Yaron Har-Shai

Intralesional Cryotherapy for Enhancing the Involution of Hypertrophic Scars and Keloids

&NA; Although therapeutic management of hypertrophic scars and keloids using contact or spray cryosurgery has yielded significant improvement or complete regression of hypertrophic scars and keloids, it requires one to 20 treatment sessions. This study was designed to assess the clinical safety and efficacy of an intralesional needle cryoprobe method in the treatment of hypertrophic scars and keloids. Ten patients, ranging in age from 3 to 54 years, with a total of 12 hypertrophic scars and keloids of more than 6 months duration and of diverse causes, were included in this study. The 18‐month trial evaluated volume reduction of the hypertrophic scars and keloids after a single session of intralesional cryotherapy. Objective (hardness and color) and subjective (pain/tenderness and itchiness/discomfort) parameters were examined on a scale of 0 to 3 (low score was better). Pretreatment and posttreatment histomorphometric studies of the collagen fibers included spectral picrosirius red polarization and fast Fourier transformation orientation index. A specially designed cryoneedle was inserted into the long axis of the hypertrophic scars and keloids so as to maximize the volume of the hypertrophic scars and keloids to be frozen. The cryoneedle was connected by an adaptor to a cryogun filled with liquid nitrogen, which was introduced into the cryoprobe, thereby freezing the hypertrophic scars and keloids. After the hypertrophic scars and keloids were completely frozen, the cryoprobe defrosted and was withdrawn. An average of 51.4 percent of scar volume reduction was achieved after one session of intralesional cryosurgery treatment (average preoperative hypertrophic scars and keloids volume, 1.82 ± 0.33; average posttreatment volume, 0.95 ± 0.21; p < 0.0022). Significant alleviation of objective and subjective clinical symptoms was documented. Mild pain or discomfort during and after the procedure was easily managed. Only mild local edema and epidermolysis, followed by a short reepithelialization period, were evident. During the 18‐month follow‐up period, there was no evidence of bleeding, infection, adverse effects, recurrence, or permanent depigmentation. The histomorphometric analysis demonstrated rejuvenation of the treated scars (i.e., parallelization) and a more organized architecture of the collagen fibers compared with the pretreated scars. This study demonstrated the increased efficacy of this method as a result of increased freezing area of deep scar material compared with that obtained with contact/spray probes. As a result, fewer treatment cycles are needed. Because the reepithelialization period is short, treatment intervals, if any, can be shortened to 2 to 3 weeks. This intralesional cryoneedle method is simple to operate and safe to use, it necessitates less postoperative care of the wound, and it can easily be added to any preexisting cryosurgical unit. (Plast. Reconstr. Surg. 111: 1841, 2003.)

A skin-stretching device for the harnessing of the viscoelastic properties of skin

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 surgeons 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.

Free-fat injections for the correction of hemifacial atrophy.

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.

Intralesional cryosurgery enhances the involution of recalcitrant auricular keloids : a new clinical approach supported by experimental studies

To explain the mechanism of action of a novel intralesional cryoprobe, thermal behavior measurements, and histological studies were performed in swine muscle specimens after intralesional cryosurgery ex vivo. Slow cooling (20°C/min) and thawing (25°C/min) rates, end temperature of −30°C, produced 8 mm wide diffuse coagulative‐type necrosis and a 3 mm‐wide transition zone around the cryoprobe. In contrast, contact cryosurgery showed fast cooling and thawing rates (80°C/min) and an end temperature of −100°C. Efficacy and safety of the intralesional cryoprobe was further assessed in ten recalcitrant auricular keloids in nine Caucasian patients. There was a 67.4 ± 23 percent reduction of scar volume at the end of the 18‐month follow‐up period after a single intralesional treatment (p < 0.005). Significant reduction of hardness, elevation, and redness as well as itching, pain, and tenderness was documented. The histomorphometric analysis, including spectral and fractal analysis, as well as assessment of the fast Fourier transform algorithm, showed parallel alignment and reorganization of the collagen fibers in the treated scar similar to that in the normal dermis. A long hold time in the deep scar core caused minimal damage to the superficial tissue, including melanocytes. There was no evidence of permanent hypopigmentation, active bleeding, infection, or recurrence. The major advantages of the intralesional cryoprobe, including the marked efficacy of a single treatment, may have a major importance in the clinical application of cryosurgery in the treatment of keloids and of other lesions localized deep in the skin.

A Critical Analysis of Penile Enhancement Procedures for Patients with Normal Penile Size: Surgical Techniques, Success, and Complications

CONTEXT Most men who request surgical penile enhancement have a normal-sized and fully functional penis but visualize their penises as small (psychological dysmorphism). OBJECTIVES The aim of this review is to describe the various reported techniques and to provide the available scientific data on the success and complication rates of penile enhancement procedures. EVIDENCE ACQUISITION We performed an extensive systematic review based on a search of the MEDLINE database for articles published between 1965 and 2008. The following key words were used: penis, enhancement, enlargement, phalloplasty, reconstruction, girth, lengthening, and augmentation. Only English-language articles that were related to penile surgery and dysmorphobia were sought. We excluded articles in which fewer than five cases were described and articles in which the type of surgical treatment and the outcome were not clear. Of the 176 papers found, 34 were selected and critically analyzed. EVIDENCE SYNTHESIS We found only a small number of well-designed and comprehensive studies, and most of the published articles reported data that were obtained from small cohorts of patients. The more recently published studies presented better methodologies and descriptions of the surgical techniques than did the older publications. In general, penile enhancement surgery can cause a 1-2-cm increase in penile length and a 2.5-cm augmentation of penile girth. Unwanted outcomes and complications, namely penile deformity, paradoxical penile shortening, disagreeable scarring, granuloma formation, migration of injected material, and sexual dysfunction were reported frequently in these studies. Disappointing short- and long-term patient satisfaction rates following these procedures were also reported in most studies. CONCLUSIONS To date, the use of cosmetic surgery to enlarge the penis remains highly controversial. There is a lack of any standardization of all described procedures. Indications and outcome measures are poorly defined, and the reported complications are unacceptably high. In our opinion, until new, reliable, and more objective and reproducible data are available, these procedures should be regarded as investigational and patients should be discouraged from undergoing these invasive treatments.

Static-electric field induction by a silicone cushion for the treatment of hypertrophic and keloid scars

&NA; Silicone gel and silicone occlusive sheeting are widely used at present for the treatment of hypertrophic and keloid scars, without any scientific explanation as to their mode of action. In a recent paper the possibility was raised that static electricity generated by friction‐activated silicone sheeting could be the reason for this effect, and that it can, with time, cause involution of hypertrophic and keloid scars. The objective of this study was to test this hypothesis and to observe whether a continuous and also an increased negatively charged static‐electric field will shorten the treatment period. A device to implement these requirements gradually evolved over a 5‐year period. A number of prototypes were tested until the final product was attained. Some of the patients in this study were treated initially with a silicone sponge inserted in the cushion. Later this version was changed to the final design described herein. A silicone cushion was developed with the purpose of increasing a negative static‐electric charge to accelerate the regression process. The cushion is custom‐made using a silicone occlusive sheeting envelope of 0.75‐mm thickness, which does not deteriorate with use, and is partially filled with high viscosity silicone oil. Its edges are sealed, and its size is designed to extend a little beyond the scarred area. Static electricity readings, generated by activating the cushion by pumping action with the fingers, stretching or deforming the cushion, are invariably much higher when compared with those obtained with silicone occlusive sheeting and silicone gel sheeting. The interaction between the negatively charged ions of the cushion and the ionic charges of the tissue fluids may be the critical factor in achieving hypertrophic and keloid scars involution. Of the 30 patients enrolled in the study, 3 patients dropped out. Treatment with the silicone cushions yielded 63.3 percent cessation of itching and burning followed by pallor and flattening of the scar, some markedly so, over a few weeks to 6‐month period. An additional 26.6 percent had their scars resolved in up to 12 months of treatment. Good contact of the cushion over the scar has been shown to be important in this clinical trial, and much creativity is needed for making elastic strap bindings that ensure this contact. The clinical trials extended over a 12‐month period. Ten patients (33.3 percent) who had recalcitrant scars with little response to the use of the silicone cushion were given intralesional corticosteroid injections, in addition to the continued use of the cushion, resulting in a fairly rapid resolution of these scars over a period of months to a year. (Plast. Reconstr. Surg. 101: 1173, 1998.)

Mechanical properties and microstructure of the superficial musculoaponeurotic system.

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.

Comparison of inorganic bovine bone mineral particles with porous hydroxyapatite granules and cranial bone dust in the reconstruction of full-thickness skull defect.

Twenty adult rabbits were used to evaluate the biocompatibility and osteoconductivity of Bio-Oss, an inorganic bovine bone mineral, in the reconstruction of full-thickness skull defects. Skull defects were treated with either autogenous bone dust, porous hydroxyapatite granules, Bio-Oss particles, or were left untreated as controls. Histological examination of decalcified sections showed incorporation of Bio-Oss into the host tissue without a significant inflammatory reaction. Measurement of the profile area occupied by the bone revealed that Bio-Oss, hydroxyapatite, and the control had the same amount of bone ingrowth, whereas autogenous bone dust produced a greater amount of bone (p < 0.01). We conclude that Bio-Oss, like porous hydroxyapatite, has sufficient osteoconductive properties and can also be used as a bone substitute material.

The vascular anatomy of the galeal flap in the interparietal and midline regions.

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.

Intralesional Cryosurgery for the Treatment of Hypertrophic Scars and Keloids Following Aesthetic Surgery: The Results of a Prospective Observational Study

Hypertrophic scars and keloids following aesthetic surgery, which ignite patient dissatisfaction, are difficult to handle. Intralesional cryosurgery for the treatment of such scars has been introduced. This study was designed to evaluate the efficacy of this technology in the treatment of such scars and to assess the reduction of dissatisfaction. Eleven scars (on 11 patients) were treated by intralesional cryosurgery, following breast surgery, otoplasty, face-lifting, and brachioplasty. Each patient scored the concern from the scar and the scar deformity (scale from 1 to 5) prior and following treatment (higher score represents least satisfaction and a severe deformity). The follow-up period was between 3 months and 8 years. The results demonstrated a significant reduction in concern and deformity scores compared with before the cryotreatment (P = .001). The intralesional cryosurgery technique provides the plastic surgeon with an effective instrument to treat hypertrophic scars and keloids following aesthetic surgery, thus reducing the dissatisfaction of patients.