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Recent advancements and innovations in the burgeoning field of vascularized composite allotransplantation has enabled face and hand transplant to become a reality in the Western world. Plastic surgeons from the United States, France, and Spain have since performed vascularized composite allotransplantation as a novel therapeutic option in patients suffering from severe facial disfigurement and limb loss. Results have demonstrated remarkable functional and esthetic outcomes with improvements in the immense psychological, social, and emotional burdens that can arise in these patients. Despite the success of existing national solid organ transplant programs, face and hand transplant has yet to be established in this region. The specific aims of this study were to assess the attitudes and amount of risk Singaporeans are willing to accept towards receiving or donating face and hand transplants; and hence ultimately evaluate the feasibility of establishing such a program in Singapore.

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BACKGROUND AND OBJECTIVE: [corrected] Evaluation of the long-term effects of the laser resurfacing on development of the skin cancer after chronic ultraviolet B light exposure calls for the development of the appropriate animal model. STUDY DESIGN/MATERIALS AND METHODS: The 27 C3H nu/nu nude mice were used in the experiment. Five experimental groups were designed to evaluate the effects of laser energy delivered. RESULTS: Tru-Pulse(trade mark) Laser System produced char-free crust immediately after application. There was no histologic difference in laser effects on the skin between groups. Complete re-epithelialization occurred within 7 days. CONCLUSIONS: An entire lifetime in this mammal model can be studied in under 2.5 years. The back skin of the mice can be resurfaced by using one pass 500 mJ/cm(2) and complete healing will occur within a 7-day period. We believe that establishment of this experimental model has set the stage for the further study of the effect of laser energy on sun-damaged skin. Carbon dioxide laser resurfacing has become an increasingly popular method of facial rejuvenation, allowing the plastic surgeon to repair sun-damaged skin and wrinkles. Results obtained by laser resurfacing seem to be long lasting. Carbon dioxide laser resurfacing brings about histologic changes in the skin. This finding raises a new question: Does carbon dioxide laser skin resurfacing modulate the effects of ultraviolet (UV) light exposure on the skin? The purpose of this study was to establish a new experimental model for studying the long-term effects of laser skin resurfacing.

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It is generally accepted that chronic adhesive lumbar arachnoiditis is a cause of symptoms, notably back pain and/or pain (of almost any type, not necessarily 'anatomical') in the lower limbs, although there is no clearly defined clinical pattern which is clearly associated with this syndrome. There is no doubt that arachnoiditis occurs as a pathological and radiological entity due to a number of causes. In the view of the present authors, the nexus between the pathology and radiology on the one hand, and the patients' symptoms on the other hand, has not been demonstrated with any degree of scientific rigor.

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CONTEXT: Prophylactic mastectomy is a preventive option for women who wish to reduce their risk of breast cancer. There has been concern about possible negative psychological sequelae following this procedure. However, few data are available regarding long-term satisfaction and psychological and social function following this procedure. OBJECTIVE: To evaluate patients' long-term satisfaction and psychological and social function following prophylactic mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Descriptive study of all women known to be alive (n = 609) who had a family history of breast cancer and elected to undergo bilateral prophylactic mastectomy at a large, tertiary US health care clinic between 1960 and 1993, 94% (n = 572) of whom completed a study questionnaire. MAIN OUTCOME MEASURES: Satisfaction with procedure and effects on psychological and social function, based on responses to the study-specific questionnaire. RESULTS: Mean time from prophylactic mastectomy to last follow-up was 14.5 years. Most women (70%) were satisfied with the procedure; 11% were neutral; and 19% were dissatisfied. Among the psychological and social variables, the most striking finding was that 74% reported a diminished level of emotional concern about developing breast cancer. The majority of women reported no change/favorable effects in levels of emotional stability (68%/23%), level of stress (58%/28%), self-esteem (69%/13%), sexual relationships (73%/4%), and feelings of femininity (67%/8%). Forty-eight percent reported no change in their level of satisfaction with body appearance; 16% reported favorable effects. However, 9%, 14%, 18%, 23%, 25%, and 36% reported negative effects in these 6 variables, respectively. CONCLUSIONS: This study suggests that positive outcomes following prophylactic mastectomy include decreased emotional concern about developing breast cancer and generally favorable psychological and social outcomes. These must be weighed against the irreversibility of the decision, potential problems with implants and reconstructive surgery, and occurrence of adverse psychological and social outcomes in some women. JAMA. 2000;284:319-324

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BACKGROUND: Perineal wounds, created at the time of extended resection for locally advanced malignancy and following chemoradiation, are at risk of serious complications. METHODS: To determine whether immediate myocutaneous flap closure prevents complications, 57 patients treated with multimodality therapy and proctectomy (35 perineal wounds) or sacrectomy (22 posterior wounds) were studied. Patients were categorized according to whether they underwent primary skin and pelvic closure (group 1; ,n = 20); primary skin and omental pelvic closure (group 2; n = 24); or immediate myocutaneous flap closure (group 3; n = 13). RESULTS: Groups were similar with respect to age and sex; however, group 1 had more primary tumours and required less radical surgery and chemoirradiation than groups 2 and 3. Groups 1 and 2 experienced more complications overall (eight of 20, nine of 24 and three of 13 patients in groups 1, 2 and 3 respectively), more acute wound complications (seven of 20, nine of 24 and two of 13), delayed wound healing (three of 20, six of 24 and one of 13) and more reoperations for perineal wound problems (five of 20, seven of 24 and zero of 13). Patients in group 2 had a significantly longer hospital stay than those in group 1. Flap closure (group 3) did not increase the length of stay. The routine use of primary flap closure reduced overall wound complications (eight of 31 versus ten of 26 patients) and length of hospitalization (13 versus 17 days). CONCLUSION: Complete wound healing was achieved in all patients; however, immediate myocutaneous flap closure reduced the need for readmission and reoperation.

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BACKGROUND: Options for women at high risk for breast cancer include surveillance, chemoprevention, and prophylactic mastectomy. The data on the outcomes for surveillance and prophylactic mastectomy are incomplete. METHODS: We conducted a retrospective study of all women with a family history of breast cancer who underwent bilateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. The women were divided into two groups - high risk and moderate risk - on the basis of family history. A control study of the sisters of the high-risk probands and the Gail model were used to predict the number of breast cancers expected in these two groups in the absence of prophylactic mastectomy. RESULTS: We identified 639 women with a family history of breast cancer who had undergone bilateral prophylactic mastectomy: 214 at high risk and 425 at moderate risk. The median length of follow-up was 14 years. The median age at prophylactic mastectomy was 42 years. According to the Gall model, 37.4 breast cancers were expected in the moderate-risk group; 4 breast cancers occurred (reduction in risk, 89.5 percent; P<0.001). We compared the numbers of breast cancers among the 214 high-risk probands with the numbers among their 403 sisters who had not undergone prophylactic mastectomy. Of these sisters, 38.7 percent (156) had been given a diagnosis of breast cancer (115 cases were diagnosed before the respective proband's prophylactic mastectomy, 38 were diagnosed afterward, and the time of the diagnosis was unknown in 3 cases). By contrast, breast cancer was diagnosed in 1.4 percent (3 of 214) of the probands. Thus, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90 percent. CONCLUSIONS: In women with a high risk of breast cancer on the basis of family history, prophylactic mastectomy can significantly reduce the incidence of breast cancer.

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Treatment for recurrence after surgical removal of parotid benign pleomorphic adenoma (PBPA) has not been well defined and is often followed by further recurrence. Surgery is overwhelmingly the most common approach. The risk of facial nerve injury is greater at reoperation since the nerve is less well defined. The value of radiation therapy (RT) has not been determined and incurs with it the risk of possible late occurrence of malignancy or nerve damage. The charts of patients with recurrent PBPA treated consecutively by a single surgeon from 1965 to 1993 were reviewed. All patients had a histopathologically verified diagnosis of PBPA both at the time of primary and subsequent surgeries. Follow-up was obtained from clinical charts and correspondence communication. Recurrence curves were generated using the Kaplan-Meier method. Thirty-nine patients with recurrent PBPA (36 referred and 3 treated primarily at Mayo) were evaluated. The patients were classified according to the type of surgery: 14 patients had previously undergone some form of parotidectomy or had only resection of the tumor for recurrence, and 25 patients underwent parotidectomy since this had not been performed primarily. The mean age in the two groups was 49 and 50 years respectively. The mean follow-up was 10 years after the recurrence treatment. The mean time between initial resection and recurrence in the two groups was 14 and 15 years. The mean time between the recurrence treatment and a second recurrence was 7.5 years. Nine patients had RT in addition to the local resection. Of this group 3 patients (33%) developed another recurrence. Five patients had local resection only, and of this group 1 patient (20%) developed another recurrence. Of the group that had superficial parotidectomy, 3 patients had additional RT and one of these patients (33%) developed another recurrence. Twenty-two patients had superficial parotidectomy only, and of this group 3 patients (14%) developed another recurrence. Only 2 of the 39 patients had complications. One patient developed Frey's syndrome after superficial parotidectomy and 1 patient developed facial paralysis after RT. As in other series, the number of patients is inadequate to allow for firm conclusions. However, it appears that when previous parotidectomy has been performed, simple excision with a margin of surrounding tissue would seem appropriate. Parotidectomy should be carried out if not performed previously. In simple excision after previous parotidectomy, there is a greater risk to the facial nerve because of difficulty in distinguishing the facial nerve from surrounding scar tissue. Our preference is to use general anesthesia so that branches of the nerve are not paralyzed and stimulation of the nerve aids in safe dissection. The value of RT is still indeterminate.

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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 microg/gm of tissue. These data ranged from 4 to 446 microg/gm of tissue, with a median of 27.0 microg/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.

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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 bra-strap 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.

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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 abdominal-wall fascia, obviating the need for interposition of prosthetic material or extraabdominal flaps.

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A zygomatic mass is a rare occurrence. We describe a 52-year-old man with a zygomatic arch mass and a recent history of facial trauma. Findings on a computed tomographic scan of the facial bones were interpreted as callus formation, consistent with fracture of the zygomatic arch. The level of the prostate-specific antigen was increased to 62.3 ng/mL, and a biopsy of a nodular prostate specimen revealed adenocarcinoma (Gleason sum, 3 + 4 = 7). Because the laboratory data, history, and findings on physical examination did not correlate, we suspected a tumor metastatic to the facial bones.

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A method for analysis of silicon in tissue was developed to determine silicon content in breast parenchymal and periprosthetic capsular tissues of patients with silicone or saline implants and to compare levels in tissues from normal (nonaugmented) breasts. It is of interest to determine whether increased silicon content in tissues can be associated with morbidity in patients who have received silicone implants. This manuscript addresses the issues involved in analysis of breast tissue samples for silicon and compares silicon levels with tissue histologic findings and patient morbidity. One hundred sixty tissue samples were obtained for silicon analysis from 72 patients during augmentation, capsulectomy with or without replacement mammoplasty, mastectomy, or biopsy procedures and were frozen in acid-washed polystyrene tubes at 220 degrees C until analysis. Samples were thawed, sectioned to approximately 0.1 g (dry weight), and digested in nitric acid before analysis by inductively coupled plasma emission spectroscopy, monitoring emission intensity at 251.6 nm. Tissue silicon levels (breast parenchymal and periprosthetic capsular tissue) in patients with silicone gel implants were much higher (mean, 9,287 micrograms/g, n = 106) than in patients with saline implants (mean, 196 micrograms/g, n = 37) or nonaugmented breasts (mean, 64 micrograms/g, n = 17). Histologic examination was performed on 54 tissue samples stained with hematoxylin-eosin. Tissue samples were rated as to degree of inflammation and calcification, and amount of giant cells, foamy histiocytes, and vacuoles containing a colorless refractory material. Vacuolization and foamy histiocyte ratings correlated significantly with tissue silicon concentration. No correlations were found between tissue silicon concentration and inflammation, calcification, or giant cell rating. Implant age (number of years an implant was in place before sampling) correlated with capsular tissue silicon concentration in patients with intact implants but not in those with ruptured implants. No difference in tissue silicon concentration was found between patients with or without signs or symptoms of morbidity. Using 0.1 g of tissue, the method was linear to 1,000 micrograms/g, and sensitivity was 3.7 micrograms/g. Precision between runs (mean, 5.1 micrograms/g; coefficient of variance, 13.7%; n = 13) was calculated from multiple analyses of a bovine liver standard (National Bureau of Standards, reference material 1577a). Significant biologic variability (21.4% to 52.5%) was seen in tissues with high silicon levels. Paraffin-embedded, formalin-fixed tissues are not amenable to silicon analysis by this method, because of leaching of silicone from the tissues during preparation. Thus only fresh frozen tissue samples were used.

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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 gel-filled 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.

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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.

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A brief review of some current views of consciousness is provided. Edelman's view of there being both 'primary consciousness' and 'higher order consciousness' is supported. The basis for the clinical view that primary consciousness is the result of the dynamic interaction between the cerebral cortex and the brainstem reticular activating system is presented. It is suggested that an audacious theoretical breakthrough is needed in order to advance our understanding of this complex and fascinating problem.

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A large perianal defect resulting from resection of Bowen's disease was reconstructed with a pair of sliding V-Y perineal flaps. The anatomical basis of the flaps is described, based on the inferior rectal vessels as fasciocutaneous units. Both continence and sensibility are preserved with the procedure.

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

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