[Evaluation of the result of 50 face-lifts with monobloc suspension]. / Evaluation de 50 liftings cervicofaciaux monobloc avec suspension.

PURPOSE OF STUDY: To evaluate the efficacy, while performing a face-lift, of a monobloc suspension, by a wide loop of Prolene 2/0, of the deep tissues of the face and the neck. PATIENTS AND METHOD: Fifty patients have been operated, 48 women and two men, mostly thin patients and often, it was a secondary face-lift. In favorable cases, a limited undermining has been performed followed by a strong pull on the deep layers by the loop of 2/0 Prolene. RESULTS: An acceptable social appearance at eight days post operatory has been obtained in over 50% of the cases. A slight recurrence of ptosis is observed between 1 and 6 months, but at 1 year, the results were very satisfactory for 36 patients out of 50. CONCLUSION: This simple and fast technique is mostly suitable for moderate ptosis in thin patients and especially for secondary face-lifts.

Long-term experience with methylmethacrylate cranioplasty in craniofacial surgery.

Cranioplasty is a procedure commonly performed by plastic surgeons involved in craniofacial surgery, in which it is generally accepted that the ideal reconstructive material is autogenous bone. When this is not available or when its use is inappropriate, alloplastic materials are the next best option. A retrospective analysis was carried out to review the senior author's experience of 98 cranioplasties with methylmethacrylate (MM) from 1980 to 2001. The site and size of the implant and complications thereof were recorded and an assessment of the quality of the final result made. The patients were divided into two groups: Group 1: Methylmethacrylate as a full thickness inlay. Group 2: Methylmethacrylate as an onlay only. In group 1 there were 32 patients for whom the average follow up was 8.2 years (range 2-16 years). In group 2 there were 66 patients with an average follow up of 7.1 years (range 2-20 years). After a minimum follow up of 2 years, 89 out of 98 of the patients retained their implants. Nine implants in total were removed. Of the 89 patients retaining their implants, 85 had excellent or good results at long-term follow up. The infection and implant removal rate was very high if nasal or frontal sinus tissue was in direct contact with the implant during the operative procedure. The keys to the successful use of methylmethacrylate are discussed and representative case examples are presented. There is increasing evidence that the long term results of newer alternatives to methylmethacrylate for cranioplasty such as hydroxyapatite cement are disappointing and do not justify their expense. Methylmethacrylate is cheap, readily available and easy to use and it remains the alloplastic material of choice for cranioplasty in our hands.

[Quadruple internal distraction with early frontal-facial avancement for faciocraniodysostosis]. / Quadruple distraction interne avec avancement fronto-facial précoce pour faciocraniosténose.

INTRODUCTION: Frontofacial monobloc advancement (FFMA), known as a high risk procedure, was evaluated in combination with distraction. PATIENTS AND METHOD: Twenty patients with faciocraniosynostosis, were treated with FFMA and quadruple internal distraction. Mean age at surgery was 3.2 Years and mean follow-up was 14 Months (3-32 Months). Four distractors were used per patient in combination with complete osteotomy FFMA. Rate of distraction was classical (0.5 mm to 1mm per day) starting on day 7. The rate of short-term complications was evaluated. Correction of exorbitism and the dental occlusion relationship were assessed to evaluate achievement of advancement. Rate of relapse was evaluated by measuring the orbital bony gap on horizontal CT slices, before and 6 Months after removal of the distractor. Respiratory impairment when present was also evaluated. RESULTS: Distraction was completed in 18/20 patients. Fifteen patients completed their distraction uneventfully during the initial period. In three patients with CSF leaks, distraction was delayed at day 14 and 16, but was resumed and completed normally. Second operations were required for two patients during the early phase: the distractor failed in one requiring immediate reoperation to change the device; distraction was completed successfully. Device infection developed in two patients requiring removal of the device and abortion of distraction. One patient died the day after surgery from acute tonsillar herniation before distraction could be initiated. Exorbitism was clinically corrected in all cases in whom distraction was completed (n=18). Class I occlusion was obtained in 16/18 patients. When present, respiratory impairment was corrected in all cases. Septic frontal necrosis occurred in one patient two Months after distraction was completed and necessitated removal of the forehead flap. Distractors were easily removed through a coronal approach at 6 Months, but reossification was limited. Relapse was observed in three patients whose retaining phase was less than five Months. Rate of relapse was much lower when distraction was maintained more than six Months. DISCUSSION: Internal distraction can provide early correction of respiratory impairment due to faciocraniosynostosis in infancy and can reduce the major risks of frontofacial monobloc advancement. Morbidity is higher in patients with prior surgery before FFMA. Further evaluation is necessary to determine whether the two stage treatment strategy for faciocraniosynostosis (fronto-orbital advancement before one Year of age, and later facial Lefort III type advancement) could be replaced by a routine FFMA procedure.

[Is there a boundary between reconstructive and aesthetic surgery?]. / Y a-t-il une frontière entre chirurgie reconstructrice et chirurgie esthétique ?

Reconstructive and aesthetic surgery are the two closely bond facets of plastic surgery. The training, the techniques are the same, and limits are often difficult to define in many cases, intermixing indications. One should well explain to the lay public and to other doctors the complementarity of the two aspects of plastic surgery. One should also help the young plastic surgeons to be the best in reconstruction and embellishment.

[Distraction osteogenesis with double internal devices combined with early frontal facial advancement for the correction of facial craniosynostosis. Report of clinical cases]. / Double distraction interne avec avancement frontofacial précoce pour faciocraniosténose. A propos de cinq cas cliniques.

Frontofacial monobloc advancement is a surgical procedure which corrects at the same time both frontal and facial retrusions in faciocraniosynostosis. The high risk morbidity limited its use to major exorbitism or severe breathing impairment. We report the results of a preliminary experience in five children with a mean age of 3.8 years. All patients presented with a Crouzon or Pfeiffer syndrome. The procedure performed was a frontofacial monobloc osteotomy with peroperative mobilization. Two pairs of distractors (Martin-Medizin) were implanted. The upper pair of frontal distractors was located behind the supraorbital bar. The pair of temporo-zygomatic distractors (a modification of the MicroFrance prototypes) was implanted behind the zygomatic bone. In one patient a transfacial pin was connected to the anterior part the lower distractors, to avoid facial bipartition. Distraction was performed according to classical protocols with a 1 mm advancement per day, until sufficient advancement was obtained. The correction of exorbitism and facial retrusion was obtained in all cases. An open-bite was created by the advancement in two out of the five patients. Minor infection occurred in one patient. This combination of distractors with frontofacial advancement seemed to increase the efficacy and reduce the morbidity. This might lead to a one stage strategy for faciocraniosynostosis treatment, even if minor additive procedures will be necessary when children get older and that insufficient facial growth still reoccurs.

[Diagnosis of facial and craniofacial asymmetry]. / Diagnostic d'une asymétrie faciale et crânio-faciale.

Craniofacial asymmetry is caused by various aetiologies but clinical examination remains the most important criteria since minor asymmetry is always present. The diagnosis can be confirmed by anthropometric measurements and radiological examinations but only severe asymmetries or asymmetries with an associated functional impairment should be treated. The treatment depends on the cause, and on the time of appearance. Congenital asymmetries might be treated early, during the first year of life if a craniosynostosis is present. Hemifacial microsomia are treated later if there is no breathing impairment. Since the pediatricians have recommended the dorsal position for infant sleeping, an increasing number of posterior flattening of the skull has been appearing, and could be prevented by adequate nursing. Other causes of craniofacial asymmetries are rare and should be adapted to the cause (tumors, atrophies, neurological paralysis, hypertrophies) by a specialized multidisciplinar team.

Management of craniosynostoses.

Although it is currently thought that surgery is indicated mainly for cosmetic reasons in isolated craniosynostoses, the functional aspects of the treatment must not be underestimated. Prospective studies on intracranial pressure and mental evolution of these children have shown that there were functional consequences in a significant proportion of cases even of single suture fusion. The frequency of increased intracranial hypertension and the risk of mental impairment depend on the age of the child and the type of craniosynostosis. In nonsyndromic cases, the higher risks are observed in multisutural craniosynostoses (brachycephaly, oxycephaly). In syndromic cases, the risk of intracranial hypertension is higher in Crouzon syndrome, and Apert syndrome carries the higher risk of mental retardation. The study of a personal series of 2,137 craniosynostoses shows that the functional and the cosmetic results are better after early surgery, and that the operative risks are not higher in infants than in older children.

[Musculoskeletal tissue engineering with resorbable polymers]. / Ingénierie des tissus musculosquelettiques avec polymères résorbables.

Musculoskeletal tissues can present congenital or acquired defects as a result of disease, accidental trauma or iatrogenous causes. This loss of bony substance is traditionally treated by the replacement of bony tissue (grafts or flaps), or by synthetic materials. Each of these methods of treatment, however, entails its specific disadvantages, limitations and complications. The recent approach for treatment of musculoskeletal defects has been the development of the growing of neotissues derived from autogenous cells, and artificial biodegradable matrixes. This method assumed the name "tissue engineering" in the late 1980s. Tissue Engineering, or TE, has employed advances made in the area of cellular culture, intercellular matrix biology, and also, in the area of biomaterial science. TE is an multi-disciplinary approach. Musculoskeletal TE, although in its preliminary stages, should allow access to treatments of the future.

Midface surgery from Tessier to distraction.

The wall separating the face and the cranium was broken by Paul Tessier and Gérard Guiot in the 1960s, making it possible to perform a combined operation around the orbits and forehead, and opening up close cooperation between plastic surgeons and neurosurgeons, especially for treatment of the major malformations such as hypertelorism of major facial retrusions. The principles of mobilization of the orbits to correct teleorbitism or orbital dystopia are recalled with reference to the different variations and with clinical examples. Facial advancement to correct the retrusions created by faciocraniosynostosis is explained with the many possible variants, combined with a intracranial approach or not, with or without a bipartition. The indications are discussed as is the risk linked to combined advancement of face and forehead. The progressive bone elongation principle introduced by Ilizarov for the limbs has been applied to the face at the mandibular level by McCarthy, with great success. The distraction of bone structures is now also applied at the level of the midface and makes it possible to overcome the retraction of soft tissues and lower the risk of relapse of facial retrusion. Many technical problems have still to be solved, but the results are already very promising. Many other applications of the distraction principle will be developed for the midface level, with other technical improvements such as the use of absorbable mini-plates and screws.

[Trigonocephaly: isolated, associated and syndromic forms. Genetic study in a series of 278 patients]. / Trigonocéphalie: formes isolées, associées et syndromiques. Etude génétique d'une série de 278 patients.

UNLABELLED: From a series of 1,833 patients with craniosynostosis, 278 cases with metopic synostosis were analysed. The prevalence of metopic synostosis was estimated in the region of 1 in 15,000 children. PATIENTS AND METHODS: All patients with metopic suture fusion were selected, excluding cases where additional sutures were involved. The age at diagnosis was between 15 days and 15 years. The diagnosis was based on clinical and radiological evaluation. The search for associated malformations was based on clinical evaluation, CT or MRI scans, bone X-rays and ultrasounds. If possible, a study of the karyotype was performed in case of associated malformation. Family information was obtained through contact with the families, generally in person or sometimes by telephone. The series was divided into three groups: isolated trigonocephaly (group 1), trigonocephaly associated with other malformations without any known syndrome (group 2) and well delineated syndromes (group 3). RESULTS: There were 213 males and 65 females, a sex ratio of 3.3. Family information was obtained from 222 probands distributed among 216 families. There was no maternal or paternal age effect. The frequency of twinning was 7.9%, with three concordances for metopic synostosis in three monozygotic twin pairs. A positive family history was obtained in 13 of the 216 pedigrees, giving a 6% figure of familial cases. A vertical transmission was observed in only one case; in all other cases, there were two affected children with normal parents. Eleven familial cases were isolated trigonocephalies, and two were syndromic. Nine of the 53 available karyotypes were abnormal, involving the chromosomes 7, 9, 11 or 13. There were 208 observations in the group 1. In 53 cases (group 2), associated malformations involved mainly the heart (12 cases), the limbs (six cases), the brain (five cases) and the genito-urinary tract (four cases). These malformations were unique in 32 cases and multiple in 21 cases. Some: of the observations could represent new syndromes. Seventeen syndromes represented group 3. Nine were chromosomal syndromes. Eleven presented with multiple malformations. An in utero exposure to valproic acid was observed in two cases of the group 1, five cases of the group 2 and one case of the group 3.

[Aplasia of the skull without scalp anomalies. A case report]. / Aplasie du crâne osseux sans anomalie du scalp. A propos d'un cas.

The authors report an extremely rare case of cranio-facial anomaly, which, to our knowledge has previously been reported only once (1993, Chakraborty and al.). This male infant presented with a giant congenital bone defect of the skull in the vertex region (10 x 20 cm) with no scalp deficiency. Minimal turricephaly and moderate telorbitism were associated with minor limb anomalies, but psychometric assessment appeared normal. Non-surgical follow-up was initially decided, but spontaneous reossification was so moderate that skull reconstruction was decided at 28 months of age, because of traumatological risks. A full-size resin cephalic skeletal reconstruction was obtained by 3D computerized tomography utilizing stereolithography techniques. A titanium plate was customized on the resin model for ideal adaptation to the convex skull defect (8 x 16 cm). Surgery was simply performed, consisting of preliminary undermining between the dura mater and scalp, and screwing of the custom titanium plate. The initial follow-up was uneventful.