Hereditary progressive nodular lipomatosis: a report and selective review of a new syndrome.

Multiple hereditary lipomatosis has been reported very rarely in the literature. The largest number of lipomas previously reported in a single patient was 160. We report on a 45-year-old man who began to experience multiple lipomas at about age 26. The lipomas multiplied until they severely disfigured his entire torso, arms, and upper legs. Both sides of his body were affected to approximately equal degrees. A family history revealed that the patient's father, two brothers, and two nephews have all experienced multiple subcutaneous lipomas, although to a lesser degree. In treating the patient, what appeared to be very large lipomas were in fact found to be subcutaneous clusters of hundreds of small encapsulated lipomas. Lipomas were excised using suction lipectomy to treat different involved areas on eleven separate occasions. A total of 8,475 cc was removed over a two-year period. A modified, slightly less blunt cannula was developed to aspirate the clustered lipomas individually.

Practice locations of Texas family practice residency graduates, 1979-1987.

The location of a physician's residency training is known to be a factor in selection of a practice location. In this paper, the authors analyze the practice locations of 689 family physicians who graduated from residency programs in Texas between 1979 and 1987 and who were practicing in Texas in 1988. One-third of these graduates were practicing in cities the same size as their residency program city. More than half were in counties located within 60 miles of the residency city. Both of these trends can be explained to a large degree by the fact that a high percentage of graduates remained in their residency city to practice. When these nonmobile graduates are removed from the sample, the findings show no correlation between the size of the residency city and the size of the practice city. More than two-thirds of those graduates who left their residency city were in counties beyond a 60-mile radius. Almost two-thirds were practicing in communities of less than 25,000 population. The authors conclude that state support for family practice residency training has been effective in distributing family physicians in a manner that addresses the needs of the state of Texas as a whole.

Cross-linked silver-impregnated skin for burn wound management.

Biological skin is effective in restoring the missing water vapor barrier and promoting healing in burn wounds. Its effectiveness in wound management has been limited, however, by its inherently limited antibacterial properties and the fact that it is sometimes rejected before healing is complete, even reversing previous beneficial effects. Limited availability and storage difficulties have posed further problems. Impregnation of biological skin with silver ions has been proven to provide a potent bactericidal effect directly at the wound surface. We hypothesized that aldehyde cross-linking of silver-impregnated skin would mask the histocompatibility sites from the recipient's immune system. This has been demonstrated previously with aldehyde cross-linking of allografts and xenografts, prolonging retention sufficiently to permit complete wound healing. Commercially available skin was treated with an aldehyde compound and impregnated with silver. Initial studies of this cross-linked skin for treatment of burn wounds showed average retention to be between 117 and 161 days, far exceeding that of any untreated skin. It was subsequently found that the aldehyde cross-linking permitted impregnation with higher concentrations of silver than had previously been possible--2,600 to 2,830 ppm as compared to an average of 1,020 to 1,350 ppm in previously available silver-impregnated skin. This results in a more potent, immediate antibacterial effect at the wound surface and an extended period of time-release antibacterial action before the silver is exhausted. The antibacterial properties of this aldehyde cross-linked silver-impregnated skin are effective in decontaminating even grossly infected wounds and in protecting against contamination of clean wounds from adjacent infected areas or external sources.(ABSTRACT TRUNCATED AT 250 WORDS)

Suction-assisted lipectomy for correction of 202 figure faults in 101 patients: indications, limitations, and applications.

Since its introduction in the United States, suction-assisted lipectomy has proven to be a safe, effective technique for correction of figure faults. It has been greeted with considerable skepticism by many practitioners, however, owing to the poor results many have obtained in their initial attempts to apply similar techniques. Suction lipectomy using the blunt technique is a safe procedure that can yield consistently good results when appropriately applied. It is suggested that the principal reason others have had difficulty involves problems in patient selection. The technique may not be effective for the correction of generalized obesity and cannot be expected to dramatically alter overall appearance. Patients should be selected for treatment of specific "figure faults" and educated as to what may realistically be expected. The patient's emotional and psychological condition must be taken into consideration. We report a series of 101 patients treated with a total of 202 separate suction lipectomy procedures with good results and only two minor complications. A survey of patients treated by the method reveals a generally high level of satisfaction and some of the ambivalence that might be anticipated from such a technique.

Breast biopsy technique: a plea for cosmesis.

Breast cancer is the leading cause of cancer death among American women. Early detection and treatment greatly increase long-term survival rates, but many women delay seeking treatment of suspected lesions out of fear of mutilation. Unfortunately, this fear is compounded by the fact that although 60% to 80% of all biopsies prove benign, many women are left with unsightly scars from the biopsies themselves. The great majority of these avoidable scars result from the use of radial biopsy incisions, which are unnecessary in virtually all cases. Most lesions can be reached via periareolar incisions and even those few that require incisions away from the areola can be reached through incisions that follow Langer's lines circumferential to the breast. Even total subcutaneous mastectomy and reconstruction can often be done via periareolar incisions, with minimal scarring, less likelihood of keloid formation, no deformity, and less emotional trauma for the recovered patient.

Silver-impregnated porcine xenografts for treatment of meshed autografts.

Meshing of skin grafts has gained wide acceptance as a means of conserving donor sites in cases of extensive skin loss. In smaller injuries, meshed grafts have the advantage of providing for more efficient wound drainage than unmeshed grafts. Covering widely meshed skin grafts with meshed allografts has been found to result in reductions in infection-related rejection of the allografts. Porcine xenografts have been widely used as temporary wound coverings as they protect the wounds and provide a hospitable environment for reepithelialization. We have used silver-impregnated porcine xenografts to cover meshed skin grafts with excellent results. The porcine xenograft provides a protective wound covering that promotes epithelialization in the interstices of the meshed graft, and the silver ion in the collagen of the xenograft provides an improved means of controlling infection. Three cases are described.

Rhinophyma: treatment with electrocautery and silver-impregnated porcine xenograft.

A typical case of advanced rhinophyma is reported. Partial excision reduced the size of the nose by two-thirds, leaving a thin layer of dermis. This was covered with silver-impregnated porcine xenograft, which allowed efficient drainage and remained adherent in its initial application for 2 weeks. A total of four applications of silver-impregnated porcine xenografts--the last two involving only very small areas--were required for complete epithelialization at 5 weeks after surgery. We believe that this xenograft is an ideal dressing for wounds resulting from partial excision of rhinophymatous tissue, providing the beneficial effects of biological dressings, including the hemostatic effects of collagen with the added benefit of silver's potent antibacterial properties. Silver-impregnated porcine xenograft reduces patient discomfort and results in rapid healing with excellent cosmetic results.

Clinical use of an improved processed bovine cartilage for contour defects.

We have combined irradiation with a new chemical processing to cross-link the collagen of bovine cartilage, thereby stabilizing the collagen molecule and rendering it antigenically inert and dimensionally stable. Irradiated allograft cartilage has been successfully used for repair of facial contour defects since the 1950s, but the usefulness of this material has been limited by lack of availability. Chemically processed bovine cartilage had previously been used, but the implants were subject to slow degradation and were usually absorbed completely within 2 years. After first testing this new material on rabbits and primates, we experimentally placed 40 implants in 28 patients over the course of 3 years. Thirty-six of these implants have survived without change in size or shape for more than 1 year, 20 of these for more than 2 years. In 2 cases, full or partial absorption of the implants occurred secondary to operative infection. In another case 2 implants were lost, probably because of infection. In the absence of infection, neither primary nor second-set provocative implant tests of processed irradiated bovine cartilage elicit any foreign body reaction, either cellular or noncellular. The material performs well aesthetically and appears to undergo no absorption during the 1- to 4-year follow-up observed to date. The period of follow-up of 1 to 4 years reported here may be insufficient to reach a definitive conclusion that no very slow absorption of processed irradiated bovine cartilage implants occurs. It is noteworthy, however, that half of the implants have already survived with no apparent absorption for a period longer than that at which nonirradiated bovine cartilage implants would be expected to have been absorbed completely. This result suggests that any absorption that may occur, other than that associated with infection, takes place at a rate so slow as to be unobservable in anything but the very long run. We believe that this evidence of the long-term survivability of processed irradiated bovine cartilage, together with its excellent performance aesthetically and the fact that it can be made readily available commercially, indicates that it may represent an effective implant material for repair of contour defects.

Processed bovine cartilage: an improved biosynthetic implant for contour defects.

Irradiated human cartilage has been found to be a superior implant material for correction of contour defects; however, availability problems have prevented this material from gaining wide acceptance. Implantation of processed irradiated bovine cartilage in primates and rabbits, as described here, provides strong evidence that this material performs like irradiated allograft cartilage antigenically and has certain cosmetic advantages over allograft cartilage. Our studies in primates have shown that there is no systemically measurable antibody-antigen reaction, either cellular or noncellular, to irradiated processed bovine cartilage. Neither primary nor second-set provocative implantations produced any measurable rejection. In rabbits, composite grafts of two pieces of irradiated bovine cartilage adjacent to each other were also well tolerated, with no measurable absorption and with capsule formation typical of a foreign body reaction to an inert object.