Percutaneous Radio-Frequency Rhizotomy in the Treatment of Trigeminal Neuralgia

A percutaneous technique of selective partial trigeminal root coagulation was evaluated in the treatment of 38 patients suffering from trigeminal neuralgia, 1 patient with pain secondary to oral carcinoma and 1 patient with atypical facial pain. The pain of trigeminal neuralgia was relieved in 94.7 percent of patients. Pain was relieved in the patient with oral carcinoma, but not in the patient with atypical facial pain. There was no mortality and no permanent morbidity outside of the trigeminal nerve lesion. The procedure requires only a brief hospital stay without the time, expense and hazards of open cranial surgical procedures.     

Microsurgical Vascular Decompression for Trigeminal Neuralgia and Hemifacial Spasm

Vascular cross-compression of cranial nerves has been proposed as the cause of cranial neuropathies, including trigeminal neuralgia and hemifacial spasm. Over the last decade we have used microsurgical vascular decompression to treat these two disorders. Results in 50 patients treated for trigeminal neuralgia have been excellent in 42, good in 5 and poor in 2; and 1 patient was cured after a second operation. Results in 22 patients treated for hemifacial spasm have been excellent in 18, good in 2 and fair in 1. One patient died. There were no late recurrences of symptoms.The pathophysiological mechanisms of trigeminal neuralgia and hemifacial spasm remain unknown.     

Five-and-a-half years' experience with percutaneous retrogasserian glycerol rhizotomy in treatment of trigeminal neuralgia

The results of treating trigeminal neuralgia with percutaneous retroganglionic glycerol rhizotomy in 319 patients from an overall series of 394 patients with 459 operations carried out over a period of 5 1/2 years are reported. Idiopathic trigeminal neuralgia was the diagnosis in 252 patients. 34 patients had trigeminal neuralgia associated with multiple sclerosis. The remaining 33 patients suffered from symptomatic trigeminal neuralgia or atypical facial pain. 230 patients (91.3%) with idiopathic trigeminal neuralgia and 30 patients (88.2%) with multiple sclerosis reported complete freedom from pain. In 12 patients (4.8%) of those with tic douloureux and in 1 patient (2.9%) with multiple sclerosis, pain was alleviated, and the patients required a reduced pharmacotherapy. 10 patients (3.9%) and 3 patients (8.8%) were considered to be treatment failures. The rate of recurrences within the first 2 years was 10.9 and 40.0%, respectively. In the long-term, the rate of recurrences in patients with tic douloureux was 36.9%. 144 patients (45.1%) noticed a hypesthesia. 132 patients (41.4%) had hypalgesia following the procedure, and there was a decrease of symptoms in the long-term observation in 20.0% of the patients. 59 patients (18.5%) developed dysesthesia postoperatively which regressed only to an inappreciable extent in the long-term course. In 16 patients (5.0%) exclusively with a preexisting organic lesion or who had received surgical pretreatment, there was a loss of corneal sensation. The investigation showed on the one hand the effectiveness of the method, but on the other hand also the possibility of marked sensory disorder in selected cases.     

Treatment of Trigeminal Neuralgia with Percutaneous Glycerol Injection into Meckel’s Cavity: Experience in 4012 Patients

Percutaneous glycerol injection into Meckel’s cavity is widely used to treat trigeminal neuralgia. Reports published to date summarized clinical experiences in small or intermediately sized groups of patients. The efficacy of this procedure in a large group of patients has not been evaluated so far. From December 1983 to November 2008, patients with primary trigeminal neuralgia were treated in our clinic using percutaneous glycerol injection into Meckel’s cavity which was conducted according to the Hakanson’s anterior puncture method with some modifications. In total, 4012 patients (2205 female) with a mean age of 56.5 (23–87) years were treated. The majority of patients (99.23%) experienced unilateral pain, while a small cohort of patients (31; 0.77%) had bilateral pain. The immediate success rate of the procedure was 97.1%. There was a significant (P < 0.01) positive correlation between the presence of cerebrospinal fluid (CSF) outflow and the curative effect. Follow-up was done in 3157 patients for the period of 1–25 years. The long-term success rate was 81.18%. No serious adverse effects were observed. The procedure is very effective and applicable to a wide variety of patients with trigeminal neuralgia. The presence of CSF outflow during puncture predicts better immediate and long-term outcomes.     

原发性三叉神经痛和疱疹后三叉神经痛临床特征及射频热凝术后效果分析

摘要 目的：探讨原发性三叉神经痛（PTN）和疱疹后三叉神经痛（PHN）的临床特征,并比较经卵圆孔射频热凝术（RF-TC）治疗PTN和PHN的临床疗效。方法：随机选取2019年1月至2020年8月在我院治疗的三叉神经痛患者123例,其中原发性三叉神经痛90例,带状疱疹后神经痛33例。所有患者均通过RF-TC进行治疗,治疗后通过视觉模拟量表（VAS）、巴罗神经研究所疼痛强度量表对面部疼痛评分进行疼痛评估,通过巴罗神经研究所麻木评分进行麻木评定,通过健康问卷-9对患者抑郁情况进行评估,通过匹斯堡睡眠质量指数测量患者心理状态。结果：PTN患者发病年龄显著低于PHN患者（P<0.05）,而病程显著高于PHN患者（P<0.05）;PHN患者的眼支发生率高于PTN患者（39.39% vs 8.89%, P<0.05）。两组患者经RF-TC治疗前后VAS评分无显著差异（P>0.05）。PHN组从轻度到重度影响睡眠质量的比例显著高于PTN组（30.30% vs 10.00%, P<0.05）。PTN组患者治疗后中重度抑郁患者比例显著高于PHN组患者（21.11% vs 9.09%, P<0.05）。两组患者经RF-TC治疗后,临床治疗有效率、面麻木程度以及巴罗神经研究所疼痛强度量表评定的面部疼痛无显著差异（P>0.05）。结论：经卵圆孔射频热凝术治疗原发性三叉神经痛和带状疱疹后三叉神经痛是安全有效的,但治疗后疱疹后三叉神经痛失眠的发生率较高,而原发性三叉神经痛的抑郁发生率较高。     

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.     

Treatment of Post-Herpetic Neuralgia by Prolonged Electric Stimulation

The results of treating patients with severe post-herpetic neuralgia with prolonged self-administered electric stimulation from a portable apparatus were good in 11 out of 30 patients. None of these patients had had as good relief of pain with other forms of treatment. In 10 patients some effects from stimulation continued after stimulation stopped. In eight there was an improvement in the course of the neuralgia, and in two there was a cure.     

家族性三叉神经痛

三叉神经痛是一种临床常见疾病,典型的三叉神经痛主要表现为阵发性、闪电样的疼痛发作,疼痛剧烈,常无法忍受,呈电灼、针刺、撕裂样,每次发作持续时间数秒至数分钟不等。疼痛多发生于单侧,常有扳机点表现,其多表现为散发,而家族性三叉神经痛报道罕见,至今世界范围内报道仅50余个家系,其临床表现及发病特点与散发性三叉神经痛存在明显差别,尽管散发三叉神经痛患者的病因为责任血管压迫三叉神经REZ区已被普遍接受,但关于家族性三叉神经痛的病因是否为血管压迫存在争议,其遗传模式也没有达成一致的意见,文章复习了相关文献,并通过对这些文献进行分析综合,结合我们治疗三叉神经痛的经验,对其病因、发病机制、诊断和治疗原则、遗传模式等作了系统综述。     

Effectiveness of radiofrequency thermocoagulation in recurrent trigeminal neuralgia after previous retrogasserian rhizotomy

Between 1974 and 1984, 428 trigeminal neuralgia cases were treated by controlled radiofrequency thermocoagulation (RFTC). 29 had recurrent trigeminal neuralgia after intracranial surgery. 26 of the 29 patients were treated by retrogasserian rhizotomy and 3 by posterior fossa exploration. Among the 26 recurrent trigeminal neuralgia following retrogasserian rhizotomy, RFTC was effective in 23 cases (88.5%), and in 3 cases (11.5%) RFTC was effective for a short period. Repeated RFTC was unable to control the pain attacks which were later relieved by posterior fossa exploration and root section. Of the 3 recurrent trigeminal neuralgia following posterior fossa exploration, RFTC was effective in 2 cases (66.6%).     

Early trigeminal evoked potentials in tumours of the base of the skull and trigeminal neuralgia

Early scalp responses evoked by stimulation of the infraorbital nerve (W1, W2, W3) have been investigated in 23 patients affected by tumours of the base of the skull (parasellar area and cerebello-pontine angle) and in 38 patients suffering from ‘idiopathic’ trigeminal neuralgia. Differences in conduction times between healthy and affected side were evaluated and confronted with data obtained from 30 normal volunteers.Alterations of the response were found in all the patients with tumours of the base of the skull who had clinical signs in the trigeminal area and in 7 of the 12 cases without such signs. The usual pattern of alteration in cases with tumours of the parasellar area was a parallel involvement of W2 and W3 (both absent or delayed to the same extent), whereas in tumours of the cerebello-pontine angle W3 was more seriously affected than W2. Wave W1 was never altered. Pre- and post-operative recording sessions in 2 patients showed definite improvement of the responses after removal of the tumour.In 9 patients suffering from ‘idiopathic’ trigeminal neuralgia delays of conduction were found on the painful side, suggesting that damage to the trigeminal root, possibly at its entry zone into the pons, had taken place. Retrogasserian injection of glycerol was performed in 12 of the 38 patients with trigeminal neuralgia. Stimulation of the operated side showed disappearance of W2 and W3 in 9 cases, prolonged W1–W3 interval in 2 cases and no alterations in 1 case. The extent of response alteration usually paralleled the clinical results.     

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.     

A comparison of conventional and low-bleed implants in augmentation mammaplasty.

We conducted a double-blind, retrospective comparison between low-bleed and non-low-bleed (conventional) mammary implants because no controlled study has shown a difference in the degree of capsular contracture between the two types of implants. Twenty-five patients had conventional implants and form group A; twenty-eight patients had low-bleed implants and form group B. All patients had submuscular augmentation. The mean Baker score was 1.51 for group A and 1.04 for group B for the entire patient population and 1.65 for group A and 1.07 for group B for patients with more than 1 year of follow-up. For the entire population, 34 percent of group A and 3.6 percent of group B had a Baker score of 2 or greater. For the population with more than 1 year of follow-up, 42 percent of group A and 7 percent of group B had a Baker score of 2 or greater. There was significantly (p less than 0.007) less contracture with the low-bleed implants for the entire population as well as for those patients with greater than 1 year of follow-up (p less than 0.015).     

Treatment modalities for hypospadias cripples

Hypospadias cripples can be defined as patients with remaining functional complications after previous hypospadias repair. A retrospective follow-up study was performed on the long-term results of a group of 94 patients disabled by hypospadias. The records of 94 patients showed that they presented with the following problems: 82 had a major meatal dystopia (87 percent), 43 (46 percent) had residual curvature of the penile body, 19 (20 percent) showed meatal stenosis, and only 5 (5 percent) had one or more fistulas. The techniques used to solve these problems were circumferential advancement of penile skin, dorsal transposition flap of preputial skin, distally based transposition flap of penile skin, and full-thickness skin graft. Between one and nine operations were needed to achieve the desired result (mean and median of two operations). The complications after these procedures were 11 fistulas in nine patients, meatal stenosis caused by tight scarring in six patients, and a residual curvature after an orthoplasty that had to be released once before a urethroplasty could be performed. Forty-three men were seen at long-term follow-up (range, 2 to 25 years; mean, 12 years). Functional complaints that were seen included spraying at micturition (5 patients, 12 percent), dribbling (6 patients, 14 percent), and deviation of urinary stream (7 patients, 16 percent). No patients complained of painful miction, hesitation, or straining. At physical examination, 4 patients had a residual curvature (three of which were mild without functional problems), 5 had a skin surplus, 1 presented with a fistula after an operation in another hospital, and 13 had a penile torsion. Only 6 patients had a penile torsion greater than 10 degrees, which was evenly distributed to the left and right. There was no correlation between any functional complaint and the presence of a physical abnormality.     

Technical variations of the bipedicled TRAM flap in unilateral breast reconstruction: effects of conventional versus microsurgical techniques of pedicle transfer on complications rates

In cases of unilateral breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap, poorly perfused tissue, which is normally excised to avoid subsequent fat necrosis, must sometimes be used to achieve adequate breast size and projection. In such cases, incorporation of a second vascular pedicle into the flap design improves perfusion. The authors retrospectively examined their experience with bipedicled TRAM flap-based unilateral breast reconstruction to determine whether the use of microsurgical rather than conventional (nonmicrosurgical) techniques for flap transfer resulted in lower incidences of flap-site fat necrosis and donor-site hernia/bulge. The authors retrospectively reviewed the medical records of all patients who underwent unilateral breast reconstruction with a bipedicled TRAM or deep inferior epigastric perforator flap between January of 1991 and March of 2001. Group 1 consisted of patients who had undergone flap transfer using a conventional technique for both pedicles; group 2, patients who had flap transfer using a conventional technique for one pedicle and a microsurgical technique for the other; and group 3, patients who had flap transfer using a microsurgical technique for both pedicles. Of the 863 patients identified, 72 (8.3 percent) had undergone reconstruction using a bipedicled flap. There were 43 patients in group 1, 24 patients in group 2, and five patients in group 3. Only one case of total flap loss had occurred (group 1). Partial flap loss occurred in two patients in group 1 (5 percent) and three patients in group 2 (13 percent). Fat necrosis occurred more frequently in groups 1 (23 percent) and 2 (29 percent) than in group 3 (0 percent) (p = 0.5, Fisher's exact test). Similarly, bulge or hernia was more common in groups 1 (12 percent) and 2 (4 percent) than in group 3 (0 percent) (p = 0.6, Fisher's exact test). In this study, patients who received a bipedicled TRAM flap using microsurgical techniques alone (group 3) appeared to have better flap perfusion and less frequent hernia/bulge than did patients who underwent flap transfer using conventional (group 1) or combined techniques (group 2). However, these differences were not statistically significant, and this trend must be verified in a larger study.     

An outcome evaluation of sphincter pharyngoplasty for the management of velopharyngeal insufficiency

Sphincter pharyngoplasty is frequently used for the management of children with velopharyngeal insufficiency. The purpose of this study was to evaluate outcome and revision rates of sphincter pharyngoplasty at the authors' institution. Two hundred fifty patients underwent sphincter pharyngoplasty for velopharyngeal insufficiency between January of 1987 and March of 2001. There were 117 female patients and 133 male patients, with a mean age at primary sphincter pharyngoplasty of 7.6 years (range, 1 to 45 years). Diagnoses included velopharyngeal insufficiency alone (n = 63), velopharyngeal insufficiency associated with cleft palate (n = 127), velocardiofacial syndrome (n = 32), submucous cleft (n = 15), and other (n = 13). Pharyngoplasty revision was defined as any secondary surgical revision of the sphincter as determined by clinical evaluation and objective speech assessment. The pharyngoplasty revision rate was found to be 12.8 percent (n = 32). A favorable outcome was demonstrated in 30 of these patients (93.8 percent) after pharyngoplasty revision. Two patients, one with a diagnosis of a submucous cleft and velocardiofacial syndrome and the other with a cleft palate, required a second revision because of persistent velopharyngeal insufficiency. The revision rate was highest in those patients with velocardiofacial syndrome (21.8 percent) and lowest in patients with velopharyngeal insufficiency alone (6.3 percent). Patients who required revision had significantly higher preoperative oral sentence nasometry (55.2 percent versus 46.1 percent; p < 0.01) and larger velopharyngeal areas (23.7 mm2 versus 18.9 mm2). There was no significant difference in age or sex for those patients who required a revision compared with those who did not require revision. Mean follow-up was 2.4 years (range, 4 months to 13.6 years). Sphincter pharyngoplasty is an effective procedure for the treatment of velopharyngeal insufficiency using revision rate as the standard of success. It had an 87 percent primary success rate that increased to 99 percent after a single revision. Patients with velocardiofacial syndrome, more severe preoperative hypernasal resonance, and larger velopharyngeal areas were more likely to require pharyngoplasty revision.     

Management of parotid hemangioma in 100 children

Most problematic infantile hemangiomas are successfully treated with pharmacological therapy. However, there are reports that hemangioma of the parotid gland responds poorly to corticosteroid and interferon. To better clarify the management of parotid hemangioma, the authors retrospectively studied the records of 100 consecutive patients, seen between 1975 and 2002. The characteristics of the tumor, including sex ratio, presence at birth, size, side, complications, and involvement of adjacent structures, were recorded. The indications for and response to treatment and the need for surgical procedures were documented and statistically analyzed. The female-to-male ratio was 4.5:1. Forty percent of parotid hemangiomas were on the right side, 36 percent were on the left, and 24 percent were bilateral. Forty-five percent of patients had a premonitory cutaneous lesion at birth. Fifty-nine percent of parotid hemangiomas ulcerated during the early proliferative phase. Eighty-eight percent involved nearby structures (ear, 70 percent; lip, 34 percent; subglottic region, 21 percent; eye, 18 percent; and nose, 3 percent). Seven percent of patients required tracheostomy, and 3 percent had signs of congestive heart failure. Seventy infants received pharmacological treatment. Sixty-seven patients were initially managed with corticosteroids; regression or stabilization was noted in 83 percent of tumors (56 of 67 tumors). Twenty-one patients received interferon: 11 in whom corticosteroid therapy had failed, seven in whom the tumor stabilized with corticosteroid therapy but further regression was needed, and three who had interferon as primary therapy. Ninety-five percent of the lesions that were resistant to corticosteroid subsequently responded to interferon alfa-2a or -2b. The overall response rate to pharmacological therapy was 98 percent. A reconstructive procedure was necessary during the involuting or involuted phase in 66 percent of patients: 92 percent had preauricular excision of redundant skin and/or fibrofatty tissue and 37 percent of patients had auricular revision. In summary, drug therapy was effective in the majority of infants with parotid hemangioma, whether given because the tumor was large, deforming, ulcerated, or involved nearby structures with functional consequences. Infantile hemangioma in the parotid gland responded to pharmacological treatment in a similar manner as hemangioma in other locations.     

Myocardial Infarction and Carbohydrate Metabolism Relating to Diabetes Mellitus

Fifteen non-obese males with acute myocardial infarction and no diabetic history were evaluated for diabetes. During infarction, results of oral glucose tolerance tests were “diabetic” or “probably diabetic” in 10 of the 15 patients (67 percent). The plasma immuno-reactive insulin response in 12 patients (80 percent) was of a pattern observed in patients with maturity-onset diabetes. Six months after infarction, follow-up glucose tolerance tests in 12 surviving patients were diabetic or probably diabetic in three cases (25 percent). In seven of twelve patients (58 percent) had delay in the peaking of the plasma insulin response to an oral glucose tolerance test, a phenomenon that is observed in patients with maturity-onset diabetes.Glucose tolerance tests were abnormal in one of fourteen control subjects (7 percent). There was a delayed plasma insulin response to an oral glucose test in two of fourteen controls (14 percent).Patients with myocardial infarction have an increased incidence of diabetes mellitus.     

改良微血管减压术治疗复发性三叉神经痛的疗效及安全性分析

目的:探讨改良微血管减压术(MVD)治疗复发性三叉神经痛的疗效及安全性。方法:回顾性分析2010年至2015年收治的50例复发性三叉神经痛患者,2012年前采取常规MVD手术方法(MVD组,n=22),2012年后采取改良MVD的手术方法(改良MVD组,n=28)。MVD组采用传统MVD对三叉神经根进行全程减压,即沿首次切口入路,依次切开皮下、肌筋膜,充分分离骨窗边缘的瘢痕组织,适当扩大骨窗直至硬脑膜充分暴露。切开硬膜,锐性分离蛛网膜后探查Meckel腔至神经出脑区(REZ),仔细探查三叉神经全段,分离压迫神经的责任血管以及首次手术置入的Teflon垫棉,对三叉神经进行全程减压。改良MVD组在此基础上,探查三叉神经颅内段及其周围结构,解剖三叉神经脑干延伸段,垫开小脑上动脉对三叉神经脑干延伸段的压迫。比较两组术后缓解率、并发症、复发情况。结果:改良MVD组术后缓解率为100.0%,显著高于MVD组72.7%(P0.05);两组术后并发症的发生率比较差异无统计学意义(P0.05);改良MVD组术后1年复发率为0%,显著低于MVD组22.7%(P0.05)。结论:MVD术中三叉神经根全程减压联合脑干延伸段减压治疗复发性三叉神经痛患者可有效缓解疼痛,降低术后复发风险,且不增加术后并发症。     

The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes

Little has been published regarding the treatment of patients with long-established capsular contracture after previous submuscular or subglandular breast augmentation. This study reviews 7 years of experience in treating established capsular contracture after augmentation mammaplasty by relocating implants to the "dual-plane" or partly subpectoral position. A retrospective chart review was performed on all patients who were treated for capsular contracture using this technique between 1993 and 1999. Data collected included the date of the original augmentation, the original implant location, date of revision and type of implant used, length of follow-up, outcome, and any ensuing complications. Different surgical techniques were used, depending on whether the prior implant was located in a subglandular or submuscular plane. All patients had revisions such that their implants were relocated to a dual plane, with the superior two thirds or so of the implant located beneath the pectoralis major muscle and the inferior one third located subglandularly. Of 85 patients reviewed, 54 had their original implants in a submuscular position and 31 had their initial augmentation in a subglandular position. Of the 54 patients whose implants were initially submuscular, 23 patients (43 percent) had silicone gel implants, 15 patients (28 percent) had double-lumen implants, and the remaining 16 patients (30 percent) had saline implants. Of the 31 patients whose implants were initially subglandular, 20 patients (65 percent) had silicone gel implants, three patients (10 percent) had double-lumen implants, and the remaining eight patients (26 percent) had saline implants. Fifty-one patients (60 percent) had replacement with saline implants (37 smooth saline, 14 textured saline), whereas 34 (40 percent) had silicone gel implants (seven smooth gel, 27 textured gel). The average time from previous augmentation to revision was 9 years 9 months. The average follow-up time after conversion to the dual-plane position was 11.5 months. Only three of 85 patients required reoperation for complications, all of which involved some degree of implant malposition. Of patients converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II. There were no Baker level III or IV contractures at follow-up. The dual-plane method of breast augmentation has proved to be an effective technique for correcting established capsular contracture after previous augmentation mammaplasty. This technique appears to be effective when performed with either silicone or saline-filled implants.     

Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.

Osseous free flaps have become the preferred method for reconstructing segmental mandibular defects. Of 457 head and neck free flaps, 150 osseous mandible reconstructions were performed over a 10-year period. This experience was retrospectively reviewed to establish an approach to osseous free flap mandible reconstruction. There were 94 male and 56 female patients (mean age, 50 years; range 3 to 79 years); 43 percent had hemimandibular defects, and the rest had central, lateral, or a combination defect. Donor sites included the fibula (90 percent), radius (4 percent), scapula (4 percent), and ilium (2 percent). Rigid fixation (up to five osteotomy sites) was used in 98 percent of patients. Aesthetic and functional results were evaluated a minimum of 6 months postoperatively. The free flap success rate was 100 percent, and bony union was achieved in 97 percent of the osteotomy sites. Osseointegrated dental implants were placed in 20 patients. A return to an unrestricted diet was achieved in 45 percent of patients; 45 percent returned to a soft diet, and 5 percent were on a liquid diet. Five percent of patients required enteral feeding to maintain weight. Speech was assessed as normal (36 percent), near normal (27 percent), intelligible (28 percent), or unintelligible (9 percent). Aesthetic outcome was judged as excellent (32 percent), good (27 percent), fair (27 percent), or poor (14 percent). This study demonstrates a very high success rate, with good-to-excellent functional and aesthetic results using osseous free flaps for primary mandible reconstruction. The fibula donor site should be the first choice for most cases, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of alternative donor sites (i.e., radius and scapula) is best reserved for cases with large soft-tissue and minimal bone requirements. The ilium is recommended only when other options are unavailable. Thoughtful flap selection and design should supplant the need for multiple, simultaneous free flaps and vein grafting in most cases.