IDEAS AND INNOVATIONS

SHRINER'S BURN INSTITUTE BOSTON 1975

As a senior medical student, I was accepted for a surgical externship on the Harvard Surgical Service at MGH. I noticed grafting surgeries took so long because we had to individually sew skin graft pieces together for hours in these 80% burned children. When I returned two years later as junior surgical resident in charge for a three month rotation, I tried laying the grafts down without sewing. I then took coarse mesh gauze unfolded in large sheets and stapled them strategically over the grafts to secure them. This worked so well that we were able to double the surgeries per day. I beat James May Jr.’s record and held it many years after I left. A few decades later on my annual visit to say hello, I was told my record had been beaten. How, I asked? We doubled the number of operating rooms! Best burn center for children in the world.

FIRST AMPUTATED EAR SAVED WITH HYPERBARIC OXYGEN

He stole a car drunk and flipped it over cutting off the top of his ear. It was found six hours later. The coincidence of a disheveled HBO nurse passing home through the ER as the EMTs came in with the ear at 5:45 am sparked an idea. If I stagger the incision to double the surface area and stick him in a hyperbaric chamber twice a day for ten days, will it revascularize? Dr. David Bright in charge of HBO said “let’s try”, and history was made.

RECLUSE SPIDER BITE TREATED WITH HBO

Recluse spider bites required early excision and skin grafting because the necrotic wounds rapidly spread if ignored. I was new and clueless in Florida and when this homeless young man came to the ER with a 5 inch necrotic lesion on his back, I biopsied it in curiosity. The ER doctor came in and said “you have cut that whole thing down to fascia and graft it before it gets bigger”. I called Dr Bright and asked him what would happen if we put him in the HBO chamber. He called around the country and nobody knew. So despite not having any insurance, we put him in the chamber twice a day for ten days and the wound healed without surgery. After two more cases succeeded, I would tell the ER just call Dr. Bright. This is now a standard of practice by those in the know. 

PERMANENT EYEBROW INNOVATIONS

I had perfected a technique for precise tapered eyelid pigmentation by placing the lid in an eye clamp and stretching it out with Xylocaine. Instead of adjacent dot technique in use then, I would draw the line like a painter. With the skin stretched out, I could taper the line laterally. When the clamp was released, the skin would contract and a beautifully fine taped line resulted. It was far superior to the dot technique which resulted in shaky jagged lines.

Dr. Patipa in WPB invited me to his course and I demonstrated my technique drawing a dinosaur on a pig’s ear. He confided they had spent a fortune on teaching videos with the adjacent dot technique, and most people did not have steady enough hands to draw the lines.

At the time they devised a three needle tip for eyebrows. The results were miserable because they were using a formula measuring from the corner of the lip and other landmarks to draw out an “ideal” arch for the brow. Then permanently inking it. I thought this was crazy. All eyebrows are different. They also tried drawing little hairs which looked bizarre to me.

REMOVING LIPOMA MONSTER

The challenge was to remove a giant lipoma through a stab wound incision. The traditional incision was a long one along the axis of the lipoma, painful and unsightly. There had to be a better way. The problem was how to remove the sack around the lip. Reaching in with a clamp merely tore it. But clamping it across and rolling like spaghetti on a fork was the was the breakthrough. A new procedure was born. One of my first videos with Jaws and Rocky music. This went world wide and showed me the educational power of the internet.

PERMANENT EYELINER

Natural Eyes by Cooper Vision was the first medical grade equipment for permanent eyeliner. The brochure had a photo which showed a shaggy line which resulted from the technique of laying a line of individual dots spaced along the lower lid. Then a dot would be laid between each of two dots.

BOTULINIUM DAY - FIRST IN FLORIDA 1989

In 1987 Dr. Jean Carruthers, a Vancouver-based ophthalmologist first experimented on his secretary, Cathy Swann, for wrinkles with a botulism based neurotoxin used for strabismus. In 89 John Connelly Md asked me to inject his wrinkles with Oculinum toxin. “What the hell is that?”, I asked. 

MOHS NOSE FROM HELL

A dermatologist in Miami trained by Mohs himself, asked if I would close a patient that lived locally. Sure.

At 3 pm a male arrived with a full thickness loss of his right nose! My first introduction to MOHS before modern H & E stains were used. I now was faced with having to provide an inner lining for the nose, an outer skin, and a cartilage support for the nostril rim! Thinking on your feet is the exciting part of trauma and reconstructive surgery. The problem was defined, now the solution. 

FIRST YELLOW DYE TUNABLE LASER WITH HEXA-SCANNER IN USA

The French developed a device (hexascanner) to rapidly administer laser hits in a rapid fire alternating sequence to avoid the heat buildup of adjacent skin hits before heat is dissipated. This was a major breakthrough. We used it primarily to research treatment of port wine stain birth defects and spider veins. We found it effective on the face but a disappointing failure on the legs.

IMBRICATION TECHNIQUE FOR SYNMASTIA AND POCKET HERNIATIONS

Fixing synmastia and double bubble deformities was performed with external mattress sutures or internal suture to obliterate the pocket. These were prone to failure because the root causes were not addressed. Pressure caused by pectorals contraction on sub muscular implants was a factor in double bubble deformity and over dissection over the midline accounted for most uniboob (synmastia) deformities. An innovative technique of imbrication was found reliable in preventing recurrences. A detailed video of the procedure for young surgeons can be found at https://vimeo.com/813887782. 

LATISSIMUS DORSI FLAP FOR BREAST RECONSTRUCTION. 'LDF'

Tansini introduced the latissimus dorsi flap back in 1906 for reconstruction of large mastectomy defects. Before antibiotics these were risky business. The flap faded into obscurity until my generation rediscovered it in the late 1970s when we were reattaching fingers, arms, and legs. We transitioned from random flaps to vascularized flaps and mapping of the vascular supply to skin regions opened a whole new world.

THREADLIFTS

After enthusiastically engineering a way of fixating the threads during the early excitement and promise of the concept, it became evident that it did not withstand the test of time. Too many complications.



BELLY BUTTON by Villar

Unhappy with the conventional belly button scars on tummy tucks, a method had to be engineered to solve the problem of the ugly belly button scar. A solution eventually was devised to hide the scar by bring the skin down to a short stalk, instead of bringing a long stalk up to the skin.



FIRST 3D CAT SCAN FOR RADIESSE LIP INJURY

20 years ago a young lady was disfigured by a disastrous attempt to inject Radiuses into her lips. To remove this without injuring her, I took advantage of a new technology at our hospital, 3D CAT scan.



This enabled me to identify the location and track of the material and remove some of it safely. A challenging engineering problem.

PRE-WETTING FILLERS

Pre-wetting fillers was not an original idea, but I found it so intriguing that I experimented with the concept. My first attempt on a friend the day before a cruise did not go well. But it paved the way for for very exciting results and a great leap forward in mastering hyaluronic acids.



MORPHEUS 8 + MICRO-LIPOSUCTION

We are rsearching the combination of micro-liposuction of the submittal fat pouch in young patients not suitable for facelift surgery. Encouraging results



MORHEUS 8 + NANOFAT

Nanofat was was applied by injection and topical absorption via micro needling by a presenter from Europe many years ago at the Backer Gordon Meeting in Miami. I experimented with this, but the micro needling was very bloody and left a raw surface for a few days. The injected nanofat worked. Now Morpheus 8 micro needles down to 4mm without the bruising and bleeding. We are combining these two technologies.