Topographic superficial craniectomy for invasive scalp carcinoma.

The management of non-melanoma skin cancer of the scalp that invades the deep structures can be challenging. An operative technique of topographic superficial craniectomy using a piezoelectric instrument (Piezosurgery (Mectron S.p.A., Carasco, Italy)) for tumours with periosteal invasion without diploic space invasion is presented here. The tumour was resected including the periosteum of the craniectomy area. A grid was carved through the outer table using the Piezosurgery device. The grid squares measured approximately 1.5 cm on each side. A bony strip was removed from one side of the grid to complete a deep cut while avoiding crossing the inner table. The squares were collected individually with a chisel and sent for pathological analysis. This technique was used to identify and localize any possible bone invasion. As this method allowed an accurate pathological diagnosis to be obtained from the Piezosurgery squares, it was possible to determine the appropriate adjuvant treatment, thereby reducing the risk of malignant cells spreading.

Replantation of a lip thrown in the bin.

Management of soft tissue avulsion after facial bites could be challenging in some situation. We presented the case of a 32 years old men suffering from a full thickness avulsion of the left lower lip and cheek after a dog bite. Even if the lip fragment was initially put on the bin, a microvascular replantation was performed. The vascularization was based on the left inferior labial artery. No veins were found. We used post-operative leech therapy to avoid venous congestion during 10 days. A large antibiotherapy was conducted. Adaptation of antibiotics blood concentration was also necessary due to the permanent bleeding caused by leech therapy. At the 6 month consultation, the patient recovered an impressive labial function and sensibility. Replantation gives the best functional and esthetical outcomes in these rare and complex cases. Artificial blood drainage, large antibiotic therapy and close post-operative follow-up are significant parts of the replantation success.

Improvement in accuracy of maxillary repositioning of Le Fort I osteotomy with Orthopilot™ Navigation System: evaluation of 30 patients.

Traditional model surgery with facebow transfer is not very accurate. We aimed to demonstrate that the Orthopilot™ Navigation System improves the accuracy of maxillary repositioning during Le Fort I osteotomy. Thirty patients underwent Le Fort I osteotomy alone or associated to sagittal split osteotomy. The maxilla positioning was done in two phases. First, the maxilla was positioned with the traditional occlusal splint, the position ("without Orthopilot™") was recorded by the Orthopilot™. In the second phase, the Orthopilot™ was used to improve positioning; and the final position ("with Orthopilot™") was recorded, after osteosynthesis. Positioning data were compared with planned data. Positioning data with and without the Orthopilot™ were also compared. Accuracy was classified in distinct classes with three major criteria (conformity, non-conformity, failure) according to the discrepancies. Conformity rate was significantly greater with the Orthopilot™ (2 without the Orthopilot™ compared with 8 with the Orthopilot™; p=0.01). The failure rate was significantly lower with the Orthopilot™ (18 without Orthopilot™ compared with 7 with the Orthopilot™; p=0.002). Dispersions of discrepancies were usually lower in all directions with the Orthopilot™. Navigation reduced the risk of discrepancy without cancelling it, especially when large movements are planned. The Orthopilot™ therefore improved the accuracy of traditional occlusal splint during Le Fort I osteotomy.

Quantification of the inaccuracy of conventional articulator model surgery in Le Fort 1 osteotomy: evaluation of 30 patients controlled by the Orthopilot® navigation system.

Occlusal splints are commonly used to position the maxilla during traditional orthognathic surgery. We aimed to quantify the inaccuracy of the maxillary positioning (in three dimensions) in traditional model surgery with the Orthopilot® navigation system. Thirty Le Fort I osteotomies were made using a standard technique. The position of the maxilla was recorded by the navigation system and defined by three values of translation and three of rotation. The recorded data were compared with the planned data. The accuracy of positioning was classified in distinct classes with three major criteria (conformity, non-conformity, and failure) according to the discrepancy. The positioning of the maxilla was in conformity with operative planning in 3/30 of our Le Fort I osteotomies (95% CI 2% to 27%) and in failure in 22/30 (95% CI 54% to 88%). The dispersion of the discrepancy was more important in the sagittal plane, particularly for the sagittal rotation and for the back-front translation, which reflected greater inaccuracy in this plan. The frontal orientation of the maxilla was better controlled. The risk of maxillary malposition was proportional to the planned maxillary advancement.

Learning condyle repositioning during orthognathic surgery with a surgical navigation system.

Condyle repositioning during bilateral sagittal splint osteotomy (BSSO) is a challenging step for the inexperienced surgeon. We aimed to demonstrate the benefit of navigation for learning the condyle repositioning. We treated 100 patients who underwent a BSSO. A trainee performed the condyle repositioning of one side in two phases. In the first one, the trainee positioned without watching the screen of the Orthopilot Navigation system (ONS). In the second one, the trainee could use the ONS to replace the condyle. Heuristic, anatomical and functional scores of each phase were recorded. Heuristic (17% vs. 75%; p<0.0001), anatomical (35% vs. 86%; p<0.0001) and functional (14% vs. 56%; p<0.0001) scores were significantly greater with the ONS. The ONS is a promising and original intraoperative learning tool for the repositioning of the condyle during BSSO.

Porcine abdominal cutaneous flap model: A simple and reliable method.

The increase of reconstructive microsurgery procedures leads to the development of various technologies. Before being validated in human clinical studies, these technologies and devices need to be validated on animal models. We present a simple, reliable and reproducible model of a cutaneous flap in pigs. This flap is pedicled on the superficial inferior epigastric pedicle (SIEP). The surgical technique is described. This flap can be buried and, if necessary, harvested on both sides. It did not alter the abdominal wall, and so it has allowed painless long-term follow-up of the animals. To our knowledge, this technique has never been reported in pigs.

Nasal glial heterotopia or congenital hemangioma? A case report.

Nasal glial heterotopia (NGH) is a rare benign tumor of the median line. We describe the case of a child presenting a lateral nasal mass. The characteristics of the prenatal ultrasound and the postnatal clinical examination argued in favor of a congenital hemangioma (CH). The MRI performed at 6 weeks of life suggested glial heterotopia. This diagnosis was confirmed by the pathological analysis. Congenital hemangiomas and nasal glial heterotopies have similar clinical presentations. Prenatal ultrasound diagnosis between NGH and CH is difficult. Fetal MRI is not yet highly specific for these two lesions, but it can eliminate an intracerebral connection in cases of NGH. Postnatal exams are more specific. Flow on the Doppler exam is rapid for CH and slow for NGH. On MRI, these two lesions appear as a hypersignal on T2-weighted sequences, but less intense for NGH than for CH. Distinguishing between NGH and CH can be difficult. This does not have a direct incidence on treatment because it is surgical in both cases.