Shortened penis post penile prosthesis implantation treated with subcutaneous soft silicone penile implant: case report

Penile prosthesis surgery for erectile dysfunction has the highest satisfaction rates among all treatment options but is often associated with subjective and objective loss of penile length and girth following surgery. To present a novel technique using a subcutaneous soft silicone implant for reversal of penile shortening and narrowing after prosthesis surgery, with additional gains in overall penile length and girth. Nine patients were treated with the insertion of a subcutaneous soft silicone penile implant. All patients had previously reported a loss in penile length (0.5-2 cm), and seven of nine patients also reported a loss in penile girth (0.5-2.6 cm) after penile prosthesis surgery. During a follow-up period of 4-24 months, penile length and girth measurements showed a mean increase in length of 2.4 cm (±0.75 cm) and a mean increase in girth of 3.4 cm (±0.94 cm). The additional insertion of a subcutaneous soft silicone implant in patients with decreased penile length and girth after penile prosthesis surgery is an effective treatment option that provides reversal of lost penile length and girth.

Komplikationen nach Faltenunterspritzung und ihre Behandlung

All dermal fillers are associated with the risk of both early and late complications. Early side effects such as swelling, redness, and bruising occur after intradermal or subdermal injections. The patient has to be aware of these risks and be prepared to accept them. Adverse events that last longer than 2 weeks can be attributable to technical shortcomings (e.g., the implantation of a long-lasting filler substance was too superficial). Such adverse events can be treated with intradermal 5-fluorouracil and steroid injections, vascular lasers, or intense pulsed light, and later with dermabrasion or shaving. Late adverse events also include immunological phenomena such as late-onset allergy and non-allergic foreign body granulomas. Both react well to intralesional steroid injections, which often have to be repeated to establish the right dose. Surgical excisions should remain the last option and are indicated for hard lumps in the lips and visible hard nodules or hard granulomas in the subcutaneous fat.

A classification of facial wrinkles

An increasing number of injectable filler materials for facial wrinkles and folds points to the need for objective measurements of their effectiveness. Patient satisfaction is the goal, but proof of the value of a particular product requires objective measurement. A wrinkle assessment scale was developed as a simple tool for use by plastic surgeons, dermatologists, and aesthetic surgeons who want to assess the changes resulting from injecting filler materials in their patients. By correlating the grade of the wrinkle in the reference photographs with the wrinkle in a patient's face, a classification of 0 to 5 is assigned. Reliability of the scale was assessed by "live" judgment of 76 wrinkles by nine observers. The same rating was given to 92.7 percent of all wrinkles. In a second trial, photographs from 130 wrinkles were presented to eight observers who rated 89.4 percent of all wrinkles equally. A significant correlation of 87 percent was found between subjective ratings and objective wrinkle depth measured by profilometry on 40 silicone impressions. Manufacturers, monitors of clinical trials, health authorities, and most important, patients will benefit from objective data on current and new injectable materials.

[Reconstruction of severe facial defects due to noma]

Noma is an ulcerative-necrotizing gingivo-stomatitis eventually leading to severe destruction of the midface, including lips and cheek, maxilla/mandible, nose and rarely the orbit. The defects are usually unilateral. Children from economically underdeveloped countries are predominantly affected. Medically untreated the disease has a high mortality rate, which can be dramatically lowered by adequate antibiotic therapy started in time. Predisposing factors include malnourishment, immunosuppression, and poor oral hygiene. Forty-eight noma patients were surgically treated in Sokoto, Nigeria during October 1997 by an Interplast Germany team sponsored by AWD Stiftung Kinderhilfe. Interdisciplinary surgical strategies and results, e.g. ankylosis release, local flap coverage and 12 pedicled musculocutaneous latissimus dorsi island flaps, as well as a noma classification (NOMAC), are presented.

The resection of gastrocnemius muscles in aesthetically disturbing calf hypertrophy

In some patients, oversized calves lead to mental distress and avoidance of certain social activities. They hide their legs in pants and seek medical advice. If the thickness of the subcutaneous fat is normal and cannot be diminished by liposuction, the oversized calves are caused by pure muscle hypertrophy. Using the gastrocnemius for muscle flaps in covering knee defects does not impair the function of the patient's leg; therefore, resection of the total gastrocnemius muscle for aesthetic calf reduction was performed in 15 consecutive patients without any lasting impairment with stability or sports activities. The patient was placed in a prone position, and the muscles were bluntly freed and pulled through two incisions of 5-cm length in the hollow of the knee and above the Achilles tendon. The resected muscles weighed between 410 and 810 g each. In two patients, the sural nerve was stretched or cut during the operation. The consequent numbness of the lateral ankle and sole persisted for 9 and 13 months, respectively. All 15 patients were satisfied with the results; none complained of lack of stability or insecurity in walking; and all became active in sports or changed their dress habits.

PMMA-Microspheres (Artecoll) for long-lasting correction of wrinkles: refinements and statistical results

The corium is diminished to about half of its thickness in skin defects and wrinkles. All biological materials that increase the thickness of the corium are resorbed within a certain time. Therefore, a lasting effect can be achieved only with nonresorbable synthetic substances. Artecoll consists of microspheres of 30-40 microm in diameter, of exceptional surface smoothness, purity, and homogeneity related to PMMA. These microspheres are suspended in atelocollagen which serves as a vehicle for subdermal implantation. Due to its smooth surface and consequential lack of electrical charges, each single microsphere is immediately encapsulated with the patient's own collagen fibers, thus preventing dislocation. Within 3 months, collagen (making up 75% of Artecoll) is replaced by the body's own connective tissue. The microspheres (25% of Artecoll) serve merely as a stimulus to the fibroblasts. Indications for Artecoll are all facial folds, lip- and philtrum augmentation, chin- and malar augmentation, dark-shadowed eyelids, enophthalmos, bony defects in face and hands, nipple reconstruction and augmentation, and urinary incontinence. Questionnaires were sent to all patients who had received Artecoll in 1993 and 1994. Of a total of 950 questionnaires sent, 515 were returned by September 1995. Satisfaction was rated "very good" in 29%, "good" in 38%, "satisfactory" in 23%, and "no difference" in 8% of the patients. The question, "Would you repeat the treatment again?" was answered by 91% of the patients with "yes." The overall complication rate was 3%. Strictly subdermal implantation will prevent longer lasting redness or visibility of the Artecoll.

Elevated levels of testosterone receptors in keloid tissue: an experimental investigation

Testosterone-binding receptor protein analyses were performed in keloids of 24 patients. According to their clinical appearance (hyperemia, pain, rapid growth, etc.), the lesions were subdivided into regions of minor and major clinical keloid activity. Biopsies were taken from active and inactive parts of the keloids, respectively, as well as from normal adjacent skin. The mean receptor amount in femtomoles per milligrams of tissue was 0.046 for active (SD = 0.037), 0.038 for inactive keloidal lesions (SD = 0.032), and 0.012 for normal skin. The corresponding receptor amount per microgram of DNA was 3.356 fmol (SD = 2.171) for active, 2.077 fmol (SD = 1.427) for inactive keloidal, and 1.010 fmol (SD = 1.190) for normal tissue. Statistical evaluation was performed using a two-way analysis of variance, with the two factors being individual subject and type of tissue. When differences were found, then Tukey's comparison was done to assess where those differences were. Comparisons of the receptor amount per milligram of tissue significant at the 0.05 level revealed significant differences between active keloid tissue and normal skin tissue and inactive and normal tissue (p < 0.01) respectively, while different receptor amount per microgram of DNA was significant between active and inactive and active and normal tissue (p < 0.01). These data suggest that elevated androgen receptor levels exist in clinical active keloid tissue and that possible therapeutic means might include topical antiandrogen therapy.

The tuberous breast deformity: classification and treatment

To date there are many descriptive terms for the tuberous breast deformity but there is no widely accepted nomenclature. A retrospective study was undertaken of 68 tuberous breasts and the operative corrections performed. The deformities were classified into four types. Type I (hypoplasia of the lower medial quadrant), type II (hypoplasia of the lower medial and lateral quadrants, sufficient skin in the subareolar region), type III (hypoplasia of the lower medial and lateral quadrants, deficiency of skin in the subareolar region) and type IV (severe breast constriction, minimal breast base). Areolar prolapse, usually regarded as a major symptom, was only found in 30 (44%) deformed breasts. Postoperative review of 51 breasts in 31 patients showed that type I cases treated by reduction mammaplasty of adequately sized breasts or augmentation of hypoplastic breasts had excellent results. These procedures with additional spreading of the breast tissue in type II deformities give good results. Severe cases (types III and IV) treated by augmentation and tissue spreading procedures have an unsatisfactory shape and have a 'second crease' deformity. For types III and IV, additional skin in the subareolar region by tissue expansion or flap procedures is necessary. There is no one method to correct 'the' tuberous breast but there are many procedures which should be used according to the type of deformity. The classification developed could end the confusion in nomenclature.

[Treatment of wrinkles by Artecoll implant and resurfacing with the CO2 laser]

In general, all biological materials are resorbed in places where they do not belong. Therefore, artificial substances have to be implanted under deep skin folds and skin defects in order to achieve a permanent skin augmentation. Artecoll, a suspension of polymethylmetcrylate (PMMA)-microspheres in collagen solution, has been proven, for more than 5 years, to underlay wrinkles effectively without noticeable side-effects. Small wrinkles around the eyes, the mouth and cheeks, however, have to be treated by dermabrasion, chemical peel or vaporization by CO2-laser. Using all three methods, the effectiveness depends on the depth of skin traumatisation. Resurfacing using the CO2-laser has the advantage of absolute precision, no bleeding, less swelling and faster healing-but still high costs.

PMMA microspheres (Artecoll) for skin and soft-tissue augmentation. Part II: Clinical investigations

Artecoll is an injectable implant for long-lasting correction of wrinkles and other skin defects. Artecoll consists of fine polymethyl-methacrylate (PMMA) microspheres suspended 1:3 in a 3.5% collagen solution. The microspheres are characterized by exceptional surface smoothness, homogenicity, and purity. The size of the microspheres of 30-40 microns diameter is small enough to allow subdermal implantation using a 27-gauge needle. Phagocytosis and dislocation of the implant is prevented by fast encapsulation of each single microsphere with connective tissue. Increased scarring but no granuloma formation has been detected as is common with other injectable implants with irregular surfaces. The experience from more than 600 patients and a prospective study in 118 patients with 200 implantation sites were evaluated. The good early results have continued for 5 years. Of the patients evaluated, 89.5 percent were satisfied and would ask for the treatment again. The overall complication rate is very low, and prolonged redness or visible granules are due to implantations that are too superficial. Other applications in soft-tissue augmentation are discussed.

Free transplantation of fat autografts expanded by tissue expanders in rats

Inguinal fat pads of 28 rats were expanded by tissue expanders for 10 days and transplanted to the back of the same animal. The non-expanded contralateral inguinal fat pads were also transplanted and served as controls. Histology showed that adipocytes lose their lipid droplets under mechanical pressure; the expanded adipocytes have an elongated contour with a central nucleus. By the end of the expansion period, the thickness of the fat pads had decreased by 53%. One week after transplantation, expanded fat grafts had regained their previous volume with little sign of necrosis. Among normal adipocytes numerous smaller cells, containing multiple vacuoles, were seen. In contrast, about 25% of the substance of the non-expanded control fat graft consisted of necrotic oil cysts. These findings indicate that pre-expanded fat grafts survive better.

[A three-year aid program for plastic surgery in Peshawar (Pakistan). Ongoing management of severely injured patients of the Afghanistan war: 1,528 large operations, 5,171 smaller interventions, 15,932 patients examined]

Since 1980 Interplast Germany has sent many plastic surgeons to developing countries. In 1989 a new Interplast Germany program for helping Afghan refugees in Pakistan's Peshawar was started. The Federal Republic of Germany financed the first two years; thereafter, the European Community and Help supported the project. Twenty-four teams with 123 nurses, surgeons and anesthesiologists operated on 1,528 patients in two hospitals. In the same period 5,171 smaller operations have been performed and 15,932 patients have been examined. Low expense for the teams, good support by officials, and professional administration have made this project highly effective for 3 years.

Calf augmentation with new solid silicone implants

Calf augmentation has been standardized by the use of banana-shaped silicone gel implants for almost 20 years. Capsule formation and resulting distignement, dislocation, gel bleeding, and implant rupture are rare but unpleasant complications. A new implant of solid silicone (McGhan, Santa Barbara, CA, USA) in the anatomical shape of one belly of the M. gastrocnemius placed subfascially appears to overcome these problems.

Effect of cortisone on capsular contracture in double-lumen breast implants: ten years' experience

Two groups of patients are compared with respect to capsular contracture after insertion of silicone breast prostheses. Six hundred seventy four women received single-lumen gel prostheses and 700 received double-lumen prostheses with cortisone. The addition of 12.5 mg of prednisolone to double-lumen prostheses diminished capsular contracture (Baker II to IV) dramatically; in patients with simple augmentation from 19% to 4.9%, in patients with subcutaneous mastectomy from 54% to 14.9%, and in patients with breast reconstruction from 64% to 24.4%. The use of double-lumen implants has three distinct advantages: (1) There is no bleeding and therefore no contact of the body with the silicone gel. (2) There is no danger of ruptured implants, even if the outer shell shows leakage. (3) If prednisolone is administered, capsular contracture is prevented to a significant degree.

External skin excision in the sebaceous nose and supratip deformity

Some sebaceous noses cannot be properly reduced in size because of redundant skin. After standard rhinoplasty some noses develop a supratip deformity that recurs even after subcutaneous removal of the scar tissue. These noses can be corrected only by wedge-shaped skin excision. Most patients much prefer a pleasantly shaped nose, even at the cost of a midline scar on the nose. Most surgeons are hesitant to add scars to the face. However, the vast experience with wounds following accidents, tumor excisions, or corrections of malformations has shown that generally scar formation on the nose is inconspicuous. Nineteen patients were treated successfully by skin excision at the time of primary rhinoplasty or by a second operation.

[Siliconoma and rheumatic symptoms--a familial and a questionable complication of silicone implantation]

Ruptured silicone-gel filled implants after breast augmentation or reconstruction may cause siliconomas. These lesions frequently develop years later and should be surgically excised. Since the use of modern double lumen implants they do not occur anymore. The possibility of a correlation between silicone implants and the incidence of rheumatologic disorders is critically evaluated by case reports from the world literature. Up to now, no statistically significant cumulation of these disorders in women with silicone implants can be observed.

Reduction of capsular formation around silicone breast implants by D-penicillamine in rats

In a controlled study in 109 female rats we evaluated the effect of soluble D-Penicillamine in doses of 10 mg/ml or 100 mg/ml on capsular formation around semipermeable 2 cm3 mini-prostheses. This was compared with methylprednisolone 1 mg/ml or 10 mg/ml, and a group given saline served as controls. The drugs were injected into the lumen. Capsular wet weight and capsular tensile strength were measured after a period of 40 days. Rats given D-Penicillamine showed a significant, dose-dependent, reduction in wet weight and tensile strength compared with the saline group. There was no significant difference between the groups given D-Penicillamine and those given steroids. Topical treatment with diffused D-Penicillamine can significantly reduce the amount of capsular formation around silicone implants. This drug, which is highly specific for the systemic treatment of fibrotic diseases, should be evaluated further to use in reducing capsular formation.

[Surgical treatment of male baldness using Juri's crescent flap]

This is a report on thirty six patients with male pattern baldness, surgically treated with one or two parieto-occipital flaps according to Juri. In six patients with isolated occipital baldness, specially designed flaps were used. Since male baldness usually is genetically determined and hairroots of the temporo-occipital scalp remain active throughout life, one can expect that they continue growing within the transposed flaps. There are three indications for parieto-occipital flaps: 1. psychological burden of the patient, 2. genetic background in the family of young patients, and 3. prior punch hair grafts whose roots have atrophied.

[Sonographic findings in silicone-induced granulomas and lymphadenopathy following mammaplastic surgery]

Ultrasound examination of the breast and its lymphatic drainage was undertaken in 78 patients who--after mammoplasty with silicone implants--had palpable lymph nodes, pain and sensation of tension in the area surrounding the implant. Five patients had space-occupying echo-dense inner structures and dense echos from structures dorsal to the space-occupying ones. In this way silicone granuloma could be demonstrated even preoperatively in tissues, musculature or lymph nodes, although the changes were palpable in only two of the five patients. Ultrasonography can thus be of great importance not only in the diagnosis but also in the preoperative localization of silicone-induced granulomas.

[Primary management of fresh bite injuries of the face]

The danger of dog bites is often exaggerated. The reason for this is a gram negative bacterium Pasteurella multocida, which causes a serious infection within 12 h. Among 143 dog bites we saw only two of these infections. The bacterial swabs from the mouths of 20 dogs revealed E. coli in 43%, Streptococci in 33%, Proteus in 30%, Staph. epidermidis in 27% and Enterococci in 25%. Since the blood supply of the face is much more superior to that for instance of the legs, infections are rare and primary closure of wounds of dog and human bites is recommended. Additional drainage, hospitalisation and local and systemic antibiotics are possible. Open wound therapy in the face can be called obsolete.

[Surgical therapeutic possibilities in extensive chest wall and rib metastases]

87 extensive tumors of the chest wall were resected in an 8 year period. The defects including subtotal sternectomies and segment resections up to 7 ribs were reconstructed with musculocutaneous flaps without any osteoplasty or implants. The latissimus dorsi flap closes pleural defects safely. The innervated muscle stabilizes the chest wall. The rectus abdominis flap fits defects of greater volume but the blood supply is less reliable. The use of pectoralis major or free microsurgical tissue transfer may be indicated in absence of any other possibility.

[Buruli ulcer--necrotizing infection of the hand of a plastic surgeon]

The Buruli ulcer is caused by mycobacterium ulcerans. The clinical features of this atypical mycobacteriosis are similar to tuberculosis. Differentiation is only possible by microbiological investigation. In cases of chronic soft tissue infections mycobacteriosis must be taken into consideration. Since microbiological differentiation needs 8-12 weeks and chemotherapy is not effective, early and wide surgical excision is the treatment of choice.

[Retrograde or orthograde anatomic perfusion of the free forearm flap?]

The free forearm flap is ideal for vascularized tissue transfer because of its large vessels and multiple nerve supply. In the case presented a distally based forearm flap on a long vascular pedicle was employed relying on a reversed blood flow. Unfortunately the reversed venous flow did not develop and therefore in order to provide a venous drainage an autologous vein graft was used.

Surgical treatment of anterior nasoethmoid encephaloceles

Two cases are reported with anterior nasoethmoid encephaloceles. The clinical, radiological and surgical results are described. The significance of a primary intracranial and intradural treatment of the defect of the base of the skull is pointed out. Secondary extirpation of the encephalocele and plastic correction of the face is recommended. Interdisciplinary cooperation with related specialties in the treatment of anterior encephaloceles is emphasised.

[Treatment of funnel chest with RTV-silicone implants]

The funnel chest is no physiological but a psychological problem for the majority of patients. Only 5% suffer from pathological parameters which require a surgical elevation of the funnel. After these rather complicated operations, however, only 60-80% are followed by good long-term results. The described RTV-silicone implant is formed preoperatively directly in the funnel and appears to be a simple safe and lasting alternative for most patients with a funnel chest.