Another look at breast projection after breast reduction.

A controversy exists between vertical mammoplasty and the "traditional" keyhole\inferior pedicle method of breast reduction. This article examines factors affecting breast projection by considering the difference in concept between vertical mammaplasty (using the modification proposed by Hall-Findley as an example) and the inferior pedicle\keyhole pattern. This article is not about "how to do" but rather about "why" things are done in a certain way. The emphasis is on understanding what is done and its effects rather than on technique. The breast can be considered a cone. Breast projection then is the ratio between the nipple projection and the breast base. Two key concepts need to be considered: the orientation of the ellipses during excision of breast tissue in breast reduction and the role of the breast base\inframammary fold. Breast projection is not determined by the scars. After an examination of each technique, methods to enhance projection are discussed.

Significance of the portal vein helix.

BACKGROUND: The portal venous system plays a major role in a variety of disease processes. Although the anatomy, histology and physiology of the portal vein have been extensively studied over the last century, very little attention has been given to its unique helical structure. Previous documentation of the helical structure has been based on microscopic, macroscopic and radiological appearances. MATERIALS AND METHODS: A more refined method than the above was used to image the portal vein helix. Resin casts of the portal venous system were performed in 6 rats, 1 baboon and 1 human. RESULTS: All species had a clearly demonstrated helical structure of the portal vein situated above the splenic vein. CONCLUSION: The unique structure of the portal vein and its subsequent helical flow has been neglected in medical research. The significance of the activated portal helix and its effect on the blood flow into the liver needs further investigation.

Staged TRAM breast reconstruction: combining the advantages of tissue expansion with surgical delay.

The TRAM flap has become the gold standard in breast reconstruction but suffers from the disadvantages of poor color match, different texture, and impaired sensation compared to the normal breast. This study reports on a two-stage procedure to address these problems. The first stage consists of insertion of a tissue expander and surgical delay of the TRAM flap. The second stage consists of removal of the tissue expander and transposition of a deepithelized TRAM flap into the tissue expanded cavity. (The capsule is excised.) Four cases of breast reconstruction are reported. The advantage of this procedure is that it offers the benefits of tissue expansion, viz., normal color match, texture, and sensation, and in addition, reconstruction is achieved with autologous tissue by a pedicled TRAM flap. The vascularity of the TRAM is enhanced by a surgical delay procedure.

Another method to prevent venous thrombosis in microsurgery: an in situ venous catheter.

Free-flap failure is in the order of 4 to 10 percent. Heparin is more effective at preventing venous thrombosis than arterial thrombosis. This study was undertaken to investigate the efficacy of delivering heparin at a high dose locally but low dose systemically (heparin infusion via a catheter placed proximal to the venous anastomosis) to prevent venous thrombosis in microsurgery. A model of venous thrombosis was first established by a venous inversion graft in the rat femoral vein (this was performed in seven animals and resulted in 100 percent thrombosis). Saline and heparin were delivered proximal to the inverted vein graft to assess the effect of each in preventing venous thrombosis. Flow/patency distal to the inverted vein graft was assessed by observation under the microscope, the milk test, and rate of flow (flowmeter). Saline infused via a catheter proximal to the venous inversion graft resulted in 100 percent thrombosis in 10 animals. Heparin (100 U/ml at 2 to 3 ml/hour) infused through a catheter for 2 hours proximal to the anastomosis resulted in flow in all 10 animals during the infusion. Blood was also taken before beginning the procedure (control) and after the heparin infusion distal to the anastomosis (local partial thromboplastin time) as well as in the contralateral femoral vein (systemic). The control for all animals that received heparin was <3 minutes. The systemic partial thromboplastin time after heparin infusion was <3 minutes in seven animals, 3.3 minutes in two animals, and >7 minutes in one animal. The local partial thromboplastin time distal to the inverted vein graft was >10 minutes in nine animals and 3.7 minutes in one animal. The study also had a clinical component, in which a catheter was placed in a vein of the free flap, and heparin was infused over 5 days. This technique has been used in 83 consecutive free flaps. In three recent free flaps performed on the limbs, the local partial thromboplastin time (close to the anastomosis) was raised but the systemic time was normal. This technique offers a method in preventing venous thrombosis in microsurgery. It is simple to implement and is not associated with the systemic complications of heparin.

The mini rhytidectomy.

A technique is described in which superficial musculoaponeurotic system (SMAS) is plicated from the deep temporal fascia above the zygoma to the level of the earlobe. This procedure requires only an extended preauricular incision. The neck is dealt with by liposuction. This technique is ideally suited to the younger patient requesting facelift and is based on a sound understanding of the anatomy of SMAS. The outcome of 35 patients who underwent this procedure during a 3.5-year period are described. There were no cases of facial nerve paresis or hair loss. There were no cases of skin necrosis but two patients developed small hematomas and one patient complained of a stretched preauricular scar. The mini facelift leads to a satisfactory result in the younger patient requesting rhytidectomy. The technique is simple and safe and can easily be performed on an ambulatory basis. Complications are uncommon and of a minor nature.

Microembolectomy in the treatment of arterial occlusion of the hand: report of two cases.

The treatment of distal arterial occlusion is controversial. There is no commercial embolectomy catheter available, and fibrinolytic agents may not be effective after prolonged periods of ischemia. Two cases are reported in which microembolectomy was used to re-establish digital artery perfusion.

Hot water burns in Cape Town.

Scalds are common in South Africa and accounted for 21.6 per cent of the admissions to the Burns Unit of the University of Cape Town. Two hundred and forty adult patients (160 males, 80 females) with a mean age of 34.2 years were admitted for treatment of scalds between 1985 and June 1992. One hundred and thirteen sustained their scalds accidentally while 127 patients were assaulted with hot water. Epilepsy accounted for 11 per cent of the accidental burns. The head and neck was involved in 16.8 per cent of accidental burns and in 84.9 per cent of assaults. A quarter of the scalds to the trunk and limbs were caused by assault compared with 75 per cent caused by accidents. Beta haemolytic streptococcus was the second commonest organism isolated from the burn wound (57 patients). In 19 per cent of these patients a weekly course of penicillin and erythromycin did not eradicate the streptococcus and clindamycin was required. Accidental scalds usually affect the lower body and limbs whereas assault with hot water commonly involves the head and neck. Streptococcus is a common organism in the Burns Unit and is becoming more difficult to eradicate.

Microvascular replantation of avulsed tissue after a dog bite of the face.

Various authors have described successful microsurgical replantation of totally avulsed facial tissue. In a significant number of cases difficulties were experienced with the venous anastomoses and/or venous drainage of the tissue. Many different methods were used to overcome the problem. Despite these difficulties, good cosmetic and functional results were reported. These injuries are often caused by animal bites. Adequate wound care and the excellent local blood supply make immediate reconstruction after animal bites of the face a safe procedure. Other authors describing similar lesions and immediate repair have not reported the complication of wound infection. We report on a patient who suffered a dog bite with total avulsion of most of the left upper lip, cheek and left alar rim. Venous congestion was overcome by multiple needle punctures to drain blood from the outer surface of the flap and local of application of heparin. A good cosmetic result and the return of sensation and function of the orbicularis oris muscle were obtained.

Assault inflicted by hot water.

Assault inflicted by hot water is uncommon although such injuries have been reported from many parts of the world. The patient characteristics, burn distribution and outcome in 127 patients who had been intentionally assaulted with hot water during a 7 1/2 year period are reported. More than half of the males were assaulted by their wives. The female was often assaulted by her spouse or another family member. Most patients came from lower socioeconomic groups. The average burn surface area was 13.7 per cent (range 1-45 per cent). The upper part of the body was much more frequently burned than the pelvic and lower limb areas (12 per cent). Males (94) were assaulted more commonly than females (33). Eighty-four patients suffered partial skin thickness burns requiring debridement and skin grafting. The average hospital stay was 17 days (range 1-61 days). Upper body hot water burns in adults should raise the possibility of assault in the minds of attending medical personnel, especially where predisposing factors exist (alcohol abuse, lower socioeconomic strata, poor education). Most patients sustain partial skin thickness burns and will require debridement and grafting. Psychosocial factors require investigation and professional intervention.

[Stromal luteoma of the ovary. Differential diagnosis of steroid cell tumors]. / Le lutéome du stroma ovarien. Diagnostic différentiel des tumeurs à cellules stéroïdes.

An observation of a stromal luteoma of the ovary is reported. It is a rare tumor (only about thirty cases of it have been published yet), occurring mostly in post menopausal women. Endocrine symptoms and sometimes virilizing signs may be observed. Abnormal vaginal bleeding is the most frequent clinical manifestation. This macroscopically observed tumor is surrounded by ovarian stroma and entirely composed of luteinized cells devoid of crystals of Reinke. Hyperthecosis of ovarian stroma is often observed. Its evolution is always benign. The authors recalled the place of stromal luteoma of the ovary among steroid (lipid) cell tumors and the elements of a differential diagnosis. These tumor might derive from ovarian stromal cells.

New rapid technique for renal transplantation in the rat.

Present techniques for renal transplantation in the rat include a period of 20-25 minutes warm ischemia. Our method combines a recently described sleeve anastomotic technique for the renal artery, conventional end-to-end anastomosis of the renal vein, and implantation of the ureter into the bladder. This has resulted in a reproducible ischemic interval of 12-14 minutes. Plasma creatinine and histological features in animals sacrificed from 10 to 30 days after transplantation were within normal limits with no evidence of ischemic damage. A further advantage of the technique is that kidneys can be exchanged between the donor and recipient. It is recommended that this procedure, which reduces the ischemic interval by up to 50%, should be learned and employed in studies of renal transplantation in the rat, especially if such studies include the prior administration of cyclosporine, which may aggravate the effects of ischemia.

[Lethal polymalformative syndrome with 13q deletion secondary to a maternal X; 13 translocation]. / Syndrome polymalformatif léthal avec délétion 13q secondaire à une translocation maternelle X; 13.

The authors report the case of a newborn full term delivered by cesarean section for evolutive hydrocephalus, in the last month of pregnancy. This hydrocephalus was confirmed by echography after birth. This also having ambiguous genitalia and atresia ani, he died a few hours later. No evidence of infectious or toxic embryofetopathy was found out as an etiologic factor, but the karyotype of the baby showed a 13 q deletion and that of the mother a non reciprocal Xqter; 13q31.3 translocation. The study of inactivation of X indicated that the inactivated X chromosome in each cell was normal. On this occasion, the authors try to bring together the main points of "13q-syndrome" and discuss on the practical approach of antenatal diagnosis which they could propose to the couple.

A new microvascular "sleeve" anastomosis.

A new technique for performing a microvascular end-in-end or "sleeve" anastomosis is described. The new method utilizes two asymmetrically placed, looped sutures that do not enter the active lumen or breach the active intima. It has advantages over previous methods because it consistently saves time and because of the decrease in the number of possible technical complications. In 77 anastomoses performed in white rats by different surgeons, including a few inexperienced students of microsurgery, there was only one failure (24-hr patency). After eight practice anastomoses, the average time taken from vessel division to final clamp release in 30 procedures was 7 min 33 sec, with a standard deviation of 1 min 45 sec. The sleeve anastomosis performed by this method has shown itself to be as reliable as a conventional end-to-end suture method and has the advantages of significant time saving and minimization of intimal trauma. The anastomosis of vessels of differing sizes is facilitated by the conformation of this new method and the technique has clinical potential in the anastomoses of interposition vein grafts and in human intravenous anastomoses.