Presacral donor site for lip augmentation.

For over a century surgeons have been in search of the perfect tissue filler. In recent years lip augmentation has become quite popular. Despite the numerous methods employed to enhance the fullness of lips, autogenous free dermal fat grafting (FDFG) still remains a preferred method. FDFG has been extensively investigated clinically as well as histologically. However, despite its efficacy, FDFG has failed to gain widespread clinical acceptance. One reason has been concern about donor-site morbidity. In this paper, we describe a method of lip augmentation, which utilizes a dermal fat graft from the presacral region. This site is optimal because it has thick skin with minimal hair follicles and leaves a minimal scar.

Skin-sparing mastectomy with Sun flap closure.

Skin-sparing mastectomy lends itself to immediate reconstruction with autologous tissue, allowing a one-stage reconstruction (a nipple-areolar complex is made at the time of the initial surgery). It has been difficult to obtain equally pleasing results when immediate reconstruction with a skin-sparing technique is performed with expanders. The authors describe a modification of previously described techniques that enhance the aesthetic result of expander/implant reconstruction. This modification is called the sun flap closure.

Direct K-wire fixation technique during endoscopic brow lift.

Endoscopic brow lift has now become a well-established procedure for restoring a youthful brow. Multiple techniques have been described for fixation of the scalp; however, these methods do not allow for direct positioning of the brow. A simple method is described that establishes precise and direct brow fixation using K-wires. Twelve female patients underwent direct fixation of the brow with one or more K-wires to the supraorbital rim. No complications occurred as a result of this technique. Direct brow fixation with K-wires appears to be a simple effective technique for precise restoration of brow position.

Familial polythelia without associated anomalies.

Of the many forms of supernumerary breast tissue, the most common form is the isolated presence of an accessory nipple, polythelia. While familial polythelia is recognized, it is extremely rare. In the past several years, polythelia has been noted to be associated with nephrourological anomalies. All reports of such a relationship are in random, nonfamilial cases of polythelia. We report three cases of polythelia in a family over two generations who had no urinary tract abnormalities. Discussion includes a comprehensive review of familial polythelia and its association with renal anomalies. From this review, the association of familial polythelia with nephrourological abnormalities will be delineated. Although in this report of a single family with polythelia we did not demonstrate any renal anomalies, we feel that a thorough physical exam, urine analysis, and renal ultrasound should be pursued in any patient with a significant familial history of polythelia.

Management of cutaneous manifestations of extensive purpura fulminans in a burn unit.

Purpura fulminans is a rare disease, which may have devastating cutaneous manifestations. It usually follows an infectious illness, and although it most commonly occurs in children, it can occur in adults. The pathogenesis may be related to a relative deficiency of protein C and/or protein S. A case of an adult male is presented to illustrate the management of the severe full-thickness skin loss and the use of surgical excision and allograft in this disease.

Sealed rupture of abdominal aortic aneurysms.

Sealed rupture of abdominal aortic aneurysms, even if uncommon, deserves particular attention for the possibility of misdiagnosis and for the deleterious effects of such a misdiagnosis. Sixteen patients (mean age 72 years; range 65 to 84 years) with chronic sealed rupture of abdominal aortic aneurysms are reported. Two patients had acute rupture of the aneurysm, and at operation chronic contained rupture was found along with the recent hemorrhage. One patient died after surgery. The remaining patients underwent successful resection with long-term survival and regression of symptoms. Consideration of sealed abdominal aortic aneurysm rupture should be included when examining elderly patients with history of unexplained back pain or femoral neuropathy. Computed tomography is a useful aid in the diagnosis of sealed rupture. Ultrasonography is less accurate; in three patients ultrasonography failed to diagnose the presence of the rupture.

Inflammatory aneurysms of the abdominal aorta: incidence, pathologic, and etiologic considerations.

Among 486 patients undergoing repair for abdominal aortic aneurysm (AAA) during a 12-year period, 30 (6.2%) had evidence of "inflammatory" AAA. One patient (3%) had acute rupture, and six patients (20%) had chronic contained rupture. Ureteral obstruction was evident in 20% of the patients. In the early period of the study there were two postoperative deaths and operative time and blood loss were significantly increased. In the last period of the study, no attempt was made to separate the duodenum and the ureters from the aneurysm; there was no operative mortality, and operative time and blood loss were similar to that of patients with atherosclerotic aneurysms. In 23 of 100 specimens of atherosclerotic AAA, microscopic findings resembling inflammatory AAA were found. On the basis of our study we conclude the following: (1) Inflammatory AAAs are simply atherosclerotic aneurysms that show an unusual accentuation of the chronic inflammation observed in relation to atherosclerotic aneurysms. (2) Operative technique should be modified to avoid excessive dissection and lysis of ureters and duodenum. (3) Excellent early and late results can be expected with proper surgical technique. (4) The causes of AAA are multiple, and chronic contained rupture of the aneurysm and reactive lymphatic hyperplasia might play a role of greater significance than previously thought.

Seeding with endothelial cells derived from the microvessels of the omentum and from the jugular vein: a comparative study.

Segments of an experimental polytetrafluoroethylene graft (9 cm long, 6 mm I.D.) of high porosity were implanted in 25 dogs as aortic interposition grafts. Nine grafts were seeded with a mean of 7 x 10(5) viable endothelial cells (ECs) derived from the jugular vein (group A) and eight were seeded with a mean of 7 x 10(5) viable ECs derived from the microvessels of the omentum (group B). Eight grafts were not seeded and they served as controls (group C). Animals were put to death 5 weeks after graft implantation. The thrombus-free area was measured at 81% +/- 10% in group A, 65% +/- 22% in group B, and 25% +/- 13% in group C (p less than 0.05, group A vs group B; p less than 0.05, group B vs group C). The thickness of the subendothelial layer was 151 +/- 60 microns in group A, 280 +/- 60 microns in group B, and 100 +/- 75 microns in group C (p less than 0.001, group B vs groups A and C). The production of 6-keto-PGF1 alpha in the presence of sodium arachidonate was higher in seeded grafts (p less than 0.05). Omentally derived microvessel ECs can be seeded in vascular grafts; refinements in the technique of EC procurement are required to minimize contamination and to obtain ECs with more effective biologic activity.