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Patients with gigantomastia have severely distorted anatomical breast structures. Reduction mammaplasty in such cases using the inferiorly based pedicle containing the nipple-areola complex can be technically difficult, yield poor results, and cause postoperative complications such as nipple necrosis and loss. Alternative traditional methods such as amputation mammaplasty with free nipple-areola transplantation usually results in a flattened, nonaesthetic breast with poor projection. This unacceptable result is due to the lack of central breast tissue required for normal anatomical projection. Herein, we describe a method of reduction mammaplasty for gigantomastia combining free nipple transplantation and an inferiorly based pyramidal parenchymal flap for augmentation of breast fullness and nipple projection.

The local immune response to allograft dermis and epidermis was studied in a rat skin-graft model. Biopsies taken at varying times after transplantation were analyzed using routine light microscopy and a panel of monoclonal antibodies. The dermis appeared to be spared by the rejection process, whereas the epithelium and adnexal elements of the dermis were destroyed. The persistence of dermis transplanted across major histoincompatibilities may allow it to be useful in reconstructing large skin losses.

A 10-month-old Hispanic male infant with expansile lesions of the third metacarpal and proximal phalanx positively diagnosed as Coccidioides immitis osteomyelitis is presented. Treatment consisted of combined surgical debridement and systemic antifungal therapy and resulted in complete resolution of the lesions. Treatment was guided by clinical response and complement fixation titers. Osteomyelitis is a relatively infrequent manifestation of disseminated coccidioidomycosis. Neonates and infants appear to be more susceptible to the development of dissemination, but less likely to develop toxicity due to systemic therapy. Current therapy consists of concomitant surgical excision of involved lesions and systemic antifungal therapy. Complement fixation titers correlate closely with clinical response to therapy and are useful in detecting subclinical recurrences.

Lower-extremity burns and skin grafts to these wounds have traditionally required extended hospitalization. We have used early tangential excision of the burn wounds and application of an Unna boot to fresh skin grafts in an attempt to shorten the hospitalization for such patients. Over a six-month period, 9 patients were treated with Unna boots to fresh skin grafts on the lower extremity. The average hospital stay was 0.9 days (range, 0 to 3 days). Graft take was 85% to 100%; no regrafting was required. Ambulation was begun 24 hours postoperatively. The technique described is a safe, effective, and inexpensive alternative to prolonged immobilization and hospitalization in patients with lower-extremity skin grafts.

We report the variability of the rejection process among the several tissues of a limb allograft. We used a rat hind limb allograft model transplanting across a well-defined minor histocompatibility barrier (Fischer RT-1(1v1)), donor animals, and Lewis (RT-1(1)) recipient animals. Continuous cyclosporin and prednisone immunosuppression was used. Four immunosuppressive regimens all produced extended limb survival. The rejection process was most severe and difficult to control in the skin. Nonskin tissues reverted to a nearly normal appearance after a period of cellular infiltration 2 to 3 weeks posttransplantation. Clinical and electromyographic evidence of nerve regeneration and end-organ reinnervation was demonstrated in long-term surviving animals.

To obtain objective data on the consequences of delayed treatment of facial fractures we reviewed the records of 220 patients who had suffered facial fractures concomitantly with extrafacial trauma severe enough in its own right to warrant hospital admission. Fractures studied were those of the mandible, maxilla, zygoma, and frontal sinus. Seventy-three patients fit inclusion criteria. Most injuries occurred in motor vehicle accidents. Associated extrafacial injuries were common and frequently multiple, the more serious of which generally took priority over the facial injuries in the triage system. The two most common reasons for delay were instability of the patient's neurological status, or initial non-recognition or poor definition of the facial fracture. Delays in treatment ranged from 0 to 24 days. In patients with mandible fracture only, delay of up to 24 days in definitive treatment led to no noticeable increase in morbidity due to malocclusion, infection, or nonunion. In no other facial fracture did treatment delay lead to an increased incidence of complications. Retrospective analysis of the patients who did suffer complications almost always revealed predisposing conditions that placed these patients at higher risk for poor results.

Thirty-one earlobe keloids in 20 patients were treated by complete surgical excision and three postoperative injections of .1 to .2 ml of 40 mg per milliliter of triamcinolone solution at four-week intervals beginning three weeks postoperation. Only 1 recurrence developed in a follow-up of twelve to sixty-two months.

We have employed a two-stage operative approach to the correction of Crouzon's/Apert's deformity. Extensive use of methyl methacrylate in cranioplasty and frontal bone advancement is employed to obtain finely detailed contours with excellent stability. By adhering to principles of separation of oral contamination and the methyl methacrylate, as well as the provision of adequate soft tissue coverage of the methyl methacrylate, the problems of infection and soft tissue breakdown can be minimized.