[The application of endoscopy in aesthetic breast surgery]. / Endoskopische Verfahren in der ästhetischen Mammachirurgie.

During the last decades, numerous surgical techniques have been described for breast augmentation. In addition to the very popular inframammary and the periareolar approaches, the transaxillary technique provides an elegant means of conducting a safe and accurate implant placement without producing visible scars on the breast mound. Due to a questionable lack of intraoperative visualisation with resultant higher complication rates,we conducted a retrospective analysis comparing the endoscopy-assisted transaxillary approach with the inframammary technique. A retrospective analysis was conducted comparing the endoscopy-assisted transaxillary approach with the more commonly chosen inframammary aditus. Patients undergoing breast augmentation from 1997 to 2005 were analysed retrospectively. The analysis was conducted in patients undergoing this procedure for aesthetic reasons only. Underlying breast pathology as well as previously performed breast surgery were among the exclusion criteria. The Client Satisfaction Questionnaire (CSQ-8) was applied for assessment of patient satisfaction. From 1997 to 2005, 96 patients underwent breast augmentation at our institution. Implant volumes ranged from 150 to 400 ml.62.5% preferred the transaxillary technique vs. 37.5% who chose the inframammary route. Complication rates were low in both patient subsets, the statistics revealing no differences. Assessment of patient satisfaction displayed high levels of satisfaction in both groups without any significant differences. The endoscopy-assisted transaxillary breast augmentation is a safe technique which generates high levels of patient satisfaction. Predictable results can be achieved by this approach which is preferred by the majority of patients when offered.

The attractive lip: A photomorphometric analysis.

BACKGROUND: Throughout literature, there are different parameters defining the ideal shape of the lip and lower third of the face. This study was conducted to clarify what it is that makes lips attractive - and whether there are gender-related differences of an attractive lip and lower third of the face. PATIENTS AND METHODS: Pictures of the lip and chin region of 176 patients were photographed in a standardised way and evaluated by 250 voluntary judges through an internet presentation by means of an analogue Likert scaling system. RESULTS: We found a significant higher ratio of upper vermillion height/mouth-nose distance in frontal-view images of attractive compared to unattractive female (p < 0.001) and male (p < 0.05) perioral regions. Furthermore, the ratio of upper vermillion height/chin-nose distance was significantly higher in attractive than in unattractive female (p < 0.005) and male (p < 0.05) lip and chin regions. The nasolabial angle was significantly sharper in attractive compared to unattractive female perioral regions (p < 0.001). Moreover, attractive female lip and chin regions showed a wider mentolabial angle compared to unattractive female lip and chin regions (p < 0.05). Comparing men and women, we found that attractive female perioral regions showed a higher ratio of lower vermillion height/chin-mouth distance (p < 0.05) and lower vermillion height/chin-nose distance than attractive male perioral regions (p < 0.05). CONCLUSION: We were able to define certain parameters of the lip and lower third of the face that seem to add to the attractivity of female and male individuals and prove that there are gender-related differences in form and shape of an attractive lower third of the face.

Cultured human keratinocytes on type I collagen membranes to reconstitute the epidermis.

The development of new techniques and modifications to overcome some of the disadvantages in cultured keratinocyte grafting has been motivated by several well-known drawbacks in the use of cultured epithelial autografts such as long culture periods, lack of adherence, difficulty in handling, lack of dermal substrates, and high costs. Two recent insights have influenced further research. On the one hand, it has been shown that the use of undifferentiated proliferative cells in fibrin glue suspensions is effective in epithelial reconstitution. On the other hand, the enzymatic release of cells from the culture surfaces is a critical step leading to at least temporary destruction of anchoring structures of the cultured cells. In this study, we tried to combine these two aspects in an attempt to modify common modalities of keratinocyte transplantation. To avoid dispase dissolving of the cultured cells, keratinocytes were seeded onto bovine collagen type I membranes without feeder layers and under serum-free culture conditions. Subconfluent monolayers of cultured human keratinocytes were transplanted as an upside-down graft on collagen membranes (keratinocyte collagen membrane grafts [KCMG], n = 12) after 3 days of culture or as membrane grafts alone (n = 12) onto standard nude mice full-thickness wounds. Fully differentiated epidermis was found at 21 days after grafting KCMG with persistence of human keratinocytes. This study demonstrates that upside-down grafts of undifferentiated monolayers of keratinocytes on non-cross-linked bovine type I collagen membranes do lead to an early reconstitution of multilayered squamous epithelium with enhanced wound healing compared to the control group. The upside down KCMG grafting technique is able to transfer actively proliferative keratinocytes and simplifies the application compared to conventional epithelial sheet grafting.

Modulation of in vitro angiogenesis in a three-dimensional spheroidal coculture model for bone tissue engineering.

One of the major challenges in tissue engineering of bone substitutes remains vascularization of the transplant. We have developed a three-dimensional collagen-based coculture system to assess interactions between human endothelial cells (hECs) and human osteoblasts (hOBs) in vitro. Human umbilical vein endothelial cells (HUVECs) were grown as three-dimensional multicellular spheroids and seeded in a collagen matrix to assess sprouting of the spheroids, that is, formation of tubelike structures resembling early capillaries. Direct cell contact between hOBs and HUVECs was established by incorporating hOBs into the EC spheroids, thus forming heterogeneous cospheroids. Spatial organization of cospheroids and sprout configuration were assessed by immunohistochemical wholemount staining techniques and confocal laser microscopy. Cumulative sprout length of spheroids was quantitatively analyzed by digital imaging planimetry. In this model HUVECs and hOBs formed heterogeneous cospheroids with distinct spatial organization. The ability of HUVEC spheroids to form tubelike structures on angiogenic stimulation with vascular endothelial growth factor and basic fibroblast growth factor was suppressed in heterogeneous HUVEC/hOB cospheroids. The model system introduced in this study may be useful to assess the mechanisms involved in regulating angiogenesis during bone formation and to further investigate the mechanisms by which heterotypic cell-cell interactions inhibit endothelial tube formation for applications in bone tissue engineering.

Fibrin glue as matrix for cultured autologous urothelial cells in urethral reconstruction.

In the present study, we have established a technique to create an artificial urethra in a rat animal model by transplantation of in vitro-expanded urothelial cells onto an in vivo-prefabricated tube formation using tissue engineering methods. Urothelial cells from isogenic rats were harvested for culture. A silicon catheter was used to induce a connective tissue capsule-tube formation underneath the abdominal skin. Two weeks later, the cultivated urothelial cells were seeded onto the lumen of this tube using fibrin glue as delivery matrix. The histomorphological and immunohistochemical studies revealed a viable multilayered urothelium, lining the inner surface of the prior formed connective tissue tube-formation 4 weeks after grafting the cells. We have shown that cultured and in vitro-expanded urothelial cells can be successfully reimplanted onto a prefabricated tube-like structure using fibrin glue as a delivery matrix and native cell expansion vehicle. The results suggest that the creation of an artificial urethra may be achieved in vivo using tissue engineering methods, showing potential for urethral reconstruction and providing autologous urothelium for reconstructive surgery in the genitourinary tract.

Human recombinant EGF protein delivered by a biodegradable cell transplantation system.

We have previously shown a new approach to expand cultured human keratinocytes and reconstitute the epidermis in full-thickness wounds using a new microsperical transport system. This was a new approach to increase the cell yield for seeding without altering the anchoring proteins by enzymatic steps. That time we used Cytodex 3 which failed to be degraded and induced an inflammatory reaction in a t-cell-deficient organism. Therefore, we have investigated another microcarrier consisting of PLGA, which is a well-known carrier material for cell culture and transplantation. After coating the PLGA carrier with gelatine the seeding time of viable cells reached 4 h and the cell gain after 7 days of spinner culture was 16-fold. At 14 days after transplantation, we could detect a new stratified epithelium in our full-thickness wound healing model. Because cytokines play a major role in wound healing, we loaded this carrier material with different concentrations of rhEGF, showing a dose dependent release of the protein in vitro and in vivo. This result might lead to a different approach in the treatment of wounds.

Single-cell suspensions of cultured human keratinocytes in fibrin-glue reconstitute the epidermis.

To overcome common disadvantages of standard cultured epidermal sheet grafts (CEG) we have developed a new technique of transplanting cultured human keratinocytes suspended as single cells in a fibrin-glue matrix (Keratinocyte-fibrin-glue suspension-KFGS). In an athymic mouse model with reproducible standardized full thickness wounds this new technique was compared directly to CEG. Reepithelialization was similar in both groups, but reconstitution of the dermo-epidermal junction zone, as shown by electron microscopy and immunohistochemistry was significantly enhanced by the fibrin-glue suspension technique. The new KFGS technique is earlier available than sheet grafts, is able to transfer actively proliferative single keratinocytes, and simplifies the application.

[The value of sonography for the discovery of complications after the implantation of silicone gel prostheses for breast augmentation or reconstruction]. / Stellenwert der Sonographie für die Aufdeckung von Komplikationen nach Implantation von Silikongelkissen zur Mammaaugmentation bzw. -rekonstruktion.

PURPOSE: To determine sensitivity and specificity of real-time ultrasonography in detecting breast implant complications. MATERIAL AND METHODS: The results of preoperative ultrasonography of 121 silicone implants in 65 patients were compared with the results after operative implant removal. RESULTS: With a sensitivity of 89.25% and a specificity of 92.1%, complications such as gel bleeding (n = 43), rupture with leakage (n = 63), and implant dissolution (n = 4) become manifest. Capsule formation, fibrosis, siliconoma and calcifications were often underestimated in their extent. Negative ultrasonography findings were found in 10.7% (n = 13) with positive clinical findings. CONCLUSIONS: The combination of clinical and ultrasonography findings leads to the detection of implant complications.

Elongation of axial blood vessels with a tissue expander.

The authors present a rat model and a surgical technique for the study of elongation of axial blood vessels using a tissue expander. The successful demonstration of elongation of axial vessels while maintaining patency further encourages use of the concept in other organ systems such as bowel, ureter, and so on.

Fibrin/Schwann cell matrix in poly-epsilon-caprolactone conduits enhances guided nerve regeneration.

The goal of this study was to investigate if a three dimensional matrix, loaded homogeneously with Schwann cells and the neurotrophic factor LIF (leukemia inhibitory factor), enhances regeneration in a biodegradable nerve guidance channel as compared to non-structured cell suspensions. Therefore a 10 mm nerve gap in the buccal branch of the rat's facial nerve was bridged with tubular PCL (poly-epsilon-caprolactone) conduits filled with no matrix, Schwann cells, the three dimensional fibrin/Schwann cell matrix or the fibrin/Schwann cell matrix added with LIF Four weeks after the nerve defects were bridged histological and morphometric analyses of the implants were performed. In conclusion, the three dimensional fibrin/Schwann cells matrix enhanced the quantity and the quality of peripheral nerve regeneration through PCL conduits. The application of LIF prevented hyperneurotization. Therefore, tissue engineered fibrin/Schwann cells matrices are new invented biocompatible and biodegradable devices for enhancing peripheral nerve regeneration as compared to non-structured cell suspensions without neurotrophic factors.

Prosthetic vascular graft infection--defect covering with delayed vertical rectus abdominis muscular flap (VRAM) and rectus femoris flap.

Prosthetic vascular graft infection is associated with high rates of morbidity and mortality. When infections lead to an open exposure of vascular prosthesis special techniques may be necessary to cover tissue defects in regions with often very poor circulation/perfusion conditions. Even when there are large tissue defects associated with vascular prosthetic graft infections and exposure of prosthesis local cure can be achieved after radical debridement and defect coverage through transposition of myocutaneous flaps. The cases of two patients with open exposure of prosthesis in the groin who had been successfully treated by delayed vertical rectus abdominis muscular flap (VRAM) or rectus femoris rotation are presented. The contralateral VRAM myocutaneous flap is an excellent alternative if local measures fail to close large groin defects with exposed prosthesis. In addition the delayed flap rotation offers a greater safety in conditioning the vascularity of the flap.

Comparison of the effect of a collagen dressing and a polyurethane dressing on the healing of split thickness skin graft (STSG) donor sites.

Recent advances in the resurfacing of burn wounds with dermal equivalents and collagen preparations have shown the efficacy of collagen. To investigate the benefits (if any), standardised split skin donor areas were chosen to compare the influence of collagen on re-epithelialisation. A bovine collagen preparation consisting of type-I collagen was prospectively compared with polyurethane film dressing in a study of 20 split thickness skin graft donor sites. The rates of epithelialisation, the discomfort experienced by the patients and the convenience of the dressings were assessed. The median time from operation to the observation of complete healing was 7.5 (+/- 2.5) days for the donor sites dressed with the collagen membrane and 12.5 (+/- 3.4) days for the the donor areas dressed with a polyurethane film (p < 0.001). The discomfort experienced by the two groups of patients was significantly less after wound coverage with collagen (p < 0.005). Haematomas or seromas that required repeated aspiration was seen under the polyurethane film dressing. The collagen dressing was more expensive than the polyurethane film, but improved wound healing compared with the polyurethane dressings.

Evaluation of processed bovine cancellous bone matrix seeded with syngenic osteoblasts in a critical size calvarial defect rat model.

INTRODUCTION: Biologic bone substitutes may offer alternatives to bone grafting procedures. The aim of this study was to evaluate a preformed bone substitute based on processed bovine cancellous bone (PBCB) with or without osteogenic cells in a critical size calvarial defect rat model. METHODS: Discs of PBCB (Tutobone) were seeded with second passage fibrin gel-immobilized syngenic osteoblasts (group A, n = 40). Cell-free matrices (group B, n = 28) and untreated defects (group C; n=28) served as controls. Specimens were explanted between day 0 and 4 months after implantation and were subjected to histological and morphometric evaluation. RESULTS: At 1 month, bone formation was limited to small peripheral areas. At 2 and 4 months, significant bone formation, matrix resorption as well as integration of the implants was evident in groups A and B. In group C no significant regeneration of the defects was observed. Morphometric analysis did not disclose differences in bone formation in matrices from groups A and B. Carboxyfluorescine-Diacetate-Succinimidylester (CFDA) labeling demonstrated low survival rates of transplanted cells. DISCUSSION: Osteoblasts seeded into PBCB matrix display a differentiated phenotype following a 14 days cell culture period. Lack of initial vascularization may explain the absence of added osteogenicity in constructs from group A in comparison to group B. PBCB is well integrated and represents even without osteogenic cells a promising biomaterial for reconstruction of critical size calvarial bone defects.

Fibrin gel-immobilized primary osteoblasts in calcium phosphate bone cement: in vivo evaluation with regard to application as injectable biological bone substitute.

Osteogenic injectable bone substitutes may be useful for many applications. We developed a novel injectable bone substitute based on osteoblast-fibrin glue suspension and calcium phosphate bone cement (BC). Human osteoblasts were isolated from trabecular bone samples and cultured under standard conditions. Osteoblasts were suspended in fibrinogen solution (FS). BC was cured with thrombin solution. 8 x 4 mm injectable bone discs were prepared using silicon molds and a custom-made applicator device. Discs containing BC, BC/FS, or BC/FS/osteoblasts were implanted subcutaneously into athymic nude mice. After 3, 9 and 24 weeks, specimens were explanted and subjected to morphologic and biomechanical evaluation. In vitro fibrin gel-embedded osteoblasts displayed a differentiated phenotype as evidenced by alkaline phosphatase, collagen type 1 and von Kossa stains. A proportion of osteoblasts appeared morphologically intact over a 3-day in vitro period following application into the BC. BC/FS and BC/FS/osteoblast discs were sparsely infiltrated with vascularized connective tissue. There was no bone formation in implants from all groups. However, positive von Kossa staining only in BC/FS/osteoblast groups suggests engraftment of at least some of the transplanted cells. Biomechanical evaluation demonstrated initial stability of the composites. Young's modulus and maximal load did not differ significantly in the BC/FS and BC/FS/osteoblast groups. The practicability of osteoblast-containing injectable bone could be demonstrated. The dense microstructure and the suboptimal initial vascularization of the composites may explain the lack of bone formation. Modifications with regard to enhanced osteoblast survival are mandatory for a possible application as injectable osteogenic bone replacement system.

[Treatment of keloids and hypertrophic scars. Pilot study with intralesional Lipotalon injections]. / Behandlung von Keloiden und hypertrophen Narben. Pilotstudie mit intraläsionären Lipotalon-Injektionen.

A pilot study was conducted to establish whether intralesional injection of a microsomal corticoid, Lipotalon, would reduce the development of keloids and hypertrophic scars. Thirteen patients with 17 scars and keloids were admitted to the study. In all the patients investigated, injection of Lipotalon into the lesion led to a moderate to appreciable improvement in the hypertrophic scars and keloids. Injections of 0.5 to 4 mg Lipotalon were given, for the most part, at intervals of 4 to 6 weeks, and were oriented to the respective findings. No side effects were observed. Some of the patients received topical application of Lipotalon as adjuvant treatment to surgical scar resection. Here, too, a trend towards positive results was observed, although in one case, disordered wound healing was seen.

Intraluminal cyclosporine A reduces capsular thickness around silicone implants in rats.

One theory of the cause of connective tissue capsule formation around silicone mammary prostheses is based on an immunological interaction. In an in vitro pilot study, it is shown that intraluminal cyclosporine A, a potent T-lymphocyte-specific immunosuppressive agent, can diffuse slowly through the outer shell of a standard double-lumen silicone breast implant. Round silicone tissue expanders containing 50 mg of cyclosporine A were implanted subcutaneously in 10 rats. Ten animals served as controls. Evaluation was performed after three months. A significant decrease in collagen capsular thickness of 21.6 +/- 5.4 microns (mean +/- standard deviation was measured histomorphometrically in the treated group compared with 39.6 +/- 8.6 microns in the control group (p less than 0.001).

[Tissue engineering: possibilities and perspectives]. / Tissue Engineering--Möglichkeiten und Perspektiven.

Successful tissue engineering requires intensive co-oporation between clinicians, biologists (cell culture, gene therapy), chemical engineers (biomaterials) and industrial partners. In case of wound healing tissue engineered constructs have already been applied successfully in burns and chronic wounds. In order to improve carrier and matrix function biomaterials still have to be optimized. The potential of such constructs might even be enhanced by gene therapeutical methods. The complex mammalian organism has to be considered as the gold standard and the model for perfect tissue engineering. The problem of vascularization of complex organs yet has to be solved. In general it seems to be more promising to substitute deficient components in vivo and to rely on modulating influences within the host organism rather than to create complex organs ex vivo.