[Osteotomies in rhinoplasty]. / Ostéotomies en rhinoplastie.

Osteotomies are performed to modify the shape of the bony part of the nose, therefore they should not be done systematically. Main indications are correction of deviated nose, narrowing of bony vault and roofing of an open roof after important hump resection. The nose should be very precisely analyzed before osteotomies if the surgeon doesn't want to create deformities such as step, inverted V, pinched nose or saddle nose. When too narrowed, bones can also block the airway and lead to functional problems.

[Tip sutures]. / Sutures de la pointe du nez.

Suture techniques are widely used and can be very useful and efficient to support the nasal tip and correct its deformities. Nevertheless, they are so powerful that they have to be performed very precisely if the surgeon does not want to create cosmetics as well as functional problems. The authors describe the main tip sutures and their effects, expected or not.

[Secondary rhinoplasty]. / Rhinoplastie secondaire.

Secondary rhinoplasty is very usual. Some patients are not satisfied by the previous surgery because the result is poor with obvious defaults but, sometimes, the result is good but the patient expects perfection. These two different situations will not lead to the same answer from the surgeon. Techniques of secondary rhinoplasty are the same than primary, but are often more difficult to perform because of scar tissue, retraction and loss of lining. The authors analyse the more frequent deformities in secondary rhinoplasty and the way they fix them.

[Surgical approaches in rhinoplasty]. / Voies d'abord en rhinoplastie.

In the first step of rhinoplasty, the surgical approach will expose through different types of incisions and dissection planes the osteocartilaginous framework of the nasal pyramid prior to performing actions to reduce or increase the latter. This exposure can be performed by a closed approach or by an external approach--the choice depends on the type of nose and the habits of the surgeon. Far from being opposites, closed and external approaches are complementary and should be known and mastered by surgeons performing rhinoplasty.

[Middle third of the nose and internal valve. Alar wall and external valve]. / Tiers moyen du nez et valve interne. Paroi alaire et valve externe.

To many surgeons, nasal airway obstruction is synonymous with either septal deviation or inferior turbinate hypertrophy. The role of internal and external nasal valves is often less known by surgeons even if it is crucial in nasal breathing and strongly interrelated with esthetic of the middle third of the nose and alar wall. Therefore, precise examination of the two valves and conservative surgery should help to avoid many functional and esthetic problems.

[Over projected tip]. / Pointe du nez hyper-projetée.

Overprojected tip is a pretty usual request not easy to manage. Preop analysis is crucial in order to evaluate tip support and skin thickness and ability to retract. For example, if the skin is very thick and has poor chance to retract, the surgeon should be very careful in the tip projection decreasing to avoid a skin pollybeak deformity. In such cases, he has to analyze the facial proportions, especially other areas projection (radix, dorsum and chin) and think about augmenting them to balance the profile rather than decreasing tip projection. Correction should always be conducted incrementally, starting with weakening the tip support mechanisms and, only if necessary, continue with alar cartilage interruption. This can be performed on many areas (lateral cruras, domes, medial cruras) and with several techniques (resection or interruption+overlapping).

[Preoperative analysis in rhinoplasty]. / Analyse préopératoire en rhinoplastie.

Preoperative analysis in rhinoplasty consists in analyzing individual anatomical and functional characteristics without losing sight of the initial requirements of the patient to which priority should be given. The examination is primarily clinical but it also uses preoperative photographs taken at specific accurate angles. Detecting functional disorders or associated general pathologies, which will reduce the risk of complications. All of these factors taken into account, the surgeon can work out a rhinoplasty plan which he or she will subsequently explain to the patient and obtain his or her approbation.

[History of aesthetic rhinoplasty]. / Histoire de la rhinoplastie esthétique.

One of the first surgical procedures described in the history of medicine is reconstructive surgery of the nose. Over the centuries, surgeons have developed techniques aimed at reconstructing noses amputated or traumatized by disease. The concept of aesthetic rhinoplasty was only introduced at the end of the 19th century. Since then, techniques have evolved toward constant ameliorations. Nowadays, this surgery is one of the most performed aesthetic procedures. Current technical sophistication is the result of over a century of history marked by many surgeons. All of these techniques derive from a detailed understanding of the anatomical nose from the surgical and artistic point of view.

[Standard rhinoplasty]. / Rhinoplastie standard de réduction.

Most patients who consult a surgeon for rhinoplasty do not want a radical change in their nose. They seek a reduction in the volume of the nasal pyramid and correction of a precise element that they judge to be ungainly--most often an osteocartilaginous hump. The procedure that we qualify as "standard" will eliminate the osteocartilaginous hump, decrease the dimensions of the septum and reduce the size of the alar crus of the alar cartilage. Although the required technical maneuvers are simple, their sequence must be coherent with a few basic rules that are simple but rarely explained in order to avoid defects linked to excessive, or on the contrary, insufficient corrections.

[Surgical anatomy of the nose]. / Anatomie chirurgicale de la pyramide nasale.

Thorough knowledge of the anatomy of the nose is an essential prerequisite for preoperative analysis and the understanding of surgical techniques. Like a tent supported by its frame, the nose is an osteo-chondral structure covered by a peri-chondroperiosteal envelope, muscle and cutaneous covering tissues. For didactic reasons, we have chosen to treat this chapter in the form of comments from eight key configurations that the surgeon should acquire before performing rhinoplasty.

[Nostril surgery]. / Chirurgie cutanée des bords libres et des ailes narinaires.

The decision to perform nasal resection follows a comprehensive analysis of the aesthetic objective depending on the anatomic and artistic criteria. Fear of leaving visible scars leads many surgeons to hesitate vis-à-vis the indications. However, this surgical technique can be very useful during rhinoplasty. The patient should always be informed preoperatively of the possibility of cutaneous resection of the nostrils and the type of scar than can ensue. It is important to know the foreseeable elements of nasal resection in order to provide a more systematic approach to routine rhinoplasty.

[Rhinoplasty and dermal fillers]. / Rhinoplastie et produits de comblement.

The use of fillers for camouflage after surgical rhinoplasty or during medical rhinoplasty process represent an attractive technique which allows to avoid or to delay surgical time often dreaded by the patients. This technique apparently quite simple, must be applied carefully in order to avoid possible complications that can sometimes be very serious. Through their seven years of experience, the authors have selected absorbable type of products: hyaluronic acid or calcium hydroxylapatite, both approved by ANSM. Preference is given to microcannulas (27G) over needles and injection techniques through multiple tunnels fitted with small fragmented boluses. Due to possible Tyndall effect and skin necrosis risk, a one-shot injection with a lot of product should be avoided. Calcium hydroxyapaptite is preferred for the dorsum area while hyaluronic acid is recommended for the tip. The authors also relate the major encountered complications and describe the appropriated treatments. Nevertheless the strict application of the described technique represents the best way to prevent adverse complications.

[Autologous fat grafting and rhinoplasty]. / Rhinoplastie et injection de tissu adipeux autologue.

Revision rhinoplasty can be very challenging especially in cases of thin skin. Autologous fat graft is utilized in numerous applications in plastic surgery; however, its use relative to the nasal region remains uncommon. Adipose tissue, by virtue of its volumetric qualities and its action on skin trophicity, can be considered to be a gold standard implant. From 2006 until 2012, we have treated patients by lipofilling in order to correct sequelae of rhinoplasty. The mean quantity of adipose tissue injected was 2.1cm(3) depending on the importance of the deformity and the area of injection: irregularity of the nasal dorsum, visible lateral osteotomies, saddle nose. Following the course of our practice, we conceived micro-cannulas that allow a much greater accuracy in the placement of the graft and enable to perform interventions under local anesthesia. These non-traumatic micro-cannulas do not cause post-operative ecchymosis and swelling which shorten the recovery time for the patient. On patients who have undergone multiple operations, lipofilling can be a simple and reliable alternative to correct imperfections that may take place after a rhinoplasty.

[Reconstruction of an extensive endonasal chondromucosal defect with a composite graft]. / Reconstruction d'une perte de substance chondromuqueuse endonasale étendue par greffe composite.

INTRODUCTION: Reconstruction of an endonasal chondromucosal defect without skin defect is a rare event, which involves functional and esthetic outcomes. We report the original use of a composite graft, for the repair of an endonasal chondromucosal defect. OBSERVATION: A 57-year-old woman presented with extensive tissue loss after the complete resection of an arteriovenous malformation. The excision procedure removed a cartilaginous part of the dome, the lateral crus of the alar cartilage, and the adjacent mucosa. An auricular composite graft allowed for an effective reconstruction, with a very satisfactory result, in a single surgical step. DISCUSSION: Using an endonasal composite graft has rarely been reported even though there are few alternatives for the reconstruction of an endonasal chondromucosal defect.

[Hypertrophic adipose tissue transplantation secondary to a lipopenisculpture]. / Hypertrophie de greffon adipocytaire et lipopénosculpture: gestion d'une complication rare.

Reconstruction of the penile skin requires a functional and esthetically perfect result, combining a high degree of skin elasticity to allow regular erections and a satisfactory cosmetic appearance. Demand for cosmetic surgery penile augmentation continues to increase for several years. The surgical technique most commonly used is now widening and lengthening lipopenisculpture (LPS), combining an adipocyte graft to a section of the suspensory ligament of the penis. A patient who underwent LPS presented several years after a major hypertrophy of the adipocyte graft, making it impossible to have sexual activities, imposing to perform liposuction. This liposuction was being complicated by necrosis of the penile skin. Reconstruction was required and consisted of an unexpanded thin skin graft associated with artificial dermis. Through technical adaptation of the skin graft on the erect penis, the use of artificial dermis and external stabilization by negative pressure therapy, reconstruction of the penile skin provides excellent aesthetic and functional results. Finally, it is rarely reported in the literature complications of lipofilling like alteration of the aesthetic result after weight gain.

Correction of sequelae of rhinoplasty by lipofilling.

BACKGROUND: Rhinoplasty sequelae can be difficult to treat, especially in patients with thin skin. Autologous fat grafting is already used in numerous applications in plastic surgery. However, its use in the nasal region remains relatively uncommon. Given its volumetric qualities and its action on cutaneous trophicity, adipose tissue can be considered the reference product for filling. METHODS: From 2006 to 2012, 20 patients were treated by autologous fat injections according to the Coleman technique in order to correct rhinoplasty sequelae. The procedures were performed under local or general anaesthesia. The quantity of adipose tissue injected ranged from 1 to 6 cc depending on the size of the deformation and the zone being injected: dorsum irregularities, inverted V deformations, visible lateral osteotomies and saddle nose deformity. RESULTS: Of the 20 patients followed up for 18-24 months, 18 had satisfactory aesthetic results after one procedure and two required a second session. Our experience gradually led us to design micro-cannulae for greater injection precision and enabled us to perform these procedures under local anaesthesia. The reduction in ecchymoses and postoperative oedema through the use of these cannulae has significantly reduced convalescence time. CONCLUSION: In patients who undergo multiple procedures, lipofilling can be a simple and reliable alternative to correct imperfections following rhinoplasty.

Development of micro-injection as an innovative autologous fat graft technique: The use of adipose tissue as dermal filler.

BACKGROUND: Autologous fat graft, by virtue of its volumetric qualities and its action on skin trophicity, can be considered as a gold standard implant. Current techniques do not allow very superficial or subdermal injections of adipose tissue. The authors report technical modifications that enable fat transfer through a 25-gauge cannula. The viability of grafted fat was assessed after subcutaneous injection on a murine model. METHODS: Micro-fat grafting consists of harvesting fat tissue using a multiperforated cannula with holes of 1 mm. Fat tissue is refined as described by SR Coleman and transferred through a micro-cannula. Initially, human fat was first harvested using two different procedures: Coleman's technique and the modified harvesting technique. Preliminary comparative histologic analyses were performed. Sixteen nude mice received human fat tissue: one side was filled with 0.7 cc through a 17-G cannula using Coleman's technique, and the opposite side was grafted using smaller cannulae (20G, 23G and 25G) following the modified harvesting technique. Mice were euthanised at 12 weeks and skin biopsies were performed. RESULTS: Experimental fat grafts on mice were observed and analysed: macroscopically, the fat tissue of each side showed the same healthy aspect. Haematoxylin-eosin-saffron staining revealed intact adipocytes and anti-CD31 antibody immunohistochemical staining highlighted an abundant neo-vessel network. CONCLUSION: Fat graft obtained by the modified technique maintains a normal histologic structure. Fat injection with micro-cannulae extends the application of lipostructure to the superficial layers of the skin.

[Correction of the deep nasolabial fold using a temporalis superficialis fascia graft]. / Le comblement du sillon nasogénien par greffon de fascia temporalis superficialis.

SUBJECT: The deep nasolabial fold (NLF) due to age is a frequent complaint from patients in plastic surgery. Various surgical and medical management solutions have been described in literature and are often based on different concepts to justify their interest. We present a new surgical treatment of this region using a temporalis superficialis fascia graft in order to fill the NLF. We also propose a review of the literature about the anatomy and the physiology of this major fold of the face. PATIENTS AND METHODS: From 1990 to 2010, we practiced the replenishing of the NLF using a temporalis superficialis fascia graft on 24 female patients. They all were presenting NLF of great or mild importance due to ageing. We also performed on patients with a great importance NLF a lipofilling of the cheek and the lips in order to recover the volumes lost with ageing. The evaluation items were the quality of the filling (importance and symmetry), quality of the scars and complications occurring on the donor and receiving sites. RESULTS: Objective and subjective results were good. Projection of the NLF was in most of cases strongly and durably restored. CONCLUSION: Filling of the deep nasolabial fold using a temporalis superficialis fascia graft is a simple and reliable technique. Depending on the patients this method can be associated with a lipostructure of the cheek and the lips in order to optimize the facial rejuvenation. According to us this tissular implant allows a long lasting and important correction of the NLF.

[Treatment of hand ischemia with arterialization of the venous system of the hand: report of three cases]. / Traitement de la main en ischémie chronique par artérialisation du système veineux superficiel : à propos de trois cas.

INTRODUCTION: Hand ischemia is a rare phenomenom of various etiologies among which can be found Raynaud's phenomenon and autoimmune arteritis. The limitations of symptomatic medical treatment and the frequent plurisegmental and distal affection of arteries make the management of chronic hand ischemia difficult. The arterialization of the superficial venous system, which consists in redirecting the arterial flow to the fingertip through the dorsal venous system, could be an interesting alternative to the disappointing results of medical therapy and surgical sympathectomy. The authors present here the preliminary results of this technique. PATIENTS AND METHOD: We carried out a retrospective study analyzing the indications, the operative technique and results of three hands operated on two patients. An arteriography was carried out on each patient prior to perform the arterialization of the superficial venous system, in order to make sure that none of the patients was eligible for a technique of direct re-vascularization. RESULTS: Postoperatively, for each patient, the following points were evaluated: pain reduction, ulcer healing, and then we tried to obtain a more objective assessment by performing angio-MRI. CONCLUSION: This last resort technique in management of critical ischemia of the fingers led to an immediate and lasting improvement of symptoms in all the patients treated. This technique seems reliable and reproducible in selected cases aiming to re-vascularize hands that have reached the stage of critical ischemia. This treatment option should be known by hand surgeons, and distributed to internists who usually manage these patients.