Submuscular Position Research Articles

The modified fascial sling technique for ulnar nerve anterior transposition: surgical techniques and results

Approaches to surgical treatment to cubital tunnel syndrome include simple decompression, decompression with medial epicondylectomy, and decompression with anterior transposition of the ulnar nerve. Transposition of the ulnar nerve involves decompression and transposition of the nerve anteriorly to a subcutaneous, intramuscular, or submuscular position. However, transposing the ulnar nerve to subcutaneous plane renders it more susceptible to external trauma. Hence, this technique article introduces the use of a modified fascial sling. The modified fascial sling technique for anterior transposition of the ulnar nerve involves careful dissection to identify the ulnar nerve, decompression of the nerve, then transposition of the ulnar nerve anterior to the medial epicondyle. An AlloWrap (Stryker, Kalamazoo, MI, USA) is first wrapped around the ulnar nerve, followed by wrapping a fascial sling fashioned from the flexor carpi ulnaris fascia. A prospective case series for this surgical technique was conducted. Wilcoxon signed-rank test compared preoperative and postoperative qDASH-9 scores, an abbreviated questionnaire to assess functional limitations of the upper limb. Five patients were included in this study, with a mean duration of follow-up of 530.4 days. The mean QuickDASH-9 functional disability score was 36.5 ± 25.1 preoperatively and 20.6 ± 12.8 postoperatively, demonstrating statistically significant improvement (P= .008). The modified fascial sling technique for anterior transposition of the ulnar nerve was developed to address the complications of perineural adhesions after transposition causing tethering of the ulnar nerve. At the same time, the fascial sling prevents posterior subluxation of the ulnar nerve back to its original location, thereby reducing the risk of recurrent symptoms.

Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery.

Simultaneous application of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA. The aim of this study was to present the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluate its aesthetic benefits after primary/secondary BA. In total, 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant. Mean patient age was 34.6 years (range, 28-56 years), mean BMI was 18.8 kg/m2 (range, 14.4-26.1 kg/m2). The most common implant (Motiva SmoothSilk surface Ergonomix style) volume was 255 cc (range, 175-355 cc), patients received a mean fat volume of 96 mL (range, 60-145 mL) per breast in the subcutaneous tissue. The average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days postprocedure and 10 days to 18 months postprocedure, respectively. Postoperative complications included subcutaneous banding in the axilla (n = 3, 7.1%), small wound dehiscence (n = 1, 2.3%), and hypertrophic scarring (n = 1, 2.3%). No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (range, 6-32 months). SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

Smooth Prosthesis: Our Experience and Current State of Art in the Use of Smooth Sub-muscular Silicone Gel Breast Implants.

The objective of this clinical review is to provide an overview of the use of silicone gel-filled breast implants placed in the sub-muscular position, with a focus on complication rates reported for both smooth and textured implants. Furthermore, our experience in this field is also reviewed. MEDLINE, EMBASE, Web of Science, Scopus, the Cochrane Central and Google Scholar databases were reviewed to identify the literature related to smooth breast implants. Each article was reviewed by two independent reviewers to ensure all relevant publications were identified. The literature search identified 98 applicable articles. Of these, just a few articles were found to have a therapeutic level of evidence. The reference lists in each relevant paper were screened manually to include relevant papers not found through the initial search. Eight articles report the risk of capsular contracture when the breast implants were placed in the sub-muscular position. Six of these articles report a similar rate of capsular contracture in smooth and textured implants. Local complications such as wrinkling, late seroma and double capsules were found to be associated with the use of textured breast implants (4 articles). All articles concerning BIA-ALCL reported a total absence occurring in smooth breast implants. All cases have been associated with textured mammary prostheses. With our expertise in the field and the results of this up-to-date literature review, it can be concluded that there are no significant advantages of using one type of implant surface over the other when placed in the sub-pectoral position. 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.

Aberrant course of superficial radial nerve in the forearm: an anatomical variation and its clinical implications

The superficial radial nerve (SRN) is the terminal pure sensory branch of the radial nerve supplying dorsal aspects of the proximal portion of the lateral three and a half digits...

ПЕРВЫЙ ОПЫТ ПРИМЕНЕНИЯ СИЛИКОНОВЫХ ИМПЛАНТАТОВ ПРИ АУГМЕНТАЦИОННОЙ ГЛУТЕОПЛАСТИКЕ В ТАДЖИКИСТАНЕ

The article describes the first experience of the use of silicone gluteal implants with the achievement of the aesthetic effect in 2 young patients aged 24 and 30 years. After a careful individual conversation, the method of placement in each case, there would be a combined procedure: in one observation – directly by gluteal muscle fascia, in the other – a submuscular position. The article notes that regardless of the method of implant placement, in both cases the optimal result was obtained, although there were certain features during the operation and in the postoperative period.

008 Submuscular Ectopic Inflatable Penile Prosthesis Reservoir Placement: A Cadaveric Study of Anatomic Location

Ectopic submuscular placement of the inflatable penile prosthesis (IPP) reservoir via the inguinal canal has become popularized as an alternative to the traditional retropubic space of Retzius. Published results suggest minimal complications and high patient satisfaction. However, in our practice, we identified several patients presenting for IPP revision after submuscular ectopic placement who were found to have reservoirs within the peritoneal cavity. Given the potential for associated complications, we performed a cadaveric study to define the anatomic location of reservoirs placed in the high submuscular position via the inguinal canal. We secured 10 fresh male cadavers (prior to the embalming process) without history of prior intra-abdominal surgery. Bilateral submuscular ectopic reservoir placement was performed using published techniques via the inguinal canal. After placement, an anatomic dissection was performed to identify the location within the abdominal wall layers. Cadaver specific data, surgical technique, and anatomic reservoir location were recorded.

High-Resolution Sonography of Posttraumatic Neuroma of the Superficial Radial Nerve

The superficial radial nerve (SRN) is a sensory branch of the radial nerve which supplies the dorsolateral aspect of the hand and the first 3 digits. The radial nerve, a nerve with mixed fibers, branches into the pure motor posterior interosseous nerve and the pure sensory superficial radial nerve just above the arcade of Frohse in the proximal forearm. In the distal forearm, the superficial radial nerve transverses a superficial subcutaneous course between the tendons of the brachioradialis and extensor carpi radialis longus muscles as it crosses the lateral edge of the radius. Many factors may contribute to the development of a lesion of the SRN. The most common anatomic site of compression corresponds to the area of transmission of the nerve from its submuscular position beneath the brachioradialis muscle to its subcutaneous position on the surface of the extensor carpi radialis longus muscle.

Is Hyaluronic Acid Gel a Good Option for Breast Augmentation?

We have clinical experience with Macrolane in body contouring dating back to 2002. Initially, it was used exclusively in clinical studies, but since the European conformity marking in 2007, it has found its place as a routine clinical treatment in our unit. It is agreed that the absorption time (albeit with great variability) is relatively quick in many patients, making the procedure expensive. The expense notwithstanding, this type of procedure is greatly in demand because many patients are uncertain about the outcome of a surgical procedure (e.g., a beast augmentation). It is not uncommon for patients undergo Macrolane augmentation and then after absorption of the material, convert to having breast implants. Thus, we see a new group of patients unwilling to undergo surgery for consultations. Even if mammographic evaluation can be impaired after hyaluronic acid injections, radiologists (e.g.,. Dr. Magnus Tengvar) involved in our clinical studies have stated that ultrasound added to the mammography provides the same sensitivity and specificity as mammography alone for breasts without Macrolane. To facilitate radiologic examination, it is recommended that the material be placed more like an implant between the gland and muscle with our described pocket technique or in a partial submuscular position. We also recommend that all Macrolane patients older than 40 years should have a mammogram taken less than 3 months before the treatment. Due to the current limited experience with larger series of breasts augmented with Macrolane, we also recommend avoiding treatment of patients with an increased risk for breast cancer. In relation to the nodule and capsule formation treatment, this obviously is something the patient should be well informed about before deciding to undergo the treatment. However it also is important to underscore that treatment of these problems is simple and that in spite of these complications, very few patients (\2%) request removal of the material. In discussing the place for Macrolane in the clinical setting, it must be recognized that many other indications besides breast augmentation exist. In our experience, buttocks, calves, and male chest enhancements have provided patient satisfaction levels that equal those for breast augmentations.

Characteristics of patients and implantable defibrillators associated with failure to sense device alert systems

In the era of increasing implantable cardioverter defibrillator (ICD) complexity, the ICD patient alert is deemed to be an important feature in the early detection of ICD system malfunction and is either an audible or a vibratory alert. We sought to evaluate the patient's ability to detect these ICD alerts in the device clinic setting as a surrogate endpoint of clinical utility. From 1 November 2006 to 31 March 2008, 563 patients with an ICD equipped with either an audible patient alert (APA, Medtronic and Guidant; n = 485) or a vibratory monitoring alert ([VMA, St Jude Medical; n = 78) had their alarm demonstrated in the quiet clinic setting. The ability to recognize the alert was analysed and then stratified by gender, age, manufacturer, type of alert, and pocket location. The average patient age was 63.3 (± 13.6) years and 82.8% of patients were male. Implantable cardioverter defibrillator manufacturers were Medtronic (n = 464), Boston Scientific (n = 21), and SJM (n = 78). The APA was heard in 86.0% of patients. This was less likely in patients who were older, male, and where the device was placed in the submuscular position. Every patient with a VMA sensed their alert. In the current ICD alert technology, the ability to sense the ICD alert in the device clinic appears to be higher for the VMA than for the APA. In particular, older patients and male patients are less likely to sense the APA.

Multicenter Study on Breast Reconstruction Outcome Using Becker Implants

The use of tissue expanders and implants is the simplest option for breast reconstruction following mastectomy. In the 1980s, Hilton Becker introduced a round, inflatable breast implant that could be used as a permanent implant. Since then, the original implant has been improved in both design and architecture. The new Becker device consists of an anatomical implant composed of 35% cohesive silicone gel in the outer chamber and 65% normal saline in the inner chamber. This multicenter study describes our experience with the new anatomical Becker implants in a large series of patients, in both immediate and delayed breast reconstruction. We reviewed the clinical records of 204 patients who underwent a breast reconstruction with an anatomical Becker-type implant in the sub-muscular position between November 2004 and December 2006. Data on the patients' characteristics, indications for reconstruction, operative technique, device size used, complications, and need for further operations were collected and analyzed. A total of 248 breast reconstructions were performed in 204 patients. One hundred forty-three patients (70%) underwent an immediate reconstruction; in the remaining 61 cases (30%), the breast reconstruction was performed later. The patients' age ranged from 26 to 66years, with a median age of 47.5years. The implant was placed unilaterally in 160 women (78.5%) and bilaterally in the remaining 44 (21.5%). Complications occurred in 85 cases (34.2%), in both the immediate and delayed reconstruction groups, and were related to wound healing, bleeding, seroma, and problems with the inflatable expanders. Iatrogenic implant rupture was documented in one case (0.4%). Inflation was impossible in 7 cases (2.8%) as a result of valve obstruction (3 cases, 1.2%) and valve displacement (4 cases, 1.6%). Implant malposition was the most troublesome complication; indeed, 34 patients (13.7%) complained of device malposition. Capsular contracture was assessed in all the patients. Significant capsular contracture (Baker grade III and IV) was detected in 6 cases (2.4%) at the follow-up approximately 1year after surgery. Breast reconstruction with permanent inflatable expanders is widely acknowledged as a useful technique for breast cancer patients undergoing simple or modified radical mastectomy. The use of this device eliminates the need to replace a temporary tissue expander with a breast implant, thus avoiding a second operation. Although we believe autologous tissues afford the best method of reconstruction in the majority of patients, the results of our study show that expander implant placement may yield a reasonable reconstruction.

Protective Effect of Topical Antibiotics in Breast Augmentation

Previous studies indicate that antibacterial lavage and/or use of topical antibiotics may reduce infection in breast implant surgery and perhaps also reduce occurrence of capsular contracture. A retrospective analysis was performed to evaluate this effect. The study participants included all women (n = 436) who underwent breast augmentation during two different time periods: 2000 to 2002 (n = 218) and 2005 to 2007 (n = 218). During the first period (2000 to 2002), cephalothin (Keflin), was added to the saline/epinephrine solution, which was used to irrigate the implant pocket and filled into the outer lumen of the saline/gel implants. In the second period (2005 to 2007), only saline/epinephrine was used. All women were operated on at the same clinic and by the same surgeon. Recorded postoperative complications included occurrence of infection, seroma, and capsular contracture. Medical records were identified for 414 women (94.9 percent): 2000 to 2002 (n = 203) and 2005 to 2007 (n = 211); 99.8 percent of all implants were placed in the submuscular position and 99.8 percent of all incisions were periareolar. Frequency of infection in the 2005 to 2007 cohort (12.8 percent) exceeded substantially the frequency among the 2000 to 2002 cohort (6.7 percent; p = 0.044), as did the frequency of seroma (7.6 percent versus 2.9 percent, respectively; p = 0.036). There was no significant difference in development of capsular contraction between the two groups (8.1 percent versus 5.9 percent; p = 0.393). The authors' data support the use of topical antibiotics in cosmetic breast surgery, because significant increases of both infections and seroma were seen in patients not treated with topical antibiotics compared with a cohort of similar patients where topical antibiotics were used.

Striae Distensae as a Complication of Augmentation Mammaplasty

Sir: Only 10 cases of striae distensae as a complication of breast augmentation have been reported in the plastic surgery literature thus far.1–6 Although the cause of striae distensae is not yet completely understood, it has been suggested that striae following augmentation mammaplasty are related to nulliparity, young age, and oral contraceptive use.2,4 Of the 10 cases reported, seven occurred in the subglandular position1,2,4,5 and only three occurred in the submuscular position.3,6 Implant size was not a factor. We present a case series of 22 patients who developed striae distensae following augmentation through a transaxillary subpectoral approach by a single surgeon. Of 1546 augmentation mammaplasties performed by the senior author (D.C.M.), 22 patients (1.4 percent) returned postoperatively with evidence of new onset striae distensae. All had undergone the transaxillary subpectoral approach to augmentation. A retrospective chart review was performed for these patients to ascertain their age, parity, history of breastfeeding, smoking, use of oral contraceptives, and preoperative breast volume. Prior personal history of stretch marks was determined by telephone survey and review of preoperative photographs. Postoperatively, newly developed striae were classified subjectively as mild, moderate, or severe (Figs. 1 and 2). Patients were counseled that the stretch marks would fade with time, but vitamin E, cocoa butter, or bag balm cream were also recommended.Fig. 1.: Moderate postoperative striae. This 19-year-old nulliparous nonsmoker developed moderate striae 10 weeks after placement of 460-cc implants.Fig. 2.: Severe postoperative striae. This 22-year-old nulliparous smoker developed severe striae 5 1/7 weeks after placement of 480-cc implants.All patients were healthy and ranged in age from 18 to 32 years (mean, 23 ± 4.3 years). Ninety-five percent of patients (n = 21) had not had term pregnancies, with 82 percent of patients (n = 18) specifically being nulliparous (Table 1). One patient (5 percent) had breastfed in the past. Twenty-one of the 21 patients for whom data were available had striae elsewhere on their body before augmentation. Twenty-eight percent (n = 6) were smokers and 45 percent (n = 10) used oral contraceptives at the time of surgery. Implant volume ranged from 345 to 600 cc (mean, 452.5 ± 58.8 cc). Time from surgery to onset of the striae ranged from 1 1/7 to 26 5/7 weeks (mean, 11.17 ± 5.25 weeks). Sixty-eight percent (n = 15) of the striae were classified as mild, whereas 27 percent (n = 6) were moderate and one case (5 percent) was severe. The mean follow-up period was 17.5 months (range, 2 to 76.5 months).Table 1: Summary of Patient DataBreast augmentation was the second most common cosmetic surgical procedure performed in the United States last year according to the American Society for Aesthetic Plastic Surgery. The development of striae following this procedure is a morbid complication that must be recognized, especially given the lack of effective therapies. In our case series, we confirm the roles of young age, nulliparity, and history of striae distensae as risk factors for the new development of striae following augmentation. All cases occurred in the subpectoral position, and association with oral contraceptives was not established. Although our series is small in number, it offers some insight into the character of striae distensae. Until a proven treatment is found for striae, we emphasize the importance of informing patients preoperatively of their risk factors to recognize the possibility that striae distensae may develop following breast augmentation. Georgeanna J. Huang, M.D. Thousand Oaks Clare E. York, M.P.A.S., P.A.-C. Aesthetic Plastic Surgical Institute, Inc. Laguna Beach Dan C. Mills, M.D. Department of Surgery Division of Plastic Surgery Loma Linda University Loma Linda, Calif. DISCLOSURES We hereby certify that, to the best of our knowledge, no financial support or benefits have been received by me or any coauthor, by any member of our immediate families, or by any individual or entity with whom or with which we have a significant relationship from any commercial source that is related directly or indirectly to the scientific work reported on in the article. We understand any example of such a financial interest would be a stock interest in any business entity that is included in the subject matter of the article or that sells a product relating to the subject matter of the article.

Acellular Dermis-Assisted Breast Reconstruction

In 2004, the authors reported their findings with placement of tissue expanders for breast reconstruction in the partial submuscular position, the equivalent of the "dual-plane" technique for breast augmentation. Limitations with subpectoral expander placement include difficulty controlling the lower pole of the pocket during expansion, unprotected device coverage by a thin inferior mastectomy flap, possible effacement of the inframammary fold, and limited control over the superior migration of the pectoralis major muscle. This study aimed to examine the safety and efficacy of an acellular dermal sling in providing inferolateral support to the device during immediate breast reconstruction and expansion. This study prospectively investigated 58 breasts of 43 consecutive women who underwent immediate breast reconstruction with tissue expanders and acellular dermis. After completion of adjuvant therapy and expansion, the devices were exchanged for implants. The patients were tracked through January, 2007. The study parameters included demographic information, oncologic data, complications, and aesthetic outcomes. The mean time required to complete reconstruction was 8.6 months. The overall complication rate after expander/acellular dermis placement was 12%, whereas the complication rate after exchange to implants was 2.2%. The aesthetic outcome for reconstructed breasts did not differ significantly from that for the control subjects who had no surgery. Acellular dermis appears to be a useful adjunct in immediate prosthetic breast reconstruction. Acellular dermis-assisted breast reconstruction has a low complication rate, helps to reconstruct an aesthetically pleasing breast, and facilitates expeditious completion of the reconstruction.

PR50 TANSAXILLARY ENDOSCOPIC BREAST AUGMENTATION

Transaxillary endoscopic breast augmentation is a very attractive option for women who desire increased mammary volume and projection but do not want a scar on their breasts. For primary augmentations, the procedure offers advantages over the traditional blunt axillary technique due to direct visualization and precise pectoralis muscle dissection and hemostatis. While the technique has been performed for submuscular and subglandular placement, the procedure has been most commonly used over the past decade with saline implants in the submuscular position. Smooth and textured silicone implants can also be used via transaxillary access into a subpectoral location. The results have been satisfactory with improved placement and a reduction incomplications associated with traditional transaxillary augmentation including hematoma, capsular contracture and implants which are positioned too high.Methods Transaxillary endoscopic breast augmentation was performed under general anesthesia with the patient in a prone position with arms are abducted to ninty degrees. Local anesthesia with epinephrine was injected into the axillary incision and in the soft tissue overlying the anterior axillary fold for hemostasis. A 2–3 cm incision (4–5 cm when silicone implants are used) was placed in the axilla in one of the natural folds within the hair‐baring zone. Dissection was carried out infero‐medially until the lateral edge of the pectoralis major was identified. Under direct visualizaion, the pectoralis fascia was divided with scissors and the subpectoral space entered. The subpectoral pocket was initially created bluntly with an Agris Dingman retractor to create a bloodless optical cavity without avulsing any muscle. The endoscope and retractor were inserted and the undersurface of the pectoralis muscle was divided with the Bovie electrocautery. The infero‐medial quadrant of pectoralis muscle was partially released from the chest wall. The prepectoral fascia, however was preserved to prevent synmastia, inferior implant migration and palpability. Pocket irrigation and hemostasis were performed. When saline implants were used, the device was rolled, inserted and inflated to the desired volume. When silicone devices were used, the tunnel was bluntly widened with Ashe forceps. A marcaine pain pump can be placed in the pocket for postoperative pain control.Results Over 12 years 384 primary breast augmentations have been performed using this method by the senior author. Over 90% of the implants were Mentor smooth round saline implants. The average patient age was 30. High or excellent levels of patient and surgeon satisfaction was present in over 95%. Complications requiring re‐operation were present in less than 2% of patients. The rate of long‐term revision was capsular contracture in 5%. The most common cause of revision was asymmetry or desire to be larger.Conclusions Transaxillary Endoscopic breast augmentation is an attractive option for the primary breast augmentation patient which avoids placement of a scar directly on the breast. The advantages are for patients with no ptosis or inframammary fold within which to hide the scar or breasts with a small areolar diameter. Additional advantages include controlled and precise surgical dissection and hemostatis which have reduced the complications associated with traditional blunt transaxillary techniques. Potential disadvantages may include the need for a second inframammary scar if reoperative surgery is required, theoretical interference with sentinel lymph node dissection if required in the future, and the additional technical equipment required to perform the procedure.

PR51 AUGMENTATION MASTOPEXY

Introduction Augmentation‐Mastopexy is a more complex procedure than either breast augmentation or mastopexy performed individually. Since the operation both increases breast size and corrects ptosis in one surgical procedure, the combination has been considered to be associated with increased risk of complications. Complications most commonly include ischemic related complications of the breast flaps or nipple areolar complex and loss of sensibility. While some authors have suggested a staged approach with augmentation followed by mastopexy, I prefer to perform augmentation mastopexy as a single technique which is an attractive alternative to two operations. The principles include initial insertion of the implant in either the subglandular or submuscular position followed by mastopexy which can be periareolar, vertical, or inverted‐T scar based on the degree of ptosis and size of the breast.Methods/Technique Augmentation is performed first so the amount of ptosis can be evaluated after the augmentation in order determine the type of mastopexy performed. The implant is placed through a periareolar incision or a vertical lower pole incision if one anticipates a vertical mastopexy scar. Implant placement is generally subglandular when sufficient soft tissue exits to provide adequate implant coverage. Care should be taken to preserve a dermal pedicle for blood supply to the nipple since subglandular dissection reduces the blood supply to the nipple areolar complex. When the breast soft tissue envelope is thin, submuscular placement is preferred for additional implant coverage. Since submuscular placement provides better coverage, there is generally less palpability and rippling. Furthermore, submuscular dissection preserves better blood supply exits to the NAC. A disadvantage of submuscular placement is increased risk of a high riding implant. The mastopexy should adequately elevate the breast to avoid a double bubble deformity is performed.Results Over the past 12 years, 98 augmentation mastopexies were performed. The average pre‐operative bra size was B‐cup and the average degree of ptosis was Grade II. The mean patient age was 55. Smooth round gel implants were used for 90% of the patients. 80% were placed submuscular and 20% were placed subglandular. A Periareolar mastopexy was performed in 25% of patients and an inverted T mastopexy was performed 75% patients. Periareolar augmentation mastopexy was performed commonly for the correction of tubular breast deformity.Generally, most patients were satisfied with their procedure as only 5% underwent revision for aesthetic indications. 2% patients suffered acute complications including hematoma and loss of nipple sensation. 9% suffered subacute and chronic complications including delayed wound healing, loss or partial loss of the NAC, and loss of nipple sensation. 5% patients required revisions surgery to correct the sequelae of delayed wound healing or NAC tissue loss.Conclusions Augmentation‐mastopexy is one of the most complex and technically demanding procedures performed in aesthetic breast surgery. Nonetheless, there is a role for the procedure due to its ability to reduce the number of procedures and provide improved breast shape. The key to success is to be aware of the most common complications and to proceed in a stepwise in order to minimize the risk of complications and maximize patient satisfaction.

Does the Surface Structure of Implants Have an Impact on the Formation of a Capsular Contracture?

The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture. This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker's clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis. The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 +/- 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05). The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.

Simultaneous Endoscope-Assisted Contralateral Breast Augmentation with Implants in Patients Undergoing Postmastectomy Breast Reconstruction with Abdominal Flaps

Unilateral breast reconstruction after mastectomy provides the challenge of achieving symmetry with the opposite side. Reduction mastopexy is a common balancing procedure for the contralateral breast used to achieve pleasing and symmetrical breasts. Although symmetry is the ultimate goal, some women have a hypoplastic and/or ptotic contralateral breast, and the recreation of this shape would therefore not be desirable. From April of 2000 to April of 2005, a total of 158 patients underwent postmastectomy breast reconstruction using either free deep inferior epigastric perforator flaps (n = 142) or superficial inferior epigastric artery flaps (n = 16) at Chang Gung Memorial Hospital. Of the 158 patients, 19 (12.0 percent) underwent endoscope-assisted placement of implants into the contralateral breast at the same surgical stage to form a more pleasing breast mound. Mean patient age was 46.1 +/- 7.6 years. All patients had a slender body habitus, with small to medium-sized breasts. Saline-filled implants were placed in a submuscular position with the assistance of endoscopy. Five different incisions for access were used: transaxillary (n = 6), Port-A-Cath catheter scar (n = 4), inframammary (n = 1), biopsy scar (n = 1), and transmidline (n = 7). The success rate was 100 percent, with complete survival of the 19 flaps. In three patients, revision procedures were carried out at 12 to 44 months' follow-up because of implant leakage, capsular contracture, and nipple ptosis (one patient each). The remaining patients were highly satisfied with the cosmetic result, and symmetry was achieved, with soft, natural appearing breasts during the follow-up period of 29.2 +/- 16.9 months. The transmidline approach was superior to the other routes, because no additional scar was produced and access was easier. Contralateral breast augmentation at the same stage with deep inferior epigastric perforator or superficial inferior epigastric artery flap surgery can be performed with high success rates and poses no surgical risks or morbidity to patients. The combined procedure does not significantly extend the time of operation, and aesthetically pleasing results and symmetry can be achieved and sustained over the long term.

Determination of Serum Fibrosis Indexes in Patients with Capsular Contracture after Augmentation with Smooth Silicone Gel Implants

Several studies have confirmed a correlation between the concentration of serum hyaluronan and progressive fibrotic disorders such as liver cirrhosis. The aim of this study was to explore the relationship between serum hyaluronan levels and capsular contracture after aesthetic breast augmentation. The study included 25 female patients (average age, 40 +/- 12 years) with capsular contracture after cosmetic breast augmentation with smooth silicone gel implants (Mentor, Santa Barbara, Calif.). The implants were placed in a submuscular position through an inframammary fold incision. The implant removals were prompted by development of capsular fibrosis (Baker grades I through IV). Samples of capsular tissue were obtained from all patients for standard histologic and immunohistochemical analysis. Blood samples were drawn from all patients immediately before operation. Sera from 20 healthy female patients (average age, 34 +/- 9 years) were used as control. : Capsular tissue revealed significantly higher thickness in patients with grade III/IV contracture than in women with grade II contracture, according to Baker's classification. There was a moderate (n = 15) or severe (n = 10) chronic inflammatory reaction in the capsules around the implants. Fibroblasts, fibroblast-like cells, and macrophages represented the major cell populations found within the fibrous capsules, along with scattered polymorphonuclear leukocytes, lymphocytes, plasma cells, and mast cells. In addition, activated CD4+ cells were detected. An inner layer with synovia-like metaplasia and multinucleated giant cells was found. There was a significantly higher level (p < 0.05) of hyaluronan serum concentration in patients with capsular contracture (26 +/- 14 microg/liter) compared with control subjects (12 +/- 6 microg/liter). There was a positive correlation between the grade of capsular contracture (Baker grades I through IV) and the hyaluronan serum concentration (Baker grade II, 15 +/- 3 microg/liter; Baker grade III, 34 +/- 13 microg/liter; Baker grade IV, 42 +/- 11 microg/liter) (r = 0.73; p < 0.05). Serum hyaluronan levels were significantly elevated in patients with capsular contracture after breast augmentation, and there was a positive correlation with stage of capsular contracture. Further study is necessary to determine whether hyaluronan might be useful as a predictor for the development and progress of capsular fibrosis.

Serologic and Histologic Findings in Patients with Capsular Contracture After Breast Augmentation with Smooth Silicone Gel Implants: Is Serum Hyaluronan a Potential Predictor?

In this study, breast implant capsular tissues and blood samples from 25 cases were studied to characterize the relationship between capsular findings and serum analysis. The serum fibrosis indexes hyaluronan and the aminoterminal propeptide of procollagen type III (PIIINP) are fairly well correlated in several other studies with the inflammation grade and fibrosis in patients with progressive fibrotic disorders such as liver cirrhosis. The study enrolled 25 female patients (average age, 40 +/- 12 years) with capsular contracture after bilateral cosmetic breast augmentation using smooth silicone gel implants (Mentor). The implants were placed in a submuscular position through an incision in the inframammary fold. The implant removals were prompted by development of capsular fibrosis (Baker grades 1-4). Samples of capsular tissue were obtained from all the patients for standard histologic and immunohistochemical analyses. Blood samples were drawn from all the patients immediately before surgery. Sera from 20 healthy female patients (average age, 34 +/- 9 years) who had undergone plastic surgery for reduction mammaplasty were used as controls. Histology. Capsular tissue was significantly thicker in patients with grades 3 and 4 contracture than in women with grade 2 contracture according the classification by Baker. There was a moderate (n = 15) or severe (n = 10) chronic inflammatory reaction in the capsules around the implants. Fibroblasts and macrophages represented the major cell population found in the fibrous capsules. In addition, activated CD4+ cells were detected. An inner layer with synovia-like metaplasia and multinucleated giant cells was found. Fibroblast-like cells formed the most common cell type in the capsules, along with macrophages, scattered polymorphonuclear leukocytes, lymphocytes, plasma cells, and mast cells. Serum analysis. There was a significantly higher level (p < 0.05) of hyaluronan serum concentration in patients with capsular contracture (26 +/- 14 microg/l) than in control subjects (12 +/- 6 microg/l). There was a positive correlation between the grade of capsular contracture (Baker 1-4) and the hyaluronan serum concentration (Baker 1-2: 15 +/- 3 microg/l; Baker 3-4: 35 +/- 12 microg/l) (r2 = 0.73; p < 0.05). : In this study, serum hyaluronan levels were significantly elevated in patients with constrictive fibrosis after breast augmentation, and there was a positive correlation with the stage of capsular contracture. Serum hyaluronan concentration may help in defining patients at risk for capsular fibrosis. If treatment with new drugs can be started as a preventive measure, it may be possible to reduce the rate of patients who require surgical intervention.

Morphogenesis of Paragordius varius (Nematomorpha) during the parasitic phase

The development of Paragordius varius (Nematomorpha), in the parasitic phase of the life cycle, was followed ultrastructurally from 10 days after controlled infection of crickets (Gryllus firmus) to mature animals at 30 days after infection. During this time span, specimens grow from about 1 cm to more than 10 cm and from 93 μm to about 400 μm in diameter. A thin larval cuticle is replaced at about day 20 by a robust adult cuticle. Epidermis and intestine appear physiologically active during the early stages, but decrease in size and cytological components during further development. This is probably connected to the uptake of nutrients through the larval cuticle, whereas the adult cuticle has only protective function. The longitudinal musculature grows continuously and changes from fewer platymyarian cells to abundant coelomyarian cells. The ventral nerve cord shifts from an intraepidermal to a submuscular position during development. Additionally, basiepidermal nerves are present. Gonads develop from paired dorsolateral compact strands. It seems that in males, cells within these strands separate into epithelial and central cells, which become the gametes, while in females, gametes proliferate from the strands into the primary body cavity and fill it up completely. In males, there is a large quantity of parenchyma, restricting the body cavity to a small periintestinal space, while in females, parenchyma occurs only in the periphery of the gametes.