Shortened penis post penile prosthesis implantation treated with subcutaneous soft silicone penile implant: case report.

Penile prosthesis surgery for erectile dysfunction has the highest satisfaction rates among all treatment options but is often associated with subjective and objective loss of penile length and girth following surgery. To present a novel technique using a subcutaneous soft silicone implant for reversal of penile shortening and narrowing after prosthesis surgery, with additional gains in overall penile length and girth. Nine patients were treated with the insertion of a subcutaneous soft silicone penile implant. All patients had previously reported a loss in penile length (0.5-2 cm), and seven of nine patients also reported a loss in penile girth (0.5-2.6 cm) after penile prosthesis surgery. During a follow-up period of 4-24 months, penile length and girth measurements showed a mean increase in length of 2.4 cm (±0.75 cm) and a mean increase in girth of 3.4 cm (±0.94 cm). The additional insertion of a subcutaneous soft silicone implant in patients with decreased penile length and girth after penile prosthesis surgery is an effective treatment option that provides reversal of lost penile length and girth.

[Complications after dermal fillers and their treatment]. / Komplikationen nach Faltenunterspritzung und ihre Behandlung.

All dermal fillers are associated with the risk of both early and late complications. Early side effects such as swelling, redness, and bruising occur after intradermal or subdermal injections. The patient has to be aware of these risks and be prepared to accept them. Adverse events that last longer than 2 weeks can be attributable to technical shortcomings (e.g., the implantation of a long-lasting filler substance was too superficial). Such adverse events can be treated with intradermal 5-fluorouracil and steroid injections, vascular lasers, or intense pulsed light, and later with dermabrasion or shaving. Late adverse events also include immunological phenomena such as late-onset allergy and non-allergic foreign body granulomas. Both react well to intralesional steroid injections, which often have to be repeated to establish the right dose. Surgical excisions should remain the last option and are indicated for hard lumps in the lips and visible hard nodules or hard granulomas in the subcutaneous fat.

A classification of facial wrinkles.

An increasing number of injectable filler materials for facial wrinkles and folds points to the need for objective measurements of their effectiveness. Patient satisfaction is the goal, but proof of the value of a particular product requires objective measurement. A wrinkle assessment scale was developed as a simple tool for use by plastic surgeons, dermatologists, and aesthetic surgeons who want to assess the changes resulting from injecting filler materials in their patients. By correlating the grade of the wrinkle in the reference photographs with the wrinkle in a patient's face, a classification of 0 to 5 is assigned. Reliability of the scale was assessed by "live" judgment of 76 wrinkles by nine observers. The same rating was given to 92.7 percent of all wrinkles. In a second trial, photographs from 130 wrinkles were presented to eight observers who rated 89.4 percent of all wrinkles equally. A significant correlation of 87 percent was found between subjective ratings and objective wrinkle depth measured by profilometry on 40 silicone impressions. Manufacturers, monitors of clinical trials, health authorities, and most important, patients will benefit from objective data on current and new injectable materials.

[Reconstruction of severe facial defects due to noma]. / Die Rekonstruktion schwerer Gesichtsdefekte nach Noma-Erkrankung.

Noma is an ulcerative-necrotizing gingivo-stomatitis eventually leading to severe destruction of the midface, including lips and cheek, maxilla/mandible, nose and rarely the orbit. The defects are usually unilateral. Children from economically underdeveloped countries are predominantly affected. Medically untreated the disease has a high mortality rate, which can be dramatically lowered by adequate antibiotic therapy started in time. Predisposing factors include malnourishment, immunosuppression, and poor oral hygiene. Forty-eight noma patients were surgically treated in Sokoto, Nigeria during October 1997 by an Interplast Germany team sponsored by AWD Stiftung Kinderhilfe. Interdisciplinary surgical strategies and results, e.g. ankylosis release, local flap coverage and 12 pedicled musculocutaneous latissimus dorsi island flaps, as well as a noma classification (NOMAC), are presented.

The resection of gastrocnemius muscles in aesthetically disturbing calf hypertrophy.

In some patients, oversized calves lead to mental distress and avoidance of certain social activities. They hide their legs in pants and seek medical advice. If the thickness of the subcutaneous fat is normal and cannot be diminished by liposuction, the oversized calves are caused by pure muscle hypertrophy. Using the gastrocnemius for muscle flaps in covering knee defects does not impair the function of the patient's leg; therefore, resection of the total gastrocnemius muscle for aesthetic calf reduction was performed in 15 consecutive patients without any lasting impairment with stability or sports activities. The patient was placed in a prone position, and the muscles were bluntly freed and pulled through two incisions of 5-cm length in the hollow of the knee and above the Achilles tendon. The resected muscles weighed between 410 and 810 g each. In two patients, the sural nerve was stretched or cut during the operation. The consequent numbness of the lateral ankle and sole persisted for 9 and 13 months, respectively. All 15 patients were satisfied with the results; none complained of lack of stability or insecurity in walking; and all became active in sports or changed their dress habits.

PMMA-Microspheres (Artecoll) for long-lasting correction of wrinkles: refinements and statistical results.

The corium is diminished to about half of its thickness in skin defects and wrinkles. All biological materials that increase the thickness of the corium are resorbed within a certain time. Therefore, a lasting effect can be achieved only with nonresorbable synthetic substances. Artecoll consists of microspheres of 30-40 microm in diameter, of exceptional surface smoothness, purity, and homogeneity related to PMMA. These microspheres are suspended in atelocollagen which serves as a vehicle for subdermal implantation. Due to its smooth surface and consequential lack of electrical charges, each single microsphere is immediately encapsulated with the patient's own collagen fibers, thus preventing dislocation. Within 3 months, collagen (making up 75% of Artecoll) is replaced by the body's own connective tissue. The microspheres (25% of Artecoll) serve merely as a stimulus to the fibroblasts. Indications for Artecoll are all facial folds, lip- and philtrum augmentation, chin- and malar augmentation, dark-shadowed eyelids, enophthalmos, bony defects in face and hands, nipple reconstruction and augmentation, and urinary incontinence. Questionnaires were sent to all patients who had received Artecoll in 1993 and 1994. Of a total of 950 questionnaires sent, 515 were returned by September 1995. Satisfaction was rated "very good" in 29%, "good" in 38%, "satisfactory" in 23%, and "no difference" in 8% of the patients. The question, "Would you repeat the treatment again?" was answered by 91% of the patients with "yes." The overall complication rate was 3%. Strictly subdermal implantation will prevent longer lasting redness or visibility of the Artecoll.

Elevated levels of testosterone receptors in keloid tissue: an experimental investigation.

Testosterone-binding receptor protein analyses were performed in keloids of 24 patients. According to their clinical appearance (hyperemia, pain, rapid growth, etc.), the lesions were subdivided into regions of minor and major clinical keloid activity. Biopsies were taken from active and inactive parts of the keloids, respectively, as well as from normal adjacent skin. The mean receptor amount in femtomoles per milligrams of tissue was 0.046 for active (SD = 0.037), 0.038 for inactive keloidal lesions (SD = 0.032), and 0.012 for normal skin. The corresponding receptor amount per microgram of DNA was 3.356 fmol (SD = 2.171) for active, 2.077 fmol (SD = 1.427) for inactive keloidal, and 1.010 fmol (SD = 1.190) for normal tissue. Statistical evaluation was performed using a two-way analysis of variance, with the two factors being individual subject and type of tissue. When differences were found, then Tukey's comparison was done to assess where those differences were. Comparisons of the receptor amount per milligram of tissue significant at the 0.05 level revealed significant differences between active keloid tissue and normal skin tissue and inactive and normal tissue (p < 0.01) respectively, while different receptor amount per microgram of DNA was significant between active and inactive and active and normal tissue (p < 0.01). These data suggest that elevated androgen receptor levels exist in clinical active keloid tissue and that possible therapeutic means might include topical antiandrogen therapy.

The tuberous breast deformity: classification and treatment.

To date there are many descriptive terms for the tuberous breast deformity but there is no widely accepted nomenclature. A retrospective study was undertaken of 68 tuberous breasts and the operative corrections performed. The deformities were classified into four types. Type I (hypoplasia of the lower medial quadrant), type II (hypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region), type III (hypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar region) and type IV (severe breast constriction, minimal breast base). Areolar prolapse, usually regarded as a major symptom, was only found in 30 (44%) deformed breasts. Postoperative review of 51 breasts in 31 patients showed that type I cases treated by reduction mammaplasty of adequately sized breasts or augmentation of hypoplastic breasts had excellent results. These procedures with additional spreading of the breast tissue in type II deformities give good results. Severe cases (types III and IV) treated by augmentation and tissue spreading procedures have an unsatisfactory shape and have a 'second crease' deformity. For types III and IV, additional skin in the subareolar region by tissue expansion or flap procedures is necessary. There is no one method to correct 'the' tuberous breast but there are many procedures which should be used according to the type of deformity. The classification developed could end the confusion in nomenclature.

[Treatment of wrinkles by Artecoll implant and resurfacing with the CO2 laser]. / Faltenbehandlung durch Unterfütterung mit Artecoll und Resurfacing mit dem CO2-Laser.

In general, all biological materials are resorbed in places where they do not belong. Therefore, artificial substances have to be implanted under deep skin folds and skin defects in order to achieve a permanent skin augmentation. Artecoll, a suspension of polymethylmetcrylate (PMMA)-microspheres in collagen solution, has been proven, for more than 5 years, to underlay wrinkles effectively without noticeable side-effects. Small wrinkles around the eyes, the mouth and cheeks, however, have to be treated by dermabrasion, chemical peel or vaporization by CO2-laser. Using all three methods, the effectiveness depends on the depth of skin traumatisation. Resurfacing using the CO2-laser has the advantage of absolute precision, no bleeding, less swelling and faster healing-but still high costs.

PMMA microspheres (Artecoll) for skin and soft-tissue augmentation. Part II: Clinical investigations.

Artecoll is an injectable implant for long-lasting correction of wrinkles and other skin defects. Artecoll consists of fine polymethyl-methacrylate (PMMA) microspheres suspended 1:3 in a 3.5% collagen solution. The microspheres are characterized by exceptional surface smoothness, homogenicity, and purity. The size of the microspheres of 30-40 microns diameter is small enough to allow subdermal implantation using a 27-gauge needle. Phagocytosis and dislocation of the implant is prevented by fast encapsulation of each single microsphere with connective tissue. Increased scarring but no granuloma formation has been detected as is common with other injectable implants with irregular surfaces. The experience from more than 600 patients and a prospective study in 118 patients with 200 implantation sites were evaluated. The good early results have continued for 5 years. Of the patients evaluated, 89.5 percent were satisfied and would ask for the treatment again. The overall complication rate is very low, and prolonged redness or visible granules are due to implantations that are too superficial. Other applications in soft-tissue augmentation are discussed.

Free transplantation of fat autografts expanded by tissue expanders in rats.

Inguinal fat pads of 28 rats were expanded by tissue expanders for 10 days and transplanted to the back of the same animal. The non-expanded contralateral inguinal fat pads were also transplanted and served as controls. Histology showed that adipocytes lose their lipid droplets under mechanical pressure; the expanded adipocytes have an elongated contour with a central nucleus. By the end of the expansion period, the thickness of the fat pads had decreased by 53%. One week after transplantation, expanded fat grafts had regained their previous volume with little sign of necrosis. Among normal adipocytes numerous smaller cells, containing multiple vacuoles, were seen. In contrast, about 25% of the substance of the non-expanded control fat graft consisted of necrotic oil cysts. These findings indicate that pre-expanded fat grafts survive better.

[A three-year aid program for plastic surgery in Peshawar (Pakistan). Ongoing management of severely injured patients of the Afghanistan war: 1,528 large operations, 5,171 smaller interventions, 15,932 patients examined]. / Ein dreijähriges Hilfsprogramm für Plastische Chirurgie in Peshawar (Pakistan). Kontinuierliche Versorgung schwerverletzter Patienten des afghanischen Krieges: 1528 grosse Operationen, 5,171 kleinere Eingriffe, 15,932 untersuchte Patienten.

Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistan's Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.

Calf augmentation with new solid silicone implants.

Calf augmentation has been standardized by the use of banana-shaped silicone gel implants for almost 20 years. Capsule formation and resulting distignement, dislocation, gel bleeding, and implant rupture are rare but unpleasant complications. A new implant of solid silicone (McGhan, Santa Barbara, CA, USA) in the anatomical shape of one belly of the M. gastrocnemius placed subfascially appears to overcome these problems.

Effect of cortisone on capsular contracture in double-lumen breast implants: ten years' experience.

Two groups of patients are compared with respect to capsular contracture after insertion of silicone breast prostheses. Six hundred seventy four women received single-lumen gel prostheses and 700 received double-lumen prostheses with cortisone. The addition of 12.5 mg of prednisolone to double-lumen prostheses diminished capsular contracture (Baker II to IV) dramatically; in patients with simple augmentation from 19% to 4.9%, in patients with subcutaneous mastectomy from 54% to 14.9%, and in patients with breast reconstruction from 64% to 24.4%. The use of double-lumen implants has three distinct advantages: (1) There is no bleeding and therefore no contact of the body with the silicone gel. (2) There is no danger of ruptured implants, even if the outer shell shows leakage. (3) If prednisolone is administered, capsular contracture is prevented to a significant degree.

[Siliconoma and rheumatic symptoms--a familial and a questionable complication of silicone implantation]. / Silikonome und rheumatische Symptomatik--eine bekannte und eine fragliche Komplikation von Silikonimplantaten.

Ruptured silicone-gel filled implants after breast augmentation or reconstruction may cause siliconomas. These lesions frequently develop years later and should be surgically excised. Since the use of modern double lumen implants they do not occur anymore. The possibility of a correlation between silicone implants and the incidence of rheumatologic disorders is critically evaluated by case reports from the world literature. Up to now, no statistically significant cumulation of these disorders in women with silicone implants can be observed.