Facial surgery for cosmetic purposes: Practice guidelines.

OBJECTIVES: Facial surgery for cosmetic purposes aims to improve the physical appearance and self-image of normal individuals. The aim of the guidelines is to answer questions related to legislation, patient evaluation and motivations, relevance and risk assessment, patient information and patient follow-up. METHODOLOGY: Analysis and synthesis of the medical literature through research of bibliographic databases in French and English from 2000 to 2017. Research and use of guidelines from evaluation agencies and academic societies. Drafting of guidelines with indications on levels of evidence. RESULTS: 24 guidelines with levels of evidence B (scientific presumption), C (low level of evidence) or EO (expert opinion) were selected to answer the questions. Cosmetic facial surgery must be performed by certified, qualified professionals in authorized structures. It must follow certain specific rules as well as a charter and code of ethics so as to enforce the rules of practice.

Angina bullosa haemorrhagica: a systematic review and proposal for diagnostic criteria.

The aim of this study was to perform a critical review of published data on the epidemiological, aetiological, clinical, histological, biological, and therapeutic characteristics of patients with angina bullosa haemorrhagica (ABH). A literature search was conducted in the PubMed, Science Direct, Web of Science, and Cochrane Library databases. All publications fulfilling the selection criteria were included in the eligibility assessment according to the PRISMA statement. The full texts of 54 retrieved articles were screened. Forty articles published between 1985 and 2016 describing 225 cases of ABH were finally selected. The mean age of the patients was 55.4 years; the male to female ratio was 0.7. The predominant localization was the palate (66%). A third of patients had no medical history. When specified, a triggering event or promoting factor was frequently found (82%). Biological tests were normal. A biopsy was performed on 35% of the patients. Treatment was symptomatic with a favourable outcome. Recurrences were frequent (62%). In conclusion, ABH is poorly documented and only by studies of low-level evidence. This review did not allow any aetiopathogenic association to be made with a general pathology or treatment. On the basis of this systematic review of the literature, diagnostic criteria aiming to improve the care of patients presenting with ABH are proposed.

[Anatomic study of the submental artery relationships for submental flap raising]. / Étude anatomique des rapports de l'artère sous-mentonnière pour le prélèvement du lambeau sous-mentonnier.

INTRODUCTION: Submental flap is useful for intra-oral reconstructions and reconstructions of the lower two thirds of the face. Dissection is delicate because of a difficult exposure under the lower rim of the mandible, numerous collateral arterial branches and the proximity of the marginal branch of the facial nerve. The aim of our work was to propose anatomical landmarks in order to facilitate the submental flap raising. MATERIAL AND METHOD: Ten bodies preserved in Biomet liquid were dissected bilaterally. The anatomic relationships between the marginal branch of the facial nerve and the mandible, the relationships of the submental artery, the amount and the location of its collateral branches were measured by means of a caliper. RESULTS: The highest marginal branch observed was located 0.5 cm above the mandibular lower rim, while the lower one was located 0.6cm below this rim. The mean length measured between the facial artery at its crossing over the mandibular rim at the level of the pre-angular notch and the origin of the submental artery was 1.5cm. The average number of collateral branches was 3.6. DISCUSSION: A skin incision made directly under the mandibular lower rim, as mentioned by some authors, may endanger the mandibular marginal branch of the facial nerve. Three positions of the submental artery in relation to the sub-maxillary gland are reported. The collateral branches are intended for gland, muscle, skin and bone. It is necessary to pay particular attention to the sub-lingual artery, an artery of big diameter that arises at 2.8cm on average from its origin and plunges towards the mouth's floor. It must not be followed at risk of clamping the thin pedicle destined to the digastric muscle. It is important to preserve the fat tissue around the submental pedicle in order to avoid venous congestion of the flap.

[Acute respiratory distress syndrome complicating an acute chest syndrome: potential benefit of early combination of exchange transfusion and prone positioning]. / Syndrome de défaillance respiratoire aiguë sévère au cours d'un syndrome thoracique aigu chez une enfant drépanocytaire de 8ans : bénéfice potentiel de l'association précoce échange transfusionnel et décubitus ventral.

We report the case of an 8-year-old sickle cell anemia child admitted for acute respiratory failure complicating acute chest syndrome. Because of threatening respiratory failure, tracheal intubation was performed immediately after ICU admission. The patient met the criteria for ARDS with a PaO2/FiO2 ratio of 94mmHg. An exchange transfusion was performed immediately after admission. HbS fraction failed from 69 % to 30 %. Fluid resuscitation with crystalloids and continuous norepinephrine infusion was needed because of arterial hypotension. Due to persistent severe hypoxemia with PaO2/FiO2 ratio below 100, the patient was placed in prone positioning 16hours after admission, for a total duration of 14hours. A second 12-hour session of prone positioning was performed 41h after admission and PaO2/FiO2 ratio reached 300mmHg after. Treatment also included transfusion of two red-cell pack on day 1 and 2 after admission in order to maintain hemoglobin level above 8g/dL, and a daily folic acid supplementation. The control of hyperthermia was achieved by a systematic parenteral administration of paracetamol. Cefotaxime and erythromycine were continued until day 7 despite the negative results of all bacteriological samples. The outcome was favorable from day 3 and the patient met the criteria for extubation on day 5. A first attempt of extubation was performed on day 5, but re-intubation was required because of laryngeal edema. Steroids were given for 48h and the patient was successfully extubated on day 7. She was discharged from the ICU on day 8, and from the hospital on day 12. We discuss the various treatments available for the management of acute chest syndrome and their actual relevance in acute respiratory distress syndrome in the absence of strong evidence-based guidelines in pediatric ARDS.

[Screening for psychiatric risk factors in a facial trauma patients. Validating a questionnaire]. / Dépistage des facteurs de risques psychiatriques dans une population de traumatisés faciaux. Validation d'un questionnaire.

INTRODUCTION: We recorded similarities between patients managed in the psychiatry department and in the maxillo-facial surgical unit. Our hypothesis was that some psychiatric conditions act as risk factors for facial trauma. We had for aim to test our hypothesis and to validate a simple and efficient questionnaire to identify these psychiatric disorders. MATERIALS AND METHODS: Fifty-eight consenting patients with facial trauma, recruited prospectively in the 3 maxillo-facial surgery departments of the Marseille area during 3 months (December 2012-March 2013) completed a self-questionnaire based on the French version of 3 validated screening tests (Self Reported Psychopathy test, Rapid Alcohol Problem Screening test quantity-frequency, and Personal Health Questionnaire). RESULTS: This preliminary study confirmed that psychiatric conditions detected by our questionnaire, namely alcohol abuse and dependence, substance abuse, and depression, were risk factors for facial trauma. DISCUSSION: Maxillo-facial surgeons are often unaware of psychiatric disorders that may be the cause of facial trauma. The self-screening test we propose allows documenting the psychiatric history of patients and implementing earlier psychiatric care.

[Damage control applied to severe maxillofacial trauma]. / Damage control appliqué aux traumatismes maxillofaciaux graves.

Damage control is defined by the extreme emergency implementation of a first resuscitation and surgical step, during which there is no attempt at repairing lesions but only at restoring adequate physiological function. In recent years, "damage control" has considerably improved the management of polytrauma patients, especially in war surgery. Respiratory distress or hemorrhagic shock requirements are critical maxillofacial emergencies. We present the specificities of "damage control" management for patients with severe maxillofacial trauma. Some clinical and biological criteria have been defined to choose "damage control" strategy, in patients presenting with life-threatening facial hemorrhage after facial trauma. A rapid initial stage restores vital functions. Airways are maintained and secured: oro-tracheal intubation, cricothyroidotomy, surgical tracheotomy. Facial bleeding is controlled with various means: oronasal packing, angiographic embolization, selective ligation then external carotid artery if necessary. The resuscitation step stabilizes the lethal triad: hypothermia, coagulopathy, metabolic acidosis. The second step that comes in later is a surgical repair of facial injuries. "Damage control" can be adequately applied to the management of patients with severe maxillofacial trauma.

[Palatal fibromucosal graft to correct lower eyelid retraction]. / Greffe de fibromuqueuse palatine pour corriger la rétraction de la paupière inférieure.

INTRODUCTION: Retraction of the lower eyelids has multiple etiologies. Its surgical treatment is a vertical elongation of the tarsus. This can be obtained by using a graft. We describe a sampling and grafting technique using palatal fibromucosa intratarsal graft. TECHNICAL NOTE: The procedure is performed in two steps under general anesthesia. The graft is harvested on the lateral sides of the palatine vault to avoid neurovascular bundles. This area corresponds to the maxillary fibromucosa according to Delaire's classification. The graft is then inserted in the lower eyelid tarsus. DISCUSSION: Many "spacers" are available to extend the posterior lamella vertically; the palatal fibromucosa graft may be used directly and is easy to harvest. It has a similar stiffness to that of the tarsus and there is no need to harvest periosteum. Sparing the periosteum allows for a better healing of the donor site and decreases postoperative pain. The lateral harvesting area, away from the anterior palatine artery, seems more accessible than the median area, especially in ogival palates.

Trigeminal neuralgia: a new therapy?

Trigeminal neuralgia (TN) is a rare form of neuropathic pain that results in sudden, unilateral and recurrent pains in the distribution of one or more branches of the trigeminal nerve. The aetiology of TN remains unclear and several theories have been proposed. Many medical and surgical methods have been applied with only partial effectiveness and several side effects. New hypotheses and therapeutic methods are urgently needed. Using evidence presented in a literature review and in our own case report, we hypothesize that pain resulting from trigeminal neuralgia can be caused by demyelinating lesions in the trigger zone. These lesions can be repaired through the injection of fat containing Adipose-Derived Stem Cells (ADSC).

[Micro-re-injection of autologous fat]. / Micro ré-injection de tissus graisseux autologue.

INTRODUCTION: Autologous fat graft has become the gold-standard defect filling technique. "Lipostructure(©)" was described by Colman in 1994. It is perfectly codified and gives excellent results. The filling of superficial skin layers with the routine technique is difficult. It can be performed with a new technique developed by G. Magalon called micro-re-injection of autologous fat. TECHNIQUE: The adipose tissue is harvested without any incision, using a specific 2 mm cannula. The harvested fat tissue is centrifuged according to Coleman's recommendations. Re-injection of purified fat is performed with 0.8 mm specific cannulas, without any incision. 500-micron grafts are injected in multiple layers in the subdermal stratum. DISCUSSION: This autologous fat graft respects Coleman's procedure principles and preserves the histological structure. This technique is well adapted for facial defects, especially for the lips. It is more precise because the fat deposits are thinner. It does not require any skin incision. It proved to be less painful for our patients, and there was less postoperative edema than with the reference technique. Micro re-injection broadens the indications of autologous fat tissue graft in the fields of plastic (lip, eyelids) and reconstructive (retractile scar) surgery.

[Multiple organ failure complicating a severe acute necrotising pancreatitis secondary of a severe hypertriglyceridemia: a case report]. / Défaillance multiviscérale compliquant une pancréatite aiguë au décours d'une hypertriglycéridémie majeure: à propos d'un cas.

We report the case of a 42-year-old man admitted for a multi-organ failure with a coma, a hemodynamic instability, a respiratory distress syndrome, an acute renal failure and a thrombocytopenia. The blood samples highlighted a milky serum and allowed to diagnose an acute pancreatitis associated with a major dyslipidemia: hypertriglyceridemia 11,800 mg/dL and hypercholesterolemia 1195 mg/dL. The CT-scans do not reveal any cerebral abnormalities but highlighted pancreatic lesions without biliary obstruction. A multi-organ failure complicating a severe acute pancreatitis secondary of a major hypertriglyceridemia was mentioned. Despite the absence of clear guidelines, a session of plasma exchange was started in emergency. Symptomatic treatment with protective ventilation, vasopressors, continuous heparin and insulin was continued. The clinical and biological course was good in parallel of the normalization of lipid abnormalities. The patient was discharged at day 17 with a lipid-lowering therapy. We discuss the various treatments available for the management of acute pancreatitis complicating a severe hypertriglyceridemia and their actual relevance in the absence of clear recommendations.

[Total nasal reconstruction with a titanium miniplate as structural support]. / Rhinopoïèse totale avec armature par miniplaque en titane.

INTRODUCTION: Total nasal reconstructions using bone graft, as structural support is the gold standard. We retrospectively studied an alternative technique relying on a titanium miniplate as a structural support. PATIENTS AND METHODS: Five patients underwent total nasal reconstruction, using a 1mm titanium miniplate fixed to the frontal bone and to the anterior maxilla. The miniplate was covered by a fascia lata graft in three cases. The functional and aesthetic results were evaluated on a scale from 0 (disappointing results) to 3 (excellent results) by the patient and by the surgeon, at 1 month and at 3 years after the total nasal reconstruction. RESULTS: The functional results were assessed on average at 2.2/3 at 1 month, and 2.4/3 at 3 years postoperatively. The aesthetic results are estimated at 2 (patient) and 1.8 (medical team) at 1 month and at 2.6 (patient) and 2.2 (medical team) at 3 years. There were no major complications. The minor complications were exposure of the two miniplates, which had not been covered with fascia lata. These complications were resolved by local surgery. DISCUSSION: The functional and aesthetic results of total nasal reconstruction relying on a titanium miniplate were similar to those obtained with a bone graft. This technique is simple, there is no need for an osseous donor site, it is stable at long-term, and its cost is moderate.

Minimal iliac bone harvesting in sinus lift surgery.

For sinus grafting, the authors propose a minimal posterior iliac bone harvesting, with local anesthesia. Autogenous bone grafting continues to be considered the gold standard for sinus grafting. The classic harvesting sites are calvarial, anterior iliac, and tibial, and harvesting is usually practiced under general anesthesia. We performed this technique in 7 patients under local anesthesia. In the posterior iliac crest, with a specific trocar for bone puncture biopsy, bone was harvested. We performed 1 cm longer for 5-mm diameter of bone. Three bone biopsies were harvested on each side. The harvested cancellous bone (5 cm(3)) was mixed with triphosphocalcic (TCP) material (2 cm(3)), and blood (1 cm(3)). A classic sinus lift was realized. After 6 months, the success rate of bone grafting was 100%. Each of the 7 patients could be implanted by an average of 4 dental implants by superior maxillary. For sinus lift, this simple posterior iliac-bone biopsy harvesting under local anesthesia is very comfortable for the patient and also safe. It provides enough marrow bone to be mixed with TCP for a sinus lift.

[Lifting of the oval face--LOV: technical note]. / Lifting de l'ovale du visage--LOV: note technique.

OBJECTIVE: The authors describe a rejuvenation surgical technic of cervical area ptosis. It is called LOV for "Lifting of the Oval of Visage". LOV is realised under local anaesthesia, lasts about 40 minutes. In this study, post-operative results are evaluated after one year. MATERIAL AND METHODS: retrospective study with anonymous questionnaire measuring patient's satisfaction, operated between january 2011 and december 2011, by the same surgeon in the department. RESULTS: 43/45 questionnaires were analyzed, 40 females (93%) and 3 males (7%). Average age was 56 years, with a range of 51 years to 66 years. Our satisfaction ratings values after surgery were: very good: 32 (74.4%), good: 8 (18.6%), intermediate: 2 (4.6%), unsatisfied: 1 (2.3%), will not undergo LOV again: 1 (2.3%), would not recommend LOV to a friend: 2 (4.6%), recommend LOV to a friend: 37 (86%). The only complication (2.3%) was an unilateral hypoesthesia earlobe. CONCLUSION: LOV is simple and effective. It is a surgical alternative in the treatment of cervical area ptosis. Performed under local anesthesia, this short procedure responds to complaints of patients: safe rejuvenation and natural looking. Since 2008, LOV is performed in our department. Recruitment is most often "word of mouth", as confirmed by 86% of patients who would "recommend it to a friend". In cosmetic procedure, we should always keep in mind "a good result is measured to good patient satisfaction".

[Marionette fold treatment by depressor anguli oris section: technical note]. / Traitement des plis d'amertume par section du depressor anguli oris: note technique.

Marionette folds are typical signs of facial aging. They result from contraction of depressor anguli oris (DAO) muscle, which tracts the corner of the mouth inferiorly and laterally. Marionette folds express sadness, contrary to the real mood of patient, and constitute a purpose of consultation. A systematic classification of facial aging types has been developed by Glogau in 1994. It differentiates four types of wrinkles according to their severity. Type IV of marionette folds resists to treatment with filler injection or botulinum toxin type A. Some authors, like Le louarn C., have developed surgery techniques to correct those types IV of marionette folds. In this article, we describe the DAO section technique we use. Intervention occurs under local anaesthesia, by intrabuccal approach. Horizontal mucosal incision is performed 1cm long, at the vestibular projection of DAO insertion. Orbicularis oris and buccinator muscles are retracted horizontally to let appear the DAO fibers, which are cut until subdermal fat is seen. This technique must be completed by botulinum toxin type A injection in the inferior part of the DAO to avoid muscular regeneration. DAO section is an easy, quick and efficient surgery, which allows perennial correction in marionette folds treatment. It completes other less invasive techniques to enlarge therapeutic possibilities available for surgeons and patients.

[Vade mecum for a surgical humanitarian mission]. / Vade-mecum du chirurgien en mission humanitaire.

Humanitarian surgical missions provide cares in developing countries and in difficult conditions. Preparation of these missions is a mandatory step for both technical and human points of view. Before the departure, care must be taken to accomplish all the administrative (visa application, valid passport…) and the medical formalities (mandatory and recommended vaccinations). The aim of this article is to present a helpful vade mecum allowing any surgeon, especially the juniors, to prepare a humanitarian mission abroad.

[Primary malignant schwannoma of the buccal branch of facial nerve]. / Schwannome malin primitif du rameaux buccal supérieur du nerf facial.

INTRODUCTION: Primary malignant schwannomas are rare neoplasms of nerve sheath origin, especially in the location of the head and neck where few cases are described in the literature. REPORT CASE: We report the case of a 65-year-old male diagnosed with malignant schwannoma in the left cheek. The patient underwent surgery with wide local excision, reconstruction were made later by skin graft. DISCUSSION: The treatment of choice is radical excision of the lesion with wide margins. In fact, to reduce local tumor recurrence, the use of adjuvant radiation or chemotherapy is still controversial.

[Tooth abscess: management in the field]. / Abcès dentaires: diagnostic et prise en charge sur le terrain.

Tooth abscess can be diagnosed based solely on clinical findings. No additional studies are required. Abscess can be treated using a few basic instruments.

[A giant chondroblastic osteosarcoma of the mandible. A case report]. / Ostéosarcome chondroblastique géant de la mandibule. À propos d'un cas.

INTRODUCTION: Osteosarcoma of the craniofacial bones location is less common, usually with low grade of malignancy; it has better prognosis when surgical excision is complete. REPORT CASE: We report a case of a 35-year-old male diagnosed with a low-grade chondroblastic osteosarcoma of the mandible. The patient was treated with surgery alone and recovered with pectoralis major myocutaneous flap. After 48 months, the oncology's and aesthetics results are good. DISCUSSION: We will discuss the treatment of chondroblastic osteosarcoma of the mandible.