[Facial anatomy and botulinum toxin: the muscular balances]. / Anatomie faciale et toxine botulique : les balances musculaires.

The muscular topographic anatomy of the face has long been known. The functional anatomy of the face has been studied by many neurologists, with Duchenne of Boulogne one of the first. The possibility of correcting not only wrinkles, but also certain regional balances gives botulinum toxin a certain number of advantages as well as limitations that should be well known by future injectors as well as the more experienced of practitioners who seek to treat the most difficult zones.

[Eye rings: morphological classification and treatment]. / Le cerne: classification morphologique et applications thérapeutiques.

Eye rings are multifactorial so a combined treatment is often thought. The discoloration of the skin, the border between thin and thick skin, the skeletonisation, the eye rings accentuated by fat pads are an entity making the approach to treatment far more complex. The morphological classification proposed by the author based on face and profile analysis, permits a standardized treatment. Now our possibilities are more medical, non invasive and less surgical.

[Facial threads for face lift]. / Les fils crantés de suspension faciale.

Facial threads have been in use for ten years as an alternative to early face lifting, in case of premature drooping of the face. These threads, combined with other techniques (lipostructure, lipoaspiration), are used for rejuvenation of aging face. Their mean time of action is 2 to 4 years. Main complications are lack of efficacy and exposure of threads through the skin or mucosa and a short duration of action.

[National survey of the deep vein thrombosis in plastic and aesthetic surgery, consequences and guidelines]. / Le risque thrombo-embolique en chirurgie plastique et esthétique: enquête de pratique, conséquences et recommandations.

This first French national survey of the deep vein thrombosis and embolism risk during plastic and aesthetic surgery shows the reality of this complication. Eighty percent of the french plastic surgeons had deep vein thrombosis in their patients and 53% had pulmonary embolism. There are no guidelines in our speciality in French. The author reviews the bibliography and guidelines of all the other societies around the world as experts' recommendations during the national congress of the French Plastic Reconstructrice and Aesthetic Surgery (SOF.CPRE) in 2004.

[Rejuvenation of the lower third of the face and the neck]. / Rajeunissement du tiers inférieur du visage et du cou.

One of the marks of the youth of a face is the absence of ptosis of the cheek and the perfect delimitation of the neck with an angle well defined. The objective of this work is to present our surgical technique for the treatment of the lower third of the face and the neck. After a degreasing of the neck and lower part of the cheek, we carry out an extensive cutaneous separation of these areas. The cervical face lift is performed in different layers. A suspension with posterior direction of the platysma is systematic. It is associated or not, according to the importance with the platysma bands, with an anterior approach or with counter side incisions. A reinforcement of the angles is obtained by a fat grafting. One fills the mandibular ligament and one underlines the relief of the chin.

[Postoperative complications after breast implantation]. / Les complications postopératoires en chirurgie d'augmentation mammaire.

Augmentation mammoplasty is one of the most popular and frequently performed aesthetic operations. The implants are not, however, without complications; and many have been reported in order to this surgical procedure: hematoma, infection, seroma, capsular contracture, rupture ... Current surgical practices and modern implants used for breast augmentation produce fewer complications than procedures and devices of the past. The aim of this work is to index most common post operative breast complications. The prevention and the treatment procedure of these complications are also reported. A good knowledge of all these points seems to be essential to improve the quality of the final results and patients satisfaction.

[Interest of cutaneous resection after reduction of volume by decongestive physiotherapy in huge primary lymphedema of lower limb]. / Intérêt de la résection cutanée après réduction volumétrique par physiothérapie décongestive des lymphoedèmes primitifs volumineux des membres inférieurs.

Treatment of lymphedema is based upon decongestive physiotherapy including low stretch bandages. We reported 3 cases of huge primary lymphedema of lower limb treated with cutaneous resection after decongestive physiotherapy. Two men and a woman (47, 48, 48 years old) had unilateral right lymphedema which appeared at the age of 38, 38 and 37 years. Patients were hospitalized and treated during 3 to 5 weeks with decongestive physiotherapy and then followed by one (n=2) or two cutaneous (n=1) resections. Lymphedema volume calculated with the method of truncated cones decreased of 32, 38 and 59%. Largest differences between the two calves were 54, 38 and 57 cm before treatment and 17, 9 and 12 cm after treatment. Cutaneous resections on external side of the calf were longitudinal without complications. Lymphedema volume remained stable after 24, 6 and 12 months with two superposed elastic stockings and regular self bandaging.

[Lymphedema of male external genitalia: a retrospective study of 33 cases]. / Lymphoedèmes pénoscrotaux: étude rétrospective de 33 cas.

INTRODUCTION: The aim of this retrospective study was to describe the main characteristics and treatment of male external genitalia lymphedema. PATIENTS AND METHODS: From 1987 to 2003, all patients seen in a single hospital for lymphedema of male external genitalia were included. For each patient, the following characteristics were recorded: primary or secondary lymphedema, cause of secondary form, date of onset of lymphedema, associated lower limb lymphedema, clinical signs, and complications. In the primary forms, lower limb lymphoscintigraphy was performed. Specific surgery was proposed in all cases of symptomatic lymphedema (circumcision, scrotum and/or penile cutaneous excision). RESULTS: Thirty-three patients with lymphedema of external genitalia (17 primary, 16 secondary) were recruited. Two primary lymphedema were congenital, one isolated. Mean age +/- SD of the onset of the 15 other primary genital lymphedema was 23.4 +/- 17.5 years, always after the appearance of lower limb lymphedema. Sixteen men had secondary lymphedema (bladder, prostate, or rectum cancer, Hodgkin or non-Hodgkin lymphoma, aorto-bifemoral bypass grafting, biopsy or curretage of inguinal nodes). Secondary genitalia lymphedema was not associated with lower limb lymphedema in two cases and, in the others it occurred 66 +/- 122 months after (n=11), at the same time (n=2) or before lower limb lymphedema (n=1). Clinically, we noted genitalia heaviness (n=31), lower limb lymphedema (n=30), vaginal hydrocele (n=13), impaired miction due to prepucial swelling (n=10), leakage of lymphatic fluid (n=10). Lower limb lymphedema was complicated by at least one erysipelas (n=20), spreading to the external genitalia (n=4). In primary forms, lymphoscintigraphy showed ipsilateral hypoplasia of inguinal nodes in lower limb lymphedema (n=14) and/or external genitalia backflow (n=7). Surgical treatment was performed in 17 cases (11 primary, 6 secondary) with good results after 21 months' median follow up (1 month-10 years). Two patients died of cancer. One secondary lymphedema improved spontaneously and one disappeared after withdrawal of lower limb pneumatic compression. DISCUSSION: Lymphedema of external genitalia is responsible for discomfort and local complications. Surgical treatment is the main procedure of this disorder.

[Quantitative evaluation and qualitative results of surgical lymphovenous anastomosis in lower limb lymphedema]. / Evaluations quantitative et qualitative des résultats de l'anastomose lymphoveineuse chirurgicale dans les lymphoedèmes des membres inférieurs.

PURPOSE: Treatment of lymphedema (LE) includes complex decongestive physiotherapy (manual lymphatic drainage, bandaging, exercises, skin care, elastic stockings). Surgical therapy is rarely useful. However, lymphovenous anastomosis (LVA) is the most used surgery in LE. We have assessed LVA in lower limb LE. METHODS: Thirteen patients (5 women, 8 men) with primary (n=10) or secondary LE (n=3) were included. Primary LE started at a mean âge (+/- SD) of 28.9 +/- 14.5 years. LE was located in left lower limb (n=7), right (n=4) or both (n=2). LVA was performed 7.1 +/- 4.9 years after the onset of LE by the same surgeon. Two to five lymphatic vessels were used for LVA. Assessment of LVA was based upon objective criteria (volumetry, erysipelas) and subjective criteria (global discomfort, heaviness, cutaneous tenderness, difficulties for doing significant effort or walking more than 1 km). Global assessement of LVA was collected for each patient. RESULTS: Before LVA, excess of volume (+/- SD) of LE was 1906 +/- 1277 ml or 28.5 +/- 18% in comparison with the controlateral limb. After LVA, excess of volume (+/- SD) remained stable with 1863 +/- 1468 ml or 24.4 +/- 18.9%. Volumetry was appreciated with a mean (+/- SD) follow-up of 52 +/- 3 months. Frequency of erysipelas was unchanged for the 6 patients with recurrent episodes. Only heaviness and cutaneous tenderness were significantly reduced after LVA. But global discomfort (+/- SD) decreased from 6.7 +/- 2.7 to 5 +/- 3.2 on visual analogic scale (NS). No differences were observed for significant effort or walking more than 1 km. Global assessment of LVA by the patient was very good (n=3), good (n=2), intermediate (n=5) and bad (n=3). CONCLUSION: LVA failed to improve the volume of lower limb LE and reduce the frequency of erysipelas. LVA improves few subjectives criteria but not global discomfort. Further studies are needed to evaluate LVA and to select patients to obtain best results.

[Role of surgery in the treatment of lymphedema]. / Place de la chirurgie dans le traitement des lymphoedèmes.

Treatment of lymphedema includes essentially complex decongestive physiotherapy. Surgical methods are various but the main problem is to select patients. Genital organs may benefit from excisional procedures. Results of surgery in upper or lower limb lymphedema are variable. Secondary lymphedema is considered as the best indication using microlymphaticovenous anastomosis. Surgery in lymphedema should be considered as an additional tool of treatment.

[The thromboembolic risk in abdominal plastic surgery. A randomized statistical study of 190 cases]. / Le risque thrombo-embolique en chirurgie plastique abdominale. Etude statistique randomisée à propos de 190 cas.

The authors studied the risk of thromboembolism in a randomized study of 190 abdominoplasties. In this study, none of the classical risk factors (weight, operating time, weight of the surgical specimen, combined surgery) were significant. Only contention associated with anticoagulants (low molecular weight heparin) decreased this risk to 2.74%. In view of this residual percentage, the authors recommend systematic postoperative duplex scan on the 5th postoperative day.

[Diabetic arteriopathy of the lower limbs]. / Artériopathie diabétique des membres inférieurs.

Diabetic arteriopathy is a specific entity as it associates macro-angiopathy ischemia factor and micro-angiopathy leading to peripheral neuropathy. This association leads to specific clinical manifestations dues to interplay of ischemic and infectious phenomena. Diffuse occlusive lesions predominate distally with mediacalcosis. Wider surgical indications for revascularization of distal vessels of the leg, the ankle and the foot have reduced the number and extent of amputation. Long-term permeability after salvage surgery is identical to that in non-diabetic patients as shown by our series of 695 distal revascularizations. Endovascular techniques with or without stents or recanalization are alternatives which may be indicated in case of short occlusions or trophic disorders contraindicating surgery. Associating stents with conventional surgery may also be indicated in diabetic patients. One final progress in reducing the number of amputations has been provided by free-transfer micro-surgery techniques which allow both vascular supply and coverage of distal tissue loss.

[Immediate vaginal reconstruction with a musculocutaneous flap from the gracilis muscle after extended abdomino-perineal resection]. / Reconstruction vaginale immédiate avec un lambeau musculo-cutané de muscle droit interne après amputation abdomino-périnéale élargie.

Reconstruction of a functional vagina after radical abdomino-perineal resection is a difficult surgical problem. The use of the gracilis myocutaneous flap provides a satisfactory solution. This article describes the surgical procedure of immediate vaginal reconstruction using the gracilis myocutaneous flap. Unfortunately, this technique is still not widely used by surgical teams. Nevertheless, it is a useful flap because of its low morbidity and the satisfying result of the functional neovaginal cavity.

[New trends in limb salvage. Vascularized flaps]. / Nouvelles perspectives dans le sauvetage de membre. Lambeaux d'apport vasculaire.

UNLABELLED: Femoro-distal bypasses are not always feasible or indicated in patients presenting with "critical" chronic ischemia. The results of nutrient flaps carried out over a 2-year period are analyzed. PATIENTS--METHODS: 12 patients had extensive gangrene compromising limb salvage (heel, dorsal or lateral aspect of foot or ankle at high risk of tendon or joint sepsis). Coverage of tissue loss was provided by a latissimus dorsi flap in 8 patients, a radial artery free flap in 1 patient, a supra-malleolar flap in 3 patients. RESULTS: The hospital mortality rate was 8.3%. The cumulative patency and limb salvage rates are respectively 58% and 67% at 6 months, 44% and 67% at 12 months. DISCUSSION: The challenge of inframalleolar reconstruction in patients presenting with critical ischemia is not always amenable to surgical revascularization to the foot, due to the lack of a suitable artery for bypass implantation or due to the lack of run-off, when arteriosclerosis of the plantar arch, or when distal embolisms are present. Some patients present with extensive gangrene, and in most of cases infection of the foot, and carry a high risk of arthritis: they are not likely to heal properly if surgical bypass alone to a foot artery is done. Bypass surgery is not indicated in diabetic patients with extensive foot infection, in whom no significant macroangiopathy is present. These 3 situations are a good indication for flaps, in order to cover the tissue loss, to fight the infection, and to provide a vascular supply to the foot. When conventional therapies cannot face critical ischemia, nutrient flaps can provide a fair limb salvage rate.

[External rhinoplasty. 250 cases over a 6-year period]. / La rhinoplastie externe. 250 cas sur 6 ans.

Description by the authors of their experience on external rhinoplasty in 250 cases, the advantage of this technique, compared to the classical extramucosa rhinoplasty and its main indications.

[Miniforum: rhinoplasty by external approach. Technical aspects of rhinoplasty by external approach]. / Mini forum: rhinoplastie par voie externe. Aspects techniques de la rhinoplastie par voie externe.

The authors present the principle techniques of external transcolumellar rhinoplasty and stress the excellent exposure it provides, allowing effective treatment under direct vision of the anatomical structures of the nose tip, nasal spine and septum. Based on a series of 186 operated cases with a follow-up of between one and more than six years, the advantages and indications of this technique are briefly defined. The best indications are difficult nose tips, whether rhinoplasty is primary or, more particularly, when it is secondary.

[The gracilis muscle as musculocutaneous flap. Evaluation of 20 cases]. / Le lambeau musculo-cutané de droit interne. Bilan de 20 cas.

The use of gracilis as muscular or myocutaneous flap is very well-known. The authors report 20 cases of gracilis flap including 13 reconstructions of the vaginal cavity following extended abdomino-perineal resection. Some technical points concerning the localization of the cutaneous part of the flap and the pedicle dissection are discussed. The use of gracilis flap is still limited in surgical teams following extended abdomino-perineal resection, nevertheless it is a very useful flap because of its low morbidity, the shortening of patient hospitalization and the very satisfying aesthetic result of the neo-vaginal cavity.