Alessandra Campa

Late-onset gluteal Escherichia coli abscess formation 7 years after soft tissue augmentation with Bio-Alcamid™ in a HIV-positive patient

In 2002, a 41-year-old woman had been treated for severe buttock lipodystrophy resulting from highly active antiretroviral (HAART) therapy medication. During a single session the loss of subcutaneous fatty tissue had been compensated by injections of an undefined quantity of polyalkylimide 4% (Bio-Alcamid , Polymekon Biotech Industry, Milan, Italy). The post-treatment course had been uneventful and the patient had initially been satisfied with the result of this treatment. Seven years later, the patient presented with a redness and swelling of the area (Figure 1) by our unit. The area was hard and extremely painful on touch. All previous antibiotic therapies led only to temporary relief of these symptoms. A bedside drainage of the abscess was performed through a 20-gauge intravenous cannula that was inserted in the thin collagen capsule

Abdominoplasty as a reconstructive surgical treatment of necrotising fasciitis of the abdominal wall

OBJECTIVES Necrotising fasciitis (NF) is a potentially fatal, uncommon infection of the soft tissue with rapid progression. This article presents one case of NF of the abdomen wall, describing the presentation, diagnosis and long-term successful treatment. METHODS The defect of the abdominal wall was treated with medical support (antibiotics broad-spectrum coverage), V.A.C. therapy and plastic surgery procedures. RESULTS The coverage of the abdominal wall defect has been achieved by abdominoplasty-type advancement flaps in one step with the preservation of the umbilicus. One month after the surgical procedure, the patient returned to a normal lifestyle with a good quality of life. CONCLUSION The success of this case should be attributed to an early diagnosis, aggressive debridement and a good intensive medical management; these elements are essential to a better prognosis for NF.

Mesotherapy Should not Replace the Surgical Approach in the Treatment of Benign Symmetric Lipomatosis

We comment on the article by Hasegawa et al. [1] entitled Mesotherapy for Benign Symmetric Lipomatosis. Benign symmetric lipomatosis is a rare disorder characterized by multiple, symmetric, nonencapsulated fat masses in different body areas creating significant cosmetic deformity. Brodie [2] first described benign symmetric lipomatosis (BSL) in 1946, and Madelung [3], who named the syndrome, further characterized it, reporting 33 cases in 1888. Madelung disease usually is found between the third and seventh decade of life in middle-aged men of Mediterranean descent with a significant history of alcohol abuse [4]. In type 1 syndrome, the neck region and upper part of the trunk are involved, with a possible extension into the mediastinum. These masses generally are asymptomatic, but dysphagia, airway compression, and functional disability with neck movement limitation often have been described. A diffuse involvement of the body is seen in type 2 disorder, leading to an overweight-like aspect of the patient. Aesthetic deformities and peripheral neuropathy coupled with reports of movement limitation could be considered the major problem of Madelung disease. In only one case has malignant transformation of benign fatty masses been described [5]. At this writing, the true origin of Madelung disease is not clear. The most plausible advanced hypotheses are represented by an enzymatic defect or an alteration in the membrane receptors that would cause a reduction in adrenergic mediated lipolysis [6–9], a sympathetic denervation of brown fat adipocytes that would result in their hypertrophy [7], and mutations in the mitochondrial DNA [6, 8, 10]. In this context, alcohol could work as a cofactor by causing a reduction in both the number and activity of b-adrenergic receptors, promoting lipogenesis. However, alcohol intake certainly could not be the only cause of Madelung disease because the disorder is found also in patients who do not abuse alcohol. Association with several metabolic disorders such hyperuricemia, hyperlipidemia, diabetes mellitus, hypertension, hepatic disease, hypothyroidism, and renal tubular acidosis also is described in the literature [11–13]. Because the real etiology of Madelung disease still is unknown, only symptomatic treatment may be offered to patients. Alcoholic abstinence and correction of associated metabolic abnormalities are advocated to reduce the relapse rate once these patients have undergone surgery, although this has no effect on the dimension of fat masses already developed [6–8, 13]. The use of a b-2 agonist such as salbutamol has been emphasized by some authors [7–13]. Recently, Hasegawa et al. [1] proposed a conservative treatment for BSL. In addition to bilateral surgery at the shoulders, they treated neck masses with mesotherapy. Noninvasive intralesional injection of phosphatidylcholine combined with its emulsifier, deoxycholate (injected into lipomas, it causes focal necrosis, acute inflammation, and hemorrhage histologically) [1], were effective for removing small collections of adipose tissue. Cell lysis, resulting from the detergent action of deoxycholate, may account for this clinical effect of lecithin [1]. We appreciated the outcomes of the case shown in the article by Hasegawa et al. [1], who suggested conservative L. Rosato (&) D. Lazzeri M. Campana M. Vaccaro A. Campa S. Ciappi G. Nisi C. Brandi L. Grimaldi C. D’Aniello Plastic and Reconstructive Surgery Operative Unit, University Hospital of Siena, Policlinico Santa Maria alle Scotte, viale Bracci 1, 53103 Siena, Italy e-mail: chirplastica@gmail.com