Intermediate hair follicles: a new more clinically relevant model for hair growth investigations

BACKGROUND

Alopecia causes widespread psychological distress, but is relatively poorly controlled. The development of new treatments is hampered by the lack of suitable human hair follicle models. Although intermediate and vellus hair follicles are the main clinical targets for pharmacological therapy, terminal hair follicles are more frequently studied as smaller hair follicles are more difficult to obtain.

OBJECTIVES

This investigation was designed to quantify in vivo morphological and in vitro behavioural differences in organ culture between matched intermediate and terminal hair follicles, in order to develop a new clinically relevant model system.

METHODS

Microdissected terminal and intermediate hair follicles, from the same individuals, were analysed morphometrically (250 follicles; five individuals), or observed and measured over 9 days of organ culture (210 follicles; six individuals).

RESULTS

Intermediate hair follicles were less pigmented and smaller, penetrating less below the skin surface (mean +/- SEM) (2.59 +/- 0.07 vs. 3.52 +/- 0.10 mm; P = 0.02), with smaller fibre (0.03 +/- 0.002 vs. 0.07 +/- 0.002 mm), connective tissue sheath (0.24 +/- 0.01 mm vs. 0.33 +/- 0.01 mm), bulb (0.19 +/- 0.01 vs. 0.31 +/- 0.01 mm) and dermal papilla (0.06 +/- 0.002 vs. 0.12 +/- 0.01 mm) diameters (P < 0.001). Intermediate hair follicle bulbs appeared 'tubular', unlike their 'bulbous' terminal follicle counterparts. In organ culture they also grew more slowly (0.044 +/- 0.002 vs. 0.067 +/- 0.003 mm per day; P < 0.001), remained in anagen longer (84 +/- 0.03% vs. 74 +/- 0.03% at day 9; P = 0.012) and produced less hair fibre (0.36 +/- 0.02 vs. 0.50 +/- 0.03 mm; P < 0.001) than terminal follicles.

CONCLUSIONS

Smaller intermediate hair follicles showed major morphological differences from terminal follicles in vivo and retained significant, biologically relevant differences in vitro in organ culture. Therefore, intermediate hair follicles offer a novel, exciting, more clinically relevant, albeit technically difficult, model for future investigations into hair growth. This should be particularly important for developing new therapies.

Re-visiting Luck's classification: a histological analysis of Dupuytren's disease

Luck (1959) described a histological staging system for Dupuytren's disease, classifying the disease into three stages. Previous biochemical and immunochemical studies have detailed the decrease in type III/I collagen ratio with disease progression. Herovici (1963) described a histological stain that produced a differential red/purple and blue colour for type I and III collagen respectively. We stained 15 specimens of Dupuytren's disease and quantified the different collagen types in each using computer analysis. We found a corresponding decrease in the amount of type III collagen as a percentage of the total collagen with disease progression: stage I range 35-49% (mean 38%); stage 2 range 21-33% (mean 27%) and stage 3 range 11-19% (mean 14%). We propose a new staging system based on the relative amount of type III collagen, where stage 1: >35%, stage 2: >20% and <35%, and stage 3: <20%.

17beta-estradiol regulates the secretion of TGF-beta by cultured human dermal fibroblasts

Estrogen plays an important role in skin homeostasis, as demonstrated by the changes seen in the skin of post-menopausal women, changes reversed by HRT. Estrogen also has a role in wound healing, since estrogen deficiency as occurs post-menopausally and in ovariectomised animals, is associated with a reduced rate of wound healing. Estrogen appears to modulate all phases of wound healing with effects on inflammatory cells, epithelialization, angiogenesis, extracellular matrix deposition and tissue remodelling. This study was designed to investigate the effects of 17beta-estradiol on cultured human dermal fibroblasts using an in vitro wound-healing assay. The end points investigated were cell migration, proliferation, total collagen secretion and active TGF-beta1 secretion. 17beta-estradiol significantly increased the migration and proliferation of cultured dermal fibroblasts following mechanical wounding, although the secretion of total soluble collagen was not altered. An increase in TGF-beta1 was demonstrated by unwounded confluent dermal fibroblast monolayers in response to 17beta-estradiol, but paradoxically, a decrease in the secretion of TGF-beta1 was demonstrated in the mechanically wounded dermal fibroblasts. These results identify human dermal fibroblasts as estrogen target cells and provide further evidence for a role by which estrogen regulates this particular cell type as part of the wound-healing process. However, the paradoxical nature of the effect of estrogen on TGF-beta1 secretion following mechanical wounding suggests that the cellular mechanism of action is complex. A greater understanding of the cell-specific action of estrogen may help to develop therapies that will improve cutaneous wound healing in the future.

The Bradford Burn Study: the epidemiology of burns presenting to an inner city emergency department

OBJECTIVE

The Bradford Burn Study prospectively reviewed all burn attendances at a single emergency department in the UK over a 1 year period. The study reviewed the epidemiology, demographics and outcomes of all patients entered into the study.

DESIGN AND SETTING

A 12 month prospective study of burn injuries attending an inner city emergency department serving a population of 1 million people.

RESULTS

460 patients were enrolled into the study. Average patient age was 22.7 years, male: female ratio was 1:1.4, and children <10 years of age accounted for 36% of the case mix. Asian patients accounted for 41% of all attendances; 85% of the cases in the study were accidental in nature, with scalds accounting for 52% of the injuries. Final outcomes were as follows: 54% of patients were reviewed by the emergency department physicians and only one of these patients ultimately needed skin grafting; 19% had follow-up by their primary care physicians; 12% were reviewed by plastic surgeons, and 5% were admitted; of those patients admitted, 16% needed surgery; only 12 patients (3%) were admitted to specialised burn units.

CONCLUSIONS

Emergency departments manage patients with burns well, and referrals to plastic surgery departments are appropriate. The majority of burns can be prevented by addressing educational issues and vulnerable sections of the population.

Skin nodules after semipermanent cosmetic dermal filler

The authors present what they believe is only the third reported incidence of orofacial granulomas after injection of semipermanent cosmetic filler.

Pentoxifylline inhibits mature burn scar fibroblasts in culture

Fibroblasts are thought to be (in part) responsible for the persisting contractile forces that result in burn contractures. Using monolayer and fibroblast populated collagen lattice (FPCL) models we subjected burn scar fibroblasts to the anti-fibrinolytic agent Pentoxifylline (PFX) in an attempt to reduce proliferation and contraction of these cells. Fibroblasts were isolated from mature burn scars at reconstructive surgery. Fibroblasts were grown in monolayer or incorporated into FPCL's and exposed to PFX. Fibroblast numbers and FPCL surface areas were calculated using digital photography and image analysis. PFX showed a dose-dependent inhibition of contraction and reduced proliferation of burn scar fibroblasts. In monolayer, cell number proliferation was markedly reduced. FPCL's containing 0, 0.25, 0.5, 1, and 2 mg/ml of PFX had relative surface areas of 31, 40, 43, 59, and 85%, respectively. One and 2 mg/ml FPCL's contracted significantly less than controls (p < 0.0001). This is the first study to show the dose-dependent effects of Pentoxifylline on the proliferation and contraction of burn scar fibroblasts. This study suggests that Pentoxifylline has a direct effect on inhibiting burn scar fibroblasts. Further study of PFX on burn scars will provide opportunities to reduce burn scar contractures in vivo.

Burn patterns of Asian ethnic minorities living in West Yorkshire, UK

Whereas burn morbidity and mortality have been well studied among natives of Southeast Asia, few have studied the epidemiology of burn injury among UK Asian ethnic minority immigrants. A 1 year prospective study of all patients presenting with burns to Bradford Royal Infirmary was carried out. Four hundred and sixty patients were studied, 188 (41%) were Asian ethnic minorities. The average patient age was 17 years for the Asian group and 27 years for the non-Asian patients. Contact burns were responsible for 29% of injuries in Asian patients and 19% in the other group. Thirty-seven percent of contact burns in the Asian ethnic minority group were caused by hot irons. Eleven percent of Asian patients had treated their burn with inappropriate remedies including saiti, butter, and toothpaste. There were no significant differences between Asian and non-Asian patients in terms of large or deep burns, nor in mortality. Morbidity and mortality from burn injury among UK Asian patients and other groups in the UK are similar; however, a disproportionate number of Asian patients sustain smaller burns. Much of this is behaviour related, and it is hoped that through preventative measures a marked reduction in the number of Asian ethnic minority burns can be achieved.

Cervical midline Z-plasty revision surgery for pseudoxanthoma elasticum

A 30-year-old woman with known pseudoxanthoma elasticum was referred for surgical correction of extensive loose neck skin. She underwent a standard rhytidectomy, which produced minimal improvement. Revision surgery using a vertical elliptical skin excision, incorporating a Z-plasty was undertaken 3 months later and resulted in a satisfactory outcome.

Video microsurgery: early experience with an alternative operating magnification system

Since Nylen first used an operating microscope in 1921, its basic design has remained fundamentally unchanged. Microsurgical procedures are still performed while viewing the subject through binocular eyepieces. This article examines the potential to perform microsurgery using video technology, operating with a television monitor. The development of the videomicroscope is discussed together with its early trials. The results show the potential to perform simple microsurgical procedures while viewing the procedure in a two-dimensional format. The advantages and disadvantages of such a system are discussed, together with future implications.

The aesthetic implication of scar position in breast reconstruction

In these enlightened times of patient involvement in operative planning, the patient has a much greater input into procedure selection, especially where several options are available. Breast reconstruction is a prime example of combined decision making, although options are still limited by pre-existing scars and previous treatment. In this study we eliminated all variables of reconstruction except the resulting scar pattern in an attempt to discover what was most acceptable to the patient. Various postoperative results, such as single scars and flaps, were mimicked unilaterally and bilaterally by drawing them on the same live subject. These photographic images were then formulated into a questionnaire and distributed to various female groups for scoring. Results show a preference for single-line horizontal scars in unilateral and bilateral reconstructions; scars that encroached the upper medial quadrant scored less well. The preferred flap reconstruction is also positioned horizontally, but in the lower pole. Overall, the preferred reconstruction in all groups was a single unilateral horizontal scar.

Video microsurgery: early experience with an alternative operating magnification system

Since Nylen first used an operating microscope in 1921, its basic design has remained fundamentally unchanged. Microsurgical procedures are still performed while viewing the subject through binocular eyepieces. This article examines the potential to perform microsurgery using video technology, operating with a television monitor. The development of the videomicroscope is discussed together with its early trials. The results show the potential to perform simple microsurgical procedures while viewing the procedure in a two-dimensional format. The advantages and disadvantages of such a system are discussed, together with future implications.

Ten-year review of a prospective randomized controlled trial of textured versus smooth subglandular silicone gel breast implants

Although textured silicone breast implants have been shown to reduce the incidence of capsular contracture, there is little evidence if this effect is maintained in the long term. It has been 10 years since the double-blind randomized trial in which 53 patients received either Mentor smooth (26) or textured silicone gel implants (27). Of the 14 patients who were not known to have developed a contracture in the smooth group, 11 were reviewed. Three had bilateral contractures. In the textured group, 18 of the 24 patients not known to have contractures were reviewed. None had developed contractures. At 10 years, the incidence of capsular contracture was 65 percent of patients with smooth implants (an increase of 6 percent on the 3-year results) and 11 percent for the textured implant patients (no change on the 3-year results). A database containing the details of 1100 patients reinforces these results by examining the differences in contracture rates of textured, smooth, and polyurethane-coated implants. The effect of submuscular placement on reducing contracture rates regardless of texturing is discussed, as is the apparent increase in capsular contracture in patients who smoke.

Recurrence of subglandular breast implant capsular contracture: anterior versus total capsulectomy

The objective of this study was to determine whether the type of capsulectomy, anterior or total, affects the recurrence of capsular contracture around subglandular silicone-gel breast implants. A retrospective analysis was performed of patients who underwent either anterior or total capsulectomy for Baker grade 3 or 4 subglandular capsular contracture in our unit. All patients were invited to a review clinic where their capsular status was assessed. There were 100 anterior- disc capsulectomies in 60 patients between 1988 and 1997 and 99 total capsulectomies in 60 patients between 1990 and 1998. The follow-up in the former group was a median of 7 years and mean 6.9 years, compared with median 2.5 and mean 3.1 years in the latter group. Eighty-six percent of the implants removed from both groups at capsulectomy were smooth-walled gel-filled implants. Sixty-nine breasts in the anterior group received textured gel implants at capsulectomy; the remaining 31 received polyurethane-coated Meme implants. In the total capsulectomy group, all but two breasts (one patient) received textured gel implants. After review, the capsular status was known in 80 percent of the anterior and 92 percent of the total capsulectomy group. The review clinic found eight new contractures in five patients to have developed in the anterior compared with none in the total group. Recurrent contractures affected 50 percent of patients (46 percent of breasts) in the anterior and 11 percent of patients (10 percent of breasts) in the total capsulectomy group. Kaplan-Meier survival analysis was applied to the data. By including only patients who received textured gel implants at capsulectomy, the Logrank found a statistical difference between the two treatment groups (0.01 < p < 0.5). We believe that this study provides some evidence that total capsulectomy for subglandular silicone breast implant capsular contracture results in a lower capsular recurrence than anterior- disc capsulectomy. The pattern and risk of recurrence after total capsulectomy and exchange for a modern textured prosthesis appear to approach those following primary augmentation.

Silicone gel-filled breast implant integrity: a retrospective review of 478 consecutively explanted implants

Concern has been expressed over the long-term integrity of silicone gel breast implants. There are no large series representing experience with these implants outside of the United States. A retrospective case note review of explanted silicone breast implants was performed; 478 implants have been explanted during the past 11 years and relate to the use of these devices since 1971. Loss of implant integrity was not simply related to its age in vivo. Failure was more likely with implants of the late 1970s and early 1980s (second generation) and with subpectoral placement. Implant failure was independent of capsular contracture as the indication for removal (p = 0.09). There is no evidence that the currently used textured silicone gel breast implants are subject to the same loss of integrity as previous examples of these devices. The life span of these implants, the first of which are approaching 10 years in vivo, is at present unknown. Information concerning the integrity of silicone gel breast implants is essential in the current climate for counseling of both new and old implant recipients.

Breast reconstruction by tissue expansion. A retrospective technical review of 197 two-stage delayed reconstructions following mastectomy for malignant breast disease in 189 patients

Despite the advent of free tissue transfer, breast reconstruction by tissue expansion is an important technique in the armamentarium of the reconstructive breast surgeon. The concept is deceptively simple and yet in reality can produce difficult complications and poor results. A database was compiled of all the patients receiving tissue expanders and/or implants for cosmetic, congenital and reconstructive purposes between 1986 and 1998. 189 patients had 197 delayed two-stage tissue expansion breast reconstructions following mastectomies for malignant breast disease between 1986 and 1997. 103 breasts (52%) had two uncomplicated stages. The remainder had one or more complications, revisional procedures for complications or alterations to the reconstruction for size, position or shape. Overall each breast reconstruction required 2.9 procedures (range 2-9). The complications and additional procedures are discussed. In particular, capsular contracture of the definitive implant (12%) was related to implant type and not to the speed of tissue expansion or the degree or duration of over-expansion. Although 17% of patients received radiotherapy, none of those who developed contracture around the definitive implant had this adjuvant therapy, P< 0.05. Twelve reconstructions (6%) totally failed due to complications of which six underwent secondary flap reconstruction. Twenty-one patients have subsequently developed metastatic disease of which 15 have died to date. Breast reconstruction by tissue expansion is still an important technique. It should be used carefully and thoughtfully by surgeons trained to deal with any complications. Patients need to be carefully selected and counselled prior to undertaking this process.

Plastic surgery and pseudoxanthoma elasticum

Pseudoxanthoma elasticum is a cause of abnormal skin laxity. A case of lower face and neck skin laxity is presented with its treatment by cutaneous rhytidectomy.

Reduction of potential contamination of breast implants by the use of 'nipple shields'

Forty-three breast implant operations in 25 patients were studied prospectively to determine the effectiveness of covering the nipple-areolar complex with an adhesive film dressing in preventing perioperative expression of bacteria from nipple ducts contaminating the operative field. One swab from the nipple after skin preparation and none of the swabs taken from the outer surface of the film dressing postoperatively yielded any bacterial growth. Fourteen breasts (33%) in 11 patients (44%) yielded bacterial growth from swabs under the film postoperatively. Six of 9 breasts (67%) in 5 patients who had capsulectomies had bacteria isolated from under the film postoperatively. Ten of 14 (71%) control breasts (no shields) in 6 of 7 patients (86%) had positive postoperative swabs. This study confirms the potential risk of bacterial contamination arising from nipple duct flora during intra-operative breast manipulation, and the effectiveness of a perioperative adhesive film placed over the nipple-areolar complex in preventing subclinical bacterial contamination of implanted breast prostheses.

Cellulite treatment: a myth or reality: a prospective randomized, controlled trial of two therapies, endermologie and aminophylline cream

Cellulite is a common phenomenon that particularly affects the thighs and buttocks of women. Little scientific evidence exists to support any of the many advertised treatments for it. A total of 52 of 69 women, who were divided into three groups, completed a 12-week, randomized, controlled trial in which the effectiveness of two different treatments for cellulite was assessed. The patients acted as their own controls. The treatments investigated were twice-daily application of aminophylline cream and twice-weekly treatment with Endermologie ES1. Group 1 (double blind) received aminophylline to one thigh/buttock and a placebo cream to the other. Group 2 (singly blind) received Endermologie to one thigh/buttock. Group 3 received Endermologie to both sides and used the same cream regimen as group 1. Results were assessed subjectively by the patient and by clinical examination and photographic assessment by the surgeon (before and after the trial). Morphologic assessment included body mass index, thigh girth at two points, and thigh fat depth measurement by ultrasound. No statistical difference existed in measurements between legs for any of the treatment groups (paired t test, p > 0.4). The best subjective assessment, by the patients themselves, revealed that only 3 of 35 aminophylline-treated legs and 10 of 35 Endermologie-treated legs had their cellulite appearance improved. The authors do not believe that either of these two treatments is effective in improving the appearance of cellulite.

Breast implants: a survey of cosmetic clinics

The quality of information available to prospective cosmetic breast implant recipients in the private sector was assessed. Sixteen women telephoned 14 clinics requesting written information about breast implants and their safety. The information received varied enormously in quality. Of the purely cosmetic clinics offering information, it was generally of better quality and more consistent than private hospitals where accredited plastic surgeons operate. In the current climate of consumer choice and negative attention given to silicone breast implants by the media, more comprehensive information should be readily available to guide potential patients.

Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial

Silicone breast implant surface texturing has been shown to reduce the short-term incidence of adverse (Baker III/IV) capsular contracture in augmentation mammaplasty in double-blind randomised controlled trials. It is, however, undetermined whether the textured surface merely delays the onset of severe contracture or its effect on capsular contraction is persistent. The current study reviewed, after three years, 49 of the 53 patients who had undergone subglandular breast augmentation mammaplasty in a randomised double-blind study with textured or smooth silicone gel-filled implants in 1989. The incidence of adverse capsular contracture was 59% for smooth implants and 11% for textured ones (P = 0.001; chi 2 = 10.60). Eight patients (31%) with smooth prostheses underwent breast implant exchange for severe capsular contracture between the one and three year assessments, compared with a revisional surgery rate of only 7.4% (2/27 patients) for the textured group (P < 0.04). These adverse capsular contracture and revisional breast implant surgery rates clearly demonstrate that the effect of textured implants in reducing capsular contracture in augmentation mammaplasty found at one year is maintained at three years, and suggest that it may be long lasting.

Tissue expansion: clinical applications

In this second article, the authors outline the process of reconstructive surgery using the tissue expansion technique described in the January 1995 issue of JWC.

Tissue expansion: an overview

A review of a surgical technique which uses the skin's ability to stretch to obtain tissue for reconstruction

The role of ultrasound imaging in the diagnosis of breast implant rupture: a prospective study

Breast ultrasound to assess possible implant rupture was performed on 24 consecutive patients (43 breasts) by the same radiologist immediately before revisional breast implant surgery. Comparison of the clinical, ultrasound and operative findings showed ultrasound to be three times as sensitive as clinical judgement in predicting implant rupture. The sensitivity of ultrasound in predicting impaired implant integrity was 70% (versus 23% for clinical examination) with a specificity of 96%. The ultrasound features indicating leakage are outlined later. The positive predictive value of an abnormal scan was 90% and that of a normal scan 87%. It is concluded that breast ultrasound is a simple, quick, non-invasive method which contributes significantly to the assessment of patients with suspected breast implant rupture.

Congenital breast asymmetry: subjective and objective assessment

There is currently no standard objective method for the assessment of developmental breast asymmetry. The results of corrective surgery in 24 patients with congenital breast deformities were evaluated subjectively (symmetry scores by patients and panels of observers), and objectively (linear measurements of nipple position and stereophotogrammetrically determined breast volumes). The latter were obtained using a newly developed prototype computer based technique (Bodymap). This study is the first reported use of stereophotogrammetry in assessing results of surgery for the correction of congenital breast asymmetry. The results obtained, their clinical implications, and the usefulness of Bodymap in the objective measurement of breast asymmetry are discussed.

Silicone breast implant rupture: common/serious complication?

Of the potential health risks of silicone breast implants it is the concern about implant durability, life span and the possible association with connective tissue disease which has attracted most attention. A prospective study addressing these factors was therefore undertaken over an 11 month period. 51 patients presenting with significant capsular contracture, suspected prosthesis rupture or unrelieved implant-induced anxiety underwent revisional breast surgery after biochemical, haematological and immunological screening. Of these 51 patients (83 breasts), 14 (19 breasts) had ruptured implants (23% incidence). These were all smooth prostheses belonging to a cohort manufactured more than 10 years ago; their mean in situ duration being 12 years vs. 5.5 years for the intact group (p = 0.0024; Kruskal-Wallis one-way ANOVA). There were no systemic complications from implant rupture and the mean blood silicon level was normal. One patient with pre-existing pernicious anaemia had elevated autoantibodies. The mean ESR in the ruptured implant group was 6 mm/hour. It is concluded that rupture of breast implants is not as uncommon as hitherto thought and is strongly correlated with their in situ duration. In this study implant gel leakage was not associated with serious systemic effects.

Determination of relative contributions of 'mechanical' and 'biological' creep in tissue expansion using in vivo pressure monitoring: a preliminary report

This work outlines the theory underlying tissue deformation in response to an applied force and presents a model to evaluate relative contributions to tissue generation from mechanical and biological creep. Using in vivo pressure measurement, this model has been tested with clinical data generated from a heterogeneous series of 10 patients undergoing tissue expansion. Preliminary results indicate that the model proposed is able to fit accurately both in vitro and in vivo data. Extrapolation of the model, in time, may lead to a prediction of the relative contributions of 'biological' and 'mechanical' creep.

The role of the contractile fibroblast in the capsules around tissue expanders and implants

The occurrence, structure and contractility of myofibroblasts in the capsules around tissue expanders and static implants has been studied in the rat, pig and humans. The capsules showed a characteristic layered structure with myofibroblasts being the predominant cell type. Capsular strips contract in vitro in a manner characteristic of fibroblast contraction. The contractile ability decreased with the time since expander insertion; and increased with expander exposure, peri-expander infection and clinical evidence of adverse capsular contracture. An hypothesis is proposed that capsular contracture is analogous to wound contraction, and that intraimplant pressure usually inhibits capsular contraction. Evidence is shown from intraexpander pressure measurements to support this hypothesis. The clinical implications for tissue expansion and breast augmentation are discussed.

Postburn breast reconstruction: tissue expansion prior to contracture release

Tissue expansion of the scarred chest following burns results in a poor breast mound shape with little projection or inframammary fold, since the expander, like normal developing breast tissue, is kept flat by the scarred skin envelope. We present a case that demonstrates that adequate projection of the breast and formation of an inframammary fold can be achieved by expansion if extensive release and skin grafting of contractures over the breast mound are performed after expansion. Maintained expansion will act as a stent reducing secondary contracture of the grafted-areas.

Delay between expansion and expander/implant exchange in breast reconstruction--a prospective study

It has been suggested that delay between expansion and insertion of the definitive prosthesis in breast reconstruction reduces the incidence of adverse capsular contracture. We have carried out a prospective trial to examine this hypothesis. 65 patients were randomly allocated into two groups; in one, insertion of the definitive prosthesis was 2 weeks following expansion ("immediate") and in the other, 6 months ("delayed"). The incidence of adverse capsular contracture assessed both by the Baker Scale and a linear analogue scale showed no difference between the two groups. A new objective method for measuring ptosis using a specially designed template is described. The degree of ptosis was not affected by the delay.

Gold eyelid weights in patients with facial palsy: a patient review

Lid loading with gold weights inserted into a submuscular pocket in the upper eyelid is a useful, simple, and effective method for the treatment of lagophthalmos in patients with temporary or permanent facial nerve palsy. The incidence of complications in our series was high. The reason for this are discussed, and methods of reducing the rate of complications are suggested.

Textured or smooth implants for breast augmentation? A prospective controlled trial

This study examines the hypothesis that textured surface silicone implants reduce the incidence of adverse capsular contracture in breast augmentation. A total of 53 patients were entered into a prospective study; they were randomly assigned to receive either smooth or textured implants which were placed in the submammary plane. Of these, 50 patients were assessed at 12 months by a panel of observers who did not know which type of implants had been used. Adverse capsular contracture (Baker grades 3 and 4) was found in 28 breasts augmented with smooth surface implants (58%) and in 4 breasts in the textured surface implant group (8%). This reduction in adverse contracture using textured surface implants was highly significant (p less than 0.0001). Careful trial design is essential in studies of this sort in order that we can obtain useful data regarding the causes and prevention of adverse capsular contracture.

Immediate placement of tissue expanders in the management of large excisional defects on the face

Where excision of a facial lesion leaves a defect too large for local flap reconstruction, tissue expansion is frequently a more desirable option than a skin graft, providing as it does tissue which exactly matches that which has been lost. For malignant skin lesions where removal should not be delayed by preliminary expansion of the flap, the expander can be placed simultaneously with tumour excision thus keeping the reconstruction to two stages. A temporary skin graft is employed in the interim. Our experience with this approach in five patients with large facial malignancies is presented and discussed.

Management of burns in major disasters

This paper discusses the problems of handling major burns in disasters with particular reference to the disaster that occurred in Bradford. Several major features of the Bradford fire, in which 56 people died, made its management much simpler than might be expected in subsequent burns disasters; these are discussed. Lessons that have been learned from handling this disaster are indicated.

The use of a latissimus dorsi myocutaneous flap to cover an axillobifemoral vascular prosthetic graft

We describe a case of seroma formation with skin necrosis overlying an axillobifemoral dacron graft, which was treated by excision of the affected skin and closure using a latissimus dorsi myocutaneous flap.

Tissue expansion in perspective

Tissue expansion is a recent advance in skin cover technique. Its empirical use has enabled many previously difficult reconstructions to be completed without recourse to distant flaps. Its high complication rate and lack of basic scientific understanding at present restrict its use to selected cases, but the quality of repairs possible by this method encourage further serious scientific study.

Custom-made nipple-areola prostheses in breast reconstruction

The nipple-areola prosthesis is a useful temporary or permanent adjunct to breast reconstruction. The commercially available prostheses, however, are unable to reflect the remarkable normal variation in this anatomical feature. We describe the production and use of custom-made prostheses using the remaining nipple-areola complex as a template. Their success in 72 patients has led us to adopt such prostheses as routine in breast reconstruction.

Experience with an external valve in small volume tissue expanders

Tissue expansion has been a reconstructive technique for nearly 10 years. All published work has described serial expansion by percutaneous injection into a buried reservoir. This paper reviews a small series of patients who had tissue expansion using small volume expanders with an external valve. The complications with small expanders are discussed. The external valve is shown to be satisfactory and free from infection in this series.

Extraskeletal osteogenic sarcoma occurring in the tongue

A case of osteogenic sarcoma of the tongue is described occurring 25 years following radiotherapy for a squamous cell carcinoma.