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Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma and precursor lesions J.J. Bonerandi, C. Beauvillain, L. Caquant, J.F. Chassagne, V. Chaussade,** P. Clavere, C. Desouches, F. Garnier, J.L. Grolleau, M. Grossin,*** A. Jourdain, J.Y. Lemonnier, H. Maillard, N. Ortonne, E. Rio,**** E. Simon, J.F. Sei,** J.J. Grob, L. Martin,* for the French Dermatology Recommendations Association (aRED) Department of Dermatology, La Timone University Hospital, Marseille, France Department of ENT, Nantes University Hospital, Nantes, France Department of Maxillofacial Surgery, Saint-Etienne University Hospital, Saint-Etienne, France Department of Maxillofacial Surgery, Nancy University Hospital, Nancy, France **Department of Dermatology, Ambroise-Pare University Hospital, Boulogne-Billancourt, France Department of Oncoradiotherapy, Limoges University Hospital, Limoges, France Plastic Surgery, Private Practice, Marseille, France General Practitioner, Angers, France Department of Plastic Surgery, Toulouse University Hospital, Toulouse, France ***Department of Pathology, Louis-Mourier University Hospital, Colombes, France ENT, Private Practice, Laval, France Department of Gerontology, Orleans Hospital, Orleans, France Department of Dermatology, Le Mans Hospital, Le Mans, France Department of Pathology, Henri-Mondor University Hospital, Creteil, France ****Department of Oncoradiotherapy, CLCC Nantes, Nantes, France Department of Dermatology, Angers University Hospital, Angers, France *Correspondence: Prof. Ludovic Martin. E-mail: lumartin@chu-angers.fr

Resume Introduction Le cylindrome de Poncet-Spiegler (CPS) est une tumeur cutanee benigne annexielle qui siege preferentiellement au niveau du cuir chevelu, du cou et du front. Les localisations peuvent etre isolees ou multiples. Il atteint souvent l’adulte jeune. Il s’agit de lesions a croissance progressive. Lorsque le cuir chevelu est entierement envahi, il presente l’aspect de « tumeur en turban ». Le traitement est chirurgical et peut etre delicat quand la tumeur est etendue. Nous presentons la prise en charge d’une tumeur turban. Observation Une patiente de 25 ans a d’abord beneficie de l’exerese partielle de lesions nodulaires du cuir chevelu dont l’histologie mettait en evidence un CPS. Elle a ete perdue de vue. Neuf ans plus tard, elle a ete prise en charge pour un CPS en aspect de turban. Le traitement a consiste en l’exerese totale du cuir chevelu et une reconstruction secondaire par greffe cutanee. Le suivi a ete marque par une amelioration fonctionnelle et esthetique et apres deux ans de suivi, il n’y avait pas de signe de recidive. Discussion Comme la plupart des tumeurs, la taille du CPS guide la prise en charge. Un traitement chirurgical agressif doit etre envisage si la forme est etendue. En cas d’aspect en turban, une exerese complete du cuir chevelu et une reconstruction secondaire par greffe cutanee est preconisee.

Resume Introduction La region mediojugale est un site frequent de lesions cutanees qu’elles soient benignes ou malignes. Leur prise en charge est essentiellement chirurgicale et peut conduire a des resections cutanees larges. L’objectif de ce travail etait de presenter une technique de reconstruction jugale utilisant le reservoir cutane sous-mental par un lambeau cervicofacial a translation verticale. Materiel et methode Notre etude portait sur neuf patients (trois femmes et six hommes). L’âge moyen etait de 46 ans (21–74). La perte de substance etait mediojugale dans tous les cas et le diametre moyen etait de 5 cm (4–6). L’incision a ete realisee a la jonction des sous-unites esthetiques jugale, face laterale du nez, labiale superieure et inferieure et mentonniere. Ce lambeau trifolie a ensuite ete translate verticalement et son pole superieur a ete solidement arrime au perioste adjacent. Le recul etait de quatre ans. Resultats Toutes les pertes de substance ont ete recouvertes en totalite. Aucun cas de necrose cutanee, notamment distale n’a ete constate. Un cas de paresie labiomentonniere definitive est survenu en periode postoperatoire ainsi que deux cas d’ectropion sans lagophtalmie. Discussion Selon notre experience, ce type de lambeau est indique dans les larges pertes de substance mediojugales sans extension a l’aile narinaire, a la levre superieure et a la paupiere inferieure.

Summary Introduction The use of resorbable materials in orthognathic surgery is presently the object of numerous clinical and experimental studies. Their main drawbacks are their lack of rigidity and induced chronic inflammatory reactions. The purpose of this study was to propose and to test an original system of hybrid osteosynthesis associating a single titanium plate with three resorbable plates in Le Fort I osteotomies in the absence of maxillary expansion, or two titanium plates with two resorbable plates in case of maxillary expansion. Methods Our retrospective study concerned 28 patients operated between 2002 and 2005. A clinical follow-up of over one year detected the specific complications of the hybrid system and a cephalometric study analyzed the secondary relapse 5 months after surgery. These results were compared to the literature. Results One case of mobility and a case of instability of the jaw were observed, along with 5 cases of local chronic inflammatory reaction. The radiological results found a secondary sub-clinical relapse. The removal of the titanium material under local anesthesia was performed without difficulties in ambulatory care, which avoided a new hospitalization for the patient and a new general anesthesia. Discussion The hybrid system allowed obtaining a postoperative stability of the jaw comparable to that obtained by the exclusive use of titanium plates with an acceptable morbidity. This method of osteosynthesis combined the advantages of the resorbable material (removal of titanium plates under local anesthesia) and of titanium material (stability of the procedure). However this method requires a good experience of working with resorbable material, a good follow-up, and cooperative patients. These encouraging results urge us to extend the indications to mandibular sagittal osteotomy and to bi-maxillary osteotomies.

Resume Introduction. – La macrostomie congenitale fait partie des fentes faciales dites rares par opposition aux fentes labioalveolopalatines. Materiel et methode. – Nous rapportons une serie de dix patients porteurs de macrostomies congenitales. Une etude retrospective epidemiologique et clinique de chaque cas a ensuite ete realisee. Resultats et Discussion. – De ces constatations cliniques, ressort une classification simple ayant des repercussions directes sur la sequence therapeutique.

Resume Introduction L’evolution intracrânienne du melanome cutane est habituellement due a des metastases. L’evolution neurotrope des tumeurs malignes vers l’endocrâne concerne principalement les nerfs trijumeau et facial. Parmi les types histologiques de tumeurs neurotropes, le melanome constitue une entite rare. Observation Un patient a presente un melanome desmoplastique palpebral inferieur. L’evolution a ete marquee par l’envahissement du sinus caverneux, puis du nerf mandibulaire a partir du nerf maxillaire. Discussion Cette evolution neurotrope doit attirer l’attention en cas de lesion tumorale a proximite d’un nerf. Une chirurgie d’exerese large doit etre preconisee dans ce type de tumeur. Dans le cadre de la surveillance d’un melanome, notamment desmoplastique, tout signe neurologique moteur ou sensitif doit faire discuter une exploration approfondie par IRM.

The Poncet-Spiegler cylindroma (PSC) is a benign annexal cutaneous tumor which preferentially develops on the scalp, neck, or forehead. Localizations may be isolated or multiple and often affect the young adult. The lesions grow progressively. When the scalp is completely involved, it presents as a "turban tumor". Treatment is surgery and may be difficult when the tumor is extended. We report the management of turban tumor.A 25 year-old female patient was first treated by partial scalp nodule exeresis and histology documented a PSC. She was lost to follow-up. But 9 years later, she was managed for a turban like PSC. The treatment was a complete scalp exeresis and secondary reconstruction with a skin graft. Follow-up was uneventful with a progressive functional and cosmetic improvement and after 2 years, there was no relapse.As for most tumors, management depends on the size of the PSC. An aggressive surgical treatment must be considered if the PSC is extended. In case of turban tumor, total scalp exeresis and secondary reconstruction with a skin graft is recommended.

A pneumomediastinum was discovered fortuitously on a CT scan prescribed to a patient for facial and cranial trauma. Emphysema was attributed secondarily to an anterolateral maxillary wall fracture. The evolution was favorable after simple clinical and radiological surveillance.The observation of a pneumomediastinum should first be related to a tracheal or esophageal wound with a severe prognosis. Endoscopy under general anesthesia was not necessary for our patient thanks to CT scan with 3D reconstruction. There is no consensus for systematic antibioprophylaxis.

The intracranial evolution of cutaneous melanoma is usually due to metastases. Neurotropic invasion mainly concerns the trigeminal and the facial nerves. The melanoma is a rare entity among neurotropic tumors.A patient presented with a desmoplastic melanoma of the lower lid, complicated by a perineural extension to the cavernous sinus and the mandibular nerve via the maxillary nerve.This neurotropic evolution should be carefully monitored when close to a nerve. Extensive surgical excision including peripheral nerves in the vicinity of such tumors is recommended. MRI should be performed when a motor or sensitive disorder appears in the course of a desmoplastic melanoma.

Introduction Nous rapportons deux cas de syndrome de choc toxique apres exerese chirurgicale de tumeurs cutanees. Observations Deux patients sans comorbidites (ASA1, PS : 0), sont operes de volumineuses tumeurs cutanees avec recherche de ganglion sentinelle. La chirurgie s’est compliquee d’un syndrome de choc toxique. Premier cas : une patiente de 67 ans presentait un melanome nodulaire achromique de l’avant-bras, indice de Breslow 15 mm, diagnostique sur une biopsie. Une exerese avec marges de 3 cm est realisee avec recherche de ganglion sentinelle. Le ganglion n’a pu etre preleve, le traceur n’ayant pas fixe. Le lendemain de l’intervention, la patiente a presente une hyperthermie dans un contexte de choc vasoplegique avec apparition d’une erythrodermie generalisee. Les hemocultures ne montraient pas de germe. Six jours apres l’intervention initiale, la patiente est reoperee pour une fasciite necrosante de l’avant-bras dont les prelevements montraient la presence d’un Staphylocoque aureus sensible a la meticilline avec presence d’Enterotoxine C. Les prelevements locaux a la recherche de gites staphylococciques etaient negatifs. Deuxieme cas : un patient de 60 ans etait opere d’un carcinome epidermoide cutane recidivant, necrotique, de 6 cm de grand axe, du vertex. L’analyse du ganglion sentinelle etait negative. Au 2 e jour postoperatoire, le patient presentait un tableau de choc septique avec un exantheme diffus et un placard necrotique pectoral. Les hemocultures etaient positives et montraient un Streptocoque communautaire du groupe A. Le diagnostic de syndrome de choc toxique etait retenu. Le patient avait ete en contact quelques jours avant l’operation avec un membre de sa famille ayant la scarlatine. Discussion Les syndromes de choc toxiques sont dues a la secretion de toxines superantigenes par le Staphylocoque aureus (SA) (TSST-1, enterotoxines A, B, C, D, E) ou par les Streptocoque beta-hemolytique (SBH) des groupes A, B ou C (exotoxines A, B, C) responsables d’une activation inadaptee et disproportionnee du systeme immunitaire entrainant la liberation massive de cytokines. Bien qu’exceptionnels, les chocs toxiques sont une des complications connues des interventions chirurgicales et peuvent entrainer d’importantes sequelles, voire engager le pronostic vital. Une porte d’entree cutanee ou l’atteinte des tissus mous est souvent presente. L’injection du traceur au cours du ganglion sentinelle, en peripherie d’une tumeur potentiellement colonisee, pourrait egalement favoriser la penetration du germe. Un interrogatoire a la recherche d’un contage ainsi que des prelevements bacteriologiques sur la tumeur cutanee pourraient permettre de limiter les risques de developper un choc toxique dans les suites d’une intervention chirurgicale dermatologique. Conclusion Le syndrome de choc toxique est une complication rare mais grave en chirurgie dermatologique, concernant notamment les volumineuses tumeurs cutanees.

Cheeks are frequently the sites of common skin tumors. Surgery is the common treatment of those lesions and the operative defect can be important. The aim of this study was to present reconstruction of lateromedial cheek defects with a vertical translation flap.Nine patients (three women and six men) with a mean age of 46 years (21-74) were included. The defect was located in the medial part of the cheek in all cases with a mean diameter of 5 cm (4-6). The incision was made between the cheek, lateral nasal area, upper and lower lips, and chin aesthetic units. Then the flap was vertically translated and the upper end was fixed to the adjacent periosteum. The average follow-up was four years.In all cases the defect was covered and there was no case flap necrosis. In one case a postoperative paresia of the marginal ramus was noted and two patients presented with minor ectropion without lagopthalmia.In our experience this type of flap is indicated in large cheek defects without extension to nasal ala, upper lip, and lower eyelid.

The use of resorbable materials in orthognathic surgery is presently the object of numerous clinical and experimental studies. Their main drawbacks are their lack of rigidity and induced chronic inflammatory reactions. The purpose of this study was to propose and to test an original system of hybrid osteosynthesis associating a single titanium plate with three resorbable plates in Le Fort I osteotomies in the absence of maxillary expansion, or two titanium plates with two resorbable plates in case of maxillary expansion.Our retrospective study concerned 28 patients operated between 2002 and 2005. A clinical follow-up of over one year detected the specific complications of the hybrid system and a cephalometric study analyzed the secondary relapse 5 months after surgery. These results were compared to the literature.One case of mobility and a case of instability of the jaw were observed, along with 5 cases of local chronic inflammatory reaction. The radiological results found a secondary sub-clinical relapse. The removal of the titanium material under local anesthesia was performed without difficulties in ambulatory care, which avoided a new hospitalization for the patient and a new general anesthesia.The hybrid system allowed obtaining a postoperative stability of the jaw comparable to that obtained by the exclusive use of titanium plates with an acceptable morbidity. This method of osteosynthesis combined the advantages of the resorbable material (removal of titanium plates under local anesthesia) and of titanium material (stability of the procedure). However this method requires a good experience of working with resorbable material, a good follow-up, and cooperative patients. These encouraging results urge us to extend the indications to mandibular sagittal osteotomy and to bi-maxillary osteotomies.

Macrostomia or lateral cleft or commissural cleft or transverse cleft is a rare facial cleft in comparison with standard cleft lip and palate.A retrospective study of 10 cases of congenital macrostomia is realised. For each case a retrospective study with epidemiologic and clinic features was realised.From these clinical considerations, a new classification with direct surgical consequences is proposed.

Resume Observation Un pneumomediastin a ete decouvert fortuitement sur un scanner prescrit dans un contexte de traumatisme crânien et facial. L’emphyseme a ete secondairement rapporte a une fracture de la paroi anterolaterale du maxillaire. L’evolution a ete favorable apres une simple surveillance clinique et radiographique. Discussion La decouverte d’un pneumomediastin doit en premier lieu faire evoquer une plaie tracheale ou œsophagienne, dont le pronostic est grave. Le scanner en coupes axiales avec reconstructions tridimensionnelles nous a permis d’eviter une endoscopie sous anesthesie generale. L’antibioprophylaxie systematique est discutable.