Areolar Pigmentation Research Articles

Development of low-cost and personalized external silicone breast prosthesis produced by additive manufacturing for women who have undergone mastectomy: A pilot study

BackgroundThe aim of this study was to develop a low-cost and personalized method for external breast prosthesis production. MethodsThe projected light method was used for the acquisition of the 3D geometry of the left breast of a healthy 29-year-old woman, 69 kg and 1.69 m. The 3D modeling software Blender was used to make the prosthesis model and mold with adjustments to the model's mesh, such as smoothing, assigning thickness, and creating the walls of the prosthesis mold. Two counter-molds were created. The pieces were manufactured on the 3D printer Stella Lite 3 using polylactic acid filament. Finally, the silicone was pigmented, and the mold was filled. FindingsPrototype 1 of the prosthesis was produced using a mold without a counter-mold, which resulted in a prosthesis of 495 g, considered heavy compared to traditional prostheses for the same breast size. To solve this issue, a counter-mold with pins was used to produce prototype 2 with a mass of 393 g, 20.6% lighter than prototype 1. Prototype 3 was made with a central-volume counter-mold and presented a mass of 355 g, a reduction of 28.3% compared to prototype 1. The definitive breast prosthesis was made with the pin counter-mold with a different silicone. It has nipple and areola pigmentation and a mass of 294 g, 25.2% lighter than prototype 2. InterpretationThe results suggest that the projected light method and additive manufacturing are potential tools for developing external breast prostheses, which may improve the health conditions and quality of life of mastectomized women.

THU198 Peripheral Precocious Puberty In Girls Due To Ovarian Cyst

Abstract Disclosure: H. Lee: None. J. Hwang: None. Y. Shim: None. S. Heo: None. Objective: Peripheral precocious puberty (PPP) is precocious development of secondary sexual characteristics caused by mechanisms that do not involve activation of pulsatile GnRH secretion. PPP in girl is less frequent than central precocious puberty (CPP). it is caused by various disease such as gonadal and adrenal tumors, ovarian cysts, hypothyroidism and exposure to exogenous sex steroids. In particular, discordant pubertal development with vaginal bleeding within one year of breast development suggests hyperestrogenic state, and may be caused by autonomous ovarian cysts, McCune-Albright syndrome (MAS) and hypothyroidism. We aimed to investigate clinical characteristics and long-term clinical course of PPP in girls with ovarian cyst. Methods: This study was conducted through a retrospective medical record analysis. We studied 12 patients who were diagnosed with PPP due to ovarian cyst after pelvic sonography from January 2003 to May 2022. Patients were examined for pelvic sonography when there was vaginal bleeding and/or nipple pigmentation in PPP. pelvic sonography findings, clinical characteristics, management and prognosis of patients with ovarian cysts were investigated. Results: Ten out of 12 cases had vaginal bleeding and the 3 cases had nipple pigmentation. E2 was elevated to median value 36 pg/mL ([IQR], 19-61). There was a total of 18 episodes of ovarian cyst including recurrence. The median size of cyst was 28 mm ([IQR], 24- 34). Surgical management was performed in one patient with large cyst of 70 mm. Aromatase inhibitor was used in three cases. Follow-up pelvic sonography was performed to confirm regression of ovarian cyst. Median time to regression of ovarian cyst was 6 months ([IQR], 3-9). Five cases were diagnosed with MAS. Later, In 4 out of 12 cases were progressed to CPP and cyst was recurred more than 2 episodes in 3 cases. Median total follow-up duration of cases was 2.5 years ([IQR], 0.9-5.3). Conclusion: Most of ovarian cysts in PPP disappear spontaneously. However, It may appear as a one of findings with MAS or can progress to CPP in recurrent case. Therefore, careful follow-up is necessary in ovarian cysts of PPP. Presentation: Thursday, June 15, 2023

Clinical course of peripheral precocious puberty in girls due to autonomous ovarian cysts.

Peripheral precocious puberty (PPP) is the precocious development of secondary sexual characteristics without pulsatile gonadotropin-releasing hormone (GnRH) secretion. In girls, PPP suggests a hyper-oestrogenic state, such as autonomous ovarian cysts and McCune-Albright syndrome (MAS). We aimed to investigate PPP in girls with ovarian cysts, with or without MAS. A retrospective study design was used. The study included 12 girls diagnosed with ovarian cysts with PPP between January 2003 and May 2022. Pelvic sonography was performed in cases of vaginal bleeding or areolar pigmentation in PPP. The clinical characteristics, clinical courseand pelvic sonographic findings of girls with ovarian cysts were investigated. We found 18 episodes of ovarian cysts in the 12 girls. The median size of the ovarian cysts was 27.5 mm. Five of the girls were diagnosed with MAS. The median time to spontaneous regression was 6 months. Later, 4 out of 12 girls progressed to central precocious puberty (CPP), and three of them had a recurrence of ovarian cysts. Compared to the non-recurrent and recurrent groups, there was a difference in peak luteinizing hormone (LH) in the GnRH stimulation test and period to cyst regression. Most ovarian cysts in PPP spontaneously disappear. However, this couldbe one of the findings of MAS. Some girls progress from PPP to CPP. Therefore, follow-up isnecessary for ovarian cysts in patients with PPP. The recurrence of ovarian cysts may occur when spontaneous regression is prolonged.

100 years of Thorek method - is this technique of breast reduction still actual?

In 1922, Max Thorek described the method of breast reduction with the transfer of the nipple-areola complex as free grafts. Initially, this method met with quite a lot of criticism. Therefore, the search for solutions guaranteeing better aesthetic results of breast reduction have been evolved.The aim of the study is to present our own experiences related to the Thorek method of breast reduction in patients with gigantomastia and to consider whether this technique is still relevant in the 21st century.The study included women operated on for large breasts at the Plastic, Reconstructive and Aesthetic Surgery Clinic between 2012-2021. In the analysis 95 women aged 17 to 76 were involved.In the analyzed group of 95 women, 14 patients underwent breast reduction with transfer of the nipple-areola complex as a free graft (modified Thorek's method). In the remaining 81 cases, breast reduction was performed with the transfer of the nipple areola complex on the pedicle (upper-medial - 78, lower - 1, upper-lower - McKissock's method - 2).The usage of Thorek's method is still actual in a selected group of women. This technique seems to be the only safe one in patients with gigantomastia, with a high risk of nipple-areola complex necrosis related to the distance of nipple transfer, as well as after the end of the reproductive period. Its main disadvantages (tendency to breasts being too wide and flat, unpredictable nipple projection and nipple pigmentation) can be minimized by modification of the Thorek method or minimally invasive follow-up techniques.

Evaluation of concentric periareolar subcutaneous mastectomy outcomes in transsexual patients during 2016–2017 in Iran: A clinical study

Background: Transsexual (TS) people are those who assigned one sex at the birth but identified their gender in what society considers the opposite direction. Studies showed that gender reassignment surgery (GRS) had greatly improved the quality of life in TS patients. Materials and Methods: We studied 20 patients who had legally the permission of being underwent the sex reassignment surgery in Imam Khomeini Hospital Complex of Tehran, Iran. For all patients, concentric periareolar subcutaneous mastectomy was performed. The patients were followed up for 1 year and the results were evaluated. Results: Our findings show an acceptable scar formation after 1 year of the sex reassignment surgery. There was only one complication which was managed conservatively. About 90% of patients were satisfied from the results of surgery, and no one was less/unsatisfied. The average score of nipple sensation was 7.9 and no changes in nipple pigmentation was observed. Conclusion: Concentric periareolar mastectomy is probably a good technique of subcutaneous mastectomy in female to male GRS in patients with small and medium size of the breast and poor skin elasticity. The result scar in this method is acceptable and gives the patients a good feeling of having male chest.

SAT-307 Sudden Unexpected Vaginal Bleeding Caused by Temporal Reactivation of Hypothalamic-Hypophyseal-Gonadal Axis during Gonadotropin Releasing Hormone Agonist Treatment for Central Precocious Puberty

The Gonadotropin-releasing hormone(GnRH) agonist has been the treatment of choice for central precocious puberty. These drugs suppress gonadotropin secretion through desensitization and downregulation of GnRH receptors, leading to reduced secretion of gonadal steroids to prepubertal levels. The regression of secondary sexual characteristics, delayed menarche, and maximization of linear growth can be achieved through this treatment. Due to initial agonistic action of this drug, withdrawal vaginal bleeding can occur after the first or second dose of the treatment. This phenomenon could occur after 6 months in rare cases. In this report, we would like to introduce a rare case of unexpected vaginal bleeding with rapid breast engorgement during the treatment course without any evidence of insufficient suppression of hypothalamic-hypophyseal-gonadal(HPG) axis. The condition was normalized with increased dosage of drug for 2 months, and suppression of HPG axis was maintained with same initial dosage untill completion of treatment. Therefore, we believed that idiopathic reactivation of HPG axis was likely a cause of this unusual condition. A 7 year-old girl visited our clinic with breast buds which was examined as Tanner stage 2-3, with pigmentation of areola. Her bone age was advanced as 10 years of age. LHRH stimulation test showed a pubertal response(LH>5.0 IU/L). Pelvic ultrasonography showed a pubertal uterus shape. Brain MRI showed no specific abnormalities. Leuprolide acetate 3.75mg was administered to the patient every 4 weeks, and until the 4th injection, she exhibited no progression of secondary sexual characteristics and changes in hormonal levels, indicating that the HPG axis was properly suppressed. However, after 5th injection, the patient complained of rapid breast engorgement and abrupt vaginal bleeding 2 weeks later. LH and estradiol was measured 0.3 IU/L(normal < 0.2 IU/L) and 38.7pg/ml(normal < 10pg/ml), respectively. Pelvic ultrasonography revealed enlarged uterus without any other pathologic findings. Leuprolide acetate 3.75mg was boosted and administered every 2 weeks for 2 months. After confirming the HPG axis suppression on studies, the injection interval was rescheduled to 4 weeks. The status of patient was stabilized without any other clinical or hormonal deterioration until completion of treatment. In conclusion, GnRH agonist can suppress HPG axis successfully in most cases, however, temporal reactivation of HPG axis can occur during the treatment course although HPG axis suppression has been maintained in serial check up. Therefore, clinician should be aware of possibility of unexpected vaginal bleeding and reevaluation should be performed to check up the status of the patient, including pelvic ultrasonography and hormonal assessment. Finally, careful advice should be given in an attempt to avoid unnecessary anxiety and achieve better compliance.

Androgenic and estrogenic indices in human newborns and infants: the MIREC-ID study.

Prenatal sex steroid exposure plays an important role in determining child development. Yet, measurement of prenatal hormonal exposure has been limited by the paucity of newborn/infant data and the invasiveness of fetal hormonal sampling. Here we provide descriptive data from the MIREC-ID study (n=173 girls; 162 boys) on a range of minimally invasive physical indices thought to reflect prenatal exposure to androgens [anogenital distances (AGDs); penile length/width, scrotal/vulvar pigmentation], to estrogens [vaginal maturation index (VMI) - the degree of maturation of vaginal wall cells] or to both androgens/estrogens [2nd-to-4th digit ratio (2D:4D); areolar pigmentation, triceps/sub-scapular skinfold thickness, arm circumference]. VMI was found to be associated with triceps skinfold thickness (β=0.265, P=0.005), suggesting that this marker may be sensitive to estrogen levels produced by adipose tissue in girls. Both estrogenic and androgenic markers (VMI: β=0.338, P=0.031; 2D:4D - right: β=-0.207, P=0.040; left: β=-0.276, P=0.006; AGD-fourchette - β=0.253, P=0.036) were associated with areolar pigmentation in girls, supporting a role for the latter as an index of both androgen and estrogen exposure. We also found AGD-penis (distance from the anus to the penis) to be associated with scrotal pigmentation (β=0.290, P=0.048), as well as right arm circumference (β=0.462, P<0.0001), supporting the notion that these indices may be used together as markers of androgen exposure in boys. In sum, these findings support the use of several physical indices at birth to convey a more comprehensive picture of prenatal exposure to sex hormones.

Breast shape (ptosis) as a marker of a woman's breast attractiveness and age: Evidence from Poland and Papua.

A women's breast is a sex-specific and aesthetic bodily attribute. It is suggested that breast morphology signals maturity, health, and fecundity. The perception of a woman's attractiveness and age depends on various cues, such as breast size or areola pigmentation. Conducted in Poland and Papua, the current study investigated how breast attractiveness, and the further estimate of a woman's age based on her breast's appearance, is affected by the occurrence of breast ptosis (ie, sagginess, droopiness). In the Polish sample, 57 women and 50 men (N = 107) were presented with sketches of breasts manipulated to represent different stages of ptosis based on two different breast ptosis classifications. The participants were asked to rate the breast attractiveness and age of the woman whose breasts were depicted in each sketch. In Papua, 45 men aged 20 to 75 years took part in the study, which was conducted using only one of the classifications of breast ptosis. Regardless of the classification used, the results showed that the assessed attractiveness of the breasts decreased as the estimated age increased with respect to the more ptotic breasts depicted in the sketches. The results for Papuan raters were the same as for the Polish sample. Breast ptosis may be yet another physical trait that affects the perception and preferences of a potential sexual partner. The consistency in ratings between Polish and Papuan raters suggests that the tendency to assess ptotic breasts with aging and a loss of attractiveness is cross-culturally universal.

Etiological analysis of vaginal bleeding in girls

Objective To investigate the etiological factors for abnormal vaginal bleeding in girls. Methods Data of 65 female children aged from 3 months and 10 years old with abnormal vaginal bleeding, who were treated in Department of Endocrinology, Wuhan Children's Hospital from March 2009 to October 2013 were collected by using medical records and follow-ups.By means of pelvic ultrasound, bone age assessment, hysteroscope, hormone level and genetic testing, the causes of the disease were analyzed. Results Of 65 patients, 37 cases had breast developed, 21 cases had nipple, areola and vulva pigmentation increased, 16 cases with genital secretions increasing and odor, the height growth in 21 cases accelerated, abdominal pain was presented in 5 cases, and 6 cases had skin milk coffee spots.The leading etiological factors for vaginal hemorrhage in these girls were sexual precocity.The peripheral precocious puberty accounted for the first place(30/65 cases, 46.2%), and followed by the central precocious puberty(20/65 cases, 30.8%). Hyperphlogosis accounted for 12.3%(8/65 cases), vaginal foreign body accounted for 6.2%(6/65 cases), and genital tract tumors accounted for 4.6%(3/65 cases). In the 30 peripheral precocious puberty cases, exogenous precocious puberty accounted for 16.9% (11 cases), 8 cases(12.3%) were of solitary ovarian cyst, 8 cases(12.3%) of McCune-Albright syndrome, and 3 cases of ovarian tumors.In the 20 central precocious puberty cases, idiopathic central precocious puberty accounted for 18.5%(12 cases), 4 cases(6.2%) were of organic disease of central nervous system, and 4 cases(6.2%) of hypothyroidism.Of 65 children, 12 cases lost follow-up and 1 case abandoned treatment.The rests received appropriate treatment according to different causes, and the vaginal bleeding were effectively controlled after 3 months to 2.5 years of follow-ups without recurrence of bleeding.But there were 2 cases of isolated ovarian cyst and 3 cases of McCune-Albright syndrome turned into central precocious puberty. Conclusions Endocrine diseases are the common factors for children's vaginal bleeding.Neoplasm is not rare in girl's abnormal vaginal hemorrhage. Key words: Uterine hemorrhage; Etiology; Puberty precocious; Child

The free-nipple breast-reduction technique performed with transfer of the nipple-areola complex over the superior or superomedial pedicles.

Although the free-nipple breast-reduction technique is essentially an amputation, achieving aesthetic results still is important. The authors present their technique for free nipple-areola complex (NAC) transfer over the superomedial or superior pedicle full-thickness flaps in patients for whom a free-nipple technique is inevitable due to certain risk factors. The study included 25 patients who underwent surgery with the aforementioned method for addressing severe gigantomastia. The patients had a mean age of 43 years (range 34-59 years) and a mean body mass index (BMI) of 35.8 kg/m(2) (range 28-42 kg/m(2)). During the operation, the NAC was elevated as a full-thickness skin graft, then transposed to the superior or superomedial pedicles, which had been planned previously. The subsequent stages of the operation thus became a Wise-pattern breast reduction. The mean resection per breast was 1,815 g (range 1,620-2,410 g). Breast projection, shape, and areolar pigmentation were assessed during the follow-up visit. One patient experienced a partial loss of the NAC graft, which healed secondarily, and three patients experienced a patchy hypopigmentation of the NAC. Breast projection and conical structure were observed to be preserved during the follow-up period. The modified free-nipple technique aimed to convert the reduction procedure to a technique similar to pedicle methods, yielding successful results during the early phases. The full-thickness flap constructed in this way provides more fullness and a maximum contribution to projection in patients who will inevitably undergo breast reduction with the free-nipple method. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Men’s Preferences for Women’s Breast Morphology in New Zealand, Samoa, and Papua New Guinea

Sexual selection via mate choice may have influenced the evolution of women's breast morphology. We conducted an image-based questionnaire quantifying and comparing the preferences of men from Papua New Guinea (PNG), Samoa, and New Zealand (NZ) for images of women's breast size, breast symmetry, areola size, and areolar pigmentation. Results showed that men from PNG preferred larger breasts to a greater extent than men from Samoa and NZ, providing some support for the hypothesis that men from subsistence living cultures have a greater preference for morphological cues indicative of caloric reserves. Symmetrical breasts were most attractive to men in each culture. However, preferences were highest among NZ men, followed by men from Samoa, and were lowest among men from PNG. These results did not support the hypothesis that people living in higher pathogen environments have a greater preference for traits indicative of pathogen resistance and developmental stability. Large areolae were preferred among men from PNG, and to a lesser extent in Samoa, while in NZ men preferred medium-sized areolae. Thus, men's preferences for women's areolar size appear to be highly culturally specific. Darkly pigmented areolae were most attractive to men from Samoa and PNG, whereas men from NZ preferred areolae with medium pigmentation. These findings suggest that areolar pigmentation indicative of sexual maturity is preferred by men rather than lighter pigmentation, which may signal that a woman is in the early years of reproductive maturity. This study highlights the importance of cross-cultural research when testing the role of morphological cues in mate choice.

Eye Tracking of Men’s Preferences for Female Breast Size and Areola Pigmentation

Sexual selection via male mate choice has often been implicated in the evolution of permanently enlarged breasts in women. While questionnaire studies have shown that men find female breasts visually attractive, there is very little information about how they make such visual judgments. In this study, we used eye-tracking technology to test two hypotheses: (1) that larger breasts should receive the greatest number of visual fixations and longest dwell times, as well as being rated as most attractive; (2) that lightly pigmented areolae, indicative of youth and nubility, should receive most visual attention and be rated as most attractive. Results showed that men rated images with medium-sized or large breasts as significantly more attractive than small breasts. Images with dark and medium areolar pigmentation were rated as more attractive than images with light areolae. However, variations in breast size had no significant effect on eye-tracking measures (initial visual fixations, number of fixations, and dwell times). The majority of initial fixations during eye-tracking tests were on the areolae. However, areolar pigmentation did not affect measures of visual attention. While these results demonstrate that cues indicative of female sexual maturity (large breasts and dark areolae) are more attractive to men, patterns of eye movements did not differ based on breast size or areolar pigmentation. We conclude that areolar pigmentation, as well as breast size, plays a significant role in men's judgments of female attractiveness. However, fine-grained measures of men's visual attention to these morphological traits do not correlate, in a simplistic way, with their attractiveness judgments.

Hypophyseal coma

Pituitary coma is a rare case of emergency and primarily due to ACTH and TSH deficiency. Pituitary coma occurs more often in patients with well-known pituitary deficiency than in patients with intrasellar tumor. Clinical manifestations are hypotonia, bradycardia, decreased skin and nipple pigmentation, muscle weakness, vomitus, nausea, obstipation, hypothermia, and hypoventilation. A postpartal agalactia is often the first sign of Sheehan's syndrome. Unlike primary adrenal insufficiency (Addison's disease) ACTH deficiency does not cause hyperpigmentation, hyperkalemia, or salt loss. The suspicion of pituitary coma requires replacement with 100 mg hydrocortisone iv, 200 mg hydrocortisone iv/24 h, 500 micro g levothyroxine iv and fluid substitution. Since thyroxine accelerates the degradation of cortisol and can precipitate adrenal crisis in patients with limited pituitary reserve, hydrocortisone replacement should always precede levothyroxine therapy. ACTH stimulation test, CRH stimulation test and insulin tolerance test (optional) should be performed after therapeutic compensation to determine pituitary function.

The Current Use of Estrogens for Growth-Suppressant Therapy in Adolescent Girls

Objective: To assess the current prevalence of growth-suppressant therapy using oral estrogens for tall adolescent girls among U.S. pediatric endocrinologists.Methods: A questionnaire was mailed to pediatric endocrinologists practicing in the United States, asking how many patients each clinician had recently treated for tall stature using oral estrogens, whether he/she continued to offer such treatment, reasons for offering or declining to offer it, criteria for initiating and terminating treatment, choice of estrogen, and typical doses, durations, and effects.Results: Of 411 respondents, 92 (22%) reported having treated 1–5 girls for tall stature during the preceding five years. Only 4 (1%) had treated more than 5 cases during this period. Growth-suppression treatment was currently offered by 137 respondents (33.3%). Reasons for doing so included parents' and patients' concerns about stature and the adverse social effects of unusually tall stature. Reasons for not offering such treatments were that its long-term risks are unknown, that tall stature is not a disease, and a lack of referrals. Few clinicians initiated treatment if predicted mature height was below 183 cm. Treatment was typically terminated based on evidence of epiphyseal fusion, usually within less than two years, although extended treatments were common. Frequently reported adverse effects included weight gain, nausea/vomiting, areolar or nipple pigmentation, headache, and irregular menses.Conclusions: Although treatment is less commonly initiated than in the past, many pediatric endocrinologists continue to offer oral estrogens to suppress growth for tall adolescent girls.

North Carolina macular dystrophy. Hereditary macular disease with good functional prognosis

North Carolina macular dystrophy (NCMD) is a rare autosomal dominant maculopathy with highly variable expressivity. Genetic analysis of an American family consisting of 247 members out of which 96 were affected with NCMD allowed chromosomal assignment of the NCMD locus to 6q14-q16.2. Few families with NCMD are known in Europe, one of these is living in Germany. By routine investigation, a second family affected with NCMD was detected in Germany. As some authors still doubt the good prognosis of this disease, our results should be added to the experience of others. In a total of 18 family members from three generations between the age of 2 and 65 years, clinical investigations and genetic analysis was carried out. Some individuals had additional examinations such as colour contrast sensitivity, EOG, ERG, and microperimetry. Ten of 18 family members turned out to be affected. All grades of NCMD were present with great variability. Visual acuity ranged from 0.32 to 1.0 and did not correlate to the grade of the disease or to the age of the person. In those patients who underwent microperimetry, central fixation was confirmed. Genetic linkage analysis further narrowed the region harbouring the NCMD locus and supported the assumption that the central areolar pigment epithelial dystrophy (CAPED) is an allelic disorder. Similar visual acuity in three generations of NCMD patients supports the observation that NCMD is not a progressive disorder. If geographic atrophy is found in a patient with good visual acuity, NCMD should be considered and genetic analysis should be carried out.

An ancestral core haplotype defines the critical region harbouring the North Carolina macular dystrophy gene (MCDR1).

Autosomal dominant North Carolina macular dystrophy (NCMD) or central areolar pigment epithelial dystrophy (CAPED) is an allelic disorder that maps to an approximately 7.2 cM interval between DNA markers at...

GENETIC AND PHENOTYPIC PROFILES OF ENDANGERED ANDALUSIAN SHEEP AND GOAT BREEDS

SUMMARYThe Grazalema Merino and Lebrija Churro Sheep and the Andalusian White and Andalusian Black goat breeds, previously chosen as priority breeds in need of conservation, were considered as having priority for this study. In order to define the genetic as well as the phenotypic profiles the following characters were used: head profile, ear size, ear orientation, ear consistency, horns, pigmentation of mucous, hoofs, udder, ñneness of fur, hair or wool, length of hair or wool, presence of wattles and goatee bear, supernumerary nipples., udder shape, orientation and pigmentation of nipple, and peculiarities of coat. The allelic frequencies for each system were calculated to obtain the genetic profiles of each breed. In the two goat breeds and in the Grazalema Merino breed, the majority of the loci were genetically in Hardy-Weinberg equilibrium, but this was not true of the Lebrijan Churro breed which seems to indicate that the latter was either subjected to natural or artificial selection for these genes or crosses with outside breeds had taken place. The profiles of the breeds were compared with foreign breeds considered traditional or unmodified by man. The profile of the Andalusian White has already been studied by Rodero and they reached the conclusion that this breed can be considered traditional, completing the studies made on other breeds from the Mediterranean area. The data on the Andalusian Black seems to indicate that this breed might be considered traditional or subtraditional with strong polymorphism in most of its characters. Although less markedly than in the latter breed, the same is true of the Lebrijan Churro. In this breed the deñning characters of Archaism fit well within those common to an archaic breed. The Grazalema Merino is more standardised than the above mentioned not as ñxed than the precocious ones.

The Variable Expressivity of a Family with Central Areolar Pigment Epithelial Dystrophy

To clarify the nosology of autosomal dominant central areolar pigment epithelial dystrophy (CAPED) as previously described. The authors studied a family of 69 members spanning six generations with a macular dystrophy. Thirty-four patients were examined, and those found to be affected underwent further testing, including visual fields, electrophysiologic studies, and fluorescein angiography. Family history and medical records were used in three additional deceased patients. Eleven patients were identified as having CAPED. The phenotype was inherited in an autosomal dominant fashion. Six of these patients were examined by us and had mid-life onset (at 32-53 years) of progressive visual loss (20/50--counting fingers), occurring over a 3- to 10-year period. These subjects had circumscribed hypopigmented maculae, retinal pigment epithelial window defects on fluorescein angiography, central scotomas, and electrophysiologic studies, ranging from normal to severely abnormal. Three deceased patients were presumed to have CAPED by review of records or family history. Two additional patients examined had mild macular changes but good visual acuity and no significant abnormalities on electrophysiologic studies. The latter two patients are presumed to have had early manifestations of CAPED. This family demonstrates that CAPED is an autosomal-dominant hereditary macular dystrophy which has late-onset and variable expressivity.

Nipple—Areola Reconstruction with Intradermal Tattoo and Double-Opposing Pennant Flaps

Reconstruction of the nipple-areolar complex is an important part of postmastectomy breast reconstruction. Intradermal tattooing is effective for creating areolar pigmentation and is simpler than skin grafting. However, a simple method for the construction of a normal nipple using local tissues remains a challenge. Several techniques achieve long-term nipple projection but at the expense of complicated flap design, multidirectional scars, and often a need for skin grafting to obtain a uniform-appearing areola. Our one-stage method of nipple-areola reconstruction uses intradermal tattooing for pigmentation and double-opposing pennant flaps for nipple reconstruction. The entire procedure is simple and fast, routinely performed in < 30 minutes under local anaesthesia in the office. From September 1989 to March 1992 we performed 102 reconstructions. The method produces a realistic appearing nipple. We have had no flap necrosis.

PHYTOESTROGENS AS A CAUSE OF CHILDHOOD GYNECOMASTIA

A 5 and 2/12 y.o. male presented with bilateral breast tissue (4.5cm), areolar pigmentation, slight non-velous pubic hair, prepubertal (2cc) testes, and growth acceleration. Height was 120cm (HT-SDS for CA = +1.9), bone age was 10 yrs (HT-SDS for BA = −2.8), predicted final HT 160.6cm (mid-parental HT 172cm). Laboratory studies revealed sex-chromatin negative buccal smear, non-detectable serum and urine estrone, 24-hour urine estrogens 19 ug/gmCr, LH 0.1 mIU/L, FSH 0.7 mIU/L, prolactin 5.9ng/ml, beta-HCG <5mIU/ml. A testicular ultrasound and adrenal steroidogenic profile were normal. On-site environmental evaluation revealed that this child habitually fed calves fresh wet alfalfa mixed with Rumensin, a monocarboxylic, highly lipophilic cation chelating agent. The skin of both arms and hands were exposed repeatedly to the mixture over a 12 month period. Repeated analysis of the alfalfa revealed significant quantities (50 and 35 ppm) of the phytoestrogen coumesterol. Cessation of this activity resulted in gradual reduction in breast size and slowing of skeletal maturation. However, growth velocity of 7.7cm/year, plasma T of 0.36ng/ml, and peak LHRH-stimulated gonadotropins (LH 5.5mIU/L, FSH 3.8mIU/L) suggest probable impending precocious puberty. We propose that gynecomastia and accelerated growth and maturation in this child resulted from topical absorption of the phytoestrogen coumesterol, enhanced by hand-mixing of the wet coumesterol-containing alfalfa with a lipophilic, monocarboxylic ionophore.