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Resume Introduction La section des nerfs alveolaires superieurs lors de l’osteotomie de Le Fort I entraine habituellement une perte de la sensibilite des dents maxillaires. Le but de notre etude a ete d’analyser la cinetique de recuperation de la sensibilite dentaire postoperatoire. Materiel et methode Une etude prospective a ete menee chez des patients operes pour osteotomie de Le Fort I isolee, associee a une osteotomie mandibulaire ou a une disjonction intermaxillaire (DIM). Les mouvements effectues au cours de l’intervention ont ete notes. Une dent par secteur alveolaire (incisivo-canin, premolaire, molaire, au mieux) a ete testee pour chaque patient a l’aide d’un testeur electrique. Les tests ont ete effectues en preoperatoire (j1), a j2, j15, M2 (+2 mois), M3 et M6 postoperatoires. Resultats Vingt-deux patients ont ete inclus. A j1, 91,9 % des dents testees etaient sensibles, a j2, 12,7 % des dents etaient sensibles. A j15, M2, M3 et M6, les pourcentages de dents sensibles etaient respectivement de 33,3 %, 43,1 %, 50 % et 61,8 %. La recuperation sensitive a ete significativement plus rapide et plus complete chez les patients âges de moins de 35 ans et au niveau des dents situees dans le territoire des nerfs alveolaires superieur et moyen. Il n’a pas ete note de difference significative en fonction des mouvements effectues. Discussion Parmi les dents sensibles a j1, 87,3 % ne l’etaient plus a j2. La recuperation sensitive des dents atteintes s’effectue des j15. Une grande amplitude de mouvement semble etre un facteur aggravant.

Resume Introduction Le carcinome hyalinisant a cellules claires (CHCC) des glandes salivaires accessoires (GSA) est une tumeur rare (inferieure a 1 % de l’ensemble des tumeurs des glandes salivaires) de faible grade de malignite. Sa localisation la plus courante est le palais et la base de langue, plus rarement la parotide. Nous rapportons une localisation exceptionnelle au maxillaire. Observation Un homme de 48 ans, sans antecedents medicaux, nous a ete adresse pour une lesion gingivale maxillaire droite, indolore, developpee de 14 a 17. Elle etait apparue quelques mois auparavant. Le reste de l’examen clinique etait normal. La biopsie a confirme un CHCC. Au scanner cervicofacial le sinus maxillaire etait envahi avec une lyse osseuse et des ganglions cervicaux etaient suspects. Le traitement a associe une resection carcinologique, un evidement cervical fonctionnel et une radiotherapie adjuvante, en raison du caractere incomplet de l’exerese sur une tranche osseuse. Discussion Le CHCC maxillaire est extremement rare. Cette tumeur est potentiellement recidivante. Le risque metastatique est faible et principalement ganglionnaire. Il n’y a pas de consensus therapeutique compte-tenu de la rarete de cette pathologie, mais l’exerese large suivie ou non d’une radiotherapie externe semble etre le traitement de reference.

Resume Introduction Les faux-anevrismes de l’artere temporale superficielle (ATS) sont des lesions rares. Ils surviennent generalement apres un traumatisme direct d’une branche de l’artere temporale. Ils se caracterisent par une rupture localisee de la paroi vasculaire. Leur diagnostic est fait sur l’anamnese et l’examen clinique, et le traitement est chirurgical. Nous presentons deux cas de faux-anevrisme de l’ATS. Observations Deux hommes, de 20 et 82 ans, ont ete adresses pour une masse pulsatile respectivement temporale et frontale evoluant depuis plusieurs semaines. Le diagnostic a ete evoque a l’anamnese (notion de traumatisme ancien a l’interrogatoire), a l’examen (abolition du caractere pulsatile apres compression de l’artere en amont) et a l’echodoppler. Il a ete confirme histologiquement. Le traitement a consiste en une resection chirurgicale apres ligature de l’artere temporale en amont et en aval. Discussion Le diagnostic de faux-anevrisme de l’ATS est aise et sa prise en charge est simple. Les faux-anevrismes se distinguent des anevrismes vrais par une rupture de la paroi vasculaire. L’interrogatoire doit s’efforcer de retrouver le traumatisme initial souvent passe inapercu. L’examen clinique et les eventuels examens complementaires eliminent les autres tumeurs pulsatiles de cette region (anevrisme vrai de l’ATS ou de l’artere meningee).

The authors present a retrospective study about 20 patients operated for important breast hypertrophy and gigantomastia by the postero-inferior reduction technique. They compare the results obtained by this technique on the breast (projection, breast-feeding) and on the nipple-areola complex (sensibility, pigmentation, nipple projection), with those obtained by the Thorek technique (free nipple grafting). The authors show that this technique is reliable for such breasts hypertrophies, with good esthetics results, and avoid free nipple grafting.

Resume Introduction L’utilisation de substituts osseux dans les greffes sinusiennes massives a visee pre-implantaire est controversee. Nous avons evalue la fiabilite a long terme du phosphate tricalcique sous forme β (βTCP, Cerasorb ® , Curasan, Kleinostheim, Allemagne) dans cette indication. Materiel et methode Vingt patients (33 sinus) presentant une atrophie osseuse severe (classes 4 a 6 selon Cawood) ont eu un comblement sinusien par βTCP. Ils ont ete suivis prospectivement entre janvier 2002 et mai 2008. La voie d’abord laterale etait classique (sous anesthesie locale chez huit patients). Le sinus a ete comble par 6 cm 3 de βTCP en moyenne. Des facteurs de croissance autologues de type PRP et PRF ont ete associes selon la technique decrite par Dohan et Weibrich. Cent vingt-trois implants ont ete mis en place entre le quatrieme et le huitieme mois postoperatoire (implants Nobel Biocare MK III et MK IV–longueur moyenne 12,44 mm) selon une technique enfouie suivie d’une mise en charge entre le quatrieme et le sixieme mois. La surveillance comportait des examens cliniques et des orthopantomogrammes reguliers a la recherche de complications sinusiennes et/ou implantaires. Les radiographies ont egalement servi a la mesure de la resorption du biomateriau. Resultats Le recul postoperatoire moyen a ete de 4,5 ans pour les greffes sinusiennes et de quatre ans pour les implants. Pour les greffes sinusiennes, un cas d’infection locale a ete note au 15 e jour postoperatoire (3 %). Le taux de succes implantaire a ete de 97,6 % (deux absences d’osteo-integration et une perte apres mise en charge). Le taux de succes prothetique a ete de 100 %. La resorption moyenne du materiau a ete de 20,3 % et le gain moyen de hauteur a ete de 16,9 mm. Discussion L’utilisation de βTCP, sans apport osseux, associes aux facteurs de croissance (PRP ou PRF) dans les greffes sinusiennes entraine peu de complications. Le taux de succes implantaire est equivalent a celui obtenu par greffe d’os autologue. La resorption du materiau est comparable a celle de l’os autologue.

Resume Introduction L’hemangioendotheliome epithelioide (HEE) est une tumeur rare d’origine vasculaire et de malignite intermediaire, avec un risque potentiel de recidive. Cette pathologie atteint principalement les tissus mous des extremites, le foie et le poumon. L’atteinte cervicofaciale est rare. Nous en presentons une localisation exceptionnelle au maxillaire. Observation Une enfant de huit ans, sans antecedents personnels ou familiaux, nous a ete adressee pour ulceration gingivale du maxillaire droit apparue il y a deux mois. Il n’y avait pas d’adenopathie cervicofaciale. L’orthopantomogramme etait normal. Le scanner mettait en evidence une osteolyse palatine, sous-jacente a l’ulceration. La biopsie a diagnostique un HEE. Le bilan d’extension etait negatif. Le traitement definitif a ete une maxillectomie partielle 11 mois plus tard, aucun signe de recidive locoregionale ou a distance n’a ete note. Discussion Vingt-six localisations orales d’HEE ont ete publiees. Les localisations sont essentiellement gingivales et linguales. La localisation gingivale est plus volontiers pediatrique. Le faible nombre de localisations orales publiees ne permet pas de preciser le risque de recidives locoregionales ou de metastases des cas. Le traitement n’est pas consensuel. Comme d’autres auteurs, nous preconisons une exerese lesionnelle large et un suivi regulier.

Summary Background The aim of the study was to evaluate the mean-term efficacy and tolerance of the polylactic acid injections (New-Fill®) for the correction of facial lipoatrophy occurring in HIV-positive patients under tri-therapy. Material and method The patients were managed at the University Hospitals of Besancon and Strasbourg (France) from January 2002 to December 2005 for a prospective study. The patients were consecutively included in this study once their consent was obtained. Patients not stabilized by their antiretroviral treatment were excluded. Facial lipoatrophy was classified in four clinical stages (stage I: mild, stage II: moderate, stage III: important, stage IV: severe) after a clinical examination. The polylactic acid solution was prepared according to the manufacturer's recommendations, and injected in a retrotracing manner in the hypoderm at the rate of one 5 ml flask per side, with an interval of one month. The number of sessions varied according to the severity of the stage. Treatment efficacy, assessed after a minimal follow-up of one year, was established clinically by comparing the initial and final photographs (changes in the clinical stage) and by the patient's and surgeon's satisfaction rate (from zero to ten). Treatment tolerance was established on the painfulness of injections and on socioprofessional constraints reported by the patients and made on a visual analogical scale. The occurrence of adverse-effects was checked. Finally, we compared the cost of the treatment with that of lipostructure. Results Twenty-five patients were included (mean age: 44, sex-ratio: 23 male/2 female patients). The mean body mass index was 21. The mean CD4 cell count was 600/mm3. The mean HIV-1 RNA was 276 copies/ml. The severity of the lipoatrophy was stage one in two patients (8%), stage two in 12 patients (48%), stage three in nine patients (36%), and stage four in two patients (8%). The mean number of sessions was 5.2. The mean follow-up time was 26 months. In 76% of the cases we observed a complete correction of lipoatrophy (100% of stages I, 92% of stages II, 66% of stages III, 0% of stages IV). However, among stages II, III, and IV that were incompletely corrected, an improvement was noticed in all patients (grading to an inferior stage, at least). The mean satisfaction rate was 8/10 by patients and 7.2/10 by surgeons. In six patients (24%) a renewal of the treatment was proposed because of inadequate results. The painfulness of injections was rated at 3.3/10 and constraints at 3/10 by patients. One single case of visible and palpable sub-cutaneous granuloma was noticed in a patient at the end of the follow-up period (18 months). Discussion The use of polylactic acid is a safe and efficient procedure for the treatment of facial lipo-atrophy in HIV-infected patients, however severe the clinical stage may be, after a two-year follow-up period. We recommend hypodermic (and not dermic) injections to prevent adverse effects. This treatment is not more expensive then lipo-structure and the progressive correction is considered as an important advantage by patients. Considering our results, the simplicity of the procedure, and the low rate of complications observed, the injection of poly-lactic acid has become our first intention treatment for this condition.

INTRODUCTION: Postoperative monitoring of free flaps with microdialysis allows early diagnosis of anastomotic complications. Feasibi-lity studies are required to examine flap accessibility for oral cavity reconstruction. CASES: We present our preliminary findings in two patients who underwent radial free flap reconstruction of the floor of the mouth. For the first patient, a microprobe was used to monitor the flap for 45 hours. In the second case, an abdominal microprobe served as a control in healthy skin with another probe located in the cutaneous flap for 4 days. Flap monitoring, starting from the recovery room, was successful with easy manipulations for the nurse. Correlation between the monitoring curves and the clinical aspect of the flap was excellent. DISCUSSION: The microprobe should be short (1 cm), and carefully anchored. Naso-gastric feeding is required during monitoring. A close correlation has been found between glucose level and systolic pressure. The use of a comparative microprobe in healthy abdominal skin is helpful in learning to use the dialysis curves.

A partir d’une cohorte de 102 blesses presentant un fracas facial les auteurs ont voulu etudier leur devenir a long terme, soit au moins 5 ans. Vingt-cinq blesses ont ete examines par un observateur chirurgien et un observateur medecin. Ont ete analysees les donnees suivantes : circonstances du traumatisme, la nature du traumatisme crânien, les sequelles neurologiques, sensorielles et douloureuses, le traumatisme psychologique et les sequelles, le devenir socioprofessionnel et enfin la reparation et les suites judiciaires. Des tableaux comprenant l’ensemble des donnees recueillies sont commentes et discutes.

La neuropsychologie traite des fonctions mentales superieures dans leur rapport avec les structures cerebrales, etant ainsi au centre de preoccupation d’ordre psychiatrique, psychologique et des sciences cognitives. L’atteinte de ces fonctions semble evidente pour les traumatismes crâniens graves avec sequelles importantes motrices. Il apparait de plus en plus clairement que les traumatismes crâniens legers (TCL) ou moderes (TCM) ont tres souvent des troubles sequellaires, difficiles a analyser et surtout a quantifier cliniquement. Ils constituent pourtant un « handicap invisible » qui peut grandement penaliser la vie cognitive socioprofessionnelle et relationnelle du blesse. L’evaluation neuropsychologique doit etre systematique et complete et faite avec un recul suffisant de 2 a 3 ans. Elle doit etre realisee a l’aide d’echelles neuropsychologiques et comportementales d’evaluation de deficience. Les tests psychometriques sont egalement indispensables. Les elements tires de cette evaluation doivent etre correctement interpretes et constituent une piece majeure de l’expertise du traumatise crânien.

Dans le Service de CMF de Besancon, une prise en charge globale au long cours des grands blesses s’est imposee comme une therapeutique efficace pour les accompagner depuis l’accident jusqu’a une stabilisation favorable de leur etat. L’utilisation de groupes de therapie a mene progressivement a la creation de la « Famille Maxillo », prenant un peu modele sur les « Gueules Cassees ». L’edition d’un « Journal de Maxillo » ou les patients s’expriment a leur guise, s’avere etre therapeutique autant pour les patients que pour les soignants. Le temoignage d’une victime d’AVP avec fracas facial illustre l’interet de cette approche.

Les lesions resultant de traumatismes maxillo-faciaux obligent souvent a rediger un certificat medical initial (CMI) descriptif des lesions mentionnant l’Incapacite Totale de Travail (ITT). En cas de traumatismes resultants de coups et blessures involontaires ou volontaires, la duree de cette ITT determinera la competence du tribunal qui jugera et condamnera l’auteur des faits. Cette ITT a donc une valeur penale et c’est dans ce sens seulement qu’elle devrait etre utilisee. Nous avons tente, a l’aide d’une enquete nationale, de determiner, au sein de la specialite, les pratiques de chaque service hospitalier concernant les informations mentionnees sur le CMI et plus particulierement la duree de l’ITT pour les fractures du massif facial les plus courantes. Le but de ce travail est d’etablir si, au vu des reponses donnees, il est licite de proposer un bareme d’ITT en traumatologie maxillo-faciale.

Introduction La plupart des victimes d’un fracas facial vont presenter des sequelles morphologiques et/ou fonctionnelles de leur traumatisme. Le but de ce travail a ete d’evaluer, a l’aide d’une etude retrospective, l’importance de ces sequelles a long terme. Materiel et methode Cent deux patients presentant un fracas facial ont ete pris en charge dans le service entre 1995 et 2000. Vingt-quatre de ces patients ont pu etre revus en 2006 pour evaluer leurs sequelles a long terme. Tous les patients presentaient un traumatisme crânien associe plus ou moins severe. Resultats Malgre un taux de satisfaction globale important (19/24), tous les patients presentaient des sequelles definitives. Les sequelles fonctionnelles les plus frequentes consistaient en des traumatismes dentaires (17/24), des atteintes sensitives d’au moins une branche du nerf trijumeau (15/24), des baisses de l’acuite visuelle ou des cecites (10/24), des douleurs invalidantes (10/24), des hypo ou anosmies (9/24), des obstructions des voies lacrymales (8/24) et des deviations symptomatiques de la cloison nasale (7/24). Les sequelles esthetiques les plus frequentes etaient des cicatrices faciales (23/24), des asymetries faciales (13/24), des dystopies du globe oculaire (11/24) et des modifications d’aspect de la pyramide nasale (10/24). Discussion La qualite de la prise en charge initiale, souvent multidisciplinaire, des traumatismes faciaux graves est un element primordial du pronostic tant fonctionnel qu’esthetique. Les interventions secondaires, techniquement plus difficiles, ne permettent le plus souvent qu’une attenuation des sequelles. Il apparait de ce fait clairement qu’il faut privilegier le traitement primaire, en un temps, mais que le retour a l’etat pre-traumatique est une utopie.

Introduction Le cherubisme est un processus extensif kystique atteignant surtout la mandibule, dont le diagnostic est souvent fait devant un facies joufflu chez l’enfant. Son determinisme familial est anciennement connu. Recemment identifiee, la mutation de l’exon 9 de SH3BP2 permet d’identifier les cas autosomiques dominants de la maladie. Observation Les auteurs rapportent le cas d’un enfant de 14 ans, de grade I, de diagnostic tardif. Une recherche genetique familiale, faite a Berlin, n’a pas retrouve la mutation du gene candidat. Discussion A cote des cas familiaux dominants, on retrouve des cas sporadiques, parfois lies a une neo-mutation identifiee du gene codant pour SH3BP2. Le cas presente a des antecedents familiaux de troubles de l’homeostasie osseuse et dentaire qui peuvent argumenter l’hypothese d’un mode de transmission autosomique recessif ou d’un autre gene candidat.

Introduction Le neurothecome est une tumeur rare. Elle est benigne mais doit etre distinguee de certaines tumeurs malignes notamment les tumeurs fibro-histiocytaire a cellules plexiformes, les melanomes neurotropes et les sarcomes a cellules claires. Observation Une enfant de 11 ans a consulte pour la recidive d’une tumeur sous-cutanee mentonniere, operee 4 mois plus tot. L’exerese avait ete incomplete. Une reprise chirurgicale au large a permis de controler l’evolution. L’etude histologique a etabli le diagnostic de neurothecome en particulier en raison de l’existence d’atypies et de mitoses, de nodules cellulaires et de l’extension a l’hypoderme. La confirmation a ete apportee par l’immuno-histo-chimie. Discussion Le neurothecome cellulaire est une tumeur benigne de la femme jeune, qui atteint souvent la face. Elle se presente comme un nodule dermique avec respect de l’epiderme. Ses caracteristiques immuno-histo-chimiques specifiques permettent le diagnostic differentiel avec la forme myxoide et les tumeurs melanocytaires et nerveuses. Le traitement est l’exerese chirurgicale.

Die Lippen konnen als ein phylogenetischer Zusammenschluss des Lippen-Nase-Gesichtsmuskulatur-Wachstums gesehen werden. Sie bilden das Zentrum der Gesichtsmorphogenese. Die progressive Entwicklung der Mund- und Gesichtsfunktion (Ernahrung und Kommunikation) ist mit elementaren Bedurfnissen wie Greifen der Nahrung, Saugen, Speichelhalten, Schlucken, Sprechen und Mimik verbunden. Jede Diskontinuitat bewirkt funktionelle und anatomische Storungen. Bei jedem Trauma oder Defekt der Lippen entsteht ein Ungleichgewicht zwischen Form und Funktion. Fur eine optimale Rekonstruktion ist die genaue Kenntnis der Lippenfunktion unverzichtbar.

An important study of lips arterial supply was enabled using multiple sources of information: anatomical dissection, cadaver and "in vivo" arteriography and phlebography. Literature was a great help, especially a recent analysis of lips microvascularisation done by H. Sick. The classical figure of labial circular artery was found out to be quite seldom, whereas an important number of anatomical variations where shown. Also there was a total independence between inferior and superior lip venous drainage, for embryological reasons. Finally lymph drainage was studied by anatomical dissection with the use of Gerota mass and the G. Hidden's work. It appeared that cutaneous and mucosal drainage were separate, since the nodes were different. All these information have been useful and confirmed during more than a thousand surgical procedures performed in our maxillo-facial surgery unit of Besancon medical school.

Upper alveolar nerves, when injured during Le Fort I osteotomies, alter maxillary tooth sensitivity. We had for aim to analyze post-operative maxillary tooth sensitivity recovery.We conducted a prospective study in a series of patients having undergone Le Fort I osteotomy, with, or without mandibular osteotomy or intermaxillary disjunction (IMD). The direction and range of displacement of the maxillary bone were recorded. One tooth in each alveolar sector (incisivocanine, premolar, molar) was tested with an electric stimulator for each patient. The tests were performed before (D-1), and after surgery (D2 or day+2, D+15, M2 (or month +2), M3, and M6).Twenty-two patients were included. Among the tested teeth, 91.9 % were sensitive at D-1. At D2, only 12.7 % of teeth were sensitive. At D15, M2, M3, and M6, the sensitivity was respectively 33.3 %, 43.1 %, 50 %, and 61.8 %. The recovery of sensitivity was faster in young patients (under 35 years of age) and for upper middle and superior alveolar nerves. There was no difference regarding the direction of maxillary movement.Among the teeth that were sensitive before surgery, 87.3 % had not regained sensitivity at D2. The recovery of sensitivity increased at D15. A great displacement of the maxillary bone was an aggravating factor for loss of tooth sensitivity.

Hyalinizing clear cell carcinoma (HCCC) of minor salivary glands (MSG) is a rare low-grade malignant neoplasm accounting for less than 1% of all salivary gland tumors. It usually affects the palate and the base of the tongue, and more rarely the parotid gland. We report a very rare maxillary localization.A 48-year-old male patient, without prior medical history, was referred to us for a painless gingival lesion of the right maxilla, extending from tooth 14 to 17, having appeared a few months before. The clinical examination was otherwise normal. Biopsy proved the diagnosis of HCCC. The CT scan revealed extension in maxillary sinus with bone osteolysis, and suspicion of cervical lymph nodes metastasis. The treatment was subtotal maxillectomy, cervical lymph node dissection, and postoperative radiotherapy because of incomplete bony resection.HCCC localization in the maxilla is extremely rare. This tumor may recur. The risk of metastasis is low; it concerns mainly lymph nodes. There is no treatment protocol consensus because the tumor is rare. Nevertheless, a wide local excision, with or without postoperative radiotherapy, seems to be the gold standard treatment.

False aneurysms of the superficial temporal artery (STA) are rare and usually occur after a direct trauma to one of its branches. It is characterized by the local rupture of the artery wall. The diagnosis is made by clinical history and clinical examination. The treatment is surgery.Two patients, a 20-year-old man and an 82-year-old man, were referred with a pulsatile mass respectively in the temporal and the frontal area having evolved for several weeks. The diagnosis was made on clinical history (history of trauma was an important clue) and clinical examination (compression of the proximal STA should reduce pulsation) and confirmed by ultrasonography. The treatment was surgical, the STA was ligated proximally and distally and the pseudoaneurysm was resected successfully.False aneurysms can be differentiated from true aneurysms by a rupture in the arterial wall. A thorough clinical history must screen for the initial trauma often gone unnoticed. The aim of clinical and paraclinical examination is to eliminate other causes of pulsatile tumors that can be found in this area (true aneurysms of the STA or of the meningeal artery).

The use of bone substitutes in massive sinus-lift pre-implant procedures remains controversial. The aim of our study was to evaluate the long-term reliability of pure-phase beta-tricalcium phosphate (betaTCP, Cerasorb, Curasan, Kleinostheim, Germany) used in this particular indication.Twenty patients (33sinus) presenting with severe sinus floor atrophy (class 4 to 6 according to Cawood) and having undergone a sinus lift procedure by mean of betaTCP were followed in a prospective study between January 2002 and May 2008. The surgical approach was classical (under local anesthesia in eight patients) and the sinuses were filled with betaTCP (6 cm3 on average per sinus) and autologous growth factors (platelet rich plasma PRP and platelet rich fibrin PRF, according to the technique described by Dohan and Weibrich). One hundred and twenty-three dental implants were inserted in the grafted sinuses between the fourth and the eighth postoperative month (Nobel Biocare MK III and MK IV-mean length: 12.44 mm) using a 2-step buried technique and loaded between the fourth and the sixth month. Follow-up included regular clinical examination and panoramic X-rays to screen for possible sinus and implant complications. The control X-rays also allowed measuring the biomaterial resorption rate.The mean postoperative follow-up was 4.5 years for the sinus lift procedures and 4 years for the implants. We noted one case of local infection at the 15th postoperative day (3%). The implant success rate was 97.6% (lack of osteo-integration for two implants in the same patient, one failure after loading). The prosthetic success rate was 100%. The mean resorption rate of the material was 20.3% and the mean gain of height was 16.9 mm.The use of betaTCP associated to growth factors (PRP ou PRF) without bone graft, in massive sinus-lift procedures induces few complications. The implant success rate is comparable to the one obtained by using autologous bone grafts. The resorption rate of the material is comparable to that of autologous bone.

The authors present a retrospective study about 20 patients operated for important breast hypertrophy and gigantomastia by the postero-inferior reduction technique. They compare the results obtained by this technique on the breast (projection, breast-feeding) and on the nipple-areola complex (sensibility, pigmentation, nipple projection), with those obtained by the Thorek technique (free nipple grafting). The authors show that this technique is reliable for such breasts hypertrophies, with good esthetics results, and avoid free nipple grafting.

Epitheloid hemangioendothelioma is a rare vascular tumor with a borderline malignancy and a potential risk for recurrence. It usually affects the soft tissue of extremities, the liver, and the lungs. The cervicofacial localization is rare. We report a very rare maxillary localization.An 8-year-old girl with no personal or family history was sent to us by her dentist for a painless ulceration of the right maxilla having developed months before. There was no cervicofacial lymphadenopathy. The orthopantomography was normal. CT scan revealed palatine osteolysis under the ulceration. Biopsy proved the diagnosis of an epitheloid hemangioendothelioma. Screening for metastases was negative. The final treatment was partial maxilectomy 11 months later. No sign of locoregional recurrence was observed.Twenty-six cases of oral epitheloid hemangioendothelioma have been reported. The localizations are mostly gingival and lingual. The gingival localization is more frequent in children. The small number of reported cases does not allow determining the risk of locoregional recurrence or metastasis. There is no consensus on treatment. Like other authors, we suggest performing a wide local excision and careful follow-up.

Physicians are often asked to draft a descriptive medical certificate for victims of traumatic maxillofacial injuries. Among other requisites, this certificate must mention the subject's total work disability. If the injury results from intentional or unintentional assault and battery, the duration of the work disability will determine the competence of the court that will try and condemn the perpetrator. Thus the total work disability certificate has penal value and should be used only for this purpose. Using the data acquired from a national inquiry in France, we evaluated common practices among a panel of maxillofacial teams concerning the information mentioned on the initial medical certificate and, in particular, the duration of work disability allocated for the most frequent facial fractures. The aim of this study was to establish, based on the observed practices, whether it would be licit to propose a total work disability scale for maxillofacial trauma.

Unlike severe head injuries upon which much attention is focused, mild or moderate brain injuries are not or not well known and often neglected in maxillofacial surgery. Nevertheless, they are frequent in our routine facial traumatology activity. Studying the epidemiological data shows that mild brain injuries account for 64 to 94% of all head injured patients whereas moderate injuries occur in 3 to 23%. Furthermore, owing to their frequent occurrence, their high potential for sequelae and because they especially affect young people, they are a real public-health problem.

Most victims of complex facial trauma will have permanent sequelae. The goal of our work was to evaluate, by means of a retrospective study, the long-term sequelae in these patients.102 victims of complex facial trauma were treated in our department between 1995 and 2000. Twenty-four could be re-examined in 2006 in order to evaluate their long-term sequelae. All the patients suffered a mild brain injury.The overall satisfaction rate was good (19/24), but all patients presented either functional or aesthetic sequelae. The major functional sequelae were dental lost (17/24), sensory impairment of the trigeminal nerve (15/24), partial or complete loss of vision (10/24), pain (10/24), hypo- or anosmia (9/24), stenosis of the lacrimal ducts (8/24) and symptomatic deviation of the nasal septum (7/24). The main esthetic sequelae were facial scarring (23/24), facial asymmetry (13/24), dystopia of the eyeball (11/24) and modification of the aspect of the nose (10/24).The prognosis of severe facial trauma is highly dependent on the quality of the initial pluridisciplinary care. Secondary revision procedures are technically more difficult and only enable partial resolution of persisting sequelae. Thus, primary single-course surgical procedures should be a priority, recognizing that complete recovery is almost always illusory.

The cases of 102 people who suffered brain and facial trauma were reviewed, noting the long-term outcome at more than 5 years. Results of complete physical examinations performed by a surgeon and an internist were available for 25 patients. Data noted were: circumstances of the traumatic event, classification of brain injuries, sensory and sensorial disorders, and persistent pain, psychological trauma, social and occupational consequences and at the final legal and financial compensation. These data were summarized in tables to facilitate discussion of the findings.

For patients with severe facial injuries, global management from trauma to "cure", is the leitmotif in the department of maxillofacial surgery of Besançon. The progressive development of therapy groups led to the creation of the "Maxillo Family" which is more or less modelled after well known "Gueules Cassées" French Association. We also created the "Journal of Maxillo" in which every injured patient can write his own story. This seems to be a very good therapeutic approach not only from the patients' point of view but also for practitioners and nurses. The testimony of a young woman victim of a dramatic accident with severe facial injury illustrates the interesting aspects of this therapeutic approach.

Neuropsychology, which deals with the relationships between upper mental functions and brain structures is directly involved with psychiatric and psychological disorders and thus constitutes one of the major domains of cognitive sciences. The impairment of upper mental functions is evident after severe brain injuries causing significant motor deficits. However, it is becoming increasingly evident that even mild or moderate brain injuries can cause sequelae which are difficult to analyze and quantify clinically. These sequelae constitute an "invisible handicap" which may greatly interfere with the patient's professional, relational and social life. The neuropsychological evaluation must be systematic and complete and has to be carried out with a sufficient hindsight (two to three years after the trauma) using neuropsychological and behavioural deficiency evaluation scales. Psychometric tests are also necessary. The data obtained from this evaluation must be correctly interpreted and constitutes the main exhibit in the forensic examination of the brain injured patient.

The aim of the study was to evaluate the mean-term efficacy and tolerance of the polylactic acid injections (New-Fill) for the correction of facial lipoatrophy occurring in HIV-positive patients under tri-therapy.The patients were managed at the University Hospitals of Besançon and Strasbourg (France) from January 2002 to December 2005 for a prospective study. The patients were consecutively included in this study once their consent was obtained. Patients not stabilized by their antiretroviral treatment were excluded. Facial lipoatrophy was classified in four clinical stages (stage I: mild, stage II: moderate, stage III: important, stage IV: severe) after a clinical examination. The polylactic acid solution was prepared according to the manufacturer's recommendations, and injected in a retrotracing manner in the hypoderm at the rate of one 5 ml flask per side, with an interval of one month. The number of sessions varied according to the severity of the stage. Treatment efficacy, assessed after a minimal follow-up of one year, was established clinically by comparing the initial and final photographs (changes in the clinical stage) and by the patient's and surgeon's satisfaction rate (from zero to ten). Treatment tolerance was established on the painfulness of injections and on socioprofessional constraints reported by the patients and made on a visual analogical scale. The occurrence of adverse-effects was checked. Finally, we compared the cost of the treatment with that of lipostructure.Twenty-five patients were included (mean age: 44, sex-ratio: 23 male/2 female patients). The mean body mass index was 21. The mean CD4 cell count was 600/mm(3). The mean HIV-1 RNA was 276 copies/ml. The severity of the lipoatrophy was stage one in two patients (8%), stage two in 12 patients (48%), stage three in nine patients (36%), and stage four in two patients (8%). The mean number of sessions was 5.2. The mean follow-up time was 26 months. In 76% of the cases we observed a complete correction of lipoatrophy (100% of stages I, 92% of stages II, 66% of stages III, 0% of stages IV). However, among stages II, III, and IV that were incompletely corrected, an improvement was noticed in all patients (grading to an inferior stage, at least). The mean satisfaction rate was 8/10 by patients and 7.2/10 by surgeons. In six patients (24%) a renewal of the treatment was proposed because of inadequate results. The painfulness of injections was rated at 3.3/10 and constraints at 3/10 by patients. One single case of visible and palpable sub-cutaneous granuloma was noticed in a patient at the end of the follow-up period (18 months).The use of polylactic acid is a safe and efficient procedure for the treatment of facial lipo-atrophy in HIV-infected patients, however severe the clinical stage may be, after a two-year follow-up period. We recommend hypodermic (and not dermic) injections to prevent adverse effects. This treatment is not more expensive then lipo-structure and the progressive correction is considered as an important advantage by patients. Considering our results, the simplicity of the procedure, and the low rate of complications observed, the injection of poly-lactic acid has become our first intention treatment for this condition.

Cherubism is an extensive kystic process of the mandibula. The diagnosis is often established in children presented swelling of the jaws. The familial determinism of cherubism is well-known, and recently autosomal dominant cases have been described with detection of the exon 9 - SH3BP2 mutation.We describe the case of a 14-year-old boy with grade I cherubism diagnosed late. The familial genomic analyze conducted in Berlin was negative for the recently identified candidate gene.Apart from dominant cases cherubism sometimes occurs sporadically, some of the cases resulting from a neomutation of the candidate gene. The present case with familial bone homeostasis and dental disorders is an argument for the recessive transmission hypothesis or for another candidate gene.

Neurothekoma is a rare benign tumor which must be distinguished from certain malignant tumors such as fibrohistiocyte tumors or plexiform cell tumors, neurotropic melanomas and clear-cell sarcoma.An 11-year-old girl consulted for a recurrent subcutaneous tumor of the chin which had been operated 4 months earlier. The resection was incomplete. A wider revision resection successfully stopped recurrence. The histology study established the diagnosis of neurothekoma due to the presence of mitosis atypia, cellular nodules, and extension to the hypodermis. Immunohistochemistry confirmed the diagnosis.Neurothekoma is a benign tumor observed in young women, mainly on the face. It occurs as a dermal cohesive mass without infiltration of the epidermis. The typical immunohistochemical pattern enables differential diagnosis with myxoid neurothekoma, melanocytic and nervous system tumors. Surgical resection is indicated.

An important study of lips arterial supply was enabled using multiple sources of information: anatomical dissection, cadaver and "in vivo" arteriography and phlebography. Literature was a great help, especially a recent analysis of lips microvascularisation done by H. Sick. The classical figure of labial circular artery was found out to be quite seldom, whereas an important number of anatomical variations where shown. Also there was a total independence between inferior and superior lip venous drainage, for embryological reasons. Finally lymph drainage was studied by anatomical dissection with the use of Gerota mass and the G. Hidden's work. It appeared that cutaneous and mucosal drainage were separate, since the nodes were different. All these information have been useful and confirmed during more than a thousand surgical procedures performed in our maxillo-facial surgery unit of Besançon medical school.

The authors describe the characteristics of the pterygium colli, symptom of several congenital diseases. Based on a review of the literature, they report the surgical techniques available to correct this deformity. This malformation may be due to asymmetrical development, inducing a vertical skin defect, which requires correction. The so-called posterior techniques are recommended; they allow good morphologic improvement (restoration of neck outline and natural posterior hairline), with minimal scarring. One case treated by a posterior technique is reported. Laterocervical skin expansion has been used by some authors, and seems to allow correction of these cutaneous anomalies, with a better morphologic and cosmetic result.

The deformation of the posterior part of the skull (occipito-vertebral region) induced directly, occurs in numerous pathological situations. Its significance is frequently overlooked. Lesions of the cranial content, alterations of the lambdoid suture or other premature synostosis, abnormal constraint related to posture or to muscular activity can modify the posterior curvature of the skull, generally flattening it. The authors propose a classification based on three points: intracranial pathology, bone pathology and extrinsic pathology. Concerning intracranial pathology, alterations of the brain or CSF fluid can induce either insufficient (microencephaly) or excessive (hydrocephalus, Dandy Walker or Arnold Chiari malformations) expansion. Concerning bone pathology, sagittal synostosis (scaphocephaly) induces a bulging and coronal synostosis a flatness of the posterior skull. Bilateral premature lambdoid synostosis (pachycephaly) produces total flatness of the back of the skull. Concerning extrinsic pathology, dysmorphism is often asymmetrical and results from extracranial mechanical application dysfunction such as inborn torticollis, cervical spine pathology (Klippel-Feil syndrome), or prolonged decubitus during the first year of life. The different surgical procedures are described and the authors describe a personal technique for correcting this dysmorphism: the turned biparietal flap transposition. The back of the skull is remodelled (either asymmetrical or bilateral flatness), and patients with no need for a helmet can lie on their backs immediately after the operation.

A madreporic coral graft was used for orbital floor reconstruction following facial trauma. This report presents a multicentric study of 83 patients with a follow-up period of 15 to 24 months. The results of this study indicate no significant rejection or infection opposed to so many synthetic implants outcome. The radiological follow-up demonstrates a partially resorption of the implant within about 2 years and its replacements by new bone. Coral implant was used to correct enophthalmos or diplopia due to enlarged orbital dimensions. It was technically easy to insert and its anatomic shape does not require to be fashioned before use. Its inflexibility allows to bridge large bone defects and this implant should be considered as an attractive alternative to autogenous grafts, avoiding a second surgical site, in reconstructing orbital floor fractures.

The treatment of craniostenoses has not been revolutionized over the last decade, but the methods of investigation, particularly 3D CT scan, histological studies, and refinement of techniques, have allowed substantial progress in the understanding of the aetiopathogenesis and treatment of craniostenoses. The deformities of the components of the base of the skull can now be more precisely analysed. The authors present these elements for each of the various types of craniostenosis. The role of soft tissues has been more clearly defined; the dura mater, corresponding to an internal periosteum, has an osteogenic, but also directional role. The concept of the brain as the essential determinant of cranial morphology has led to the proposal of treatments adapted to each deformity. Specific craniectomies have been completed by mobilization of flaps, and segmentation of the vault allowing almost ideal reconstruction of the skull. In most treated cases, directed osteogenesis results in good consolidation after seven to eight months; partial non-ossification remains frequent in children treated after the age of eighteen months.

The authors propose two simple techniques to improve the adaptation of the frontal vault after remodeling the orbito-naso-frontal flap in anterior craniostenosis. In trigonocephaly: the metopic suturectomy is enlarged by lateral translation of the two half frontal bones, then to fall the place the coronal suture is used. The temporal plates are moved forward and turned to fill the failure of fronto-temporal junction due to valgisation of orbito-naso-frontal band. In plagiocephaly: the frontal flattened flap is cut with oblique radial osteotomies starting at bregma so called "Daisy petal". The first internal petal is sacrificed. The others are rotated axially in a medial direction. Internal table corticotomies must be performed at two levels to recurve the flattening and to obtain a curve in the coronal plane. In this two techniques the pericranium and dura-mater must be carefully teated to obtain a better adaptation of the new bone shape and to permit the spontaneous reossification.

The authors present 87 patients with trigonocephaly who were operated on. They take an interest in the consequence of the early synostosis of the metopic suture. The metopic suture combine with the sagittal sutural system, but his spot of manifestation is unambiguous. Its manage the dimension of the frontal bone which himself has repercussions on the set of the orbits. Thereby the fronto-orbito-facial dysmorphy has two component parts. One direct with little frontal bone and a thick sutural spot which extend more or less to the bregma and a second indirect with early deformation of the orbits and late deformation of the parietal bones. Three clinical patterns are described: micro-frontal shape, medio-frontal shape and orbito-frontal shape. In the pure shapes there is no direct impact on the encephalon but the venous stasis is high and probably liable for the encephalic damage when they exist. A single surgical proceeding does not meet the many varieties of deformations. Resection of fused metopic suture from a bifrontal flap; confection of orbito-fronto-nasal band which is opened by greenstick fracture on the metopic site; transposition of an hemicoronal suture between the two hemifrontal valves lateraly translated; foreward mobilisation and interventing temporal flaps. To finish the modeling it is necessary to open the periosteum sheet in order to translate temporal muscles then to overlay with interparietal pedicularly periosteum the anterior step. Metopic synostosis is ordinarily only an aesthetic deformity infrequently associated with intracranial pathology. The treatment must be required for pronounced deformities to prevent significant psychosocial consequences.

The authors report their experience of cutaneous expansion in a retrospective study of 78 cases. They compare the two methods usually applied: discontinuous slow expansion in two thirds of cases versus rapid continuous expansion in one third of cases. Both methods, as they are defined in the department, are described. Statistical analysis revealed two important facts: the complication rate was considerably lower in continuous expansion. Length of hospital stay was similar for both techniques. The results, not yet studied in a strictly scientific way, do not appear to argue against continuous expansion. Rapid cutaneous expansion may be considered to be a valuable technique in the future, but it must be chosen for certain people only and must be adapted to each patient.

Convinced of the importance of a precise understanding of anatomy in modern surgery, the author studied the arterial blood supply and venous and lymphatic drainage and re-evaluated the innervation of the mammary gland; 60 fresh cadavers, 350 thermographies and 5 in vivo arteriographies were analysed. Twenty years of surgical practice either supported or contradicted these anatomical findings. Schematically, the arterial blood supply is ensured by three plexuses: cutaneoglandular plexus, retroglandular plexus, intraglandular anastomotic plexus; the cutaneoglandular plexus corresponds to a combination of the dermal and the glandular blood supplies. The ectodermal embryological origin of the mammary gland clearly accounts for this common blood supply. This concept allowed the development of deepithelialised periareolar pedicle reduction mammaplasty and acts as a guide for subcutaneous mastectomies. The retroglandular plexus is supplied, in particular, by the musculocutaneous and, in this case, musculoglandulocutaneous arteries. This plexus ensures the blood supply of the remaining gland following posterior or inferior pedicle reduction mammaplasty techniques. The venous drainage was studied in particular detail. Two venous plexuses are present: one runs parallel to the arterial blood supply and the other is superficial, subcutaneous and anastomotic not only with the deep plexus, but also with the all of the surrounding regions. This plexus, quiescent under normal conditions, becomes functionally important in certain pathological conditions or after correction of mammary hypertrophy. The external and internal pathways of lymphatic drainage have been described for a long time. The authors describe the lesser known accessory pathways which nevertheless play an essential role in certain forms of metastatic spread or recurrence of breast cancer. Lastly, the authors describe the sensory innervation of the mammary gland which is an essential element for preservation of nipple sensitivity, in particular, following reduction or augmentation mammaplasty or even breast reconstructions.

The superior orbital syndrome has been reported as a very rare complication of orbital fracture. In emergency clinical examination and computed tomography of the cranio-orbital region have provided diagnosis of the compression of the superior orbital fissure content by oedema and/or hematoma. These examinations have determined the type of cranio-orbital fractures and the absence of extra-dural haemorrhage, optical nerve damage or compression, which required emergency treatment. After surgical treatment of the cranio-orbital fracture by temporal and transconjunctival approach, the orbital fissure syndrome has required supervision. The recovery of ophthalmoplegia has taken several months. Minor after effects have been observed for the patient reported.

Tissue expansion is often unpleasant for the patient because of its long duration. The authors present a series of 16 rapid expansion prostheses implanted in 10 patients. The expansion was monitored by measuring the percutaneous oxygen partial pressure and intraprosthetic pressure. The expansions were performed without any complications. Monitoring of the expansion by measuring the pcPO2 appears to ensure good results.

The author describes a technique for one-stage repair of the columella which he has used since 1984. The procedure is based on the anatomical concept of the venous drainage of the columellar region and philtrum. Two vascularised para-alar flaps are raised from the philtrum then raised 90 degrees with an equivalent horizontal rotation. The donor site is closed by primary suture with no cicatricial sequelae. A columellar support can be inserted between the two flaps. The long-term results were considered to be good in every case.

Is the inframammary fold an anatomical entity? In order to answer this question, the authors conducted an anatomical, histological and radiological study. The results of these studies were concordant and were able to anatomically define the inframammary fold. The inframammary fold corresponds to a division of the fascia superficialis. It contains numerous fibres stretched between the fascia superficialis and the fascia prepectoralis. In contrast, there are no fibres connecting the fascia superficialis to the deep dermis.