784 BREAST RECONSTRUCTION AFTER SUBCUTANEOUS MASTECTOMY
RESOLUTION OF HYPERPROLACTINÆMIA AFTER BROMOCRIPTINE-INDUCED PREGNANCY
SIR,-Professor McColl (Jan. 20, p. 134) described reconstruction of the breast with omentum after subcutaneous mastectomy. We routinely offer subcutaneous mastectomy to our younger patients if the tumour is clinically less than 4 cm diameter and not fixed to skin or muscle. We have done 58 such operations during the past 3yyears. So far 40 patients have subsequently received silicone prostheses subcutaneously or
SiR,—The report by Dr Cowden and Dr Thomson (March 17, p. 613) prompts me to describe a similar case. The patient, then aged 28, first presented with amenorrhoea
subpectorally. McColl suggests that infection can be a problem with implants of foreign material. This has not been our experience with mammary implants. Only one prosthesis has become infected, and in that case a second implantation was successful. We agree that omentum could provide a more natural breast since in many silicone implants capsules will develop. Although the capsule can usually be ruptured easily, it can lead to patient dissatisfaction. However, the few patients with whom we have had a chance to discuss the use of omentum are unwilling to undergo abdominal surgery, and have opted for a silicone
implant. P.J.D. is meriv.
WHS
a
Cancer Research
Campaign
research fellow, as, for-
C LD,
Department of Surgery, City Hospital, Nottingham NG5 1PB
P. T. DOYLE C. J. DAVIES R. W. BLAMEY
NEUROLOGICAL COMPLICATIONS OF MITRAL-LEAFLET PROLAPSE
SIR,-An omission from
your Jan. 20 editorial on the mitral valve was the neurological complications of mitral-leaflet prolapse (M.L.P.). 1 of 4 patients reported by Barlow and Bosman1 had transient left-arm weakness followed years later by left hemiparesis. Malcolm et al.1 analysed 85 consecutive cases of M.L.P. and found major neurological complications in 11 (13%), including transient ischxmic attacks (T.I.A.S) in 9, hemiparesis in 1, and hemichorea in 1. Minor neurological disturbances (dizziness, lightheadedness, and peripheral paroesthesias) were seen in 15 patients. Barnett et al.3 and Kostuk et al.4 reviewed 12 and 14 patients, respectively (from the same institution), and noted T.l.A.s, recurrent T.I.A.S, and completed strokes. Both studies stressed the young age of patients, acute onset of neurological symptoms, and focal nature of cerebral lesions (hemiparesis, hemihypaesthesia, homonomous hemianopsia, dysarthria, and aphasia). Hirsowitz and Saffer5 presented 4 additional cases of M.L.P.-related strokes; angiograms showed middle-cerebral-artery occlusions in 2 and computerised tomography demonstrated an internal capsule infarction in a third case. Major neurological complications of M.L.P. in the absence of infective endocarditis consist of T.I.A.s and strokes and have only recently been emphasised. The acute onset, focal signs, and frequent middle-cerebral-artery distribution suggest an embolic cause. Pathological studies showing valvular thrombus or fibrin material in some cases support a cardiac source of the emboli, and the paroxysmal arrhythmias seen with M.L.P. may promote the embolic process. The value of anticoagulants and antiplatelet agents for prophylactic treatment of M.L.P.-related cerebral ischaemic events is uncertain. Because it is relatively common in the general population, M.L.P. must be considered in the evaluation ofT.LA. or stroke in young patients.
"floppy"
Neurological Institute of New York, New York, N Y. 10032, U.S.A.
GEORGE ZITO
in September, 1975. She had had oligomenorrhoea since menarche at the age of 16; she had periods lasting 1-2 days every 2-3 months. In 1974 her periods had become scantier, finally ceasing altogether in December. She failed to respond to clomiphene. In 1976 laparoscopy revealed small inactive ovaries and her serum-prolactin was found to be raised. She was fully investigated in February, 1977. There was no history of drug therapy, headaches, or visual disturbance. She did not complain of galactorrhcea nor could any be demonstrated on examination. Her weight and secondary sexual characteristics were normal. Basal serum-prolactin was raised (three determinations 65, 83, and 98 ug/l,
RESOLUTION OF HYPERPROLACTINÆMIA AFTER BROMOCRIPTINE-INDUCED PREGNANCY
SIR,-Professor McColl (Jan. 20, p. 134) described reconstruction of the breast with omentum after subcutaneous mastectomy. We routinely offer subcutaneous mastectomy to our younger patients if the tumour is clinically less than 4 cm diameter and not fixed to skin or muscle. We have done 58 such operations during the past 3yyears. So far 40 patients have subsequently received silicone prostheses subcutaneously or
SiR,—The report by Dr Cowden and Dr Thomson (March 17, p. 613) prompts me to describe a similar case. The patient, then aged 28, first presented with amenorrhoea
subpectorally. McColl suggests that infection can be a problem with implants of foreign material. This has not been our experience with mammary implants. Only one prosthesis has become infected, and in that case a second implantation was successful. We agree that omentum could provide a more natural breast since in many silicone implants capsules will develop. Although the capsule can usually be ruptured easily, it can lead to patient dissatisfaction. However, the few patients with whom we have had a chance to discuss the use of omentum are unwilling to undergo abdominal surgery, and have opted for a silicone
implant. P.J.D. is meriv.
WHS
a
Cancer Research
Campaign
research fellow, as, for-
C LD,
Department of Surgery, City Hospital, Nottingham NG5 1PB
P. T. DOYLE C. J. DAVIES R. W. BLAMEY
NEUROLOGICAL COMPLICATIONS OF MITRAL-LEAFLET PROLAPSE
SIR,-An omission from
your Jan. 20 editorial on the mitral valve was the neurological complications of mitral-leaflet prolapse (M.L.P.). 1 of 4 patients reported by Barlow and Bosman1 had transient left-arm weakness followed years later by left hemiparesis. Malcolm et al.1 analysed 85 consecutive cases of M.L.P. and found major neurological complications in 11 (13%), including transient ischxmic attacks (T.I.A.S) in 9, hemiparesis in 1, and hemichorea in 1. Minor neurological disturbances (dizziness, lightheadedness, and peripheral paroesthesias) were seen in 15 patients. Barnett et al.3 and Kostuk et al.4 reviewed 12 and 14 patients, respectively (from the same institution), and noted T.l.A.s, recurrent T.I.A.S, and completed strokes. Both studies stressed the young age of patients, acute onset of neurological symptoms, and focal nature of cerebral lesions (hemiparesis, hemihypaesthesia, homonomous hemianopsia, dysarthria, and aphasia). Hirsowitz and Saffer5 presented 4 additional cases of M.L.P.-related strokes; angiograms showed middle-cerebral-artery occlusions in 2 and computerised tomography demonstrated an internal capsule infarction in a third case. Major neurological complications of M.L.P. in the absence of infective endocarditis consist of T.I.A.s and strokes and have only recently been emphasised. The acute onset, focal signs, and frequent middle-cerebral-artery distribution suggest an embolic cause. Pathological studies showing valvular thrombus or fibrin material in some cases support a cardiac source of the emboli, and the paroxysmal arrhythmias seen with M.L.P. may promote the embolic process. The value of anticoagulants and antiplatelet agents for prophylactic treatment of M.L.P.-related cerebral ischaemic events is uncertain. Because it is relatively common in the general population, M.L.P. must be considered in the evaluation ofT.LA. or stroke in young patients.
"floppy"
Neurological Institute of New York, New York, N Y. 10032, U.S.A.
GEORGE ZITO
in September, 1975. She had had oligomenorrhoea since menarche at the age of 16; she had periods lasting 1-2 days every 2-3 months. In 1974 her periods had become scantier, finally ceasing altogether in December. She failed to respond to clomiphene. In 1976 laparoscopy revealed small inactive ovaries and her serum-prolactin was found to be raised. She was fully investigated in February, 1977. There was no history of drug therapy, headaches, or visual disturbance. She did not complain of galactorrhcea nor could any be demonstrated on examination. Her weight and secondary sexual characteristics were normal. Basal serum-prolactin was raised (three determinations 65, 83, and 98 ug/l,
