Initial aesthetic breast augmentation with inflatable saline implants has always had the distinct advantage of insertion through a small breast or axillary skin incision. Adapting established techniques utilized in suction-as-sisted lipectomy, operative endoscopy, and tissue expansion with inflatable saline implants, breast augmentation is possible through an umbilical incision. Under general anesthesia, an incision is made in the umbilicus; a new tubular instrument with an obturator [designated an endotube (Johnson) or mammascope (Christ)] is inserted into the umbilical incision like a suction cannula; it is pushed over the abdominal fascia across the costal margin until it literally pops under the breast fascia; through this tunnel is then inserted an implant coiled like a tobacco leaf; the implant is then inflated to 50 percent more than the final volume and manipulated to help expand the pocket; finally, the excess volume is removed, methylprednisolone acetate is placed in the final volume, and the fill tube is removed. The endoscope (laparoscope) is utilized to visualize positioning and to document the absence of bleeding. The umbilical incision is closed after insertion of both implants through the same incision. A series of 91 young women have undergone this procedure with 188 breast implantations without significant bleeding. Implants appear to ride high initially, but they settle into place by 6 weeks. Patients have reported less chest discomfort and some visible temporary upper abdominal swelling. The long-term follow-up is currently being monitored. (Plast. Reconstr. Surg. 92: 801, 1993.)

Initial aesthetic breast augmentation with inflatable saline implants has always had the distinct advantage of insertion through a small breast or axillary skin incision. Adapting established techniques utilized in suction-assisted lipectomy, operative endoscopy, and tissue expansion with inflatable saline implants, breast augmentation is possible through an umbilical incision. Under general anesthesia, an incision is made in the umbilicus; a new tubular instrument with an obturator [designated an endotube (Johnson) or mammascope (Christ)] is inserted into the umbilical incision like a suction cannula; it is pushed over the abdominal fascia across the costal margin until it literally pops under the breast fascia; through this tunnel is then inserted an implant coiled like a tobacco leaf; the implant is then inflated to 50 percent more than the final volume and manipulated to help expand the pocket; finally, the excess volume is removed, methyl-prednisolone acetate is placed in the final volume, and the fill tube is removed. The endoscope (laparoscope) is utilized to visualize positioning and to document the absence of bleeding. The umbilical incision is closed after insertion of both implants through the same incision. A series of 91 young women have undergone this procedure with 188 breast implantations without significant bleeding. Implants appear to ride high initially, but they settle into place by 6 weeks. Patients have reported less chest discomfort and some visible temporary upper abdominal swelling. The long-term follow-up is currently being monitored.

Injectable silicones have been applied to an undetermined number of men for penile augmentation. The practitioners of this art, whether lay or medical, have allegedly long discontinued treating penile size. In the literature to date, four men have been identified as having complications from this mode of therapy; three have had excisions of granulomatous masses secondary to the silicone; the third refused surgery. This paper reports an additional case of silicone granuloma of the penis, documented by biopsy, which necessitated two excisions to obtain a satisfactory size for copulation. Moreover, because of impotence, a Dow-Corning (Gerow design) penile prosthesis was inserted. The inflammatory response in this new case is identical to that found in other parts of the body, namely, multiple silicone droplets surrounded by multinucleated giant cells and chronic inflammatory cells.

Real-time ultrasonography in pregnancy can accurately detect gestational age, position of the fetus, position of the placenta, sex of the fetus, and many congenital anomalies before birth. To date, however, there has been no report of detection of a cleft lip-palate deformity by ultrasound. Two cases, in approximately 200 scans, have been found in patients with no previous family history of cleft lip-palate. The first case was a bilateral cleft lip-palate visualized at 28 weeks gestation. The second was a unilateral cleft lip-palate detected at 33 weeks gestation. Diagnosis of cleft lip-palate is dependent on appreciation of facial topography in multiple planes, adequate experience in the technique, and observation of the degree of excursion of the undulating tongue. Detection of the facial clefting in utero by ultrasound has resulted in our formulation of a routine for informing the parents of the deformity and referring them for consultation with a plastic surgeon. This is recommended before birth, so that the parents are well acquainted with what the deformity will look like and the sequential steps necessary for its correction. We encourage plastic surgeons, obstetricians, pediatricians, and ultrasonographers to be aware of the ability to diagnose cleft lip-palate before birth.

Holter monitoring has been used extensively for the detection, diagnosis, and evaluation of therapy for cardiac arrhythmias. The availability of three-channel monitors allows for the recording of vectorcardiographic leads X, Y, and Z. One method, which was recently described by Dower et al., (J Electrocardiol 1988;21:5182–5187), uses modified vectorcardiographic leads and allows for the acquisition of a derived 12-lead ECG of selected rhythm strips during the recording. In the present study, we evaluated the usefulness of the derived 12-lead ECG in the detection of P-wave and ST-segment shifts, assessment of QRST changes, and distinction between ventricular ectopic and aberrant supraventricular complexes. Our preliminary findings indicate that careful analysis of the derived 12-lead ECG provides additional information for a more accurate diagnosis of arrhythmias that are detected by the Holter monitor. The clinical importance and cost-effectiveness of the derived 12-lead ECG needs further evaluation.

Synchrony of atria and ventricles is an infrequent observation in total A-V block. Serial electrocardiograms were made of a 19-year-old woman with complete A-V block. In all records there appeared an atrial arrhythmia related to the presence of QRS. The A-V block appeared complete and the two rhythms were essentially indepencent except on January 22, 1969, when atrioventricular synchrony appeared for a total period of 14 min 9 sec. The atria and ventricles on this date appeared to be linked together in a 2:1 relationship, the P wave having a very precise assocation with R. Similar results have led other authors to the conclusion that there is an active interaction caused by ventricular systole. Whether these observations result from anything more than pure coincidence has not been resolved.

In complete A-V block a type of arrhythmia occurs in which atrial cycle length or instantaneous rate is a function of the presence and position of a ventricular QRS complex within that cycle. The immediately following atrial cycle without QRS is invariably longer than the preceding atrial cycle. The so-called PR interval has been plotted against two consecutive atrial cycles, the initial cycle which contains the PR and QRS, and the immediately following cycle without QRS. Both atrial cycles were then plotted against each other to demonstrate their relation. Linear regressions were performed and the correlation coefficients computed. The mechanism of the interaction of atria and ventricles in complete block has not been completely settled, but several proposals have been made among which the more promising include: a vagal reflex arising from baroreceptor stimulation, traction of one contracting chamber on the other, and electrotonic or “field effect” induction. The observed phenomenon has been studied statistically, several previously unreported observations have been made, and an attempt has been made to interpret the phenomenon in terms of the several proposed mechanisms.