V. E. Meyer

Baseline staging in cutaneous malignant melanoma.

Background  Baseline staging in patients with primary cutaneous malignant melanoma (MM) is routine, but the diagnostic accuracy and the impact on clinical outcome are still unclear.

Configuration and localization of the nipple-areola complex in men

&NA; The causes of bilateral absence of the nipple‐areola complex in men are seldom congenital, but attributable rather to destruction as a result of trauma, or after mastectomy in female‐to‐male transsexuals and in male breast cancer, or after the correction of extreme bilateral gynecomastia. Such a bilateral loss becomes a major reconstructive challenge with respect to the configuration and localization of a new nipple‐areola complex. Because there is very little information available in the literature, we carried out a cross‐sectional study on the configuration and localization of the nipple‐areola complex in men. A total of 100 healthy men aged 20 to 36 years were examined under standardized conditions. The first part of the study dealt with the configuration of the nipple‐areola complex (dimensions, round or oval shape). The second part concentrated on the localization of the complex on the thoracic wall with respect to anatomic landmarks and in correlation to various parameters such as weight and height of the body, circumference of the thorax, length of sternum, and position in the intercostal space. Of the 100 subjects examined, 91 had oval and seven had a round nipple‐areola complex. An asymmetry between the right and the left side was found in two cases. The mean ratio of the horizontal/vertical diameter of an oval nipple‐areola complex was 27:20 mm and the mean diameter for a round nipple‐areola complex was 23 mm. The center of the nipple‐areola complex was in the fourth intercostal space in 75 percent and in the fifth intercostal space in 23 percent of the subjects. To localize the nippleareola complex on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of a horizontal line (distance from the midsternal line to the nipple = A) and a vertical line (distance from the sternal notch to the intersection of line A, = B). The closest correlation for the horizontal distance A was given by the circumference of the thorax: A = 2.4 cm + [0.09 × circumference of thorax (cm)], (r = 0.68). The best correlation to calculate the vertical distance B was found using the distance A and the length of the sternum: B = 1.2 cm + [0.28 × length of sternum (cm)] + [0.1 × circumference of thorax (cm)], (R = 0.50). In cases of bilateral absence, we recommend creating an oval nipple‐areola complex in men. The appropriate localization can be calculated by means of two simple equations derived from the circumference of the thorax and the length of the sternum. (Plast. Reconstr. Surg. 108: 1947, 2001.)

Oral premedication for operations on the face under local anesthesia : a placebo-controlled double-blind trial

Modern strategies for preventing or controlling pain and anxiety demand a premedication for operations using local anesthesia and for those using sedation or general anesthesia. For optimal patient care, the premedication should be given orally and, with respect to the outpatient basis of the operations, should have a short recovery period. Midazolam, one of the most favored premedications for general anesthesia, has been recommended as a premedication for operations using local anesthesia as well. However, midazolam has only sedative‐anxiolytic effects and does not reduce pain sensation, which should be mandatory for operations using local anesthesia. A further requirement is the maintenance of stable hemodynamics for the prevention of postoperative hematomas, especially in the face. For these reasons, another premedication meeting all requirements (anxiolysis, analgesia, and stable hemodynamics) was researched. A randomized, doubleblind prospective study was performed from March of 1997 to June of 1998. Five groups totalling 150 patients were included in the study; each group contained 30 patients who had operations performed solely on the face. In the first four groups, the effect of midazolam (0.15 mg/kg‐1), morphine (0.3 mg/kg‐1), and clonidine (1.5 &mgr;g/kg‐1) administered orally was compared with a placebo. The fifth group was the control group and received no premedication. To evaluate the effects of the premedications, a corresponding questionnaire was completed independently by the patient and surgeon. With regard to the anxiolytic or analgesic properties of the premedication, 61 percent of the patients preferred pain reduction to anxiety control, and 24 percent of patients preferred reduction of anxiety. The remainder insisted on a reduction of both properties (8 percent) or had no preference (7 percent). Reduction of anxiety was largest in the midazolam and the clonidine groups, but the difference was not significant. The least pain during the application of local anesthesia was experienced by the morphine group (37 percent) and the clonidine group (33 percent), in contrast to the midazolam group (60 percent) (p = 0.04). Morphine and clonidine met the requirements of pain reduction equally well. Nevertheless, considering the rate and intensity of adverse effects with respect to hemodynamic compromises, nausea, and emesis, clonidine is even better suited as an oral premedication for operations on the face using local anesthesia. (Plast. Reconstr. Surg. 108: 637, 2001.)

Malignant Tumors Associated with Nevus Sebaceous: Therapeutic Consequences

Abstract. Nevus sebaceous has been considered a relatively infrequent and unimportant congenital hamartoma for plastic surgeons unless the lesions are so big that they require a demanding defect closure. As the dignity of such tumors is primarily benign and the malformed sebaceous glands are localized abnormally high in the dermis, the temptation is appealing not to excise these tumors any more but to eradicate them by laser beam therapy. Yet a nevus sebaceous not only affects sebaceous glands but includes various other malformations of the affected skin and its appendages. In addition, different malignant tumors may occur in nevus sebaceous, even in children and young adults. We encountered 4 such malignant tumors of 18 nevi sebaceous operated on from 1989 to 1997. All nevi had been unsuspicious macroscopically. In three patients, one of them only 15 years old, an associated basal cell carcinoma was found. In the fourth patient there was a mixture of three additional tumors, a cystadenoma, a keratoacanthoma, and a basal cell carcinoma, besides the sebaceous malformations. These findings have two consequences: first, to continue surgical treatment of nevus sebaceous instead of dermabrasion or dermablation and to have the specimen examined histologically and, second, to excise such tumors as early in childhood as possible.

The extensor digitorum brevis island flap: possible applications based on anatomy.

&NA; In the past few years, the proximally based extensor digitorum brevis island flap has been recognized as a useful method in the reconstruction of the lower extremity. The major goal of this study, which was performed in 16 cadavers, was to show the possible application of the extensor digitorum brevis island flap based on its anatomy. The vascularization and morphology of the muscle were also studied. We are able to show that, with sufficient mobilization of the vascular pedicle, the extensor digitorum brevis easily can reach both the lateral and the medial malleoli. In most cases, the island flap even reaches the Achilles tendon, the posterior aspect of the heel, and the lower to middle part of the anterior crural region. The vascular supply of the extensor digitorum brevis muscle shows a great consistency, with the lateral tarsal artery being the dominant supply of the muscle. The mean surface of 27 cm2 allows coverage of small to medium‐sized defects. (Plast. Reconstr. Surg. 101: 107, 1998.)