Subdermal Tissue Research Articles

Tightening effects of high-intensity focused ultrasound on body skin and subdermal tissue: a pilot study.

High-intensity focused ultrasound (HIFU) has been introduced as a new treatment modality for skin tightening through application mainly to the face and neck. This pilot study assessed the efficacy and safety of HIFU for body tightening in Asian females. Six Asian female adults were enrolled in this pilot study. All subjects were treated with HIFU to the both cheek, upper arm, lower abdomen, thigh and calf using the following probes: 7 MHz, 1.5 mm focal depth; 2 MHz, 3.0 mm focal depth; 2 MHz, 4.5 mm focal depth; 2 MHz, 6.0 mm focal depth and 2 MHz, 9.0 mm focal depth. Three blinded independent dermatologists assessed results using the Investigator Global Aesthetic Improvement Scale (GAIS) using paired pre- and post-treatment (week 4) standardized photographs. Also, we evaluated skin elasticity at all treated sites using a cutometer. Participants used the subject GAIS to assess their clinical improvement after treatment and rated their pain using a visual analogue scale (VAS) immediately, 1 and 4 weeks after treatment. The three blinded evaluators judged all treated sites as showing clinical improvement 4 weeks after treatment. Skin elasticity measured via cutometer was significantly improved 4 weeks after treatment at all treated sites (P < 0.05). All patients scored themselves subjectively as more than 'improved' on the GAIS. Immediately after treatment the mean VAS score was 5.17 ± 2.48, but no pain was reported at weeks 1 and 4. No permanent adverse effects were observed during the follow-up period. For body tightening, we applied HIFU using transducers with a lower frequency and deep focal depth to effectively deliver ultrasound energy to skin tissues. HIFU appears to be a safe and effective treatment modality for dermal and subdermal tightening.

FINITE ELEMENT PREDICTION OF SUB-DERMAL TISSUE STRESSES OF THE BUTTOCKS DURING WHEELCHAIR PROPULSION

Pressure ulcers, involving sub-dermal tissue damage and originating in deep tissue injury (DTI), have attracted much attention of physicians and researchers for three decades. Finite element (FE) model is a very efficient tool to investigate internal stresses and strains in human body that induce pressure ulcers. However, there was scarce report available to explore stresses distribution in human buttocks during manual wheelchair propulsion. A three-dimensional (3D) comprehensive FE model, incorporating ischial tuberosities (ITs), muscle, fat, and custom-contoured cushion (CCC), was developed to investigate internal stress distribution in soft tissue of the buttocks. Based on the FE model, pressure distribution under ITs in static sitting and during different wheelchair propulsions is studied. Internal stresses in fat and muscle were about three times and five times higher than that on cushion surface in terms of static sitting and wheelchair propulsion. All peak pressures under wheelchair propulsion were higher than those of static sitting, and peak pressures went on increasing with increase of wheelchair movement speed. This method based on the comprehensive FE model allowed for the optimization of wheelchair seat cushion design.

Safe Planes for Injection Rhinoplasty: A Histological Analysis of Midline Longitudinal Sections of the Asian Nose.

Dorsal nasal augmentation is an essential part of injection rhinoplasty on the Asian nose. Aesthetic physicians require detailed knowledge of the nasal anatomy to accurately and safely inject filler. One hundred and thirty-five histological cross sections were examined from 45 longitudinal strips of soft tissue harvested from the midline of the nose, beginning from the glabella to the nasal tip. Muscles and nasal cartilage were used as landmarks for vascular identification. At the nasal tip, a midline longitudinal columellar artery with a diameter of 0.21 ± 0.09 mm was noted in 14 cadavers (31.1 %). At the infratip, subcutaneous tissue contained cavernous tissue similar to that of the nasal mucosa. The feeding arteries of these dilated veins formed arteriovenous shunts, into which retrograde injection of filler may be possible. All of the nasal arteries present were identified as subcutaneous arteries. They coursed mainly in the superficial layer of the subcutaneous tissues, with smaller branches forming subdermal plexuses. A substantial arterial anastomosis occurred at the supratip region, in which the artery lay in the middle of the subcutaneous tissue at the level of the major alar cartilages. These arteries had a diameter ranging between 0.4 and 0.9 mm and were found in 29 of 45 specimens (64.4 %). This was at the level midway between the rhinion above the supratip and the infratip. This anastomotic artery also crossed the midline at the rhinion superficial to the origin of the procerus on the lower end of the nasal bone. Here the arterial diameter ranged between 0.1 and 0.3 mm, which was not large enough to cause arterial emboli. Fascicular cross sections of the nasalis muscle directly covered the entire upper lateral cartilage. The subdermal tissue contained few layers of fat cells along with the occasional small artery. The procerus arose from the nasal bone and was continuous with the nasalis in 16 cadavers (35.6 %). There was fatty areolar tissue between the procerus and the periosteal layer and no significant arteries present. The procerus ascended beyond the brow to insert into the frontalis muscle with very few cutaneous insertions. The supratrochlear vessels and accompanying nerve were occasionally found on the surface of the frontalis muscle. Most nasal arteries found in the midline are subcutaneous arteries. Filler should be injected deeply to avoid vascular injury leading to compromised perfusion at the dorsum or filler emboli at the nasal tip. This journal requires that the 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.

Development and Validation of a High Anatomical Fidelity FE Model for the Buttock and Thigh of a Seated Individual.

Current practices for designing new cushions for seats depend on superficial measurements, such as pressure mapping, which do not provide sufficient information about the condition of sub-dermal tissues. Finite element (FE) modelling offers a unique alternative to integrate assessment of sub-dermal tissue condition into seat/cushion design and development processes. However, the development and validation of such FE models for seated humans requires accurate representation of the anatomy and material properties, which remain challenges that are yet to be addressed. This paper presents the development and validation of a detailed 3D FE model with high anatomical fidelity of the buttock and thigh, for a specific seated subject. The developed model consisted of 28 muscles, the pelvis, sacrum, femur, and one layer of inter-muscular fat, subcutaneous fat and skin. Validation against in vivo measurements from MRI data confirmed that the FE model can simulate the deformation of soft tissues under sitting loads with an accuracy of (mean±SD) 4.7±4.4mm. Simulation results showed that the maximum strains (compressive, shear and von-Mises) on muscles (41, 110, 79%) were higher than fat tissues (21, 62, 41%). The muscles that experienced the highest mechanical loads were the gluteus maximus, adductor magnus and muscles in the posterior aspect of the thighs (biceps femoris, semitendinosus and semimembranosus muscles). The developed FE model contributes to the progression towards bio-fidelity in modelling the human body in seated postures by providing insight into the distribution of stresses/strains in individual muscles and inter-muscular fat in the buttock and thigh of seated individuals. Industrial applications for the developed FE model include improving the design of office and household furniture, automotive and airplane seats and wheelchairs as well as customisation and assessment of sporting and medical equipment to meet individual requirements.

Cryopreserved human umbilical cord patch for in-utero spina bifida repair.

To identify a patch system to repair surgically created spina bifida in a sheep model for its efficacy in healing the skin defect, protecting the underlying spinal cord and reducing the Chiari II malformation. Spina bifida was created surgically in 16 fetuses from eight timed-pregnant sheep at gestational age of 75 days. Two fetuses did not survive the procedure. Repeat hysterotomy was performed at 95 days' gestation to cover the defect with either biocellulose film with underwater adhesive (BCF-adhesive) (n = 7) or human umbilical cord with suture (HUC-suture) (n = 7). Three fetuses without formation of the defect served as reference controls. The skin healing was examined by direct visualization after a planned Cesarean section at term, followed by histological analysis using hematoxylin and eosin and Masson's trichrome stains. Mid-sagittal sections of the fetal cranium and upper cervical spine were analyzed by a pediatric neuroradiologist who was blinded to the type of patch received. Three fetuses that received the BCF-adhesive and six fetuses that received the HUC-suture survived to term for final analysis. As a result of dislodgment of the BCF-adhesive, all spina bifida defects repaired using BCF-adhesive were not healed and showed exposed spinal cord with leakage of cerebrospinal fluid. In contrast, all spinal defects repaired by HUC-suture were healed with complete regrowth of epidermal, dermal and subdermal tissue components, with no exposed spinal cord. The maximal skin wound width was 21 ± 3.6 mm in the BCF-adhesive group but 3 ± 0.8 mm in the HUC-suture group (P < 0.001). The spinal cord area (P = 0.001) and the number of anterior horn cells (P = 0.03) was preserved to a greater degree in the HUC-suture group than in the BCF-adhesive group, whilst psammoma bodies, signifying neuronal degeneration, were only observed in the BCF-adhesive group. Anatomic changes, indicative of Chiari II malformation, were seen in all three fetuses of the BCF-adhesive group but in none of the HUC-suture group (P < 0.01). Cryopreserved umbilical cord graft is a promising regenerative patch for intrauterine repair of spina bifida.

Management of a Common Breast Augmentation Complication: Treatment of the Double-Bubble Deformity With Fat Grafting.

The double-bubble deformity is one of the most common problems in breast augmentation, with or without mastopexy. Classically, open techniques have been used to treat this deformity, including elevation and reconstruction of the inframammary crease or parenchymal scoring. In this study, the author reports experience with a simple, closed technique of serial fat grafting procedures to treat the double-bubble deformity. Twenty-eight patients with double-bubble deformities were retrospectively evaluated. Fifteen patients had undergone primary augmentation, whereas 13 patients had undergone augmentation mastopexy. Eight patients presented with bilateral double-bubble deformity. Up to 3 sessions of fat grafting were performed on each patient, with a mean of 2.1 sessions required for patients in the series. An average of 27 cm3 of fat was injected with each treatment per breast. Fat was injected with a 1.5-mm blunt cannula into the subdermal and superficial breast tissue layers beneath the old inframammary fold. There were no oil cysts, infections, or donor site problems noted in the series. Twelve patients with limited breast tissue underwent magnetic resonance imaging examination at the conclusion of the fat grafting sessions, and no implant injury or disruption was noted. All patients were pleased with the results of treatment, and no revisional surgery was required. This study suggests that fat grafting is an effective treatment of the breast double-bubble deformity. The procedure allows the correction of a challenging deformity with a simple, closed technique which is safe and cost-effective.

A cause of severe thigh injury: Battery explosion

IntroductionIn parallel with technological improvements, humankind encounter with equipments/devices transforming chemical energy to electrical energy. Especially automobile batteries, watch and mobile phone batteries are the most encountered ones. In the literature, there are mainly facial burn cases due to mobile phone battery explosion. On the other hand very few examples of serious lower limb. injury is present.Presentation of case12-year-old female patient referred to emergency room with skin and soft tissue injuries on bilateral anteromedial thigh area as a result of battery explosion. The widest axis of skin defect was approximately 16 × 8 cm on the right side, and 17 × 4 cm on the left side. In addition, there were tattooing caused by chemical injury and multiple pin-point like lesions extending to dermal level on anterior region of thigh. Chemically dirty and necrotized dermal and subdermal tissues were debrided and foreign materials were removed from regions with multiple tattooing. Left thigh was closed primarily. In order to close the defect on right anterior thigh, skin flap from right medial thigh is advanced in Y–V fashion.DiscussionBattery explosion causing lower extremity tissue defect is a type of injury that is rarely seen in the literature. Regardless of battery size and energy level, they should be considered as potential explosive material and protector masks, clothing should be worn during contact with this type of material.

A Rare Case of Ecthyma Gangrenosum Caused by Proteus vulgaris and Candida albicans in a Patient with Castleman Disease.

Ecthyma gangrenosum (EG) is an ulcerative pyoderma of the skin that extends into the dermis and subdermal tissue with necrotic changes, and is generally described as a round, deep, punched-out ulceration with a central black eschar surrounded by an erythematous halo [[1]]. Development of EG is most commonly associated with Pseudomonas aeruginosa and is often seen in immunocompromised patients. However, cases of EG caused by other bacterial, viral, and fungal pathogens have been reported in the literature, albeit rarely. Prompt surgical debridement with appropriate antibiotic therapy is crucial for lowering the mortality rate in EG patients [[1]]. We describe an interesting case of EG caused by Proteus vulgaris (P. vulgaris) and Candida albicans (C. albicans) in a patient with multicentric Castleman disease (MCD), which involves hyperactivation of the immune system and multiple organ system dysfunction. Our patient showed extensive lesions involving necrotic ulcerative changes on the lower abdomen and on the right upper arm. To the best of our knowledge, this was a rare case of EG associated with P. vulgaris and C. albicans.

Facial rejuvenation starts in the midface: three-dimensional volumetric facial rejuvenation has beneficial effects on nontreated neighboring esthetic units.

Facial aging is a major indication for minimal invasive esthetic procedures. Dermal fillers are a cornerstone in the approach for facial sculpturing. But where to start? Our concept is midfacial volume restoration in first place. This will result in a healthy and youthful appearance creating a facial V-shape. But midfacial filler injection does not only improve the malar area. It has also beneficial effects on neighboring esthetic units. We report on such improvements in periocular and nasolabial region, upper lips and perioral tissue, and the jaw line and discuss anatomical background. We hypothesize that midfacial deep filler injections also may activate subdermal white adipose tissue stem cells contributing to longer lasting rejuvenation.

Periareolar Closure With Barbed Sutures.

Periareolar closure in augmentation, mastopexy, and breast reduction has evolved dramatically over the past 10 years with changes in technique and technology. Plastic surgeons have tried many techniques from simple purse string closures using permanent sutures1 to interlocking purse string closures with GORE-TEX2 (Gore Medical, Newark, DE) or absorbable sutures. Running and interrupted suture techniques or combinations of both have all been utilized. I began using absorbable barbed sutures in 2007 for abdominoplasty3,4 to eliminate knot tying and decrease complications associated with permanent sutures such as knot palpability, extrusion, and infection.5 I then applied this new suture technology to surgical closures of the breast and developed a technique for periareolar closure that has improved my efficiency. First the areolar is marked into eight quadrants. A surgical staple is placed at the 12 o'clock position to stabilize the tissues. Starting at the 6 o'clock position of the areola, a double-armed 2-0 polydioxanone (PDO) Quill (Surgical Specialties Corporation, Wyomissing, PA) suture is looped to include the subdermal areolar tissues and the two corners of the adjacent skin comprising the top of the vertical limb. Each arm of the barbed suture is deployed in the subdermal plane and passed up to the 12 o'clock position in an interlocking fashion, …

Histological and immunohistochemical characterization of Hypoderma lineatum (Diptera: oestridae) warbles

Hypoderma larvae are tissue invading parasites which spend several months migrating within the host tissues before completing their development in the sub-dermal tissues of the back. Subcutaneous stages of the parasite produce an inflammatory reaction in the skin called “warbles”, as well as holes through which larvae breathe. In order to elucidate the microscopical structure of the warbles, three hides from warbled cows were collected in a slaughterhouse in Lugo (NW, Spain) between March and May 2012. A total of 60 skin samples, including warbles at different phases of development, were chosen for histopathological and immunohistochemical examination. Microscopic lesions were classified into three groups, according to the predominance and distribution of different cell populations. In warbles containing living or recently dead larvae with apparently well preserved cuticle (type 1), plasma cells were observed in high number. However, macrophages and lymphocytes were the predominant cells in granulomas (type 2) formed in relation to remnants of the dead parasite, containing or not remains of the altered cuticle. Scars (type 3) were characterized by granulation tissue. Immunohistochemistry showed that B lymphocytes and IgG+ cells were predominant in the lesions, as long as the cuticle of the larvae is intact. On the other side, CD3+ lymphocytes increased once cuticle is destroyed and a granuloma is formed. Macrophages, revealed by CD68+, MAC387+ and lysozyme immunolabelling, were detected in all types of lesions, but they were more abundant in type 2 and scarce in scars. These cells appeared isolated around the intact larvae or forming aggregates around its remains in the granuloma. Moreover, a strong immunolabelling against MAC387 antibody was registered in the squamous epithelium covering the breathing pore. This finding may be associated with the expression of calprotectin, a molecule involved on the healing process of the skin after larvae outcome. Our results suggest the predominance of a humoral response inside the warble as long as larvae are intact. Once they are destroyed, cellular response occurred, isolating and destroying the remains of the larvae until healing process completes and scars with low numbers of inflammatory cells appear.

Two-dimensional finite difference model to study temperature distribution in SST regions of human limbs immediately after physical exercise in cold climate

Thermoregulation is a complex mechanism regulating heat production within the body (chemical thermoregulation) and heat exchange between the body and the environment (physical thermoregulation) in such a way that the heat exchange is balanced and deep body temperatures are relatively stable. The external heat transfer mechanisms are radiation, conduction, convection and evaporation. The physical activity causes thermal stress and poses challenges for this thermoregulation. In this paper, a model has been developed to study temperature distribution in SST regions of human limbs immediately after physical exercise under cold climate. It is assumed that the subject is doing exercise initially and comes to rest at time t = 0. The human limb is assumed to be of cylindrical shape. The peripheral region of limb is divided into three natural components namely epidermis, dermis and subdermal tissues (SST). Appropriate boundary conditions have been framed based on the physical conditions of the problem. Finite difference has been employed for time, radial and angular variables. The numerical results have been used to obtain temperature profiles in the SST region immediately after continuous exercise for a two-dimensional unsteady state case. The results have been used to analyze the thermal stress in relation to light, moderate and vigorous intensity exercise.

Clinical potential of resistin as a novel prognostic biomarker for cellulitis.

Cellulitis is an acute, subacute or chronic inflammation of the dermis and subdermal tissues, which is typically caused by bacteria, although other causes are possible. The present study aimed to evaluate the association between resistin levels and the recovery time of patients with cellulitis. In addition, the effect of resistin and insulin resistance on the prognosis of cellulitis was investigated. In total, 52 patients with cellulitis (male, 21; female, 31) and an age-matched group of 42 healthy individuals (male, 18; female, 24) were included in the study. The levels of serum resistin, fasting plasma glucose (FPG), homeostasis model assessment-insulin resistance (HOMA-IR), C-reactive protein (CRP) and other biochemical parameters were compared between the groups. The mean resistin levels in the cellulitis and control groups were 9.4±5.3 and 5.8±3.1 ng/ml, respectively. The levels of resistin, FPG, HOMA-IR and CRP were significantly higher in the cellulitis group compared with the control group (P<0.001). Furthermore, the mean recovery time of the patients with cellulitis was 21.2±5.6 days. Thus, increased levels of resistin (P=0.002) and HOMA-IR (P=0.005) could be used as predictive factors for the recovery time. The enhanced levels of resistin and HOMA-IR were shown to correlate with the high CRP levels in the cellulitis group. Therefore, the results indicated that increased levels of resistin may function as a prognostic marker for cellulitis.

Sol Bel Bölgesinde Dev Lipom: Olgu Sunumu ve Literatürün Gözden Geçirilmesi

Lipomas are benign soft tissue neoplasms comprised of mature adipocytes encapsulated by a layer of connective fibrous tissue. Our case was 56 years old man who has a slow growing mass on his left loin for ten years. Lately, he suffered from this mass because he complained about wearing pants, sitting a chair and failing daily activities. On physical examination, 25x15 cm soft, mobile mass lining through his left loin was seen. An elliptical incision consisting of expanded skin was made. 21x5 cm expanded skin and 25 cm length, 15 cm width and 6cm depth superficial lipoma was removed by the monopolar electrocautery over the fascia. A hemovac suction drain was placed. Dermis and subdermal tissue have sutured by 3-0 absorbable sutures. Skin was closed by stapler. In our study, we represent a case of giant lipoma in left loin which has a 25x15x6 cm dimensions. We suggest that this lipoma is among the biggest ones in the literature which has been reported.

Nonexcisional, Minimally Invasive Rejuvenation of the Neck Using Radiofrequency Tissue Tightening (FaceTite™)

There are nonsurgical and nonexcisional alternatives for lower face and neck lifts, including traditional liposuction, laser-assisted liposuction (LAL), skin surface skin tightening technologies, and minimally invasive skin tightening (MIST). Although traditional tumescent neck liposuction is highly effective at contouring and fat removal, it fails to address the residual skin laxity left behind completely in a number of cases [1-3]. While easily facilitating lipolysis and removal, neck LAL fails to manage residual skin laxity adequately [4]. In contrast to skin surface technologies, the use of needle electrodes or fiber cannula MIST delivers the laser or radiofrequency (RF) energy immediately into the dermis or subdermal tissue, maximizing efficacy in treating lower face and neck laxity [5,6]. Noninvasive RF and lasers have been used for skin tightening and body contouring since the 1990s. An RF device (BodyTite; Invasix Ltd, Yokneam Ilit, Israel) was introduced in 2008 to contract skin and soft tissue, and treat subcutaneous adipose regions. The RF energy elicits its effects on the fibroseptal network and triggers skin tightening and soft tissue contraction [7,8]. RF energy inJin Seok Kang, Seong Eun Cho, Seung Min Nam, Eun Soo Park

356 SLEEPING BEAUTY TRANSGENESIS IN CATTLE

Transposon-mediated transgenesis is a well-established tool for genome modification in small animal models. However, translation of this active transgenic method to large animals warrants further investigations. Here, the Sleeping Beauty (SB) transposon system was assessed for stable gene transfer into the cattle genome. The transposon plasmids encoded a ubiquitously active CAGGS promoter-driven Venus reporter and a lens-specific α A-crystallin promoter driven tdTomato fluorophore, respectively. The helper plasmid carried the hyperactive SB100x transposase variant. In total, 50 in vitro-derived zygotes were co-injected (Garrels et al. 2011 PLoS ONE 6; Ivics et al. 2014 Nat. Protoc. 9) and cultured up to blastocyst stage (Day 8). Two blastocysts were Venus-positive and were transferred to synchronized heifers, resulting in one pregnancy. The resulting calf was normally developed and vital; however, it died shortly after cesarean section due to spontaneous bleeding from an undetected aneurism. Phenotypic analysis suggested that the calf was indeed double-transgenic, showing widespread expression of Venus and lens-specific expression of tdTomato. Genotyping and molecular analyses confirmed the integration of both reporter transposons and the faithful promoter-dependent expression patterns. Subdermal tissue of an ear biopsy was used to culture fibroblasts, which were employed in somatic cell nuclear transfer experiments. In total, 39 embryos were reconstructed, of which 34 underwent cleavage, and at the end of culture 12 morulas and 12 blastocysts were obtained. Ten of the blastocysts were Venus positive, and embryo transfer of Venus-positive blastocysts is planned. In summary, we showed that the cytoplasmic injection of SB components is a highly efficient method for transgenesis in cattle. Due to the modular composition of SB plasmids, even double transgenic cattle can be generated in a one-step procedure. Importantly, the SB-catalyzed integration seems to favour transcriptionally permissive loci in the genome, resulting in faithful and robust promoter-dependent expression of the transgenes. The transposon constructs carry heterospecific loxP sites, which will be instrumental for targeted insertion of functional transgenes by Cre recombinase-mediated cassette exchange.Financial support of DFG (Ku 1586/3-1), UNRC, CONICET and Agencia Nacional de Promoción Científica y Tecnológica de la Argentina (ANPCyT) is gratefully acknowledged.

A finite element approach for analyzing the effect of cushion type and thickness on pressure ulcer

Immobilization or continuous sitting with a constant posture for a long time in office environment causes sub-dermal tissue damage. Tissue damage occurs because of continuous prolonged compression of buttock soft tissue under body weight. It is treated as the end result of cell death or tissue deformation which ultimately gives rise to pressure ulcer. Although the sub-dermal tissue refers to the tissue beneath the skin, it is the tissue just below the bony portion undergoes maximum deformation because the muscle endures a continuous high stress. In this work, a simple but practical numerical approach has been proposed to estimate the maximum stress beneath the bony structure (ischial tuberosity). The model is validated with experimental data from the literature. Effect of properties of cushion material, loading angle and thickness of cushion has been analyzed. The cushion properties and thickness that can reduce maximum stress at ischial tuberosity have been demonstrated. The effect of sitting posture on maximum stress at ischial tuberosity has also been shown. Relevance to industryThe study can possibly help the practitioners to select type of cushion and its thickness that can reduce pressure ulcer during prolonged sitting. The simplified but practical model presented in this paper can provide a platform to study the behaviour of different type of cushion material and thickness reducing expensive experimental burden.

Aplasia cutis congenita and limb anomaly: A case of non-scalp lesion

SUMMARY Aplasia cutis congenita is a rarely seen disease in which dermis, subdermal tissue and extremely rarely bone are absent. Significant number of cases are lost due to infections, electrolyte imbalance, and massive hemorrhage. In this report, we present a 2-day-old infant who had a wide aplasia cutis area on the right lower limb.

Labiopexy and labioplasty for labium majus rejuvenation in light of a newly discovered anatomic structure.

Currently, removal of excessive cutis with subdermal adipose tissues is done for labium majus rejuvenation. The objectives of this study were to determine the accurate labium majus anatomy, to develop new labiopexy and labioplasty techniques, to attest to the applicability of these two new operations, and to determine the impact of the operations on self-perceived body image and sensation of nerve endings. A prospective case series study was conducted. Eleven fresh human female cadavers and three living subjects were studied. Living subjects were healthy women and presented with labium majus deformities. The study was conducted in three phases: phase I, the labium majus anatomy of the cadavers was studied; phase II, anatomic findings from phase I were used to develop and standardize new stepwise surgical interventions; and phase III, newly developed operations were implemented on living subjects. Labial sensation tests of nerve endings were performed preoperatively and at 6 months postoperatively. The primary outcome measured the labial anatomy and applicability of the new operations. The secondary outcome measured the self-perceived body image and sensation of nerve endings before and after surgery. A new anatomic feature, the labium majus adipose sac, was discovered and was present in each subject. Labium majus labiopexy and labioplasty were executed without technical difficulties or complications. Postoperatively, the self-perceived body image improved and sensation of nerve endings was intact. The labium majus adipose sac is present in each woman. Intraoperatively, newly developed labium majus labiopexy and/or labioplasty do not create technical problems. Self-perceived body image improves and sensation of the nerve endings is intact after labiopexy or labioplasty. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Strengthening the Skin with Topical Delivery of Keratinocyte Growth Factor-1 Using a Novel DNA Plasmid

Fragile skin, susceptible to decubitus ulcers and incidental trauma, is a problem particularly for the elderly and for those with spinal cord injury. Here, we present a simple approach to strengthen the skin by the topical delivery of keratinocyte growth factor-1 (KGF-1) DNA. In initial feasibility studies with the novel minimalized, antibiotic-free DNA expression vector, NTC8385-VA1, the reporter genes luciferase and enhanced green fluorescent protein were delivered. Transfection was documented when luciferase expression significantly increased after transfection. Microscopic imaging of enhanced green fluorescent protein–transfected skin showed green fluorescence in hair follicles, hair shafts, and dermal and superficial epithelial cells. With KGF-1 transfection, KGF-1 mRNA level and protein production were documented with quantitative reverse transcriptase–polymerase chain reaction and immunohistochemistry, respectively. Epithelial thickness of the transfected skin in the KGF group was significantly increased compared with the control vector group (26 ± 2 versus 16 ± 4 µm) at 48 hours (P = 0.045). Dermal thickness tended to be increased in the KGF group (255 ± 36 versus 162 ± 16 µm) at 120 hours (P = 0.057). Biomechanical assessment showed that the KGF-1–treated skin was significantly stronger than control vector–transfected skin. These findings indicate that topically delivered KGF-1 DNA plasmid can increase epithelial thickness and strength, demonstrating the potential of this approach to restore compromised skin.