Revision surgical hair restoration: repair of undesirable results

Surgical hair restoration has been performed as a treatment for male pattern hair loss for more than 40 years. Although techniques have changed dramatically over the past several years, making it possible to achieve natural-appearing results, there are still many patients with unacceptable outcomes. These patients may have had procedures performed in the past with antiquated techniques or performed recently with substandard techniques. The causes of unfavorable results can be classified into one of three categories: technical errors, poor planning, or complications. The results in these patients can be dramatically improved through a number of different reparative surgical techniques. The majority of these techniques can be performed in an office outpatient setting. More than 40 patients unsatisfied with previous surgical hair restoration have been treated with the different techniques reviewed in this article. All patients had successful outcomes with significant improvement in appearance. Despite the increased challenges when performing reparative surgery, outcomes were favorable in all patients, with small to significant improvements in appearance achieved. Some of these challenges include the limited supply of donor hairs, reduced scalp laxity, and theoretically reduced vascularity due to scarring and transected blood vessels, and patient skepticism. Furthermore, the few complications that occurred were minor and correctable, including one case each of poor hair growth associated with extensive small graft (consisting of one to four hairs) transplanting, and of scalp scarring associated with the removal and primary closure of a large number of "plug" grafts (typically grafts 3 to 4 mm in size consisting of seven or more hairs) in a single procedure.     

DERMABRASIVE ABLATION OF ACNE SCARS

Dermabrasion offers cosmetic improvement of acne pits and scars, but only well-adjusted patients should be selected for this esthetic improvement. In the dermabrasion operation the deep cup-shaped pits are made shallow by saucerization, for the deep sharp shadows are eliminated as the pits are shallowed. It is the elimination of the shadow effect which is so gratifying to the patient.Although dermabrasion is a superficial skin operation, it involves dangerous instruments and thousands of minute incisions. The procedure is a surgical operation, whether done in an office or in a hospital. The author performs the operation entirely as a hospital procedure, using pentothal anesthesia with meperidine added in small increments during the operation. Thus the operation may be unhurriedly and meticulously performed.     

Occult Enterobacter aerogenes pneumonia diagnosed by indium 111-labeled leukocyte scan.

A major earthquake may strike while a surgeon is performing an operation in an office surgical facility. A sudden major fault disruption will lead to thousands of casualties and widespread destruction. Surgeons who operate in offices can help lessen havoc by careful preparation. These plans should coordinate with other disaster plans for effective triage, evacuation, and the treatment of casualties.     

THE PREPARATION AND STERILIZATION OF OPHTHALMIC SOLUTIONS

Ophthalmic solutions should be prepared and preserved according to whether they are to be used in surgical procedures, in the clinic or office, or by the patient at home.There is an optimum pH level at which the solutions of individual drugs should be buffered in order to obtain the maximum efficiency and stability.Deterioration of the drugs used is greatly diminished when they are dispensed at the proper pH.Quaternary ammonium chloride solutions in proper strength have been shown to be adequate for the preservation of ophthalmic solutions.     

The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases

The use of conscious sedation is rapidly gaining acceptance and popularity in plastic surgery. At the present time, many procedures are performed using intravenous sedation and local anesthesia. The purpose of this article was to examine the safety and outcome of full abdominoplasties performed under conscious sedation at the authors' institution. Over a 6-year period from 1997 to 2002, 266 abdominoplasties were performed by the two senior authors. One hundred thirteen of these (42 percent) were performed under a general or regional anesthetic because a concurrent procedure was performed that precluded the use of conscious sedation (64 hysterectomies, 18 hernia repairs, six urogynecologic procedures, 10 breast reductions, and one laparoscopic cholecystectomy) or because of patient and surgeon preference (14 cases). One hundred fifty-three abdominoplasties (58 percent) were performed under conscious sedation using intravenous midazolam and fentanyl along with a local anesthetic. No patients had an unplanned conversion to deep sedation or general anesthesia. Eighty percent of these cases were performed with a concurrent procedure (80 liposuctions, 19 breast augmentations, 20 mastopexies, three capsulotomies, and 13 varied facial aesthetic procedures). In addition, 12 patients had concurrent hernia repairs (five ventral and seven umbilical) under conscious sedation. Mean follow-up was 10 months (range, 1 to 56 months). There were no intraoperative complications and no major postoperative complications. The minor complication rate was 11.1 percent (10 seromas requiring needle aspiration in the office, three superficial wound infections, two cases of marginal skin necrosis, one stitch abscess, and one pseudobursa requiring reexcision). Seven revisions were performed for suboptimal scars (5 percent). The results of this study demonstrate that abdominoplasties can be performed under conscious sedation in a safe and cost-effective manner for almost all patients. This type of procedure is well tolerated, has a low complication rate, and has high patient satisfaction. Increasing experience and small modifications in local anesthesia and surgical technique have strengthened the authors' conviction that conscious sedation is the preferred method of anesthesia for most patients undergoing abdominoplasty.     

Postapproval monitoring and the role of the compliance office

Postapproval monitoring (PAM) of research animal use is becoming increasingly common, and the compliance office plays a leading supportive role for the institutional animal care and use committee (IACUC) in implementing PAM at many institutions. Several other groups--higher administration, veterinary and husbandry staff, scientific staff, and occupational health and safety--are important participants in the process, and the compliance office should strive to work collegially with them as a team that facilitates research while meeting compliance requirements. Maintaining a cooperative and open attitude and developing an interest in the science will enhance the research staff's trust in both the compliance office and the PAM program. Resources required by the compliance office to oversee PAM include adequate physical facilities, funding, personnel, and time. Of these, appropriately trained quality assurance coordinators who have the requisite interpersonal and communication skills to interact constructively with researchers are vitally important. Education is key to minimizing the possibility of postapproval noncompliance, and the director of the compliance office, together with the quality assurance coordinators, should assume responsibility for teaching the IACUC, research staff, and higher administration about compliance requirements as well as correct practices and improved techniques. Postapproval noncompliance will occur despite even the best-run PAM program, and adequate documentation and communication will be necessary to address it. The compliance office, on behalf of the IACUC, should assume a primary role in facilitating the institutional response to noncompliance.     

Facial burns as a complication of office surgery lighting

Three patients underwent rhytidoplasty in an office surgical facility under dual ceiling-mounted lights. Each patient incurred a third-degree burn on the left cheek. A particular combination of a specific defective light fixture and bulb appeared to be the causative factor. The risk of burning human tissue is enhanced when epinephrine is injected for vasoconstriction and the tissue is undermined. In addition, focusing dual lights on the surgical field increases the radiant energy delivered. The maximum radiant energy safe for human tissue should not exceed 25 mW/cm2.     

Large-volume liposuction complicated by retroperitoneal hemorrhage: management principles and implications for the quality improvement process

Large-volume liposuction can be associated rarely with major medical complications and death. The case of exsanguinating retroperitoneal hemorrhage that led to cardiopulmonary arrest in an obese 47-year-old woman who underwent large-volume liposuction is described. Extensive liposuction is not a minor procedure. Performance in an ambulatory setting should be monitored carefully, if it is performed at all. Reporting of adverse events associated with outpatient procedures performed by plastic surgeons should be mandated. Hemodynamic instability in the early postoperative period in an otherwise healthy patient may be due to fluid overload, lidocaine toxicity, or to hemorrhagic shock and must be recognized and treated aggressively. Guidelines for the safe practice of large-volume liposuction need to be established.     

Secondary corrections of the vulva in male-to-female transsexuals

From December of 1980 to May of 1998, 390 male-to-female transsexuals underwent vaginoplasty by inversion of the penile skin and a triangular perineoscrotal flap. Although minor modifications were made throughout the years, the basic surgical technique remained the same over this 17.5-year period. In 86 of the 390 patients (22 percent), secondary corrections of the vulva were deemed necessary. A total of 130 corrections were performed in these 86 patients. In the same 17.5-year period, the authors performed 26 secondary corrective procedures in 19 patients in whom the initial vaginoplasty had been done elsewhere. Bilateral Z-plasties were performed 69 times to center the labia in instances when the ventral part of the labia majora remained too far apart. This is not advisable, primarily because it will reduce the vascular supply of the penile skin flap. Introital widening by five-flap advancement was performed in 40 cases in which a dorsal skin fold obstructed the introitis. The use of the triangular perineoscrotal flap favors the vaginal and introital width, but its base should be close to the anal ring to prevent such a skin fold. Secondary construction of the labia minora was performed 27 times, and a skin reduction of the labia majora was performed 20 times. So far, the authors have been unable to develop a satisfactory method for primary construction of the labia minora. Because the appearance of the vulva may charge gradually during the first postoperative year, secondary vulvar corrections should not be performed in that period.     

Unsuspected Carcinoma Found Histologically After Minor Anorectal Operations

The unsatisfactory results of radical operations in advanced anal cancer could be bettered by earlier diagnosis of the malignant lesion. The possibility of cancer should always be kept in mind when treating any of the common chronic anal diseases. Preliminary biopsy studies should be done more frequently if suspicious lesions are present and all tissues removed during minor anorectal operations should always be examined by a pathologist. Each surgical specimen should be labeled to show the site from which it was removed. Follow-up care of the patient would be simplified if the exact site of cancer origin could be identified.A recent ten-year survey of minor anorectal surgical procedures at the University of California Medical Center showed clinically unsuspected anal cancer found in 2 per cent of cases on tissue examination by the pathologist. The cancers were generally early and of the keratinizing squamous cell and nonkeratinizing varieties.     

Some experience in an area health authority child health clinic.

Three years'' experience as a doctor taking two clinics a week in an area health authority child health clinic was reviewed. A wide range of clinical conditions was seen, including: problems associated with feeding in breast- and bottle-fed infants; minor developmental abnormalities (mental, behavioural, and physical); surgical and orthopaedic conditions requiring treatment; medical conditions, mainly respiratory and alimentary infections, skin conditions, and problems of over-treatment for minor ailments; and minor genetic abnormalities. Mothers asked for advice on a wide range of topics, risks and benefits of immunisation being the most common. The clinic doctor needs a wide experience in paediatrics to deal with such problems. It is suggested that all lecturers in child health and paediatric and senior registrars should take one clinic a week for six months, and all medical students should attend some clinics as part of their paediatric training. Health visitors have an important role in helping the clinic doctor, but their training should be more realistic and appropriate facilities should be provided to keep them up to date in their work.     

Minor Gynaecological Outpatient Operations

Altogether 143 patients had minor gynaecological operations performed under general anaesthesia in the outpatient department. This method proved to be very acceptable to patient, gynaecologist, and anaesthetist. No complications occurred requiring admission to hospital, and the short recovery time confirmed the safety of early discharge from hospital. This procedure had a beneficial effect on the waiting list, and expensive beds were used more efficiently for major surgical cases. It is recommended that this procedure should be more widely practised, provided that the patients are adequately screened.     

Office Treatment of Lower Extremity Injuries—A View of Feasibility,Limitations and Hazards

The injuries to the lower extremities seen in a surgical office may be classified as contusions, lacerations, sprains, lesions of tendons and their sheaths, involvement of bursae, chronic muscle fatigue, infections and deformities of the nails, leg ulcers, and fractures of the ankle, foot and toes.The treatment of these conditions in an office will vary under different circumstances, but one should be guided by certain fundamental rules. Contusions are best treated by the application of elastic compression bandages. Extensive lacerations should be explored under local anesthesia with the tourniquet in place, injured tissue excised, and the wound sutured. Ankle sprains should be strapped. Immediate hospitalization must be considered in all moderate to severe initial sprains to the knee. Lesions of bursae usually respond to the injection of hydrocortisone preparations. The same treatment is used in chronic muscle fatigue, plus immobilization of the part. Chronic recurrent infection and deformities of the nails are treated by removal of the nail under local anesthesia. Fractures of the ankle, the foot and toes may be reduced under local anesthesia and a cast applied. If further swelling is feared, the patient should be put in hospital immediately.     

Automated sequencing of complete mitochondrial genomes from laser-capture microdissected samples

Mitochondrial DNA mutations have been related to both aging and a variety of diseases such as cancer. Due to the relatively small size of the genome (16 kb) and with the use of automated DNA sequencing, the entire genome can be sequenced from clinical specimens in days. We present a reliable approach to complete mitochondrial genome sequencing from laser-capture microdissected human clinical cancer specimens that overcome the inherent limitations of relatively small tissue samples and partial DNA degradation, which are unavoidable when laser-capture microdissection is used to attain pure populations of cells from heterogeneous tissues obtained from surgical procedures. The acquisition of sufficient template combined with a standard set of 18 pairs of PCR primers allows for the efficient amplification of the genome. Subsequent single-stranded amplification is performed using 36 sequencing primers, and samples are run on an ABI PRISM 3100 Genetic Analyzer. The use of this procedure should allow even investigators with little experience sequencing from clinical specimens success in complete mitochondrial genome sequencing.     

The significance of fine needle aspiration cytology for the diagnosis and treatment of malignant lymphomas

Fine needle aspiration biopsy of a laesion, thought to be a lymph node, is a minor procedure, which provides quick and valuable information. It should be performed with a fine needle (0.6 mM outer diameter = 23 Gauge) and a special syringe, which needs only one hand during the aspiration itself. From the experience obtained in over 6000 own patients a f.n.a.b. gives the first place information whether the laesion actually is a lymph node, or a cyst, a salivary gland, a chemodectoma or any other lesion which can mimic a lymph node, In 3000 cases a benign lymph node was found and this finding often is as important as reporting malignancy. In 2000 cases metastatic malignancy was found. In 90% of these the primary tumour could be ascertained by coupling the clinical and the cytological data. False-negatives and false-positives practically do not occur with our technique. In 1023 patients primary lymphoma was found; 523 of them being Hodgkin's disease and 500 non-Hodgkin's lymphoma. In fresh cases of lymphoma surgical biopsies should always be done. In relapses cytology alone will as a rule be sufficient. In case of doubt repeat the f.n.a.b. after one week and do not immediately proceed to histological biopsy.     

Sulfamylon allergy simulating chondritis

A case of atopic reaction to Sulfamylon is described that occurred in a patient receiving this medication as a topical treatment for burned ears. The presenting signs were similar to those of a persistent chondritis, with which it was initially confused. All signs and symptoms cleared rapidly after the Sulfamylon was discontinued. Physicians should be aware of this entity so as to avoid inappropriate surgical debridement of ears with this relatively minor problem.     

Recent developments in pig embryo transfer.

Porcine embryo transfer has been performed for approximately 50 years, and surgical methods have proven to be reliable for collection and transfer of embryos. However, surgical collection and transfer have the disadvantage of being less useful on the farm. Recently, new procedures for both collection and transfer of embryos have been developed to improve usefulness. The surgical procedure has been refined to a minimally invasive procedure, using endoscopy for collection and transfer of embryos. A nonsurgical procedure for embryo collection has also been devised, but is limited to use in sows with surgically shunted (shortened) uterine horns. Nonsurgical embryo transfer procedures have been developed recently and have proven to be successful. The nonsurgical procedures are preferable to surgical procedures from an animal welfare point of view and because these procedures can be performed on farms without the need for special facilities.     

Witch's chin: a progressive, three-step technique

Witch's chin is an unpleasant aesthetic defect characterized by ptosis of premental tissue and a deep submental fold, which may be exaggerated by hyperprojection of the mandible. These three elements determine the different degrees of deformity; therefore, the ideal treatment should be directed to one, two, or all three of them. Despite unanimity on the surgical approach of the defect, a large variety of techniques have been proposed by various authors. The need to use a technique suitable for different clinical pictures, characterized by a progressive surgical aggression, as usually performed in this practice, has led to standardize a technique to correct witch's chin, by means of three progressive steps, depending on the degree of deformity. The advantage of this procedure is that once a good result has been achieved, the subsequent steps may be omitted. The technique has been successfully performed in five patients, and the mean follow-up is 12 months. Figures from two representative cases are presented.     

INVO: a simple, low cost effective assisted reproductive technology

⁵Correspondence address. E-mail: clauderanoux{at}bioxcell.com INVO procedure is a simple and effective infertility treatmentthat uses a new device, the INVOcell. INVO can be performedin a physician's office or in a satellite facility of an IVFcenter. The INVO procedure consists of fertilization of oocyte(s)and early embryo development in the INVOcell placed into thematernal vaginal cavity for incubation. The vaginal cavity replacesthe complex in vitro fertilization (IVF) laboratory. This studypresents the specially designed device, INVOcell that has receivedCE Certification. INVOcell overcomes the disadvantages of thepreviously used prototype and makes the procedure simpler andreproducible. INVO is a proven procedure that has demonstratedcomparable results to conventional IVF when comparative studieswere performed. Over 800 cycles have been published worldwidethat showed a clinical pregnancy rate of 19.6%. The INVO technologycan be performed in an office setting with minor capital equipment.INVO is a simple low-cost procedure that can be available almosteverywhere. INVO allows the treatment of a new population ofinfertile couples who could not benefit from IVF due to costand availability. The participation of the patient in the processof fertilization and early embryo development is a psychologicalbenefit that creates a high level of acceptance of INVO.     

Staff surgery--the inevitable question

The results of a survey of 450 plastic surgeons regarding the practice of operating on their staff members is presented. An overwhelming majority (85 percent) of responding surgeons do operate on their staff. Whether surgery is a "right" of employment or a "reward" for service was addressed. Seventy-two percent felt surgery was a "reward," while only 8 percent felt it was a "right." The results found complications to be relatively minor but numerous (23.5 percent). The need for an office policy is stressed to help eliminate misunderstandings with other employees, and a model office policy is presented and endorsed.