Paediatric spinal cord low-grade gliomas-evaluation and management of post-surgical residual disease.

PURPOSE: To assess the evaluation and management of post-surgical residual disease for low-grade intramedullary spinal cord tumours (IMSCT) in childhood. METHODS: A single-centre retrospective review of low-grade IMSCTs treated between 2000 and 2019. All surgeries were performed with intent of safe maximal resection guided by intra-operative neurophysiological monitoring (IONM). Pre- and post-operative MRIs were reviewed to assess the extent of resection (EOR), recorded as follows: gross total resection (GTR), near total resection (NTR), sub-total resection (STR) and partial resection (PR). Outcome measures were time to recurrence, need for and modality of additional therapy and ambulatory status at last follow-up. RESULTS: Thirty patients underwent surgery for IMSCT (median age 6.9 years). EOR was GTR = 8, NTR = 4, STR = 9, PR = 9. All patients were alive at last follow-up (median follow-up 73 months [IQR 93 months]). Eighteen patients (60%) remained radiologically stable. Twelve patients (40%) developed recurrence during surveillance. Progression free survival was significantly better in cases with GTR + NTR in comparison to either STR or PR (p = 0.039). 10/30 (33%) patients were treated with additional therapy. At last follow-up, 26/30 patients were independently mobile. CONCLUSION: Survival rates for low-grade IMSCT are excellent. Radical micro-surgical resection, guided by IONM provides effective means of balancing the objectives of maximal safe resection, functional outcome and tumour control. Whilst evidence of 'residual disease' was identified in over 2/3 of immediate post-operative MRI scans, additional treatment was required in only 1/3 of cases. Critical appraisal of post-operative imaging findings is required to better define 'residual disease'. Small volume residual disease (< 5%) does not compromise progression-free survival.

Vertical lobule division in rhinoplasty: maintaining an intact strip.

OBJECTIVE: To review the indications for, surgical techniques of, and results of vertical lobule division (VLD) of the alar cartilages. DESIGN: Prospective study of patients assigned to undergo variations of VLD of the lower lateral cartilages. SETTING: Private facial plastic surgery practice in a major university teaching hospital. PATIENTS: Twenty-four patients who underwent variations of VLD of the lower lateral cartilages with re-creation of an intact strip, including 4 patients undergoing revision. MAIN OUTCOME MEASURES: Postoperative photographs were reviewed for tip projection and rotation, tip symmetry, bossae, knuckles, columellar position and length, and alar retraction. Patients were polled about their overall satisfaction with nasal aesthetics and degree of subjective nasal obstruction preoperatively and postoperatively. RESULTS: Vertical lobule division decreased projection in 22 of 22 patients, increased rotation in 12 of 12 patients, decreased rotation in 1 of 2 patients, corrected tip asymmetry in 3 of 4 patients, and shortened a long infratip lobule in 1 patient. Postoperatively, bossae and knuckling developed in 1 patient, and 2 patients demonstrated alar retraction that did not exist preoperatively. One patient undergoing revision noted worsened nasal obstruction not related to VLD. CONCLUSIONS: Vertical lobule division is a reliable, safe technique with predictable outcomes in tip repositioning. It allows for preservation of a strong tip complex while adding versatility to tip refinement.

Midfacial effects of the deep-plane facelift.

Rejuvenation of the midface is a challenge in facial plastic surgery. To this end, several techniques have been developed to address the changes seen in the midface with aging. Specifically, ptosis of the malar fat pad and deepening of the nasolabial fold contribute to the aesthetic changes that characterize midfacial aging. The history of modern facelifts and deep-plane facelift techniques to correct the nasolabial fold are presented.

Complications of static facial suspensions with expanded polytetrafluoroethylene (ePTFE).

BACKGROUND: Expanded polytetrafluoroethylene (ePTFE) is a synthetic porous material that has been used for static suspension in facial paralysis. It is manufactured in thin (1-mm or 2-mm) sheets that can be cut into strips and implanted through keyhole facial incisions. Regional deformities are addressed by multiple suspensions that provide cosmetic and functional therapy. The use of ePTFE eliminates donor site morbidity associated with the traditional harvest of fascia from either the temporal area or fascia lata. However, properties unique to this alloplast contribute to the complications that have occurred after its use in facial reanimation. OBJECTIVE: To describe complications with the use of ePTFE for facial suspension. SETTING: Academic medical center. METHOD: Retrospective chart review and review of literature. RESULTS: Six patients with facial paralysis who were treated with the ePTFE sling procedure had complications. Five slings failed because of stretch despite prestretching at implantation. One patient developed a late wound infection requiring removal of the sling. CONCLUSION: An ePTFE facial sling is an option for static facial suspension that can be therapeutic for patients with seventh nerve damage. There is a high rate of complications leading to revision surgery. Future studies are needed to evaluate alloplastic alternatives to ePTFE.

Curative radiotherapy for anterior commissure laryngeal carcinoma.

There is continuing controversy surrounding the most effective treatment of glottic carcinoma involving the anterior commissure (AC). Surgery has been the preferred method of treatment, since studies previously indicated early tumor invasion of the thyroid cartilage at the AC, thereby assuming less curability by radiotherapy (RT). Subsequent laryngeal anatomic studies and refinement of RT techniques have brought into question the ineffectiveness of curative irradiation. A retrospective review of 174 patients with early-stage glottic carcinoma treated with standard fractionation curative RT revealed 34 patients with T1 and T2 lesions involving the AC. Allowing for a follow-up of at least 3 years, we observed only a 12% (4 of 34 patients) local recurrence rate after RT alone, with excellent voice quality and no major complications related to the irradiation. The 4 local recurrences were controlled by total laryngectomy, although 2 patients developed distant metastatic disease. Radiotherapy represents an effective method of treating T1 squamous cell carcinoma of the glottis with AC involvement. The small number of T2 glottic carcinomas in this study prevents a meaningful conclusion concerning treatment of these lesions.

Softform for facial rejuvenation: historical review, operative techniques, and recent advances.

The deep nasolabial fold and other facial furrows and wrinkles have challenged the facial plastic surgeon. A variety of techniques have been used in the past to correct these troublesome defects. Advances in the last five years in new materials and design have created a subcutaneous implant that has excellent properties. This article reviews the development and use of Softform facial implant.

Malar, submalar, and midfacial implants.

A resurgence of malar augmentation using alloplastic implants can be attributed to the safety, simplicity of technique, and reliable good results of these implants. As the more sculpted face becomes a common aesthetic goal, malar augmentation plays an increased role in facial plastic surgery practices. It provides a natural, "unoperated" look that is preferred by most patients today. The history of our current aesthetic and how new alloplasts have contributed is reviewed. The development of simpler techniques of malar analysis will also be reviewed. An indepth look at aesthetic analysis, implant choice, surgical approach, postoperative results, and possible complications will provide a thorough review of current malar implantation.

The long-term effects of open cosmetic septorhinoplasty on nasal air flow.

OBJECTIVE: To determine if elective cosmetic septorhinoplasty impacts on nasal air flow resistance over the long-term. DESIGN: Case series. Mean postoperative follow-up period was 41.5 months (range, 16 to 77 months). PATIENTS: A consecutive sample of 200 patients having undergone cosmetic open septorhinoplasty by one of us (P.A.A.) before July 1992 were contacted by telephone; 50 agreed to participate, and 27 actually participated in the study. INTERVENTIONS: Open cosmetic septorhinoplasty performed by one of us (P.A.A.). MAIN OUTCOME MEASURES: Comparison of preoperative and postoperative nasal resistance values by headout body displacement plethysmography; correlation of preoperative and postoperative nasal valve anatomy with nasal resistance values; and correlation of postoperative nasal resistance values with subjective evaluation of nasal air flow as reported on a 10-point analogue scale. RESULTS: Of the 27 patients, 10 had normal preoperative nasal resistance values and 17 had elevated resistance values. Preoperative Normal Group: Four of the 10 patients' mean resistance values exceeded normal limits postoperatively. One of these four patients reported subjective nasal obstruction. Preoperative Abnormal Group: Of the 17 patients, surgery resulted in normal resistance values postoperatively in six, decreased but still above normal resistance values in eight, and no decrease in postoperative resistance values in three. CONCLUSIONS: (1) Patients with normal nasal resistance values may suffer long-term, asymptomatic increase in nasal resistance values after cosmetic open septorhinoplasty, often with no quantifiable change at the nasal valve. (2) Patients with elevated nasal resistance measurements generally improve with open septorhinoplasty. Patients with isolated septal deformities improve with septoplasty. Patients with upper lateral cartilage collapse improve with spreader grafts. The lasting objective improvement on the nasal valve using spreader grafts is reported herein for the first time. (3) Subjective estimations of nasal patency do not correlate well with objective measures of patency, namely nasal resistance measurements. (4) Cosmetic septorhinoplasty can alter nasal patency. Continued care must be exercised when manipulating the nasal framework for cosmetic purposes, as slight changes to the nasal valve may result in significant alterations in nasal air flow resistance.

Vertical dome division in open rhinoplasty. An update on indications, techniques, and results.

OBJECTIVE: A new modification of vertical dome division (VDD) in rhinoplasty using cartilage overlap and suturing to reestablish the integrity of the alar cartilages is analyzed and compared with the more standard technique of cartilage resection and suturing. DESIGN: Retrospective before-and-after trial. SETTING: Private patients of one of the authors (P.A.A.) undergoing surgery in the Department of Otolaryngology of the University of Toronto (Ontario). PATIENTS: A consecutive sample of 116 patients having undergone open rhinoplasty with VDD between 1981 and 1990 were evaluated. Seventy-five had VDD before 1987, when a cartilage resection and suturing technique was used (P.A.A.); 41 had their surgery after 1987, with the cartilage overlap and suturing technique. All patients were available for follow-up. The mean follow-up time was 15.2 months, with a range of 6 to 63 months. INTERVENTION: Indications for VDD were lobule asymmetry (47%), retrodisplacement (24%), wide domal arch (22%), hanging infratip lobule (6%), and rotation (1%). Prior to 1987, VDD was performed by dividing the alar cartilages, resecting certain portions, and then suturing the cartilages together again to recreate the alar margin. After 1987, VDD was revised by overlapping the portions of cartilage that would have been previously resected and suturing the overlapping portions to recreate the alar margin. MAIN OUTCOME MEASURES: Patient satisfaction; physician evaluation; physical examination; blinded comparison of preoperative and postoperative photographs; need for revision surgery. RESULTS: Overall, six (5.0%) of 116 patients required revision surgery or had photographic and/or physical evidence of nasal tip irregularities. Three (4.0%) of 75 patients from the cartilage excision group and one (2.4%) of 41 patients from the overlap group required revision surgery. The other two patients, one in each group, had minor tip irregularities not requiring surgery. The tip irregularities were due to nasal bossae in four patients and lobule asymmetries in two. There was no alar notching or lower nasal third pinching. Tip irregularities were three times as likely to occur in patients presenting for revision rhinoplasty than in those for primary rhinoplasty. CONCLUSIONS: Vertical dome division is a powerful tool in rhinoplasty, allowing for complex manipulations of alar cartilages to selectively enhance projection, rotation, and domal arch width. It also allows for correction of lobule asymmetries and elongation or hanging of the infratip lobule. The cartilage overlap technique reduces the occurrence of several common postoperative tip abnormalities and lowers the need for revision surgery when compared with cartilage resection VDD. The reported results can only be considered trends, as sample sizes in the series were too small to allow for statistical significance.

Squamous cell carcinoma in older patients without risk factors.

Ten patients over sixty years of age with no history of tobacco or alcohol use were treated for squamous cell carcinoma of the upper aerodigestive tract between 1979 and 1991. Nine of these ten patients were women with lesions confined to the oral cavity and oropharynx. Modes of treatment included surgery, radiation, or a combination of surgery and radiation. Followup from 1 to 10 years revealed two deaths from local and distant spread, and eight patients with no evidence of disease. Recurrences after treatment were aggressive and occurred within the same region as the primary lesion. Although most patients with upper aerodigestive squamous cell carcinoma are men with alcohol and/or tobacco exposure, this study demonstrates findings consistent with field cancerization in a group of older women with no risk factors.

Optimal population growth and the social welfare function.

PIP: The social welfare function criterion offers an approach to the theory of optimal economic growth that is intermediate between the 2 most frequently used utilitarian models--those that maximize per capita utility and those that maximize total utility. According to the welfare criterion, societal welfare depends not only on the level of per capita consumption, but also on the population density in the area in which an individual resides. The model postualtes that, for a given level of per capita consumption, total utility increases with increasing density, reaches a maximum, and then declines with further population increases due to the deleterious effect of overcrowding on the quality of life (e.g., the quality of education, recreational facilities, and environmental factors such as clean air and pure water). The overall objective of the model is to identify the optimal per capita consumption and population size that maximize the discounted social welfare. Optimal population growth occurs when the increase in the discounted social welfare resulting from the introduction of a new member equals the reduction in welfare created by that addition (modified Meade Rule), while per capita accumulation equals the sum of the population growth rate and the social rate of time preference (modified Golden Rule). This model could be extended to consider technological change more explicitly and its effect on optimal outcomes.^ieng

Serum beta 2 microglobulin in malignant lymphoproliferative disorders.

Serum beta-2-microglobulin (S-beta 2M) was measured at diagnosis in 44 patients with lymphocytic leukemias and 47 with malignant lymphomas. Among patients with chronic lymphocytic leukemia (CLL) S-beta 2M was raised (greater than 3 mg/l) in 74% and in 23.5% of those with acute lymphoblastic leukemia (ALL). The frequencies for non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD) were 59.2% and 40%, respectively. In CLL patients high serum values correlated with large tumor mass, as estimated by Rai's clinical criteria (P less than 0.001), by total peripheral lymphocytes (r = 0.41, P less than 0.05) and by the percentage of bone marrow infiltration of the lymphocytes (P less than 0.01). A significant relation was also found in CLL patients between S-beta 2M level and survival (P less than 0.05). In ALL no association was found between S-beta 2M level with peripheral lymphoblast concentration, French-American-British (FAB) subclassification, splenomegaly, and survival. In NHL patients a significant association was found between S-beta 2M levels and stage of disease (P less than 0.01) and an obscure relation (P less than 0.1) with the presence of lymph nodes greater than 3 cm in diameter, splenomegaly, and hepatomegaly. No significant association was found between S-beta 2M level and histologic subtypes, presence of B symptoms, bone marrow involvement, and survival. In HD patients a significant association was found between the level of S-beta 2M and stage of disease (P less than 0.05) and presence of splenomegaly (P less than 0.05). No association was found between S-beta 2M level and histologic subtypes, lymph nodes greater than 3 cm in diameter, bone marrow involvement, and B symptoms. A significant relation was found between S-beta 2M level and survival in HD patients with widespread disease (P less than .025).

Phosphorylase phosphatase regulatory subunit. "Western" blotting with immunoglobulins against inhibitor-2 reveals a protein of Mr = 60,000.

Rabbit muscle phosphorylase phosphatase has been isolated in different laboratories as an inactive complex of Mr = 70,000, composed of separate catalytic (Mr = 38,000) and regulatory (Mr = 31,000) proteins. The regulatory protein is identical to one of two heatstable inhibitors called inhibitor-2 (I2). Antiserum raised in sheep against I2 by repeated immunization potently blocked inhibitory activity, whereas preimmune serum did not. Immunoglobulins which blocked inhibitory activity were purified by affinity chromatography with I2 as the immobilized ligand. Using a "Western" immunoblotting procedure, as little as 1-5 ng of pure I2, obtained by electroelution of the Mr = 31,000 band of I2 from a polyacrylamide gel segment, were detected. Immunoblotting of the immunogen revealed only a band at Mr = 31,000, indicating the absence of contaminating antigenic proteins. When extracts of skeletal muscle and other rabbit tissues were denatured directly in dodecyl sulfate for immunoblotting the most intensely stained band was present at Mr = 60,000, rather than at Mr = 31,000 as expected. A small amount of I2 and other bands were detected, in particular at Mr = 36,000 and 25,000. Subsequent to heat treatment of the tissue extracts, there was an enrichment of I2 content relative to the Mr = 60,000 band. The results indicate the existence of a Mr = 60,000 protein related to I2. Activation of phosphorylase phosphatase in a muscle extract by treatment with Co2+ plus trypsin exactly coincided with digestion of the Mr = 60,000 immunoreactive protein. Available data indicate that this protein may function as a regulatory subunit of phosphorylase phosphatase.

99MTc-HIDA, a gallbladder imaging agent: experimental aspects.

The molecule N-(2,6-dimethyl-phenyl-carbamoyl-methyl)-iminodiacetic acid (HIDA), capable of chelating reduced 99mTc, was synthesized, characterized, labeled with 99mTc, and studied in experimental animals. The results indicated that the new 99mTc-radiopharmaceutical is rapidly cleared from the blood to the liver, then rapidly removed to the gallbladder and excreted into the duodenum through the common bile duct. A comparative kinetic study of 99mTc-HIDA and 131I-Rose Bengal performed in rabbits demonstrated that both radiopharmaceuticals had a similar blood clearance rate, but cleared at a different rate from liver to gallbladder. 99mTc-HIDA showed a faster accumulation in the gallbladder than 131I-Rose Bengal. These findings, combined with the advantage of the low acute toxicity of HIDA, were promising enough to encourage a further evaluation and clinical investigation of this new Tc-99m hepatobiliary agent.