Re: Re: Fw: Subject Reference: Fw: SILICONE BREAKDOWN AND CAPSULAR SYNOVIAL METAPLASIA IN

[Guest guest]

I suspect two factors. One is infection and the other genetic

predisposition to autoimmune problems. .

----- Original Message -----

From: carrie_heer <cjheer@...>

< >

Sent: Tuesday, January 22, 2002 10:36 AM

Subject: Re: Fw: Subject Reference: Fw: SILICONE BREAKDOWN

AND CAPSULAR SYNOVIAL METAPLASIA IN

> I apreciate this post and the facts in it, I too would love to know

> why some women with smooth implants are just as sick as women with

> textured and gel and so forth, it still seems to me it is just the

> reaction many women have to a foriegn object.

>

> I think it is great that you are trying to study this, I think there

> needs to be allot more studying before they are marketed the way they

> are, but that is again, only my own opinion, and maybe no one

> elses.If I jumped to any conclusions then i am sorry but I guess i

> did misunderstand some of what was said, regarding smooth vs textured.

>

> Thanks,

>

>

>

>

>

> - In @y..., " Dr. Kolb " <drkolb@m...> wrote:

> >

> > ----- Original Message -----

> > From: Dr. Kolb <drkolb@m...>

> > Patty <fdp@l...>; <Carina063@h...>

> > Sent: Tuesday, January 22, 2002 8:43 AM

> > Subject: Fw: Subject Reference: Fw: SILICONE BREAKDOWN AND CAPSULAR

> SYNOVIAL

> > METAPLASIA IN

> >

> >

> > > : This is an article which describes what is well known in

> silicone

> > > biomaterials research. The clinical experience of all doctors I

> have

> > spoken

> > > with is that textured implants are much more likely than smooth

> to cause

> > > problems both systemic and local. In 1997 when I had my implants

> replaced

> > > we did not have clinical evidence that smooth saline implants

> that were

> > not

> > > infected were nearly as dangerous as leaking silicone gel

> implants. We

> > > still do not have this evidence. I have never stated that smooth

> implants

> > > are safe. I am still trying to identify what puts a patient at

> risk. All

> > > plastic surgeons that you recommend on this board put in smooth

> saline

> > > implants so it is unfair to single me out as you have done in the

> past.

> > You

> > > misunderstood what I was saying in the posts. I would again ask

> you to

> > > carefully read what is said before jumping to conclusions. You

> are at a

> > > higher level of responsibility as a moderator. .

> > > ----- Original Message -----

> > > From: Martha Murdock & (gigi*) Lawrence <MAM-NSIF@P...>

> > > BreastImplantNews <BreastImplantNews@t...>

> > > Sent: Tuesday, January 22, 2002 1:05 AM

> > > Subject: Subject Reference: Fw: SILICONE BREAKDOWN AND CAPSULAR

> SYNOVIAL

> > > METAPLASIA IN

> > >

> > >

> > > > ============================================================

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> > > >

> > > >

> > > > From: " Myrl Jeffcoat " <myrlj@j...>

> > > > Sent: Monday, January 21, 2002 11:40 PM

> > > > Subject: SILICONE BREAKDOWN AND CAPSULAR SYNOVIAL METAPLASIA IN

> > > > TEXTURED-WALL SALINE BREAST PROTHESIS

> > > >

> > > >

> > > > SILICONE BREAKDOWN AND CAPSULAR SYNOVIAL METAPLASIA IN TEXTURED-

> WALL

> > > SALINE

> > > > BREAST PROTHESIS

> > > >

> > > > http://www.newwomyn.com/nw012i.html

> > > >

> > > > Authors: Copeland, Choi, Bleiweiss

> > > > Source: Plastic & Reconstructive Surg Jnl, October, 1994, Vol.:

> 94, No.

> > 5,

> > > > 628-633

> > > > Address: Mt. Sinai Medical Center, NY.

> > > >

> > > > Saline-filled prostheses are currently the only type of

> prostheses

> > > available

> > > > for cosmetic use in the U. S. because of concerns raised about

> the

> > > > possibility of systemic toxicity of silicone-filled artificial

> mammary

> > > > implants. Although the approved implants are saline-filled,

> their

> > > potential

> > > > to release silicone particles from the shells has not been

> > systematically

> > > > evaluated. We performed microscopic examination of the

> pericapsular

> > tissue

> > > > of 54 patients with textured-surface implants and compared

> these with 51

> > > > patients with smooth- walled implants over a two year period.

> > > >

> > > > The capsules that had formed around virtually all textured-

> surface

> > > implants

> > > > had silicone fragments present either in extracellular spaces,

> in

> > > vacuolated

> > > > histiocytes, or in the form of foreign-body granulomas in

> surrounding

> > > > fibroadipose tissue but not in capsules associated with smooth-

> walled

> > > > implants. In 87% of samples of pericapsular tissue from

> textured saline

> > > > implants, the contact surface displayed exuberant reactive

> synovial

> > > > metaplasia, a histologic pattern not previously described with

> these

> > > > devices.

> > > >

> > > > Our finding suggest that smooth-walled prostheses are

> associated with

> > less

> > > > silicone fragmentation than textured devices in the peri-

> implant tissue

> > > > capsules that tend to form around artificial surfaces used for

> this purp

> > > > ostheses have been implicated in connective tissue inflammatory

> > syndromes

> > > > including systemic sclerosis.1-9 The U. S. Food and Drug

> Administration

> > > > (FDA) curtailed the clinical use of these implants in 1992

> because of

> > > > questions concerning the safety of silicone contents.10,11

> Saline filled

> > > > mammary implants also have a silicone shell but are filled with

> saline

> > and

> > > > are therefore considered safer, since resorption of an

> innocuous fluid

> > > would

> > > > be expected to occur in the event of rupture or leakage of the

> > prosthesis.

> > > > These are currently the only breast prostheses available for

> cosmetic

> > use

> > > in

> > > > the United States. Both smooth walled and textured surface

> implants are

> > in

> > > > widespread clinical use as implants and as tissue expanders.

> Many

> > surgeons

> > > > favor textured implants, which are reportedly less prone to

> capsular

> > > > contracture and may produce a smoother, softer result.12-17

> Textured

> > > > prostheses are often selected not only for primary mammoplasty

> but also

> > as

> > > a

> > > > replacement device for patients who seek removal of silicone

> filled

> > > > implants.

> > > >

> > > > To determine the histologic characteristics of capsular tissue

> excised

> > in

> > > > association with saline filled breast implant removal, we

> reviewed the

> > > > surgical specimens of patients undergoing prosthesis removal at

> the

> > Mount

> > > > Sinai Medical Center in 1992 and 1993. Although not prone to

> spillage of

> > > > encased silicone, saline-filled breast implants have a silicone

> lining.

> > > Our

> > > > results raise concerns about tissue reaction to the linings of

> all

> > > > artificial prostheses but about textured surface implants in

> particular.

> > > >

> > > > MATERIAL AND METHODS

> > > >

> > > > One-hundred ninety-one mammary implants were removed at the

> Mount Sinai

> > > > Medical Center during 1992-1993 from 139 patients. These

> implants had

> > been

> > > > in place for varying periods of time, ranging from 6 weeks to

> several

> > > years.

> > > > The implants were removed for a variety of reasons, including

> staged

> > > > reconstruction procedure and patient dissatisfaction with size,

> shape or

> > > > type of implant.

> > > >

> > > > Surgical pathology specimens of 57 saline filled implants (54

> patients)

> > > > included portions of t fibrous tissue capsules, all of which

> were

> > examined

> > > > histologically. Fifty-four of the saline filled implants were

> textured

> > > > surface prostheses, and the other three were smooth walled

> implants.

> > > > Forty-nine (91%) of the textured saline implants were McGhan

> Biospan

> > > tissue

> > > > expanders that had been placed under the pectoralis muscle for

> breast

> > > > reconstruction after mastectomy and inflated according to the

> > > manufacturer's

> > > > recommendations and serially expanded over a course of 6 to 25

> weeks.

> > > >

> > > > For comparison we examined the 92 peri-implant capsules of 51

> patients

> > > whose

> > > > (mostly bilateral) silicone gel implants were removed; 90 of

> these were

> > > from

> > > > smooth walled silicone implants and 2 were textured walled.

> Surgical

> > > > pathology specimens were prepared with 10% buffered formalin,

> embedded

> > in

> > > > paraffin, and stained with hematoxylin and eosin for microscopic

> > > examination

> > > > under direct incident and polarized light. Immuno-histochemical

> studies

> > of

> > > > selected areas in two samples were carried out using monoclonal

> > antibodies

> > > > directed against vimentin, desmin (both Biogenex Laboratories,

> Dublin,

> > > > Calif.), antitrypsin, lysozyme, myoglbin (Dako Laboratories,

> Inc., Santa

> > > > Barbara, Calif.), macrophage marker, myocyte actin HHF-35 (Enzo

> > > > Laboratories, Syosset, NY), cytokeratin (Becton Dickinson

> Laboratories,

> > > > Inc., Mountain View, Calif.), and another macrophage marker (KP-

> 1,

> > > courtesy

> > > > of Dr. Strauchen).

> > > >

> > > > RESULTS

> > > >

> > > > Light microscopic examination of the fibrous capsules

> associated with 46

> > > of

> > > > 54 textured walled saline implants revealed large fragments of

> silicone

> > > > within giant cell granulomas. For example, the inner lining of

> one was

> > > > arranged in a pseudopapillary configuration resembling synovial

> tissue.

> > > The

> > > > deeper tissue showed foreign-body granulomas containing

> fragments of

> > > > silicone.

> > > >

> > > > Hematoxylin and eosin staining left silicone colorless,

> refractile to

> > > > decreased incident light, and onbirefringent in polarized

> light. These

> > > > granulomas were found exclusively in tissue deep to the capsule

> itself

> > > > rather than proximate to the prosthetic surface. Silicon in

> diameter

> > > within

> > > > foreign body giant cells. Unlike " gel bleed " silicone, which

> usually

> > > appears

> > > > as diffuse extracellular material or in microvesicular form

> within

> > > > histiocytes, the silicone associated with textured saline

> implants was

> > > > entirely intracellular and compact. Many capsular sections had

> an inner

> > > > lining containing wide pseudopapillary formations

> histologically nearly

> > > > indistinguishable from synovial tissue. High powered view of an

> area of

> > > one,

> > > > for example, revealed that the inner surface of the capsule is

> composed

> > of

> > > > palisading, uniform epithelioid cells. Silicone was visible as

> large,

> > > > refractile, nonpolarizable fragments contained within

> aggregates of

> > > > foreign body type giant cells.

> > > >

> > > > The surface that had been in contact with the prosthesis had a

> > > discontinuous

> > > > layer of epithelioid columnar cells with polarized and

> occasionally

> > > > palisading nuclei. Beneath this layer, making up the core of the

> > > > pseudopapillae, was a layer of histiocytes and fibroblasts

> associated

> > with

> > > > dense collagen both perpendicular and parallel to the surface.

> Deep to

> > > this

> > > > layer was vascular fibrofatty tissue. This type reaction--

> synovial

> > > > metaplasia--was found in varying intensity in 47 of the 54

> patients with

> > > > textured walled saline (87%). One of 47 with synovial

> metaplasia was

> > > > associated with an MSI implant, which has a brushlike textured

> silicone

> > > > surface, but no silicone fragments were identified in this

> case. The

> > > > remaining 7 patients had densely fibrous connective tissue

> capsules with

> > > > little or no cellular reaction at the inner surface; there was

> wall

> > > > calcification in one. Immunohistochemcial studies demonstrated

> surface

> > > > epithelioid cells strongly positive for vimentin and negative

> for

> > > > cytokeratin and all other antigens tested. The underlying

> fibroblast and

> > > > histiocytes also were positive for vimentin (antigen), although

> less

> > > > intensely and less consistently positive for antitrypsin,

> lysozyme,

> > > > macrophage marker, and KP-1. Stains for muscle markers (desmin,

> > myoglobin,

> > > > and mycyte actin HHF-35) were negative in all types

> > > > of cells. Three were fibrous and generally acellular. No

> silicone

> > > fragments

> > > > were identified in association with this type prosthesis.

> > > >

> > > > The capsules of 90 specimens obtained from 51 patients with

> smooth

> > walled

> > > > silicone gel implants showed no synovial metaplasia. These

> capsules

> > almost

> > > > uniformly consisted of densely fibrotic tissue, sometimes

> calcified,

> > > > associated with histologically identifiable silicone in small

> amounts

> > with

> > > > intact implants and in larger amounts when the implant had

> ruptured.

> > > > Silicone was present in extracellular spaces or in vacuolated

> > histiocytes

> > > or

> > > > both. Two additional capsules were from double lumen implants

> that had

> > > > silicone on the outside and saline on the inside. The

> pericapsular

> > tissue

> > > > from one of the double lumen implants showed a minor degree of

> focal

> > > > synovial metaplasia. No silicone fragments were identified in

> > association

> > > > with this type of prosthesis.

> > > >

> > > > DISCUSSION

> > > >

> > > > The possible association of silicone gel breast implants with

> certain

> > > > connective tissue disease syndromes1-7 prompted the Food and

> Drug

> > > > Administration to curtail use of these devices in surgical

> practice.

> > > Saline

> > > > filled prostheses and tissue expanders remain available and are

> widely

> > > > viewed as safer, 10,11 even though their walls are composed of a

> > silicone

> > > > elastomer. Textured surface implants are reputed to produce

> better

> > > cosmetic

> > > > results and few complications related to capsular contracture

> than

> > smooth

> > > > walled prostheses or expanders, although these observations

> have not

> > been

> > > > adequately tested in randomized trials.12,17 Our findings

> demonstrate

> > that

> > > > saline filled implants may release fragments of silicone into

> the

> > > > surrounding tissues and that textured surface implants may be

> associated

> > > > with synovial metaplasia.

> > > >

> > > > In 1990, Maxwell and Falcone13 described 84 consecutive breast

> > > > reconstructions using textured silicone tissue expanders and

> reported no

> > > > visible silicone particles in the capsules after the expanders

> were

> > > removed.

> > > > Barone et al.16 observed, in a rabbit model, that capsules

> surrounding

> > > > smooth walled prostheses were relatively acellula s. Capsules

> around

> > > > textured implants contained histiocytes, giant cells, and

> intracellular

> > > > silicone fragments. Although photomicrographs were not

> provided, this

> > > > reaction seems analogous to the pattern of synovial metaplasia

> we

> > observed

> > > > in the majority of our textured implants. Capsular tissue is

> > infrequently

> > > > excised when saline implants and expanders are removed, and

> this account

> > > for

> > > > the small number of specimens available for analysis. Our

> experience has

> > > > been, however, that when capsules are removed and histologically

> > examined,

> > > > silicone fragments are a frequent finding.

> > > >

> > > > Silicone was located within granulomas in fibroadipose tissue

> deep to

> > the

> > > > capsular surface, and therefore, the presence of silicone in

> the capsule

> > > > cannot be explained by mechanical disruption of the elastomer

> surface

> > > during

> > > > implant explantation. Furthermore, a granulomatous reaction

> takes

> > several

> > > > days to develop, so fragmentation of silicone during

> explantation could

> > > not

> > > > account for this histologic picture.18 Synovial metaplasia

> developed in

> > a

> > > > number of cases, and it seems reasonable to speculate that this

> is a

> > > > response to the textured surface and not to silicone. Indeed,

> in one

> > > capsule

> > > > that formed around a brushlike textured surface MSI saline,

> implant, no

> > > free

> > > > silicone was found, yet there was extensive synovial

> metaplasia. None of

> > > the

> > > > smooth walled saline implants showed capsular silicone

> fragments, and

> > > > synovial metaplasia was seen focally in only one case.

> Examinations of a

> > > > larger number of specimens will be necessary to permit proper

> > conclusions

> > > > about the relative safety of smooth versus textured walled

> prostheses.

> > > > Synovial metaplasia (metaplastic synovial cyst formation) is a

> tissue

> > > > reaction first described in chickens with experimentally

> implanted

> > > silicone

> > > > joints by Brody and White19 and in humans after total hip

> replacement by

> > > > Goldring et al.20 Synovial membranes were described at bone

> cement

> > > > interfaces and resembled reactive synovium. Similar phenomena

> have been

> > > > reported in skin and subcutaneous tissue at sites of previous

> surgery or

> > > > trauma.21-26 Immunohistochemical findings were similar to those

> we

> > > observed

> > > > with breast implants: positive staining of the epithelioid

> cells for

> > > > vimentin and inconsistent positivity in underlying cells for

> > antitrypsin,

> > > > and lysozyme (macrophage markers); KP-1, an additional

> macrophage

> > marker,

> > > > was negative. Epithelial markers (cytokeratin, AE-1,

> > > > and EMA) were uniformly negative in all cells. Although by no

> means

> > > > specific, these staining characteristics are typical of normal

> > > synoviocytes.

> > > > We also found negative staining with muscle markers (MCA,

> desmin, and

> > > > myoglobin), excluding myfibroblastic differentiation.

> > > >

> > > > A few cases of metaplastic synovial cysts have been described

> containing

> > > > clear, vicious fluid,26 and these suggest that cells may have

> secretory

> > > > functions similar to those of normal synovium. We found such

> fluid in

> > one

> > > > patient between the capsule and the outer surface of a textured

> saline

> > > > implant. We postulate that a secretory mechanism may be operant

> in

> > > textured

> > > > surface breast implants and expanders corresponding to the

> clinical

> > > tendency

> > > > to seroma formation, requiring drainage at the time of

> implantation.

> > > > Although improved cosmetic results reported with textured

> implants have

> > > been

> > > > attributed to better tissue fixation,15-17 they may actually be

> related

> > to

> > > > greater movement stimulating synovial evolution.27-28

> > > >

> > > > The mechanism by which silicone containing prostheses are

> sometimes

> > > > associated with systemic inflammatory disorders is not clear. A

> foreign

> > > body

> > > > histologic reaction to silicone has been described,29 and an

> association

> > > > between systemic inflammatory syndromes such as systemic

> sclerosis and

> > > > silicone breast prostheses has been reported.1-8 Large amounts

> of

> > silicone

> > > > may not be required for such responses, and we have described

> persistent

> > > > clinical and serologic evidence of immune inflammation even when

> > > microscopic

> > > > quantities of silicone are left in place in a retained fibrous

> capsule

> > > after

> > > > removal of silicone filled prostheses. Saline filled implants

> are often

> > > > considered safer than silicone filled implan ar surface of

> textured

> > > implants

> > > > may become incorporated with capsular tissue. This suggests

> that in

> > > patients

> > > > with a history of inflammatory reactions to silicone, smooth

> walled

> > saline

> > > > filled implants may reduce the risk of recurrent problems.

> > > >

> > > > Copeland, D. M. D., M. D.

> > > >

> > > > We acknowledge the support of the following colleagues for

> providing

> > > access

> > > > to clinical case material: Jin Chun, M. D., Saul Hoffman, M.

> D., Elliott

> > > > Rose, M. D., Skolnik, M. D., Carlin Vickery M. D., and

> Hubert

> > > > Weinberg, M. D. References: Wish to review abstracts of any of

> these

> > > > articles? Most should be available at the following Web Site .

> Once

> > there,

> > > > click on " Medline " and then scroll to under the search field

> and click

> > on

> > > > " Advanced Search. " Put in the name of one of the authors that

> is most

> > > > unusual and that has two initials available to input for the

> search.

> > When

> > > > you find the article, click to tab it and then go to the bottom

> of the

> > > page

> > > > and click on " Retrieve Articles. "

> > > >

> > > > HEALTHGATE

> > > >

> > > > 1. Press, R. I. , Peebles, C. L, Kumagai, Y., Ochs, R. L. and

> Tan, E. M.

> > > > ANTINUCLEAR AUTOANTIBODIES IN WOMEN WITH SILICONE BREAST

> IMPLANTS,

> > Lancet,

> > > > 340, 1304, 1992.

> > > >

> > > > 2. Varga, J., Schumacher R. and Jimenez, S. A.. SYSTEMIC

> SCLEROSIS AFTER

> > > > AUGMENTATION MAMMOPLASTY WITH SILICONE IMPLANTS. Ann. Intern.

> Med., 111:

> > > > 377, 1987.

> > > >

> > > > 3. Spiera, H. SCLERODERMA AFTER SILICONE AUGMENTATION

> MAMMOPLASTY,

> > > J.A.M.A,

> > > > 260: 236, 1988.

> > > >

> > > > 4. Truong, L. D., Cartwright, Goodman and Woznicki, D. SILICONE

> > > > LYMPHADENOPATHY ASSOCIATED WITH AUGMENTATION MAMMOPLASTY;

> MORPHOLOGIC

> > > > FEATURES OF NINE CASES. Am. J. Surg. Pathol. 12: 484, 1988.

> > > >

> > > > 5. Brody S. C., SCLERODERMA AFTER AUGMENATATION MAMMOPLASTY, J.

> A. M.

> > A.,

> > > > 260: 236, 1988.

> > > >

> > > > 6. Brozena, S., Fenske N., Cruse, W. Espinoza, C., Vasey, F. B.,

> > Germanin

> > > > and Espinoza, L. HUMAN ADJUVANT DISEASE FOLLOWING AUGMENTATION

> > > MAMMOPLASTY.

> > > > Arch. Dermatol. 126, 1198, 1990.

> > > >

> > > > 7. Sahn, E., Garen, P. Silver, R. and Maize, J. SCLERODERMA

> FOLLOWING

> > > > AUGMENTATION MAMMOPLASTY. Arch. Dermatol. 126: 1198. 1990.

> > > >

> > > > 8. Hirmand, H. Latrenta, G. S. and Hoffman. AUTOIMMUNE DISEASE

> AND

> > > SILICONE

> > > > BREAST IMPLANTS. Oncology 7: 17, 1993.

> > > >

> > > > 9. Copeland, N. Kressel, A., Spiera, H., Hermann, G and

> Bleiweiss, I.

> > > > SYSTEMIC INFLAMMATORY DISORDER RELATED TO FIBROUS BREAST

> CAPSULES AFTER

> > > > SILICONE IMPLANT REMOVAL: A CASE REPORT AND REVIEW OF THE

> LITERATURE.

> > > Plast.

> > > > Reconstr. Surg. 92; 1179, 1993.

> > > >

> > > > 10. Dunn, K. W. E., Hall, P. N. and Khoo, C. T. K. BREAST

> IMPLANT

> > > MATERIALS:

> > > > SENSE AND SAFETY. Br. J. Plast. Surg. 45: 315, 1992.

> > > >

> > > > 11. Brody, G. S. D., Conway, D Shons and Wesiman. CONSENSUS

> STATEMENT ON

> > > THE

> > > > RELATIONS OF BREAST IMPLANTS TO CONNECTIVE-TISSUE DISORDERS.

> Plast.

> > > > Reconstr. Surg. 90: 1102, 1992.

> > > >

> > > > 12. Lilla, J. A. and Vistnes., L. M. LONG-TERM STUDY OF

> REACTIONS TO

> > > VARIOUS

> > > > SILICONE BREAST IMPLANTS IN RABBITS. Plast. Reconstr. Surg. 57:

> 637,

> > 1976.

> > > >

> > > > 13. Maxwell, G. P., and Falcone, P. A. EIGHTY-FOUR CONSECUTIVE

> BREAST

> > > > RECONSTRUCTIONS USING A TEXTURED SILICONE TISSUE EXPANDER.

> Presented at

> > > the

> > > > 69th Annual Meeting of the American Association of Plastic

> Surgeons in

> > Hot

> > > > Springs, VA, May, 1990.

> > > >

> > > > 14. Vogt, P. A., Seider, H. A., and Moufarege, R. I. SURFACE

> PATTERNED

> > > > SILICONE IMPLANTS DECREASE CONTRACTURE FOR SOFT BREAST

> PROSTHESES.

> > > Contemp.

> > > > Surg. 37: 25, 1990.

> > > >

> > > > 15. , D. J., Foo, I. T. H., and Sharpe, D. T. TEXTURED

> OR SMOOTH

> > > > IMPLANTS FOR BREAST AUGMENTATION? A PROSPECTIVE CONTROLLED

> TRIAL. Br. J.

> > > > Plast. Surg. 44: 444, 1991.

> > > >

> > > > 16. Barone, F. E., , L. Keller, T. and Maxwell, G. P. THE

> > > BIOMECHANICAL

> > > > AND HISTOPATHOLOGIC EFFECTS OF TEXTURING WITH SILCIONE AND

> POLYRETHANE

> > IN

> > > > TISSUE IMPLANTATION AND EXPANSION. Plast. Recontr. Surg. 90:

> 77, 1992.

> > > >

> > > > 17. Brohim, R. M. Foresmann, P. A., Hildrebrandt, P. K. and

> Rodeheaver,

> > G.

> > > > T. EARLY TISSUE REACTION TO TEXTURED BREAST IMPLANT SURFACES.

> Ann.

> > Plast.

> > > > Surg. 28: 354, 1992.

> > > >

> > > > 18. Robbins, S. L. Cotran, R. S. and Kumar, V. INFLAMMATION AND

> REPAIR.

> > In

> > > > Pathologic Basis of Disease, Philadelphia, Saunders, 1984,

> Pages 61-65.

> > > >

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> > > >

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