John T. Hueston

A Compound Pectoral Flap

The principle of including an underlying skeletal muscle in the design of a large skin flap, to assure a safer blood supply during transfer, has been applied to the chest wall. Pectoralis major is included in a chest flap used for the repair of a large defect of all layers of the anterior chest wall, including the medial ends of the clavicles and upper two ribs and the manubrium sterni.

Blindness after blepharoplasty: mechanism and early reversal.

Based on our close personal observation of several patients after blepharoplasty who developed retrobulbar hemorrhage progressing to blindness, the mechanism appears to operate through ischemia of the anterior optic nerve head. Relief of this blindness has followed prompt surgical intervention, with supportive medical therapy. The importance of close nursing observation for some hours after the operation is stressed, as it may be the only means of detecting this complication while the sight can still be saved.

A second case of relief of blindness following blepharoplasty. Case report.

A second case of blindness following blepharoplasty is reported. The symptoms became relieved and the vision became restored after prompt decompression of the orbit by opening the wound and evacuating clots. The importance of vigilant nursing care and observation after these operations is emphasized.

Some Observations on Knuckle Pads.

Although knuckle pads are histologically similar to the palmar nodules in Dupuytren’s Disease, they do not produce contraction. By considering the anatomical situation of the knuckle pad overlying the joint line and comparing it with a unique case of a dorsal nodule occurring between the joint lines, an explanation is profferred for this lack of contraction by knuckle pads. That contraction in the extensor mechanism was produced by the nodule between the joint lines is used to support further the “extrinsic” hypothesis of the pathogenesis of Dupuytren’s Disease.

Surgical Correction of Breast Asymmetry1

Breast asymmetry sufficient to be of social or psychological significance requires surgical correction to bring the two breasts into acceptable balance. The principal causes of breast asymmetry are illustrated along with those procedures used to correct this asymmetry. The value of the silastic Cronin prosthesis in augmentation of deficient breast contour is demonstrated.

External skeletal fixation as a method of immobilization for large skin grafts of the neck.

A case is presented to illustrate a method of external skeletal fixation by which extension of the neck is maintained in a large skin grafting procedure for burn scar contracture.

Endolymphatic isotope and BCG in the management of malignant melanoma

Endolymphatic isotope therapy had such promising early clinical results that the M.R.C. (Medical Research Council) U.K. set up a clinical trial in 1966. This was to compare the effect of endolymphatic isotope therapy with the results of standard methods in the treatment of lower limb malignant melanoma. The interim report had three groups for analysis: Standard Methods (S); Endolymphatic Satisfactory (ES); and Endolymphatic Unsatisfactory (EU). This third group was a subdivision, as a significant number of patients did not have the correct endolymphatic treatment. The five-year survival figures expressed as actuarial percentages were ES=78.8%; S=82.3%; and EU=57.3%. Lymph node recurrence showed a significant difference: ES=2.3%; EU=12%; and S=19%. The conclusions were that endolymphatic isotope therapy was justified in specialized centres where good results could be obtained. Further animal experiments using the VX2 tumour in rabbits indicated that BCG given intracutaneously or intravenously had no therapeutic effect, whereas when applied by intralymphatic injection BCG was successful in treating lymph node metastases. Nineteen patients with poor-prognosis malignant melanoma have received endolymphatic BCG. The clinical results are recorded in this paper and are sufficiently encouraging to warrant its continued use.

Preliminary results of a randomized trial of adjuvant immunotherapy in patients with malignant melanoma who have lymph node metastases

This study evaluates the effect of adjuvant immunotherapy with BCG alone, or combined with melanoma cell vaccine, on the recurrence and survival rates of patients with metastatic melanoma in the regional lymph nodes who were treated by lymphadenectomy. Patients were prospectively randomized and stratified on the basis of age, sex, site of primary tumour, and clinical estimate of the regional nodes. During the past four years, 134 patients were entered into this trial, and to date, the incidence of recurrence among the two arms mentioned and the control arm is not significantly different; however, patients receiving BCG alone had longer survival than those in either the tumour cell vaccine or control groups. The improved survival in the BCG-only group was found to be due to the fact that patients survived longer with their recurrent disease than the patients in the other two groups. At the present time, these differences do not appear to be significant enough to justify routine adjuvant immunotherapy in patients with melanoma metastatic to regional nodes. Longer follow-up will be necessary to evaluate the role of adjuvant immunotherapy of Stage II melanoma.

Malignant melanoma. Some aspects of pathology and prognosis

This is a report on the periods of survival, and the factors that influence survival, in a series of 509 patients treated for malignant melanoma in the Peter MacCallum clinic, Melbourne. Not the least of these factors is education of the public and the medical profession in its early recognition, which has greatly improved the prognosis. In this context, it is also firmly believed that whenever possible, one clinician only should be responsible for the total surgical management of any suffering from this disease.

Secondary malignant melanoma in lymph nodes: incidence, time of occurrence and mortality

During a follow-up period of six to 12 years, 15.4% of patients in the Queensland Melanoma Project (Q.M.P.) developed histologically proven secondary deposits in lymph nodes. The incidence rate in males (21%) was twice that in females (11%), but the mortality rate was similar (M., 67%; F., 61%). Thirty-two patients (2%) had positive nodes with no known primary lesion. Metastases developed in males with lesions on the foot (50%), on the thigh (29%), and on the back (22%); and in females with lesions on the lower leg (9%) and thigh (20%). About one-half of the nodes were removed at the time of treatment of the primary growth or within two months. Three-quarters were removed in the first year. However, it was found that tumour could remain dormant for more than eight years. Dormant tumours behaved in a similar aggressive fashion on regrowth as non-dormant secondaries. Nodal metastases were present in 5% of patients at the time of their first presentation with primary melanoma. Elective node dissections were done in 6% of males and 11% of females.