[Rhinopoiesis after traumatic total amputation in childhood in an 11-year-old child]. / Rhinopoïese après amputation traumatique totale dans l'enfance chez un enfant de 11 ans.

Fortunately, traumatic total amputations of the nose are rare, especially in children. Their reconstructions generally require several operative steps, most often associating cartilaginous grafts (rib and/or concha), a free radial antebrachial flap for mucosal reconstruction and a frontal flap for the skin covering. These are therefore long and complex procedures requiring a trained surgical team and maximum patient adherence to their treatment plan. The clinical case described is that of an 11-year-old child presenting a sub-total amputation of the nose and having undergone reconstruction with skin expansion of the frontal flap due to a horizontal frontal scar of unknown origin and a particularly low hair implantation.

[Secondary rhinoplasties]. / Rhinoplasties secondaires.

As a very challenging surgery, primary rhinoplasty can lead to secondary. After a primary, patient's concerns can sometimes be pretty easy to fix (remaining bump), but may some other request long and very difficult surgeries (short nose). This article describes the most common reasons of secondary rhinoplasties and provides, for each of them, a surgical treatment.

Should we consider the hemi-tip as a proper aesthetic subunit in a nasal reconstruction?

BACKGROUND: Defects involving several aesthetic subunits (ASUs) or lying at the junction of an ASU are challenging and require a complex reconstruction. This study aimed to describe the hemi-tip as a new ASU. MATERIAL AND METHODS: We conducted a retrospective study including patients who underwent a nasal reconstruction for lower nasal pyramid defects according to our modified ASU principle. Patients who suffered from a subtotal alar defect, which also involved <50% of the tip, were reconstructed after excising the remaining tissue of the hemi-tip subunit. An aesthetic evaluation was performed using a patient satisfaction scale and by independent raters. RESULTS: From 2010 to 2014, 21 patients underwent a lower hemi-nose reconstruction. All patients had a full-thickness defect and underwent a reconstruction of the three layers of the nose. Sixty-four percent of our patients were very satisfied, 26% were satisfied, and only 10% were unsatisfied with their nasal tip appearance, with a mean score of 4.4/5. The nasal tip was also rated by independent raters with a mean score of 4.1/5. DISCUSSION: Our results and experience showed that a midline scar between the two hemi-tips is inconspicuous. The majority of the defects involving only one side of the tip would benefit from the hemi-tip ASU reconstruction. CONCLUSION: We have modified the number of ASUs by considering the hemi-tip as a proper subunit.

Plantar keloids: diagnostic and therapeutic issues in six patients.

BACKGROUND: Keloids are benign fibro-proliferative skin lesions that very rarely occur on the soles. Because of their rarity, the diagnosis of plantar keloids can be difficult. We describe the clinical and histopathological characteristics of eight plantar keloids. METHODS: All patients presenting with plantar keloids between 2005 and 2012 in our Dermatology unit were retrospectively included. Diagnosis was definitely established by re-reading of pathological slides in all cases. Clinical characteristics, histopathological features, treatments given and their results were collected. RESULTS: Six patients were included. Five patients had a single plantar keloid and one had three lesions. They all were of African descent. Only one patient remembered of a previous injury at the site of the keloid. Three patients presented with associated extra-plantar keloids. In four patients, the diagnosis of keloid was not initially suspected clinically or histologically. Re-reading of the clinical photographs showed that the eight plantar keloids shared common morphological features, leading to a distinctive clinical picture, defined by a hardened lesion of rounded or polycyclic shape, with a pink surface crossed by keratotic furrows and the presence of a hyperkeratotic rim. Concerning pathological features, typical hyalinized collagen can be missing and deep fibrosis should not rule out the diagnosis of keloid. Intralesional injection of triamcinolone acetonide and orthopaedic shoes were useful. All patients who had surgical excision presented recurrence. CONCLUSION: The knowledge of the clinical features of plantar keloids is helpful to the diagnosis. There is no well-established treatment, but supportive measures are important.

[Submental island flap: a review of the literature]. / Le lambeau sous-mental: revue de la littérature.

The submental island flap is a precious tool in reconstructive surgery. It was described by Martin in 1993, inspired by platysma flaps. In our days, we can find many reliable techniques for this procedure. We reviewed the main studies of the literature that described a total of 528 patients. The rate of partial necrosis was 5.1%, complete necrosis 1.7%, and reversible lesions of the marginal mandibular branch of the facial nerve 1.1%. His versatility makes this flap appropriate for the reconstruction of every part of the face: cheeks, nose, forehead, moustache, beard, and hairs. It can also be used de-epidermised with very good results, for the reconstruction of the buccal cavity, the tongue, the roof of the mouth, the larynx, and the proximal part of the esophagus. The SMAP (Submentalis Artery Perforator flap) is an alternative flap that provides even better cosmetic results. The development of indocyanine green and infrared cameras will allow in a close future to decrease the postoperative complications.

[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.

[Cartilaginous graft in rhinoplasty]. / Greffes cartilagineuses en rhinoplastie.

Nowadays, cartilage grafts are widely used in secondary as well as primary rhinoplasty. Even if their fixation is often easier and more precise using an open approach, most of them can also be positioned with a close approach. In this article, the authors describe various cartilage donor sites. For each of them, they describe benefits, inconveniences, harvesting techniques and preferred indications. Cartilage can be harvested on the septum, ear and ribs. For the authors, septal cartilage is often the best material but can be insufficient or totally missing (especially in secondary rhinoplasty). In such cases, concha cartilage is a good material for tip and alar grafts because of its pliability and convexity whereas rib cartilage, which is stiffer and thicker, will provide good supporting grafts. Described more recently, diced cartilage wrapped in fascia (DCF) can be a very good option for dorsal onlay graft, avoiding irregularities of conchal cartilage and risk of rib cartilage's twisting.

[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.

[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.

[Full thickness reconstruction of the nasal pyramid]. / Reconstruction de pleine épaisseur de la pyramide nasale.

Nasal lesions, which are often carcinomas, require a histological control of the excision sometimes forcing to postpone the reconstruction source of nasal mutilation disfiguring. Reconstructive procedures have made steady progress and the notion of reconstruction in three planes advocated by Tiersch has been improved in a major way by Millard, Burget and Menick, who added an essential aesthetic dimension. We present our experience in this field by selecting procedures that seem most appropriate and describing the key points of the operating process, which remain the guarantee of both therapeutic and aesthetic success.

[Aesthetic aspects of eyelid reconstruction]. / Aspects esthétiques de la reconstruction des paupières.

In eyelid reconstruction, filling the defect is not sufficient. In young patients, the aim is to obtain a reconstructed eyelid, as normal as possible. In elderly patients, the large amount of available skin and the good quality of scars seem to be favorable. But weakening and stretching of the connective tissue and eyelid structures and deficient production of tears may compromise the functional result. In every case, restoring aspect and function are going together. The purpose of this chapter is to show how different techniques may be used in eyelid reconstruction with good cosmetic result. Different cases are carefully described and illustrated.

[A case of nasal tip necrosis after hyaluronic acid injection]. / Nécrose de la pointe du nez secondaire à une injection d'acide hyaluronique.

Hyaluronic acid (HA) is the most used dermal filler. Some complications associated with its use have been described, but most of them are rare and benign. We report an exceptional case of skin necrosis of the tip of the nose, in a 22-year-old patient, after HA injection. The initial appearance may occurred subsequent aesthetic sequels. After necrotic tissue excision, patient was followed in rapid succession. Daily local care has led to wound healing, without any important sequel. This rare complication reminds us that HA injections are not without risk, despite their apparent simplicity of use. Moreover, the case presented confirms the potential healing of the nasal tip, allowing treatment with wound healing, rather than other early invasive procedure.