SA MEDIESE TYDSKRIF DEEL 62 24 JULlE 1982 125

Gangrenousfasciitis

erysipelas and • •necrotIzIng

Occurrence in elderly White women in the Pretoria area, with a study ofsome effects on blood coagulation

G. H. FINDLAY, J. A. HAZELHURST, . R. C. FRANZ

Summary

This study considers two' types of bacterial.gangrene of the skin - gangrenous erysipelas andnecrotizing fasciitis - as encountered in Pretoria.Photographic documentation, bacteriologicalstudy and some observations on thrombelasto­graphy are presented. The prevalence in this seriesof elderly White women was noteworthy, and a highmorbidity and mortality were recorded. A possibleprogramme for improving the management ofthesedisorders is set out.

S AIr Med J 1982; 62: 125-131.

Over the last few decades the once-familiar erysipelas has slippedout of the medical spotlight, while the allied disorder ofnecrotizing fasciitis or acute streptococcal gangrene has,possibly, not gained the publicity it deserves, Althougherysipelas ceased to be notifiable in 1980, it was hitherto eitherunrecognized as such, or diagnosed and treated withoutnotification, to avoid unnecessary fuss. Necrotizing fasciitis stillremains a formidable disorder, and has lost none of itsimportance through improvements in management,

Gangrene in erysipelas

The traditional view of gangrene in erysipelas is somewhatvague, but the presence of a severe infection is usually thoughtnecessary, some impairment of circulation presumed, and anelement of pressure necrosis at times implied. l Spread to thesuperficial fascia (subcutaneous fat) can then occur bydownward extension from the dermis,

This view of gangrenous erysipelas is of little service whendealing with necrotizing fasciitis, which is the primarilysubcutaneous form of acute streptococcal infection withgangrene. Indeed, some dermatologists are not fully aware of thisrather different disorder, despite the existence of lucid surgicalpapers on the subject written over the past 60 years, Only onedermatological textbook describes it well.

Departments of Dermatology and Surgery, University ofPretoriaG. H. FINDLAY, M.D., D.se, FRS. S.AF.

l A. HAZELHURST, M.B. eRB.R. C. FRANZ, M.MED. (CHIR)

Date received: 22 December 1981.

Necrotizing fasciitis

Early perspectivesMeleney wrote the classic papers on haemolytic str~ptococcus

gangrene, based on his experience in Peking, China, in the early19205, to be extended later in New York.2

,3 The leading idea wasthat of a spreading subcutaneous infection, usually occurring in alimb, causing an interruption of the blood supply to theoverlying skin with a moist or dry gangrene resulting at thesurface after a couple of days. Except where the deeperstructures were damaged, as with a compound fracture, themuscle below and the deep fascia remained free from infection.Meleney pointed out that the therapeutic choice might bethought to lie between two alternatives, i.e. a conservative delayor an amputation, both of which would, in his opinion, bedisastrous mistakes. He advised instead that the necrotic fasciabe fully opened by single long incisions for drainage,debridement and relief of tension within I hour of making theclinical diagnosis.

Although haemolytic streptococcus gangrene couldcomplicate war wounds and other major injuries, it has beennoteworthy for the way it could start abruptly after quite trivialcivilian accidents within the household. In the late 19405Meleney's original views were still upheld: the dominating lesionwas always a subcutaneous necrosis with some abscessformation, and long drainage cuts were preferable to 'bearscratch' incisions.' Since the anatomical site of the disease was,strictly speaking, the superficial fascia (sparing the deep fascia)and the haemolytic streptococcus with gangrene were not suchconstant features, the name 'necrotizing fasciitis' was thought tobe more descriptive. This was suggested by Wilson,S in place ofthe term 'haemolytic streptococcus gangrene'. He had seen arather large number of cases, clustered for some reason in theperiod 1948-1951 in Dallas, Texas, USA, and his descriptivename, necrotizing fasciitis, has found favour. In his cases haemo­lytic staphylococci were often recovered; he noted also that trueerysipelas was sometimes a sequel to necrotizing fasciitis, thatgangrene need not appear, and that sometimes there was a delayafter an injury before the disease set in.

Wilson further enriched the clinical picture and managementin several ways, He favoured early diagnosis by local incision ofsuspicious inflammatory swellings, particularly if the surface isnumb, and an exploratory probing of the fascia for evidence ofundermining. By this means, non-gangrenous cases ofnecrotizing fasciitis could be discovered, more widely opened,drained, and the necrotic tissue removed. He also emphasized anumber of general results of necrotizing fasciitis: the salt andfluid loss, sequestration of blood and bacterial haemolysis withanaemia and jaundice, the trapping of calcium by necrotic fatproducing tetany, etc. Venous thromboses in the presence of anintact arterial circulation also promoted tissue ecchymosis, and.the loss of sensation from interference with cutaneous nerves bythe inflammation was stressed.

The real threat of necrotizing fasciitis always came from thesepticaemia, pyaeJ1lia, metastatic skin lesions and toxaemia.

126 SA MEDICAL JOURNAL VOLUME 62 24 JULY 1982

These complications arose from the subcutaneous accumulationof organisms and necrotic tissue under tension and undergoingconstant resorption. Moreover, the superficial fascia is, in thesecircumstances, largely impenetrable to antibiotics - hence thecontinued need for free release of infected and necrotic materialto the outside. The psychiatric aspects were also nor to beoverlooked - the clouding of consciousness and confusionalstates, apathy, and prostration, which herald death in the severecase, as well as shock.

Recent advancesOver the last decade many lesser aspects ofnecrotizing fasciitis

have been documented, though many unsolved problemsremain.

Histopathological features in the skin6 have been betterstudied. These comprise the thromboses in the microvasculatureincluding a fibrinoid arteriolitis producing tissue necrosis, theoedematous disruption of the papillary layer with subepidermalbulla formation, and the initial presence in the dermis ofIymphocyres and histiocytes only.

Microbiological features have been extended to include asynergistic action of bacterial mixtures,7 which do not requiregroup A haemolytic streptococci or aerobic staphylococci, butproduce necrotizing fasciitis through a mixture of anaerobes,other groups of streptococci, Pseudomonas, Bacleroides, etc.

Choice of antibiotics is altered as a result of the above.Benzylpenicillin and cloxacillin would be standard drugs, butmetronidazole, the aminoglycosides and cephalosporins may berequired. In diabetics the anaerobes or coliforms may bring ongas production without implying the presence of clostridia. Inhis first paper from China Meleney2 indicated that he hadobserved these bacterial mixtures, but seemed later to discounttheir importance. In passing, we may note the employment bysome of maggots or applications of honey to the wounds.

Special features of age, site and causative organisms haverepeatedly been observed. Particular differences are noted ininfants and children (with Haemophi/us or Pseudomonas as causes,needing appropriate treatment); the old-established type offulminant gangrene of the genital region described by AlfredFournier in 1883 can now also be claimed as a special type ofnecrotizing fasciitis; lesions on the trunk due to Gram-negativeorganisms are seen to be related to bowel infections and surgery,and puerperal and perineal infections occur. All these varietieshave widened the concept of necrotizing fasciitis. Anothercomplication is disseminated intravascular coagulation. Havinga decisive effect on the prognosis is the patient's general conditionin other respects - the state of the kidneys, liver, arteries, heart,general defence, metabolism, lymph flow, other drugs used, etc.,each of which bring their respective complications into thepicture and may compromise the sufferer.

Unsolved questionsEpidemic grouping. It is puzzling that in some regions and

at some times the cases occur in runs, suggesting the localemergence of strains of the group AB-haemolytic SlreplOcoccUSwith selective pathogenicity.

Microbial pathogenicity. Once inside the superficial fasciaof the host, there has been no satisfactory account of how thenecrosis and thromboses occur, apart from a general theory thatvarious toxins, Iysins, enzymes, immunological phenomena andcoagulative disturbances are responsible.

Illustrative cases

We wish to present a part of our experience with gangrenouserysipelas and necrotizing fasciitis in Pretoria through the

medium of colour pictures of representative cases. Thepredominance of elderly women in our series has made uswonder whether flabby skin tissue predisposes them in some wayto these infections.

Erysipelas of the face with gangrene of theeyelids

Fig. I. Erysipelas began at a crack in the right ear region in this47-year-old woman, and spread forward over the face from rightto left. It resulted in a haemorrhagic gangrene of the right uppereyelid, the scarring from which was later corrected by plasticsurgery.

Fig. 1.

Fig. 2. A similarly asymmetrical erysipelas of the face in a 70­year-old diabetic woman resulted in gangrene of the left upperand lower eyelids. The scarring after separation of the sloughsdid not require reconstructive surgery.

Fig. 2.

Epidermal signs in necrotizing fasciitis anderysipelas

Some uncertainty exists about epidermal detachment, bullaformation and haemorrhagic bullae in this group of diseases.

Fig. 3. This illustration shows an erysipelas of the leg withwidespread dermal-epidermal detachment. This detachmentresults in a loose epidermis which is crinkly amd movable overthe underlying tissue. It has the appearance of scalded skin, andcould be a prelude to haemorrhage and gangrene. It does notfollow the pattern of toxic epidermal necrolysis or thestaphylococcal scalded skin syndrome in other respects. In thispatient the condition proceeded to necrotizing fasciitis.

Fig. 3.

Fig. 4. Here an erysipelas was complicated in the later stagesby haemorrhagic bullae. In our experience such bullae are sterileand are not a prelude to gangrene, although the contrary has beenstated.

Fig. 4.

Necrotizing fasciitis of the foot with metastaticlesions in the inguinal region with uraemia andimpaired arterial circulation in the leg

Fig. 5. This 87-year-old woman was afebrile, confused anddehydrated, with diffuse swelling of the leg, radiating patches ofgangrene on the leg and foot, and some white areas where theblack slough had come off. Blistering with apparent bruisingappeared in the groin, which progressed into a full-thicknessgangrenous slough. Later it dissected itselfloose from the deeperlayers of fat (Fig. 6). There was an uncertain history ofa fall withinjury to the leg. The gangrenous areas yielded a mixture oforganisms, including Pseudomonas aeruginosa, Pro£eus mirabilis,Escherichia coh~ and S£repr. faecalis for which the specificantibiotics were given. She died 10 weeks after admission,presumably from septicaemia, after the leg had been amputated.

SA MEDIESE TYDSKRIF DEEL 62 24 JULlE 1982 127

Fig. 5.

Fig. 6.

Necrotizing fasciitis of the hand and arm in adiabetic

Fig. 7. A 71-year-old woman injured her left arm when fallingin a faint, and developed a purple bulla on the hand dorsum,blisters round the wrist, and black sloughs up the arm to theshoulder. Ps. aeruginosa, E. coh~ Pr. mirabilis, Klebsiella sp., etc.were repeatedly found and treated with intravenous cefoxitin.

Fig. 7.

Fig. 8. This photograph" shows the dry gangrenous sequel tothe large bulla on the hand dorsum, seen in part of Fig. 7. Threeweeks later the sloughs were surgically removed and 3 weeks

128 SA MEDICAL JOURNAL VOLUME 62 24 JULY 1982

Fig. 8.

after that she died. Postmortem findings were of cardiac failureand bronchopneumonia.

Necrotizing fasciitis of the arm with pepticulceration and heart failure

Fig. 9. A 69-year-old woman innocently hurt her right elbowduring housework and was seen a week later with this picture: anintensely swollen and red right arm with patchy haemorrhagicnecrosis and extensive epidermal necrolysis. Group A E­haemolytic streptococci and Scaph. aureus were isolated.

Fig. 10. Oose-up of the right elbow crease with gangrene.

Fig. 9.

Fig. 10.

Figs 11 and 12. Further spread of the gangrene and laterrestriction of the redness. She was treated with penicillin,gentamicin, metronidazole and corticosteroids. Treatment forheart failure was needed throughout, and a peptic ulcer wasdemonstrated gastroscopically. While convalescing she diedsuddenly 4 weeks after the onset of her trouble, and atpostmortem examination a mycocardial infarct was found.

Fig. 11.

Fig. 12.

Necrotizing fasciltis of the right hand dorsum,complicated by necrotizing cholecystitiswithout stones, and a syndrome of hyper­coagulability

Fig. 13. A 75-year-old woman was uraemic and confused, andcould say linle about the history of a necrotizing ulcer withfasciitis of the back of the right hand. Tendons and thrombosedveins were exposed. Group A E-haemolytic streptococci wereisolated from it, and recovery took place with intravenouspencillin and gentamicin. Platelets were increased and a thrombo­elastogram showed hypercoagulability. After I week inhospital she underwent a laparotomy tor what proved to be anecrotic gallbladder free from stones, possibly due to thrombosisof the cystic artery. She left hospital after 10 weeks.

Necrotizing fasciitis of the left ankle followinga trivial domestic injury

Fig. 14. A 70-year-old woman developed a confused mentalstate together with redness, swelling and commencing gangreneof the left ankle following a knock on the leg. An extensive slough

SA MEDIESE TYDSKRIF DEEL 62 24 JULlE 1982 129

Fig. 13.

Fig. 14.

formed, upon removal of which the appearance was as shown inthe figure. The thrombosed long saphenous vein can be seenacross the ulcer. Group A R-haemolytic streptococci wereisolated at first, and the surface was later complicated by ProTeusand Pseudomonas infection. After removal of the slough and skingrafting she left hospital (stay 10 weeks).

Patchy gangrene of the leg resemblingnecrotizing fasciitis resulting from thrombosisof the aorta.

Figs 15 and ·16. These pictures are included because ofoccasional overlaps in diagnosis when infection is accompaniedby arterial obstruction. The gangrene is attended by rather litdeswelling or epidermal change, i.e. it is a dry gangrene which inposition and form may resemble the above cases fairly closely.

Skin pathology

Streptococcal necrotizing fasciitisOur biopsy material from 2 cases showed that there were two

sites for early pathological change - the dermal papillary layerand the cutis-subcutis junction. In the papillary layer, theground substance was dissolved out and the layer becameconverted into a wide and tenuous web of fibrils withhaemorrhaging into the spaces so formed. Epidermal necrosisdeveloped later. In the upper subCUTis there was acute necrotizinginflammation, with breakdown of fat cells and a thick layer ofpolymorphs lying in the subcutaneous debris. The dermis was

Fig. 15.

Fig. 16.

the last layer to alter and be filled with polymorphs, accompaniedby a necrotizing thrombosis of the superficial bloodvessels.

Gram-negative necrotizing fasciitisIn I case only, the most prominent change seen in three biopsy

specimens was the presence of red blood cells in-between theconnective tissue fibres of the dermis. In the upper dermis thered cells were fused into compact masses and me vessels werethrombosed with fibrin thrombi. These alterations wouldprobably have preceded a black gangrenous slough in the area.

Coagulation studies

Fig. 17 shows me thrombo-elastographic findings in me 2 casesillustrated in Figs 11, 12 and 13, derived from recalcified citratedwhole blood samples. These tracings demonstrate a mrombo­elastographic hypercoagulability, which was unalteredby a constant infusion of heparin (20000 V/d). In both cases thereaction time, or the rate of thromboplastin generation (me r­time) is shortened. The rapidity of fibrin build-up, or thrombinconstant (the k-time) is also shortened, while the maximalamplitude, or maximal elasticity of me fibrin clot (the ma-value)is increased.

The sum of the r-time plus the k-time equals me cloning time,and indicates the heparin tolerance. Shortened times are usuallyassociated with accelerated coagulability. An increase in me ma­value is similarly associated with a hypercoagulable state.8

Although the concept of hypercoagulability is stillcontroversial, various definitions have nevertheless been

130 SA MEDICAL JOURNAL VOLUME 62 24 JULY 1982

7/5/1881

NORMAL CONTROL

11/5/1981

r • 13.0

k • 11,5

HEPARIN

r :: 11,0

1,0

r :: 11,0

HEPAR&.;

k :: 2,0

k

ma::75,O

20000U/d.....

m8=75,O

20 OOOU/dlem

k :: 2,0

r • 7,0

k. 2.0

m_=74,O

ma.72,o

r :: 10,0

NECROTIZING FASCIITIS

NECROTIZING FASCIITIS

MYOCARDIAL INFARCTION

ACALCULOUS CHOLECYSTITIS

Fig. 17. Thrombo-elastographic patterns in the 2 cases illustrated in Figs 11, 12 and 13.

suggested. Fisch er al. 9 define thrombo-elastographic hyper­coagulability as an accelerated rate of cloning and increasedfirmness of the formed clot. However, a hypercoagulablethrombo-elasrogram only indicates an increasedlikelihood of cloning and not acrual clot production. Thrombosisprobably requires other factors such as stasis and intimal damagebefore cloning sets in, bur the thrombelastogram enables one tomeasure a phenomenon that previously existed only in theory. 10

Discussion

Ipvestigation and managementOur cases of gangrenous erysipelas and necrotizing fasciitis in

elderly women showed a mortality and morbidity which hardlylook creditable, but which at least emphasize the seriousness ofthe condition. At the onset the disorder was sometimes difficultto recognize. An afebrile disorienrated old woman comes in, whosefamily cannot tell the nature of the alleged limb injury, and whoconfuse the issue further by suspecting spider bites. Arterialpulses may be obscured by swelling. Time may be spent lookingfor fractures. The general medical condition is usually

. unfavourable, with obesity, uraemia, heart failure, diabetes,arteriosclerosis and various immediate disrurbances in themental state, the fluid balance, shock, etc. The angulated andreticular form of the skin necroses misleads one into diagnosing aprimary disorder of the arteries of the skin.

The collection of photographs which forms our main personalcontribution in this article is designed to direct anention to somefearures of the condition and its management. The firstrequirement after considering the diagnostic possibility ofnecrotizing fasciitis is bacteriological study. This shouldcomprise direct Gram-staining of smears from the exudate,syringe puncrure and aspiration of a swollen area near to (bur notat) a site of ulceration for aerobic and anaerobic culture, and abiood culrure. The choice of antibiotics can be decided on the

smear, failing which a combination of penicillin and cloxacillinplus coverage for Gram-negative organisms can be given. Itshould be borne in mind that the healing stages can becomplicated by subsequent infections in the raw area which maycall for a modification of the treatment.

As can be seen from our series, none of the patients was treatedby the primary surgery which Meleney2 thought was vital. It isquite possible that a plaque of necrotizing fasciitis obstructs theflow ofblood and lymph from the dermis mechanically, and earlyincision would relieve the tension, limit the spread of gangrene,and make the final repair more manageable. Thus, by shorteningthe illness some of the cumulative morbidity may be averted.

HypercoagulabilityThe development of acure cholecystitis in the case illustrated

by Fig. 13 is of special interest. Acalculous cholecystitis is aserious, often fatal disease that is seen among patients sufferingfrom bacterial sepsis, burns, trauma and cancer. II These clinicalconditions may be associated with the activation of factor XII(Hageman factor) and consequently the intrinsic pathway ofblood coagulation. In order to test this hypothesis, Becker et al. 12

injected E. coli endotoxin intravenously into dogs. This resultedin thrombosis of vessels and necrosis that was most marked in theserosa and muscularis of the gallbladder. These authors suggestthat the bloodvessels of the gallbladder are specially sensitive tothe activation in vivo of factor XII. The aggressivehypercoagulability found in the cases of necrotizing fasciitis(illustrated by Figs 11, 12 and 13) may provide additionalsupport for this view. It could also support the concept ofgallbladder necrosis as part of a Shwarrzman-Sanarelliphenomenon, as proposed by Vorster er al. 13,14

This work was supported by the South African Medical ResearchCouncil.

REFERENCES

I. Delbanco E, Callomon F. Erysipel. In: Jadassohn J, ed. Handbueh der Hallf­Imd GesehleehlSkrankheilen, vol. 9, pan I. Berlin: Springer, 1929: 9-11.

2. Meleney FL. Haemolytic srreptococcus gangrene.JAMA 1929; 92: 2009-20 12.3. Meleney FL. A differemial diagnosis berween certain types of infectious

gangrene of the skin. Surg G.,·neeol Obslef 1933; 56: 847-867.4. McCafferty EL, Lyons C. Suppurative fasciitis as the essemial feature of

haemolytic streptococcus gangrene. Surge~,' 1948; 24: 438-442.5. Wilson B. Necrotizing fasciitis. Am Surg 1952; 18: 416-431.6. Laugier P, Mach RS, Robert M, Oruso M, Bouzakura C. La fasciite

gangreneuse (gangrene srreprococcique). Alln DenllalOl Syphiligr (Puns) 1970;97: 493-500.

SA MEO:ESE TYOSKRIF OEEL 62 24 JULlE 1982 131

7. GuiJiano A, Lewis F, Hadley K, Blaisdell FW. Bacreriology of necrotizingfasciitis. Am J Surg 1977; 134: 52-57.Marchal G, Le Roux ME, Samama M. Alias de la Thrombodynamographie.Paris: Service de Propagande Edition, Information, 1961.

9. Fisch IR, Freedman SH, Pellegrin FA. Effect of oral contraceptives on rhethrombelasrogram. Clin Phanllaeol Ther 1973; 14: 238-249.

10. Franz RC, Coerzee WJc. The rhromboelasrographlc dIagnoSIs ot haemostaticdefects. In: Nyhus LM, ed. Surg Ann 1981; 13: 75-107.

11. Glenn F. Acute acalculous cholecystitis. Am Sur/? 1979; 189: 458-465: .12. Becker CG, Dubin T, Glenn F. Induction of acute cholecystitIS by acuvaDon

of factor XII..7 Exp Med 19 0; 151: 81-90.13. Vorsrer C, Biitrcher G. Isolierte Gallenblasennekrose als Unfallfolge. Chir

Praxis 1971; 15: 45-49.14. Vorsrer C, Engel W, Wolters J. Tiereksperimemelle Umersuchungen zur

isolierten Gallenblasennekrose. Zemralbl Chir 1972; 97: 1847-1850.

BreastP. B. WHITE,

•reconstructIonL. A. CHAIT

Summary

Advances in breast reconstruction make it a f~asible

and worthwhile operation. Three cases arepresented, illustrating two methods of breastreconstruction and the results achieved. Themethod used is determined by the type of trea~mentoriginally carried out. Several problems which maybe encountered are discussed.

S Alr.Med J 1982; 62: 131-134.

The restoration of the female body after ablative surgery forcarcinoma of the breast has been performed, often with poorresults, for many years. The advances in breast reconstructionover the last 5 years have been dramatic and rewarding for boththe patient and the surgeon.

Two basic methods of breast reconstruction are used. Firstly,in cases where extra skin and muscle cover is required, forinstance after radical mastectomy or radiation therapy, alatissimus dorsi myocutaneous flap is used. This provides bulk torestore the deformity due to the removal of the pectoralis majormuscle, as well as ensuring adequate cover for the silicone breastprosthesis. The second method merely involves the insertion ofthe silicone prosthesis into a pocket created beneath thepectoralis major muscle. This method is used following a simplemastectomy or a modified"radical mastectomy.

During the last 2 years we have performed 22 suchreconstructions; 8 of these involved the use of a latissimus dorsi

Department of Plastic and Reconstructive Surgery,Johannesburg Hospital, JohannesburgP. B. WHITE, F.R.C.S., ConsullamL. A. CHAIT, F.R.C.S., Consultam

Dare received: 10 September 1981.Reprint requests to: Mr P. B. White, Suite 19, Rosebank Medical and Dental Cemre, 11 SturdeeAve, Rosebank, 2196 RSA.

myocuraneous flap and in the remainder subpectoral insertion ofthe silicone prosthesis was undertaken. In most cases anoperative adjustment on the normal breast was necessary toanain symmetry. This involved either breast reduction, breastlift, or breast augmentation using a silicone prosthesis.

Three cases are presented, showing the two basic methods ofbreast reconstruction. Some of the problems that can beencountered are outlined.

Case reports

Case 1A 48-year-old woman presented 12 years after radical

mastectomy and postoperative radiotherapy to the axilla andchest wall for carcinoma of the breast (Fig. 1). Extra skin andmuscle cover was needed for the breast reconstruction.

Bostwick el al. 'Si method of breast reconstruction was used;this entails elevation and anterior transposition of a latissimusdorsi myocutaneous flap. A skin island, the size of which isdetermined by the estimated skin deficit, is designed over thelatissimus dorsi muscle. The skin island can be vertically,obliquely or transversely positioned on the muscle, dependingon the mastectomy scar. The skin island required is incised downto the muscle and secured to it by 3/0 silk sutures to prevent itfrom becoming detached from the muscle. The entire latissimusdorsi muscle is identified and elevated from the chest wall,working from the lowest point upwards. The vascular pedicle isidentified on the under-surface of the muscle and preserved. Themyocutaneous flap is then transposed anteriorly and sutured tothe clavicle and sternum to simulate the pectoralis major muscle.The required size silicone breast prosthesis is insertedunderneath the muscle and the muscle is then sutured to thesubcutaneous tissue of the lower skin flap. The skin island issutured into position. In this patient, simultaneous breastaugmentation of the opposite breast was performed.

During a second procedure I month later the nipple and areolawere fashioned on the reconstructed breast,2 the areola beingformed from a split-skin graft of the medial aspect of the upper