Correction of bilateral breast hypoplasia and pectus excavatum with single-unit customized silicone implant

The cosmetic defects of pectus excavatum and bilateral mammary hypoplasia can be corrected with a single-unit customized silicone implant. An extended pocket is made across the anterior chest wall through two inframammary incisions. It is then possible to insert and position the breast prostheses subpectorally and the sternal prosthesis subcutaneously using these incisions. A good cosmetic result can occur with minimal morbidity and scarring.     

Breast capsulorrhaphy revisited: a simple technique for complex problems

Implant malposition without capsular contracture is a common problem that has received little attention. Malposition of the implant in the inferior, lateral, or medial direction can be corrected predictably and relatively simply with capsulorrhaphy and mirror-image selective capsulotomy. In addition, capsulorrhaphy can be used to create a smaller pocket to preserve anterior projection and prevent lateral and inferior displacement when changing to a smaller implant. Eleven patients underwent capsulorrhaphy for either implant malposition or implant size reduction. Improved appearance and symmetry of the breast was accomplished in all patients without increased complications.     

Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction

The long-term cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate postmastectomy breast reconstruction with various types of implants have been analyzed prospectively over a 9-year period. Of these patients, 334 who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (< 2 months) was 9.2 percent, with an explantation rate of 1.7 percent. The late complication rate (> 2 months) was 23 percent, with a pathological capsular contracture rate of 11 percent at 2 years and 15 percent at 5 years and an implant removal rate of 7 percent. The revisional surgery rate was 30.2 percent.The cosmetic results were assessed prospectively using an objective five-point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorated in a linear fashion, from an initial acceptable result of 86 percent 2 years after patients completed their reconstruction to only 54 percent at 5 years. This decline in cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient, or the type of mastectomy incision employed. Radiotherapy was not a significant factor because only 28 patients were irradiated. Upon Cox model analysis, pathological capsular contracture was the only factor that contributed significantly to a poor cosmetic outcome in which p < 0.0001 (relative risk 6.3). Despite a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of the patients without capsular contracture who demonstrated deterioration in their cosmetic scores, it became clear that a possible reason for their poor results was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis with aging.     

Poland's syndrome: correction of thoracic anomaly through minimal incisions

A method that minimizes residual scarring following Poland's syndrome correction by latissimus dorsi muscle transposition and placement of a submuscular breast implant is described. In order to reduce any resulting unsightly scarring and, in particular, eliminate the anterior thoracic scar, both a dorsal S-shape and an axillary incision were made and the muscle flap was raised. A prosthesis was then inserted and the muscle flap sutured to the anterior chest wall through an anterior incision symmetrical to the inferior border of the contralateral areola. The latter is a previously undescribed approach that produces good cosmetic results.     

Breast cancer stage at diagnosis and survival among patients with prior breast implants

Longstanding concern exists regarding the potential for women with breast implants to experience delayed detection of breast cancer. Furthermore, survival among cosmetic breast implant patients who subsequently develop breast cancer is a concern. Since 1976, this institution has monitored cancer incidence in a cohort of 3182 women who underwent cosmetic breast augmentation between 1959 and 1981. The distributions of stage at diagnosis and survival of the 37 women who subsequently developed in situ or invasive breast cancer were compared with the observed population distributions. The distribution of stage at diagnosis for cosmetic breast implant patients who subsequently developed breast cancer was virtually identical to that of all breast cancer patients in Los Angeles County who were of the same age and race, and were diagnosed during the same time period. Furthermore, the 5-year survival rate of the 37 patients did not differ from that which would be expected based on rates established by the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. These results suggest that cosmetic breast implant patients are not at increased risk of delayed detection of breast cancer, nor do they suffer a poorer prognosis when breast cancer does occur. Although the number of breast cancer patients in this study is small, the results are highly consistent with the existing epidemiologic evidence related to breast cancer detection and survival among breast implant patients. Although breast implant patients should continue appropriate breast cancer screening behavior, there seems to be no cause for alarm.     

Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types

In breast augmentation, surgeons usually choose a pocket location for the implant behind breast parenchyma (retromammary), partially behind the pectoralis major muscle (partial retropectoral), or totally behind pectoralis major and serratus (total submuscular). Each of these implant pocket locations has specific indications, but each also has a unique set of tradeoffs. When applied to a wide range of breast types, each pocket location has limitations. Glandular ptotic and constricted lower pole breasts offer unique challenges that often are not solved without tradeoffs when using a strictly retromammary, partial retropectoral, or total submuscular pocket. This article describes specific indications and techniques for a dual plane approach to breast augmentation in several different breast types, introducing techniques that combine retromammary and partial retropectoral pocket locations in a single patient to optimize the benefits of each pocket location while limiting the tradeoffs and risks of a single pocket location. A total of 468 patients had dual plane augmentation between January of 1992 and March of 1998 using the specific techniques of dual plane augmentation described in this article. All patients were treated as outpatients and received general anesthesia. Indications, operative techniques, results, and complications for this series of patients are presented. Dual plane augmentation mammaplasty adjusts implant and tissue relationships to ensure adequate soft-tissue coverage while optimizing implant-soft-tissue dynamics to offer increased benefits and fewer tradeoffs compared with a single pocket location in a wide range of breast types.     

Premaxillary augmentation: adjunct to rhinoplasty

Recession of the premaxillary area is a relatively common deformity. Typically, it presents as a mild weakness of the central maxilla, but in certain instances, such as in the Black and Asian communities, it may be moderate to severe. This condition can be compounded by a narrow nasolabial angle, recessed alar bases, and sunken cheeks. To resolve this deficiency, a new design for premaxillary augmentation is suggested. A bat-shaped premaxillary implant is used for correction. The implant is introduced by means of an intranasal or intraoral approach, while the patient is under either local or general anesthesia. Thirty-three patients have been managed for premaxillary recession and have been corrected by premaxillary augmentation. Satisfactory cosmetic results have been achieved, with only a few minor complications.     

Local complications and subsequent symptom reporting among women with cosmetic breast implants

Epidemiologic studies have found no association between breast implants and cancer or well-defined connective tissue diseases. However, women with cosmetic breast implants continue to report specific as well as nonspecific physical and psychological symptoms after receiving their implants. In an attempt to determine whether local complications of implantation may contribute to this excess of symptom reporting, the authors studied a large cohort of women in Sweden with cosmetic breast implants (n = 1280) and a comparison cohort of women who had cosmetic breast reduction surgery (n = 2211). Both groups of women had operations between 1969 and 1996. Medical record reviews of local complications revealed that approximately 31 percent of the women with cosmetic breast implants had an implant change, implant leakage, or a capsulotomy. Capsulotomies occurred more often in women who were age 35 or older at the time of the operation, had ever smoked, and had implants with a smooth surface. On self-administered questionnaires, symptoms were reported more often by the women who had implants regardless of whether they had local complications. Twenty of the 28 symptoms occurred more frequently among women with local complications and breast implants, compared with the women in the breast reduction comparison group or the women with breast implants but no local complications. This study suggests that local complications, particularly capsular contractures as indicated by capsulotomy, may be an important factor to consider when studying symptom reporting among women with breast implants.     

Surgical treatment of breast cancer in previously augmented patients

The incidence of breast cancer is increasing each year. Concomitantly, cosmetic breast augmentation has become the second most often performed cosmetic surgical procedure. As the augmented patient population ages, an increasing number of breast cancer cases among previously augmented women can be anticipated. The surgical treatment of these patients is controversial, with several questions remaining unanswered. Is breast conservation therapy feasible in this patient population and can these patients retain their implants? A retrospective review of all breast cancer patients with a history of previous augmentation mammaplasty who were treated at the Revlon/UCLA Breast Center between 1991 and 2001 was performed. During the study period, 58 patients were treated. Thirty patients (52 percent) were treated with a modified radical mastectomy with implant removal. Twenty-eight patients (48 percent) underwent breast conservation therapy, which consisted of lumpectomy, axillary lymph node dissection, and radiotherapy. Twenty-two of the patients who underwent breast conservation therapy initially retained their implants. Eleven of those 22 patients (50 percent) ultimately required completion mastectomies with implant removal because of implant complications (two patients), local recurrences (five patients), or the inability to obtain negative margins (four patients). Nine additional patients experienced complications resulting from their implants, including contracture, erosion, pain, and rupture. The data illustrate that breast conservation therapy with maintenance of the implant is not ideal for the majority of augmented patients. Breast conservation therapy with explantation and mastopexy might be appropriate for rare patients with large volumes of native breast tissue. Mastectomy with immediate reconstruction might be a more suitable choice for these patients.     

Structural Identification and Systematic Comparison of Phorbol Ester,Dioleoylglycerol, Alcohol and Sevoflurane Binding Sites in PKCδ C1A Domain

Protein kinase C (PKC) is a family of signal transducing enzymes that have been implicated in anesthetic preconditioning signaling cascade. Evidences are emerging that certain exogenous neuromodulators such as n-alkanols and general anesthetics can stimulate PKC activity by binding to regulatory C1A domain of the enzyme. However, the accurate binding sites in C1A domain as well as the molecular mechanism underlying binding-stimulated PKC activation still remain unelucidated. Here, we report a systematic investigation of the intermolecular interaction of human PKCδ C1A domain with its natural activator phorbol ester (PE) and co-activator dioleoylglycerol (DOG) as well as exogenous stimulators butanol, octanol and sevoflurane. The domain is computationally identified to potentially have three spatially vicinal ligand-binding pockets 1, 2 and 3, in which the pockets 1 and 2 have previously been determined as the binding sites of PE and DOG, respectively. Systematic cross-binding analysis reveals that long-chain octanol and DOG are well compatible with the flat, nonpolar pocket 2, where the nonspecific hydrophobic contacts and van der Waals packing are primarily responsible for the binding, while the general anesthetic sevoflurane prefer to interact with the rugged, polar pocket 3 through specific hydrogen bonds and electrostatic forces. Short-chain butanol appears to bind effectively none of the three pockets. In addition, the pocket 1 consists of two angled arms 1 and 2 that are also involved in pockets 2 and 3, respectively. Dynamics characterization imparts that binding of long-chain octanol and DOG to pocket 2 or binding of sevoflurane to pocket 3 can induce a conformational displacement in arm 1 or 2, thus further opening the included angle and enlarging pocket 1, which can improve the pocket 1-PE affinity via an allosteric mechanism, consequently stimulating the PE-induced PKCδ activation.     

Challenges in elucidating structure and mechanism of proton pumping NADH:ubiquinone oxidoreductase (complex I)

Proton pumping NADH:ubiquinone oxidoreductase (complex I) is the most complicated and least understood enzyme of the respiratory chain. All redox prosthetic groups reside in the peripheral arm of the L-shaped structure. The NADH oxidation domain harbouring the FMN cofactor is connected via a chain of iron–sulfur clusters to the ubiquinone reduction site that is located in a large pocket formed by the PSST- and 49-kDa subunits of complex I. An access path for ubiquinone and different partially overlapping inhibitor binding regions were defined within this pocket by site directed mutagenesis. A combination of biochemical and single particle analysis studies suggests that the ubiquinone reduction site is located well above the membrane domain. Therefore, direct coupling mechanisms seem unlikely and the redox energy must be converted into a conformational change that drives proton pumping across the membrane arm. It is not known which of the subunits and how many are involved in proton translocation. Complex I is a major source of reactive oxygen species (ROS) that are predominantly formed by electron transfer from FMNH₂. Mitochondrial complex I can cycle between active and deactive forms that can be distinguished by the reactivity towards divalent cations and thiol-reactive agents. The physiological role of this phenomenon is yet unclear but it could contribute to the regulation of complex I activity in-vivo.     

Crystal structure of CD14 and its implications for lipopolysaccharide signaling

Lipopolysaccharide, the endotoxin of Gram-negative bacteria, induces extensive immune responses that can lead to fatal septic shock syndrome. The core receptors recognizing lipopolysaccharide are CD14, TLR4, and MD-2. CD14 binds to lipopolysaccharide and presents it to the TLR4/MD-2 complex, which initiates intracellular signaling. In addition to lipopolysaccharide, CD14 is capable of recognizing a few other microbial and cellular products. Here, we present the first crystal structure of CD14 to 2.5 angstroms resolution. A large hydrophobic pocket was found on the NH2-terminal side of the horseshoe-like structure. Previously identified regions involved in lipopolysaccharide binding map to the rim and bottom of the pocket indicating that the pocket is the main component of the lipopolysaccharide-binding site. Mutations that interfere with lipopolysaccharide signaling but not with lipopolysaccharide binding are also clustered in a separate area near the pocket. Ligand diversity of CD14 could be explained by the generous size of the pocket, the considerable flexibility of the rim of the pocket, and the multiplicity of grooves available for ligand binding.     

Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction

Breast conservation has been associated with poor cosmetic outcome when used to treat breast cancer in patients who have undergone prior augmentation mammaplasty. Radiation therapy of the augmented breast can increase breast fibrosis and capsular contraction. Skin-sparing mastectomy and immediate reconstruction are examined as an alternative treatment.Six patients with prior breast augmentation were treated for breast cancer by skin-sparing mastectomy and immediate reconstruction. One patient underwent a contralateral prophylactic skin-sparing mastectomy. Silicone gel implants had been placed in the submuscular location in five patients and in the subglandular position in one patient a mean of 10.2 years (range, 6 to 20 years) before breast cancer diagnosis. The mean patient age was 41.3 years (range, 33 to 56 years). Four independent judges reviewed postoperative photographs to grade the aesthetic results in comparison with the opposite native or reconstructed breast.The American Joint Committee on Cancer staging was stage 0 in one patient, stage I for four patients, and stage II for one patient. Five of the six patients presented with a palpable breast mass. Latissimus dorsi flap reconstruction was performed in four patients (bilaterally in one) and a transverse rectus abdominis muscle (TRAM) flap was used in two patients. Three patients were treated by skin-sparing mastectomy with preservation of the breast implant (two patients with latissimus flaps, and one patient with a TRAM flap). The tumor location necessitated the removal of implants in two patients (one patient with a latissimus flap and one with a TRAM. A saline implant was placed under the latissimus flap after gel implant removal. The patient who underwent bilateral skin-sparing mastectomies desired explantation and placement of saline implants. No remedial surgery was performed on the opposite breast to achieve symmetry. Complications occurred in two patients at the latissimus dorsi donor site (seroma in one patient, and seroma and infection in one). Five patients underwent complete nipple reconstructions. The mean duration of follow-up was 33.6 months (range, 15.5 to 70.3 months), and there were no recurrences of breast cancer. The aesthetic results were judged to be good to excellent in all cases.Skin-sparing mastectomy and immediate reconstruction can be used in patients with prior breast augmentation, with good to excellent cosmetic results. Depending on the tumor and implant location, the implant may be preserved without compromising local control.     

Definitive diagnosis of breast implant rupture by ultrasonography

Silicone breast implantation is entering its fourth decade. Our ability to monitor the integrity of "old" prostheses is questioned. Clinical and mammographic examinations are reliable indicators of implant rupture only if there has been gel migration away from the implant pocket. Ultrasonography is presented as a reliable, sensitive method of evaluation of implant integrity. It should be considered the definitive study of prosthesis integrity. When sonography is added to mammographic and clinical examination, the preoperative evaluation of symptomatic augmented breasts is complete. Ultrasonography may be considered with mammography in the routine breast examination of all previously augmented patients.     

The SoxYZ complex carries sulfur cycle intermediates on a peptide swinging arm

The bacterial Sox (sulfur oxidizing) system allows the utilization of inorganic sulfur compounds in energy metabolism. Central to this process is the SoxYZ complex that carries the pathway intermediates on a cysteine residue near the C terminus of SoxY. Crystal structures have been determined for Paracoccus pantotrophus SoxYZ with the carrier cysteine in the underivatized state, conjugated to the polysulfide mimic beta-mercaptoethanol, and as the sulfonate adduct pathway intermediate. The carrier cysteine is located on a peptide swinging arm and is bracketed on either side by diglycine dipeptides acting as molecular universal joints. This structure provides a novel solution to the requirement that the cysteine-bound intermediates be able to access and orient themselves within the active sites of multiple partner enzymes. Adjacent to the swinging arm there is a conserved, deep, apolar pocket into which the beta-mercaptoethanol adduct extends. This pocket would be well suited to a role in protecting labile pathway intermediates from adventitious reactions.     

Reconstruction of mammary hypoplasma associated with chest wall deformities.

Three young women who had significant unilateral hypoplasia of the breast, accentuated by marked rib deformities and hypoplasia of the pectoralis muscle, were treated by two-staged reconstructions. A custom-made chest wall implant and a breast prosthesis were used. In the absence of cardiorespiratory compromise, these are simpler operations than rib osteoplasties and the cosmetic result is better.     

Long-term stability of Teflon orbital implants

Teflon orbital floor implants have become controversial owing to reports of implant-related complications. To determine the actual incidence of Teflon implant-related complications and factors associated with complications, we conducted a long-term follow-up study of 77 selected patients. We obtained data on 35 implants in 31 patients with a mean follow-up period of 16 years, representing an experience of 528 patient-implant years. The short-term complication rate (within 1 month of surgery) was 3.9 percent. The long-term complication rate was 2.8 percent. Concomitant antral packing and implantation of Teflon sheet were associated with a markedly higher risk of implant pocket infection. There was no case of implant migration with proper fixation. Facial growth was normal in three children in the series. We conclude that Teflon sheet is well-tolerated in the orbit in the long term. The low complication rate can be further reduced with proper fixation of the implant and avoidance of antral packing at the time of implantation.     

Locally administered ketorolac and bupivacaine for control of postoperative pain in breast augmentation patients

With recent developments in the field of analgesia, the question arises whether there is a role for placing local anesthetics, nonsteroidal anti-inflammatory drugs, or both into the breast implant pocket. The objective of this study was to test the effectiveness of locally administered intraoperative ketorolac and bupivacaine with epinephrine at reducing pain in the postoperative period. The study was a prospective, randomized, double-blind clinical trial. One hundred consecutive retropectoral breast augmentation patients were enrolled, and informed consent was obtained. A standard anesthetic protocol and surgical procedure were followed. Normal saline, ketorolac alone (30 mg), bupivacaine alone (150 mg), or ketorolac and bupivacaine (30 mg and 150 mg respectively) were placed into the implant pocket before implant insertion. All patients completed the study. The power of this study to detect a 20 percent difference with respect to the primary outcome was 0.90 and confidence intervals of 95 percent were used to determine significance. The primary outcome was pain as measured by the visual analogue pain scale. The secondary outcome was time spent in the recovery room. Intraoperative placement of ketorolac combined with bupivacaine reduced pain in the postoperative period. It did not appear that anesthesiologist, anesthesia time, surgeon, operating room time, difficulty of dissection, breast incision, or implant size had a significant effect on postoperative pain. There was a trend that the ketorolac and bupivacaine patients spent less time in the recovery room and used fewer analgesics postoperatively than the other patients. There were no hematomas requiring reoperation and no complications. Locally administered intraoperative ketorolac and bupivacaine with epinephrine significantly reduced pain in the postoperative period.     

Determining the binding capability of the mouse major urinary proteins using 2-naphthol as a fluorescent probe

The mouse major urinary proteins (MUPs) are an ensemble of isoforms secreted by adult male mice and involved in sexual olfactory communication. MUPs belong to the lipocalin superfamily, whose conserved structure is a beta-barrel made of eight antiparallel beta-strands forming a hydrophobic pocket that accommodates small organic molecules. A detailed knowledge of the molecular mechanism associated to the binding of those molecules can guide protein engineering to devise mutated proteins where the ligand specificity, binding affinity, and release rate can be modulated. Proteins with such peculiar properties may have interesting biotechnological applications for pest control, as well as in food and cosmetic industries. In this work, we demonstrate that the fluorescent molecule 2-naphthol binds to the natural ligand's binding site of MUPs with high affinity. In addition, we show that 2-naphthol binds to MUPs in its protonated form, that its fluorescence is blue-shifted, and the quantum yield is increased, thus confirming the high hydrophobicity of the protein pocket and the absence of proton acceptors inside the binding site. At large the results presented, besides demonstrating that the use of 2-naphthol provides a convenient and quick method for testing MUPs binding activity and to ascertain the quality of the protein preparation, suggest that MUPs can represent an interesting system for studying the photophysical characteristics of fluorescent molecules in a highly hydrophobic environment.