[Not Available]

During a judicial inquiry, the forensic doctor is frequently required to examine the hospitalized fire victim. He has to produce a certificate on the burns, defining their origin, seriousness and prognosis. The expert assessment of serious burn victims consists in an overall evaluation of functional and psychological sequelae, and can be conducted only after the long period of treatment needed for them to heal. The expert must know the forensic rules concerning the specific features of sequelae that follow a cutaneous burn injury. The forensic doctor can intervene where a body is discovered, and the aim of the autopsy is to check if burns were the cause of death. The most common lesions observed are serious thermal burns and they are frequently associated with inhalation of fumes. Often the body is carbonized to conceal a homicide therefore it is crucial that postmortem results are compared with the police investigation data. Due to modifications to the body brought about by fire and charring, a specific protocol for identification is required, especially in the event of a disaster.

Vulnérologie: un néologisme pour magnifier le concept «plaies et cicatrisation»

Wound healing, though probably the most critical aspect of essential medical and surgical care, has been neglected for a long time. With the tremendous surge over the last two decades in basic research and in new techniques, wound healing is emerging more and more as a well-defined medical entity transcending existing specialties and subdivisions. Specialists working on the same subject must be known by a common name. There is a need to fill the gap in our current medical nomenclature in order to define all those interested in this subject. With etymologic, semantic and botanical arguments, Vulnerology seems to be an appropriate neologism. It will unite in the same group people who share a common interest and way of thinking to promote the concept of wound healing.

Tuberous breast: revised classification and a new hypothesis for its development

The tuberous breast classification proposed by Grolleau does not account for a minor form of the deformity characterized by isolated nipple-areola protrusion with a normal breast base. We have observed this minor form in six patients with normal breast shape and in ten patients with hypertrophic breasts. We propose an anatomical and physiological hypothesis for the development of the mammary gland. The breast is subjected to hormonal influences as early as the prepubertal period. These influences result in thrusting forces with both horizontal (estrogen) and vertical (progesterone) vectors, unfortunately not always balanced and harmonious. Close observation of the anomaly in our patients substantiated the basic anatomical defect, namely, the structural congenital dermal weakness of the nipple-areola complex (NAC) already described in all forms of tuberous breast deformity. This weakness explains the morphologic anomaly and confirms that all types of tuberous breast deformity constitute a spectrum of a single entity. It indicates also that the classification of tuberous breasts should include, in addition to the three types (types I-III) already described, a fourth type (type 0) to describe isolated simple areola protrusion, either permanent or intermittent, that is associated with a normal mammary base. The revised classification of tuberous breasts and the proposed hypothesis of breast development allow better assessment of all possible variants of breast morphologic anomalies. In the six cases of isolated herniated NAC, the deformity was corrected through a perinipple approach (not circumareolar), with adequate stable correction of the deformity and minimal scarring.

An innovative procedure for the treatment of primary and recurrent capsular contracture (CC) following breast augmentation

BACKGROUND

Capsular contracture (CC) is the most frequently reported complication following alloplastic breast augmentation. At present, none of the available preventive measures are effective, and various treatment modalities have been advocated. Reduction of the inflammatory process is critical for successful treatment. Late intracapsular glucocorticosteroid (GC) injections have been somewhat effective for the treatment, but the fine balance between the effectiveness of therapeutic GC dosages and their potential serious side effects is of utmost importance.

OBJECTIVES

The authors investigate whether instillation of a rapid-acting water-soluble GC in the implant pocket during the early proliferative phase of wound healing is more effective than delayed instillation during the remodeling phase.

METHODS

Between 2003 and 2009, 33 consecutive patients presenting with CC (Baker grades III and IV) were managed by capsulectomy with implant replacement and corticosteroid therapy immediately as well as 2 to 3 days later through an indwelling catheter left in place for that period. This delayed but early administration is a novel technique for GC injection.

RESULTS

Complete correction of the contracture with no recurrence was achieved in all patients with a follow-up range of 2 to 10 years.

CONCLUSIONS

This GC administration technique avoids the potential complications of long-term, slow corticosteroid release. It has a targeted anti-inflammatory effect, probably at a critical stage of the healing process, and could effectively prevent CC following alloplastic breast augmentation.

Vulnerology: a new term to describe the discipline of wound care

Although wound healing is probably the most critical aspect of essential medical and surgical care, it has been neglected for a long time. With the tremendous surge over the last two decades in basic research, wound healing is emerging as a well-defined medical entity transcending existing specialties and subdivisions. In view of the multitude of health professionals interested in the field of wounds and wound healing, it seems reasonably warranted to group them under one and single appellation. We suggest 'vulnerology' as a new term to describe the discipline of wound care.

[Medico-legal assessment in the sequelae of burns (1st part)]

The assessment of physical injury in after-effects of burns is very specific. Indeed, the evolution of burn scars is particular compared to the scarring process in general. The expert needs to know these specific aspects in order to objectively assess the after-effects due to burns, in order to compensate for the loss of autonomy in major burn victims. The assessment has to analyze all the effects, functional and aesthetic, of the after-effects due to burns and has to particularly specify: the mending, which can never be set before one year, the pressure test allowing to check the complete maturation of the scars; the functional disability which results from skin retractions (due to after-effects) on the limbs mobility but which also must consider the burnt skin surface; the aesthetic damage, often important, with a discrimination between hypertrophic and keloid scars; the suffering, always significant in view of specialized and prolonged therapeutics; the sexual damage, often unrecognized in this type of injured people.

[A comparative study of bacterioplankton structure in Argentinian Sea waters by the 454-tag pyrosequencing method]

The present study provides the first information about diversity and abundance of microbial communities in two environments of the Argentinian Sea by the 454 - tag pyrosequencing technique. We observed more than 4,600 unique bacterial sequences from 36,188 tag amplicons, forming 280 phylotypes. In addition, nearly 2,700 unique sequences from more than 47,700 tags identified as Archaea, defined only 5 different phylotypes. The Jaccard distance (0.6 for Bacteria and 0.2 for Archaea) indicated higher differences among Bacteria rather than among Archaea in both studied sites. The dominant phylotypes in marine environment were Bacteroidetes Flavobacteriaceae, Proteobacteria Gammaproteobacteria, Proteobacteria Rhodobacteraceae and Proteobacteria Rickettsiales SAR11; and Pseudoalteromonadaceae Pseudoalteromonas, Proteobacteria Gammaproteobacteria, Proteobacteria Shewanella, Proteobacteria Rickettsiales SAR11 in the estuary sampling site. Archaea Euryarchaeota and Archaea Crenarchaeota were the major archaeal phylotypes found. The most abundant tag sequences included previously characterized taxa, although we also retrieved a large number of highly diverse, low-abundant phylotypes which constitute a largely unexplored "rare" biosphere. These microorganisms could have a crucial ecological role.

Burn prevention mechanisms and outcomes: pitfalls, failures and successes

Burns are responsible for significant mortality and morbidity worldwide and are among the most devastating of all injuries, with outcomes spanning the spectrum from physical impairments and disabilities to emotional and mental consequences. Management of burns and their sequelae even in well-equipped, modern burn units of advanced affluent societies remains demanding and extremely costly. Undoubtedly, in most low and middle income countries (LMICs) with limited resources and inaccessibility to sophisticated skills and technologies, the same standard of care is obviously not possible. Unfortunately, over 90% of fatal fire-related burns occur in developing or LMICs with South-East Asia alone accounting for over half of these fire-related deaths. If burn prevention is an essential part of any integrated burn management protocol anywhere, focusing on burn prevention in LMICs rather than treatment cannot be over-emphasized where it remains the major and probably the only available way of reducing the current state of morbidity and mortality. Like other injury mechanisms, the prevention of burns requires adequate knowledge of the epidemiological characteristics and associated risk factors, it is hence important to define clearly, the social, cultural and economic factors, which contribute to burn causation. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs) such as the United States due to sustained research on the epidemiology and risk factors, the same cannot be said for many LMICs. Many health authorities, agencies, corporations and even medical personnel in LMICs consider injury prevention to have a much lower priority than disease prevention for understandable reasons. Consequently, burns prevention programmes fail to receive the government funding that they deserve. Prevention programmes need to be executed with patience, persistence, and precision, targeting high-risk groups. Depending on the population of the country, burns prevention could be a national programme. This can ensure sufficient funds are available and lead to proper coordination of district, regional, and tertiary care centres. It could also provide for compulsory reporting of all burn admissions to a central registry, and these data could be used to evaluate strategies and prevention programmes that should be directed at behavioural and environmental changes which can be easily adopted into lifestyle. Particularly in LMICs, the emphasis in burn prevention should be by advocating change from harmful cultural practices. This needs to be done with care and sensitivity. The present review is a summary of what has already been accomplished in terms of burn prevention highlighting some of the successes but above all the numerous pitfalls and failures. Recognizing these failures is the first step towards development of more effective burn prevention strategies particularly in LMICs in which burn injury remains endemic and associated with a high mortality rate. Burn prevention is not easy, but easy or not, we have no options; burns must be prevented.

Effect of silver on burn wound infection control and healing: review of the literature

Silver compounds have been exploited for their medicinal properties for centuries. At present, silver is reemerging as a viable treatment option for infections encountered in burns, open wounds, and chronic ulcers. The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process and that silver may have serious cytotoxic activity on various host cells. The present review aims at examining all available evidence about effects, often contradictory, of silver on wound infection control and on wound healing trying to determine the practical therapeutic balance between antimicrobial activity and cellular toxicity. The ultimate goal remains the choice of a product with a superior profile of infection control over host cell cytotoxicity.

Second-degree burns: a comparative, multicenter, randomized trial of hyaluronic acid plus silver sulfadiazine vs. silver sulfadiazine alone

AIMS

This multicenter, multinational, randomized, double-blind, controlled, parallel-group study, was designed to assess the efficacy and safety of a fixed combination topical medicinal product, containing 0.2% hyaluronic acid and 1% silver sulfadiazine (HA-SSD) (Connettivina Plus cream) versus 1% silver sulfadiazine cream alone (SSD), in the treatment of second-degree burns.

METHODS

111 adult patients (age 18-75 years) of both sexes, with IIa-degree (superficial) and IIb-degree (deep dermal) burns, were randomized to receive HA-SSD or SSD. Treatments (approximately 5 g/100 cm2) were applied once a day until the wounds healed, but for no longer than 4 weeks. Burns had to have occurred within 48 hours from the start of treatment, be caused by thermal injury, and be confined to the trunk and/or upper and lower extremities.

RESULTS

Results showed that both the fixed combination HA-SSD, and SSD alone, were effective and well tolerated topical agents for the treatment of second-degree burns. All burns were healed except in one patient treated with SSD. It was also observed that the fixed combination HA-SSD caused a significantly more rapid re-epithelialization of burns, i.e. a shorter time to healing, than SSD alone. The difference recorded--4.5 days--was statistically significant (p = 0.0073).

CONCLUSION

The observed shorter time to healing caused by the fixed combination is clinically relevant and further demonstrates the wound healing activity of HA.

Keloid or Hypertrophic Scar

Keloid and hypertrophic scars are 2 types of excessive scarring observed clinically that require different therapeutic approaches. The clinical course and physical appearance define keloids and hypertrophic scars as separate entities; however, they are often confused because of an apparent lack of morphologic differences. Nevertheless, clinical differences between hypertrophic scars and keloids have long been recognized by plastic surgeons and dermatologists. Yet, translating these differences into morphologic or biochemical distinctions has prompted much conflict in the literature. The present report is an attempt to clarify the longstanding controversy regarding these 2 similar yet separate and nonidentical entities by highlighting the reported points of differentiation as well as the similarities.

Moist exposed therapy: an effective and valid alternative to occlusive dressings for postlaser resurfacing wound care

BACKGROUND

Laser resurfacing has now become an accepted and important component of facial rejuvenation. With the introduction of computerized scanning systems, the actual laser resurfacing technique has been greatly simplified; however, the final outcome still depends to a large extent on the efficiency of the postlaser wound care in promoting wound healing and preventing early and late complications. It has been repeatedly confirmed that a moist environment is the single most important external factor affecting the rate of re-epithelialization. Occlusive moisture-retentive dressings, however, are difficult to apply and maintain in position and may as well be complicated by serious infections.

OBJECTIVE

Moist exposed burn ointment has been shown to maintain adequate moisture for optimal healing by frequent ointment application without the need for a secondary overlying dressing. It would be ideal for postoperative laser care.

METHODS

Twenty-eight consecutive patients treated with coherent ultrapulse CO2 laser in Toulouse, France, were included in the trial. Moisture-retentive ointment was applied over the treated areas every 4 to 6 hours. Healing was assessed clinically and with repeated transepidermal water loss measurements. Swab cultures were taken, and pain was evaluated with a visual analog scale. Colorimetric analysis of pictures taken was statistically compared with picture analysis of 20 patients treated earlier with an occlusive dressing.

RESULTS

Uneventful timely healing occurred in all patients with minimal pain and discomfort. Healing with moist exposed therapy resulted in faster recovery of cutaneous erythema, as evidenced by colorometry.

CONCLUSION

Moist exposed burn ointment application can be safely considered a good and valid alternative to occlusive dressings for postoperative laser care.

[Treatment of facial lesions in Parry-Romberg and Barraquer-Simons syndromes: report of 12 clinical cases]

The authors report their personal experience in surgical treatment of facial atrophies. The series present two types of facial atrophy: Parry-Romberg syndrome and Barraquer-Simons syndrome. After reviewing the etiology, pathogenesis and clinical features of these two entities, the authors describe their series of 12 patients: six presenting Parry-Romberg unilateral facial atrophy, six presenting from Barraquer-Simons bilateral facial atrophy. After a review of the literature, they draw conclusions about surgical repair techniques used (free or pedicled flaps, alloplastic grafts, lipofilling) and compare them with those reported in the literature.

Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry

A variety of breast deformities of differing appearances can be grouped together within an extensive syndrome that is characterized by anomalies of the breast base and preferentially involves the lower quadrants. Tuberous breasts are the most typical, but not the only, form of the deformity. The authors studied a series of 37 patients who had breast surgery, and they used a classification of three types: I, II, and III (in increasing order of severity). In type I breasts (minor form), only the lower medial quadrant is deficient; in type II breasts, both lower quadrants are deficient; and in type III breasts, all four quadrants are deficient. The study showed a predominance of minor forms (54 percent of breasts operated on) and of combinations including at least one minor form (81 percent of patients). Seventy percent of women had a breast asymmetry of more than 100 g. Only 27 percent of breasts operated on were hypotrophic, 45 percent were of normal volume, and 28 percent were hypertrophic. The authors propose a procedure to treat the minor forms of the deformity, using a mammaplasty with a superior pedicle and a lower lateral dermoglandular flap to fill the deficient lower medial quadrant. They define the indications of the classic techniques according to the type of deformity and stress the frequent need for secondary revision.

Surgical treatment of sacrococcygeal pilonidal sinus disease by excision and skin flaps: the Toulouse experience

OBJECTIVE

To compare various techniques for the treatment of pilonidal sinus.

DESIGN

Retrospective study

SETTING

University Hospital of Toulouse, France.

SUBJECTS

246 consecutive patients who presented between 1979 and 1996. The male:female ratio was 2:1, and the mean age 26 years (range 18-69).

INTERVENTIONS

218 one or two stage excision and rotation skin flaps, and 28 simple incisions.

RESULTS

16 sinuses recurred, and no flaps necrosed.

CONCLUSION

Excision and rotation skin flaps offers an effective and elegant alternative to the more classic operations for pilonidal sinus as it causes less postoperative pain and shortens convalescence.

["Saphenous vascular loop" technique in the treatment of lower limb defects. Report of five cases]

Five patients with high energy trauma of the lower limb with tissue defect located in the knee or the proximal third of the leg underwent reconstruction with a free latissimus dorsi flap. This flap was connected to a vascular saphenous loop which initially creates an arterioveous shunt between proximal femoral vessels. This was performed in a single operation with two teams of surgeons. This technique was chosen because a healthy recipient pedicle was not available in the vicinity of the defect. Application of vein grafts is not the usual procedure but there are situations in which it becomes necessary. Our aim in this paper is to discuss these situations, to describe the technique used in our Hospital and to analyze the advantages and disadvantages of a one or two-stage operation.

A predetermined design for easier aesthetic abdominoplasty

The authors have presented a predetermined design of cutaneous resection for abdominoplasty without relocation of the umbilicus. The design is characterized by two lateral tips, pointing upward, and a central dome. The upper and lower edges of the cutaneous incision are of the same length, which prevents puckers and allows optimal evolution of the scar. The median cutaneous resection removes the horizontal base of the triangular area of pubic hair, producing a lower final scar and giving the mons pubis a more youthful appearance. The lateral cutaneous resections allow transverse redraping of the abdominal skin, and the oblique scars, placed in the natural folds, are easily concealed even under brief attire. Unlike individual resection techniques that require practice and experience, this technique is perfectly codified and can be carried out by less experienced surgeons.

[Effect of irradiation fields on the results of breast reconstruction with skin expansion after radiotherapy]

Deferred prosthetic breast reconstruction after skin expansion is considered to be difficult after radiotherapy. The authors report a series of 14 cases of reconstruction after radiotherapy, compared with 6 cases of reconstruction without radiotherapy. They reported a similar quality of results after radiotherapy not including irradiation of the chest wall and in the absence of radiotherapy (p = 0.742). On the other hand, a significant deterioration of the results was observed when radiotherapy included chest wall irradiation (p = 0.0015). Finally, no direct correlation was observed between the macroscopic appearance of the skin and presence or absence of a history of irradiation of the chest wall. They conclude that the indications for reconstruction by tissue expansion after radiotherapy must be based more on the irradiation protocol than on the macroscopic appearance of the skin.

[Morphological anomalies of breasts in adolescent girls and their surgical correction]

BACKGROUND

Morphological anomalies of the breast in adolescent girls cause considerable psychological distress. Plastic and reconstructive surgery offer the possibility of improving such conditions. The aims of this work were to define and illustrate the various types of anomalies, clarify their distribution and present the repair methods that can be used and the results obtained.

POPULATION AND METHODS

A consecutive series of 33 girls under the age of legal majority, admitted over a 1-year period for surgical modifications of breast shape, was studied. The basic anomalies were classified as mammary hypertrophy, hypotrophy, asymmetry, and abnormal shape, among which were Poland's syndrome, tuberous breasts, thelorism and pute ptosis. The basic techniques used were reduction, augmentation with placement of an implant and breast remodeling. Distribution of anomalies was as follows: symmetrical bilateral hypertrophy, 33%; asymmetric bilateral hypertrophy, 30%; unilateral hypertrophy, 6%; combined hyper- and hypotrophy, 3%; unilateral hypotrophy with abnormal shape, 9%; abnormal shape with normal size, 15% and bilateral hypotrophy, 0.3%. Mean hospital stay was 3 days and there were no serious postoperative complications.

DISCUSSION

Bilateral hypertrophy was the most frequent disorder and the main drawback was residual scaring. Bilateral hypotrophy was rarely seen since only congenital absence of mammary glands is surgically treated before legal coming of age. The main problem of implants was formation and contraction of fibrous capsules around the implants in 5% of cases. Asymmetry and anomalies of shape were more difficult to treat because each breast requires a different procedure. At the present time, because of the cost/benefit ratio of such procedures, they are reimbursed by health services.

CONCLUSION

Although the results are not perfect, the psychological impact of such treatment is highly positive, suggesting that the requests of adolescent girls for this type of surgery may be encouraged.

[Imaging of abdominal wall eventration: role and value of x-ray computed tomography]

The role of imaging in preoperative investigation of incisional hernia was studied in a series of 332 operated patients. CT scan (220 patients) remains the reference investigation. Magnetic resonance imaging (8 patients) does not provide any supplementary information at the present time. The classical features of median and lateral incisional hernia are described and the importance of evaluation of the elasticity and strength of the abdominal wall is stressed. In the authors' experience, this evaluation has implications for pre- and intraoperative strategy.

[Severe cutaneous necrosis after ultrasound lipolysis. Medicolegal aspects and review]

The authors report the case of a young patient who developed extensive skin necrosis after ultrasound liposuction of the medial surface of the thigh. These lesions required excision, split-skin graft and installation of an expansion prosthesis. The medicolegal aspects of this case are discussed, in particular the responsibility of the doctor who performed this damaging procedure, from three points of view: damage, fault, causality. In this case, the damage corresponded to necrosis which can be due to a chemical, infectious or thermal mechanism. It is responsible for serious damages due to the number of operations, the length of hospital stay, immobilization, rehabilitation and the time off work. The aesthetic damage, the pretium doloris, and the inconvenience are certainly considerable, but was there fault in this case? Fault by clumsiness if the equipment was used abnormally; fault by negligence or imprudence when the equipment was not approved or when the operator was not a qualified physician, submitting his patient to undue risks. The causality is envisaged in the case of chemonecrosis and burns. It would be strongly presumed in a civil procedure in case of non-approved equipment. The authors are in favour of a hypothesis of a burn and review the current state of ultrasound liposuction, which was the subject of an intense media campaign several years ago.

[Occipital forehead pedicle for one-stage repair of defects of the upper third of the face]

The authors describe a reconstruction technique for defects of the superior third of the face using a fascio-cutaneous flap with a forehead paddle supplied by an occipital pedicle. This flap has been successfully used in three cases to cover defects of the temporo-zygomatic area indeed, the superior part of the cheek. Our three patients presented recurrent cutaneous carcinoma, a local and general poor condition. This process suits reliability and easiness to a good carcinologic, functional and aesthetic result.

[Reconstruction of the shape of the shoulder after scapulothoracic amputation]

Few papers have been published in the international literature on reconstruction of the shape of the shoulder stump after scapulothoracic amputation. The authors report a case of reconstruction using a solid silicone implant after prior skin expansion. The essential objective of this reconstruction is to eliminate the need for an external prosthesis, which constitutes a major handicap for these patients.

[Reconstruction of the anterior chest wall by a sandwich-type combination of a synthetic support and a muscle flap from the latissimus dorsi. Apropos of a case]

Reconstruction of the chest wall after balistic or other trauma requires good and muscle cover and creation of a new, stable and airtight wall. The authors present a case of balistic trauma of the right anterolateral chest wall which was urgently debrided and subsequently reconstructed by sandwich combination of a latissimus dorsi muscle flap and synthetic material composed of a sheet of PTFE and creation of two methylmethylacrylate ribs. The advantage of this technique is that it avoids the use of autologous tissue from an already weakened chest wall and confers a new chest stability in several sites corresponding to the wall defect with easily available and easy-to-use materials.

[An unusual complication of cervicofacial lift: paralysis of the external branch of the accessory spinal nerve]

Paralysis of the lateral branch of the accessory nerve is an extremely rare lesion during cervico-facial facelift. Based on 3 detailed and published personal cases observed over a period of 15 years, the authors review the literature, revealing a total of 9 cases over a period of 30 years, but other cases have probably not been published. Their review reveals the following points. This is an exceptional lesion. However, the nerve can be damaged as it emerges from the posterior border of the sternocleidomastoid muscle during slightly deep dissection and the electrical scalpel must be used cautiously. Even, partial paralysis of the trapezius muscle induces pain and considerable functional impairment with partial permanent disability. The natural history of this paralysis is very long and may be followed by regression after several years. Although there is an obvious cause-and-effect relationship between the operation and accessory nerve paralysis, it is always difficult to attribute this lesion to a possible surgical error, as the exact mechanism of the nerve lesion remain hypothetical and once again raises the problem of therapeutic risk.

[Merkel cell carcinoma of the skin]

This study reports five cases of Merkel-cell carcinoma of the skin. Then the authors review the present state of the art from the data already available in the literature concerning this malignant primary skin tumor. A part from local excision, no standard procedures are described. The literature provides a lot of discrepancies concerning the additional treatments such as lymph mode excision, radio and chemotherapy. The prognosis of this tumor remains poor because of a high incidence of local recurrence, a frequent spread to regional lymph modes and the development metastases.

[Continuous administration of vancomycin in patients with severe burns]

OBJECTIVES

In the severely burned patient, a marked, rapid fall in serum concentrations is often observed after intermittent infusion of vancomycin at the usual dose of 30 mg/kg. This specific "jagged" pharmokinetic course with inadequate residual concentrations raises the problem of the efficacy of this time-dependent antibiotic. Studies in patients in general resuscitation units have shown the interest of vancomycin administration in continuous infusion.

METHODS

We analyzed variations in serum concentrations of vancomycin during continuous infusion in 18 patients with burns involving a mean of 40% total body surface and reported the doses necessary to maintain serum vancomycin at therapeutic levels; the possible correlations between serum vancomycin concentrations, burn parameters, age and renal function; and clinical and biological tolerance.

RESULTS

Higher initial doses were required in burn patients (40 mg/kg in patients aged under 60) than in other patients. Impairment of renal function is a contra-indication of continuous infusion.

CONCLUSION

This mode of administration has the advantage of ensuring greater efficacy by preventing fluctuations in serum concentrations.

[Difficult diagnosis of a hypervascularized tumor: "angiomatous epulis"]

Based on a case presented by the patient himself, the authors describe the difficult management of a very large, recurrent epulis arising in a context of flat angioma of one half of the face according to a vascular mode. After a brief review of the clinical and aetiopathogenic aspects, the authors discuss the value of complete surgical treatment and raise the question of the possible relation, in this particular case, between angioma and this recurrent so-called angiomatous epulis.

Histologic assessment of low-voltage electrical burns: experimental study with pigskin

The authors have carried out an experimental protocol on pigs, producing identical electrical burns to examine clinically and histologically the evolution of these burns with time. A clinical lesion in the form of a rosette was observed. It was composed of three zones: a central zone of carbonization, a pale ischemic intermediate zone, and an erythematous peripheral zone. Microscopic observation showed vascular thrombosis in the intermediate and peripheral zones in addition to necrosis of the central zone. These vascular lesions can be classified in three stages, I, II and III, according to the degree of vascular damage. The evolution of the lesions was stabilized at 72 hours after burn injury. These observations are important in determining the surgical treatment, particularly debridement, on postburn day 3, when the prognosis of the intermediate and peripheral zones must be taken into account.

[Launois Bensaude disease. Focus apropos of 16 cases]

After a review of the clinical, pathological and aetiological features, the authors describe the various surgical techniques used (conventional surgery or liposuction) to restore a normal social life to these patients, deformed by their disease. They confirm the predominant role of conventional surgery and define the limited indications in which liposuction can be used. Based on a review of 16 cases, the surgeon must make sure that the patient has ceased his or her alcohol abuse before performing this difficult treatment associated with a number of complications.

[Iliac transosseous transposition of rectus abdominis muscle flap to cover a sacral pressure sore]

The use of an inferiorly based rectus abdominis myocutaneous flap to cover a pelvic pressure sore offers a solution when the possibilities of other local flaps have been exhausted. For sacral pressure sores, the iliac bone is an obstacle for the transposition of this flap. In this case report, we describe how this obstacle can be overcome by creating a trans-osseous tunnel in the ala of the iliac bone through which the flap takes the most direct route to the recepient site.

[Esthetic reconstruction of the face in burnt patients]

All reconstruction should be aesthetic but in burned patient, everything combines to make a cosmetically satisfactory result more difficult to achieve. However the burns patients, deformed and disfigured has to confront the gaze of others in daily life. Three points are discussed by authors: skin quality can be improved or replaced by a full thickness pressure graft; surgical modification of the underlying structures; repair of peri-orificial areas and free edges.