[Restoration of the labial barcode by simultaneous "one shot" injection of botulinum toxin-hyaluronic acid in the same syringe]. / Restauration du code barre labial par injection simultanée « one shot ¼ toxine botulique-acide hyaluronique dans une même seringue.

The purpose of this technique is to offer patients wishing a labial restoration without morphological changes a simple, fast, discreet, comfortable, adaptable and reversible method by combining the two compounds most used in aesthetic medicine, botulinum toxin and hyaluronic acid. The originality of this combination is based on their mixing in the same syringe and their injection with cannula through a paracommissural approach which makes it possible to treat the entire upper lip in a very homogeneous manner. Botulinum toxin diffuses directly into the underlying muscle layer; hyaluronic acid allows to unfold the damaged cutaneous fan. The useful reciprocal dose of the two products remains intuitive; for starting barcodes the dose of botulinum toxin will be 8-10 Speywood units (4 Allergan units), for those already marked at rest 10-20 Speywood units (4-8 Allergan units); the hyaluronic acid will be chosen according to the depth of the wrinkles. We present a series of 63 patients with an average age of 67 years with a result deemed positive in 79% of cases. The incidents reported are generally due to excessive doses of botulinum toxin which can lead to the classic incidents of fluid leaks in this location (6%). The expected efficacy of the treatment depends on that of the components used (four to six months) but prolonged results have been regularly observed (up to 18 months). All complementary resurfacing treatments have been discarded here since the aim pursued is that of a natural labial restoration allowing an immediate return to socio-professional activities.

[Lip lifting and philtral restoration with a mustache flap]. / Lifting de lèvre et restauration philtrale par le lambeau en moustache.

The restoration of the philtrum is an often neglected aspect in the technique of labial lifting with a perinasal scar, or it is secondarily resorted to by simple injections of hyaluronic acid. We are not in favor of the classic continuous bull's horn scar because, on the one hand, we consider that most of the labial shortening is due to the nasal floor resection -the internal excursion of which determines the final result-, and on the other hand that the approximation of 2 skins of very different nature (columella and lip) may cause a visible scar. The base of the columella is particularly well vascularized by the anastomosis of branches derived from the external carotid artery via the superior labial artery and septal branches distributed from the internal carotid system. We therefore consider that this zone on each side of the base of the columella constitutes the vascular pivot of our "mustache flap" drawn according to the classic peri nasal incision: this flap is desepidermized and then totally elevated from the orbicularis muscle except for its internal part where it is simply discarded so as not to compromise its vascularity; it is then rotated at 90° and inserted into a tunnel fitted in the subcutaneous plane down to the red lip corresponding to the restoration of the 2 philtral crests. Thus, all of the superior labial deformations observed over time (elongation and convexity of the white lip, flattening of the philtrum are corrected in a long lasting manner. The intervention is carried out under local anesthesia and, if necessary, the other elements of aging (loss of volume of the red lip, vertical wrinkles, defect of pigmentation etc.) can be corrected without risk at the same time.

Patient satisfaction after the treatment of glabellar lines with Botulinum toxin type A (Speywood Unit): a multi-centre European observational study.

BACKGROUND: Whilst the efficacy and safety of glabella complex treatment with botulinum toxin type A (Speywood Unit) [BoNT-A (s.U)] has been comprehensively studied, there are very few trials on patient-reported outcomes and patient satisfaction associated with this treatment. OBJECTIVE: To assess the level of patient satisfaction 3 weeks and 4 months after the treatment of glabellar lines with BoNT-A (s.U). METHODS: This is a multi-centre, prospective, non-interventional observational study carried out in France, Germany, Spain and the United Kingdom. Subjects were eligible if the investigator had already decided to prescribe BoNT-A (s.U), according to the labelling. Subjects completed a questionnaire at both 3 weeks and 4 months after treatment. RESULTS: About 533 subjects completed at least one of the two questionnaires. About half of the subjects (47.9%) were naive to BoNT-A treatment of the glabella, while 50.6% had previously received another product. A high level of satisfaction was observed after the treatment, with 94.7% and 89.6% of subjects being satisfied or very satisfied with the aesthetic outcome at week 3 and month 4, respectively. Treatment was safe and well tolerated, as directly determined in the survey. Major reasons for satisfaction included the positive aesthetic outcome, a natural appearance, a rested look and comfort of injection. Most subjects felt the treatment brought them 'harmony', 'self-esteem/confidence' or 'youth'. Of the subjects who had previously been treated with another product, 51.2% considered the results obtained in the present study with BoNT-A (s.U) were better. CONCLUSION: Treatment of the glabellar lines with BoNT-A (s.U) led to a high level of patient satisfaction and a more positive self-perception up to 4 months after the treatment, regardless of whether the patients were naive or not to BoNT-A treatment.

Ritidoplastia con doble anclaje. Una técnica para principiantes / The double locking face lift. A technic for beginners

Nuestra opción técnica del lifting cérvico-facial reposa sobre los tres principios siguientes: disección subcutánea después de haber efectuado una pasada con una cánula fina, introducida por 2 o 3 mini-incisiones, primer anclaje clásico a la altura del SMAS y segundo anclaje tras lograr la tensión apropiada del colgajo cutáneo a 1 cm de la incisión inicial. Reconocemos las siguientes ventajas de este método: seguridad en el plano de disección, ausencia de tracción a nivel de las cicatrices y respeto del capital capilar, proporcionando un resultado final natural de acuerdo a la solicitud por parte del tipo de pacientes que por lo general vemos en Francia. La técnica propuesta puede ser particularmente útil para aquellos cirujanos con experiencia limitada. Presentamos una serie de 132 casos recogidos en los últimos 5 años. La tasa de reintervención fue del 3 % , pero pensamos que subestima la calidad de los resultados y que debemos continuar esforzándonos por evitar las eventuales correcciones insuficientes de la ptosis yugal, de los surcos nasogenianos y del contorno mandibular. Preconizamos como vía de acceso la vía anterior, sobre todo en los cuellos difíciles y limitamos al máximo la disección mastoidea. Limitamos en lo posible las técnicas de tensión malar, origen de postoperatorios difíciles de manejar, y preferimos la restauración del volumen de la región empelando lipoinfiltración secundaria o el uso si es necesario, de algunos de los productos voluminizadores que actualmente están disponibles (AU)

We report our favourite cervicofacial lift technique based on 3 principles: secondary undermining after subcutaneous canulation through 2 or 3 small incisions, a first lock at the level of any classic SMAS technique and a second subdermic lock after appropriate tension on the skin flap 1cm in front of the primary incision. We consider that this method provides the following advantages: safe undermining plane without any traction on the final scar, hair preservation, and a final natural looking consistent with the usual request in France. We therefore believe that this technique could be particularly useful for those whose experience is still limited. We report the survey of the 132 cases operated over the past 5 years without any major incident. Revision rate is 3 %, but we believe it underestimates the quality of the results and efforts must be continued on the possible shortcomings of cheek ptosis, correction of nasolabial fold and jowls. We recommend a medial approach for difficult necks and are reluctant to undermine extensively the mastoid area. We limit as much as possible malar lifts which recovery is sometimes difficult to manage, preferring the restoration of this area through lipofilling later complemented if necessary by one of the many fillers now available (AU)

[Scratched faces: treatment of dynamic facial wrinkles through the simultaneous combined use of botulinium toxin A and hyaluronic acid]. / Griffose faciale: traitement des rides dynamiques du visage par injections dermiques simultanées de toxine botulique A et d'acide hyaluronique.

We use the term "scratched face" to define a face which has been streaked by deep wrinkles stretching from the orbital frame up to the temples and neck. Although the origin of these wrinkles seems to be the mime muscle effect; it may also be linked to the presence of Acetylcholine skin receptors in the superficial skin. This would certainly explain the reason for the presence of these wrinkles far from the muscle areas. We can therefore offer very superficial and targeted injections of diluted botulinium Toxin A. In the case of a strongly dehydrated skin, the toxin will be combined in the same syringe with a weak or not reticulated hyaluronic acid. We present a case study of 25 patients who have received this treatment, with a follow-up from 3 to 18 months. These patients had not received until now a satisfactory answer to the problem of their particularly striking facial distortions.

[The double locking face lifting]. / Le lifting cervicofacial à double verrouillage.

We report our favourite cervicofacial lift technique based on three principles: secondary undermining after subcutaneous canulation through two or three small incisions, a first lock at the level of any classic SMAS technique and a second subdermic lock after appropriate tension on the skin flap 1cm in front of the primary incision. We consider that this method provides the following advantages: safe undermining plane without any traction on the final scar, hair preservation, and a final natural looking consistent with the usual request in France. We therefore believe that this technique could be particularly useful for those whose experience is still limited. We report the survey of the 122 cases operated over the past five years without any major incident. Revision rate is 3.5%, but we believe it underestimates the quality of the results and efforts must be continued on the possible shortcomings of cheek ptosis, correction of naso labial fold and jowls. We recommend a medial approach for difficult necks and are reluctant to undermine extensively the mastoid area. We limit as much as possible malar lifts which recovery is sometimes difficult to manage, preferring the restoration of this area through lipofilling later complemented if necessary by one of the many fillers now available.

[A five years experience of subcutaneous chemical lipolysis with phosphatidylcholine injections]. / La lipolyse chimique sous-cutanée par la phosphatidylcholine : une expérience de cinq années.

Instead the fact that chemical lipolysis through phosphatidylcholin injections really works, this procedure eliminating limited fat deposits remains confidential in France. Inconstant results, necessity to repeat injections, unclear legacy may explain that this very basic procedure remains unsuccessful. We have proceeded to lipolysis injections for five years on a very limited number of patients: in our hands, it may be efficient on puffy cheeks, double chin, superficial cellulitis, liposuction and lipofilling sequellaes. Eyelid bags may also be considered but not recommended. On the other hand, chemical lipolysis cannot compete with liposuction. We have not noticed any drawbacks or complications which confirm the lipolysis network practitioners' opinion in more than 1000 users.

Niche-specificity and the variable fraction of the Pectobacterium pan-genome.

We compare genome sequences of three closely related soft-rot pathogens that vary in host range and geographical distribution to identify genetic differences that could account for lifestyle differences. The isolates compared, Pectobacterium atrosepticum SCRI1043, P. carotovorum WPP14, and P. brasiliensis 1692, represent diverse lineages of the genus. P. carotovorum and P. brasiliensis genome contigs, generated by 454 pyrosequencing ordered by reference to the previously published complete circular chromosome of P. atrosepticum genome and each other, account for 96% of the predicted genome size. Orthologous proteins encoded by P. carotovorum and P. brasiliensis are approximately 95% identical to each other and 92% identical to P. atrosepticum. Multiple alignment using Mauve identified a core genome of 3.9 Mb conserved among these Pectobacterium spp. Each core genome is interrupted at many points by species-specific insertions or deletions (indels) that account for approximately 0.9 to 1.1 Mb. We demonstrate that the presence of a hrpK-like type III secretion system-dependent effector protein in P. carotovorum and P. brasiliensis and its absence from P. atrosepticum is insufficient to explain variability in their response to infection in a plant. Additional genes that vary among these species include those encoding peptide toxin production, enzyme production, secretion proteins, and antibiotic production, as well as differences in more general aspects of gene regulation and metabolism that may be relevant to pathogenicity.

[Long-lasting filling procedures]. / Procédés de comblement à durée prolongée.

A long-lasting filling product is accepted as such when, once the result has been obtained, no correction is required before the end of an arbitrary 2-year period. Other than silicone oil, which is not officially recognized for this indication in France, pure products can be distinguished from microparticle suspensions in a vector that will disappear in a short time. Flexible implants represent a totally separate entity and remain relatively little used since surgery is necessary for implantation. Our experience has led us to prefer monomolecular filling gels, in particular polyacrylamide hydrogels, with which we have had extensive experience, over gels with microparticles that we believe expose the patient to much greater inflammatory reactions that are sometimes difficult to overcome.

[Phosphatidylcholine lipolysis-lipodissolve: myth or reality?]. / Lipolyse-lipodissolution par la phosphatidylcholine: mythe ou réalité?

The use of phosphatidylcholine through superficial injections in the aim to destroy adipocytes has recently become in great favour in Europe. This appealing idea nevertheless needs to be more argued. After one year of use the author advocates the fact that lipodissolution will not replace any traditional liposuccion, but may be helpful in the unfavourable indications of that procedure, thanks to the inflammatory reaction following adipolysis.

[Lasting treatment of facial HIV and non HIV lipoatrophies through the use of SAM GoreTex malar implants and polyacrylamide hydrogel filler Eutrophill. About 90 consecutive cases]. / Traitement durable des lipoatrophies faciales VIH et autres par implants malaires SAM GoreTex et hydrogel de polyacrylamide (Eutrophill). A propos de 90 cas consécutifs.

HIV-related lipoatrophy (HIV LA) stands out with regard to its recent discovery, increasing incidence, multiple etiologies, relatively low morbidity, apparently irreversible effects, and unequivocal clinical features. The underlying cause of HIVLA is still controversial but there is an increasing demand of correction. We describe a technique using soft malar implants and acrylamid gel injections separately or in combination. Expanded polytetrafluoroethylene (Gore SAM) malar implants are used for augmentation of the most sunken areas below the eye; they should be placed subperiostealy and more medially than conventional implants. After trying sheets and custom made implants, preshaped GoreTex) Sam implants are now used systematicaly. Eutrophill) is a 2.5% polyacrylamide hydrogel obtained by polymerization of acrylamide monomers with an official half-life of 5 years. The soluable chains are more or less slowly released by enzymatic degradation and subsequently cleared via interstitial tissue without further metabolism or degradation. Injection should be performed continuously and evenly from one side to the other in the deepest part of the sunken area at the subcutaneous level only. A total of 90 consecutive patients were treated using implants alone in 11 cases, injections alone in 68 cases, and both implants and injections in 11 cases. Drawbacks were very few except three cases of chronic inflammation (dental conflict) with sheets and custom made implants which were never observed since the use of preshaped forms, and some very light bulgings with acrylamid injections which usually desapear in a few months. Mean follow-up was 17 months for injections and 29 for implants.

Rejuvenecimiento frontal. Tríptico de tratamiento: cirugía endoscópica, peeling, toxina botulínica / The triple association endoscopy –peeling– botulinum toxin in forehead rejuvenation

La combinación de una técnica tradicional de rejuvenecimiento (Peeling de tricloroacético o fenol) junto con dos recientes avances técnicos (endoscopia y toxina botulínica) puede realzar los resultados del rejuvenecimiento facial de una forma más natural. Los malos resultado de algunos de nuestros primeros casos en una serie de 70 cirugías consecutivas sobre el área frontal pueden atribuirse seguramente a la debilidad de la suspensión hecha con suturas percutáneas. Resolvimos este punto desde 1998 mediante el uso sistemático de suspensiones transóseas. El éxito creciente de la Toxina Botulínica explica el notorio descenso de la cirugía endoscópica. Este tipo de procedimientos se usan actualmente para corregir ptosis frontales significativas que requieran una elevación de no más de 1,5 cm., intentando evitar los resultados poco naturales que vemos en muchas publicaciones; también se pueden obtener beneficios con el abordaje transpalpebral sin usar endoscopia. Hoy en día la blefaroplastia superior se lleva a cabo sistemáticamente en la mayoría de los casos para obtener resultados más naturales. El uso de peelings suaves y de inyecciones de Toxina Botulínica puede contribuir a mantener estos resultados de una forma sencilla (AU)

The combining of a traditional resurfacing technique with 2 recent technological advances (endoscopic forehead plasty, Botulinum Toxin) may enhance the forehead rejuvenation in a more natural way.The desapointing results of some of our earlier results on a serie of 70 concecutive foreheadplasties can probably be attibuted to the weakness of the suspension through percutaneous sutures. This has been remedied since 1998 by the systematic use of transosseous suspensions. The growing success of Botulinum Toxin explains the noticiable decrease of endoscopic surgery. This type of procedure is now used to correct significant frontal ptosis requiring un uplifting of no more than 1,5 cm., thereby avoiding the unnatural results encountered in many publications; some benefits can be obtained by the way of a transpalpebral approach without using the endoscope. Nowadays upper blepharoplasties are almost systematically done in the majority of our cases in order to obtain the most natural result.Light peels and Botulinum Toxin injections can maintain this result relatively easily (AU)

[High frequency ultrasonography and celluscore: an improvement in the objective evaluation of cellulite phenomenon]. / L'ultrasonographie à haute fréquence et le celluscore : un progrès dans l'évaluation objective du phénomène de cellulite.

As they usually do not have any serious effect on health condition, cellulite phenomenons are not considered as potentially hazardous by general practitioners; unfortunately they involve almost all the feminine population after the forties and may really induce bad side effects either psychological or physical whatever the confusing origin of that cutaneous deformation: heredity, nutrition, circulatory and hormonal diseases etc. Trying to appreciate in a more scientific way this superficial skin disorder, we have developed a computerised questionnaire which can be combined with the finest upto date way of skin exploration, high frequency ultrasonography. It seems possible to consider now cellulite as the result of various disorders which can be separate into fibrotic or retentional phenomenons (surrounding superficial fat tissues) and the direct adipocyte reaction (adiposis). We hope to be able in the future to extend the treatment of cellulite beyond the limits of liposuction which seems until today the only way to bring some improvement to that phenomenon in spite of the very delicacy of the surgical approach.

[Optimal forehead rejuvenation. Combining endoscopy-peel-botulinum toxin]. / Optimisation du rajeunissement frontal. Combinaison chirurgie endoscopique-peeling-toxine botulique.

The combining of a traditional resurfacing technique (trichloracetic or phenol peel) with 2 recent technological advances (endoscopic forehead plasty, botulinum toxin) may enhance the forehead rejuvenation in a more natural way. The disappointing results of some of our earlier results on a serie of 70 consecutive foreheadplasties can probably be attributed to the weakness of the suspension through percutaneous sutures. This has been remedied since 1998 by the systematic use of transosseous suspensions. The growing success of botulinum toxin explains the noticeable decrease of endoscopic surgery. This type of procedure is now used to correct significant frontal ptosis requiring an uplifting of no more than 1,5 cm, thereby avoiding the unnatural results encountered in many publications. Some benefits can be obtained by the way of a transpalpebral approach without using the endoscope; nowadays, upper blepharoplasties are almost systematically done in the majority of our cases in order to obtain the most natural result. Light peels and botulinum toxin injections can maintain this result relatively easily.