Women gain weight and fat mass despite lipectomy at abdominoplasty and breast reduction.

OBJECTIVES: In animal models, fat removal results in compensatory weight gain. No study has reported measurement of weight following lipectomy in humans. We have examined changes in weight in patients who underwent lipectomy. METHODS: In a retrospective analysis, 16 patients who had abdominoplasty and 17 patients who underwent bilateral breast reduction were compared with 16 patients who had carpal tunnel syndrome release. Following this, a prospective study was carried out on 7 subjects awaiting abdominoplasty and 12 subjects awaiting bilateral breast reduction surgery. RESULTS: In the retrospective study, all three patient groups gained weight following surgery. The abdominoplasty group was heavier before surgery and showed greatest weight gain but there was no statistically significant difference in weight gain between the groups. In the prospective study, the abdominoplasty group had a mean fat removal of 1.77 kg and breast reduction group had a mean of 3.22 kg. Eighteen months following surgery the abdominoplasty group showed a significant mean increase in body weight (mean increase: 4.82 kg) and body mass index (BMI) (mean increase: 1.66 kg/m(2)). In the bilateral breast reduction group, there was a non-significant mean gain in weight (mean increase: 0.67 kg) and BMI (mean increase: 0.21 kg/m(2)). CONCLUSIONS: Patients undergoing lipectomy during abdominoplasty and bilateral breast reduction will gain weight in the long term. This weight gain probably reflects the expected gain in weight without surgery as a similar finding is observed in patients who have undergone surgery without lipectomy. These results highlight the limitation of lipectomy as a weight control measure.

Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper?

An analysis of peripheral and deep margins of histological clearance around 1539 consecutive basal cell carcinomas excised by conventional surgery showed that 81 lesions (5.3%) were incompletely excised peripherally; 36 lesions (2.3%) were incompletely excised deeply; 13 lesions (0.8%) were incompletely excised peripherally and deeply. Nine hundred and ninety-six lesions (65%) were excised with a peripheral histological clearance margin<5mm (0.1-4.9mm), whereas 1303 lesions (85%) were excised with a deep histological clearance margin<5mm (0.1-4.9mm). Four hundred and eight lesions (27%) had a peripheral histological clearance margin of 5.0-9.9mm, whereas 170 lesions (11%) had a deep histological margin of 5.0-9.9mm. Peripheral histological clearance margins exceeded 10mm in 41 lesions (3%) and deep histological margins exceeded 10mm in 17 lesions (1%). Thus 30% of peripheral histological margins were 5mm or more but only 12% of deep histological margins were 5mm or more. Despite a relative sparing of deep tissue, incomplete excision in depth affected only 36 lesions compared with 81 incomplete peripheral excisions. Peripheral histological clearance was <5mm (0.1-4.9mm) for 55% of temple lesions, 50% of scalp lesions and 43% for limb lesions. In the cosmetically sensitive areas of peri-orbital region, nose, cheek, lip, neck and chin more than 70% of lesions were excised with a peripheral histological margin<5mm. This study of conventional surgical excision of basal cell carcinomas with an incomplete excision rate of 8% has shown that 65% of lesions were excised with <5mm histological clearance peripherally and 85% with <5mm deep clearance. These figures for 'normal tissue sacrifice' are not excessive when compared with those of 'tissue sparing' Mohs' micrographic surgery in which the operator may take a margin of several millimetres of normal tissue in the initial 'slice', or in the subsequent 'safety margin' beyond the eventual tumour free plane. However, peripheral margins did exceed 5mm in more than 30% of lesions of scalp, temple and forehead, and for these sites where even with loupe magnification the tumour edge could be difficult to define, either frozen section control or Mohs' technique, might with benefit be more often used in order to minimise normal tissue sacrifice.

Expression of the 5T4 oncofoetal antigen in renal cell carcinoma: a potential target for T-cell-based immunotherapy.

The 5T4 oncofoetal antigen is a heavily glycosylated cell surface protein found on human placental trophoblast and on diverse types of human cancer but is not expressed at significant levels on adult human tissues in health. It therefore satisfies the criteria for a tumour-associated antigen and is an ideal target for the immunotherapy of cancer. We report here that 5T4 is strongly expressed on the majority of renal cell carcinomas and therefore this population of patients is suitable for trials of 5T4-targeted therapies. In particular, we have shown that T cells from renal cell carcinoma patients can be genetically modified to kill 5T4 expressing renal cancer cell lines by introduction of a chimeric-signalling protein. This protein consists of a single chain antibody fragment capable of binding antigen directly at the cell surface and then activating the T cell by virtue of a CD3zeta-signalling domain. This is a powerful tool that bypasses a number of mechanisms that allow tumours to escape T-cell killing and can be readily scaled up for clinical use.

Do basal cell carcinomas recur after complete conventional surgical excision?

For 1378 patients treated in the 11 years 1988-1998 by conventional excision of 1635 basal cell carcinomas, 1516 first index lesions were histologically completely excised. All patients having more than one BCC excised were identified from the data base from 1988 to 2003 to give minimum 5 years follow for last treated primary lesions in 1998. Measured clearance margins around the initial lesions at or near sites of presumptive recurrent lesions were noted and the lesions recorded photographically. All incompletely excised lesions whether or not re-excised were excluded. The median age for all patients was 70 years. Over minimum 5 years follow up, six patients developed nine subsequent lesions contiguous with the scar or graft repair of primary index lesion excision site (probable recurrences). The median interval to recurrence was 41 months (4 months-8 years 10 months), with median lateral clearance margin around the primary tumour of 2 mm (0.3-6.8 mm). A further nine patients developed 11 new lesions near (within 1cm of) the scar or graft of primary index lesion excision site (possible recurrences). The median interval to recurrence was 59 months (1 year-8 years 6 months). The median lateral clearance margin around the primary tumour was 4.1 mm (0.8-5.8 mm). For the two groups combined the maximum recurrence rate expressed as a percentage of index lesions was 1.3% (20/1516). Two thirds of possible and probable recurrences occurred in the temple and forehead, although these sites represented only 22% of all lesions, which may rather suggest new lesions in an area of field change as opposed to residual disease. The measured clearance margins reported here perhaps suggest that some original lesions may well have been completely excised primarily and many 'recurrences' were new primaries. These figures indicate there is a low order of probability for the incidence of recurrent basal cell carcinoma during minimum 5 years follow period after conventional surgical excision and conventional histological assessment of tumour resection margins.

Ectropion following excision of lower eyelid tumours and full thickness skin graft repair.

A retrospective review was performed to define the incidence of post operative lower eyelid ectropion after excision and full thickness grafting of lower eyelid tumours. In a 7-year period (1995-2001) 106 consecutive patients were identified who had undergone such surgery with mean follow-up period of 7.4 months (median 5 months, range 1-41.5 months). The majority of lesions were basal cell carcinomas 89/106 (84%). A total of 15/106 (14.2%) patients developed ectropion. The length of follow-up for patients with ectropion was on average 11.7 months (median 10 months, range 2-34 months). Ten patients underwent corrective surgery with five of these showing cosmetic and symptomatic improvement. Of five patients treated conservatively, three showed spontaneous improvement. The incidence of lower eyelid ectropion after lower eyelid skin grafting is defined and this does not seem to have been reported before for a consecutive series of patients. We offer a classification for eyelid zones with regard to ectropion and anatomical and pathological factors that may be important for ectropion formation are discussed. Finally we suggest a new classification of ectropion based on cosmetic and functional consequences.

Re-evaluating selection criteria for local anaesthesia in day surgery.

Day surgery is an increasing element of surgical practice, particularly in plastic surgery. A large proportion of work is undertaken using local anaesthesia in the elderly who have associated co-morbidity. At present no national guidelines exist for the use of local anaesthesia in day surgery. This study aimed to examine the relationship between patient selection and complications, in order to identify those who should be excluded from local anaesthetic day surgery treatment. A retrospective analysis of patients undergoing local anaesthetic plastic surgical procedures over a 10-month period identified 328 operative episodes. There were 37 complications, two of which required admission 5 days post surgery for treatment of wound infection. The remaining complications were treated on an outpatient basis. An increased level of complication was seen in males with elevated systolic blood pressure and with the use of full thickness skin grafts in reconstruction. Age, smoking, ASA grade, and medication that altered coagulation (aspirin, warfarin and steroids) were not associated with increased complication levels. We conclude that local anaesthetic plastic surgical procedures are associated with a very low level of risk, and are suitable for those patients traditionally regarded as unsuitable for general anaesthetic day surgery.

Laboratory models of the thermal evolution of the mantle during rollback subduction.

The subduction of oceanic lithosphere plays a key role in plate tectonics, the thermal evolution of the mantle and recycling processes between Earth's interior and surface. Information on mantle flow, thermal conditions and chemical transport in subduction zones come from the geochemistry of arc volcanoes, seismic images and geodynamic models. The majority of this work considers subduction as a two-dimensional process, assuming limited variability in the direction parallel to the trench. In contrast, observationally based models increasingly appeal to three-dimensional flow associated with trench migration and the sinking of oceanic plates with a translational component of motion (rollback). Here we report results from laboratory experiments that reveal fundamental differences in three-dimensional mantle circulation and temperature structure in response to subduction with and without a rollback component. Without rollback motion, flow in the mantle wedge is sluggish, there is no mass flux around the plate and plate edges heat up faster than plate centres. In contrast, during rollback subduction flow is driven around and beneath the sinking plate, velocities increase within the mantle wedge and are focused towards the centre of the plate, and the surface of the plate heats more along the centreline.

Fleur-de-Lys abdominoplasty--a consecutive case series.

Sixty-eight consecutive patients who had undergone Fleur-de-Lys abdominoplasty are described. The mean age was 39 years, (22-62 years) and the mean body mass index (BMI) was 29 kg/m(2) (17-47 kg/m(2)). Forty patients had documented weight loss, mean 39 kg (10-103 kg). The operation duration ranged from 1 h 10 min to 4 h 15 min. The mean mass of tissue resected was 2.4 kg, (0.3-9.1 kg). The overall complication rate was 42/68 (62%) and complications were categorised as early, late, general and aesthetic. Complications were significantly related to patients with a greater age (p=0.0091), increasing BMI (p=0.0039), greater weight (p=0.0014) and greater mass of tissue resected (p=0.0002). There was no significant association between smoking and complications. There was no significant association between previous gastric partitioning surgery and complications. Despite the significant complication rate, a single operation achieved a satisfactory outcome in 82% of patients. Our data reinforce findings from previous studies, which have demonstrated that patients should be required to reduce weight prior to body contouring surgery.

Do plastic surgeons resect basal cell carcinomas too widely? A prospective study comparing surgical and histological margins.

Basal cell carcinoma is a common condition facing the plastic surgeon. When formally excised, a surrounding margin of normal skin is included in an attempt to ensure complete excision. We set out to investigate our excision margins in a prospective study of 100 basal cell carcinomas in 86 patients treated by conventional surgical excision. The edge of each lesion was delineated, an excision margin was drawn, and the closest point was identified and measured. The tumours were excised, and the specimens were examined to determine the closest histological margin. A comparison was made between the marked surgical margins and the margins observed on microscopy. The mean observed surgical margin was 3.0 mm and the mean histological margin was 3.7 mm; 44% of the margins agreed to within 1 mm, 79% to within 2 mm and 92% to within 3 mm. There were four incomplete excisions, all at the lateral margin. There was agreement in the position of the closest margin in 69% of cases. The measured surgical excision margins correlated well with those assessed histologically, as did the position of the closest margin. Given a 3 mm margin, 96% of lesions would have been excised completely. We feel that our current practice represents a satisfactory balance between maintaining a low rate of incomplete excision and minimising the sacrifice of normal skin.

Audit of clinical and histological prognostic factors in primary invasive squamous cell carcinoma of the skin: assessment in a minimum 5 year follow-up study after conventional excisional surgery.

In an attempt to evaluate the prognostic factors for primary squamous cell carcinoma of the skin treated by conventional surgery, a 6 year (1990-1995) cohort comprising 171 patients was analysed. Of these 171 patients, 157 were confirmed as having been treated for invasive squamous cell carcinoma, of whom 64 (41%) died within 5 years of treatment from causes other than squamous cell carcinoma, and were therefore defined as indeterminate. The remaining 93 patients were determinate patients; 85 lived without recurrence or metastasis for at least 5 years after treatment, and eight died of their disease. Comparing the groups who were alive or had died of disease at 5 year follow-up, the tumour diameter and tumour thickness were significantly greater in the eight patients who died (P = 0.02 and P = 0.0057, respectively) but there were no significant differences between the two groups with regard to age, deep resection margin clearance, lateral epidermal resection margin clearance, lymphocyte response or degree of tumour differentiation. This study defines the 5 year follow-up outcome following conventional surgery for squamous cell carcinoma of the skin, related to histological parameters, which, if routinely reported, would allow valid comparisons to be made between differing primary therapies.

Patterns of contraction in human full thickness skin grafts.

It is taught that full thickness skin grafts contract minimally in humans. We aimed to examine this assumption. In a prospective study, a scale photograph of each of 54 human full thickness skin grafts was taken at operation once the graft had been inset, but before the application of any tie-over or other dressing. For 50 grafts, a subsequent scale photograph was taken at follow-up (mean 111 days post-operation). The photographs were digitised and the areas of the grafts recorded. Significant area reduction in human full thickness skin grafts was found (P< 0.01, mean area change -38%). Greater contraction was associated with infection than without (P = 0.02, mean area change with infection -48%, without infection -33%). Full thickness skin grafts applied to the peri-orbital area and nose contracted more than those applied to the scalp and temples (P = 0.002). No differences in contraction were found between donor sites, between methods of fixation, between males and females or between those taking no medication and those taking steroids or non-steroidal anti-inflammatory medication. Area change did not correlate with initial graft area, patient age or time to second photograph.

Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision.

In an audit of 1392 basal cell carcinomas arising in 1165 patients, excised under the care of one consultant in the 10 years from 1988 to 1997, 99 (7%) were reported histologically as incompletely excised. Lateral margins alone were involved in 54 (55%), deep margins in 36 (36%) and both in 9 (9%). Although the policy throughout this period was to re-excise all such lesions, 74/99 (75%) were re-excised (compared with an average re-excision rate of 30% through other published series). For those patients undergoing re-excision, residual tumour was reported histologically in 40/74 (54%). Peri-orbital lesions showed an overall incomplete excision rate of 13% (range 11-17%); however, only 4/16 of re-excisions in this area revealed residual tumour. Many clinicians have traditionally observed patients with incompletely excised basal cell carcinomas. The present study reports the largest series of re-excisions after incomplete excision of basal cell carcinoma, and has revealed that on the balance of probability such re-excisions will reveal residual tumour. Re-excision appears the appropriate course in almost all the anatomical areas studied although, with the exception of the inner canthus, periorbital lesions will have a low probability of residual tumour being identified.

A retrospective analysis of the results of 218 consecutive rhinoplasties.

In a 7-year period, 218 consecutive rhinoplasties were performed within a joint rhinoplasty service comprising a plastic surgeon and an otorhinolaryngologist. Retrospective analysis of these procedures revealed a minor surgical complication rate of 5%, no major complications and requests for revisional surgery in 10% of patients after primary rhinoplasty by the service. However when patients had not had their first operation by our joint service, the revisional operation rate after our first operation was 19%. These results are discussed in relation to other published series. The data generated should enable more precise preoperative patient counselling and act as a useful baseline for subsequent audit of performance. Specifically, patients should know that after rhinoplasty 1 in 10 patients may request revisional surgery. All trainers and trainees should be aware of such data on their own patients in order that standards be set and enhanced with time.

Pharmacokinetics of lignocaine in children after infiltration for cleft palate surgery.

We have studied the pharmacokinetics of lignocaine in children after local infiltration for cleft palate surgery. After induction of anaesthesia, lignocaine 2.5 mg kg-1 with adrenaline 1:200,000 was injected into the palate. Blood samples were collected before and at 2, 5, 10, 15, 20, 30, 60 and 120 min after infiltration. Plasma concentrations of lignocaine were measured by a gas-liquid chromatographic technique. There were no signs of systemic toxicity on routine monitoring of the patients and the peak plasma concentrations were less than the accepted toxic values. Mean half-life was 72.9 (SEM 9.9) min, similar to that found previously in adults and children. However differences in mean clearance (24.6 (2.04) ml kg-1 min-1) and volume of distribution (0.80 (0.07) litre kg-1) were found between this and previous studies.

Giant alopecic nodule of the scalp: unusual presentation of a cellular blue naevus in an adult.

A giant cellular blue naevus of the scalp is described in a man with presentation in the third decade of life. In contrast with previous reports of children with this condition, there was no abnormality of the underlying skull bones and no evidence of malignancy.

Mantle plumes and continental tectonics.

Mantle plumes and plate tectonics, the result of two distinct modes of convection within the Earth, operate largely independently. Although plumes are secondary in terms of heat transport, they have probably played an important role in continental geology. A new plume starts with a large spherical head that can cause uplift and flood basalt volcanism, and may be responsible for regional-scale metamorphism or crustal melting and varying amounts of crustal extension. Plume heads are followed by narrow tails that give rise to the familiar hot-spot tracks. The cumulative effect of processes associated with tail volcanism may also significantly affect continental crust.

Plastic surgery outpatient audit: principles and practice of "consultant only" clinics.

The effect of instituting "consultant only" clinics on plastic surgery outpatient activity was to produce a 19% reduction in both clinic sessions and new patient bookings, but a 50% reduction in booked follow-up patients; non-attender rates reduced from 20% to 11% (Northern General Hospital, April 1986-March 1989). Mean clinic attendances reduced from 35 to 26 (Northern General Hospital) and from 33 to 27 (Barnsley District Hospital)--26% and 18%, respectively. Analysis of new referrals to such clinics in the 6 months January-June 1989 showed 41% of patients came from general practitioners, although 80% of "aesthetic" conditions came from this source. 31% of referrals were for malignancy, 51/72 (70%) being basal cell carcinomas. Malignancies waited on average 4 weeks, benign conditions 15 weeks, and "aesthetic" conditions 28 weeks from referral to consultation. Such clinic management has dramatically reduced follow-up episodes, but regulation of new patient attendances is associated with appreciable waiting times for non-malignant conditions. To reduce such waiting times and pursue a "consultant only" clinic policy nationally requires many more consultants.