Ernest N. Kaplan

Injectable collagen for soft tissue augmentation

Collagen from allogenic and xenogeneic sources has been made soluble by controlled proteolytic digestion. The monomeric, telopeptide-poor collagen so prepared forms a cohesive mass when warmed to body temperature (upon injection), creating a structural basis for new soft connective tissue. We have treated 28 patients with human and/or bovine collagen injections for the correction of soft tissue contour defects, and we have followed them for 3 to 18 months. In most instances, there has been lasting and substantial correction of the defects treated. The complications have been few and transient.

Silicone-induced human adjuvant disease?

Human adjuvant disease is an immunologically mediated disorder manifested by arthritis, arthralgias, skin lesions, malaise, pyrexia, and weight loss. Clinically, it often resembles rheumatoid arthritis and Reiters syndrome. While scattered cases of adjuvant disease have been reported following injections with silicone fluid of unknown purity, paraffin, and petroleum jelly, no cases of adjuvant disease following silicone gel implant mammaplasty have been reported. We present such a case, discuss the pertinent biology of silicone, and review the literature describing adjuvant disease

Clinical Utilization of Injectable Collagen

The applications for an injectable, highly purified form of calfhide collagen (Zyderm Collagen Implant) were first described byKnapp et al in 1977. Since that time, the material has undergone evaluation in a nationwide clinical trial in which 728 physicians participated under a cooperative protocol. In these trials—which culminated in marketing clearance by the Food and Drug Administration—over 5,000 patients were treated for a variety of soft-tissue depressions resulting from surgery, atrophy, acne, viral pox, and aging. We participated in the clinical trial and have used injectable collagen in our practices since 1977 when the material was undergoing evaluation in California. We have treated over 400 patients with injectable collagen for a variety of facial cutaneous defects. The material has proved to be an effective tool for correction of certain soft-tissue defects not previously amenable to correction, and a useful surgical adjunct. Simplicity and safety are its major advantages. The persistence of correction afforded by injectable collagen is variable, but the majority of our patients have maintained improvement twelve or more months since the end of treatment. Hence we believe that there is a definite role for injectable collagen but that its long-term persistence must still be confirmed. This paper represents our state-of-the-art assessment of injectable collagen after six years of personal experience.

Fascicular tubulization: a cellular approach to peripheral nerve repair

Present techniques of nerve repair by suture are based on an anatomical approach. The severed layers of connective tissue are reapproximated. Another approach to nerve repair is to separate the specific cellular components of the peripheral nerve that contribute to fibrous healing and nerve regeneration. The perineurium normally separates the extrafascicular epineurium of mesodermal origin from the intrafascicular endoneurium of ectodermal origin. A cellular approach to nerve repair would use a tube around the fascicle as an artificial perineurium to separate fibrous healing from axonal regeneration until the perineurium reestablishes its continuity. Fascicular tubulization with polyglycolic acid tubes was studied in 25 rats. The polyglycolic acid tube is resorbed after the perineurium has reestablished its continuity. The repairs by fascicular tubulization demonstrated improved organization of the repair site compared to suture repairs. The diameter histograms of the regenerated myelinated axons were similar in repairs by tube and suture techniques. The total regenerated cross-sectional area of the myelinated axons was similar in the repairs by fascicular tubulization to repairs by fascicular suture.

Commissuroplasty and Myoplasty for Macrostomia

The morphology of macrostomia and a method of myoplasty and commissuroplasty are described. The important operative considerations are accurate commissure positioning, muscle reconstruction, obliteration of the lateral subdermal groove, placement of a vermilion flap across the commissure, and Z-plasty of skin in the nasolabial crease.

An arterial medial arm flap--vascular anatomy and clinical applications.

We describe the vascular distribution to the skin of the arm as determined by cadaver dye injections and anatomical dissection. The superior ulnar collateral cutaneous artery provides a direct cutaneous branch that supplies the proximal two-thirds of the medial arm. An arterialized flap from the medial arm is very thin, elastic, and hairless--therefore excellent for hand resurfacing and facial reconstruction. Five examples of the use of arm skin from 21 patients using local and distant flaps are shown. The indications, methods, and anatomical bases for flap delay are detailed. The Doppler flow meter is used to determine artery position.

Cleft palate repair at three months

&NA; Evidence has been presented that soft palate repair at 3 to 6 months results in the best speech. Controversy remains as to the value of delayed hard palate repair or simultaneous early repair of the hard palate in combined cleft lip and palate. However, we prefer the combined hard palate and soft palate repair for reasons described. Traumatic surgery, genetically inherent maxillary hypoplasia, and the importance of lip repair in isolated cleft palate are also discussed.

The surgical treatment of necrobiosis lipoidica diabeticorum.

We review the literature on the surgical treatment of necrobiosis lipoidica diabeticorum, and we describe 7 cases treated at Stanford University Medical Center. Experiences with them prompt us to recommend surgical excision of the lesions down to the deep fascia, ligation of the associated perforating blood vessels, and the use of split-skin grafts to cover the defects. There were no recurrences when we did all these things.

Cephalometric study of facial growth in children after combined pushback and pharyngeal flap operations.

Linear and angular cephalometric measurements of children who had had combined palatal pushbacks and superiorly-based pharyngeal flaps do not show later growth retardation of the face. There was an inherent tendency for children with overt clefts of the secondary palate, classic submucous clefts, or occult submucous clefts to demonstrate pre-operatively a narrow SNA and SNB--but the difference between these angles (ANB) was normal.

Use of the Medial Upper Arm Skin as an Arterialised Flap

The skin on the underside of the upper arm is supplied in part by the superior ulnar collateral artery, a direct cutaneous artery arising from the brachial artery four to six cm distal to the pectoralis major insertion. Two-thirds to three-quarters of the length of the medial arm skin can be reliably transferred as an arterialized undelayed pedicle flap. This skin provides excellent coverage for the opposite hand from a relatively inconspicuous donor site. Transfer of this flap is safe and patient discomfort is minimal. It is recommended for elective reconstruction and emergency procedures.