Transconjunctival surgery.

Transconjunctival surgery provides excellent exposure of the inferior orbit, leaves no visible scar, and poses less risk of the complications typically associated with transcutaneous techniques. The transconjunctival approach can be combined with lateral canthal techniques to increase exposure and surgical options. We review applications of the transconjunctival approach in blepharoplasty, the repair of orbital floor fractures, socket reconstruction, inferior orbital tumor excision, and orbital decompression.     

Cosmetic surgery.

The psychotherapeutic nature of cosmetic surgery is emphasised by outlining the range of symptoms from which patients suffer and by explaining the sequence of psychological reactions which cause them. The principles which govern the selection of patients are defined. A brief account of each of the main cosmetic operations is given together with notes on their limitations and risks.     

Complications of foot surgery. Laser surgery

The carbon dioxide laser, when used surgically, is a possible source of complications. Knowledge of laser physics, tissue effects, and target tissue anatomy are of the utmost importance for minimizing complications. This article seeks to elucidate the factors involved in laser beam physics and the effect of these factors on target tissue, based on specific tissue anatomy. Common tissue complications and specific procedure-oriented complications that may arise as a result of laser surgery will be discussed and reviewed.     

Breast surgery.

Initial diagnostic errors are related to the presumption that symptoms or findings are due to benign causes. Physical examination augmented by mammographic study will disclose those benign-appearing lesions which may harbor a carcinoma. All palpable lesions and mammographically suspicious areas require that their identity be determined. The final resolution depends upon biopsy. Missing the tumor also causes diagnostic error. An accurate biopsy or "sample" must be obtained for study. Negative results of sampling techniques should be followed by formal biopsy. Failure to eliminate the primary disease by leaving tumor or breast tissue behind increases the incidence of recurrence. Total mastectomy reduces this risk. It is our view that removal of the axillary nodes also aids in obtaining cure, as well as providing prognostic information. Well intentioned attempts to obtain a better cosmetic appearance or to reconstruct the breast are secondary to the patient's chief need which is to achieve cure. Complications of the surgical procedures are due to improper flap dissection, desiccation and trauma to tissues, incomplete hemostasis, and inadequate drainage. Attention to operative details and adherence to well established surgical principles will minimize complications.     

Ultrasonic surgery.

Animal and clinical studies of a new approach in general surgery using an ultrasonic aspiration device have been encouraging. On 31 patients 11 liver procedures, 12 extensive head and neck dissections, 5 ultrasonic fulgurations for rectal cancer, and excision of 2 local oral lesions, 1 para-aortic mass, 1 pancreatic cancer, 1 giant subfascial lipoma, and 1 rectal villous adenoma have been carried out.     

Oesophageal surgery.

A wide variety of benign conditions affecting the oesophagus which have long been recognized in association with hiatus hernia are now known to be attributable to reflux oesophagitis. The development of modern methods of treatment of these conditions is described with reference to a number of illustrative cases.     

Revision surgery for failed back surgery syndrome.

Results of surgical treatment in 50 failed back surgery patients were retrospectively reviewed to determine what factors influenced surgical outcome. Before surgery, all patients had disabling pain and limited function. Overall significant improvement in pain and function was obtained in 66% of the patients. Thirteen of 16 patients (81%) who had successful fusion of pseudarthrosis had a satisfactory outcome, whereas only 3 of 13 patients (23%) who had failed pseudarthrosis repair had a satisfactory outcome. Successful pseudarthrosis repair is the key to a high clinical success rate in revision surgery for failed back surgery syndrome. Pseudarthrosis repair by conventional posterolateral fusion with postoperative lumbosacral corset immobilization showed a high failure rate. The success rate of reoperation on failed back surgery syndrome patients is low.     

Lasers in surgery.

In January 1991 the winter meeting of the Surgical Research Society was held at St. Bartholomew's Hospital and the Institute of Education, London. During the meeting a symposium was held entitled 'Shedding light on lasers'. Speakers addressed the general principles of lasers, laser-tissue interactions and the applications of lasers in gastro-enterology and in vascular disease. This was followed by an open discussion of the current indications, complications and outcome, together with future possible applications for lasers in medicine.     

Icons in surgery.

This company of surgeons, the Pacific Coast Surgical Association, has honored me greatly, and I am grateful. In a turbulent, changing world, as physicians, you are among the most important people on earth. More important, by far, than any technologic aspect of your craft, is your character. As the pen is mightier than the sword, your beliefs and values are the sustaining force that will guide you in troubled times. Icons are Everyman's "pointers of the way" in meeting the challenges of tomorrow.