Investigation of 72 patients following subcutaneous mastectomy. A clinical evaluation of current surgical techniques.

Different surgical techniques for subcutaneous mastectomy (SCM) have been evaluated and compared in this retrospective study of 72 patients. It has been clearly demonstrated that SCM followed by immediate reconstruction is a serious operation with a high frequency of both primary and late complications. It is important to have strong indications and a well informed and motivated patient before performing an SCM. A high frequency of postoperative tissue necroses was found for breasts of over 500 grams, when operated on using technique (VI) which entails skin reduction and transposition of the nipple-areola complex. In the very large breast a total mastectomy with skin reduction and transplantation of the nipple-areola complex is recommended. To obtain a good take of the graft it is advantageous to postpone the insertion of the prosthesis until a later occasion. For small breasts the lazy-S-shaped horizontal incision (technique V) is recommended. This technique gave perfect accessibility to the gland together with good cosmetic results and satisfied patients. At the follow-up examination it was found that the size and position of the implants were appropriate in about 80% of the breasts. Twenty-five per cent of the breasts were somewhat hard, although acceptable. The majority of the implants, however, were soft. The erotic sensibility of the breast is lost after an SCM.(ABSTRACT TRUNCATED AT 250 WORDS)

A model to study cell injury: morphological changes of the proximal tubule of the rat kidney during ischemia and during recovery from ischemic injury in vivo.

Studies on structural cell changes as a function of ischemia time and studies on the recovery process of ischemically injured cells have implications for our general understanding of the features of cellular reaction to injury. For this reason a model was worked out to follow the morphological changes taking place in the proximal tubule of the rat kidney during ischemia and during recovery from an ischemic episode. The pars convoluta and the pars recta of the proximal tubule were examined separately and compared with one another.

Effect of mannitol, dextran (macrodex), allopurinol, and methylprednisolone on the morphology of the proximal tubule of the rat kidney made ischemic in vivo.

Rats were anesthetized and their lift kidneys were made ischemic for 1 h by clamping of the aorta just above the left renal artery. Mannitol (2.5 g/kg), Dextran 70 (0.6 g/kg), methylprednisolone (50 and 100 mg/kg), and allopurinol (100 mg/kg body weight) were administered before, during, or after the ischemia period in order to test the effect of each of these drugs upon this model of renal injury. At 24 h after the release of the aortic clamp the left kidneys of the drug treated animals wwere perfusion fixed and processed for light and electron microscopy. Dextran administration to animals with ischemic kidneys gave rise to a pronounced vacuolization ("osmotic nephrosis"), in the entire proximal tubule and especially in the pars recta. This was in contrast to dextran administration to rats with nonischemic kidenys, which showed no or very mild "osmotic nephrosis." This demonstrates that ischemia makes rat kidneys more susceptible to the development of "osmotic nephrosis." In controls (no drug treatment) one hour of renal ischemia gave partial necrosis of pars recta of the proximal tubule, while the pars convoluta tubule survived. Mannitol treatment significantly reduced the amount of necrosis of the pars recta, whereas dextran, methylprednisolone, and allopurinol had no or a negative effect on the survival of the cells of the pars recta segment. It is suggested that mannitol protects against the development of necrosis by increasing medullary blood flow in combination with a counteractive influence on the cellular swelling, which is known to occur in ischemia.

A pilot study of some psychological aspects of subcutaneous mastectomy.

The report describes how the patients reacted to the information given them before the operation, their reactions following the operation, and their sexual behaviour before and after the operation. Patients who have undergone subcutaneous mastectomy with simultaneous insertion of implants have to cope with two different psychological factors: loss of the breast and sudden acquisition of an unfamiliar substitute. This study indicates that these factors may interfere with each other in a detrimental way. It may be better for patients if they are given opportunities to psychologically prepare themselves well in advance of the operation. Such preparation should include provision of full information and the opportunity to become familiar with the implants, as well as emotional counselling.

Studies on the pathogenesis of ischemic cell injury. III. Morphological changes of the proximal pars recta tubules (P3) of the rat kidney made ischemic in vivo.

The pars recta of the proximal tubule of the rat kidney was examined by means of light and electron microscopy after 15, 30, 60 and 120 min of ischemia produced by clamping of the aorta. Also the effects of 24 hrs of blood reflow following the same ischemia periods were determined. The maximal changes occurring after ischemic periods of up to 60 min included: marked cell swelling, swelling of the inner compartments of the mitochondria, swelling of the endoplasmic reticulum and of microvilli, pronounced chromatin clumping in the nuclei and distortion of the Golgi apparatus. These cell changes were reported to be reversible in the previous paper of this series. After 24 hrs of blood reflow it was found that with increasing periods of primary ischemia, ranging from 15 to 120 min, an increasing number of pars recta tubules cells were undergoing necrosis. Theses findings indicate that some additional mechanism other than the initial ischemia per se must be responsible for the progressive cellular damage leading to the necrosis. This is in contrast to the pars convoluta of the proximal tubule, which does not undergo further degenerative changes after the primary ischemia has been ended. The "no reflow" phenomenon may satisfactorily explain the necrosis seen in the pars recta segments following various periods of ischemia after 24 hrs of arterial renal reflow.

Studies on the pathogenesis of ischemic cell injury. II. Morphological changes of the pars convoluta (P1 and P2) of the proximal tubule of the rat kidney made ischemic in vivo.

The pars convoluta of the proximal tubules of the rat kidney was examined by means of light and electron microscopy after 15, 30, 60 and 120 min of complete ischemia produced by clamping of the aorta. The same ischemia periods were also examined after 24 hrs of blood reflow. It was found that the vast majority of the cells of pars convoluta survived 60 min of ischemia as seen after 24 hrs of reflow. The following pattern of changes were observed at time intervals up to 60 min: progressive clumping of chromatin, progressive distortion of microvilli with bleb formation, increasing dilatation and finally vesiculation of rough-surfaced endoplasmic reticulum and initially condensation and later high amplitude swelling of mitochondria. It is concluded that these subcellular changes are compatible with cell survival. Also tubule cells containing swollen mitochondria with small flocculent densities are potential candidates for survival. 120 min of ischemia was associated with marked mitochondrial swelling with large flocculent densities, severe cell damage and necrosis and was not compatible with cell survival. A working hypothesis is presented relative to the pathogenesis of acute renal failure caused by complete ischemia.

Studies on cellular recovery from injury. II. Ultrastructural studies on the recovery of the pars convoluta of the proximal tubule of the rate kidney from temporary ischemia.

The pars convoluta of the proximal tubule of the rat kidney was studied by light and electron microscopy during the recovery phase from transient ischemia. The left kidney was made ischemic by clamping the aorta just above the left renal artery leaving the blood supply to the right kidney and the intestine intact. The pars convoluta (P1 and P2 segments) of the proximal tubule was examined both immediately after various periods of ischemia (15, 30, 60 and 120 min) and after the same ischemic periods followed by 3, 6, 12 and 24 h of blood reflow (= recovery phase). It was found that ischemia for periods up to 60 min were compatible with cell survival whereas 120 min of ischemia gave rise to irreversible cellular changes. Before regaining a normal conformation during the recovery phase, cells made ischemic for 15 min were characterized by slightly decreased cell height, dispersed nuclear chromatin, mitochondria in orthodox conformation and increased numbers of digestive vacuoles and of lipid droplets (stage A2). Most cells made ischemic for 15 min appeared normal when examined after 24 h of reflow. Cells made ischemic for 30 min were also characterized by stage A2 changes after 3 h of reflow and remained in this stage during all recovery periods studied. Cells made ischemic for 60 min first passed into a stage designated A1 and then later during the recovery phase into stage A2. Stage A1 cells were characterized by decreased height, condensed mitochondria, apparently increased numbers and sizes of secondary lysosomes and slightly dilated rough surfaced endoplasmic reticulum; 120 min of ischemia followed by reflow was not compatible with cell survival. Cells made ischemic for 120 min showed the following alterations denoted as stages C and D: shrunken with pyknotic nuclei, swollen mitochondria with large flocculent densities, and filled with different sized vesicles in the apical portion (stage C). Stage D included cells which had undergone necrosis, i.e., phasma membranes and organelles were fragmented and occurred as debris in the tubule lumens.

Resection margins of 2 versus 5 cm for cutaneous malignant melanoma with a tumor thickness of 0.8 to 2.0 mm: randomized study by the Swedish Melanoma Study Group.

BACKGROUND: The traditional surgical treatment for primary malignant melanoma has often been a wide excision with a margin of about 5 cm. Since the risk of local recurrences is dependent on tumor thickness, thin tumors (<1 mm) have routinely been excised with a narrow margin. For thick tumors, the optimal resection margin is controversial, and can be determined only by prospective, randomized trials. METHODS: The Swedish Melanoma Study Group performed a prospective, randomized multicenter study to evaluate an excision margin of 2 versus 5 cm for patients with cutaneous malignant melanoma with tumor thickness > 0.8 and < or = 2.0 mm. The trial includes 769 patients. Patients with melanomas of the skin of the head, neck, hands, feet, or vulva were not included in the trial. In the event of an excision biopsy for diagnosis, radical surgery was completed within 6 weeks. The median follow-up time was 5.8 years for estimation of survival and 4.0 years for diagnosis of recurrent disease. RESULTS: No significant differences have been observed between the treatment groups regarding local or regional recurrences or survival. CONCLUSIONS: We recommend an excision with a margin of 2 cm for cutaneous malignant melanoma with a tumor thickness > 0.8 and < or = 2.0 mm.