The aging face

Facial aging is a dynamic process which continues throughout adult life. Individuals are affected to a variable degree depending on facial motor habits, exposure and susceptibility to damaging ultraviolet radiation, smoking, and the microscopic tissue changes inherent to the aging process. Aside from avoiding smoking and utilizing sunscreens and other solar protection, there is little that can be done to prevent or retard the development of these changes. There is, however, a vast array of corrective procedures which may be utilized in a planned, sequential fashion to deal with age-related deformities as they occur.

The analysis and correction of nasal columella deformity--a review

Rhinoplasty surgeons must often adjust the nasal columella as part of a functional or cosmetic operative procedure and may, on occasion, be called upon to correct the columella as an isolated deformity. The anatomy of the nasal columella with its various components provides a framework for the classification and analysis of deformities of this structure. Discussion of the various approaches and techniques of correction of this deformity is undertaken. It is our intent to share a system of analysis and correction of columellar deformities to both simplify and improve the end result of undertakings for correction of this area of the nose as well as the whole nose.

Adrenal glands in patients with congenital renal anomalies: CT appearance

The CT appearance of the adrenal glands was investigated in 30 patients with congenital renal anomalies (17 cases of unilateral renal agenesis, 11 of inferior ectopy, and 2 of crossed fused ectopy). The ipsilateral adrenal was clearly identified in 83% of these patients; in all of them, the adrenal was a paraspinal disk-shaped organ, which appeared linear on CT. Conversely, the adrenals retained their normal shape in a control group of 20 patients with acquired renal atrophy or prior simple nephrectomy.

Scrotal masses caused by meconium peritonitis: prenatal sonographic diagnosis

Although uncommon, meconium peritonitis can present with a scrotal mass. Usually calcified, this mass may be the initial or only sign of meconium peritonitis. We detected such a scrotal mass prenatally with ultrasound.

Rehabilitation of the paralyzed lower lip

There is a continuum of smiles from the one of the reserved Mona Lisa to a full dental smile where there is maximal exposure of teeth and full triggering of all the major and minor smile muscles. The ramus mandibularis paralysis is more obviously noted in the full dental smile. The ramus mandibularis paralysis is best corrected through a technique of wedge resection of the lower lip with a segmental sling to the nasolabila groove.

Collagen implant: an early assessment

Injectable collagen has been used successfully to improve skin contour defects. This paper will briefly review the biosynthesis, the preparation, and the clinical application of this new material. Collagen is the major structural protein of the extracellular matrix and provides a scaffolding for the support cells. Skin collagen is composed of short fibriles grouped in bundles which are randomly orientated to provide strength and resiliency in all directions of the skin place.

Pulmonary veno-occlusive disease in association with Hodgkin's disease

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Narrowing of the wide nasal tip

The causes of wide nasal tips include: 1) bulbous lateral crura; 2) wide arching between the medial and lateral crura; 3) thick skin; and 4) wide interdomal distance. In primary rhinoplasty, most tip width is found to be caused by the bulbous lateral crura and wide arching between the lateral crura of the lower lateral cartilages. In some patients the interdomal distance must be narrowed to give the esthetic desired result. An interdomal distance greater than 3 mm should be corrected. The technique of unilateral partial delivery of the right crus up to and including the dome, with removal of the soft tissue between the separated medial crura, is described as an efficient way of narrowing the interdomal distance. This technique was required in 5% of the cases.

Subacute massive pulmonary embolism treated with plasminogen and streptokinase

Major pulmonary embolism occurring insidiously over several weeks (subacute massive pulmonary embolism) has a high mortality and may not respond well to standard anticoagulant or thrombolytic treatment. A priming dose of plasminogen was used to enhance thrombolysis produced by a streptokinase infusion in five consecutive patients with subacute massive pulmonary embolism. In each patient a dramatic clinical improvement occurred with a substantial increase in pulmonary blood flow. All five patients survived to leave hospital. Malignant disease was the underlying cause of embolism in three patients, two of whom died of their malignant disease in the six months after treatment of their pulmonary embolism. The third patient with malignant disease had a choriocarcinoma; at least some of the pulmonary obstruction may have been tumour tissue but this obstruction was dramatically cleared by the treatment. The use of a combination of plasminogen with streptokinase should be considered in severely ill patients with subacute massive pulmonary embolism, particularly if other treatment, including streptokinase alone, has failed.

Role of lung scanning in assessing the resectability of bronchial carcinoma

Ventilation and perfusion lung scans were performed in 58 patients before operation for bronchial carcinoma to determine in which patients the lung scan was most useful for assessing mediastinal spread and resectability of the tumour. Perfusion of the affected lung was less with larger and more centrally situated tumours. Perfusion was also less for left-sided than for right-sided tumours but this is explained by the normal differential perfusion of the right and left lungs. The lung scan was unhelpful in predicting resectability of peripheral tumours, but with central tumours if perfusion of the affected lung was less than 25% of the total perfusion the lesion was likely to be non-resectable because of spread to the mediastinum. Airways obstruction was present in 67% of the patients but did not interfere with the interpretation of the scans. In most cases ventilation scans provided no additional information, and the use of krypton-81 m as a sensitive indicator of regional ventilation did not improve on the predictive value of the perfusion scan.

Effect of oral salbutamol and slow-release aminophylline on exercise tolerance in chronic bronchitis

In a double-blind placebo-controlled trial in 24 patients fulfilling the MRC criteria for chronic bronchitis, oral salbutamol 4 mg and slow-release aminophylline (Phyllocontin) 450 mg produced similar and significant (p less than 0.05) mean increases in forced expiratory volume in one second (FEV1). A significantly greater increase in mean FEV1 and forced vital capacity (FVC) was seen when both drugs were given although there was no statistical evidence of synergistic interaction. Salbutamol significantly increased the mean distance walked in 12 minutes (12MD) (p less than 0.02) by 56 metres and a similar increase of 54 metres (p less than 0.001) was seen after Phyllocontin. With both drugs in combination mean 12MD increased by 51 metres (p less than 0.02 cf placebo), a change not significantly different from that observed with either drug alone. Oral salbutamol and Phyllocontin improve exercise tolerance in chronic bronchitis. The significantly greater changes in FEV1 and FVC resulting from simultaneous administration of the two drugs are not associated with further improvement in exercise tolerance.

Present outlook in bronchiectasis: clinical and social study and review of factors influencing prognosis

One hundred and sixteen patients with proven bronchiectasis diagnosed at least five years previously were studied to determine the clinical outcome, change in pulmonary function, and degree of social disability. Twenty-two patients had died and the mean duration of follow-up in the survivors was 14 years. The patients who died were characterised by a poorer initial ventilatory capacity than the survivors and cor pulmonale was present in 37% at the time of death. The survivors showed a tendency for improvement in symptoms whether treated surgically or medically. Thirty per cent were better than at diagnosis while only 11% were worse. Measurements of FEV1 and FVC were made at diagnosis and at review, mild airways obstruction being the predominant abnormality. The change in pulmonary function was expressed as the decline in FEV1 in ml/yr. The decline in FEV1 was no greater than expected in 80% of patients and in a further 15% was of the order seen in cigarette smokers with mild airways obstruction. Poor ventilatory capacity was therefore not an important limitation in these patients. Of the survivors 77% had a good work record with less than two weeks loss of work annually from chest illness. The spouses of all married patients were interviewed at home by a trained social worker. Fifty per cent reported no social problem but 46% of spouses found the patient's cough distasteful and 29% of couples had experienced difficulties with normal sexual life. Seven per cent of the patients were severely disabled. While the overall prognosis of our patients was good a minority still have severe physical and social problems as a result of bronchiectasis.

Major facial trauma--the effect of legislation

In January 1976, new seat belt legislation was enacted and speed limits in Ontario were reduced from 70 to 60 miles per hour. This has led to a significant decrease in major facial trauma reducing the medical experience of the surgeons handling these problems. Major facial trauma, however, is often complex and may require the services of neurosurgery and ophthalmology. It compels the otolaryngologist to be aware of these complications so that effective and efficient treatment may be instigated. A recent case illustrates these complications.

Use of the fascial plane system in the facelift operation

The shifting of skin and superficial musculo-aponeurotic system (SMAS) fascia in the facelift procedure represents an important development in the improvement of the lax and sagging skin of the face and neck. The pathology of aging skin is reviewed, the anatomy of the SMAS fascia is described, and the use of SMAS fascia in surgery along with attendant potential hazards are discussed.

Indications for internal maxillary artery ligation in the treatment of epistaxis

Following a review of 13 cases of epistaxis treated by internal maxillary artery with anterior ethmoidal artery ligation over a three year period at the Toronto General Hospital certain indications for ligation have evolved. These are: 1) hospital stay longer than five days, 2) total number of nasal packs more than three, 3) concomitant disease aggravating control, 4) blood transfusion in excess of five units, 5) massive epistaxis.

Failure of propranolol and metoprolol to alter ventilatory responses to carbon dioxide and exercise

Neither propranolol (80 mg) nor metoprolol (100 mg) give orally to eight normal subjects altered mean ventilatory responses to carbon dioxide or to moderate graded exercise. Incremental doses of the drugs to totals of 320 mg propranolol and 400 mg metoprolol also did not effect these ventilatory responses. Both drugs markedly decreased the heart rate response to exercise. Neither propranolol nor metoprolol are likely to cause CO2 retention by an effect on the ventilatory responses to inhaled carbon dioxide or to exercise.

Evaluation of the paralyzed face

The face is a dynamic organ of expression and communication. It is the most important area for recognition and identification of an individual. Paralysis of the face disturbs these social factors deeply. An understanding of facial movment and anatomy is presented to allow for better cosmetic and functional analysis. Hence, medico-legal documentation and the selection of the appropriate techniques for surgical rehabilitation becomes a simpler task.

The bite in the temporomandibular joint pain dysfunction syndrome

After reviewing the anatomy of the temporomandibular joint, the soft tissue classification of this syndrome is divided into three groups: macrotrauma, microtrauma, and stress situation. In each group, the etiology, physical findings, pathophysiology, and treatment are discussed. Bite assessment is reviewed so that the otolaryngologists will have a fuller understanding of the role that occlusal status plays in this syndrome. Before contemplating surgery, this status should be assessed by a competent dental colleague.

The effect of aerosol ipratropium bromide and salbutamol on exercise tolerance in chronic bronchitis

In a double-blind placebo controlled trial in 24 patients fulfilling the MRC criteria for chronic bronchitis, ipratropium bromide 40 microgram and salbutamol 200 microgram produced similar and significant (P less than 0.001) increases in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). A greater increase in FEV1 and FVC was seen when both drugs were used together, but this increase did not differ significantly from that produced by either drug alone. Salbutamol increased 12-minute walking distance significantly (P less than 0.001) by 62 +/- 15 metres, whereas the increase of 43 +/- 15 metres observed after ipratropium was not significant (P less than 0.05). With both drugs in combination 12-minute walking distance increased by 72 +/- 15 metres, but this change was not significantly different from that observed with salbutamol alone. If aerosol bronchodilators in the doses used in this study are to be given with a view to improving exercise tolerance in such patients than salbutamol would appear to be the aerosol of choice.

Exacerbations of chronic bronchitis: exogenous or endogenous infection?

Six male patients with chronic bronchitis, who were known previously to have excreted Streptococcus pneumoniae and/or Haemophilus influenzae, both at the times of exacerbations and during remission, were studied for 43 to 52 months. Sputum was examined fortnightly and at the time of exacerbations. Strains of Strep. pneumoniae were serotyped and those of Haemophilus species were typed by antibiograms along with other supporting methods. Sera collected before or at the time of an exacerbation and seven and 30 days afterwards were examined by complement fixation tests against respiratory viruses and Mycoplasma pneumoniae. In 18 out of 25 exacerbations there was evidence of a new type of Strep. pneumoniae and/or Haemophilus spp. or of a current virus infection, suggesting exogenous infection in the majority of these cases. There was a possible reason for failure to detect a new pathogen in three of the seven cases in which none was found. In five further exacerbations adequate investigation was not possible.

Pre- and postoperative management of the rhinoplasty patient

The role of the otolaryngologist has widened to include facial cosmetic surgery. As such it encompasses all aspects of age-diminishing surgery as well as facial contour augmentation, surgical and traumatic scar camouflage, and otoplasty as well as rhinoplasty. It necessarily follows that the rhinoplasty surgeon must view the total face rather than the nose in isolation. A complete understanding of the indications and contra-indications of rhinoplasty is necessary for adequate pre- and postoperative assessment of the patient. These ideas are developed and the analysis of the nasal pathology is discussed.

Incorporation of [U-14C]glucose into neutral lipids and sn-glycerol-3-phosphate in muscle from Duchenne muscular dystrophy and control patients

Muscle biopsy tissue from patients suffering from a wide range of neuromuscular disorders, normal muscle removed during regular orthopaedic procedures, and muscle from aborted human fetuses of 12--20 weeks gestation was dissected into fibre-bundles and incubated at 37 degrees C with [U-14C]glucose at a final concentration of 4 mM. Extracts made: (i) after 30 min were used to determine content and radioactivity of sn-glycerol-3-phosphate, and (ii) after 160 min for separation of lipid species. Dystrophic muscle from 8 patients with typical Duchenne dystrophy converted significantly more glucose than normal muscle (11 samples) into neutral lipids, but less into polar lipids. Of total lipid radioactivity a mean value of 66% was found in neutral lipid in the Duchenne group, while in various control groups this proportion was about 40%. The disparity observed was the result of greater incorporation of glucose label into triglycerides, chiefly in the glycerol moiety of the Duchenne group lipids, and was some 3 times greater than normal. Other muscle disease groups also showed slightly raised levels of incorporation but these were not statistically significant in the present series of results. The content and radioactivity of glycerol phosphate in muscle from 15 patients with Duchenne dystrophy were also significantly higher than in normal muscle. These findings are discussed in relation to glucose metabolism in muscle and the energy cost of transforming glucose into triglyceride.

Immunologic mechanisms in the pathogenesis of virus-induced murine leukemia. III. Target cell specificity of autoreactive thymocytes

Thymocytes from preleukemic mice persistently infected with Moloney murine leukemia virus (MuLV-M-carriers) were vigorously autoaggressive toward normal syngeneic target cells; they exhibited a graded response to allogeneic cells, but they spared xenogeneic cells or syngeneic cells infected with MuLV-M or MuLV-G (Gross). Syngeneic target cells infected with nononcogenic lymphocytic choriomeningitis virus (LCMV), or transformed by the chemical carcinogen 3-methylcholanthrene were not similarly spared. This phenomenon, apparently induced by MuLV-M, is not associated with all persistent virus carrier states. Thymocytes from mice persistently infected with LCMV or with the lactic dehydrogenase virus (LDHV) failed to demonstrate an autoaggressive behavior. That transplantable lymphoma cells (derived from MuLV-M-carriers) were autoreactive in a pattern similar to thymocytes from preleukemic mice suggests a unique role for MuLV in the events leading from altered recognition of "self" to lymphoma.

Complication and correction of the pierced ear

This paper emphasizes three major complications that are corrected by techniques of soft tissue surgery. These are: (1) keloid formation; (2) bifid earlobe; (3) recurrent itching and weeping. Other complications are also mentioned.

The buoyant titration of native and carbamylated bovine serum mercaptalbumin

The buoyant density titration curves of native and carbamylated bovine serum mercaptalbumin were measured throughout the pH range 5.3-12.7. Large increments in the buoyant density were observed above pH 10, with inflection pH values of 11.2 and 11.4 for native and carbamylated bovine serum mercaptalbumin, respectively. For the modified protein in which 25 out of 58 lysine residues were carbamylated, the buoyant densities were 0.048 g/ml higher at neutral pH and 0.024 g/ml higher at the extrapolated pH 13. The carbamyl groups apparently produce a larger residual density at pH 13 than they did in the case of ovalbumin. Homopolymer buoyant density titration data were demonstrated to be of value in calculating the contributions of titratable residues to the buoyant density of both proteins. The buoyant density increment at high pH was due largely to the deprotonation of the lysines as indicated by the diminished change in buoyant density between pH 10 and 12.7 for the modified protein. These density changes were attributable primarily to a gain of cesium ions. The limited modification of the lysine residues under mild reaction conditions and the rather high intrinsic dissociation constant of tyrosine residues in mercaptalbumin may indicate a preferential modification of easily accessible lysine residues. Phenolic deprotonation is facilitated by the neutralization of normally charged lysine residues and demonstrates ionic interactions between internal lysines and certain carboxyl and tyrosine residues thereby stabilizing the native state of the protein.

Activation of C-type viruses during skin graft rejection in the mouse. Interrelationships between immunostimulation and immunosuppression

Both mouse-tropic and zenotropic C-type RNA viruses were activated in BALB/c mice during rejection reactions against skin grafts from mice differing at the major histocompatibility locus (A/J) or sharing this locus (DBA/2). Animals that maintained their skin grafts following immunosuppression with antilymphocyte serum (ALS) or cyclophosphamide had a much higher incidence of virus-positivity than animals that did not receive ALS or cyclophosphamide, or that rejected their skin grafts despite immunosuppressive therapy. ALS itself activated type-C viruses from a small proportion of BALB/c mice whereas cyclophoshamide alone did not. Type C viruses were detected in spleens and regional nodes draining skin-graft sites between 1 and 2 weeks following transplantation; thereafter they reached maximum titers in spleens. Viruses were not detected at skin-graft sites, in tails or in thymuses of grafted animals. Virus activation was associated with splenic histological changes consisting of germinal center formation, diffuse hyperplasia of reticulum cells, depletion of periarteriolar lymphocytes and hyperplasia of red pulp hematopoietic elements.

Leukemia virus activation during homograft rejection

Activation of murine leukemia viruses, as detected by the mixed culture cytopathogenicity (XC) assay, followed the transplantation of A/J skin onto immunosuppressed BALB/c mice. Virus was found in most of the mice receiving both skin grafts and antilymphocyte serum, but not in animals receiving either the serum alone, skin graft alone, or no treatment.

The direct interconversion of glucose and fructose in human skeletal muscle with special reference to childhood muscular dystrophy

1. Acid extracts of muscle-fibre preparations from human biopsies incubated with [U-14C]glucose were chromatographically analysed.

2. Radioactivity of fructose was significantly greater in muscle from childhood dystrophy patients and also in female carriers of the disease compared with normal, foetal, neurogenic muscle disease and polymyositis control groups.

3. Measurements of the activity of polyol-NADP oxidoreductase (EC 1.1.1.21) and L-iditol-NAD oxidoreductase (EC 1.1.1.14) in muscle extracts compared with the ability of extracts to dephosphorylate fructose 6-phosphate, indicated that the probable route of fructose formation from glucose is via glucitol. The mean activities of the two specified enzymes in dystrophic muscle showed 13- and 3–5-fold increases respectively compared with normal muscle, and smaller increases compared with other controls.

4. Direct comparison of labelling patterns following incubation of muscle-fibre preparations with d-[U-14C]glucose, d-[U-14C]fructose and d-[U-14C]glucitol showed that these three substances are rapidly interconvertible mutual major metabolic products, confirming the glucitol pathway as a major route of fructose formation.

5. [U-14C]fructose is readily metabolized by dystrophic muscle, excluding the possibility of its accumulation being the result of poor utilization.

6. Inhibition of polyol oxidoreductase in dystrophic muscle preparations by 3,3′-tetramethyleneglutarate drastically reduces the ability of the fibres to utilize [U-14C]-glucose, and prevents the formation of [14C]fructose.

7. Some implications of these results are discussed in relation to the pathogenesis of childhood muscular dystrophy.