Reduction of face and neck laxity with anchored, barbed polypropylene sutures (Contour Threads).

The use of nonabsorbable sutures for lifting lax, aging skin is an increasingly popular option for cosmetic surgeons. Contour Thread (Surgical Specialties Corp.) are novel modified polypropylene sutures recently approved for this purpose by the US FDA. Design and technical modifications incorporated into this implant may reduce complications and limitations seen with previous, similar products. Early experience has been positive, although the durability of cosmetic effect and the potential for long-term complications remain to be seen.

Limited breast reduction by liposuction.

Traditionally, dermatologic surgeons have referred women seeking breast reduction to plastic surgeons for excisional mammoplasty. However, with recent advances in small cannula tumescent liposuction surgery, referral for such surgery may be unnecessary in some cases. Breast liposuction can reduce the size of female breasts that have essentially normal architecture with a minimum of visible scarring and an aesthetically pleasing result. We describe a method for liposuction reduction of female breasts that is safe, efficacious, and associated with high levels of patient satisfaction. Liposuction for breast reduction in women is an appropriate addition to the array of liposuction procedures available to the dermatologic surgeon.

Acne scarring: a classification system and review of treatment options.

Acne is a common condition experienced by up to 80% of people between 11 and 30 years of age and by up to 5% of older adults. In some patients, the severe inflammatory response to Propionibacterium acnes results in permanent, disfiguring scars. Over the past several decades, numerous descriptive terms and surgical techniques have been used to diagnose the types, and improve the appearance, of scarring in those persons with acne. We propose a descriptive, simple, universally applicable acne scar classification system that includes 3 scar types: icepick, rolling, and boxcar. We also have developed an effective treatment algorithm for reconstructing and improving the appearance of acne scars including punch excision, punch elevation, subcutaneous incision (Subcision), and laser skin resurfacing. This new classification system for acne scars enables the physician to more precisely identify scar subtypes. Once the scar type has been defined, appropriate and effective treatment protocols can be developed.

Liposuction and surgical recontouring of the neck: a retrospective analysis.

BACKGROUND: With the advent of tumescent liposuction, many advances in cosmetic surgery have occurred. Liposuction of excess adipose tissue from the submental area, jowls, and neck, along with cold steel surgery, has become an attractive alternative to the facelift for cervicomental aesthetic surgery. OBJECTIVE: To describe new techniques for tumescent neck liposuction, platysma repair, and subcutaneous musculoaponeurotic system plication, evaluate results, and assess complications with the procedures. METHODS: We reviewed the results of the last 35 patients who underwent neck liposuction, simultaneous platysma plication, subdermal CO2 laser resurfacing, and/or subcutaneous musculoaponeurotic system plication at our institution. RESULTS: Three of 35 patients (9%) experienced mild complications from the procedure. Two of the three complications (66%) were in patients who underwent subdermal and/or platysma laser resurfacing at the time of liposuction. Good to excellent results were achieved in 91% of patients and fair to good results were achieved in 9%. No major complications such as nerve injury occurred. CONCLUSION: Neck liposuction can be a safe method for facial rejuvenation when performed properly. Platysma repair, and in some cases subcutaneous musculoaponeurotic system plication, can further improve results when combined with the liposuction procedure.

Benign familial pemphigus (Hailey-Hailey disease). Treatment with the pulsed carbon dioxide laser.

BACKGROUND: Benign familial pemphigus (BFP) is a chronic blistering disease with significant morbidity. Surgical methods are often needed to control flares in difficult cases. OBJECTIVE: To describe the response of BFP to vaporization with a pulsed carbon dioxide (CO2) laser. METHODS: A 38-year-old woman with chest and axillary involvement unresponsive to conventional therapy was treated with the UltraPulse 5000 Laser (Coherent Medical Group, Palo Alto, CA). After active sites of BFP showed good response to treatment, we treated uninvolved skin of the left axilla to assess the efficacy of prophylactic therapy. RESULTS: Treatment of affected areas, except biopsy sites, resulted in clearing of active lesions after 1-2 weeks. We noted striking sparing of the treated areas from developing subsequent disease. The region that was later treated prophylactically has shown minor, asymptomatic recurrence of BFP in less than 5% of the area treated over an 18-month follow-up period. CONCLUSION: The pulsed carbon dioxide laser is a useful modality in treatment of BFP. In our patient, prophylactic treatment led to near complete eradication of disease in the treated area. A controlled, larger study is needed to confirm our results, and to determine optimal laser parameters. Long-term effects and duration of remission remain to be determined.

Connective tissue mast cells exhibit time-dependent degranulation heterogeneity.

Previous studies have identified two ultrastructurally distinct forms of mast cell (MC) degranulation following activation. Immunoglobulin E (IgE)-mediated reactions are characterized by a very rapid swelling and fusion of MC granules and abrupt mediator release. In certain chronic disease states (e.g., bullous pemphigoid), there is "piecemeal" degranulation with a more-gradual mediator release effected by microvesicular transport of "pieces" of granules to the cell surface. It is unclear whether these two degranulation patterns are determined by the different natures of the stimuli, heterogeneity among responding MC granules, or temporal factors. To investigate these issues, we have carried out electron microscopic studies with skin biopsies obtained from ragweed-sensitive subjects 15 and 30 s and 1, 3, 5, and 10 min after intradermal ragweed injection. "Anaphylactic"-type granule changes began by 15 s after ragweed injection and were complete by 5 min; unaffected granules were juxtaposed with granules that were swollen and fused. The remaining granules subsequently underwent changes in appearance similar to those seen in piecemeal degranulation. However, microvesicular transport of granule components to the surface was not observed. These findings indicate that skin MC changes in sites of IgE-mediated reactions include not only the typical very rapid anaphylactic degranulation but also a slower onset of gradual alteration of other granules, frequently within the same MC. These different patterns could reflect MC granule heterogeneity with attendant different responses to IgE-mediated stimuli.

Role of laminin in localization of human dermal mast cells.

Human connective tissue type mast cells (CTMC) are frequently located in close proximity to microvascular and neural basement membranes (BM). We have explored the interaction between human dermal connective tissue-type (chymase positive) mast cells and laminin, a component of BM. In this report, we document that normal CTMC express laminin receptors and are intimately associated with laminin of BM in vivo and pericellular laminin complexes in vitro. Upon degranulation in vitro, CTMC-laminin complexes dissociate and CTMC do not adhere to laminin substrates. In cutaneous mastocytosis/urticaria pigmentosa, CTMC do not express laminin receptors detectable by immunohistochemistry, and are frequently not in close association with laminin of vascular BM. These same features could be induced by degranulation of normal mast cells in organ culture. These findings indicate that CTMC-laminin interactions may be important determinants of mast cell localization in tissue compartments.

Extracellular localization of human connective tissue mast cell granule contents.

In early phases of cutaneous inflammation, connective tissue mast cell degranulation is associated with apparent secretion and externalization of immunoreactive chymotryptic serine proteinase. To determine whether this event is associated with structural evidence of granule externalization, we studied the sequential evolution of IgE-mediated hypersensitivity in vivo, as well as mast cell degranulation provoked by a variety of stimuli in cultured explants of human skin. By 1 min after intradermal antigen challenge with ragweed extract, mast cell degranulation was associated with apparent extrusion of intragranule constituents into the pericellular connective tissue. Similar features typified cultured skin explants exposed for 45 min to anti-IgE and other mast cell secretagogues (morphine sulfate, calcium ionophore A23187, compound 48/80, and substance P). Once externalized, granule constituents could be identified within the dermal matrix by their rounded contour and structural similarity to solubilized granule matrices remaining within actively secreting cells. These data indicate that externalization of connective tissue mast cell granule contents occurs early after secretagogue exposure, potentially accounting for infrequent documentation of this event in naturally occurring dermatoses. The ability to recognize externalized granule products at a morphologic level should facilitate the understanding of interactions between mast cell-derived mediators and target structures of the dermal microvasculature.

Computerized image analysis of full-hand touch plates: a method for quantification of surface bacteria on hands and the effect of antimicrobial agents.

A method is described for quantification of the bacterial flora on the hand surface. Computer-assisted image analysis of bacterial growth of large full-hand touch plates provides a quantifiable measure of the bacterial flora on the hand surface. Image analysis pixel intensity values showed a significant correlation (P less than 0.0001) with colony forming unit values determined by the glove juice method. Image analysis of impressions from hands treated with various antimicrobial agents in detergent bases showed that 4% chlorhexidine gluconate produces a 96% reduction after a 30 s washing and 98% reduction after a 3 min washing while 7.5% povidone-iodine and 1% triclosan produce a 77% and 70% reduction after 3 min respectively, and 70% isopropanol produces a 98% reduction after a 30 s wash.