Facial surgery for cosmetic purposes: Practice guidelines.

OBJECTIVES: Facial surgery for cosmetic purposes aims to improve the physical appearance and self-image of normal individuals. The aim of the guidelines is to answer questions related to legislation, patient evaluation and motivations, relevance and risk assessment, patient information and patient follow-up. METHODOLOGY: Analysis and synthesis of the medical literature through research of bibliographic databases in French and English from 2000 to 2017. Research and use of guidelines from evaluation agencies and academic societies. Drafting of guidelines with indications on levels of evidence. RESULTS: 24 guidelines with levels of evidence B (scientific presumption), C (low level of evidence) or EO (expert opinion) were selected to answer the questions. Cosmetic facial surgery must be performed by certified, qualified professionals in authorized structures. It must follow certain specific rules as well as a charter and code of ethics so as to enforce the rules of practice.

Spontaneous atopic dermatitis due to immune dysregulation in mice lacking Adamts2 and 14.

Since its first description, ADAMTS14 has been considered as an aminoprocollagen peptidase based on its high similarity with ADAMTS3 and ADAMTS2. As its importance for procollagen processing was never experimentally demonstrated in vivo, we generated Adamts14-deficient mice. They are healthy, fertile and display normal aminoprocollagen processing. They were further crossed with Adamts2-deficient mice to evaluate potential functional redundancies between these two highly related enzymes. Initial characterizations made on young Adamts2-Adamts14-deficient animals showed the same phenotype as that of Adamts2-deficient mice, with no further reduction of procollagen processing and no significant aggravation of the structural alterations of collagen fibrils. However, when evaluated at older age, Adamts2-Adamts14-deficient mice surprisingly displayed epidermal lesions, appearing in 2 month-old males and later in some females, and then worsening rapidly. Immunohistological evaluations of skin sections around the lesions revealed thickening of the epidermis, hypercellularity in the dermis and extensive infiltration by immune cells. Additional investigations, performed on young mice before the formation of the initial lesions, revealed that the primary cause of the phenotype was not related to alterations of the epidermal barrier but was rather the result of an abnormal activation and differentiation of T lymphocytes towards a Th1 profile. However, the primary molecular defect probably does not reside in the immune system itself since irradiated Adamts2-Adamts14-deficient mice grafted with WT immune cells still developed lesions. While originally created to better characterize the common and specific functions of ADAMTS2 and ADAMTS14 in extracellular matrix and connective tissues homeostasis, the Adamts2-Adamts14-deficient mice revealed an unexpected but significant role of ADAMTS in the regulation of immune system, possibly through a cross-talk involving mesenchymal cells and the TGFß pathways.

Outcomes of septorhinoplasty: a new approach comparing functional and aesthetic results.

The aim of this study was to compare objective and subjective functional results of septorhinoplasty with subjective aesthetic results. A prospective study was performed including global and subgroup analyses (primary versus secondary septorhinoplasty). Three instruments were used to evaluate pre- and postoperative results: rhinomanometry for the objective functional analysis, the Nasal Symptom Obstruction Evaluation (NOSE) scale for the subjective functional analysis, and the Rhinoplasty Outcome Evaluation (ROE) scale for the subjective aesthetic analysis. A septorhinoplasty was performed in all cases. Thirty-five patients were included (22 female), of whom 74% underwent primary septorhinoplasty. The correlation between rhinomanometry, NOSE and ROE scores was analysed. Mean resistance of the two nasal cavities was 4.9 (standard deviation (SD) 8.35) sPa/ml before surgery and 0.8 (SD 0.7) sPa/ml after surgery. NOSE and ROE scores were, respectively, 72.5/100 (SD 21.7) and 7.5/24 (SD 11.3) before surgery and 22/100 (SD 20.6) and 18/24 (SD 17.3) after surgery. Patients complaining of postoperative nasal obstruction had a worse aesthetic evaluation. Correction of the functional disease appears to be as important as aesthetic correction. This study comparing functional and aesthetic results after septorhinoplasty could provide a basis for future studies.

Long-term results of Gamma-knife stereotactic radiosurgery for vestibular schwannomas in patients with type 2 neurofibromatosis.

INTRODUCTION: The aim of this study was to analyze the long-term results of Gamma-knife radiosurgery treatment of vestibular schwannomas in type 2 neurofibromatosis patients. MATERIALS AND METHODS: A cohort of 129 treatments for vestibular schwannomas in 103 patients was selected from a prospectively-maintained clinical database. Tumor control was assessed by volumetric analysis of the tumor at the last follow-up. Any need of a further procedure such as microsurgical removal or second treatment was regarded as a failure of tumor control. Hearing function was assessed based on Gardner-Robertson classification. Progression-free survival and functional hearing preservation rates were estimated using the Kaplan-Meier method. RESULTS: The median age at treatment was 34 years with no gender predominance. The median tumor volume was 1.5cm3. At a median clinical follow-up of 5.9 years, five patients had died, four underwent a second radiosurgical procedure and eight underwent microsurgical resection. Progression-free survival was 88 and 75% respectively at 5 and 10 years. Hearing was considered serviceable in 70 ears and remained functional in 28 ears. Kaplan-Meier estimates for 5 and 10 years functional hearing was 47 and 34%, respectively. Three patients developed new facial nerve palsy after radiosurgery at 15 days, 6 and 19 months respectively and only one partially recovered. Five patients complained of a subjective instability worsening. Four cases developed trigeminal neuropathy. No predictive factors were found to be statistically correlated with a better hearing outcome or an improved tumor growth control. CONCLUSION: Results prove less satisfying than in sporadic unilateral schwannomas. However, the lower rate of mortality and morbidity compared with microsurgical resection may support a proactive role of Gamma-knife in this pathology.

The MiRa scale, a new standardised scale for evaluating nasal deformities before and after septorhinoplasty: A prospective study comparing patient satisfaction and the surgeon's assessment.

OBJECTIVES: The objective was to assess the reliability of a new standardised scale for evaluating nasal anomalies in order to compare the surgeon's assessment and patient satisfaction. DESIGN: Monocentric prospective cohort study. SETTINGS: First, we validated the reliability of the MiRa scale; then, we compared the surgeon's assessment and patient satisfaction. PARTICIPANTS: Fifty-two patients underwent septorhinoplasty surgery and gave their written consent before inclusion. MAIN OUTCOME MEASUREMENTS: Primary outcome measurement was to validate the reliability of the MiRa scale: two observers analysed all records twice. Intra-observer reproducibility and interobserver reproducibility were evaluated using the intraclass correlation coefficient (ICC). Secondary outcome measurement was to compare the surgeon's assessment and patient satisfaction: MiRa and ROE (Rhinoplasty Outcome Evaluation) scores were established for each patient prior to and 6 months after surgery. RESULTS: Using the MiRa scale, ICC for intra- and interobserver reproducibility was, respectively, 95.4% and 96%, showing no statistical difference (P=.70, P=.45). Good correlation scores were, respectively, 93% and 92%. Mean ROE scores were 7.1/24 (SD=11.3) before and 19.3/24 (SD=17.3) after surgery (P<.05). We found an increase in MiRa and ROE scores of +19.75% and +51.25% (P<.05), respectively. The average postoperative ROE score in the primary septorhinoplasty group was 20.4 (SD=14.4) and 17.2 (SD=23.1) in the secondary septorhinoplasty group (P<.05). CONCLUSION: MiRa scale is a reliable, standardised tool to evaluate surgical outcome in septorhinoplasty surgery. It provides an objective and reproducible score. The surgeon's assessment was more critical than patient satisfaction. Patient satisfaction is more difficult to achieve in cases involving a secondary septorhinoplasty.

Drug loading of polymer implants by supercritical CO2 assisted impregnation: A review.

Drug loaded implants also called drug-eluting implants have proven their benefits over simple implants. Among the developed manufacturing processes, the supercritical CO2 (scCO2) assisted impregnation has attracted growing attention to load Active Pharmaceutical Ingredients into polymer implants since it enables to recover a final implant free of any solvent residue and to operate under mild temperature which is suitable for processing with thermosensitive drugs. This paper is a review of the state-of-the-art and the application of the scCO2 assisted impregnation process to prepare drug-eluting implants. It introduces the process and presents its advantages for biomedical applications. The influences of the characteristics of the implied binary systems and of the experimental conditions on the drug loading are described. Then, the various current applications of this process for manufacturing drug-eluting implants are reviewed. Finally, the new emerging variations of this process are described.

In situ investigation of supercritical CO2 assisted impregnation of drugs into a polymer by high pressure FTIR micro-spectroscopy.

An original experimental set-up combining a FTIR micro-spectrometer with a high pressure cell has been built in order to analyze in situ the impregnation of a solute into microscopic polymer samples, such as fibers or films, subjected to supercritical CO2. Thanks to this experimental set-up, key factors governing the impregnation process can be simultaneously followed such as the swelling of the polymeric matrix, the CO2 sorption, the kinetics of impregnation and the drug loading into the matrix. Moreover, the solute/polymer interactions and the speciation of the solute can be analyzed. We have monitored in situ the impregnation of aspirin and ketoprofen into PEO (Polyethylene Oxide) platelets at T = 40 °C and P = 5; 10 and 15 MPa. The kinetics of impregnation of aspirin was quicker than the one of ketoprofen and the final drug loading was also higher in the case of aspirin. Whereas the CO2 sorption and the PEO swelling remain constant when PEO is just subjected to CO2 under isobaric conditions, we noticed that both parameters can increase while the drug impregnates PEO. Coupling these results with DSC measurements, we underlined the plasticizing effect of the drug that also leads to a decrease in the crystallinity of PEO in situ thus favoring the sorption of CO2 molecules into the matrix and the swelling of the matrix. The plasticizing effect increases with the drug loading. Finally, the speciation of drugs was investigated considering the shift of the carboxyl bands of the drugs. Both drugs were found to be mainly homogeneously dispersed into PEO.

[Septoplasties and associated procedures]. / Les septoplasties et gestes associés.

Observing a morphological alteration of the nasal septum should in no way automatically lead to a septoplasty. Only poorly tolerated septal deviations creating a mechanical nasal obstruction are a surgical indication. This delicate operation requires meticulousness to preserve the muco-perichondrial envelope. The statement follows a rigorous clinical assessment where endoscopy is important because it points out the septal deformities, the size of the inferior turbinates and possible valvate problems. Performing a rhinomanometry and sometimes a CAT scan will complete the preoperative assessment.

[Rhinoplasty: medicolegal issues]. / Aspects médico-légaux en rhinoplastie.

In rhinoplasty, satisfying the patient both aesthetically and functionally can be complex. In aesthetic surgery, the rhinoplastician has a reinforced obligation of means. In our experience, the functional outcome of the patient is closely linked to the morphological result. When a rhinoplasty provides the patient with full aesthetic satisfaction, even if he/she has breathing difficulties, there will be very few disputes. In primary rhinoplasty, unsatisfactory results occur in 15%-30% of the cases. While orally informing the patient is paramount, the practitioner must also have written proof of the information via documents given or sent to the various players including the patient. The taking of pre- and postoperative photographs is essential and the surgeon must keep them on file for support in case of conflict.

[Twisted noses]. / Les nez déviés.

Correction of a twisted or crooked nose can be very complex and require the use of a broad range of surgical techniques. Patient needs are often mixed--aesthetic and functional--particularly in post-trauma cases. The quality of postoperative breathing is therefore as important as correction of the nasal deviation. Extracorporeal septoplasty or spreader grafts are very effective not only in correction of the nasal pyramid deformation, but also in resolution of functional respiratory issues. Reconstruction and proper support of the septum are necessary components for a straight nose. Aesthetic deformation can be difficult to correct owing to the memory of the bone and cartilage. Although minor deformations can be corrected with simple techniques, a more aggressive procedure is often necessary in the most complex cases. Despite attempts to correct deformation thanks to the various techniques described here, a postoperative deviation can persist. Preoperative discussion is very important and enables the surgeon to explain to the patient that it is very difficult to obtain a perfectly straight nose.

[Ventilatory examination before an aesthetic rhinoplasty]. / Le bilan ventilatoire pré-rhinoplastie esthétique.

Nose and nasal cavity provide ventilation, inspired air conditioning and olfaction. They may be the seat of inflammatory, infectious and malignant disease, or preoperative or postoperative architectural abnormalities, altering these functions, for which clinical examination will be a variable return. First of all, we'll see, after a brief physiological reminder, descrambling examination which allows non-ENT surgeon to select patients justifying a further preoperative functional exploration. In total, there will be three groups of patients: those who have no cons-indication to rhinoplasty, those with an indication of aesthetic and functional rhinoseptoplasty, those with cons-indication for rhinoplasty.

Characterization and optimization of GMO-based gels with long term release for intraarticular administration.

Osteoarthritis is characterized by slow degenerative processes in the articular cartilage within synovial joints. It could be interesting to develop a sustained-release formulation that could be effective on both pain/inflammation and restoration of mechanical integrity of the joint. Recently, an injectable system based on glycerol monooleate (GMO), containing clonidine as a model hydrophilic analgesic/anti-inflammatory drug and hyaluronic acid as a viscoelastic scaffold, showed promising potential as a biodegradable and biocompatible preparation to sustain the drug activity. However, drug release from the system is relatively fast (complete within 1 week) and the underlying drug release mechanisms not fully understood. The aims of this study were: (i) to significantly improve this type of local controlled drug delivery system by further sustaining clonidine release, and (ii) to elucidate the underlying mass transport mechanisms. The addition of FDA-approved inactive ingredients such as sodium oleate or purified soybean oil was found to be highly effective. The release rate could be substantially reduced (e.g., 50% release after 10 days), due to the increased hydrophobicity of the systems, resulting in slower and reduced water uptake and reduced drug mobility. Interestingly, Fick's second law of diffusion could be used to quantitatively describe drug release.

[Aesthetic profiloplasty: retrospective study of 101 cases]. / La profiloplastie esthétique : étude rétrospective à partir de 101 cas.

OBJECTIVES: Aesthetic profiloplasty focuses on patients with normal dental occlusion and summarizes the association of a rhinoplasty and genioplasty. The aim of our study is to analyze the dysmorphoses overall profile, as well as different surgical techniques. This also allows to validate a method of analysis and construction of an aesthetic project based on a profile photograph. MATERIALS AND METHODS: This is a retrospective study of 101 adult patients undergoing profiloplasty at our institution over a period of 35 years. RESULTS: 18 patients (17.8%) had an abnormality of the nasofrontal angle, 62 (61.3%) abnormal and the nasolabial angle 101 a chin dysmorphia. CONCLUSION: We studied profiloplasty focusing on its borders, first of all the nasal profile and then the facial profile with the chin. Our profilometric building is simple, didactic and to obtain a good cosmetic result. The Marseilles School Pech and Cannoni was intended, regarding rhinoplasty, trying to get a natural result for a consistent look. Through profiloplasty we continued this teaching of "natural reworked" to achieve the most harmonious profile.

[Role of radiosurgery and stereotactic radiotherapy in the management of vestibular schwannomas]. / Radiochirurgie et radiothérapie stéréotaxique des schwannomes vestibulaires.

PURPOSE OF THE STUDY: In order to investigate the role of radiosurgery and stereotactic radiotherapy in the management of vestibular schwannomas, we have reviewed our own prospective cohort and the main series of the modern literature. PATIENTS AND METHODS: Between July 14th 1992 and June 1st 2011, 2991 vestibular schwannomas were operated on the Stereotactic and Functional Neurosurgery Department of Timone University Hospital. All the patients have been evaluated prospectively, with a follow up longer than 3 years for 2336 patients, excluding patients suffering from type 2 neurofibromatosis (148 patients). In 7% of the patients, the vestibular schwannoma had previously been resected. According to Koos classification, in 17.6% of the patients, vestibular schwannomas were stage I, 51.8% stage II, 27% stage III and 3.6% stage IV. The mean tumour volume was 2.63 cm(3). According to Garner Robertson classification, the hearing was still functional at the time of radiosurgery in 46% and subnormal in 20.9% of the patients. RESULTS: Long term tumour control was achieved in 97.5% of the patients. A transient facial palsy was observed in 0.5% of the cases. The rate of trigeminal injury was 0.5%. Useful hearing was preserved at 3 years in 78%. This rate reached 95% in patients with no past history of sudden hearing loss. Other predictors of functional hearing preservation are the young age, the small size of the lesion and a dose to the modiulus of the cochlea lower than 4Gy. We observed no radio-induced tumour. Only large, Koos IV vestibular schwannomas are contraindicated for upfront radiosurgery. In these patients, we propose a combined approach with a deliberately partial microsurgical removal, followed by a radiosurgery of the residue. CONCLUSION: This cohort is unique by the size of the population and the length of the follow up and results demonstrate the efficacy of radiosurgery and its safety, especially its high rate of hearing preservation.

Sinonasal mucormycosis: case report.

OBJECTIVES: To present and discuss the case of a diabetic patient admitted with acidoketotic coma, with inner canthus tumefaction due to mucormycosis. CASE STUDY: A 38-year-old diabetic man was admitted with acidoketotic coma and poor general health status. Clinical examination found right inner canthus tumefaction and mucopurulent rhinorrhea. Endoscopy of the nasal fossae found medial meatus sphaceluses. Sinus CT scan found a bilateral ethmoid infiltrating and osteolytic infectious process. Emergency endoscopic bilateral ethmoidectomy was performed. Mucormycosis was diagnosed, and liposomal amphotericin B was administered intravenously for 1 month then replaced by posaconazole. The patient was followed up monthly; the antifungal treatment was terminated after 8 months, the disease appearing to have resolved. COMMENTS AND CONCLUSION: Mucormycosis is one of the most rapidly fatal fungal infections. Facial and cerebral CT scan is essential and is systematically abnormal in case of sinonasal mucormycosis. Emergency multidisciplinary treatment should address the diabetes and include rapid surgical debridement and effective antifungal medication. The reference antifungal is amphotericin B, to be administered at maximal dose (3 to 5 mg/kg per day). Posaconazole, available in Europe since July 2005, proved successful in the present case.

Endoscopic anatomy of the posterior tympanum.

OBJECTIVES: This study aims to describe anatomical variations in the posterior tympanum. Different configurations which influence surgical decisions in middle ear surgery are described. Surgical access to the sinus tympani remains a challenge for otologic surgeons. Usually, the retrotympanum is approached through the middle ear in the anterior-posterior direction during chronic ear surgery. An endoscopic approach is necessary to detail all reliefs of the middle ear and control the total removal in a cholesteatoma surgery. MATERIALS AND METHODS: Our study included 120 ears with otosclerosis that were operated on. We have performed an intra-operative endoscopic examination with different endoscopes from the Storz company (3.0 mm diameter 45 and 70 degrees). Its rigid endoscopes have been used to obtain a detailed inspection of the entire middle ear cavity. Three main anatomical configurations increase difficulty for the otologic surgeons. RESULTS: One hundred and twenty ears were included in this retrospective study. We described 44 shallow sinus tympani of type I (36.6%), and 46 intermediary sinus tympani of type II which account for 38.4% of the ears. In these two groups, a disease such as cholesteatoma is quite easy to control. In 30 ears we observed a deep sinus tympani of type III (25%). This type of sinus is a real difficulty for the surgeon, which means that a total exploration without an endoscope is not possible and entails intraoperative risks. Some anatomical variations were noted: indeed, six high jugular bulbs were described in the middle ear (5%). In 4 other ears (3.3%), there was a posterior extension which passes under the pyramidal eminence and the fallopian canal. CONCLUSION: For 8.3% of the ears, some important intraoperative risks are involved, which can cause damage to the facial nerve or the jugular bulb. Moreover a quarter of the ears have deep sinus tympani which can not be explored with a microscope. This makes the endoscope an essential complement to the microscope in otologic surgery.

["Mini-rhinoplasty"]. / La mini-rhinoplastie.

OBJECTIVES: To define the interest of the so called "mini-rhinoplasty" in aesthetic nose surgery and to report the surgical technique. METHOD: The experience of the authors, based on more than 500 mini-rhinoplasty surgical procedures is reported. The surgical procedure such as technical tips are reported. RESULTS: Mini-rhinoplasty procedure is indicated in patients with small deformities, particularly in patients with nasal hump or hyper-projected noses, with no deviation. The nasal tip should be normal or slightly drooping. The surgical technique is safe and reproducible. Surgical aesthetic outcomes are excellent. This technique is also indicated in elderly patients willing a facial rejuvenation. CONCLUSION: Mini-rhinoplasty surgical technique is a minimal invasive procedure with no complication in the postoperative period. The postoperative management of patients undergoing this procedure is of main importance.

[Saddle nose surgery: long term aesthetic outcomes of support grafts]. / Ensellures nasales. Résultats esthétiques à long terme des greffons de soutien.

UNLABELLED: Saddle nose surgery requires support grafts to improve the aesthestic of the nose such as the functional ventilation. Many kind of graft are available: Calvarial bone graft, iliac crest, septal cartilage, conchal cartilage, nasal hump, bony inferior turbinate. OBJECTIVES: To define the surgical strategy and long term aesthetic outcomes of rhinoplasty with support graft for saddle nose correction. MATERIAL AND METHOD: Retrospective study during the period 1985-2005: 160 patients underwent rhinoplasty with support graft for saddle nose correction. Patients were divided into 3 groups depending on the deformation (group I: Minor saddle nose; group II: Intermediate saddle nose; group III: Major saddle nose). Long term results were analysed at least 5 years after surgery, in 70 patients. RESULTS: An intranasal approach was performed in 92 cases, while an open approach was performed in 68 cases. A bony support graft was used in 85% of patients of group II and 94% of patients of group III. These grafts allowed a more rigid correction of the saddle nose than cartilage. For groups II and III patients, cartilage support grafts were not used because of the lack of quantity to correct the saddle nose. CONCLUSION: Calvarial bone support graft has a great role in saddle nose surgery. The postoperative aesthetic outcomes are interesting and its absorption is low.

Cervical paragangliomas: neurovascular surgical risk and therapeutic management.

Paragangliomas of the neck region arise most commonly in the carotid and vagal bodies. The goal of this retrospective study is to evaluate intraoperative vascular and neurological morbidity and to define the therapeutic strategy. During the period 1990-2004, 32 patients with 42 neck paragangliomas were referred to our institution (Head and Neck Service, Otolaryngology Federation, CHU La Timone, Marseilles, France). There were 29 carotid body tumors and 11 vagal body tumors. There were 14 men and 18 women. Forty paragangliomas were surgically excised. Mean age of patients with family history of paragangliomas was 34 years and that of patients without any familial history was 47 years. Only one patient had a malignant paraganglioma. A vascular repair procedure was performed in 10% and always occurred in carotid body tumors including the malignant one. Postoperative hypoglossal nerve deficit was reported in five cases (12.5%). Paralysis of vagus nerve was reported in 11 cases (27.5%), nine of whom were patients with vagal body tumors. Knowledge of number of paragangliomas and their location is of main importance and influences the therapeutic strategy. The goal of this strategy is to avoid major neurovascular morbidity and to optimize treatment of multiple or bilateral tumors. Early management of patients prevents progressive neurological deficit due to an enlarging tumor mass and minimizes neurovascular complications.