Intermediate hair follicles: a new more clinically relevant model for hair growth investigations.

BACKGROUND: Alopecia causes widespread psychological distress, but is relatively poorly controlled. The development of new treatments is hampered by the lack of suitable human hair follicle models. Although intermediate and vellus hair follicles are the main clinical targets for pharmacological therapy, terminal hair follicles are more frequently studied as smaller hair follicles are more difficult to obtain. OBJECTIVES: This investigation was designed to quantify in vivo morphological and in vitro behavioural differences in organ culture between matched intermediate and terminal hair follicles, in order to develop a new clinically relevant model system. METHODS: Microdissected terminal and intermediate hair follicles, from the same individuals, were analysed morphometrically (250 follicles; five individuals), or observed and measured over 9 days of organ culture (210 follicles; six individuals). RESULTS: Intermediate hair follicles were less pigmented and smaller, penetrating less below the skin surface (mean +/- SEM) (2.59 +/- 0.07 vs. 3.52 +/- 0.10 mm; P = 0.02), with smaller fibre (0.03 +/- 0.002 vs. 0.07 +/- 0.002 mm), connective tissue sheath (0.24 +/- 0.01 mm vs. 0.33 +/- 0.01 mm), bulb (0.19 +/- 0.01 vs. 0.31 +/- 0.01 mm) and dermal papilla (0.06 +/- 0.002 vs. 0.12 +/- 0.01 mm) diameters (P < 0.001). Intermediate hair follicle bulbs appeared 'tubular', unlike their 'bulbous' terminal follicle counterparts. In organ culture they also grew more slowly (0.044 +/- 0.002 vs. 0.067 +/- 0.003 mm per day; P < 0.001), remained in anagen longer (84 +/- 0.03% vs. 74 +/- 0.03% at day 9; P = 0.012) and produced less hair fibre (0.36 +/- 0.02 vs. 0.50 +/- 0.03 mm; P < 0.001) than terminal follicles. CONCLUSIONS: Smaller intermediate hair follicles showed major morphological differences from terminal follicles in vivo and retained significant, biologically relevant differences in vitro in organ culture. Therefore, intermediate hair follicles offer a novel, exciting, more clinically relevant, albeit technically difficult, model for future investigations into hair growth. This should be particularly important for developing new therapies.

Re-visiting Luck's classification: a histological analysis of Dupuytren's disease.

Luck (1959) described a histological staging system for Dupuytren's disease, classifying the disease into three stages. Previous biochemical and immunochemical studies have detailed the decrease in type III/I collagen ratio with disease progression. Herovici (1963) described a histological stain that produced a differential red/purple and blue colour for type I and III collagen respectively. We stained 15 specimens of Dupuytren's disease and quantified the different collagen types in each using computer analysis. We found a corresponding decrease in the amount of type III collagen as a percentage of the total collagen with disease progression: stage I range 35-49% (mean 38%); stage 2 range 21-33% (mean 27%) and stage 3 range 11-19% (mean 14%). We propose a new staging system based on the relative amount of type III collagen, where stage 1: >35%, stage 2: >20% and <35%, and stage 3: <20%.

17beta-estradiol regulates the secretion of TGF-beta by cultured human dermal fibroblasts.

Estrogen plays an important role in skin homeostasis, as demonstrated by the changes seen in the skin of post-menopausal women, changes reversed by HRT. Estrogen also has a role in wound healing, since estrogen deficiency as occurs post-menopausally and in ovariectomised animals, is associated with a reduced rate of wound healing. Estrogen appears to modulate all phases of wound healing with effects on inflammatory cells, epithelialization, angiogenesis, extracellular matrix deposition and tissue remodelling. This study was designed to investigate the effects of 17beta-estradiol on cultured human dermal fibroblasts using an in vitro wound-healing assay. The end points investigated were cell migration, proliferation, total collagen secretion and active TGF-beta1 secretion. 17beta-estradiol significantly increased the migration and proliferation of cultured dermal fibroblasts following mechanical wounding, although the secretion of total soluble collagen was not altered. An increase in TGF-beta1 was demonstrated by unwounded confluent dermal fibroblast monolayers in response to 17beta-estradiol, but paradoxically, a decrease in the secretion of TGF-beta1 was demonstrated in the mechanically wounded dermal fibroblasts. These results identify human dermal fibroblasts as estrogen target cells and provide further evidence for a role by which estrogen regulates this particular cell type as part of the wound-healing process. However, the paradoxical nature of the effect of estrogen on TGF-beta1 secretion following mechanical wounding suggests that the cellular mechanism of action is complex. A greater understanding of the cell-specific action of estrogen may help to develop therapies that will improve cutaneous wound healing in the future.

The Bradford Burn Study: the epidemiology of burns presenting to an inner city emergency department.

OBJECTIVE: The Bradford Burn Study prospectively reviewed all burn attendances at a single emergency department in the UK over a 1 year period. The study reviewed the epidemiology, demographics and outcomes of all patients entered into the study. DESIGN AND SETTING: A 12 month prospective study of burn injuries attending an inner city emergency department serving a population of 1 million people. RESULTS: 460 patients were enrolled into the study. Average patient age was 22.7 years, male: female ratio was 1:1.4, and children <10 years of age accounted for 36% of the case mix. Asian patients accounted for 41% of all attendances; 85% of the cases in the study were accidental in nature, with scalds accounting for 52% of the injuries. Final outcomes were as follows: 54% of patients were reviewed by the emergency department physicians and only one of these patients ultimately needed skin grafting; 19% had follow-up by their primary care physicians; 12% were reviewed by plastic surgeons, and 5% were admitted; of those patients admitted, 16% needed surgery; only 12 patients (3%) were admitted to specialised burn units. CONCLUSIONS: Emergency departments manage patients with burns well, and referrals to plastic surgery departments are appropriate. The majority of burns can be prevented by addressing educational issues and vulnerable sections of the population.

Skin nodules after semipermanent cosmetic dermal filler.

The authors present what they believe is only the third reported incidence of orofacial granulomas after injection of semipermanent cosmetic filler.

Burn patterns of Asian ethnic minorities living in West Yorkshire, UK.

Whereas burn morbidity and mortality have been well studied among natives of Southeast Asia, few have studied the epidemiology of burn injury among UK Asian ethnic minority immigrants. A 1 year prospective study of all patients presenting with burns to Bradford Royal Infirmary was carried out. Four hundred and sixty patients were studied, 188 (41%) were Asian ethnic minorities. The average patient age was 17 years for the Asian group and 27 years for the non-Asian patients. Contact burns were responsible for 29% of injuries in Asian patients and 19% in the other group. Thirty-seven percent of contact burns in the Asian ethnic minority group were caused by hot irons. Eleven percent of Asian patients had treated their burn with inappropriate remedies including saiti, butter, and toothpaste. There were no significant differences between Asian and non-Asian patients in terms of large or deep burns, nor in mortality. Morbidity and mortality from burn injury among UK Asian patients and other groups in the UK are similar; however, a disproportionate number of Asian patients sustain smaller burns. Much of this is behaviour related, and it is hoped that through preventative measures a marked reduction in the number of Asian ethnic minority burns can be achieved.

Pentoxifylline inhibits mature burn scar fibroblasts in culture.

Fibroblasts are thought to be (in part) responsible for the persisting contractile forces that result in burn contractures. Using monolayer and fibroblast populated collagen lattice (FPCL) models we subjected burn scar fibroblasts to the anti-fibrinolytic agent Pentoxifylline (PFX) in an attempt to reduce proliferation and contraction of these cells. Fibroblasts were isolated from mature burn scars at reconstructive surgery. Fibroblasts were grown in monolayer or incorporated into FPCL's and exposed to PFX. Fibroblast numbers and FPCL surface areas were calculated using digital photography and image analysis. PFX showed a dose-dependent inhibition of contraction and reduced proliferation of burn scar fibroblasts. In monolayer, cell number proliferation was markedly reduced. FPCL's containing 0, 0.25, 0.5, 1, and 2 mg/ml of PFX had relative surface areas of 31, 40, 43, 59, and 85%, respectively. One and 2 mg/ml FPCL's contracted significantly less than controls (p < 0.0001). This is the first study to show the dose-dependent effects of Pentoxifylline on the proliferation and contraction of burn scar fibroblasts. This study suggests that Pentoxifylline has a direct effect on inhibiting burn scar fibroblasts. Further study of PFX on burn scars will provide opportunities to reduce burn scar contractures in vivo.

Cervical midline Z-plasty revision surgery for pseudoxanthoma elasticum.

A 30-year-old woman with known pseudoxanthoma elasticum was referred for surgical correction of extensive loose neck skin. She underwent a standard rhytidectomy, which produced minimal improvement. Revision surgery using a vertical elliptical skin excision, incorporating a Z-plasty was undertaken 3 months later and resulted in a satisfactory outcome.

The aesthetic implication of scar position in breast reconstruction.

In these enlightened times of patient involvement in operative planning, the patient has a much greater input into procedure selection, especially where several options are available. Breast reconstruction is a prime example of combined decision making, although options are still limited by pre-existing scars and previous treatment. In this study we eliminated all variables of reconstruction except the resulting scar pattern in an attempt to discover what was most acceptable to the patient. Various postoperative results, such as single scars and flaps, were mimicked unilaterally and bilaterally by drawing them on the same live subject. These photographic images were then formulated into a questionnaire and distributed to various female groups for scoring. Results show a preference for single-line horizontal scars in unilateral and bilateral reconstructions; scars that encroached the upper medial quadrant scored less well. The preferred flap reconstruction is also positioned horizontally, but in the lower pole. Overall, the preferred reconstruction in all groups was a single unilateral horizontal scar.

Video microsurgery: early experience with an alternative operating magnification system.

Since Nylen first used an operating microscope in 1921, its basic design has remained fundamentally unchanged. Microsurgical procedures are still performed while viewing the subject through binocular eyepieces. This article examines the potential to perform microsurgery using video technology, operating with a television monitor. The development of the videomicroscope is discussed together with its early trials. The results show the potential to perform simple microsurgical procedures while viewing the procedure in a two-dimensional format. The advantages and disadvantages of such a system are discussed, together with future implications.

Ten-year review of a prospective randomized controlled trial of textured versus smooth subglandular silicone gel breast implants.

Although textured silicone breast implants have been shown to reduce the incidence of capsular contracture, there is little evidence if this effect is maintained in the long term. It has been 10 years since the double-blind randomized trial in which 53 patients received either Mentor smooth (26) or textured silicone gel implants (27). Of the 14 patients who were not known to have developed a contracture in the smooth group, 11 were reviewed. Three had bilateral contractures. In the textured group, 18 of the 24 patients not known to have contractures were reviewed. None had developed contractures. At 10 years, the incidence of capsular contracture was 65 percent of patients with smooth implants (an increase of 6 percent on the 3-year results) and 11 percent for the textured implant patients (no change on the 3-year results). A database containing the details of 1100 patients reinforces these results by examining the differences in contracture rates of textured, smooth, and polyurethane-coated implants. The effect of submuscular placement on reducing contracture rates regardless of texturing is discussed, as is the apparent increase in capsular contracture in patients who smoke.

Recurrence of subglandular breast implant capsular contracture: anterior versus total capsulectomy.

The objective of this study was to determine whether the type of capsulectomy, anterior or total, affects the recurrence of capsular contracture around subglandular silicone-gel breast implants. A retrospective analysis was performed of patients who underwent either anterior or total capsulectomy for Baker grade 3 or 4 subglandular capsular contracture in our unit. All patients were invited to a review clinic where their capsular status was assessed. There were 100 anterior- disc capsulectomies in 60 patients between 1988 and 1997 and 99 total capsulectomies in 60 patients between 1990 and 1998. The follow-up in the former group was a median of 7 years and mean 6.9 years, compared with median 2.5 and mean 3.1 years in the latter group. Eighty-six percent of the implants removed from both groups at capsulectomy were smooth-walled gel-filled implants. Sixty-nine breasts in the anterior group received textured gel implants at capsulectomy; the remaining 31 received polyurethane-coated Meme implants. In the total capsulectomy group, all but two breasts (one patient) received textured gel implants. After review, the capsular status was known in 80 percent of the anterior and 92 percent of the total capsulectomy group. The review clinic found eight new contractures in five patients to have developed in the anterior compared with none in the total group. Recurrent contractures affected 50 percent of patients (46 percent of breasts) in the anterior and 11 percent of patients (10 percent of breasts) in the total capsulectomy group. Kaplan-Meier survival analysis was applied to the data. By including only patients who received textured gel implants at capsulectomy, the Logrank found a statistical difference between the two treatment groups (0.01 < p < 0.5). We believe that this study provides some evidence that total capsulectomy for subglandular silicone breast implant capsular contracture results in a lower capsular recurrence than anterior- disc capsulectomy. The pattern and risk of recurrence after total capsulectomy and exchange for a modern textured prosthesis appear to approach those following primary augmentation.

Silicone gel-filled breast implant integrity: a retrospective review of 478 consecutively explanted implants.

Concern has been expressed over the long-term integrity of silicone gel breast implants. There are no large series representing experience with these implants outside of the United States. A retrospective case note review of explanted silicone breast implants was performed; 478 implants have been explanted during the past 11 years and relate to the use of these devices since 1971. Loss of implant integrity was not simply related to its age in vivo. Failure was more likely with implants of the late 1970s and early 1980s (second generation) and with subpectoral placement. Implant failure was independent of capsular contracture as the indication for removal (p = 0.09). There is no evidence that the currently used textured silicone gel breast implants are subject to the same loss of integrity as previous examples of these devices. The life span of these implants, the first of which are approaching 10 years in vivo, is at present unknown. Information concerning the integrity of silicone gel breast implants is essential in the current climate for counseling of both new and old implant recipients.

Breast reconstruction by tissue expansion. A retrospective technical review of 197 two-stage delayed reconstructions following mastectomy for malignant breast disease in 189 patients.

Despite the advent of free tissue transfer, breast reconstruction by tissue expansion is an important technique in the armamentarium of the reconstructive breast surgeon. The concept is deceptively simple and yet in reality can produce difficult complications and poor results. A database was compiled of all the patients receiving tissue expanders and/or implants for cosmetic, congenital and reconstructive purposes between 1986 and 1998. 189 patients had 197 delayed two-stage tissue expansion breast reconstructions following mastectomies for malignant breast disease between 1986 and 1997. 103 breasts (52%) had two uncomplicated stages. The remainder had one or more complications, revisional procedures for complications or alterations to the reconstruction for size, position or shape. Overall each breast reconstruction required 2.9 procedures (range 2-9). The complications and additional procedures are discussed. In particular, capsular contracture of the definitive implant (12%) was related to implant type and not to the speed of tissue expansion or the degree or duration of over-expansion. Although 17% of patients received radiotherapy, none of those who developed contracture around the definitive implant had this adjuvant therapy, P< 0.05. Twelve reconstructions (6%) totally failed due to complications of which six underwent secondary flap reconstruction. Twenty-one patients have subsequently developed metastatic disease of which 15 have died to date. Breast reconstruction by tissue expansion is still an important technique. It should be used carefully and thoughtfully by surgeons trained to deal with any complications. Patients need to be carefully selected and counselled prior to undertaking this process.

Cellulite treatment: a myth or reality: a prospective randomized, controlled trial of two therapies, endermologie and aminophylline cream.

Cellulite is a common phenomenon that particularly affects the thighs and buttocks of women. Little scientific evidence exists to support any of the many advertised treatments for it. A total of 52 of 69 women, who were divided into three groups, completed a 12-week, randomized, controlled trial in which the effectiveness of two different treatments for cellulite was assessed. The patients acted as their own controls. The treatments investigated were twice-daily application of aminophylline cream and twice-weekly treatment with Endermologie ES1. Group 1 (double blind) received aminophylline to one thigh/buttock and a placebo cream to the other. Group 2 (singly blind) received Endermologie to one thigh/buttock. Group 3 received Endermologie to both sides and used the same cream regimen as group 1. Results were assessed subjectively by the patient and by clinical examination and photographic assessment by the surgeon (before and after the trial). Morphologic assessment included body mass index, thigh girth at two points, and thigh fat depth measurement by ultrasound. No statistical difference existed in measurements between legs for any of the treatment groups (paired t test, p > 0.4). The best subjective assessment, by the patients themselves, revealed that only 3 of 35 aminophylline-treated legs and 10 of 35 Endermologie-treated legs had their cellulite appearance improved. The authors do not believe that either of these two treatments is effective in improving the appearance of cellulite.

Plastic surgery and pseudoxanthoma elasticum.

Pseudoxanthoma elasticum is a cause of abnormal skin laxity. A case of lower face and neck skin laxity is presented with its treatment by cutaneous rhytidectomy.

Reduction of potential contamination of breast implants by the use of 'nipple shields'.

Forty-three breast implant operations in 25 patients were studied prospectively to determine the effectiveness of covering the nipple-areolar complex with an adhesive film dressing in preventing perioperative expression of bacteria from nipple ducts contaminating the operative field. One swab from the nipple after skin preparation and none of the swabs taken from the outer surface of the film dressing postoperatively yielded any bacterial growth. Fourteen breasts (33%) in 11 patients (44%) yielded bacterial growth from swabs under the film postoperatively. Six of 9 breasts (67%) in 5 patients who had capsulectomies had bacteria isolated from under the film postoperatively. Ten of 14 (71%) control breasts (no shields) in 6 of 7 patients (86%) had positive postoperative swabs. This study confirms the potential risk of bacterial contamination arising from nipple duct flora during intra-operative breast manipulation, and the effectiveness of a perioperative adhesive film placed over the nipple-areolar complex in preventing subclinical bacterial contamination of implanted breast prostheses.

Breast implants: a survey of cosmetic clinics.

The quality of information available to prospective cosmetic breast implant recipients in the private sector was assessed. Sixteen women telephoned 14 clinics requesting written information about breast implants and their safety. The information received varied enormously in quality. Of the purely cosmetic clinics offering information, it was generally of better quality and more consistent than private hospitals where accredited plastic surgeons operate. In the current climate of consumer choice and negative attention given to silicone breast implants by the media, more comprehensive information should be readily available to guide potential patients.