Atlas and Talus.

This article explores the history of the terms atlas and talus and discusses the unexpected implications of their use in human anatomy. Renaissance anatomists decided to call the first cervical vertebra the atlas. But the name atlas was first used by the ancient Romans for the seventh cervical vertebra. The most common explanation why the first cervical vertebra is called atlas is that the vertebra holds up the globe of the cranium the way Atlas holds up the globe of the heavens. However, an important part of the myth of Atlas is that the Titan was being punished. The seventh cervical vertebra was so named due to its suitability for supporting burdens. (Pollux, 1900) Switching the designation atlas from the seventh to the first cervical vertebra in human anatomy implies that the point of man's burden has shifted from his shoulders to his head. What an anatomist is saying by making, or accepting, this change is that man's true burden is not a physical load, but rather, it is his mind. We explore the implications of this switch, and how it is represented in Renaissance anatomy diagrams. Long before the first cervical vertebra was called atlas it was known as the astragalus, the same term used for the talus, or ankle bone. We examine the many different terms that were used for the ankle bone during the Middle Ages and Renaissance, as well as the connection of the term talus with Greek mythology.

The Aleph and the écorché

The woodcuts in Vesalius' De humani corporis fabrica reflect both philosophical and theological ideas. A previously unrecognized Hebrew symbol in De humani is the écorché in the second muscle tableau. Its pose is evocative of an Aleph, the first letter of the Hebrew alphabet. The Aleph is a symbol of the brain and represents the highest level of knowledge and wisdom beneath that of god himself. With arms pointing to heaven and earth, the second écorché appears to anthropomorphize this ancient Hebrew symbol and may be a Humanist re-imagination of Old Testament imagery to demonstrate the famous Latin aphorism, nosce te ipsum, and the importance of anatomic dissection for the understanding of the human condition

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Selection criteria for expander/implant breast reconstruction following radiation therapy.

PURPOSE: Breast reconstruction with expander/implants is generally discouraged in patients who have undergone radiation therapy. However, not every patient treated with radiation develops sequelae severe enough to preclude the use of prostheses. To date, there have been no studies that have established criteria for selecting which patients may still be considered for expander/implant reconstruction. We present a series of 27 patients--the largest of its kind to date--all of whom underwent bilateral mastectomies, radiation therapy to only one chest wall, and delayed reconstruction with submuscular expander/implants. The aesthetic outcomes of the irradiated and the non-irradiated breasts were compared, and a classification of post-radiation skin changes was devised for selecting candidates for expander/implant reconstruction. METHODS: Patient records were reviewed to identify those who had undergone bilateral mastectomies, radiation treatment to only one chest wall, and delayed expander/implant reconstructions of both breasts. Twenty-seven patients were identified who met our inclusion criteria. Early post-radiation skin changes were classified as "moderate" or "severe," while aesthetic assessments were classified as "good," "acceptable" or "poor." RESULTS: Irradiated chest walls with moderate skin changes and absent induration have aesthetic outcomes comparable to the nonirradiated chest walls (p > 0.50). In contrast, patients who develop induration or severe post-radiation skin changes have a greater rate of modified Baker class IV capsular contracture and poor results that range from 75% to 100% of reconstructed breasts. CONCLUSIONS: A history of chest wall radiation should not itself exclude patients from receiving expander/implant reconstruction. Patients who develop neither severe skin changes nor induration may still be considered for prostheses.

Combined preoperative use of celecoxib and gabapentin in the management of postoperative pain.

BACKGROUND: In 2005 we reported a study on the efficacy of the preoperative use of the selective COX-2 inhibitor celecoxib (Celebrex) for reducing both postoperative pain and opioid requirements in patients undergoing bilateral subpectoral breast augmentation. Our findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly less postoperative opioid analgesics compared with those given a placebo. Gabapentin (Neurontin) is an agent commonly used to control neuropathic pain. Here we describe a prospective study assessing the efficacy of preoperative gabapentin in combination with celecoxib for reducing postoperative pain and opioid requirements in elective subpectoral breast augmentation. METHODS: One hundred eighteen patients were given 1200 mg of gabapentin and 400 mg of celecoxib 30-60 min before surgery. From the day of surgery until postoperative day 5, patients documented any use of analgesics and recorded their degree of pain. Results were then compared with those of our previous study in which only celecoxib was used. RESULTS: The combination of gabapentin and celecoxib was found to be significantly superior (p < 0.001) in reducing postoperative pain and opioid requirements than celecoxib alone in the management of postoperative pain and opioid requirements. CONCLUSION: To decrease postoperative opioid requirements, we recommend 400 mg of celecoxib and 1200 mg of gabapentin taken 30-60 min before surgery by patients undergoing subpectoral breast augmentation or a comparable plastic surgery procedure.

Basket submandibular gland suspension.

BACKGROUND: Correction of a ptotic submandibular gland is a considerable challenge in neck rejuvenation. The procedures available to treat this condition either provide only short-term success or carry perceived risk of significant postoperative morbidities. The authors describe a new technique, basket submandibular gland suspension, for the effective long-term treatment of submandibular fullness. METHODS: The ptotic gland is accessed through a submental incision or combined submental and rhytidectomy incision. The gland is protected in a piece of deep temporal fascia or superficial musculoaponeurotic system graft. Two Mitek fixation sutures are placed at each corner of the fascia and secured to the medial surface of the mandible after passing through a small portion of glandular tissue to create a basket-like structure that lifts and suspends the gland. RESULTS: Nineteen submandibular glands were suspended on 10 patients. The average follow-up was 1.8 years. Six patients (11 glands) experienced a complete elimination of bilateral submandibular fullness, whereas three patients had minimal residual fullness. One patient with a hypertrophic gland required resection after 1 year due to residual ptosis. None of the patients developed dryness of the mouth; loss of taste; or difficulties with phonation, articulation, or swallowing. One patient required removal of the suspension sutures due to infection. One patient developed temporary paresthesia along the lingual nerve distribution. One patient noted a palpable Mitek anchor on one side, which was removed without subsequent adverse outcome. CONCLUSION: Basket submandibular gland suspension produces effective long-term results for the elimination of submandibular fullness in patients who have normal sized, ptotic glands.

Modified tip grafts and tip punch devices.

BACKGROUND: Nasal tip aesthetics depend on the graceful synergism between soft tissue and the underlying frame. Nasal projection and the nasal tip width are the two most important components of nasal aesthetics. The cartilage graft, which has a predictable ability to affect several of the anatomical components contributing to nasal tip aesthetics, is one of the most versatile tools used to modify nasal projection. The fundamental shortcoming of the current graft sculpturing technique, namely, the requirement of time to create an optimal tip graft, prompted the design of a tool for the precise and rapid sculpturing of cartilage used for nasal tip onlay and shield grafts. METHODS: This report describes a modified design of the Peck and Sheen grafts and introduces a new instrument, the tip graft punch. The unique features of the tip graft punch that facilitate the production of a symmetric, precisely proportioned cartilage grafts are highlighted. RESULTS: The tip graft punch has been successfully used on 49 patients over the past 2 years. CONCLUSIONS: The authors report a modification of nasal tip grafts and a simple and useful device for harvesting these grafts. This modification produces more natural and aesthetically pleasing results. The device saves surgery time, and provides a symmetric and anatomical graft design.

New insight into the enigmatic white cord in Rembrandt's The Anatomy Lesson of Dr. Nicolaes Tulp (1632).

The anatomic accuracy of Rembrandt's The Anatomy Lesson of Dr. Nicolaes Tulp (1632) has been debated in the literature for many years. The white cord that courses along the ulnar aspect of the carpus and small finger of the cadaver in Dr. Tulp's dissection conforms to no normal anatomic structure and is believed to represent an anomalous branch of the ulnar nerve, an artistic error, or a combination of both. After the discovery of an accessory abductor digiti minimi (AADM) during a routine dissection of a late-middle-aged male cadaver, we noted that the course of its tendon over the hypothenar eminence resembled the white cord in the painting. After conducting a detailed literature search and anatomic interpretation of the painting, we established 4 criteria for identifying the white cord. Using these criteria, we evaluated the plausibility of an AADM being represented in the painting. We conclude that an AADM should be considered as a possible explanation for the white cord.

Simultaneous obliteration and treatment of infected frontal sinus fractures: novel use of the fibula flap.

We present two cases of infected frontal sinus fractures requiring simultaneous obliteration of the frontal sinus and reconstruction of the horizontal buttress. In both cases, a free fibula flap was used for obliteration and bony reconstruction in a single stage. We believe that this is a novel technique for treatment of infected frontal sinus fractures obviating the need for secondary staged procedures.

Pc 4 photodynamic therapy of U87-derived human glioma in the nude rat.

BACKGROUND AND OBJECTIVES: As a potential therapy for malignant glioma, we tested the phthalocyanine photosensitizer Pc 4 for: (1) rapid clearance from the vasculature, (2) specificity for glioma, and (3) tumoricidal photosensitizing capability. STUDY DESIGN/MATERIALS AND METHODS: Parenchymal injection of U87 cells into athymic rat brains (N = 100) was followed after 12 days by tail vein injection of 0.5 mg/kg Pc 4. After 1 day, the tumor was illuminated with either 5 (N = 11) or 30 (N = 16) J/cm(2) red light at 672 nm. Sacrifice was 1 day later. The brains from these 27 animals underwent H&E (necrosis) and TUNEL assay (apoptosis) histology. Pc 4 concentration of explanted brains and tumors (N = 16), and all blood samples (N = 52) were determined by HPLC-MS 1 day post Pc 4 administration. RESULTS: Tumor-specific apoptosis was almost uniformly seen; however, necrosis was found mostly in the high-light-dose group. Pc 4 concentration in bulk tumor averaged 3.8 times greater than in normal brain. CONCLUSIONS: These results warrant expanding this pre-clinical study to seek effective baseline Pc 4 drug- and light-doses and infusion-to-photoirradiation timing that would be necessary for a Pc 4-mediated PDT clinical trial for glioma patients.