Charles Hsu

Tumours of the hand

Hand tumours of soft-tissue and bony origin are frequently encountered, and clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. In this Review, we present a diagnostic approach to hand tumours and describe selected cancers and their treatments. Soft-tissue tumours include ganglion cysts, giant-cell cancers and fibromas of the tendon sheath, epidermal inclusion cysts, lipomas, vascular lesions, peripheral-nerve tumours, skin cancers, and soft-tissue sarcomas. Bony tumours encompass enchondromas, aneurysmal bone cysts, osteoid osteomas, giant-cell lesions of bone, bone sarcomas, and metastases. We look at rates of recurrence and 5-year survival, and recommendations for adjunct chemotherapy and radiotherapy for malignant lesions.

The hemitransdomal suture for narrowing the nasal tip.

The classic transdomal (dome-defining) suture successfully reduces tip width but on occasion also causes a pinched tip (concave alar rim) and an inversion of the lateral crus. We present a modification of that suture technique which only reduces the cephalic end of the dome. By suturing only the posterior (deep) part of the cephalic end of the dome, the lateral crus is everted and a pinched tip is minimized. It is referred to as the hemitransdomal suture because it only reduces the cephalic half of the dome. Twelve cases were studied indicating dramatic correction of dome width without unwanted side effects.

Nasal base reduction: a treatment algorithm including alar release with medialization.

Background: The broad nasal base is occasionally not correctable by excisional procedures alone because nostril distortion or stenosis may result (if resection enters the vestibule). Moreover, recurrence is a common problem when alar mobilization and suture approximation techniques are used. The authors developed an algorithm for nasal base reduction to prevent these complications. Methods: A new classification of the broad nasal base was utilized that included patients with general nasal base enlargement and patients with a vertically oriented alar axis (traditionally difficult to correct without distortion). Both groups received an alar release including the following: (1) the soft tissues and pyriform ligament of the anterior maxilla; (2) the periosteum posterior to the pyriform rim (in the bony nasal vault); and (3) when necessary, soft tissues along the horizontal pyriform rim. Interalar sutures maintained the alae in their new medialized position. Twelve patients who only underwent alar release were evaluated. Results: Nasal base reduction was achieved in all cases without distortion. Three patients required release of the horizontal tissues of the pyriform rim (including a condensation of the pyriform ligament). After a follow-up period of 11 months to 3¾ years, there were two cases of partial recurrence and one partial airway obstruction. Conclusions: Not all causes of a broad nasal base are amenable to resection procedures, especially the generally broad nasal base such as that due to thick skin or a vertically oriented alar axis. However, a tension-free alar release with medialization by suture fixation is effective. The incidence of recurrence can be expected to be reduced.

Nasal base reduction by alar release: a laboratory evaluation.

Background: When reducing the broad nasal base, there is a limit to the amount of soft tissue that can be resected, beyond which the anatomy distorts and the nostrils become stenotic (if resection enters the nostril). Alar mobilization by freeing soft-tissue attachments helps. This study purported to examine the nature of those attachments and the extent of medialization. Methods: The supporting tissues of the ala were sequentially divided in 16 fresh hemifacial cadavers. Key structures included the following: (1) the soft tissues and pyriform ligament of the anterior maxilla, (2) the periosteum posterior to the pyriform rim (in the bony nasal vault), and (3) the soft tissues along the horizontal pyriform rim. After release of each tethering region, the ala-pyriform distance was measured. Results: After releasing the anterior maxillary periosteum and pyriform ligament along the vertical pyriform rim, the ala-pyriform distance was reduced by a mean of 1.9 mm. After releasing the periosteum posterior to the pyriform rim (in the nasal vault), it was reduced by a mean of 1.7 mm. Releasing the soft tissues (which were thick medially) of the horizontal pyriform rim reduced the mean distance 1.0 mm for a total of 4.6 mm. Medialization resulting from anterior and posterior releases was significantly greater than that from the horizontal pyriform rim (p < 0.0006 and p < 0.015, respectively), but they were not significantly different from one another. Conclusions: This cadaver study confirmed the role of the stabilizing effect of the pyriform ligament and the periosteum lateral and posterior to the pyriform rim. The total release was substantial, suggesting a clinical means of achieving tension-free alar medialization.

Prediction of Face-Lift Outcomes Using the Preoperative Supine Test

BackgroundPatients considering a facelift (facial rhytidectomy) need some means of predicting their surgical outcomes. This will help them decide whether to proceed with the operation.MethodsA total of 50 consecutive patients were asked to examine themselves with a hand-held mirror while lying supine on an examining table to give them a reasonable approximation of their postoperative result.ResultsThe tissues of the face redrape in a very aesthetic manner when lying completely supine. The appearance that the patient sees of himself or herself during the “supine test” correlated very well with the actual postop result after rhytidectomy consisting of subcutaneous undermining, SMAS plication, and platysmaplasty.ConclusionThis supine test may be useful in helping patients preoperatively predict their facelift outcomes and may serve as a good adjunct to imaging.

Transfection and cloning of genes for membrane antigens using the FACS

In order to facilitate cloning of genes for cell surface molecules, we cotransfected LTK− mouse fibroblasts with thymidine kinase (TK) genes and total human or mouse DNA. TK+ cells, selected by growth in HAT medium, were stained with fluorochrome conjugated monoclonal antibodies or other fluorescent ligands which bind to one or another membrane differentiation antigen or receptor. We isolated fluorescent transfectants expressing these molecules using a fluorescence activated cell sorter (FACS). For some antigens, spontaneous gene amplification occurred. By repeated cycles of FACS sorting and regrowth we obtained high expressing clones. We then isolatedcDNA and genomic clones using selectedcDNA probes to screen phage withcDNA inserts. DNA from virtually any tissue source transfected equally well for the various molecules except for DNA from a trophoblast derived choriocarcinoma cell line which did not transfect for Leu-2.