Complications in breast augmentation: prevention and correction.

The decision-making process for breast augmentation begins at the initial consultation. Most complications can be avoided with careful planning and decision making. Primary augmentation demands a careful evaluation of the breast morphology and chest wall anatomy. Perioperative techniques such as precise dissection of the pectoralis muscle under direct vision can ensure an adequate pocket, which minimizes the risk for capsular contracture and implant malposition. Secondary breast augmentation for problems such as thinning of the breast skin envelope, long-term pressure atrophy of existing parenchyma, and visibility of the implant can be minimized with appropriate selection of implant type, size, and placement. Patients should understand clearly the immediate and long-term risks associated with breast augmentation and the requirement for future reoperation.

Jamaican nurses' perception of their work experiences with foreign nurses

OBJECTIVE: To explore the perception of Jamaican nurses regarding their work experiences with nurses from Cuba, Nigeria and Ghana. METHOD: A 24-item pretested self-administered questionnaire was distributed to 30 Registered Nurses working with foreign nurses on five selected wards at Kingston Public Hospital. Twenty-three nurses (77 percent) completed the questionnaire. Data were analysed using SPSS Version 6.13. RESULTS: In terms of clinical performance, ability to communicate with patients and staff and pleasant work attitude, the nurse rated those from Ghana highest, followed by Nigerians and Cubans (p<0.001). The majority (91 percent) of the respondents were concerned about the cost of recruiting foreign nurses, some of whom they perceived to be lazy and incompetent. They felt that Jamaican nurses should be treated better by improving salaries and benefits. Sixty-one per cent suggested that the benefits to foreign nurses surpassed their own. CONCLUSION: Nurses from Ghana were the most popular with Jamaican nurses. The cost of improving salaries and benefits to retain Jamaican nurses should be weighed against the cost of recruiting foreign nurses to work in Jamaica.(Au)

Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.

During the past 5 years, the authors have used a direct trans-lower lid blepharoplasty subperiosteal approach to the lower lid and midface for the purpose of correction of midfacial aging in 757 patients. In a smaller but significant group, this approach has proven valuable in difficult reconstructive situations. The purpose of this article is twofold: (1) to provide a comprehensive retrospective evaluation of the value and promise of the technique and (2) to provide a comprehensive discussion of the pitfalls and complications that have been associated with use of this technique. In addition, technical modifications that may lower the rate of morbidity associated with the use of the procedure are described.

Redraping the inferior orbicularis arc.

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.

The delayed TRAM flap.

As surgeons gain increased clinical experience with the transverse rectus abdominis myocutaneous (TRAM) flap, or autologous breast reconstruction, technical modifications aimed at improving flap reliability continue to evolve. These modifications have allowed the TRAM flap to be performed safely in a higher-risk patient population. The delayed TRAM flap appears to have an augmented arterial supply and a lesser degree of venous congestion following division of the deep inferior epigastric vessels 2 weeks prior to reconstruction. Ischemia-related complications have been reduced in high-risk patients with the use of the delayed TRAM.

Free gastro-omental flap reconstruction of the complex, irradiated pharyngeal wound.

BACKGROUND: Reconstruction of the complex pharyngeal wound after radiotherapy presents a surgical challenge. METHODS: Evaluation of the gastro-omental flap in the reconstruction of the pharynx and overlying soft tissue after local flap failure. RESULTS: A 70-year-old patient underwent a total laryngectomy and radical neck dissection after 70 Gy of external beam radiotherapy for an advanced squamous cell carcinoma of the pyriform sinus. Postoperatively, a large pharyngocutaneous fistula developed. Attempted closure with a pectoralis major flap was unsuccessful. A tubed gastro-omental free flap based on the right gastroepiploic vessels was used to reconstruct the pharynx. The accompanying greater omentum was skin grafted after filling the large soft tissue defect in the neck. The wounds healed primarily, and oral alimentation was resumed on the seventh postoperative day. CONCLUSIONS: The gastro-omental flap is a versatile composite flap which can provide mucosal lining as well as abundant soft tissue. It should be considered a secondary option in irradiated, complex pharyngeal wounds when local flaps are not available to be used in conjunction with free jujunal transfer.

Reconstruction of the pharynx and overlying soft tissue by a partitioned free jejunal flap.

The partitioned free jejunal flap has proven useful in cases where soft-tissue coverage is required after pharyngeal reconstruction. It provides durable coverage and eliminates a second flap procedure.

TRAM flap vascular delay for high-risk breast reconstruction.

The purpose of this study was to evaluate the intraoperative changes in physiologic blood pressure following vascular delay of the TRAM flap. Ligation of the superficial and deep inferior epigastric vessels 2 weeks prior to the TRAM flap was performed. The incidence of fat necrosis was 4.3 percent in 23 high-risk patients who underwent 30 immediate breast reconstructions. Direct measurement of blood pressure in the deep inferior epigastric artery and vein was performed in a control group without delay consisting of 13 low-risk patients and in the study group of 7 high-risk patients who underwent vascular delay. Changes in TRAM flap perfusion pressure were examined following the change in location of the flap from the abdomen to the chest. Blood pressure measurements demonstrated that arterial pressure in the proximal stump of the deep inferior epigastric artery was 64 percent in the study group prior to delay and 72 percent in the control group. The physiologic response to vascular delay included an overall increase in arterial pressure with a decrease in venous congestion. TRAM flap perfusion pressure was significantly increased from 13.3 mmHg (control) to 40.3 mmHg (delayed) in the region of the midrectus perforators (p < 0.05). These data suggest that the technique of TRAM flap delay may increase the reliable tissue volume and improve the safety of the TRAM flap.

Bone marrow-derived chimerism in non-irradiated, cyclosporin-treated rats receiving microvascularized limb transplants: evidence for donor-derived dendritic cells in recipient lymphoid tissues.

Tolerance to donor transplantation antigens develops when recipients are made chimeric with donor bone marrow. To establish chimerism, the haemopoietic system of recipients typically is severely compromised. We report on a system in which chimerism develops without ablative therapies. Immunosuppression with cyclosporin A allowed the lower limb of a rat to be replaced by a microvascularized transplant from a fully allogeneic donor. Many donor-derived cells populated recipient lymph nodes and spleen, and most had the large size, irregular shape and strong major histocompatibility complex (MHC) class II expression that typify dendritic cells. Donor cells were not found in the macrophage-rich regions of lymphoid tissues, but instead occupied splenic white pulp and lymph node cortex. The donor cells were derived from radiosensitive marrow precursors, as chimerism was abolished if the grafted limb was irradiated, or if muscle and skin flaps devoid of bone were grafted. Donor cells were rare or not detectable in blood, thymus and liver. Whereas lymphoid chimerism was prominent following limb transfer, donor cells were not detected 1-2 weeks after an injection of two femur equivalents of a marrow suspension. We suggest that dendritic cells that undergo rapid turnover in lymphoid organs are replaced from allogeneic precursors in bone grafts. The combination of cyclosporin and vascularized bone provides a means for inducing chimerism in lymphoid tissues of non-irradiated recipients.

The gluteal free flap breast reconstruction. Making it work.

The inferior gluteal flap represents our second choice for free autologous tissue breast reconstruction when the TRAM is unavailable. The safety and reliability of the inferior gluteal flap has been demonstrated in 25 consecutive flaps. To make the free gluteal flap work, careful elevation and preparation of recipient vessels with the liberal use of vein grafts, and proper insetting are important factors.

Donor leukocyte migration following extremity transplantation in an experimental model.

In an effort to further define the immunologic mechanisms leading to acute composite-tissue allograft rejection, the migratory patterns of donor leukocytes were evaluated. Using a rat model, 52 orthotopic vascularized hindlimb transplants were performed in strains representing major histocompatibility mismatches. In order to evaluate the effect of allogeneic skin on limb rejection, all donor skin was removed in a second group of allografts. Recipient lymphoid organs were examined during the week following transplantation for antigen-presenting cells using a donor-specific class II monoclonal antibody. Donor leukocytes, with dendritic cell morphology, were identified in recipient spleen and lymph nodes draining the allograft. Significantly higher numbers of donor leukocytes were present during postoperative days 1 through 4 for both groups. Association of these important passenger leukocytes with host T-lymphocytes may represent the site of initiation of the immune response.

CT diagnosis of cecal herniation through the foramen of Winslow.

The computed tomographic (CT) appearance of a case of cecal herniation through the foramen of Winslow is described. This is an extremely uncommon type of internal hernia, and, to the best of our knowledge, its CT appearance has not been reported. Its recognition is important to both establish a preoperative diagnosis and to distinguish it from a lesser sac collection or abscess.

Migration of donor leukocytes from limb allografts into host lymphoid tissues.

This study was undertaken in an initial effort to characterize the immunology of extremity transplantation by examining the pattern and kinetics of leukocyte migration from rat limb transplants. Migration of donor leukocytes was evaluated by examining recipient lymphoid tissues with a donor-specific, anti-major histocompatibility complex, class I monoclonal antibody. Double-antibody, two-color labeling was used to localize donor cells to specific regions within these tissues. Donor leukocytes, with dendritic cell morphology, were found in the T-cell-rich areas of lymph nodes draining the allograft and spleen. The donor cells were present on postoperative days 1 through 3 but were not present on days 5 to 7. Donor leukocytes were not present in distant lymph nodes or liver. These findings indicate a migration of leukocytes, most likely the highly immunogenic dendritic cell, from rat limb transplants to the draining lymphoid tissues. Migration occurs shortly after transplantation and may lead to the sensitization of alloreactive T-cells.

Effect of a Prudhoe Bay crude oil on hepatic and renal peroxisomal beta-oxidation and mixed-function oxidase activities in rats.

The effect of oral administration of a Prudhoe Bay crude oil (PBCO) to male rats (PBCO, 2.6 g/kg body weight, daily) for 5-12 days on hepatic and renal microsomal monooxygenase activities and peroxisomal beta-oxidation has been investigated. PBCO administration leads to liver enlargement. This is associated with induction of microsomal cytochrome P-450 levels (1.6- to 2.0-fold) and dependent mixed-function oxidase activities (7-ethoxyresorufin-O-deethylase and 7-pentoxyresorufin-O-depentylase, representing cytochrome P-450I and cytochrome P-450IIB isoenzymes respectively, 9- to 15-fold; omega-oxidation of lauric acid representing the cytochrome P-450IVA1 isoenzyme, 1.4- to 1.5-fold) along with peroxisomal beta-oxidation (palmitoyl CoA oxidation, 2- to 5-fold). It was observed that rats exposed to PBCO showed an increase in renal microsomal cytochrome P-450 content (1.6- to 2.3-fold), cytochrome P-450I activity (5- to 8-fold) and omega-oxidation activity (1.3- to 1.4-fold). However, renal peroxisomal beta-oxidation was unaltered. Serum total triglycerides were lowered by 41-46% after PBCO exposure. These results suggest that induction of peroxisomal beta-oxidation and possibly mono-oxygenases may be related to the carcinogenic/tumorigenic potential of crude oil.

Axilloaxillary bypass: is it worthwhile?

To evaluate the efficacy and long-term patency results of axilloaxillary bypass, a review of 32 patients with follow-up extending to 11 years was done. Twenty-two bypasses were performed for vertebrobasilar symptoms or subclavian steal and 10 for upper extremity claudication and/or ischemia. The mean age of the operative group was 66 years, 94% of patients had more than one atherosclerotic risk factor (hypertension, diabetes, coronary artery disease, smoking), and 75% had undergone a previous arterial reconstruction operation. There were no operative deaths, and the only postoperative complication was a sterile seroma which responded to aspiration. At late follow-up extending to 11 years, three grafts had thrombosed while another became infected and had to be removed; no limb loss resulted from these graft failures and the actual late patency rate was 87%. Carotid-subclavian bypass, intrathoracic bypasses, and endarterectomy at the site of occlusion have all been suggested for the treatment of symptomatic proximal subclavian artery disease. With axilloaxillary bypass, however, the hazards associated with carotid artery manipulation, operation on the notoriously treacherous subclavian artery, and the morbidity related to thoracotomy in this older, high-risk patient population can be avoided. The axilloaxillary bypass is safe and simple, and the excellent long-term patency rates make it the procedure of choice for symptomatic subclavian artery disease.

Activities of the hepatic enzymes of vitamin B6 metabolism for patients with cirrhosis.

Patients with cirrhosis and other hepatic diseases frequently exhibit lower concentrations of plasma pyridoxal 5'-phosphate (PLP), which is derived primarily from liver. To determine the biochemical basis for this abnormality, the enzymes of vitamin B6 metabolism--pyridoxal kinase, pyridoxine (pyridoxamine) 5'-phosphate oxidase, PLP phosphatase(s), and pyridoxal oxidase(s)--were analyzed in liver. The activities of the two biosynthetic enzymes, pyridoxal kinase and pyridoxine (pyridoxamine) 5'-phosphate oxidase were similar for both. The phosphatase activities were significantly higher (mean +/- SD of 9.55 +/- 8.03 versus 3.97 +/- 2.36 nmol X min X mg protein, p less than 0.05) for cirrhotics. Pyridoxal oxidase activities appeared slightly lower for cirrhotics. There was considerable variation in many indices of liver function, which suggests that the defects contributing to altered vitamin B6 metabolism may be complex and individualistic. These analyses have shown that cirrhotics are capable of apparently normal PLP synthesis and that increased hepatic dephosphorylation may be responsible for low levels of plasma PLP.

The fasting B6 vitamer profile and response to a pyridoxine load in normal and cirrhotic subjects.

This study established the fasting plasma and urine profiles of vitamin B6 in cirrhotics and assessed the response to an oral dose of pyridoxine. High-performance liquid chromatography was used to measure all vitameric coenzymatic and degradatory forms. In 31 patients with cirrhosis and 15 healthy controls, fasting plasma and 24-hr urine collection showed: plasma pyridoxal-5'-phosphate, the biologically active form, was significantly (p less than 0.001) reduced in cirrhotics (mean +/- S.D.: 5.7 +/- 3.2 ng per ml) compared to normals (14.2 +/- 7.5 ng per ml); plasma pyridoxal was detected in more cirrhotics (48%) than normals (28%); pyridoxic acid, the end catabolite, was significantly (p less than 0.05) lower in plasma of cirrhotics compared to normals, but 24-hr urine excretion was not different. Administration of 25 mg of pyridoxine to 7 cirrhotics and 5 normals showed the following plasma changes: pyridoxine rapidly peaked at 30 min and was totally cleared from plasma by 3 hr; plasma pyridoxal and pyridoxic acid increased in parallel up to 40-fold over baseline by 1 to 2 hr and rapidly fell toward baseline by 8 hr, and plasma pyridoxal-5'-phosphate, in contrast, increased significantly (p less than 0.05) from baseline by 60 min and was maintained above normal for 24 hr. The area under the plasma concentration vs. time curve (AUC) for pyridoxal-5'-phosphate was significantly (p less than 0.05) less for the cirrhotics than normals and showed a significant negative correlation to hepatocyte function and blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)