The history and development of breast implants.

This review discusses the historical development of smooth and textured silicone gel filled implants, and examines the reasoning behind product development and aspects of surgical technique from a surgeon's perspective.

Modifying integra as a regeneration template in deep tissue planes.

Contour defects resulting in deformity caused by lack of tissue can be improved by conventional surgery using autologous tissue, but there is always a donor site morbidity. Integra has been available since the early 1980's for use in acute burns and more recently in reconstruction. It has been shown histologically to act as a tissue regeneration template. The regenerated dermis is buried under an autologous thin split-skin graft. In this study, the principle of burying Integra (without the silicone layer) has been applied to deep tissue defects in 12 reconstructive cases. Such regenerated tissues survive at least 3 years after burying. Modification to the technique to avoid visible edges are being developed.

The concept of safer face-lifting.

Face-lifting is now a common aesthetic procedure, performed mainly by plastic surgeons but increasingly also by ENT surgeons, oral surgeons, general surgeons and dermatologists. The level of expertise is dependent on training and exposure to patients, in addition to basic surgical skills. With cosmetic surgery clients, a holistic approach to patients is becoming increasingly important and, with increasing demands from the Care Standards Committee, there should be less demand for part-time aesthetic surgeons. This paper describes the working practice and thought processes of a single surgeon, based on 14 years of a busy aesthetic surgery practice. There are numerous types of face-lift described in the literature but, in practical terms, the simplest technique often gives the best result, with little risk of morbidity. Undoubtedly, some clients need an aggressive approach but, in most cases, the vertical pull mini-face-lift gives consistently good results in cases that are carefully assessed preoperatively and managed by skilled aesthetic/plastic nurses in the postoperative period. This paper is unique in its holistic approach to assessment, technique and aftercare. It is designed for the sensible surgeon, looking for a low-risk technique that reaps professional satisfaction and a happy client base. The more complex face-lift should be referred to recognized specialists in the field.

A study to evaluate primary dressings for the application of cultured keratinocytes.

Despite the recent improvements in cell culture and dermal regeneration methods, tissue engineering of skin has yet to receive widespread acceptance in the management of burn injuries. The reasons for this are complex and include not only the inherent costs of (particularly) setting up and running such a system but also the continuing difficulties in achieving successful engraftment of the neoepidermis. The latter has previously been addressed in a number of ways, including improving the recipient bed and using pre-confluent delivery systems to allow earlier application of cells to that wound bed. One area that has received little attention is that of the optimal wound dressing to use with this technology; the cells are very poorly attached at early time points, and, in this context, the traditional dressing of paraffin gauze has never been formally assessed in comparison with newer materials. Using a porcine acute wound chamber model, we performed a prospective randomised trial to assess four different wound dressings with reference to the amount of epidermal cover gained and the histological quality of the regenerated skin after 3 weeks. Out of the four materials tested, polyurethane foam (Allevyn) was superior histologically (although equal in take rate with paraffin gauze), whilst polythene sheet (Opsite) and silicone sheet were substantially inferior. We conclude that the traditional dressing used with this technology should be compared with polyurethane foam in a clinical trial. In the future, novel dressings should be formally tested against traditional methods before being adopted.

In vitro characterization of an artificial dermal scaffold.

The treatment of extensive burn injuries has been enhanced by the development of artificial skin substitutes. Integra Artificial Skin, an acellular collagen-glycosaminoglycan (C-GAG) dermal equivalent requires a two-stage grafting procedure. However, preseeding the C-GAG dermal equivalent with cultured fibroblasts and keratinocytes, with the aim of performing a single-stage grafting procedure, may be beneficial in terms of replacing the requirement for traditional split-skin grafts. In this comparative in vitro study, the interactions of cultured human dermal fibroblasts and epidermal keratinocytes in Integra Artificial Skin in comparison to cadaver deepidermalized dermis (DED) was investigated. An increase in cell proliferation and migration in the C-GAG dermal equivalent was observed over time. Cocultures of fibroblasts and keratinocytes on both dermal equivalents showed positive expression of proliferation, differentiation, and extracellular matrix (ECM) protein markers. Organization of keratinocytes in the epidermal layers of DED composites were better compared to the C-GAG composites. Deposition of ECM proteins was enhanced in the presence of keratinocytes in both dermal equivalents. Results demonstrate that in vitro the C-GAG dermal equivalent is biocompatible for cell attachment, migration, proliferation, and differentiation. Preseeding Integra Artificial Skin with cultured autologous fibroblasts and keratinocytes for in vivo application, as a single-stage grafting procedure, warrants testing. A better clinical outcome may be achieved as shown by our in vitro results of the coculture composites.

Reconstructive surgery with a dermal regeneration template: clinical and histologic study.

Integra artificial skin was introduced in 1981 and its use in acute surgical management of burns is well established, but Integra has also been used in patients undergoing reconstructive surgery. Over a period of 25 months, the authors used Integra to cover 30 anatomic sites in 20 consecutive patients requiring reconstructive surgery and then analyzed the clinical and histologic outcomes. The most common reason for surgery was release of contracture followed by resurfacing of tight or painful scars. The authors assessed patients' satisfaction using a visual analog scale and scar appearance using a modified Vancouver Burn Index Scale. They evaluated the progress of wound healing by examining weekly punch-biopsy specimens with standard and immunohistochemical stains. Patients reported a 72 percent increase in range of movement, a 62 percent improvement in softness, and a 59 percent improvement in appearance compared with their preoperative states. Pruritus and dryness were the main complaints, and neither was improved much. Four distinct phases of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. Full vascularization of the neodermis occurred at 4 weeks. The color of the wound reflected the state of neodermal vascularization. No adnexa, nerve endings, or elastic fibers were seen in any of the specimens. The new collagen was histologically indistinguishable from normal dermal collagen. The authors conclude that Integra is a useful tool in reconstructive surgery. The additional cost of its use can be justified by its distinct benefits compared with current methodology.

Exogenous interleukin-10 increased in vitro rejection of allogeneic keratinocytes.

Interleukin-10 (IL-10) is an anti-inflammatory cytokine that has been shown to alter HLA expression in some hemopoietic cells. In skin, the presenting capacity of Langerhans' cells is reduced by IL-10, but little is known about the effect of IL-10 on keratinocytes. Using in vitro experiments, we have shown that IL-10 augments the HLA-DR expression of keratinocytes in the presence of interferon gamma. The increase in HLA-DR expression increased the stimulation and proliferation of allogeneic peripheral blood mononuclear cells, which in turn increased the in vitro rejection of allogeneic keratinocytes. Therefore exogenous application of IL-10 to cultured keratinocytes augments the rejection by allogeneic peripheral blood mononuclear cells in vitro conditions rather than having the suspected protective effect.

Turret exostosis of the thumb.

Eighteen cases of turret exostoses of the hand have been reported, all associated with dorsal injuries. We present a case of turret exostosis involving the volar aspect of the thumb.

Pyoderma gangrenosum following breast reconstruction.

Pyoderma gangrenosum is an unusual cause of skin necrosis following surgery, particularly in those without an associated systemic condition. There have been reports of the condition in this context but not in relation to breast reconstruction. We present a case of pyoderma gangrenosum following latissimus dorsi flap reconstruction of a breast.

Aspergillosis presenting as Koebner's phenomenon in a healed scald.

Koebner's phenomenon is an uncommon postburn complication. The following report describes a female child who sustained an 80% total body surface area scald which healed with conservative treatment. She developed a cutaneous Aspergillus infection involving only the previously scalded areas. The uninjured skin remained normal. She went on to develop systemic aspergillosis and died of multi-organ failure.

Toxic shock syndrome in adult burns.

Toxic shock syndrome is associated with burn injuries in children and is a cause of significant morbidity in this group. Despite multiple cases of toxic shock syndrome in adults being reported since its original description it has not been reported in adult burn patients. We report a case of toxic shock syndrome in an adult following 25% flame burns.

Immunohistochemical analysis of burn depth.

Clinical assessment of burns is accurate for very deep and very shallow burns, but it has been suggested that there is a high degree of inaccuracy in the assessment of dermal burns. Histologic analysis has, by some, been considered too time-consuming for routine diagnosis. It also requires an expert skin histopathologist to categorize the depth. With the use of an in vitro model, we have found the use of cryosections and an immunofluorescent staining method to be quicker and more clear-cut than standard light microscopic techniques. We believe this method plays a role in helping to define burns that would benefit from early excision and grafting. However, further investigation is required to transform the method from an experimental model to standard practice in the clinical setting.

Lightning: the multisystem group injuries.

In this article, we present our experience of group lightning injury. Individual injuries are most common after single strikes. The largest group previously reported was 10 patients. In our series, 17 victims were hit by a single strike; 11 were admitted to the hospital and 6 were discharged from the accident and emergency department. Although injured under the same circumstances, these patients presented with a wide range of symptoms and signs. We also describe a characteristic burn pattern, the "tip-toe sign."

Risk of Helicobacter pylori infection among long-term residents in developing countries.

The seroprevalence and incidence of Helicobacter pylori infection were determined among 312 North American missionaries who were serving in developing countries between 1967 and 1984. The majority (81%) resided in sub-Saharan Africa. When initially evaluated, the missionaries had a mean age of 40 years, 65% were female, and all were of white race/ethnicity. An ELISA showed that the initial prevalence of IgG antibody to H. pylori was 17%. After a mean of 7.4 years of service (1917 person-years of exposure), 37 (14%) of 259 initially seronegative subjects seroconverted to anti-H. pylori, giving an annual incidence of 1.9%. These data indicate a relatively higher risk of H. pylori infection among missionaries compared with an annual incidence of seroconversion of 0.3-1.0% in industrialized nations. Long-term residents in developing countries should be evaluated for H. pylori infection when gastrointestinal symptoms develop.

Pectoralis major ruptures postsuction lipectomy for surgical management of gynecomastia.

Over the last decade, suction-assisted lipoplasty has been shown to be a safe and reliable procedure in the hands of trained individuals. A large number of plastic surgeons employ liposuction as an adjunct to surgery for gynecomastia with excellent results and low morbidity. An unusual problem, traumatic rupture of the pectoralis major muscle, has been observed by us in a patient who had undergone the procedure. The physical deficit arising from the injury may go unnoticed in all but the most physically active people, and surgeons should be wary of the possibility of this previously unreported complication.

Silicone breast implants: complications.

Silicone breast implants have been used for augmentation mammoplasty for cosmetic purposes as well as for breast reconstruction following mastectomy for more than three decades. Though the use of the silicone gel filled variety has been banned in the USA except for special cases, they continue to be available elsewhere in the world including the UK. Despite the immense benefit they provide, their usage is associated with some complications. Most of these are related to the surgery and can be reduced by good surgical management. The major complications associated with their use is adverse capsular contracture, an outcome which can be very frustrating to manage. This article reviews the commonly reported complications and suggested management alternatives.