Alan A. Parsa

Mycobacterium Cheloneae Infection After Breast Augmentation

Augmentation mammaplasty is one of the most commonly performed plastic surgery procedures. Infection, still one of the most feared complications of the procedure, usually is caused by skin commensal organisms. A wide variety of other organisms also may be responsible for these postoperative infections, including atypical mycobacteria. A case of a prosthetic breast implant infected with Mycobacterium cheloneae is presented, and the presenting signs and symptoms, diagnosis, and treatment options of such an infection are discussed. The importance of promptly isolating the pathogen for potential salvage of the prosthesis also is stressed, as well as the operative intervention necessary when conservative therapy fails.

Lower Blepharoplasty with Capsulopalpebral Fascia Hernia Repair for Palpebral Bags : A Long-Term Prospective Study

Background: In December of 1998, the authors published a prospective study in Plastic and Reconstructive Surgery (102: 2459, 1998) comparing standard lower blepharoplasty with lipectomy on one side and fat-preserving capsulopalpebral fascia hernia repair on the contralateral side; comparable aesthetic outcomes were demonstrated after 6 months of follow-up. In the present study, the authors report their findings on the original patient cohort with an average follow-up of 11.3 years. Methods: From 1991 to 2007, 26 patients were identified who had previously undergone lower blepharoplasty for palpebral bags, using fat removal on one side and fat preservation on the contralateral side. These patients were evaluated, and the incidence and locations of palpebral bag recurrence, lower lid hollowing, lid malposition, and eyelid dysmobility were documented. Results: The overall recurrence rate of palpebral bags under the eyes following standard fat resection (30.8 percent) was significantly higher than for eyes following capsulopalpebral fascia hernia repair (7.7 percent) (p = 0.043). Recurrences of fat herniation, of generally less significance than the original preoperative status, were not found in any of the lower eyelid compartments in the former group, and only in the lateral compartment in the latter. Conclusions: At long-term follow-up, fat-preserving capsulopalpebral fascia repair for palpebral bags demonstrates superiority to standard blepharoplasty with lipectomy, with significantly lower recurrence of palpebral bags. In a small percentage of patients undergoing capsulopalpebral fascia hernia repair, limited fat resection in selected patients may eliminate hernia recurrence.

Steroid 21-hydroxylase deficiency in congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) refers to a group of inherited genetic disorders involving deficiencies in enzymes that convert cholesterol to cortisol within the adrenal cortex. There are five key enzymes involved in the production of cortisol. Of these key enzymes, deficiency of 21-hydroxylase is the most commonly defective enzyme leading to CAH representing more than 90% of cases. The low adrenal cortisol levels associated with CAH affects the hypothalamic-pituitary-adrenal negative feedback system leading to increased pituitary adrenocorticotropic hormone (ACTH) production, which overstimulates the adrenal cortex in an attempt to increase cortisol production resulting in a hyperplastic adrenal cortex. The deficiency of enzyme 21-hydroxylase results from mutations or deletions in the CYP21A2 gene found on chromosome 6p. The disorder is transmitted as an autosomal recessive pattern and specific mutations may be correlated to enzymatic compromise of varying degrees, leading to the clinical manifestation of 21-hydroxylase deficiency (21-OHD) CAH.

HIV and thyroid dysfunction

Human Immunodeficiency virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS) are associated with dysfunction of many endocrine organs and their axis. HIV infectivity leads to altered metabolism, poor oral intake and increased prevalence of weight loss and wasting which may have a role in thyroid dysfunction. Overt thyroid dysfunction occurs at similar rates as the general population while subclinical disease such as nonthyroidal illness (sick euthyroid syndrome), subclinical hypothyroidism and isolated low T4 levels are more frequent. Moreover, HAART therapy can complicate thyroid function further through drug interactions and the immune reconstitution inflammatory syndrome (IRIS). In this review we report the common thyroid dysfunctions associated with HIV before and after HAART therapy. We discuss presentation, diagnostic work up, treatment and follow up in each condition.

Congenital Adrenal Hyperplasia Owing to 21-Hydroxylase Deficiency

Abstract Congenital adrenal hyperplasia (CAH) refers to a group of autosomal recessive genetic disorders that arise from defective steroidogenesis. The 21-hydroxylase deficiency (21OHD) is the most common form of CAH, accounting for more than 90% of cases. It is the most common disorder of sexual development (DSD) in females. The gene is encoded by CYP21A2, which is located on the short arm of chromosome 6 (6p21.3). The activity of the enzyme 21-hydroxylase, encoded by the CYP21A2 gene, is deficient, leading to an accumulation of 17-hydroxyprogesterone (17-OHP) and subsequent elevation of androgens. The three forms of 21OHD are the salt-wasting form, simple-virilizing form, and non-classical form. The first two forms are classical forms of the disease where the hallmark finding is ambiguity of the genitalia in affected female newborns. Patients with the non-classical form have normal genitalia, yet may present with signs of early sexual development and other symptoms of hyperandrogenemia such as short stature, hirsutism, acne, and impaired fertility. Hormonal testing is important in making the diagnosis of 21-hydroxylase deficiency, yet genetic testing is crucial to secure the diagnosis. More than 100 mutations have been identified caused by gene conversions, large scale gene deletions, and de novo mutations, and novel mutations are continuously being identified. Genotype–phenotype non-concordance is observed in a significant number of patients.

Low-Renin Hypertension of Childhood

Low-renin hypertension occurs in children as a result of several genetic mutations that cause mineralocorticoid excess or excess stimulation of the mineralocorticoid receptor. This article discusses the genetic disorders that cause low-renin hypertension.

The Use of Celecoxib for Reduction of Pain After Subpectoral Breast Augmentation

A study was conducted to determine whether a single 400-mg dose of oral celecoxib administered 30 min before surgery reduces the opioid requirement for patients undergoing aesthetic subpectoral breast augmentation. A total of 695 patients undergoing breast augmentation were randomly selected into either a placebo or a treatment group. The findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly fewer opioid analgesics after the operation than those given a placebo (p < 0.001). It also was found that nonsmokers and multiparous women required significantly fewer opioids than smokers and nulliparous women (p < 0.001). On the basis of this prospective study, the authors recommend a single 400-mg dose of celecoxib administered 30 min before surgery to decrease opioid analgesic requirements after subpectoral breast augmentation.

Long Range Outcome of Prenatal Treatment

Prenatal diagnosis and treatment has been carried out since 1986. The prenatal diagnosis is based on DNA analysis of fetal tissue obtained by amniocentesis or chorionic villus biopsy. Because the genetic analysisis usually not available before treatment with low-dose dexamethasone, all fetuses are treated until the diagnosis of CAH is genetically secured. Congenital adrenal hyperplasia is transmitted as an autosomal recessive trait; both male and female fetuses are at risk. As only affected female fetuses require treatment and male fetuses and unaffected female fetuses do not require treatment, seven out of eight fetuses are temporarily treated unnecessarily. We have evaluated the long-range effect of prenatal low-dose dexamethasone treatment in male and female fetuses who are now 12 years and older. The data include male and female fetuses treated or not treated with low-dose dexamethasone treatment. The following parameters were evaluated: (1) medical outcome including diabetes, hypertension, and fractures and (2) psychoendocrine outcome including cognition, gender, behavior, and performance. This was a collaboration between the USA (indicated as A) and France (indicated as Fr). The number of patients with CAH both males and females who were studied, including patients salt wasting CAH (SW), patients with the simple virilizing form of CAH (SV), and patients with non-classical CAH (NC), and patients not affected with CAH (no CAH) is depicted in this chapter. There were 78 patients who were not treated, 4 who were partially treated, and 14 who were treated throughout pregnancy for a total of 136 patients

Comparison of mean labial width in patients requesting labioplasty to a healthy control: an anatomical study.

1. Witte MB, Barbul A. General principles of wound healing. Surg Clin North Am. 1997;77:509–528. 2. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: A meta-analysis. Obstet Gynecol. 2004;103:974–980. 3. Kore S, Vyavaharkar M, Akolekar R, Toke A, Ambiye V. Comparison of closure of subcutaneous tissue versus non-closure in relation to wound disruption after abdominal hysterectomy in obese patients. J Postgrad Med. 2000;46:26–28. 4. Molea J, Poitras DJ, Van De Water JA. Technique for fixation of retention sutures using two bolsters. Surg Gynecol Obestet. 1989;169:167–168.

Thyroxine Therapy for Thyroid Nodules

The administration of thyroid hormones at suppressive doses to shrink thyroid nodules remains controversial. While suppressive therapy may lead to nodular size regression, this is only seen in a small minority of patients and is, importantly, associated with complications caused by chronic low TSH. Here we offer some historical reference to this practice along with recent reports supporting current recommendations not to treat thyroid nodules with suppressive T4 therapy.