[Intralesional Cryosurgery in the Treatment of Keloids - A Differentiation of Keloid Types for the Improvement of Patient Selection]. / Keloidbehandlung mit intraläsionaler Kryochirurgie.

The overproduction of altered collagen fibers and the overexpression of Tumor Growth Factor-ß must be blocked in order to interrupt the growth process within a keloid scar. This can barely be achieved with the classical therapeutic methods. The results of keloid treatment are difficult to predict and the recurrence rate is usually over 50 %. In addition, some of the procedures used (e. g. irradiation) may induce additional health risks. Intralesional cryosurgery offers a therapeutic alternative that has been evaluated since more than a decade. Our own experience in more than one thousand keloid treatments allows a critical evaluation of the classification in those keloid types, which are recommended to be treated with the technique and those, which may not respond.

A prospective case-control study of non-healing wounds of the lower limbs - the value of biopsies for ulcerating carcinoma.

BACKGROUND: In some leg ulcer patients there is cancer that is responsible for lack of healing of such a wound. AIM: This study was aimed at prospective analysis of histopathology of non-healing wounds (NHWs) in the patient presenting with high and low suspicion for ulcerating carcinoma. MATERIAL AND METHODS: Forty patients with NHWs were enrolled and had been prospectively divided into two groups: 25 patients with high suspicion for ulcerating carcinoma according to their medical history and physical examination, and the second group of 15 patients without suspicion for malignancy (control group). All NHWs were photographed and underwent biopsies. RESULTS: In the control group biopsies did not reveal cancers. On the contrary, in 10 patients (40%) from high suspicion group biopsies revealed cancers: seven basal cell carcinomas (BCCs), one - malignant melanoma, one - Bowen's disease and one - squamous cell carcinomas. Histopathology of six of seven BCCs suggested that non-healing benign wound might have preceded malignancy. We found that leg ulcers which were small (wound area less than 3 cm(2) ), longstanding (duration 24 ≤ weeks), presenting with granulation tissue covering ≥75% of the wound area, with a dull pink appearance of the granulation tissue, or an atypical clinical presentation, can actually be an ulcerating carcinoma. Dull pink granulation tissue or an atypical clinical presentation of ulceration, as a single clinical finding, suggested an underlying malignancy with a statistical significance (71.5% vs. 0%; P = 0.001 and 27.8% vs. 0%; P = 0.0049 respectively). CONCLUSIONS: Prevalence of malignancy, primarily: BCCs in NHWs, may be higher than expected and clinical features suggestive of such a nature of ulcer are an indication for diagnostic biopsy.

Pain evaluation and control during and following the treatment of hypertrophic scars and keloids by contact and intralesional cryosurgery--a preliminary study.

BACKGROUND: Intralesional cryosurgery effectively treats hypertrophic scars and keloids (HSK), but pain experienced by the patient during treatment can limit the application of cryosurgery. OBJECTIVES: To characterize the pain response during cryosurgical treatment of HSK, and to evaluate the pain experienced during contact and intralesional cryosurgery that employs a pain-control protocol. METHODS: Twenty-nine patients (17 women, 12 men) aged 17 years and older (mean ages 31.9±12.5 and 38.9±18.6 years, respectively, P=0.24), who were treated for a total of 36 HSKs by intralesional (n=20; 22 cryotreatments) or contact (n=9; 14 cryotreatments) cryosurgery were evaluated. The pain-control protocol involved oral pain-relief tablets (Dipyrone) and translesional local anaesthesia with Bupivacaine hydrochloride 0.5%. Pain evaluation according to the Visual Analogue Scale (VAS) (0-10 cm) was compared between the two groups at three time points: during cryosurgery, immediately after it, and 4 h later. Scores ≤3 cm were considered to define the 'zone of analgesic success'. These results were compared with control data (contact cryosurgery without a pain-control protocol; n=56). RESULTS: Pain in the intralesional group was significantly lower than that in the contact group during and immediately after cryotreatment. During: mean VAS=1.68±2.21 vs. 5.07±4.01 cm; median VAS=0.5 vs. 5.5 cm, respectively; P<0.0001. Immediately after: mean VAS=1.22±1.77 vs. 5.38±3.81 cm; median VAS=0 vs. 6.0 cm, respectively; P=0.001. The control group had more pain during treatment (mean VAS=5.34±2.31, median=6.0) and 4 h later (mean=3.79±2.35, median=4.0) than the intralesional group (P<0.0001 and P=0.988, respectively). The pain level in the control group during the cryotreatment did not differ from that in the contact group (P=0.988). In the intralesional, contact and control groups analgesic success (VAS ≤3 cm) was achieved in 77.3%, 35.7% and 33.9%, respectively, of cases (P=0.002) during cryotreatment, and in 54.5%, 42.9% and 33.9%, respectively, of cases 4 h after treatment (P=0.24). CONCLUSIONS: The pain-control protocol significantly reduced pain severity to tolerable levels (VAS ≤3 cm) during and following intralesional and contact cryosurgery. Intralesional cryosurgery caused the least pain during and immediately after treatment.

Keloid histopathology after intralesional cryosurgery treatment.

BACKGROUND: Keloid presents a great healthcare challenge. The patients suffer from aesthetic disfiguration and occasionally from pruritus, pain and discomfort. Although various treatments are recommended, a single, highly effective treatment represents a great clinical need. OBJECTIVE: The cellular events and histopathology that follow intralesional cryosurgery were evaluated including cell proliferation, the number of cells expressing fibroblast markers, collagen synthesis and organization and mast cell infiltration. METHODS: Biopsies were collected before and after intralesional cryoneedle procedure. Collagen structure was evaluated with confocal microscopy. Mast cells, blood vessels and cell proliferation were evaluated using immunohistochemistry. RESULTS: Keloids contain abnormally thick collagen bundles, organized in swirls comprising closely bound fibrils. After intralesional cryosurgery, the collagen bundles lost their swirl structure, the thickness of the collagen layer decreased, and the bundles became more compact with less space between the fibres. A clear distinct transition zone separated the treated from the unaffected area. The frozen tissue was devoid of proliferating cells and mast cells whereas the number of blood vessels remained unaltered. Most of the fibroblasts expressed all tested myofibroblast markers although some exclusively expressed one and not the other. Few nuclei were observed in the affected area after treatment and very few of them expressed any fibroblast markers. CONCLUSIONS: Intralesional cryosurgery resulted in major changes in collagen structure and organization. The treatment reduced the number of proliferating cells, of myofibroblasts and of mast cells. These results may explain the reduction in no-response rate and the amelioration of the clinical symptoms after intralesional cryosurgery treatment.

Partial breast necrosis after MIDCABG via small anterolateral thoracotomy.

We report a case in which partial breast necrosis developed after minimally invasive direct coronary artery bypass grafting using an IMA Retractor (Cardio-Thoracic Systems Inc, Cupertino, CA). We suggest that during minimally invasive direct coronary artery bypass grafting in the presence of a large breast, it is advisable to reduce the intraoperative additive forces of pressure and traction caused by the retractor arm on the breast tissue, thus avoiding further excessive compression on the partially compromised blood circulation of the breast.

Evaluation of penile revascularization for erectile dysfunction: a 10-year follow-up.

The objective of this study was to report long-term success rates for penile revascularization (PR) and investigate factors responsible for failures. During the past 10 y, data were obtained on 52 patients who underwent PR. Surgical technique was selected according to preoperative arteriographic findings. The mean age was 28.5 y and the mean follow-up was 70.8 months. Success was defined as satisfactory intercourse without additional therapy. Overall success was 48%. Patients under 28 y showed a 73% success rate vs 23% in the older ones (P=0.0003). Nonsmokers had a 57% success compared to 29% in smokers (P=0.05). The presence of venous leak and type of procedure had an insignificant impact on success (P=0.33 and 0.23 respectively). To conclude, this curative treatment option is limited to a selective population with vasculogenic erectile dysfunction. We found that the cure rate of this procedure is maintained and long-term follow-up shows good results, especially in the young nonsmokers.

Arterial blood supply to the infrahyoid muscles: an anatomical study.

The arterial supply to the infrahyoid strap muscles originating from the superior thyroid artery (STA), the inferior thyroid artery (ITA), and the internal mammary artery (IMA), also called the internal thoracic artery, were investigated. Intraarterial silicone dye was injected into eight fresh cadavers followed by dissections. The blood supply to the infrahyoid muscles was found to be segmented in nature with the dividing line at the level of the cricoid ring. No axial pattern of vascularization could be demonstrated within the strap muscles. The skin overlying these muscles is supplied by tributaries arising from the above-described arteries. Application of the information gathered is discussed in consideration of local myocutaneous and myoosseous flaps for reconstructive surgery, particularly of the larynx and trachea.

Case report: ofloxacin-induced hypersensitivity vasculitis.

Since its introduction in 1985, the new fluoroquinolone antibiotic ofloxacin has gained widespread use, and much information has accumulated about its possible adverse effects. Skin reactions have been uncommon, and there have been very few reports about hypersensitivity vasculitis directly related to ofloxacin. The authors report such a case, in which the patient needed plastic surgery because of severe vasculitis in both legs.

A skin-stretching device for the harnessing of the viscoelastic properties of skin.

A skin-stretching device that is designed to harness the viscoelastic properties of the skin using incremental traction is presented as an addition to the surgeon's armamentarium. It has proved to be of value in helping to close problematic areas of skin shortage which would otherwise have required more complicated procedures for their solution. It is simple in application and can even be put to use at the bedside. It consists of two pins that are threaded through the dermis of the wound margins on either side of the defect and which are in turn engaged by the hooks of the stretching device. The stretching force on the skin margins is spread over a wide area, thus preventing damage to the skin itself that individual hooks applied to the skin might cause. The device is employed over a duration of 20 to 30 minutes to 1 to 3 days depending on the condition of the skin adjoining the defect. The device can be applied over three different periods of time: (1) preoperatively (presuturing), lasting 1 to 2 days, (2) intraoperatively, extending over a period of 20 to 30 minutes, and (3) postoperatively (or delayed), which takes place over a time span of hours to 1 to 3 days. Five illustrative cases are presented.

Chordee: different concept and new trend of treatment.

Chordee or ventral curvature of the penis is commonly associated with and occasionally without hypospadias. The usual recommended treatment is excision of the fibrous tissue that is responsible for the bowing. This results in a proximal retraction of the meatus. With a different concept and explanation of the ventral curvature, we treat this abnormal condition as a shortage of tissue. More than a hundred consecutive cases of chordee with and without hypospadias were treated by skin release and dorsal to ventral transposition of preputial skin as well as hypospadias repair. The whole procedure is simple, planned as a single-stage operation with less morbidity or fewer complications. The meatus is not pushed back proximally, no dissection distal to the meatus is performed, and there is no need for tissue excision. The results were very successful, with no recurrence of the ventral curvature.

The securing of a polyethylene tube prior to intravascular dye injection in anatomic microcirculation research: the three-tie technique.

A simple and reliable method for securing the cannulated polyethylene tube to the blood vessel wall prior to intravascular dye injection is described. The three-tie technique has been used in many vascular anatomic studies without any leakage of the injection fluid taking place around the tube.

External longitudinal splitting of the tibialis anterior muscle for coverage of compound fractures of the middle third of the tibia.

In this modern era, compound fractures of the middle third of the tibia are relatively common. With the advent of external fixation, these fractures can be more rapidly and effectively dealt with, and attention can be directed to immediate coverage of the exposed bone. External longitudinal splitting of the anterior tibialis muscle offers a convenient and safe method for converting the open fracture to a closed one. The uniqueness of the tibialis anterior muscle is two-fold. It is circumpennate, and it has an internal axial tendon corresponding to almost its total length. Both these features impart to it considerable strength, and the muscle splitting herewith described does not appear to impair its function. Five treated limbs, each with loss of soft tissues overlying compound mid-third tibial fractures, are presented. Rapid healing and virtual absence of bone infection was observed in all cases.

Free-fat injections for the correction of hemifacial atrophy.

Three adult patients with long-standing hemifacial atrophy were treated with repeated free-fat injections at 4- to 8-week intervals. The longest follow-up study to date is 18 months, and following the expected postoperative resorption, no further loss of bulk of injected fat has been observed. On palpation, the feel of the fat is normal, and facial expression is also good. The relative ease of this procedure, which does not entail any scarring, appears to justify more widespread use of free-fat injections to restore facial soft-tissue depressions.

Computerized morphometric quantitation of elastin and collagen in SMAS and facial skin and the possible role of fat cells in SMAS viscoelastic properties.

Recently, the superficial musculoaponeurotic system (SMAS) was found to be a composite tissue comprising collagen, elastic fibers, and fat cells in an extracellular viscous matrix. Both SMAS and facial skin tissues exhibit viscoelastic properties, but SMAS tissue has delayed stress relaxation. As a consequence, SMAS is viewed as a firmer elastic foundation for the more viscous facial skin. In some patients, a slackening effect of SMAS tissue takes place over a period ranging from weeks to months after tightening. To determine the relative quantity of viscoelastic components and better understand their biomechanical behavior, a quantitative morphometric study of the elastic and collagen fibers in the SMAS and facial skin was conducted. Thirty-four SMAS preparations were taken from 17 patients during either primary face lift operations (12 women) or reoperative face lift procedures (4 women, 1 man), which were performed 4 to 9 months after the original surgery, to examine the elastin and collagen content. For comparison, preauricular skin was also gathered from these patients. The specimens were stained with Weigert's staining to identify elastin and collagen fibers. Using a computerized morphometric analysis, 100 fields of each SMAS and skin specimen were examined. According to our findings, the average percentage of elastin and collagen fibers in SMAS and facial skin was as follows: (1) the percentage of elastin fibers in the SMAS was 4.71 +/- 1.2 (standard error of mean +/- 0.0291); (2) the percentage of elastin fibers in the skin was 6.1 +/- 1.8 (standard error of mean +/- 0.0436); (3) The percentage of collagen fibers in the SMAS was 38.7 +/- 5.9 (standard error of mean +/- 0.1430); and (4) the percentage of collagen fibers in the skin was 48.47 +/- 6.96 (standard error of mean +/- 0.1688). A statistical significance of p < 0.0001 was demonstrated between the collagen and elastin groups. A different percentage of elastin and collagen fibers was found among the 17 patients and within each of them separately. Neither gender nor age differences were found regarding elastin and collagen fiber content. No statistical differences were demonstrated between specimen sources, i.e., whether the operations were primary or reoperative face lift procedures. Findings from previous studies indicate that the cheek has two viscoelastic layers, the skin and the SMAS. The proportional similarity in average percentages of elastin and collagen in SMAS and facial skin cannot explain the relatively delayed stress relaxation effect of the SMAS. Therefore, the fat cells that are found exclusively in the SMAS probably lend a certain degree of firmness to this layer and play a significant role in the long-term efficacy of SMAS surgery.

Static-electric field induction by a silicone cushion for the treatment of hypertrophic and keloid scars.

Silicone gel and silicone occlusive sheeting are widely used at present for the treatment of hypertrophic and keloid scars, without any scientific explanation as to their mode of action. In a recent paper the possibility was raised that static electricity generated by friction-activated silicone sheeting could be the reason for this effect, and that it can, with time, cause involution of hypertrophic and keloid scars. The objective of this study was to test this hypothesis and to observe whether a continuous and also an increased negatively charged static-electric field will shorten the treatment period. A device to implement these requirements gradually evolved over a 5-year period. A number of prototypes were tested until the final product was attained. Some of the patients in this study were treated initially with a silicone sponge inserted in the cushion. Later this version was changed to the final design described herein. A silicone cushion was developed with the purpose of increasing a negative static-electric charge to accelerate the regression process. The cushion is custom-made using a silicone occlusive sheeting envelope of 0.75-mm thickness, which does not deteriorate with use, and is partially filled with high viscosity silicone oil. Its edges are sealed, and its size is designed to extend a little beyond the scarred area. Static electricity readings, generated by activating the cushion by pumping action with the fingers, stretching or deforming the cushion, are invariably much higher when compared with those obtained with silicone occlusive sheeting and silicone gel sheeting. The interaction between the negatively charged ions of the cushion and the ionic charges of the tissue fluids may be the critical factor in achieving hypertrophic and keloid scars involution. Of the 30 patients enrolled in the study, 3 patients dropped out. Treatment with the silicone cushions yielded 63.3 percent cessation of itching and burning followed by pallor and flattening of the scar, some markedly so, over a few weeks to 6-month period. An additional 26.6 percent had their scars resolved in up to 12 months of treatment. Good contact of the cushion over the scar has been shown to be important in this clinical trial, and much creativity is needed for making elastic strap bindings that ensure this contact. The clinical trials extended over a 12-month period. Ten patients (33.3 percent) who had recalcitrant scars with little response to the use of the silicone cushion were given intralesional corticosteroid injections, in addition to the continued use of the cushion, resulting in a fairly rapid resolution of these scars over a period of months to a year.

The surgical anatomy of the fat in the upper eyelid medial compartment.

The surgical anatomy of the upper eyelid fat in the medial compartment was investigated in 388 patients and in 12 cadavers. We found two individual fat pads comprising this compartment. The difference among the investigated cases was found to be the extent of their separation. In 16.7 percent of the cadavers' eyelids the fat pads were entirely separated, in 45.8 percent they were separated to about half their length, while in 37.5 percent only the tips were separated. Among the patients in whom only the protruded fat was inspected, 59.8 percent of the fat pads were separated, and in the rest, only the tips were isolated. On histologic examination we could always identify two well-circumscribed fat pads, each surrounded by a fibrocollagenous tissue. At the level of their interconnection, a loose fibroareolar tissue was found. In practice, during blepharoplasty, both fat pads should be addressed in order to achieve the expected results.

An integrated approach for increasing the survival of autologous fat grafts in the treatment of contour defects.

Autologous fat grafting as a technique to correct soft-tissue defects is a controversial subject. The high percentage of fat resorption and the resulting need for additional grafting considerably reduce the value of this method. The purpose of this study was to evaluate the clinical application of tissue-culturing methodology in the handling of the lipocyte aspirate in an endeavor to improve the survival rate and therefore the take of the grafted lipocytes. The method consists of syringe aspiration of the lipocytes from the donor site, isolation of intact lipocytes by gentle centrifugation, suspension of the aspirate in an enriched cell culture medium, and injection of the cell suspension into preformed subdermal tunnels. A number of media were tested and shown to prolong the survival of lipocytes ex vivo using fluorescent acridine orange stain. Implementing the integrated cell culture techniques increased the lipocytes' viability, as indicated in clinical evaluation in which the amount of graft take ranged between 50 and 90 percent. The results of 15 patients with varied types of cases who were operated on using this new methodology show that the tissue defect was filled and remained so in postoperative follow-ups of 6 to 24 months. A three-dimensional CAT scan-aided evaluation method was developed and used in one of four case histories presented herein.

Sensitivity and positive predictive values of presurgical clinical diagnosis of excised benign and malignant skin tumors: a prospective study of 835 lesions in 778 patients.

This article reports on the sensitivity and positive predictive value of clinical diagnosis of benign and malignant skin tumors by expert plastic surgeons in an Israeli clinic. Most published reports have focused on the sensitivity of clinicians' diagnoses, a general measure of the physician's skill that does not predict the rate of accuracy of a physician's diagnoses. Our study of 835 lesions in 778 patients, one of the largest Israeli series, assesses the clinical diagnosis of malignant and benign skin tumors and is one of the few that provide information on the positive predictive value, the measure that is of interest to both physicians and patients. The majority of tumors were benign (56.8 percent), 31.6 percent were malignant, and 11.6 percent were premalignant. Among the 474 benign lesions, 46 percent were nevi. The most common nevi subclass was compound nevi (53 percent), 9 percent of the nevi were dysplastic, and 5 percent were blue nevi. The most common malignant tumor was basal cell carcinoma, accounting for 78 percent of malignant tumors. Although sensitivity for clinical diagnosis of malignancy was 91.3 percent, the positive predictive value for clinical diagnosis of malignancy was 71.3 percent. The sensitivity rate for clinically diagnosing premalignant tumors was 42.3 percent, whereas the positive predictive value for these diagnoses was higher (64.1 percent). The sensitivity rate for diagnosis of all benign lesions was 85.9 percent, and the positive predictive value was 94.2 percent. The sensitivity rate for diagnosis of all nevi was 87.6 percent, and the positive predictive value was 85.7 percent: i.e., only seven of the 218 pathologically proven diagnoses of nevi (3.2 percent) were falsely diagnosed as malignant lesions. Even more interestingly, five of the 223 clinical diagnoses of nevi (2.2 percent) were pathologically proven to be malignant melanomas, and seven were found to be premalignant lesions (3.1 percent). It was concluded that publications which report only on the sensitivity neglect to provide information of interest regarding the positive predictive value. Often, positive predictive value is qualitatively different from the sensitivity, and thus relying only on the sensitivity may lead to incorrect evaluation of a clinical judgment, which may result in erroneous surgical decisions.

Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study.

Immediate breast reconstruction with the tissue expander is now established as an accepted procedure after mastectomy, and large series have been published concerning the technique and its complications. Unfortunately, only scarce information is available regarding the long-term aesthetic results and patient satisfaction achieved by immediate reconstruction using tissue expansion. In this study, we reviewed 52 patients who had undergone immediate breast reconstruction using the tissue expander with a follow-up of at least 1 year after completion of the reconstruction. We developed an objective assessment of patient satisfaction, aesthetic results, and the factors affecting them. The results show remarkable concordance of assessment by patient, surgeon, and independent observer: All gave good scores for aesthetic appearance (6.4 to 7.4 on a scale of 1 to 10). A total of 92.3 percent of patients rated their satisfaction as good to excellent. Symmetry was the main parameter influencing the patients' score, while the surgeon's score also was affected by the quality of the inframammary fold and capsular contracture. Breast size, chemotherapy, complications, time interval, and additional procedures had no relation to either scoring or patient satisfaction.