Secondary reconstruction of burned nasal alae using rolled dermal flap with overlying full-thickness skin graft.

INTRODUCTION: Surgical reconstruction of the nasal tip is a very delicate procedure, as it must rebuild three different anatomical planes: mucosa, cartilage and skin with functional and aesthetic requirements. This procedure is even more difficult in burns patients, due to more limited donor sites and poor skin quality. Numerous flap options are available to reconstruct defects of the tip of the nose. The authors report their experience of nasal alar reconstruction by a scar tissue remodelling technique using a rolled dermal flap with overlying full-thickness skin graft. PATIENTS AND METHODS: The medical charts of seven patients (five women and two men with a mean age of 30) treated between 1991 and 2006 were retrospectively reviewed. Six patients presented sequelae of a facial burn and one patient had congenital facial hemiagenesis. RESULTS: Reconstruction was bilateral for all burns patients and unilateral for the patient with facial hemiagenesis. The skin graft was raised from the medial aspect of the forearm in four cases, the retroauricular region in two cases and the groin in one case. One patient required a second surgical procedure for necrosis of the nasal tip. No nasal obstruction was reported with a mean follow-up of five years (range: six months to 15 years). CONCLUSION: The rolled dermal flap with overlying full-thickness skin graft is a simple and reliable procedure for reconstruction of the nasal alae. Filling of the nasal alae defect and reconstruction of all anatomical planes are achieved in a single surgical procedure. The aesthetic and functional results were satisfactory, with minimal scarring of the donor site. This technique is very suitable for the treatment of burn sequelae and can also be used to treat nasal hemiagenesis and nasal mutilation by biting or facial trauma.

[Subperiostal orbital hemorrhage induced by effort for vomiting]. / Hémorragie sous-périostée orbitaire après un effort de vomissement.

UNLABELLED: Subperiostal orbital hemorrhage is a rare condition. It usually occurs as a result of trauma or because of a vascular disorder. We present a case of subperiostal orbital hemorrhage induced by effort for vomiting. CASE: A 41-year-old pregnant patient (30 weeks of amenorrhea), with no prior history, was referred to the ENT emergency by her gynecologist for unilateral ptosis and proptosis secondary to efforts for vomiting. Clinical examination and CT scanner showed a subperiostal hematoma of the orbital roof. The hematoma resolved in ten days without sequels, under simple surveillance. DISCUSSION: Non-traumatic subperiostal orbital hemorrhage remains rare. Clinical examination and orbital CT scan allow making the diagnosis. If the optic nerve is not compressed, clinical surveillance during hematoma resorption is sufficient.

[Transnasal canthopexy]. / La canthopexie transnasale.

Medial canthopexy is a permanent and stable fixation of the internal canthus and its elements in an anatomical position. Transnasal canthopexy is difficult to perform. The specific material includes two square pins, a large and a small one, plus material to explore the lachrymal duct. After infiltration with adrenalin xylocaine at 1 %, the Tessier's orbitonasal incision follows a bayonet route along the medial canthus and then a sub-tarsal route. A succession of broken lines allows increasing the maxillary upward branch and a larger sub-periosteal dissection. The medial canthal tendon (MCT) is exposed. After intubating the inferior lachrymal duct and pushing the lachrymal sac downwards, any resistance to medial traction is freed with a raspatory. The contralateral approach is arch formed, in front of the MCT, 10mm away from the medial eyelid commissure. The frontal apophysis of the maxillary bone is exposed. The bone is perforated with a square pin while protecting the lachrymal sac and the ocular globe. The MCT is pulled by twisted metallic wire, which is anchored on a wedge. Closing the wound is performed in two layers. A large dressing is applied for 48hours. In case of medial bone defect, parietal bone graft is used to stabilize canthopexy. There are few complications and esthetic and functional results are favorable and long lasting.

[The paralyzed eyelid: an alternative to gold weight, levator palpebrae lengthening]. / Les paupières paralysées: une alternative à la plaque d'or, l'allongement du muscle releveur.

PURPOSE: Patients with complete facial nerve palsy are at risk of severe eye complications due to corneal exposure. The aim of this study was to highlight the effects of using a gold weight in paralyzed eyelid, and to prove the safety of the levator palpebrae lengthening. MATERIAL AND METHODS: This retrospective study compared the records of 24 patients who received a gold weight of the upper eyelid between 1976 and 2003 with those of 22 patients who benefit from levator palpebrae lengthening between 1997 and 2005. Two endpoints were seen in postoperative: the occurrence of complications related to lagophthalmia secondary to facial palsy, and the occurrence of complications related to surgical technique. RESULTS: The occurrence of a complication related to the facial palsy is significantly associated with the surgical technique. Patients with gold weight had significantly more complications related to their pathology than others (67% versus 18%, respectively, p=0.001). The occurrence of a surgical complication was significantly associated with the surgical technique. Patients with gold weight have significantly more complications due to surgery than others (83% versus 5%, respectively, p<0.0001). CONCLUSION: Our clinical study and statistical comparison of the two surgical techniques for paralysed eyelid clearly show that the oldest is unsatisfactory and that it should be abandoned. Levator palpebrae lengthening improves eye symptoms with a very low morbidity.

Rehabilitation of the paralysed or lax lower eyelid using a graft of conchal cartilage.

Excessive laxity of the tarso-ligamentous sling of the lower eyelid may be caused by inadequate muscular support (resulting from injury to the muscle, facial palsy or senile degeneration) or prolonged mechanical distension (exophthalmia). Numerous techniques have been devised for functional reconstruction of the distended lower eyelid, based upon the principle that restoring the lower eyelid to its anatomical position will improve lacrimal transit andre-establish its natural protective function. We now use an autologous conchal cartilage graft to treat the distended or atonic lower eyelid. We review our results in a retrospective study of 20 patients, and aim to identify the indications for this procedure and to evaluate its advantages and disadvantages relative to other existing methods. All of our patients reported functional improvement after the operation in terms of decreased dry-eye symptoms, less epiphora and a decline in keratitis and conjunctivitis. All patients also reported a visible cosmetic improvement postoperatively. The major drawback of this operation is the partial loss of the visual field when looking down, due to the limited lowering of the lower eyelid. The stability of our results compares favourably with that achieved using other currently available techniques. We conclude that autologous conchal cartilage grafting is an effective procedure for improving both the function and the appearance of the atonic lower eyelid.

[Localized loss of facial tissue. Criteria of use of extra-oral implants and clinical cases]. / Pertes de substance faciale localisées. Critères de recours aux implants extra-oraux et cas cliniques.

Osseointegrated maxillofacial epitheses are an interesting therapeutic response for rehabilitation after loss of facial tissue when reconstructive plastic surgery cannot be proposed. We analyzed the criteria used for deciding on this type of treatment for the loss of local areas of auricular tissue, the nasal pyramid and the orbitopalpebral region, presenting individual clinical examples.

Surgical management of the anophthalmic orbit, part 1: congenital.

Congenital microphthalmos and anophthalmos are rare conditions in which orbital growth is deficient. Hypoplasia of the globe affects the bony orbit (micro-orbitism), the conjunctival sac, and eyelids (microblepharism), and it may be associated with abnormalities of the entire hemifacial skeleton (hemifacial microsomia). In the present article, the authors review a series of 19 patients with microphthalmos (nine had right-sided, one had bilateral, and nine had left-sided microphthalmos) who were treated in the Orbitopalpebral Unit at Hospital Foch over a period of 15 years (follow-up, 5 months to 18 years).Orbital expansion was achieved using spherical implants (n = 13), orbital osteotomies (n = 4), and orbital expanders (n = 2). Both expanders were removed within 6 months because of failure (one infection and one rupture). The current preferred method for orbital expansion is to use serial implants in the growing orbit and osteotomies in cases of late referral or insufficient orbital volume in the older child. The target proportions of the reconstructed orbit are not planned to mirror the healthy side exactly. The inferior orbital rim is kept higher to support the orbital implant, and the orbit is kept shallow to avoid a sunken appearance. Cranial bone grafts were used to augment deficient orbital contours; they were assisted by anterior transposition of the temporalis muscle (n = 5) when additional orbital volume was required. Conjunctival sac reconstruction was achieved by the use of serial conformers placed in the conjunctival sac during the neonatal period, followed by grafts of buccal mucosa and full-thickness skin maintained in place with a tarsorrhaphy for 3 to 6 months. Eyelid reconstruction using local flaps and skin grafts proved to be necessary in cases treated by osteotomy expansion, although reconstruction was not required after expansion using serial solid shapes. The results illustrate an evolution in approach and concepts of reconstruction of the microphthalmic orbit and emphasize the need for an integrated craniofacial approach for this complex deformity.

Surgical management of the anophthalmic orbit, part 2: post-tumoral.

Ablative surgery for tumors of the globe and its adnexal structures is frequently the cause of major orbitofacial deformity. Radiotherapy compounds the problem because it suppresses skeletal growth in the growing patient and induces a contraction of the remaining soft tissues in the orbit. Goals for reconstruction in these patients include the restoration of orbital structures to allow the fitting of an ocular prosthesis and the correction of distorted orbitofacial relationships. The authors present a series of 53 patients (mean age, 29 years; 28 male) who were treated over the past 18 years by composite reconstruction of the post-tumoral anophthalmic orbit. The follow-up ranged from 5 months to 18 years (mean, 7.75 years). Four patients were treated primarily (immediate reconstruction after tumor ablation), and 49 were treated secondarily (mean oncological follow-up since ablative surgery, 14.8 years). Twenty-eight patients underwent orbital enucleation (including three bilateral cases), 23 underwent orbital exenteration, and two underwent evisceration. Forty-two patients received radiotherapy, including 20 enucleation patients, 15 exenteration patients, and seven others in whom details of primary therapy were incomplete. A staged reconstruction was undertaken in each case; it considered, in turn, the bony orbital volume (orbital remodeling and cranial bone grafts), orbital contents (implant, temporalis muscle transposition, cranial bone grafts, and dermafat grafts), conjunctival sac (mucosal and skin grafts), ocular prosthesis, eyelids (local flaps and skin grafts), and additional procedures to restore orbitofacial symmetry. The authors conclude that the long-term results of post-tumoral orbital reconstruction are favorable, and they particularly recommend the use of autogenous tissues in irradiated orbits.

[Reconstruction of orbital floor fractures using autologous materials]. / Reconstruction du plancher orbitaire fracturé par des matériaux autologues.

Bone and Cartilage Autograft gather all the necessary qualities for an interpositional material to be used in the fractured orbital floor reconstruction, leading to the binocular vision recovery and in term of tolerance. The initial material choice depends on the clinic and orbital tomodensitometry datas, but the final decision is made on the operating findings. However, schematic indications can be drawn up, depending on material characteristics, curve, rigidity and resorption degree, and fracture particularities.

[Tissue expansion. Presentation of a model of external filling valve]. / Expansion tissulaire. Présentation d'un modèle de valve externe.

Based on their experience of facial tissue expansion, the authors present a model of an external filling valve and illustrate its advantages in 9 cases in which 13 external valve were used: painful injection, absence of leakage, fast and confortable filling. The indications are sequelae of facial burns, face scars, treatment of orbito-temporal neurofibromatosis. The major advantage is rapid tissue expansion which reduces the problems of infection and skin loss.

[Frontal mucoceles of orbital or cerebral extension: therapeutic strategy]. / Mucocèles frontales à extension orbitaire ou cérébrale: stratégie thérapeutique.

The aim of this study was to investigate ten patients who underwent surgery for mucoceles of the frontal sinus. Bicoronal direct access was required by the localization of the mucocele limited to the frontal sinuses, its extension to the orbit and/or the brain and because of the anatomy of the frontal sinuses (large size, lateral horn...) as evidenced at imaging. Direct access to the frontal sinuses was achieved in 9 patients allowing marsupialization associated with repermeabilization of the naso-frontal duct (7 cases) or exeresis of the mucocele by cranialization (2 cases). Mean follow-up is 27 months. Repermeabilization of the naso-frontal duct was effective in 7 out of 8 cases. There were no complications after cranialization and no recurrence has been observed. Drainage of frontal mucoceles is a first intention strategy. In case of complication or recurrence, cranialization of the frontal sinuses would appear to be better than an exclusion-filling procedure.

[The chondromucosal graft. Its use in the correction of entropion caused by tarsoconjunctival cicatrix, trichiasis and distichiasis]. / La greffe chondro-muqueuse. Son intéret dans la correction de l'entropion par cicatrice tarso-conjonctivale, du trichiasis et du distichiasis.

The use of chondromucosal grafts is the classical treatment for reconstruction of the eyelids, whereas these grafts are less employed for correction of tarso-conjunctival scars due to either disease or surgery. The ideal nasal graft is the triangular cartilage, as its mucosa is more delicate and more adhesive than that of the septum, and it separation and positioning do not involve any problems if certain rules are followed. The technique appears attractive to us, as it is simple to perform, there is a lack of postoperative complications and it is logical (replacing a pathological tissue or a missing tissue by an identical one, keeping the lids framework). It appears to be not enough employed in trachomatous entropion (both eyelids being generally affected). However, the technique is useful: during first intention surgery (whether associated or not with tarsectomy); in all cases of recurrence, where it appears to be the only worthwhile treatment (trachomatous eyelids already operated upon by another method, tarsectomy alone).

[Conjunctival sac of anophthalmic orbits]. / Le sac conjonctival de l'orbite anophtalme.

Reconstruction of the conjunctival sac is never a simple procedure. It is a question of positioning a prosthesis in the orbital cavity which will have no anatomic support, as the eye has been enucleated, reduced to a stump (microphthalmos) or has been replaced by an implant that has just been expelled. All described techniques consist in enlarging the existing conjunctival sac, and then positioning a mucosal or dermo-epidermical graft in the orbital cavity maintained by a conformer. In order to limit the effects of the inevitable retraction during the first weeks following surgery, operative enlargement beyond the needs of the conjunctival sac is essential. The conformer should be supported by tarsorraphy until the phenomenon of retraction has reached an end (4 to 6 months). The problem of the "orbital cavity" must be understood so that indications for surgical remodelling of the conjunctival sac can be established. This is simple after enucleation, but more complex in the case of a microphthalmos, an injury, or an exenteration of the orbit where remodelling represents only the last operative stage after bone remodelling, or lids remodelling and sometimes transposition of the temporalis muscle in the socket.

[Eyelid burns]. / La paupière du brûlé.

Reconstruction of eyelids following burns has two fold objective: functional and esthetic. Except in the must severe forms (carbonization) eyelids' burns usually involve only superficial lesions. Surgery, by means of a skin graft only, may be required after initial medical treatment. The choice of a graft among those considered standard, (full-thickness skin graft for the lower lid, thinner graft for the upper lid) should be guided by anatomophysiological considerations. Treatment in each case varies according to the anatomic type and the stage of evolution of the burn; whether the orbicularis muscle has been affected or not, should determine the choice of the graft. Certain points of this surgical technique have to be emphasized: the need for respecting esthetic unity; for careful dissection sparing the orbicularis; for fixation of the graft on the medial canthus, and lastly, the necessity of performing surgery of upper and lower lids in two stages so that the lid is "in surocclusion" during each operative procedure. Treatment of eyelids' burns as described above, is well established. It is very different from that for total facial burns, which requires total operative strategy.