Hieronymus P. Stevens

Scarless Umbilicoplasty A New Umbilicoplasty Technique and a Review of the English Language Literature

Many techniques have been described for umbilicoplasty after abdominoplasty, but none of these techniques seems ideal. In this report, we wish to report a new “scarless” umbilicoplasty technique, which bears many of the characteristics of an ideal technique: it is easy to perform and results in the complete absence of visible scars and with a preferred vertical orientation. The aesthetic results of this technique are subjectively and objectively evaluated as compared with the classic umbilicoplasty and these results are discussed among the English language literature. In the period of 2004 to 2005, a series of 138 female patients have had an abdominoplasty with either the classic umbilicoplasty (n = 31) or with our scarless umbilicoplasty (n = 107). After a follow-up period of at least 3 (of 6) months, a questionnaire was send to all of these patients to evaluate patient satisfaction. Twenty-five patients from the classic umbilicoplasty group responded, 53 patients from the scarless umbilicoplasty group. Age (mean 45 with range, 22–66 years) and body mass index (29 with range, 22–35) did not differ among both groups. Also a random selection of fifteen photos from both groups was analyzed and rated according to the system of Strasser by an independent panel. There were no major complications in both groups, but in the classic group, there were some cases with hypertrophic scarring. Patients who underwent the scarless umbilicoplasty technique graded the appearance of their umbilicus significantly better on shape, depth, hygiene, and scar. No significant differences were found in grading size and wound healing. Objective evaluation of the photos demonstrated significant better results for the scarless umbilicoplasty technique. Based on our subjective and objective analysis we conclude that our new technique of the scarless umbilicoplasty features many of the characteristics of the ideal umbilicoplasty: a rather simple and reliable method for creating a natural looking umbilicus when performing an abdominoplasty.

The fractionation of adipose tissue procedure to obtain stromal vascular fractions for regenerative purposes.

Autologous adipose tissue transplantation is clinically used to reduce dermal scarring and to restore volume loss. The therapeutic benefit on tissue damage more likely depends on the stromal vascular fraction of adipose tissue than on the adipocyte fraction. This stromal vascular fraction can be obtained by dissociation of adipose tissue, either enzymatically or mechanical. Enzymatic dissociation procedures are time‐consuming and expensive. Therefore, we developed a new inexpensive mechanical dissociation procedure to obtain the stromal vascular fraction from adipose tissue in a time sparing way, which is directly available for therapeutic injection. This mechanical dissociation procedure is denoted as the fractionation of adipose tissue (FAT) procedure. The FAT procedure was performed in eleven patients. The composition of the FAT‐stromal vascular fraction was characterized by immunohistochemistry. Adipose derived stromal cells isolated from the FAT‐stromal vascular fraction were compared with adipose derived stromal cells isolated from nondissociated adipose tissue (control) for their CD‐surface marker expression, differentiation and colony forming unit capacity. Case reports demonstrated the therapeutic effect of the FAT‐stromal vascular fraction. The FAT‐stromal vascular fraction is an enrichment of extracellular matrix containing a microvasculature and culturable adipose derived stromal cells. Adipose derived stromal cells isolated from FAT‐stromal vascular fraction did not differ from adipose derived stromal cells isolated from the control group in CD‐surface marker expression, differentiation and colony forming unit capacity. The FAT procedure is a rapid effective mechanical dissociation procedure to generate FAT‐stromal vascular fraction ready for injection with all its therapeutic components of adipose tissue: it contains culturable adipose derived stromal cells embedded in their natural supportive extracellular matrix together with the microvasculature.

The rainbow scale: A simple, validated online method to score the outcome of aesthetic treatments

Photographs have become an important integral part of documentation in an aesthetic surgery practice, both for medico-legal as well as scientific purposes.1 Only by evaluating pre- and postoperative photographic documentation are we able to evaluate our success and treatment outcomes in an objective way. Several photographic scales have already been developed for this purpose.2-4 However, an easy online system to evaluate aesthetic outcomes in a validated, fast, reliable, and standardized way is still lacking. We have therefore designed what we call the “Rainbow Scale” method based on the Merz Scales (Merz Pharmaceuticals GmbH, Frankfurt, Germany) (Figure 1).2 In this online system, 6 photographs are presented in a block of two rows of 3 photographs. The photograph of the patient to be evaluated is located in the central position of the lower row. Other photographs show the five grades of severity of the area to be evaluated, with the lowest score left of the photograph to be evaluated, the second score on the upper left side, etc. until the highest score on the lower right side of the photograph. The different scores are thus presented around the patient in a rainbow fashion. …

The Rainbow Scale for Assessing Breast Ptosis: Validation of Three Different Views.

BACKGROUND Photographic scales have become an increasingly used tool in objectively assessing outcomes in aesthetic surgery. However, no online photographic scale for assessing breast ptosis has been developed yet that is readily available. OBJECTIVES This study was designed to validate the online Rainbow Scale for the assessment of breast ptosis for the anterior-posterior (AP), lateral, and oblique views. METHODS For the five grades of the Rainbow Scale format, standardized reference photographs were selected. Six plastic surgeons rated 15 photographs for each view three times. Intra- and inter-observer agreements were calculated by using the weighted kappa coefficient and differences in intra- and inter-observer agreements between the three views were assessed for statistical significance using the Kruskal-Wallis test. RESULTS The mean intra-observer agreements were 0.91 (range, 0.82-0.98) for the AP view, 0.88 (range, 0.77-1.00) for the oblique view, and 0.86 (range, 0.74-0.97) for the lateral view and did not vary significantly between all three views. The mean inter-observer agreements were 0.88 (range, 0.77-0.95) for the AP view, 0.84 (range, 0.72-0.94) for the oblique view, and 0.82 (range, 0.58-0.95) for the lateral view. The mean inter-observer agreements of the AP view varied significantly from the oblique view (P = .012) and the lateral view (P = .001). CONCLUSIONS The Rainbow Scale for breast ptosis has been validated for the AP view, the lateral view, and the oblique view and is reproducible and reliable for the assessment of breast ptosis in three different views in an online setup. LEVEL OF EVIDENCE 4 Diagnostic.

Lipofilling With Minimal Access Cranial Suspension Lifting for Enhanced Rejuvenation

BACKGROUND Loss of volume is an important aspect in facial aging, but its relevance is frequently neglected during treatment. OBJECTIVES The authors discuss lipofilling as an ancillary procedure to improve the impact of facelifting procedures. METHODS Fifty patients who underwent minimal access cranial suspension (MACS) lifting alone were retrospectively analyzed, and their results were compared to 42 retrospective cases of MACS lifting with adjuvant lipofilling. The results were evaluated with a photographic ranking system by two panels (five plastic surgeons and five medical students). RESULTS Combined MACS lifting and lipofilling yielded overall cosmetic results that were significantly better than the results achieved with MACS lifting alone. Photographic evaluations showed that improvements were more pronounced in the tear trough (P < .05) and malar eminence (P < .01) than in the nasolabial groove (P > .05). CONCLUSIONS Volume restoration with lipofilling following MACS lifting procedures produces significantly better postoperative results than MACS lifting alone. This combined procedure produces the most dramatic improvements in the tear trough and malar eminence regions.

Introducing Platelet-Rich Stroma: Platelet-Rich Plasma (PRP) and Stromal Vascular Fraction (SVF) Combined for the Treatment of Androgenetic Alopecia

Background Androgenetic alopecia (AGA) is characterized by miniaturization of the hair follicles gradually causing conversion of terminal hairs into vellus hairs, leading to progressive reduction of the density of hair on the scalp. Approved therapeutic options are limited and show side effects. Objectives To evaluate injections of stromal vascular fraction (SVF), which is rich in adipose-derived stromal cells (ASCs) in combination with platelet-rich plasma (PRP) in the upper scalp as a new autologous treatment option for AGA. Methods Ten male patients (age range, 25-72 years), suffering from AGA at stage II to III according to the Norwood-Hamilton scale, have been treated with a single injection of autologous PRS (ACPSVF: combination of PRP and SVF) in the upper scalp. Preinjection and 6 and 12 weeks postinjection changes in hair density were assessed using ultra high-resolution photography (Fotofinder). Results Hair density was significantly increased after 6 weeks and 12 weeks postinjection (P = 0.013 and P < 0.001). In hair-to-hair matching analyses, new hair grew from active follicles. Furhtermore nonfunctioning hair follicles filled with hyperkeartotic plugs, up to today assumed incapable of forming new hair, proved to grow new hair. No side effects were noted after treatment. Conclusions A single treatment of platelet-rich stroma injected in the scalp of patients with AGA significantly increased hair density within 6 to 12 weeks. Further research is required to determine the optimal treatment regimen. Preferred options to our opinion include the repetition of PRS or additional treatments with PRP. Level of Evidence 4

Augmentation of Dermal Wound Healing by Adipose Tissue-Derived Stromal Cells (ASC)

The skin is the largest organ of the human body and is the first line of defense against physical and biological damage. Thus, the skin is equipped to self-repair and regenerates after trauma. Skin regeneration after damage comprises a tightly spatial-temporally regulated process of wound healing that involves virtually all cell types in the skin. Wound healing features five partially overlapping stages: homeostasis, inflammation, proliferation, re-epithelization, and finally resolution or fibrosis. Dysreguled wound healing may resolve in dermal scarring. Adipose tissue is long known for its suppressive influence on dermal scarring. Cultured adipose tissue-derived stromal cells (ASCs) secrete a plethora of regenerative growth factors and immune mediators that influence processes during wound healing e.g., angiogenesis, modulation of inflammation and extracellular matrix remodeling. In clinical practice, ASCs are usually administered as part of fractionated adipose tissue i.e., as part of enzymatically isolated SVF (cellular SVF), mechanically isolated SVF (tissue SVF), or as lipograft. Enzymatic isolation of SVF obtained adipose tissue results in suspension of adipocyte-free cells (cSVF) that lack intact intercellular adhesions or connections to extracellular matrix (ECM). Mechanical isolation of SVF from adipose tissue destructs the parenchyma (adipocytes), which results in a tissue SVF (tSVF) with intact connections between cells, as well as matrix. To date, due to a lack of well-designed prospective randomized clinical trials, neither cSVF, tSVF, whole adipose tissue, or cultured ASCs can be indicated as the preferred preparation procedure prior to therapeutic administration. In this review, we present and discuss current literature regarding the different administration options to apply ASCs (i.e., cultured ASCs, cSVF, tSVF, and lipografting) to augment dermal wound healing, as well as the available indications for clinical efficacy.

Use of Stem Cells in Orthopaedics

Mesenchymal stem cells have for some time been gaining interest in the context of their potential applications in the treatment of musculoskeletal disorders. Mesenchymal stem cells (MSCs) are capable of differentiating into one of several mesenchymal phenotypes such as osteoblasts, chondrocytes, myocytes, marrow stromal cells, tendon–ligament fibroblasts and adipocytes [ 1– 4]. Due to the relative ease of obtaining and administering them, compared to the alternative surgical treatment (or in combination with surgical treatment), they offer an attractive therapeutic option, for both physicians and patients alike, and find an increasing range of applications in orthopaedics. According to the most recent thinking on mesenchymal stem cell physiology, these cells are actually pericytes, that is, perivascular cells which are activated in response to trauma or local inflammation, and act to repair the damage using various types of chemotactic factors [ 5]. These secreted bioactive factors suppress the local immune system, inhibit fibrosis (scar formation) and apoptosis, enhance angiogenesis and stimulate mitosis and differentiation of tissue-intrinsic reparative or stem cells [ 6]. It has been proposed that the pericyte is released from its position on a vascular tube in the case of a focal injury, and, as such, it functions as an immunomodulatory and trophic MSC [ 7]. MSC-induced immune modulation turns off T-cell supervision of the injured area and blocks autoimmunological reactions. Its trophic activity limits the field of damage so that scarring does not occur and that tissue-intrinsic progenitors replace the expired cells.