Mustoe TA, Han H. Copyright American Medical Association. Plastic surgery has always been a technique- and technology-driven surgical discipline, given "Latest technology for no surgery facial" there is no regional anatomic focus. There has been a remarkable evolution in technique over the last 25 years with an increased understanding of anatomy leading to a whole host of new and more reliable flaps, which has transformed reconstructive surgery, breast reconstruction being one notable example.
The and maturation of microsurgery has led to the full fruition of anatomic principles. With better understanding of blood supply to the skin, fascia, muscle, and bone, many traditional reconstructive procedures are constantly being superseded by the new,
Latest technology for no surgery facial use of various tissue flaps. Advances in technology will accomplish another transformation of the specialty, notably the recent advances in tissue engineering, the potential of gene therapy, new alloplastic materials, and computer-assisted imaging technology.
It would be impossible to address all of the recent advances in this rapidly expanding field of surgery in a short article. We have selected a few topics that we thought would be the most interesting to all surgeons to give a wide view of a variety of challenges addressed by the modern plastic surgeon. Major advances in surgery often come from cross-fertilization between specialties, and plastic surgeons have frequently been involved in this process.
Wound healing is no longer considered to consist of 3 distinctive phases inflammation, proliferation, and remodeling. It is now recognized that the process is a dynamic, overlapping sequence of coordinated cellular processes involving multiple cell types with a highly orchestrated complex soup of growth factors controlling the processes of cell migration, proliferation, matrix synthesis and breakdown, inflammation, and the resolution of the process with programmed cell death.
The potential for therapeutic interventions arose from the observation that in many chronic wounds there was a deficiency of growth factors, and in animal models, even when healing was progressing in normal fashion, it could potentially be accelerated.
Over the last 12 years, the potential for therapeutic interventions in wound healing have evolved from basic surgical principles to the recognition that a dozen or more growth factors, made available by recombinant gene technology, can promote wound healing in animal models. New growth factors are being isolated, cloned, and tested each year with no slowing in pace.
Nevertheless, the tremendous excitement over the potential for therapeutic intervention in wound healing that existed 5 years ago has been tempered by the failure of several large studies to see a significant therapeutic effect in the treatment of chronic wounds. Acute surgical wounds have tremendous potential for intervention, but owing to the low rate of surgical complications and the consequent need for very large numbers of patients to show a therapeutic effect, this area has not yet been looked at with any notable attention by pharmaceutical companies.
The variability in healing and the multiple factors that impair healing ischemia, bacteria, aging, and suboptimal nutrition undoubtedly explain much of the difficulty in demonstrating a therapeutic effect with growth factors. Nevertheless, as experience has been gained in conducting prospective randomized trials in wound healing and new formulations and growth factors are being tested, there exist some other promising growth factors in clinical trials and several others in animal studies.
The use of alloplastic materials to alter soft tissue or bony appearance has undergone tremendous advances. The ideal implant materials must meet several stringent criteria. They must be nonallergenic, non—foreign body—reaction forming, noncarcinogenic, resistant to stress and strain, and sterilizable. They must also match the biomechanical characteristics of the tissue they are replacing. No such material that perfectly satisfies all of the criteria yet exists, although the current advances in material science continually improve implant properties.
Implants have been in the armamentarium of plastic surgery for thousands of years. However, it was not until the s that advances in material science allowed for the development of several implantable materials that led to widespread implant use. Continued advances in biomaterials have led to their increased use, both for hard and soft tissue. Bony fixation has traditionally been accomplished with metal plates and screws. With the recognition that the same principle could be applied in the hand and facial skeleton with miniplates and microplates, they became useful for a much broader range of indications.
Currently, the best available metal plating systems for these uses are made of Latest technology for no surgery facial alloy and vitallium. Titanium alloy is composed of titanium, aluminum, and vanadium, while more rigid vitallium is an alloy of cobalt and chromium.
Both have very low bioreactivity and corrosivity, and both have no magnetic properties, making the systems safe when using magnetic resonance imaging. Titanium, in particular, has minimum radiographic scatter artifact, allowing for postoperative computed tomography CT with minimal distortion of surrounding tissues. Light weight and ease of bending has allowed their widespread use.
In complex facial fractures, more than 10 microplates might be used. Although these small plates infrequently require removal, the recent introduction of biodegradable polyesters as plating material conveniently solves the potential problems of foreign body reaction, implant extrusion, delayed infection, and altered bone remodeling on pediatric facial skeleton.
The 2 most commonly used absorbable plate systems are composed of polyglycolic acid and poly-L-lactic acid, both of which become hydrolyzed and degraded in the body at physiological pH levels.
The absorbable minifixation system has tensile strength equal to titanium and holds the craniofacial bones together as strongly as those made of titanium, resulting in the same rate of consolidation. The follow-up study of patients who underwent mandibular osteotomy fixed with the absorbable screws demonstrated normal clinical recovery and radiological osteotomy healing after 2 years.
The advance in biomaterial technology has direct implications for tissue engineering, which uses an alloplastic biodegradable scaffold to grow human cells. Polyglycolic acid and poly-L-lactic acid have been used to create absorbable scaffolds for tissue-engineered cartilage and bone. Hydroxyapatite has replaced calcium phosphate and methyl methacrylate as the new bone substitute material in recent years. The material properties of hydroxyapatite, chemical composition Ca 10 PO 4 6 OH 2are similar to those of bone and teeth, and its strength is a function of its pore size and degree of pore continuity.
Hydroxyapatite "Latest technology for no surgery facial" commercially available in 2 forms. As a plate or block, it can be sculpted into the desired shape in the operating room; as granules, it is mixed with Avitene Davol Inc, Cranston, RI microfibrillar collagen hemostat and autologous blood to form a paste, which then can be contoured as needed.
Animal studies have shown that can reach full integration with living cortical bone. The highly interconnected porosity of hydroxyapatite allows for easy ingrowth of surrounding tissue, resulting in new bone formation and implant incorporation.
The use of hydroxyapatite ceramic plates in place of autologous bone grafting has been highly successful in craniofacial surgery, with no foreign body reaction and an infection rate no higher than in a study 18 using grafted bone while saving considerable time and potential complications of bone grafting.
Follow-up postoperative CT scans have documented the complete bony substitution of the hydroxyapatite granules used in pediatric cranioplasty after 2 years. The recent application of cyanoacrylates to substitute suture to close small skin wounds may have opened the door for myriad other potential tissue adhesives.
There are several cyanoacrylate derivatives in clinical use, but no measurable differences have been found in their clinical efficacy. Despite the initial limitations of its use on the low-tension wound alone, with the appropriate use of splints to restrict the movement of the affected area, cyanoacrylates have been successfully employed on high-tension skin lacerations.
One study 22 concludes Latest technology for no surgery facial the cosmetic outcome of small traumatic wounds closed with cyanoacrylate is superior to suture-closed wounds at 1-year follow-up with high patient satisfaction. Currently, its most widespread use in plastic surgery has been for the closure of pediatric lacerations in which suture removal can be problematic.
Surgically, its indications are still evolving. It clearly works, but the need for meticulous closure of the dermal layers to avoid deeper penetration has somewhat limited the potential for saving time.
Nevertheless, it seems clear that this area will evolve, and sutureless wound closure will become more common in the future. The recent advances in cell biology and molecular physiology contribute to the parallel advances in tissue engineering.
With the better understanding of the fundamental cellular response to external stimuli and the tissue culture technique, medical scientists are able to manipulate the behavior of cell lines in vitro, and wound care is one of the first fields to recognize the benefit of tissue engineering. Although this area is being covered by other authors, 23 it is important to discuss specific indications in wound healing and burn therapy.
It has been recognized that a functional bilayer structure of both dermis and epidermis is required for a permanent skin substitute, and the newer generations of tissue-engineered synthetic skin are composed of such a construct.
Tissue-engineered skin has had several developmental pathways, but currently the bilayer structure is essentially insoluble dermal extracellular matrix components populated with cultured epidermal cells.
The extracellular matrix is composed of fibroblast-embedded collagen gel interspersed with glycosaminoglycan and hyaluronic acid. Coverage of open wounds is one of the fundamental problems plastic surgeons face.
For large burns in which the traditional split-thickness skin graft is not available, topical antibiotic dressings and porcine skin have been used extensively.
However, the use of xenograft was limited as a temporizing measure owing to intense foreign body reaction and eventual rejection, accompanied by a high rate of graft infection. The new generations of synthetic skin equivalents have been shown to be far superior, with a considerable reduction in the partial-thickness burn healing rate and hospitalization in a clinical trial. In the application of chronic wounds, the first Food and Drug Administration—approved skin equivalent came into clinical use in for the indication of venous ulcers Apligraf; Novartis, East Hanover, NJ.
Apligraf, like other skin equivalents, has a bilayered structure with live keratinocytes on an acellular dermal matrix, 27 which was shown to enhance the healing of venous ulcers present for longer than 1 year in a pivotal trial 28 involving about patients. Integra Integra LifeScience, Plainsboro, NJ is another commercially available bioengineered skin substitute introduced this year. It is made of reconstituted collagen and danaparoid sodium chondroitan sulfate backed by a polymer layer and used as a biological dressing for the coverage of large burn wounds.
An exciting future potential for tissue engineering is in the area of cartilage. Its absence of an intrinsic blood supply makes it the ideal grafting material. Using the basic approach of seeding living cells onto a biomaterial synthetic matrix, ear cartilage frameworks seeded with human chondrocytes have been successfully implanted in athymic mice, which in turn grew human elastic cartilage. The use of endoscopy has been widely adapted from gynecology and orthopedic surgery to abdominal and thoracic surgery over the last decade.
In plastic surgery, which does not involve body cavities, the advantages of minimally invasive procedures are less in terms of decreasing morbidity, but nevertheless are potentially still substantial. In addition, there is a necessity to create an optical cavity in soft tissue dissection rather than working in a preexisting space, such as the abdominal, pleural, or joint cavityand this has necessitated the development of endoscopes that also hold tissues apart.
Since then, the techniques of limited-incision surgery have been widely adapted, with the endoscope frequently serving as an assist or adjunct, but nevertheless an important one. It is worthwhile discussing the areas in which minimally invasive endoscopic surgery has found its broadest applications in plastic surgery.
Nowhere are the benefits of endoscopic surgery more apparent than in the selected cosmetic procedures of the face, particularly the browlift. The classic forehead rejuvenation with coronal incision has been largely supplanted by the endoscopic browlift with considerable reduction of incision scars, reduction in postoperative scalp sensory changes, and faster recovery.
The procedure has also been advanced by new fixation techniques such as bony anchors that allow soft tissues to be anchored and elevated to fixed bony points with subsequent skin redraping without the need for skin excision. It has also been applied to aid the subperiosteal tissue dissections in the face-lift. Another plastic surgery procedure in which endoscopic surgery approaches widespread use is in the carpal tunnel approach, which avoids a scar the proximal palm.
There has been a notable shortening of the postoperative recovery owing to the reduction in pillar pain, with an associated earlier return to normal activities. Modifications of the limited-incision surgery without the use of the endoscope have also found widespread use.
Other procedures in which the endoscope have had definite applications but have not yet found widespread use have been in the placement of tissue expanders and breast implants. The advantages of hiding incisions and "Latest technology for no surgery facial" allowing optimal visualization of dissection planes have been substantial in some surgeons' hands.
A particularly exciting use has been in craniofacial surgery for the release of craniosynostosis, pioneered by F. Vicari, MD oral communication, April 17, There are multiple other Latest technology for no surgery facial in which the advantages of limited incisions have some applications that are still not widely employed: The basic limitations are difficulties in maintaining an adequate optical cavity it is hard to keep carbon dioxide insufflation in an artificial cavity, and retractors are not yet optimally designedas well as the more limited reduction in morbidity.
The advantage in some of these cases is limited to the benefit of a shorter incision, which can be offset by the increased length of the procedure and the need for all the additional equipment.
The principles of bony distraction have been borrowed from the orthopedists and applied to craniofacial surgery with increasing success. Since the first application of distraction osteogenesis in craniofacial surgery in31 there has been an explosion of ingenious applications of distraction osteogenesis to treat various craniofacial skeletal deformities.
The system consists of the initial corticotomy with placement of gradual distraction apparatus connected to the percutaneous pins through the osteotomized segments. Within the last 5 years, it has gone through several improvements from the initial large, external devices derived from orthopedic distraction equipment to the new, modular internal distraction system with a single percutaneous activation screw. The external devices are capable of applying distraction forces in multiplanar direction, but they are large and cumbersome with serious compromise in cosmesis during the treatment period.
The internal or intraoral devices, while smaller and less Latest technology for no surgery facial to the patient, can only distract in one direction.
non-surgical technologies and treatments to tighten loose skin on the face and Not effective on more advanced skin sagging, such as pronounced jowling or. Plastic surgery has always been a technique- and technology-driven surgical New growth factors are being isolated, cloned, and tested each year with no.
surgery more apparent than in the selected cosmetic procedures of the face. We report on the costs, risks and effectiveness of non-surgical treating areas of the face that move less will last longer than those that move more, "Latest technology for no surgery facial." yet – according to Dr Phillip Artemi, "The technology is still in its infancy.
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