A mysterious pacemaker suture: an uncommon foreign body reaction

Surgical suture material is usually inert and nontoxic and causes minimal inflammation of tissue. However, foreign body reactions to various suture types can lead to granuloma, abscess, or even sinus formation. We report an elderly female who was incidentally detected to have a mass protruding from the incision site which was confirmed histopathologically a chronic granulomatous reaction to non absorbable suture. The foreign body granulomatous reaction to suture material in the setting of pacemaker implantation has not been described in the literature. We also discuss the existing literature on this underrecognised entity.     

Facial soft-tissue augmentation with injectable autologous and allogeneic human tissue collagen matrix (autologen and dermalogen)

Facial soft-tissue augmentation has become increasingly popular as an option for those patients in whom age-related changes manifest as contour defects or who desire volume enhancement for various areas of the face. A variety of agents and techniques are currently available that, when used appropriately, can improve or correct facial rhytids and regional volume depletion. Failures of some agents are due to reduced biocompatibility, inadequate administration technique, or failure to match the actual underlying defeat with the most appropriate solution. Dermal soft-tissue augmentation with human tissue collagen matrix (Autologen and Dermalogen) is physiologic, appears to be ultimately safe and effective, and has many qualities consistent with an ideal dermal filler. Several autologous, allogeneic (cadaver-derived), heterologous, and alloplastic agents will be discussed in this article with regard to rationale, patient selection, optimum administration technique, and persistence.     

The use of scapular and parascapular flaps for cheek reconstruction.

This is a retrospective review of our experience with microvascular transfer of scapular and parascapular flaps for the correction of lateral facial contour deficiencies. Twenty-eight patients with congenital (n = 8) and acquired (n = 20) defects were treated with 30 flaps; two patients had bilateral flaps. The etiology of the defects included hemifacial microsomia (n = 2), oblique facial cleft (n = 1), Romberg's hemifacial atrophy (n = 5), neoplasm (n = 4), irradiation (n = 8), trauma (n = 4), tumor excision (n = 4), facial lipodystrophy (n = 2), and silicone granuloma (n = 2). The follow-up evaluation was from 2 to 13 years, with an average of 6 years. Fabrication of a facial moulage was part of the preoperative planning for each patient. These were compound flaps, including skin, deepithelialized skin, fat, fascia, and bone, if necessary. All flaps were constructed with an intact skin paddle for postoperative monitoring. Based on dissections and anatomic findings at operation, several variations in the level of emergence of the circumflex scapular artery from the triangular space and its branching patterns were noted. All flaps survived; changes in the patients' weights were reflected in the flaps. Twelve patients required secondary procedures: excision of skin monitor islands, scar revisions, debulking, or flap resuspension to the malar region. Bone grafts or alloplastic implants were necessary in four patients in whom the malar eminence could not be adequately corrected by transfer of a flap. The deepithelialized scapular/parascapular flap is preferred for correction of large lateral facial defects.     

Proliferation rate of human osteoblast-like cells on alloplastic biomaterials and their clinical application for the transnasal duraplasty procedure

The possibility of transmission of slow virus infection (HIV) and Creutzfeld-Jakob disease by cadaveric dura implants makes it necessary to find synthetic, absorbable materials for the reconstruction of the dura mater. Various procedures with autologous or alloplastic material are described. Four commercially available biomaterials were choosen to study the proliferation rate and the biocompatibility of human osteoblast-like cells (HOB-like cells) on 2- dimensional material by biochemical analysis. With a proliferation assay, the viability and the proliferation capacity of osteoblast-like cells were evaluated. A clinical trial was added to study resorbable fleece as one of the previously tested biomaterial in a small patient group (8 patients) to close anterior cranial fossa dura defects. The results of the proliferation assay showed the highest proliferation rate of HOB-like cells on resorbable fleece. All patients in our clinical trial with anterior cranial fossa dura defects were successfully treated with resorbable fleece. There was no evidence for persisting cerebrospinal fluid rhinorrhea or foreign body reaction after the period of wound healing. The present study demonstrated an excellent biocompatibility of resorbable fleece. The vicryl fleece is an alternative alloplastic material for endonasal closure of defined substantial defects of the dura with cerebrospinal fluid.     

Infraorbital rim augmentation

In patients with recessive infraorbital rims, alloplastic augmentation of the infraorbital rims makes the eyes appear less prominent and improves appearance. Ten patients (seven women and three men) with an average age of 30 years (range, 23 to 45 years) underwent augmentation of the infraorbital rim with alloplastic implants over a 9-year period. With an average follow-up of 3 years (range, 6 months to 6 years), reconstructions have remained stable and satisfactory, with no incidence of infection, infraorbital nerve damage, or palpebral fissure distortion. One patient underwent additional surgery to correct contour irregularities, and one patient requested implant removal 1 month after surgery.     

Granulomatous reaction to silicone in axillary lymph nodes. A case report with cytologic findings

BACKGROUND: Silicone lymphadenopathy is a rare complication in patients with breast implants and is often confused with metastases from breast carcinoma. CASE: A 36-year-old female who had undergone bilateral breast augmentation six years earlier was referred for a mass in the left axilla. Fine needle aspiration showed a granulomatous reaction to birefringent material with predominance of foreign body giant cells in a lymphoid background. CONCLUSION: This report illustrates the usefulness of fine needle aspiration in axillary nodes of patients with breast implants in ruling out malignancy and diagnosing implant disruption.     

Improving aesthetic outcomes after alloplastic chin augmentation

A novel approach to increase chin projection with alloplastic material is presented. Key aspects of the technique include the consideration of anthropometric normal values in preoperative assessment and planning, a submental approach with wide subperiosteal exposure of the area to be augmented, the use of two-piece porous polyethylene implants for augmentation, and screw fixation of the implant to the mandible. Screw fixation improves the predictability and precision of reconstruction by preventing implant displacement, by obliterating gaps between the implant and the facial skeleton, and by facilitating final implant contouring. In a series of 46 patients (24 primary and 22 secondary) operated on over a 6-year period, this approach allowed anatomically correct, stable chin contours to be created. Iatrogenic problems with macrogenia, mentalis dysfunction, and soft-tissue distortion resulting from implant migration and capsular contracture have been avoided. There have been no infections. Two patients who had had multiple previous chin operations requested revisional surgery to refine contour.     

Macrophagal polykaryons

The mechanisms of formation, morphology and functions of macrophagal polykaryons are discussed. These giant multinuclear cells are formed by means of macrophagal cell fusion ("natural hybridization") and specialized on the extra- and intracellular processes of resorption of the foreign body and tissues of the proper organism. The formation of macrophagal polykaryons seems to be one of the possible manifestation of reactive histiocytosis in chronic inflammation and tumor growth. The role of macrophagal polykaryons in such disease as giant cell arteritis, giant cell granuloma and fibrohistiocytic tumors is considered in details. It is proposed that one and the same mechanism of regulations served as a basis of developing of both osteoclastic remodelling of the bone tissue (morphogenetic process) and resorption of the foreign body and tissues of the proper organism in inflammation in the process of evolution.     

Autogenous augmentation mammaplasty with microsurgical tissue transfer

Many patients dream of reducing their abdominal or gluteal fat tissue and, in the same procedure, enlarging their breasts without the need for implants and their related problems. Following this demand, a new "natural" alternative to breast augmentation with autogenous tissue is presented. Since 1993, 16 patients have undergone either unilateral or bilateral breast augmentation with free fat transfer. These 20 augmentation mammaplasties consisted of nine deep inferior epigastric perforator flaps, eight superior gluteal artery perforator flaps, and three superficial inferior epigastric artery flaps. The postoperative results were judged aesthetically by independent examiners and by the patients according to Netscher's score. The additional operations for final shaping of the breasts and the postoperative complications at the donor and recipient sites are reported. The augmented breasts improved the aesthetic proportions more than 100 percent. All flaps survived, and except for minor postoperative complications such as small areas of wound dehiscence, the breasts could be shaped aesthetically in a second-stage procedure several weeks later. Breast augmentation with autogenous tissue offers a natural alternative to alloplastic augmentation mammaplasty.     

Permanent lip augmentation employing polytetrafluoroethylene grafts.

There is a paucity of literature regarding aesthetic enhancement of the lips. This is due to the lack of reliable techniques employing autogenous tissue and the reluctance on the part of surgeons to use an alloplastic implant in this anatomic region, which is superficial, subject to trauma, and must conform to innumerable geometric shapes. The ideal lip augmentation procedure should provide for a predictable, permanent enlargement without visible scars or donor-site deformity, can be customized to the particular patient's anatomy, and can be reversed if so desired. A series of 21 alloplastic lip implants employing polytetrafluoroethylene with a mean follow-up of 14.33 months is presented. The overall complication rate was 9.52 percent. Permanent lip augmentation can be achieved with alloplastic sheet grafts of polytetrafluoroethylene in a safe and predictable fashion. Stiffness of the lips develops with progressive thickness of the grafts. Grafts exceeding 3 mm in thickness should be avoided.     

Comparative study of physical properties of three suture materials: silk, e-PTFE (Gore-Tex), and PLA/PGA (Vicryl)

The aim of this in-vitro study was to compare the physical properties of three suture materials used in periodontal surgery: silk, expanded polytetrafluoroethylene (e-PTFE), and polylactic acid/polyglycolic and (PLA/PGA). Five physical tests were carried out on each of the three suture materials: strain to failure, tensile strength, knot tensile strength, knot slippage, and capillarity. For each test, 30 samples of each suture material were used. In all cases, the statistical results showed that the e-PTFE and the PLA/PGA threads were superior.     

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.     

Upper labial deficiency in Mobius syndrome: a previously unreported feature and its correction

Bilateral facial palsy in M?bius syndrome remains one of the greatest challenges in reconstructive plastic surgery. Facial reanimation is an invaluable aid to such patients because it allows for greater social interaction by means of the ability to smile. In performing facial reanimation surgery on patients with M?bius syndrome, it is the observation of the senior author (Harrison) that upper labial deficiency is a consistent and previously unreported feature of the syndrome. It has been the practice of the senior author to perform upper labial augmentation on M?bius syndrome patients by insertion of a lipodermal autograft, in addition to facial reanimation. Nine patients with M?bius syndrome who presented to the Department of Plastic Surgery during an 8-year period were reviewed. All nine possessed bilateral facial palsy and upper labial deficiency in addition to other abnormalities consistent with M?bius syndrome. Six patients underwent bilateral facial reanimation and upper labial augmentation alone. One patient refused facial reanimation surgery but consented to upper labial augmentation. One patient, with concomitant micrognathia, underwent bilateral facial reanimation, upper labial augmentation, and insertion of a Silastic chin implant. In one patient, a child who also exhibited micrognathia, bilateral facial reanimation alone was carried out, with further procedures for upper labial and chin cosmesis being postponed until adulthood. The indication for performing upper labial augmentation was cosmetic. The procedure improved upper labial appearance and restored balance to the mouth. Patients also expressed higher satisfaction with eating and drinking, which they related to the improved fullness of the upper lip. This was before the facial reanimation had become functional. Upper labial deficiency warrants addition to the list of facial features of M?bius syndrome and is something that must be assessed in the context of facial reanimation surgery.     

Comparison of the biological activities of high-density porous polyethylene implants and oxidized regenerated cellulose-wrapped diced cartilage grafts

The use of alloplastic materials in plastic surgery has become more extensive with advancement of autogenous-tissue reconstruction techniques for the repair of defects, tissue augmentation, and the stabilization of bones. An ideal alloplastic material should be nonallergenic, noncarcinogenic, sterilizable, and easy to shape and should not cause rejection. Alloplastic material used for tissue augmentation should have a low rate of resorption and distortion. High-density porous polyethylene implants (Medpor) have been used widely and successfully for tissue augmentation. The Turkish Delight is a material composed of diced cartilage grafts wrapped in oxidized regenerated cellulose (Surgicel). Its indications are similar to those of the Medpor implant, and an additional donor site is usually not needed. Both materials are used in the same anatomical locations, especially for augmentation. Therefore, the authors evaluated the long-term stability of and suitable anatomical sites for these materials. Medpor implants or Turkish Delights were placed subperiosteally or subfascially in 10 young rabbits, and the resultant changes were evaluated 16 weeks after the operation by macroscopy and histopathology. Changes in projections were measured with an ocular micrometer. Medpor implants were neither resorbed nor distorted when placed subperiosteally or subfascially, and were highly stabilized by the surrounding tissues. Turkish Delight also enabled tissue augmentation, but had a significantly higher rate of resorption compared with the Medpor implant and was loosely bound to the surrounding tissue. The Turkish Delight was less resorbed and better fixed to adjacent tissues when placed subperiosteally than when placed subfascially.     

Nasal augmentation with split calvarial grafts in Orientals

This study reports on my experience with autogenous split calvarial grafts in nasal augmentation in 62 Orientals. In 78 percent of patients, the procedure was performed under local anesthesia in an outpatient setting. Total operating time for harvesting of split calvarial grafts ranged from 20 to 55 minutes, with a mean of 32 minutes. Patients ranged in age from 16 to 48 years, with a mean of 27 years. Follow-up was from 6 months to 8 years, with an average of 3.1 years. Intraoperative discomfort was uniformly low and well tolerated when local anesthesia was used. The complication rate was 8.0 percent, with three cases of minor seroma-hematoma formation at the bone-graft donor site. These were treated with aspiration. There were two recipient-site complications, with one case of complete bone resorption that occurred in a densely fibrotic nose with preexisting septal perforation and a case of overcorrection that was successfully rasped 1 year later. Because of their easy accessibility beneath the scalp, split calvarial grafts to the nose are useful in various types of nasal augmentation, and the technique is offered as a practical alternative to the use of alloplastic materials.     

Development of a chitosan nanofibrillar scaffold for skin repair and regeneration

The final goal of the present study was the development of a 3-D chitosan dressing that would shorten the healing time of skin wounds by stimulating migration, invasion, and proliferation of the relevant cutaneous resident cells. Three-dimensional chitosan nanofibrillar scaffolds produced by electrospinning were compared with evaporated films and freeze-dried sponges for their biological properties. The nanofibrillar structure strongly improved cell adhesion and proliferation in vitro. When implanted in mice, the nanofibrillar scaffold was colonized by mesenchymal cells and blood vessels. Accumulation of collagen fibrils was also observed. In contrast, sponges induced a foreign body granuloma. When used as a dressing covering full-thickness skin wounds in mice, chitosan nanofibrils induced a faster regeneration of both the epidermis and dermis compartments. Altogether our data illustrate the critical importance of the nanofibrillar structure of chitosan devices for their full biocompatibility and demonstrate the significant beneficial effect of chitosan as a wound-healing biomaterial.     

Ultrasonography and computed tomography in the detection of overlooked gauze surgical dressings]

USI and CT were performed in 14 patients with textile foreign bodies left in the abdominal cavity and retroperitoneal space during operation on the biliary tracts (6 cases), kidneys (4 cases), pancreas (2), stomach (1), and during appendectomy (1). A decisive sign in USI that enabled one to detect gauze foreign bodies, was a stable echogenic zone corresponding to a proximal body contour with a solid acoustic shadow behind. Extra-organic localization of these changes contributed to making diagnosis. A certain amount of fluid could be seen around a foreign body during an exudative reaction. In CT, diagnosis was based on the detection of a formation with a capsule containing calcinates and air masses.     

Insulin resistance of adjuvant-induced granuloma pouch formation in genetically diabetic KK-CAy mice

The characteristics of adjuvant-induced pouch granuloma in genetically diabetic KK-CAy mice with hyperinsulinemia were investigated. Both the dose-response relationship and the time-course experiments showed that the wet weight of pouch granuloma in diabetic KK-CAy mice was lower than in ddY normal mice. Insulin treatment enhanced granuloma formation in KK-CAy mice, and it restored the suppressed DNA content in the granuloma tissue to the level in ddY mice. Although the DNA content was dose-dependently increased by insulin, the ratio of DNA content to granuloma weight was constant. In severely diabetic mice, the granuloma weight was not different from that in normoglycemic mice, despite significantly higher blood insulin levels and greater body weight. Insulin stimulated granuloma formation in severely diabetic KK-CAy mice only when higher doses (1 mg/kg) were given. This evidence suggests that suppression of granuloma formation in diabetic KK-CAy mice is due to insulin resistance and that restoration requires pharmacological doses of insulin.