Serial suction lipectomy.

Serial suction lipectomy is a safe method whereby larger areas and larger amounts of subcutaneous fat can be removed in several subsequent steps to minimize transfusion, minimize hospitalization, and maximize the improved health and safety of our patients. Six weeks should elapse between major resections, and a maximum of 2000 cc can be removed at one time unless transfusion is available.

Transplantation of purified autologous fat: a 3-year follow-up is disappointing.

The idea of autologous fat microtransplants has recently resurfaced because of interest by the press. Past experiments have shown that small amounts of fat may be transplanted with an expected survival rate between 10 and 50 percent without ectodermis. A great fund of knowledge exists showing that skin grafts will survive quite dependably if their thickness is up to about 0.0020 inch. For the first week or so, they live by diffusion and inosculation, and then neovascularization enables them to continue viability. I have developed a technique whereby fat is harvested through a blunt cannula with minimal vacuum to prevent explosion of the cellular fat globules. Fibrin and cellular debris are removed, and the fat globules are separated from the free fat, blood, and other constituents of the aspirate. Individual, free-floating 1- to 3-mm adipose fragments are then suspended in nutrient solution and injected through an 18-gauge needle. Multiple radial pathways, with each fat segment being separated from the other by host tissue, maximizes the host-prosthesis interface and the possibility for exchange of nutrients. I have attempted this procedure in more than 100 patients with widely varying results. In acne pits of the face, no significant improvement could be noted 6 weeks after injection. For the first few weeks, a near-perfect result was obtained, but none of these transplants in scarred areas of this kind have been of benefit. Injection of 10 to 50 cc in other areas has resulted in some cells (perhaps 10 percent) surviving over 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Rate and incidence of capsular contracture: a comparison of smooth and textured silicone double-lumen breast prostheses.

Capsular contracture results in dissatisfaction and deformity among the 2 million women who have had silicone implants. The literature describes contracture rates as high as 74 percent. I present a comparison of rates and incidences of contracture in patients augmented with smooth and textured double-lumen silicone implants. A total of 165 "smooth" and 63 "textured" implant patients were included in this study, which spans 12 years, 1978-1990. All patients underwent bilateral aesthetic augmentation performed by the same surgeon. Of the 165 smooth implant patients, 74 (44.8 percent) experienced contractures requiring treatment. Of the 63 textured implant patients, 3 (4.8 percent) previous contracture patients experienced sudden fibrosis within 3 months. All others remained soft. It appears that deeply textured silicone surfaces delay or decrease the rate and incidence of clinical capsular contracture, at least for 2 years.

Textured surface, nonsilicone gel breast implants: four years' clinical outcome.

Since the development of smooth silicone breast implants in 1962, more than 1 million women throughout the world have opted for breast augmentation surgery. Although initially successful, smooth implants are prone to develop surrounding scar capsules that may harden and contract, resulting in discomfort, weakening of the shell with rupture, asymmetry, and patient dissatisfaction. This phenomenon has been shown to occur in as many as 70 percent of implanted patients over time. We have reviewed all of our patients and the Medical Device Reporting System for Bioplasty, Inc. (Minneapolis, Minn.) for the history of this device. At 18 months, more textured implants remain soft than the smooth group. After an additional 30 months of follow-up, for a total of 48 months maximum and 18 months minimum, most textured implants still remain soft. Since 1990 we have used AU24K, bio-oncotic hydrogel filling material in molecular impact surface textured implants (MISTI) that is similar to breast tissue in color, radiodensity, and viscosity. Complications have been late leaks, infection, and capsular contracture. Several asymptomatic implants were removed because of anxiety over the FDA controversy. Our experience so far indicates that such a breast implant is a reasonable alternative to the prior art. The longer-term performance of these implants must await the availability of further clinical outcome data.

Subcutaneous pseudobursa secondary to suction and surgery.

Suction lipectomy has been used throughout the regions of the body to remove vast amounts of subcutaneous fat. The blunt technique allows for a multiplicity of small (4 to 6 mm) channels to be created and the fat removed by suction with little disturbance of the overlying skin, the supporting septa, vessels, or nerves. Abdominolipectomy has been successfully performed for decades, in which large amounts of skin and subcutaneous fat are removed by sharp dissection. The undermining involved in an adbominolipectomy extending from the xiphoid to pubis and laterally to the level of the iliac crest and then supplemented by the suction technique has led to the formation, in some cases, of chronic seromas not relieved by multiple aspirations. Healing and contractions of these seromas causes a deformity of the overlying skin, because it is puckered and drawn upon itself. This results in the formation of a subcutaneous pseudobursa lined by collagen sheets but no epithelial cells. We present 9 patients who have demonstrated this phenomenon. We suggest that in the largest resections, safety is best served by waiting a period of at least 6 weeks between suction and subsequent resection.

Bioplastique: a new textured copolymer microparticle promises permanence in soft-tissue augmentation.

Migration, absorption, or toxicity of prosthetic materials has always plagued the plastic surgeon attempting to ameliorate soft-tissue deficiencies and other contour abnormalities. Our previous work to develop textured-surface breast prostheses has led to the development of micronized, inert, biphasic copolymer particles that neither migrate nor become absorbed by the body. These particles are textured, of critical dimension, and, when mixed with a bioexcretable gel vehicle, can be implanted using a special blunt-tipped cannula. Our experimentation in rabbit ears has shown that the bioexcretable gel component is rapidly phagocytized and is replaced by fibrin-like matrix within 3 days. The fibrin is then replaced by host collagen that gradually converts into a fibrotic encasement around each texturized particle. Clinical use of the substance in a variety of soft-tissue deficiencies has been generally effective, with only a few complications, when followed for 1 year.

Rhinophyma: treatment with electrocautery and silver-impregnated porcine xenograft.

A typical case of advanced rhinophyma is reported. Partial excision reduced the size of the nose by two-thirds, leaving a thin layer of dermis. This was covered with silver-impregnated porcine xenograft, which allowed efficient drainage and remained adherent in its initial application for 2 weeks. A total of four applications of silver-impregnated porcine xenografts--the last two involving only very small areas--were required for complete epithelialization at 5 weeks after surgery. We believe that this xenograft is an ideal dressing for wounds resulting from partial excision of rhinophymatous tissue, providing the beneficial effects of biological dressings, including the hemostatic effects of collagen with the added benefit of silver's potent antibacterial properties. Silver-impregnated porcine xenograft reduces patient discomfort and results in rapid healing with excellent cosmetic results.

Anhidrotic ectodermal dysplasia.

A diagnosis of anhidrotic ectodermal dysplasia should be considered for patients with an undeveloped breast or other deformities. Recognition of the syndrome can lead to necessary and helpful genetic counseling and will ensure that other members of the family, who may also be affected by the syndrome, are under proper care.

Biodegradable positive fixation for the endoscopic brow lift.

Development of endoscopic techniques allows the separation and repositioning of the periosteum of the orbital rims and zygomaxilla for a brow lift without skin excision. Questions have been raised about the permanence of this repositioning without fixation. We have developed a technique using biodegradable polylactide pericranial pins that serve as fixation points to allow specific suspension of the periosteum with positive positioning until the third phase of wound healing is complete. Through two inconspicuous incisions near the midportion of the scalp, subperiosteal dissection is carried to the orbital rims and the zygomatic arch anteriorly and all the way to the base of the occiput posteriorly. This allows for contracture of the occipitalis muscle to contribute to the repositioning and lifting of the brow. Up to seven sutures are then placed through and through the pericranium of the periosteum and frontalis along the superior and lateral border of the orbital rim. These stitches of long-acting polylactide acid are secured to two pins placed in the outer table of the cranium to maintain positive fixation for more than 6 weeks. In this way precise, positive positioning is maintained until wound healing and reattachment of the structures are complete. We began these procedures in 1993; our results at 24 months are promising.

Lipo layering of autologous fat: an improved technique with promising results.

When using free fat autologous grafts as a filling material was first proposed in 1893 by Neuber, the idea rapidly gained enthusiasm and endorsements. Our early experience with autologous fat transplantation was disappointing, but even then it was clear that fat could be transferred with partial success. Since then, further clinical works by Guerrerosantos, Coleman, and others have shown that it is possible, by careful handling of transplanted fat, to improve the survival of this tissue. We have reviewed our recent experiences and have found several patients with whom autologous fat transplant has been successful with up to an 8-year postoperative follow-up.

Bioplastique at 6 years: clinical outcome studies.

Bioplastique is a biphasic polymer for the permanent augmentation of some soft tissues. It was developed in 1987, and clinical studies at this institution were begun in 1990. The combination of low molecular weight polyvinylpyrrolidone and solid polymer particles allows the implantation of permanent polymer spheres through a small needle under local anesthesia. In this study 127 cases are reviewed of consecutive patients who have received Bioplastique for scar revision, wrinkles, and augmentation for soft-tissue defects at 6 years after application. All patients who had not been in for follow-up recently were contacted by mail and questioned on the permanence of augmentation and migration of particles. About 30 percent of the patients were unreachable and had their charts reviewed for permanence and migration of particles. In eight of these cases, Bioplastique was removed because of overcorrection, two of them may have had infection. Bioplastique has gained wide use throughout the world and although some complications have been reported, in general, it functions quite well when used in selected cases.

Chin augmentation using minimally invasive technique and bioplastique.

The plethora of problematic techniques for improving minor chin recessions has left the plastic surgeon inevitably uncertain of the most effective remedy. Research we began in 1968 has led us to the development of a new biphasic polymer and minimally invasive implantation techniques aimed at solving the soft-tissue deficiency dilemma. Bioplastique consists of inert, textured particles of critical dimension dispersed within a bioexcretable gel vehicle. Previous experimentation in rabbit ears has shown that the gel component is rapidly phagocytosed, excreted, and replaced by a fibrin matrix within 3 days. The matrix is then replaced by host collagen, gradually forming a stable encasement around each microparticle. Further evaluation has revealed that the implant resists migration and absorption. Based on these encouraging results, a clinical phase was initiated. Thirteen patients lacking chin prominence have subsequently been improved with Bioplastique implants. The infection rate was 0 percent, and other complications were minor. At 26 months, no evidence of migration or absorption has been observed, and the aesthetic results remain.

Results of reaugmentation with MISTI prostheses after failure of smooth silicone prostheses.

In 1988 and 1989, we replaced smooth silicone double-lumen implants with Molecular Impact Surface Textured Implants (MISTIs) in 28 of our patients. Of these, 20 had experienced recurrent capsular contracture and sought an alternative prosthesis that would provide long-term relief from this problem, and 8 simply wanted larger prostheses. Among the reaugmentation patients who had experienced recurrent contractures, 4 have had problems with the texturized implants; 1 developed an infection, and 3 developed unilateral fibrosis within weeks of surgery. The infection was resolved with antibiotics, and the fibrosis was resolved with capsulectomy, biweekly methylprednisolone irrigation in the surgical pocket, and lenticular suction drainage over a 3-week period. After a 2-year follow-up, these 4 problematic patients have remained soft and asymptomatic following their treatment, and the remaining 16 patients have remained soft and asymptomatic since their surgery.

Method for the prevention of firm breasts from capsular contraction.

The permeability of inflatable silicone implants to water creates a diffusion gradient which may result in a continuous early disparity between the volume of the implant and its fibrous capsule. We submit suggestive evidence that the addition of 50 ml of water to the desired volume of normal saline in an inflatable implant may be a helpful adjunct in the prevention of firm breasts due to capsular contracture.

Radiolucent prosthetic gel.

The successful use of silicone breast implants is complicated by their interference with mammography. We have evaluated clinically available implant filling materials and found that a new Bio-Oncotic gel approximates the radiolucency of normal breast tissue. Silicone implants completely obscure areas of the breast in mammography. Recently proposed as a filler material, peanut oil is significantly more radiolucent than normal tissue. Physiologic saline solution compares favorably as a tissue-density-simulating substance. However, saline's lack of lubricating properties results in leakage, making it less than optimal. Bio-Oncotic gel is biologically compatible. We conclude that this gel is the most appropriate filler for breast prostheses. Clinical studies are indicated.

Interrelationship of capsule thickness and breast hardness confirmed by a new measurement method.

All implants initiate a foreign-body response that leads to their encapsulation by scar tissue. In order to better understand this encapsulation process and the differences between soft (comfortable) and firm (contracted) breasts, we studied 22 patients who had come in for reaugmentation during a 2-year period. The capsules removed were prepared and measured using a new method. The capsules were (1) removed and stored in physiologic solution until the time of measurement (30 minutes to 2 hours) and (2) measured using a Mitutoyo dial-thickness gauge (MDTG) that employs a uniform pressure of 85 gm. The measurements revealed that soft breasts (Baker 1) have the thinnest scar-tissue capsules, which ranged in thickness from 0.002 to 0.010 inches. Firm breasts yielded the thickest capsules. Baker 3 measured between 0.010 and 0.078 inches thick, and Baker 4 measured between 0.018 and 0.162 inches thick. We also compared the precision of measurement between the MDTG and a standard (screw-type) micrometer by taking a series of readings on a soft, pliable substance (textured silicone rubber).

Suction-assisted lipectomy for correction of 202 figure faults in 101 patients: indications, limitations, and applications.

Since its introduction in the United States, suction-assisted lipectomy has proven to be a safe, effective technique for correction of figure faults. It has been greeted with considerable skepticism by many practitioners, however, owing to the poor results many have obtained in their initial attempts to apply similar techniques. Suction lipectomy using the blunt technique is a safe procedure that can yield consistently good results when appropriately applied. It is suggested that the principal reason others have had difficulty involves problems in patient selection. The technique may not be effective for the correction of generalized obesity and cannot be expected to dramatically alter overall appearance. Patients should be selected for treatment of specific "figure faults" and educated as to what may realistically be expected. The patient's emotional and psychological condition must be taken into consideration. We report a series of 101 patients treated with a total of 202 separate suction lipectomy procedures with good results and only two minor complications. A survey of patients treated by the method reveals a generally high level of satisfaction and some of the ambivalence that might be anticipated from such a technique.

Cross-linked silver-impregnated skin for burn wound management.

Biological skin is effective in restoring the missing water vapor barrier and promoting healing in burn wounds. Its effectiveness in wound management has been limited, however, by its inherently limited antibacterial properties and the fact that it is sometimes rejected before healing is complete, even reversing previous beneficial effects. Limited availability and storage difficulties have posed further problems. Impregnation of biological skin with silver ions has been proven to provide a potent bactericidal effect directly at the wound surface. We hypothesized that aldehyde cross-linking of silver-impregnated skin would mask the histocompatibility sites from the recipient's immune system. This has been demonstrated previously with aldehyde cross-linking of allografts and xenografts, prolonging retention sufficiently to permit complete wound healing. Commercially available skin was treated with an aldehyde compound and impregnated with silver. Initial studies of this cross-linked skin for treatment of burn wounds showed average retention to be between 117 and 161 days, far exceeding that of any untreated skin. It was subsequently found that the aldehyde cross-linking permitted impregnation with higher concentrations of silver than had previously been possible--2,600 to 2,830 ppm as compared to an average of 1,020 to 1,350 ppm in previously available silver-impregnated skin. This results in a more potent, immediate antibacterial effect at the wound surface and an extended period of time-release antibacterial action before the silver is exhausted. The antibacterial properties of this aldehyde cross-linked silver-impregnated skin are effective in decontaminating even grossly infected wounds and in protecting against contamination of clean wounds from adjacent infected areas or external sources.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular impact surface textured implants (MISTI) alter beneficially breast capsule formation at 36 months.

Since the development of smooth silicone breast implants in 1962, over two million women throughout the world have opted for breast augmentation surgery. While initially successful, smooth implants are prone to developing surrounding scar capsules that may harden and contract--resulting in discomfort, weakening of the shell with rupture, unsightliness, and patient dissatisfaction. This phenomenon has been shown to occur in as much as 70% of implanted patients over time. Our work on the texturing of implantable prosthesis material (published in 1968), and subsequent discoveries, has led us to the development of textured silicone breast implants. Because the host interface is altered by the texture, collagen fibrils select a formation that is multiplanar which results in thinner, more pliable capsules that are more resilient and less likely to contract. At 18 months (August, 1989), with 116 implants, all remain soft, after an additional 18 months follow-up, for a total of 36 months maximum and 18 months minimum. The long-term performance of these implants must await the availability of further clinical data.