The endoscope as an adjunct to correction of nipple inversion deformity.

BACKGROUND: Correction of the inverted nipple requires release of constricting fibrous tissue and suspension of the nipple. Despite the simplicity, lasting repair is often difficult to achieve, as is the ability to assure preservation of functioning lactiferous ducts during release. METHODS: Since 2002, the authors have used the endoscope to guide selective division of retracted fibrous bands, followed by the use of a dermal fat graft and purse-string suture to the base to achieve stable nipple projection. RESULTS: In this series of 28 nipples of 15 patients, the patients were followed up for a mean period of 14 months (range, 6 to 26 months). The outcome was judged to be excellent in 23 nipples (82 percent) and fair in five (18 percent). There were no instances of any changes in sensitivity of the nipple-areola complex. Four patients experienced lactation afterward. CONCLUSIONS: The endoscope clearly delineated band from duct. The authors' technique was able to maintain excellent projection, with preservation of breast feeding as well as normal breast sensation, except in grade IIIB inverted nipples.

The effects of anti-P-selectin antibody on leucocyte activity related to cigarette smoke in rats.

Nicotine-induced expression of P-selectin is implicated in endothelial cell damage related to smoking. Thirty male Sprague-Dawley rats were divided into three groups: two experimental and one control. Both experimental groups were exposed to cigarette smoke for four weeks, but one group was also given anti-P-selectin antibody (100 microg IgG per 100 g body weight) intravenously. Rolling and adhesion leucocytes within the microcirculation of the cremaster muscle were measured. The urine cotinine concentrations of rats exposed to smoke were 612 ng/ml higher than those of non-smokers. Both rolling and adherent leucocytes were highest and steady in the group given anti-P-selectin antibody at about 50 and 10, respectively. There was a significant drop in both rolling and adherent leucocytes (31 to 4 and 5 to 2) after the anti-P-selectin antibody had been given. However, this effect was short-lived as both increased above those at 35 minutes by 120 minutes (p<0.001). The increase in leucocyte rolling and adherence caused by smoking can be lowered by giving anti-P-selectin antibody. The effective period in rats was two hours, with the maximal effect one hour after injection.

Strategies for a successful corrective Asian blepharoplasty after previously failed revisions.

Asian blepharoplasty, although a common procedure, has a relatively high rate of complications. Subtle imperfections and more serious iatrogenic complications often require immediate attention by the aesthetic surgeon. After attempted correction of the deformities, residual problems or new ones can arise. Blepharoptosis, supratarsal depression, an excessively high or low crease, a short or discontinuous crease, multiple creases, and asymmetric creases are the most commonly encountered complications that require special attention in this group, which has already undergone more than one surgical procedure. Between January of 1996 and December of 2002, 168 Asian blepharoplasty revisions were performed by one surgeon (S. H.-T. Chen); of these, 36 patients (21 percent) had previously undergone failed revisions. This subgroup of patients consisted of six with blepharoptosis, six with asymmetrical eyelid creases, three with supratarsal depressions, three with high creases, two with short creases, and 16 with combinations of these deformities. The results were graded as excellent, good, fair, or poor, based on the symmetry of the eyelids, palpebral fissures, crease heights, lengths, shapes, eyelid fullness, and overall aesthetics of the final outcome. A survey was performed of patient and surgeon satisfaction and factored into the grading system. With an average follow-up period of 16 months (6 to 60 months), 22 patients (61 percent) were found to have excellent results, 10 (28 percent) had good results, two (5.6 percent) had fair results, and two (5.6 percent) had poor results. Corrective procedures after failed revision Asian blepharoplasty require special strategic considerations because of the presence of extensive scarring and inadequate skin, muscle, and preaponeurotic fat and because of the occasional presence of dehiscence of the levator aponeurosis. By using careful preoperative evaluation, accurate measurements, precise preoperative planning, intraoperative fat repositioning or grafting, skin excision or redraping, and proper placement of anchoring sutures, successful outcomes can be achieved. The authors evaluate the outcomes and detail the surgical procedures that were used to achieve successful outcomes in this particularly challenging group of patients.

The use of ultrasonography in preoperative localization of digital glomus tumors.

Small glomus tumors of the digits of the hand are difficult to excise and may be associated with relatively high rates of recurrence. This study was designed to prospectively evaluate the utility of preoperative ultrasound localization of such tumors to facilitate removal and to reduce recurrence rates. During a 5-year period, 34 patients clinically diagnosed with glomus tumors involving their digits were examined with high-resolution ultrasonography (5 to 9 MHz). Color duplex sonography was further applied if flow characteristics were identified. The ultrasound-predicted and actual intraoperative sizes were correlated and analyzed using the paired t test. Patients were followed for 1 to 6 years, and results were documented. Sonography showed a hypoechoic nodule with prominent vascularity between the nail body and the dorsal cortex of the distal phalanx in all subungual tumors. Complete resection was possible in all 35 glomus tumors, with assistance by accurate preoperative ultrasound localization. There was no long-term recurrence among the 29 patients available for evaluation 1 to 6 years postoperatively. Ultrasonography has great advantages in defining the exact location and size of the glomus tumor preoperatively. Prior knowledge of the exact site and size of the glomus tumor facilitates excision and appears to reduce rates of recurrence. The collaboration between hand surgeons and radiologists is useful to successfully treat glomus tumors of the digit.

Toe-to-hand transplantation.

In the mutilated hand microsurgical toe-to-hand transplantation provides thumb and finger reconstruction that is superior to conventional techniques in appearance and function. Hand reconstruction using toe transplantation should be individually planned and carefully executed to obtain optimal results and minimal disability in the donor foot.

Free deepithelialized anterolateral thigh myocutaneous flaps for chronic intractable empyema with bronchopleural fistula.

BACKGROUND: Free deepithelialized anterolateral thigh (DALT) flaps have been used for treatment of chronic intractable empyema with bronchopleural fistula at Chang Gung Memorial Hospital since 1997. METHODS: Twelve patients with chronic empyema were treated at Chang Gung Memorial Hospital from January 1997 to January 2001. Their age ranged from 31 to 70 years (mean age 48.6 years). Left-sided involvement was predominant (left to right ratio = 9:3). All patients had bronchopleural fistula, and all were cured. The average numbers of previous thoracotomy were 5.4. The ipsilateral DALT flaps were harvested with primary closure of donor site. RESULTS: At a mean follow-up of 1 year, no recurrence was noted. All flaps survived well. The average hospital stay was 25.8 days. Complications after reconstruction included chrondritis, partial muscle necrosis, and wound dehiscence (1 patient each). There was no donor site morbidity. CONCLUSIONS: Free DALT flaps can be selected according to different situations during surgery as long as they meet the following requirements: (1) tissue of sufficient volume and good blood supply, and (2) closure of the bronchial leak. Based on this retrospective study, use of free DALT flaps with technical refinement is a reliable method for treatment of chronic intractable empyema combined with bronchopleural fistula.