Post-pneumonectomy syndrome. Surgical correction using Silastic implants.

A post-right pneumonectomy syndrome is described which manifests symptoms of exertional dyspnea and inspiratory stridor on rapid inspiration. These symptoms were associated with marked rightward and posterior deviation of the trachea, over-distention of the left lung with its herniation into the right side of the chest and kinking of the left lower lobe bronchus. At the time of surgery, the tracheal deviation, lung herniation and the kink in the left lower lobe bronchus were immediately corrected by releasing the adhesions between the malpositioned structures and the right chest wall. To maintain the corrected positions, Silastic implants totalling a volume of 990 ml were placed into the space created in the right chest. Following surgery, exertional dyspnea was present with only extraordinary activity, and inspiratory stridor was eliminated. The patient remains asymptomatic three years following surgical correction, and is able to carry on a normal and productive life. We conclude that a syndrome associated with marked exertional dyspnea and inspiratory stridor might develop in situations of marked tracheal shift and overdistention of the remaining lung following right pneumonectomy.

Extended clinical use of the argon laser for cutaneous lesions.

A safe, easy, and effective outpatient modality for the treatment of various cutaneous lesions such as hemangiomas and decorative tattoos has long been sought. The argon laser has proved satisfactory for such treatment of port-wine hemangiomas, capillary/cavernous hemangiomas, telangiectasia, and decorative tattoos as well as a variety of cutaneous pigmented lesions. The intense laser light is attracted and absorbed by pigmented skin lesions producing heat that selectively destroys the intradermal pathologic condition and spares overlying skin. Hemangiomas and tattoos have undergone satisfactory subtotal blanching in the majority of cases with a low incidence of hypertrophic scarring. Thus, the argon laser has proved useful in the outpatient treatment of a variety of pigmented cutaneous lesions.

Subungual osteochondroma. Differential diagnosis and treatment.

Subungual osteochondroma, a rare disorder of the fingers and toes, occurred in five patients. Clinical features of the condition include nail deformation, history of long, slow growth, and characteristic radiologic features. Surgery is directed toward total tumor resection with preservation of the nailbed to achieve normal nail growth. Differential diagnosis included bony, cartilagionous, and soft tissue tumors as well as cystic lesions. Malignant tumor should be suspected by not confused with this benign disorder. Roentgenologic examination is indicated in the differential clinical diagnosis of any subungual mass.

Granuloma faciale. Treatment with the argon laser.

Three patients with granuloma faciale were successfully treated by argon laser therapy. The intense blue-green laser light is readily absorbed by these inflammatory lesions, resulting in resolution of the clinical and microscopic abnormalities. There were no recurrences during follow-up periods of 23, 21, and 5 months, respectively. Argon laser therapy appears to be an important addition to the treatment armamentarium for this uncommon, but difficult to treat, entity.

Surgical management of impotence: progress report.

Our experience utilizing a new design Lash-Maser silicone implant in the surgical management of impotence has been detailed. The present series includes twenty-five patients, twenty-three of whom achieved satisfactory intercourse without problems or complications. The implant's simplicity of design, function, and surgical implantation is appealing.

Pathophysiology and treatment of decorative tattoos with reference to argon laser treatment.

Pathophysiology, psychosocial implications, and treatment modalities for decorative tattoos are reviewed in this article. There still exists a need for a precise, noninvasive technique that will not leave secondary scar deformities. Laser physiology and technologic refinements may offer the best hope for such a treatment.

Two unusual umbilicoplasties.

We describe the creation of an umbilicus where none previously existed, during an abdominoplasty, and the cosmetic shaping of a stretched umbilicus after an umbilical hernia repair.

Deltopectoral flap with a segmental dermal pedicle in head and neck reconstruction.

Eight cases of extensive oromandibular resections have been reconstructed by the use of deltopectoral shoulder flaps with a segment denuded for deep placement. The operative technique is described, and the various uses of this flap are outlined. This technique has allowed us to extend the versatility of the deltopectoral flap, and to avoid the occurrence of the often annoying and occasionally dangerous orocutaneous fistula.

"De-epithelization" and dermal pedicles.

Biopsy specimens from 38 "de-epithelized" dermal pedicles were examined microscopically. There was considerable variation in the depth of the plane among surgeons, procedures, and even between specimens from two sides of a bilateral procedure done by the same surgeon. Usually, the "de-epithelization" removed all the epidermis plus the upper layer of dermis containing the pilosebaceous apparatus. The significance of this finding as related to the future development of epidermal inclusion cysts is uncertain. Also, it brings into question the importance of "the dermal plexus circulation," which many have thought to be critical for viability of the nipple.

Use of Trendelenburg position to reveal open blood vessels and prevent hematomas in face lifts.

We have had a substantial decrease in the number of postoperative hematomas following face lifts since we started putting the patients in extreme Trendelenburg position after all the cutting was done, to reveal any potential bleeding points. These are then coagulated or ligated to obtain more complete hemostasis.

Study of carcinogenic effects of in vitro argon laser exposure of fibroblasts.

Safety of laser exposure and tissue interaction and possible future carcinogenic effects of laser energy are investigated in this study. Mouse fibroblasts of the BALB/3T3 strain have now become the standard in science for the investigation of carcinogenic effects of a variety of physical and chemical/toxic agents. BALB/3T3 fibroblasts were grown in tissue culture and then exposed to x-ray irradiation and argon laser energy. The cells were then grown nine generations and scored for malignant type III foci in a randomized double-blind manner. Argon laser-treated cell groups were then compared with normal untreated controls and known carcinogenic x-ray controls. The results demonstrated that exposure of mouse fibroblasts in vitro tissue culture to argon laser energy did not produce a statistically significant transformation frequency as compared with that of known carcinogenic agents such as x-ray or untreated controls.

Trichoepithelioma: successful treatment with the argon laser.

The cosmetic concern associated with multiple trichoepitheliomas is obvious. Previous modes of therapy have proven to be only temporary. However, multiple trichoepitheliomas appear to respond to the thermocoagulation and epidermal atrophic effects of the argon laser without recurrence over an extended follow-up period. Although these lesions are not as highly vascular as port-wine hemangiomas, their dramatic response to the argon laser is similar. This report documents a case of multiple trichoepitheliomas treated successfully with the argon laser from the face and scalp of a 29-year-old white woman. The benefits of the argon laser in treatment of multiple trichoepitheliomas include eradication of the lesions without apparent recurrence, restriction of spread of solitary trichoepithelioma into adjacent tumors, and prevention of obstruction of the periorbital region and auditory canal. The treatment may be accomplished as a simple outpatient procedure under local anesthesia with minimal pain or disability.

Benefits of the CO2 laser in oral hemangioma excision.

Twenty-one patients with small localized oral cavity hemangiomas of the lips, tongue, and buccal mucosa are reported in this series. Although the lesions were not massive or high-flow/high-pressure vascular tumors, the simultaneous cutting and coagulation capabilities of the CO2 laser were demonstrated, rendering such excisional surgery more precisely and easily accomplished with a great deal less bleeding and a marked reduction in postoperative pain and edema. Many of the patients in this series were done as outpatients under local anesthesia. Results were acceptable and complications were minimal. Thus this laser is recommended both for the patient care and comfort aspects and the ability to render oral cavity hemangioma excisional surgery much more safely and easily done with a significant decrease in hospital utilization and overall medical expenses.

Sapphire tip technology for YAG laser excisions in plastic surgery.

Thirty-two patients with a variety of vascular and nonvascular lesions have been resected over a 3-year period with the neodymium:YAG laser utilizing sapphire peripheral scalpel devices. These innovative peripheral devices concentrate the YAG laser energy to a small area at the end of the scalpel, providing precise incisions with excellent hemostasis. In addition, the tactile sensation of the scalpel contacting tissue is more comfortable and familiar than the "no touch" aspect of other lasers that are held away from the surface and depend on laser light transmission to approach the skin. Total excision with excellent hemostasis was achieved in 17 patients, while 15 patients had subtotal resection. The YAG laser with sapphire scalpels has allowed resection of very difficult and massive hemangiomas previously considered unresectable by standard techniques.

Computerized suction lipectomy aspirator monitor for improved results in suction lipectomy.

A new computerized suction aspirator monitor is described. This device offers the benefits of instantaneous and concurrent scientifically accurate readout of aspirate contents in five separate bodily areas. Thus knowledge of amounts of blood versus fat can be immediately known without resorting to guess, estimate, or cumbersome lipocrit determination by centrifuging. Advantages of such a device include better accuracy in determination of fat removal from each area, with improvement of symmetrical fat removal. More exact determination of blood loss with improved hemodynamic replacement is also more easily and safely accomplished. In an area of mystique, experience, artistry, and aesthetic appreciation which has cloaked the initial enthusiasm for suction lipectomy, a new generation of scientific accuracy is now possible. Thus accurate determination of aspirate content vis-a-vis fat and blood can now transform this procedure into a more sophisticated and scientifically accurate operation which traditionally is desired by most practitioners of suction lipectomy.

Angiokeratoma of Fordyce: successful treatment with the argon laser.

Argon laser photocoagulation of angiokeratomas of Fordyce, or scrotal angiomas, has been described. The benefits of the argon laser in treatment of these lesions include permanent eradication of the lesions and alleviation of the symptoms of pruritus and episodic bleeding. This method of treatment is safe, does not produce iatrogenic malignant neoplasms, is noninvasive, and is accomplished as an outpatient procedure under local anesthesia with minimal discomfort or disability.

Customized silicone implants of the breast and chest.

Custom-fabricated silicone implants were used in 17 patients to reconstruct thoracic deformities associated with pectus excavatum, hypoplasia of the thorax, and radical mastectomy. The implants have been in place an average of 2 1/2 years. Custom implants have been permanently removed in only two of these patients. These implants can provide accurate, complex contour restoration without creating donor defects. However, problems of extrusion, capsule formation, slippage, and infection requiring implant removal are characteristic of nonautogenous materials. Because these are foreign bodies, well-vascularized soft-tissue coverage is especially essential to retain these implants.

Results of argon laser exposure of capillary hemangiomas of infancy--preliminary report.

Argon laser photocoagulation of capillary hemangiomas of infancy ("strawberry marks") has been described in three cases. Treatment in the first case was necessitated by repeated alarming hemorrhage. The second case was treated totally and resulted in immediate induced resolution of the hemangioma, which preceded (by 9 months) the spontaneous involution of an untreated control comparison area and resulted in virtually complete blanching without secondary deformity. The third case demonstrated the laser's ability to stop rapid growth immediately. Spontaneous involution then ensued naturally and was complete 12 months later. It should be emphasized that the argon laser is not recommended for the routine treatment of a normally spontaneously involuting hemangioma. Each case must be examined and the usual indications for intervention should be present. The argon laser has demonstrated the ability to coagulate vascular lesions such as port wine hemangiomas and telangiectasias and can be expected to have a similar favorable effect on the aggressive, rapidly expanding juvenile hemangioma, although further clinical documentation clearly remains to be demonstrated.

Breast reconstruction following mastectomy: a comparison of submuscular and subcutaneous techniques.

An analysis of the benefits of submuscular versus subcutaneous implantation was made on mastectomy patients. Ninety-one breast were reconstructed following mastectomy. In 30 breasts, the implants were placed subcutaneously; in 19, subpectorally, and in 42, beneath both the pectoralis and the serratus. The follow-up averaged 2 to 3 years, and recent cases included postoperative tonometry measurements to quantitate the degree of capsular contraction. In addition, 12 cadaver dissections were done to delineate muscle insertion and origins. Results indicate that (1) submuscular implants are clearly superior to subcutaneous ones; (2) subpectoral implantation requires complete detachment of the muscular origin from the ribs; (3) subserratus implantation provides extra muscular coverage, but dissection is more difficult owing to its firm rib attachment; and (4) the subserratus technique provided the lowest incidence of capsular contracture, although the breast was slightly flatter initially, but improved with time.

Temporomandibular joint disease: results of a ten-year study.

Ninety patients with clinically documented temporomandibular joint disease were followed for ten years. Sixty-four of these patients were treated by conservative means alone, and over 90% responded with complete relief of symptoms. Conservative therapy consisted primarily of jaw rest, with adjunctive use of heat, analgesics, and antiinflammatory agents.