Pressure monitoring during lipofilling procedures.

BACKGROUND: Grafting of autologous lipoaspirate for various clinical applications has become a common procedure in clinical practice. With an estimated mortality rate of 10-15 percent, fat embolism is among the most severe complications to be expected after lipofilling therapies. OBJECTIVE: The aim of this study was to determine the level of interstitial pressure after the injection of defined volumes of lipoaspirate into the subcutaneous tissue of female breasts. It was hypothesized, that interstitial pressure levels exceed the physiologic capillary pressure during lipofilling procedures and hence increase the potential risk for fat embolism. Further it was investigated if external tissue expansion has the potential to significantly reduce interstitial tissue pressure. METHODS: Interstitial pressure was monitored in 36 female patients, that underwent autologous fat injections into the breast. Measurements were conducted with a sensor needle connected to a pressure transducer (LogiCal Pressure Monitoring Kit, Smiths medical int. Ltd., UK). Patients were divided into 4 subcohorts differing in their pre-treatment regimen or local tissue conditions. Pre-treatment consisted of tissue expansion, achieved with the Brava™ (Brava LLC Miami, Fla., USA) vacuum-chamber. RESULTS: The increase in interstitial pressure after injection volumes of 100 ml (p = 0.006), 200 ml (p = 0.000) and between 100 ml and 200 ml (p = 0.004) respectively, were significant in non-mastectomized patients without pre-treatment. Patients pre-treated with Brava™ did not show such statistically significant differences in interstitial pressures before and after the injection of 100 ml and 200 ml of lipoaspirate (p = 0.178). The difference in interstitial pressure in mastectomized patients between 0 ml and 100 ml (p = 0.003), as well as 0 ml and 200 ml (p = 0.028) was significant. The difference in pressures between pre-treated patients and patients without pre-treatment did not differ significantly in the mastectomized patient cohort. CONCLUSION: During lipofilling procedures interstitial pressures are reached that exceed pressure limits defined as hazardous for fat embolism. To date it is unknown what pressure levels need to be considered critical for complications in soft tissue interventions. Further the results indicate higher interstitial pressures for patients that had undergone mastectomy, whereas pre-treatment with external tissue expansion seemed to diminish pressure values.

[Quo vadis? Breast implants--current trends and new concepts]. / Quo vadis? Brustimplantate--aktuelle Entwicklungen und neue Konzepte.

BACKGROUND: Breast augmentation is one of the most frequent surgical procedures performed by plastic surgeons. Furthermore, in the majority of breast reconstructions implants are still in use. With the focus on surface modifications and biomaterials, the article provides an overview of the latest trends and concepts in increase of implant biocompatibility and reduction of capsular contracture. Because of the recent events regarding PIP® implants, a short report on this topic is presented as well. MATERIALS AND METHODS: The literature was searched for experimental and clinical studies, as well as meta-analysis and reviews, using the databases PubMed, Embase and Cochrane Collaboration. Based on the title, year of publication and abstracts, thematically relevant and recent publications in English or German were selected and full text articles were studied. RESULTS: According to the classification, 4-5 generations of breast implants have been developed since the 1960s. Modifications affected diverse areas including various surface textures as well as coatings with polyurethane or titanium. Some of these changes were able to reduce capsular contracture, however, without resolving the issue sufficiently. Recent experimental studies mostly evaluated different surface coatings with antifibrotic and antibacterial substances. For the local drug release various carrier substances were used. Furthermore, drugs were covalently bonded to the implant surface or applied by surface impregnation. In different approaches biocompatibility could be increased by biomimicry or nanotechnologically modified biomaterials, which could additionally contribute to the reduction of capsular contracture. CONCLUSION: The development of coating technologies for the locally controlled sustained drug release using the implant surface as drug delivery system could potentially enable the local administration of drugs, which were orally delivered in clinical trials, and effectively reduced capsular contracture. This kind of application could potentially minimize the risk of adverse side effects. However, there are still some questions concerning controlled drug release systems for implant surfaces, as well as long-term results and possible side effects of drugs in a continuous local administration to be answered in further studies.

The "jaguar's eye" as a new beauty trend? Age-related effects in judging the attractiveness of the oblique eye axis.

BACKGROUND: The eye area plays an important role in the assessment of a person. Although plastic surgery in this area is quite common, only a few studies have evaluated the features that create an attractive eye. This study aimed to determine whether a preference exists for a certain eye axis. METHODS: The stimulus material comprised portrait images of seven women. Two versions of each face were generated that differed only in the position of the eye axis (normal vs rotated). The eye axis was rotated by raising the lateral canthus of the eye about 5 degrees . A total of 250 experimental subjects ranging in age from 15 to 84 years stated their preferential position of the eye axis (horizontal vs oblique). RESULTS: Clear evidence showed that age has an impact on the type of eye axis preferred. Young subjects (age, B 19 years) regarded the oblique type of eye axis as more attractive, whereas older subjects (age, C50 years) preferred the eyes more horizontal (p \ 0.001), independently of the interviewees' gender. CONCLUSION: Because young people judge eye attractiveness differently than older people and because beauty trends are normally determined by young people, a future ideal of beauty could be characterized by eyes with a gently oblique eye axis.

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.

Gigantomasty: treatment with a short vertical scar.

BACKGROUND: During the past 15 years, reduction mammoplasty with a short vertical scar has become increasingly common in the world of plastic surgery. Still, the indication for this technique often is limited to smaller reduction weights, so that the inverted T-scar techniques have yet to be regarded as the gold standard for excessive breast hypertrophy. METHODS: In the authors' department, their own modification of vertical scar reduction mammoplasty, based on the techniques of C. Lassus, G. Maillard, and M. Lejour, has been performed since 1990. During the past 10 years, the authors have used it for all breast sizes. To investigate the safety and the results for patients with very large breast volumes (gigantomasty involving at least > or =1,000 g of excised tissue per one side), this study retrospectively evaluated 25 women with a mean age of 43.1 +/- 11.2 years who underwent surgery from January 2002 to June 2003. A protocol was used to record patient satisfaction and complaints and to quantify the final result objectively. RESULTS: The average resection weight for the 25 women was 1,227 +/- 300 g (maximum, 2,300 g) on the right side and 1,218 +/- 343 g (maximum, 2,100 g) on the left side. The sternal notch-to-nipple distance was reduced from 37.1 +/- 4 cm to 23.4 +/- 2.1 cm on the right side and from 37.4 +/- 3.5 cm to 24 +/- 2 cm on the left side. The brassiere size was reduced by about three cup sizes on the average. During an average follow-up period of 2 years (n = 15), patient satisfaction was high, with good acceptance of the breast shape and a low rate of major complications (12%). CONCLUSION: The results suggest that the authors' modified vertical scar technique can be used successfully for all dimensions of reduction mammoplasty regardless of breast weight.

Does the surface structure of implants have an impact on the formation of a capsular contracture?

BACKGROUND: The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture. METHODS: This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker's clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis. RESULTS: The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 +/- 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05). CONCLUSIONS: The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.

[Histological and immunohistochemical investigations with capsular contracture after breast augmentation with smooth silicone gel implants]. / Histologische und immunhistochemische Untersuchungen bei Kapselkontraktur nach glatten Brustimplantaten.

INTRODUCTION: A prospective study was performed to analyse the cellular and molecular composition of fibrous capsules around silicone breast implants. The necessity of an exact histological classification for comparing objectively the different findings of capsular contracture is shown. PATIENTS AND METHODS: The prospective study (investigation time 1/2003 to 6/2005) included 24 female patients (average age: 40+/-12 years) with contracture after bilateral cosmetic breast augmentation with smooth silicone gel implants (Mentor). In each patient the baker score was determined preoperatively. Samples of capsular tissue from all patients were evaluated histologically and immunohistochemically and classified according to the histological classification introduced by Wilflingseder and co-workers. RESULTS: All capsules showed the same basic histological structure with a three-layer composition. For the correlation analysis we had to exclude one patient with repeated implant change. There was no correlation between the patient's age, time of implantation, length of implant period, and capsular contracture. Greater amounts of silicone particles were associated with increased degrees of capsular contracture (Baker: r = 0.687, n = 23, p < or = 0.001; Wilflingseder: r = 0.784, n = 23, p < or = 0.001). High silicone amounts were associated with an increased local inflammation (r = 0.489, n = 23, p , 0.05). A moderate to severe local inflammation was found in 23 patients (95.8%). In summary, there was a positive correlation (r = 0.797, n = 23; p , or = 0.001) between the clinical classification (Baker score I to IV) and the histological classification (Wilflingseder score I to IV). CONCLUSIONS: We demonstrated in our study, in spite of using implants with high gel cohesiveness (fourth generation), the presence of vacuolated macrophages with microcystic structures containing silicone and silicone particles in the capsular tissue. Greater capsular thickness was associated with an increased number of silicone particles ans silicone-loaded macrophages in the peri-implant capsule. The histological classification introduced by Wilflingseder and co-workers takes into consideration this pathogenetic mechanism of inflammatory reaction which seems to be one of the major key factors in the development of capsular contracture.

Serologic and histologic findings in patients with capsular contracture after breast augmentation with smooth silicone gel implants: is serum hyaluronan a potential predictor?

BACKGROUND: In this study, breast implant capsular tissues and blood samples from 25 cases were studied to characterize the relationship between capsular findings and serum analysis. The serum fibrosis indexes hyaluronan and the aminoterminal propeptide of procollagen type III (PIIINP) are fairly well correlated in several other studies with the inflammation grade and fibrosis in patients with progressive fibrotic disorders such as liver cirrhosis. METHODS: The study enrolled 25 female patients (average age, 40 +/- 12 years) with capsular contracture after bilateral cosmetic breast augmentation using smooth silicone gel implants (Mentor). The implants were placed in a submuscular position through an incision in the inframammary fold. The implant removals were prompted by development of capsular fibrosis (Baker grades 1-4). Samples of capsular tissue were obtained from all the patients for standard histologic and immunohistochemical analyses. Blood samples were drawn from all the patients immediately before surgery. Sera from 20 healthy female patients (average age, 34 +/- 9 years) who had undergone plastic surgery for reduction mammaplasty were used as controls. RESULTS: Histology. Capsular tissue was significantly thicker in patients with grades 3 and 4 contracture than in women with grade 2 contracture according the classification by Baker. There was a moderate (n = 15) or severe (n = 10) chronic inflammatory reaction in the capsules around the implants. Fibroblasts and macrophages represented the major cell population found in the fibrous capsules. In addition, activated CD4+ cells were detected. An inner layer with synovia-like metaplasia and multinucleated giant cells was found. Fibroblast-like cells formed the most common cell type in the capsules, along with macrophages, scattered polymorphonuclear leukocytes, lymphocytes, plasma cells, and mast cells. Serum analysis. There was a significantly higher level (p < 0.05) of hyaluronan serum concentration in patients with capsular contracture (26 +/- 14 microg/l) than in control subjects (12 +/- 6 microg/l). There was a positive correlation between the grade of capsular contracture (Baker 1-4) and the hyaluronan serum concentration (Baker 1-2: 15 +/- 3 microg/l; Baker 3-4: 35 +/- 12 microg/l) (r2 = 0.73; p < 0.05). CONCLUSION: : In this study, serum hyaluronan levels were significantly elevated in patients with constrictive fibrosis after breast augmentation, and there was a positive correlation with the stage of capsular contracture. Serum hyaluronan concentration may help in defining patients at risk for capsular fibrosis. If treatment with new drugs can be started as a preventive measure, it may be possible to reduce the rate of patients who require surgical intervention.

Recurrence of isolated unilateral temporalis muscle hypertrophy: case report.

A case of isolated unilateral temporalis muscle hypertrophy of unknown cause is presented. It had been treated surgically 10 years previously. The histologic workup showed normal muscle tissue. A year before, the patient had reported a slowly enlarging mass in the right temporal region next to the eye. The recurrence of temporalis muscle hypertrophy was idiopathic. It was managed using a combination of surgical treatment and botulinum toxin A injection.

Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: a preliminary report.

In 1998, the German Association of Plastic Surgeons started a new quality assurance program based on a standardized questionnaire to examine the tracer diagnosis "breast hypertrophy." The authors present the results of a pilot study evaluating 799 patients (mean age, 38 years). Breast reduction was performed as an inpatient procedure in 99% of patients. Mean weight reduction was 1,135 g (range, 140-3,870 g). The inverted-T scar technique was used in 45% of patients, the vertical scar technique in 52% of patients, and other techniques were restricted to 2% of patients. The selection of technique was based on the choice of the surgeon. The overall incidence of complications was 21.5%, and included predominantly wound dehiscence, without marked differences between the two techniques. Less than 10 years after the introduction of a new technique for breast reduction with reduced length of scar, it is now used as often as traditional methods.

[Guidelines and quality assurance in national and international practice in the area of plastic surgery]. / Leitlinien und Qualitätssicherung auf nationaler und internationaler Ebene in dem Gebiet Plastische Chirurgie.

Multiple quality assurance activities in the German plastic surgery association are outlined, such as the collection of structural data, inspections of units by expert commissions, tracer diagnosis, continuous evaluation of health outcome by patient questionnaire, training programs for residents and a credit point system for congress activities. Interdisciplinary groups are formed for internal quality management within hospitals. EBOPRAS is responsible for accreditation of training centers and the European (Union) Board certification. EQUAM activities aim for quality improvement of biomaterials. Quality management activities within the International Confederation of Plastic, Reconstructive and Aesthetic Surgery concentrate on the definition of minimal requirements for training units and the establishment of a quality management philosophy.