Zygomatic implant placement using a robot-assisted flapless protocol: proof of concept.

Robotic assistance can help in physically guiding the drilling trajectory during zygomatic implant positioning. A new robot-assisted strategy for a flapless zygomatic implant placement protocol is reported here. In this protocol, a preoperative computed tomography scan is used to plan the surgical path. After surface registration, the ROSA robot (Zimmer Biomet Robotics) guides several steps, which are performed with shared control. The surgeon performs the drilling and tapping, guided by the robotic arm, which is positioned according to the planned trajectory. Placement of the zygomatic implant is done manually. Immediate intraoperative 3D verification is performed by cone beam computed tomography (flat-panel detector, Medtronic O-arm II). Four zygomatic implants were placed in the case patient according to the flapless protocol, with a mean vector error of 1.78 mm (range 0.52-4.70 mm). A screw-retained temporary prosthesis was placed on the same day. No significant complications were observed. The application of this robot-assisted surgical protocol, which guarantees a very high degree of precision, may reduce inaccuracies in the positioning of zygomatic implants that could deviate from the surgeon's plan. This appears to be a potentially safe flapless surgery technique. Drill slipping on the crest or on the maxillary wall is the main source of error in this procedure, emphasizing the usefulness of the assisted surgical guidance with haptic feedback.

[Lessons from a master in tissue transfer: A study of the surgical notebooks of General Gustave Ginestet during the Foch years]. / Leçons d'un maître en déplacement de tissus : études des carnets opératoires du médecin général Gustave Ginestet dans ses années Foch (1945­1959).

The surgical notebooks (1945-1959) of General Gustave Ginestet are the last direct testimony of the quintessential period in which autoplastic techniques were used, before their twilight, favored by the advent of axial pedicle flaps, musculocutaneous flaps and later free flaps. They summarize all the refinements of the experience accumulated at the National Center for Reconstructive Surgery (Centre Médico-Chirurgical Foch-Suresnes). They appear to be more informative than the various books of the time, which were intended for an experienced public or for those benefiting from a companionship, thus eluding a certain number of precautionary advice, which are undoubtedly tacit but essential to obtain a successful operation in the hypothesis of their current use. This paper aims to establish the principles of historical surgical techniques and to integrate them into the management of patients in therapeutic impasse. One hundred and seven clinical situations requiring tissue displacement were analyzed by reconstructed region and by type of flap used. This technical view of the past, as close as possible to the daily practice of a famous reconstructive surgery center, does not offer absolute methodological or technical precepts. From the surgical notebooks studied, the only thing that emerges is a rigorous approach that allows us to contain a permanent doubt and an experimental process. This notion of constant evolution of the autoplastic practice, guided by its errors, intuitions and beliefs, highlights the importance of a surgical culture, which, with a humanistic approach, must be nourished by the paths of the past.

Second metatarsal free transfer in total temporomandibular joint reconstruction for ankylosis in a child: 10-year follow-up.

The management of temporomandibular joint (TMJ) ankylosis requires complete removal of the ankylosed block and the prevention of recurrence. For this purpose, the ramus-condyle unit can be reconstructed with a second metatarsal free flap. This article reports the use of this flap in a young patient treated for left TMJ ankylosis, post costochondral graft for the treatment of hemifacial microsomia. Data from the 10-year follow-up are reported. The glenoid fossa was reconstructed with a graft of the second metatarsal base, enabling the juxtaposition of two cartilaginous joint surfaces, with the aim of optimizing the functional result and preventing the recurrence of ankylosis. At the 10-year follow-up after this surgery, there was no recurrence of the ankylosis and no articular disorder, and the morphological result was satisfactory. Bone fixation was stable over the 10-year period and the metatarsal head was still in place. Quantitative measurements obtained by computed tomography scan did not show any growth of the second metatarsal free flap compared to the right unaffected condylar process.

Fraser syndrome: review of the literature illustrated by a historical adult case.

Fraser syndrome (cryptophthalmos-syndactyly syndrome) is a rare autosomal recessive malformation disorder. The first description of the syndrome was reported by George Fraser in 1962. Diagnosis is based on the major and minor criteria established by van Haelst et al. in 2007. Unilateral or bilateral cryptophthalmos, syndactyly, unilateral renal agenesis, and genital anomalies are the most frequent anomalies. Several maxillofacial, oro-dental, ear-nose-throat, hormonal, and anorectal disorders are reported. Cardiac malformations and musculoskeletal anomalies are uncommon. The syndrome is related to mutations in three different genes (FRAS1, FREM2, and GRIP1) resulting in failure of the apoptosis program and disruption of the epithelial-mesenchymal interactions during embryonic development. Prenatal diagnosis is based on the detection of renal agenesis and laryngeal atresia, together with a family history. Most foetuses with severe anomalies are terminated or are stillborn. All patients or pregnancies with a diagnosis of Fraser syndrome should be referred to expert centres. A collaborative approach including anaesthetists, ENT specialists, maxillofacial surgeons, and geneticists is necessary for the management of this syndrome. In vivo and in vitro research models are available to better understand the underlying aetiology.

Reduction of morbidity of the revascularization surgery in the management of mandibular osteoradionecrosis by basilar edge preservation.

INTRODUCTION: The chronic complications of bone free-flap revascularization surgery are mainly characterized by skin fistulization of the osteosynthesis material, which sometimes leads to reactivation of the osteoradionecrotic phenomenon. The objective of the study is to evaluate the benefit of mandibular basilar edge preservation in bone reconstructive surgery in irradiated areas performed for the treatment of advanced mandibular osteoradionecrosis. MATERIALS AND METHODS: A retrospective monocentric study conducted between 2003 and 2018 including all patients undergoing revascularization surgery for the treatment of advanced osteoradionecrotic lesion with respect to the basilar margin was conducted. RESULTS: Eight patients (7 males and 1 female, aged 50 to 63 years) who had a marginal mandibulectomy with reconstruction by bone free flap or composite free flap were included. The stability of the reconstruction (junction native mandible/bone free flap) was achieved on average by using 1.75 [range 0-4] mini plates (Medartis® Modus 2.0, Medartis AG, Basel, Switzerland). During the follow-up (30±13 months) no chronic complication related to a dissociation of the osteosynthesis material or a reactivation of the osteoradionecrotic phenomenon were identified. CONCLUSIONS: Despite the limited number of patients, it seems that the increase in the friction surface between the free flap and the native mandibular bone, linked to the preservation of the basilar edge, improves the primary stability of the reconstruction. This reduction in mechanical stress on osteosynthesis materials limits its use and reduces the rate of chronic complications of bone flap revascularization surgery in irradiated areas.

The value of reconstructive surgery in the management of refractory jaw osteoradionecrosis: a single-center 10-year experience.

Mandibular osteoradionecrosis (mORN) is a severe complication of head and neck irradiation. International consensus on the management of mORN is currently lacking. The present study sought to evaluate the effectiveness and benefits of early reconstructive surgery (resection of the diseased bone and immediate reconstruction with a free flap) in treatment-refractory mORN. A single-center retrospective study was carried out of operations performed in a French university medical center between 2003 and 2013 inclusive. For each patient, the surgical modalities and postoperative outcomes were recorded. A total of 55 operations (19 marginal resections and 36 segmental resections) were performed, and the overall success rate was 92.3%. Relative to marginal resections, segmental resections were associated with longer operating times (440±62min vs. 531±72min, respectively; P<0.05 in Student's t-test), a longer length of hospital stay (16.5±6.5 days vs. 25.6±11.3 days, respectively; P<0.05), and a higher complication rate (26.3% vs. 63.9%, respectively; P<0.05 in Fisher's test). Given the unpredictable progression of treatment-refractory mORN and the risk-benefit ratio observed here, the value of early reconstructive surgery with curative intent should be reassessed.

Treatment of mandibular osteoradionecrosis by periosteal free flaps.

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

Technical note on the harvest of periosteal forearm composite free flaps in the treatment of early mandibular osteoradionecrotic injury.

Periosteal radial forearm free flaps allow functional and curative treatment of osteoradionecrotic jaw lesions. The flap responds physiologically to hypoxia, hypocellularity, and hypovascularity, which are characteristic results of osteoradionecrotic injury. Here, we propose a reproducible, simple, and safe method for harvesting a forearm free flap, allowing us to obtain a periosteal composite free flap. Our technique offers potential early management of osteoradionecrotic lesions resistant to medical treatment. Furthermore, the forearm periosteal composite free flap offers the advantage of a long vascular pedicle which is ideally suited for necks which have been submitted to irradiation or multiple operations. Thusly, vascular anastomosis can be performed at a distance from the irradiated areas. Compared to other periosteal free flaps, such as those harvested from the iliac crest or the internal femoral condyle, the presence of a skin paddle facilitates clinical flap monitoring, optimizes the restoration of bone sealing, and facilitates the treatment of scarring.

[Feminism and cosmetic surgery: Suzanne Gros-Noël (1878-1954)]. / Féminisme et chirurgie esthétique : Suzanne Gros-Noël (1878­1954).

Born at the late 19th century, Suzanne Noël achieved, despite prejudices, to become at the same time the first female cosmetic surgeon and an influential feminist activist. Trained as a dermatologist by Professor Brocq, she first became fascinated by rejuvenation surgery during her studies by meeting Sarah Bernardh, who had undergone a facelift in the United States. As a surgeon, she mainly performed procedures under local anaesthesia in her salon, where she maintains worldly relations with her women clients. As an activist, she founded feminist clubs all over the world since 1923, under the aegis of a still flourishing organization: "Soroptimist International", which provided assistance in the field to women in need. She successively lost her first husband, then her single daughter and her second husband to be 46 years old, widowed, indebted and without any medical license. Their personal difficulties are not foreign to what she advocates: the women's emancipation by achieving economic independence. Suzanne Noel's journey is a singular paradox on the relationship between the earliest days of cosmetic surgery and feminist ideology. She structured the controversy within the various thinking movements at that time: does embellishing a woman serve her cause? Provocative but necessary question for thinking the surgical act. Suzanne Noël, as a liberal feminist, however, supported the idea that cosmetic surgery could be a transitional solution to integrate a working environment in which there was significant discrimination in women's employment.

Small cell carcinoma of the floor of mouth: Difficulties of a therapeutic choice.

INTRODUCTION: With only 14 cases and as many different therapeutic strategies reported in the literature, small cell carcinoma of the oral cavity remains a real challenge with diagnostic and therapeutic pitfalls. CLINICAL CASE SUMMARY: A 65-year-old patient with an active smoking habit consulted for a painful oral pelvic mass. The staging confirmed the diagnosis of small cell carcinoma of the anterior floor of mouth, classified as cT3N0M0. By analogy with pulmonary locations, medical management combining chemotherapy specific for small bronchial cell carcinoma (carboplatin-etoposide) and radiotherapy (tumor bed and cervical lymph nodes) was preferred. We found no recurrence of the disease 12 months after treatment. DISCUSSION: Local invasiveness and metastatic potential of small cell carcinoma of the oral cavity require harmonization of therapeutic strategies. We suggest initiating chemotherapy associated with radiotherapy as quickly as possible, a treatment to which these tumors are known to have histological sensitivity.

Brain ameloblastoma: metastasis or local extension case report and physipathological reflexion.

BACKGROUND: Ameloblastoma is a rare benign odontogenic tumor with a metastasis rate estimated at 2% of cases, mainly involving the lung (80%) and lymph nodes (20%). METHODS: We hereby present the case of a 26 year old patient with a history of locally recurrent mandibular ameloblastoma who developed a temporal intracranial ameloblastoma tumor requiring a collaborative neurosurgical and maxillo-facial radical surgical approach. CONCLUSION: Although ameloblastomas are histologically benign, the temporal topography questions the dissemination pathophysiology of the tumor (metastasis or local extension through temporal muscle fibers), mainly relevant in cases of multiple recurrences.