[Phalloplasty: Microsurgical options and management algorithm]

The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.

Is there any place for spontaneous healing in deep palmar burn of the child?

Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

[Treatment of persistent cardiac failure by ultrafiltration]

Ultrafiltration, a method of extra renal filtering, which accomplishes an iso-osmotic removal of water an sodium from the plasma, was used in twelve patients. It is reserved for terminal persistent heart failures. In one case, it preceded a heart transplant. Simple to carry out, this technique is well tolerated when the pulmonary pressure is elevated, respecting an ultrafiltration output inferior or equal to 500 ml/h. Immediate improvement of the patients is spectacular. A new treatment failure may impose long-term ultrafiltration sessions. Failure of the medical treatment, impossibility of heart transplant, must be an indication for ultrafiltration which improves the comfort, and most likely the life expectancy of patients with persistent heart failure.

[Severe hypophosphoremia in a toxic shock syndrome]

A case of toxic shock syndrome occurring during a menstrual period, and associated with severe hypophosphataemia, is reported. The patient was a 21-year old woman using tampons. On the fourth day, she developed encephalopathy with decreased consciousness and hyperventilation. Severe hypophosphataemia was noted. A phage-group-1 Staphylococcus aureus, producing TSST-1 and enterotoxin A, was isolated from vaginal, pharyngeal and skin sites. Pathogenesis and role of hypophosphataemia in toxic shock syndrome are emphasized.

[Peridural anesthesia in thoraco-abdominal surgery. Propofol-methohexital comparison for complementary anesthesia]

Two groups of 20 patients scheduled for major abdominal surgery or thoracic surgery received analgesia by thoracic peridural route: 850 and 837 micrograms.kg-1 of bupivacaine, plus 4.30 and 4.20 micrograms.kg-1 of fentanyl. Anaesthesia was induced and maintained with either infusion of propofol 0.2% or infusion of methohexital 0.1% and patients were intubated and ventilated. The quality of induction was good in the two groups (3.48 mg.kg-1 in 4 min with propofol and 2.76 mg.kg-1 in 5 min with methohexital). But only 4 of propofol group needed vecuronium for intubation; they were 19 in the other group. Maintenance was extremely smooth with propofol (0.088 mg.kg-1.min-1) in 18 cases. In contrast, poor anaesthetic control was obtained with 14 methohexital patients and had to be abandoned. Hemodynamic data show fc, Pa and Ppa decreased with propofol but increased with methohexital in response to laryngoscopy and intubation. In this study, the onset of 5 sinusal bradycardias was noted with propofol. Two of them were severe 39 and 38 b.min-1 with major decrease of LVSWI to 32.45 and 24.47 g.mm-2. The role of hypovolemia (Bainbridge reflex) or vagomimetic effect of propofol is discussed. Nevertheless, this study shows that propofol given by infusion can better achieve adequate anaesthesia than methohexital.