Yitzchak Ramon

Enhancing the survival of aspirated human fat injected into nude mice

Injection of aspirated fat is now the most commonly used technique for the filling of depressed areas. Partial absorption of the injected fat is the main limitation of this procedure. Cariel T.M. is an enriched serum-free cell culture medium, its ability to enhance the survival of human aspirated fat grafts was investigated in the nude mouse model. A volume of 0.75-cc Cariel preprocessed fat was injected under the scalp skin of 16 nude mice in the experimental group, and the same volume of saline preprocessed fat was injected to 15 control group of mice. Significant maintenance of the weight, 46 percent in the experimental group compared with 29 percent in the control group (p < 0.008), and the volume, 44 percent in the experimental group compared with 31 percent in the control group (p < 0.026), was observed, after 15 weeks, in this newly used model. It seems that addition of the nutrients enriched with anabolic hormones enabled the survival and take of more adipose cells in the graft.

Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head.

Avascular necrosis (AVN) of the head of the femur is a potentially crippling disease which mainly affects young adults. Although treatment by exposure to hyperbaric oxygen (HBO) is reported as being beneficial, there has been no study of its use in treated compared with untreated patients. We selected 12 patients who suffered from Steinberg stage-I AVN of the head of the femur (four bilateral) whose lesions were 4 mm or more thick and/or 12.5 mm or more long on MRI. Daily HBO therapy was given for 100 days to each patient. All smaller stage-I lesions and more advanced stages of AVN were excluded. These size criteria were chosen in order to compare outcomes with an identical size of lesion in an untreated group described earlier. Overall, 81% of patients who received HBO therapy showed a return to normal on MRI as compared with 17% in the untreated group. We therefore conclude that hyperbaric oxygen is effective in the treatment of stage-I AVN of the head of the femur.

The Effect of Interleukin-8 on the Viability of Injected Adipose Tissue in Nude Mice

Adipose tissue injection as a free graft for the correction of soft-tissue defects is a widespread procedure in plastic surgery. The main problem in achieving long-term soft-tissue augmentation is partial absorption of the injected fat and hence the need for overcorrection and re-injection. The purpose of this study was to improve the viability of the injected fat by the use of interleukin-8. The rationale for the use of interleukin-8 was its abilities to accelerate angiogenesis and attract inflammatory cells and fibroblasts, providing the injected adipocytes more feeding vessels and a well-established graft bed to enhance their viability. Human adipose tissue, obtained by suction-assisted lipectomy, was re-injected into the subcutis in the scalp of nude mice. Interleukin-8 (0.25 ng) was injected subcutaneously to the scalp as a preparation of the recipient site 24 hours before the fat injection and was added to the fat graft itself (25 ng per 1 cc of injected fat). In the control group, pure fat without interleukin-8 was injected and no interleukin-8 was added for the preparation of the recipient site. One cubic centimeter of fat was injected in each animal in both the study and control groups. There were 10 animals in each group. The animals were euthanized 15 weeks after the procedure. Graft weight and volume were measured and histologic evaluation was performed. In addition, triglyceride content and adipose cell sizes were measured as parameters for fat cells viability. Histologic analysis demonstrated significantly less cyst formation in the group treated with interleukin-8. No significant differences were found between the groups with regard to graft weight and volume or the other histologic parameters investigated. No significant differences were demonstrated in adipose cell sizes and their triglyceride content. In conclusion, less cyst formation, indicating improved quality of the injected fat, can be obtained by the addition of interleukin-8. Further studies of various dosages of interleukin-8 and their long-term effect are required before these encouraging results could be applied clinically.

Use of synthetic mesh for the entire abdominal wall after TRAM flap transfer.

&NA; Abdominal wall competence is a major concern of all plastic surgeons using the TRAM flap for breast reconstruction. Low hernia rates and adequate abdominal stability are standard expectations in abdominal wall closure. Described here is this institutions experience with the use of a large piece of synthetic mesh as a supplementary reinforcement for the entire abdominal wall in an attempt to stabilize it and achieve a superior abdominal aesthetic result. Twenty‐five consecutive patients had routine reinforcement with the extended mesh technique. Mean patient follow‐up was 24 months with a minimum of 1 year. No hernia or mesh‐related infection were encountered and only one patient had a lower abdominal bulge. We recommend the use of a large synthetic mesh for improved strength and aesthetic quality of the abdominal wall after TRAM flap breast reconstruction.

Hyperbaric oxygen therapy for cutaneous/soft-tissue zygomycosis complicating diabetes mellitus.

A 24-year-old female diabetic patient was hospitalized because of ketoacidosis and a necrotic wound on the hand. Debridement and antibiotic therapy failed to halt the process. After demonstration of Mucor in cultures from the wound, the patient underwent extensive surgery and amphotericin B was administered. When the necrotic process continued despite these measures, adjunctive hyperbaric oxygen (100% O2 at 2.5 ATA for 90 minutes) was administered daily for a total of 21 treatment sessions. She gradually improved, and at 2 months follow-up most of the wound had healed. Although the mortality rate of cutaneous/soft-tissue zygomycosis is markedly lower than that of the rhinocerebral form, morbidity is still considerably high. Successful use of hyperbaric oxygen has been reported in rhinocerebral zygomycosis, and it may have been of benefit in this high-risk patient by preventing local and systemic spreading of the fungus. This report is the first case of the use of hyperbaric oxygen for cutaneous/soft-tissue zygomycosis. It is suggested that hyperbaric oxygen be considered for this indication in diabetic patients as an adjunct to surgery and amphotericin B.

Early nonsurgical correction of congenital auricular deformities.

&NA; Congenital auricular deformation is not an uncommon phenomenon, and it may cause substantial annoyance to the growing child. Many parents of affected children will seek surgical correction of the deformed auricles. The variety of techniques that have been described for the correction of this anomaly suggests that none has been considered satisfying. The consequent possible surgical complications should also be considered, when the surgical procedure can be replaced by an effective conservative treatment. The authors describe their experience using early splinting for congenital auricular deformities. Fifty‐two newborn infants with lop, prominent, Stahls, and constricted ears referred to us by the neonatal department staff were enrolled in this study. Putty Soft, a vinyl polysiloxane impression material, has been used for early molding of the auricles. Surgical tapes were used for the fixation of the mold and to fix the auricle to the scalp. The results were evaluated by one of the parents and by a layperson (medical student) 6 months after completion of the procedure. The above‐described early splinting procedure was applied onto 92 auricles of 52 newborn infants aged 1 to 10 days, mostly around day 3. The mean treatment time was 6.8 weeks. All treated auricles were improved, 87 percent were rated as excellent improvement, and there were no complications related to the treatment. The authors conclude that early splinting of deformed auricles should be offered to parents of affected children, and the awareness of this procedure by neonatologists, pediatricians, and nursery staff should be increased. (Plast. Reconstr. Surg. 109: 907, 2002.)

The effect of hyperbaric oxygenation on the viability of human fat injected into nude mice.

&NA; Autologous free‐fat injection for the correction of softtissue defects has become a common procedure in plastic surgery. The main shortcoming of this method for achieving permanent soft‐tissue augmentation is the partial absorption of the injected fat, an occurrence that leads to the need for both overcorrection and repeated fat reinjection. Improving the oxygenation of the injected fat has been suggested as a means of helping to overcome the initial critical phase that occurs postinjection (when the fat cells are nourished by osmosis), increasing phagocyte activity, accelerating fibroblast activity and collagen formation, and enhancing angiogenesis. In addition, the hyperbaric oxygen‐mediated decrement in endothelial leukocyte adhesion will decrease cytokine release, thereby reducing edema and inflammatory responses. The purpose of the present study was to examine the effect of hyperbaric oxygenation on improving the viability of injected fat. Adipose tissue obtained from human breasts by suctionassisted lipectomy was injected into the subcuticular nuchal region in nude mice. The mice were then exposed to daily hyperbaric oxygen treatments, breathing 100% oxygen at 2 atmospheres absolute (ATA) for 90 minutes. The duration of the administered hyperbaric oxygen therapy was 5, 10, or 15 days, according to the study group. Mice exposed to normobaric air alone served as the control group, and each group included 10 animals. The rats were killed 15 weeks after fat injection. The grafts were dissected out, weight and volume were measured, and histologic evaluation was performed. In all of the study groups, at least part of the injected fat survived, giving the desired clinical outcome. No significant differences could be found between the groups regarding fat weight and volume. Histopathologic examination of the dissected grafts demonstrated a significantly better integrity of the fat tissue in the group that received hyperbaric oxygen for 5 days (p = 0.047). This finding was manifested by the presence of well‐organized, intact fat cells, along with a normal appearance of the fibrous septa and blood vessels. The worst results were found in animals treated by hyperbaric oxygenation for 15 consecutive days. An inverse correlation was found between an increased dose of the high‐pressure oxygen and fat tissue integrity (r= ‐ 0.87, p = 0.076). The toxic effects of highly reactive oxygen species on fat cells might explain the failure of an excessively high dose of hyperbaric oxygen to provide any beneficial outcome. The clinical relevance of these results should be further investigated. (Plast. Reconstr. Surg. 106: 1390, 2000.)

Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock's vertical bipedicle dermal flap techniques.

In the last two decades, McKissock’s technique for reduction mammaplasty was largely replaced by Robbins’s inferior pedicle technique. However, a substantial number of plastic surgeons still perform McKissock’s technique in the belief that it is superior to the inferior pedicle technique in terms of aesthetic results and complication rate. In this study, the authors compared the aesthetic results, complication rates, and patient satisfaction with the two techniques. Numerous studies in the past few years have shown an improvement in physical symptoms in addition to excellent patient satisfaction after breast reduction. However, almost all of these studies have used questionnaires that were mailed to the patients for evaluation. In the present study, aesthetic evaluations by the surgeon and an objective observer were performed in addition to evaluations by the patients themselves, thereby increasing the objectivity and the significance of the patients’ evaluations. Two groups of 24 and 27 patients were compared. The groups were almost identical in terms of demographic data and the amount of breast tissue removed. The aesthetic results were good to excellent in both groups, and the groups had similar complication rates. When the patients’ evaluations were compared with those of the surgeon and the objective observer, no significant difference was found between the observer and the patients. In one of the groups, the surgeon’s evaluations were significantly higher than those of the patients, although they were not significantly higher than the observer’s. In terms of aesthetic results, complication rates, and patient satisfaction, no differences existed between the groups. In addition, the patients’ evaluations were determined to be a reliable index of aesthetic results and, in these cases, they were often identical to objective evaluations.

Effect of hyperbaric oxygen on a rat transverse rectus abdominis myocutaneous flap model

&NA; The single‐pedicle transverse rectus abdominis myocutaneous (TRAM) flap is frequently associated with partial flap necrosis. Hyperbaric oxygen has previously been shown to increase the survival of skin flaps, although there has been no investigation of possible beneficial effects of hyperbaric oxygen on survival of the TRAM flap. The present study compares the effectiveness of hyperbaric oxygen therapy, normobaric 100% oxygen, a hyperbaric air‐equivalent mixture, and no treatment at all (control group), in the prevention of TRAM flap necrosis in a rat model. Forty‐eight animals were randomly assigned to one of the four above‐mentioned groups. The surviving area of the flap was evaluated 7 days after surgery. The hyperbaric oxygen treatment protocol consisted of five 9‐minute sessions breathing 100% oxygen at a pressure of 2.5 atmospheres absolute during the first 48 hours, starting within 1 hour of surgery. The areas of surviving skin paddles ranged from 38.5 percent in the control group to 52.5 percent in the group treated with hyperbaric oxygen. One‐way analysis of variance indicated that flap area survival was significantly greater in the hyperbaric oxygen group (F = 2.69, p = 0.05). Tukeys pairwise comparison and the two‐sample t test indicated that the group treated with hyperbaric oxygen differed significantly from the control group (Tukeys critical value = 3.8, rejection level = 0.05, t test p = 0.01). Our results suggest that the hyperbaric oxygen treatment protocol used improves survival in the rat TRAM flap. However, the optimal treatment protocol to achieve this objective even in the rat seems to be variable, and further studies are required before extrapolating these data to human applications. (Plast. Reconstr. Surg. 102: 416, 1998.)

Fate of exposed breast implants in augmentation mammoplasty.

Exposure of silicone breast implants usually leads to infection and extrusion. According to the literature, implant extrusion rates are not higher than 2%1 and removal of the implant is recommended. 2 During the past 3 years, the authors dealt with eight implant exposures (six women: two cases of bilateral exposure and four cases of unilateral exposure). All the pockets were infected. Patients were offered two alternatives: immediate removal of the implant and reimplantation after a few months or conservative treatment with an effort to close the exposed area after the discharge stopped. All the patients in this study chose the latter alternative. Four out of eight implants were saved. The authors had to remove the other four. The average follow-up of these women was 2 years and there were no signs of capsular contracture or any other problems. According to this series, 50% of eight exposed breast implants could be saved with conservative treatment.