The Minimal Facelift: Liposuction of the Neck and Jowls

We have used blunt liposuction for removing excess fat from the neck and jowls since 1983 with generally good results and few complications. Under local anesthesia with Valium and ketamine sedation and the use of the super-wet technique, and by using special precautions to avoid the complications of prominent platysmal bands, wrinkling of the neck, and salivary gland prominence, carefully performed liposuction to the neck and jowls has been shown to be a safe and dependable procedure with good results, and may delay or obviate the need for a facelift.     

游离上臂外侧皮瓣在头颈肿瘤术后缺损修复的临床应用

目的 探讨以桡侧副动脉后支供血的游离上臂外侧皮瓣的设计和应用技术.方法 临床应用游离上臂外侧皮瓣修复头颈肿瘤术后缺损9例.结果 9例皮瓣均完全存活,效果良好.结论 上臂外侧皮瓣血管蒂恒定,皮瓣薄且质地佳,手术操作方便,供区隐蔽,适合修复头颈肿瘤尤其口腔术后缺损.     

Accuracy of MRI-based Diagnoses for Distal Upper Extremity Soft Tissue Masses

To determine the accuracy of the pre-operative MRI-based diagnosis of soft tissue masses in the forearm, wrist, and hand, the records of 144 patients who underwent an MRI followed by excision of a soft tissue mass in the forearm, wrist, or hand were reviewed. The MRI-based diagnosis was compared to the histological diagnosis, which was considered the gold standard. The sensitivity, specificity, positive predictive value, and negative predictive value of the MRI-based diagnosis were calculated. A multivariate regression analysis was performed.While the accuracy of the MRI-based diagnosis varied widely, there was an overall sensitivity of 75 %. The most accurate diagnosis was an MRI-based diagnosis of ganglion cyst, which had a sensitivity of 94.7 % and a specificity of 94.4 %. Of particular concern was that the MRI-based diagnosis of a malignancy was only 66.7 % sensitive, with a positive predictive value of 44.4 %. On multivariate regression analysis, there was a trend towards improved accuracy in the wrist when compared to the finger, although this did not reach statistical significance.While pre-operative MRI remains a valuable tool for the evaluation of soft tissue masses in the distal upper extremity, caution is warranted when basing the diagnosis on MRI evidence alone.Level of Evidence: Level IV/Diagnostic     

乳晕弧形切口切除乳腺良性肿物270例临床分析

目的探讨乳晕弧形切口切除乳腺肿物的优点。方法对270例乳腺肿物的患者采取乳晕弧形切口，行肿物切除术。结果270例中266例伤口I期愈合，占98．5％，37例（1．4％）发生皮下积液。本组中无皮瓣坏死，且瘢痕小，不影响外观。结论对于乳腺良性病变，均可采用乳晕弧形切口，既可完整切除病灶，又不影响美观，满足了患者对美学的要求。     

Benign Neck Metastasis of a Testicular Germ Cell Tumor

Germ cell tumors (GCTs) are relatively rare neoplasms considered to be curable malignancies since the introduction of cisplatin. The presence of neck metastasis has been reported, with fewer reports of metastatic mature teratoma. In this study, 3 cases of “benign neck” metastasis in patients with GCT between 1998 and 2010 were reviewed retrospectively. In all 3 cases the presenting clinical sign was a left lower neck mass, leading to the diagnosis of the primary site in the testis. All had surgical salvage following chemotherapy, with benign lesions or mature teratoma in histopathology of the neck mass. Chemotherapy was followed by salvage lower-half neck dissection showing benign features in the neck specimen, even though malignancy was proven histologically in other areas. Only 1 patient had a postoperative chyle leak, which resolved spontaneously after several days. Neck dissection is recommended in those patients because malignancy cannot be excluded.Key words: Germ cell tumor, Metastasis, Neck, TeratomaTeratoma comes from the Greek words terato, meaning “a monster,” and onkoma, meaning “swelling or mass.” Both teratomas and germ cell tumors (GCTs) arise from postmeiotic germ cells and may occur in both gonadal and extragonadal locations. GCTs are relatively rare neoplasms that account for 0.8% of all cancers in males, and they comprise 95% of testicular neoplasms.¹ GCTs are the most common malignancy among men ages 15 to 44 years, with a peak incidence between the age of 25 and 35 years.^2,3 GCTs have been considered to be curable malignancies, even in the advanced stage, since the introduction of cisplatin,⁴ and a dramatic improvement has been shown by using a treatment protocol of neoadjuvant cisplatin-based chemotherapy followed by surgical resection of residual tumor mass, with a complete response rate of 70% to 80%.⁵Testicular teratomas may present in both prepubertal and adult males. The prognosis differs greatly between these two groups. In children, teratomas most often occur before the age of 4 years, and they have a benign behavior in this age group. In adults, teratomas are usually part of mixed GCTs and have the potential to metastasize. The presence of neck metastasis in patients with testicular GCT is a rare but known phenomenon and has been reported to be present in up to 5% of cases.^6,7 Metastatic disease from the testis first involves the retroperitoneal lymph nodes, and then the tumor spreads via the thoracic duct to its emptying site near the junction of the left internal jugular and subclavian veins. Hence, the left supraclavicular region is one of the possible places where testicular teratomas can metastasize.^8,9 Because testicular carcinoma is the most common malignancy in men ages 20 to 30 years, a left supraclavicular mass in this age group should raise suspicion for a concomitant testicular mass.Our literature search has shown few reports of mature teratomas in patients who had been treated for GCT with neoadjuvant chemotherapy and surgical resection.^10–13 We present here our experience with 3 patients who were treated with neoadjuvant chemotherapy and surgical resection of highly malignant lesion, followed by surgical resection of a metastasis in the left lower neck, with benign histology.     

Retromammary Approach for Endoscopic Resection of Benign Breast Lesions

Background  

One of the merits of endoscopic surgery is that it can be performed through small remote incisions made in inconspicuous areas. To improve cosmetic outcomes of surgical treatment of benign breast lesions, we performed endoscopic surgery through minimally sized axillary incisions with the goal of achieving scar-free breasts.     

Defining Anatomical Landmarks for Robotic Facelift Thyroidectomy

Background

Robotic facelift thyroidectomy (RFT) is a straightforward remote access thyroidectomy technique. While the anatomy encountered during RFT is well known to surgeons, the vector of approach during this technique may be less familiar. In order to facilitate safe and efficient performance of RFT, the relationships of key anatomical landmarks associated with this technique were determined.

Methods

Eight anatomical dissections were performed in cadavers and included performance of RFT and definition of discrete anatomical relationships. Morphologic assessments of the great auricular nerve (GAN), omohyoid (OH) muscle, inferior constrictor (IC) muscle, and recurrent laryngeal nerve (RLN) were conducted.

Results

The mean distance from the incision apex to the anterior and posterior aspects of the GAN were 3.8 ± 1.2 and 7.7 ± 0.8 cm. From the apex of the incision to the OH muscle was 11.1 ± 1.7 cm on average. The OH muscle was located 1.3 ± 0.5 cm inferior to an axial line drawn through the inferior aspect of the thyroid notch. The anterior branch of the RLN was identified coursing deep to the inferior margin of the IC muscle a mean of 1.2 ± 0.2 cm lateral to the origin of this muscle on the cricoid cartilage.

Conclusions

Characterization of the key anatomical landmarks of the lateral neck and thyroid compartment associated with RFT, including the GAN, OH muscle, and RLN, allows for rapid recognition of these critical structures during this operation. Surgeons learning this approach should be familiar with these relationships.     

后腹腔镜输尿管上段切开取石术

我院于2003年2月～2005年4月采用腹腔镜经腹腔后间隙输尿管切开取石治疗输尿管上段结石7例，疗效满意，报告如下。     

Resecting and nonresecting techniques for posterior mitral leaflet prolapse

Abstract Background: Posterior leaflet (PL) prolapse is commonly treated with quadrangular resection, but nonresecting techniques were proposed as an alternative. We evaluated our experience to identify specific indications to nonresecting techniques. Methods: From March 2006 to February 2009, 60 patients were treated for PL prolapse, 21 using resecting (group R), and 39 nonresecting (group NR) techniques. Patients in group R had fibroelastic deficiency with isolated P2 prolapse and P1 or P3 (or both) thin or short (n = 15); need of excessive P2 resection (more than 1/3 of the posterior annulus) (n = 10); dominant or codominant circumflex artery (n = 10). Some of them were young and were operated on without preoperative coronary angiography (n = 4). Results: One patient (1.7%) in group R died during the first 30 days after surgery. Three‐year survival was 89.6 ± 4.5, similar in both groups. A postoperative echocardiogram was obtained 20 ± 6 months after surgery in every survivor. Mitral regurgitation decreased significantly soon after surgery without any significant modification at follow‐up in both groups. Conclusions: nonresecting techniques provide good midterm results, similar to resecting ones. To resect or not resect part of the PL has, in our personal practice, its own indications and contraindications. Extensive use of artificial chords and reduction of PL height, when indicated, is able to provide other tools to safely expand mitral repair for PL prolapse . (J Card Surg 2011;26:119‐123)     

经颈入路良性胸骨后甲状腺肿切除的手术技巧

目的 探讨良性胸骨后甲状腺肿经颈入路切除的可行性与安全性并总结手术技巧.方法 对我院2002年8月至2011年10月期间的85例良性胸骨后甲状腺肿患者的临床资料进行回顾性分析.结果 85例患者均经颈入路行胸骨后甲状腺肿切除,未发生围手术期死亡及呼吸道梗阻,无大出血、气胸、血胸及乳糜漏,未发生永久性喉返神经损伤及永久性甲状旁腺功能低下.3例患者术后1～3 d出现声音嘶哑,对症处理后恢复正常.4例患者术后1～2 d出现四肢末端麻木,1例患者出现轻度抽搐,予以静脉及口服补钙治疗3～7 d后症状缓解.术后颈部引流量(68±4.9) ml (35～220 ml),2～6 d(平均4.2d)拔除引流管.术后2年82例患者得到随访,无低钙、低甲状旁腺激素的病例,无声音嘶哑及局部甲状腺肿复发的病例,2例患者出现甲状腺功能低下,给予调整口服甲状腺素剂量后恢复正常.结论 坠入型良性胸骨后甲状腺肿经颈入路切除是安全、可行的,而充分的暴露、循序渐进的操作、寻准间隙的钝性分离和托拽结合是保证手术成功的关键.     

Follow-Up After Surgery for Benign Nodular Thyroid Disease: Evidence-Based Approach

Background

There is no consensus on what constitutes appropriate methodology and timing for follow-up of patients after surgery for benign nodular disease.

Methods

A systematic review of the medical literature using evidence-based criteria was used to address the following four issues: (1) How often should patients who have undergone thyroidectomy for the treatment of benign nodular goiter be followed, and what constitutes appropriate follow-up? (2) What is the most appropriate method for detecting recurrent nodular thyroid disease? (3) Does thyroid hormone administration prevent recurrent nodular thyroid disease? (4) Does iodine administration prevent recurrent nodular thyroid disease?

Results

Altogether, 742 articles were found in MEDLINE using a keyword search strategy; we then narrowed them to 23 articles. There were a total of four articles with Level I data, five articles with Level II data, one article with Level III data, and 13 articles with Level IV or retrospective data.

Conclusions

Based on the available data, it is our recommendation that patients undergoing thyroid lobectomy for benign nodular thyroid disease should be followed with an annual physical examination, neck ultrasonography, and serum thyroid-stimulating hormone (TSH) measurement. Patients undergoing total thyroidectomy should be followed with an annual physical examination and a serum TSH measurement. Routine thyroxine and/or iodine supplementation may be useful for preventing recurrence in patients from iodine-deficient regions.

     

上颈段椎管内哑铃型神经鞘瘤的外科治疗

目的：探讨枕大孔区至颈2椎管内哑铃型神经鞘瘤的手术与稳定性重建方法及技巧。方法：2002年1月～2007年1月收治的19例患者，枕大孔到颈1水平5例，颈1到颈2水平14例。后正中入路，显露枕骨大孔至颈3水平，肿瘤位于枕大孔至颈1水平者，先切除枕骨大孔，依据情况切除寰椎后弓。肿瘤位于颈1、2水平者切除颈2椎板。从背外侧显露肿瘤的全貌，先自肿瘤移行部将肿瘤横断，切除椎管内肿瘤，然后切除椎管外肿瘤。肿瘤若与神经根粘连紧密可切除宿主神经根。然后依据情况重建其稳定功能。结果：19例完全切除，所有患者术后第3天颈围领保护下下床活动。恢复良好13例，改善4例，无明显改善1例，恶化1例，无手术死亡。随访1～6年，MRI检查未见肿瘤复发。所有患者术后6个月均获得骨性融合，稳定性良好。结论：上颈段哑铃型椎管内神经鞘瘤手术难度火，术中尽可能的减少骨性结构的破坏。稳定性的重建非常必要。