Paul M. Petty

Reduction mammaplasty: an outcome study.

&NA; Outcome studies of the value of reduction mammaplasties have only recently appeared in the literature. Medical directors of insurance companies and managed care plans have been reluctant to pay for reduction mammaplasties, citing the uncertainty of the medical necessity of the procedure. They have defended their position by stating that the medical literature is devoid of studies documenting that reduction mammaplasty is medically beneficial to the patient. For this reason, reduction mammaplasty is often excluded from health care benefit plans. Because of the need for outcome studies for this procedure, the charts of 363 consecutive patients who had reduction mammaplasty at the Mayo Clinic from January of 1986 to December of 1993 were reviewed. Questionnaires were sent to all these patients asking them to evaluate their outcome, and 328 responded (90.4 percent response rate). Of the respondents, 94.2 percent believed that the procedure was completely or very successful, and only 1.5 percent believed that it was not very successful or completely unsuccessful. The symptoms most frequently reported by patients preoperatively were as follows: uncomfortable feeling about their body, 97.0 percent; inability to find clothes that fit, 95.7 percent; pain in brastrap groove, 92.4 percent; shoulder pain, 86.0 percent; inability to run, 79.3 percent; upper back pain, 79.0 percent; inability to participate in sports, 77.4 percent; neck pain, 70.7 percent; lower back pain, 64.0 percent; and intertrigo, 61.0 percent. The symptoms least frequently reported by patients preoperatively were as follows: pain or numbness in the hands, 22.6 percent; headaches, 30.2 percent; arm pain, 35.4 percent; and breast pain, 58.2 percent. These symptoms were either relieved or partially relieved in 88 percent or more of the patients. Of the 328 patients, 97.3 percent responded that they definitely or probably would have the procedure again, and only 1.2 percent definitely or probably would not have the operation again. Evaluation of medical treatment used to relieve symptoms showed a marked decrease in the need for such measures after reduction mammaplasty. Study of the charges for the procedure revealed that the setting of practice parameters for the procedure and the use of an ambulatory surgery center significantly decreased the charges for the procedure. This outcome study supports the hypothesis that reduction mammaplasty is an effective procedure and the treatment of choice for symptomatic mammary hyperplasia. (Plast. Reconstr. Surg. 100: 875, 1997.)

Massive abdominal-wall hernia reconstruction with expanded external/internal oblique and transversalis musculofascia

&NA; We describe a technique for expansion and primary closure of massive and large recalcitrant abdominal‐wall hernias in the middle and lower abdomen utilizing expanders placed in the lateral abdominal wall between the external oblique and the deeper complex of the internal oblique and transversalis fasciae. Since this technique describes expansion of the lateral abdominal wall, insertion incisions are made in the lateral abdominal wall away from the primary zone of injury surrounding the abdominal hernia and without interrupting the blood supply or innervation to the abdominal‐wall muscle, fascia, or skin. This technique, described in four patients with massive abdominal‐wall hernias, has been used successfully for primary closure with vascularized autogenous abdominalwall fascia, obviating the need for interposition of prosthetic material or extraabdominal flaps. (Plast. Reconstr. Surg. 100: 326, 1997.)

The uremic gangrene syndrome : Improved healing in spontaneously forming wounds following subtotal parathyroidectomy

&NA; Patients with end‐stage renal disease often demonstrate retarded healing of surgical wounds, but the basis for spontaneous wound formation in these patients is less well understood. We report our experience with four patients with a unique clinical entity previously described as the uremic gangrene syndrome (also known as calciphylaxis) that involves spontaneously forming and insidiously progressive wounds of the skin and soft tissue in uremic patients with hyperparathyroidism. The importance of recognizing this phenomenon relates to the potential benefit to wound‐healing efforts resulting from subtotal parathyroidectomy and adjustment of serum calcium and phosphate levels when severe hyperparathyroidism is present. Disrupted parathyroid homeostasis as a mechanism for soft‐tissue ischemia and subsequent infarction is supported by wound biopsies demonstrating microarterial calcification. As experts in factors resulting in refractory wounds, plastic surgeons need be aware of this peculiar vulnerability for spontaneously forming wounds in uremic patients. Clinical and laboratory findings, success with wound treatment in four patients, and currently popular pathophysiologic mechanisms are discussed.

Rigid stabilization of sagittal fractures of the maxilla and palate

Rigid stabilization of sagittal fractures of the palate is described that utilizes plate and screw fixation in the palatal vault. Accurate reduction of facial width is obtained, and stability is significantly enhanced. An existing laceration or a longitudinal incision in the palatal mucoperiosteum provides exposure for maxillary adaption plate application. The transpalatal reduction should be supplemented by fixation at the piriform aperture, the zygomaticomaxillary and nasomaxillary buttresses, and by the use of an arch bar. Since slower bone healing may be observed following palatoalveolar fractures, the occlusion must be observed for deviation throughout a full 16-week period even though early motion and soft diet are permitted. Removal of the plate and screws in the roof of the mouth is sometimes required and utilizes local anesthesia.

Silicon analysis of breast and capsular tissue from patients with saline or silicone gel breast implants : II. Correlation with connective-tissue disease

&NA; The silicone breast implant controversy rages on. Recent work has demonstrated that normal or baseline breast tissue silicon levels in women who had had no prior exposure to any type of breast implant may be as high as 446 &mgr;g/gm of tissue. These data ranged from 4 to 446 &mgr;g/gm of tissue, with a median of 27.0 &mgr;g/gm of tissue. In addition, numerous other epidemiologic and rheumatologic studies have demonstrated no association between silicone breast implants and any connective‐tissue diseases. Despite these reports, the use of silicone implants remains restricted. The present study measured breast and capsular tissue silicon levels from 23 breasts in 14 patients with saline implants, and from 42 breasts in 29 patients with silicone implants. No patient in the saline implant group presented with signs or symptoms of connective‐tissue disease. Patients with silicone implants, however, were divided into three groups based on the presence or absence of signs or symptoms of connective‐tissue disease: group I, no symptoms or signs; group II, + symptoms, no signs; and group III, + symptoms, + signs. Six patients in group III were diagnosed with a specific connective‐tissue disease, including systemic lupus erythematosus, rheumatoid arthritis, or scleroderma. The most common indications for implant removal or exchange were capsular contracture and implant rupture, although 41 percent of patients with silicone implants expressed media‐related concern over the implant issue. The most common symptoms described by patients in groups II and III were joint pain and stiffness, arm pain and numbness, and fatigue. In all groups, capsular tissue silicon levels were significantly greater than breast tissue levels. This finding may indicate that the capsule serves as a barrier to the distribution of silicone from the implant into adjacent breast tissue. Although breast tissue silicon levels in patients with silicone implants were not significantly greater than those in patients with saline implants (p = 0.48), capsular tissue levels in patients with silicone implants were, indeed, significantly greater than those in patients with saline implants (p < 0.001). However, no statistically significant differences in tissue silicon levels were observed with relation to the presence or absence of connective‐tissue disease signs or symptoms in patients with silicone implants (groups I to III). Therefore, these data strengthen the conclusion that there is no association between tissue silicon levels and connective‐tissue disease. (Plast. Reconstr. Surg. 101: 1836, 1998.)

Silicon analysis of breast and periprosthetic capsular tissue from patients with saline or silicone gel breast implants.

&NA; The ubiquitousness of silicon is well known. Recent work has demonstrated measurable baseline levels of silicon in nonaugmented cadavers, subsequent to numerous reports of significant elevations of such levels within patients with silicone breast implants and even more reports alleging a causal relation between silicone gel prostheses and connective‐tissue diseases. Despite the lack of scientifically substantiated data that such a relation exists, the calamitous silicone breast implant controversy has ensued. Saline‐filled breast implants are constructed with a silicone elastomer envelope that remains in direct contact with periprosthetic capsular tissue following implantation. Although there is no evidence to link saline implants with any disorders, it is important to know if saline breast implants contribute any silicon to human body baseline silicon levels. The present study measured tissue silicon levels in 28 breasts of 16 patients with saline‐filled implants to determine if the silicone envelope of these prostheses can contribute to the elevation of such levels. These data were compared with data from 116 breasts of 65 patients with silicone gel‐filled prostheses as well as breast tissue from 17 patients (controls) who had never been exposed to either type of implant. Samples of breast tissue and periprosthetic capsular tissue were obtained from patients with both intact and ruptured implants. Silicon levels of breast tissue specimens from patients with saline‐filled implants were within the range of the controls if the implants were intact. Silicon levels in periprosthetic capsular tissue from patients with intact saline‐filled implants were significantly higher than controls (p < 0.02); however, they were still 100‐fold less than capsular tissue levels from patients with intact gel‐filled implants. Silicon levels measured in both types of tissue were significantly elevated in patients with silicone gelfilled implants compared with controls (p < 0.01). In the case of ruptured gel implants, breast tissue demonstrated higher silicon levels than did similar specimens from patients with intact implants (p < 0.054); periprosthetic capsular tissue levels also were elevated, although the differences were not statistically significant (p = 0.54). These findings are independent of the implant brand or length of exposure to the particular prosthesis. The finding of elevated levels of silicon in both breast and periprosthetic capsular tissue in patients with silicone gel‐filled implants in no way implies or substantiates any claim of a causal relationship between silicone and any reported illnesses. (Plast. Reconstr. Surg. 98: 798, 1996.)

Patient fire safety in the operating room

Two cases of patient fires are presented. Components necessary for this complication to occur are outlined, in addition to recommendations for prevention.