Robert Finn

MONTEREY, CALIF. — Nail surgery can be fun, and dermatologists are perfectly positioned to offer this treatment to patients, Dr. Stuart J. Salasche said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The hand surgeons don't want nail surgery, and the plastics people don't want nail surgery, so it's ours," said Dr. Salasche of the University of Arizona Health Sciences Center, Tucson. He offered several pearls that reflect his years of experience:

▸ When a finger injury causes a hematoma, the blood normally collects under the proximal portion of the nail plate, where it's loose, and cannot progress further up the nail bed. A simple way of treating this short term is just to unfold a paper clip and heat the end. Touch the heated end to the nail plate and it sizzles right through, releasing the hematoma.

▸ Similarly, with acute paronychia, which is often caused by a staph infection, take a No. 11 blade and insert it into the lateral nail fold, releasing the pressure. "Generally a patient feels relief immediately," Dr. Salasche said.

▸ For more complex surgeries, such as nail avulsions and matricectomies, Dr. Salasche has two favorite instruments. The Freer septum elevator is critical in both proximal and distal approaches to nail avulsion. The English nail splitter is useful for partial nail avulsions. It has an anvil-like undersurface that slides between the nail bed and the nail plate and a scissorlike upper portion for cutting through the nail plate.

▸ For anesthesia, most nail surgery requires a nerve block, then a distal block, followed by a local injection. The dorsal digital nerve and the proper palmar digital nerve run along the lateral portion of the finger. Dr. Salasche injects about 1 cc of 2% lidocaine (without epinephrine and using a 30-gauge needle) into the medial side of the finger above the metacarpophalangeal joint. "I don't go down to the bone, and I don't march around," he said. "I just inject slowly until I balloon up the area and let the anesthetic diffuse down to the nerves. It's much less dangerous that way." After 10 minutes he uses the same needle to inject into the proximal lateral nail fold area. Once again waiting until the patient is comfortable, he then injects a local anesthetic into the distal area. This injection contains epinephrine to promote local vasoconstriction.

▸ Both distal and proximal approaches are possible for nail avulsion, depending on the patient. For the distal approach Dr. Salasche inserts the septum elevator under the nail tip, which takes some force. He pushes the elevator proximally as well as up underneath the nail plate to avoid digging down into the nail bed. When the elevator reaches the matrix, the force required will suddenly decrease, and the physician should take care not to jam the instrument back into the cul de sac of the proximal nail groove. Then the physician could either rock the elevator back and forth to loosen the rest of the nail or remove the elevator and reinsert it. Dr. Salasche prefers the latter technique because rocking the elevator back and forth tends to cause bleeding. After he has inserted the elevator several times, he uses the elevator on the nail plate's proximal edge to go back underneath the cuticle into the proximal nail fold, loosening any attachments back there. Then it's possible to grasp the nail with a hemostat and pull it off, snipping any remaining small attachments with a pair of scissors.

▸ If the patient's nail is so damaged that it has no distal free edge to get underneath, it's better to use a proximal approach. Take the septum elevator and come up underneath the proximal nail fold. Fulcrum this over to get underneath the newly developing nail and then run it out and up. There's a danger that one could damage the nail bed, so it's important to direct the elevator both distal and up underneath the surface of the nail bed.

▸ Ingrown nails respond well to a partial nail avulsion followed by a partial matricectomy. After removing the portion of the nail that's ingrowing, Dr. Salasche uses phenol to destroy the part of the nail matrix responsible for generating that part of the nail. He likes to make his own cotton-tip applicator by taking a sturdy, double-pointed toothpick and twisting some cotton around the top. It's important to use fresh, full-strength (88%) phenol. He dips the applicator into the bottle of phenol, removes excess liquid by holding it against the side of the bottle, and then applies it directly to the matrix, where he leaves it in place, rotating it for about 30 seconds.

MONTEREY, CALIF. — Nail surgery can be fun, and dermatologists are perfectly positioned to offer this treatment to patients, Dr. Stuart J. Salasche said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The hand surgeons don't want nail surgery, and the plastics people don't want nail surgery, so it's ours," said Dr. Salasche of the University of Arizona Health Sciences Center, Tucson. He offered several pearls that reflect his years of experience:

▸ When a finger injury causes a hematoma, the blood normally collects under the proximal portion of the nail plate, where it's loose, and cannot progress further up the nail bed. A simple way of treating this short term is just to unfold a paper clip and heat the end. Touch the heated end to the nail plate and it sizzles right through, releasing the hematoma.

▸ Similarly, with acute paronychia, which is often caused by a staph infection, take a No. 11 blade and insert it into the lateral nail fold, releasing the pressure. "Generally a patient feels relief immediately," Dr. Salasche said.

▸ For more complex surgeries, such as nail avulsions and matricectomies, Dr. Salasche has two favorite instruments. The Freer septum elevator is critical in both proximal and distal approaches to nail avulsion. The English nail splitter is useful for partial nail avulsions. It has an anvil-like undersurface that slides between the nail bed and the nail plate and a scissorlike upper portion for cutting through the nail plate.

▸ For anesthesia, most nail surgery requires a nerve block, then a distal block, followed by a local injection. The dorsal digital nerve and the proper palmar digital nerve run along the lateral portion of the finger. Dr. Salasche injects about 1 cc of 2% lidocaine (without epinephrine and using a 30-gauge needle) into the medial side of the finger above the metacarpophalangeal joint. "I don't go down to the bone, and I don't march around," he said. "I just inject slowly until I balloon up the area and let the anesthetic diffuse down to the nerves. It's much less dangerous that way." After 10 minutes he uses the same needle to inject into the proximal lateral nail fold area. Once again waiting until the patient is comfortable, he then injects a local anesthetic into the distal area. This injection contains epinephrine to promote local vasoconstriction.

▸ Both distal and proximal approaches are possible for nail avulsion, depending on the patient. For the distal approach Dr. Salasche inserts the septum elevator under the nail tip, which takes some force. He pushes the elevator proximally as well as up underneath the nail plate to avoid digging down into the nail bed. When the elevator reaches the matrix, the force required will suddenly decrease, and the physician should take care not to jam the instrument back into the cul de sac of the proximal nail groove. Then the physician could either rock the elevator back and forth to loosen the rest of the nail or remove the elevator and reinsert it. Dr. Salasche prefers the latter technique because rocking the elevator back and forth tends to cause bleeding. After he has inserted the elevator several times, he uses the elevator on the nail plate's proximal edge to go back underneath the cuticle into the proximal nail fold, loosening any attachments back there. Then it's possible to grasp the nail with a hemostat and pull it off, snipping any remaining small attachments with a pair of scissors.

▸ If the patient's nail is so damaged that it has no distal free edge to get underneath, it's better to use a proximal approach. Take the septum elevator and come up underneath the proximal nail fold. Fulcrum this over to get underneath the newly developing nail and then run it out and up. There's a danger that one could damage the nail bed, so it's important to direct the elevator both distal and up underneath the surface of the nail bed.

▸ Ingrown nails respond well to a partial nail avulsion followed by a partial matricectomy. After removing the portion of the nail that's ingrowing, Dr. Salasche uses phenol to destroy the part of the nail matrix responsible for generating that part of the nail. He likes to make his own cotton-tip applicator by taking a sturdy, double-pointed toothpick and twisting some cotton around the top. It's important to use fresh, full-strength (88%) phenol. He dips the applicator into the bottle of phenol, removes excess liquid by holding it against the side of the bottle, and then applies it directly to the matrix, where he leaves it in place, rotating it for about 30 seconds.

MONTEREY, CALIF. — Nail surgery can be fun, and dermatologists are perfectly positioned to offer this treatment to patients, Dr. Stuart J. Salasche said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The hand surgeons don't want nail surgery, and the plastics people don't want nail surgery, so it's ours," said Dr. Salasche of the University of Arizona Health Sciences Center, Tucson. He offered several pearls that reflect his years of experience:

▸ When a finger injury causes a hematoma, the blood normally collects under the proximal portion of the nail plate, where it's loose, and cannot progress further up the nail bed. A simple way of treating this short term is just to unfold a paper clip and heat the end. Touch the heated end to the nail plate and it sizzles right through, releasing the hematoma.

▸ Similarly, with acute paronychia, which is often caused by a staph infection, take a No. 11 blade and insert it into the lateral nail fold, releasing the pressure. "Generally a patient feels relief immediately," Dr. Salasche said.

▸ For more complex surgeries, such as nail avulsions and matricectomies, Dr. Salasche has two favorite instruments. The Freer septum elevator is critical in both proximal and distal approaches to nail avulsion. The English nail splitter is useful for partial nail avulsions. It has an anvil-like undersurface that slides between the nail bed and the nail plate and a scissorlike upper portion for cutting through the nail plate.

▸ For anesthesia, most nail surgery requires a nerve block, then a distal block, followed by a local injection. The dorsal digital nerve and the proper palmar digital nerve run along the lateral portion of the finger. Dr. Salasche injects about 1 cc of 2% lidocaine (without epinephrine and using a 30-gauge needle) into the medial side of the finger above the metacarpophalangeal joint. "I don't go down to the bone, and I don't march around," he said. "I just inject slowly until I balloon up the area and let the anesthetic diffuse down to the nerves. It's much less dangerous that way." After 10 minutes he uses the same needle to inject into the proximal lateral nail fold area. Once again waiting until the patient is comfortable, he then injects a local anesthetic into the distal area. This injection contains epinephrine to promote local vasoconstriction.

▸ Both distal and proximal approaches are possible for nail avulsion, depending on the patient. For the distal approach Dr. Salasche inserts the septum elevator under the nail tip, which takes some force. He pushes the elevator proximally as well as up underneath the nail plate to avoid digging down into the nail bed. When the elevator reaches the matrix, the force required will suddenly decrease, and the physician should take care not to jam the instrument back into the cul de sac of the proximal nail groove. Then the physician could either rock the elevator back and forth to loosen the rest of the nail or remove the elevator and reinsert it. Dr. Salasche prefers the latter technique because rocking the elevator back and forth tends to cause bleeding. After he has inserted the elevator several times, he uses the elevator on the nail plate's proximal edge to go back underneath the cuticle into the proximal nail fold, loosening any attachments back there. Then it's possible to grasp the nail with a hemostat and pull it off, snipping any remaining small attachments with a pair of scissors.

▸ If the patient's nail is so damaged that it has no distal free edge to get underneath, it's better to use a proximal approach. Take the septum elevator and come up underneath the proximal nail fold. Fulcrum this over to get underneath the newly developing nail and then run it out and up. There's a danger that one could damage the nail bed, so it's important to direct the elevator both distal and up underneath the surface of the nail bed.

▸ Ingrown nails respond well to a partial nail avulsion followed by a partial matricectomy. After removing the portion of the nail that's ingrowing, Dr. Salasche uses phenol to destroy the part of the nail matrix responsible for generating that part of the nail. He likes to make his own cotton-tip applicator by taking a sturdy, double-pointed toothpick and twisting some cotton around the top. It's important to use fresh, full-strength (88%) phenol. He dips the applicator into the bottle of phenol, removes excess liquid by holding it against the side of the bottle, and then applies it directly to the matrix, where he leaves it in place, rotating it for about 30 seconds.

SAN DIEGO — Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.

"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."

While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.

Traditional blepharoplasty often results in an aging—not rejuvenation—of the periorbital area, as it tends to emphasize hollows that result from the loss of fat.

"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."

In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.

The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."

Several techniques may fill those hollows:

▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."

▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.

With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."

▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.

▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)

The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.

These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."

The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.

SAN DIEGO — Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.

"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."

While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.

Traditional blepharoplasty often results in an aging—not rejuvenation—of the periorbital area, as it tends to emphasize hollows that result from the loss of fat.

"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."

In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.

The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."

Several techniques may fill those hollows:

▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."

▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.

With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."

▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.

▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)

The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.

These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."

The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.

SAN DIEGO — Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.

"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."

While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.

Traditional blepharoplasty often results in an aging—not rejuvenation—of the periorbital area, as it tends to emphasize hollows that result from the loss of fat.

"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."

In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.

The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."

Several techniques may fill those hollows:

▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."

▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.

With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."

▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.

▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)

The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.

These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."

The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.

SAN DIEGO — Temporalis grafts, performed at the same time as endoscopic brow lifts, can reduce residual glabellar furrows, Allan E. Wulc, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Of the 78 patients who received such grafts and who were followed for 6 months to 3 years, 100% were judged by an independent observer to be "improved," and in 80% the results were "good."

A total of 20% of the patients still had some residual furrowing, and 22.5% returned for Botox (botulinum toxin type A) treatments, said Dr. Wulc, an ophthalmologist and plastic surgeon in private practice in Abington, Pa.

In contrast, Dr. Wulc estimated that 48% of his patients who underwent technically successful endoscopic brow lifting without additional temporalis grafts required further Botox treatments for glabellar furrows.

The procedure involves first harvesting temporalis fascia at the temporal incision site for the endoscopic brow lift. After incisions in two locations with a No. 11 blade, Dr. Wulc explained that he subcises the glabellar furrow with an 18-gauge needle.

Early in his development of this procedure, Dr. Wulc discovered that simply entering with the 18-gauge needle and subcising without the prior incisions can result in a depressed scar.

After the subcision, Dr. Wulc inserts the graft with a 0.3-mm or 0.5-mm Castroviejo forceps. Then he said he puts in a single 6-0 Prolene suture to control scarring. He then removes the suture 1-2 days later.

A dermis graft works as well as a temporalis graft, he said, especially when the procedure is done separately from an endoscopic brow lift.

Dr. Wulc cautioned that it is important to harvest dermis from a non-hair-bearing area of the patient's body or the patients will start growing hair under their skin.

Another possibility is that the surgeon can use filler material instead of the temporalis graft. "I think that the way [subcision] works is by denuding the underlying dermis from its attachment," thereby preventing muscular readhesion, Dr. Wulc said.

"The temporalis functions as a useful spacer, and the dermal-subdermal pocket is filled. It's possible that you could use a filler … and maybe get the same effect without going to the trouble of getting a temporalis graft. On the other hand, I'm there [at the temporalis for the endoscopic brow lift], so it's an easy thing to do at the same time."

Among the 78 patients, 7 reportedly complained of palpable lumps, and 1 patient had an infection that required antibiotics.

Bilateral brow ptosis is shown at baseline and 6 months after endoscopic brow lifting with subcision of glabellar furrows and insertion of temporalis grafts. Photos courtesy Dr. Allan E. Wulc

SAN DIEGO — Temporalis grafts, performed at the same time as endoscopic brow lifts, can reduce residual glabellar furrows, Allan E. Wulc, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Of the 78 patients who received such grafts and who were followed for 6 months to 3 years, 100% were judged by an independent observer to be "improved," and in 80% the results were "good."

A total of 20% of the patients still had some residual furrowing, and 22.5% returned for Botox (botulinum toxin type A) treatments, said Dr. Wulc, an ophthalmologist and plastic surgeon in private practice in Abington, Pa.

In contrast, Dr. Wulc estimated that 48% of his patients who underwent technically successful endoscopic brow lifting without additional temporalis grafts required further Botox treatments for glabellar furrows.

The procedure involves first harvesting temporalis fascia at the temporal incision site for the endoscopic brow lift. After incisions in two locations with a No. 11 blade, Dr. Wulc explained that he subcises the glabellar furrow with an 18-gauge needle.

Early in his development of this procedure, Dr. Wulc discovered that simply entering with the 18-gauge needle and subcising without the prior incisions can result in a depressed scar.

After the subcision, Dr. Wulc inserts the graft with a 0.3-mm or 0.5-mm Castroviejo forceps. Then he said he puts in a single 6-0 Prolene suture to control scarring. He then removes the suture 1-2 days later.

A dermis graft works as well as a temporalis graft, he said, especially when the procedure is done separately from an endoscopic brow lift.

Dr. Wulc cautioned that it is important to harvest dermis from a non-hair-bearing area of the patient's body or the patients will start growing hair under their skin.

Another possibility is that the surgeon can use filler material instead of the temporalis graft. "I think that the way [subcision] works is by denuding the underlying dermis from its attachment," thereby preventing muscular readhesion, Dr. Wulc said.

"The temporalis functions as a useful spacer, and the dermal-subdermal pocket is filled. It's possible that you could use a filler … and maybe get the same effect without going to the trouble of getting a temporalis graft. On the other hand, I'm there [at the temporalis for the endoscopic brow lift], so it's an easy thing to do at the same time."

Among the 78 patients, 7 reportedly complained of palpable lumps, and 1 patient had an infection that required antibiotics.

Bilateral brow ptosis is shown at baseline and 6 months after endoscopic brow lifting with subcision of glabellar furrows and insertion of temporalis grafts. Photos courtesy Dr. Allan E. Wulc

SAN DIEGO — Temporalis grafts, performed at the same time as endoscopic brow lifts, can reduce residual glabellar furrows, Allan E. Wulc, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Of the 78 patients who received such grafts and who were followed for 6 months to 3 years, 100% were judged by an independent observer to be "improved," and in 80% the results were "good."

A total of 20% of the patients still had some residual furrowing, and 22.5% returned for Botox (botulinum toxin type A) treatments, said Dr. Wulc, an ophthalmologist and plastic surgeon in private practice in Abington, Pa.

In contrast, Dr. Wulc estimated that 48% of his patients who underwent technically successful endoscopic brow lifting without additional temporalis grafts required further Botox treatments for glabellar furrows.

The procedure involves first harvesting temporalis fascia at the temporal incision site for the endoscopic brow lift. After incisions in two locations with a No. 11 blade, Dr. Wulc explained that he subcises the glabellar furrow with an 18-gauge needle.

Early in his development of this procedure, Dr. Wulc discovered that simply entering with the 18-gauge needle and subcising without the prior incisions can result in a depressed scar.

After the subcision, Dr. Wulc inserts the graft with a 0.3-mm or 0.5-mm Castroviejo forceps. Then he said he puts in a single 6-0 Prolene suture to control scarring. He then removes the suture 1-2 days later.

A dermis graft works as well as a temporalis graft, he said, especially when the procedure is done separately from an endoscopic brow lift.

Dr. Wulc cautioned that it is important to harvest dermis from a non-hair-bearing area of the patient's body or the patients will start growing hair under their skin.

Another possibility is that the surgeon can use filler material instead of the temporalis graft. "I think that the way [subcision] works is by denuding the underlying dermis from its attachment," thereby preventing muscular readhesion, Dr. Wulc said.

"The temporalis functions as a useful spacer, and the dermal-subdermal pocket is filled. It's possible that you could use a filler … and maybe get the same effect without going to the trouble of getting a temporalis graft. On the other hand, I'm there [at the temporalis for the endoscopic brow lift], so it's an easy thing to do at the same time."

Among the 78 patients, 7 reportedly complained of palpable lumps, and 1 patient had an infection that required antibiotics.

Bilateral brow ptosis is shown at baseline and 6 months after endoscopic brow lifting with subcision of glabellar furrows and insertion of temporalis grafts. Photos courtesy Dr. Allan E. Wulc

RENO, NEV. — Half of all pregnant women with hypertension have abnormal findings on echocardiography, but these abnormal findings did not predict differences in pregnancy outcomes, according to a study of 87 hypertensive patients.

Although some pregnant women with hypertension will require echocardiograms because of their clinical symptoms, the study suggests that routine echocardiograms are not indicated in otherwise asymptomatic women, investigators wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The study involved 87 pregnant women with hypertension seen over a period of more than 5 years in a single specialty clinic. The women underwent echocardiography, typically before 20 weeks of gestation, said Julie A. Gainer, D.O., of the University of Texas Southwestern Medical Center in Dallas, and associates.

Forty of the women (46%) had normal findings on echocardiography, and 47 (54%) had at least one abnormal finding. The most common abnormalities were concentric left ventricular hypertrophy, seen in 21 (24%) of the women; concentric left ventricular hypertrophy with a dilated left atrium, seen in 11 (13%) of the women; and dilated left atrium, seen in 12 (14%) of the women.

A comparison of women who had normal echocardiography results with those who had at least one abnormal finding revealed no significant differences in any measure.

The groups did not differ in any demographic variable, nor did they differ significantly in any of 10 measured pregnancy outcomes. These outcomes included the estimated gestational age at delivery, the proportion of women undergoing vaginal or cesarean delivery, the proportion with superimposed preeclampsia, and the length of their hospital stays.

RENO, NEV. — Half of all pregnant women with hypertension have abnormal findings on echocardiography, but these abnormal findings did not predict differences in pregnancy outcomes, according to a study of 87 hypertensive patients.

Although some pregnant women with hypertension will require echocardiograms because of their clinical symptoms, the study suggests that routine echocardiograms are not indicated in otherwise asymptomatic women, investigators wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The study involved 87 pregnant women with hypertension seen over a period of more than 5 years in a single specialty clinic. The women underwent echocardiography, typically before 20 weeks of gestation, said Julie A. Gainer, D.O., of the University of Texas Southwestern Medical Center in Dallas, and associates.

Forty of the women (46%) had normal findings on echocardiography, and 47 (54%) had at least one abnormal finding. The most common abnormalities were concentric left ventricular hypertrophy, seen in 21 (24%) of the women; concentric left ventricular hypertrophy with a dilated left atrium, seen in 11 (13%) of the women; and dilated left atrium, seen in 12 (14%) of the women.

A comparison of women who had normal echocardiography results with those who had at least one abnormal finding revealed no significant differences in any measure.

The groups did not differ in any demographic variable, nor did they differ significantly in any of 10 measured pregnancy outcomes. These outcomes included the estimated gestational age at delivery, the proportion of women undergoing vaginal or cesarean delivery, the proportion with superimposed preeclampsia, and the length of their hospital stays.

RENO, NEV. — Half of all pregnant women with hypertension have abnormal findings on echocardiography, but these abnormal findings did not predict differences in pregnancy outcomes, according to a study of 87 hypertensive patients.

Although some pregnant women with hypertension will require echocardiograms because of their clinical symptoms, the study suggests that routine echocardiograms are not indicated in otherwise asymptomatic women, investigators wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The study involved 87 pregnant women with hypertension seen over a period of more than 5 years in a single specialty clinic. The women underwent echocardiography, typically before 20 weeks of gestation, said Julie A. Gainer, D.O., of the University of Texas Southwestern Medical Center in Dallas, and associates.

Forty of the women (46%) had normal findings on echocardiography, and 47 (54%) had at least one abnormal finding. The most common abnormalities were concentric left ventricular hypertrophy, seen in 21 (24%) of the women; concentric left ventricular hypertrophy with a dilated left atrium, seen in 11 (13%) of the women; and dilated left atrium, seen in 12 (14%) of the women.

A comparison of women who had normal echocardiography results with those who had at least one abnormal finding revealed no significant differences in any measure.

The groups did not differ in any demographic variable, nor did they differ significantly in any of 10 measured pregnancy outcomes. These outcomes included the estimated gestational age at delivery, the proportion of women undergoing vaginal or cesarean delivery, the proportion with superimposed preeclampsia, and the length of their hospital stays.

RENO, NEV. — Digital or manual rotation of fetuses in the persistent occipitoposterior position reduces the need for instrumental deliveries and cesarean section, reported O. Reichman, M.D., and colleagues at Shaare Zedek Medical Center, Jerusalem.

In a prospective, nonrandomized study, the investigators studied 61 women with a fetus in the occipitoposterior position who had completed half of the normal second stage of labor. The first group of 30 women was allowed to continue labor without intervention. The second group of 31 women underwent digital or manual rotation, the authors wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

There were no significant differences in demographic characteristics between the two groups.

The digital maneuver entails first placing the tips of the index and middle fingers onto the edge of the part of the anterior parietal bone that overlaps the occipital bone in the area of the posterior fontanelle. Next, the clinician exerts pressure with the tips of the fingers to rotate the posterior fontanelle upward and toward the symphysis pubis.

With manual rotation, the clinician inserts the entire hand into the birth canal. He or she first positions the fingers under the lateral posterior parietal bone and the thumb on the anterior parietal bone, and then rotates the fetus's head.

Only 8 of the women in the no-rotation group (27%), compared with 24 in the rotation group (77%), experienced a spontaneous delivery, a significant difference.

A significantly greater percentage of the women in the no-rotation group underwent vacuum extraction (50% vs. 23%) and cesarean section (23% vs. 0%).

In addition, digital/manual rotation was associated with a significantly shorter second stage of labor. As a group, women who underwent digital/manual rotation had a significantly shorter mean hospital stay (3.5 days) than did women in the no-rotation group (4.4 days).

Previous epidemiologic studies have estimated the prevalence of the occipitoposterior position to be about 5%. Among such pregnancies, there is a high incidence of cesarean section, instrumental delivery, third- and fourth-degree perineal tear, postpartum hemorrhage, and puerperal infection.

Although the poster did not mention any adverse events that may have been associated with digital/manual rotation, the authors suggested that the maneuver be considered in cases of occipitoposterior malposition.

RENO, NEV. — Digital or manual rotation of fetuses in the persistent occipitoposterior position reduces the need for instrumental deliveries and cesarean section, reported O. Reichman, M.D., and colleagues at Shaare Zedek Medical Center, Jerusalem.

In a prospective, nonrandomized study, the investigators studied 61 women with a fetus in the occipitoposterior position who had completed half of the normal second stage of labor. The first group of 30 women was allowed to continue labor without intervention. The second group of 31 women underwent digital or manual rotation, the authors wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

There were no significant differences in demographic characteristics between the two groups.

The digital maneuver entails first placing the tips of the index and middle fingers onto the edge of the part of the anterior parietal bone that overlaps the occipital bone in the area of the posterior fontanelle. Next, the clinician exerts pressure with the tips of the fingers to rotate the posterior fontanelle upward and toward the symphysis pubis.

With manual rotation, the clinician inserts the entire hand into the birth canal. He or she first positions the fingers under the lateral posterior parietal bone and the thumb on the anterior parietal bone, and then rotates the fetus's head.

Only 8 of the women in the no-rotation group (27%), compared with 24 in the rotation group (77%), experienced a spontaneous delivery, a significant difference.

A significantly greater percentage of the women in the no-rotation group underwent vacuum extraction (50% vs. 23%) and cesarean section (23% vs. 0%).

In addition, digital/manual rotation was associated with a significantly shorter second stage of labor. As a group, women who underwent digital/manual rotation had a significantly shorter mean hospital stay (3.5 days) than did women in the no-rotation group (4.4 days).

Previous epidemiologic studies have estimated the prevalence of the occipitoposterior position to be about 5%. Among such pregnancies, there is a high incidence of cesarean section, instrumental delivery, third- and fourth-degree perineal tear, postpartum hemorrhage, and puerperal infection.

Although the poster did not mention any adverse events that may have been associated with digital/manual rotation, the authors suggested that the maneuver be considered in cases of occipitoposterior malposition.

RENO, NEV. — Digital or manual rotation of fetuses in the persistent occipitoposterior position reduces the need for instrumental deliveries and cesarean section, reported O. Reichman, M.D., and colleagues at Shaare Zedek Medical Center, Jerusalem.

In a prospective, nonrandomized study, the investigators studied 61 women with a fetus in the occipitoposterior position who had completed half of the normal second stage of labor. The first group of 30 women was allowed to continue labor without intervention. The second group of 31 women underwent digital or manual rotation, the authors wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

There were no significant differences in demographic characteristics between the two groups.

The digital maneuver entails first placing the tips of the index and middle fingers onto the edge of the part of the anterior parietal bone that overlaps the occipital bone in the area of the posterior fontanelle. Next, the clinician exerts pressure with the tips of the fingers to rotate the posterior fontanelle upward and toward the symphysis pubis.

With manual rotation, the clinician inserts the entire hand into the birth canal. He or she first positions the fingers under the lateral posterior parietal bone and the thumb on the anterior parietal bone, and then rotates the fetus's head.

Only 8 of the women in the no-rotation group (27%), compared with 24 in the rotation group (77%), experienced a spontaneous delivery, a significant difference.

A significantly greater percentage of the women in the no-rotation group underwent vacuum extraction (50% vs. 23%) and cesarean section (23% vs. 0%).

In addition, digital/manual rotation was associated with a significantly shorter second stage of labor. As a group, women who underwent digital/manual rotation had a significantly shorter mean hospital stay (3.5 days) than did women in the no-rotation group (4.4 days).

Previous epidemiologic studies have estimated the prevalence of the occipitoposterior position to be about 5%. Among such pregnancies, there is a high incidence of cesarean section, instrumental delivery, third- and fourth-degree perineal tear, postpartum hemorrhage, and puerperal infection.

Although the poster did not mention any adverse events that may have been associated with digital/manual rotation, the authors suggested that the maneuver be considered in cases of occipitoposterior malposition.

RENO, NEV. — While many physicians commonly use oral tocolysis maintenance after intravenous tocolysis in patients with preterm labor because they have a clinical impression of its effectiveness, solid evidence for this practice has been lacking until recently, according to Perkin Stang, M.D., of Wayne State University, Detroit, and colleagues.

Their population-based historical cohort study suggests that pregnant patients who are not maintained on oral tocolysis are more than twice as likely to deliver prematurely as are those who do receive oral maintenance, the investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The study involved 170,258 patients from a perinatal database in the state of Schleswig-Holstein, Germany.

Of those patients, 9,542 with preterm labor who received intravenous tocolysis were included in the study. Women with premature rupture of membranes and medically indicated inductions before 37 weeks of gestation were excluded from the analysis.

Investigators compared 4,936 women who received oral maintenance tocolysis with a β-sympathomimetic agent to 4,536 women who did not receive oral tocolysis. (Data were unavailable for the remaining 70 patients.)

In the oral tocolysis group, 366 patients (7%) delivered prematurely versus 1,094 patients (24%) in the control group.

After adjusting the results for possible confounding variables such as prior preterm delivery, cerclage, incompetent cervix, duration of intravenous tocolysis, and obesity, investigators calculated an odds ratio of 2.4 for preterm delivery in patients who were not maintained on oral tocolysis.

RENO, NEV. — While many physicians commonly use oral tocolysis maintenance after intravenous tocolysis in patients with preterm labor because they have a clinical impression of its effectiveness, solid evidence for this practice has been lacking until recently, according to Perkin Stang, M.D., of Wayne State University, Detroit, and colleagues.

Their population-based historical cohort study suggests that pregnant patients who are not maintained on oral tocolysis are more than twice as likely to deliver prematurely as are those who do receive oral maintenance, the investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The study involved 170,258 patients from a perinatal database in the state of Schleswig-Holstein, Germany.

Of those patients, 9,542 with preterm labor who received intravenous tocolysis were included in the study. Women with premature rupture of membranes and medically indicated inductions before 37 weeks of gestation were excluded from the analysis.

Investigators compared 4,936 women who received oral maintenance tocolysis with a β-sympathomimetic agent to 4,536 women who did not receive oral tocolysis. (Data were unavailable for the remaining 70 patients.)

In the oral tocolysis group, 366 patients (7%) delivered prematurely versus 1,094 patients (24%) in the control group.

After adjusting the results for possible confounding variables such as prior preterm delivery, cerclage, incompetent cervix, duration of intravenous tocolysis, and obesity, investigators calculated an odds ratio of 2.4 for preterm delivery in patients who were not maintained on oral tocolysis.

RENO, NEV. — While many physicians commonly use oral tocolysis maintenance after intravenous tocolysis in patients with preterm labor because they have a clinical impression of its effectiveness, solid evidence for this practice has been lacking until recently, according to Perkin Stang, M.D., of Wayne State University, Detroit, and colleagues.

Their population-based historical cohort study suggests that pregnant patients who are not maintained on oral tocolysis are more than twice as likely to deliver prematurely as are those who do receive oral maintenance, the investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The study involved 170,258 patients from a perinatal database in the state of Schleswig-Holstein, Germany.

Of those patients, 9,542 with preterm labor who received intravenous tocolysis were included in the study. Women with premature rupture of membranes and medically indicated inductions before 37 weeks of gestation were excluded from the analysis.

Investigators compared 4,936 women who received oral maintenance tocolysis with a β-sympathomimetic agent to 4,536 women who did not receive oral tocolysis. (Data were unavailable for the remaining 70 patients.)

In the oral tocolysis group, 366 patients (7%) delivered prematurely versus 1,094 patients (24%) in the control group.

After adjusting the results for possible confounding variables such as prior preterm delivery, cerclage, incompetent cervix, duration of intravenous tocolysis, and obesity, investigators calculated an odds ratio of 2.4 for preterm delivery in patients who were not maintained on oral tocolysis.

RENO, NEV. — First-trimester aneuploidy screening is practical not just in the context of clinical trials but also in the everyday world of the clinic, according to a poster presented by Sriram C. Perni, M.D., and colleagues at the annual meeting of the Society for Maternal-Fetal Medicine.

Among 2,515 women evaluated at a single institution, trisomy 21 was detected in 91% of 22 pregnancies when the false-positive rate was set to 5% and in 77% of 22 pregnancies when the false-positive rate was set to 1%.

In that same group, trisomy 18 was detected in all eight affected pregnancies, whether the false-positive rate was set to 5% or 1%.

Aneuploidy screening in the first trimester relies on an algorithm incorporating four pieces of data: maternal age, blood levels of pregnancy-associated plasma protein A (PAPP-A), blood levels of free β-human chorionic gonadotrophin (free β-hCG), and ultrasound measurements of fetal nuchal translucency, Dr. Perni said.

A large, multicenter, clinical trial involving 8,514 patients found this algorithm to have a good sensitivity and an acceptable false-positive rate (N. Engl. J. Med. 2003;349:1405-13).

But it remained unclear whether the algorithm would perform as well in the real-world setting of a single institution, reported Dr. Perni and his colleagues at Weill Medical College of Cornell University, New York.

At their clinic, 4,883 pregnant women, who together had 5,167 fetuses, were offered first-trimester aneuploidy screening, and 2,515 women agreed.

Of those pregnancies, there were a total of 37 aneuploid fetuses—1 with trisomy 13, 8 with trisomy 18, 22 with trisomy 21, 4 with 45X, 1 with 47XXY, and 1 with triploidy.

Of the 22 cases of trisomy 21, 3 resulted in a live birth, and 19 were electively terminated. All eight fetuses with trisomy 18 were electively terminated.

Asked in an interview whether first-trimester aneuploidy screening remained controversial, Dr. Perni replied, “I don't think it's controversial, but right now it's not the standard of care. There needs to be more evidence that it's reproducible at a single institution like this.

“This is a very, very good test,” continued Dr. Perni, who disclaimed any financial interest in the test.

“It can be done very early and has a very good detection rate for fixed false-positive rates,” he said.

He said that many insurance carriers in New York City do cover the screening test. And while the test has become “almost the standard of care” in certain parts of the United States, “it just hasn't become vogue over the whole country.”

He added, “I think the most exciting thing about this is that we can get information for couples and women specifically very early on to help them determine what they want to do.”

RENO, NEV. — First-trimester aneuploidy screening is practical not just in the context of clinical trials but also in the everyday world of the clinic, according to a poster presented by Sriram C. Perni, M.D., and colleagues at the annual meeting of the Society for Maternal-Fetal Medicine.

Among 2,515 women evaluated at a single institution, trisomy 21 was detected in 91% of 22 pregnancies when the false-positive rate was set to 5% and in 77% of 22 pregnancies when the false-positive rate was set to 1%.

In that same group, trisomy 18 was detected in all eight affected pregnancies, whether the false-positive rate was set to 5% or 1%.

Aneuploidy screening in the first trimester relies on an algorithm incorporating four pieces of data: maternal age, blood levels of pregnancy-associated plasma protein A (PAPP-A), blood levels of free β-human chorionic gonadotrophin (free β-hCG), and ultrasound measurements of fetal nuchal translucency, Dr. Perni said.

A large, multicenter, clinical trial involving 8,514 patients found this algorithm to have a good sensitivity and an acceptable false-positive rate (N. Engl. J. Med. 2003;349:1405-13).

But it remained unclear whether the algorithm would perform as well in the real-world setting of a single institution, reported Dr. Perni and his colleagues at Weill Medical College of Cornell University, New York.

At their clinic, 4,883 pregnant women, who together had 5,167 fetuses, were offered first-trimester aneuploidy screening, and 2,515 women agreed.

Of those pregnancies, there were a total of 37 aneuploid fetuses—1 with trisomy 13, 8 with trisomy 18, 22 with trisomy 21, 4 with 45X, 1 with 47XXY, and 1 with triploidy.

Of the 22 cases of trisomy 21, 3 resulted in a live birth, and 19 were electively terminated. All eight fetuses with trisomy 18 were electively terminated.

Asked in an interview whether first-trimester aneuploidy screening remained controversial, Dr. Perni replied, “I don't think it's controversial, but right now it's not the standard of care. There needs to be more evidence that it's reproducible at a single institution like this.

“This is a very, very good test,” continued Dr. Perni, who disclaimed any financial interest in the test.

“It can be done very early and has a very good detection rate for fixed false-positive rates,” he said.

He said that many insurance carriers in New York City do cover the screening test. And while the test has become “almost the standard of care” in certain parts of the United States, “it just hasn't become vogue over the whole country.”

He added, “I think the most exciting thing about this is that we can get information for couples and women specifically very early on to help them determine what they want to do.”

RENO, NEV. — First-trimester aneuploidy screening is practical not just in the context of clinical trials but also in the everyday world of the clinic, according to a poster presented by Sriram C. Perni, M.D., and colleagues at the annual meeting of the Society for Maternal-Fetal Medicine.

Among 2,515 women evaluated at a single institution, trisomy 21 was detected in 91% of 22 pregnancies when the false-positive rate was set to 5% and in 77% of 22 pregnancies when the false-positive rate was set to 1%.

In that same group, trisomy 18 was detected in all eight affected pregnancies, whether the false-positive rate was set to 5% or 1%.

Aneuploidy screening in the first trimester relies on an algorithm incorporating four pieces of data: maternal age, blood levels of pregnancy-associated plasma protein A (PAPP-A), blood levels of free β-human chorionic gonadotrophin (free β-hCG), and ultrasound measurements of fetal nuchal translucency, Dr. Perni said.

A large, multicenter, clinical trial involving 8,514 patients found this algorithm to have a good sensitivity and an acceptable false-positive rate (N. Engl. J. Med. 2003;349:1405-13).

But it remained unclear whether the algorithm would perform as well in the real-world setting of a single institution, reported Dr. Perni and his colleagues at Weill Medical College of Cornell University, New York.

At their clinic, 4,883 pregnant women, who together had 5,167 fetuses, were offered first-trimester aneuploidy screening, and 2,515 women agreed.

Of those pregnancies, there were a total of 37 aneuploid fetuses—1 with trisomy 13, 8 with trisomy 18, 22 with trisomy 21, 4 with 45X, 1 with 47XXY, and 1 with triploidy.

Of the 22 cases of trisomy 21, 3 resulted in a live birth, and 19 were electively terminated. All eight fetuses with trisomy 18 were electively terminated.

Asked in an interview whether first-trimester aneuploidy screening remained controversial, Dr. Perni replied, “I don't think it's controversial, but right now it's not the standard of care. There needs to be more evidence that it's reproducible at a single institution like this.

“This is a very, very good test,” continued Dr. Perni, who disclaimed any financial interest in the test.

“It can be done very early and has a very good detection rate for fixed false-positive rates,” he said.

He said that many insurance carriers in New York City do cover the screening test. And while the test has become “almost the standard of care” in certain parts of the United States, “it just hasn't become vogue over the whole country.”

He added, “I think the most exciting thing about this is that we can get information for couples and women specifically very early on to help them determine what they want to do.”

RENO, NEV. — Newer, less invasive techniques have decreased morbidity associated with fetal surgery, but morbidity is still a concern in these surgeries, Robert H. Bell, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The morbidity data come from a retrospective study of all fetal surgeries at the University of California, San Francisco, between July 1985 and May 2003, said Dr. Bell of the university.

During the early days of fetal surgery, most of the procedures involved open hysterotomy. Then fetal endoscopy (FETENDO) became popular, and now ultrasound-guided radiofrequency ablation (RFA) is the dominant procedure.

In all, 187 women with a mean maternal age of 29 (range 19-43) were treated during this period. Nine cases were marked by procedure-related fetal demise. Of the remaining 178 procedures, 79 involved a laparotomy and hysterotomy, 68 involved FETENDO, and 31 involved RFA.

Indications for the procedures included congenital diaphragmatic hernia in 38% of cases, monochorionic twin complications in 31%, hydrops in 11.8%, meningomyelocele in 8.6%, teratomas in 6.4%, and urinary obstruction in 2.1%.

The average gestational age for both hysterotomy and FETENDO was about 25 weeks, but RFA was done significantly earlier, at an average gestational age of about 21 weeks.

There were no significant differences in gestational age at delivery, with hysterotomy patients delivering at an average of 30.1 weeks, FETENDO patients delivering at 30.4 weeks, and RFA patients delivering at 32.7 weeks.

“Premature delivery, sadly, at this point is [a matter of] 'when' and not 'if,'” Dr. Bell said, although he pointed out that the data, averaged over a number of years of surgical experience, do not reflect recent improvements in lengthening pregnancies.

Premature rupture of membranes (PROM) is the primary cause of preterm delivery in these cases, and the rates of PROM are 52% in hysterotomy patients, 44% in FETENDO patients, and a significantly lower 13% in RFA patients.

About a quarter of the hysterotomy and FETENDO patients suffered pulmonary edema, a complication Dr. Bell attributed to deep inhalational anesthesia in the hysterotomy patients and the use of tocolytics in both hysterotomy and FETENDO patients.

None of the RFA patients suffered pulmonary edema (a statistically significant difference), reflecting recent changes in the treatment algorithm for preterm labor.

Another impressive improvement occurred in the average length of the patient's hospital stay. Although Dr. Bell said that clinicians at his institution are very cautious in managing patients in terms of surveillance and limitations of movement, the average length of stay has declined significantly from 11.9 days in the hysterotomy patients, to 7.9 days in the FETENDO patients, to 2.5 days in the RFA patients. And this understates the degree of improvement, since many RFA patients can now go home within 24 hours.

RENO, NEV. — Newer, less invasive techniques have decreased morbidity associated with fetal surgery, but morbidity is still a concern in these surgeries, Robert H. Bell, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The morbidity data come from a retrospective study of all fetal surgeries at the University of California, San Francisco, between July 1985 and May 2003, said Dr. Bell of the university.

During the early days of fetal surgery, most of the procedures involved open hysterotomy. Then fetal endoscopy (FETENDO) became popular, and now ultrasound-guided radiofrequency ablation (RFA) is the dominant procedure.

In all, 187 women with a mean maternal age of 29 (range 19-43) were treated during this period. Nine cases were marked by procedure-related fetal demise. Of the remaining 178 procedures, 79 involved a laparotomy and hysterotomy, 68 involved FETENDO, and 31 involved RFA.

Indications for the procedures included congenital diaphragmatic hernia in 38% of cases, monochorionic twin complications in 31%, hydrops in 11.8%, meningomyelocele in 8.6%, teratomas in 6.4%, and urinary obstruction in 2.1%.

The average gestational age for both hysterotomy and FETENDO was about 25 weeks, but RFA was done significantly earlier, at an average gestational age of about 21 weeks.

There were no significant differences in gestational age at delivery, with hysterotomy patients delivering at an average of 30.1 weeks, FETENDO patients delivering at 30.4 weeks, and RFA patients delivering at 32.7 weeks.

“Premature delivery, sadly, at this point is [a matter of] 'when' and not 'if,'” Dr. Bell said, although he pointed out that the data, averaged over a number of years of surgical experience, do not reflect recent improvements in lengthening pregnancies.

Premature rupture of membranes (PROM) is the primary cause of preterm delivery in these cases, and the rates of PROM are 52% in hysterotomy patients, 44% in FETENDO patients, and a significantly lower 13% in RFA patients.

About a quarter of the hysterotomy and FETENDO patients suffered pulmonary edema, a complication Dr. Bell attributed to deep inhalational anesthesia in the hysterotomy patients and the use of tocolytics in both hysterotomy and FETENDO patients.

None of the RFA patients suffered pulmonary edema (a statistically significant difference), reflecting recent changes in the treatment algorithm for preterm labor.

Another impressive improvement occurred in the average length of the patient's hospital stay. Although Dr. Bell said that clinicians at his institution are very cautious in managing patients in terms of surveillance and limitations of movement, the average length of stay has declined significantly from 11.9 days in the hysterotomy patients, to 7.9 days in the FETENDO patients, to 2.5 days in the RFA patients. And this understates the degree of improvement, since many RFA patients can now go home within 24 hours.

RENO, NEV. — Newer, less invasive techniques have decreased morbidity associated with fetal surgery, but morbidity is still a concern in these surgeries, Robert H. Bell, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The morbidity data come from a retrospective study of all fetal surgeries at the University of California, San Francisco, between July 1985 and May 2003, said Dr. Bell of the university.

During the early days of fetal surgery, most of the procedures involved open hysterotomy. Then fetal endoscopy (FETENDO) became popular, and now ultrasound-guided radiofrequency ablation (RFA) is the dominant procedure.

In all, 187 women with a mean maternal age of 29 (range 19-43) were treated during this period. Nine cases were marked by procedure-related fetal demise. Of the remaining 178 procedures, 79 involved a laparotomy and hysterotomy, 68 involved FETENDO, and 31 involved RFA.

Indications for the procedures included congenital diaphragmatic hernia in 38% of cases, monochorionic twin complications in 31%, hydrops in 11.8%, meningomyelocele in 8.6%, teratomas in 6.4%, and urinary obstruction in 2.1%.

The average gestational age for both hysterotomy and FETENDO was about 25 weeks, but RFA was done significantly earlier, at an average gestational age of about 21 weeks.

There were no significant differences in gestational age at delivery, with hysterotomy patients delivering at an average of 30.1 weeks, FETENDO patients delivering at 30.4 weeks, and RFA patients delivering at 32.7 weeks.

“Premature delivery, sadly, at this point is [a matter of] 'when' and not 'if,'” Dr. Bell said, although he pointed out that the data, averaged over a number of years of surgical experience, do not reflect recent improvements in lengthening pregnancies.

Premature rupture of membranes (PROM) is the primary cause of preterm delivery in these cases, and the rates of PROM are 52% in hysterotomy patients, 44% in FETENDO patients, and a significantly lower 13% in RFA patients.

About a quarter of the hysterotomy and FETENDO patients suffered pulmonary edema, a complication Dr. Bell attributed to deep inhalational anesthesia in the hysterotomy patients and the use of tocolytics in both hysterotomy and FETENDO patients.

None of the RFA patients suffered pulmonary edema (a statistically significant difference), reflecting recent changes in the treatment algorithm for preterm labor.

Another impressive improvement occurred in the average length of the patient's hospital stay. Although Dr. Bell said that clinicians at his institution are very cautious in managing patients in terms of surveillance and limitations of movement, the average length of stay has declined significantly from 11.9 days in the hysterotomy patients, to 7.9 days in the FETENDO patients, to 2.5 days in the RFA patients. And this understates the degree of improvement, since many RFA patients can now go home within 24 hours.

SANTA FE, N.M. — Although the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported at the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.” Although some women with FSAD do complain chiefly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused. All women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and those with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All women responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but women with FSAD reported less arousal. Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who complained of problems with genital arousal. These women showed no significant increase in vaginal pulse amplitude in response to the erotic films. Women who complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal.

Although the control women and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. This finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD. Another implication is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

SANTA FE, N.M. — Although the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported at the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.” Although some women with FSAD do complain chiefly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused. All women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and those with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All women responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but women with FSAD reported less arousal. Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who complained of problems with genital arousal. These women showed no significant increase in vaginal pulse amplitude in response to the erotic films. Women who complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal.

Although the control women and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. This finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD. Another implication is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

SANTA FE, N.M. — Although the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported at the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.” Although some women with FSAD do complain chiefly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused. All women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and those with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All women responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but women with FSAD reported less arousal. Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who complained of problems with genital arousal. These women showed no significant increase in vaginal pulse amplitude in response to the erotic films. Women who complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal.

Although the control women and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. This finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD. Another implication is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

RENO, NEV. — The influenza vaccine is both safe and effective for women in the second half of pregnancy, results of a large prospective study suggest.

When given at least 2 weeks before exposure, the vaccine reduced the rate of influenza 19-fold, with no evidence of worsening in several obstetric and neonatal outcomes, including premature rupture of membranes, stillbirth, low birth weight, neonatal pneumonia, neonatal death, and major malformations.

The study, which was conducted at the University of Texas Southwestern Medical Center at Dallas, included 2,889 women who received the inactivated influenza vaccine during the 2003-2004 flu season, which began earlier than usual and was moderately severe. They were compared with 1,988 gestational age-matched pregnant women who did not get vaccinated during the same time period, Jeanne S. Sheffield, M.D., and her associates wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Six women in the vaccinated group (2.4 per 1,000 women) and 13 women in the nonvaccinated group (6.5 per 1,000 women) developed laboratory-confirmed influenza, a statistically significant difference. The overall efficacy of the vaccine was 68%.

But when the analysis was restricted to women who developed influenza more than 2 weeks after vaccination (the time required to develop immunity), there was only one case of influenza (0.4 per 1,000 women) in the group, yielding an efficacy of 94%. The relative risk of developing influenza decreased almost 19-fold when the vaccine was given 2 weeks before exposure.

There were some statistically significant differences between the groups, study co-investigator Scott W. Roberts, M.D., told this newspaper.

Women in the vaccination group were seen more frequently than the controls, they had more repeat cesarean deliveries and cases of dystocia, and larger body-mass indexes.

The estimated gestational age (EGA) at delivery was slightly, but significantly, higher in the vaccination group (39.6 weeks), compared with the unvaccinated group (39.4 weeks).

The vaccinated group had significantly fewer births with EGAs of 36 weeks or less, compared with the unvaccinated group. Infants whose mothers were vaccinated were significantly less likely to be admitted to the intensive care nursery.

Women in the vaccinated group were significantly more likely to undergo a cesarean delivery (27% vs. 23%). Dr. Roberts said that most or all of these differences may reflect the fact that women who were seen in the clinic more often were more likely to choose vaccination.

When given at least 2 weeks before exposure to influenza, the vaccine dramatically reduced the rate of infection. Lynda Banzi

RENO, NEV. — The influenza vaccine is both safe and effective for women in the second half of pregnancy, results of a large prospective study suggest.

When given at least 2 weeks before exposure, the vaccine reduced the rate of influenza 19-fold, with no evidence of worsening in several obstetric and neonatal outcomes, including premature rupture of membranes, stillbirth, low birth weight, neonatal pneumonia, neonatal death, and major malformations.

The study, which was conducted at the University of Texas Southwestern Medical Center at Dallas, included 2,889 women who received the inactivated influenza vaccine during the 2003-2004 flu season, which began earlier than usual and was moderately severe. They were compared with 1,988 gestational age-matched pregnant women who did not get vaccinated during the same time period, Jeanne S. Sheffield, M.D., and her associates wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Six women in the vaccinated group (2.4 per 1,000 women) and 13 women in the nonvaccinated group (6.5 per 1,000 women) developed laboratory-confirmed influenza, a statistically significant difference. The overall efficacy of the vaccine was 68%.

But when the analysis was restricted to women who developed influenza more than 2 weeks after vaccination (the time required to develop immunity), there was only one case of influenza (0.4 per 1,000 women) in the group, yielding an efficacy of 94%. The relative risk of developing influenza decreased almost 19-fold when the vaccine was given 2 weeks before exposure.

There were some statistically significant differences between the groups, study co-investigator Scott W. Roberts, M.D., told this newspaper.

Women in the vaccination group were seen more frequently than the controls, they had more repeat cesarean deliveries and cases of dystocia, and larger body-mass indexes.

The estimated gestational age (EGA) at delivery was slightly, but significantly, higher in the vaccination group (39.6 weeks), compared with the unvaccinated group (39.4 weeks).

The vaccinated group had significantly fewer births with EGAs of 36 weeks or less, compared with the unvaccinated group. Infants whose mothers were vaccinated were significantly less likely to be admitted to the intensive care nursery.

Women in the vaccinated group were significantly more likely to undergo a cesarean delivery (27% vs. 23%). Dr. Roberts said that most or all of these differences may reflect the fact that women who were seen in the clinic more often were more likely to choose vaccination.

When given at least 2 weeks before exposure to influenza, the vaccine dramatically reduced the rate of infection. Lynda Banzi

RENO, NEV. — The influenza vaccine is both safe and effective for women in the second half of pregnancy, results of a large prospective study suggest.

When given at least 2 weeks before exposure, the vaccine reduced the rate of influenza 19-fold, with no evidence of worsening in several obstetric and neonatal outcomes, including premature rupture of membranes, stillbirth, low birth weight, neonatal pneumonia, neonatal death, and major malformations.

The study, which was conducted at the University of Texas Southwestern Medical Center at Dallas, included 2,889 women who received the inactivated influenza vaccine during the 2003-2004 flu season, which began earlier than usual and was moderately severe. They were compared with 1,988 gestational age-matched pregnant women who did not get vaccinated during the same time period, Jeanne S. Sheffield, M.D., and her associates wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Six women in the vaccinated group (2.4 per 1,000 women) and 13 women in the nonvaccinated group (6.5 per 1,000 women) developed laboratory-confirmed influenza, a statistically significant difference. The overall efficacy of the vaccine was 68%.

But when the analysis was restricted to women who developed influenza more than 2 weeks after vaccination (the time required to develop immunity), there was only one case of influenza (0.4 per 1,000 women) in the group, yielding an efficacy of 94%. The relative risk of developing influenza decreased almost 19-fold when the vaccine was given 2 weeks before exposure.

There were some statistically significant differences between the groups, study co-investigator Scott W. Roberts, M.D., told this newspaper.

Women in the vaccination group were seen more frequently than the controls, they had more repeat cesarean deliveries and cases of dystocia, and larger body-mass indexes.

The estimated gestational age (EGA) at delivery was slightly, but significantly, higher in the vaccination group (39.6 weeks), compared with the unvaccinated group (39.4 weeks).

The vaccinated group had significantly fewer births with EGAs of 36 weeks or less, compared with the unvaccinated group. Infants whose mothers were vaccinated were significantly less likely to be admitted to the intensive care nursery.

Women in the vaccinated group were significantly more likely to undergo a cesarean delivery (27% vs. 23%). Dr. Roberts said that most or all of these differences may reflect the fact that women who were seen in the clinic more often were more likely to choose vaccination.

When given at least 2 weeks before exposure to influenza, the vaccine dramatically reduced the rate of infection. Lynda Banzi