Virginal breast hypertrophy.

Macromastia is the massive enlargement of the breast, unilateral or bilateral, disproportional to growth in the remainder of the body. Most patients seen with macromastia have breasts that develop normally at puberty but simply reach excessive size. Virginal breast hypertrophy is a rare and distinct disorder with the rapid onset of macromastia at the onset of puberty. Although the disorder has been reported in the surgical, pediatric, and gynecologic literature, virginal breast hypertrophy has not been reported in dermatologic journals. We report two cases of virginal breast hypertrophy. Patient 1 is a 14-year-old girl who developed macromastia 6 months after a liver transplant for alpha 1-antitrypsin deficiency. She had intense erythema as well as verrucous hyperplasia overlying the breasts. Patient 2 was a 12-year-old girl who experienced severe bilateral breast enlargement 4 months after beginning treatment for thyrotoxicosis. She had extreme tenderness, erythema, and edema of the breasts and was treated with tamoxifen citrate, with improvement of her symptoms. Although virginal breast hypertrophy is a rare disorder, the dermatologist may be asked to consult on the associated skin changes in these cases and should be aware of its existence. The definitive therapy is surgical, but until breast growth is stabilized, cutaneous manifestations need to be managed.

Vulvodynia: a dermatologist's perspective with emphasis on an irritant contact dermatitis component.

Vulvodynia (vulvar burning and itching) is a symptom complex with a number of potential triggering/exacerbating factors. We reviewed the management and outcomes of 60 patients seen in a referral dermatology clinic for vulvodynia. The composite patient profile is that of a 44-year-old white woman with a 2-year history of vulvar burning who has tried multiple topical therapies. Dermatological factors in these patients included candidiasis (37%), atopy (27%), dermatographism (27%), and irritant contact dermatitis (83%). Identification of these factors and directed management led to symptomatic improvement in 72% of patients within 4 months. No patients were treated with amitriptyline. A dermatological approach to discern the contributing factors for individual patients with vulvodynia can be helpful in directing therapeutic management.

Tobacco smoking contributes little to facial wrinkling.

BACKGROUND: The potential detrimental effects of tobacco smoking have been widely cited. Tobacco smoking has been linked with facial wrinkling, but some previous studies have failed to take into account a number of potential confounders or were unblinded and thus subjective to bias. OBJECTIVE: This study was designed to determine if there was increased facial wrinkling in smokers directly associated with tobacco usage after controlling for solar risk behavior. SUBJECTS: Eighty-two smokers (> 10 cigarettes per day) and 118 non-smokers (< 100 lifetime cigarettes) were recruited. Caucasian participants completed a questionnaire designed to assess demographic variables and other suspected factors related to wrinkling. METHODS: Three dermatologists, blinded to demographic information, reviewed three photographs of each subject and rated the wrinkling on a 100 mm visual analog scale. Stepwise linear regression was performed on all variables which attained a P < 0.1 level of independent significance. RESULTS: Overall the model accounted for 75.4% (P = 0.0001) of the variance in wrinkling, and predictive variables (P < or = 0.02) included age (partial R2 = 0.69), smoking pack years (R2 = 0.04), hours of outdoor work (R2 = 0.008), freckling (R2 = 0.007), and eye color (R2 = 0.004). A second model was created excluding age which accounted for 37.8% of the variance. The predictive variables in the second model (P < 0.08) included education (partial R2 = 0.08), smoking pack years (R2 = 0.05), hours of outdoor work (R2 = 0.03), weight change (R2 = 0.02), female sex (R2 = 0.02), hours of lifetime sun (R2 = 0.03), tanning bed use (R2 = 0.01), and sunscreen use (R2 = 0.02). CONCLUSIONS: Smoking may significantly contribute to facial wrinkling, but accounts for only 6% of the explained variance. If there is a role for tobacco smoking in causing wrinkling, this role is a minor one.

Reconstruction of the mandible using the scapular spine pedicled upon trapezius muscle; description of the posterior approach to the transverse cervical vessels.

We describe the reconstruction of the mandible using the spine of the scapula pedicled upon trapezius in a woman who had undergone previous mandibular irradiation and surgery. We show how the vascular supply to the trapezius scapular spine compound flap can be approached posteriorly and the spine of the scapula used to provide good length and contour for replacement of a wide mandibular defect.

The medicinal leech and its use in plastic surgery: a possible cause for infection.

Recent interest in the use of the medicinal leech (Hirudo medicinalis) in microsurgical practice prompted us to undertake a bacteriological study. Aeromonas hydrophila was consistently cultured from 9 leeches that we examined. This organism is pathogenic to man and we consider that there is a significant risk of infection, particularly in those procedures where the vascularity of the tissues is compromised. There are several pharmacological preparations which have similar properties to the secretion of the medicinal leech and we submit that these non-infective preparations may be worthy of investigation.

Experience with the tensor fasciae latae free flap.

Six cases of reconstruction using the tensor fasciae latae myocutaneous free flap are described and in three of these a neuro-sensory flap was used. Four cases involved a lower limb reconstruction, one an upper limb reconstruction and one an abdominal wall reconstruction. Reduction of the bulk of the flap by transection of the muscle between the superior and inferior branches of the vascular pedicle was performed in four cases. One case of partial failure occurred in the lower limb group.

Reconstruction of major abdominal wall defects using the tensor fasciae latae myocutaneous flap.

Five cases of abdominal wall reconstruction using the tensor fasciae latae myocutaneous flap are described. This flap provides a deep layer of tissue of sufficient strength to prevent herniation and external cover in a single stage repair. We regard it as the method of choice in the reconstruction of major defects of the abdominal wall.