Study of medical education in 3D surgical modeling by surgeons with free open-source software: Example of mandibular reconstruction with fibula free flap and creation of its surgical guides.

INTRODUCTION: Benefits of 3D printing techniques, biomodeling and surgical guides are well known in surgery, especially when the same surgeon who performed the surgery participated in the virtual surgical planning. Our objective was to evaluate the transfer of know how of a neutral 3D surgical modeling free open-source software protocol to surgeons with different surgical specialities. METHODS: A one-day training session was organised in 3D surgical modeling applied to one mandibular reconstruction case with fibula free flap and creation of its surgical guides. Surgeon satisfaction was analysed before and after the training. RESULTS: Of 22 surgeons, 59% assessed the training as excellent or very good and 68% considered changing their daily surgical routine and would try to apply our open-source software protocol in their department after a single training day. The mean capacity in using the software improved from 4.13 on 10 before to 6.59 on 10 after training for OsiriX® software, from 1.14 before to 5.05 after training for Meshlab®, from 0.45 before to 4.91 after training for Netfabb® and from 1.05 before and 4.41 after training for Blender®. According to surgeons, using the software Blender® became harder as the day went on. DISCUSSION: Despite improvement in the capacity in using software for all participants, more than a single training day is needed for the transfer of know how on 3D modeling with open-source software. Although the know-how transfer, overall satisfaction, actual learning outcomes and relevance of this training were appropriated, a longer training including different topics will be needed to improve training quality.

Three-dimensional surgical modelling with an open-source software protocol: study of precision and reproducibility in mandibular reconstruction with the fibula free flap.

Very few surgical teams currently use totally independent and free solutions to perform three-dimensional (3D) surgical modelling for osseous free flaps in reconstructive surgery. This study assessed the precision and technical reproducibility of a 3D surgical modelling protocol using free open-source software in mandibular reconstruction with fibula free flaps and surgical guides. Precision was assessed through comparisons of the 3D surgical guide to the sterilized 3D-printed guide, determining accuracy to the millimetre level. Reproducibility was assessed in three surgical cases by volumetric comparison to the millimetre level. For the 3D surgical modelling, a difference of less than 0.1mm was observed. Almost no deformations (<0.2mm) were observed post-autoclave sterilization of the 3D-printed surgical guides. In the three surgical cases, the average precision of fibula free flap modelling was between 0.1mm and 0.4mm, and the average precision of the complete reconstructed mandible was less than 1mm. The open-source software protocol demonstrated high accuracy without complications. However, the precision of the surgical case depends on the surgeon's 3D surgical modelling. Therefore, surgeons need training on the use of this protocol before applying it to surgical cases; this constitutes a limitation. Further studies should address the transfer of expertise.

Use of the 3D surgical modelling technique with open-source software for mandibular fibula free flap reconstruction and its surgical guides.

INTRODUCTION: Tridimensional (3D) surgical modelling is a necessary step to create 3D-printed surgical tools, and expensive professional software is generally needed. Open-source software are functional, reliable, updated, may be downloaded for free and used to produce 3D models. Few surgical teams have used free solutions for mastering 3D surgical modelling for reconstructive surgery with osseous free flaps. We described an Open-source software 3D surgical modelling protocol to perform a fast and nearly free mandibular reconstruction with microvascular fibula free flap and its surgical guides, with no need for engineering support. PROCEDURE: Four successive specialised Open-source software were used to perform our 3D modelling: OsiriX®, Meshlab®, Netfabb® and Blender®. Digital Imaging and Communications in Medicine (DICOM) data on patient skull and fibula, obtained with a computerised tomography (CT) scan, were needed. The 3D modelling of the reconstructed mandible and its surgical guides were created. CONCLUSIONS: This new strategy may improve surgical management in Oral and Craniomaxillofacial surgery. Further clinical studies are needed to demonstrate the feasibility, reproducibility, transfer of know how and benefits of this technique.

[The "two positions" lipoabdominoplasty]. / Plastie abdominale en deux positions.

BACKGROUNDS: Lipoabdominoplasty is a way to improve morphological outcomes by treating the areas not accessible to resection during classical abdominoplasty, especially hips. However, patients can present a lateral and posterior fat extension, not accessible to an anterior liposuction. This situation is managed by a first step with liposuction in the prone position. The aim of this study was to determine whether lipoabdominoplasty performed in two positions increases morbidity compared with lipoabdominoplasty in supine position only. METHODS: This was a retrospective study of 137 patients who underwent lipoabdominoplasty between 2009 to 2013. Eighty-five patients underwent a one position lipoabdomynoplasty and 52 a two positions lipoabdomynoplasty. Medical records were reviewed to collect data regarding patient demographics, operative technique, volume of liposuction and complications. RESULTS: The posterior liposuction has significantly increased the length of procedure (mean: 43.3 minutes). The volume of liposuction was significantly higher when the procedure was performed with prone and supine position (2789.6 mL versus 1373.8 mL, P<0.001). There was no significant difference between the two groups regarding complications and blood loss. CONCLUSION: Lipoabdominoplasty in two positions is an effective technique with the same morbidity as a lipoabdominoplasty in supine position only. The procedure finds its indication, between classic abdominoplasty and bodylift, for patients with lateral and posterior fat extension without posterior skin excess.

[Horizontal V-Y advancement flap for lower eyelid reconstruction in young patients]. / Le lambeau d'avancement horizontal en V-Y dans les reconstructions des pertes de substances non transfixiantes de la paupière inférieure chez le sujet jeune.

PURPOSE: The reconstruction of lower eyelid defects is a complex issue because of the thinness of eyelid tissues and the need for protection of the globe. The surgery must address two requirements: a functional goal, avoiding eyelid malposition, and a cosmetic goal, limiting aesthetic compromises. In young patients, direct closure is rarely possible if the defect is superior to 1cm. The horizontal V-Y advancement flap is a simple and reliable method but is hardly ever reported. The purpose of this study is to review the surgical technique and report our experience with this flap in the reconstruction of younger patients. PATIENTS AND METHODS: Nine patients, 5 men and 4 women, with a mean age of 54 years, underwent a lower eyelid reconstruction by horizontal V-Y advancement flap between 2011 and 2014. In every case, the initial pathology was a basal cell carcinoma and the surgical margins were uninvolved. The mean diameter of the surgical defect was 1.9 centimeters and the average procedure duration was 40 minutes. RESULTS: All patients were managed as outpatients. Functional and aesthetic results were judged satisfactory or very satisfactory by all the patients and their surgeon. No flap necrosis and no ectropion or scleral show were reported. In one patient, lower lid edema lasted until the third postoperative month. CONCLUSION: The horizontal V-Y advancement flap enables to repair lower eyelid defects using nearby skin of similar characteristics. Aesthetic results are very satisfactory, and scars, concealed in the eyelid creases, are nearly invisible in the long term. The lack of tension on the eyelid margin limits the risk of eyelid position. This simple and reliable one-step procedure, possible under local anesthesia, is appropriate for young, active patients, limiting the cosmetic sequelae and social ramifications.

[Morphological evaluation of genioplasty associated with orthognathic surgery]. / Évaluation morphologique des génioplasties associées à la chirurgie orthognathique.

INTRODUCTION: The maxillo-mandibulary dysphormias are frequently associated with morphological abnormalities of the chin. Their correction in the sagittal and transverse planes can benefit both morphologically and functionally. The purpose of this study was to evaluate the morphological benefit of the osseous genioplasty associated with orthognathic surgery depending on the type of technique used, as well as complications occurred. PATIENTS AND METHODS: We identified patients who underwent osseous genioplasty associated with orthognathic surgery in our department between 2004 and 2010. For each patient Angle class, type of osteotomy, genioplasty and postoperative complications were recorded. The morphological results were evaluated by a group of surgeons and a group of observers using standardized photographs. RESULTS: Of the 203 facial osteotomies performed during this period, 101 osseous genioplasties were made. In most cases, there was a height reduction associated with advancement of the chin. The morphological results were considered as satisfactory all evaluators alike (3.92). The best results were obtained in height reductions with advancement techniques as sliding genioplasty (4.03) and jumping divided genioplasty (4.19). Five patients (5.9%) had a postoperative complication. This was especially one mental nerve injury and two dental mortifications. No default of consolidation or necrosis or hematoma of mouth floor have been reported. CONCLUSION: Osseous genioplasty is a safe, reliable procedure with morphological satisfactory outcome, in combination with orthognathic surgery. The best results were obtained with cases of height reduction with advancement of the chin, especially the original technique of the jumping divided genioplasty.

[An adjustable distractor for transverse maxillary distraction osteogenesis]. / Un distracteur modulable pour la distraction transversale du maxillaire.

INTRODUCTION: The posterior skeletal widening in conventional distractions (Surgical Assisted Rapid Maxillary Expansion) is often modest, in contrast with a predominant anterior expansion. Until recently, it was not possible to consider transverse palatal distraction osteogenesis and Le Fort I impaction or advancement in the same procedure, as the osteosynthesis plates impeded maxillary anterior opening. We developed new sliding osteosynthesis plates allowing to perform an advancement or impaction Le Fort I osteotomy associated with a low-resistance bipartite palatal distraction osteogenesis. We had for aim to describe the device and to determine its clinical applications. MATERIAL: This new palatal distractor is made up of two independent stainless steel jacks allowing for an adjustable distraction in the anterior or posterior area as needed. Bone-borne and tooth-borne versions are available. DISCUSSION: This new distractor can be adjusted sagittally. The distraction can be angular or parallel, and the distraction mode can be modified during post-operative distraction. This device should be adapted to all clinical presentations. It can be used in combination with sliding osteosynthesis to perform a Le Fort 1 osteotomy and at the same time a complete correction of vertical, horizontal, and sagittal deficiencies.

[Sliding osteosynthesis: a new technique for transverse palatal distraction osteogenesis associated with advancement and/or impaction Le Fort I osteotomy]. / L'ostéosynthèse coulissante: une nouvelle technique de distraction transversale associée à une ostéotomie de Le Fort 1, d'avancée et/ou d'impaction.

BACKGROUND: The orthopedic and surgically assisted maxillary expansion is often followed by maxillary advancement osteotomy. The posterior width gain is often small. The expansion is often more extended anteriorly. It impairs posterior correction. The authors describe a new device, ensuring both transversal and sagittal maxillary correction in a single procedure. MATERIAL AND SURGICAL TECHNIQUE: The sliding internal fixation device is in titanium, 0.8mm thick. It is made up of two plates (Deltex(®), Paris cedex 15, France): an inferior plate with a 45°-angulated slide, a superior plate with a spur. The surgical technique is a Le Fort 1 segmented osteotomy. The distractor is activated between the fifth and 10th postoperative day. Contention is maintained for 1 year after the end of activation. DISCUSSION: This sliding osteosynthesis technique allows stabilizing the advancement and/or impaction as well as transversal expansion for large transversal deficits in adult patients. This technique avoids performing a second procedure.

[Which treatment for the malar bags?]. / Existe-t-il un traitement approprié aux poches prémalaires ?

The treatment of malar bags is known to be particularly difficult; although it is not the most frequent palpebral anomaly justifying a surgical recourse, this problem cannot be ignored. It is important to distinguish their minor forms and to be able to analyze them in order to propose the best to our patients. We review the literature concerning this subject. The various surgical techniques are discussed and we present five of our cases. Even taking into account its various evolutions, the standard lower eyelid blepharoplasty can correct neither the ptosis nor the excess of orbicularis oculi muscle, which appear to be the main components of the malar bag. Publications, precisely mentioning malar bags or festoons, analyzing their physiopathology or their treatments, are few. We discuss the current data of the literature and on the results obtained in our experiment, and the surgical techniques suggested for their treatment. All the techniques suggested for the malar bags remain local or regional approaches. Results obtained with those techniques do not seem effective to us: although it has not been specifically proposed for the treatment of malar bags, the midface sub-periosteal lift, combining a skin flap lower eyelid dissection and a subperiosteal malar dissection, seems to be able to correct the lowest part of the orbicularis oculi muscle due to its concentric action and its major vertical vector of traction. This study underlines the importance of clinical analysis of the malar bags to appreciate the contribution of each element. So the surgeon will be able to choose the most adapted treatment, which is most often a midface sub-periosteal lift associated with a blepharoplasty.

[Unfavorable effects induced by mandibular surgery in Class II malocclusions]. / Effets disgracieux induits par la chirurgie mandibulaire des classes II.

The sagittal split ramus osteotomy is probably the most frequently used procedure for correction of mandibular skeletal dento-facial deformities. In the 30 years since the procedure was introduced, a number of complications has been reported: unfavorable fracture during surgery, paresthesia or anesthesia and relapse. The literature seems to be very poor concerning the esthetical and morphological complications of the sagittal split ramus osteotomy; especially when treating Class II dento-facial deformity frequently associated with a genioplasty. The purpose of this study was to determine and analyze the esthetical complications occurring after mandibular surgery in patients with Class II dento-facial deformities: Pre-angular notches, Widening of the bi-angular distance, The unaesthetic effects of the associated genioplasty, Class III like "dento-facial deformities", Plates and screws visibility. Each of those complications has been analyzed to find a preventive treatment.

[Peroperative use of a silicone occlusal block for palatal and lingual support in orthognathic surgery]. / Utilisation per-opératoire d'un bourrelet occlusal en silicone à appui palatin et lingual en chirurgie orthognatique.

We present an alternative to acrylic occlusal wafers in orthognatic surgery. We propose using a silicone wafer that is easier to position preoperatively.

[Sagittal osteotomy of the ascending ramus. Technic and value of transcutaneous basilar osteotomy]. / Ostéotomie sagittale des branches montantes. Technique et intérêt de l'ostéotomie basilaire transcutanée.

Dalpont II sagittal osteotomy is the procedure of choice for prognathism. The surface for bone consolidation can be significantly increased by an anterior extension of the section, favored in cases with major skeletal imbalance. Neurosensorial or bone complications often compromise sagittal surgery. Section may be difficult if the basilary bone is particularly solid; simple section is not entirely satisfactory due to the risk and is not well adapted to Dalpont II osteotomy. We present a novel technique for transcutaneous basilar osteotomy using a modified transjugal retractor and a mini saw blade. This technique gives a Dalpont II sagittal osteotomy with a long reproducible and safe valve.

[Correction of nose deviations using latero-septal grafts from irradiated bovine cartilage]. / Correction des nez déviés par greffes d'appui latéro-septal en cartilage bovin irradié.

Deviated noses corrective surgery is not without problems. Authors give the result obtained by the use of processed irradiated bovine cartilage (Chondroplast) as spreader graft in eighteen rhinoplasty, associated with a classical septorhinoplasty technique. The maximum background is five years. The future of the grafts can be appreciated on direct signs obtained by palpation, or indirect ones such as stability of the functional or aesthetic result, radiological visualisation of the bovine cartilage graft. Their volumetric stability is satisfactory and their guide role is excellent. This undisputed aid in the aesthetic and functional correction of deviated noses, associated with availability, easy use and a good tolerance, made the authors use spreader grafts in processed irradiated bovine cartilage as a choice technique in this indication, associated with bone and septal surgery, when local cartilage autografts are not available in sufficient quantities.

[Allografts of cryo-preserved and radio-sterilized spongy bone tissue. Their use in orthognathic surgery]. / Les allogreffes de tissu osseux spongieux cryo-conservées et radio-stérilisées. Utilisation en chirurgie orthognathique.

In some circumstances, the orthognathic surgery creates inter-fragmentary spaces which have to be filled to ensure that the osteotomized segments are wedged and consolidated, and to avoid the appearance of unsightly subcutaneous contours. The authors report the results obtained through the use of cryo-preserved radio-sterilized cancellous bone allografts, coming from femoral heads, used as fillers, in diverse types of osteotomy. Thus, 19 centers of osteotomy have been filled. Follow-up periods ranged from 5 to 20 months. In 8 cases, evidence was made through radiology of the blending of the grafts. The stability of the correction was constantly noticed as well as the perfectly harmonious facial contours, which testifies the osteogenic qualities of this material. No sepsis was observed. It is a quantitatively available material, of easy shaping, the use of which does not lead to a lengthening of the operation, nor to the creation of cutaneous scars. The risk of viral transmission through allografts, specially H.I.V. and hepatitis non A - non B - non C virus is nil due to the radiosterilization.

[Neurovascular sequelae related to the removal of forearm fasciocutaneous free flaps with radial pedicle. Preliminary study]. / Séquelles neuro-vasculaires liées au prélèvement des lambeaux libres fascio-cutanés anti-brachiaux à pédicule radial. Etude préliminaire.

The authors study the consequences of amputation of the radial artery in order to create a Chinese forearm graft on the blood supply and innervation of the upper limb. After a brief review of the anatomy, the haemodynamics of the upper limb are studied in detail. Preoperative assessment by Hallen's test is generally sufficient. Postoperatively, pulsed Doppler studies provide the most useful information. Compensatory development of the interosseous artery is always observed and, in seven out of nine cases, this is associated with a marked increase in the blood flow in all of the arteries of the upper limb, especially in the hand. Of all of the methods of investigation available, this examination is able to demonstrate the safety of forearm grafts in the very great majority of cases.

[Testicular autotransplantation in children. Apropos of 2 cases]. / Auto-transplantation testiculaire chez l'enfant. A propos de 2 cas.

The authors presents 2 observations of testicular autotransplantation at 11 and 13 years age; the 2 boys had bilateral cryptorchism. Analysis of the literature allows good conclusions for the liability of this technique with less than 20% of secondary atrophies. Particularly interesting to note 2 successful operation on children 2 years old. The indications are limited, mainly discussed is bilateral abdominal cryptorchism (mostly Prune Belly Syndrome). The autotransplantation is reserved for the normal appearance testicles with good hormonal function. The operation is preferable using inguino-iliac extra-peritoneal pass; that exploration is very important and at last only in 20% of abdominal cryptorchism could autotransplantation be considered. The malignancy transformation risk is poor if break down is done before 10 years old, however a regular and very long follow-up is necessary: Clinic, vascular, biopsies sometimes at a little doubt. Preservation of hormonal function and fertility hope represent the expected advantages; spermatic analysis are still absent because the too recent autotransplantation. As for usual testicular ectopies for sure it would be preferable to do early autotransplantation, just after 2 years of age, if this is possible.

[Respective indications for free and pedicle flaps of the latissimus dorsi in maxillofacial surgery]. / Indications respectives du lambeau libre et pédiculé de latissimus dorsi en chirurgie maxillo-faciale.

Retrospective analysis of 41 cases of transfer of free and pedicle musculocutaneous flaps of latissimus dorsi for selected or obligatory maxillofacial indications resulted in the review and critical assessment of the different modes of utilization of these flaps. Experience acquired, and continuously updated by new scientific data or a new clinical case, justifies the use of this exceptional technic, which should not be extended to include those cases able to be treated by simpler, more reliable methods. Similarly the fact that this muscle can be transferred using a microsurgical technic cannot enlarge its use beyond that motivated by reasoned medical imperatives. Modalities of preparation of the flap are described and its multiple applications demonstrated using several examples: indications for latissimus dorsi flap in maxillofacial surgery and reasons for performance of micro-anastomotic transfer.

[Christ-Siemens-Touraine syndrome. Completed management is unrelated to the number of years]. / Syndrome de Christ-Siemens-Touraine. Le complet n'attend pas le nombre des années.

The authors report a case of anhidrotic ectodermal dysplasia (A.E.D.) or Christ-Siemens-Touraine syndrome, which was completely edentated and fitted with prostheses at school age for two reasons: for nutritional reasons, as the child was unable to eat under normal physiological conditions; and for psychological and cosmetic reasons.