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Results from a study conducted at the University of Southwest Texas Medical School reported in the Journal of the American Society of Plastic Surgeons as well as clinical trial results reported in the Aesthetic Surgery Journal, Lipoplasty magazine, and at the scientific meeting of The American Vein and Lymphatic Society, all demonstrate that patients taking InflammEnz® experience resolution of their pain, discoloration and swelling caused by soft tissue trauma significantly faster than those not taking InflammEnz®.*
Although research to date has focused on surgical wound healing, many different types of healthcare practitioners have found InflammEnz® to be beneficial in speeding the repair of a variety of soft tissue injuries, not just surgical wounds.*
Three common problems in the post-lipoplasty patient are bruising, edema, and discomfort. Changes in technology, technique, and post-operative care are all directed at reducing one or all of these problems. The majority of changes which have occurred in lipoplasty have come about as an attempt to reduce either the cause or the effect of the aspiration of adipose tissue on surrounding structures.
Nutritional therapy is critical for wound healing in people with severe malnutrition or specific metabolic deficiencies. Medical claims from manufacturers of many oral supplements are marketed to surgical patients for decreasing edema, bruising, and discomfort. The effect of supplementing nutrients on soft-tissue wound healing in otherwise normal, healthy adults is an area of clinical importance, but little information is available. Proteolytic enzymes have been reported to moderate the inflammatory cycle and may up-regulate the healing process.
The goal of this study was to perform a clinical trial in normal, healthy adults that examined the effects of an oral nutritional supplement (InflammEnz™, Enzymes Inc, Kansas City, MO.) on soft-tissue healing times. Twenty-six normal, healthy volunteers were recruited into a randomized, crossover, placebo-controlled, clinical trial consisting of two phases, each lasting 21 days.
In phase I, subjects were subjected to a 3-mm forearm skin biopsy and randomly received a placebo or oral supplement (four capsules per day for 7 days). After a 2-week washout period, a second biopsy was performed to start phase II, with each subject receiving the respective placebo or supplement capsules. Digital photographs were taken during wound healing in both phases and analyzed for wound areas (in square millimeters) and perimeters (in millimeters). Twenty-two subjects completed the clinical trial. On the basis of wound surface areas, 17 subjects had improved wound healing and five subjects did not respond or responded only slightly to the supplement treatment. The mean +/- SD healing time of the subjects responding to supplement-treated wounds was 15 +/- 2.2 days, compared with 18 +/- 2.5 days for the placebo group. The 17 percent acceleration of wound-healing time was significant (p < 0.005). In subjects responding to oral supplements, less redness in the wounds was observed that may have been associated with less inflammation.
The authors’ results demonstrate that InflammEnz™ oral supplementation accelerated soft-tissue wound healing in 77 percent of normal, healthy subjects studied. The authors’ study validates observations made that this supplement modulates the wound-healing process and suggests that many patients with minor soft-tissue wounds may benefit from treatment.
A double-blind, placebo-controlled clinical study demonstrating that oral proteolytic enzyme supplementation significantly reduced post-sclerotherapy bruising, swelling, and discomfort, supporting faster and more comfortable recovery following vein treatment.
A peer-reviewed plastic surgery publication outlining a progressive, three-step surgical technique for correcting witch’s chin deformity, offering a flexible approach that adapts to patient anatomy while minimizing unnecessary surgical intervention.
In the patient who has significant ecchymosis after undergoing blepharoplasty, the ecchymosis usually does not start to resolve earlier than the fourth or fifth day after surgery and may persist for up to 10 days. In my experience this type of patient should have had swelling and bruising for at least a week and possibly longer. The only change made in routine postoperative care was the addition of the InflammEnz® dietary supplement.
Three common problems in the post-lipoplasty patient are bruising, edema, and discomfort. Changes in technology, technique, and post-operative care are all directed at reducing one or all of these problems.1,2 The majority of changes that have occurred in lipoplasty have come about as an attempt to reduce either the cause or the effect of the aspiration of adipose tissue on surrounding structures. The damage to the surrounding structures is what results in bruising, edema, and discomfort. Vitamins, trace elements, and other dietary supplements have been used by many physicians to help reduce post-lipoplasty morbidity.3 These regimens are usually based on personal experience, anecdotal patient reports, or studies done on the effect of dietary supplementation in the treatment of athletic injuries.4 There has been very little data in the plastic surgery literature during the past 20 years to direct us in how we might use dietary supplements to help our patients recover from lipoplasty. I would like to report on three patients who saw a reduction in post-lipoplasty morbidity when taking a specific dietary supplement.5 These three patients prompted a double-blind clinical research study and the results of the initial phase of this study will also be reported.
In the three case report patients, all underwent lipoplasty of both flanks and the abdomen in two separate procedures. The procedure was performed using a modified tumescent technique and IV sedation. The patients were required to wear the appropriate compression garments for two weeks. After surgery, each patient also received six ultrasound treatments to the area of lipoplasty. The only medications taken were oral analgesics containing acetaminophen and hydrocodone. Two patients had the abdominal lipoplasty done first and then the flanks. The other patient had the flanks done first. A minimum of ten weeks separated the two procedures. All patients received a protease-based dietary supplement following the second procedure. The patients were evaluated for post-lipoplasty bruising, edema, and discomfort beginning on the day of surgery and continuing for 4 days. Bruising and edema were evaluated by the surgeon on a scale of O to 5, and the patients evaluated their discomfort on a scale of O to 5. All patients were seen on the third, tenth, and twentieth-day post-lipoplasty by the surgeon.
Patient number one was a 35-year-old white male who underwent a 400 cc aspiration of the right and left flanks. On Day 3 he was noted to have significant bruising of the flanks with the migration of the ecchymosis to the genitalia. Pitting edema was noted throughout the area of ecchymosis. The patient was unable to rest without analgesia. Day 10 there were minimal changes in the ecchymosis and edema. The discomfort level was diminishing. Day 20 there was minimal yellowing of the skin. The edema and discomfort had resolved. Twelve weeks later the patient underwent a 475 cc aspiration of the lower abdomen with the protease-based dietary supplement added to the normal post-operative management. On Day 10, he showed complete resolution of bruising, and edema had almost completely resolved. On Day 20, he showed complete resolution of all symptoms. The discomfort was present only on the first night after surgery and no analgesia was required after the first post-surgical day.
Patient number two was a 39-year-old female who underwent a 900 cc aspiration of the lower abdomen. On Day 3 and Day 10, she had 4+ bruising, edema, and discomfort. The bruising and edema were localized to the areas of aspiration. Analgesics were required for nearly three weeks following the procedure. Day 20 revealed some mild yellowing of the skin and edema was still palpable in the tissue. The discomfort was minimal but still present. Ten weeks later the same patient underwent a 1,700 cc aspiration of the flanks. Again the protease-based dietary supplement was added to postoperative management. Day 3 revealed moderated bruising and edema with a severe discomfort level. Day 10 saw a complete resolution of bruising. The edema and pain levels were unchanged. Day 20 showed complete resolution of pain and only minimal edema on deep palpation.
Patient number three was a 38-year-old white female who had a 1,000 cc aspiration of the lower abdomen. Day 3 revealed significant bruising and ecchymosis with associated edema and discomfort. Day 10 showed a reduction in bruising and edema to moderate levels but the discomfort level was unchanged. Day 20 revealed some residual bruising, edema, and complete resolution of the discomfort. Twelve weeks later she underwent an 1,150 cc aspiration of the flanks with the dietary supplement added to the post-lipoplasty protocol. Day 3 showed low to moderate bruising and edema. The discomfort had fully resolved. Day 20 had resolution of bruising, discomfort, and only edema on deep palpation.
The three patients prompted the development of a double-blind study to determine if the decrease in post-lipoplasty morbidity was reproducible on a regular basis. Twenty-five patients underwent a total of 41 procedures. These ranged from a submental lipoplasty to bilateral lower leg lipoplasty (see Table 1). The volume of aspirate ranged from 50 cc to 2,500 cc (Table 2). The post-lipoplasty management of the patient remained as described in the case reports with one exception. All patients received a post-lipoplasty oral supplement. Twenty-three procedures received the oral enzyme compound after lipoplasty and 18 procedures received a placebo. All patients were placed in compression garments and all patients received postlipoplasty ultrasound therapy, as in the case studies.
The results of the double-blind study demonstrate a significant decrease in the post-lipoplasty morbidity of the study participants who received oral enzyme compounds. The most common complaints seen in the recovery period after lipoplasty include ecchymosis, edema, and pain. Each of the patients was evaluated for these three features and each was graded on a scale of O to 5 (Tables 3, 4, 5). The evaluations were done by the surgeon on the third, tenth, and twentieth day post-lipoplasty. The group that received the enzyme supplement underwent 23 procedures. The average volume of aspirate was 1,039 cc. The average age of the patients was 44 years. The placebo group underwent 18 procedures with an average aspirate of 910 cc. The average age for this group of patients was 44.5 years. All procedures in both groups were performed by the same surgeon to minimize any variations in technique.
The first feature evaluated was ecchymosis or the amount of bruising seen. In the placebo group (Table 6) 16 of the 18 procedures or 89 percent resulted in ecchymosis which covered the entire surgical area at Day 3. In 15 of the procedures this persisted to Day 10. In the supplement group (Table 7) 5 of the 23 procedures or 22 percent resulted in significant ecchymosis and in only 1 of 23 patients did this persist until day 10. The supplement group demonstrated less significant ecchymosis which resolved more rapidly than did the placebo group.
The second feature evaluated was edema. In the placebo group 14 of the 18 procedures or 78 percent developed significant post-lipoplasty edema. In eight of these procedures notable edema persisted until Day 10, and 10 procedures had demonstrable edema at Day 20. The supplement group had significant edema in four of 23 or 17 percent of procedures. Four procedures resulted in mild edema which persisted for 10 days and one procedure resulted in demonstrable edema at the 20th day. The supplement group had fewer procedures which produced significant edema and it resolved in a shorter period of time.
Pain was the last feature evaluated in each group. The placebo group procedures resulted in significant pain in 10 of 18, or 56 percent of lipoplasties at Day 3. Five procedures were continuing to produce pain on Day 10 and 3 procedures produced persistent pain until Day 20. The supplement group procedures resulted in significant pain in 3 of 23, or 13 percent of cases. Seven procedures resulted in pain on Day 10. All patients had resolution of their pain by Day 20. The supplement group had a lower incidence and shorter duration of pain when compared to the placebo group.
Protease dietary supplements have been available as an over-the-counter nutritional supplement for more than 30 years. The rationale for the use of protease enzymes can be found in a large body of scientific data. Despite what is commonly taught, evidence exists to support the intestinal absorption of hydrolytic enzymes.6,7,8,9 Up to 40 percent of enzymes may be absorbed functionally intact.10 If macromolecules such as enzymes are absorbed functionally intact, then is there any evidence to support the use of enzymes in the post-surgical period? Data has been collected on both trauma11 and surgically created12 hematomas which would indicate a benefit from taking proteolytic enzymes. Studies have also shown how enzymes can impact on inflammation by reducing its severity and duration.13 Clinical data also exists to demonstrate the absorption and efficacy in the treatment of post-surgical bleeding, swelling, and pain by oral enzyme compounds.14,15 The problem with past studies was that there was not a good standard to compare one injury with another. With lipoplasty the mechanism of injury is controlled and thus other variables such as age, gender, location, and volume of aspirate could be accommodated in a broad double blind study.
The results of this clinical study indicate a role for oral dietary enzyme supplements in the treatment of post-lipoplasty patients. The mechanism by which this occurs is not clearly understood. There are four primary pathways to suggest how oral enzyme supplements may act as biological response modifiers. The first mechanism of action is thought to be by increasing the activity of macrophage.16 The level of activity may be increased several fold resulting in increased clearance of tissue debris by the macrophage. Oral enzyme supplements may also act by altering the normal fibrinolytic pathways.17 This may also be enhanced by improvements in the microcirculation brought about by the response to oral hydrolytic enzymes.18 With improvements in microcirculation the body is better able to clear tissue debris and the products of hemolysis and fibrinolysis. The improvement in microcirculation should also enhance the delivery of substrate needed for tissue repair. Oral enzyme preparations may also stimulate macrophage to release tumor necrosing factor, interleukin 1-B and interleukin 6.19 These compounds and other cytokines play an important role in the inflammatory response and the breakdown of various cells. Oral enzyme preparations are also believed to work by altering the complement cascade and by reducing adherence of cellular and tissue debris to healthy tissue.20 This allows for more rapid clearance of these unwanted by-products of surgery. The oral enzyme supplement used in this study is a combination of several proteolytic enzymes. The method of action of the supplement is probably a combination of all these pathways. The key feature of enzymes used in this fashion is that they stimulate and enhance normal responses within the body and do not block or inhibit function like pharmaceuticals such as steroids do.
The three initial case reports demonstrated the possible efficacy of InflammEnz® in the treatment of patients following lipoplasty. A subsequent double blind study was created to determine if the initial results were reproducible. The outcome of the study of 41 separate procedures performed on 25 patients indicates the beneficial effect of InflammEnz® in reducing post-lipoplasty ecchymosis, edema, and pain. No patient experienced adverse effects associated with the enzyme supplement. The duration and severity of pain were most dramatically reduced in the supplement group. Bruising and edema were also significantly reduced in duration and severity in the supplement group. Overall the supplement group was in better condition at 10 days than the placebo group was at 20 days. The use of InflammEnz® will not take the place of improvements in equipment and technology but they should improve the outcome. InflammEnz® can be used in virtually all patients who are on all oral diets and the benefits are not dependent on the skill or experience of the surgeon. The results of this study would seem to indicate the use of InflammEnz® will enhance the body’s normal recovery mechanisms and allow for a more rapid and less painful recovery from lipoplasty.
The purpose is to evaluate the potential efficacy of oral proteolytic enzyme supplements in the reduction of post-sclerotherapy morbidity. Thirty patients were placed in a double-blind study using a placebo and a specific oral enzyme preparation. The post-sclerotherapy symptoms examined were ecchymosis, edema, and pain. All patients underwent sclerotherapy for lower extremity telangiectasias and varicose veins up to 6mm in diameter. Following sclerotherapy with either sodium morrhuate or tetradecyl sodium, the patients were placed in compression garments. They were evaluated on Day 3, Day 10, and Day 20. Those patients receiving the oral enzyme supplement demonstrated a significant reduction in the duration and severity of post-sclerotherapy morbidity. This study would indicate a benefit to patients who receive oral proteolytic enzymes in the post-sclerotherapy period. This benefit did not appear to be age, sex, or vessel-size related. The benefits received are not dose or skill related but determined by patient’s response to the therapy.
Correction of chin ptosis is like lateral canthopexy. Some surgeons perform it routinely and others shy away. Although both procedures are anatomically uncomplicated, some mysterious forces stop the surgeon, and these forces relate to the patient’s desire for perfection and the surgeon’s ability to deliver. This article deals with noniatrogenic ptosis and offers an appealing, although somewhat flawed, schematic for correction.
When the illustration does not equal the real anatomy, problems arise for the surgeon. Anatomically, the drawing is very incorrect and should have been changed. The mentalis arises immediately submucosal in the sulcus for a centimeter or so; there is no space as drawn. The muscle never arises as it is drawn partly from pogonion, and the fibers go right into the dermis, which is also not depicted properly; the platysma comes to and often covers the mention; it does not insert into the genial tubercle.
First, let us consider some basic concepts regarding the ptosis examination; second, let me assess and analyze their process of correction; and third, let me provide some simple caveats.
The side view of chin ptosis must be both static and dynamic. Static ptosis, i.e., the patient does not smile and there is soft tissue below the mention, can be caused by aging, denture resorption of the mandibular ridge, or zealous excessive submental liposuction (iatrogenic). I have not noted that these patients are usually hyper-projected, as the authors suggest. Often, there is a high labiodental fold, which makes the pad look big. Sometimes, it is just excessive chin pad thickness (normal value, 8 to 11 mm)., and that should be checked digitally.
This procedure or some part of it can be done for the drooping soft tissue after chin implant removal as long as the lower lip position does not expose the lower incisors at rest. For patients who have a short vertical chin and ptosis, usually denture wearers, the removal of ptotic soft tissue will make the chin even shorter. If the submental creases extend upward onto the face, the crease on the face requires undermining, not an extension of the ellipse. Finally, regarding the postoperative dressing, I have found that facial chin supports work well for a couple of days (not necessarily 5 days, as the authors suggest) and that the addition of enzymes such as InflammEnz™ may help reduce the swelling.
A 73-year-old nonsmoking, nondiabetic white man with hypertension complained chiefly of bilateral visual field defects resulting from palpebral dermatochalasis of the upper lids and redundant skin and fat on the lower lids. Because of the visual field defects, he was referred for consultation for a blepharoplasty by his primary care physician. During the examination, the patient was found to have 3.5 cm of excess skin in the upper lids bilaterally and weakness in the lower lids, with early senile ectropion, protuberant periorbital fat, and moderate skin laxity. I suggested a bilateral upper lid blepharoplasty, primarily involving skin resection with a small rim of orbicular muscle. The lower lids would be treated with a lateral canthopexy, the elevation of a skin muscle flap, and resection of herniated periorbital fat. The patient agreed to this procedure after I explained the risks and benefits and alternative procedures.
In spite of the patient’s history of hypertension and mild cardiovascular disease, his primary care physician believed he was a good candidate for surgery. Additional risk factors included urinary retention resulting from benign prostatic hypertrophy and the daily use of aspirin as prophylaxis against future cardiovascular problems. However, the patient did not take any aspirin before surgery or any other medication that would have altered his bleeding time or affected his clotting studies. The surgery was performed on an outpatient basis with the patient receiving intravenous sedation and a local anesthetic.
In most surgical procedures, bleeding is a self-limiting problem. Small punctate bleeding is controlled with cautery and large bleeding by ligation. Bleeding during blepharoplasty can be kept to a minimum with meticulous dissection and close attention to tissue management, which allows for hemostasis to be maintained throughout all stages of the procedure. During this procedure, bleeding became a significant problem in spite of all attempts to minimize it. Two factors brought about the bleeding: (1) The patient’s hypertension, which was believed to be well controlled before surgery, was extremely labile during the procedure; mean arterial pressures were as high as 136 mm Hg and never dropped below 113 mm Hg. (2) The patient’s anxiety, brought about by his urinary retention, persisted in spite of what should have been adequate intravenous sedation. The bleeding resulted in postoperative ecchymosis and intraoperative ecchymosis, even with a dry surgical field at the time of wound closure. The right eye, which had been operated on first, became swollen and ecchymotic during surgery on the left eye. Before completion of the left blepharoplasty, the right-side wounds were opened and explored, but no points of active bleeding were noted. By the end of the operation, the right periorbital tissue was profoundly ecchymotic, and both eyelids were swollen shut. The left side had also begun to swell and became ecchymotic.
After surgery, the patient and his family were given routine postoperative care instructions: ice packs as needed, artificial tears three times daily, pain medication, antibiotic, and the protease-based enzyme dietary supplement InflammEnz™ (Enzymes Inc., Kansas City, MO). The follow-up office examination on the second postoperative day revealed no periorbital swelling. The ecchymosis was limited to a 1.0 x 2.0 cm area of yellow discoloration along the inferior orbital rim bilaterally. By the fifth postoperative day, the discoloration was 0.5 x 1.5 cm and was not visible when the patient wore his regular glasses.
In the patient who has significant ecchymosis after undergoing blepharoplasty, the ecchymosis usually does not start to resolve earlier than the fourth or fifth day after surgery and may persist for up to 10 days. In my experience this type of patient should have had swelling and bruising for at least a week and possibly longer. The only change made in routine postoperative care was the addition of the protease-based dietary supplement. The rationale for the use of protease-based enzymes is found in a large body of scientific data. In spite of what is commonly taught, evidence exists to support the intestinal absorption of hydrolytic enzymes; up to 40% of enzymes may be absorbed intact by the process of phagocytosis. These enzymes may also be absorbed functionally intact. If macromolecules such as enzymes are absorbed functionally intact, is there evidence to support the use of enzymes in the postsurgical period? Data have been collected on both trauma and surgically created hematomas indicating a benefit from proteolytic enzymes. Studies have shown how enzymes reduce the severity and duration of inflammation. Clinical data exist to show how orally administered enzymes help reduce posttraumatic and postsurgical pain. In this patient, the recovery time was much shorter than would have been expected by routine treatment. Although a single case does not constitute clear proof of their function, it is well documented that oral enzyme compounds play an important role in the postsurgical treatment of patients undergoing cosmetic surgery, especially in the reduction of hematomas, edema, and pain after surgery and trauma. In this patient, enzymes may have played a significant role in reducing the postoperative morbidity, but a more thorough study is needed to prove such an assumption.
Taken from AESTHETIC SURGERY, St. Louis Vol. 18, No. J, pp. 40-41, February 1998 (Printed in the U.S.A.)
(Copyright© 1998, by American Society for Aesthetic Plastic Surgery, Inc.)
Add InflammEnz® to your next formula and deliver enzyme-driven recovery support backed by published human clinical research.* Designed to support inflammatory resolution, tissue repair, and faster recovery, InflammEnz® helps your products stand apart in post-procedure, performance, and recovery-focused applications.
