About a pediatric facial trauma.

Less-lethal weapon are more and more used in law enforcement to neutralize combative individuals and to disperse riot crowds. Even if this type of weapon has been created to be less damaging than classical firearms, it has been incriminated many times in cases of facial injuries with functional consequences, even death. In many countries, these guns can be possessed by average citizens. They could be extremely harmful when handled by inexperienced users and cannot be considered solely as defense weapons. Interestingly, little literature is available concerning facial injuries caused by the less-lethal weapons. We report the case of a ballistic wound on a 3-year-old child.

[Posttraumatic enophthalmos correction by bone graft: Why the unpredictable results?]. / Correction de l'énophtalmie post-traumatique par greffe osseuse: pourquoi des résultats inconstants?

PURPOSE OF THE STUDY: Posttraumatic enophthalmos cause complex cosmetic problems to fix. In order to get better results, we wanted to calculate the volume of parietal bone graft needed to be put in place, know where to place it in orbit and study soft tissues' participation. PATIENTS AND METHOD: In a retrospective study, we have calculated on scanner the volume of bone and soft tissue as well as the volume and the location of the graft. We have compared, between two groups ("good result" and "insufficient result"), graft volumes, taking into account differences in bone's volume between the healthy and the traumatized orbit. A comparison of the locations of the graft was also made. We were trying to find out if these factors were involved in the quality of the result. RESULTS: Twenty-nine surgeries on 24 patients were analyzed. The average bone's volume of an orbit with enophthalmos was 24.76 cm(3) for 17.12 cm(3) of soft tissue. Retro-lens distance was the most reliable measurement method of enophthalmos (P=0.001). There was a trend to a more substantial over-correction in the group "good result". A significant increase (P=0.0008) of soft tissue volumes in the traumatized orbit was found. CONCLUSION: This last result is surprising. Many authors believe that there is a scar retraction of soft tissues. But Kronish et al. showed an increase of the fat density and connective tissue. This, together with the assumption of a weathering of the ligament suspension of the globe, may affect our aesthetic results. MRI, ultrasound and anatomopathological studies would allow a better understanding of the fat, muscle and ligament pathophysiologies of an orbit with enophthalmos.

[CT-scan evaluation of calvarial bone donor site reconstruction using calcium phosphate cement]. / Évaluation tomodensitométrique de la reconstruction des sites donneurs calvariaux par ciment de phosphate de calcium.

UNLABELLED: The aim of reconstructing a calvarial donor site with biomaterial is to reconstruct the skull vault. The aim of this retrospective study was to assess the quality of reconstruction of calvarial bone with Hydroset™ (Stryker™) in patients having undergone monocortical parietal bone graft harvesting. PATIENTS AND METHOD: The donor sites of patients having undergone calvarial bone harvesting had been reconstructed with Hydroset™ cement over a period of four years. Calvarial bone reconstruction and the thickness of the parietal bone were evaluated by CT scan. RESULTS: Twenty-six patients had undergone reconstruction. The CT scan revealed a good integration of Hydroset™ with maintained thickness of the biomaterial. The parietal bone thickness was increased by 0.67 mm on average (P=0.002). DISCUSSION: The reconstruction of calvarial donor site bone defect with Hydroset™, after a monocortical harvesting, demonstrates parietal osseous thickness maintained in time.

[Becker's nevus and hemimaxillary hypoplasia: coincidence or syndrome?]. / Nævus de Becker et hypoplasie hémimaxillaire: association fortuite ou syndrome ?

INTRODUCTION: Becker's nevus is a dermatological disease sometimes associated with a malformation such as hemifacial bone dysplasia. OBSERVATION: A 11-year-old male patient presented with a delayed growth of the left maxillary and dental impactions. At 15 years of age, Becker's nevus appeared on the upper torso, both shoulders and cheeks. Le Fort I segmented osteotomy with an iliac bone graft was complicated because of maxillary dysplasia. DISCUSSION: The chronology of our patient's cutaneous and maxillary abnormalities was similar to previously reported cases. Conversely, the Becker's nevus-bone dysplasia association has been reported only twice. It may not be a coincidence and could belong to a Becker's nevus syndrome.

[Reconstruction of calvarial donor site using a biomaterial]. / Reconstruction des sites donneurs calvariaux par biomatériau.

INTRODUCTION: Calvarial bone graft is widely used in cranio-maxillo-facial surgery. But the main sequel is an unsightly depression of the donor site. Reconstruction of the donor site using biomaterial could decrease this depression. The aim of this retrospective study was to evaluate the tolerance of biomaterials and the esthetic result of reconstruction. PATIENTS AND METHODS: During a 24-month period, 18 patients were reconstructed with Hydroset™ cement after calvarial bone harvesting. They were followed up for 24 months. The clinical tolerance and esthetic result were assessed, using a questionnaire. RESULTS: There were neither complications nor residual pain. One patient complained of esthetic impairment. A feeling of depression on touch persisted in 44% of patients. Ninety-eight percent of patients would accept another calvarial graft if needed. DISCUSSION: Hydroset™ is well tolerated. It improves local esthetics by filling cranial bone defects after calvarial bone harvesting.

Cemento-ossifying fibroma of the mandible.

INTRODUCTION: Cemento-ossifying fibroma is a rare benign tumor most often discovered incidentally. CASE REPORT: A 72-year-old patient was referred for a subclinical lesion of the mandible. The orthopantomogram showed a well-circumscribed radiolucent osteolytic image, 1 cm in diameter, on the mandibular angle. On CT, the single lesion had a tissue aspect with a peripheral halo without enhancement after contrast injection. A cortical lacuna on the lingual side was noted. Surgical enucleation of the lesion was performed. The pathological examination confirmed the ossifying fibroma. DISCUSSION/CONCLUSION: Slow and progressive, cemento-ossifying fibroma is a rare benign tumor that reaches the maxilla and more frequently the mandible. The ossifying and cementifying fibromas are differentiated by their clinical, radiological, and histological findings. The authors discuss the pathogenesis and radiological signs guiding the choice of diagnostic and therapeutic methods. The treatment is surgical with an enucleation or wider resection with bone reconstruction for large fibromas.

[The free anterolateral thigh flap for head and neck reconstruction: Technical particularities of the harvesting and results about six cases]. / Le lambeau libre antérolatéral de cuisse en reconstruction faciale : particularités techniques du prélèvement et résultats à propos de six cas.

UNLABELLED: The anterolateral thigh flap is a perforator flap vascularised by one or several perforators arising from the descending branch of the lateral circumflex femoral artery. THE AIM OF THIS STUDY: The aim of this study is double. On the technical aspect, we have looked for some tricks allowing harvesting the flap easier and reproducible. On the practical aspect, we have evaluated the functional an esthetical result of the reconstruction and the morbidity on donor site. PATIENTS AND METHOD: Six patients had a reconstruction using this flap between 2007 and 2007: two patients for oral floor and tongue defect, and four patients for soft tissues defects. The patients ranged in age from 55 to 76 years old, the sex-ratio was four males to two females. The follow-up period ranged from six months to 14 months. RESULTS: All the flaps survived. The dissections enabled us to make useful and reliable anatomical observations for the surgeon. Concerning the reconstruction of soft tissues defects, the esthetical quality was good. Concerning the reconstruction of oral floor defects, the functional quality was good. There were few complications and morbidity on donor-site. CONCLUSION: The anterolateral thigh free flap is a reliable flap for head and neck defects. It offers an additional alternative to the other flaps. The use of some tricks allows evading the difficulties encountered during the harvest.

[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.

[Microdialysis monitoring of a free omentum flap]. / Surveillance par microdialyse d'un lambeau libre de grand épiploon.

INTRODUCTION: Microdialysis allows postoperative monitoring of free flaps. It allows determining their cellular metabolism in vivo by measuring glucose, lactate, and pyruvate. We report an application on a greater omentum free flap. CASE REPORT: A 77 year old female patient was operated for a vertex angiosarcoma. A large loss of vertex substance (175cm(2)) was rebuilt with a greater omentum free flap. Monitoring included hourly clinical observation (color, temperature, aspect), and flap surveillance using microdialysis CMA 60((R)) catheter. The first value was obtained 1h 30 after revascularization. The following recordings were made every hour for 48hours, then every 2hours for the next two days, then every 4hours. The following parameters were assessed: glucose (G), lactate (L), and pyruvate (P). The lactate/pyruvate (L/P) ratio was calculated after each dosage. Critical and alert values were the same as for other types of flaps. The first values for G, L, P, and L/P were respectively: 0.92mmol/l, 0.92mmol/l, 72micromol/l, and 13. The mean G, L, P, and L/P values were respectively: 5.9mmol/l, 6mmol/l, 269micromol/l, and 22. The values corresponding to a stable metabolism were obtained on the first postoperative day with the following mean G, L, P, and L/P values of: 5.9mmol/l, 5.3mmol/l, 256micromol/l, and 21. Surgical evolution was uneventful. DISCUSSION: In cervicofacial reconstruction, the greater omentum free flap is often associated to a gastric strip (gastroepiploic flap) and either greatly or completely covered. It is thus little accessible to postoperative clinical surveillance and ischemic complications may be overlooked and compromise the flap's survival. Complementary surveillance techniques such as microdialysis are necessary.

[Black bone disease of the skull and facial bones]. / Coloration noire des os du crâne et de la face.

INTRODUCTION: We report the case of a patient with a craniofacial black bone disease. This was discovered accidentally during a coronal approach. CASE REPORT: A 38-year-old patient was referred to our unit for facial palsy having appeared 10 years before. Rehabilitation of the facial palsy was performed with a lengthening temporal myoplasty and lengthening of the upper eyelid elevator. An unusual black color of the skull was observed at incision of the coronal approach. Subperiostal dissection of skull and malars confirmed the presence of a black bone disease. A postoperative history revealed minocycline intake (200mg per day) during 3 years. DISCUSSION: This craniofacial black bone disease was caused by minocycline intake. The originality of this case is to see directly the entire craniofacial skeleton black. This abnormal pigmentation may affect various organs or tissues. Bone pigmentation is irreversible unlike that of the mouth mucosa or of the skin. This abnormal pigmentation is usually discovered accidentally.

[Microdialysis: experience in postoperative monitoring of 30 free flaps]. / Microdialyse : expérience en surveillance postopératoire de 30 lambeaux libres.

AIM OF THE STUDY: Free flaps have become a usual practice in maxillofacial surgery. A postoperative follow-up is crucial to detect any thrombotic events. Microdialysis is a technique of monitoring for free flaps, which has been proposed recently. It is being assessed, but stay confidential in the clinical practice. We report our experience of microdialysis. PATIENTS AND METHOD: This prospective series includes 30 free flaps performed in our unit during the last 30 months. The critical values used as warning indicators were glucose lesser than 1 mmol/L and lactate more than 10 mmol/L. These values were assessed during the first five days of the post-operative period. RESULTS: Twenty-six monitoring were effective versus four incidents. Seven thrombosis occurred, and one flap had an extrinsic compression of the pedicle. All of these events were detected early by microdialysis. There were no false positive and no false negative. Four flaps were lost. For the 19 flaps without complication, the mean values were for glucose 6.8 mmol/L, lactate 4.4 mmol/L, pyruvate 235 micromol/L and 20 for the ratio lactate/pyruvate (L/P). CONCLUSION: The authors' experience in this mode of recent surveillance is reported. Problems and answers are discussed. Microdialysis is a reliable technique for postoperative surveillance of free flaps but a practice on few cases is needed to master this technique.

[Technical note:simple tools in preimplant surgery]. / Les petits moyens en chirurgie préimplantaire.

Osteotomes, the bone scraper, and the bone trap are simple tools used for preprosthetic surgery. They are not very invasive, present little risks, and they can be used in private surgical practice with local anaesthesia. The osteotome preserves, dilates, and condenses the alveolar bone instead of eliminating it like drilling does. It does not require any motor or irrigation. It increases the width and the height of the alveolar crest. It allows the localized expansion of narrow or misshapen alveolar crest when its width ranges between 3 and 4.5mm. It also allows performing a localized sinus lift, when the sinus floor height ranges between 4 and 8mm. The bone scraper is used to retrieve cortical chips of parietal bone for sinus lift. The bone trap is connected to the suction tube. It is used to collect bone powder after milling or bone drilling. These simple tools should be available for all maxillofacial surgeons in specific indications.

[Post-traumatic disinsertion of the superior oblique muscle trochlea]. / Desinsertion post-traumatique de la poulie du muscle oblique supérieur.

INTRODUCTION: Ophthalmologic examination may rule out an ocular wound in the event of orbital traumatism. Some lesions are obvious but others may not be detected. We report a case of superior oblique muscle trochlea trauma. This infrequent pathology is illustrated with a scanned imagery and magnetic resonance imaging (MRI). OBSERVATION: The initial penetrating trauma was caused by a hook in the medial canthus. The wound was sutured in the emergency unit. Three days later, oblique diplopia developed. Three weeks later, abnormal ocular movements appeared when contracting the frontal muscle. The patient then decided to consult. One month after the traumatism, the orthoptic assessment confirmed the presence of an acquired Brown syndrome suggesting a lesion of the superior oblique muscle. Orbital MRI could not find the trochlea and revealed a thickening by retraction of the posterior portion of the muscle and a hypotrophic aspect of the anterior portion. A fracture of the right orbital edge was revealed by the scanner. Surgical exploration was performed. DISCUSSION: The trochlea is located very anteriorly and likely to be affected in the event of an internal palpebral wound. A direct traumatism of the pulley and/or the superior oblique muscle leads to an acquired Brown syndrome. This observation stresses the importance of surgical wound exploration for the supero-medial palpebral area as well as using MRI which allows proving the diagnosis.

[Pre-implantation apposition grafts for edentuous anterior maxillary. Retrospective study of 36 patients]. / La greffe d'apposition à visée pré-implantaire pour édentation maxillaire antérieure.

INTRODUCTION: Apposition grafting is a method of choice for reconstruction of the anterior maxillary. The purpose of this work was to evaluate the success rate, the degree of bone resorption and the osteointegration of these grafts. MATERIAL AND METHODS: We reviewed retrospectively 36 cases of pre-maxillary bone apposition in patients operated from 1998 to 2002. Autografts were used for all patients. The harvesting site was parietal for 24 patients, intraoral for 8 and iliac for 4. RESULTS: There was two graft failures. The success rate was 94.5%. Partial resorption with effect on implantation was noted in 3 patients. Eighty implants were inserted successfully in 234 grafted sites with on average 2.4 implants per graft. Three implants were removed. Implant survival was 96.2%. DISCUSSION: This study demonstrated that the premaxillary apposition technique using autologous grafts provides sufficient bone volume to enable optimal implant insertion and stability.