[Clinical analysis before surgery in facial and neck rejuvenation]. / Analyse clinique avant chirurgie de rajeunissement cervico-facial.

The first step to determine a medical or surgical intervention is the clinical exam. The clinical exam is the paramount step to provide a treatment plan that can be modified and individualized accounting the patient preferences. During the consultation for facial rejuvenation, attention should be paid to understand the patient's motivation and expectations. A thorough understanding of the anatomy and the natural history of ageing will facilitate the analysis of the face. Not only the degree of ptosis but also the degree of volume loss will need to be assessed, as well as the influence of the facial muscles, the skin quality, and the different causes of rythids. The comprehensive age-related anatomical changes are often perceived and described as tiredness or sadness. Patients very commonly only point out a single anatomical region. During the consultation, the surgeon should provide the patient with the information of the comprehensive interplay of the different anatomical regions and their individual ageing process. Obtaining a harmonious, natural appearing outcome is the result of excellent surgical skills and applied knowledge. The clinical exam should also find out traps and technical difficulties. Although standardized photographs allow a static evaluation of one's result, video may deliver additional information about the postoperative result, and may contribute to the understanding of the technique used. Spending the additional time by performing a thorough facial analysis and preoperative planning is well-invested time. Having a good understanding of the possible surgical improvements and limitations will be beneficial for both, the patient and the surgeon. Managing the expectations of the patient and careful preoperative planning will increase patient's satisfaction. At the same time, the surgeon will able to critically assess his/her own result and taking pleasure improving their own technique.

[Breast reconstruction with TRAM flap after selective embolization of the deep inferior epigastric artery (series of 69 patients)]. / Reconstruction mammaire par TRAM après embolisation sélective de l'artère épigastrique inférieure (série de 69 patientes).

Vascular complications of the unipedicled TRAM flap pointed out the need for solutions to decrease such occurrences. The flap surgical delay before transfer has been advocated to improve the blood supply but, at the same time, it increases the risk of wound infection at the donor site and imposes a general anesthesia. The DIEP and the free TRAM flap are more complex procedures and need heavy structural resources. Preferential use of the ipsilateral muscular pedicle suggests a lower partial flap necrosis rate. Selective embolization of the deep inferior epigastric arteries prior to surgery realizes an alternative delay and brings a decrease in the vascular complication rate as shown in a study of 40 patients by Scheufler in 2000. We present a series of 69 patients who were reconstructed by means of a delayed pedicled TRAM flap with selective embolization and a predominant use of the ispsilateral pedicle. Sonographic studies performed in 48 patients prior to surgery showed no significative difference in the diameter of the superior epigastic arteries, with or without previous radiotherapy. The mean interval between embolization and surgery was 30 days; the embolization was performed bilateraly in five patients (4 %), and unilaterally in 64 patients (96 %). The mean age of patients was 54 years, radiotherapy was applied in 43 patients (62 %), smoking patients: 11 (16 %), obesity: five (7 %). The ispsilateral pedicled was used in 67 patients (97 %), controlateral pedicle in two patients (3 %). Postoperative flap complications were comprised of partial flap necrosis in two cases (2,9 %), fat necrosis in six cases (8,7 %), impaired wound healing in three cases (4,3 %), abdominal wall weakness in two cases (2,9 %). We compared the present study of ispsilateral delayed pedicled flap to a study from the same authors concerning controlateral pedicled flaps without delay. It has been demonstrated that the complications rate of partial necrosis was divided by four in the first study compared to the second. The preoperative selective embolization of the deep inferior epigastric artery in association with the use of ipsilateral pedicule in TRAM flap decrease the complications rate significatively compared to the controlateral pedicled flap in TRAM flaps.

[Difficult necks. Diagnosis and treatment. Retrospective study of 145 cases using the method of Feldman]. / Les cous difficiles. Diagnostic et traitement. Étude rétrospective de 145 cas utilisant la méthode de Feldman.

To identify a neck as difficult seems an easy thing. Nevertheless, we must admit that various clinical situations are represented under this single designation. A clinical and anatomical classification is proposed regarding the surgical strategy presented in this paper. Predominant tissue laxity and predominant fat accumulation are presented as progressive forms. Short platysma muscles and low hyoid bones are presented as constitutional. According to this classification, 145 patients among 438 facial rejuvenations were designated as difficult necks. The surgical strategy was intended, in each case, to address the underlying anatomical features, using a short incision system. A combination of wide skin undermining, fat removal under direct vision and corset platysmaplasty was performed in the 145 patients between November 2003 and May 2008. The average age was 59 years old and medium follow-up at 22 months. There was only 2% of secondary touch up for aesthetic reasons. Difficult necks, as described in this article, responded adequately to the present protocol. The postoperative results on the neck were consistent with the rest of the rejuvenated face and stood the test of time.

[Breast hypertrophy and dorsolumbar spine. Prognostic influences of lumbar lordosis: preliminary results]. / Hypertrophie mammaire et rachis dorso-lombaire. Influences pronostiques de la lordose lombaire: résultats préliminaires.

In a prospective study, the influence of a mammary hypertrophy on some clinical and radiological parameters of the lumbar and dorsal spine had been studied in 14 women comparatively to 14 control women, before and after a reduction surgery. Clinically, the frequency of the lumbar pain was identical in the two groups of patients before surgical treatment but a significant decrease of the frequency and the intensity of the lumbar pain was found after the surgery in the mammary hypertrophic group (p less than 0.01). Some radiological parameters of lordosis and the dorsal kyphosis were significantly higher in mammary hypertrophic patients than in control patients. After surgery, an increase of parameters of lordosis was observed associated with a significant decrease of the dorsal kyphosis (p less than 0.05). Nevertheless, by use of a radiological classification of the lumbar lordosis with the Ferguson's indice, two main groups of lordosis had been distinguished. The intensity of the lumbar pain and the dorsal kyphosis were significantly higher in patients with a low indice than in those with an high indice. More, the dorsal kyphosis has decreased only in patients with a low anterior lumbar indice. In conclusion, a mammary hypertrophy must be searched in women with a lumbar pain and an surgical treatment may be proposed.

[Covering of ischial pressure sores using a fasciocutaneous flap from the posterior surface of thigh (modified Griffith method) after mattressing with the biceps femoris. Apropos of 11 cases]. / Couverture des escarres ischiatiques par lambeau fascio-cutané de face postérieure de cuisse (Griffith modifié) après matelassage par le biceps femoris. A propos de onze cas.

The ischial region is the commonest site for pressure sores in paraplegics capable of sitting. The choice of treatment must be guided by two imperatives: the need for a thick tissue cover (mattressing) and perfect trophicity, the risk of recurrence which always remains possible. The association of a modified Griffith fasciocutaneous flap from the posterior surface of the thigh and a hamstring muscle flap (preferably biceps femoris) providing mattressing of the ischial region, appears to satisfy these imperatives. The other repair procedures are discussed in order to ensure the best management of the paraplegic patient's cutaneous capital, due to the continual risk of a new pressure sore or a recurrence of the ischial pressure sore.

[Presuture: back-up technique in plastic surgery. Review of 18 cases]. / La pré-suture: méthode d'appoint en chirurgie plastique. A propos de dix-huit observations.

The recent technique of "presuturing" has been used in 18 cases of skin lesions in which primary wound closure after resection would not have been possible without undermining. This method, which takes a few more minutes, on the day before the operation, allows an easier surgical closure after resection. Our case reports concern melanomas, giant nevi, Bowen's disease and tattoos measuring 6 to 84 cm2. Some sites respond better than others to presuturing. The cosmetic gain for the patient confirms the surgical gain of this method.