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Recently, the superficial musculoaponeurotic system (SMAS) was found to be a composite tissue comprising collagen, elastic fibers, and fat cells in an extracellular viscous matrix. Both SMAS and facial skin tissues exhibit viscoelastic properties, but SMAS tissue has delayed stress relaxation. As a consequence, SMAS is viewed as a firmer elastic foundation for the more viscous facial skin. In some patients, a slackening effect of SMAS tissue takes place over a period ranging from weeks to months after tightening. To determine the relative quantity of viscoelastic components and better understand their biomechanical behavior, a quantitative morphometric study of the elastic and collagen fibers in the SMAS and facial skin was conducted. Thirty-four SMAS preparations were taken from 17 patients during either primary face lift operations (12 women) or reoperative face lift procedures (4 women, 1 man), which were performed 4 to 9 months after the original surgery, to examine the elastin and collagen content. For comparison, preauricular skin was also gathered from these patients. The specimens were stained with Weigert's staining to identify elastin and collagen fibers. Using a computerized morphometric analysis, 100 fields of each SMAS and skin specimen were examined. According to our findings, the average percentage of elastin and collagen fibers in SMAS and facial skin was as follows: (1) the percentage of elastin fibers in the SMAS was 4.71 +/- 1.2 (standard error of mean +/- 0.0291); (2) the percentage of elastin fibers in the skin was 6.1 +/- 1.8 (standard error of mean +/- 0.0436); (3) The percentage of collagen fibers in the SMAS was 38.7 +/- 5.9 (standard error of mean +/- 0.1430); and (4) the percentage of collagen fibers in the skin was 48.47 +/- 6.96 (standard error of mean +/- 0.1688). A statistical significance of p < 0.0001 was demonstrated between the collagen and elastin groups. A different percentage of elastin and collagen fibers was found among the 17 patients and within each of them separately. Neither gender nor age differences were found regarding elastin and collagen fiber content. No statistical differences were demonstrated between specimen sources, i.e., whether the operations were primary or reoperative face lift procedures. Findings from previous studies indicate that the cheek has two viscoelastic layers, the skin and the SMAS. The proportional similarity in average percentages of elastin and collagen in SMAS and facial skin cannot explain the relatively delayed stress relaxation effect of the SMAS. Therefore, the fat cells that are found exclusively in the SMAS probably lend a certain degree of firmness to this layer and play a significant role in the long-term efficacy of SMAS surgery.

Excess skin of the upper lids is often accompanied by lateral overlap of skin with crow's feet because of the absence of fixation to the tarsal plate, giving the eye a sad, heavy look that often disturbs the lateral visual field. The accepted crescent-shaped blepharoplasty is somewhat convex, which is widest at the center of the lid with or without a lateral extension. However, in patients who have normal brow position or minimal eyebrow ptosis and whose main concern is the excess upper eyelid skin and lateral hooding, such a crescent excision may not suffice. A scalpel-shaped excision that is widest laterally and that tapers to a point medially will extirpate the maximal skin where it is most needed and overcome the skin excess in the lateral aspect of the upper lid. Between 1990 and 2002, 301 white patients (275 women and 26 men) between the ages of 33 and 79 years were operated on using the extended scalpel-shaped upper blepharoplasty technique. The follow-up period was more than 1 year. The lower margin of the incision is along the supratarsal crease, about 10 mm above the ciliary line. It begins medially about 1 cm above and lateral to the medial canthus. Above the lateral canthus, the skin marking is gently curved upward and outward, often within a natural skin crease or crow's feet to reach a little below and slightly beyond the lateral extremity of the eyebrow. The upper border of the incision joins the two extremities of the skin outline in a gentle convex curve. The general outline of the incision takes on the shape of a number 20 scalpel blade in which the maximal width is located laterally. Following excision of the excess skin and removal of protuberant fat pads if needed, suturing is executed from lateral to medial. The final suture line is in the form of an oblique flattened lazy S. Following the removal of the stitches on the fifth postoperative day, no wound dehiscence was noticed at the lateral scar zone. In the older individuals, due to the lax skin, the scar becomes scarcely noticeable with time and often falls within a pre-existent crow's feet crease. Elimination of some of the crow's feet was also demonstrated. In patients with visual field impairment, significant functional and visual improvement was achieved. Most patients mentioned a pleasing postoperative open "Oriental" look of the eyes. The extended scalpel-shaped upper blepharoplasty adequately deals with the hooding of the skin laterally. This technique overcomes the excess of skin in both vertical and horizontal directions, since in suturing the lateral part of the skin defect in an oblique plane, slack skin is taken up transversely, and the technique provides some indirect upward support to the lateral eyebrow. In the absence of crow's feet in the younger person, this technique is not recommended because the lateral part of this suture line is visible, especially if the scar widens.

This study was designed to test the efficacy of enriched cell culture medium as a wound dressing. The rationale was to create within the wound space an optimal microenvironment, conducive to cellular proliferation, vascular granulation tissue formation, and epithelialization. This study was performed on various wounds that failed to respond to previous conventional treatments.A total of 288 wounds were within the inclusion criteria, with only contaminated and neoplastic wounds excluded. Most of the patients (80 percent) were ambulatory, and the wounds were examined by the attending physician once every 7 to 14 days at an outpatient clinic. The remaining 20 percent of patients were admitted to the study while hospitalized. Cell culture medium MCDB, supplemented with insulin, thyroxin, and growth hormone, was gelled. The gel was self-applied once a day to freshly washed wounds, covered with a gauze pad, and anchored with netting. Healing started 7 to 14 days after the initiation of treatment with enriched cell culture medium. However, the criterion for success of the treatment was determined on complete wound closure, which was achieved in 189 of 288 wounds (65.6 percent). Wound closure was correlated with the initial wound volume, stage, and origin. The average time required for closure of wounds caused by systemic pathologies (n = 181) and those based on regional status (n = 107) were 12.0 and 4.4 weeks, respectively, compared with 290 and 10.3 weeks of the previous conventional treatment. In 19 extensive wounds, when vascularized granulation tissue was established, a successful surgical closure was attained. Most wounds of patients who did not continue the enriched cell culture medium treatment (34.4 percent) manifested reduced wound volume, ranging from 11 to 98 percent of initial volume. Discontinuation of treatment was associated with difficulties in reaching the clinic for the weekly examination, rather than for reasons directly related to the treatment itself, and occurred significantly earlier during the treatment period.Thus, enriched cell culture medium was effective in stimulating wound healing in recalcitrant wounds. The healing was rapid with minimum scarring and pain. No side effects or allergic reactions were reported or observed.

A one-stage procedure is described for restoring the scrotum in a patient who suffered from Fournier's gangrene. The proximal superiomedial-based thigh flaps employed are most likely arterial flaps. These flaps are also well innervated, which makes them ideal for the purpose of scrotal reconstruction.

The microarchitecture of collagen fibers in preauricular dermis specimens that were obtained during two-phase rhytidectomy were visualized and recorded using the scanning electron microscope. Examination of photomicrographs revealed that both spatial arrangement and degree of convolution of the collagen fibers were completely different in the specimens of the two phases. The results are interpreted in terms of the viscoelastic properties of the skin.

A recently introduced polymer preparation (Iodoplex) is described. It is based on a new type of hydrophilic polymeric carrier into which iodine can be incorporated to the extent of 50% or more. Its main feature is that the polymer and the petroleum jelly base are water-insoluble. The iodine is slowly released from the polymer by body fluids, which are rich in protein and dead cells. Iodine has been found to be useful in the treatment of donor sites; no pain or discomfort attends its use, and the dressing peels off easily from the healed epithelium. A controlled study comparing iodoplex-impregnated and scarlet red-impregnated gauze on donor sites was carried out, and the use of Iodoplex was found to have some real advantages over scarlet red.

Twenty-one patients with hemangiomas on the face and lip who were treated with injections of sclerosing agents are discussed. The mode of action of these drugs was also studied experimentally on rats, which were injected through the pampiniform plexus of the spermatic cord. In the clinical study all patients showed satisfactory resolution of the hemangiomas with commensurate improvement in their appearance. The experimental study provides an explanation for the replacement of blood vessels by young connective tissue.

A clinicopathological study of 150 patients with primary malignant melanoma of the skin is presented. Information concerning the site, type, depth of invasion and thickness of the tumor is reported. The value of tumor thickness in assessing prognosis is emphasized.

Following burns of the upper respiratory tract, laryngotracheal stenosis is associated with considerable morbidity. This paper deals with the cumulative effect of various pathologic processes involved in burn trauma of the upper airway. Emphasis is placed on the extended use of endotracheal intubation and the avoidance of tracheostomy whenever possible. When laryngotracheal stenosis develops, it may be safely and successfully treated by prolonged stenting, as has been borne out by our experience with the T-shaped silicone tubes. Limited reconstructive procedures can be performed to facilitate proper placement of the stent. In our opinion, laryngotracheal resection and reconstruction are not the procedures of choice in burn cases. Our experience in following the preceding guidelines is described. Three illustrative cases serve to exemplify the difficulties and problems involved in the various stages of treatment and the results obtained. The patients are symptom-free 18 to 24 months following stenting, and all enjoy an adequate airway and good voice. There were no complications resulting from this treatment and we suggest that it is worthy of trial.

Fifty-eight patients with keloid scars were subjected to combined cryosurgery and intralesional corticosteroid therapy. Complete regression of the scars occurred in 41 patients. In 8 patients the scars improved, and there was no improvement in 9 patients. Keloid scars of the earlobes were the most responsive to treatment. The possibility of differing biological activity of cryosurgery and corticosteroids complementing each other is postulated, and a combination of their respective actions may offer promise in treatment.

In this modern era, compound fractures of the middle third of the tibia are relatively common. With the advent of external fixation, these fractures can be more rapidly and effectively dealt with, and attention can be directed to immediate coverage of the exposed bone. External longitudinal splitting of the anterior tibialis muscle offers a convenient and safe method for converting the open fracture to a closed one. The uniqueness of the tibialis anterior muscle is twofold. It is circumpennate, and it has an internal axial tendon corresponding to almost its total length. Both these features impart to it considerable strength, and the muscle splitting herewith described does not appear to impair its function. Five treated limbs, each with loss of soft tissues overlying compound mid-third tibial fractures, are presented. Rapid healing and virtual absence of bone infection was observed in all cases.

The use of bilateral superomedial thigh flaps for primary reconstruction of scrotum and vulva is presented. These flaps have proved to be reliable, ensuring good healing and providing almost normal sensation. Further indirect evidence that these are arterial flaps is given.

The efficacy of prophylactic therapy with cimetidine or antacids combined with early enteral feeding to prevent gastrointestinal bleeding in patients with severe burns was evaluated. Fifty patients with burns exceeding 30 per cent of the total body surface area (TBSA) were divided into two groups, each of them treated by one of these agents in combination with early feeding. Bleeding was not encountered in either group. It is assumed that the combination of either agent with enteral feeding early in the post-burn course equally protected against gastrointestinal bleeding. Because of the ease and lack of side-effects of cimetidine in this series, its use was preferable.

Summary Irradiation of basal cell carcinoma of the mid-face is complicated in certain cases by uncontrolled spread of the tumour. Four such cases are presented of widespread local infiltration by the tumour. A slow painful death, resultant directly from the effects of local invasion, occurred in three of the patients with the fourth patient tragically moving to the same inevitable conclusion. The anatomical features of the mid-face may account for this type of spread. There may also be an alteration of tumour-host relationship following radiotherapy. Surgery, rather than irradiation, is the treatment of choice for basal cell carcinoma of the mid-face.