "ideal" and can serve as a theoretical model for all similar cases. But, in dealing with apparently similar problems: cleft lips and palates, Class II or Class III cases... in reality, we are treating individual patients, none quite the same as any other. These differences derive from the varying characteristics of individual patients and from the varying and unpredictable responses of their tissues, and from their varying capacities to accommodate to and withstand insults, suffering, and the sensory-motor effects of their deformities and of the treatment they undergo, and, finally, from their variable readiness to submit to and to pay for treatment with their time and with their money. Any therapeutic technique must take into account these realities which sometimes oblige us to modify an ideal technique so that it will fit the specialized needs of a patient, an accommodation that can be defined as "therapeutic realism". When we ignore this reality, we risk the paradox of providing patients with technically ideal results that they find unsatisfactory or discover that what we thought was a technically mediocre outcome has delighted our patient: ultimately, it is the patient's judgment that determines the "therapeutic result" and is, in effect, the Final Evaluation of the technical result.

[The whole treatment of cleft lip and/or palate by the team of Dr. Chancholle in Toulouse]. / Prise en charge des fentes labio-palatines par l'équipe du docteur Chancholle à Toulouse.

Our choice in the treatment of the C.L.P. child is that the child is accepted by his parents and by Society as well as possible. In this way, the most important points are: to inform parents and Society of the ability of the child to a normal and satisfactory life. This information must be based upon the exact knowledge of what is really the cleft disease, its causes, and not only the genetic ones, the whole troubles induced by the cleft, local and general, and their treatment: by neonatal operation and, however was the choice of operative technic, by educative and reeducative means based on an exact knowledge of the modified physiology of the child: above all, sensory-motricity coordination and early speech-therapy before speech. The follow-up of the child at the difficult time of school admission, and cooperation between all the members of the team and the teachers.