Giant lipoma of the breast.

Lipomas of the breast are usually small, benign neoplasms which can be treated by simple excision. Diagnosis of these masses, however, can be difficult because of the normal fatty composition of the breast. A number of radiological manoeuvres have been described for diagnosing deep lipomas in the breast, yet the clinical and radiographic identification of these masses remains challenging. We present a case of giant lipoma of the breast which was not appreciated on initial clinical and radiographic evaluation, and which was later found to comprise most of the mass of the breast. Following resection, the deformed breast was reconstructed using folded dermoglandular flaps from the areas expanded by the lipoma with excellent results. This case is an excellent illustration of the difficulties associated with diagnosis of these tumours and the reconstructive options available following excision.

Lemierre's syndrome: a case of postanginal septicemia and bilateral flank abscesses.

Lemierre's syndrome is characterized by pharyngeal infections in young healthy adults with secondary septic thrombophlebitis and multiple metastatic infections. In the preantibiotic era, Lemierre's syndrome was common and lethal. With the advent of antibiotics, Lemierre's syndrome has become such a rare entity that the diagnosis is often delayed or missed. With prompt recognition, appropriate antibiotic therapy, and surgical drainage of metastatic abscesses, the majority of patients can be cured. A case of Lemierre's syndrome in a 22-year-old previously healthy man treated on a plastic surgery service is presented. Surgeons who can be consulted for deep space infections should be aware of this disease so that the diagnosis and treatment can be initiated promptly to prevent patients from succumbing to this life-threatening but curable disease.

Correction of scaphocephaly secondary to ventricular shunting procedures.

Craniosynostosis following ventricular shunting procedures for hydrocephalus has become a recognized complication of shunting procedures. Secondary synostosis results from a decrease in intracranial volume leading to collapse of the cranial vault. Since this represents a distinct etiopathogenesis different from that typically involved, the surgical approach should be altered. Eight patients with secondary scaphocephaly underwent surgical reconstruction. The clinical data and radiographic studies were reviewed for these patients. The surgical approach consisted of sagittal or parasagittal strip craniectomies, lateral osteotomies with bone-flap expansion, occipital and frontal remodeling as needed, and the application of rigid fixation to maintain contour and prevent recurrent collapse of the cranial vault. Patient follow-up ranged from 3 to 37 months. Five of these patients were premature infants, an association not previously recognized in the literature. Satisfactory results were obtained in all patients. Keeping the craniectomy sites parent and achieving a more normal cranial contour through cranial remodeling have provided good results in this population.

An old friendship revisited: plastic surgery and transplantation.

Plastic surgery has a rich history in the development of the field of transplantation. Many prominent plastic surgeons, while undertaking experimental as well as clinical efforts, pioneered and assisted in the establishment of journals and societies devoted exclusively to the field of transplantation. Much of this work was initiated during World War II, a time when transplantation was viewed with suspicion by both scientists and clinicians. While work in this area has undergone a quiescence among members of our specialty, advances in microsurgery and immunology have rekindled interest among plastic surgeons.

Donor leukocyte migration following extremity transplantation in an experimental model.

In an effort to further define the immunologic mechanisms leading to acute composite-tissue allograft rejection, the migratory patterns of donor leukocytes were evaluated. Using a rat model, 52 orthotopic vascularized hindlimb transplants were performed in strains representing major histocompatibility mismatches. In order to evaluate the effect of allogeneic skin on limb rejection, all donor skin was removed in a second group of allografts. Recipient lymphoid organs were examined during the week following transplantation for antigen-presenting cells using a donor-specific class II monoclonal antibody. Donor leukocytes, with dendritic cell morphology, were identified in recipient spleen and lymph nodes draining the allograft. Significantly higher numbers of donor leukocytes were present during postoperative days 1 through 4 for both groups. Association of these important passenger leukocytes with host T-lymphocytes may represent the site of initiation of the immune response.

Migration of donor leukocytes from limb allografts into host lymphoid tissues.

This study was undertaken in an initial effort to characterize the immunology of extremity transplantation by examining the pattern and kinetics of leukocyte migration from rat limb transplants. Migration of donor leukocytes was evaluated by examining recipient lymphoid tissues with a donor-specific, anti-major histocompatibility complex, class I monoclonal antibody. Double-antibody, two-color labeling was used to localize donor cells to specific regions within these tissues. Donor leukocytes, with dendritic cell morphology, were found in the T-cell-rich areas of lymph nodes draining the allograft and spleen. The donor cells were present on postoperative days 1 through 3 but were not present on days 5 to 7. Donor leukocytes were not present in distant lymph nodes or liver. These findings indicate a migration of leukocytes, most likely the highly immunogenic dendritic cell, from rat limb transplants to the draining lymphoid tissues. Migration occurs shortly after transplantation and may lead to the sensitization of alloreactive T-cells.