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The incidence, clinical presentation, pathophysiology, and possible treatment of two rare but clinically meaningful complications of tissue augmentation with Zyderm and Zyplast Collagen Implant are described. Abscesses as a manifestation of hypersensitivity to bovine collagen occur rarely (4 in 10,000 cases) and may persist for days to weeks. Periods of remission and exacerbation may occur from 1 month to more than 24 months. Localized tissue necrosis also occurs rarely (9 in 10,000 cases) after implantation and is probably the result of local vascular interruption and not hypersensitivity. The incidence varies greatly between the anatomic sites of implantation; more than half the reported cases involve the glabella. Evidence strongly suggests that the increased vulnerability of the glabellar region is due to its unique vascular distribution.

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Reconstruction of upper lip defects demands careful attention in order to reconstitute both normal function and normal appearance. These defects may involve mucosa, orbicularis oris muscle, skin, vermilion, or any combination of these structures. We will describe five cases in which there were defects created by Mohs micrographic surgery and present the concept of partial-thickness wedge in combination with a flap to repair these wounds.

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My travels were not a disappointment because I had the privilege of seeing the little personality differences in each office--the tenor of the staff, the physical plant and how it was decorated, how important lunch is, how it is necessary for some to start early. But for being able to report the one and only best way to do liposuction, I can only say there is no such thing. It is proper for each physician to believe he or she is doing the procedure correctly. We may take our own little technique variations too seriously; they probably do not much matter.

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Secondary intention healing is an ancient and well-established method of wound management. Since the advent of various reconstructive techniques, it is often forgotten as a valuable alternative to immediate surgical reconstruction of wounds. In certain situations the cosmetic and functional results of secondary intention healing are equal to the results of more complex reconstructive surgery. We describe a case in which remarkable results were obtained from spontaneous healing of a facial wound.

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We present a case of erythroplasia of Queyrat in a 77-year-old man involving the distal two-thirds of the penis. There was no urethral or periurethral involvement. Due to the location of the lesion, its recognition as carcinoma in situ, and the technical difficulty of cold-steel excision in this area, we used the carbon dioxide (CO2) laser to selectively destroy the tumor. In this case the laser provided controllable tissue destruction, ease of surgery, and excellent cosmesis.

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Four patients received Zyderm collagen implant (ZCI) or Zyplast implant (ZI) in preauricular and infraauricular regions of facial skin periodically between one and nine months. Both materials were identified microscopically in the mid- to deep dermis at all points of the study and, in 60% to 70% of the injected sites, some material was also present subdermally. A slow, gradual colonization of ZCI by fibroblasts was noted compared with a delayed intense interaction of these cells with ZI. Also, there was some new collagen deposition associated with remodeling of the ZI, while no demonstrable synthetic activity occurred in relationship to ZCI. The results suggest that ZCI and ZI "migrate" deeper and eventually move into the subcutaneous plane. This movement could explain the loss of correction at six to nine months that is noted when this implant is used for age-related changes.

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Modifications for split-thickness grafting techniques are discussed, including the use of incontinuity, semipermeable, biologic dressings during harvesting, spiral basting sutures for graft attachment, and meshing to increase graft coverage.

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Six patients underwent dermabrasion while on or having recently completed isotretinoin (Accutane) therapy. All patients developed keloids in atypical locations; the keloids eventually responded to topical or intralesional steroid therapy. Retinoids have a modulatory effect on connective tissue metabolism, including suppression of collagenase, which may enhance keloid formation. Dermabrasion should be delayed in those patients taking or recently on isotretinoin therapy.

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Although they are common, careful attention is necessary to detect basal cell carcinomas and squamous cell carcinomas early on. Suggestions for easier detection, as well as proper selection of therapy, are discussed.

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