The pinwheel technique: an adjunct to the periareolar approach in gynecomastia resection.

The most common surgical approach to gynecomastia is through Webster's intra-areolar incision. The authors have modified the excisional phase of the operation to facilitate the delivery of a large mass of breast tissue through a relatively small incision. The essential features of this procedure are (1) delineation of the perimeter of the breast on the pectoral fascia; (2) elevation of the anterior chest wall skin and subcutaneous tissues over the entire breast mass; (3) serial application of Kocher clamps at the perimeter of the breast and, with gentle traction, sequential lysis of the peripheral and posterior attachments of the breast mass; and (4) delivery of the the mass simultaneously through the periareolar incision, as the dissection proceeds, until the entire specimen is exteriorized. The specimen then consists of the entire breast mass encircled by a pinwheel-like arrangement of Kocher clamps. Thirty-one patients (61 gynecomastic breasts) were operated using this method. En bloc tissue specimens weighing as much as 285 g were removed without the need for dividing the specimen or extending the single incision. The authors recommend this technique, which is straightforward and efficacious with minimal blood loss and good postoperative cosmesis.

A surgical approach to the motor branch of the ulnar nerve.

Isolated injury to the motor branch of the ulnar nerve is a relatively rare injury, often initially misdiagnosed. If repair is attempted through the original laceration without complete motor branch exposure, results can be less than satisfactory. A recent case illustrates this injury and provides us with an opportunity to review the surgical anatomy of the motor branch of the ulnar nerve. The surgical approach to the motor branch has been detailed and specifically emphasizes complete motor branch exposure from the main ulnar nerve trunk to the most distal motor branch entry into the adductor pollicis muscle. This approach permits definition of the exact level of the nerve injury, preservation of any intact proximal fine motor branches, and facilitates the mechanics of nerve repair.

Treatment of keloids by combined surgical excision and immediate postoperative X-ray therapy.

Sixty-eight histopathologically confirmed keloids were excised in 40 patients from 1970 to 1979. Surgery involved intrakeloidal excision with wound closure by direct, multilayered advancement repair or split-thickness skin grafting. All patients received x-ray therapy totaling 1,500 rads delivered in 3 equal doses, the first within several hours after surgery and the rest at two- to three-day intervals. There was a minimum of one year's follow-up in all cases, with a mean follow-up time of approximately twenty-four months. Recurrence rates of 21% per lesion and 28% per patient were obtained for the series. Earlobe keloids had recurrence rates similar to those noted for the series of a whole. Seventy-five percent of recurrences were evident within twelve months following treatment. Intrakeloidal excision combined with immediate postoperative x-ray therapy is effective in treating keloids.