Open Otoplasty Through Ventral Skin Incision and Abrasion of the Antihelix Under Vision.

BACKGROUND: Common otoplasties through incisions behind the ear with blind scoring or scratching the anterior perichondrium often leave an irregular surface of the antihelix. METHOD: To avoid these tiny side effects, a skin incision along the ventral antihelical fold (scapha) is used to thin and fold the flat antihelix under vision. After local anesthesia of the ventral ear skin, an incision along the scapha allows its blunt lifting toward the concha and to expose the cartilaginous antihelix. Its future shape is marked and the thickness of the cartilage is thinned with a dermabrader by approximately half or until one sees the gray of the inner cartilage. The now missing perichondrium causes the antihelix to fold by itself with an absolute smooth surface and is fixed with three absorbable mattress sutures. RESULTS: The technique has been developed in 1985 in Frankfurt and has since been performed on over 1000 patients with optimal results and a low complication rate. The skin flap is so well perfused that no skin necrosis and only 5.7% wound healing problems were experienced. CONCLUSION: This approach from ventral is safe, timesaving, and avoids contour irregularities of the antihelix often seen after traditional techniques. It can be left to beginners in plastic surgery without hesitation. The fear of hypertrophic scars or even keloids can be dispelled with the fact that ear keloids only occur after wound infection. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Dermatoporosis in Upper Limbs Treated With Polymethylmethacrylate Microspheres Using the BioSculpt® Technique.

Dermatoporosis is a syndrome of fragility or chronic cutaneous insufficiency. It presents with localized violaceous spots on the extensor face of the upper limbs of older people, with signs such as senile purpura, actinic purpura, or Bateman purpura, in addition to atrophy of the skin and subcutaneous tissue. These lesions can be painful and a source of morbidity. We report a case of an 80-year-old patient presented for the treatment of dermatoporosis in the upper limbs with polymethylmethacrylate (PMMA) using the BioSculpt®technique. The photographic and ultrasonographic clinical responses of the soft tissue were evaluated before and after nine months of treatment.

Widening Aging Eyes and Ending Outdoor Tearing with Retrobulbar Injections of Dermal Fillers.

As people age, the intraorbital fat may diminish and palpebral fissures may narrow, causing the eyes to increasingly tear outside in cold weather. As the bulbus recedes from the conjunctiva, a "wind trap" is formed in the lateral corner of the eye. This wind trap appears to irritate the adjacent lacrimal gland. In this article, an 84-year-old patient experienced annoying outdoor tearing despite having undergone three tarsal strip canthopexies during the past 20 years. Methods: Retrobulbar injections of 3.5-mL high-viscous dermal fillers (Bellafill or Radiesse) pushed the eyeballs forward, aligned the bulbus with the conjunctiva, and closed the wind trap behind the lateral canthus. Magnetic resonance imaging confirmed the filler material in the posterior lateral corner of the orbit. Results: The effect was immediate: the patient's constant outdoor tearing had resolved after the first treatment of his senile enophthalmos. In addition, the narrow palpebral fissure had widened by 2 mm and rejuvenated his aging eyes. Conclusions: An eyeball that has receded with age can be pushed forward with a retrobulbar injection of a long lasting dermal filler to reattach to the eyelids.

Otoplasty through Ventral Skin Incision and Shaping of the Antihelix by Abrasion-A Retrospective Study.

(1) Background: Protruding ears are the most common auricular malformation affecting approximately 5% of the population. One common factor leading to auricular protrusion is a deficiency or total absence of the antihelix. A technique first described by Gottfried Lemperle in 2003 attempts cartilage thinning, folding, and fixation by non-absorbable mattress sutures after ventral skin incision along the ventral helical rim. (2) Methods: Retrospective analysis of patient records was performed for otoplasties according to this technique, performed between 1985 and 2014 at Agaplesion Markus Hospital in Frankfurt, Germany. All recorded complications were examined. (3) Results: A total of 912 single otoplasties were performed according to this technique from 1985 to 2014. Overall complications included 26% minor complications not requiring further surgery and 11% major complications leading to revision surgery. Within those requiring revision surgery, the most common reason was recurrence of auricular protrusion (5%), followed by suture granulomas (5%) and hematomas (2%). (4) Conclusions: Lemperle's otoplasty technique addresses the open thinning and shaping of the antihelix through a ventral incision along the helix to prevent irregularities and possible ridges. Results show a low complication rate comparable to data found in published studies. This technique is easy to perform, safe, and avoids often seen contour irregularities of the antihelix compared to techniques with a posterior approach.

Human Histology and Persistence of Various Injectable Filler Substances for Soft Tissue Augmentation.

An increasing number of soft tissue filler substances have been introduced to the beauty market outside the U.S. which lackexperimental and clinical data in support of their claim. Ten commercially available filler substances were examined for biocompatibility and durability: 0.1 cc of each substance was injected deep intradermally into the volar forearm of one of the authors and observed for clinical reaction and permanence. At 1, 3, 6, and 9 months the test sites were excised, histologically examined, and graded according to foreign body reactions classification. Collagen (Zyplast) was phagocytosed at 6 months and hyaluronic acid (Restylane) at 9 months. PMMA microspheres (Artecoll) had encapsulated with connective tissue, macrophages, and sporadic giant cells. Silicone oil (PMS 350) was clinically inconspicuous but dissipated into the tissue, causing a chronic foreign body reaction. Polylactic acid microspheres (New-Fill) induced a mild inflammatory response and had disappeared clinically at 4 months. Dextran microspheres (Reviderm intra) induced a pronounced foreign body reaction and had disappeared at 6 months. Polymethylacrylate particles (Dermalive) induced the lowest cellular reaction but had disappeared clinically at 6 months. Polyacrylamide (Aquamid) was well tolerated and remained palpable to a lessening degree over the entire testing period. Histologically, it dissipated more slowly and was kept in place through fine fibrous capsules. Polyvinylhydroxide microspheres suspended in acrylamide (Evolution) were well tolerated, slowly diminishing over 9 months. Calcium hydroxylapatite microspheres (Radiance FN) induced almost no foreign body reaction but were absorbed by the skin at 12 months.Host defense mechanisms react differently to the various filler materials, but all substances- resorbable or nonresorbable-appeared to be clinically and histologically safe, although all exhibit undesirable side effects. Since the mechanism of late inflammation or granuloma formation is still unknown, early histological findings are not useful in predicting possible late reactions to filler substances.

Keloids: Which Types Can Be Excised without Risk of Recurrence? A New Clinical Classification.

A surgical team from Interplast-Germany removed 387 keloids in 302 patients during 4 visits to Goma, Democratic Republic of the Congo, from 2015-2018. Preoperative and postoperative photographs and a thorough anamnesis of keloids were done for all patients. In addition, 18 selected biopsies from 4 types of keloids were histologically examined in Germany. METHODS: Treatment options were tested and keloid recurrence rates were compared with data from questionnaires, photographs, and histology. RESULTS: Keloids were classified accordingly as follows: (1) fresh nodular (continuously growing) keloids had a 30% recurrence rate after surgery: no common adjuvant therapy but triamcinolone acetonide (TAC) injections on onset, only; (a) earlobe keloids had the lowest recurrence rate after complete excision with negative resection margins; (2) superficial spreading (or butterfly) keloids were treated with TAC injections only; (3) mature (nongrowing or burned-out) keloids had also a low recurrence rate of 4.5%, which were then treated with TAC on onset, only; and (4) multiple keloids comprise various types in different stages. CONCLUSIONS: According to this classification, about 50% of keloids may be removed surgically without risk of recurrence in the examined patient population in Africa, where only TAC injections, but no radiation, are available. Adjuvant TAC or radiation should be started at the onset of recurrence and not generally.

Potential new treatment strategies for COVID-19: is there a role for bromhexine as add-on therapy?

Of huge importance now is to provide a fast, cost-effective, safe, and immediately available pharmaceutical solution to curb the rapid global spread of SARS-CoV-2. Recent publications on SARS-CoV-2 have brought attention to the possible benefit of chloroquine in the treatment of patients infected by SARS-CoV-2. Whether chloroquine can treat SARS-CoV-2 alone and also work as a prophylactic is doubtful. An effective prophylactic medication to prevent viral entry has to contain, at least, either a protease inhibitor or a competitive virus ACE2-binding inhibitor. Using bromhexine at a dosage that selectively inhibits TMPRSS2 and, in so doing, inhibits TMPRSS2-specific viral entry is likely to be effective against SARS-CoV-2. We propose the use of bromhexine as a prophylactic and treatment. We encourage the scientific community to assess bromhexine clinically as a prophylactic and curative treatment. If proven to be effective, this would allow a rapid, accessible, and cost-effective application worldwide.

Minimal Scar Formation After Orthopaedic Skin Incisions Along Main Folding Lines.

BACKGROUND: Patients, particularly those who are young, often develop noticeable orthopaedic scars. In order to achieve minimal scarring, surgeons should attempt to place incisions in skinfolds or skin creases. METHODS: Optimal incision lines can be determined from the direction of stretch marks (striae distensae), which develop perpendicular to lines of tension or main folding lines. A composite diagram of photographs of 213 individuals with striae distensae was created and compared with 276 images of incisions and scars derived from the Internet. RESULTS: Classically described Langer cleavage lines often run counter to real tension lines and poorly predict the optimal direction for skin incisions. CONCLUSIONS: Whenever possible, main folding lines should be utilized as a guide in planning surgical incisions for young patients as well as for correction of problem scars.

Differentiating Nonpermanent Injectable Fillers: Prevention and Treatment of Filler Complications.

Though the incidence of complications and adverse events with dermatological fillers is inherently low, practitioners should be well versed in both prevention of filler complications and the treatment algorithms for addressing "granulomas," nodules, infection, and vascular compromise. Appropriate preventative measures, coupled with timely and effective treatment, are critically important for patient safety and satisfaction. In addition to the preventive measures and treatment algorithms outlined here, the authors emphasize that the broad classification and treatment of nodules as "granulomas" is likely to lead to ineffective treatment, or worse, unnecessary exposure to incorrect treatment. In practice, nodules are classified and treated based on clinical manifestation (eg, late vs early or noninflammatory vs inflammatory) rather than on histology. Indeed, classification of a nodule as a granuloma requires a histological examination, rarely available (or necessary) in clinical practice to guide treatment. Thus, the apparent inflammatory nature of the nodule and the time of onset should drive treatment approach. The treatment algorithms presented here are based on these clinically meaningful parameters.

Unexpected Effect of Propranolol and Prednisolone on Infantile Facial Rhabdomyosarcoma.

A 14-month-old Nepalese infant had developed a rapidly growing facial tumor originating from a dark spot on her upper eyelid. A cavernous hemangioma was suspected and treated with high doses of propranolol and prednisolone. Remission was dramatic. Histology confirmed alveolar rhabdomyosarcoma. Chemotherapy was planned but not carried out due to complicated logistics. The girl died at the age of 3. We present this case for discussion as to whether propranolol and prednisolone might be effective in rapidly growing rhabdomyosarcomas.

Penile Girth Enhancement With Polymethylmethacrylate-Based Soft Tissue Fillers.

INTRODUCTION: An unknown percentage of men will take every risk to develop a larger penis. Thus far, most injectables have caused serious problems. Polymethylmethacrylate (PMMA) microspheres have been injected as a wrinkle filler and volumizer with increasing safety since 1989. AIM: To report on a safe and permanently effective method to enhance penile girth and length with an approved dermal filler (ie, PMMA). METHODS: Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill, a suspension of PMMA microspheres in carboxymethyl-cellulose. MAIN OUTCOME MEASURES: The data of 729 patients and 203 completed questionnaires were evaluated statistically. RESULTS: The overall satisfaction rate was 8.7 on a scale of 1 to 10. After one to three injection sessions, average girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm = 134.31%). Penile length also increased by weight and stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules had to be surgically removed in three of the 24% of patients who had a non-circumcised penis. CONCLUSION: After 5 years of development, penile augmentation with PMMA microspheres appears to be a natural, safe, and permanently effective method. The only complication of nodule formation and other irregularities can be overcome by an improved injection technique and better postimplantation care.

Prevention and treatment of complications after polymethylmethacrylate-microspheres injections.

The present article focuses on the peculiarities of polymethylmethacrylate as facial filler highlighting the injection technique, known adverse effects, and all options for complication management. Supplemented by a historical overview and case series, the authors share their experience with this widespread and in the last decade heavily criticized injectable filler substance.

The direction of optimal skin incisions derived from striae distensae.

BACKGROUND: In an effort to achieve inconspicuous scars, plastic surgeons try to place their incisions in established creases and folds of skin. Although well established in the face and abdomen, these folding lines are often disputable on other parts of the body. Striae distensae always develop perpendicular to lines of tension, and their direction can be used to determine optimal incision lines. METHODS: The authors examined photographs of 213 individuals with striae, and a composite diagram was created. This composite along with descriptions of Langer lines, Pinkus main folding lines, and Kraissl lines were compared with a clinical scar revision database and 276 images of incisions and scars from the Internet. RESULTS: Pinkus described the main folding lines in 1927 and Kraissl in 1951 recommended that incision lines be placed perpendicular to the direction of underlying muscles. Both references bear some similarities to what we noted in our composites. In comparison, Langer lines, although of historical interest, poorly predicted the direction of optimal skin incisions. CONCLUSIONS: The optimal direction for surgical skin incisions should take into strong consideration patterns defined by nature's striae distensae, which always develop perpendicular to skin tension lines. Main folding lines can be used as guides when addressing or refining problem scars and similarly facilitate surgical planning of elective incisions, which may prevent problem scar formation for our patients.