An alternative open reading frame of the human macrophage colony-stimulating factor gene is independently translated and codes for an antigenic peptide of 14 amino acids recognized by tumor-infiltrating CD8 T lymphocytes.

We show that cytotoxic T lymphocytes (CTLs) infiltrating a kidney tumor recognize a peptide encoded by an alternative open reading frame (ORF) of the macrophage colony-stimulating factor (M-CSF) gene. Remarkably, this alternative ORF, which is translated in many tumors concurrently with the major ORF, is also translated in some tissues that do not produce M-CSF, such as liver and kidney. Such a dissociation of the translation of two overlapping ORFs from the same gene is unexpected. The antigenic peptide encoded by the alternative ORF is presented by human histocompatibility leukocyte antigen (HLA)-B*3501 and has a length of 14 residues. Peptide elution indicated that tumor cells naturally present this 14 mer, which is the longest peptide known to be recognized by CTLs. Binding studies of peptide analogues suggest that it binds by its two extremities and bulges out of the HLA groove to compensate for its length.

[Empirical antibiotic therapy for febrile neutropenia]. / Antibiothérapie empirique lors de neutropénie fébrile.

Immediate broad-spectrum empirical antibacterial therapy is the key of management in febrile neutropenic patients. These patients can be stratified according to the risk of complications with the clinical MASCC score. Patients at low risk of complications can be efficaciously treated with oral antibiotics (e.g. fluoroquinolone and beta-lactam), provided that compliance and drug absorption are adequate. Early discharge is possible if clinical, logistic, and social criteria are fulfilled. Intravenous antibiotic therapy with broad-spectrum beta-lactam antibiotics in the hospital remains the standard in high-risk patients. The empirical addition of an aminoglycoside and/or a glycopeptide is recommended if the local incidence of infections due to beta-lactam resistant pathogens is high or in critically ill septic patients.

Surgery of the aging face. Advances and functional considerations in facial plastic surgery.

With an aging patient population, many more individuals will seek advice from a trusted primary care physician regarding improvement of their appearance and related functional considerations. The physician plays a key role in understanding patients' concerns, counseling their needs and desires, and recognizing the important psychological benefits associated with surgery of the aging face. Recent advances and techniques for both aesthetic and functional problems have made surgery for the aging face safer, more precise, and more predictable, resulting in a much more positive outcome. By keeping in mind the preoperative assessment, indications, and specific procedures discussed in this article, many patients referred for consideration should enjoy the benefits of rejuvenation surgery of the aging face.

External septorhinoplasty: a tool for teaching and for improved results.

The external septorhinoplasty incision is basically a 5 mm. incision across the columella connecting a left and right alar margin incision. This allows retraction of the dorsal skin to expose the entire dorsal skeletal structure. It has great advantage to both surgeon and assistant for teaching and studying deformed nasal anatomy, and for improved rhinoplasty results because it allows binocular visual monitoring of surgery, the use of both hands, control of bleeding by electrocautery, accurate diagnosis of revisional surgery, and structures so that postoperative distortion from healing does not occur. If grafts or implants are needed they can be accurately modelled and sutured in place to prevent post-operative wobbling. The columellar scar it properly closed becomes inconspicuous in a few months, and even early in the healing process it is not noticed because the observer is viewing it at a very oblique angle. It is felt that this operation will be a very valuable addition to every doing rhinoplasties and septoplasties.

Controlled nasal tip rotation via the lateral crural overlay technique.

Pronounced nasal tip ptosis is generally regarded as an unattractive facial feature. Besides its aesthetic ramifications, marked inferior displacement of the nasal tip adversely affects nasal function by restricting airflow through the nares. We present a new technique that is a modification of a lateral crural flap procedure that was described in 1975. This technique, which is performed using an open rhinoplasty approach, predictably rotates the nasal tip upward by restructuring the alar cartilages via controlled overlay of the lateral crura. When overprojection accompanies tip ptosis, the controlled lateral crural overlay technique permits graduated retrodisplacement of the tip, in addition to rotation, giving the surgeon full control for reliably and accurately repositioning the nasal tip superiorly and posteriorly.

Lateral crural steal and lateral crural overlay: an objective evaluation.

OBJECTIVE: To assess objectively the effect of 2 cartilage-modifying techniques, lateral crural steal (LCS) and lateral crural overlay (LCO), on the degree of nasal tip projection and rotation. DESIGN: A prospective trial using computer imaging techniques for assessment. SETTINGS: Half of the patients were seen at a university hospital and the other half at a private practice. PATIENTS: A selected series of 30 patients seeking rhinoplasty mainly for nasal tip repositioning. Only patients with no history of previous nasal operations were included. INTERVENTION: All patients were operated on using an external rhinoplasty approach. Only 1 of the 2 techniques was adopted for each patient. The technique selected depended purely on clinical judgment. MAIN OUTCOME MEASURES: The nasofacial angle and the Goode ratio were used to assess tip projection, and the nasolabial angle and rotation angle were used to assess tip rotation. RESULTS: The use of the LCS technique resulted in an increase in both nasal tip projection and rotation, but the use of the LCO technique resulted in an increase in tip rotation and a decrease in tip projection (P<.001). Additionally, the LCO technique resulted in significantly higher degrees of rotation than the LCS technique (P<.001). CONCLUSIONS: The LCS procedure is indicated when a moderate increase in nasal tip projection and rotation is desired. The LCO technique is useful in patients where severe underrotation is associated with overprojection.

Irradiated cartilage grafts in the nose. A preliminary report.

Many nasal deformities require some form of graft or implant material for complete correction. Various well-recognized disadvantages are associated with currently used autografts, allografts, and alloplastic materials, thereby maintaining a continued search for the ideal nasal graft. Irradiated homograft costal cartilage is an allograft that has been used with variable success in the head and neck region. Isolated reports have suggested favorable results with irradiated homograft costal cartilage implantation in the nose. This study details the findings of 306 irradiated homograft costal cartilage grafts that were used in 122 nasal augmentation procedures.

Septal perforation repair with acellular human dermal allograft.

BACKGROUND: Connective tissue autografts are commonly used as interpositional grafts between septal flaps in the repair of septal perforations. The most common graft materials used include temporalis fascia and pericranium, both of which are accompanied by donor site morbidity, do not provide septal bulk, and are exceedingly thin and difficult to manage. OBJECTIVE: To study the use of an acellular human dermal allograft (AlloDerm, LifeCell Corp, The Woodlands, Tex) as a connective tissue interpositional graft in septal perforation repair. SETTING: Private facial plastic surgery and reconstructive practice of 1 of the authors (R.W.H.K.), Houston, Tex, and the private and university practice of another author (H.F.), Alexandria, Egypt. PATIENTS: Twelve consecutive patients with septal perforation who received the acellular dermal allograft constituted this evaluation. The causes of the septal perforations were previous nasal surgery, previous nasal cautery, or cocaine use by the patient. DESIGN: Interposition grafting between mucoperichondrial flaps for septal perforation repair was accomplished with decellularized human dermal grafts. Follow-up periods ranged from 3 to 14 months. MAIN OUTCOME MEASURES: The repair was considered successful when, on postoperative examination at 3 months, the right and left mucoperichondrial flaps were entirely healed. From the experience of 1 author (R.W.H.K.) with the repair of more than 75 septal perforations, no perforation that was healed at 3 months broke down at a later date, unless trauma or cocaine use occurred after the operation. An outcome was considered acceptable but nondesirable if a perforation was still present after the operation but the number and severity of the patient's symptoms were reduced and the perforation was considerably smaller than before the operation. RESULTS: Eleven of the 12 patients had successful outcomes with complete closure of their perforations. The 1 remaining patient had an acceptable result but incomplete closure; his initial perforation of 3 cm was reduced to 5 mm, making him asymptomatic after surgery. CONCLUSION: Acellular human dermal grafts can be used as connective tissue interpositional grafts in the repair of septal perforations with success rates similar to the use of temporalis fascia, mastoid periosteum, or pericranium. One distinct advantage is the absence of donor-site morbidity. In addition, this graft material is thicker and easier to place and suture and may give more substance to the repaired septum.

Septal perforation closure utilizing the external septorhinoplasty approach.

Nasal septal perforations can be technically difficult to close permanently, particularly if they are large, located posteriorly, or associated with little residual septal cartilage and bone. By allowing direct access to the usually undisturbed dorsal septum, septal flaps are easier to elevate with the external septorhinoplasty approach. Also, better visualization and more room in which to work are afforded by this approach, enabling the surgeon to close perforations that might be more technically difficult to close using standard intranasal incisions. The technique of external septorhinoplasty combined with septal mucoperichondrial advancement flaps and a supporting graft of mastoid periosteum, cartilage, or ethmoid bone was used to close perforations up to 4 cm in diameter in 22 patients from 1981 to 1983 with a 77% (17/22) complete closure rate. Symptomatic improvement was noted by all patients.

Tissue expansion in the treatment of alopecia.

Tissue expanders have been used in multiple body sites. We successfully used the Radovan tissue expander in the scalp of patients with cicatricial alopecia and in hair replacement surgery for male pattern alopecia. The expander is placed in the subgaleal plane beneath a hairbearing area and is inflated over a six- to eight-week period. In a second procedure, the device is removed and the bald area is excised. Closure of the defect is accomplished, with the stretched hairbearing scalp replacing the area of alopecia. Scalp reduction and pedicle scalp flap procedures have benefited by preliminary scalp expansion.

Advances in nasal tip surgery. The lateral crural steal.

Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.

The tongue-in-groove technique in septorhinoplasty. A 10-year experience.

BACKGROUND: Correction of the lower third of the nose is perhaps the most challenging component of performing a rhinoplasty. The tongue-in-groove (TIG) technique provides a method for correcting excess columellar show and maintaining correction of caudal deviation. It is also indicated for controlling nasal tip rotation and projection while preserving the integrity of the lobular cartilaginous complex and may be combined with either the external or endonasal rhinoplasty. It is typically used in combination with other septorhinoplasty maneuvers. The TIG technique consists of a method by which the medial crura are advanced cephaloposteriorly onto the caudal septum into a surgically created space between them. OBJECTIVE: To determine the effectiveness of the TIG technique to aid in correction of columellar show, a deviated caudal septum, and various tip rotation and projection problems. SETTING: Private practices of 2 authors (R.W.H.K., Houston, Tex, and H.M.T.F., Alexandria, Egypt). PATIENTS: The records of 287 patients who underwent TIG rhinoplasties in one private practice from 1989 through early 1999 (n = 203) and in another practice from 1994 through early 1999 (n = 84) were reviewed. MAIN OUTCOME MEASURES: Physician judgment of outcome was based on reduction of columellar show, change in tip rotation or projection, narrowing of the columella, and straightening of a deviated caudal septum as indicated in preoperative and postoperative photographs taken of all but 4 of the 287 patients. Patient judgment of outcome was measured by patient requests for revision and patient comments made during follow-up visits. RESULTS: Of 287 patients, 278 (97%) had satisfactory to excellent results. Only 9 (3%) required revisions related to the TIG technique. Eight of these 9 did not achieve enough reduction of columellar show or adequate rotation or projection. A repeated TIG technique was used in these 8 patients with satisfactory revision results. One of the 9 was overprojected and required revision. Of the 108 patients who had preoperative caudal septal deviation, none needed further surgery. CONCLUSIONS: The TIG technique provides a direct, effective solution to columellar show and is a reliable, reproducible method for achieving predictable tip rotation and projection. Furthermore, when used in conjunction with septoplasty techniques, it helps maintain the correction of a deviated caudal septum.

Septal perforation repair.

Nasal septal perforations present a distinct challenge to the otolaryngologist-head and neck surgeon, and a problem to the patient. The techniques for repairing septal perforations that have the best physiologic result, the highest success rate, and the best long-term patient acceptance and comfort, require the use of bilateral intranasal mucosal advancement flaps with the interposition of a connective tissue graft. The presenting symptoms and findings, the history and physical examination, the causes of septal perforations, helpful hints for prevention, and surgical and nonsurgical treatment options and outcomes are discussed in this article.

Adjunctive measures to rhinoplasty.

In the profile analysis of the rhinoplasty patient, consideration should be given to adjunctive measures that may enhance the overall appearance of the patient. This article discusses augmentation of the chin and cheekbones with particular emphasis on technique. Refinements in surgery for the nasal alae and base of the nose are explained as adjunctive procedures to improve the proportions of the inferior triangle (base) of the nose.

Acellular human dermis for facial soft tissue augmentation.

The search for safe, permanent, and natural-appearing materials for soft tissue augmentation is ongoing. This article discusses two autologous dermal preparations available in injectable forms that do not cause cyst formation and its associated problems.

Dome truncation for management of the overprojected nasal tip.

The nasal tip highlights the facial profile, and in its most aesthetic configuration subtly projects anterior to the dorsum to create a soft supratip break. Overprojection of the tip in relation to the vertical facial plane and the nasal dorsum represents one variant of nasal-facial disproportion that can adversely affect an otherwise pleasant facial appearance. Several strategies for reducing either the lateral or the medial crus to deproject the tip have been suggested. This article describes a method of direct truncation of the dome using an external rhinoplasty approach that can reliably produce tip retrodisplacement while maintaining, or enhancing, tip rotation. Tip definition and projection are optimized by precise, direct reduction of the overprojected dome region and accurate sculpting and realignment of the remaining crural units. When the tip is retrodisplaced, alar flaring can occur; therefore, alar base reduction can substantially enhance the final outcome.