[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.

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.

[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.

[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.

[Mandible dislocation: diagnosis and reduction technique "in the field"]. / La luxation de mandibule: diagnostic et technique de "réduction sur le terrain".

Diagnosis of temporomandibular joint dislocation can be achieved based on clinical findings. No complementary studies are required. Reduction can be performed without specific equipment in remote areas.

[Transverse maxillary deficiency: interest in the management of chronic nasal obstruction]. / Disjonction intermaxillaire : intérêt dans la prise en charge de l'obstruction nasale chronique.

OBJECTIVES: To describe the surgical orthodontic technique of correcting transverse maxillary deficiency associated with nasal obstruction and malocclusion. SURGICAL PROCEDURE: The surgical-orthodontic correction of transverse maxillary deficiency consists in an incomplete Le Fort I procedure, without down-fracture, associated with a sagittal palatal osteotomy. This procedure is called SARE (Surgically Assisted Rapid Expansion). A pre-fabricated orthodontic appliance is cemented to premolars and molars prior to the surgical procedure. The patient activates the appliance allowing a 1 mm widening a day up to 10 mm. A stabilisation phase is mandatory to avoid early relapse of the correction. This phase involves ossification of the midline osteotomy site. RESULTS: A 22 year old female consulted for a chronic nasal obstruction. Previous treatments, medical and surgical (septoplasty) did not improve her symptoms. She presented with a typical transverse maxillary hypoplasia. She underwent a surgery with the technique described above. Nasal patency improvement was noted on the first post-operative day. This was confirmed by comparing pre and post-operative rhinomanometry. An orthodontic treatment followed for several months to stabilize the result. DISCUSSION AND CONCLUSION: Main advantages of this surgical intervention are to correct both the dental malocclusion and the nasal obstruction by widening the nasal floor and the maxillary arch. Post-operative period is mostly uneventful. It can take up to six months to achieve a good result that is why a strong collaboration has to exist between the surgeon, the orthodontist and the patient.

[Fractures of the nose: simplified diagnosis and management]. / Fractures du nez: diagnostic et prise en charge simplifiée.

Fracture of the nose is a frequent injury. Careful management is necessary to avoid not only cosmetic but also functional sequels. Therapeutic modalities are simple and can easily be carried out under local anesthesia.

[Transoral removal of submandibular hilar calculi: 36 cases]. / Exérèse endobuccale des lithiases submandibulaires postérieures: 36 cas.

INTRODUCTION: Proximal submandibular calculi are usually removed by transcervical submandibular sialadenectomy. The aim of this study was to show that intraoral removal of hilar submandibular calculi gives the same results with fewer complications than submandibulectomy. PATIENTS AND METHODS: The surgical indication is assessed by palpability of the stone and confirmed by simple CT scan. The surgical procedure is performed under local or general anaesthesia. At the end of the procedure, the duct is controlled with a sialendoscope to remove remaining concretions. We prospectively followed 36 patients with a mean follow-up of six months (one to 36 months). RESULTS: The transoral removal of calculi was performed in 34 patients without any definitive neurological complication. The procedure failed in two patients with nonpalpable calculi. Two patients had a recurrence of symptoms due to small intraglandular calculi, which were evacuated later. DISCUSSION: The transoral removal of submandibular hilar calculi is a safe and reproducible procedure with less morbidity than submandibulectomy. It should be recommended for posterior palpable submandibular calculi.

[Transoral removal of submandibular hilar calculi]. / Exérèse des lithiases postérieures de la glande submandibulaire par abord endobuccal.

INTRODUCTION: Sialolithiasis is the most common non-neoplastic salivary gland disease, accounting for 1.2% of the autoptic population. More than 80% of salivary calculi are located in the submandibular ductal system. Hilar calculi are usually removed by transcervical submandibular sialadenectomy. However, intra-oral removal of hilum submandibular calculi is an interesting alternative. INDICATIONS: The main criterion for intra-oral removal is the calculi palpability, knowing that calculi under 8mm of diameter are often treated by other techniques (sialendoscopy and lithotripsy). OPERATIVE PROCEDURE: We describe a conservative and gland-preserving transoral surgical technique for hilar submandibular calculi with postoperative sialendoscopic control. The different surgical steps are illustrated. DISCUSSION: Preservation of the submandibular gland has been attempted in the treatment of sialotithiasis by transoral resection of calculi from the hilum of the gland. This technique features a low morbidity and leads to a complete recovery of glandular function.

[Polylactic acid injections: usefullness for the treatment of facial lipoatrophy in HIV+ patients under tritherapy]. / Injections d'acide polylactique: intérêt dans la correction des lipoatrophies faciales chez les patients VIH+ sous trithérapie.

BACKGROUND: The aim of the study was to evaluate the mean-term efficacy and tolerance of the polylactic acid injections (New-Fill) for the correction of facial lipoatrophy occurring in HIV-positive patients under tri-therapy. MATERIAL AND METHOD: The patients were managed at the University Hospitals of Besançon and Strasbourg (France) from January 2002 to December 2005 for a prospective study. The patients were consecutively included in this study once their consent was obtained. Patients not stabilized by their antiretroviral treatment were excluded. Facial lipoatrophy was classified in four clinical stages (stage I: mild, stage II: moderate, stage III: important, stage IV: severe) after a clinical examination. The polylactic acid solution was prepared according to the manufacturer's recommendations, and injected in a retrotracing manner in the hypoderm at the rate of one 5 ml flask per side, with an interval of one month. The number of sessions varied according to the severity of the stage. Treatment efficacy, assessed after a minimal follow-up of one year, was established clinically by comparing the initial and final photographs (changes in the clinical stage) and by the patient's and surgeon's satisfaction rate (from zero to ten). Treatment tolerance was established on the painfulness of injections and on socioprofessional constraints reported by the patients and made on a visual analogical scale. The occurrence of adverse-effects was checked. Finally, we compared the cost of the treatment with that of lipostructure. RESULTS: Twenty-five patients were included (mean age: 44, sex-ratio: 23 male/2 female patients). The mean body mass index was 21. The mean CD4 cell count was 600/mm(3). The mean HIV-1 RNA was 276 copies/ml. The severity of the lipoatrophy was stage one in two patients (8%), stage two in 12 patients (48%), stage three in nine patients (36%), and stage four in two patients (8%). The mean number of sessions was 5.2. The mean follow-up time was 26 months. In 76% of the cases we observed a complete correction of lipoatrophy (100% of stages I, 92% of stages II, 66% of stages III, 0% of stages IV). However, among stages II, III, and IV that were incompletely corrected, an improvement was noticed in all patients (grading to an inferior stage, at least). The mean satisfaction rate was 8/10 by patients and 7.2/10 by surgeons. In six patients (24%) a renewal of the treatment was proposed because of inadequate results. The painfulness of injections was rated at 3.3/10 and constraints at 3/10 by patients. One single case of visible and palpable sub-cutaneous granuloma was noticed in a patient at the end of the follow-up period (18 months). DISCUSSION: The use of polylactic acid is a safe and efficient procedure for the treatment of facial lipo-atrophy in HIV-infected patients, however severe the clinical stage may be, after a two-year follow-up period. We recommend hypodermic (and not dermic) injections to prevent adverse effects. This treatment is not more expensive then lipo-structure and the progressive correction is considered as an important advantage by patients. Considering our results, the simplicity of the procedure, and the low rate of complications observed, the injection of poly-lactic acid has become our first intention treatment for this condition.

[An unusual jugal abscess after third molar extraction: a complication of hemostatic wax]. / " Abcès atypique" jugal après extraction de dents de sagesse: complication de l'utilisation de cire hémostatique.

Bleeding is a common complication after third molar extraction. Hemostatic agents can be helpful in controlling intraoperative bleeding. Infection is another common complication. Horseley's wax is frequently used for bone surgery and less often for dental surgery. We report an unusual case of abscess formation in the jaw after third molar extraction. Surgical exploration of the abscess disclosed the presence of surgical wax in the center of a foreign body granuloma. We discuss the use of surgical wax and other local hemostatic agents and the subsequent risk of complications.

[Long-term functional and aesthetic sequelae after complex facial trauma associated with a mild brain injury]. / Séquelles esthétiques et fonctionnelles à long terme des victimes d'un fracas facial associé à un traumatisme crânien.

INTRODUCTION: Most victims of complex facial trauma will have permanent sequelae. The goal of our work was to evaluate, by means of a retrospective study, the long-term sequelae in these patients. MATERIAL AND METHOD: 102 victims of complex facial trauma were treated in our department between 1995 and 2000. Twenty-four could be re-examined in 2006 in order to evaluate their long-term sequelae. All the patients suffered a mild brain injury. RESULTS: The overall satisfaction rate was good (19/24), but all patients presented either functional or aesthetic sequelae. The major functional sequelae were dental lost (17/24), sensory impairment of the trigeminal nerve (15/24), partial or complete loss of vision (10/24), pain (10/24), hypo- or anosmia (9/24), stenosis of the lacrimal ducts (8/24) and symptomatic deviation of the nasal septum (7/24). The main esthetic sequelae were facial scarring (23/24), facial asymmetry (13/24), dystopia of the eyeball (11/24) and modification of the aspect of the nose (10/24). DISCUSSION: The prognosis of severe facial trauma is highly dependent on the quality of the initial pluridisciplinary care. Secondary revision procedures are technically more difficult and only enable partial resolution of persisting sequelae. Thus, primary single-course surgical procedures should be a priority, recognizing that complete recovery is almost always illusory.

[Long-term functional, psychic, social, occupational and judiciary outcome in victims of facial trauma]. / Devenir fonctionnel, psychique, socio-professionnel et judiciaire à long terme des patients victimes d'un fracas facial.

The cases of 102 people who suffered brain and facial trauma were reviewed, noting the long-term outcome at more than 5 years. Results of complete physical examinations performed by a surgeon and an internist were available for 25 patients. Data noted were: circumstances of the traumatic event, classification of brain injuries, sensory and sensorial disorders, and persistent pain, psychological trauma, social and occupational consequences and at the final legal and financial compensation. These data were summarized in tables to facilitate discussion of the findings.