editorial - sebbin deutschland · editorial the expander is five years old. our “guests”, all...

Issue 20

( The plastic surgery newsletter from Groupe SEBBIN

L’EXPANDER

www.sebbin.com

ISSN

227

4-32

51

M a r c h 2 0 1 7

by Doctor Julien GlicensteinEDITORIAL

The Expander is five years old. Our “guests”, all of whom are highly qualified, have written clear and paedagogical articles to discuss various aspects of plastic and cosmetic surgery: techniques, results, medical and legal consequences.We have attempted to sprinkle a few distractions in among these very serious articles, in the form of historical texts, descriptions of ancient techniques, and reminders of the origins of syndromes and techniques.

Each month, we analyse the major journals in plastic and cosmetic surgery.In the last five years, cosmetic medicine has gained in importance as well as in the number of followers: plastic surgeons, dermatologists, but also other practitioners with all kinds of backgrounds. “Open” conferences are hosted for their benefit. Injected products can sometimes lead to devastating

complications. Plastic surgery journals have a duty not to promote new products before multicentre studies have been conducted. A recent issue of a major American newspaper whose subscribers include thousands of plastic surgeons from all over the world was distributed with a copy of a dermatologic surgery journal entirely devoted to promoting a new product for dissolving fat. We can discuss the ethicality of this process without needing to question the quality of the product itself. Whether for reconstructive or cosmetic purposes, plastic surgery is experiencing deep reform. As new techniques are developed, we need to assess their reliability and potential consequences. All new injected products, whether natural or chemical, require guarantees in the form of irreproachable studies.

The “guests” featured in the Expander post their articles in complete freedom without any form of pressure or conflict of interest.

Happy reading!

2

The plast ic surgery newsletter from GroupeL’EXPANDERIssue 20/ March 2017

from Doctor Julien GlicensteinTHE WORD

A new legal trap has emerged…Doctor Jean-Pierre Reynaud ...................... p3

Death after gluteal lipoinjection ................. p4

Eponyms Schwann sheath and Langer's lines ....................... p5

Facial feminisation .......................................... p6

The dangers of using hyaluronic acid ........... p7

What treatment should be used forhidradenitis suppurativa? ............................ p9

Prevention of haematomas after a facelift .... p9

Yesterday / Today:Anaesthesia .................................................. p10

Flashback on the historyof breast augmentation:First complications ...................................... p11

CO

NTE

NTS

OF

Issue 20

(

Meeting the patient before the operation to explain and present the surgery

in detail (twice if possible!), clarifying the surgical indications, following

standards during the procedure, writing an explicit and well-researched

information sheet to be approved by the patient after an appropriate

period of reflection - plastic surgeons do all of these things as part of

their daily work. But, as explained by our guest Dr Jean Pierre Reynaud, a

renowned expert in the field, this can still fail to satisfy the courts, since

unpreparedness is legally acceptable as a basis for damages...

3


A NEW LEGAL TRAP HAS EMERGED... Doctor Jean-Pierre Reynaud

Expert surgeon for the Branchet Insurance firm Head of pole Plastic and Aesthetic Surgery

L’EXPANDERInvited guest of(

As if the arsenal of measures intended to compensate patients for claims and civil proceedings were not already sufficiently comprehensive and effective, a judgement issued by the Court of Cassation on the 3rd June 2010 has introduced a new instance of legal injury which may give rise to compensation: “injury due to unpreparedness”, or “autonomous” injury. We shall explore the conditions in which this new concept of injury applies below.The injury stems from the lack of

information or the surgeon’s failure to fulfil his or her humanistic duty towards patients. It is considered a breach of privacy (civil code!).

Experience has shown that nearly 45% of claim procedures feature a lack, insufficiency, or absence of documentation in the information given to the patient, whether before a medical procedure or during aftercare. Technical mistakes, errors, or negligence are far from the most common grievances for which practitioners are admonished by experts or judges. Instead, the lack or non-documentation of information is commonly taken as the legal basis for awarding compensation to the patient... Before the above judgement, this required a “loss of opportunity” argument. This argument needed to establish that the lack of information had led to a loss of opportunity (the percentage varies depending on the case): if the patient had been properly informed of the risks, the patient would have had the choice and the opportunity to decline the medical procedure. If it was established that a patient who was uninformed or improperly informed of the risks would necessarily have been prevented from declining the medical procedure as a result of the urgency for the patient's health or life, the loss-of-opportunity argument could not be used and the patient could not claim compensation.The judgement of the Court of Cassation fundamentally revisits this principle: even if there was no loss of opportunity, the lack or absence of evidence of information represents

an injury which follows from the surgeon’s failure to fulfil his or her humanistic duty. In plain language, the surgeon must allow the patient to “prepare” mentally (and in some ways physically) for the materialisation of the risk associated with the medical procedure, even if this procedure is necessary and inevitable, so that the patient may manage his or her affairs as well as those of his or her entourage. This injury can exist no matter the assessment of permanent functional deficit, which explains why it is described as an “autonomous” injury. It can, however, be combined with other injuries, including injuries relating to loss of opportunity. The judge evaluates the amount of compensation "in concreto" (i.e. on a case-per-case basis).For purely elective surgery (cosmetic surgery), judges take the view that, excluding any technical medical errors or failures, in the face of risk, loss of opportunity can apply in up to 100% of cases, and very often does if the complications are serious. Injury to unpreparedness automatically applies.

CONSIDER THE FOLLOWING TWO EXAMPLES

1. A patient undergoes a medical procedure for breast implants, but must later have them removed (due to rupture):

• She initiates proceedings against the surgeon, and when preparing the practitioner's defence, it is found that information regarding this risk was not presented satisfactorily (no indisputable record in the file proving that the patient was given the information sheet, no record of informed consent documenting the receipt of the sheet...). The patient of course claims that “if she had known, she would not have wanted the procedure”... It is impossible to prove that the information was correctly given, since the surgeon's records are “poor” in information.

• The experts might conclude that there was no technical fault, but that there was a lack of information which supports the conclusion of loss of opportunity.

DoctorJean-Pierre Reynaud

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Death after gluteal lipoinjection(

The injection of fat to increase the size of the buttocks is a technique increasingly used, especially in Latin America, and is considered to be simple and safe. Yet serious complications have been reported, both local infections and alarming conditions (pulmonary embolism and fat embolism).

The authors collated the deaths recorded in Mexico and Colombia, during or following a combined liposuction-buttock fat injection operation over a 10 year period in Mexico and a 15 year period in Colombia.The cases were identified from plastic surgery company members in both countries.Mexican surgeons counted 64 deaths in 10 years, during a combined operation (13 fat embolisms, one myocardial infarction). 9 deaths occurred during surgery, 5 in the 24 hours following surgery.Colombian surgeons recorded 28 deaths associated with liposuction, including 9 when combined with a buttock fat injection.Of these 9 deaths two thirds were due to a macroscopic fat embolism. 6 occurred during surgery, 3 in the eighteen hours that followed surgery.All cases concerned fairly young women (27-53 years of age). A significant amount of fat was removed during liposuction (2,700 to 7,200 grams), but only 120 to 300 grams were injected into each buttock.The authors of the article show striking photographs of fat found in the vena cava, the right heart and lungs.The injection of fat in the muscle allows for a better revascularisation of adipocytes and longevity of the fat. However there is a risk of vascular penetration, with alarming consequences. The authors identify an embolic syndrome that has a generalised inflammatory response, with fat embolisms causing the mechanical obstruction of vessels.

At the deep surface level of the buttock muscles, there is a major venous system. Autopsies of the patients who died during the injections showed massive vascular obstructions. Later deaths were due to smaller fat embolisms.The authors recommend injecting the fat superficially, while keeping the cannula parallel to the skin.

Ref. Cardenas-Camarrena L, Bayter JE et al. Deaths caused by gluteal lipoinjection. What are we doing wrong? Plast Reconstr Surg 2015; 136: 58-66.

The judge will accept the argument of loss of opportunity (often 100%), award compensation accordingly, and will add compensation on the basis of injury due to unpreparedness.

2. A patient undergoes a medical procedure for a malignant skin tumour (he could therefore not have declined the procedure):

• There is a complication (hematoma with mismatched scars...) followed by surgical recovery and aftercare.

• The surgeon did not commit fault; this is one of the risks.

• The patient complains that he was not informed of the possibility that this complication could occur, and the file does not contain any record that the information was properly given.

• There is no loss of opportunity.

• But : the judge admonishes the surgeon for failing to prepare the patient for the occurrence of risks and their consequences. The judge therefore declares “injury due to unpreparedness”.

The administrative branch of the justice system has also adopted this principle, although they were admittedly slower to do so.This legal development should prompt surgeons to further strengthen their approach to informing patients and documenting that this approach was properly executed. Informing patients should be emphasised more than ever in the medical contract between surgeons and patients. Medical care, relief, recovery, improving quality of life should continue as before, but now surgeons must ensure with the same diligence that the patients have properly understood the risks presented by the medical procedures that they receive, and that sufficient documentation of this is available. The guidelines are straightforward; it must be possible to demonstrate that the patient was properly informed of the risks associated with the procedure and that they were taken into account in the patient's decision:

• Comprehensive consultation prior to the operation (two consultations are highly recommended for cosmetic surgery).

• A period of reflection should be observed.

• Detailed, precise, informed consent stating the exact nature of the procedure, signed and carefully archived.

• A record of the receipt of an information sheet, in the form of a simple statement in the consent document: “I acknowledge having received, read, and understood the information sheet explaining procedure x”.

Good luck!

5


Schwann sheath, Schwann cells, schwannomas.

Schwann cells are glial cells which isolate the axons in the nervous system. They form a myelin sheath, increasing the speed of nervous impulses. They are associated with some nervous system disorders, such as Charcot Marie Tooth disease... Schwannomas (or neuromas) are tumours whose development negatively affects the Schwann cells. They can form in any part of the nervous system (acoustic nerve, spinal nerve roots, peripheral nerves, small subcutaneous nerves).

Theodor Schwann (1810-1882)

He was one of the greatest physiologists and pathologists of the nineteenth century. He studied medicine at Bonn, Würzburg and Berlin and became a professor of anatomy at Berlin and Leuven. He made his greatest discoveries during his internship at Bonn: cells and myelin sheaths, the role of pepsin in digestion, the role of yeast in the fermentation of alcohol (before Pasteur). He developed a cell-based theory of life and invented the term “metabolism”.

Ref. Muller J. Handbuch des Physiologie des Menschen füre Vorlesungen. Coblenz Verlag von Hölscher 1837-1840.

Langer's lines

These are skin tension lines as defined by Karl Langer after his experiments on corpses. He observed that round wounds tended to take on an elliptical shape due to skin tension. He formulated a full map of the subcutaneous tension lines. Before Langer, in 1832, Dupuytren had observed that a young man bore elliptically shaped wounds after attempting suicide with a punch. Modern studies have shown that the line diagrams developed by Langer were approximate, as they do not take into account natural folds and the direction of dermal collagen.

Karl Langer (1819-1887)

He studied medicine in Vienna and Prague. He worked as assistant to Joseph Hyrtl (1810-1894) in Vienna, before becoming a professor of anatomy there.

Ref. Langer K Zur Anatomie und Physiologie der Haut. Sitzungsb. Acad . Wissensch. 1861; 45: 223.

Eponyms(

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The number of transgender people wanting male to female transformation is increasing steadily. Although the quality of body surgery has improved considerably, facial feminisation has not been the subject of much study.The authors searched for articles focused on the feminisation of the face in the medical literature. They found 24 facial feminisation studies and only used 15 studies involving 1121 patients. Only 7 complications were described.Even though facial morphological differences between men and women are well defined, there are many techniques to remove them and there is no consensus on the subject.Forehead remodelling is an important step. The goal is to smooth the forehead, mitigate the wrinkles above the eyes and create a non-receding hairline. The orbital rim is abraded, the anterior wall of the frontal sinus is thickened by inclusion (methyl or hydroxyapatite) as are the temporal regions. These interventions are not without complications (alopecia - irregularities). The eye shape can be feminised using side canthopexy (almond eyes) and by reducing the height of the supratarsal fold in the upper eyelid. The ethnicity of the patient must be considered.Women's cheeks are rounder and more prominent in the malar region. The list of possible interventions is long: implants, osteotomies. Fat injections are increasingly used. Malar implants may cause asymmetry or infection.The refinement of the nose and its volume reduction, must not compromise the nasal valve.The distance between the nose and the vermillion is shorter in women. In men the lip is thinner, with a less exposed vermilion. Skin excision under the nose has the potential to leave a visible scar. Hyaluronic acid and especially fat injections are used more than silicone or GORE-TEX® inclusions. Dermal matrices have been successfully used. The reduction of the mandibular angle is performed through the endobuccal route (grinding, osteotomies). The volume of the masseter can be decreased.

The removal of the laryngeal prominence (Adam's apple) is a critical part of the feminisation of the face. The thyroid cartilage upper edge and notch are excised by the sub mental route or by cutting into a fold.Finally, skin and soft tissues are treated during a second phase (facelift, blepharoplasty, peeling, and laser).If hormonal treatment is begun early, male characteristics of the face are reduced.Of course, these interventions are often carried out by specialised teams and after psychiatric evaluation.

Ref. Morrison SD, Vyas K et al. Facial feminization. Systematic review of the literature. Plast Reconstr Surg 2016: 137: 1757-70.

Facial feminisation(

Breast Surgery course: April 20-21st 2017 in Oviedo, Spain

RBSPS - Spring meeting: April 22nd 2017 in Brussels, Belgium

Breast surgery workshop: April 28-29th 2017 in Rome, Italy

SACPER: May 9-12th 2017 in Buenos Aires, Argentina

Voorjaarscongres: May 11-12th 2017 in Amsterdam, Netherlands

17. Frühjahrsakademie VDÄPC: May 11-13th 2017 in Berlin, Germany

Join theGROUPE SEBBIN(

7


Hyaluronic acid is widely used in aesthetic medicine (1.6 million injections by qualified practitioners in the US in 2014) and is often considered to cause serious complications. It can cause adverse reactions and, in some rare cases, deadly complications. An expert group has reviewed the literature on this topic and established a consensus based on the experience of its members. The complication rate is low, but it must be detailed on the patient's informed consent.The most sensitive areas are the glabella, nose and temple area. A good knowledge of peri-orbital and peri-nasal vascularisation is required. The injection procedures are well known: varying concentrations of product according to the area to which it is applied, sucking first with the needle, stopping in case of resistance and, if possible, using foam nozzles.The aseptic technique should be followed: removing makeup, using a sterile kit, use of an antiviral prophylaxis if there is a history of herpes. It is possible to create a biofilm around the product injected in the event of repeated injections in the same area.The main risk is intravascular injection (see the article by Bernard Mole in Expander 17). If there is a chance that intravascular injection has occurred, the intervention must be stopped immediately, hyaluronidase must be injected, especially if there are these particular signs: pale complexion and a noticeable and painful rash. The authors specify the conditions, for the use of hyaluronidase, in detailed tables. If there is an acute infection, it is not possible to take a sample, it will be necessary to start a mixed antibiotic and antiviral treatment, which is specified in the article.In cases where a hematoma or bruising develops, it should be treated by compression, using compresses soaked with cold serum. Non-satisfactory injections: “balls”, asymmetry, deformation, should be treated with a massage or by withdrawing the product with the needle.

The most common late complications are inflammatory nodules and granulomas. The therapeutic approach discussed describes performing an incision, drainage or the application of hyaluronidase, and using antibiotics.This article may be useful thanks to its treatment tables and algorithms. It is important to remember: what hyaluronidase is and how to use it, to warn an ophthalmologist urgently in the case of blurred vision and of course, obtaining informed consent.

Ref. Signorini M et al. Global aesthetics consensus and management of complications from hyaluronic acid fillers. Evidence and opinions based review and consensus recommendations. Plast Reconstr Surg, 2016; 137; 961e.

The dangers of using hyaluronic acid(

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w

Expander N° Invited guest Subject

1 Professor Jean Paul Meningaud Facial transplantation

2 Doctor Julien Glicenstein Lymphomas and breast prostheses

3 Doctors Gilbert Aiach / Jean-Brice Duron Aesthetic rhinoplasty

4 Doctors Claude Le Louarn / Jean-François Pascal Surgery for excess skin

5 Doctor Daniel Marchac Facelift

6 Professor Catherine Bruant-Rodier Breast reconstruction

7 Doctor Gérard Flageul Therapeutic purposes of cosmetic surger

8 Doctors Julien Glicenstein / Alain Fogli SOF.CPRE is 60 years old / Blepharoplasty

9 Doctors Jean-Claude Talmant / Jean-Christian Talmant / Jean-Pierre Lumineau

Progress in the treatment of lip-jaw-palate clefts

10 Professor Frank Duteille / Doctor Pierre Perrot Post-traumatic lower limb tissue loss

11 Doctors Jean-Pierre Chavoin / Benjamin Moreno Surgery of congenital malformations and computer assisted reconstruction techniques

12 Professor Véronique Duquennoy-Martinot Advices for a successful cutaneous expansion in children

13 Professor Isabelle Auquit-Auckbur About “Dupuytren's contracture”

14 Doctor Julien Glicenstein Brody's report and anaplastic large cell lymphomas

15 Doctor JM O'Donoghue Late Periprosthetic Fluid Collections (seromas) in Patients with Breast Implants

16 Doctor Nathalie Bricout Textures: structure and concerns

17 Doctor Bernard Mole Visual issues during the injection of a dermal filling product: An emergency but not a fatality!

18 Professor Weiguo Hu Transfers of the toe in the treatment of digital hypoplasias

19 Doctor Daniel Labbé Neck lift

Do not hesitate in asking them on a pdf format to:[email protected]

The Expander celebrates its 20th issue and proposes a retrospective of the already published issues

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(What treatment should be used for hidradenitis suppurativa?

Hidradenitis suppurativa (Verneuil's disease) is a debilitating, chronic condition, which often has a strong psychological impact. In the US, it often affects patients of African American origin.Although it seems related to a malfunction of the apocrine glands dependent on hair follicles, its pathophysiology is still uncertain. Patients with hidradenitis suppurativa (HS) undergo inflammatory episodes with abscesses and fistulas in the affected areas (armpits, groin, perineum, buttocks, etc.).Many treatments have been proposed: medical (general and local antibiotics, corticosteroids, retinoids, anti androgens, immunotherapy) and surgical excision of the area containing the apocrine glands which is allowed to heal by secondary intention or by covering it with a skin graft or a flap.The authors have chosen, in severe cases, to completely excise the lesion and allow the defect to heal by secondary intention. Their retrospective study focuses on 17 cases, 4 men and 13 women, mostly (12) of African American origin. The initial excision overflowing the affected area is guided by a methylene blue instillation. The procedure is

done under general anaesthetic. The goal of postoperative dressings is to keep the wound moist and clean, using local antibiotics corresponding to the local flora and hydrotherapy.Prevention of joint contractions is essential and physiotherapy should start from the first dressing. There were two localised recurrences, which is low compared to studies where the wound was closed with a skin graft. However, the healing process can be very long (up to 16 months) requiring, during this period, repeated dressings and physiotherapy.The photographs published in the article show very extensive tissue loss after excision (inguino-abdominal, perineal) having healed in 6 months.

Ref. Humphries LS, Kueberuwa E et al. Wide excision and healing by secondary intent for the surgical treatment of hidradenitis suppuration. A single center experience. J Plast Reconstr Aesth Surg 2016; 69: 554-66.

(Prevention of haematomas after a facelift

The most common complication of a facelift is a haematoma, caused by adhesion and skin necrosis, which affects 2 to 9% of patients. Many methods seek to mitigate this risk: treatment before and during the operation of high blood pressure, stoppage of herbal therapy, anticoagulant therapy, use of biological glue, drainage, compression bandage...The article summarises the experience of R.J. Rohrich (who is also editor of the PRS). He recommends 5 elements to reduce the risk of haematomas: continuous monitoring of blood pressure during the operation, “super infiltration” (superwet technique), meticulous haemostasis, drainage, use of plasma rich in platelets. He believes that infiltration plays a critical role in enabling better visualisation of the operative field. To assess the effectiveness of his technique, he reviewed 1 089 records of patients who underwent operations between 1990 and 2013.

The operation was always performed under general anaesthetic. Since 1995, it has included a resection or plication of the SMAS. Since 2000, facelifts have been associated with localised injections of fat. For preoperative infiltration, he uses a 300mL saline solution containing

30mL of 0.50% lidocaine and 1.5mL of epinephrine. 80 to 120mL are injected on each side, using a self-filling syringe provided with a spinal needle, through the line of incision and until the skin swells firmly without turning white. The incision takes place 10 to 15 minutes later. After anesthetic induction, venous blood of the patient is extracted with a syringe containing 6mL of anticoagulant and centrifuged. The platelet-rich plasma is drawn into a 2nd syringe comprising a mixture of calcium chloride and thrombin. 4mL of mixture were injected on each side and in the SMAS. Out of the 1089 patients operated on (994 women and 95 men), there were only 10 haematomas, 8 of which occurred in the operating theatre. This study contains some bias: the extent of dissection is not specified. This series is not compared to those relating only a limited infiltration or the use of biological glue. Some refuse all use of adrenaline due to the rebound effect.There is always some risk of a haematoma.

Ref. Costa CR, Rohrich RJ et al. The role of superwet technique in facelift. An analysis of 1089 patients over 23 years. Plast Reconstr Surg 2015, 135: 1566-72.

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ANAESTHESIA

Anaesthesia did not exist until the mid-nineteenth century. Since ancient times, many substances have been used to alleviate the often excruciating pain of limb amputation or tumour removal: sponges soaked in opium, mandrake, alcohol given to patients to drink. The great surgeon Alfred Velpeau (1795-1867) stated in 1840: “Avoiding pain in surgery is a fantasy that we can no longer pursue today” (1).

However, in the early nineteenth century, after the discovery of nitrous oxide by John Priestley (1733-1804), the chemist Humphry Davy (1778-1829) observed that this gas could be used to suppress pain. It was nicknamed “laughing gas” and was used at fairs and circuses on volunteers who were made to laugh in front of an audience. When attending one of these shows, the young American dentist Horace Wells (1815-1848) from Hartford in Connecticut (Figure 1) noticed that one of the volunteers was relatively badly injured, yet felt no pain. He asked the fairground worker who was hosting the show, Gardner Colton, to administer laughing gas to him while one of his colleagues ripped out a tooth. The first anaesthesia took place on 10th December 1844. Wells used the technique to perform around 15 tooth extractions, all of them without pain. Encouraged by his partner William Morton (1819-1868) (Figure 2), he asked a famous surgeon from Boston, John Collins Warren (1778-1856), for permission to demonstrate the technique in public. On 20th January 1845, the patient cried out during the tooth extraction, and Wells was forced to flee from the booing of the students in the amphitheatre. The patient was obese, and the gas had probably been badly dosed. Wells was deeply upset by this failure, and committed suicide in 1848. William Morton had attended Wells' first

attempts. He was related to the physician and chemist Charles Thomas Jackson (1805-1880), who was studying the properties of sulphuric ether. The ether produced the sensation of drunkenness, well-known to the youth of Boston, who used it as a narcotic. Morton tried it on himself and on his patients, and was able to extract a decayed tooth without pain. Despite the memory of Wells' failure, John Warren gave the go-ahead for further attempts at anaesthesia, this time using the ether, under Morton's supervision. The first procedure was a dental extraction, successfully performed on a music teacher, Eben Frost, on 30th September 1846 at the Massachusetts General Hospital in Boston. The second procedure was performed on 16th October 1846, in the same hospital. John Warren removed a vascular tumour from the neck of a young printer, Gilbert Abbott. The operation, which was completed without pain, was greeted by enthusiasm in the audience (Figure 3). The very next day, “etherised” procedures began to proliferate. By the end of 1846, they were offered in both England and France (by Jobert de Lamballe on 22nd December at the Saint Louis Hospital in Paris). In January 1847, a Scottish gynaecologist, James young Simpson (1811-1870), used ether to perform difficult deliveries, followed by chloroform, after testing it on himself and on the physicians in his service. Queen Victoria's midwife, John Snow (1813-1858), used chloroform to deliver her children in 1853 and 1857 (“the Queen's anaesthesia”).

This merely marked the beginning of the long history of anaesthesia.

Ref. 1. Velpeau A Leçons orales de clinique chirurgicale Paris Germer Baillière 1840 p65.

Fig.1: Horace Wells Fig. 2: William Morton Fig. 3: The first anaesthesia

TODAYYESTERDAY

11


FLASHBACKON THE HISTORY OF BREAST AUGMENTATION(

CHAPTER V: THE F IRST COMPLICATIONS

Editor-in-Chief: Dr J. Glicenstein / Director of Publication: Olivier Pérusseau / Artistic Management: Plate ou GazeuseL’Expander is a publication of GROUPE SEBBIN SAS - 39 parc d’activités des Quatre Vents - 95650 Boissy l’Aillerie.

By 1964, all plastic surgeons were using prostheses filled with silicone gel. But complications quickly arose. The first such complication was related to the structure of Cronin's prosthesis.

To prevent it from moving, he had placed Dacron pellets on the posterior face of the implant. These pellets caused a reaction in the fibres that caused the prosthesis to attach to the pectoral muscle and detach from the mammary gland. The first models had a thick envelope, and could only be inserted by making a long incision under the breast. Their thick lower edge was often palpable.

In 1965, a French surgeon, Henri Georges Arion, had the idea of an “ i n f l a t a b l e ” p r o s t h e s i s that could be i n t r o d u c e d through a short i n c i s i o n . H e used a silicone e l a s t o m e r bag that was filled with liquid

(dextran or 40% polyvinylpyrrolidone) via a tube then

closed tightly with a wire and a plug. This plugging system was not ideal. The prosthesis sometimes emptied, causing one of the patient's breasts to flatten suddenly. The Swiss surgeon Jenny devised a valve system to prevent fluid leaks in collaboration with an American laboratory. Dextran was replaced by physiological saline.

Many surgeons preferred silicone gel implants, but wanted a way to introduce the material discretely by sub- or trans-areola or -axillary means, which was impossible with Cronin's prostheses. New prostheses were designed with increasingly fine envelopes and extremely low-cohesion gel.In the early seventies, complications began to be reported (seroma, infection, hematoma, malposition) (1). But the patients' primary complaint was that their breasts were too firm. Cronin noted that a fibrous capsule formed around the implant, especially in very thin patients with large implants positioned prepectorally. Some practitioners believed that this complication was less common or less apparent if the prosthesis was placed retropectorally (2).The primary concern of plastic surgeons became the development of a periprosthetic capsule that might negatively affect the aesthetics of the breast and make the procedure more obviously visible.

Ref. 1. Cronin TD, Brauer RO, Augmentation mammaplasty Surg. Clin. North Amer 1971.; 51: 441-522. Dempsey WC, Latham WD Subpectoral implants in augmentation mammaplasty Plast Reconstr Surg 1968; 42: 515-21.

Cronin's prosthesis

Arion's prosthesis Next chapter: “capsules” and how to get rid of them.

This document is intended for health professionals .

Find the previous issues of the scientific newsletter L'EXPANDER by connecting to the private space at:

www.sebbin.com

According to the Directive concerning medical devices 93/42 / EEC, injection cannulas and injection syringes are class IIa medical devices, manufactured by INEX and distributed by Groupe Sebbin. They are intended to be used in plastic, reconstructive and aesthetic surgery. These devices are CE marked by EZU notified body number 1014. Groupe Sebbin reserves the use of its devices to physicians trained in plastic, reconstructive and aesthetic surgery. Please read carefully the instructions on labels and IFU if any before using these devices.

editorial - sebbin deutschland · editorial the expander is five years old. our “guests”, all...

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