Liver blood flow and systemic hemodynamics were measured intraoperatively in 34 patients after liver transplantation. Ultrasound transit-time flow probes measured hepatic arterial and portal venous flow over 10 to 75 min 1 to 3 hr after reperfusion. Cardiac output was measured by thermodilution. Mean cardiac output was 9.5 +/- 2.8 L/min; the mean total liver blood flow of 2,091 +/- 932 ml/min was 23% +/- 11% of cardiac output. Mean portal flow of 1,808 +/- 929 ml/min was disproportionately high at 85% +/- 10% of total liver blood flow. Correlation analysis showed a significant (p less than 0.01; r = 0.42) correlation between cardiac output and portal venous flow and a trend toward negative correlation (p = 0.087) between cardiac output and hepatic arterial flow. These data show that increased flow in the newly transplanted liver is predominantly portal venous flow and is associated with high cardiac output and reduced hepatic arterial flow. In the last 13 patients studied, portal flow was reduced by 50% and the hepatic artery response was measured. We saw a significant (p less than 0.05) increase in hepatic artery flow from 322 +/- 228 to 419 +/- 271 ml/min, indicating an intact hepatic arterial buffer response. The hepatic artery response also showed that it is a reversible rather than a fixed resistance that contributes to the low hepatic artery flow in these patients.

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.

The omentum can be safely harvested and reliably used to reconstruct a diverse range of extraperitoneal wounds and defects. Donor-site complications can be significant but are usually limited to abdominal wall infection and hernia. Risk factors associated with complications include the use of pedicled flaps, mediastinitis, and pulmonary failure. This low rate of donor-site complications strongly supports the use of the omentum in the reconstruction of complex wounds and defects.

This study measured cardiac output before and 1 or 2 yr after orthotopic liver transplantation in 23 patients. Cardiac output was measured by thermodilution before transplantation and by first-pass radionuclide angiocardiography at follow-up. Study patients were selected as those doing well clinically and by standard laboratory tests at 1-yr and 2-yr reevaluations with no evidence of rejection: six had mild recurrent hepatitis shown on biopsy samples. Hepatocyte function was normal at the time of the study as shown by galactose elimination capacity of 442 +/- 90 mg/min. Medications were cyclosporine and prednisone in all patients, azathioprine in 10 patients and a combination of antihypertensive therapy to maintain diastolic blood pressure less than 90 mm Hg in 20 patients. Mean (+/- S.D.) pretransplantation cardiac output was 9.1 +/- 3.1 L/min and remained elevated at 8.3 +/- 2.1 L/min 1 yr, and 9.6 +/- 2.6 L/min (n = 13) 2 yr after transplantation. A significant (p less than 0.001) correlation was found between pretransplant and follow-up cardiac output. End diastolic, end systolic and stroke volumes are all increased in a pattern similar to that seen in end-stage cirrhosis. These data show that the high cardiac output of the hyperdynamic state of advanced liver disease persists after liver transplantation. The mechanisms and consequences of this require further study.

Management of melanoma of the external ear is controversial. Thirty-one patients treated for this disease were identified at our institution between January 1, 1974 and December 31, 1989. Follow-up was an average of 7.12 years (range 1-15). Local therapy performed included 16 wedge resections, 3 split thickness skin grafts after excision to the perichondrium, 10 partial and 2 total amputations. There were two local recurrences, four metachronous cervical metastases, and four distant metastases. Three elective and five therapeutic neck dissections were performed. Survivors at 1, 5, and 10 years were 93, 77, and 47%, respectively. There was no relationship between DNA ploidy, local surgical therapy, and eventual recurrence. Clinical stage and tumor thickness demonstrated a statistically significant correlation with likelihood of recurrence (P = .02 and .05). There is no evidence that melanoma of the ear has a poorer prognosis or different prognostic factors than melanoma at other cutaneous sites. In selected cases, local disease can be controlled by excision and skin graft rather than the more aggressive current procedures.