Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique.

Carbon dioxide (CO2) laser blepharoplasty with orbicularis oculi muscle tightening and periorbital skin resurfacing is a safe procedure that produces excellent aesthetic results and diminishes the occurrence of complications associated with skin and muscle resection in the lower lid, particularly permanent scleral show and ectropion. The authors present a review of 196 cases of carbon dioxide laser blepharoplasty and periocular laser skin resurfacing performed at their center from April of 1994 to September of 1998. Of these cases, 113 patients underwent four-lid blepharoplasty, 59 underwent upper lid blepharoplasty only, and 24 underwent lower lid blepharoplasty only. Prophylactic lateral canthopexy was performed in 24 patients. Concomitant procedures (brow lift/rhytidectomy/rhinoplasty) were performed in 92 patients. The carbon dioxide laser blepharoplasty procedure resulted in no injuries to the globe, cornea, or eyelashes. Combined with laser tightening of the orbicularis oculi muscle and septum and periocular skin resurfacing, the transconjunctival approach to lower blepharoplasty preserves lower lid skin and muscle. Elimination of the traditional scalpel skin/muscle flap procedure results in a dramatically lower complication rate, particularly with regard to permanent ectropion and scleral show. Laser shrinkage of the orbicularis muscle and septum through the transconjunctival incision enables the correction of muscle aging changes such as orbicularis hypertrophy and malar festoons. The addition of periocular resurfacing enables the correction of skin aging changes of the eyelid that are not addressed by traditional scalpel blepharoplasty. In addition, lateral canthopexy constitutes an important adjunct to the laser blepharoplasty procedure for the correction of lower lid canthal laxity.

Tubulation repair of peripheral nerves in the rat using an inside-out intestine sleeve.

This study compared the regeneration of peripheral nerves in the Sprague-Dawley rat through a nerve guide prepared from rat small intestine to nerve regeneration using a standard autogenous nerve-graft repair strategy. In one experimental group (n = 15), inside-out rat intestine sleeves were used as nerve guides to bridge a 10-mm defect created in the right sciatic nerve. These nerve guides were prepared by harvesting 14-mm segments of small intestine from Sprague-Dawley rats not otherwise used in the study. The segments were turned inside-out to expose the serosa as the lumen of the guide, and transected nerve stumps were secured 2 mm into the guide on each end with an epineural-to-guide stitch. The control group (n = 15) had an identical gap repaired with a standard autologous nerve graft. Five animals from each group were sacrificed at 4, 8, and 12 weeks. The extent of axonal regeneration was assessed by axon-counting, retrograde tracer analysis, electromyography, and qualitative histologic assessment. The inside-out intestine sleeve group exhibited faster conduction velocities and greater axon counts when compared to the autologous nerve-graft controls. These novel nerve guides proved simple to manufacture and were completely absorbed by 12 weeks.

Hyaluronic acid enhances peripheral nerve regeneration in vivo.

Hyaluronic acid has been shown to enhance peripheral nerve regeneration in vitro. It has been proposed that, during the fibrin matrix phase of regeneration, hyaluronic acid organizes the extracellular matrix into a hydrated open lattice, thereby facilitating migration of the regenerating axons. Hyaluronic acid solutions and saline control solutions were injected into a nerve guide spanning a transected gap in the sciatic nerve of Sprague-Dawley rats (five in each group). Nerve conduction velocities were measured at 4 weeks by electromyography (EMG) before sacrifice of the animals. These studies demonstrated increased conduction velocities in the hyaluronic acid group compared with control animals (P = 0.006). After the animals were sacrificed, regenerated axon cables were quantified histologically, and axon branching was delineated by retrograde tracer analysis. In addition, the hyaluronic acid group showed an increase in myelinated axon counts at 4 weeks (P= 0.03). An increase in retrograde flow was demonstrated in the hyaluronic acid groups compared with animals receiving saline solution.

Skin tightening effects of the ultrapulse CO2 laser.

This study analyzed the skin tightening or contracture effect of the Ultrapulse carbon dioxide (CO2) laser on the skin of hairless guinea pigs by light and electron microscopic, histologic, and tensiometric evaluations. Two 2 X 2 cm squares of back skin were precision tattooed on each of the animals in the study (n = 12). One square served as the control, and the other square was used as experimental skin. The experimental skin was treated with three passes of the CO2 laser at 500 mJ and 5 W using a 3-mm collimated hand-piece. Skin specimens from three animals were analyzed at 1, 4, 8, and 12 weeks. After three passes, the length of the square was reduced by 27 percent, and the width was reduced by 40 percent. Over the next 12 weeks, as the animals grew, the dimensions of the control areas also increased. The laser-treated areas continued to maintain their contracted dimensions, however. By the 12th week, the laser-treated areas were 28.35 percent shorter in length and 15.5 percent shorter in width than the control areas. Histologic examination demonstrated a significantly higher content of collagen in the reticular layer, which was more compact than that of the normal skin. Electron microscopy revealed that the laser had induced shortening of the collagen fibers (7.45 percent; p = 0.026), which persisted beyond the 12th week. Laser treatment did not significantly alter the tensile strength of the skin, although, at the 8th week, the treated areas had a slightly higher tensile strength.

Transcutaneous access to retrograde axonal flow.

Transcutaneous entry of fluorescent tracer and subsequent retrograde neuronal transport achieved by the use of dimethyl sulfoxide (DMSO) as a vehicle fluorescent dye dissolved in DMSO and applied topically to the hind limb of rats was found in corresponding dorsal root ganglia; aqueous absorption of tracer dye by neuronal tissue was not demonstrated. This example of transcutaneous access and retrograde transport may have implications as to the entry of various toxins, viruses, chemicals, and therapeutic agents to the nervous system.

Complications of laser resurfacing.

The laser demonstrates significant benefits over traditional resurfacing and incisional techniques. Serious complications of laser surgery are easily avoidable provided practitioners and support staff receive proper education and training. The following article describes the more common complications of laser resurfacing followed by a brief discussion of avoidance techniques.

Inframammary crease ligament.

This study was designed to clarify and define the anatomic components of the inframammary crease in the female breast. Thirteen blunt dissections of the female breast were performed in cadavers and one dissection was performed in a living patient undergoing mastectomy. During the course of these dissections, a ligament was identified. This ligament originates from the fifth rib periosteum medially and the fascia between the fifth and sixth ribs laterally. The ligament inserts distally into the deep dermis of the inframammary skin fold. Histologic sections confirmed the proximal bony origin of this structure. In three cadavers, the contralateral breast was studied as it pertains to transaxillary subpectoral mammaplasty using the Agis-Dingman dissector (Padgett Instruments, Kansas City, Mo.). If too forceful a sweep were made in the inferior portion of the dissection, the ligament would be disrupted. This separation of the ligament from its origin could lead to the "double-bubble" phenomenon. Further, the horizontal position of this ligament determines the medial versus lateral fall of the ptotic breast.

Continuous alteration of the internal milieu of a nerve-guide chamber using an osmotic pump and internal exhaust system.

The use of non-neural conduits to span gaps in regenerating peripheral nerves has been noted in the literature for many years. An intriguing addition to this so-called entubulation repair method is the continuous instillation of neuronotrophic or growth factors into the lumen of the guide to bathe the regenerating nerve. A model is presented which uses an osmotic pump that supplies a constant, reproducible amount of solution into the lumen of a nerve guide without disrupting the regeneration process.

Hyaluronic acid through a new injectable nerve guide delivery system enhances peripheral nerve regeneration in the rat.

The use of non-neural conduits to bridge gaps in peripheral nerves has been noted in the literature for many years. A logical extension of this concept is the introduction of neurotrophic or growth promoting factors into the lumen. We present here an injectable nerve guide that allows percutaneous access to the microenvironment of the regenerating peripheral nerve within the guide's lumen. Hyaluronic acid, a compound associated with decreased scarring and improved fibrin matrix formation, is added sequentially to the regenerating peripheral rat sciatic nerve via this injectable nerve guide. Assessment of nerve regeneration and reinnervation shows better conduction velocity, higher axon counts, and a trend toward earlier myelination with hyaluronic acid compared with saline. This work not only implies hyaluronic acid's role as an agent that aids nerve growth but also describes a new tool that allows percutaneous access to the milieu of a regenerating nerve.

Inside-out vein graft repair compared with nerve grafting for nerve regeneration in rats.

The inside-out vein graft is a vein conduit pulled through itself to invert the normal orientation and place the adventitial layer within the lumen of the conduit. Our study compares regeneration of peripheral nerves in the rat through two conduits: inside-out graft of the jugular vein and autogenous nerve graft. In 10 rats, the right jugular vein was harvested, turned inside out, and used to bridge a 10 mm defect created in the right sciatic nerve. The 10 mm nerve segment from the right was then used as a standard nerve graft to bridge a 10 mm gap created in the left sciatic nerve. Rats were sacrificed at 8 and 12 weeks. Regeneration on the inside-out vein graft side showed superior functional results (faster conduction velocities) and improved histological results (greater axon counts) compared with the nerve grafted side. We feel the adventitial surface of the wall of the vein promotes nerve regeneration by providing an environment rich with collagen, laminin, and Schwann cells and promotes increased vascularization of the new nerve.

Nipple placement in simple mastectomy with free nipple grafting for severe gynecomastia.

Severe gynecomastia with excessive skin is difficult to treat by only periareolar excision or suction-assisted lipectomy or both. In these patients, total mastectomy and free nipple grafting may be the best option. Placement of the nipple, however, has been arbitrary. With use of 20 "aesthetically perfect" men as models, standard nipple distances were identified. The average sternal notch-to-nipple measurement was 21 cm. In addition, two consistent ratios were identified. The nipple plane was located 0.33 times the distance from the sternal notch to the pubis, and the internipple distance was 0.23 times the chest circumference. With use of preoperatively obtained measurements of the sternal notch to pubis and chest circumference, accurate nipple placement can be accomplished.

Normal sensation of the human face and neck.

A total of 116 adult volunteers were studied to determine normal values for static two-point discrimination and sensation of pressure of the head and neck. Thirteen regions of the head and neck corresponding to major sensory innervation were examined bilaterally for static two-point discrimination with the Mackinnon-Dellon Disk-Criminator and for sensation of pressure with Semmes-Weinstein monofilaments. Perception of two-point discrimination improved from lateral and posterior areas (17 to 25 mm) to the midline toward the lips (3 to 7 mm). Semmes-Weinstein monofilaments proved inadequate in determining sensitivity to cutaneous pressure because of low thresholds in the face and neck. Static two-point discrimination is a reliably reproducible method for assessing sensation of the face and neck.

Immunocytochemistry of skeletal muscle basal lamina grafts in nerve regeneration.

The influence on nerve regeneration of the extracellular matrix glycoprotein laminin was studied after sciatic nerve transection in 90 outbred Sprague-Dawley rats. Nerve regeneration through basal lamina grafts was comparable with regeneration through traditional nerve grafts across gaps up to 2.0 cm in length. True axonal regeneration rather than axonal branching was demonstrated by retrograde horseradish peroxidase labeling of nerve cables. Pretreatment of basal lamina grafts with antilaminin antibodies reduced the total number of regenerated axons by 90 percent with a significant decrease of nerve conduction velocity and a significant impairment of walking track patterns. The basement membrane glycoprotein laminin serves a critical role in the regeneration of peripheral nerves through basal lamina grafts.

Total versus partial musculofascial coverage for steroid-containing double-lumen breast implants in augmentation mammaplasty.

The use of intraluminal steroids in double-lumen breast implants is effective in preventing fibrous capsular contraction around the implant. This technique has not been accepted widely, however, and remains controversial primarily because steroid-related complications, including extrusion, late inferior migration, and atrophy of the skin, have been associated with their use. This nonrandomized retrospective study of 76 patients (146 breasts) who underwent submuscular augmentation of the breast through inframammary and periareolar incisions compares results after total musculofascial coverage of the implant with partial muscle coverage of the implant. In patients with partial muscle coverage of the implant, 7.8% steroid-related complications were observed. In the group with total musculofascial coverage of the implant, no steroid-related complications and no symptomatic contractions of the capsule were observed. Our study suggests that total musculofascial coverage provides a statistically significant margin of protection from steroid-related complications compared with techniques using only partial muscle coverage of the implant in patients who underwent cosmetic augmentation mammaplasty.

Inside-out vein graft promotes improved nerve regeneration in rats.

Vein grafts have been used both experimentally and clinically to bridge gaps in peripheral nerves. This study describes a modification of the vein graft technique in which vein graft conduits are pulled inside-out before anastomosis with proximal and distal nerve stumps. This technique creates an autogenous vein conduit with the collagen-rich adventitial surface exposed to the regenerating axons. The inside-out technique is a fast and simple modification of the standard vein graft technique and produces an accelerated rate of nerve regeneration and significantly earlier myelination compared with the results obtained from the use of polyethylene nerve guides and standard vein graft conduits.

Sleeve insertion and collagen coating improve nerve regeneration through vein conduits.

Vein grafts have been used as conduits for nerve regeneration in both research protocols and clinical situations. Results to date are encouraging. This study investigated several variations in the vein graft model in an attempt to enhance peripheral nerve regeneration. Results showed that the jugular vein, with an improved suture technique made possible by its larger diameter, is superior to the femoral vein as a conduit for regeneration of the sciatic nerve in the rat. The larger diameter of the jugular vein and its lack of valves provided less hinderance to regenerating axons. Results also showed that coating the luminal epithelium of the jugular vein with type I collagen gel greatly improved regeneration.

Common complications of wound healing. Prevention and management.

The culmination of any operation is a healed wound. Failure of a wound to heal increases time spent in the hospital and the expense, and may start a cascade of progressive complications. Thus, it is important to optimize as many factors as possible before operation and to have the knowledge and resources to deal with wound problems should they occur. This approach involves understanding basic wound healing with its multiple factors, including nutrition, and knowing how to deal with potential adverse factors in wound healing, such as chemotherapy, corticosteroids, and radiation.

Single-dose electron beam irradiation in treatment and prevention of keloids and hypertrophic scars.

Low megavolt electron beam irradiation was used on 354 sites in 199 patients at the Lahey Clinic either for palliation of symptomatic hypertrophic scars or as post-operative irradiation in an attempt to prevent formation or recurrence of hypertrophic scars. Electron energies used ranged from 1.5 to 3.5 MeV. The median age of the 59 male patients was 22 years and of the 140 female patients, 35 years. All patients had at least one follow-up visit, and the median follow-up was 35 months. Of the 294 sites treated for the first time, 272 (93%) were irradiated with a single fraction with a skin dose ranging from 2 to 20 Gy. Of the 85 sites in 63 patients without excision of symptomatic hypertrophic scars, single-dose electron beam irradiation was of clinically significant value in only 41 sites (48%). No patients have been treated without surgical excision since 1973. Because of a history of formation of hypertrophic scars elsewhere in the body, 13 patients with 19 incisions were treated prophylactically after operation for other diseases. All sites were irradiated with single doses ranging from 8 to 20 Gy, and hypertrophic scars did not subsequently develop in any patient. Altogether, 119 patients with 174 sites were irradiated after surgical excision of hypertrophic scars to prevent recurrence; 168 sites (97%) received single-fraction irradiation, and 161 received a dose of 8 Gy or greater, up to 15 Gy. No statistically significant differences were observed in complete success rates, ranging from 82 to 90% with doses of 9 Gy or greater.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhancement of peripheral nerve regeneration.

Numerous factors external to the nerve cell can support and enhance nerve regeneration after injury. The definition of these factors and the elucidation of their mechanisms of action are the central goals of much contemporary neurobiologic research. This research will hopefully lead to the discovery of factors that will prove to be therapeutically beneficial for patients with either peripheral nervous system (PNS) injury or central nervous system (CNS) injury. This article reviews the biology of the regeneration response of the nerve to injury and discusses many of the factors that enhance nerve growth. Finally, the nerve guide or nerve regeneration chamber model for the evaluation of putative nerve regeneration enhancing agents in vivo is also discussed.