Improved postoperative analgesia with isoflurane than with propofol anaesthesia.

PURPOSE: The impact of hypnotic drugs on postoperative analgesia has not been evaluated. We compared the influence of the maintenance of anaesthesia with either propofol or isoflurane on postoperative pain. METHODS: Forty ASA 1-2 women, undergoing cosmetic abdominoplasty were randomized to receive either 6-12 mg.kg-1.hr-1 propofol i.v. (P, n = 20) or MAC 1-1.5 isoflurane inhalation (Iso, n = 20). The lungs were ventilated with N2O 60% and O2 40%, and 1 microgram.kg-1 fentanyl i.v. provided intraoperative analgesia. Before surgical closure, 2 g propacetamol i.v. were administered. Postoperative analgesia was provided after hourly assessment of pain (VAS 0-100 mm), with 10 mg nalbuphine i.v. if VAS > or = 50 mm, during the eight hours after surgery. Sedation score (awake 0 to unrousable 4) was also recorded. Analgesia satisfaction score (nil 0 to excellent 4) obtained from the patient on discharge. RESULTS: Sedation scores were similar in both groups except in the first postoperative hour, when it was higher in the Iso group. The VAS at rest (15.4 +/- 18.6 vs 29.7 +/- 19.8 mm, P = 0.0001) and nalbuphine requirements (0.13 +/- 0.35 vs 0.70 +/- 0.80 doses, P = 0.004) were lower in the Iso group during the first six hours, although emesis was more frequent than in P (60 vs 25%; P = 0.03). The incidence of analgesia satisfaction score (> or = 3) was similar between the two groups (P: 95; Iso: 75%). CONCLUSION: These results suggested that isoflurane anaesthesia provides better analgesia than propofol anaesthesia in the first six hours after abdominoplasty.

[Desmoplastic malignant melanoma of the ear. A case report]. / Le mélanome malin desmoplastique. A propos d'un cas localisé au pavillon auriculaire.

A case of desmoplastic melanoma in a 72-year-old patient is reported. In the light of this case, the authors review the literature and analyse the therapeutic implications.

[Retiform hemangioendothelioma]. / Hémangioendothéliome rétiforme.

Hemangioendotheliomas are vascular tumors of intermediate malignancy considered as low-grade angiosarcomas. The authors report two cases of a distinctive type, named retiform hemangioendothelioma because of its particular morphologic features, and recently delineated by Calonje and al. This tumor of the skin recurs frequently but has a very low metastatic rate.

[Microsurgical reconstructions of the lower face, after projectile injuries. Value of fibular flaps. Apropos of 20 cases]. / Reconstructions microchirurgicales de l'étage inférieur de la face, après traumatismes par projectiles. Intérêt du lambeau fibulaire. A propos de 20 cas.

Projectile trauma of the lower face causes major functional damage and disfigurement. Reconstruction with tissue flaps, after microsurgical revascularization to guarantee tissue vitality, can restore satisfactory mental function. We report 26 mental reconstructions, including 20 using free fibular flaps which, due to its vascular pedicle and length of the available bone, appears to be the best adapted for reconstruction of the lower face. When used with cutaneo-aponevrotic flaps, only one operation is needed.

[Mechanical vascular clips with an automatic stapler in reconstructive microsurgery. Apropos of 16 clinical cases]. / L'agrafage vasculaire mécanique par pince automatique en microchirurgie reconstructrice. A propos de 16 cas cliniques.

From October 1995 through March 1997, we performed 30 microsurgical reconstructions and achieved microvascular anastomoses in 16 with an automatic stapler (VCS) which allows insertion of titanium clips in the everted vessel walls. The mean age of the patients (15 men, 1 woman) was 42 years. Mean vessel diameter of the donor and recipient sites was 2 mm for the arteries and 3 mm for the veins. Recipient vessels had suffered radiation damage in 3 cases. Micro-anastomoses were performed in 26 cases, with end-to-end sutures in 24 and end-to side sutures in 2. There were 11 arterial procedures including 3 bypasses and 15 venous procedures with 1 bypass. Peroperative thrombosis occurred in 2 cases and were treated by undoing the anastomoses and resuturing manually. There were no early or late postoperative vascular complications. This clinical experience confirms the advantages of this mechanical approach to microanastomotic procedures for small vessels as previously demonstrated in experimental work: a system avoiding transfixation, rapid procedure, reliability.

[Dentigerous cysts. Developmental aspects. Apropos of 3 cases]. / Les kystes dentigères. Aspect évolutif. A propos de trois observations.

Dentigerous cysts, also called follicularor corono-dental cysts, are malformative odontogenic cysts in the WHO classification of odontogenic tumors. We review the general characteristics of these frequent odontogenic tumors which always occur in associated with an included tooth. Diagnosis is based on clinical features, X-ray findings and pathology results. We report the evolutive aspect in three patients of different ages.

[Fasciocutaneous flap of the posterior surface of the thigh with distal pedicle. Anatomical study and surgical value. A propos of 3 cases]. / Le lambeau fascio-cutané de la face postérieure de cuisse a pédicule distal. Etude anatomique et intérêt chirurgical. A propos de trois cas.

In the light of previous studies, the authors conducted an anatomical study on 21 cadaveric dissections with injection in order to define the characteristics of the distally based fasciocutaneous flap of the posterior surface of the thigh, described for the first time in 1988 by Maruyama. This leaf-shaped flap extends from the popliteal region to the gluteal sulcus. It possesses an axial arterial network derived from the popliteal artery, reinforced by the perforating arteries derived from the vessel or the profunda femoris artery. The venous return is ensured by venae comitantes and the communicating saphenous vein. The flap raising technique is described. From 1991 to 1994, 3 patients were operated in order to cover a defect of the knee (1 case) and amputation stumps (2 cases). The postoperative course was uneventful and the results were considered to be stable and of excellent quality with a follow-up of 2 to 4 years.

[The folded fibula flap: anatomical study and clinical application to septic post-traumatic femoral reconstruction. A propos of 6 cases]. / Le lambeau dédoublé de fibula: étude anatomique et application clinique a la reconstruction fémorale post-traumatique septique. A propos de six cas.

The reconstruction of extensive femoral defects, particularly septic, by revascularized free fibula flap has become part of routine practice for many years. Following the demonstration of secondary stress fractures, splitting of the fibula into two vascularized barrels was proposed in 1987 to avoid this complication. The authors conducted an anatomical study on 100 dry bones in order to define the situation of the fibular foramen which is usually found at about 1.45 cm from the midpoint of the fibula. This foramen must be spared during the intermediate splitting osteotomy in order to obtain two bone barrels: one with a double centromedullary and periosteal blood supply which will be used like a contromedullary pin, and the other with only a periosteal blood supply, which will be used as a medial or lateral splint. The deductions concerning the preoperative strategy and splitting technique are explained as a function of the length of the defect. From 1989 to 1993, 6 male patients underwent extensive femoral reconstruction (average length of 9.8 cm). Four free revascularized transfers were performed, including one osteocutaneous flap. In two cases, the osteocutaneous transfer was a proximally based island pedicle flap. Apart from one patient who was subsequently amputated, five patients underwent a secondary autologous bone graft after an average of three months. Consolidation was achieved after a mean of 12.6 months. A secondary stress fracture was observed in one case. With a minimum follow-up of two years, all patients are able to walk with a mean shortening of 2 cm of the reconstructed limb and without any donor site sequelae.

[Posterolateral sural fasciocutaneous island flap with proximal aponeurotic pedicle. Anatomical study and use for cutaneous cover of the knee. Apropos of 9 clinical cases]. / Le lambeau sural postéro-latéral en îlot fascio-cutané à pédicule aponévrotique proximal. Etude anatomique et application à la couverture cutanée du genou. A propos de neuf cas cliniques.

The authors propose an elaborate variant of the classical saphenous or lateral leg fascio-cutaneous flap with a proximal pedicle for the cover of post-traumatic skin defects of the knee. The original feature of this flap resides in the purely aponeurotic or adipo-fascial pedicle which increases the arc of rotation, while minimizing cutaneous sequelae of the donor site. Twenty four injected cadaveric dissections were used to define the neurovascular content of the lateral sural fascia: the lateral and medial superficial sural arteries and their territory of perfusion, accompanying veins and the short saphenous vein, as well as the lateral and medial sural cutaneous nerves. The technique of harvesting of the island flap is described. Nine patients were operated between 1991 and 1994, with an uncomplicated postoperative course in terms of flap vitality and donor site. The skin cover of the knee was considered to be of excellent quality, stable and sensitive, with a follow-up ranging from 6 months to 3 years four months.

[Choice of free composite flap in the reconstruction of loss of substance in the mandible. Apropos of 28 cases]. / Le choix du transplant libre composé avec os dans la reconstruction des pertes de substance interruptrices de la mandibule. A propos de 28 cas.

The retrospective analysis of 56 mandibular defects, 28 of which were reconstructed by free revascularised bone flaps, and the difficulties of their reconstruction led the authors to propose a new anatomosurgical bony classification of mandibular defects. This classification, a theoretical transcription of traumatic and oncological realities, distinguishes more or less extensive anterior defects (Aa and Ab), lateral defects (La), lateroterminal defects (Lb) and defects exceeding the hemimandible (T). These bony imperatives, either alone or associated with skin lesions, depending on the traumatic or neoplastic aetiology, influence the indication for microsurgical reconstruction and the choice of particular bone and integument combined or composite flaps. The authors have deliberately adopted the option of one-stage multiple tissue reconstruction by the same composite flap and propose a justification for this microsurgical choice based on the proposed classification as well as the the theoretical and practical advantages and disadvantages of the various composite free revascularised bone flaps. Two donor sites appear to be particularly suitable: iliac and fibular.

[Fascia superficialis temporalis in facial reconstructive surgery. Apropos of 35 cases]. / Le fascia superficalis temporalis en chirurgie reconstructrice faciale. A propos de trente-cinq cas.

The fascia superficialis temporalis (FST), one of the planes of cranial cover, can be raised to form an axial pedicle flap or a vascular island flap on superficial temporal vessels. Its fibrovascular structure, the area able to be raised and the possible addition of other superficial tissues (scalp, forehead skin) and deep tissues (calvarial bone) mean that this flap can be used in surgery of the external and intracavitary facial contours and shapes. The authors report their experience of 35 facial reconstructions: 7 ear reconstructions, 5 suspensions of a paralysed labial commissure, 10 conjuctivo-palpebral revisions, repair of 5 subcutaneous defects, 3 haired resurfacings, 1 inferior labial, 1 cheela, 1 orbitomalar reconstruction, 1 malo-commissuro-labial repair, 1 prefabricated free flap. The donor site sequelae were considered to be negligible: 1 case of temporal anaesthesia with dysaesthesiae, 4 cases of band alopecia. The analysis of these 35 reconstructions reveals the quality of all cases of defect repair, especially palpebral; the ease and persistence of suspensions of the labial commissure; the value of FST as a conjunctival and buccal mucosal substitute; the density of the hair contribution. However, total or partial ear reconstruction using this technique constitutes a more limited indication.

[Cheek-commissuro-labial reconstruction using a fascia superficialis temporalis composite island flap. Apropos of a clinical case]. / Reconstruction jugo-commissuro-labiale par lambeau composite en îlot de fascia superficialis temporalis. A propos d'un cas clinique.

Management of full thickness defects of cheek and lips area is a challenge with both aesthetic and functional aims. Many surgical procedures can be proposed. A composite island temporal flap gathering fascia superficialis temporalis, an heary portion and a beardless skin paddle is a very interesting alternative. Surgical procedure and results are explained, concerning a gun shot injury clinical case.

[Dedifferentiated chondrosarcoma with maxillary involvement. An anatomo-clinical study, surgical treatment and prosthetic rehabilitation. Apropos of a case]. / Chondrosarcome dédifférencié à localisation maxillaire. Etude anatomo-clinique, traitement chirurgical et réhabilitation prothétique. A propos d'un cas.

A 19 year old girl presented with a dedifferentiated chondrosarcoma of maxilla. The recurring tumor, diagnosed initially from the provoked pain, appeared on the scan image as a heterogeneous mass containing numerous calcifications. Histology showed, within a well differentiated chondrosarcoma, an anaplastic sarcomatous zone of the malignant fibrous histiocytoma (MFH) type. This histologic appearance is consistent with a poorer clinical prognosis. Radical surgery of the 4th tumor recurrence was combined with maxillofacial prosthetic rehabilitation. This appears to be first reported case of a dedifferentiated chondrosarcoma of the MFH type located in the maxilla.

[Free composite flaps with the fibula and their adaptation to mandibular reconstructive surgery. Apropos of 9 cases]. / Les lambeaux libres composites avec péroné et leur adaptation à la chirurgie reconstructrice mandibulaire. A propos de neuf cas.

Although revascularized fibula bone transfers have been used in reconstructive surgery of long bones for about fifteen years, the first reported cases of mandibular reconstruction were only published in 1989 by Hidalgo. The mandible and the fibula actually have very few points in common apart from their respective length and a certain similarity of cross-section. However, free composite flaps including the fibula are adapted to reconstruction of the mandible for several reasons: the length of the bone which can be raised (25 cm) and osteotomized into several fragments; the addition of other components (skin, aponeurosis, muscle, etc.) for skin and/or mucosal repair; the spatial independence of these various elements; the microsurgical qualities of the peroneal artery. This possibility of multidirectional and multiple tissue bony mandibular reconstruction is analysed on the basis of 9 clinical cases: 5 cases of traumatic sequelae of the lower third of the face following gunshot injuries, 2 cases of radiation osteonecrosis, 2 benign bone diseases. The triple bone, integument and vascular adaptation between the fibular donor site and the recipient site must be assessed preoperatively. Due to the quality of the morphological and functional results compared with the limitations of other free composite bone transplants, the authors propose free composite fibular flaps as adapted and adaptable solutions for one-stage reconstruction of extensive mandibular defects (> 10 cm) associated with small or large mucocutaneous lesions.

[Dentascan in dental implantation]. / Le dentascan en implantologie dentaire.

The software called dentascan utilizes the data acquired during a conventional CT examination to reconstruct accurate images with a 1/1 scale, both of sections taken at right angles to the axis of curvature of the bony relief of the maxillary or mandibular arch and of sections taken parallel to this axis. This means of investigation proves to be practical and useful for assessment before implantation.

[Temporomandibular joint dysfunction and neurofibromatosis. Apropos of a case]. / Dysfonctionnement des A.T.M. et neurofibromatose. A propos d'un cas.

The authors report one case of Von Recklinghausen's disease localized to the temporomandibular joint capsule and unilaterally associated with other cephalic manifestations. Although no other study, notably a CAT-scan, showed this tumor localization, surgical exploration was imperative and led to exeresis of the lesion which proved to be the treatment of choice.