The Effect of 3-Dimensional-Printed Sequential Dual Drug-Releasing Patch on the Capsule Formation Around the Silicone Implant in a Rat Model

BACKGROUND

Implant-based breast reconstruction is associated with increased risk of early infection and late-stage capsular contracture.

OBJECTIVES

We evaluated the feasibility of a dual drug-releasing patch that enabled the controlled delivery of antibiotics and immunosuppressants in a temporally and spatially appropriate manner to the implant site.

METHODS

The efficacy of a dual drug-releasing patch, which was 3-dimensional-printed (3D-printed) with tissue-derived biomaterial ink, was evaluated in rats with silicone implants. The groups included implant only (n = 10); implant plus bacterial inoculation (n = 14); implant, bacterial inoculation, and patch loaded with gentamycin placed on the ventral side of the implant (n = 10), and implant, bacterial inoculation, and patch loaded with gentamycin and triamcinolone acetonide (n = 9). Histologic and immunohistochemical analyses were performed 8 weeks after implantation.

RESULTS

The 2 drugs were sequentially released from the dual drug-releasing patch and exhibited different release profiles. Compared to the animals with bacterial inoculation, those with the antibiotic-only and the dual drug-releasing patch exhibited thinner capsules and lower myofibroblast activity and inflammation, indicating better tissue integration and less foreign body response. These effects were more pronounced with the dual drug-releasing patch than with the antibiotic-only patch.

CONCLUSIONS

The 3D-printed dual drug-releasing patch effectively reduced inflammation and capsule formation in a rat model of silicone breast reconstruction. The beneficial effect of the dual drug-releasing patch was better than that of the antibiotic-only patch, indicating its therapeutic potential as a novel approach to preventing capsular contracture while reducing concerns of systemic side effects.

An unusual presentation of localized bullous morphea

Bullous morphea is a rare variant of localized scleroderma characterized by occasional intermittent blisters. Lichen sclerosus is a chronic inflammatory disease. The coexistence of morphea and lichen sclerosus has been reported in different sites in the same patient and more rarely in the same lesion. We report the case of a 54-year-old woman with an atypical presentation of bullous morphea and some histological features of lichen sclerosus. She presented with a 5-year history of an ulcerated plaque, with a sclerotic and atrophic center and indurated budding margins, localized on the lumbar back. Initially the diagnosis of a squamous cell carcinoma was suggested. A skin biopsy confirmed the diagnosis of bullous morphea and showed some histological features of lichen sclerosus. Topical betamethasone and silicone gel ointment were prescribed leading to complete healing of the ulceration within five months. Our case is unusual because of the atypical clinical presentation, the histological aspect combining signs of bullous morphea and lichen sclerosus, and the favorable results with the use of local corticotherapy and silicone gel.

Implant Insertion Time and Incision Length in Breast Augmentation Surgery with the Keller Funnel: Results from a Comparative Study

BACKGROUND

The Keller funnel is an easy-to-use mechanical device that aids breast implant insertion. This study analyzed implant insertion time and incision length using the Keller funnel versus conventional manual insertion.

METHODS

This was an analysis of two cohorts of adult patients undergoing primary breast augmentation with anatomical implants at a single center. In the 'insertion time cohort' (N = 20), implants were inserted with a Keller funnel on one side and manually on the other; follow-up lasted 4 years. In the 'incision length cohort,' both implants were inserted with a Keller funnel (N = 50) or manually (N = 50), with follow-up lasting 12 months.

RESULTS

In the insertion time cohort, mean total insertion time (from implant sterile-package opening to final positioning in the pocket) was 35 s (range 13-76 s) with the Keller funnel and 25 s (range 13-43 s) using manual insertion (p = 0.07); the mean time needed to push the implant through the incision was 6 s (range 3-10 s) with the Keller funnel and 16 s (range 13-40 s) with manual insertion (p = 0.04). In the incision length cohort, mean incision length was shorter with the Keller funnel versus manual insertion (35.5 ± 2.1 mm vs. 46.2 ± 3.2 mm; p < 0.001). There were no differences in complications based on insertion method.

CONCLUSION

The Keller funnel was associated with decreased incision length and reduced time to push the implant through the incision. This brings potential clinical advantages in minimizing scarring and reducing contamination of the device.

LEVEL OF EVIDENCE III

This 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 www.springer.com/00266 .

Role of mechanical and thermal damage in pericapsular inflammatory response to injectable silicone in a rabbit model

Silicone is used widely for tissue augmentation in humans. However, late complications, such as delayed inflammation and capsular contracture, remain uncharacterized, despite their importance. In the present study, we aimed to determine whether mechanical and thermal damage induce capsular inflammation around a foreign body, and elucidate the biological mechanism underlying this phenomenon. We injected silicone into the subcutaneous layer of the skin of New Zealand white rabbits. The rabbits were divided into two groups: the control group received no treatment; in the experimental group, external force was applied near the injection silicone using high-intensity focused ultrasound (HIFU). Tissues near the injected silicone were harvested from both groups on Days 4, 7, and 30 after HIFU treatment for comparative analysis. Visual and histological examinations showed clearly increased inflammation in the experimental group compared with that in the control group. Furthermore, capsular tissue from the experimental group displayed markedly increased collagen production. Immunofluorescence revealed marked activation of macrophages in the early stages of inflammation (Days 4 and 7 after HIFU treatment), which decreased on Day 30. Assessment of cytokine activation showed significantly increased expression of heat shock protein (HSP)27, HSP60, HSP70, toll-like receptor (TLR)2, TLR4, and interleukin-8 in the experimental group. The expression of transforming growth factor-β1 did not increase significantly in the experimental group. In conclusion, damage to tissues around the injected silicone induced capsular inflammation. Macrophages and damage-associated molecular pattern molecules were involved in the early stages of inflammation. HSP release activated TLRs, which subsequently activated innate immunity and induced the inflammatory response.

[ASSESSMENT OF COMBINED PROPHYLAXIS OF PATHOLOGICAL POSTOPERATIVE FACE SKIN SCARS ACCORDING TO THE VANCOUVER SCALE]

The aim of the research was to study the effectiveness of combined prophylaxis of pathological postoperative face skin scars according to the Vancouver scale. The research involved 29 patients, aging 16-48 years old, who underwent maxillofacial surgery by extraoral accesses with wound primary intention healing. The patients were divided into three groups: the control group, which involved the patients, who after the surgery did not undergo any preventive measures to avoid pathological skin scars development, and two study groups. The patients of the first study group underwent the monotherapy comprising three sessions of extracorporeal shock wave therapy once every 4-5 days. The patients of the second study group underwent three sessions of extracorporeal shock wave therapy once every 4-5 days and local use of silicone gel Strataderm. The Vancouver scale was used to evaluate clinically the effectiveness of the suggested methods of pathological scars development prevention. It involved evaluation (in points) of their consistency, pigmentation, and vascularization. The scars were assessed on the 7th, 30th day after the surgery and in 6 months. Positive results were attained in the patients of both study groups; they were manifested by increased elasticity and compliance of scars, pigmentation becoming of just about surrounding skin natural color, normalization of blood supply to scars, and more rapid disappearance of suture marks. However, these positive signs were more significant in the patients of the second study group that allowed us concluding that combined use of extracorporeal shock wave therapy and local applying of silicone gel Strataderm was advisable.

Does the form of dressings matter?: A comparison of the efficacy in the management of postoperative scars between silicone sheets and silicone gel: a randomized controlled trial

BACKGROUND

Silicone sheet is commonly used for scar management but hard to apply to irregular surfaces or mobile areas, and difficult to conceal. On the contrary, silicone gel is easy to apply and nearly unnoticeable. Therefore, we conducted this study to compare their effectiveness.

METHODS

Patients undergoing horizontal cesarean section were included. Surgical wounds were divided into 2 halves. Patients randomly applied silicone sheets and silicone gel on either side of their wounds for 3 months. The wounds were assessed at 1, 3, 6, and 12 months after surgery. We used the Vancouver Scar Scale (VSS) for an objective evaluation and the visual analog scale (VAS) for a subjective evaluation.

RESULTS

There was no statistical significance between the silicone sheet and silicone gel groups with respect to VSS score. The silicone sheet group showed a statistically significant higher VAS score for itch at 1 month follow-up (1.18 ± 2.04 vs 0.35 ± 0.85, P = .01). However, the difference was less than 1 on a scale of 10, so it might not be clinically meaningful.

CONCLUSION

Silicone sheet group showed statistically significant worse VAS score in terms of itch. However, the difference was too small to be clinically meaningful.

Topical Agents for Scar Management: Are They Effective?

Scar formation is the body's natural healing response to reestablish dermal integrity following an injury. Excessive scarring, however, can cause significant cosmetic, functional, and psychological problems. A wide variety of topical creams, lotions, and oils are available for scar treatment or wound healing. Sieving through the options and selecting the best option for their patients can be challenging for clinicians, especially given that clinical evidence for many of the active agents in commonly used topical treatments is lacking. The goal of this review is to provide an overview of topical treatments utilized for scar management, including their mechanism of action and evidence of efficacy. As knowledge of the wound healing process is critical to understanding the effects of topical treatments, the pathophysiology of wound healing is also reviewed. <p><em>J Drugs Dermatol. 2018;17(4):421-425.</em></p>.

Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children: study protocol for a randomised controlled trial

BACKGROUND

Abnormal scar development following burn injury can cause substantial physical and psychological distress to children and their families. Common burn scar prevention and management techniques include silicone therapy, pressure garment therapy, or a combination of both. Currently, no definitive, high-quality evidence is available for the effectiveness of topical silicone gel or pressure garment therapy for the prevention and management of burn scars in the paediatric population. Thus, this study aims to determine the effectiveness of these treatments in children.

METHODS

A randomised controlled trial will be conducted at a large tertiary metropolitan children's hospital in Australia. Participants will be randomised to one of three groups: Strataderm® topical silicone gel only, pressure garment therapy only, or combined Strataderm® topical silicone gel and pressure garment therapy. Participants will include 135 children (45 per group) up to 16 years of age who are referred for scar management for a new burn. Children up to 18 years of age will also be recruited following surgery for burn scar reconstruction. Primary outcomes are scar itch intensity and scar thickness. Secondary outcomes include scar characteristics (e.g. colour, pigmentation, pliability, pain), the patient's, caregiver's and therapist's overall opinion of the scar, health service costs, adherence, health-related quality of life, treatment satisfaction and adverse effects. Measures will be completed on up to two sites per person at baseline and 1 week post scar management commencement, 3 months and 6 months post burn, or post burn scar reconstruction. Data will be analysed using descriptive statistics and univariate and multivariate regression analyses.

DISCUSSION

Results of this study will determine the effectiveness of three noninvasive scar interventions in children at risk of, and with, scarring post burn or post reconstruction.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616001100482 . Registered on 5 August 2016.

[How I treat... minor superficial wounds]

Superficial minor wounds represent frequent events in daily practice. Their evolution is often favourable and without any mishap. However, they possibly evolve to some serious episodes. Normal healing develops in three successive phases. They correspond to the inflammatory, proliferative and remodeling phases, respectively. Their treatments are distinct. The major active agents are cleaning products, antiseptics, corticosteroids and silicone gels. By contrast products claiming some healing properties are disappointing in most cases, and in some instances, they are of no use.

Nipple sparing mastectomy with immediate silicone implant reconstruction for malignant phyllodes tumor in a 19-year-old girl

OBJECTIVE

Due to the rarity of MPT, the clinical records in the literature, collected along decades, lack to address a modern approach to breast reconstruction after mastectomy.

CASE PRESENTATION

We report a case of a teen-aged female diagnosed to have a malignant phyllodes in her right breast.

DISCUSSION

The surgical treatment of choice, taking in account the relation between the volume of the mass and the breast dimension, was considered to be a mastectomy. As the disease didn't involve the skin envelope a nipple-areolar-sparing gland removal allowed an immediate prosthetic reconstruction with a contralateral augmentation for symmetrization, so obtaining a satisfactory aesthetic outcome.

CONCLUSIONS

At our knowledge we present for the first time this surgical approach that, in selected patients, can reach the oncologic radicality and an adequate cosmetic result too.

[Reaction to a black henna tattoo treated with mometasone furoate and silicone gel: case report]

Black henna tattoos have paraphenylenediamine (PPD), which contains a product of herbal origin, which due to its molecular characteristics is capable of inducing, in susceptible individuals, a type IV hypersensitivity reaction. It clinically manifests as a contact dermatitis that usually when it disappears, scarring and hypopigmentation are left in the injured area.

OBJECTIVE

To describe the case of a patient with hypersensitivity to henna tattoo and to present the most relevant phenomena associated with this condition.

CASE REPORT

The case of a 6 year-old patient with a black henna tattoo on his right leg, who was diagnosed with contact dermatitis probably attributed to PPD, is presented. Mometasone furoate and topical silicone gel treatment was started with good response.

CONCLUSION

Mometasone furoate and silicone gel are a good possible therapeutic option for treating contact dermatitis caused by PPD as the dermatosis was resolved without residual lesions.

Prevention of postsurgical scars: comparsion of efficacy and convenience between silicone gel sheet and topical silicone gel

To date, few studies have compared the effectiveness of topical silicone gels versus that of silicone gel sheets in preventing scars. In this prospective study, we compared the efficacy and the convenience of use of the 2 products. We enrolled 30 patients who had undergone a surgical procedure 2 weeks to 3 months before joining the study. These participants were randomly assigned to 2 treatment arms: one for treatment with a silicone gel sheet, and the other for treatment with a topical silicone gel. Vancouver Scar Scale (VSS) scores were obtained for all patients; in addition, participants completed scoring patient questionnaires 1 and 3 months after treatment onset. Our results reveal not only that no significant difference in efficacy exists between the 2 products but also that topical silicone gels are more convenient to use. While previous studies have advocated for silicone gel sheets as first-line therapies in postoperative scar management, we maintain that similar effects can be expected with topical silicone gel. The authors recommend that, when clinicians have a choice of silicone-based products for scar prevention, they should focus on each patient's scar location, lifestyle, and willingness to undergo scar prevention treatment.

In vivo effectiveness of silicone gel sheets as barriers at the inner microgap between a prosthetic abutment and an external-hexagon implant platform

PURPOSE

Bacterial penetration and colonization of the microgap at the implant-abutment interface have been reported in several studies. The aim of this study was to evaluate the effectiveness of placing a silicone membrane between the abutment and the implant platform in an attempt to seal the interface.

MATERIALS AND METHODS

A total of 15 external-hex implants were placed in 10 patients with clinically healthy peri-implant tissues, and all of the patients had ceramic prosthetic crowns. Samples were collected from the microgaps before, 30 days after, and 90 days after insertion of a silicone membrane. Bacterial DNA was extracted and submitted in triplicate to polymerase chain reaction using primers specific for four peri-implant pathogens: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, and Tannerella forsythia.

RESULTS

In the initial samples, a positivity of 52% was found, which was different from that found in samples collected after 30 days (32%) and 90 days (27%) after insertion of the membrane.

CONCLUSION

It was evident that the silicone membrane reduced, but did not prevent, penetration of these species into external-hex implants.

Improved scar appearance with combined use of silicone gel and vitamin C for Asian patients: a comparative case series

BACKGROUND

In Asians, facial scars, even fine surgical scars, often can be conspicuous and uncomfortable. The authors used a topical silicone gel containing vitamin C on facial scars for the purpose of making the scar less distinct.

METHODS

The study enrolled 80 patients. For the experimental group, the topical silicone gel mixture containing vitamin C was applied from the time of stitch removal to 6 months after the operation. The control group did not undergo any adjunctive treatment. Each participant was evaluated using the modified Vancouver Scar Scale (VSS) as well as erythema and melanin indices by spectrophotometer.

RESULTS

With the modified VSS, the experimental group showed a significant decrease in scar elevation (p = 0.026) and erythema (p = 0.025). The hypo- or hyperpigmentation of the scars was more normalized in the experimental group. In the measured results via spectrophotometer, the experimental group showed a significant decrease in the melanin index (p = 0.045). The erythema index showed a statistically significant difference between the time of stitch removal and 6 months after the operation in the experiment group only.

CONCLUSIONS

Topical use of silicone gel containing vitamin C has the effect of improving the appearance of fine surgical scars in Asian facial skin.

LEVEL OF EVIDENCE IV

This 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 www.springer.com/00266 .

The safety, efficacy, and tolerability of a novel silicone gel dressing following dermatological surgery

Silicone gel has for many years had a primary role in the treatment and prevention of abnormal scars, in the form of hypertrophic scars and keloids after epithelialization. The authors report preliminary findings on the use of a new, medical-grade, film-forming silicone gel dressing approved for use on open wounds and injured skin as monotherapy and in combination with other treatments prior to re-epithelialization. An observational study involving 105 patients examined the silicone gel's effectiveness in promoting accelerated epithelialization, reducing the inflammatory response and in the prevention of scarring. The study was conducted on a range of dermatological surgical interventions. The authors' observations confirmed silicone's role in promoting accelerated wound healing, scar prevention, and the utility of this new film-forming silicone dressing when used in combination with various other treatment modalities.

Gait-related strategies for the prevention of plantar ulcer development in the high risk foot

High plantar pressures lead to ulceration in the diabetic foot, particularly in the forefoot region around the metatarsal heads. High plantar pressures persist during gait due to factors such as peripheral neuropathy, foot deformities, limited ankle dorsi flexion range of motion and reduced plantar tissue thickness. Strategies impinging upon gait such as the use of appropriate therapeutic footwear, custom-moulded insoles and injectable silicone can help to reduce plantar pressures and attenuate the risk for ulceration. Shoes adapted with external rocker profiles facilitate plantar flexion and restrict sagittal plane motion of the metatarsophalangeal joint, reducing pressures in the region of the metatarsal heads. Insoles custom-moulded to patient's feet help to reduce plantar pressures and minimise the risk of ulceration in the forefoot region. The loss of subcutaneous fat tissue in the diabetic foot enhances bony prominences and predisposes the foot to high-pressure areas. Silicone is a biocompatible material that can be safely injected into plantar soft tissue to augment tissue thickness and prevent the development of ulceration. This enhancement to the subcutaneous layer is remarkably well retained and is a generally well-adopted procedure in the clinical setting.

Efficacy of topical cyanoacrylates compared to topical silicone gel in the treatment of hypertrophic scars

AIM

The effectiveness of cyanoacrylates compared to silicone gel in improving healing of hypertrophic scars was evaluated.

PATIENTS AND METHODS

Patients presenting hypertrophic scars 6 to 24 months old were enrolled. Asymmetrical scars were treated with cyanoacrylates, linear scars were divided in two parts, one treated with cyanoacrylates, the other with silicone gel. For 3 months, cyanoacrylates were applied every 3-5 days, silicone gel twice a day. Patients' and external observers' assessments were recorded over one year, and photographic records taken. Objective evaluations included width, length and elevation measurements. Statistical significance of parameter modifications was analysed with the Wilcoxon test.

RESULTS

A total of 150 patients were enrolled. Positive effects of both tested products were observed without major adverse effects, achieving final scars of better quality. Scar elevation was reduced significantly for both tested products, but apparently more for topical cyanoacrylates.

CONCLUSION

Cyanoacrylates have a positive effect on pathological scars at least comparable to that of silicone gel.

Soft tissue fillers in the nose

Using soft tissue fillers to correct postrhinoplasty deformities in the nose is appealing. Fillers are minimally invasive and can potentially help patients who are concerned with the financial expense, anesthetic risk, or downtime generally associated with a surgical intervention. A variety of filler materials are currently available and have been used for facial soft tissue augmentation. Of these, hyaluronic acid (HA) derivatives, calcium hydroxylapatite gel (CaHA), and silicone have most frequently been used for treating nasal deformities. While effective, silicone is known to cause severe granulomatous reactions in some patients and should be avoided. HA and CaHA are likely safer, but still may occasionally lead to complications such as infection, thinning of the skin envelope, and necrosis. Nasal injection technique must include sub-SMAS placement to eliminate visible or palpable nodularity. Restricting the use of fillers to the nasal dorsum and sidewalls minimizes complications because more adverse events occur after injections to the nasal tip and alae. We believe that HA and CaHA are acceptable for the treatment of postrhinoplasty deformities in carefully selected patients; however, patients who are treated must be followed closely for complications. The use of any soft tissue filler in the nose should always be approached with great caution and with a thorough consideration of a patient's individual circumstances.

Injectable fillers: an American perspective

Since 1981, there has been a significant repertoire of United States Food and Drug Administrtion (FDA) approved fillers for both cosmetic rejuvenation and facial lipoatrophy. Currently available dermal fillers include bovine, human and porcine collagens, hyaluronic acids of animal and biosynthetic origin, poly-L-lactic acid, calcium hydroxylapatite, and polymethylmethacrylate. Many of these fillers were first available in Europe and Canada before their arrival in the United States (USA) and many of the complications known about these products have come from studies conducted both in the USA and abroad. Several of the fillers that are currently available abroad or are used in the USA off-label have been associated with significant complications. The authors review three of these fillers: liquid injectable silicone, DermaLive/DermaDeep, and Bio-Alcamid.

Morphological analysis of the connective tissue reaction in linear hypertrophic scars treated with intralesional steroid or silicone-gel sheeting. A light and electron microscopic study

The linear hypertrophic scar has become the most common type of pathologic scarring. Silicone-gel sheeting is the first line therapy while intralesional steroid is the second. A light and electron microscopic analysis was carried out to reveal differences in tissue reaction following the two different treatments. Two groups of 12 patients each were treated for 4 months. For the first group, diluted Triamcinolone acetonide was injected until an inactive state was achieved. The other group of patients was treated with silicone-gel sheeting. The scars were examined every two weeks and their appearance documented. After reaching the expected therapeutic response, inactive scars were removed. The excised scars were evaluated through light microscopic histopathology and electron microscopy. The light and electron microscopic observations revealed marked differences following treatments. The activity of fibroblasts and the numbers of collagen fibers forming bundles decreased and the orientation of the collagen fibers was more variable in the treated scars. The amount of elastic fibers increased after both steroid and silicone-gel sheeting treatment. Vascularization was also slightly changed, with more capillaries and fewer pre-capillary arteries detected in the treated scars. Both treatments resulted in the same decrease in score but steroid treatment was more rapid in onset. We suggest that the two different treatments work through different mechanisms, although the final functional outcome is similar.

The efficacy of topical silicone gel elastomers in the treatment of hypertrophic scars, keloid scars, and post-laser exfoliation erythema

BACKGROUND

Dermatix is a Food and Drug Administration (FDA)-registered substantial equivalent to silicone gel sheeting for the prevention and management of hypertrophic scars and keloids.

METHODS

A 90-day prospective study evaluated the efficacy of Dermatix, silicone gel sheeting, and a combination of these treatments in improving scars for 30 patients. Each patient had a bilateral scar that served as an untreated control. The outcome measures included profilometry analysis of scar topography before and after punch biopsies of the control and treated scars, symptoms associated with the scars, and patient evaluations of the ease of treatment.

RESULTS

The results showed better resolution and improvement of scars with Dermatix treatment or the combined use of Dermatix and silicone gel sheeting than with silicone gel sheeting alone. Wound erythema was reduced, and collagen architectural reorientation was demonstrated histologically. Patients rated Dermatix as easier to use than silicone gel sheeting. Both Dermatix and silicone gel sheeting reduced symptoms of itching, irritation, and skin maceration.

CONCLUSION

The results of this study indicate that Dermatix is a useful treatment for the management of abnormal scarring.

Keloids: pathophysiology and management

Keloid formation occurs as a result of abnormal wound healing. Despite the high prevalence of keloids in the general population, they remain one of the more challenging dermatologic conditions to manage. More than a cosmetic nuisance, they are often symptomatic and can have a significant psychosocial burden for the patient. Although multiple treatment modalities exist, no single treatment has proven widely effective. In fact, recurrence following treatment is generally the norm. Combination therapy is likely the optimal strategy. In this review, we highlight the clinical features, pathophysiology and management of keloids.

[Cosmetic soft-tissue augmentation treatment]

An increasing number of patients undergo soft-tissue augmentation. The quality depends on the applied filler substance, the compliance of the patient and the physician. Long-term adverse reactions are referred to as nodules or granulomas. Nodules following degradable gels and polyacrylamide hydrogel are always caused by bacteria. Nodules following inert, hydrophobic silicone gel and combination gels may emerge years after the injection. They are often caused by a low-grade infection with ensuing enhanced fibrosis and treatment requires a specialist.

Clinical evaluation of a new self-drying silicone gel in the treatment of scars: a preliminary report

Topical silicone gel sheeting and intralesional steroids are the only evidence-based recommendable forms of treatment to control the quality of a scar. The advantages and disadvantages of both are well known. This study was undertaken to verify the efficacy of a new topical silicone treatment: a self-drying spreadable gel that needs no means of fixation and cannot be seen because of complete transparency. Fresh surgical scars treated with the tested product showed significantly better outcomes than those untreated in a prospective trial involving a group of 160 patients. Patient compliance was particularly good, especially for scars on exposed areas such as the face, where the traditional gel sheeting is frequently discontinued at an early stage by patients who object to its visibility. The results of the self-drying silicone gel have indeed been satisfactory. Considering the effective results obtained and the good patient compliance, the authors currently rate this concept of treatment as the first choice for preventing hypertrophy of recent scars.

[Sequelae after illegal injection of liquid silicone for breast augmentation: report of two cases]

The use of liquid silicone for breast augmentation was widespread in the 1960s but was abandoned at the end of the decade due to numerous studies describing the development of a large number of local complications, as well as remote migration of small amounts of silicone. The use of liquid silicone also leads to enormous difficulty in the early diagnosis of breast cancer; these patients are precluded from routine screening programs and must undergo exhaustive periodic examinations. Magnetic resonance imaging has become the most effective test for the early detection of breast cancer in these patients. Indications for subcutaneous mastectomy are the presence of local complications, suspicion of a malignant lesion, or the patient's desire to prevent both these potential problems.

Etanercept therapy for silicone granuloma

A patient developed a typical, painful, and debilitating reaction on the thighs following injection of ostensibly medical grade "silicone" to achieve alteration of body contours. The refractory silicone granuloma responded dramatically to treatment with etanercept.

Topical treatments for hypertrophic scars

Hypertrophic scars represent an abnormal, exaggerated healing response after skin injury. In addition to cosmetic concern, scars may cause pain, pruritus, contractures, and other functional impairments. Therapeutic modalities include topical medications, intralesional corticosteroids, laser therapy, and cryosurgery. Topical therapies, in particular, have become increasingly popular because of their ease of use, comfort, noninvasiveness, and relatively low cost. This review will discuss the properties and effectiveness of these agents, including pressure therapy, silicone gel sheeting and ointment, polyurethane dressing, onion extract, imiquimod 5% cream, and vitamins A and E in the prevention and treatment of hypertrophic scars.

The Composition and Behavior of Capsules around Smooth and Textured Breast Implants in Pigs

BACKGROUND

The surface of the implant is one of the many factors often associated with the occurrence of capsular contracture, the etiopathogeny of which remains unclear. The purpose of this study was to analyze the behavior of capsular contracture by means of applanation tonometry and histology using a midsized animal model.

METHODS

Silicone breast implants were implanted into 33 pigs and observed at 30, 60, 180, and 270 postoperative days.

RESULTS

Capsular contracture in smooth implants showed significantly greater pressure values of tonometry, and the smooth implant capsule was significantly thicker than the textured implant capsule. Both pressure and thickness of the capsules increased at each period. The collagenous layer did not show any difference considering the periods of time in which the total thickness was analyzed; on the other hand, the increase in total capsular thickness occurred by thickening of the noncollagenous layer in both smooth and textured implants. Taking into consideration both kinds of implants, histomorphometric analysis showed that thin fibers were replaced by thick fibers in later postoperatives periods (180 and 270 days).

CONCLUSIONS

The greater incidence of capsular contracture in smooth implants was correlated with the progressive increase in total capsule thickness, due to a higher concentration of collagenous fibers, when compared with textured implants (p = 0.011; mean difference, 6.61), and a higher concentration of thick fibers (p = 0.034; average, >5.51 percentage points per field of thick fibers than the textured implants in all periods). Pigs are good animal models for studying the healing process after breast augmentation with implants.

Granulomatous facial reaction to injected cosmetic fillers--a presentation of five cases

The use of substances to augment soft tissues as aesthetic purpose is associated with, among other undesirable effects, the appearance of foreign body granulomas. The improvements made to these substances have reduced the incidence of adverse reactions, but not eliminated them. We present five cases of foreign body reactions to three different products, dimethylpolysiloxane (silicone), bovine collagen, and polylactic acid, which were injected into the subcutaneous cellular tissue of the patients (all five were women), between two and sixteen years before the appearance of the foreign body reaction. All five presented painless, diffuse facial tumefaction, of firm, elastic consistency. The magnetic resonance image (MRI) studies showed signs of intense inflammatory reaction in the affected areas. The histology revealed the presence of foreign body granulomas with giant multi-nucleated cells. The patients were treated with systemically administered corticoids, except in one case which did not require pharmacological treatment.

Keloid Pathogenesis and Treatment

BACKGROUND

Keloid management can be difficult and frustrating, and the mechanisms underlying keloid formation are only partially understood.

METHODS

Using original and current literature in this field, this comprehensive review presents the major concepts of keloid pathogenesis and the treatment options stemming from them.

RESULTS

Mechanisms for keloid formation include alterations in growth factors, collagen turnover, tension alignment, and genetic and immunologic contributions. Treatment strategies for keloids include established (e.g., surgery, steroid, radiation) and experimental (e.g., interferon, 5-fluorouracil, retinoid) regimens.

CONCLUSION

The scientific basis and empiric evidence supporting the use of various agents is presented. Combination therapy, using surgical excision followed by intradermal steroid or other adjuvant therapy, currently appears to be the most efficacious and safe current regimen for keloid management.

[Analysis of curative result for keloid with integrated methods]

OBJECTIVE

To study the curative effects of keloid by operation combined with postoperative beta radiation and silicone gel sheeting.

METHODS

From 1996 to 2002, 598 patients with keloid (243 males, 355 females, aging 15-55 years with an average of 28.6 years) were treated by integrated therapy. Their disease courses were from 6 months to 6 years. The keloid area ranged from 1.0 cm x 1.5 cm-8.0 cm x 15 cm. First, keloid was removed by operation, and then the wounds were sutured directly (group suture) or covered with skin graft (group graft). In group suture, the operational sites were managed by beta ray radiotherapy 24-48 hours after operation. The total doses of radiation were 12-15 Gy, 5 times 1 week (group suture A) and 10 times 2 weeks (group suture B). Radiotherapy was not taken until stitches were taken out in group graft, and then the same methods were adopted as group suture B. After radiotherapy, silicone gel sheeting was used in 325 cases for 3-6 months.

RESULTS

All patients were followed up for 12-18 months. (1) The overall efficacy was 91.3% in group suture A (n = 196), and 95.8% in group suture B (n = 383), respectively. There was significant difference between the two groups (P < 0.01). (2) Radiotherapy was of no effect in 6 cases of group graft (n = 19). (3) Silicone gel sheeting had effectiveness in 185 cases. Silicone gel sheeting had no obvious effect on the overall efficacy, but it could improve the quality of texture and color of skin.

CONCLUSION

By use of integrated methods to treat keloid, if the wound can be sutured directly, skin grafting should not be adopted. The results in group suture B are better than those in group suture A; silicone gel sheeting should be used as possible.

Internationale Klinische Empfehlungen zur Narbenbehandlung

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence- based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicon gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practice and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.

Placebo-controlled clinical trial of a 19% sodium percarbonate whitening film: initial and sustained whitening

PURPOSE

To evaluate in a randomized, double-blind, placebo-controlled clinical trial the initial, cumulative and sustained whitening with a brush-applied, peroxide-based, overnight tooth whitener.

METHODS

50 adults were randomized to Crest Night Effects, a 19% sodium percarbonate gel that dries to form an adherent film, or a placebo gel without any peroxide source. The treatments were brush-applied at night, and removed the next morning with normal toothbrushing. Subjects were evaluated biweekly during the 6-week treatment period to evaluate initial and cumulative color change, and again, 4 weeks after completion of treatment to evaluate color relapse. Efficacy was determined by evaluating reduction in tooth yellowness (delta b*), increase in tooth brightness (delta L*) and overall change relative to white (delta W*) from standardized digital images. Tolerability was assessed by examination and interview conducted at treatment and post-treatment visits.

RESULTS

Relative to baseline, the 19% sodium percarbonate film group had significantly (P < or = 0.013) whiter teeth after 2 weeks overnight use. For maxillary teeth, delta b* and delta L* means (SD) were: -1.35 (0.858) and 1.06 (0.886), respectively. For mandibular teeth, delta b* and delta L* means (SD) were: -1.27 (0.903) and 0.56 (0.790), respectively. Relative to placebo, the 19% sodium percarbonate group was significantly (P < 0.005) better than placebo for delta b*, delta L*, and delta W*. There was a cumulative benefit with additional treatment, as evidenced by significant (P < 0.0001) improvement in mean delta b* after the initial 2 weeks of treatment. Approximately 90% of the 6-week cumulative color improvement was still evident after 4 weeks post-treatment. Tooth sensitivity (20% of the peroxide group) represented the only adverse event with increased occurrence over placebo, and these events were mild and fully resolved during/after treatment.

Randomized clinical trial comparing overnight use of two self-directed peroxide tooth whiteners

PURPOSE

To directly compare tooth color change and spatial uniformity of two brush-applied, peroxide-based overnight tooth whiteners in a 2-week randomized clinical trial.

METHODS

57 adult volunteers were randomly assigned to Crest Night Effects, a 19% sodium percarbonate system packaged in unit dose sachets that when applied, dries to form an adherent film, or Colgate Simply White Night, a paint-on liquid in an applicator bottle at a concentration of 8.7% hydrogen peroxide. Both groups applied their assigned gel on the facial surfaces of the six maxillary anterior teeth for 14 nights. Efficacy was measured objectively as change in L*a*b* tooth color from standard digital images of maxillary teeth, while safety was evaluated by clinical examination and interview.

RESULTS

After 14 nights treatment, adjusted mean (SE) change in yellowness (delta b*) was -0.95 (0.092) for the 19% sodium percarbonate film and -0.17 (0.096) for the 8.7% hydrogen peroxide gel, with these groups differing statistically (P < 0.0001). Other individual and composite color parameters also demonstrated significantly greater whitening for the 19% sodium percarbonate film compared to the 8.7% hydrogen peroxide gel after 14 nights use. Only the 19% sodium percarbonate film exhibited significant (P< 0.0001) proximal color improvement (delta b*) after 2 weeks, approximately 98% of that seen on the body of the tooth, providing evidence of proximal bleaching and uniform spatial whitening following use of this barrier-free system. Both products were well-tolerated, with no subjects discontinuing treatment early due to a causal adverse event.

Delivery, substantivity and clinical response of a direct application percarbonate tooth whitening film

PURPOSE

A novel overnight bleaching system containing 19% sodium percarbonate and silicone film forming agents (Crest Night Effects) is described, along with research supporting the substantivity of the product on tooth surfaces and its resulting whitening efficacy.

METHODS

Nine adult volunteers were enrolled in a study to determine overnight retention (substantivity) of the product. A non-reactive blue pigment was added to the product to aid in evaluating retention. The participants applied the product to their anterior dentition at night and then had digital images taken. After 7 hours of sleep, the patients were awakened and re-imaged. The percent coverage with blue pigment on the surfaces of the 12 anterior teeth was calculated from the digital images after application and after awakening. The product was also evaluated in a 2-week efficacy study with 16 adult volunteers. Each night the participants brushed their teeth before going to bed as they normally would, dried their teeth with a towel, and then applied the product to their six maxillary and mandibular anterior teeth. The product was left on the teeth overnight and then removed in the morning via toothbrushing. Color (baseline and after 2 weeks of product usage) was determined using digital imaging and the standard L*a*b* measurement scale.

RESULTS

In the substantivity study, 84.7% of the subject teeth surfaces were covered on average with the blue pigment-containing film immediately after application. Following overnight use, excellent retention was demonstrated as 77.4% of the initially covered surfaces still had pigment-containing film on them. These means did not differ significantly (P > 0.44). In the clinical efficacy study, there was significant (P < 0.0001) color improvement versus baseline after 2 weeks of treatment as measured by a mean (SD) delta b* of -1.71 (0.85) and mean (SD) delta L* of 1.62 (0.68). The product was well-tolerated, with the primary adverse events being oral irritation (13%) and tooth sensitivity (6%). No participants discontinued product use because of a product-related adverse event.

Silicone gel sheeting for the management and prevention of onychocryptosis

BACKGROUND

Onychocryptosis, commonly referred to as ingrown nails, has many therapeutic alternatives for its management. Although mild cases can be treated conservatively, in severe cases, surgical treatment is preferred. Silicone gel sheeting is found to be effective in the treatment of hypertrophic scars and keloids.

OBJECTIVE

To document the effectiveness of silicone gel sheeting in the management of patients with onychocryptosis and in the prevention of the recurrences by breaking the devil's circle, which usually took place after the surgical procedures used in the treatment of the onychocryptosis.

METHODS

Fourteen patients were enrolled in the study. Entry criteria required the presence of slight (2 patients), moderate (2 patients), or severe (10 patients) onychocryptosis. The simple technique used in the study was the excision of the one-quarter part of the lesional side of the nail plate without excising the granulation tissue. After 24 hours, the silicone was placed on the granulation tissue and the exposed nail bed. Silicone gel sheet was bandaged loosely without applying any pressure. Patients entering the study were given detailed instructions in applying and using the gel for 12 hours during the daytime. The study lasted for 14 months and was composed of a treatment period of 4 months and a follow-up period of 10 months. The patients were evaluated every 2 weeks in the first month and then monthly. The change in thickness of granulation tissue was evaluated by comparing them with the baseline photographs and those taken at each visit.

RESULTS

The management and prevention of onychocryptosis were achieved in 12 of 14 patients (85.71%). The silicone gel sheeting treatment was well tolerated except for an occasional transient exudation, which was resolved when the treatment was withdrawn.

CONCLUSION

The results show that the new method that we used for the treatment of onychocryptosis is successful in reducing the thickness of the hypertrophic nail fold and prevents the recurrence of the condition during the regrowth of the nail plate by breaking the devil's circle. The advantage of this method is that it is not destructive to the nail matrix and the adjacent tissue.

Injectable silicone biomaterial for faecal incontinence due to internal anal sphincter dysfunction

BACKGROUND

A weak or disrupted internal anal sphincter can cause passive faecal incontinence. Conservative measures may help some patients but there is no simple surgical solution for those who fail conservative treatment. A successful technique using trans-sphincteric injection of a bulking agent to augment the internal anal sphincter was developed in a previous pilot study.

AIM

To determine the clinical results and underlying physiological effects of biomaterial injection.

PATIENTS

Six patients (four males, median age 53 years (range 36-65)) with faecal incontinence to solid or liquid stool related to poor internal anal sphincter function, of varied aetiology, were recruited.

METHODS

Silicone based biomaterial injections were performed, under local anaesthesia, with antibiotic cover. Three injections were placed circumferentially, trans-sphincterically, entering away from the anal margin and injecting at or just above the dentate line. Anorectal physiological studies, endoanal ultrasound, a bowel symptom diary, a validated incontinence score, and quality of life questionnaires were completed before treatment and on completion of follow up.

RESULTS

At a median follow up of 18 months (range 15-19), five of six patients had marked symptom improvement. Faecal incontinence scores improved from a median of 14/24 (range 11-20) before to 8/24 (6-15) after injection. Short form-36 quality of life physical and social function scores improved from a median of 26/100 (5-33) to 79/100 (25-100) and from 10/100 (5-37) to 100/100 (50-100), respectively. There was a corresponding physiological increase in maximum anal resting and squeeze pressures. Ultrasound showed the Bioplastique to be retained in the correct position in the improved patients without migration. There were no complications.

CONCLUSION

Trans-sphincteric injection of silicone biomaterial can provide a marked improvement in faecal incontinence related to a weak or disrupted internal anal sphincter. This is associated with improved sphincter function and quality of life.

Breast reconstruction with perforator-based inframammary de-epithelized flap: a case report

Patients with silicon gel-injected breasts sometimes appear even now, demanding removal of this foreign body. These requests are often challenging for us-the removal leaves distortion of the breast contour. Musclocutaneous flap transfer is a good method for reconstruction, but scar formation for flap harvest is a problem. Most patients are reluctant to accept these scars. Reconstruction with prostheses has been another method. But the absence of subcutaneous tissue and degenerated muscle make implantation difficult. For one of these patients, the authors applied a method for breast reconstruction with perforator-based inframammary flap. After the removal of the siliconoma with surrounding degenerated tissues, a crescent-shaped skin flap was designed on the inframammary area. Preserving perforators into the flap, it was elevated with adipose tissue. After the skin was de-epthelized, the adipose tissue and skin flap were turned over to make the breast protrusion. The donor site is closed primarily. Ten months after the operation, there was little atrophy of the reconstructed breast, and the patient is satisfied with the result, especially with the softness of the reconstructed breast. Although this method has limitation for volume, less morbidity for donor site and volume reduction in inframammary area are advantageous. In conclusion, this inframammary flap seems to be a good tool for breast surgery.

The effect of silicone gel sheets on perfusion of hypertrophic burn scars

The mechanism of action of topical silicone gel sheets on hypertrophic scars is not well understood and their effect on the blood flow within hypertrophic scars has not been investigated. The purpose of this study was to examine whether application of silicone gel sheets produced any acute effects on blood flow in hypertrophic burn scars. Perfusion of hypertrophic scars and adjacent normal skin was measured using a laser Doppler with and without application of silicone gel sheets. Continuous measurements were made for 5 minutes before gel application, for 30 minutes during gel application and for 5 minutes following gel removal. Surface temperature of the scar was continuously monitored. An occupational therapist, blinded to the perfusion level, rated each scar using the Vancouver Scar Scale. Eighteen scars and adjacent control sites in sixteen adult burn patients (11 male, 5 female; mean age: 42 +/- 14 years) were evaluated. The mean scar age was 5.4 +/- 3.7 months. The mean Vancouver Scar Scale was 5.5 +/- 2.4. Hypertrophic scars demonstrated higher perfusion measurements at baseline compared to control areas (58.5 +/- 19.3 flux units vs 25.0 +/- 8.4 flux units; P < 0.001). Application of silicone sheeting gel did not significantly alter perfusion in either the hypertrophic scar or normal tissue from the baseline measurements. However, application of silicone gel sheeting did significantly increase the mean baseline surface temperature of the hypertrophic scar from 29 +/- 0.8 degrees C to 30.7 +/- 0.6 degrees C (P < 0.001). The mechanism of action of silicone gel sheeting probably does not involve an acute alteration in blood flow within the scar. However, surface temperature of the scar increased significantly following gel application, raising the possibility that temperature alteration is involved in the mechanism of action.

Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting

BACKGROUND

Topical silicone gel sheeting has been used for more than 20 years to help reduce the size of hypertrophic scars and keloids. Its clinical efficacy and safety is well established.

OBJECTIVE

To determine whether topical silicone gel sheeting can be used to prevent hypertrophic scars and keloids from forming following dermatologic skin surgery.

METHODS

Patients undergoing skin surgery were stratified into two groups: those with no history of abnormal scarring (low-risk group) and those with a history of abnormal scarring (high-risk group). Following the procedure, patients within each group were randomized to receive either routine postoperative care or topical silicone gel sheeting (48 hours after surgery). Patients were followed for 6 months.

RESULTS

In the low-risk group, there were no statistical differences between individuals using routine postoperative care or using topical silicone gel sheets. In the high-risk group, there was a statistical difference (39% versus 71%) between patients who did not develop abnormal scars and used topical silicone gel sheeting and patients who developed abnormal scars after routine postoperative treatment. Those individuals having a scar revision procedure also showed a statistical difference if topical silicone gel sheeting was used following surgery.

CONCLUSION

Topical silicone gel sheeting, with a 20-year history of satisfaction in dermatology, now appears to be useful in the prevention of hypertrophic scars and keloids in patients undergoing scar revision.

Self-adhesive silicone gel sheet: a treatment for hypertrophic scars and keloids

An open clinical trial was conducted to assess the effect of self-adhesive silicone gel sheet (SASGS) for the treatment of hypertrophic scars and keloids in Thai people. Patients were instructed to apply the SASGS to the scars as long as possible, but not less than 12 hours per day for at least 8 weeks. The subjective results of the treatment were evaluated by the patients. The scars were evaluated for color, height, weight before and after treatment at 4 and 8 weeks. Eighteen patients with 18 hypertrophic scars or keloids were recruited into the study. Their ages ranged from 6 to 33 years (mean 21 years). The average duration of the scars was 5.7 years. Twelve patients (66.67%) stated good results. All of the 18 patients wanted to continue the treatment with SASGS. Heights of the scars were reduced in 12 lesions (66.67%) after treatment for 8 weeks (P = 0.058). Weights of the lesions were decreased in 10 lesions (55.55%) but were not statistically different (P = 0.090). Seven lesions (36.84%) were improved in color. Two patients (11.11%) developed erythematous rash around the lesions which subsided after withdrawal of the treatment. The long term follow-up for the recurrence and the mechanism of action of this treatment should be studied further.