Importance of the nasal-to-cervical relationship to the profile in rhinoplasty surgery.

There is general agreement that when discussing surgery with the prospective rhinoplasty patient, one may also include discussion of the chin because of the important interrelationship between these two regions. It is apparent that on the profile-lateral view, the four prominences-the forehead, nose, chin, and neck-balance and complement one another. The cervical region, the fourth dimension, was examined to estimate the aesthetic significance of the nasal-to-cervical relationship and to determine the implications to rhinoplasty surgery. Part I of the study was a survey to test the hypothesis that the cervical region affects the perceived impression of the nose. Four standard facial-profile black-and-white photographs were chosen to represent varying degrees of nasal dorsum hump and cervical ptosis problems. Using computer-altering software, only the cervical regions were altered to create a pair of photographs for each of the four profiles: one with a youthful-looking non-ptotic cervical region, the other with a ptotic aged-looking cervical region. Raters were asked to give their first-impression opinions of which nose subjectively appeared "better." Raters consistently (84 percent of the time) chose the nose on the faces with the less ptotic neck as being better. Therefore, a less ptotic neck improved the perceived appearance of the nose. Part II was a retrospective chart review of the rhinoplasty patients of a single surgeon by independent raters. To estimate the aesthetic significance of the nasal-to-cervical relationship, the proportion of patients undergoing rhinoplasty surgery who could have potentially benefited from a youth-restoring neck procedure was determined. Criteria originally described by Ellenbogen and Karlin for judging the results of youth-restoring neck procedures were used as relative indications for neck surgery. An average of 27.2 percent of the patients did not have visible criteria and therefore by definition had relative indications for neck-rejuvenating procedures when undergoing rhinoplasty surgery. As demonstrated in part I of the study, improving the neck could improve the perceived results of the rhinoplasty. Part III of the study validated the Ellenbogen and Karlin criteria. The present authors found that the original criteria were probably based on female patients, that male and older patients had more indications for surgery, and that there was significant interrater agreement with the youthful criteria. In summary, the authors established that a strong nasal-to-cervical relationship exists whereby the perceived appearance of the nose is affected by the neck. The significance of this relationship to rhinoplasty surgery was determined, and it was found that more than 27 percent of rhinoplasty patients could obtain better perceived nasal results with a concomitant neck-rejuvenating procedure. Consequently, discussing neck-rejuvenating procedures with the rhinoplasty patient is valuable.

The crumpled-ear deformity.

The common characteristics of the crumpled-ear deformity, the steps for surgical correction, and the authors' experience are described in this article. Commonly, the ear has a folded-over appearance; a normal length and width when unfurled; and wrinkling of the skin and cartilage of the helical rim, scapha, antihelix, and concha. Principles of correction of this deformity include (1) superficial scoring of the concave segments of the cartilage to open the wrinkled segments, (2) creating the antihelical fold by a mattress-suture technique, (3) repositioning of the helical rim, and (4) repositioning of the prominent ear lobe, if present. A total of 12 crumpled ears were evaluated in six patients, three of whom underwent surgery during their teenage years. No complications have been observed. A new classification of an ear deformity has been proposed based on morphology that to the authors' knowledge has not been described in the literature. Identification of the common features of the deformity allows for precise correction using already well-defined techniques.

Abdominal contour surgery: treating all aesthetic units, including the mons pubis.

BACKGROUND: Many patients who seek [ldquo ]abdominal[rdquo ] contour surgery also desire improvement of areas of the torso adjacent to the abdomen, such as the flanks and back rolls. OBJECTIVE: We propose a classification of the abdomen into distinct aesthetic units and report on a series of cases in which this classification was used, with special emphasis on one such unit, the mons pubis. METHODS: A series of 400 consecutive patients were evaluated according the proposed designation of aesthetic units. Lipoplasty was performed as described in previous studies. A subset of 6 patients who specifically desired improvement of the mons pubis were treated by lipoplasty and/or horizontal or vertical wedge incision. RESULTS: Most patients who received treatment according to aesthetic unit were satisfied with their outcomes. Two of the patients who sought improvement of the mons pubis specifically requested additional procedures. CONCLUSIONS: An approach to abdominal contour surgery that includes consideration of all related aesthetic units can achieve more proportional, harmonious results and increase patient satisfaction.

Effects of risedronate treatment on bone density and vertebral fracture in patients on corticosteroid therapy.

Men and women (n = 518) receiving moderate-to-high doses of corticosteroids were enrolled in two studies with similar protocols and randomly assigned to receive either placebo or risedronate (2.5 or 5 mg) for 1 year. All patients received daily calcium supplementation (500-1000 mg), and most also received supplemental vitamin D (400 IU). The primary endpoint was the difference between the placebo and active groups in lumbar spine bone mineral density (BMD) at 1 year; changes in BMD at other sites, biochemical markers of bone turnover, and the incidence of vertebral fractures were also assessed. In the overall population, the mean (SE) lumbar spine BMD increased 1.9 +/- 0.38% from baseline in the risedronate 5 mg group (P < 0.001) and decreased 1.0 +/- 0.4% in the placebo group (P = 0. 005). BMD at the femoral neck, trochanter, and distal radius increased or was maintained with risedronate 5 mg treatment, but decreased in the placebo group. Midshaft radius BMD did not change significantly in either treatment group. The difference in BMD between the risedronate 5 mg and placebo groups was significant at all skeletal sites (P < 0.05) except the midshaft radius at 1 year. The 2.5 mg dose also had a positive effect on BMD, although of a lesser magnitude than that seen with risedronate 5 mg. A significant reduction of 70% in vertebral fracture risk was observed in the risedronate 5 mg group compared with the placebo group (P = 0.01). Risedronate was efficacious in both men and women, irrespective of underlying disease and duration of corticosteroid therapy, and had a favorable safety profile, with a similar incidence of upper gastrointestinal adverse events in the placebo and active treatment groups. Daily treatment with risedronate 5 mg significantly increases BMD and decreases vertebral fracture risk in patients receiving moderate-to-high doses of corticosteroid therapy.

The CD44 receptor of the mouse LB T-cell lymphoma: analysis of the isoform repertoire and ligand binding properties by reverse-transcriptase polymerase chain reaction and antisense oligonucleotides.

CD44 is a cell surface glycoprotein involved in cell migration and cell docking in target organs via interactions with various ligands, including hyaluronic acid (HA), which is the principal ligand of this receptor. Alternative splicing generates many isoforms of CD44, including standard CD44 (CD44s) and CD44 variants (CD44v). LB T-cell lymphoma, which predominantly expresses CD44s, acquires additional CD44v and HA binding capacity after activation with phorbol ester. The HA9 cell line, isolated from parental LB cells, expresses CD44v and constitutively binds HA. Downregulation of CD44v isoforms of HA9 cells, by CD44v specific antisense inhibited their ability to bind HA, indicating that CD44v, rather than CD44s, is associated with the activation status of this molecule. Using the reverse transcriptase polymerase chain reaction, we found that LB cells after infiltrating spleen and lymph nodes of BALB/c mice, contain an enriched repertoire of CD44v, implying that the metastatic cells acquired the activated form of this receptor.

The CD44 receptor of lymphoma cells: structure-function relationships and mechanism of activation.

Migration of some tumor cells, and their lodgment in target organs, is dependent on the activation of cell surface CD44 receptor, usually detected by its ability to bind hyaluronic acid (HA) or other ligands. In an attempt to reveal the mechanism of tumor cell CD44 activation, we compared the physical and chemical properties of CD44 in nonactivated LB cell lymphoma with those in phorbol 12-myristate 13-acetate (PMA)-activated LB cells and of an LB cell subline (designated HA9) expressing constitutively-active CD44. In contrast to nonactivated LB cells, PMA-activated LB cells and HA9 cells displayed a CD44-dependent ability to bind HA. The ability of activated cell CD44 to bind HA was not dependent on microfilament or microtubule integrity or on changes in CD44 mobility on the membrane plane, indicating that the CD44 activation status is not associated with cytoskeleton function. Aside from the increased expression of CD44 on the surface of PMA-activated LB cells and HA9 cells, qualitative differences between the CD44 of nonactivated and activated LB cells were also detected: the CD44 of the activated lymphoma was (i) larger in molecular size, (ii) displayed a broader CD44 isoform repertoire, including a CD44 variant that binds HA, and (iii) its glycoprotein contained less sialic acid. Indeed, after removal of sialic acid from their cell surface by neuraminidase, LB cells acquired the ability to bind HA. However, a reduced dose of neuraminidase did not confer HA binding on LB cells, unless they were also activated by a low concentration of PMA, which by itself was ineffective. Similarly, under suboptimal conditions, a synergistic effect was obtained with tunicamycin and PMA: each one alone was ineffective but in combination they induced the acquisition of HA binding by the lymphoma cells, while their CD44 expression was not enhanced. Unveiling of the activation mechanism of CD44, by exposing the cells to PMA stimulation or to deglycosylation, is not only academically important, but it also has practical implications, as activated CD44 may be involved in the support of tumor progression.

Effects of calcitonin on animal and in vitro models of skeletal metabolism.

During the 40 years since its discovery, calcitonin (CT) has been regarded primarily as an inhibitor of bone resorption and its therapeutic applications have been based on this property. A significant body of literature also indicates additional anabolic effects in animal and in vitro models. In a variety of bone loss histomorphometric models in the rat, CT, especially the salmon species, prevents or retards bone loss. In other species, similar results have been obtained, except in the beagle given human CT, in which a recent study reported increased bone resorption and bone loss. Consonant with the histomorphometric effects in several different species, bone mass (density) measured by a variety of methods increases, reversing the bone loss induced by the model. In related studies of mechanical properties, bone strength is increased by CT except in the beagle study which utilized human CT. In other species, experimentally induced fractures show either accelerated healing or heal normally, and there is no effect of CT to impair healing. Finally, studies of bone formation/mineralization strongly suggest an anabolic effect on cartilage formation, bone matrix synthetic activity, and bone growth. These animal effects are reflected by recent fracture prevention studies in humans. If its anabolic effects are ultimately found to be separable and additive to CT's basic action to inhibit bone resorption, new approaches to osteoporosis prevention, and possibly other treatment situations such as cartilage regeneration, may evolve using novel CT-like molecules.

Risedronate therapy prevents corticosteroid-induced bone loss: a twelve-month, multicenter, randomized, double-blind, placebo-controlled, parallel-group study.

OBJECTIVE: Risedronate, a new pyridinyl bisphosphonate, is a potent antiresorptive bone agent. This study examines the safety and efficacy of daily, oral risedronate therapy for the prevention of corticosteroid-induced bone loss. METHODS: This multicenter, randomized, double-blind, placebo-controlled, parallel-group study was conducted in 224 men and women who were initiating long-term corticosteroid treatment. Patients received either risedronate (2.5 mg or 5 mg) or placebo daily for 12 months. Each patient also received 500 mg of elemental calcium daily. The primary outcome measure was the percentage of change in lumbar spine bone mineral density (BMD). Secondary measures included proximal femur BMD and incidence of vertebral fractures. RESULTS: After 12 months, the lumbar spine BMD (mean +/- SEM) did not change significantly compared with baseline in the 5-mg (0.6 +/- 0.5%) or the 2.5-mg (-0.1 +/- 0.7%) risedronate groups, while it decreased in the placebo group (-2.8 +/- 0.5%; P < 0.05). The mean differences in BMD between the 5-mg risedronate and the placebo groups were 3.8 +/- 0.8% at the lumbar spine (P < 0.001), 4.1 +/- 1.0% at the femoral neck (P < 0.001), and 4.6 +/- 0.8% at the femoral trochanter (P < 0.001). A trend toward a decrease in the incidence of vertebral fracture was observed in the 5-mg risedronate group compared with the placebo group (5.7% versus 17.3%; P = 0.072). Risedronate was well tolerated, and the incidence of upper gastrointestinal adverse events was comparable among the 3 groups. CONCLUSION: Risedronate therapy prevents bone loss in patients initiating long-term corticosteroid treatment.

The risk of cystocele after sacrospinous ligament fixation.

OBJECTIVE: The aim of this study was to determine whether sacrospinous ligament fixation independently increases the risk of anterior vaginal wall defect. STUDY DESIGN: A retrospective cohort study was conducted on patients undergoing pelvic reconstructive surgical operations by a single surgeon from 1970 through 1997. Two groups were examined and divided into subgroups to evaluate the effects of exposure to sacrospinous ligament fixation: patients with anterior wall defects undergoing standard anterior colporrhaphy with (group 1A) or without (group 1B) concomitant sacrospinous ligament fixation, and patients without anterior wall defects undergoing other pelvic reconstructive procedures (but not anterior colporrhaphy) with (group 2A) or without (group 2B) sacrospinous ligament fixation. Recurrence rates were calculated for each group according to evidence of any degree of anatomic defect. RESULTS: Among 322 patients in group 1, 9 of 77 in group 1A and 23 of 245 in group 1B (11.7% vs 9.4%, P >.05) had anterior wall recurrences. Among 73 patients in group 2, 8 of 45 in group 2A and 5 of 28 in group 2B (17.8% vs 17.9%, P >.05) had subsequent anterior wall defects. CONCLUSION: The occurrence of anterior vaginal wall defects was not found to be altered by the performance of sacrospinous ligament fixation. These findings may be attributable to surgical technique emphasizing maintenance of anterior vaginal wall length during sacrospinous ligament fixation.

Reevaluating the need for routine drainage in reduction mammaplasty.

The incidence of complications after reduction mammaplasty without drains was reviewed by analysis of 50 bilateral reduction mammaplasty procedures. Patients ranged in age from 14 to 65 years; the average combined volume removed was 953 g. Eighty-four percent of the patients underwent a Pitanguy technique, and the remaining patients underwent an inferior pedicle or amputative technique with free nipple grafts. Three patients had six complications; one of these patients had three of the complications. Complications included two cases of fat necrosis and one case of wound disruption. One patient had a hematoma with wound disruption and partial nipple loss. There were no cases of infection. The purpose of this study was to determine the rate of complications in reduction mammaplasty performed without drains. Incidentally, statistical analysis using the chi-squared test revealed that this series without drains compared favorably with previously published data for reduction mammaplasty using drains. It is concluded that routine closed suction drainage after reduction mammaplasty is unnecessary and should be reconsidered.

Glioma of the tongue.

A case of glioma of the tongue that was treated successfully by simple excision and repair is presented. It may represent neural tissue that remains in the occipital somites that differentiate into the tongue muscles. Histologically, it consists of sheets of glial tissue. The literature is reviewed, and the case is discussed.