James D. Frame

Dysfunctional Skin-Derived Glucocorticoid Synthesis Is a Pathogenic Mechanism of Psoriasis.

Glucocorticoids (GC) are the primary steroids that regulate inflammation and have been exploited therapeutically in inflammatory skin diseases. Despite the broad-spectrum therapeutic use of GC, the biochemical rationale for locally treating inflammatory skin conditions is poorly understood, as systemic GC production remains largely functional in these patients. GC synthesis has been well characterized in healthy skin, but the pathological consequence has not been examined. Here we show de novo GC synthesis, and GC receptor expression is dysfunctional in both nonlesional and lesional psoriatic skin. Use of GC receptor epidermal knockout mice with adrenalectomy allowed for the distinction between local (keratinocyte) and systemic GC activity. Compensation exhibited by adult GC receptor epidermal knockout mice demonstrated that keratinocyte-derived GC synthesis protected skin from topical phorbol 12-myristate 13-acetate-induced inflammatory assault. Thus, localized de novo GC synthesis in skin is essential for controlling inflammation, and loss of the GC pathway in psoriatic skin represents an additional pathological process in this complex inflammatory skin disease.

Commentary on: Breast Implants and the Risk of Breast Cancer: A Meta-Analysis on Cohort Studies

A meta-analysis is an accepted statistical method for pooling published comparative information and an attempt to understand a disease pathway. In this study, a very small selection of peer-reviewed studies, found by key wording in the literature, are pooled and analyzed.1 The intention of this publication is to summate separate published cohorts using meta-analysis to discover if there is a statistical connection between breast cancer and use of the generation of breast implants utilized mostly before 1989. Unfortunately, this type of study is often far from persuasive and not an exact science. It very much depends on the quality of the review, the comparability between each cohort included in the study, and the quality of initial peer review of papers included within the study. In this case, there are serious flaws, but the general conclusion is that breast implants, however manufactured, do not cause breast cancer, and this is an important take-home message that the authors seek to emphasize. It does not take a genius to discover this because there has never been a publication of a cohort that can show that breast implants cause breast cancer in women. The Oppenheimer effect that can occur in the genetically predisposed rodent is not a human phenomenon. There is, however, an increasing awareness that anaplastic large-cell lymphoma (ALCL) may, extremely rarely, have an association with any silicone implant, especially textured silicone implants, particularly those textured using salt extraction technology. At reporting, Reisman2 identified 8% of a responding cohort of plastic surgeons in the United States that had personally treated ALCL and emphasized the importance of early reporting and, perhaps, centralization of care. This, however, was not known at the time of publishing the few, historical studies included within this meta-analysis, which, incidentally, appears to have analyzed data only in the …

Framing the Breast

A large number of brilliant Brazilian plastic surgeons and the flamboyant, ingenious Mendieta have described, in detail, the concept of buttock frames, techniques for safer buttock augmentation with implants and autologous fat redistribution between the zones of the buttock region.1 After listening to Mendieta lecture on numerous occasions and operating by invitation in Rio de Janeiro, it has become clear to us that sharing knowledge through medical publications alone is dependent on the descriptive accuracy of the authors, and the quality of surgical outcomes is often very subjective within different cultural groups. By describing frames and overlying soft tissues accurately, we can better understand the myriad and diverse human appearance and, in particular, what constitutes beauty. The attractive buttock is clearly defined,2 but there is no such tool available to describe the female breast. The skeleton is the foundation to which the muscles and soft tissues adhere and over which the skin and breast tissue naturally change with aging and physiological changes. The region of the breast can be divided descriptively into 8 units (Figure 1), very similar to the units of the buttock described by Centeno.3 From these 8 units, the general frame of the breast region can be further analyzed and described. The skeletal frame is obviously related to adolescent development of the thoracic skeleton into adulthood, as seen on transverse section (Figure 2). How the soft tissues attach to and cover the frame dictate the external visual appearance of the breasts. In addition, analysis of a longitudinal section of thoracic skeleton helps define the projecting vectors of the chest (Figure 3) and explains the positioning and appearance of the breast on the chest wall. For example, a negative vector skeleton needs a higher-projecting implant to produce a reasonable augmentation, in contrast to a positive …

Medial Advancement of Infraumbilical Scarpa’s Fascia Improves Waistline Definition in “Brazilian” Abdominoplasty

Abdominoplasty is a surgical procedure designed to rejuvenate truncal aesthetics, in which restoring “normal” waistline definition is one of the most challenging elements. Advancement in surgical techniques is reducing surgical risk and improving aesthetic outcomes. In this study we adopted the “Brazilian” abdominoplasty technique, originally presented by Ramos at the International Society of Plastic Surgeons Meeting in Australia (2008). Waist definition is improved by medially advancing Scarpa’s fascia and repairing any divarication of the rectus abdominis muscles before vertically reducing redundant skin. In our study we demonstrated the role of Scarpa’s fascia as an important part of the superficial fascial system, which helps define waist contour. The technique we demonstrate shows improved contouring and waist definition with lower complication rates (by minimising dissection and dead spaces).Level of Evidence IVThis 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 http://www.springer.com/00266.

Commentary on: Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique

This is a very well thought out and good example of how to set up an objective randomized clinical study of matched patients, albeit with a relatively small number of cases.1 The title of this paper is however a little misleading in that the study really only compared speed of rectus divarication closure using a continuous 2/0 monofilament nylon, with a bidirectional locking Quill system (Quill Self-Retaining System [SRS], bidirectional barbed suture, Angiotech Pharmaceuticals Inc., Vancouver, British Columbia, Canada) and then compared the incidence of dehiscence of repair. The two layer 2/0 nylon closure control group was unnecessary in my opinion because recurrence of divarication after single layer closure is uncommon and there were too few cases studied. There are still other ways of repairing divarications that have not been included or fully discussed and they may actually be more rapid and effective than closure with nylon in two segments with, I presume, four knots or no knots at all as with the Quill suture. Some of these methods become important when there are umbilical and periumbilical hernias and if there is a significant thinning of skin in the periumbiliocal region perhaps associated with low BMI. I am not a particular fan of the barbed suture, certainly not for skin closure, but the manufacturers published information on use of these products for equivalence with a 2/0 monofilament, suggest that the quill nylon suture should be size 0 but Matarasso et al even suggested the size should be at least number 2 to specifically try and avoid the known risk of dehiscence when using barbed sutures.2 I note that Quill do not make a size 0 in nylon anyway so unfortunately the study findings are not strictly valid. There is inconsistency within this study if the barbed Quill suture closure is marginally slower (61 seconds) than continuous 2/0 nylon, yet the total operation time was 11 minutes less using the Quill repair of the divarication. If all else is equal, then this does not make sense and needs explaining but I suspect the argument will be down to lack of any statistical significance. Perhaps it was simply down to the learning curve of the surgeon using the Quill sutures. The most important finding therefore was that this author’s method of repair using a number 1 Quill suture caused at least a 30% chance of recurrence of diastasis. The actual method of closure of the divarication by the Quill is not made at all clear within the text and if I correctly interpreted the authors methodology where they describe closing in separate segments above and below the umbilicus, I suspect there is every reason for dehiscence if only a few barbs are actually gripping within the short segmental closure of rectus sheath. The unsurprising finding in this paper was that neither single nor double layer 2/0 nylon repair showed a recurrence of diastasis. If good postoperative instruction and aftercare is employed, then this should not really occur in any group provided the integrity of the repair is maintained and the tissues are of good quality. I like many colleagues use an 0-loop nylon repair starting high in the epigastrium (not trying to draw in the congenitally wide

Case 105: Early Recurrent Capsular Contracture and Thin Tissue

This 25-year-old patient had subglandular breast augmentation in 2008. She developed grade 2 capsule contracture and was treated medically with some improvement. Fourteen months after surgery, the capsule contracture was grade 3 that did not respond to medical treatment. Capsulectomy was performed with implants changed to subpectoral pockets. Capsule contracture grade 3 developed on the right side postoperatively. There was a discussion on polyurethane implants and Alloderm. A second revision was performed and she returned in 2015 with flipping of the implants and indentations.

Commentary on: The Reliability of Anthropometric Measurements Used Preoperatively in Aesthetic Breast Surgery

Unfortunately, I could not really get enthused by this paper1 because it really states the obvious—that interobserver errors in breast surface measurements exist, but there are less observer errors in static measurements than so-called dynamic measurements, despite prestudy investigator training on standard assessment and usage of a caliper and measuring tape. In women with small breasts, this may perhaps be more surprising, and there are obviously inherent inaccuracies to consider, especially if measuring with a caliper over a concave or convex surface in which the true upper pole or lower pole may be difficult to elicit and be affected by the positioning or height of the observer. If the tape is used primarily, the measurement is subjective and will vary on contact pressure; the translation of a caliper distance to a measuring tape should show no error of course. …

Book Review: Clinics in Plastic Surgery: Necklift

Malcolm D. Paul, ed. Clinics in Plastic Surgery: Necklift. New York: Elsevier, 2013. ISBN-10: 0323227376 It is often hard to be critical of a book written in good faith and with every good intention by surgeons invited from different parts of the world, by a single editor himself with a strong reputation as an international speaker. I have to say, though, that this book, Clinics in Plastic Surgery: Necklift , edited by Malcolm D. Paul, is not one to get too excited about. It is not actually exclusively about lifting the neck: it is about methods to nonsurgically tighten the superficial skin and to surgically rejuvenate the aging neck but mostly at a level above the hyoid only. At first glance, the book is disappointingly small in size but not small enough to put in a pocket. It is rather unattractively color mismatched and could be easily lost behind a cupboard or under a short table leg. It is a thin book, deficient in pages, sometimes with blank sheets, yet it is supposed to contain substance and exciting tips and tricks from all of its 16 invited authors (presumably with major contributions from some junior doctor coauthors). It is not set out in chapters per se, and this adds to the somewhat difficult-to-follow and confused lack of flow to the book. It is really a collection of anecdotes and personal preferences. Some authors clearly understand what we, as readers, want to know. Others, unfortunately, say very little of interest and stick to some pre-thought-out questions presented by the editor. I will expand upon these later. On balance, I think this book may be useful to some young plastic surgeons engaging in the concept of facial aesthetic surgery and perhaps as guidance to those wanting ideas to improve their current outcomes. There are apparently some good operative videos that accompany certain chapters. I would be surprised …

Conical Polyurethane Implants

BACKGROUND Polyurethane-coated conical implants were introduced by Silimed (US distributor: Sientra, Santa Barbara, California) in 2008 and offer an alternative to round or anatomically shaped implants. By their design and volume distribution, they naturally create central volume and give a reasonable fullness to the upper pole while lifting some ptotic breasts, thus avoiding the need for classical mastopexy. OBJECTIVES The authors discuss the advantages of conical implants as an alternative to conventional silicone implants for women with breast ptosis. METHODS In the 2-year period between December 2010 and December 2012, a consecutive series of 302 women underwent implant-based breast surgery procedures (236 primary augmentations, 59 revisions, and 7 mastopexy-augmentations) with conical polyurethane devices. Implant volumes ranged from 225 to 560 cc, with low- to medium-profile devices predominating. No extra-high-profile implants were used. Only 1 patient had a drain inserted on completion of a revision augmentation. RESULTS There were no infections (0%) and no wound dehiscence (0%). Four cases required reoperation (1.3%). Patient satisfaction scores were universally high (average, 9.94/10). There have been no capsular contractures to date, but follow-up is short. CONCLUSION The modern conical, polyurethane implant has many advantages over the conventional round or anatomically shaped implants and offers patients an ideal compromise between volume, natural upper pole fullness, and a lift without mastopexy scars.

Facelift surgery: An adjunct in the treatment of capillary malformations (port wine stains)

Hemangiomas and lymphangiomas remain the most common benign tumors seen by the plastic surgeon that involve a neonates skin and deeper tissues. A significant number of tumors undergo spontaneous regression and require no treatment. The port wine stain (PWS) remains one of the most difficult variants of hemangiomas to treat and continues to be psychologically traumatic throughout a patients lifetime. Recently, advanced use of laser technology has yielded beneficial results for a significant number of these patients. This report illustrates the incorporation of facelift surgery as an adjunct in the overall management of older patients resulting in decreased use of cosmetics and great improvement in general well being.Hemangiomas and lymphangiomas remain the most common benign tumors seen by the plastic surgeon that involve a neonates skin and deeper tissues. A significant number of tumors undergo spontaneous regression and require no treatment. The port wine stain (PWS) remains one of the most difficult variants of hemangiomas to treat and continues to be psychologically traumatic throughout a patients lifetime. Recently, advanced use of laser technology has yielded beneficial results for a significant number of these patients. This report illustrates the incorporation of facelift surgery as an adjunct in the overall management of older patients resulting in decreased use of cosmetics and great improvement in general well being.