Evaluation of tests employed in serological diagnosis of brucellosis caused by Brucella ovis

A survey was carried out to verify the sensitivity and specificity of various tests (complement fixation test--CF; agar gel immunodiffusion--AGID; indirect enzyme linked immunosorbent assay--ELISA; immunoblotting--IB) employed in the serological diagnosis of brucellosis caused by Brucella ovis. The tests were executed on 44 blood serum samples of rams coming from B. ovis-free flocks, 75 of B. ovis experimentally infected rams and 1139 from rams living in flocks where B. ovis had been previously isolated. All tests were performed using B. ovis hot saline extract (HS) as antigen. Sensitivity results were 97.4% for IB, 98.68% for CF, 100% for AGID and ELISA; specificity was 100% for all methods. Concordance values were 89.62% (CF-AGID), 78.77% (CF-ELISA), 77.74% (AGID-ELISA), 65.45% (IB-CF), 62.93% (IB-ELISA), 67.24% (IB-AGID). IB identified antibodies to antigenic components with molecular weight of 67, 63, 58, 55, 38, 35, 32, 30, 28, 25, 23, 21, 20-18 kDa (proteins) and 15-12 kDa (rough lipopolysaccharide).

Vesico-ureteral reflux: diagnosis and staging with voiding color Doppler US: preliminary experience

INTRODUCTION

The aim of this study is to assess the accuracy of a new US examination: 'voiding color Doppler US ' in the early diagnosis and staging of vesico-ureteral reflux (VUR). The contrast agent US was SH U 508A (Levovist, Schering, Berlin), which produces a chromatic accentuation of the signals picked up by the color Doppler US. Eighteen patients (10 females, eight males) were recruited for the study. In two patients a second examination was performed for follow-up after a VUR conservative therapy. All patients were taken under examination for the evaluation of possible VUR. In all patients the voiding color Doppler US was followed by voiding cystourethrography (VCUG) and the data obtained were compared.

MATERIALS AND METHODS

A total of 18 patients aged between 3 months and 10 years, were recruited for the study. The results of the examination were the following: urinary tract infections, follow-up of VUR after conservative or surgical therapy, miscellaneous indications. Voiding color Doppler US was performed, followed by a VCUG. The voiding color Doppler US consists in the trans-catheter introduction of a contrast agent SHU 508 A (Levovist, Schering, Ag. Berlin) into the bladder and a subsequent test with the color Doppler US to show or exclude the presence of reflux into the ureters and/or into the pyelo-caliceal cavity of the kidneys. After the introduction of the contrast agent US the ultrasound scanning of the bladder, the ureters and the pyelo-caliceal cavity was performed to examine the reflux degree. The ultrasonographic investigations were perfomed with AU 590 asyncronus US (Esaote Biomedica, Genova) with a 3.5 MHz convex probe.

RESULTS

After the trans-catheter introduction of the contrast agent US, vesico-ureteral reflux occured in 13 patients (77.2%). The reflux degree was also measured by means of ultrasound and was later confirmed by VCUG. The mean times of each examination were as follows: initial US, 10 min; catheterization, 8 min; voiding color Doppler US, 15 min; overall VCURG examination 10 min. The overall mean duration of the voiding color Doppler US examination was 33 min. The comparable mean time for VCUG, including the catheterization time, was 20 min. No reactions of intolerance to the ultrasound contrast agent occurred.

DISCUSSION AND CONCLUSIONS

The voiding color Doppler US test has evidenced in all patients the presence of the contrast agent US in the bladder after the introduction. In 13 patients (77.2%) with presence of VUR, the voiding color Doppler US test has established the reflux degree confirmed by cystourethrography. The superimposability of the data obtained with voiding color Doppler US and VCUG would seem to confirm the importance of this new ultrasonographic technique in the diagnosis and staging of VUR.

An immunoblotting technique for the serodiagnosis of brucellosis by Brucella ovis

An immunoblotting (IB) technique was developed for the serodiagnosis of brucellosis caused by Brucella ovis. Immunoblotting was performed, using a B. ovis HS (hot saline extract) antigen, on 44 blood serum samples which came from rams belonging to known brucella-free flocks, 114 samples originating from ten experimentally B. ovis infected rams and 100 from rams of naturally B. ovis infected flocks. No bands were noted on any of the 44 serum samples which originated from known negative flocks. Sera from naturally and experimentally infected rams identified antibodies to antigenic components with molecular masses of 67, 63, 58, 55, 38, 35, 32, 30, 28, 25, 23, 21, 20-18 (proteins) and 15-12 (RLPS) kDa.

Epididymitis by Brucella ovis: experimental infection in virgin ram lambs

Ten sexually immature rams were experimentally infected with Brucella ovis, to verify the antibody kinetics and its localization in urinary and genital tracts. All animals became positive to the complement fixation test from the 2nd post infection (p.i.) week and reached the maximum titre (1:256) on the 4th p.i. week. Bacteriemia was demonstrated on 3rd, 4th and 5th p.i. weeks. Two animals, respectively slaughtered 11 and 13 weeks after the infection, showed macroscopic and microscopic genital lesions and the etiologic agent was cultured from their urine and genital organs.

[Retrograde echocystography: a new ultrasonographic technique for the diagnosis and staging of vesicoureteral reflux]

PURPOSE

We investigated the accuracy of a new US investigation technique, called retrograde cystography US, in the early diagnosis and staging of vesicoureteral reflux.

MATERIAL AND METHODS

We examined 5 patients, aged 3 months to 10 years, suffering from hydronephrosis and/or pyelonephritis. Retrograde cystography US was followed by conventional retrograde cystography. Retrograde cystography US consists in the transcatheter introduction of a contrast agent (Levovist, Schering AG, Berlin, Germany) into the bladder and a subsequent color Doppler examination to show or exclude the presence of reflux. Superpubic scanning of bladder, ureters and pyelocaliceal cavity was performed after echocontrast agent introduction to assess the reflux grade. US was performed with an Esaote AU 590 asynchronous scanner (Esaote Biomedica, Genova, Italy) with a 3.5 MHz convex probe.

RESULTS

After the transcatheter introduction of Levovist, vesicoureteral reflux was seen in 5/5 patients. Reflux grade was also measured with US and then confirmed at retrograde cystography. In a patient with pyelonephritis and no reflux at follow-up cystography, retrograde cystography US identified a unilateral reflux (grade 1).

DISCUSSION AND CONCLUSIONS

Retrograde cystography US showed the echocontrast agent in the urinary tract and assessed the reflux grade in all 5 patients, which was then confirmed at cystography. In a patient with grade 1 unilateral reflux at cystography US, follow-up conventional cystography showed no reflux, which seems to confirm a higher sensitivity of the US technique. The total agreement of conventional and US findings seems to confirm the importance of the US method for the diagnosis and staging of vesicoureteral reflux.

[Role of color Doppler ultrasonography with contrast media in the monitoring of hepatocarcinoma after intralesional treatment]

INTRODUCTION

We investigated the accuracy of contrast-enhanced color Doppler US in the assessment of the effectiveness of intralesional treatment of hepatocarcinomas.

MATERIAL AND METHODS

Eight cirrhotic patients (HCV+), Child-Pugh class B, with a single hepatocarcinoma (< 4 cm O) and ineligible for surgical resection for various reasons (age > 70 years, reduced partial hepatic reserve, esophageal varices at risk, postoperative recurrence, no consent to the operation) were submitted to radiohyperthermia (6 patients) and percutaneous alcoholization (2 patients). The diagnosis was made with alpha-fetoprotein titration. CT, B-mode and color Doppler US with the administration of Levovist (Schering AG, Berlin, Germany). Thirty and 60 days after the treatment, both the alpha-fetoprotein titration and contrast-enhanced color Doppler US were repeated.

RESULTS

Baseline color Doppler was carried out before intralesional treatment in the 8 patients and was followed by Levovist color Doppler which showed some intralesional signals, afferent vessels and rich vascularization in all the lesions. At the first follow-up (30 days), no intralesional vascular signals or afferent vessels were detected in any patient, while rich peripheral vascularization persisted in all cases, even after radiofrequency and alcoholization treatments. At 60 days' follow-up, the color Doppler pattern of all cases was the same as at 30 days.

CONCLUSIONS

The absence of any intralesional vascular signals in all the treated patients and the possible demonstration of complete tumor necrosis seem to confirm the important role of contrast-enhanced color Doppler US in monitoring focal hepatic lesions after intralesional treatment.

[Hepatic focal lesions: role of color Doppler ultrasonography with contrast media]

INTRODUCTION

The differential diagnosis of focal hepatic lesions is still studied by diagnostic imaging operators. A big step forward in the field of ultrasound (US) has come from the color Doppler mode permitting accurate studies of the vascularization of focal hepatic lesions. Echocontrast agents have further improved color Doppler sensitivity to slow flows and have permitted to visualize intralesional vascular signals which were missed at B-mode US. New data have thus been acquired which can be integrated with flowmetric findings to help make the correct differential diagnosis with a fair safety margin. We studied the pathognomonic US pattern for each type of lesion.

MATERIAL AND METHODS

We examined 55 patients with single hepatic lesions which had already been typified: they were 10 hepatic angiomas, 3 focal nodular hyperplasias (FNH), 2 hepatic adenomas, 20 hepatocarcinomas and 20 hepatic metastases. Color Doppler investigations were performed on each patient before and after the intravenous (i.v.) administration of an echocontrast agent (Levovist, Schering AG, Berlin, Germany). For each lesion we studied the morphological characteristics, the resistance index (RI) of intralesional arterial vessels, the hepatic perfusion index and the maximum speed in intralesional vessels.

RESULTS

Contrast-enhanced US showed no intralesional signals or afferent branches in 8 hepatic angiomas, which however exhibited some peripheral vascularization; weak intralesional vascular signals were demonstrated in 2 cavernous angiomas. Intralesional signals, as well as peripheral vascularization, were detected in the 3 FNH cases, which also exhibited a centripetal afferent branch; the hepatic perfusion index in these lesions never exceeded .25. The two hepatic adenomas had similar color flowmetry to FNH also after i.v. contrast agent administration, except for the contripetal afferent vessel which was not seen. In the 20 hepatocarcinomas, contrast-enhanced images showed numerous intralesional signals and afferent branches which, with the peripheral vascularization, resulted in a basket-like pattern. Flowmetry of intralesional arterial vessels showed an irregular systodiastolic range, with RI = .32 +/- .5 in 12 lesions and high in the remaining 8 lesions (RI = .82 +/- 10). The hepatic perfusion index was .65 +/- 10 in all patients. In 14 of the 20 hepatic metastases, B-mode US showed no intralesional signals except for 6 metastases from colorectal carcinoma, and contrast-enhanced findings were about the same. The hepatic perfusion index at flowmetry ranged .30 to .45 in all patients.

[Hemodynamic changes in patients with colorectal adenocarcinoma: the role of color Doppler US]

INTRODUCTION

Color Doppler US was used to study splanchnic hemodynamic changes in colorectal adenocarcinoma patients. The accuracy of the Doppler perfusion index (DPI) was also investigated. DPI measurements can provide precious information on the degree of hepatic circle arterialization and especially the early evidence of liver metastases which were previously undetected because they were below the resolution threshold of the other imaging techniques.

MATERIAL AND METHODS

Sixty patients were divided into 3 groups: a control group of 20 patients with negative laboratory and instrumental findings; a group of 20 patients with colorectal adenocarcinoma but no liver metastases; a group of 20 patients with liver metastases from colorectal adenocarcinoma. The patients were submitted to color flowmetry of the liver and splanchnic vessels following a strictly standardized protocol.

RESULTS

The DPI values were < 0.25 on all the controls and > 0.50 +/- 0.15 in the patients with liver metastases. The DPI values matched those of the controls in one third of the patients with a primary colorectal adenocarcinoma but no metastases and were > 0.30 in the remaining two thirds--though never as high as in the patients with liver metastases. A number of patients with DPI > 0.30 exhibited a marked reduction in the caliber and velocimetric profiles of the superior mesenteric artery.

CONCLUSIONS

The DPI was a very sensitive tool for measuring the degree of hepatic circle arterialization and therefore permitted the early detection of liver metastases when they are still below the resolution threshold of the other imaging modalities. The detection of reduced superior mesenteric artery caliber and flow in a number of patients with DPI > 0.30 seems to confirm the controversial hypothesis of the existence of a humoral neoplastic factor in patients with liver metastases from colorectal adenocarcinoma which would induce such changes through a direct or indirect mechanism.

Corrected transposition of the great arteries with isolated aortic coarctation: In utero echocardiographic diagnosis

Physiologically corrected transposition of the great arteries (cTGA), defined by discordant atrioventricular and ventriculoarterial connections, is an uncommon congenital cardiac malformation. It rarely exists without associated cardiac anomalies, the most common of which are ventricular septal defect, pulmonary outflow obstruction, tricuspid valve (systemic) deformity, and rhythm disturbances. Conversely, hypoplasia of the systemic ventricle and systemic inflow or outflow obstructions have seldom been reported, although their recognition may significantly influence surgical repair and the patient's prognosis. We report a case of cTGA with complete heart block, moderate hypoplasia of the systemic ventricle, and severe aortic coarctation that was echocardiographically diagnosed in utero at 30 weeks' gestation because of fetal growth retardation and persistent fetal bradycardia. After delivery the patient underwent epimyocardial pacemaker implantation and aortic coarctation repair at 2 weeks of age. Unfortunately, the patient died on the seventh postoperative day because of systemic ventricular hypertrophy. Although it is well known that fetal echocardiography may reliably diagnose uncommon congenital cardiac malformations, to the best of our knowledge, this paper represents the first reported case of antenatal diagnosis of this complex anomaly.

Leptospira interrogans in the genital tract of sheep. Research on ewes and rams experimentally infected with serovar hardjo (hardjobovis)

To verify if Leptospira hardjo can colonize the male and female genital organs of sheep, 9 animals (6 non pregnant ewes and 3 mature rams) were infected with a strain of L. hardjobovis recently recovered from the kidneys of a seropositive ewe. Postinfection controls (bacteriologic, serologic, immunohistochemistry and electron microscopy) failed to disclose the presence of leptospires in the uterus and oviducts, testicles, epididymis, prostate and bulbourethral glands of animals used for the experiment and slaughtered from 37 to 242 postinfection days. All animals showed a renal localization of L. hardjobovis lasting for the entire period of the study (over 8 months). These results emphasize the important role of sheep as maintenance hosts of the serovar.

Leptospira interrogans serovar hardjo in the kidneys and genital tracts of naturally infected sheep

A bacteriological study was carried out to identify possible renal and/or genital carriers of Leptospira interrogans serovar hardjo. L. hardjo was found at slaughter in the kidneys of three seropositive ewes, but not in uterus or salpinges of these animals.

[The echographic anatomy of the larynx and the perilaryngeal structures]

The normal laryngeal and perilaryngeal structures (neither nodal nor vascular) of 120 healthy and informed volunteers and of 46 patients with extralaryngeal neck conditions were studied with ultrasonography (US). The study was performed with a high-frequency linear probe on the transverse and sagittal planes; the patients were examined supine, with neck hyperextension, during quiet breathing, in inspiratory and expiratory breath-holding, during Valsalva maneuver or phonation. Axial scans clearly depict, in cranio-caudal direction, the base of the tongue, the hyoid and adjacent muscular structures. At the laryngeal vestibule epiglottis is always clearly demonstrated as a thin hypoechoic curvilinear rim and the pre-epiglottic space as a fat-filled and markedly echogenic structure. Pyriform sinuses are more difficult to study with US and should therefore be always distended by air during Valsalva because no suitable US contrast agent is available for their exploration yet. The ossification of thyroid laminae prevents or hinders the exploration of endolaryngeal structures because of consequent posterior acoustic shadow. In case of partial ossification or cartilaginous thyroid laminae, paraglottic spaces are easily demonstrated with US, as well as the false cords and, partially, arytenoids and posterior laryngeal wall muscles. The muscular structure of the true cords, their mobility in the M-mode and, in half of the cases, the thin vocal plicae joining anteriorly in the anterior commissure, are easily depicted with US. To conclude, US permits to demonstrate normal laryngeal anatomy by a quick and harmless examination in several breathing and phonation phases, which is an essential premise to the correct interpretation of abnormal US findings.

Isolated atrial inversion in situs inversus: a rare anatomic arrangement

Isolated atrial inversion in situs inversus is a rare congenital cardiac malformation. Its physiology resembles transposition of great vessels, and the best option for its surgical treatment is the atrial switch operation. In this article, we present a case of isolated atrial inversion in concordance with visceral situs inversus diagnosed at birth by echocardiography and cardiac catheterization, which was successfully treated at 8 months of age by a Senning procedure.

Experimental infection of dogs with Borrelia burgdorferi

Four beagle dogs were inoculated subcutaneously with the BITs1 Italian strain of Borrelia burgdorferi. Only one dog became infected and B burgdorferi was isolated from its blood and urine three and four weeks after infection. B burgdorferi antibodies were detected by immunofluorescence from four to 11 weeks after infection. An uninoculated dog kept in the same run as the infected dog, developed a positive serological response, but none of the five dogs showed clinical signs.

The effects of sulphur dioxide on the parasitism of the rust fungus Uromyces viciae-fabae on Vicia faba

Vicia faba cv. Aguadulce was grown in fumigation chambers ventilated with filtered air or air containing sulphur dioxide (SO(2)) at controlled concentrations, and inoculated with the rust fungus Uromyces viciae-fabae. The influence of the pollutant was rated in terms of production of uredia and dehiscent urediospores. Exposures to SO(2) levels around 70-90 nl litre(-1) enhanced uredia density. Pre-inoculation fumigations at 70-86 nl litre(-1) increased uredia density, whilst post-inoculation fumigations stimulated urediospore production. Lower concentrations increased diffusion resistance of the host plant and slightly increased uredia density. Concentrations between 100 and 130 nl litre(-1) were somewhat inhibitory for the parasite, even in the absence of any visible damage symptoms on the host. Total sulphur accumulation in leaf tissue was reduced by the presence of the fungal infection. Growing under SO(2) pollution neither decreased germination ability nor modified morphological parameters of the urediospores. However, elongation of the germination tube of spores coming from filtered air was adversely affected by the pollutant.

Plastic surgery for the management of palmoplantar keratodermia (palmoplantoneoplasty)

Keratodermia is an incurable genetic and regional disease located in the palmar and plantar regions. The author reports his experience with five cases of palmoplantar keratodermia that were treated by grafting onto the soles and the palms skin taken from the calves and the thighs.

Ineffectiveness of ceruletide to reduce food intake and body weight in obese women hospitalized for weight reduction and treated with a restricted diet. A double-blind study

Ceruletide is a synthetic decapeptide closely resembling the 8-carboxy-terminal peptide of cholecystokinin (CCK-8) with which it shares several biological properties. In a double-blind study versus placebo, we evaluated the effects of ceruletide on self-rated hunger and food intake at lunch time, as well as on body weight in 14 obese women hospitalized for weight reduction and on a restricted diet. During two 6-day courses of treatment with ceruletide or placebo, ceruletide 0.3 microgram/kg b.wt. or an equivalent volume of its diluent were injected IM at 11.30 a.m., i.e., 30 min before lunch. Feelings of hunger were quantitated, using a visual analogue self-rating scale, prior to the injection of ceruletide or placebo and 30 min thereafter, i.e., just prior to the start of meal ingestion, as well as 2 hr after the start of the meal. Duration and caloric content of food ingested at lunch, as well as morning body weight, were recorded daily. Ceruletide, compared to placebo, did not significantly influence any of the above variables. However, in the first three experimental days, the increase in self-rated hunger from values before the injection to 30 min thereafter was less marked, though not significantly so (0.05 less than p less than 0.1), with ceruletide than with placebo. Thus, it appears that ceruletide, under the experimental conditions of the present study, was not effective in enhancing the patients' motivation to lose weight and to further restrict their food intake at lunch time.(ABSTRACT TRUNCATED AT 250 WORDS)

A possible explanation of the effects of dietary lactose concentration during recovery of protein depletion in growing rats

It is generally accepted that lactose intolerance is a cause of delayed recovery from malnutrition. To discriminate the true importance of this factor, the effect of dietary lactose concentration on "catch up" growth was studied on rats fed a protein free diet from weaning to 34 days of age and then refed "ad libitum" with diets providing different levels of Protein Calories (P%: 5, 11, 17 and 25%) and Lactose (L%: 0, 1, 15, 27 and 37%) for 4 days. Weight changes, daily dietary intakes and gastrointestinal disorders (GID) were recorded. The growth rate (GR) -g/100g rat/day- showed a direct correlation with P% whereas a decrease in (GR) as well as in Protein Utilization (PU) was associated with increasing L%, the higher the P%, the greater the effect of L%. The observed effect of lactose on (PU) does not correlate with (GID). Analysis of intake data -expressed as calories/day/W0.73- showed that animals ate less diet when lactose was present resulting in energy restriction (ER) from 12 to 62%. A primary effect of food intake might be proposed as a limiting factor for (GR) and (PU) in rats recovering from depletion. The influence of P% on improved lactose tolerance must also be stressed.

The prominent nasal tip

The authors associate the projection of the nasal tip to hypertrophy of the alar cartilages and, more specifically, of their medial branches. The heavy, blobby, or bulbous nose is caused by an increase of the columellar-alar angle of the alar cartilages, and bears no relationship to the cephalometric nasal index. Moreover, the bulbous nose usually has excess fatty tissue present in the tip of the nose. The projecting tip may be corrected by excising a rectangular or quadrangular segment from the medial branches of the alar cartilages, or by resecting the cupula of the alar cartilages, including a small or large segment of its medial branch, in order to obtain the desired effect, namely, to lower the tip and decrease the columellar-alar angle. The nasal index remains unchanged. If in addition, the tip of the nose is bulbous, the fatty tissue should be removed at the same time.

Traumatic nasal deformities

Lateral deviations of the nose can be caused by various violent injuries or even by unsuccessful surgery (iatrogenic). Early treatment of fractures is not only bloodless but very much easier in contrast to older injuries which can only be corrected by surgery. Under these circumstances, a complete revision and repositioning of the upper and inferior lateral cartilages or alar cartilages is advisable. In both cases, the simultaneous correction of the affected septum is fundamental. The authors recommend packing of the nasal cavities for 5 days and immobilization with an aluminum splint for 7 days.

S-shaped nasal wings: rhinopteroplasty. Case reports

The authors discuss the S-shaped nasal wing that is responsible for pseudocryptocolumella. Simple excision of a spindle-shaped cutaneous wedge from the lower rim of the nasal wings corrects this imperfection. The cosmetic appearance is satisfactory and the resulting scar scarcely noticeable.

Saddle and boxer's nose

The deformities known as saddle nose and boxer's nose result from injuries or poorly planned nasal surgery. Boxer's nose may eventually be corrected using Straith's method. It is possible to correct both deformities by simply using a bone graft. Neither the use of cartilage grafts nor organic or inorganic inclusions are recommended, the former because they tend to deform, and the latter because they are not well tolerated. There are many advantages to using bone grafts taken from the tibia, including good integration and successful results. This personal method has been used by us since 1948, and is based on the principle of the first-class lever.

Surgical treatment of male impotence

There are numerous causes of male sexual impotence: these may be classified as organic or psychic. All possible clinical options should be explored before resorting to surgery for impotence. Many techniques are available for surgical correction of impotence. The authors have used Small-Carrion's implantation of a silicone prothesis with success in a number of patients, ranging in age from 28 years to 78 years.

Fecal cholesterol excretion studies in type II hypercholesterolemic patients treated with the soybean protein diet

The fecal steroid elimination profile was studied in 7 type II hyperlipoproteinemic patients given a low-lipid diet with textured soybean proteins, in order to define the mechanism of the hypocholesterolemic activity of this new dietary regimen. Four of the patients followed a 3- + 3-week cross-over protocol, comparing the soybean diet with a reference low-lipid diet with animal proteins. In these, fecal neutral steroids and bile acids were analyzed by chromatography during the two dietary periods. In spite of the clear hypocholesterolemic effect, no significant differences in steroid output were noted between the two dietary periods. In the 3 remaining patients, a chromatographic + isotopic method (by injecting 14C-labelled cholesterol i.v. 4-6 weeks prior to the dietary study) was employed. Again, no marked changes were noted in the fecal neutral steroid and bile acid outputs and the slope of the decay curve of the plasma cholesterol-specific activity was not changed by the experimental diet, in spite of the remarkable decrease in plasma cholesterol. The reported results do not provide a definitive contribution to the mode of action of the soybean protein diet. They suggest, however, that it is not an effect mediated by undigestible dietary components. The possibility of a cholesterol redistribution from plasma to tissue pools should be considered.

Plastic surgery of the breast

The authors divide the techniques of reduction mammoplasty into two groups. The first one is done by the so-called classical method in which the two important pedicles--the medial (internal mammary artery) and the lateral (lateral thoracic artery)--are preserved. The second one is made through the free transplant of the areolar, chiefly in those cases of large hypertrophic breasts. Both methods give good results in experienced and skillful hands, as well as good satisfaction to the majority of our patients. On the other hand, complications may arise, as in every field of plastic surgery.