The role of skin testing in the use of collagen injectable materials

The experience of 400 consecutive patients evaluated for soft tissue augmentation for a variety of contour defects is reviewed here. The first 200 patients were evaluated with only a single skin test prior to treatment, whereas the second group were skin tested twice. The rate of hypersensitivity to the first skin test was the same in both groups, 5 out of 200 (2.5%). In the 195 patients receiving treatment after a single negative skin test, 6 (3.1%) developed hypersensitivity reaction at treatment sites. In the second group, where double skin testing was employed, an additional 7 patients had a positive second skin test (3.5%). There were no allergic reactions in the 171 patients who received treatment after two negative skin tests.

Correction of established capsular contractures with polyurethane implants

Twelve patients with severe and recurrent capsular contractures following breast augmentation and reconstruction were improved with polyurethane-covered implants. It still has not been established whether these implants prevent or merely delay the onset of contractures, but some of these patients have been followed for over three years and all 12 were improved.

The use and abuse of external incisions in rhinoplasties

The author emphasizes his basic opposition to the use of external incisions in surgical rhinoplasty with only a few minor exceptions. External incisions are justifiable in only a limited number of cases, and when they are published these cases should be exceptional indeed and not suggested as an alternative technique or as an innovation to be used on a routine basis. The endonasal approach should be used in the vast majority of aesthetic rhinoplasties with only a few exceptions mentioned here.

Immediate reconstruction after subcutaneous mastectomy

We describe an improved technique for subcutaneous mastectomy using two surgical approaches, one through a short axillary incision and the other through an inframmary incision. Pathological breast tissue is removed from the prepectoral space through the lower incision and a silicone implant is placed in the retropectoral space through the axillary approach. A further modification is described using a laterally rotated inframmary dermis flap to reinforce the lateral margin of the retropectoral space containing the prosthesis.

Subcutaneous mastectomy data: a final statistical analysis of 1500 patients

A statistical analysis of 1500 patients who underwent subcutaneous mastectomy is presented. Their data suggest that most patients who were treated by subcutaneous mastectomy had proliferative fibrocystic disease or macrocystic disease, among other high risk factors. The data also suggest that a thoroughly performed subcutaneous mastectomy is an effective means of providing prophylaxis in women who are at high risk for breast cancer. Conclusions were confirmed by many unsolicited comments of patients who underwent the procedure and were grateful to their doctors who performed it.

Suggested nomenclature for aesthetic and reconstructive surgery of the breasts. IV: Congenital anomalies of the breast

A nomenclature for the definition, diagnosis, and surgical management of the congenital anomalies of the breast is suggested. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) code numbers pertaining to these anomalies have been tabulated.

Mammoplasty using liposuction and the periareolar incision

The major dilemma of reduction mammoplasty and mastopexy has been the difficult choice between a procedure that yields an ideal shape of the breast versus the size of the scar. With our technique, selected breasts can now be reduced through liposuction and the mastopexy performed through a periareolar incision, resulting in virtually imperceptible scarring.

Immediate breast reconstruction with subpectoral implantation after transaxillary subcutaneous mastectomy for siliconoma

Immediate breast reconstruction on 14 patients suffering from breast hardening after augmentation mammaplasty by injection of silicone gel was performed. Transaxillary subcutaneous mastectomy was done followed by insertion of a double-lumen prosthesis into the subpectoralis plane. The result was greatly influenced by the amount of injected silicone gel. The patient was carefully observed after surgery, and the prosthesis was immediately removed when abnormal skin changes became apparent. Seven cases had no hardening on either side and 1 case had hardening on one side, 3 cases had hardening on both sides and 1 case on one side, 2 cases had the prosthesis removed from both sides and 2 cases from one side. All other cases with hardening or prosthesis removal, except one with removal from both sides, were subsequently reconstructed after more than three months.

Submental-submandibular suction lipectomy: indications and surgical technique

The submental and submandibular regions play an essential role in the overall harmony of facial aesthetics. The appearance of the cervicomental area may be the result of many factors, including mandibular hypoplasia, localized lipodystrophy, a low-positioned hyoid bone, platysmal deformity, soft tissue laxity, or a combination of any of these. Although much attention has been directed toward correction of bony contour deformities of the mandible and chin, minimal emphasis has been placed on evaluation and correction of soft tissue disharmonies in the submental-submandibular areas. This article discusses the indications and contraindications, patient examination, surgical technique, and potential complications of suction-assisted lipectomy of the cervicomental region. Select cases are presented to illustrate the concepts and techniques discussed herein.

Constant compression caliper for objective measurement of breast capsular contracture

The main problem with silicone implants in augmentation mammaplasty and breast reconstruction is the development of capsular contracture. The universal method for evaluating the degree of firmness of the breast is the subjective palpation technique and the classification according to Baker. Many objective methods using calipers for measurements of compression, different devices for indentation and discs for applanation tonometry have been described, but none of these have been widely accepted. In this paper a new measuring instrument is presented based on the principle of a constant compression force between two caliper jaws applied to the breast. The inverse value of the compressibility of the breast is read on a scale on the device. This objective method correlates acceptably with the palpation technique according to the Breast Augmentation Classification (BAC) (12), which is a modification of Baker's classification (1978), except for the first follow-up.

Immunohistochemical study of the biological fate of a subcutaneous bovine collagen implant in rat

The biological fate of a bovine collagen implant (Zyderm Collagen Implant ZCI), injected subcutaneously into rats, was studied by the immunoperoxidase technique using specific antibodies against the bovine implant and against types I, III, IV, V collagens, fibronectin and elastin. The implant remained in the animals until the end of the experiment (90 days), with no visible modification, as demonstrated by immunoperoxidase labelling and scanning electron microscopy. A slight inflammatory reaction was visible around the implant 24 h after injection and within the implant 3 days after injection. Fibroblast invasion began 7 days after injection. The chronology of the deposition in the implant of the host (rat) extracellular matrix components was as follows: by 24 h after injection, fibronectin was observed throughout the implant; types I and V collagens appeared on the 7th day, and, in contrast to surrounding connective tissue, type V collagen labelling was obtained without acid pretreatment of the section. Types III and IV collagens were detected inside the implant only 30 days after injection. At the end of the experiment (90 days), there was abundant types I and IV collagens after fibroblast migration, and abundant type IV collagen demonstrating an important vascularization. No elastic fibres could be detected inside the implant but they appeared as a dense network around the implant in host connective tissue.

Results of subglandular breast augmentation using a new classification method--18-year follow-up

The main problem after augmentation mammaplasty is the formation of capsular contractures. The frequency of this complication varies in different reports. In this study the results in 60 women 15-21 years after subglandular breast augmentation are presented. The patients completed a questionnaire and the breasts were judged according to a new Breast Augmentation Classification (BAC) scale. Of all breasts examined 79% had grade III or IV, but 77% of the patients were satisfied with the final result. However, 84% thought that their breasts were too hard. Breast cancer had not developed in any patient. Rheumatoid arthritis developed in one patient 4 years after the operation. Capsular contracture and unacceptable results after subglandular breast augmentation were found in the major portion of the patients in this study.

Salvage of exposed implants

With increased use of tissue-expanders the incidence of exposed implants is expected to rise. Eight cases with salvage of an exposed implant are presented. At repair great care was taken to prevent tension on the suture lines either by reducing the volume of the implant or by using a skin flap. Seven patients healed without further complications. In one patient the implant had to be removed due to reexposure. We find that salvage of implants should be tried in suitable cases. If this procedure is not successful a traditional surgical procedure with removal of the implant only has to be delayed for a short time.

Perioperative systemic antibiotics for prophylaxis of infections in breast surgery: sulbactam/ampicillin versus mezlocillin/oxacillin

In a prospective, randomized, open trial, efficacy of one dose of sulbactam/ampicillin (1 g:2 g) was compared to three doses of mezlocillin/oxacillin (2 g:1 g), starting with induction of anesthesia in 80 breast surgery patients with an increased risk of postoperative infection. No infections at the site of operation were seen in either group. Fever due to postoperative pulmonary complications occurred in one patient in the sulbactam/ampicillin group. The only side effect was a moderate exanthema observed in one patient in the mezlocillin/oxacillin group. In this study of the prophylaxis of patients with an increased risk of postoperative infections having the potential to jeopardize the results of surgery, a single dose of sulbactam/ampicillin was as effective as a short term course of three doses of mezlocillin/oxacillin.

Treatment of keloids with surgical excision and postoperative X-ray radiation

124 patients with keloids were treated with surgical excision followed by postoperative X-ray radiation, begun within 24 hours after surgery. Only patients with a two-year keloid history were included in this study. The treatment results were evaluated 6 and 24 months after treatment. There was good correlation agreement between subjective and objective evaluations. Good or excellent results were observed in 92% of the patients. Side effects were moderate. Slight hyperpigmentation was found in 31% of the patients and telangiectasis in 15%. It was concluded that excision and early postoperative irradiation constitute effective keloid treatment.

Applanation tonometry for the evaluation of breast compressibility

Capsular contracture is the main problem following breast augmentation with silicone implants. Subjective assessment has been the predominant method for evaluating breast firmness hitherto, although several objective methods have been described. In this prospective study applanation tonometry was used on 76 women following augmentation mammaplasty. Breast firmness was measured five times during the first postoperative year. Approximation of the breast imprint area to an ellipse was shown to be accurate and to simplify the estimation of the applanation surface, which is proportional to breast compressibility. The results correlated well with the subjective assessments using the Breast Augmentation Classification (BAC). A classification based on applanation tonometry is presented.

The use of minigrafts in hair transplantation surgery

With the conventional hair transplantation method of Okuda-Orentreich, the tuft effect and the creation of an abrupt hairline have been major problems. In the method presented here, minigrafts are exclusively distributed and transplanted over the entire surface. Through the use of this technique a more aesthetic pattern of hair growth is achieved than was possible before, even after only one treatment.

Regional differences in adipocyte lactate production from glucose

Having shown that lactate is an important product of glucose metabolism by rat epididymal adipocytes, we investigated possible regional differences in adipocyte lactate production and the role of the animals' nutritional state and stage of development. [U-14C]glucose metabolism, lactate production, and response to insulin were measured in fat cells isolated from four adipose regions (subcutaneous, epididymal, retroperitoneal, and mesenteric) from young lean and older fatter rats, killed either in the fed state or after fasting for 48 h. In the absence of insulin, mesenteric fat cells from either age group metabolized significantly more glucose per cell and converted more glucose to lactate than cells from other depots, regardless of nutritional state. Adipocytes from fasted lean rats showed a significant increase (approximately 30%) in the relative glucose conversion to lactate in all depots when compared with cells from fed lean rats. Fasting of older fatter rats, however, had limited effects on the relative adipocyte glucose conversion to lactate since lactate production was already high (40-50% of glucose metabolized). Mesenteric fat cells had the lowest relative response to insulin, possibly due to the high basal rate of glucose metabolism. These findings indicate that differences exist among adipose regions in the rates of glucose metabolism, lactate production and response to insulin. The anatomical location of the mesenteric adipose depot, coupled with a high metabolic rate and blood perfusion, suggests that mesenteric adipocytes may provide a unique and more direct contribution of metabolic substrates for hepatic metabolism than adipocytes from other depots.

Apex columellar cartilage graft

The classical rhinoplasty techniques do not give the best results when used on thick skin noses. We have developed a new technique, apex columellar cartilage graft, for correcting nasal tip projection in thick skin noses.

A simple, direct correction of the constricted ear

A simple approach to correct the constricted ear is described using a V-Y advancement to lengthen the periphery. Then through a posterior incision, an anterior exposure allows the creation of cartilaginous folds with scoring and sutures under direct vision.

Aesthetic rhinoplasty in early adolescence

Aesthetic rhinoplasty was performed on a small number of select youngsters who were less than 14 years old. During the early years of the clinical study only patients with a significant anatomic deformity and a very strong desire for surgery to correct it were accepted for surgery. There was close postoperative followup. In no case was recurrence of pathology noted and no additional surgery was performed. The psychological benefit that the surgery afforded during puberty, a very critical time in emotional development, was found to be significant.

One-stage salvage of fractured nasal prosthesis with immediate calvarial bone grafting

An open fracture of a nasal prosthesis usually means the primary removal of the prosthesis and a secondary reconstruction. A case with this problem was treated by a one-stage reconstruction using a calvarial bone graft.

Role of ionizing irradiation for 393 keloids

Between 1928 and 1986, 393 keloid sites on 250 patients were presented. Three hundred seventy-five sites received superficial quality therapeutic irradiation. Etiologies were determined. The majority were excised prior to irradiation, and in these, histologic confirmation was obtained. Recurrence rate after irradiation was low, 9/375 (2.4%). When 7 of 9 recurrences are eliminated for post-irradiation ear lobe repiercing, true recurrence is only 2/375 (0.53%). Cosmetic result was considered excellent without recurrence in 92%; favorably improved with hypertrophic scar, nodule or altered pigment in 5.6%; and marginally improved with smaller, less symptomatic keloid in 2.4%. Significant complications were limited to persistent pigment disturbance in only 1 patient, and pre-irradiation hemorrhage in 1 patient (unrelated to radiotherapy). There was no wound dehiscence nor failure to heal irradiated incision site. Transient hyperpigmentation occurred in 91/375 (24%). Recurrence after irradiation was too rare to associate with etiology, specific technical factors, keloid configuration or velocity of initiating the post-operative radiotherapy. An unexpected finding was that 22/250 (9%) were Caucasian subjects. Our null (0%) carcinogenicity rate to date and the one-half of one percent true recurrence rate supports continued use of post-operative irradiation to prevent keloid formation in this group of documented troublesome keloid formers. Configuration subtypes are proposed, post-operative irradiation protocol is listed, and mechanism of action is explained in accordance with the dynamic pathophysiology of keloid.

Liposuction surgery of the lateral thigh

We report our experience in 50 patients who underwent liposuction surgery of the lateral thighs with or without concomitant liposuction surgery of the hip and buttock areas. This procedure has proven to be a remarkably safe and effective method for removal of fat in properly selected individuals. The operation avoids the problems of blood loss and scarring associated with other operations used to remove fat and makes for extremely satisfied patients.

Determining safe limits for untransfused, outpatient liposuction: personal experience and review of the literature

Limiting liposuction volumes to avoid transfusion is sound surgical practice. Although the plastic surgery literature reports frequent use of transfusions in liposuction surgery, dermatologists almost never use blood replacement after liposuction. Techniques which favor less bleeding include sufficient use of fresh epinephrine, cryoanesthesia, use of smaller cannulas, fluid preloading, proper preoperative evaluation, serial liposuction, intramuscular steroids, and rapid application of pressure garments. A review of the literature and personal experience are detailed.

Outpatient anesthesia

More complex methods of outpatient anesthesia, including I.V. sedation and general anesthesia, have become commonplace. Patient selection and preoperative evaluation are discussed, as well as the choice of who will deliver anesthesia. Appropriate outpatient facilities and monitoring are reviewed. The authors' favorite methods of anesthesia, caveats, and suggestions are presented, as well as prevention and treatment of anesthesia problems and emergencies.

Therapeutic and protective properties of the corneal collagen shield

Following completion of radial keratotomy (RK) corneal incisions, 16 rabbits had a collagen shield placed on the operated cornea. Sixteen additional rabbits did not receive a collagen shield and were studied as a control group. The operated eyes of each group were enucleated at specified intervals. Fifty patients between 18 and 30 years of age with myopia greater than -6.5 diopters (D) had RK surgery: 25 patients (31 eyes) were chosen as a control group and 25 patients (30 eyes) had a collagen shield placed on the operated cornea at the end of surgery. Each patient was followed clinically at specified intervals. Histological and clinical findings included decreased postoperative corneal edema and inflammatory reaction and accelerated epithelial and stromal healing time and corneal stability. Patients who received collagen shields noted less glare and discomfort and obtained an average of nearly 1 D greater effect than the control group.

Laser treatment of rhinophyma

The carbon dioxide laser, when used in the treatment of rhinophyma, allows accurate removal of the diseased tissue to the desired level without risk of exposure of any underlying osteocartilaginous structures. This ensures rapid reepithelialization that minimizes the untoward scarring that may occur from delayed healing using other sculpturing techniques. Precise tissue vaporization prohibits violation of surrounding normal tissues.

The surgical repair of congenital microtia and atresia

Auricular reconstruction for congenital microtia is a complex multi-staged procedure. The repair of congenital atresia of the ear is one of the most difficult operations an otologic surgeon may attempt. In order to accomplish both procedures without endangering the integrity of either, there must be proper planning and close cooperation between the otologist and the facial plastic surgeon. In this article, we present our philosophy concerning the management and timing of these operations. The steps of each operation, and the impact of each on the other, are reviewed. Only through careful planning and coordination of these operations will patients realize the full benefit of their surgery.

Experience and technical refinements in the "donut" mastopexy with augmentation mammaplasty

Minor ptosis and pseudoptosis of the breast may be corrected by a "donut" mastopexy. This technique offers the opportunity to reach a good aesthetic result with minimal scarring. A prosthesis is inserted at the time of the mastopexy and the skin is reduced in an elliptical way to achieve a good balance between the breast volume and the skin envelope.

Small incision otoplasty for prominent ears

A 5-cm incision and an elliptical skin excision are part of almost all surgical techniques designed to correct prominent ears. It is proposed that two 0.5-cm incisions be used that give access to the lateral surface of the auricular cartilage, which is thinned with a rasp along the antihelix and concha. The skin is not removed at all. Results obtained with this technique are presented.

Augmentation rhinoplasty with soft tissue and cartilage

Augmentation rhinoplasty using soft tissue and cartilage was performed on 120 patients and the results were reexamined. They were found to be satisfactory and without complication. To narrow a round tip, a resection of two-thirds of the lateral crus cephalad portion and a transection of the caudal portion with a strip resection was done. To elevate the tip, septal cartilage was sutured to one-third of the upper part of medial crus to form a columella cartilage strut. To maintain the strut and to prevent pointing, a fibrous muscle tissue stretching from the medial crus to the upper cartilage or a dermis was transplanted into the area surrounding the septal cartilage tip. For a simple elevation of the dorsum, an onlay graft of dermis was applied, but where further elevation was required, further dermis and conchal cartilage was added for suture and attachment to the dermis.

Reconstituted bovine skin collagen enhances healing of bone wounds in the rat calvaria

The value of reconstituted fibrillar collagen (Zyderm Collagen Implant I, a concentrated solution of pepsin-solubilized, bovin skin collagen) as a bone graft material was tested in 4 mm diameter surgically created defects of rat calvaria. All wounds were allowed to heal for 4 weeks, and were assessed both qualitatively and by computer-assisted morphometry. The fibrillar collagen was found to produce significantly more new bone than no graft or than heat-denatured fibrillar collagen. The fibrillar collagen was generally well tolerated, appeared to act as a hospitable osteoconductor, and became incorporated into the newly formed bone. The effect of collagen concentration was also tested by comparing the fibrillar collagen at 3.5% (Zyderm Collagen Implant I) with 6.5% suspension of collagen (Zyderm Collagen Implant II). There were no significant differences observed, but a definite trend was evident for Zyderm II to encourage more bone formation than Zyderm I. It is concluded that reconstituted fibrillar collagen is a hospitable, osteoconductive substance that enhances bone healing of calvarial defects in the rat.

Porous collagen sponge wound dressings: in vivo and in vitro studies

Collagen-based materials can be formed into a three-dimensional sponge for use as a wound dressing and as a support for cell cultured skin components. Factors such as biocompatibility, morphological structure and addition of non-collagenous molecules to collagen are analyzed and discussed. Large pores or channels, interchannel communications and combinations of macromolecules of the connective tissue enhance wound tissue infiltration in vivo as well as cell growth in vitro into collagen sponges. The presence of such factors can be useful in patients with excised burn wounds and pressure skin ulcers.