Correction of age-related changes in the skin at the dermal and subdermal level using radiofrequency macroneedling therapy.

BACKGROUND: The negative effects of skin aging are primarily related to the destruction of dermal architectural structure. More specifically, this includes changes in the spatial arrangement of collagen, elastin fibers, mucopolysaccharides, proteoglycans, and ground substances. AIMS: The purpose of this study is to investigate the histologic effects of dermal and subdermal tissue after a controlled single treatment with radiofrequency (RF) macroneedling. This therapy provides a controlled, localized, thermal effect on the dermis whereby triggering the body's own healing processes of extracellular matrix remodeling. Clinically benefits include skin tightening. METHODS: Biopsies were obtained for histologic evaluation from four patients (n = 4), 4 weeks after completing a single RF macroneedling facial treatment. RESULTS: Age-related changes of the dermal and subdermal architecture were observed at baseline. After treatment, all biopsies demonstrated an increase in epidermal cells, collagen, elastin, fibroblasts, vasculature, and a decrease in inflammatory cells. CONCLUSIONS: The results of this histologic study confirm a significant "subsurfacing" thermal effect from the noncoagulative ascendant thermal injury. The obtained results characterize RF macroneedling therapy as an effective method for correcting age-related changes in facial skin.

Introducing the tibial-dorsalis pedis osteocutaneous shin flap: a new option for oromandibular reconstruction.

BACKGROUND: The authors investigated the possibility of incorporating a well-vascularized, partial corticotomy of the anterolateral aspect of the tibia "in-series" with a dorsalis pedis fasciocutaneous free flap for oromandibular reconstruction. METHODS: A cadaveric injection study was performed to characterize the vascular territory of the anterior tibial artery with regard to the surrounding osseous and soft tissue. The two-point breaking strength of the tibia (twist) was examined with fracture strain gauge analysis to determine the threshold of tibia corticotomy that would lead to a pathologic fracture. Finally, the authors performed an in vivo prospective clinical examination of the tibial-dorsalis pedis osteocutaneous shin flap. RESULTS: The perfusion study revealed that the anterior tibial artery provided a rich matrix of musculofascial periosteal blood supply to the anterolateral cortex of the tibia that could potentially support free osseous tibial transfer. Two-point osteotomy fracture strain gauge analysis demonstrated that the threshold of tibia corticotomy that would lead to pathologic fracture of the remaining tibia was greater than 30 percent. The osteocutaneous shin flap was performed in eight patients. The mean follow-up was 61 months. There were no cases of flap loss, salivary fistula, nonunion, or tibia pathologic fracture. All patients achieved ambulation. CONCLUSIONS: The authors introduce the osteocutaneous tibial-dorsalis pedis free vascularized flap as a viable option for oromandibular reconstruction. Its most notable advantage is the independent mobility of the skin paddle, in combination with bone stock that replicates mandibular bone dimensions, facilitating primary osseointegration or denture rehabilitation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The sensate fibula osteocutaneous flap: neurosomal anatomy.

BACKGROUND: Rapid return of oral sensation enhances quality of life following oromandibular reconstruction. For predictable reinnervation of flaps, a detailed knowledge of their nerve supply is required. This study was designed to investigate the cutaneous nerve supply of the fibula osteocutaneous flap. METHODS: We dissected thirty-seven fresh cadaveric specimens to better understand the cutaneous innervation of the typical fibula flap that would be used in oromandibular reconstruction. In addition, ten volunteers were enlisted for nerve blocks testing the cutaneous innervation of the lateral aspect of the lower leg. RESULTS: The lateral sural cutaneous nerve (LSCN) is generally considered to be sole cutaneous innervation to the lateral aspect of the lower leg; however, our analysis of the cadaveric specimens revealed dual innervation to this region. We identified a previously unnamed distal branch of the superficial peroneal nerve, which we have termed the recurrent superficial peroneal nerve (RSPN). Given the cadaveric findings, both the LSCN and the RSPN were tested using sequential nerve blocks in 10 volunteers. An overlapping pattern of innervation was demonstrated. CONCLUSIONS: The lateral aspect of the lower leg has an overlapping innervation from the LSCN and the newly described RSPN. The overlap zone lies in the region of the skin paddle of the fibula flap. The exact position of the neurosomal overlap zone (N.O.Z.E.) may be an important factor in reestablishing sensation in the fibula's skin paddle following free tissue transfer.

The sensate fibular osteoneurocutaneous flap in oromandibular reconstruction: clinical outcomes in 31 cases.

Thirty-one patients requiring composite mandibular resection were reconstructed with sensate fibula osteocutaneous flaps. Preoperatively, all patients underwent lower extremity sensory testing at the location of the proposed flap site. Intraoperatively, either the Lateral Sural Cutaneous Nerve (LSCN) or the Recurrent Superficial Peroneal Nerve (RSPN) was chosen as donor. It was then joined to either the lingual or the greater auricular nerve. Both end-to-end and end-to-side neurorrhaphies were used. At least six months postoperatively, the intraoral flaps were tested for sensory function. Twenty-eight patients achieved sensory return, including hot/cold and pinprick sensation. Both the LSCN and RSPN groups demonstrated improved two-point discrimination in static and moving studies. Better results were obtained when the lingual rather than the greater auricular nerve was the recipient. Only three patients underwent end-to-side repair, with improved two-point discrimination in two patients. The average follow-up for all patients was 11.7 months. The most dramatic return of sensory function was seen in the end-to-end lingual nerve neurorrhaphies, followed by end-to-side lingual nerve neurorrhaphies. Of the five repairs using the greater auricular nerve, only three demonstrated any measurable postoperative sensory return. Functional outcomes of postoperative patients were measured via analysis of speech, type of food consumption, and oral continence. The majority of patients exhibited normal or easily intelligible speech, was able to consume a soft food or normal diet, and could maintain normal to manageable oral continence. A subset of patients enrolled in the study went on to pursue dental rehabilitation.

Radio frequency energy for non-invasive and minimally invasive skin tightening.

This article reviews the non-invasive and minimally invasive options for skin tightening, focusing on peer-reviewed articles and presentations and those technologies with the most proven or promising RF non-excisional skin-tightening results for excisional surgeons. RF has been the mainstay of non-invasive skin tightening and has emerged as the "cutting edge" technology in the minimally invasive skin-tightening field. Because these RF skin-tightening technologies are capital equipment purchases with a significant cost associated, this article also discusses some business issues and models that have proven to work in the plastic surgeon's office for non-invasive and minimally invasive skin-tightening technologies.

Noninvasive body contouring with radiofrequency, ultrasound, cryolipolysis, and low-level laser therapy.

Noninvasive body contouring is perhaps one of the most alluring areas of esthetic surgery today. This article discusses current noninvasive body-contouring modalities, including suction massage devices, radiofrequency energy, high-frequency focused ultrasound, cryolipolysis, and low-level light laser therapy devices. It also discusses imminent technologies awaiting approval by the Food and Drug Administration, reviews the basic science and clinical effects behind each of these existing and emerging technologies, addresses patient selection and clinical applications of each modality, and discusses the applicability and economics of providing noninvasive lipolysis services in office.

Lifting and wound closure with barbed sutures.

The advent of barbed sutures has been a novel and useful adjunct for the aesthetic plastic surgeon in properly selected patients. The deployment of a barbed suture minimizes the risks of cheese wiring and stress relaxation, facilitating the minimally invasive repositioning of soft tissue in the head and neck, as well as optimizing and enhancing traditionally long and potentially tedious procedures in body contouring. This article highlights the advances, advantages, and efficacy associated with the use of barbed sutures in lifting and wound closure.

Three-dimensional radiofrequency tissue tightening: a proposed mechanism and applications for body contouring.

The use of radiofrequency energy to produce collagen matrix contraction is presented. Controlling the depth of energy delivery, the power applied, the target skin temperature, and the duration of application of energy at various soft tissue levels produces soft tissue contraction, which is measurable. This technology allows precise soft tissue modeling at multiple levels to enhance the result achieved over traditional suction-assisted lipectomy as well as other forms of energy such as ultrasonic and laser-generated lipolysis.

The implications of stress patterns in the vertebral body under axial support of an artificial implant.

Clinical studies show an association between changed load patterns both in the disc and its adjacent vertebral body, with painful degenerated discs. This suggests that failure to restore the normal loading pattern on implantation of a disc replacement could be a cause of lower clinical success rate. In the present study the variations of load patterns in the vertebra after disc implantation was studied using a simplified finite element models of natural and artificial discs. The effect of implant size and presence of voids at the implant-bony endplate interface were studied, for the worst case scenario of no bone remodelling. An altered stress pattern was observed in the vertebrae of implanted segments. The use of smaller size implants and presence of voids at the interface caused localized stress concentration in the endplate and adjacent cancellous bone. The study results support the hypothesis that current implants fail to restore normal loading patterns in the vertebral body, and the localized high stress regions could be the source of pain, and the cause of low success rate of TDRs.

Silk'n--a novel device using Home Pulsed Light for hair removal at home.

A small, light-weight, low-energy, and low-cost IPL system designed for home use (Silk'n; HomeSkinovations, Kfar, Saba, Israel) was tested for efficacy and safety on 34 test individuals and 92 sites. Each of the patients underwent informed consent and performed self-treatment at the clinic supervised by an experienced laser hair removal nurse. The pre- and post-treatment hair counts were performed and the reduction counts were analyzed by a blinded observer.

Selling skin care products in your medspa.

This article explains the legalities of selling retail products in the medical practice and how to sell effectively and profitably. It additionally explains how this will help retain clients and provides advice on how to encourage those clients to refer their friends with confidence.

The myth of lumbar instability: the importance of abnormal loading as a cause of low back pain.

Spinal fusion became what has been termed the "gold standard" for the treatment of mechanical low back pain, yet there was no scientific basis for this. Operations of fusion for low back pain were initially done at the beginning of the last century for back pain thought to be related to congenital abnormalities or for past spinal infection. The recognition of the disc as a cause of sciatica, commonly associated with back pain, and the recognition that a degenerate disc led to abnormal movement suggested the concept that this abnormal movement was the cause of pain, and this abnormal movement came to be called "instability". Much biomechanical expertise confirmed the fact that degenerate discs led to abnormal movement, there were many hypothesis as to why this caused pain. However clinical results of fusion for back pain were unpredictable. The failure of pedicle screws and cage fusion to improve the clinical results of fusion despite near 100% fusion success, and the introduction of "flexible stabilization" and artificial discs, which demonstrated that despite the often unpredictable movement permitted by of these devices, clinical success was similar to fusion, directed attention to the other role of the disc, that of load transfer, which these devices also affected. Abnormal load transfer was already known to be critical in other joints in the body and had led to the use of osteotomy to realign joints. The relevance of load transfer to the future design of spinal implants used in the treatment of low back pain is discussed, and some finite element studies are reported demonstrating the likely effect of abnormal loading beneath an incompletely incorporated plate of an artificial disc, perhaps explaining in part the somewhat disappointing clinical results to date of the implantation of artificial discs.

Scientific basis for the treatment of low back pain.

Disc degeneration causes back pain because the function of the disc as a load transferring structure is abnormal, producing abnormal patterns of load which cause pain. Fusion has been unpredictable because it only fortuitously addresses loading. A fusion may be in such a position that it takes load from the disc, and this may be reflected in the way the fusion models, demonstrating a weight bearing pattern, but this is unpredictable. Recognition that we are dealing with a problem of load transfer allows us to design any surgical implant to solve this problem, without stopping movement.

Case-controlled study of patients with self-inflicted burns.

The main objectives of this study were to investigate whether patients with self-inflicted burns have larger burns, and a worse outcome, than patients with accidental burns. The secondary objective was to examine patient pre-injury characteristics to identify ways of preventing the burn occurring. A case-controlled study was performed: 36 deliberate self-burn patients were matched separately to two groups of accidental burn patients. The first group was used to compare burn severity. Patients were matched for age and sex; they were excluded if they had a psychiatric diagnosis, or a non-burn injury. The second group was used to compare outcome. The same matching and exclusion criteria were used as in the first group, with the addition of burn-size. Deliberate self-burn patients have significantly larger burns (p<0.01; median total body surface area (TBSA) 10% versus 1.5%) than accidental burn patients. They also stay in hospital longer, even when matched for burn-size (p<0.02; median stay 15 days versus 9 days). Self-inflicted burns occurred in supervised environments in 28% of cases. The number of deliberate self-burns could be reduced with simple interventions such as restricting smoking in hospitals and prisons, and also by identifying high-risk patients. The poor outcome from deliberate self-burns could be improved by well-coordinated multidisciplinary patient management with early psychiatric team involvement.

Enhanced full-face skin rejuvenation using synchronous intense pulsed optical and conducted bipolar radiofrequency energy (ELOS): introducing selective radiophotothermolysis.

BACKGROUND: The authors previously reported their experience achieving non-ablative skin enhancement with serial, full-face, intense pulsed light treatments in a large series of patients. A new method for skin renewal electro-optical synergy (ELOS), which combines intense pulsed optical energy and conducted bipolar radiofrequency (RF) energy into a single pulse, has been recently introduced. Intense pulsed optical energy and bipolar RF energy have been used in dermatologic surgery for many years; however, this study represents the therapeutic impact of the combined energies. OBJECTIVE: The authors report their experience using an ELOS system (Aurora SR, Syneron, Yokneam, Israel) on 108 consecutive patients treated with a series of full-face procedures. METHODS: Patients received 5 full-face treatments every 3 weeks. Each treatment consisted of 1 to 8 full-face and segmental passes. The number of passes, specific wavelength of pulsed optical energy, and RF energy were determined by the patient's skin type, dyschromia, wrinkle pathology, and presence of a tan. A total of 540 treatments were performed on 108 subjects. All patients had pre- and post-procedural photographs. Results were assessed by double-blinded physician photographic evaluation and patient satisfaction scales. RESULTS: Overall skin improvement was rated at 75.3%. Overall average wrinkle improvement was 41.2%, with an average Class 1 wrinkle improvement of 64.7%, Class 2 wrinkle improvement of 38.6%, and Class 3 wrinkle improvement of 20.4%. Improvement in skin laxity was rated at 62.9%. Skin texture was reported to improve 74.1%. Improvement in the appearance of pore size was rated at 65.1%. Average improvement in erythema and telangiectasia was 68.4%. Average improvement in hyperpigmentation and dyschromia was 79.3%. Overall patient satisfaction was 92%. The overall minor complication rate, including blistering, crusting, and stripping was 8.3%, and the major complication rate was less than 1%. One small, depressed nasal scar was observed in one patient. CONCLUSIONS: This study demonstrates the safety and efficacy of a new technology using combined optical and conducted bipolar RF energies for noninvasive skin rejuvenation. The results show improvement in wrinkle reduction and amelioration of erythema, telangiectasia, and hyperpigmentation comparable to that reported for other intense pulsed light technologies.

A prospective clinical study to evaluate the efficacy and safety of cellulite treatment using the combination of optical and RF energies for subcutaneous tissue heating.

BACKGROUND: There have not been any published studies on the use of radiofrequency (RF)-light-based technologies for the treatment of cellulite. Only preliminary results have recently been reported (ASDS Proceedings, September 2004). OBJECTIVE: This two-center study investigated the safety and effectiveness of combined energies for cellulite treatment using the VelaSmoothtrade mark system. METHODS: Thirty-five female subjects with cellulite and/or skin irregularities on the thighs and/or buttocks were treated with the VelaSmooth device. Patients received from eight to 16 treatments twice weekly. All patients maintained their normal lifestyle, and diet and fluid consumption. The circumference of the right and left medial thighs was measured at both baseline and approximately 4 weeks after the last treatment. During the last follow-up visit, the physician graded the level of improvement in skin smoothing and/or cellulite improvement using pre- and post-treatment photographs. Three patients provided biopsy specimens for histological assessment. RESULTS: All study patients showed some level of reduction in thigh circumference after 8 weeks of treatment; indeed, 70% of all patients showed such a reduction after 4 weeks of treatment. Also, 100% of all patients showed some level of improvement in skin texture and cellulite. The mean decrease in circumference was 0.8 inches. Some patients demonstrated reductions of more than 2 inches. There were minimal complications associated with treatment. CONCLUSION: This preliminary study demonstrates that the VelaSmooth system can have a beneficial effect on cellulite appearance. Further studies are needed to better define the mechanisms by which RF and light energies affect subdermal tissues and develop a method of quantified cellulite analysis.