Nasal augmentation using Gore-Tex. A 10-year experience.

OBJECTIVE: To determine on an ongoing basis the safety and efficacy of expanded polytetrafluoroethylene (Gore-Tex soft tissue patch and preformed nasal implants) as an implant in rhinoplasty. DESIGN: A retrospective study of 309 consecutive patients who underwent rhinoplasty, including augmentation with Gore-Tex, during a 10-year period. SETTING: Two major academic medical centers and 2 private office surgical centers. INTERVENTION: One hundred sixty-two patients (52%) presented for primary rhinoplasty; the remaining 147 (48%) presented for revision surgery. All received Gore-Tex implants to augment the nasal dorsum and/or base. The grafts ranged from 1 to 10 mm in thickness. Follow-up ranged from 5 months to 10 years, 5 months, with an average of 40.4 months. MAIN OUTCOME MEASURES: Clinically noted complications and patient satisfaction. RESULTS: Ten (3.2%) of 309 grafts became infected and were removed. One graft was removed and 1 graft was modified and replaced postoperatively because of excessive augmentation. Infection requiring removal occurred in 8 patients (5.4%) undergoing revision rhinoplasty and in 2 patients (1.2%) undergoing primary rhinoplasty. Nasal septal perforation was present preoperatively in 3 of the patients who developed infection requiring removal, and we consider it a contraindication for nasal Gore-Tex implantation. CONCLUSIONS: Gore-Tex remains an effective implant material for nasal augmentation in rhinoplasty. The complication rate in primary cases is low. The risk of infection necessitating removal rises significantly in revision cases, where its use may still be desirable but must be weighed more carefully.

Dihydrobenzofuran analogues of hallucinogens. 4. Mescaline derivatives.

Dihydrobenzofuran and tetrahydrobenzodifuran functionalities were employed as conformationally restricted bioisosteres of the aromatic methoxy groups in the prototypical hallucinogen, mescaline (1). Thus, 4-(2-aminoethyl)-6,7-dimethoxy-2,3-dihydrobenzofuran hydrochloride (8) and 1-(8-methoxy-2,3,5,6-tetrahydrobenzo[1,2-b:5,4-b']difuran-4-yl)-2- aminoethane hydrochloride (9) were prepared and evaluated along with 1 for activity in the two-lever drug discrimination (DD) paradigm in rats trained to discriminate saline from LSD tartrate (0.08 mg/kg). Also, 1, 8, and 9 were assayed for their ability to displace [3H]ketanserin from rat cortical homogenate 5-HT2A receptors and [3H]8-OH-DPAT from rat hippocampal homogenate 5-HT1A receptors. In addition, these compounds were evaluated for their ability to compete for agonist and antagonist binding to cells expressing cloned human 5-HT2A, 5-HT2B, and 5-HT2C receptors. Finally, agonist efficacy was assessed by measurement of phosphoinositide hydrolysis in NIH 3T3 cells expressing the rat 5-HT2A or 5-HT2C receptors. Although 1 fully substituted for LSD in the DD assays (ED50 = 33.5 mumol/kg), neither 8 nor 9 substituted for LSD, with just 50% of the rats administered 8 selecting the drug lever, and only 29% of the rats administered 9 selecting the drug lever. All of the test compounds had micromolar affinity for the 5-HT1A and 5-HT2A receptors in rat brain homogenate. Curiously, the rank order of affinities of the compounds at 5-HT2A sites was opposite their order of potency in the behavioral assay. An evaluation for ability to stimulate phosphoinositide turnover as a measure of functional efficacy revealed that all the compounds were of approximately equal efficacy to serotonin in 5-HT2C receptors. At 5-HT2A receptors, however, 8 and 9 were significantly less efficacious, eliciting only 61 and 45%, respectively, of the maximal response. These results are consistent with the proposed mechanism of action for phenethylamine hallucinogens, that such compounds must be full agonists at the 5-HT2A receptor subtype. In contrast to the 2,5-dimethoxy-substituted phenethylamines, where rigidification of the methoxy groups had no deleterious effect on activity, the loss of activity in the 3,4,5-trioxygenated mescaline analogues may suggest that the 3 and 5 methoxy groups must remain conformationally mobile to enable receptor activation.

The use of expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty. A 6-year experience.

OBJECTIVE: To determine the safety and efficacy of expanded polytetrafluoroethylene (Gore-Tex soft-tissue patch, W. L. Gore & Assoc Inc, Flagstaff, Ariz) as an implant in rhinoplasty. DESIGN: A retrospective study of 137 patients who underwent rhinoplasty including augmentation with Gore-Tex over a 6-year period. A review of the medical literature concerning the use of Gore-Tex as an implant in the head and neck was also conducted. SETTING: Two major academic medical centers and two private office surgical centers. PARTICIPANTS: One hundred thirty-seven consecutive patients who received Gore-Tex implants in the course of rhinoplasty. INTERVENTION: Sixty-nine patients presented for primary rhinoplasty; the remaining 68 presented for revision surgery. All received Gore-Tex nasal implants to augment the nasal dorsum and/or base. The grafts ranged from 1 to 6 mm in thickness. Follow-up ranged from 6 to 80 months, with an average of 25 months. OUTCOME MEASURES: Clinically noted complications and patient satisfaction. RESULTS: Three (2.2%) of 137 grafts became infected and were removed. One graft was removed 5 months post-operatively because of excessive augmentation. None of the patients who underwent implant removal required subsequent augmentation. All 137 patients are pleased with their results. CONCLUSION: Gore-Tex is a safe and effective implant material to use in primary and revision rhinoplasty when augmentation is needed and autogenous material is not available or desirable.

Gore-Tex for augmentation of the nasal dorsum: a preliminary report.

Many different materials have been used to provide augmentation of the nasal dorsum. This includes both autogenous and homogenous materials, as well as allografts. Many times autogenous material is not readily available and homogenous materials have recently demonstrated significant absorption. Several artificial materials have been used in the past, including Supramid, silicone, and Proplast, each with its own limitations or problems. Two years ago we began using Gore-Tex Soft Tissue Patch as a material to augment the nasal dorsum. Although our experience is preliminary, certainly, experience with this material in cardiac and abdominal surgery is extensive. Our initial impression is that this material is a very useful alternative to traditional methods of nasal augmentation.

Midforehead lift.

Ptosis of the brow-glabellar tissues with or without vertical and horizontal wrinkling accompanies aging in other areas of the face. The direct browlift is effective in elevating and shaping brow tissues, but leaves a scar at the brow-forehead juncture and does little for glabellar deformity. The coronal forehead lift allows the correction of brow-glabellar ptosis and wrinkling with camouflage of the scar in the scalp. Male pattern hairline, thinning hair, or a high hairline may contraindicate this approach. Our technique for treating these patients is the midforehead lift. We review the anatomical considerations, patient selection, and surgical technique, showing representative cases.

Paraganglioma of the sphenoid sinus appearing as labile hypertension.

Paragangliomas, also known as glomus tumors, are unusual, generally benign tumors most commonly found in association with major vessels and cranial nerves. Only a small number of these tumors have been described arising in the paranasal sinuses, and none of these has been physiologically active. The following case report describes a metabolically active paraganglioma arising in the sphenoid sinus.

Surgical experience with nasopharyngeal angiofibroma.

Recent reports have suggested that radiotherapy may be preferable to other forms of treatment of juvenile nasopharyngeal angiofibroma. There are, however, potentially serious short- and long-term complications associated with the use of radiotherapy in the head and neck. For the past three years, ten consecutive patients with juvenile nasopharyngeal angiofibroma have been treated at The Cleveland Clinic Foundation with an approach that permits accurate removal with minimal complications. With this method of treatment, intraoperative blood loss, the necessity for blood transfusion, and length of hospital stay have been greatly decreased. There have been no substantive complications and no recurrences to date. If further experience with this approach to management in a larger series of patients has the same results, it would seem that radiotherapy should be relegated to a secondary position in the treatment of juvenile nasopharyngeal angiofibroma, except for cases wherein intracranial extension would prevent total excision.

Nasal tuberculosis: a forgotten entity.

Tuberculosis of the nose has become so infrequent that it is virtually a forgotten disease entity among younger practitioners in this country. Nevertheless, it can occur in all segments of our population and may present a confusing diagnostic problem. Two cases of primary nasal tuberculosis have been diagnosed and treated at The Cleveland Clinic Foundation since 1975. The differential diagnosis of nasal granulomatous disease usually includes Wegener's granulomatosis, midline malignant reticulosis, and sarcoidosis. We point out the necessity of including tuberculosis in this differential diagnosis. The definitive work-up and treatment are also discussed.

Comparison of serum blocking factors on leucocyte adherence inhibition and PHA lymphocyte blastogenesis in breast cancer patients.

Specific and nonspecific serum blocking factors (SBF) in sera from 48 breast cancer patients were examined to evaluate the correlation of SBF to the tumor burden. Specific SBF in leucocyte adherence inhibition (LAI) assay was demonstrated in 15 of 21 patients with a recurrence, in five of 11 with local or regional involvement and in 3 of 16 with no evidence of the disease (NED). The difference between patients with recurrence and with NED was significant (P less than 0.005). SBF in LAI and lymphocyte blastogenesis correlated in 29 of 48 (60%) patients (both positive 9 of 48, both negative 20 of 48). However, SBF in LAI was demonstrated in 14 of 48 (29%) patients whose sera showed no SBF in lymphocyte blastogenesis. These results indicate that SBF in LAI and lymphocyte blastogenesis are either induced or derived from breast cancer tissue. SBF in LAI correlates closely with the tumor burden, more so than do SBF in lymphocyte blastogenesis. The blocking assays have a potential use for prognostication and a guide for clinical therapy.

Effect of serum factors and cell washings on leukocyte adherence inhibition in breast cancer patients.

A total of 81 individuals, including 41 breast cancer patients, 20 patients with other types of malignant tumors, and 20 normal volunteers, were studied in order to evaluate whether leucocyte reactivity directed to soluble tumor-associated antigens could be increased by extensive cell washings and could be blocked by preincubation with autologous serum. When 41 leucocyte samples were pretreated with autologous serum, washed 3 or 6 times, mean percentage of leucocyte adherence inhibition difference between control extract and breast cancer extract were -2.4 +/- 2.0, 5.8 +/- 1.3, and 10.0 +/- 1.2, respectively. The results of cells preincubated with serum were significantly different from those of cells washed 3 times and 6 times (both P less than 0.001 by Student's t-test). The results of cells washed 3 times were significantly different from those of cells washed 6 times (P less than 0.05 by Student's t-test). Serum blocking factors correlated with tumor burden and clinical stage. However, leucocyte reactivity against breast cancer extract did not correlate with tumor burden or clinical stage in breast cancer patients.

Automation of the leukocyte adherence inhibition assay. Counting live mononuclear cells with an automated light microscope system.

Adaptation of an automated light microscope system to the leukocyte adherence inhibition assay provides a rapid automated assay of cell mediated immunity. Comparison between the numbers of live mononuclear cells counted by eye and by machine yields no statistical differences in the per cent adherence or in the standard errors when performing either 10 or 20 replicate counts per antigen-cell mixture. Using the cell counter in a semi-automated mode, the counting is performed 10 times as fast in comparison to the manual method. A semi-automated system is described. The procedure requires from 4-6 X 10(5) mononuclear cells and from 2-3 micrograms crude KCl extract using a standard hemocytometer. The value of the technique lies in its availability as a rapid assay for both research applications and immunologic monitoring in the clinical laboratory.

Cytochemical findings in human nonneoplastic blood and tonsillar B and T lymphocytes.

The cytochemical profiles of B and T lymphocytes from the bloods of eight normal donors and the tonsils of three normal individuals were studied. An intense and localized alpha-naphthyl acetate esterase (alpha-NAE) activity was found in the majority of blood and tonsillar T lymphcytes, in contrast to the very low alpha-NAE activity observed in the blood and tonsillar B lymphocytes. A very low percentage of tonsillar B lymphocytes had beta-glucuronidase (betaG) activity, while relatively normal betaG activity was observed in the tonsillar T lymphocytes and the blood B and T lymphocytes. Acid phosphatase (AcP) activities were found to be similar in both B and T lymphocytes from blood and tonsils. These findings suggest that the alpha-NAE reaction may be useful as a cytochemical marker for distinguished B from T lymphocytic proliferations. They also revealed that there is no appreciable difference in AcP and betaG activity between B and T lymphocytes obtained from the blood of normal donors.

Acid hydrolases in normal B and T blood lymphocytes.

B and T lymphocytes were separated by means of the spontaneous sheep red blood cell rosette formation technique from 3 normal donors. The following acid hydrolases were biochemically determined on separated B and T lymphocytes: acid phosphatase, beta-glucuronidase, beta-galactosidase, beta-hexosaminidase, alpha-arabinosidase, alpha-galactosidase, alpha-mannosidase, alpha-glucosidase, and pH 4.0 and pH 5.0 beta-glucosidase. The activities of most of the acid hydrolases including acid phosphatase and beta-glucuronidase were found to be slightly decreased in B lymphocytes when compared to T lymphocytes. However, alpha-mannosidase activity was found to be significantly higher in the B lymphocytes than in the T lymphocytes and offers the possibility of using this enzyme as a B lymphocyte marker.

Leukocyte adherence inhibition by soluble tumor antigens in breast cancer patients.

The authors modified and refined the Leukocyte Adherence Inhibition Assay (LAI) first described by Halliday, et al. in 1972 by standardizing the protein concentration of tumor-associated antigens (TAA) and by utilizing paired normal tissue extracts as controls to eliminate interference of HL-A histocompatibility antigens and organ-associated antigens. When dose response studies were performed, a progressively larger percentage of patients reacted to the LAI test with increasing concentration of tumor extracts, but the optimal concentration was found to be 200 mug/ml, where 42 out of 66 (63%) leukocytes from 54 breast cancer patients reacted to the breast cancer extracts. At this dose range, only three out of 39 (7%) normal donors and four out of 30 (13%) patients with other types of cancer were positive. When breast cancer patients were tested against TAA of colon cancer and malignant melanoma, one of 24 (4%) and two of 24 (8%), respectively, were positive. Although a higher response rate (72%) was noted in Stage II disease, this was not statistically different from Stage I and Stage III disease. Likewise, no difference was noted in LAI at varying phases following the mastectomy.