Creative thinking in medicine
Sergio Capurro
Plastic Surgery and Burns Unit
San Martino Hospital, Genoa
Transillumination is useful in the functional and aesthetic treatment of venous insufficiency by means of T.R.A.P (tri-dimensional regenerative ambulatory phlebotherapy). A risk-free method of treating the superficial and perforating circulation, T.R.A.P. has enabled us to obtain permanent functional and aesthetic results that cannot be achieved by means of traditional methods. The transilluminator used by us (Veinlite) casts a circle of light. Its 30-degree inclination and 3-centimetre deep focus enable the superficial, perforating veins: to be identified; these are the “gateways” through which the non-visible vessels are regenerated. T.R.A.P. conserves the anatomical integrity of the venous circulation. Indeed, the veins are neither obliterated or removed, rather, they are “regenerated”. The method is based on a thorough knowledge of the physiopathology of venous insufficiency. The cause of the disorder lies in the incontinence of the perforating vessels. The effect is the ugly dilation of the superficial veins and telangiectasias. The miopragia, which extends to the entire superficial and perforating circulation, is responsible for the evolution of the disorder. This means that the entire superficial and perforating circulation has to be injected and “regenerated”. T.R.A.P. improves blood flow in the limb in a few treatment sessions. The aesthetic results are excellent and long-lasting, to the satisfaction of both patient and operator.
Sergio Capurro
Plastic Surgery and Burns Unit
San Martino Hospital, Genoa
Alberto Cavalchini
Institute of Social Dermatology
San Martino Hospital, Genoa
Silvia Perrella Segre
CRG
In the surgical field, the need for optimal haemostasis is most acutely felt in plastic and aesthetic surgery.
In an effort to create a method that would facilitate the work of the surgeon by markedly stimulating haemostasis in the operating phase, we conducted experiments using autologous serum. After collection in two or more 6 ml test-tubes and centrifugation at 3000 G (1) for 15 min., the serum is added in a 1:4 ratio to the local anaesthetic containing epinephrine. The results were impressive: the near-total absence of bleeding made tissue incision and dissection much easier, and edema and ecchymosis in the immediate post-operative phase were markedly reduced. The improved haemostasis is the result of local supplementation of coagulation factors: prothrombin, thromboplastin, calcium, and factors VII, VIII, IX, XI and XI.
We use serum in all our surgical operations: from transconjunctival blepharoplasty performed by means of timedsurgery (see DVD), to lipofilling and at the end of additive mastoplasty procedures. We conclude that a simple centrifuge may well become a common apparatus in all operating theatres.
1) Capurro S., Cavalchini A.: A simple technique for bloodless surgery. Plast. Reconstr. Surg (in press)
Sergio Capurro
Plastic Surgery and Burns Unit
San Martino Hospital, Genoa
The two-tipped needle was designed by the author in 1983 (1-2-3) in order to make lifting of the medial third of the face, the eyebrows and the angle of the jaw less invasive. It was subsequently rendered atraumatic (4). The needle is suited to passing an innovative elastic thread (5) through the subcutaneous tissues at a controlled depth, in any direction, without making any skin incisions other than that used for entry. Trauma is minimal (from two to six tiny cuts in order to bury the knot and fix the thread). Mounted on a traditional needle, the thread has also been used in traditional lifting procedures, in which, we feel, it offers advantages over the SMAS manipulation techniques. In addition to obviating the risks connected with these surgical procedures, the elastic thread enables natural, long-lasting results to be achieved, in that it does not cut through the tissues.
1) Capurro S.: Utility Model Patent. Pat. N° 194882 1983
2) Capurro S : ‘Un ago a due punte’ da Rivista Italiana di Chirurgia Plastica, atti del 32° Congresso di Chirurgia Plastica.Palermo Sett.1983
3) Capurro S.: Un ago a due punte . Riv. Ital. Chir. Plast. 16: 1; 1984
4) Capurro S : Patent PCT: Atraumatic two-tipped surgical needle. 2002
5) Capurro S: Patent PCT : Sheathed elastic surgical thread. 2002
Sergio Capurro
Plastic Surgery and Burns Unit
San Martino Hospital, Genoa
Timedsurgery is the most efficacious and versatile operating technique in
the dermatological, plastic and aesthetic fields (1). It is a risk-free and
extremely economical means of obtaining results that cannot be achieved
through other techniques, including laser therapy.
The technique, which is perfectly standardised, uses a range of currents
designed for specific procedures. It can easily eliminate epidermal and
dermal-epidermal hyperpigmentation, tattoos and deep wrinkles (technique of
choice), and can re-pigment stable vitiligo by means of autologous grafts of
keratinocytes and melanocytes. Timedsurgical resurfacing does not damage the
deep dermis (unlike light, electric currents travel over the surface, and
not in a straight line!), eliminates naevi flammei from the face, and levels
scars. Timedsurgery is also used to create micro-incisions without burning
of the edges, to treat in an original and efficacious manner all
neoformations of the skin, from common warts to angiofibromas, and from
sebacious hyperplasia to benign and malignant neoformations such as
melanomas, and to cleanse ulcers. Even vascular neoformations, from facial
telangiectasias to cavernous angiomas, can be treated efficaciously by means
of timedsurgy.
Sergio Capurro:
Timedsurgery. Edizioni D’Arsonval, 2001 Genova Italia
Abstract SIME 2005 Rome
Sergio Capurro
Plastic Surgery and Burns Unit
San Martino Hospital, Genoa
Transillumination is useful in the functional and aesthetic treatment of venous insufficiency by means of T.R.A.P (tri-dimensional regenerative ambulatory phlebotherapy). A risk-free method of treating the superficial and perforating circulation, T.R.A.P. has enabled us to obtain permanent functional and aesthetic results that cannot be achieved by means of traditional methods. The transilluminator enable the superficial, perforating veins: to be identified; these are the “gateways” through which the non-visible vessels are regenerated. T.R.A.P. conserves the anatomical integrity of the venous circulation. Indeed, the veins are neither obliterated or removed, rather, they are “regenerated”. The method is based on a thorough knowledge of the physiopathology of venous insufficiency. The cause of the disorder lies in the incontinence of the perforating vessels. The effect is the ugly dilation of the superficial veins and telangiectasias. The miopragia, which extends to the entire superficial and perforating circulation, is responsible for the evolution of the disorder. This means that the entire superficial and perforating circulation has to be injected and “regenerated”. T.R.A.P. improves blood flow in the limb in a few treatment sessions. The aesthetic results are excellent and long-lasting, to the satisfaction of both patient and operator.
The efficacy of traditional sclerotherapy is limited; it is unable to prevent the recurrence of varicose pathologies in the lower limbs, and frequently leads to complications. It acts on the clearly pathological superficial vessels, which represent merely the effect rather than the cause of the disorder.
Our aim is to permanently restore the entire superficial and perforating circulation in the lower limbs. The physiopathology of the circulation in the lower limbs reveals how this objective can be achieved by reducing the diameter of the vessels and strengthening the vessel walls, thereby reducing their excessive capacity and restoring valvular continence. Logically, this objective cannot be achieved by means of an obliterative and ablative procedure, but only by a “regenerative” method. To this end, we have invented a new technique: three-dimensional regenerative ambulatory phlebotherapy (T.R.A.P.). T.R.A.P. is a “gentle”, non-obliterative form of “sclerotherapy” which extends to the entire superficial and perforating network. The phenomenon that we call “regeneration” involves fibrosis that is neither sclerotic nor obliterative. Histological examination reveals reduced calibre of the lumen and consolidated connective structure of the treated vessels. T.R.A.P. is carried out by injecting a new “regenerating” solution, 6% solution of sodium salicylate in an alkaline hydroglycerin vehicle, methodically in large total quantities (from 10.5 to 31.5 ml) into all visible vessels, including those visualised by means of transillumination. We also use a 10% solution, which is injected primarily in cases of hemodynamic matting.
T.R.A.P. yields an aesthetic and functional result that cannot be achieved by means of any of the techniques previously used by us, including surgical procedures. The results obtained have proved to be stable after six years, thus demonstrating the functional effect of the method.
In this study, we used 6% and 10% BS
In order to perform more efficacious and less invasive vertical face-lif procedures on the medial third of the face , the eyebrows and the angle of the lower jaw, the 2-tipped needle invented by the author in 1983 and rendered atraumatic in 2002. The needle is designed to insert an innovative elastic thread at a controlled depth in the subcutaneous issues, in any direction and without requiring further skin incisions other than that used for entry. The new needle and thread enable long-standing results to be achieved in a procedure that does not involve blunt dissection of the tissues. Trauma is minimal (from 2 to 6 tiny incisions, from 5 mm to 1 cm in length, to sink the knot and fix the thread), no visible medication is required and the patient can resume normal activities almost immediately. It takes about 30/60 minutes to insert 4/8 threads to lift the medial third of the face. Capurro’s needle and thread can be used to advantage not only in vertical face-lift procedures without blunt dissection, but also in traditional face-lift, in which their use obviates the need for long and complex operations to lift the medial third. When mounted on a normal suturing needle, the thread can handily replace the flaps of the SMAS and, naturally, all the suspending sutures, in traditional lifting procedures. The suspension achieved is completely invisible and impalpable. In addition to avoiding the risks associated with the most complex surgical procedures, the thread enables natural, long-lasting results to be achieved, as it does not cut into the tissues. This form of elastic face-lift is consistent with the concept of non-invasiveness, thereby minimising damage to anatomical structures and interfering as little as possible with the patient’s normal activity. Other lifting techniques, by their very nature, cannot achieve such efficacious and long-lasting results. Finally, if the thread is not positioned correctly, it can easily be removed and replaced without causing any damage.
This innovative form of suturing is designed to meet the needs of those numerous patients who do not wish to undergo traditional face-lift, but rather are searching for an undemanding, brief, ambulatory procedure that is nevertheless efficacious. Elastic face-lifting is also suitable for younger patients who wish to improve their appearance and, especially, to contrast the effect of gravity, which is the chief cause of facial ageing.
Another interesting application of Capurro’s needle is their use in plastic surgery; in the removal of large scars, whether caused by burns or other injuries, they enable tension to be distributed at a distance from the wound, without blunt dissection of the skin, thereby yielding a more aesthetic result.
Elasticum® thread and Jano needle® (KORPO S.r.l., Genova, Italy)
Timedsurgery is the most efficacious and versatile physical technique in the field of aesthetic, plastic and dermatological surgery. It is a standardised, easy-to-use technique that enables any specialist to achieve results that cannot be obtained with other physical methods.
The invention of the programmable diathermocautery in 1978 enabled all the parameters that condition the effect of a diathermal emission in the tissues to be controlled. It also gave rise to the invention and development of this new method. In addition to facilitating the execution of well-known procedures, Timedsurgery has rendered feasible a large number of operations that hitherto could not be performed; this has been made possible by the use of specially designed, specific currents. Timedsurgery enables perfectly controlled incisions to be made in the skin and mucosa, without burning the edges of the cut. Micro-incisions and micro-excisions can be made even on the anterior surface of the eye, as well as on the eyelid, and high-precision, bloodless operations can be carried out both in the oral cavity and on the skin. Slow, pulsed Timedsurgical cutting, for example, enables a skin biopsy to be cut out between two lines 1 mm apart. Likewise, rapid, pulsed Timedsurgical cutting enables transconjunctival blepharoplasty to be performed with extraordinary visibility and precision. Incisions in the skin and mucosa heal rapidly. The stitches used in upper blepharoplasty can be removed in three days. Timed coagulation enables spider naevi and facial telangiectasias to be eliminated (with or without bstherapy), and is also used to achieve highly selective, definitive (zero re-growth) depilation, in which it has proved efficacious even on fair hairs. Vast telangiectatic angiomas of the face, lip wrinkles of any depth and crows feet can all be eliminated by means of Timedsurgery; tattoos disappear in a few treatment sessions without leaving the artefacts that are frequently visible after laser treatment. Timedsurgery is able to eliminate all types of hyperpigmentation and to de-pigment normopigmented skin in cases of generalised facial vitiligo. Similarly, it can be used to re-pigment the skin in cases of stable vitiligo and piebaldism (Timedsurgical de-epithelialisation + grafting of autologous melanocytes and keratinocytes). Timedsurgery can also be used to level scars caused by trauma, surgery and acne; to cleanse and “sterilise” skin ulcers; to vaporise small skin formations without anaesthesia; to eliminate venous lakes and milia (the latter by means of a micro-incision on the epidermal dome); to treat closed blackheads, skin tags, palpebral syringomas, fibroangiomas, trichoepitheliomas, sebaceous hyperplasias, common and plane warts, etc.
All procedures are standardised and can be reproduced by any operator. Our approach is to identify a problem and to design a current with features that are able to solve that problem. The programme data, procedural modalities and illustrative film footage are then made available (www.timedchirurgia.org).
Why do we use an electric current and not a light ray? We do not believe in using lasers in the dermatological field; we consider them to be poorly efficacious in most of the applications for which their use is suggested, and too expensive. We feel that powerful laser beams are of little use in the dermatological field; when used for cutting, lasers are somewhat imprecise and risky, and cause burning at the edges. These features contrast starkly with the precision and safety of Timedsurgical cutting. Using lasers to destroy neoformations is slow and all too often leaves areas of hypopigmentation. Moreover, lasers are not able to remove neoformations satisfactorily, much less to perform a procedure equivalent to the electroshaving carried out by Timedsurgery. The elimination of wrinkles by means of laser resurfacing is risky and/or inefficacious, especially if compared with Timedsurgical mixed peeling. In our view, resurfacing should not be carried out on the face. To rejuvenate the face, we currently use various techniques: revitalisation, Timedsurgical mixed peeling, chemical peeling, lipofilling, “non-surgical” lifting by means of our specially designed needle and thread, pulsed micro-coagulation to eliminate couperose (if necessary, in combination with 3-dimensional phlebotherapy), and Timedsurgical elimination of blemishes and neoformations. With regard to ectatic veins and capillaries of the lower limbs, the use of lasers is completely irrational. Indeed, treating a 3-dimensional disorder by means of a 2-dimensional technique makes no sense. For this reason, we use Timedsurgery to treat venous insufficiency; when applied to the face, this enables the vessel to be coagulated at the desired depth and at a very low cost. But what is the big difference between an electric current and laser light? While the velocity of the two forms of energy is identical - more than 300,000 km per second - an electric current flows over surfaces, while light travels in a straight line. Clearly then, a laser beam that is used for coagulation will penetrate in depth; the melanocytes, which are heat-sensitive cells, may therefore be damaged and hypopigmentation may ensue. Moreover, as the power increases, so also does the risk of scarring. In addition, light exerts a notorious ageing and pro-fibrotic effect. By contrast, diathermal energy, which flows over the surface rather than travelling in a straight line, can exert an efficacious superficial action (micro-arc and Timedsurgical resurfacing) without heating the underlying tissues, thereby allowing rapid recovery of tissue integrity. Alternatively, its controlled heat can exert an efficacious anti-viral action (see treatment of common warts on timedchirurgia.org). Finally, it can be manipulated in such a way as to act effectively on those tissues that have the highest, or lowest, water content. It is easy to imagine, then, how safely and effectively Timedsurgery works in eliminating tattoos, telangiectatic naevi, xanthelasmas, epidermal pigmentation of the hands, neck and face, etc. For what concerns de-epithelialisation of the skin, Timedsurgery utilises a specific current that is able to preserve the integrity not only of the dermal papillae, but also of the capillary-papillary complex. As dermatologists well know, this is something that not even the most sophisticated lasers can do. Another characteristic of the diathermal current is that, unlike lasers, it is not influenced by the heat of the skin or the lesion; this means that the programme data are valid for all patients, since electrical conductivity is almost the same in all individuals. A further advantage lies in the fact that Timedsurgery uses electrodes and electromaniples to transduce the current. This means that mechanics and physics can be combined, and that bipolar coagulation can be carried out subcutaneously without causing surface lesions. Moreover, this technique constitutes a useful point of contact between the operator and the patient, in that, for instance, the electrode enables the operator to realise whether a neoformation has been completely removed or not.
Timed surgery continues to discover new and intriguing applications, and is used in numerous specialist fields. The reason for its success lies in the standardisation of its programme data, the training courses available, its simplicity of use and, not least, its low cost, which allows operators to choose freely among the various techniques at their disposal.
This work utilised the TIMED TD 50 A Micropulse (Korpo S.r.l. – Genova, Italy)
Sergio Capurro Specialist in Plastic and Reconstructive Surgery.San Martino Hospital, Genova, Italy
Rapid and slow pulsed, timed Timedsurgical cutting is an innovative, standardised method of cutting in Timedsurgery (technique for the implementation of measured electrosurgical data). This technique has revolutionised electrosurgery and some major surgical procedures. In eyelid surgery, the special technique of Timedsurgical cutting has proved to be safer, more accurate and more versatile than cutting carried out by means of a laser beam or a surgical scalpel. In comparison with the surgical scalpel, Timedsurgical cutting offers several advantages: it provides haemostasis, ensures perfect visibility of the operating field, and is extremely delicate; indeed, the pressure required to make an incision (less than 5 g) is far less than the 1.5 Kg necessary when cutting with a No. 15 blade.
Comparison with laser cutting also reveals advantages. Timedsurgical cutting does not burn the edges of the incision (in upper blepharoplasty, stitches can be removed after three days), it is much safer for both the patient and the operator, and enables greater precision to be achieved (for example, a losange can be cut out between two lines as little as 1 mm apart). A perfectly perpendicular incision can be made in the skin at the desired depth. In upper blepharoplasty, Timedsurgery enables the surgeon to establish whether to make the skin incision at the centre, or at the upper or lower edge, of the line drawn on the skin (programme data: 27 Watts, Cut, EM 10 White).
For the purpose of anaesthesia, we use mepivacaine with epinephrine to which we add a small quantity of serum obtained from the patient’s blood by means of high-velocity centrifugation for 15 minutes.
Once the skin incision has been made, the power is set to 50 Watts. This innovative form of cutting exploits the elastic property of a cone-shaped, triangular-tipped electrode. It enables tiny, sub-millimetre corrections to be made (without the traction and counter-traction typical of traditional surgery), normally by removing extremely fine strips of skin (often less than 1 mm), thereby rendering excision perfectly symmetrical. Rapid pulsed Timedsurgical cutting (50 Watts) enables the medial portion of the orbicular muscle and the area where the lateral cut terminates to be excised almost bloodlessly. It is therefore possible to remove all of the orbicular muscle corresponding to the skin excision, a procedure carried out in cases of narrow orbits. Alternatively, a strip of muscle can be excised in order to improve the definition of the eyelid fold.
Rapid pulsed timedsurgical cutting is ideal for transconjunctival blepharoplasty (50 Watts, Cut, EM 10 White). The procedure is carried out by making two incisions, one medial and the other lateral, of about 1 cm in length, through which the adipose pouches are removed. The incisions are not stitched. The fine tip of the electromaniple allows excellent vision and extreme precision in isolating and removing deep adipose pouches.
Slow pulsed or timed cutting has proved to be excellent in excising
neoformations from the edge of the eyelid, an anatomical region with a high
regenerative capacity that lends itself well to electroshaving.
Electroshaving (38 Watts, Cut, EM 10 White) enables the neoformation to be
excised extremely finely. Tissue loss is not sutured, but left to heal
spontaneously. This Timedsurgery technique is frequently used by us for the
aesthetic excision of numerous benign skin formations, on both the face and
body. Indeed, excision by means of Timedsurgical cutting causes minimal
damage to the edges. This is a far cry from the old coagulation procedures
using cauteries or lasers; such procedures often left scars owing to the
extensive thermal damage caused to the residual surrounding tissues and, in
the case of the laser beam, which travels in a straight line, even to the
deep tissues. Following excision by Timedsurgical electroshaving, the
vessels are coagulated by means of the resurfacing function (50 Watts, Coag,
EM15). As this extremely delicate technique does not heat the deep tissues,
we currently use it to remove naevi flammei from the face. The Timedsurgical
electroshaving of benign neoformations exploits the regenerative capacity of
the organism and does not cause thermal damage to the residual structures.
From the aesthetic standpoint, it yields excellent results, unlike those of
surgical excision followed by suturing, which often remain visible and look
artificial.
Another extremely interesting application to the surgery of this region is
the excision of palpebral syringomas by means of slow pulsed Timedsurgical
cutting. In this mode, micro-excisions of 1 or 2 mm can be performed very
easily and without the trauma that would be caused by a surgical scalpel.
These excisions may be sutured or left to heal spontaneously.
Like lip wrinkles, wrinkles and crows feet in the region of the eyelid can be eliminated by means of Timedsurgical mixed peeling (www.timedsurgery.com).
Sergio Capurro MD and Alberto Cavalchini - San Martino Hospital, Genova, Italy
The need for good haemostasis is felt in surgery in general, and in plastic and aesthetic surgery in particular. Optimal haemostasis favours the ongoing search for ever-greater precision in surgical operations and facilitates the early phases of the scarring process. In addition, it shortens healing times. In the literature that we consulted, we found a proposal for biological supplementation with platelet-enriched plasma obtained after centrifugation of about 60 ml of autologous whole blood for between 15 and 30 minutes. At the end of a face-lifting operation, the enriched plasma is injected under the flaps obtained by blunt dissection, with a view to reducing post-operative bleeding, thereby minimising swelling and bruising (1).
In an attempt to work out a technique that could facilitate haemostasis in the operating phase, and not only in the post-operative period, we experimented with a biological preparation that can be produced more easily than enriched plasma: autologous serum obtained by means of high-velocity centrifugation, diluted in a solution containing, or not containing, a local anaesthetic. Preparation is simple and rapid. A sample of blood is placed in one or more 6 ml test tubes, without additives, and centrifuged for 6-15 minutes. We usually add this autologous serum to an anaesthetic solution containing epinephrine, in variable proportions according to the type of anaesthesia required and the type of operation to be performed. The ratio used in transconjunctival and upper blepharoplasty, for instance, is1:4.
The results appear to be noteworthy. Tissue incision and dissection have been greatly facilitated by the almost total absence of bleeding. Swelling and ecchymoses in the immediate post-operative phase have been markedly reduced (fig. 1). In some of our tests, we have compared the administration of local anaesthetic alone with that of the anaesthetic supplemented with autologous serum in the same patient, for example in blepharoplasty. A significant difference was noted, both during the operation and in the post-operative period. When the supplemented solution was used, haemostasis proved to be immediate.
We feel it is plausible that this improvement in haemostasis is due to the local addition of coagulation factors present in the autologous serum (prothrombin, thromboplastin, calcium and factors VII, VIII, IX, XI, XII) to the intrinsic and extrinsic pathways. Further advantages of using serum emerge from a recent report in The Lancet of research conducted by a group of British plastic surgeons (2). In experimental models of wound healing, these authors found that the synthesis of collagen and fundamental substance by skin fibroblasts in the scarring phase was stimulated by the addition of collagen and serum, and that the epithelial cells were activated and assumed a polarised appearance. These effects were not produced by the addition of collagen and plasma. This suggests that, as well as promoting haemostasis, serum exerts a regenerative effect on tissues undergoing scarring.
The technique described may well be refined further and extended to other uses. For example, we also add autologous serum to the centrifuged fat that is injected during lipofilling (ratio 1:4), and greater dilution ratios are currently being tested. In the future, a simple centrifuge for 6 ml test-tubes is likely to become a standard piece of equipment in many operating theatres.
References
1) Miller P. J., Constantinides M., Doud Galli S. K. Midfacial effects of the deep-plane facelift. Facial Plastic Surgery 2001; 17 n° 1: 49-56.
2) Henry G, Li W, Garner W, Woodley DT. Migration of human keratinocytes in plasma and serum and wound re-epithelialisation. Lancet 2003 Feb 15;361 (9357) : 574-6.
Fig.1) One days after transconjunctival blepharoplasty performed under
local anaesthesia with a solution supplemented with autologous serum (ratio
1:4).
from Plastic and Reconstructive Surgery march 2005
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