A Case of a Giant Borderline Phyllodes Tumor Early in Pregnancy Treated with Mastectomy and Immediate Breast Reconstruction.

Breast tumors in pregnancy are often times diagnosed at advanced stages secondary to difficulty distinguishing between pathologic from normal physiologic changes. Often benign, phyllodes tumors are rare fibroepithelial stromal tumors of the breast, most commonly diagnosed in the 4th and 5th decades of life. However, these tumors may be characterized by malignancy with metastases in 10% of cases. In this paper, we report a novel case of a young woman presenting at 8 weeks gestation with a large borderline phyllodes tumor. An exceedingly rare condition, with only nine previously reported cases, phyllodes tumors in pregnancy frequently display more aggressive characteristics with larger median tumor size, more malignant potential, and more rapid growth rate. Here, we describe our experience safely and effectively treating this rare condition in a young gravid women with mastectomy and immediate breast reconstruction in the second trimester.

Macrostomia: A Practical Guide for Plastic and Reconstructive Surgeons.

Macrostomia is a rare and debilitating congenital anomaly with incompletely understood etiopathogenesis. Despite the phenotypic variability in macrostomia, plastic surgeons should demonstrate competence in the diagnosis and management of this condition. The anatomy, embryology, classification, and clinical presentation of macrostomia are reviewed in this manuscript. A historical overview of surgical repair is presented that forms the basis for understanding modern techniques of repair. Finally, an effective method of macrostomia repair is presented along with review of 5-year results. It is our intent that this guide serve as a reference for plastic and reconstructive surgeons to accomplish safe, functional, and aesthetic macrostomia reconstruction.

Cadaveric study of the posterior pedicle nasoseptal flap: a novel flap for reconstruction of pharyngeal defects and velopharyngeal insufficiency.

BACKGROUND: The posterior pedicle nasoseptal flap has been the workhorse for endoscopic reconstruction of medium to large cranial base defects, with excellent outcomes and minimal flap failures. The authors present the anatomical foundations for the use of the nasoseptal flap for reconstruction of soft palate and pharyngeal defects and for surgical treatment of velopharyngeal insufficiency in a cadaveric model. METHODS: Posterior pedicle nasoseptal flaps were endoscopically harvested and transposed to the naso/oropharynx in seven cadavers. The reach and relationships of the flap with nasopharyngeal and oropharyngeal structures were documented. RESULTS: A total of nine nasoseptal flaps (bilateral in two specimens) were transposed into the nasopharynx and oropharynx. The most anterior aspect of the flap was visualized transorally several millimeters inferior to the soft palate in all specimens. Six flaps were sutured transorally to the posterior pharyngeal wall and three were sutured to defects of the soft palate. The width of a fully harvested flap (entire septal mucosa) was more than twice the width of the posterior nasopharyngeal/oropharyngeal wall in all specimens. Nasoseptal flaps were easily tailored endoscopically and transorally with standard instrumentation to fit the defects. CONCLUSIONS: In a cadaveric model, the nasoseptal flap can be transposed into the nasopharynx and upper oropharynx and is a potential alternative for pharyngeal reconstruction and surgical treatment of velopharyngeal insufficiency in patients in whom traditional flaps are not available. The application of this technique for reconstruction of pharyngeal and velar defects is novel, and further studies evaluating clinical outcomes are needed.

Understanding the unfavorable result after otoplasty: an integrated approach to correction.

The correction of an unfavorable outcome after otoplasty requires a thorough understanding of the anatomy of prominent ear and recognition of the spectrum of secondary deformities and their origin. The goal of this article is to describe the causes of postotoplasty deformity, including both undercorrection and overcorrection. The latter presents the more complicated reconstructive problem, as both skin shortage and permanent cartilage disruption need to be addressed. The authors propose an algorithm for revision otoplasty based on clinical findings and patient concerns. Finally, a case with overcorrection secondary to both skin deficiency and cartilage disruption is illustrated showing the sequential steps needed for optimal correction.

Community organizing goes to college: a practice-based model to implement environmental strategies to reduce high-risk drinking on college campuses.

Community organizing is a successful method to leverage resources and build community capacity to identify and intervene on health issues. However, published accounts documenting the systematic facilitation of the process are limited. This qualitative analysis explored community organizing using data collected as part of the Study to Prevent Alcohol Related Consequences (SPARC), a randomized community trial of 10 North Carolina colleges focused on reducing consequences of high-risk drinking among college students. The authors sought to develop and confirm use of a community-organizing model, based in practice, illustrating an authentic process of organizing campus and community stakeholders for public health change. Using the grounded theory approach, they analyzed and interpreted data from three waves of individual interviews with full-time community organizers on five SPARC intervention campuses. A five-phase community-organizing model was developed and its use was confirmed. This model may serve as a practical guide for public health interventions using community-organizing approaches.

Mortality and management of 96 shark attacks and development of a shark bite severity scoring system.

Humans share a fascination and fear of sharks. We predict that most shark attacks are nonfatal but require skilled, timely medical intervention. The development of a shark bite severity scoring scale will assist communication and understanding of such an injury. We retrospectively reviewed records of the prospectively maintained International Shark Attack File (ISAF) at the University of Florida. The ISAF contains 4409 investigations, including 2979 documented attacks, 96 of which have complete medical records. We developed a Shark-Induced Trauma (SIT) Scale and calculated the level of injury for each attack. Medical records were reviewed for the 96 documented shark attack victims since 1921. Calculated levels of injury in the SIT Scale reveal 40 Level 1 injuries (41.7%), 16 Level 2 injuries (16.7%), 18 Level 3 injuries (18.8%), 14 Level 4 injuries (14.6%), and eight Level 5 injuries (8.3%). The overall mortality of shark attacks was 8.3 per cent. However, SIT Scale Level 1 injuries comprised the greatest percentage of cases at 41.7 per cent. Injury to major vascular structures increases mortality and necessitates immediate medical attention and definitive care by a surgeon. Shark bites deserve recognition with prompt resuscitation, washout, débridement, and follow up for prevention of infection and closure of more complex wounds.

Principles of immunology.

The immune system, composed of innate and acquired immunity, allows an organism to fight off foreign pathogens. Healthy immunity accomplishes four essential principles: (1) ability to detect and fight off infection; (2) ability to recognize a host's own cells as "self," thereby protecting them from attack; (3) a memory from previous foreign infections; and (4) ability to limit the response after the pathogen has been removed. In an unaltered state, the intricate network of immunologic organs and cells creates an environment for proper host defense. Without adequate execution of immunologic mechanisms, a host is rendered defenseless against pathogens. Conversely, an unchecked immune response can be self-destructive. As a result of either of these untoward sequelae, immune dysfunction can elicit disease states in the host. The goal of this review is to elucidate the characteristics of a healthy immune system, focusing on the principles of immunity and the cells that participate in host protection. We also briefly discuss the clinical ramifications of immune dysfunction.