Presacral Donor Site for Lip Augmentation

For over a century surgeons have been in search of the perfect tissue filler. In recent years lip augmentation has become quite popular. Despite the numerous methods employed to enhance the fullness of lips, autogenous free dermal fat grafting (FDFG) still remains a preferred method. FDFG has been extensively investigated clinically as well as histologically. However, despite its efficacy, FDFG has failed to gain widespread clinical acceptance. One reason has been concern about donor-site morbidity. In this paper, we describe a method of lip augmentation, which utilizes a dermal fat graft from the presacral region. This site is optimal because it has thick skin with minimal hair follicles and leaves a minimal scar.     

Donor Site Morbidity Post-Conchal Cartilage Grafting

Morbidity of the conchal cartilage donor site is evaluated in this article. Forty-two patients (from 1984–1994) with 44 donor sites were reviewed retrospectively. In 27 cases an anterior approach was used and in 17 cases a posterior approach was used. Four complications were observed: two cases of delayed healing in the post auricular approach, one case of flattening of the ear after an anterior approach, and one case with an anterior hypertrophic scar was seen. Only one case needed further surgical intervention. The anterior approach is technically easy, safe, and quick to perform but should be avoided in patients with a history or genetic predisposition to keloid or hypertrophic scars.     

Fat transplantation for soft tissue augmentation in the lower limbs

Attempts at fat transplantation in humans began as early as 1893 with Neuber [1] and came to the fore again with the introduction of liposuction. In his 1988 paper, titled ``Present Results of Fat Injections,' Illouz [2] concluded that permanent results were achieved in only 20 to 30% of cases. Numerous other authors also reported poor outcomes. The uniform conclusion of almost all the authors was that the outcome was the result of the common method they followed, that is, injecting fat subcutaneously. However, the poor perfusion of the subcutaneous tissue does not appear to be adequate for the timely revascularization of adipocytes. Around 1983 Jose Guerrerosantos [3,4] successfully injected fat intramuscularly in guinea pigs. Subsequent removal and histological examination of the grafts demonstrated revascularization and almost-complete survival of adipocytes, presumably due to the rich perfusion of the muscle.     

Hair Microtransplantation by the Use of Needles

The author presents a technique of hair transplantation using needles of different gauges, which replace the scalpel, dilators, and forceps, accomplishing the functions of cutting, dilating the skin, and handling the follicles. Hair microtransplantation is faster and less tiring using this technique.     

CAST Liposuction: An Alternative to Brachioplasty

The aging female with excess arm fat and poor skin tone frequently refuses a brachioplasty scar due to permanent detectability. Traditional deep liposuction localized to the posterolateral aspect of the arm frequently leaves sagging, wrinkled skin. Circumferential para-Axillary Superficial Tumescent (CAST) liposuction was developed to maximize skin retraction and create regional harmony by preparatory compartment magnification with dilute lidocaine and epinephrine followed by circumferential treatment of the arm and adjacent areas utilizing superficial and/or subdermal liposuction. Early CAST liposuction results in patients with moderate fat and excess skin revealed excellent skin retraction. CAST liposuction was then offered as the first of two stages to patients with excess fat and poor skin tone to avoid or shorten the brachioplasty scar. Twenty-six patients underwent CAST liposuction with 9–22 months follow up. Only two patients (7.7%) eventually required brachioplasty. Although postoperative seromas were frequent (38.5%) and preexisting skin wrinkling usually returned, the final result is acceptable to the vast majority of patients (84.6%) who refuse a brachioplasty scar.     

Injection of All-Trans Retinoic Acid for Treatment of Thin Wrinkles

The authors propose a treatment to improve skin texture and to decrease thin wrinkles and creases. The treatment is based on the use of 0.1% all-trans retinoic acid intradermic injections (with biopresence of 0.02%) combined with topic cream, immediately followed by 340 Nm blue light skin exposure. These procedures determine the retinoic binding protein stabilization that provides the acid intracellular penetration with its subsequent effects. An average of 10 sessions, once a week was required.     

Influence of Skeletal Site of Origin and Donor Age on Osteoblastic Cell Growth and Differentiation

Bone loss with aging may be due, at least in part, to inadequate bone formation. Moreover, the process of bone aging is known to follow a different pattern throughout the skeleton. In this study, we examined the cell proliferation rate (area under the cell growth curve, AUC) and the secretion of C-terminal type I procollagen (PICP), alkaline phosphatase (ALP), and osteocalcin (OC) in primary cultures of osteoblastic cells from human trabecular bone. Osteoblastic cells were obtained for 168 donors (100 women and 68 men). Ninety-eight bone samples were obtained from subjects undergoing knee arthroplastia, 52 aged 50–70 years (64 ± 5) and 46 over age 70 (73 ± 2). Another 70 bone samples were obtained from subjects undergoing hip arthroplastia; 51 were 50–70 years old (64 ± 4) and 19 were over 70 (75 ± 5). Osteoblastic cells from the older donors had a lower proliferation rate and OC secretion than those from younger subjects. However, ALP secretion was higher in the former subjects, whereas PICP secretion was unchanged. Osteoblastic cells from hip had a lower proliferation rate than those from knee. PICP secretion was also lower and ALP secretion was higher in the former cells. In age-matched cell cultures, osteoblastic cells from the knee had higher proliferation rate and PICP secretion than osteoblastic cells from the hip. However, ALP secretion was lower in knee osteoblastic cells than those from hip only in the younger group. With aging, ALP secretion was found to increase in knee osteoblactic cells, whereas OC secretion decreased in osteoblastic cell cultures from the hip. Our findings suggest that bone loss with aging may be accounted for, at least in part, by a decreased osteoblastic cell proliferation and an increased osteoblastic maturation. In addition, our data indicate that these changes with aging do not occur similarly at different skeletal sites. Received: 25 March 1998 / Accepted: 1 October 1998     

Standardizing the Evaluation of Treatment Outcomes After Skin Rejuvenation: The Qualitative Scoring System

Current treatments to correct and reverse diseased or aged skin yield widely divergent results. Judging the outcome of such treatments is done in an arbitrary and subjective fashion that is often limited to a patient's feedback or the physician's opinion. This makes it difficult for inter-physician or physician-patient agreement as to the degree of improvement achieved. In an age where skin rejuvenation is being widely practiced, a tremendous void needs to be filled by a system that appropriately evaluates and scores treatment outcomes. Such a system will help physicians communicate better in lectures, help them to better assess the results of various treatment modalities, and facilitate patient-doctor communication. The objective of this paper is to present a standardized scoring system against which skin rejuvenation results can be judged. This system is based on a model of healthy skin that can be defined by practical criteria against which patients can be judged pre- and post-skin rejuvenation procedures. A gold standard for healthy skin (baby skin) is established from a clinical, functional, and histologic perspective. Each patient's skin is compared with the healthy skin model and graded before and after treatment by implementing our scoring system which encompasses objective and subjective criteria. Objective criteria include the following skin characteristics: smoothness, firmness, even coloration, normal texture, and absence of any clinically evident disease. Subjective criteria include proper hydration and normal tolerance, and are not considered in the final scoring. Grading of each element in the scoring system [minimal (1), average (2), maximal (3)], and subsequently the final score [excellent (12 to 15), average (7 to 11), poor (<7)] are done with reference to the healthy skin model defined. The scoring system is novel and easy to use, and can be implemented to help improve communication between physicians and patients as well as during the dissemination of knowledge during medical conferences. In conclusion, treatment end-results can be consistently and more accurately assessed when the scoring system (based on objective criteria and a model of healthy skin) is used. Adopting this protocol will also help in directing our treatment to achieve the best possible results.     

A Morphometric Evaluation of Allograft Matrix Combinations in the Treatment of Osseous Defects in a Baboon Model

Recent and ongoing research efforts have been made to increase the efficacy of biomaterials as structural fillers during in vivo bony reconstructions. Although the selection of the possible material choices has grown, a biomaterial that can be physically molded to the defect/void space as well as offer biomimetic tissue regeneration has yet to be made available. With the potential success of demineralized freeze-dried bone allografts (DFDBA) combined with tendonous collagen as an effective filling material, further research should help to elucidate its use. The purpose of this study was to evaluate the regenerative healing response of five allograft mixtures via the morphology of filled, periodontal defects. Critical size mandibular and maxillary osseous defects were surgically created in six adult baboons. The filling response of four combinations of DFDBA and tendon collagen was compared with an all-collagen graft after 3 months of implantation. The overall results indicate that all combinations of DFDBA and collagen provided a better fill response than the all-collagen matrix (P < 0.05). Statistically, however, all of the combinations were similar (P > 0.05) with a 60:40 collagen to DFDBA mass ratio resulting in the largest defect fill response. Received: 20 August 1998 / Accepted: 4 February 2000     

A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.     

Yucatan Pig: An Optimal Hairless Model for a True Random Cutaneous Flap

Porcine models have been used extensively for skin flap research because of the established similarity between the cutaneous blood supply of the swine and humans. The Yucatan minipig provides an excellent model for researching the properties of random cutaneous flaps, offering several advantages over other breeds of swine. In this study, a total of 67 random cutaneous dorsal flank flaps measuring 4 × 14 cm were raised on nine Yucatan minipigs. The mean survival length (10.03 ± 1.60 cm) of the nondelayed flaps was greater than others reported in the literature. The well-defined plane between the subcutaneous tissue and the panniculus carnosus facilitated flap elevation consistently above the level of the panniculus carnosus thereby ensuring the creation of a true random cutaneous flap. Furthermore, the hairless nature of the skin, particularly beneficial in studying chemical peels, permits easy visualization and monitoring of any external skin changes. These advantages make the Yucatan minipig a more desirable alternative to other breeds of swine for use in skin flap research.     

Very Superficial Ultrasound-Assisted Lipoplasty for the Treatment of Axillary Osmidrosis

Treatment of axillary osmidrosis has been mainly concerned with surgical excision of glandular tissues and involved major surgical procedures with high morbidities and many complications. Search for a less invasive procedure for axillary osmidrosis resulted in the use of liposuction. However, there have been controversies over the efficacy of this method. The problem was that liposuction could not effectively remove the apocrine gland located in the dermis and dermosubcutaneous junction. A high rate of residual malodor and dissatisfaction were reported. The author used ultrasound-assisted lipoplasty (UAL) in the very superficial plane to remove the apocrine gland located in the dermis and dermosubcutaneous junction. The purpose of this study was to prove the efficacy of the very superficial UAL (VSUAL) for the treatment of axillary osmidrosis. From December 1998 to December 1999, 21 consecutive patients underwent UAL in their axilla for axillary osmidrosis. The follow-up period ranged from 2 to 12 months (mean: 8 months). UAL was performed in the very superficial plane with an amplitude of 40%. The very superficial UAL (VSUAL) was done mainly in a withdrawing manner with the tip of the cannula against the skin. The UAL (VSUAL) was done aggressively until the skin changed slightly erythematous. The results were assessed subjectively and objectively, and classified as excellent, good, fair, and poor. Nineteen patients were graded as excellent and one patient as good. The total satisfaction rate was 95.2%. One patient complained of residual malodor in her left axilla. There were no cases of skin necrosis, hematoma, or seroma. Histology showed partial removal of the subcutaneous layer and deep dermis, and degenerative epithelial changes in the apocrine glands in the residual deep dermis. These microscopic findings meant near-total functional ablation of the apocrine gland in the axilla comparable to ``flap-to-graft conversion' or surgical excision of axillary skin. The UAL (VSUAL) for axillary osmidrosis has the advantages of a high success rate with minimal complications. Rapid recovery, less restriction of movement, and tiny scars were other major benefits of this technique. Therefore, UAL (VSUAL) is a viable option for treatment of axillary osmidrosis.     

An Outer-Table Suspension Technique for Endoscopic Browlift

For the past 2 years, we have sought to develop a stable and reliable technique for soft-tissue suspension in the endoscopic browlift, while eliminating the need for permanent or temporary anchoring screws. To this end, we have developed an outer calvarial table fixation technique. This technique allows direct fixation of the periosteum or galea to the outer table of the frontal bone through the use of an outer table calvarial tunnel. The technique has been used in 34 patients, 21 of which were followed for more than a year. The results have been consistent and reliable. We feel this technique affords precise control of soft tissue suspension during endoscopic browlift, providing long-lasting elevation and lateral advancement of the brow complex.     

Correction of Vitiligo with Contralateral Areolar Skin Graft During Mammary Reduction Plasty

Vitiligo has been reported to be a contraindication against reduction mammaplasty. However, this report shows for the first time that reduction mammaplasty may serve as a means to excise breast vitiligo lesions and to repigment the recipient areola by a contralateral areolar full-thickness skin graft onto the deepidermized recipient areola. The repigmented areolar skin remained stable and cosmetically pleasing for over 4 years by now. There was no vitiligo occurring in the incision lines.     

An Open-Label Extension Study of Alendronate Treatment in Elderly Women with Osteoporosis

We have recently reported the results of a 24-month, double-blind, placebo-controlled study in 359 elderly osteoporotic women who were treated with daily oral alendronate (ALN) 1, 2.5, or 5 mg or placebo (PBO). We report the results of a 12-month, open-label, extension study during which 246 patients from the original study were treated with ALN 10 mg/day. Significant increases in lumbar spine bone mineral density (BMD) were observed in patients who had previously received PBO or ALN 1 and 2.5 mg/day for 24 months. Significant gains in trochanter BMD were seen in all treatment groups. Small changes were observed in femoral neck, total body, and forearm BMD during the course of this extension study. In general, the greatest increases in BMD during the open-label extension year occurred in patients who received either PBO or the lower doses of ALN during the previous 2-year blinded study. The frequencies of all categories of upper gastrointestinal adverse experiences (AEs) were less during months 25–36 (open-label extension) than during months 0–24 (original study). In conclusion, treatment with ALN 10 mg/day for 12 months in elderly women with osteoporosis who were previously treated for 24 months with PBO or ALN 1, 2.5, or 5 mg/day increased or maintained BMD of the spine, trochanter, and forearm, and was generally safe and well tolerated, especially in the upper gastrointestinal tract. Received: 16 June 1998 / Accepted: 1 November 1998     

The Resorption of Vital and Devitalized Bone In Vitro: Significance for Bone Grafts

Several studies have suggested that devitalized bone is less satisfactory than live tissue for surgical grafting purposes because an initial resorption step, prior to new formation, is lacking. We have compared the osteoclastic resorption of cultured bone containing living osteocytes with that of similar bone in which the osteocytes were dead. In experiment I, transverse slices cut from freshly harvested adult rabbit femora were either placed in phosphate buffered saline (Set 1) or subjected to freezing and thawing (Set 2). In experiment II, a heated set (Set 3) was prepared in addition. All slices were cultured with osteoclasts for 24 hours, eight slices per set being seeded with bone cells in experiment I and three per set in experiment II. The areas and volumes of resorption pits formed during the culture period were measured using reflection confocal microscopy. In both experiments, the mean values for the areas of the pits were smaller in the bone containing live osteocytes (P < 0.03, Mann Whitney test), and in experiment II the volumes of the pits in Set 1 were smaller than those in Set 3 (P < 0.0001, Mann Whitney test). However, in neither experiment was there a significant difference between the Sets in the volume:area ratios (mean depths) of the pits. The findings show that devitalized bone is resorbed by osteoclasts at least as readily as bone containing vital osteocytes in vitro, and indicate that if grafted devitalized bone resorbs less well in vivo it is not because the bone tissue is intrinsically resistant to osteoclastic resorption. Received: 25 November 1997 / Accepted: 24 June 1998     

Dermabrasion: A Curative Treatment for Melasma

Melasma is fairly common in Asian patients with a dark skin tone. It has long been known for its recalcitrance to any form of treatment. The objective of this article is to propose mechanical dermabrasion as a curative treatment for this entity. Five hundred and thirty-three patients with melasma were treated by mechanical dermabrasion using a rotatory diamond fraise. Four hundred and ten patients were available for long-term follow-up (mean follow-up time 5 years, range 1–9 years). Out of 410 patients, 398 (97%) achieved persistent clearance of melasma; in the remaining cases, there was partial recurrence after initial clearance. The common temporary sequelae were postoperative erythema or hyperpigmentation, pruritus, and milia formation. Two patients developed hypertrophic scars, one on the upper lip and one on the jawline, and one patient had permanent hypopigmentation on the forehead. In conclusion, mechanical dermabrasion is a relatively safe and highly effective means for curing melasma.     

Coblation: A New Technology and Technique for Skin Resurfacing and Other Aesthetic Surgical Procedures

After years performing CO₂ laser skin resurfacing, I started testing a new technology based on the modification of a bipolar electrosurgical unit in 1998. This technology called Coblation works by a radiofrequency mechanism and from the beginning it showed many advantages over lasers. My histologic and clinical preliminary results have already been published, but now, with a larger group and a 2-year follow-up, I can state that this new device is very effective and safe for skin resurfacing. The device works at low temperatures, avoiding the great thermal injury of a CO₂ laser, but is able to cause some damage in the superficial dermis. The working temperature is high enough to cause shrinkage of collagen and the dermal damage promotes the deposition of new collagen during the postoperative months. During surgery, Coblation can act as an electrosurgical unit and can coagulate the small vessels, achieving a bloodless surgical field. The clinical results show good, long-term results with a short and comfortable recovery period and minimal complications. I combined this resurfacing with face lifts without any special problems. The new cutting-coagulating terminals allow this new technology to be used in other surgical procedures, like transconjunctival blepharoplasties. The Coblation transconjunctival blepharoplasty, combined with Coblation resurfacing, seems to be very effective, with fast healing, due to the low temperatures used during the procedure, and a good aesthetic result. The device is small, light, and it is safer than a laser since it doesn't need any safety measures, such as goggles. After two years and more than 80 patients, I can state that Coblation is a very good alternative to laser skin resurfacing and that it will be used for many other aesthetic surgery procedures in the future.     

The First Clinical Study Using a New Biodegradable Implant for the Treatment of Lips, Wrinkles, and Folds

A new tissue augmentation product, made from hyaluronic acid, was clinically evaluated at three clinics in accordance with the new directive, EN 540, for medical implants. One hundred patients were fully assessed following treatments in 285 locations. The treatment was completed when the skin was levelled following one to two injections. At 6 months follow-up of all patients and at 12 months follow-up of a randomized group of the patients all showed that close to 60% of the effect was still there. No serious or permanent adverse events were noted.     

Gluteus Augmentation with Fat Grafting

This study presents the authors' experience with gluteus augmentation with autologus fat grafts and liposuction methods, having recorded the evolution of gluteus reshaping with autologus intramuscular fat graft injections for the past 5 years. Preoperative shape is discussed and patient evaluations, operative techniques, postoperative management, and long-term results are emphasized.