Mammary augmentation by cohesive silicone gel implants with anatomic shape: technical considerations.

Anatomically formed cohesive silicon gel implants for mammary augmentation or restoration were first introduced in 1993. They have been allowed for use in the most of European countries, but not in the Northern America for the past few years. These implants are appreciated by many patients, but they are still controversial, because the whole concept of treatment is different from the techniques used for implants filled with normal saline or liquid silicone. Cohesive gel implants can give us excellent results, but the margin for mistakes is near zero. Information about the new techniques necessary to use with these implants has so far been scarce. This paper gives detailed description of the preoperative preparations, the operation step-by-step, and the postoperative care for patients with the cohesive gel implants and is based on the four years experience with 440 patients. Our personal technique using the intracutaneous wound closure with totally buried resorbable suture and the implant of new design, with the marking string on the front and fixation plate on the posterior surface, is presented.

Lip enhancement: surgical alternatives and histologic aspects.

This study included 66 consecutive patients, 58 women and 8 men, who underwent 86 surgical procedures on the lips during 1989-1998. Lip enlargement was performed in 59 patients, and lip reduction was performed in 7 patients. Indications were purely aesthetic in 61 cases and reconstructive in 5 cases. The following surgical techniques were used for lip augmentation: implantation of crystal silicone, polyacrylamide hydrogel, Gore-Tex tubes, autologous fat, and dermis-fat graft. A new instrument originally designed by the author, the dermis-fat graft passer, significantly speeded up and facilitated execution of the latter procedure. Other operations included V-Y plasty, lip lifting by buffalo horn excision, lip lengthening by frenulum plasty, and lip reduction by wavy tangential excision. Eighty-six percent of patients could be followed up; the mean length of follow-up was 4.2 years. Use of silicone microparticles (Bioplastique) was abandoned because of the tendency for lumping. Polyacrylamide gel is promising because of its ease of use, and Gore-Tex tubes are promising because of their ability to create and accentuate the Cupid's bow form for the upper lip. However, these products are new, and follow-up studies with longer observation times are needed to reach definite conclusions. Of these studied methods, autologous fat transplant was found to be particularly useful for enlargement and restoration in cases of age-related atrophy of the lips and perioral tissues. Dermis-fat grafting was the most efficient, versatile, and reliable method of lip enlargement. Long-term survival of transplanted autologous tissues was confirmed by histologic studies of biopsy specimens.

Porous polyethylene implants for nasal reconstruction: clinical and histologic studies.

This paper describes a technique of using Medpor porous high-density polyethylene implants for nasal reconstruction and chin augmentation. This biocompatible material has been used successfully during the last decade for various applications in the reconstruction of the facial skeleton. Among its most frequent uses are repair of the orbital floor and reconstruction of the burned ear, which became standard methods at many centers. Relatively little experience is, at present, on hand concerning the use of porous polyethylene in reconstruction of the nasal framework. Twenty-three consecutive, difficult nasal reconstructions were performed using this method since 1996. Patients were followed up for from 1 to 3 years (mean, 2 years). The results were durable and stable over the time. Eight patients had saddle nose deformity and 15 had catastrophe noses, mostly referrals, previously operated on from one to four times. My aesthetic goals were correction of the depressed nasal dorsum, creation of an acceptable nasal dorsum in the thick and/or twisted noses, and tip elevation. For nasal applications Medpor is available as a strut or sheet. Its body, once implanted, becomes rapidly vascularized and both soft tissue ingrowth and collagen deposition occur. This was confirmed by the microscopic investigation of biopsies. One patient of Vietnamese origin had an aesthetically pleasing result, but her family refused to accept her westernized nose. This gave me a unique opportunity to study the whole Medpor implant 6 months after implantation. There were two complications, one small implant exposure and one low-virulent infection involving the nasal tip. Following revision and antibiotic treatment, both patients healed without sequel. All reconstructions were successful in restoring nasal aesthetics and function. Four patients underwent chin augmentations with an uneventful clinical course.

Ethnic profile of patients undergoing aesthetic rhinoplasty in Stockholm.

During 1985-1995 we performed 640 rhinoplasties in 578 patients. Five hundred eighteen of them were inhabitants of the Province of Stockholm, with a population of 1,708,502. The patients from the Stockholm area were analyzed and divided into subgroups depending on their ethnic origin. It was found that 272 (52%) of them were of Nordic descent, while 248 (48%) were born in and immigrated from non-Scandinavian countries. Among the latter, the largest group were 166 people of Middle Eastern extraction, who generally strived to reduce the size of their noses to the size similar to the average nose of the native Swedes. Middle Easterners were 17 times more prone to undergo aesthetic rhinoplasty than the ethnic Swedes (p < 0.001), whereas immigrants from the other Scandinavian countries had the same rhinoplasty frequency pattern as the natives. In the Slavic group females outnumbered males by the ratio 17:1. The large prevalence of patients of foreign extraction desiring alteration of their noses may reflect the assimilation difficulties and low tolerance of the society in accepting people with a foreign look or name, both in the private sector and in the job market. Psychological aspects of decision making by patients and medico-ethical aspects of decision making by surgeons are discussed.

Two methods of anesthesia for rhinoplasty in outpatient setting.

This retrospective study was designed with the aim to evaluate suitability of two methods of anesthesia: local anesthesia combined with sedation (midazolam + pethidine) or dissociative (midazolam + ketamine hydrochloride) anesthesia for performing rhinoplasties in an outpatient setting. During 1985-1994, we performed 516 rhinoplasties in 464 patients. Sedation and local anesthesia was used in 263, and dissociative and local anesthesia in 253 procedures. Both methods were well tolerated by the patients, no serious anesthetic complications were seen, and the clinical problems in connection with anesthesia were acceptably low. The use of sedation technique and dissociative anesthesia in combination with local anesthesia have both proved to be safe and effective anesthetic methods for performing rhinoplasty.

Long-term results of fat transplantation: clinical and histologic studies.

Nine cases of idiopathic constitutional subcutaneous fat atrophy in the cheek area during the years 1988-1992 were treated by the autologous transplantation of fat for purely aesthetic reasons. The fat graft suspension was obtained by the low-power aspiration technique with the use of a vacuum pump. The contour defects were initially overcorrected by approximately 50 percent more volume than required. The patients were followed up for 1.5 to 4.5 (mean, 3.5) years. Contrary to the experience of others, only the partial resorption of the transplanted fat occurred. This result was verified by six biopsy specimens obtained in the time range of 7 to 36 months after transplantation. The additional injections of fat were not necessary. Delicate tissue handling and the small total amount of fat transplanted by careful distribution in the recipient tissues are probably the factors responsible for the long-lasting improvement in these patients. As an experiment, suction of fat under -0.5 atm and -0.95 atm was performed in five patients undergoing abdominal liposuction. Aspiration under maximum negative pressure caused partial breakage and vaporization of the fatty tissue. The diameter of the fat cells in the remaining beads of fat was in all five cases mechanically distended and thus was larger than in the lipocytes extracted at -0.5 atm.

Diagnostic criteria of vascular lesions in the face.

Diagnostic criteria of vascular lesions in the face were studied in a series of 57 patients investigated and treated during the years 1980 to 1990. Twenty-eight had hemangiomas and malformations, and 29 had telangiectasia. At present, the histological diagnoses are most commonly used to describe vascular lesions, but unfortunately this gives little idea of the actual appearance of the lesion. In the present study, the clinical appearance was compared and correlated with the findings at the time of surgery, with the angiographs, and with the histological diagnosis. An attempt was undertaken to coordinate the accepted clinical, microscopic, and angiographic classifications with our own results. Based on the modern concepts of pathology of angiogenesis and the conclusions drawn from our present investigation, the "new," unifying classification of vascular lesions was compiled. This classification is presented in the form of a diagram.

Perioral dermabrasion: clinical and experimental studies.

From 1985 through 1989, 54 patients with wrinkles around the lips and in the chin area were treated by dermabrasion. Significant improvement, lasting longer than three years, was achieved using both types of abrading tool: the wire brush and the diamond fraise. The side effects of dermabrasion were permanent but very slight bleaching in 66% of the patients and formation of milia in less than 20%. The surgical technique is described in detail. Dermabrading tools were tested at different speeds on excess cheek skin at facelift. Histological examination showed that the diamond fraise left a smooth abraded surface and the wire brush left an uneven surface. EMLA cream, usually used for skin surface analgesia, was tested as an adjunct to anesthesia in dermabrasion. EMLA's analgesic performance alone was insufficient in the sensitive perioral region, but it elevated pain threshold and decreased the required amount of local anesthetic solution. Five types of dressing were used and the speed of epithelialization and postoperative comfort were compared. At present Vigilon is the most suitable dressing for dermabrasion. The main advantage of dermabrasion over the chemical peel is the absence of severe depigmentation.

Central (third) fat pad of the upper eyelid.

A clinical study on the surgical anatomy of the upper-eyelid fat pads was performed on 55 consecutive patients who underwent a blepharoplasty. It was confirmed that the periorbital fat is encapsulated in compartments and that the number of fat pads varies. In 56% of the cases there were two fat pads and in the 44% three fat pads in the upper eyelid. The third fat pad is anatomically and histologically an accessory medial extension of the lateral fat pad. However, for the sake of clarity, the term central fat pad of the upper eyelid is proposed as a denominator of this structure. The purpose of this article is to make the less experienced surgeons aware of variations in the configuration of the periorbital fat and to remind them that after two fat pads are removed from the upper eyelid there might still be a third.

Histologic investigation of vascular malformations of the face after transarterial embolization with ethibloc and other agents.

Twenty-one vascular malformations located in the facial area, 11 high-flow arteriovenous malformations and 10 slow-flow malformations, underwent combined treatment by embolization and later surgery. Embolization was performed simultaneously with superselective angiography of the branches of the external carotid artery. The new biodegradable fibrosing agent Ethibloc was used in 16 cases. Histologic examination of the surgical specimens confirmed the good target orientation by the transarterial injection of Ethibloc. Limitations of this technique are discussed. The agent proved to have thrombogenic and fibrogenic properties. Some of the vascular walls degenerated and ruptured following the embolization, but there were no instances of necrosis of interstitial tissue or skin. Embolization treatment of vascular malformations of the face was not curative, but it facilitated subsequent surgery in all examined cases.

S-flap: a method for reconstruction of sensibility on the finger pulp.

A two-staged procedure for reconstruction of sensibility on the critically important areas of the finger pulp is described. Sensation on the radial side of the index finger was reestablished by this method in five patients. Two of the patients regained normal sensation and three almost normal sensation on the contact area for pinch grip. The disadvantages of this operation are scars and some deformity of the natural contour of the pulp.

Thumb replantation or not?

Over a three-year period 14 consecutive cases of amputated thumbs, 10 complete and 4 incomplete, were replanted/revascularized. Eight thumbs (57%) survived. These cases were compared with a control group, in which replantation had failed or had not been attempted. The control group was chosen to be as similar as possible with respect to thumb amputation level, type of trauma, age, occupation and sex. Costs for hospital care, duration of sick leave and disability rate were calculated. Hand function was estimated as the ROM of the thumb, power of pinch and grip, two-point discrimination and ability to perform a standardized hand function test (Sollerman). It was concluded that replantation yields better functional and social results than alternative treatment of thumb amputation at similar costs.

Conservative and operative treatment of mallet finger.

One-hundred and thirty-five patients with mallet finger were treated and followed up at least 1 year after injury. Ninety-two patients with tendon rupture or chip fracture were treated by splinting, and 42 percent of them had a decreased range of motion, mostly of a minor degree, but only 18 percent stated complaints at the follow-up examination. The results of treatment in 43 patients with fracture were evaluated separately. In this group, 26 patients were operated on and the postoperative results were excellent in 58 percent, improved in 36 percent, and 8 percent ended with failure due to complications. Radiographic study showed bony union in 41 of 43 patients and resorption of the small fragment in 2 patients. The indications for conservative and operative treatment in the five different types of mallet finger are discussed.

Dislocated intra-articular fracture of the base of the fifth metacarpal: a clinical study of 23 patients.

Twenty-three patients with dislocated intrarticular fractures of the base of the fifth metacarpal were treated during the last 3 years in our department. This fracture characteristically occurs in young, active males, and the most frequent mechanism of this injury is axial force striking the metacarpal head, mostly in fist fights. In 8 patients, the fracture was caused by direct force hitting the base of the fifth metacarpal. Four certain fracture patterns are described. Operative treatment by open reduction and fixation with two Kirschner wires generally gave good results.

Cutaneous keratotic hemangioma.

Eight patients with developmental vascular tumours located on the volar side of the fingers are reported. The lesions clinically appeared as small vascular ectasias covered by an area of horny overgrowth. Microscopically they were mixed type hemangiomas with dominance of capillary-like elements, located in the epidermis, the dermis and the subcutis. The operative treatment by simple wedge excision was definite. Such lesions are described and named differently in the literature and the clinical and histological aspects of the differential diagnosis are discussed. We propose this entity to be named cutaneous keratotic hemangioma.

Vascular tumours of the hand.

The series comprises 74 patients with benign and 2 with malignant vascular tumours located in the upper extremity and treated at our hospital during the period 1962-80. In 9 instances the tumour was associated with skeletal hypertrophy of the involved extremity (Klippel-Trénaunay syndrome), whereas in another 7 patients a hypotrophy of the skeleton of the affected extremity was seen. Preoperative angiography was performed on 39 patients and characteristic features for the various types of tumours are discussed. Fifty-nine patients underwent surgical treatment. The observation period ranged from 1 to 18 years (mean 7 years). Twenty-six patients were cured, 19 improved, and 14 had recurrence. The cure rate was found to depend on the presence of arteriovenous shunts, the size of the tumour and its localization. Tumours with diameters of less than or equal to 2 cm located on the fingers or on the dorsum of the hand had the best prognosis.

Angiomatosis osteohypotrophica.

Based on a clinical and radiological study of seven patients, a syndrome consisting of congenital hemangiomas with arteriovenous fistulae engaging the soft tissues and the bones, and associated with shortening of the involved extremity, for which we suggest the name angiomatosis osteohypotrophica, is reported. Angioma, varicose veins and/or arteriovenous fistulae with resulting increase in limb have been widely known since the beginning of this century as Klippel-Trénaunay syndrome. Although the patients in this series present all other features of Klippel-Trénaunay syndrome, thinning and shortening of the long bones occurred, resulting in an overall reduction in limb length. Intraosseous hemangiomas in the metacarpal, respective metatarsal bones were common characteristic findings. The arteriograms undertaken in this study showed, in addition to hemangiomas, presence of arteriovenous shunts within the area of the tumour. Their influence on skeletal growth is discussed.