- Email: [email protected]
Aesthetic Breast Surgery
Mayo Clin Proc, May 1984, Vol 59
Psychologic testing, psychologic therapy, and the use of chronic pain centers are described. The author reports "several deaths from chymopapain usage." I am aware of only four deaths attributable to chymopapain usage since its inception in 1962. I would take issue with the suggested therapeutic modality of injecting corticosteroids into "burned-out interspace infections" in patients with residual back and leg pain. I have found that the use of a corticosteroid in those patients with adequately treated interspace infections is fraught with the possibility of a recrudescence of the infection. Wilkinson mentions aspiration of these interspaces to ensure that no residual infection is present. As is well known, aspiration—even with barbotage of the interspace—that yields a negative culture does not necessarily rule out the presence of an active infection. He does not mention gallium scanning as an excellent mode of assessing the activity of an interspace infection. Prolotherapy is discussed along with facet injections for radiofrequency lesions of the articular facets. Although later in the book the author states that peripheral neurectomy is of temporary benefit, I do not believe that he stresses it enough. To the contrary, he seems to be a stronger advocate of facet rhizotomy than I believe that entity deserves. In my opinion, intrathecal and epidural injection of corticosteroids to "break up adhesions" is a part of wishful thinking mythology that is sometimes used and perpetuated in the treatment of the failed back syndrome. Any surgeon who has explored an epidural space with scarring knows what vigor has to be exerted to separate the dura from the scarred posterior longitudinal ligament. The injection of corticosteroids in that situation would be totally ineffective in lysing adhesions. Likewise, I believe that phenol rhizotomy and radiofrequency rhizotomies in the patient who is suffering from a benign disease, and iiexpected to have a normal life-span, have absolutely no place in the treatment of the failed back syndrome. Rhizotomy accomplished by open or chemical means at best has a 3-month beneficial effect, and that is inadequate for a patient who may be subjected to several years of a painful state. The discussion of the types of fusion that are possible for mechanical back pain is worth reviewing. A case is presented for each of the posterior and anterior approaches. The enthusiasm for intrathecal microsurgical lysis of adhesions in cases of arachnoiditis should be tempered with the fact that arachnoiditis is a surgical by-product. Although anecdotal cases of beneficial results may be described, the overwhelming probabilities are that surgical intervention for arachnoiditis is doomed to failure in most cases. The last chapter describes cordotomy, cingulotomy,
BOOK REVIEWS
363
and lobotomy. These procedures seem to be of historical significance only. It should be stressed that once an unfavorable result is achieved from a disk operation, repetitive attempts at surgical manipulation with progression up "the neurologic tree" until the brainstem or frontal lobes are entered are a fruitless endeavor fraught not only with medical but also with legal implications. The section on pharmacologic treatment that deals with muscle relaxers, antineuralgic agents, and topical and transcutaneous therapy is an excellent review. Overall, I think this is a thought-provoking and challenging book that has several virtues, but the later chapters should be read with reservation. Burton M. Onofrio, M.D. Department of Neurologic Surgery
Aesthetic Breast Surgery, edited by Nicholas G. Georgiade, 408 pp, with illus, $69.95, Baltimore, Williams & Wilkins Company, 1983 An alternative and appropriate title for this volume might well have been Everything You Ever Wanted to Know, and More, About Aesthetic Breast Surgery. The editor, who is well known in the field of breast reconstruction, has indeed chosen numerous qualified authors to present their techniques and share their experience in the area of aesthetic breast operations. The first three chapters appropriately deal with the foundation areas—that is, the anatomy and physiology of the breast and the psychologic aspects and contributions to understanding breast surgical reconstruction. Five chapters are devoted to different approaches to augmentation. Although an expected degree of overlap is present, it is not to the point of being a substantially distracting factor. The troublesome problem of capsular contracture is reviewed in a systematic and well-organized fashion, and the means of prevention and the methods of treatment are discussed fairly comprehensively. A chapter on asymmetry presents the more commonly recommended solutions, and several illustrative cases demonstrate good to excellent results. The great bulk of the book (Chapters 11 through 26), however, concerns itself with breast reduction or mastopexy or variations thereof, in an almost bewildering array of approaches. On the basis of my own wide experience in this area, I believe that the young surgeon
364
BOOK REVIEWS
Mayo Clin Proc, May 1984, Vol 59
would benefit most from learning two or, at most, three approaches well and considering the rest as interesting historical aspects of breast reduction. As evidenced by the results presented, and the practice of a long consensus of plastic surgeons, breast reductions involving lateral techniques yield the least satisfactory results. The most widely used and adaptable techniques may be that of McKissock and the inferior pyramidal dermal pedicle flap, both well presented in this book. The final chapters address the topics of gynecomastia, congenital anomalies of the nipple and areola, and approaches to problems in aesthetic breast operations. The last chapter is especially helpful in its treatment of some rather c a t a s t r o p h i c results of a t t e m p t e d breast reconstruction. The illustrations are generally good, and the diagrams are satisfactory although variable in their quality. The book is well bound and the quality of the paper is good, but the print is rather small—undoubtedly to limit the volume to a reasonable size. Overall, this volume is one of the more worthy additions in the field of breast surgical reconstruction. It should be useful to the plastic surgeon, especially the young surgeon just beginning in practice. John E. Woods, M.D. Department of Surgery
Orthopaedic Positioning in Diagnostic Radiology, by Andreas Bernau and Thomas H. Berquist (translated by Allan Lake Rice), 230 pp, with illus, $49.50, Baltimore, Urban & Schwarzenberg, 1983 This book is a compendium of techniques for radiographic examination of the spine and the extremities. Its purpose, as stated in the introduction, is to foster a better understanding of the various methods between radiologists and technologists and, as such, is directed toward those two groups. The book is well organized; the initial sections describe radiation dangers and radiographic materials, followed by lucidly outlined instructions for optimal radiographic exposure of the spine and the upper and lower extremities. Included in each technical outline are data on the size of cassette, speed of film, patient preparation and positioning, and average kilovoltage and milliampere readings used. The illustrations are clearly reproduced. From an orthopedic surgery standpoint, the techniques are presented and, in general, follow closely those published in the orthopedic literature. Although the book is relatively comprehensive, radiographic views common-
ly used in the practice of orthopedic surgery are notably absent—for example, the inlet and outlet views for the pelvis (important in pelvic fractures) and carpal instability views (used in evaluating pathologic conditions of the wrist). Also, the technique described for evaluating leglength inequality, that of orthoroentgenography, is acceptable but probably not the optimal method for determining such discrepancies. The benefits of clear, consistently good-quality radiographs for both the radiologist and the orthopedist are obvious. The methods presented in this book will help in attaining this goal. This text should be a useful, concise reference for the beginning and intermediate orthopedic radiographer and technologist. In addition, orthopedic surgeons who perform their own radiography or supervise technologists who have this responsibility may find the book helpful. Joseph R. Cass, M.D. Department of Orthopedics
Clinical Aspects of Aging, 2nd ed, edited by William Reichel, 642 pp, with illus, $49.95, Baltimore, Williams & Wilkins Company, 1983 During the past several years, the special needs of geriatric patients have received increasing attention. Among the reasons for this focus are the rapid growth in the geriatric subset of our population, recognition that geriatric patients require more medical services than younger patients, and rapidly increasing governmental expenditures for provision of these services. In addition to the need for medical care, geriatric citizens have special needs in the areas of housing, nutrition, protective services, and transportation. With the help of 52 contributing authors, Dr. Reichel has attempted to address this broad spectrum of needs in Clinical Aspects of Aging. This book is organized into two sections. The first section of 38 chapters presents the diagnostic evaluation and management of specific medical problems of the elderly population. Each chapter considers a different organ system, begins with information concerning the effects of aging on the particular system, indicates the diseases that most commonly affect that system among elderly patients, and concludes with more detailed discussion of a few selected diseases. In addition to topics familiar to the internist, chapters are included on dentistry; dermatology; ear, nose, and throat problems; exercise and physical fitness; eye problems; foot health; nutrition; and rehabilitation. The second section of the book covers diverse subject areas that
Psychologic testing, psychologic therapy, and the use of chronic pain centers are described. The author reports "several deaths from chymopapain usage." I am aware of only four deaths attributable to chymopapain usage since its inception in 1962. I would take issue with the suggested therapeutic modality of injecting corticosteroids into "burned-out interspace infections" in patients with residual back and leg pain. I have found that the use of a corticosteroid in those patients with adequately treated interspace infections is fraught with the possibility of a recrudescence of the infection. Wilkinson mentions aspiration of these interspaces to ensure that no residual infection is present. As is well known, aspiration—even with barbotage of the interspace—that yields a negative culture does not necessarily rule out the presence of an active infection. He does not mention gallium scanning as an excellent mode of assessing the activity of an interspace infection. Prolotherapy is discussed along with facet injections for radiofrequency lesions of the articular facets. Although later in the book the author states that peripheral neurectomy is of temporary benefit, I do not believe that he stresses it enough. To the contrary, he seems to be a stronger advocate of facet rhizotomy than I believe that entity deserves. In my opinion, intrathecal and epidural injection of corticosteroids to "break up adhesions" is a part of wishful thinking mythology that is sometimes used and perpetuated in the treatment of the failed back syndrome. Any surgeon who has explored an epidural space with scarring knows what vigor has to be exerted to separate the dura from the scarred posterior longitudinal ligament. The injection of corticosteroids in that situation would be totally ineffective in lysing adhesions. Likewise, I believe that phenol rhizotomy and radiofrequency rhizotomies in the patient who is suffering from a benign disease, and iiexpected to have a normal life-span, have absolutely no place in the treatment of the failed back syndrome. Rhizotomy accomplished by open or chemical means at best has a 3-month beneficial effect, and that is inadequate for a patient who may be subjected to several years of a painful state. The discussion of the types of fusion that are possible for mechanical back pain is worth reviewing. A case is presented for each of the posterior and anterior approaches. The enthusiasm for intrathecal microsurgical lysis of adhesions in cases of arachnoiditis should be tempered with the fact that arachnoiditis is a surgical by-product. Although anecdotal cases of beneficial results may be described, the overwhelming probabilities are that surgical intervention for arachnoiditis is doomed to failure in most cases. The last chapter describes cordotomy, cingulotomy,
BOOK REVIEWS
363
and lobotomy. These procedures seem to be of historical significance only. It should be stressed that once an unfavorable result is achieved from a disk operation, repetitive attempts at surgical manipulation with progression up "the neurologic tree" until the brainstem or frontal lobes are entered are a fruitless endeavor fraught not only with medical but also with legal implications. The section on pharmacologic treatment that deals with muscle relaxers, antineuralgic agents, and topical and transcutaneous therapy is an excellent review. Overall, I think this is a thought-provoking and challenging book that has several virtues, but the later chapters should be read with reservation. Burton M. Onofrio, M.D. Department of Neurologic Surgery
Aesthetic Breast Surgery, edited by Nicholas G. Georgiade, 408 pp, with illus, $69.95, Baltimore, Williams & Wilkins Company, 1983 An alternative and appropriate title for this volume might well have been Everything You Ever Wanted to Know, and More, About Aesthetic Breast Surgery. The editor, who is well known in the field of breast reconstruction, has indeed chosen numerous qualified authors to present their techniques and share their experience in the area of aesthetic breast operations. The first three chapters appropriately deal with the foundation areas—that is, the anatomy and physiology of the breast and the psychologic aspects and contributions to understanding breast surgical reconstruction. Five chapters are devoted to different approaches to augmentation. Although an expected degree of overlap is present, it is not to the point of being a substantially distracting factor. The troublesome problem of capsular contracture is reviewed in a systematic and well-organized fashion, and the means of prevention and the methods of treatment are discussed fairly comprehensively. A chapter on asymmetry presents the more commonly recommended solutions, and several illustrative cases demonstrate good to excellent results. The great bulk of the book (Chapters 11 through 26), however, concerns itself with breast reduction or mastopexy or variations thereof, in an almost bewildering array of approaches. On the basis of my own wide experience in this area, I believe that the young surgeon
364
BOOK REVIEWS
Mayo Clin Proc, May 1984, Vol 59
would benefit most from learning two or, at most, three approaches well and considering the rest as interesting historical aspects of breast reduction. As evidenced by the results presented, and the practice of a long consensus of plastic surgeons, breast reductions involving lateral techniques yield the least satisfactory results. The most widely used and adaptable techniques may be that of McKissock and the inferior pyramidal dermal pedicle flap, both well presented in this book. The final chapters address the topics of gynecomastia, congenital anomalies of the nipple and areola, and approaches to problems in aesthetic breast operations. The last chapter is especially helpful in its treatment of some rather c a t a s t r o p h i c results of a t t e m p t e d breast reconstruction. The illustrations are generally good, and the diagrams are satisfactory although variable in their quality. The book is well bound and the quality of the paper is good, but the print is rather small—undoubtedly to limit the volume to a reasonable size. Overall, this volume is one of the more worthy additions in the field of breast surgical reconstruction. It should be useful to the plastic surgeon, especially the young surgeon just beginning in practice. John E. Woods, M.D. Department of Surgery
Orthopaedic Positioning in Diagnostic Radiology, by Andreas Bernau and Thomas H. Berquist (translated by Allan Lake Rice), 230 pp, with illus, $49.50, Baltimore, Urban & Schwarzenberg, 1983 This book is a compendium of techniques for radiographic examination of the spine and the extremities. Its purpose, as stated in the introduction, is to foster a better understanding of the various methods between radiologists and technologists and, as such, is directed toward those two groups. The book is well organized; the initial sections describe radiation dangers and radiographic materials, followed by lucidly outlined instructions for optimal radiographic exposure of the spine and the upper and lower extremities. Included in each technical outline are data on the size of cassette, speed of film, patient preparation and positioning, and average kilovoltage and milliampere readings used. The illustrations are clearly reproduced. From an orthopedic surgery standpoint, the techniques are presented and, in general, follow closely those published in the orthopedic literature. Although the book is relatively comprehensive, radiographic views common-
ly used in the practice of orthopedic surgery are notably absent—for example, the inlet and outlet views for the pelvis (important in pelvic fractures) and carpal instability views (used in evaluating pathologic conditions of the wrist). Also, the technique described for evaluating leglength inequality, that of orthoroentgenography, is acceptable but probably not the optimal method for determining such discrepancies. The benefits of clear, consistently good-quality radiographs for both the radiologist and the orthopedist are obvious. The methods presented in this book will help in attaining this goal. This text should be a useful, concise reference for the beginning and intermediate orthopedic radiographer and technologist. In addition, orthopedic surgeons who perform their own radiography or supervise technologists who have this responsibility may find the book helpful. Joseph R. Cass, M.D. Department of Orthopedics
Clinical Aspects of Aging, 2nd ed, edited by William Reichel, 642 pp, with illus, $49.95, Baltimore, Williams & Wilkins Company, 1983 During the past several years, the special needs of geriatric patients have received increasing attention. Among the reasons for this focus are the rapid growth in the geriatric subset of our population, recognition that geriatric patients require more medical services than younger patients, and rapidly increasing governmental expenditures for provision of these services. In addition to the need for medical care, geriatric citizens have special needs in the areas of housing, nutrition, protective services, and transportation. With the help of 52 contributing authors, Dr. Reichel has attempted to address this broad spectrum of needs in Clinical Aspects of Aging. This book is organized into two sections. The first section of 38 chapters presents the diagnostic evaluation and management of specific medical problems of the elderly population. Each chapter considers a different organ system, begins with information concerning the effects of aging on the particular system, indicates the diseases that most commonly affect that system among elderly patients, and concludes with more detailed discussion of a few selected diseases. In addition to topics familiar to the internist, chapters are included on dentistry; dermatology; ear, nose, and throat problems; exercise and physical fitness; eye problems; foot health; nutrition; and rehabilitation. The second section of the book covers diverse subject areas that