Richard B. Stark

EFFECT OF SURGICAL ABLATION OF REGIONAL LYMPH NODES ON SURVIVAL OF SKIN HOMOGRAFTS

Two previous publications1 s 2 have outlined a critical experiment to assay the relationship of elements of the circulating blood to the survival of homografts of skin in the rabbit. I t was found, if 1 cc. of homologous whole blood were injected 5 days prior to the implantation of a homograft of skin from the same donor, that such pretreatment enhanced the survival of the homograft, and this was true of second-set homografts as well. The active enhancing agent in homologous whole blood was demonstrated to reside within the erythrocyte after the red cells had been hemolyzed. When the erythrocytes had been tagged with radioactive chromium, it was found that their site of deposition was the lymph node in proximity to the site of injection, which was also near the homotransplant. Such deposition suggested that here might be the site of action of the enhancing agent. As a result of these findings, the auricular lymph node was excised surgically, and a homograft of skin transplanted distally upon the ear. Transplants made soon after regional lymphadenectomy behave in a manner similar to that of enhanced grafts, and this was true of second-set as well as of first-set grafts. Enhancement following lymphadenectomy was in the magnitude of a factor of 2 for the first-set grafts. In addition, when only one auricular lymph node was removed and bilateral homografts applied to the ears, no enhancement of either graft was observed. When bilateral auricular nodes were removed, however, both homografts survived longer (FIGURE 1). The regional lymph nodes that had been immunized were weighed to see whether there was an increase in mass following homotransplantation. Control weights of normal anatomical auricular lymph nodes averaged approximately 35 mg. There was a steady increase in the weight of the auricular lymph node, following homotransplantation, from the first day onward. Average weights upon successive days progressed from 60 mg. on the first day to 100, 115, 145, 190, 206, 252, and 307 mg. on the eleventh day. An increase in weight followed autotransplantation; however, the weights were less. A slight increase in weight also was observed for several days after a sham operation upon the anesthetized rabbit. The case of an interesting human patient verified our laboratory findings concerning lymphadcnectomy. In this case the life of a homograft traniplanted upon the ipsilateral arm of a woman who had undergone radical mastectomy with removal of the axillary lymph nodes was prolonged by a factor of 2?5 beyond that of the control homograft transplanted to the opposite arm, where the axillary lymphatics were intact. The patient (M.R.) was operated on a t St. Luke’s Hospital on May 21, 1950, for lymphedema of the right arm that followed radical mastectomy for

Natural appearance restored to the unduly prominent ear

Summary It is noted that protruding ears may cause psychiatric symptoms. An example of this is cited. The anatomy of the ear is briefly reviewed. The embryological development of the ear is discussed, including a more recent concept. An historical review of the surgical procedures in correcting protruding ears is presented. The method used by the writers to produce an ear with a natural appearance is detailed.

Cross-leg flaps in patients over 50 years of age

Summary Nine cross-leg flaps in patients over 50 years of age are reviewed. Our experience confirms that of others, that the complications of permanent joint changes and thromboembolic phenomena were found to be virtually non-existent. As a result, age per se should not be used as a criterion for patient selection for this procedure.

A procedure for mammary reduction and mastopexy: Summary of 100 personally performed operations

The advantages of this modified Ragnell procedure are that a conical breast is formed, the submammary scar is short and inconspicuous, and the operation is safe.ConclusionsThe advantages of this modified Ragnell procedure are that a conical breast is formed, the submammary scar is short and inconspicuous, and the operation is safe.

The lymph node and homoplasty

T HE DEFENSE against homografts is presumed to be immunologic, vested in the reticuloendothelial system. It is logical, therefore, that the role of the lymph node in the rejection of peripheral tissue homografts should be undergoing investigation in several laboratories. We have been attempting to elucidate the rejection phenomenon, hoping to alter the host’s response to foreign tissue or to its code in the case of repeated confrontations by the same tissue. Scothorne and McGregor [l] first pointed out the increase in size and weight of the regional lymph node after transplantation of a skin homograft. Stark, Dwyer, and De Forest [Z] also found that the mass of lymph nodes increased markedly after homotransplantation, but changed little after autotransplantation or a sham operation. The lymph node desoxyribonucleic acid (DNA) : ribonucleic acid (RNA) ratio following homografting shows a rise in RNA, implying that antibodies were being formed within the nodes [3]. Mannick and coworkers [4] immunized lymph nodes in vitro by exposing them to RNA extracted from lymph nodes that had been immunized in viva. Mitchison [5] was able to transfer adoptive homograft immunity between animals by the homotransplantation of an immunized lymph node. We were able to enhance the life of homografts by subcutaneous injections of red blood cell hemolysate [6]. This was presumably due to an as yet unidentifiable enhancing factor, since blockading the node with the same material produced not enhancement but immunity. Radioactive chromium studies showed that the red cell substance acted at the lymph node locus. Surgical extirpation of the regional lymph nodes enhanced first and second set homografts. This was true in a human case in which bilateral male skin homografts were transplanted upon the upper arms of a woman who had undergone lymph node ablation as a part of radical mastectomy. Her surgical lymphedema was being treated by a Macey procedure to which the homograft challenge was added [Z]. Knox and co-workers [7J mitigated the violent and sudden end point of renal homograft by removal of the regional lymph nodes, even though they were dealing with vascular anastomosis which delivered antigen directly to the central reticuloendothelial system. In our control studies on rabbits, first set skin homografts upon the ears were rejected (50 per cent necrotic) on the fifty post-transplantation day, whereas second set grafts were rejected on the second day. In the following experiments, we have attempted to determine first, whether viability of the lymph node is essential for the typical homograft rejection; second, whether exclusion of cells from a viable node wouId minimize rejection and produce enhancement; third, whether homologous whole blood (containing enhancing substance) placed in a chamber with the regional node would exert an enhancing effect; and, fourth, whether second set homografts are destroyed by cell-bound or humoral antibodies.

Who and what influenced me to choose plastic surgery

The year was 1938. I was a second year medical student at Stanford University Medical School exposed to super surgeons Emile Holman and Frederick Leet Reichert, my professors, both of whom had been trained by William Steward Halsted. I was an artist; was it because of my own orientation towards subjects manual that surgery grabbed me? I know not, but grabbed I was. At the end of that year I transferred to Coruell University Medical College in New York City where another former Halsted resident, George Heuer, taught a strong surgical course. Exposure to other courses at Cornell only strengthened my resolve to choose surgery as a career. But to be a good surgeon I felt that I needed to know as much medicine as possible. I applied and was accepted for an extra course in internal medicine beyond the obligatory one at Cornell, in the Peter Bent Brigham Hospital, Boston, between my third and fourth years. Early in my senior year at Cornell it was time to apply for internship. But for my initial course rotation I had drawn obstetrics and gynecology, which, at Cornell, was run with almost military discipline. We students were on call for all deliveries, which meant that we lived in the house staff quarters and could forget about applying to hospitals that required an interview. Quite simply, there was no time off. As a result, I applied only at the Peter Bent Brigham where I had a track record from summer medicine. The Brigham selected six surgical interns a year, traditionally five of them from Harvard. After forcefully importuning the Chief of Obstetrics, I was granted only one day off to take the written and oral exams and to be inter-

Experience with the modified Ragnell mammaplasty.

(1980). Experience with the Modified Ragnell Mammaplasty. Scandinavian Journal of Plastic and Reconstructive Surgery: Vol. 14, No. 2, pp. 129-131.

Oral cancer: reconstruction and rehabilitation.

The five-year survival rate of patients treated for oral cancer has improved steadily over the past several decades; today, it approximates 35-40 percent. However, following successful cancer therapy, some of these patients will choose social isolation because of preoc cupying melancholy over physical dis figurement which in time erodes the in tegrity of the personality. These may be patients who have been left with an obvi ous facial deformity, a speech impedi ment, inability to swallow, drooling or whose postoperative course has been complicated by sinuses, fistulae or cavi ties which, because they are difficult to clean, are malodorous.

The management of facial trauma in infants and children

I N RECENT months we have encountered a large number of infants and children with improperly managed facial wounds. Despite the numerous excellent reports on the management of trauma, facial injuries in infants and children continue often to be treated inadequately, and this circumstance prompts this communication. The physician rendering the initial care has the optimum chance to bring about a satisfactory final result. The initial care of facial injuries and lacerations requires much more time and effort than is generally felt necessary, if a satisfactory final result is to be obtained. Scar tissue developing, both deep and superficial, in the soft tissues and skin makes secondary plastic revision difficult, and the eventual result often is far from gratifying. The conspicuous and disfiguring facial scars which result from inadequate initial surgery may represent a real catastrophe, often with long-lasting mental fixation for the patient. During the early stages of ambulation the child is subject to frequent falls and tumbles. Common sites of trauma are the supraorbital and submental areas and the lips.