Use of autologous platelet-rich clots for the prevention of local injury bleeding in patients with severe inherited mucocutaneous bleeding disorders.

Stopping or preventing local bleeding in patients with inherited bleeding disorders linked to abnormal platelet function is traditionally treated by transfusion of blood cell products or recombinant factor VIIa. We now report the use in such patients of autologous platelet-rich clots as an aid to preventing bleeding and to facilitating tissue regeneration at superficial sites. Two patients with von Willebrand's disease (VWD) type 2B and one patient with type I Glanzmann thrombasthenia were treated after tooth extraction and dental surgery. A fourth patient with platelet-type VWD underwent a skin biopsy. Whereas all four patients had a lifelong history of bleeding complications, the application of an autologous platelet-rich clot immediately after surgery combined with tranexamic acid intake to slow fibrinolysis prevented blood loss and resulted in rapid and normal healing. This new procedure is simple, safe and inexpensive; it provides extra security for patients with a bleeding risk undergoing dentistry or superficial surgery.

[Tongue reconstruction with a bilateral infrahyoid flap innervated by Ansa Cervicalis after total glossectomy]. / Le lambeau infrahyoïdien bilatéral innervé par l'Ansa Cervicalis pour la reconstruction des glossectomies totales.

INTRODUCTION: Reconstruction after total glossectomy remains a functional challenge. It must provide a large volume to ensure adequate phonation and swallowing. We present the larynx sparing bilateral infrahyoid flap reconstruction procedure after total glossectomy. PATIENTS AND METHOD: Three patients managed for an epidermoid carcinoma of the tongue, classified T4N0, underwent total glossectomy. The tongue was reconstructed with a bilateral infrahyoid flap pedicled on two superior thyroid arteries and innervated by Ansa Cervicalis. RESULTS: Oral food intake was resumed after 8 to 20 days. No false route was observed. The muscular flap mobility was clinically satisfactory. It was assessed by EMG in one case. Esophageal transit confirmed the absence of stasis and false route for one patient. DISCUSSION: This short series proves the feasibility of bilateral innervated and pedicled infrahyoid flap procedure. It is an alternative to volumetric and functional reconstruction after total glossectomy. The indications are rare and restricted to patients without IIa nodal region invasion. Our results are still limited and need to be confirmed by a larger series and by a more systematic assessment.

[Globulomaxillary cyst]. / Kyste globulomaxillaire.

Globulomaxillary cysts are located in the globular and maxillary process fusion area; they are not of odontogenic origin. Their etiology is similar to oral and facial clefts, which explains why they are classified as ontogenic fissural cysts. However, some clefts are not localized precisely on the premaxillary and maxillary process fusion area and their etiology as globulomaxillary cysts is questioned. In fact, those lesions could actually be of odontogenic origin.

[Hemophilic pseudotumors of the jaws]. / Pseudotumeurs hémophiliques maxillomandibulaires.

Hemophilic pseudotumors are observed in 1 to 2 % of severe hemophilia cases. They are very rare in the maxilla and mandible. Traumatic etiology is the most frequent. Osteolysis is the main radiological aspect. The treatment is usually enucleation, curettage, or intralesional fibrin glue injection.

A multirecurrent ameloblastoma metastatic to the lung.

INTRODUCTION: The ameloblastoma is a rare tumor of odontogenic epithelial origin. It is a neoplasm in which ameloblastic features are revealed by the primary growth in jaws and by any metastatic growth. Recurrences are usually local and distant metastases are rare. We present a case of a multirecurrent ameloblastoma of the mandible metastatic to the lung. OBSERVATION: We present a case of a mandibular malignant ameloblastoma in a 42-year old man with widespread pulmonary metastases. Some of these lesions were treated surgically. DISCUSSION: Ameloblastoma metastasis often occurs in the lung. The curative treatment is surgical. The results of palliative chemotherapy and radiotherapy are not always efficient.

Effectiveness of modified radical neck dissection and postoperative radiotherapy.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the effectiveness of a modified radical neck dissection with preservation of non-lymphatic structures usually removed in advanced-stage head and neck epidermoid carcinoma associated with postoperative radiotherapy (PORT). METHODS: We analyzed retrospectively the files of 109 patients, presenting with epidermoid carcinoma of the upper digestive/respiratory tract staged N2 or N3, over a 6-year period. The rates of regional control, mortality, and recurrence were analyzed and linked to the kind of neck-dissection (usual radical neck dissection [RND], modified radical neck dissection [MRND], selective neck-dissection [SND]) performed. RESULTS: Forty-three neck dissections were RND, 92 were MRND, and 21 were SND. PORT was used in all cases. The mean follow-up was 57.3 months. The overall rate of regional control was 93.6% (97.7% for RND and 93.5% for MRND; p=0.35). Patients having undergone MRND had a better prognosis and less recurrence then patients having undergone RND (respectively p=0.007, and p=0.0004). DISCUSSION: MRND in association with PORT is an effective treatment in patients with advanced head and neck epidermoid carcinoma staged N2 and N3.

[Psychological impact of alveolar mandibular distraction]. / Impact psychologique de la distraction alvéolaire mandibulaire.

INTRODUCTION: Implant supported dental prostheses are the most up-to-date solution for edentulous patients. This technique requires and adequate bone quantity and quality. Bone distraction may allow compensating for some bone deficit, especially mandibulary. Few studies have been dedicated to how patients adjusted to this therapy (Int J oral Maxillofac Surg 34 [2005] 238-42, Int J oral Maxillofac Surg 36 [2007] 896-9, Med Oral Pathol Oral Cir Bucal 12 [2007] E225-8). We evaluated the psychological impact of alveolar mandibular distraction. PATIENTS AND METHODS: Between 1999 and 2006, 31 patients aged 27 to 70 years underwent vertical alveolar mandibular distraction. Seventeen patients (54.8%) presented with complications. A questionnaire assessed the psychological impact by using notions used in healthcare psychology: perceived stress, perceived control, and social support. RESULTS: Twenty-three answers (74.2% of operated cases) were studied. In 87% of the cases, patients adjusted well the distraction procedure. Eighty-one percent felt no stress. Fifty-seven percent reported light to moderate pain, and 43% found the treatment painful. Confrontation to adverse events was mentioned only in 13% of the cases. In 17% of the cases, there was a slight alteration of sleep. Fifty-seven percent of the patients managed to forget the presence of the distractor. The most difficult stages were insertion of the distractor (48%) and the activation phase (17%). Seventy-one percent of the patients did not find the protocol restraining. The treatment length was not a problem for 65%. Two patients (9%) found it too long. Ninety-one percent of the patients activated the device on their own, for two (9% of the cases) the surgeon activated the device. Ninety-seven percent of the patients found supervision satisfactory. Medical information helped to adjust well to the procedure in 96% of the cases. Forty-three percent of the patients (10 cases) required specific help during the treatment: family support, attending physician, or surgical team. Among these, 70% considered the medical team's contribution as the most beneficial compared to family support, and 30% reported they were the same. For 96% of the patients, the medical team was the major actor of therapeutic success. Twenty-two percent of the patients considered they were partly responsible for treatment results (perceived internal control). Fifty-two percent of the cases reported they would be ready to undergo another distraction protocol if necessary. DISCUSSION: Alveolar mandibular distraction has only a weak psychological impact. It improves the patient's quality of life. It can be suggested that hope for improvement helped patients to better stand treatment. The information received contributed to better adjust to events. This unpredictable situation does not allow the patient to prepare himself and generates stress. Information in necessary before operating, to let the patient assess his own resources and prepare his own psychological adaptation mechanism. It is through this means that we can speak about true "informed consent or refusal".

[276 cases of horizontal infrahyoid myocutaneous flap]. / Le lambeau musculocutané infrahyoïdien à palette cutanée horizontale : à propos de 276 cas.

INTRODUCTION: The infrahyoid myocutaneous flap was described by Wang et al. in 1986. The horizontal design of the skin paddle is a modification of this technique allowing for a smaller scar. We have been systematically using this modified technique for 10 years. We had for aim to describe the interest of the horizontal infrahyoid myocutaneous flap for cervicofacial carcinology. PATIENTS AND METHODS: A horizontal infrahyoid myocutaneous flap procedure was performed in 276 cervicofacial carcinology patients for lesions of the mouth floor, the mandibular gum, the oropharynx and the tongue between March 1997 and March 2007. RESULTS: No complications were observed in 252 patients. No patient presented with total flap necrosis. DISCUSSION: Modifying the infrahyoid myocutaneous flap technique with a horizontal design of the skin paddle does not modify the reliability of the flap and prevents more extensive scars. The main indications of this technique are defects of the mouth floor, the tongue and the oropharynx.

[Aneurysmal bone cysts of the mandible]. / Kyste osseux anévrismal de la mandibule.

The aneurysmal bone cyst is a rare, expansive, osteolytic, pseudocystic lesion with an unknown etiology. It usually affects long bones and the spine. Two to 5 % of cases have mandibular localization (between 75 and 100 % present on the mandible) accounting for 1 % of all mandibular cysts. Less than 200 cases have been reported in English and French literature.

[Cancer of the cheek in a patient under etanercept]. / Carcinome jugal sous étanercept.

INTRODUCTION: Etanercept (Enbrel) is a TNF-alpha inhibitor effective in rheumatoid polyarthritis, psoriatic rheumatism, ankylosing spondyloarthritis, chronic plaque psoriasis, and juvenile idiopathic arthritis. Several cases of tumours have been described in patients under etanercept. However, no case of association with oral carcinoma had ever been described. The aim of this study was to report a case of carcinoma of the cheek mucosa in a patient treated with etanercept for rheumatoid polyarthritis. OBSERVATION: An 82-year-old female patient, non smoker, consulted for a tumour of the oral cavity. History revealed that this lesion had appeared soon after the initiation of etanercept treatment for severe and resistant rheumatoid polyarthritis. Clinical observation revealed a tumour of the right cheek mucosa 5 by 3 cm. The lesion was superficially infiltrative, budding in spots, and verrucous. The clinical observation was otherwise normal. The histological examination of the surgical piece revealed a micro-infiltrative and non-invasive orthoplastic epidermoid carcinoma. DISCUSSION: The possible development of an oral cavity carcinoma should be taken into account when following a patient under TNF-alpha inhibitor treatment. Anti-TNF treatment has improved the management of patients with severe chronic inflammatory diseases. They allow for a better quality of life. Nevertheless, their immunosuppressive effect should be taken into account when prescribed and during follow-up.

[Prognostic value of infiltration of squamous cell carcinoma of the floor of the mouth]. / Valeur pronostique de l'infiltration des carcinomes épidermoïdes du plancher buccal.

OBJECTIVE: The aim of this preliminary retrospective study was to evaluate the prognostic value of tumor thickness in squamous cell carcinoma of the floor of the mouth. MATERIALS AND METHODS: A total of 61 patients with previously untreated T1N0, T2N0 or T3N0 squamous cell carcinoma of the floor of the mouth were included in this preliminary study. An optical micrometer was used to determine the maximum of tumor thickness. We studied the relation between the overall survival at two and five years and tumor thickness. RESULTS: The cohort comprised 52 male and nine female patients. The mean and the median thickness were 7.2 and 6mm, respectively. Overall survival was 79.5 and 36.7% at two and five years, respectively. There was no significant association between thickness and overall survival (p=0.71) and between thickness and disease-free survival (p=0.63). CONCLUSION: The prognostic value of tumor thickness was not demonstrated in this preliminary study. We are currently conducting a study involving a larger patient population in our unit and we believe that tumor thickness should be considered in the management plan for patients with oral carcinoma.

[Head and neck reconstruction with antebrachial flap concerning 100 patients]. / La reconstruction par lambeau antébrachial au niveau de la sphère cervicofaciale : revue d'une série de 100 cas.

We studied the files of head and neck reconstruction with antebrachial flap used in 100 patients between May 1996 and March 2007 in the department of Maxillofacial Surgery of the CHU of Bordeaux. Flap harvesting and vascular anastomosis were performed by the same operator. Antebrachial flap was used to cover the defect after resection of head and neck cancer in 89 patients and after shotgun injuries of the face in 11 patients. This flap, by its smoothness and its plasticity, makes it possible to rebuild all the oral cavity localizations, even the most complex, by covering the defects without blocking deglutition and enunciation. It brings to the patient a better quality of life by decreasing the functional after-effects that can be seen with the traditional myocutaneous flaps. This flap is highly reliable, not requiring specific care after the operation as other micro-surgeries, which simplifies the postoperative quality of life of the aged and debilitated patients.

[Quality of life after primary parotidectomy for benign tumor]. / Parotidectomie conservatrice pour tumeur bénigne: résultats sur la qualité de vie à long terme.

INTRODUCTION: Parotidectomy is commonly performed for various indications, including benign tumors of the parotid region. Esthetic or functional sequels of various importance and lasting effects may occur, as after any surgical procedure. These disorders may impact the patient's quality of life. The authors retrospectively evaluated the long-term outcome of patients having undergone conservative primary parotidectomy for a benign tumor, with a minimum follow-up of 10 years. PATIENTS AND METHODS: A hundred and twenty-six superficial conservative primary or secondary parotidectomies were performed during 5 years, 94 (74.6%) of which for benign tumors. A flap of the sternocleidomastoid muscle (SCM) was inserted between the skin and facial nerve branches to prevent Frey's syndrome and alleviate surgical site depression according to some criteria. Questionnaires were completed at least 10 years after surgery. RESULTS: The data of 53 patients was analyzed. 88.7% of patients had undergone a superficial parotidectomy and 11.3% a total one. The average histological tumor size was 3.3 cm (2.6 to 6.3 cm). The tumors were distributed as follows: pleomorphic adenoma in 79.4% of patients, cystadenolymphoma in 15.1%, oncocytoma in 3.7%, and basal cell adenoma in 1.8%. Twenty-six SCM flaps (49.1%) were performed. No patient presented with facial paresis or facial paralysis at the end of the study. The average follow-up was 10.4 years (10-11 years). Overall, social, psychological, and professional implications were reported by 7.5% of patients, and in 1.8% of cases the impact was significant. The use of a SCM flap seemed to prevent Frey's syndrome (Fischer test P=0.00001) and improved cosmetic results (Fisher test P<0.00001). DISCUSSION: Conservative parotidectomy for primary benign tumors has a limited impact on the quality of life in the long run. This impact concerned 7.4% of patients. There was a significant impact in 2% of patients. We recommend filling the surgical site to improve functional and esthetic results and decrease long-term effects on the patient's quality of life.

Sentinel lymph node biopsy for head and neck Merkel cell carcinoma: a preliminary study.

INTRODUCTION: A retrospective preliminary study assessed the feasibility of sentinel lymph node biopsy (SLNB) in the management of Merkel cell carcinoma (MCC) of the head and neck. PATIENTS AND METHODS: Twelve patients with stage I or II head and neck MCC underwent SLNB over a 4-year period. RESULTS: Only 1 of the 12 patients had a positive SLNB. The sentinel node was not identified in 3 patients. Two of the 8 patients with negative SLNB showed regional lymph node recurrence within 2years. One patient died during follow-up. CONCLUSION: Merkel cell carcinoma is an uncommon but highly aggressive pathology; management protocols have been based on small series. The role of SLNB in the management of MCC remains to be defined.

Cutaneous versus myocutaneous flaps in the repair of major defects in head and neck cancer: a study of 331 flaps.

A retrospective analysis was carried out of 311 reconstructions of major defects following head and neck cancer treatment. Three hundred thirty-one flaps were used; they included cutaneous flaps from 1972 to 1979 and myocutaneous flaps (MCF) after 1979. The aim of this study was to compare the healing patterns of the two types of flaps used in similar circumstances. Even though the use of myocutaneous flaps reduced necrotic complications, there was no significant improvement in overall healing. In this type of reconstruction, local conditions as well as more general factors have greater prognostic significance. Apart from considerations of reliability, other criteria have led to myocutaneous flaps being the treatment of choice in cervicofacial cancer repair. However, specific indications for the use of cutaneous flaps remain.

Results of surgical treatment of T3 and T4 tumors of the oral cavity and oropharynx.

The combined use of surgery and radiotherapy is commonly accepted as the most effective treatment for locally advanced head and neck cancers. T3 and T4 tumors of the oral cavity and oropharynx often necessitate extensive local surgery. From 1981 to 1988, 199 patients with T3 and T4 tumors of the oral cavity and oropharynx were treated. One hundred seventeen patients underwent surgery plus postoperative radiotherapy; 78 had flap reconstructions. This series is extremely homogeneous because surgery was always performed by two surgeons, whereas radiotherapy was the responsibility of the same physician. The results of this study show a 96% local control rate at the end of treatment among the patients with combined treatment. The average time by which hospitalization was prolonged due to surgery was 29 days. The type and delay of recurrences and survival in relation with node involvement are also discussed. Extensive surgery in association with radiotherapy remains a reliable treatment in such patients.

Supraomohyoid neck dissection in cancer of the oral cavity.

BACKGROUND: In oral cavity cancer, supraomohyoid neck dissection (SOHND) is becoming more popular for patients with N0 and N1 disease in the neck. The aim of this study was to assess the value of this surgical procedure. METHODS: The study included 237 previously untreated patients with oral cavity cancer. The neck treatment consisted of SOHND or functional neck dissection (FND). One hundred sixty patients underwent postoperative radiation therapy. Survival probabilities, neck recurrences, and distant metastases were analyzed according to the surgical procedure. RESULTS: For patients having undergone SOHND, the 5-year survival probabilities were 70.2% and 76.5% in N0 and N1 necks, respectively. The neck recurrence rate in SOHND was 2%. CONCLUSIONS: SOHND is an effective method of treatment for the clinically negative neck in patients with squamous cell carcinoma of the oral cavity. It also proves efficient, in conjunction with postoperative radiotherapy, for control of neck metastases in selected patients.

Treatment of ameloblastoma of the jaws.

OBJECTIVE: To evaluate treatment of ameloblastoma of the jaws and suggest a more aggressive approach for well-defined cases. SETTING: Referral center. PATIENTS: Forty-one patients were treated for ameloblastoma of the jaws. RESULTS: Seventeen patients had a local recurrence; 14 had initial curettage and three had initial resection. Seven patients had two or more recurrences. Eight patients underwent radiotherapy; two died of progressive disease. CONCLUSIONS: Ameloblastoma had a high rate of local recurrence if not adequately removed. Segmental resection for the mandible and partial maxillectomy for the maxilla should be the primary treatment; marginal resection is appropriate only for small primary tumors. For multiple recurrences, radiotherapy is effective, and surgery and radiotherapy (50 Gy postoperatively) should be used in selected cases.

Approach to the pterygomaxillary space and posterior part of the tongue by lateral stair-step mandibulotomy.

Fifteen patients underwent surgery for retromandibular parotid, pharyngeal, or posterior tongue tumors. Surgical approach to the pterygomaxillary fossa, parapharyngeal space, and posterior tongue was performed by external cervical incision and lateral stair-step mandibulotomy. After resection of the tumors, the mandibular segments were replaced and secured with miniplates. The plates were removed after six weeks whenever postoperative radiation therapy was planned. By reflecting the ascending ramus, this method provides excellent exposure of the concerned areas. It makes unnecessary both incision of the lower lip and intermaxillary fixation with arch bars, thus allowing a quick resumption of oral feeding. A review of 15 patients demonstrated satisfactory results for mandibular function and morphologic appearance, with minimal complications.

Modified approach for ethmoid and anterior skull base surgery.

The use of combined craniofacial resection is well established for tumors of the ethmoid bone and the anterior aspect of the base of the skull. Mobilization of the medial fronto-orbital ridge improves the transbasal approach and can be performed with a monobloc bone flap. We describe an en bloc bifrontal craniotomy including the supraorbital ridges and the nasal bones. This provides a wider angle of approach to the anterior aspect of the base of the skull than any other method and avoids retraction of the frontal lobes. This type of bone flap procedure can be performed after a wide periosteal dissection in the coronal area of the scalp alone, without facial skin incision.