Design-enhanced breast reduction: an approach for very large, very ptotic breasts without a vertical incision.

Breast reduction and mastopexy have been performed with a number of techniques. Due to problems encountered with prior procedures (such as fat necrosis, skin and nipple necrosis, decreased nipple sensitivity, shaping difficulties, and bleeding), we have changed our approach to breast reduction and mastopexy. Eleven initial patients have been operated with a design-enhanced procedure that emphasizes (1) a wide-based, glandular deepithelialized pedicle; (2) an attempt to preserve the fourth intercostal nerve; (3) adequate vertical-dimension skin excision leaving no vertical scar; (4) mesial advancement of thick, superior skin flaps; and (5) administration of dilute lidocaine/epinephrine solution. We have been pleased with our results and recommended this technique as our procedure of choice for patients with very large, very ptotic breasts.

Surgical management of giant nonmelanoma skin neoplasia.

BACKGROUND: Management of advanced integumentary malignancy has been controversial. We have evaluated and treated 10 patients with giant nonmelanoma skin neoplasias more than 8 cm in diameter. METHODS: Aggressive surgical ablation was prospectively recommended to treat giant basal cell or mixed basosquamous tumors and two purely squamous cell tumors. Radiation therapy was given in three surgical patients. Our data are analyzed retrospectively. RESULTS: Survival of the two patients who refused surgery was measured in weeks. One patient who refused adequate surgery survived 9 months before dying. All of the adequately treated surgical patients are alive as of this writing, including one who had subsequent resection of pulmonary metastases. Three patients required free tissue transfer. The average survival of surgically treated patients was 2.7 years. CONCLUSION: An aggressive surgical approach to the management of advanced/giant skin neoplasia is justifiable and the only treatment that may produce long-term survivability.

Versatility of the microvascular serratus anterior muscle vascularized rib flap (SARIB) for multifaceted requirement reconstructions.

We have employed the serratus anterior muscle vascularized rib (SARIB) composite flap for a variety of multifaceted reconstructive applications in which bone and soft tissues were needed. Seventeen patients have undergone this procedure for reconstructions of the upper extremity (5), lower extremity reconstructions (4), and reconstruction of head and neck defects (8). Sixteen of the reconstructions (89%) have been successful, with an average follow-up over 2 years. One patient had partial loss of a rib transferred to the head and neck for palatal reconstruction. One patient had complete flap loss of a maxillectomy reconstruction owing to a necrotizing infection. We have found this procedure to be applicable to a number of clinical reconstructive situations and recommend the SARIB procedure as a versatile operation that is successful in a high percentage of cases.

Explantation of silicone breast implants.

Silicone gel-filled breast implants have been employed clinically for decades for aesthetic augmentation or postmastectomy reconstruction. Most patients and surgeons attest to the efficacy and safety of these devices. However, more recently in the medical literature and popular media, silicone gel-filled breast implants have been claimed to incite an array of clinical sequelae such as capsular formation, granulomatous disease, arthritis, arthralgia, fibromyalgia, autoimmune collagen vascular disease, human adjuvant disease, siliconosis, silicone-related disease, and silicone implant-associated syndrome. During a recent 24-month period, 25 referred patients underwent explantation of bilateral silicone gel-filled prostheses at the University of South Alabama. Patient-reported symptoms and signs included mastodynia, arthralgia, fibromyalgia, xerophthalmia, xerostomia, hypesthesia, and amblyopia. Clinical examination and mammography were reliable in diagnosing implant rupture, but only re-exploration reliably detected implant leakage. Most patients underwent concurrent replacement with saline-filled devices. Histopathologic analyses of all tissue samples revealed chronic inflammation. Subjective improvement of patient-reported symptoms and signs occurred over the course of months postoperatively. There was no mortality associated with explantation, with or without replacement, but an overall morbidity incidence of 20 per cent (5 of 25) was observed. Predicated upon review of the available scientific literature and analysis of this modest number of patients, the following perspectives are germane. 1) A small cohort of patients of status postimplantation of silicone gel-filled devices will manifest chronic morbidity. Identifying such patients prospectively remains problematic. 2) Whether or not silicone gel incites adverse systemic phenomena is unproven, although it has been implicated. 3) Symptomatic patients with silicone gel-filled implants in place should be considered for removal, with full knowledge of the morbidity associated with revisional procedures. 4) Patients currently undergoing breast augmentation or reconstruction employing prosthetics are perhaps best served by insertion of saline-filled devices. 5) Patient-physician dialogue regarding the risk-benefit analysis of prosthetic implantation is imperative. Patients consenting to such procedures must be willing to assume risks.

Subtotal midfacial/total nasal reconstruction following shotgun blast to the face employing composite microvascular serratus anterior rib, muscle, and scapular tip.

A 40-year-old man presented with near-complete mid and lower facial destruction from a shotgun blast to the face. His midface was reconstructed with a serratus anterior muscle composite flap employing rib for nasal reconstruction and scapular tip for palate. Surfacing was done with split-thickness skin grafts. A temporoparietal scalp flap completed the upper lip reconstruction, and tubed, thick, split-thickness grafts supplemented with full-thickness grafts allowed airway reconstruction. Successful restoration of form and modest function were achieved with several surgeries. Our paper discusses the controversies and difficulties encountered in achieving autogenous tissue reconstruction of this devastating injury.

Therapeutic touch with adolescent psychiatric patients.

Seven hospitalized, adolescent psychiatric patients who received a total of 31 Therapeutic Touch treatments over two 2-week periods were interviewed about their experience. Findings from the interviews were categorized within 2 overarching themes-the therapeutic relationship and the body/mind connection. The study participants enjoyed the Therapeutic Touch, and in fact, they wanted more of it. This research shows the possibility of Therapeutic Touch as a nursing intervention with adolescent psychiatric patients if all care is taken to obtain their consent and to provide them with a safe environment for touch therapy.

Bilateral forearm and hand compartment syndrome following thrombolysis for acute myocardial infarction: a case report.

A patient suffering from a cocaine-induced myocardial infarction was treated with thrombolytic therapy and developed acute bilateral compartment syndromes of the upper extremities and hands from bleeding due to attempted bilateral radial artery cannulation. He was treated with emergent decompression of the forearm compartments and intrinsic muscles of the hands and recovered excellent hand function without significant neurologic or muscular damage. The problems encountered in the management of this case are detailed, and recommendations for prevention and therapy are discussed.

Dextropropoxyphene deaths in Denmark from the health authority point of view.

All known deaths resulting from poisoning with Dextropropoxyphene (n = 234) in the Municipality of Copenhagen during the period 1982 to 1989 were surveyed. The deaths were found to have occurred in a group characterized by social stress and abuse. A decline was observed in the annual number of deaths after 1985. The influence that the health authorities efforts and debates in the professional press had with regard to this development are discussed. Furthermore, it is recommended that more explicit criteria as to how the cause of death is to be determined in the future should be compiled.

The correlation between general disease prevention and prevention of HIV-contagion among adolescents.

A representative group of young persons (N = 745), who used the youth clubs in Copenhagen were asked to fill in a structured questionnaire. A large group of the young had had their sexual debut (N = 367). In respect of this group we found no correlation between prevention regarding general health risk factors vs. prevention against HIV contraction. It is discussed as to whether this difference can be accepted as an expression of the fact that adolescents do not consider the risk of AIDS as something that can affect them. Similarly, current problems in the chain of knowledge, attitude and behaviour in relation to intervention programmes are also discussed, including ethical aspects.

Rollover injuries of the upper extremity.

Eleven patients were treated for rollover injuries of the upper extremities from 1971 to 1976 resulting from the rollover accidents of off-road vehicles in rough terrain. Injuries to the volar surfaces of the extremity were most common, but injury to the extensor surfaces seemed to be more severe. Soft-tissue injuries predominated as did injury to the nondominant hand. The majority of patients returned to their original jobs after sometimes prolonged recovery and rehabilitation. A redesign of the rollover cage with interior hand holds could reduce the frequency and severity of these novel injuries.

Disease of the left main coronary artery. Surgical treatment and long-term follow up in 267 patients.

Of 4,196 patients undergoing coronary angiography, 297 (7 percent) had left main coronary arterial narrowing. In 188 (4.5 percent) the narrowing was greater than or equal to 70 percent and in 109 (3 percent) it was between 50 and 69 percent. Three patients (1 percent) died at cardiac catheterization. Saphenous vein bypass graft surgery was performed in 267 patients with an operative mortality of 7 percent: in 179 patients the left main coronary narrowing was greater than or equal to 70 percent (operative mortality 9 percent), and in 88 between 50 and 69 percent (mortality rate 2 percent). There was an average of 2.6 grafts per patient. The course of these patients was followed up for 4 3/4 years. At 1 year there was a 92.2 percent survival rate. The rate of survival at 2, 3 and 4 3/4 years, was 91, 89 and 86 percent, respectively. After saphenous vein bypass graft surgery, 75 percent of patients are angina-free and 22.4 percent are in improved condition. Grafts were studied in 51 patients and 85 percent of 128 grafts were found to be patent. It appears that there is improvement in survival and a reduction of symptoms after saphenous vein bypass graft surgery in patients with left main coronary arterial narrowing.

Forward angiography in the identification of vegetations in tricuspid endocarditis.

A patient with staphylococcal endocarditis of unknown valvular location and resistant to antibiotic therapy was studied in order to localize the site of infection prior to cardiac surger. The injection of contrast material into the right atrium visualized tricuspid vegetations which were confirmed at surgery. In such situations, forward angiographic studies constitute a safe, simple, and potentially diagnostic procedure which avoids the hazards of advancing a catheter across an infected valve.

The self-inflicted wrist slash.

Twenty-nine patients with self-inflicted wrist slash seen in consultation from 1970 through 1974 revealed 25 nerve and 70 tendon injuries. The average age, sex distribution, and psychiatric status generally followed previously reported series of suicide attempts. A major finding was the low patient response to surgical and psychiatric followup. Intensified efforts to improve followup and primary repair of damaged structures are recommended.

Postinfarctional ventricular septal rupture. Clinical approach and surgical results.

This study represents an analysis of 13 cases of ruptured interventricular septum occurring as a complication of myocardial infarction. The cases considered appeared to divide themselves into two groups. One group survived the septal rupture for weeks or months and underwent surgery in the chronic stage. The patients in the other group were diagnosed and underwent surgery in the acute stage because of clinical indications of a rapidly deteriorating situation. There were four serious complications resulting from extensive cardiac catheterization and angiographic procedures. Those patients who were diagnosed using bedside balloon-directed catheterization techniques had no serious complications. The data indicate that: (1) the diagnostic approach should be executed quickly and by simple methods; (2) it is possible to operate successfully upon these patients in the acute phase of their disease; and (3) because of the unpredictable course and rapid deterioration, these alternatives should be strongly considered.

Treadmill exercise test in aortic stenosis and mitral stenosis.

The incidence of positive submaximal treadmill exercise tests was evaluated in patients with mitral stenosis and aortic stenosis, no electrocardiographic evidence of left ventricular hypertrophy, and normal coronary arteries on angiography. Seven of 19 patients (37 percent) with aortic stenosis (53 to 80 mm Hg gradient across the aortic valve) had greater than or equal to 1.0 mm of ischemic S-T segment depression during or after a submaximal treadmill test. Three of 15 patients (20 percent) with mitral stenosis (11 to 22 mm Hg mean gradient across the mitral valve) had greater than or equal to 1.0 mm of ischemic S-T segment depression during or after a submaximal treadmill exercise test. Patients with significant valvular disease, no electrocardiographic evidence of left ventricular hypertrophy, and normal coronary arteries may have a positive submaximal treadmill exercise test due to an unfavorable balance between myocardial oxygen supply and myocardial oxygen demand.

Aortic stenosis, angina, and coronary artery disease. Interrelations.

Sixty-nine patients over age 35 with severe valvular aortic stenosis were investigated for concomitant coronary artery disease. Forty (57.9%) had clinical angina pectoris. Sixteen (23.2%) had significant coronary occlusive disease by arteriography. Of those with angina, 13 patients (32.5) had significant coronary arterial obstruction, while in the pain-free group only (10.3%) had occlusive coronary disease. It is concluded that patients with severe aortic stenosis who are free of angina have only a small, but definite, chance of having significant coronary disease.