Quantitative analysis of the plain radiographic appearance of eosinophilic granuloma.

RATIONALE AND OBJECTIVES: To quantitate features that distinguish the plain radiographic appearance of eosinophilic granuloma (EG) from other solitary lesions of bone. MATERIALS AND METHODS: Seven hundred nine focal bone lesions, including 26 EGs, were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of EG in contrast to other lesions in the data base. RESULTS: The radiographic appearance of EGs was most consistently that of a medullary based lytic lesion (100%) with geographic destruction (76.9%), lobular contour (73.1%), and well-defined edges (73.1%). Long bone lesions showed these features more frequently than EGs in other locations. Periosteal reaction was visible in all long bone lesions but in only one nonlong bone lesion (5.9%). Characterization of EG in long bones as a lytic, medullary-based metaphyseal or diaphyseal lesion with geographic destruction, lobular contours, periosteal reaction, no matrix, and no subarticular extension showed a sensitivity of 55.6% of EG and prevalence of 22.7%. The vector analysis-generated differential diagnoses include unicameral bone cyst, aneurysmal bone cyst, giant cell tumor, Brodie's abscess, enchondroma, chondrosarcoma, and malignant fibrous histiocytoma. CONCLUSIONS: The radiographic appearance of EG is relatively nonspecific but, using vector analysis, can be better elucidated than in current textbook descriptions.

Quantitative analysis of the plain radiographic appearance of nonossifying fibroma.

RATIONAL AND OBJECTIVES: To quantitate radiographic features that distinguish the plain radiographic appearance of nonossifying fibroma (NOF) from other solitary lesions of bone. MATERIALS AND METHODS: Seven hundred nine cases of focal bone lesions, including 34 NOFs, were analyzed according to demographic, anatomic, and plain radiographic features. Vector analysis of groups of features was performed to determine those that are most sensitive and specific for the appearance of NOF in contrast to other lesions in the data base. RESULTS: The radiographic appearance of NOFs was most consistently a medullary based (97%), lytic lesion (100%) with geographic bone destruction (100%), marginal sclerosis (97%), and well-defined edges (94%). A statistically significant number of lesions were located in the distal aspect of long bones. Unicameral bone cyst shared the most radiographic features with the NOF. Vector analysis showed a large degree of overlap between NOF and other lesions such as aneurysmal bone cyst, chondromyxoid fibroma, and eosinophilic granuloma. The description that optimized sensitivity and prevalence for detection of NOF is a medullary based, ovoid lesion in the distal or proximal portions of a long bone with well-defined edges, a partial or complete rind of sclerosis, and absence of fallen fragment, periosteal reaction, and cortical disruption. CONCLUSION: The radiographic appearance of NOF is relatively nonspecific but, using vector analysis, can be better elucidated over current textbook descriptions.

Skin care and the topical treatment of aging skin.

The desire to maintain or regain a youthful appearance is the main motivation of patients who present themselves to the aesthetic plastic surgeon's office. It has become imperative for the plastic surgeon to know and understand the causes of aging and skin damage and to provide ancillary nonsurgical treatments through which their patients can achieve rejuvenation.

Orbital floor fractures--should they be explored early?

One hundred consecutive cases of orbital floor fractures from varying causes are reviewed, and the admission symptoms and signs are compared to the late results. We considered the early findings of diplopia, infraorbital rim step-off, and hypesthesia (with an associated clinical diagnosis of malar bone involvement) an indication for exploration of the orbital floor and possible placement of silicone sheeting. When this was done, minimal complications resulted.

Otoplasty: the experience of 100 consecutive patients.

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results. The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears. The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.

The superficial-plane rhytidectomy revisited.

Complex procedures for aesthetic facial rejuvenation, such as the deep-plane, extended SMAS, subperiosteal, and composite rhytidectomies, have received significant attention in the literature and at recent symposia. Young plastic surgeons striving to achieve excellent results may be intimidated by these procedures and find them difficult to perform. We suggest a renewed interest in the superficial plane approach for facial rejuvenation. On the basis of our experience with a synthesis of result-oriented technical modifications in 750 patients, we present a procedure to offer not only the beginning but also the more experienced surgeon a safe and satisfactory surgical alternative that will provide both predictable and lasting results while limiting risks and avoiding complications.

Repair of ischial pressure ulcers with gracilis myocutaneous island flaps.

Ischial pressure sores can be repaired with gracilis myocutaneous island flaps, and this technique offers numerous advantages over the use of posterior thigh flaps. Several illustrative cases are described.

Use of the temporary soft-tissue expander in posttraumatic alopecia.

Use of temporary soft-tissue expansion in five patients with posttraumatic alopecia and one patient with congenital alopecia is presented. Indications, operative technique, results, and complications are discussed. It is recommended that transpositional and free scalp flaps be expanded prior to transfer, and it is shown that to achieve greater expansion secondarily, the expanders can be reinserted and the scalp reexpanded as needed. The expansion technique provides a quantity of tissue of similar color, texture, and hair-bearing qualities for reconstruction of adjacent defects and makes secondary reconstruction of donor sites unnecessary. After a minimum follow-up of at least 1 year in each case presented, we have determined that the method is safe, simple, and reliable and provides excellent aesthetic results and high patient acceptance and satisfaction.

Retrospective cephalometric analysis of mandibular bone absorption under silicone rubber chin implants.

A longitudinal study was conducted on 85 patients who received silicone rubber implants to the chin. Over half of these patients were found to have some absorption of the bone beneath the implants, and much other information was obtained. There were no concomitant changes in the soft tissue profile in the patients who demonstrated bone absorption under their implants. It appeared that the bone absorption was less when the implant was placed over the hard bone of the lower part of the mandible, rather than higher or over alveolar bone.

Detection and correction of house staff error in physical diagnosis.

A significant number of errors in physical examination can be detected when house staff are observed by attending physicians. In this study, observation of residents and interns showed a total error of 13.1% and 15.6%, respectively, with incorrect findings of 3.3% and 4.9% and omitted findings of 9.8% and 10.7%, respectively. Approximately two thirds of all patients examined had at least one error noted. A method was instituted for detecting and correcting these errors that can be integrated into daily attending rounds. Using this method, a statistically significant decrease in the number of errors was shown. The method used emphasizes the physical examination pertinent to the patient's main problem, consumes very little rounding time, and is well received by both attending physicians and house officers.

Spectrum of diseases for house staff education on a VA general medicine inpatient service.

A significant portion of internal medicine residency training in the United States today occurs in general medicine sections of Veterans Administration hospitals. The authors studied the demographic, diagnostic, and prognostic characteristics of the patients treated by house staff members rotating through the general medical wards of the Houston, Texas, Veterans Administration (VA) Medical Center. In 2,131 admissions over 13 months, the most frequent primary causes of admissions included congestive heart failure, pneumonia, exacerbation of chronic obstructive lung disease, and malignancy. In 85 percent of the admissions, two or more chronic diseases were present. In 53 percent of admissions, the patients were deemed to be moderately or severely ill on admission. The data indicate that the residents' experience is representative of problems encountered by practicing internists and that VA hospitals make a significant contribution to internal medicine training and thus to the provision of health care for the nation.

Mercury poisoning from intravenous injection: treatment by granuloma resection.

Intravenous injection of mercury is a rare event. Mercury administered by this route may have several different consequences. In addition to elevated serum mercury levels, the diagnosis may be made by radiographic detection of metallic densities in the chest and at the sites of injection. Death due to mercury intoxication is unusual. Impairment of renal and hepatic function may occur. Our patient presented with gingivitis and a dentoalveolar abscess. Dense granulomas occur at the sites of injection. Treatment for these patients should include granuloma excision as the benefit of chelating agents, for chronic mercury intoxication is questionable. Skin and granuloma resection may leave vital structures exposed, necessitating flap coverage.