Reduction mammaplasty: the results of avoiding nipple-areolar amputation in cases of extreme hypertrophy.

In extreme cases of breast hypertrophy, amputation of the nipple-areolar complex and transplantation during reduction mammaplasty has been advocated to avoid nipple necrosis. We report our experience with 172 patients having inferior breast pedicle reduction without amputation of the nipple-areolar complex. Mean total weight of resected tissue was 1,946 g (548 to 5,100 g), with a mean nipple-areolar transposition of 10 cm (0.5 to 23 cm). Dividing patients into four groups by weight of resection, we compared complication rates. In this series, where nipple-areola amputation was avoided, there was a 99.6% survival rate of the nipple-areolar complex with 97.1% retention of nipple sensibility. Patients with extreme breast hypertrophy (3,000 g resected tissue) experienced no increase in complications when compared to smaller reductions. In most cases of gigantomastia, amputation of the nipple can be avoided using the inferior breast pedicle technique. Size of breast resection alone should not determine the fate of the nipple.

A rapid in vitro assay of cellular chemomigration in an epithelial carcinoma cell line.

We have studied the chemomigration activity of an epithelial carcinoma cell line using a modified 96-well Boyden chamber apparatus consisting of upper and lower wells separated by an 8-microns pore polycarbonate filter. Cells from the malignant squamous carcinoma cell line A-431 were plated in the upper wells over a collagen IV-coated filter. In chemokinesis assays, the cells were allowed to migrate toward NIH 3T3 fibroblast-conditioned medium or control media in the lower wells for 6 hours at 37 degrees C with 10% CO2. A-431 cells preferentially migrate across the barrier toward conditioned media but not control media. Control normal keratinocytes showed no migration. A highly metastatic melanoma cell line and poorly metastatic melanoma cell line, in which chemomigration has been shown previously to correlate with metastatic potential, were used as positive and negative cellular controls. This system provides a rapidly quantifiable method by which the invasion characteristics of multiple cell lines can be studied simultaneously in a single assay using the 96-well format.

Clinical and pathological features of pediatric dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon malignant mesenchymal tumor characterized by local invasion and recurrence. Fewer than 50 cases have been reported in the pediatric population. We reviewed our experience in the treatment of children with DFSP to define clinical and pathological characteristics. Seven pediatric patients were included in the study (mean age, 11.7 yr). Clinically, the tumors were described as firm nodules fixed to the skin but mobile over the deep fascia, with slow, progressive growth. Diagnosis was made by excisional biopsy in 6 patients and punch biopsy in 1 patient. Six of 7 patients had positive margins after the diagnostic procedure. Pathologically, diagnosis was based on histology, with confirmation by CD34 staining. Definitive surgical therapy consisted of wide local excision (1-3 cm margins) in 5 patients and Moh's micrographic resection in 2 patients. There have been no local recurrences or distant metastases, with a mean follow-up of 15.1 months. Pathological and clinical diagnostic criteria for the pediatric population are reviewed, and treatment options are discussed.

Postmastectomy reconstruction: comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction.

Over 40,000 postmastectomy breast reconstructions are performed annually. In this study, we investigated the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous (TRAM) flap versus breast implant reconstruction. Thirty-three women who had undergone postmastectomy breast reconstruction were contacted by telephone and agreed to participate in the study. Twenty-two women completed the self-assessment questionnaires regarding their quality of life, psychological symptoms, functional status, body image, and global satisfaction. The TRAM and implant groups contained 8 and 14 patients, respectively. The groups were well matched for age, employment status, marital status, race, religion, and severity of medical and surgical illnesses. The average follow-up was 36 months. Statistical analysis of the responses revealed that women who had undergone TRAM flap reconstruction were more satisfied with how their reconstructed breast felt to the touch (p = .01), and there was a trend toward greater satisfaction with the appearance of their reconstructed breast (p = .08). However, these same patients identified more difficulties as far as functioning at work or school, performing vigorous physical activities, participating in community or religious activities, visiting with relatives, and interacting with male friends (p < .04). There were no statistically significant differences in body image or overall satisfaction. In this small cohort study, both the TRAM flap group and the implant group were satisfied with the results of their breast reconstruction, but the TRAM flap group was more satisfied with how their breast felt and tended to be more satisfied with the cosmetic result. The TRAM flap group reported greater psychological, social, and physical impairments as a result of their reconstruction.

Embryology and anatomy of the cranial base.

This article provides an overview of the complex embryologic development and anatomic relationships of the cranial base. The processes of neural cell migration, and chondrocranial base formation and ossification are discussed. In addition, the relative sectional anatomy is addressed with the goal of providing a functional review for clinicians dealing with cranial base disorders. The complex influences of the surrounding matrix and diffusible factors involved in skull base development are sources of continuing investigation. Through elucidation of the mechanisms of basal cranial development, the understanding of congenital and pathologic disorders of this area as well as cranial base influence on facial growth will be enhanced greatly.

In utero brachial artery thrombosis: limb salvage with postnatal urokinase infusion.

In utero brachial artery thrombosis leading to neonatal extremity gangrene can occur from a variety of causes. Traditional management has been limited to supportive care, often leading to early amputation. We report a case of a 1-day-old neonate who presented with an in utero brachial artery thrombosis and whose treatment consisted of early, aggressive systemic thrombolytic therapy followed by serial soft-tissue debridement and ultimate skin coverage through cultured epithelial autografts. This resulted in a successfully salvaged and partially functional upper extremity.

Effect of radiation fraction size on local control rates for early glottic carcinoma. A model analysis for in vivo tumor growth and radio-response parameters.

BACKGROUND: Two recent studies have suggested that the probability of local control for early glottic carcinoma (stages T1 and T2) following radiation therapy is lower when daily fractions of 1.8 Gy are given instead of 2.0 Gy when the total dose is kept constant at approximately 66 Gy. METHODS: We reviewed our experience with a total of 42 patients with T1, N0, M0 squamous cell carcinoma of the glottic larynx who were treated with radiation alone during the period 1979 to 1989. All patients received conventional fractionation radiation therapy (one treatment per day, 5 days per week). Eight patients received 2.0 Gy per fraction for an average total dose of 64.8 Gy, and 34 patients received 1.8 Gy per fraction for an average total dose of 66.7 Gy. We also calculated overall survival statistics. Combining the clinical data from our series and those of patients from other series (171 total patients), we analyzed the tumor response curve and doubling time for early glottic carcinoma by using a time-dependent, linear quadratic equation model. The analysis is valid for the typical range of radioresponsiveness for most tumors in healthy tissue. RESULTS: Using statistical z analysis, we noted a significant difference in the local control rates at 5 years, with better local control in the group that received 2.0 Gy per fraction (100% vs 70%). Our results for the calculated doubling time and tumor response curves correspond with experimental values for in vitro squamous cell carcinoma systems. CONCLUSION: It appears from the literature and from our data that the control rates for T1, N0, M0 glottic carcinoma may be significantly improved by using 2.0 Gy per fraction dose vs 1.8 Gy per fraction dose. Our analysis has provided a model of in vivo tumor response of early glottic carcinomas based on reported local control rates using these two different treatment regimens.

Cervicofacial cystic hygroma. Patterns of recurrence and management of the difficult case.

Cystic hygromas usually present in infancy or early childhood as compressible masses that may rapidly and intermittently enlarge. While they may arise in any anatomic location, hygromas of the head and neck are especially difficult to manage since enlargement may cause serious sequela such as airway obstruction, feeding difficulties, and speech pathology. Complete extirpation of these lesions is often impossible, and recurrence rates are accordingly high. We reviewed our 10-year experience in treating cervicofacial cystic hygromas. Of 34 patients, 21 had lesions cephalad to the hyoid and 13 had lesions caudal to the hyoid. While none of the 13 children with infrahyoid lesions demonstrated feeding or respiratory difficulties, eight of 21 children with suprahyoid involvement presented with dysphagia or airway compromise. The recurrence rates for infrahyoid and suprahyoid lesions were 15% and 81%, respectively. Those children with suprahyoid hygromas also experienced an increased operative complication rate compared with patients with infrahyoid involvement. Principles of management for suprahyoid and infrahyoid lesions are described, including the specific management of lingual, submandibular, parotid, and parotofacial hygromas.

Second place--Resident Clinical Science Award 1990. A porcine model of chronic endobronchial obstruction.

To elucidate the effects of both prolonged lobar atelectasis and subsequent re-expansion in a non-thoracotomized animal, we have developed a chronic, reversible porcine model of endobronchial obstruction. Eight adolescent pigs underwent the bronchoscopic placement of a left lower lobe bronchial plug. The obstruction was left in place for 24 hours. Four pigs then had the balloon bronchoscopically removed, while four controls underwent sham removal of the balloon. All animals showed significant atelectasis of the obstructed lobe compared to non-obstructed lobes at 24 hours. Pulmonary blood flow decreased significantly 24 hours after obstruction compared to pre-obstruction values in the collapsed lobe in all animals. Re-expansion was followed by arterial hypoxemia, which was accompanied by an increase in relative blood flow to the partially re-expanded lobe in the experimental group. No significant changes in lung water content occurred in the study group compared to controls.

Fifteen- to twenty-year results after the Hill antireflux operation.

Antireflux surgery, specifically the Hill procedure, has been shown to be effective management of refractory reflux when assessed in the relatively short term. This study follows 441 patients from the time of their initial operation and reports on assessments conducted after 5 to 10 years and 15 to 20 years. The late study group comprises 167 patients (mean age 71 years) with an average follow-up of 17.8 years; 15.6% of patients had undergone a previous antireflux operation. Overall subjective good and excellent results, as determined by the patients themselves, were seen to improve significantly (p less than 0.02) between the two follow-up periods, 82% and 88%, respectively. No serious late complications such as fistula, bleeding, or obstruction were observed in this series. The Hill antireflux operation, properly performed, provides durable long-term results.

Aberrant carotid artery. Presentation in the near midline pharynx.

Three cases of an aberrant internal carotid artery presenting at or near the midline in the posterior part of the pharynx occurred. In all three cases, the anomalous finding was not correlated with the presenting symptoms of the patient. In two of the three cases intraoral pulsations were detected during initial examination. In the third case, pulsations were appreciated on reexamination after roentgenographic evaluation. Intraoral photographs, computed tomographic scan, magnetic resonance imaging, and arteriography of these findings are shown. A review of the literature and the embryology of the lateral pharyngeal carotid artery are presented along with the rare finding of the near midline carotid artery and the clinical implications of this anomaly.

[Hypothalamic phospholipid liposomes in the treatment of the climacteric syndrome]. / I liposomi di fosfolipidi ipotalamici nel trattamento della sindrome climaterica.

Phospholipid liposomes have a dopaminergic effect on the human brain. Changes in prolactin and growth hormone secretion have been observed in humans given phospholipid liposomes. The authors have investigated the therapeutic efficacy of hypothalamic phospholipids in the menopausal syndrome. The study was an open trial on 37 outpatients treated with 1 and 2 ampoules i.m. of a preparation of phospholipids (in the form of unilamellar liposomes) for a period of six months. The therapeutic effects were assessed by means of the Hamilton rating scale, MMPI (Minnesota multiphasic inventory test), and a list of psychosomatic symptoms (LSP). In the patients no change in FSH, LH, PRL, or E2 secretion was observed, whereas the neurotic symptomatology appeared remarkably reduced.

Acute blood flow changes in rapidly expanded and adjacent skin.

Random flaps raised in expanded skin demonstrate increased survival lengths when compared with flaps raised on an acute basis. Nutritive blood flow studies performed after skin expansion and elevation show augmented blood flows similar to those seen in conventionally delayed skin flaps. We utilized dermofluorometric analysis to study acute blood flow changes in sequentially, rapidly expanded porcine skin. Four subcutaneous pockets were developed in each of six pigs. The pockets were divided into the following three groups: (1) those with placement of a tissue expander inflated sequentially to 300 mL over four days and then totally deflated on day 6, (2) those with placement of a tissue expander that was not inflated, and (3) those with no tissue expander placed. Measurements were taken immediately before and after tissue expander manipulation in group 1 and daily in groups 2 and 3. Fluorescence was determined at points over and 4, 7, and 10 cm distal to the expander. Blood flow decreased immediately after skin expansion in areas over the tissue expander on days 0 and 1 and returned to baseline levels within 24 hours. Blood flow increased after tissue expander deflation on day 6 but returned to predeflation levels within 24 hours. Capillary blood flow increased over the duration of the study in all three groups. There was no significant difference in blood flow between and among the three groups on day 8, nor was there a significant difference in blood flow between and among sites over and distal to the tissue expander.

Gymnastic injuries: the Virginia experience 1982-1983.

Gymnastics has undergone a tremendous increase in popularity largely due to exposure during the Olympics. The injury rate in gymnastics is exceeded only by football, wrestling, and softball. A prospective analysis of club level gymnastic injuries over one season (1982-83) was conducted. Complete responses from 15 clubs (2,558 participants) were obtained. Parameters of clubs followed were: skill level, student, instructor ratio, safety equipment, and conditioning and warm-up exercises. Data obtained from each participant were: injuries sustained, event in which injury occurred, setting of injury, type of injury, and duration of disability. Results were 62 injuries among 542 competitive and 2,016 noncompetitive level athletes (5.3 per 100 competitors and 0.7 per 100 beginners). Of the 62 injuries, 51 were acute and 11 chronic. Twenty-one injuries occurred during floor exercises, 13 on beam, 9 on vault, 6 on uneven parallel bars, and 2 on springboard. Acute injuries included 21 sprains, 16 fractures, 6 contusions, 4 dislocations, and 4 muscle strains. A significant finding was the increased frequency of acute injury seen at dismount. Also there was a positive correlation between duration of frequency of practice (fatigue) and injury rate. We would define a high risk gymnast as one who is performing at an advanced competitive level, performing floor or beam exercises, and practicing more than 20 hours per week.