Actions and comparative efficacy of phosphatidylcholine formulation and isolated sodium deoxycholate for different cell types.

BACKGROUND: Phosphatidylcholine formulation has been used to dissolve local fat deposits. This study aimed to evaluate and compare the effects of phosphatidylcholine formulation and its vehicle sodium deoxycholate alone on different cell lines to understand better its mechanism of action. METHODS: Cells and media including 3T3-L1 preadipocytes, normal foreskin fibroblasts, neonatal human dermal microvascular endothelial cells (CADMEC), and fetal human skeletal muscle cells (HSkMC) were used. After 24 h, cells were exposed in 3-4, 5-dimethylthiazol-2-yl-2, 3-diphenyl tetrazolium bromide reagent (MTT assays) to increasing dosages of phosphatidylcholine formulation (0.0156-0.5 mg/ml) or an equivalent vehicle, sodium deoxycholate solution, pH 9.0 (0.0066-0.210 mg/ml). Viability was assessed after 1, 2, and 3 days of treatment. Fat tissue (4 x 4 cm) obtained ex vivo from the dorsal fat pads of five rabbits was injected with 2 ml of phosphatidylcholine formulation (50 mg/ml), sodium deoxycholate (21 mg/ml), or normal saline and incubated for 24 h. These were examined histologically to identify cell lysis and morphologic changes. RESULTS: At 0.125- and 0.25-mg/ml doses of phosphatidylcholine solution, CADMEC and HSkMC were more sensitive (P < 0.001, one-way ANOVA) than adipocytes at all time points examined. Phosphatidylcholine formulation at a dose of 0.5 mg/ml and the equivalent vehicle, sodium deoxycholate, at a dose of 0.21-mg/ml both induced nearly 100% fat cell lysis after 24 h, and evidence of cell lysis as early as 6 h after exposure. After incubation of fat tissue for 24 h with phosphatidylcholine formulation, loss of intracellular lipid staining with an increase in extracellular lipids was seen. CONCLUSIONS: Isolated sodium deoxycholate was almost as effective as the phosphatidylcholine formulation, at clinical concentrations, in reducing the viability of mature adipocytes over time. Similar cytotoxic effects of phosphatidylcholine formulation on normal foreskin fibroblasts, endothelial cells, and human skeletal muscle cells also were observed. The data prove that the formulation acts in a nonspecific manner and that its unintentional administration to other tissues causes cell death.

Three-dimensional computed tomographic scanning and major surgical reconstruction of the head and neck.

The major advantage of three-dimensional computed tomographic imaging is the ability to obtain accurate anatomic measurements of distance, area, and volume. This accuracy is possible because the three-dimensional relationships of soft tissue and skeleton are retained. This feature is particularly useful in reconstruction of the upper facial skeleton, where standard roentgenograms and computed tomographic scans are of limited value. Computer-interactive surgical procedures have been used for correction of congenital deformities and for removal of orbital neurofibromas and subsequent reconstruction. Because three-dimensional imaging is expensive and exposes the patient to high levels of irradiation, this approach is recommended only when a specific indication exists and when it can contribute to problem solving.

Therapeutic embolization angiography for extra-axial lesions in the head.

Percutaneous transcatheter arterial embolization has played an increasingly important role in the management of vascular lesions in the head. Embolization can promote thrombosis within vascular tumors and malformations, reduce bleeding and decrease the need for transfusion intraoperatively, and facilitate surgical approaches to otherwise unresectable lesions. It is important for the clinician to be aware of this interventional technique because many of the patients who are considered for embolization are triaged through several different clinical areas, and much can be gained from the collaboration of the clinician, the surgeon, and the angiographer. We performed 31 therapeutic particulate embolization procedures for extra-axial head lesions in 23 patients by using flow-directed techniques. Of these procedures, 11 resulted in vascular occlusion and 15 resulted in 80 to 95% obstruction, as demonstrated by angiography. In 14 patients, embolization was performed preoperatively both to decrease blood loss and to occlude inaccessible or unresectable portions of a lesion. In nine patients, embolization was the sole means of treatment for occluding an abnormal vascular shunt. Two patients (9%) experienced a minor transient neurologic change after the procedure.

Surgical technique and pitfalls of breast reconstruction immediately after mastectomy for carcinoma: initial experience.

Breast reconstruction immediately after mastectomy is being used with increasing frequency. In a study of the first 100 consecutive patients at our institution who underwent this procedure, with (21 patients) or without (79 patients) later nipple reconstruction, 85% responded affirmatively on a follow-up questionnaire when asked whether they would recommend the procedure to other patients. Moreover, 32% rated their cosmetic results as "perfect." No deaths occurred in the immediate postoperative period, but 13 patients had major complications--most commonly, wound infection or displacement or partial extrusion of the implant. All infections, however, occurred early in the study, and with increasing experience and improved selection of patients, the associated morbidity decreased. For the entire group, the mean duration of hospitalization was 7.8 days, similar to that for patients who undergo mastectomy without reconstruction (7.5 days). The high patient acceptance and the overall good results in this preliminary study support the use of breast reconstruction immediately after mastectomy.

A population-based study of craniosynostosis.

A population-based study of the incidence of craniosynostosis was conducted among residents of Olmsted County, Minnesota, born between 1 January 1976 and 31 December 1985. This study included only those with primary craniosynostosis who were less than 5 years of age at the time of diagnosis. Cases of craniosynostosis were classified as definite or probable. Definite cases had craniectomies or radiographic evidence confirming craniosynostosis, while patients for whom there was enough concern about craniosynostosis to order a skull radiograph were classified as probable cases. With these definitions, the incidence of craniosynostosis in Olmsted County was 3.1/10,000 births for definite cases (95% CI, 0.4-5.8) and 13.6/10,000 for all cases combined (95% CI, 7.9-19.3). These rates were compared to non-population-based minimal and maximal estimates of craniosynostosis frequency, 4/10,000 births and respectively. The rate observed in this study for definite cases, 3.1/10,000 births, is statistically consistent with the previous low estimate (observed/expected ratio 0.8, 95% CI, 0.2-1.8), and the rate observed for all cases in this study, 13.6, is consistent with the high estimate (observed/expected ratio 1.4, 95% CI, 0.8-2.1). Differences between definite and probable cases in this study are presented, along with comparisons with recent population-based data.

Loss of factor XIIIa in pig dermis during tissue expansion.

Considerable evidence suggests that factor XIIIa, a blood coagulation factor, also functions in tissue repair, and specifically in the dynamic process of fibroplasia. On the other hand, the dynamic process of tissue expansion would require a loosening of the dermis, the opposite of fibroplasia. We examined the effects of tissue expansion on the expression of factor XIIIa in pig skin. Standard immunohistochemical procedures were used coupled with a rabbit antibody to factor XIIIa. In this report, we demonstrate that the normal expression of factor XIIIa in pig dermis is completely inhibited at the apex overlying the tissue expander. Factor XIIIa inhibition during expansion supports the thesis that this substance is important in the production and maintenance of fibroplasia.

Infections in breast implants.

Infection following breast implants is an uncommon event. This is somewhat surprising, since the human breast is not a sterile anatomical structure. The flora found in the breast are derived from the nipple ducts and closely resemble those of normal skin. These organisms, predominantly S. epidermidis, may in some cases be responsible for firmness secondary to capsular contracture. Treatment of the periprosthetic infection usually involves implant removal, but salvage by systemic antibiotics is sometimes possible. Atypical mycobacteria are very rarely the cause of infection, but can be extremely difficult to eradicate when involved. Toxic shock syndrome has been reported to occur following breast implants and is a life-threatening problem requiring immediate removal of the implant. It may be significant that in some cases with effusion and infection occurring many months or years after implant placement, there has been a preceding event such as a laryngitis or flu-like illness. This suggests the possibility of a bacteremia being involved in the causation of the infection. If this were the case, then these patients should be handled in a fashion similar to those with prosthetic heart valves. Accordingly, in our own practice, we advise that penicillin "V" be given beforehand when a patient with breast implants is to have any dental procedure. It must be stressed that there is no statistical or scientific proof at the present time that this is of any value. In conclusion, when dealing with these large foreign bodies, absolute sterility is essential, and excellent surgical technique to obviate hematoma and the occurrence of tissue ischemia is mandatory. Evidence of severe infection necessitates implant removal, but in less severe cases a trial of intravenous antibiotics is permissible. Having removed an implant, further insertion should be deferred, preferably for 6 months. If the new implant can be placed in a different plane, that is, submuscular, this is desirable. Exposed implants can be salvaged but this requires considerable judgment and one should be prepared for re-exposure or frank infection.

Pseudohyperparathyroidism secondary to gigantic mammary hypertrophy.

Pseudohyperparathyroidism encompasses both ectopic hyperparathyroidism and the more commonly encountered nonparathyroid humoral hypercalcemia of malignancy--metastatic breast cancer being the classic example. Benign breast disease is a rare cause of hypercalcemia. We recently managed a patient with gigantic mammary hypertrophy that occurred during pregnancy who concomitantly manifested marked nonparathyroid hypercalcemia. This report strongly suggests that a casual relationship exists between benign breast disease and hypercalcemia.

Oncological aspects of immediate breast reconstruction following mastectomy for malignancy.

One hundred eighteen women treated with mastectomy and immediate breast reconstruction for carcinoma were evaluated for recurrence of disease and survival. Fourteen women (12%) suffered relapse of their cancer and 10 patients (9%) died of their disease during a median follow-up of 2.3 years. All seven local recurrences (6%) were detected at an early stage and treated without removal of the prosthesis. Recurrence of disease occurred more frequently in patients with involved axillary lymph nodes and larger tumors. Patient survival was adversely affected by nodal metastasis and the absence of tumor estrogen receptors. Adverse outcome in this series correlated to known prognostic factors for breast cancer. Disease-free and overall survivals were comparable with our previous experience with mastectomy alone for breast carcinoma. In the absence of any apparent negative impact on patient outcome, and because of the well-documented positive psychosocial benefit of immediate reconstruction, this procedure should be routinely offered to women with operable breast cancer.

A craniofacial approach to advanced recurrent cancer of the central face.

Recurrent penetrating midface cancer results from basal cell carcinoma, squamous cell carcinoma, adenocystic carcinoma, and chondrogenic and osteogenic sarcoma. In the past, surgical resection frequently resulted in meningitis. A combined neurosurgical and plastic surgical craniofacial approach has been used for total resection of these lesions. The floor of the anterior cranial fossa has been reconstructed with an extended glabellar flap incorporating a forehead Z-plasty. Over the past 2-and-a-half years, 10 patients have been operated on successfully. Five cases with a follow-up of over 2 years are presented.

Treatment of tumors involving the anterior cranial fossa.

The potential for a tumor of the upper face, either malignant or nonmalignant, to involve the anterior cranial base is often not appreciated. This leads to inadequate preoperative investigation and to surgery performed by the head and neck surgeon without the help of the neurosurgeon. In this way, complete tumor resection may be compromised or delayed. Neither of these situations is desirable. If the potential for anterior cranial fossa invasion is recognized, there should be prior consultation with the neurosurgeon and a combined operative procedure. Exposure of these lesions has considerably improved with experience in congenital craniofacial deformities: this will allow en bloc resection of most pathologies. Immediate reconstruction after resection of nonmalignant tumors is advocated, but in aggressive--particularly in recurrent--malignancies, delayed reconstruction is advised. Careful combined follow-up with frequent blind biopsies should be carried out as indicated.

Multifocal Merkel's cell tumors associated with a cutaneous dysplasia syndrome.

Multifocal Merkel's cell tumors developed in a 24-year-old patient with an unusual cutaneous dysplasia syndrome. The neoplasms behaved in an aggressive fashion, with the development of multiple lymph node metastases. In this case, the dermatologic syndrome had features of both dyshidrotic ectodermal dysplasia and the basal cell nevus syndrome. In addition to Merkel's cell tumors, basal cell carcinomas and actinic elastosis were seen in sun-exposed skin sites. These findings, in conjunction with a known tendency for Merkel's cell tumors to arise in solar-damaged areas, suggest a pathogenetic relationship between these neoplasms and the underlying cutaneous syndrome in this patient.

Neurofibromatosis of the skull base.

Neurofibromatosis of the skull base is a syndrome that may occur in an isolated fashion or as a component of Von Recklinghausen disease. This article discusses the clinical features of neurofibromatosis, diagnostic methods, and surgical treatment.

Local flap reconstruction of defects after excision of nonmelanoma skin cancer.

Reconstruction of facial defects poses the interesting challenge of finding the most satisfactory flap both aesthetically and functionally. It requires not just a knowledge of the flap, but an ability to think and plan in three dimensions. Not all individuals possess this; thus, what is obvious and simple to one surgeon, poses a great and worrisome problem for another. This can be made easier by considering certain rules. First, excise the lesion properly and then think about the reconstruction. The presence of the defect crystallizes the thought process. Next, consider the topographic and functional anatomy of the face, the differences in skin color, presence of hair, and the "idea" lines for position of scars. The flap options are rotation, transposition, and advancement. The latter, on occasions, may be as an island. These movements must be fitted into the aforementioned requirements. In this way the best choice usually is reached. Remember, there is always a way out using a skin graft or tissue expansion.

Maxillary hypoplasia.

Maxillary hypoplasia and retrusion is complex. It may involve the dentoalveolar area, or it may involve the whole midface. It may be difficult to recognize, since the patient may come only with the complaint of nasal deformity, and the occlusion may be normal. It may be difficult to treat, as in the severe Binder's syndrome, where in addition to the bony deformity, the facial mask is deficient and obviously in the wrong position. To treat the condition the surgeon must have an aesthetic sense. It is not like the situation when only the maxilla is involved; this tends to be mechanical and is related to dental malocclusion. In these patients, an aesthetic appreciation of the nose and its relationship to the maxilla, infraorbital rims, and frontal area is paramount. Unless this complete approach is used, the patient will be undertreated and end up unhappy. Patients can readily appreciate the position and the contours of the nose, but they do not understand the subtleties of the lack of a bony foundation when there is maxillary hypoplasia. Not only does this involve a high degree of aesthetic appreciation on the part of the surgeon, it also necessitates a considerable ability to convey to the patients that the problem is not the simple one that they had first imagined. When all of these subtleties are appreciated, it is possible to develop a degree of sophistication in the treatment of these patients that will yield excellent results.

Classification and treatment of orbitozygomatic and orbitoethmoid fractures. The place of bone grafting and plate fixation.

The classification of orbitozygomatic fractures is presented, and, using this, a decision can be made as to when to examine the fracture with CT scans and how to decide on employing a coronal approach for exposure. Three-point fixation is advocated using wires and miniplates. All portions of the fracture should be stabilized. In this way, the complications of enophthalmos, diplopia, dystopia, and flattening of the nose and cheek may be avoided. The method of treating late deformity resulting from orbitozygomatic and orbitoethmoid fractures is presented, stressing wide exposure, good fixation of osteotomies with miniplates, and cranial bone grafting to reduce orbital volume and correct enophthalmos.

Sphincter pharyngoplasty.

A modified version of sphincter pharyngoplasty, based on the work of Hynes and especially Orticochea, is described. The main benefit accruing from this technique is a scar-free sphincter mechanism in the correct position and therefore, it is hoped, with more physiologic function.

Craniofacial approach to tumors of the head and neck.

The type of surgery described in this article is safe and effective when performed by an experienced team of plastic surgeons and neurosurgeons. In a very extensive series of patients with tumors of the cranial base, there has been only one surgical death. It occurred the day after surgery and was thought to have resulted from an error in administering anesthesia. Reconstruction is limited in patients with malignant disease, especially when the tumor is recurrent after radiation therapy. It is better to delay and not hide any area of potential recurrence. Reconstruction can be performed at 12 to 18 months. In nonmalignant tumors, total reconstruction is performed. Extensive surgery can be carried out with a good chance of cure. Initial rehabilitation is with a prosthesis, but later reconstruction will give an acceptable result. Thus, both surgeon and patient may embark on this hazardous course with a much greater degree of security and equanimity.

Craniofacial tumors.

The management of craniofacial tumors is presented, beginning with a discussion of terminology and anatomy. The importance of imaging is stressed. The significance of the internal carotid artery and an investigation of cerebral artery supply also are given. The most significant advances in the treatment of these tumors have been the soft-tissue approaches, but methods of disassembling the bony face for the ultimate in exposure are also important. Free tissue transfer has been a great advance in reconstruction and prevention of infection and in giving some patients a second chance for further radiation. With the application of newer techniques of exposure and resection, together with vascularized reconstruction, the prognosis from these tumors has improved and the complications have been reduced.

Complex craniofacial reconstruction using an implant-supported prosthesis: case report with long-term follow-up.

In complex craniofacial reconstruction involving an implant-supported prosthesis, problems such as tumor recurrence may require additional surgical resection. The solution to such recurrence may be autogenous bone grafting or additional implant placement or both (after resection of the tumor) and revision of the prosthesis. Tumor recurrence was seen during an 11-year, 8-month follow-up of a 58-year-old woman who had had an extensive mid-face defect. The various treatments, including extraoral and intraoral prostheses, provided the patient with an acceptable quality of life without interruption in use of the prostheses.