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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.

Among the common treatments for chronic atrophic wounds, moist dressings are used to create optimal environment and prevent desiccation of the wound bed. Modified serum free cell culture medium supplemented with nonsteroidal anabolic hormones thyroxine, growth hormone, insulin and transferrin was gelled in 1% Agarose. The gel was applied to the surface of chronic atrophic wounds (1 ml/cm2) once a day. All the wounds included in this study were clear of infection following treatment with topical antiseptics and antibiotics. The study was performed on 92 patients suffering from chronic leg ulcers. Etiologies of the ulcers varied from venous insufficiency, arterial insufficiency, insulin-dependent and non-dependent diabetic ulcers or combinations of the above. Complete wound closure was obtained in 50 patients. In the remaining 42 patients, the treatment was discontinued because of unrelated medical or psychiatric problems — 13 patients, noncompliance —16 patients, relocation — 12 patients, and infection — 1 patient.

A skin-stretching device that is designed to harness the viscoelastic properties of the skin using incremental traction is presented as an addition to the surgeon's armamentarium. It has proved to be of value in helping to close problematic areas of skin shortage which would otherwise have required more complicated procedures for their solution. It is simple in application and can even be put to use at the bedside. It consists of two pins that are threaded through the dermis of the wound margins on either side of the defect and which are in turn engaged by the hooks of the stretching device. The stretching force on the skin margins is spread over a wide area, thus preventing damage to the skin itself that individual hooks applied to the skin might cause. The device is employed over a duration of 20 to 30 minutes to 1 to 3 days depending on the condition of the skin adjoining the defect. The device can be applied over three different periods of time: (1) preoperatively (presuturing), lasting 1 to 2 days, (2) intraoperatively, extending over a period of 20 to 30 minutes, and (3) postoperatively (or delayed), which takes place over a time span of hours to 1 to 3 days. Five illustrative cases are presented.

A simple and reliable method for securing the cannulated polyethylene tube to the blood vessel wall prior to intravascular dye injection is described. The three-tie technique has been used in many vascular anatomic studies without any leakage of the injection fluid taking place around the tube.

A case in which a growing cystic mass developed in the submandibular area, 6 months following fat injection to the cheek and mandibular area, is described. Histological examination revealed a liponecrotic pseudocyst. It is suggested that subcutaneous masses appearing in an area, which was previously injected with fat, should be excised. Diagnostic aspiration procedures may cause leakage of its oily content and possible further granulomatotic reactions and cysts.

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.

BACKGROUND. Photodynamic therapy (PDT) is a noninvasive selective therapy for a specific group of skin tumors. OBJECTIVE. In this study we used a modified topical medication in which ethyleneamine tetra acetic acid (EDTA) and dimethyl-sulphoxid (DMSO) were added to 5-aminolevulinic acid 20% (ALA) followed by exposure to a novel high output light source emitting red and infrared irradiation. METHODS. ALA 20%-EDTA 2%-DMSO 2% in a water in oil cream base was applied to the tumors. After 12 hours the tumor was exposed to red (585-720 nm; 150 mW/cm 2 ) and near infrared irradiation (1.25-1.6 mm; 50 mW/cm 2 ) for 10-15 minutes by the VersaLight incoherent filtered light source. RESULTS. Complete responses were achieved after one to three ALA-PDT treatments in 26/31 lesions of superficial or small nodular basal cell carcinoma (BCC) (84%), and in four of five in superficial squamous cell carcinoma (SCC) (80%). Complete clearance was achieved in one patient with Bowen's disease of the penis. CONCLUSIONS. Topical PDT utilizing ALA 20%-EDTA 2%-DMSO 2% as the photosensitizer and VersaLight as the light source is a noninvasive, nearly painless treatment with excellent therapeutic and cosmetic results. Our data show the efficiency of this therapy for patients with certain subtypes of BCC, SCC, and Bowen's disease.

A study was undertaken to determine the physical properties and microscopic structure of the superficial musculoaponeurotic system (SMAS) tissue. Forty virginal specimens and eight reoperated specimens were examined. The following findings were discovered. 1) Microscopic appearance shows the SMAS to consist of collagen fibers, a relatively high concentration of elastic fibers interspersed with fat cells. 2) On scanning electron microscopy, the virginal SMAS shows the collagen fibers to have a similar convoluted appearance as in the dermis. There is some evidence of parallelization of the collagen fibers in the reexcised SMAS specimens. 3) Mechanical testing (Instron) demonstrates that both the SMAS and preauricular skin were subjected to a series of loading/ unloading tests at various rates, amplitudes, and stress relaxation tests. Both sets of specimens indicated definite viscoelastic properties. Although the mechanical behavior of both tissues was somewhat similar, the viscoelastic effect of the SMAS was less pronounced. A slackening effect of the SMAS indicated a gradual expansion of the SMAS postoperatively. These results could provide some indication of the long-term effects of SMAS surgery.

Lipohypertrophy is one of the local side effects of repeated subcutaneous insulin injections. This case report demonstrates the successful cosmetic and therapeutic treatment of two lipohypertrophic masses in the lower abdomen of a young diabetic patient by suction-assisted lipectomy.

Because of the widespread reliance on SMAS tightening procedures in present-day face lift surgery, a study was undertaken to examine the physical properties and microscopic structure of both virginal (40 specimens) and reoperated (8 specimens) SMAS tissue. The findings could be of practical value to the surgeon and are reported herewith: First, the SMAS is a composite fibrofatty layer comprising collagen and elastic fibers interspersed with fat cells. Second, microscopic appearance shows a considerable amount of elastic fibers in close relationship to the collagen fibers. Third, on scanning electron microscopy, the collagen fibers in the virginal SMAS show a convoluted appearance similar to that found in the dermis. In the reexcised SMAS tissue, there is some evidence of parallelization of the collagen fibers as seen in the stretched dermis. Fourth, mechanical testing (Instron), i.e., a series of loading/unloading tests at various rates and amplitudes, and stress relaxation tests were performed on samples of preauricular skin and SMAS. These indicated definite viscoelastic properties for both sets of specimens, with the tendency of an increased stiffness and a reduction in viscoelastic effects on repeated working of the samples. Overall, the mechanical behavior of both tissues was somewhat similar, the viscoelastic effects in SMAS being less pronounced. A nonlinear viscoelastic model is under development to represent the behavior of both tissues. The implications of these results may help to explain the slackening effect observed in some postoperative patients.

A method of closing a large defect using a skin stretching device is presented. This was accomplished by moving neck skin cranially without caudal movement of the upper cheek skin or lower eyelid.

The clinical effect of 0.6 mm thick silicone occlusive sheeting (SOS) applied over 32 hypertrophic and keloid scars was investigated. 88% of scars so treated and followed up showed distinct improvement. These results compared favourably to those published in other series. The possible mode of action of the silicone on scar tissue is thought to be the creation of a static electrical field from friction on the silicone material surface. The passage of static electricity over a prolonged period of time may be the critical factor in scar inhibition. It is postulated that over a period of weeks to months the resulting electrical field may have some inhibitory effect on the scar tissue. The use of SOS prophylactically is suggested. A controlled study in six patients demonstrated convincingly the effectiveness of this therapy.

Toxic epidermal necrolysis (TEN) is characterized by extensive exfoliation of the epidermis, mucosal ulcerations and fever, after a recent intake of a new drug. TEN developed in an 8-year-old girl after she ingested sulfonamides and sustained skin injuries of 90% total body surface area. In addition to her critical care management, local treatment consisted of Iodoplex cream (Biosearch Laboratories, Haifa, Israel), a long-acting antimicrobial agent from which iodine is slowly released over 48 hours. Healing was observed within 8 to 17 days after initial application. Iodoplex cream is an additional topical agent for the local treatment of TEN when porcine heterografts or allografts might not be feasible.

This paper describes an approach to the treatment of exposed pacemaker generator and electrode. Local infection is controlled by the administration of systemic antibiotics and topical antibacterial solutions. Because the generator and lead are enveloped by an inert synthetic coating, it is possible to eradicate an infection without their removal if it is due to a weak opportunist pathogen fully sensitive to antibiotics. Thereafter, subcapsular relocation of the exposed generator or vertical-to-horizontal transposition of the exteriorised lead is carried out. These surgical interventions are designed to overcome the vertical force which tends to cause the extrusion of the pacing hardware.

Three adult patients with long-standing hemifacial atrophy were treated with repeated free-fat injections at 4- to 8-week intervals. The longest follow-up study to date is 18 months, and following the expected postoperative resorption, no further loss of bulk of injected fat has been observed. On palpation, the feel of the fat is normal, and facial expression is also good. The relative ease of this procedure, which does not entail any scarring, appears to justify more widespread use of free-fat injections to restore facial soft-tissue depressions.

A 23-year-old man who underwent below-knee amputation of one leg and sustained extensive soft-tissue damage with a bony defect of the other foot presented an unusual reconstructive problem. By means of microsurgical techniques a free serratus anterior-rib flap was transferred to restore function of the foot. A four-year follow-up showed good rehabilitation.

The transverse thoraco-abdominal skin flap, originally described by Baroudi et al. [1], was used for closure of postmastectomy chest defects after radical mastectomy. Some modifications to the original flap have been made which add to its reliability. These mainly consist of the preservation of musculo-cutaneous perforators on both the ipsi- and contralateral sides of the pedicle, and leaving the umbilicus intact. This flap may also be used for reconstruction of groin defects. The blood supply to the TRAS flap was investigated in six fresh cadavers. Following the raising of six TRAS flaps the contralateral superior and inferior deep epigastric arteries (epigastric arcade) were cannulated and injected with microfil. The flap specimens including their pedicles were then detached and x-rayed by mammography. Complete filling of the medial half of the flaps was observed in most of the specimens indicating anastomosis of blood vessels across the midline. Since the contralateral penetration of the microfil was not observed in larger blood vessels, it is assumed that the musculo-cutaneous perforators are the main conduit for this blood supply. Beyond the reach of the contrast material the flap “borrows” its vasculature from the pre-existent subcutaneous network on the random flap principle. Three case reports are presented, in which one supra-and two infra-umbilical TRAS flaps were employed.

A regime involving the dietary management of 8 severely burned patients has been described, the main feature of this diet being the high egg intake. The eggs were given in a variety of forms without any untoward effects and without any distaste being developed. No pathological levels of serum lipoproteins or cholesterol were attained. Serum proteins from an initial low level reached normal values within a relatively short time. It is felt that a high egg diet is a valuable and safe addition in the management of severely burned patients.

We present a case of septal perforation in Osler-Weber-Rendu's disease, treated by rotating bilateral labial-buccal flaps up into the nose to close the perforation and resurface the adjacent areas on the septum.

Four patients with acute suppurative perichondritis were successfully treated with low dose X-ray irradiation. The infection had previously not responded to conservative management including incisional drainage and cartilage debridement.

Skin under tension with "creep", i.e. stretch. This probably accounts for the fact that by far the commonest postoperative complaint of face-lift patients is of inadequate lift. Creep occurs within a few hours of the operation but is at first masked by postoperative oedema. At the second stage half as much or more skin as was excised on the first occasion may be re-excised. The conservative face-lift incision which spares the sideburns is the most conventient for the 2-stage operation.

A craniofacial malformation is caused by a developmental arrest that results in focal fetal dysplasia. The severity, location, and number of these dysplasias make a wide spectrum of abnormalities possible. In this spectrum nasal dysplasia and, more particularly, the malformations characterized by a cleft in the lateral part of the nose play a prominent role, but in past years they have received only scant attention. In Tessier's classification this nasoschizis is the Number 1 cleft. We present here our observation in 2 patients with nasoschizis and the procedure used to correct it. Both patients were operated on at the Rambam Medical Center in Haifa, Israel.

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.

THERE is considerable discussion regarding immediate plasma, electrolytes and fluid replacement in the acute phase after burns. Intravenous input of saline was begun by Reiss in 1880, and later in 1897 was advocated by Tommasoli (Hauben et al., 1981), when hypovolaemic shock and its sequelae were under study. Plasma, electrolytes and fluids have been established as routine formulae (e.g. Evans, Brooke, Parkland and Odstock formulae), differing from each other in their various constituents. The aim of this paper is to present the four main contemporary concepts regarding the efficient and ideal treatment to be given during the shock period in the acute phase after burns, as expressed by four teams treating burns in their acute and critical phase.

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.

The external longitudinal splitting of the biceps brachii muscle offers a convenient and safe method for covering exposed vessels in the medial aspect of the arm in cases with loss of soft tissue. This anatomical study reveals rather variable and inconsistent patterns of blood supply to the biceps brachii muscle. The common denominator among the patterns is the fact that the nutrient vessels to the muscle originate in its posterior deep surface and course thereafter in a fan shape upward to the surface of the anterior aspect of the muscle. This microcirculatory pattern permits the external longitudinal splitting of the biceps brachii muscle along the whole anteromedial aspect of the short-headed belly without compromising its blood supply and function. An illustrative case is described.

Neurofibromatosis is a rare inherited disease that may present as facial hamartoma or as a more generalized disease with subcutaneous tumors, skin pigmentation in the form of café-au-lait patches, and multiple pedunculated neurofibromas on a narrow skin base. The generalized form of the disease is named after von Recklinghausen, who described its main features in 1882. In this paper, we restrict ourselves to a discussion of the craniofacial manifestation of the disorder and also report our experience in treating 2 patients with orbitofacial neurofibromatosis at the Rambam Medical Center in Haifa.

Meshed human dermis allografts containing human uterine angiogenic factor were implanted over full thickness surgical skin wounds in rats. Enhanced angiogenesis of the wound bed, three times more than that observed in control grafts, was found in experimental grafts at 3 days postimplantation. This was accompanied by a greater amount of granulation tissue formation, enhanced granulation tissue penetration into the dermal grafts and accelerated incorporation of the grafts. Angiogenesis of the wound bed regressed to control levels at 7 days postimplantation. The growth and penetration of the granulation tissue and the accelerated incorporation of the dermis grafts, however, continued ahead in the experimental grafts while necrosis appeared in the control grafts. The relevance of these results for acceleration of wound healing and improvement of the wound bad for subsequent application of cultured epidermal grafts is discussed. This method may be extended to the treatment of ulcers and burns.

IN the treatment of burns, immediate and primary management has a marked influence on the mortality rate (Baxter et al., 1974). This consists of: I. Resuscitation. 2. Primary treatment of the burned area. 3. Early excision of eschar and early skin grafting. We wish to present and discuss some elements of the resuscitation stage of treatment, as have been exhibited in a series of 61 mass-injury patients, who were treated for burns during a short time in our centre. The aim in resuscitation is the re-establishment within the shortest time of the normal physiological parameters. This includes cardiorespiratory function, acid-base balance and metabolism.

Microclimate factors, such as temperature, humidity, pH, gas composition and pressure, have a significant influence on the evaporative water loss through the burn wound, local infection, healing process and skin graft take. The accumulated data regarding the influence of various combinations of microclimate conditions on the burn wound is controversial, and is evidenced by contradictory approaches to the local treatment.

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.

The supermedial thigh flap is an arterial and sensate flap. Anatomical studies reveal both large and small nutrient arteries. Its largest and most consistent artery is the superficial branch of the deep external pudendal artery, which constitutes the main circulation. The secondary blood supply to the base of the flaps is contributed by musculocutaneous perforators of the medial circumflex femoral artery. Subcutaneous branches of the superficial femoral artery, when present, are an additional source of arterial supply. Branches of the ilioinguinal nerve provide sensory innervation to the flaps.

A patient with Waldenstrom's Macroglobulinemia (WM) underwent bilateral radical vulvectomy followed by one stage reconstruction of the vulva using bilateral supero-medial thigh skin flaps. Necrosis of the distal portion of the left flap, observed post surgery, could be attributed to three findings associated with WM : IgM macroglobulin, cryoprecipitation and protein-protein interaction. Both careful pre-operative assessment of the patient's haematorheologic profile and consideration of ways of decreasing blood viscosity may be helpful in improving flap survival. Monitoring of body temperature and warming the flap during surgery is considered important. Infusion with low molecular weight dextran intra-operatively and post surgery may also help in limiting thrombosis within the flap.

Summary A combination of premedication, topical application, local infiltration and the head-up position during operation, provides reliably a virtually bloodless field durinf rhinoplasties.