Plastic surgery and the teenage patient.

Over the past year, the media have reported an increase in the number of teenagers undergoing plastic surgery, and with a tone of faint alarm have suggested that this merits some cultural self-scrutiny. This paper presents the statistics on the number and types of plastic surgery operations done in teenagers over the last eight years and discusses these in the context of cultural influences and societal concepts of beauty. The reason to have plastic surgery is psychological and involves body image, which is defined as the subjective perception of the body as it is seen through the mind's eye. To explain why changing the external appearance affects personality and behavior, the complex psychological reactions that occur after an operation that alters the size or shape of a body part are reviewed. Body image development occurs in stages, and puberty stands out as a particularly sensitive time as the teenager undergoes major changes in his or her physical appearance and does this at a time of heightened vulnerability to the opinion of others. Plastic surgery to correct a truly unattractive feature is enormously successful and remarkably free of conflict in this population. Teenagers undergo a rapid reorganization of their self-image after plastic surgery with subsequent positive changes in behavior and interpersonal interactions. The key to achieving success with plastic surgery is patient selection. The core value of the surgery lies not in the objective beauty of the visible result, but in the patient's opinion of and response to the change. Good patient management includes selecting candidates with clear and realistic expectations who are free of psychopathology. There must be true informed consent and attention to psychological issues must continue into the postoperative period. It is the responsibility of the patient's physician and plastic surgeon to recognize a need for psychiatric evaluation and to help the patient get this as needed. The eight operations most commonly done in the teenage population are rhinoplasty, ear surgery, reduction mammoplasty, surgery for asymmetric breasts, excision of gynecomastia, augmentation mammoplasty, chin augmentation, and suction assisted lipoplasty. Each of these is reviewed with regard to techniques, expectations, risks, and logistics. Guidelines for timing the referral of teenage patients for plastic surgery evaluation are given.

Peptide growth factors and wound healing.

An analysis of peptide growth factors and wound healing should not fail to give credit to its foundations in cancer research. Add the recent advances in peptide chemistry and molecular genetics that have permitted complete definitions and in vivo studies for the first time. The result is an enormous break-through in wound healing research. The potential for understanding and then using the growth factors to enhance healing in the aged or debilitated is incalculable.

The subcutaneous rheumatoid nodule.

The subcutaneous rheumatoid nodule is a common and diagnostically significant finding in rheumatoid arthritis. The presence of these extra-articular lesions correlates with the extent of joint involvement and they are an index of disease severity. The nodules themselves may give rise to clinical problems and the indications for surgical treatment include erosion and infection, peripheral neuropathy or pain from pressure, and limitation of motion because of the location of the lesion. Less frequently, rheumatoid nodules present in patients with rheumatoid nodulosis, a variant of rheumatoid disease where the nodules themselves are the primary manifestation of the disease and surgical treatment is highly useful. While subcutaneous nodules are very characteristic of rheumatoid arthritis and its variants, they are not quite pathognomonic. Rarely, they are found in the absence of rheumatoid disease, especially in lupus erythematosus and in healthy children.

Effect of external pulsing electromagnetic fields on the healing of soft tissue.

Since fibroblast behavior in bone healing can be altered electrically, it is plausible to hypothesize that fibroblast proliferation and function in soft tissue healing also would respond to an electromagnetically induced pulse. Reports of clinical impressions of accelerated closure of chronic skin wounds overlying areas being treated for nonunion have produced support for this hypothesis, but experimental data have been lacking. This study was designed to evaluate the effect of pulsed electromagnetic fields (PEMFs) with clinically employed wave-form parameters on the rate of closure of excisional wounds in normal animals and those with steroid retarded wound healing. Four groups, each containing 12 PEMF-treated rats and 12 control rats, were given different field exposures and two groups were treated with methylprednisolone. The wound areas were measured and tissue was harvested for histological examination at intervals for 28 days after wounding. There was no difference in the gross or microscopical appearance of wounds in each active group and its respective control group. Differences in the number of counted fibroblasts were not significant (p less than 0.5), and wound contraction and epithelialization proceeded at the same rate (t-test for equality of means, power = 90%). Electrical PEMF stimulation with the driving pulse used clinically for nonunion bony repair did not affect soft tissue healing in this model. No experimental support is provided for the reports of accelerated skin healing within therapeutic fields. It is possible that different wave-form characteristics are needed to provoke a response in soft tissue.

The effect of inhibition of angiogenesis in granulation tissue on wound healing and the fibroblast.

Protamine sulfate given in high doses can inhibit angiogenesis in the granulation tissue generated in an open wound. This is reflected by changes consistent with delayed vascular maturation in the morphology of the regenerating vessels seen at the gross, microscopic, and ultrastructural levels. A coincidental delay in wound healing as evidenced by impaired wound contraction occurs, although fibroblast duplication and myofibroblast differentiation appear intact. However, the fibroblasts contain little endoplasmic reticulum, the site of synthetic activity, and the surrounding collagen appears loose and disorganized. To unite these observations into a coherent pattern, we review the proposal that the endothelial cell, the fibroblast, and the extracellular stroma are interdependent and that maturation of each is necessary to maintain the momentum of wound healing. Our findings fit this mechanistic hypothesis but do not prove it. The abnormal vasoformation that may be initiated by protamine's anticoagulant properties could set the stage for impaired fibroblast synthetic activity. If collagenous stroma is deficient, both endothelial maturation and wound contraction wound fail. Although we saw these final events, to prove a series of cause and effect changes would require further study of the oxygen tension and the fibrin and collagen levels in granulation tissue.

The safety and efficacy of breast implants for augmentation mammaplasty.

This review of the efficacy and safety of breast implants was intended to focus on our current body of knowledge about these devices. There are informational gaps, but not all of these can be laid at the door of imperfect studies or failed scientific methods. Certain properties of the implants are still unmeasurable, immunologic investigation is still evolving, the cause of wound contraction is inexplicable here or in the burnscar contracture, and the indications for and results of this surgery necessarily are subjective. Still, there are a number of investigative avenues open to us, and our cumulative experience shows no reluctance on the part of plastic surgeons to initiate further studies.

Rheumatoid nodulosis of the hand.

Rheumatoid nodulosis is an uncommon variant of rheumatoid disease with distinctive clinical and radiographic characteristics and a favorable prognosis. This is in contrast to the poor prognosis for the severe form of rheumatoid disease with which rheumatoid nodules are often associated. A case of rheumatoid nodulosis of the hand treated with complete resection of the nodules is presented with a 2.5-year follow-up. Fourteen cases of documented rheumatoid nodulosis are reviewed and surgical treatment is recommended for both functional and cosmetic reasons.

The psychological impact of immediate breast reconstruction for women with early breast cancer.

Twenty-five patients were evaluated, 13 who had immediate breast reconstruction and 12 who had delayed breast reconstruction for early breast cancer. Data were elicited about the psychological impact of the cancer, the mastectomy, and the reconstruction. Our results support the conclusion that immediate breast reconstruction is accompanied by a lower incidence of psychological morbidity postoperatively, and we recommend that immediate breast reconstruction be offered as an alternative to women with early breast cancer.

Scalping: the savage and the surgeon.

The treatment of the scalped patient has challenged and fascinated the surgeon for over two millennia. It is an esthetically disastrous mutilation, and the resultant soft tissue defect is a form of trauma calling for the surgeon's most creative efforts. The story of scalping is the story of innovative surgeons, both renowned and obscure, which parallels the development of plastic surgery.

Wound geometry and the kinetics of wound contraction.

Contraction of an excisional wound can be described by a decaying exponential with a non-zero asymptote between days 6 and 39 after wounding. Regardless of size or shape, the contraction-rate constant is invariant within age- and species-matched animals. Differently shaped wounds of the same size contract at the same rate during the exponential period. Shape exerts its effect prior to the onset of contraction by defining the size of the wound entering the exponential period. Perimeter is the factor by which shape determines size.

The spatial and temporal quantification of myofibroblasts.

The number and distribution of myofibroblasts in porcine excisional wounds have been measured over a 16-week period by immunoperoxidase labeling of the smooth-muscle antigen in the cytoplasm of the contractile fibroblasts. Changes in the number of myofibroblasts over time correlate with the rate of wound contraction, and the myofibroblasts were distributed throughout the granulation tissue. These findings support the proposal that the contractile fibroblast is the agent of wound contraction. Significantly fewer myofibroblasts are found near the base of the wound and a larger number of myofibroblasts are found in close proximity to inflammatory foci, suggesting a causal relationship between inflammation and the acquisition of contractile properties by the wound fibroblast. There is evidence of a slightly lower percentage of myofibroblasts in areas of rapid fibroblast replication, and the percentage of myofibroblasts does not vary with changes in the tension across a wound. The immunoperoxidase-staining technique permits the identification of individual myofibroblasts by light microscopy and will be a useful tool for further studies of myofibroblast activity and control.

The effect of prostaglandin inhibitors on wound contraction and the myofibroblast.

The production and smooth muscle-like activity of the myofibroblast do not appear to be diminished in a granulating wound treated with prostaglandin inhibitors. Prostaglandins are mediators of inflammation and smooth-muscle stimulants, but inhibition of the prostaglandins and their precursors failed to alter the course of wound contraction and, by inference, the activity of the myofibroblast in this experimental model.