Rainer Mittermayr

How it works Fibrin sealant is a tissue sealing agent that contains a variety of substances that act via the final steps of the physiological coagulation cascade. The major components in fibrin sealant are thrombin and fibrinogen, and a critical interaction in the tissue-sealing process is the conversion by thrombin of fibrinogen into fibrin monomers. Factor XIIIa catalyzes the formation of covalent cross-links between the fibrin monomers and the tissue. The resulting fibrin network acts as a scaffold for collagen-producing fibroblasts and secures the graft transplant. In addition, the fibrin network increases phagocytosis, promotes angiogenesis and binds angiogenic factors and growth factors. As a result of this binding ability, the fibrin sealant itself includes natural growth factors such as epidermal growth factor, transforming growth factor-beta and vascular endothelial growth factor, all of which aid wound healing.

Mr. Mittermayr and colleagues at the Ludwig Boltzmann Institute collaborated with scientists at Baxter AG in Vienna to carry out a study evaluating the efficacy of each of two preparations of fibrin sealant applied as a spray compared to sutures for attachment of autologous skin grafts in a pig model. In evaluating fibrin sealant, their study objectives were threefold: to build on an earlier study investigating the influence of fibrin sealant setting time on final graft outcome, to compare the effect of thick (0.15 ml/cm² ) versus thin (0.05 ml/cm² ) application of fibrin sealant on final graft outcome, and to assess the effect on final graft outcome of diluting a concentrated thrombin preparation (500 IU/ml) to produce a slow-clotting fibrin sealant (containing 5 IU thrombin/ml).

In an earlier study evaluating the influence of setting time on final graft outcome, a fibrin sealant preparation containing 500 IU thrombin/ml had been compared to a preparation containing 4 IU thrombin/ml. "A concentration of 500 IU thrombin/ml results in a very fast clotting of the applied fibrin sealant and is excellent for hemostasis," Mr. Mittermayr says. "However, in grafting split-thickness skin you need a little more time for correct application and positioning of the graft, so this concentration would not be the best. A fibrin sealant with a lower concentration of thrombin, such as 4 IU/ml, would have a slower clotting time and this would facilitate the grafting procedure."

Lake Buena Vista, Fla. — With about 50 percent of HIV patients suffering from facial lipoatrophy and with several possible methods of correction, there is a healthy interest within the aesthetic community as to what works best to treat a rapidly growing problem.

Derek Jones, M.D., has taken part in a four-year open pilot trial to determine the efficacy and safety of highly purified 1000 centistoke silicone oil for HIV-related lipoatrophy. Early results from the study are to be published soon in the Journal of Dermatologic Surgery.

To date, 700 patients have been injected with the silicone oil with an off-label usage; highly purified 1000 centistoke silicone oil has been approved by the U.S. Food and Drug Administration (FDA) for intraocular injection for the tamponade of retinal detachment.

So far, Dr. Jones and his group are pleased with the results, but he notes, "We don't know the long-term safety of this treatment, so the patients have to be followed very, very carefully. We do have some patients who have almost four years' follow-up. But we really need to follow patients for five to 10 years before we pass judgment on long-term safety."

Silicone, of course, has been the subject of much debate — in the medical and social realms alike. Dr. Jones acknowledges this, citing its detractors believe that silicone is ultimately too unpredictable.

But, he says, "People who do a lot of this kind of thing, like David Orentreich and others who have a wealth of anec-dotal data to rely on, say that the incidence of serious complications should be rather low, using a very highly purified substance and microdroplet injection technique."

Furthermore, two studies with Dow Corning's injectable silicone MDX-4-4011 were completed in the '70s and '80s. In those studies, the results of liquid injectable silicone injected in 200 patients with facial lipoatrophy not related to HIV suggestsafety and efficacy of highly purified silicone injected correctly, with only a 1 percent severe complication rate.

The current study protocol calls for a strict microdroplet serial puncture technique (0.01 mL microdroplets injected at 2 to 4 mm intervals into the subdermal plane with a 30-gauge needle), with the filler injected in limited amounts (2 ccs per treatment) at monthly or longer intervals. Prior to treatment, Dr. Jones suggests a topical anesthetic such as benzocaine, because injectable anesthetic might alter the pre-treatment facial contours.

Just one complication Thus far, out of 700 patients, the group has only recently encountered a single patient who developed a complication. That patient experienced a hardening of the silicone in the treated areas. The patient had surgical Alloderm implants that had reabsorbed prior to the silicone injections, and Dr. Jones was considering whether that played a possible factor in the current complication. But, either way, the complication has not been disfiguring and is being treated with antibiotics and steroid injections, he says.

Dr. Jones finds highly purified 1000 centistoke silicone oil to be a desirable substance to treat these patients for several reasons. First, the volumes of temporary fillers required for optimal correction are cost-prohibitive.

Secondly, the correction with temporary fillers dissipates within a few months and these patients often demand fillers that are permanent.

Third, liquid silicone is the only permanent filler that can be legally used on an off-label basis in the United States without a formal Investigational Device Exemption (IDE) from the FDA. With liquid silicone, he believes, the results are good, and more importantly, he says, "It is by far the cheapest filler substance that we have on the market these days, on a volume-per-volume basis.

So it is extremely cost-effective for these individuals who require a fair amount of volume to correct their problem."

And, as a patient's lipoatrophy progresses, he finds that silicone tends to be "more supple, more forgiving, like regular soft tissue," unlike another permanent option, surgically placed rigid implants.

Vancouver, B.C. — Performing lipoplasty with precision is the key to better clinical results, says Peter Fodor, M.D., who adds: "The best surgeons do more than remove fat. They sculpt."

Dr. Fodor

For buttock surgery, he asks the patient to contract the muscles, and draws a vertical line to demarcate the lateral end of the banana roll and the medial end of the trochanteric fat deposit. This is to define true, as opposed to pseudo, fat deposits.

The marking is carried out with the patient first standing, facing the wall, then supine.

In the operating room, the patient wears a foil cap to preserve the body's core temperature. Small crosses are used on the fat deposits and the estimated volume of fluid to be extracted is also noted on the skin sites. A dotted line is drawn on the patient's side to guide the lateral suction.

Dr. Fodor says he does not use multiple, circular, "topographic" markings because he does not believe they add any value and they increase the risk of tattooing.

Following marking, the patient is fitted with an elasticized garment then prepared for the procedure while standing. A sheet with a slippery surface is placed on the bed to facilitate turning the patient during surgery and the patient then lies on the bed wearing sterile booties. Next, general or epidural anesthesia is administered. Sterile sheets are then stapled to the skin.

The procedure is carried out sequentially in the targeted area in order to limit the amount of medication given at any one time.

For the super-wet technique, proposed by Dr. Fodor since 1986, an infusion of 1.0 cc to 1.5 cc per cc of the estimated aspirate is given. The infusate consists of 1000 cc of Ringer's lactate, 0.5 to 1cc epinephrine 1/1000, and 25 cc of marcaine.

For small body regions such as the banana roll, Dr. Fodor infuses by hand. Skin protectors are used to protect the patient from friction burns. The protectors also prevent over-suctioning in the area immediately adjacent to the incision, Dr. Fodor says.

For larger areas, he uses a mechanical infusion pump. The pump's measurement of the rate of infusion is accurate to within 1 cc, and can be adjusted within a range of 50 cc to 600 cc per minute, Dr. Fodor says. The quantities of infusion are recorded on a data sheet, which becomes part of the patient's medical record.

For ultrasound-assisted lipoplasty (UAL), Dr. Fodor far prefers the VASER device (Sound Surgical Technologies). The machine is set at 80 percent of its maximum power in a pulsed mode.

Single groove probes are used for fibrous fat, and multiple groove probes are useful for softer fat, Dr. Fodor says. The probe is inserted into the fat tissue and moved slowly back and forth until it no longer encounters resistance.

An estimated 100 cc of subcutaneous fat can be emulsified per minute, he says. "As with any form of aspiration, the less experienced lipoplasty surgeon may be well served by using longitudinal markings in the shape of spokes of a wheel over the area to be suctioned and applying the cannulae a predetermined number of times," Dr. Fodor advises.

Small cannulae with 2 cc increments and larger cannulae with 10 cc increments are used.

Dallas —Patients who have realistic expectations when seeking treatment of mild to moderate photodamaged skin will be happy with the gradual improvements of nonablative laser treatments.

Dr. Bernstein

The Vbeam (Candela) and V-Star (Cynosure) pulsed dye lasers and the KTP (Nd:YAG) laser are also used for nonablative treatments. In addition to unwanted blood vessels and brown spots, Dr. Bernstein nonablatively treats fine lines and wrinkles, enlarged pores and sagging skin.

Dr. Kilmer

Dr. Bernstein uses the Smoothbeam, an infrared laser, to treat acne scarring, because infrared wavelengths are absorbed mostly by water, not by blood and melanin. He uses topical anesthesia (lidocaine cream) only with Smoothbeam treatments.

"The Smoothbeam — and also the CoolTouch (New Star Lasers) — heat the dermis, and I've had results with acne scarring that exceeded my expectations dramatically," he says. "In my opinion, these lasers are the treatment of choice over carbon dioxide for acne scarring. I also use the infrared laser for fine lines and wrinkles where there is not a strong vascular component."

For photoaging and acne scarring, Dr. Bernstein gives four treatments at one-month intervals so patients can go back to work immediately.

For patients with average brown spots, fine lines and wrinkles, veins and enlarged pores, Dr. Bernstein uses combinations of lasers. He treats the vascular areas with a vascular laser and the more wrinkled, less red areas with the infrared laser.

Dr. Narurkar

The perfect patients for nonablative treatments have mild-to-moderate photodamage, according to Dr. Bernstein. "The key is setting realistic expectations," he adds. "I tell patients I can 'improve,' not 'remove,' their fine lines, wrinkles and acne scars."

If the physician suspects that a patient has unrealistic expectations, Dr. Bernstein recommends treating a "test spot" and allowing the patient to see the result. "Let them know the change is subtle and requires a number of treatments. That makes for the happiest patients," he says.

Las Vegas — Facial aesthetic surgery has gone through a series of paradigm shifts over the past 40-plus years, and, undoubtedly, there are more changes to come, said Donn R. Chatham, M.D., at Facial Cosmetic Surgery 2004.

Reflecting on the evolution in facial rejuvenation procedures since the 1960s, Dr. Chatham observes that continuing shifts in views about what defines aging have affected how it should be "fixed," and in whom. Developments in techniques and technology have dramatically altered what types of interventions are performed, as well as where and by whom. And there have been changes in how the public acquires knowledge. As a result, more and more people are seeking anti-aging interventions, but they often no longer look up to the doctor as the only authority on care.

"Just as society changes over time, so, too, has the world of cosmetic rejuvenation. It has been an interesting and ongoing evolution, and it has resulted in changes that are both good and bad," says Dr. Chatham, clinical instructor, department of otolaryngology, University of Louisville Medical School.

In the "traditional" period, aging was viewed as inevitable, and surgery was the only answer for addressing its unwanted effects on the appearance of facial tissues. However, intervention was sought only when the signs of aging became extreme, and was sought very discreetly by only a select group of the "rich and famous" who could afford the expensive operations.

All procedures were performed in the hospital and only by plastic surgeons, and the physician was the sole source of information on treatment options. Pain was expected, and patients remained in hiding until they recovered.

During the "evolutionary" period in the '80s and '90s, aging was still considered inevitable, but a new philosophy emerged based on the idea that intervention for its signs should be undertaken earlier — before things got really bad, Dr. Chatham says.

In addition, nonsurgical treatments were added to the armamentarium and new surgical techniques were developed that offered the benefits with less pain and suffering.

With those developments, cosmetic surgery became something of interest not just to celebrities; "ordinary people" became patients more frequently. Surgery also moved into ambulatory settings, and while it was still considered a private affair, patients were somewhat less concerned about total secrecy.

Cosmetic surgery also moved outside the sole domain of plastic surgery into other specialties, and patients began to shop around for services. The doctor remained the definitive authority on treatment, but candidates began to get information about their options from other sources.

Current paradigm Under the current paradigm, aging is still considered inevitable. However, the current approach to intervention focuses on delay.

"Strategies now are based on anti-aging modalities designed to forestall aging, including aging of the face, and include sunscreen use year around, non-smoking, topical 'cosmeceutical creams,' improved dietary choices, and healthy stress management, to name some," Dr. Chatham says.

Nonsurgical treatments are considered first, and include some based on increased understanding of the aging process at the cellular level.

"There are now cosmetic interventions that address aging changes through metabolic mechanisms and awareness that dietary factors might also make a difference," Dr. Chatham explains.

When surgery is necessary, more minimally invasive procedures have been introduced that reduce or eliminate downtime and risk.

Cosmetic surgery is being marketed to everyone, and consumers have even more choices for where they will be treated. New groups of medical specialists, dentists and aestheticians in the community are offering cosmetic services, and physicians are no longer considered the only authoritative source for information.

Dallas — Using a newly designed shallow tip for the Thermage® System in an animal model, researchers effected changes in the eyelid dermis, without causing injury to the epidermis and without causing injury to the eyelid muscle.

In addition, they did not affect a temperature rise in the surface of the eye that was high enough to cause thermal injury or problems, according to Brian S. Biesman, M.D., an assistant clinical professor of ophthalmology at Vanderbilt University Medical Center, Nashville, Tenn.

No injury Dr. Biesman also notes that in a human model the researchers treated human skin and muscle and found that changes also could be effected in dermis without injuring the epidermis or underlying muscle.

"Extrapolating from prior clinical and research experience, we hypothesized that RF energy delivered to the eyelids may result in cosmetically desirable results. However, the center heating zone with the standard Thermage treatment tip is too far beneath the skin's surface to be safely used on an eyelid," Dr. Biesman explains.

"The standard Thermage treatment tip is 1 cm x 1 cm, and a new tip with a dimension of 1.5 cm x 1.5 cm, will also be available soon," he says. "We set out to develop a treatment tip, which would safely heat the tissue less deeply and would not injure the underlying eye or structures of the eyelid.

The shallow tip used for the eyelid treatment is 0.5 cm x 0.5 cm, which results in a treatment area of 0.25 cm² . "It is a quarter of the size of the standard treatment tip. With capacitive coupled RF energy, the larger the electrode the deeper the energy will be delivered. So, by using a smaller electrode, the treatment will be done more superficially," he says.

Animal model Using animal studies in piglets, Dr. Biesman measured the effect of different energies using the shallow tip.

"We set out to establish the range of responses, starting very low to very high, ranging from no tissue effect to a frank burn on the eyelids. After we determined the extreme upper and lower limits, we selected a zone that we thought would be a safe one to work with," he explains.

But before moving away from the piglet model, Dr. Biesman tested the effect of the temperature on the eye.

A surgical plastic corneal protector was modified with a thermocouple, which was used to sample temperature about a thousand times per second. The studies showed that there was a small elevation in temperature that was well within the safe range and significantly below the temperature that would cause injury to the eye.

In further studies in which the eyelid was unusually and deliberately treated in the same place via pulse stacking, the skin was injured, but the eye did not have a temperature rise that would be significant enough to cause injury, Dr. Biesman explains.

Slitlamp examination showed that there was no injury to the eye itself.

"Temperature did not increase to a level to threaten the eye and upon examination it appeared exactly the same after the treatments as it did before," he says.

Human model A human model was constructed in which eyelid tissue excised during routine blepharoplasty from 10 eyelids was treated with the .05 cm² electrode specially designed for shallow depth of penetration. An experimental system was designed to closely mimic an in vivo environment. Energies between 16 J and 19 J were delivered to the eyelids. Dr. Biesman says the appropriate dose range was determined from the previous animal studies.

The epidermis remained intact in all specimens. There was no evidence of obvious thermal injury in the underlying orbicularis oculi muscle. Therefore, Dr. Biesman concluded that the ThermaCool TC System with a .05 cm² treatment tip may be used to treat ex vivo human eyelid tissue without apparent injury.

Plastic surgeon T. Roderick Hester, M.D., has had a life-long love affair with flying. At age 64, he's planning his next great adventure: a trans-Atlantic flight in his prized twin-engine plane, Ole Blue Eyes.

The more Dr. Hester, the first-born of seven children, leaned toward becoming a pilot, the more his mother insisted that he become a doctor.

Dr. Hester admits to being interested in medicine as well. While he was in high school, he would go on house calls with a general practitioner in his hometown and watch the doctor perform surgery.

After graduating from Emory University School of Medicine, Dr. Hester's career in medicine, at first, curtailed his flying until he opened his first practice, in general surgery, in Moultrie, Ga. It also just happened to have a "nice airport."

Dr. Hester befriended Scott Fitzgerald, a World War II pilot who would ferry bombers across the Atlantic. Fitzgerald, who had since become a flying instructor, took Dr. Hester under his wing and was determined to teach him everything he had to know about safe flying.

Little did the plastic surgeon know how much he would rely on those life-saving maneuvers.

A proud owner Dr. Hester bought his first plane, a single-engine Piper, and started flying every time he got the chance — to football games, professional meetings and more.

But he soon realized what some people say about pilots and their airplanes, "that you always want one that will fly a little higher and a little faster," he says.

The late '70s also brought another revelation. Dr. Hester realized that he no longer wanted to send mastectomy patients off to other surgeons. He wanted to pursue plastic surgery and see patients through the reconstructive and cosmetic processes. So, off to Emory he went, again.

Today, Dr. Hester practices at Pace Plastic Surgery and Recovery Center in Atlanta and is chief of plastic surgery at the division of plastic surgery at Emory University School of Medicine. He has published extensively and he also teaches, lectures and participates on panels — which also happen to give him the opportunity to fly.

He bought his second airplane, a Beech Bonanza Craft, and flew it to professional meetings. Yet bigger and faster remained in the back of Dr. Hester's mind. So, he decided to purchase a plane he named Ole Blue Eyes for his father, T. Roderick Hester, Sr.

"It is a special airplane because it is pressurized and turbo-charged, so you can go up to 25,000 feet. I bought that airplane about eight years ago and now I really fly all over," he says. "I have a map of North America in my office, and I have these red, white and blue pins in all the places I have landed. There are only three states (in which) I have not landed: Minnesota, New Hampshire and North Dakota. I have to find an excuse to land in those states."

Refreshing for the mind Dr. Hester seems to get into another place, mentally, when he talks about flying.

"I have had some interesting, long, wonderful flights. I love to get up to 20,000 feet and I tell you it really refreshes your mind. I like the hum of the engine. Flying was the right thing for me," he says.

1) Line outlining the upper lid crease incision and the mark to orient the placement of the suture through the tarsus.

2) Double armed 6-0 silk is passed through the anterior tarsus about 3 mm below its border.

Technique

Using the Ellman Dual Frequency Surgitron, I make my skin incision using the A-10 Needle on a Cut setting. This allows for a fine incision with minimal scarring. The skin muscle flap is removed with the Empire Needle on the Hemo setting to give better hemo-stasis. Fat can also be resected at this stage. If a blepharoplasty is not done, a 1 cm incision is made where the lid crease should be.

3) Suture is tied in a loop over levator aponeurosis.

4) Wound closure.

5) Pre-op ptosis repair.

Advantages

6) Ten days post-op ptosis repair (no skin removal).

Using a single suture takes less time than multiple sutures. Since 6-0 silk dissolves very slowly, there should be ample time for good scar formation to occur between the levator and the tarsus before the silk disappears. This technique has worked well for me for the past several years and in hundreds of cases.