Philippe Pellerin

Comparative study of split thickness skin grafts taken from the scalp and thigh in children

We compared 29 split thickness skin grafts taken from the thigh (group I) and 37 taken from the scalp (group II). The study was prospective with a follow-up period of 1 year. The average age was 29 months. Included in group I were those children whose parents refused permission for their hair to be shaved and those with burns to the head. We compared ease of technique, percentage of graft accepted, quality of the graft and after-effects of the donor site. Acceptance of the graft was close to 100 per cent in both groups. Harvesting was more difficult from the scalp (P < 0.0001). The quality of the grafts was identical in both groups. After-effects at the donor site were absent in group II and evident in group I (P < 0.0001). There was no alopecia. The scalp represented a better donor site for split-thickness skin grafting than the thigh in the child.

Strategy of craniofacial reconstruction after resection of spheno-orbital "en plaque" meningiomas.

&NA; Surgical resection of spheno‐orbital “en plaque” meningiomas should be as complete as possible to prevent tumor recurrence and therefore requires a bone reconstruction. We report a series of 20 patients operated on for spheno‐orbital “en plaque” meningioma between 1981 and 1993. The surgical treatment included a resection of the involved dura and a wide resection of tumoral bone using a fronto‐temporal craniotomy extended to the orbitozygomaticomalar bone ridge. The craniofacial reconstruction was performed in the same operative procedure using iliac bone autograft in 11 patients, internal cortical bone from the bone flap in 8 patients, and a coral graft in 1 patient. The cosmetic result was scored according to the following criteria: superior frontal paralysis, appearance of the orbitomalar bone ridge, shape of the external temporal fossa, and projection of the eyeballs. The cosmetic result was scored as excellent or good in 17 patients, average in 2 patients, and poor in 1 patient. The iliac bone autograft appeared to be the best material for craniofacial reconstruction because it could be modeled easily to the desired shape. However, the reconstruction technique was modified as necessary according to the extent of tumor removal, clinical presentation, and age of the patient. (Plast. Reconstr. Surg. 100: 1113, 1997.)

Pedicle Musculocutaneous Flap Transplantation: Prediction of Final Outcome by Transcutaneous Oxygen Measurements in Hyperbaric Oxygen

In pedicle musculocutaneous flaps, a local circulatory insufficiency with a total or subtotal ischemia may occur and jeopardize the result of the reconstructive surgery. Transcutaneous oxygen pressure (PtcO2) monitoring has been shown to reflect tissue perfusion and has been advocated to predict the final outcome of ischemic flaps. Unfortunately, under normal atmospheric conditions, this test is not sufficiently discriminative. We evaluate the effect of hyperbaric oxygen conditions on the efficiency of this test. Fifteen patients with pedicle musculocutaneous flap were evaluated by clinical examination and transcutaneous oxygen tension measurements. The final outcome was healing in 7 and failure in 8. In order to determine the predictive value of transcutaneous oxygen tension, measurements were done immediately after the surgical procedure. In ambient air, neither the absolute value of transcutaneous oxygen tension (2.6 ± 3.6 versus 11.7 ± 12.6 torr; N.S.) nor the difference or the ratio between the transcutaneous oxygen tension of the flap and the subclavicular reference shows any significant difference according to the outcome (failure or success). The same is true in normobaric oxygen. In hyperbaric oxygen, however, there is a significant difference in transcutaneous oxygen tension between the two groups (12 ± 12 versus 378 ± 385 torr; p < 0.01). A transcutaneous oxygen tension higher than 50 torr in hyperbaric oxygen (2.5 atm abs) is the best cutoff value to discriminate success from failure.

Aplasia cutis congenita: review of 29 cases and proposal of a therapeutic strategy.

INTRODUCTION Aplasia cutis congenita (ACC) is a rare congenital disorder, which most commonly involves the scalp, and can affect the galea, the pericranium, the bone, and the dura mater. ACC thus is at risk of infection and hemorrhage. There is no consensus over the ideal management and the role for plastic surgery. MATERIALS AND METHODS We reviewed retrospectively our experience with 29 patients treated between 1976 and 2011. RESULTS The patients were 17 male and 12 female, 25 being referred immediately at birth. The size of the defect ranged from 1 to 192 cm2. Thirteen patients had bone aplasia. Initial conservative treatment was decided in five cases; 15 patients underwent excision-sutures with or without local plasty, 8 underwent pedicled scalp flap, and 1 had skin graft followed by further reconstruction by a free flap. Four patients died in neonatal period because of infection or associated ailments. All others patients achieved complete healing. DISCUSSION The mortality rate of ACC remains high and increases with the size of bone defect. We propose a therapeutic strategy based on the size of the skin defect and the nature of underlying exposed structures. Cranioplasty is exceptionally necessary because of good spontaneous bone regeneration within few months or years. Cosmetic appearance can be improved later by skin expansion. CONCLUSION Aplasia cutis congenita is a rare malformation with sometimes a rapid fatal issue. A precise evaluation of surface and depth of the lesion is essential to decide if and how to operate, in order to provide rapid and efficient coverage.

Midfacial distraction without osteotomy using a transfacial pin and external devices.

Introduction During the 1970s, frontofacial advancement revolutionized the treatment of severe facial stenosis. Unfortunately, this method was associated with significant morbidity due to the Le Fort III osteotomy, which creates a major communication between the frontocranial dead space and the nasal fossae. Midfacial distraction improves the complication rate by diminishing the size of this gap. The aim of our study was to present an original technique that uses external distraction frames and eliminates the need for Le Fort osteotomies. This innovative technique eliminates the gap between the skull and nose, thus avoiding related complications. Patients and Methods Between 1997 and 2008, we operated on 17 patients presenting midfacial retrusion and maxillomandibular class III malocclusion. We performed classic fronto-orbital advancement. The only facial osteotomies are vertical cuts of both the lateral orbital wall and the zygomatic arch. The distraction device is then anchored posteriorly with a K-wire and anteriorly with a transfacial pin through the maxilla. Finally, the distraction is performed horizontally until a class II overcorrection is obtained. Results No life-threatening complications or mortalities occurred. In all cases, the midfacial retrusion was corrected without relapse. All patients with complications fully recovered. It was observed that most complications were a result of either an overly rapid activation (>1 mm/d). Discussion Midface distraction using the external transfacial pin is a simple and safe procedure that allows an efficient correction of major facial retrusion. The external transfacial pin acts directly onto the maxilla and allows distraction without Le Fort osteotomy. By eliminating major osteotomies, it reduces the number of severe complications encountered in craniofacial surgery.

Distraction médiofaciale sans ostéotomie par l'intermédiaire d'une broche transfaciale. À propos de quatre cas cliniques

Resume Depuis les publications de Mulhbauer, Raposo do Amaral et surtout de Toth et Chin, la distraction du massif facial dans les crânio-faciostenoses est devenue une realite du traitement de ces affections. Les premiers essais de distraction sans osteotomie ont donne des resultats tres decevants ; les appareils agissant sur les malaires, la suture maxillo-malaire etait incapable de transmettre les contraintes au maxillaire et se disloquait. En utilisant une broche transfaciale et un appareillage externe, nous avons dans quatre cas pu obtenir une avancee importante du massif facial. Nous rapportons ici la technique et les resultats preliminaires.

Isolated bilateral coronal synostosis: early treatment by peri-fronto-orbital craniectomy.

Early strip craniectomy is commonly used for the treatment of craniosynostosis, but its effect on bilateral coronal synostosis remains disappointing. The technique developed in our institution of early (1-3 months of age) extensive perifrontal craniectomy that provides liberation of the anterior skull base is detailed, and its results in 12 cases of nonsyndromic brachycephaly are presented. Analysis of the growth of the cranial diameters of these children over a mean postoperative period of 10 years revealed a noticeable lengthening of the skull similar to the normal range, whereas no effect was noted on transversal cephalic development. Two patients needed additional surgery for focal correction despite a good morphologic result. The functional outcome was normal in all cases. For a number of carefully selected patients, early peri-fronto-orbital craniectomy provides an excellent result with functional preservation and morphologic improvement in most cases (10/12) in nonsyndromic brachycephaly. Its limited dissection and bleeding, as well as its short operating time, allow to have the procedure at a very young age and do not preclude the possibility of secondary surgery when needed.

Facial diplegia revealing ventriculoperitoneal shunt failure in a patient with Crouzon syndrome

The authors report on the case of a 15-year-old boy with Crouzon syndrome (CS) who presented with headache and facial diplegia. He had undergone several craniofacial interventions and a posterior fossa decompression for tonsillar herniation caused by the CS. A ventriculoperitoneal (VP) shunt had been inserted for hydrocephalus. Emergency computed tomography (CT) disclosed slight dilation of the ventricular cavities compared with their appearance on a baseline CT scan. Magnetic resonance imaging showed a deformed brainstem but no compression at the occipital foramen; there was no apparent explanation for the facial diplegia. The neuroophthalmological examination revealed neither papilledema nor oculomotor palsy. Electromyography confirmed incomplete peripheral facial diplegia. The patient underwent emergency shunt revision, during which complete obstruction of the ventricular catheter and severe cerebrospinal fluid hypertension were found. After surgery, cranial hypertension symptoms completely resolved and the facial diplegia improved slowly with a persistent and incomplete right superior facial palsy. Cranial 3D CT scanning reconstructions and brain magnetic resonance imaging demonstrated severe petrous bone distortion that could have been responsible for direct stretching injuries on the facial nerves at the level of the internal acoustic meatus. The present case represents the first reported occurrence of VP shunt failure as revealed by a facial palsy; the authors discuss the pathophysiology of facial palsy in intracranial hypertension.

Les brûlures de la face chez l'enfant. À propos de 197 patients

Facial burns frequently occur in child. A total of 197 burned patients with facial localisation were seen during the time period (1991-1996) covered by this retrospective study. One hundred and sixteen patients were less than three years old. A quarter of the child were issued from poor social classes with nine cases of child abuse by burning. One hundred and thirteen injuries were performed by hot water or drinks. The total burn area was less than 10% in 63% of the cases. The average facial burned area was 4%. The cheek, the front and the chin were often concerned. Low limbs and trunk were unjured in all cases. 130 patients needed hospitalisation, and stayed in average 17.31 days at hospital. Four patients died from respiratory complications, all after flame injuries. Fifty two child needed skin split grafts. Complete cicatrisation was observed after 21 days of treatment in child without grafts, and after 35.65 days in child with skin grafts. Twenty eight patients needed physiotherapy in center. The scars had a correct cosmetic appearance, without retraction and inflammatory signs in 158 child after two years. Eleven patients needed other surgical treatment. The authors analyse the results and insist on prevention. Language: fr

Maxillonasal osteochondral complex repair in maxillonasal dysplasia.

AbstractSurgical treatment of maxillonasal dysplasia or Binder syndrome is a challenge for surgeons. Its aim is to replace or substitute the missing or malformed anatomic structures. The authors report a comprehensive analysis for the understanding of the mechanisms resulting in the lack of maxillonasal development observed in Binder syndrome. The evolution of the surgical treatment due to facial function analysis is explained, and the surgical treatment of 20 consecutive cases over the last 20 years is reviewed, illustrated by three-dimensional reconstruction to emphasize the choice made and the results obtained. Bone grafts were always performed, and an arrow-shaped graft for the neospine reconstruction is described. This analysis allowed the authors to ameliorate patient self-image subsequently to facial contour improvement.