Faculty Bibliography

BACKGROUND: Gynocomastia is a relatively common condition in men, with a reported overall incidence of 32% to 36% and as high as 65% among adolescent males in some series. OBJECTIVE: We reviewed the senior surgeon's experience over the past decade in the surgical treatment of gynecomastia using suction-assisted lipoplasty (SAL) with a cross-chest tunneling technique, performed alone or in combination with direct excision. METHODS: Thirty-four patients with gynecomastia were evaluated and treated surgically at the University of Texas Medical Branch in the past 10 years. Twelve were treated with cross-chest SAL alone, 16 with cross-chest SAL and direct excision, and 6 with direct excision. Infusion of wetting solution was performed with the use of a 2.0-mm cannula, through an access site at the medial border of the contralateral nipple-areolar complex. Next, a 4.0-mm Mercedes-tip (Byron/Mentor Corp., Santa Barbara, CA) cannula was tunneled across the sternum to liposuction the contralateral prepectoral fatty breast. Patients with composite fatty and glandular tissue first underwent SAL, then direct excision through a periareolar incision; those with only retroareolar glandular tissue underwent direct excision alone. RESULTS: All patients who underwent SAL alone or SAL combined with excision had satisfactory aesthetic results and no reported postoperative complications. In one patient who underwent excision alone, a hematoma developed. CONCLUSIONS: Despite newer technologies, traditional SAL performed with a cross-chest technique and direct excision as indicated is a valuable approach that yields predictable success. This approach avoids scarring and offers a sculpted reduction of the retroareolar glandular and fatty elements, resulting in a natural, smooth breast contour

Glutathione peroxidase is a selenium-containing, antioxidant enzyme previously implicated in the risk and development of lung and breast cancer, in part the result of allelic loss at the GPx-1 locus. This study examined allelic loss at the same locus in squamous cell carcinomas of the head and neck. The frequency of a polymorphism at codon 198 resulting in either a leucine or a proline at that position was surveyed by comparing 133 DNA samples obtained from head and neck tumors and 517 samples obtained from cancer-free individuals. Tumor DNAs exhibited fewer pro/leu heterozygotes as compared to DNA obtained from the cancer-free population. Fewer GPx-1 heterozygotes were verified by determining the frequency of highly polymorphic alanine repeat sequences in the same gene. The analysis revealed an approximately 42% reduction in heterozygosity in the DNA from the tumor samples. In order to assess loss of heterozygosity (LOH) at the GPx-1 locus, DNA was genotyped from peripheral lymphocytes, tumor tissue, and microscopically normal tissues adjacent to the tumor, derived from the same patients. These studies indicated LOH at the GPx-1 locus in each of the three tumor/normal tissues sample sets examined. Furthermore, LOH in the microscopically normal tissues at the tumor margin occurred in two of the three sample sets examined. These data implicate GPx-1 in the development of squamous cell carcinoma the head and neck and suggest that allelic loss of this gene, or one tightly linked to it, is an early event in the development of this type of malignancy

CASE REPORT: We present the case of 2-year-old craniopagus twins who are in the process of undergoing a staged separation of their craniums. In addition, they will undergo a full calvarial vault remodeling to reconstruct the lacking skull and scalp tissue in each child. We elected to do a staged separation rather than a single marathon operation for various reasons, which we will detail in this report. DISCUSSION: The philosophy and surgical management of each step will be discussed along with the pros and cons behind the reasoning that was used. At the time of this report the children have undergone three of what are projected to be four stages of separation. Each of the stages has had unique characteristics and surgical judgments involved, and those will be reviewed. CONCLUSION: Successful separation of viable conjoined twins has been historically a great rarity. Successful separation of twins where both have come out of surgery without any neurological deficit remains a rare occurrence and in our mind the ultimate goal

Studies of adult patients with unoperated complete unilateral cleft lip and palate indicate that there is normal potential for maxillary growth. The maxilla in the unoperated patient is normally positioned or protruded. The protrusion of maxilla in the unoperated adult cleft patient is limited to the non-cleft side, contributing to hemifacial maxillary prognathism. Surgical scar tissue is known to interfere with the growth of the midface. Palatal surgery has more significant influence on the growth of the mid-face than the lip surgery; therefore, it is important to reduce the effect of surgery by delaying the timing of palatal surgery or changing the location of the surgical scar from the sutural areas. Delaying palatal surgery until the maxillary growth is complete is desirable but could lead to poor speech development. Therefore, it is essential to perform the palatal surgery before speech development. The other variables that affect the midface are the development genetic make-up of the cleft child, the amount of tissue deficiency, timing of surgery, surgical technique, and the skill of the surgeon. Surgeries continue to have some inhibitory effect on maxillary growth, but it is essential to recognize and perform those surgical procedures that have the least effect on growth of the maxilla. This will help minimize extensive orthodontic treatment and eliminate major secondary orthognathic surgery for correction of the abnormal growth of the maxilla

In this study we have developed and tested a novel pain questionnaire to measure the pain experienced by patients with oral squamous cell carcinoma. The questionnaire consisted of 8 questions rated by the patient on a visual analog scale. Patients completed the questionnaire at the time of initial presentation before surgical treatment. None of the patients were taking analgesics. The responses were then scored and compiled with patient data and pathology reports. Of the 15 completed questionnaires, 14 patients reported some level of functional restriction from pain (mean, 46.6 +/- 25.2, scale of 0 to 100 mm). On average, patients experienced significantly higher function-related, rather than spontaneous, pain intensity and sharpness. Men (n = 8) had a significantly higher level of function-related pain intensity and sharpness than women had (n = 7). There was a strong correlation between nodal disease and increased levels of spontaneous intensity, sharpness, throbbing, and overall functional restriction. PERSPECTIVE: The results of this study indicate the heterogeneous nature and function dependence of oral cancer pain. The questionnaire we have developed in this study will allow for correlations between pain parameters and specific tumor biology in future studies

PURPOSE: Although an important risk factor for oral cancer is the presence of epithelial dysplasia, many lesions will not progress to malignancy. Matrix metalloproteinases (MMPs) are zinc-dependent proteinases capable of digesting various structural components of the extracellular matrix. Because MMPs are frequently overexpressed in oral squamous cell carcinoma (SCC), we hypothesized that they are also overexpressed in oral dysplasias; we also hypothesized that those dysplasias that progress to oral cancer express higher levels of MMPs than those lesions that do not progress. EXPERIMENTAL DESIGN: In this retrospective study, we examined changes in MMP-1, -2, and -9 mRNA expression using quantitative TaqMan reverse transcription-polymerase chain reaction in 34 routinely processed oral dysplasias and 15 SCCs obtained from 34 patients. After several years of close follow-up, 19 dysplasias progressed to oral SCC and 15 did not. RESULTS: Overall, MMP-1 mRNA was overexpressed (>2-fold) in 24 of 34 (71%) dysplasias and 13 of 15 (87%) oral SCCs. MMP-2 overexpression was seen in 11 of 34 (32%) dysplasias and 7 of 15 (47%) cancers; for MMP-9, overexpression was identified in 29 of 34 (85%) dysplasias and 15 of 15 (100%) cancers. MMP-1 and -9 levels were significantly higher in the SCCs compared with all oral dysplasias (P = 0.004 and P = 0.01, respectively). MMP-1 and -9 mRNA levels were significantly higher in the oral dysplasias that progressed to oral cancer compared with those that did not (P = 0.04 and P = 0.002, respectively). CONCLUSIONS: Levels of MMP-1 and -9 mRNA may be markers of malignant transformation of oral dysplasia to oral cancer

PURPOSE: The study goal was to evaluate neurosensory changes after liquid nitrogen cryotherapy in the management of mandibular lesions in close proximity to the inferior alveolar nerve. PATIENTS AND METHODS: The design of the study was a retrospective review. Sixteen patients with posterior mandibular lesions (15 odontogenic keratocysts and 1 fibromyxoma) in close proximity to the inferior alveolar nerve were treated with a standardized enucleation and cryotherapy technique. Postoperative evaluation included patients report of symptoms and formal neurosensory testing. RESULTS: All patients had altered sensation in the distribution of the inferior alveolar nerve immediately after cryotherapy. Two patients experienced anesthesia, and the remaining 14 patients showed paresthesia. The average time for return or improvement in sensation was 91 days (range, 6 to 235 days). The average time of follow-up was 2.6 years (range, 0.5 to 7.3 years). At the time of last follow-up, no patients had anesthesia or dysesthesia. Four patients had full return of sensation and 12 patients had paresthesia. No patients reported significant difficulty from abnormal nerve function. All 16 patients experienced some return of sensation; 9 patients had full or near full return of sensation. CONCLUSIONS: Based on these results, the combination of enucleation and liquid nitrogen cryotherapy produces minimal alteration of inferior alveolar nerve function

PURPOSE: The association between tobacco smoking and oral squamous cell carcinoma is well established. However, few studies have evaluated the smoking history based on a smoking versus never-smoking history or analyzed the relationship between smoking history and site and stage of presentation. The purpose of this study was to examine the relationship between smoking versus never-smoking history and the stage and site of presentation of oral squamous cell carcinoma. PATIENTS AND METHODS: The design of this study was a retrospective review of all patients presented at the Legacy Emanuel Hospital Head and Neck Tumor Board in Portland, Oregon, with a biopsy-proven oral squamous cell carcinoma between 1998 and 2000. Data collected included age, gender, smoking history (smoker versus never smoker), pack-years of tobacco, site, and stage (T, N, and group stage) at presentation. RESULTS: A total of 67 patients were reviewed; 33% of patients were never smokers and 67% of patients had a history of smoking with an average of 49.4 pack-years. The floor of mouth and gingiva were the most commonly affected sites. There was a statistically significant difference between site of presentation and a history of smoking (P =.0007). The 2 sites that showed a significant association with smoking were posterolateral tongue and floor of mouth. CONCLUSIONS: The findings of this study demonstrate that approximately one third of patients with oral squamous cell carcinoma will report that they have never smoked. There was a strong association between a history of smoking and carcinoma involving the posterolateral tongue and floor of mouth