The Internet as a source of information on breast augmentation.

The Internet was evaluated as a source of information for the layperson on the topic of breast augmentation. Three commonly used search engines (Excite, AOL, and Yahoo) were employed using the term "breast augmentation." These sites were then evaluated by each of three experienced plastic surgeons for their quality and content. Separately, 17 health Web sites were identified as authoritative by means of recommendation in lay publications. Each "supersite" was accessed, and its search engine was used. The top 10 hits for "breast augmentation" on each site were then evaluated by the senior author for content (Matthews). We found the majority of sites identified by the general search engines (AOL, Excite, Yahoo) to be physician Web sites. Forty-one unique sites were found that applied to the topic. Four of the "hits" did not actually apply to the topic. In general, the applicable Web sites contained limited but accurate procedural details and offered an interactive forum, most commonly email responses. Photographic documentation was given in less than half the sites reviewed, and most of the results shown were only "good" outcomes. Most sites did not discuss any complications of surgical procedures, but those that did were usually accurate. Eighty-three percent of the sites were biased toward a particular surgical technique. The reviewers believe that only about 15 percent of the sites were acceptable to recommend to their patients. The senior author accessed 17 Web sites that are considered authoritative health information Web sites. Each of these sites was searched for information on breast augmentation by means of its internal search engine. Only 29 percent (5 of 17) had any information in their top 10 hits. Three sites had only chat transcripts. One site had limited but accurate information with a link to the American Society of Plastic Surgeons, and one site had scientific information on product safety. No site met the criteria of accurate, complete information on the surgical procedure of breast augmentation. This study demonstrates that it is difficult for the average layperson to get authoritative information quickly and easily on at least one aspect of cosmetic surgery.

Immediate breast reconstruction after mastectomy.

Immediate breast reconstruction after mastectomy can be performed safely with a low incidence of complications. There is no evidence that reconstruction with a submuscular implant interferes with subsequent oncologic care, followup, or outcome for patients.

Is routine cervical spine radiographic evaluation indicated in patients with mandibular fractures?

Fractures of the mandible are commonly seen in most urban trauma centers. Over the past decade, the authors have seen a rise in these injuries secondary to an increase in drug and alcohol abuse, violent crime, and high-speed motor vehicle accidents. Several reports have described an association between mandibular fractures and cervical spine injuries and recommend routine cervical spine radiographs in all patients with mandibular injuries. These studies have failed to show a "cause and effect" relationship because of concomitant injuries found in these patients. This study reviews mandibular fractures and cervical spine injury retrospectively and prospectively over a 3-year period. The retrospective study included patients with isolated mandibular fractures who came to Cooper Hospital/University Medical Center Emergency Room in 1987. Thirty patients were identified, 18 of whom had cervical spine x rays. No patients had a significant radiologic or clinical cervical spine injury. The prospective study included all patients with mandibular fractures seen in the emergency room during 1988 and 1989. Seventy-three patients were identified, 44 of whom had mandibular and cervical spine radiographs. None had a significant radiologic or clinical cervical spine injury. The authors conclude that routine cervical spine x rays are costly and unnecessary. Also, any patient with a suspicion of concomitant cervical spine injury (i.e., patients with a loss of consciousness, multi-organ system injury, cervical pain or tenderness, or intoxication from alcohol use) should have cervical spine x rays, including anteroposterior, lateral, and open-mouth odontoid views.

Steatocystoma multiplex with bilateral preauricular sinuses in four generations.

A rare case of steatocystoma multiplex and bilateral preauricular sinuses in four generations is presented along with a review of the literature. The cause, pathogenesis, and treatment of steatocystoma multiplex is discussed. Steatocystoma multiplex (SCM) is a rare clinical disorder characterized by numerous recurrent cutaneous cysts. Since the first case described by Bosellini in 1898, both nonfamilial and autosomal dominant inheritance patterns have been described. There have been at least 13 well-documented nonfamilial cases. However, since Noonjin and Reynolds in 1948 first described the autosomal dominant inheritance pattern, only 4 well-documented familial cases have been reported. To date, there has been one case report of SCM in four generations, and that case was not associated with any other anomaly. The present case describes the occurrence of SCM in association with bilateral preauricular sinuses in multiple generations.

Nasal airway blockage caused by displaced premaxilla mimicking posterior pharyngeal flap obstruction.

Signs of nasal airway obstruction, ranging from hyponasality, snoring, and inability to blow the nose to cardiorespiratory compromise, have been reported after posterior pharyngeal flap surgery. In some cases the symptoms are severe enough to require take-down or revision of the flap. Polysomnography has been used to document obstruction to nasal airflow and may be a guide in selecting patients for flap revision. This case report points out that in certain patients a particular coexisting anatomic abnormality--the locked-out premaxilla--may predispose patients to this symptom complex. In such patients flap revision may not relieve the symptoms, and careful evaluation of the lateral pharyngeal ports is recommended.

Congenital cardiac tumors in association with orofacial clefts.

The case of an infant with a complete cleft of the primary and secondary palate (class III) and right unilateral complete cleft lip who demonstrated failure to thrive due to a primary congenital cardiac fibroma is described. This tumor required cardiac transplantation for effective treatment. A review of the literature, although replete with associations of cleft lip/palate and congenital heart disease, does not reveal a congenital cardiac tumor/orofacial cleft association or syndrome. Failure to thrive, however, which is common in such infants, may well be associated with congenital cardiac anomalies and should be carefully ruled out. Treatment of cardiac fibromas is discussed along with the usefulness of two-dimensional echocardiography and the importance of the team approach in the management of these infants.

Polysomnographic indications for surgical intervention in Pierre Robin sequence: acute airway management and follow-up studies after repair and take-down of tongue-lip adhesion.

The major concern for neonates with Pierre Robin sequence is the stability of the airways. The accepted management has been close clinical observation followed by surgical intervention if the airway was felt to be unstable. Six newborns with this diagnosis were admitted for evaluation in a 7-month period. Each underwent transcutaneous oxygen and carbon dioxide monitoring in a resting state. Each infant then was evaluated with infant polysomnography to ascertain the presence of obstructive apnea. Pulse-oximetry was utilized to document the oxygen saturation of each child during the polysomnography. On the basis of these studies, four of the neonates required a tongue-lip adhesion to stabilize the airway. These four infants were reassessed with polysomnography postoperatively, prior to cleft palate repair, following palatoplasty, and after their tongue-lip adhesion was released. This method of evaluation allows early testing of the stability of the airway in a way that augments and confirms the clinical assessment of the infant, allowing appropriate surgical intervention when necessary. This method of evaluation also allows the safe prediction of airway stability following palatoplasty and release of the tongue-lip adhesion.

Surgical indications and techniques for posterior pharyngeal flap revision.

Twenty-four patients underwent surgical revision of posterior pharyngeal flaps for correction of abnormal vocal resonance, nasal air escape, or sleep apnea. Anatomical findings upon operation are correlated with preoperative symptoms, and an operative approach is outlined. Overall, 67% of the total group (16 patients) were improved after revision, with the most marked improvement seen in those with preoperative hypernasality or airway obstruction.

Staphylococcal scalded-skin syndrome.

Staphylococcal scalded-skin syndrome, an exfoliative dermopathy, affects neonatal and infant children. A classification of this disorder, as well as etiology and therapeutic modalities, is discussed. Topical medications such as used for treating partial-thickness burns cannot always be used in the newborn because of potential toxicity. Supportive therapy, specific antibiotics, and relatively inert dressings are recommended.

Early surgical intervention in Apert's syndactyly.

The hand deformities in Apert's syndrome are among the most complex congenital hand problems to reconstruct due to the skeletal malalignment, symphalangism, and progressive functional deficits with growth. Ten children with Apert's syndactyly underwent early surgical intervention (mean age 8.4 months) as part of a staged program of digital separation leading to completion of both hands by the age of 2 years. The incidence of major complications was low, rate of revision (18 percent) acceptable, and the aesthetic result very satisfactory. Long-term functional results tend to reflect the effect of progressive intrinsic disease despite preservation of skeletal alignment and digital form with growth. However, the aesthetic improvement and potential for greater functional gains at a young age support the concept of early surgical intervention in this syndrome.

Biologic dressings and skin substitutes.

Burn wounds require coverage for healing to occur. Many techniques have been utilized to achieve such a closed wound, including biologic dressings, autologous skin, and skin substitutes. These and other methods are discussed.

Immunocompetency in anorexia nervosa.

Twenty-two consecutively admitted patients diagnosed for anorexia nervosa were evaluated for cellular immune functioning by means of an anergy panel to test delayed hypersensitivity. The panel included candida, streptokinase-streptodornase, and mumps antigen administered by a standard protocol. A standard nutritional profile including current weight, usual weight, total protein, albumin, total iron-binding capacity, white blood cell count, total lymphocyte count, triceps skinfold, and arm muscle circumference was concurrently compiled on these subjects. Six of 22 patients studied were anergic. Visceral protein measures were generally within normal limits even in the most depleted patients. Malnutrition as measured by severity of weight loss and triceps skinfolds was significantly related to anergy, whereas visceral protein indicators (serum albumin, total iron binding capacity, transferrin) were not correlated with anergy. Anergy appeared to be related more strongly to anthropometric indices of malnutrition than to visceral protein values. Cellular immunity was generally preserved until weight loss was far advanced.

Caloric requirements in patients with inflammatory bowel disease.

Measured resting energy expenditure (REE) was compared to predicted basal energy expenditure (BEE) in 35 consecutive patients with nonseptic inflammatory bowel disease (IBD) and 20 healthy volunteers. Patients with IBD were groups greater or less than 90% ideal body weight (IBW). The BEE in kcal/day was found to be equivalent to the measured REE in both patient groups. It is suggested that the BEE be used to determine caloric requirements in nonseptic patients with inflammatory bowel disease. Patients less than 90% IBW had significantly higher measured energy expenditure (26.4 +/- 1.0) per kg body weight than either controls (21.2 +/- 0.7) or patients greater than or equal to 90% IBW (21.2 +/- 0.8), p less than 0.001. It is suggested that this increased expenditure is due to a combined effect of weight loss and intrinsic disease.

Preoperative total parenteral nutrition and surgical outcome in patients with inflammatory bowel disease.

Further trials are needed to identify the preoperative patient who will have a significantly improved postoperative outcome with the use of total parenteral nutrition. Better nutritional markers are needed to evaluate the response to total parenteral nutrition and to help identify the irreducible minimum that should be given. In our series, patients who received preoperative total parenteral nutrition for at least 5 days had significantly fewer postoperative complications (p less than 0.05) than those who did not. All patients with postoperative complications had either a preoperative serum albumin level less than 3.5 g/dl or a serum transferrin level less than 150 mg/dl. Preoperative total parenteral nutrition for at least 5 days is strongly recommended in patients with inflammatory bowel disease who have severe protein depletion.

A primate model for enteral nutrition by tube.

To establish an animal model for the controlled study of enteral nutrition by tube, five adult chair-adapted primates (Macaca fasicularis) had gastrostomy and jejunostomy tubes placed for the delivery of a modified protein isolate diet. Following 7 days of postoperative depletion with a hypocaloric infusion of dextrose (20 kcal, 0 g N/kg/day), the animals were repleted for 10 days with tube feedings (124 kcal, 0.73 g N/kg/day). There was no operative mortality or morbidity and each animal demonstrated conversion to anabolism by significant weight gain, positive nitrogen balance, and net protein synthesis as determined by [15N]glycine protein turnover rates. Significant correlation was found between caloric intake and nitrogen balance at the level of nitrogen provided in this diet (r = 0.88, p less than 0.05). This model was found to be well suited for the surgical and nutritional techniques required for the long-term study of enteral nutrition by tube.

Energy expenditure in patients with inflammatory bowel disease.

The basal energy expenditure (BEE) calculated from the Harris-Benedict equation was compared with the resting energy expenditure (REE) measured by indirect calorimetry in 12 consecutive hospitalized patients with inflammatory bowel disease. The BEE proved to be equivalent to the REE in the prediction of daily caloric requirements. Patients weighing less than 90% of their ideal body weight had significantly increased energy requirements on a per-kilogram-weight basis as compared with those weighing more than 90% of their ideal body weight. Daily caloric requirements based on 1.75 X BEE would provide 45 kcal/kg/24 hr, which is consistent with reported values necessary for anabolism.