Alessandra Grassi Salles

Complications after Polymethylmethacrylate Injections : Report of 32 Cases

Background: During the past 15 years, polymethylmethacrylate has been used as a synthetic permanent filler for soft-tissue augmentation. Methods: This article reports 32 cases of complications seen at Hospital das Clínicas, Faculty of Medicine, University of São Paulo, for procedures performed elsewhere. Results: The average age of the patients was 43.6 years (range, 22 to 70 years). Twenty-five patients were women. Sixteen injection procedures were performed by certified plastic surgeons, nine by dermatologists, two by urologists, and one by a nonphysician. Complications were classified into five groups according to main presentation as follows: tissue necrosis (five cases), an acute complication that can be related to technical mistakes but that can also be dependent on patient factors or caused by local infection; granuloma (10 cases), which usually presents as a subacute complication 6 to 12 months after the procedure; chronic inflammatory reactions (10 cases), which usually occur years later and can be related to a triggering event, such as another operation or infection in the area that was injected (these reactions are immunogenic in origin and may have cyclic periods of activation and remission); chronic inflammatory reaction in the lips (six cases), which may be present with severe symptoms, especially with lymphedema, because of mobility of the lip; and infections (one case), which are rare but possible complications after filling procedures. Conclusions: Polymethylmethacrylate filler complications, despite being rare, are often permanent and difficult or even impossible to treat. Safety guidelines should be observed when considering use of polymethylmethacrylate for augmentation.

Complications with the use of botulinum toxin type a in facial rejuvenation: report of 8 cases.

The botulinum toxin A is produced by Clostridium botulinum and causes a reversible, selective muscle relaxation that leads to a temporary flattening of the mechanical component of wrinkling without the stigmata of invasive surgery. Since the end of the 1980s, this neurotoxin has been used to treat mimic facial lines with good results. Although this is considered a safe therapy, with adverse effects typically self-limited, more severe complications have been observed when it is used by nonskilled physicians or in improper dosages. This article reports eight patients treated with botulinum toxin A for aesthetic purposes who developed different complications. Treatment of the complication included the use of electrical stimulation, lymphatic drainage, antiinflammatory therapy, dipivefrine cloridrate drops, and other approaches. With specific treatment for each patient, the lengths of these complications seemed to be reduced.

Histologic Response to Injected Phosphatidylcholine in Fat Tissue: Experimental Study in a New Rabbit Model

The application of phosphatidylcholine to the fat tissue of humans for aesthetic purposes has recently been in evidence, despite the sparse literature corroboration of this practice. The authors developed a new experimental model to study injection of substances in fat tissue in rabbits. The objective of this particular study was to verify the possible effects of phosphatidylcholine injected in the animals. The animal weight, the fat pad weight, the presence of inflammatory infiltrate, and fibrosis and necrosis at the application sites were observed. Two groups of rabbits received five weekly applications to the dorsal fat pad. The control group received saline solution 0.9%, and the study group received phosphatidylcholine. The removed fat tissue was evaluated 3, 7, 14, and 21 days after the fifth application was completed. The phosphatidylcholine group presented more intense inflammatory infiltrate and fibrosis than the control group (p = 0.05). Necrosis was not observed in any animal. There was no statistically significant difference with regard to the weights of the animal or the fat pad. On the basis of this study, the injection of phosphatidylcholine is relatively safe, but no effect was observed regarding the reduction of fat tissue volume. New studies with higher doses are needed to justify the clinical use of this substance.

Mechanical evaluation of the resistance and elastance of post-burn scars after topical treatment with tretinoin

OBJECTIVE: After burn injuries, scarred skin lacks elasticity, especially in hypertrophic scars. Topical treatment with tretinoin can improve the appearance and quality of the skin (i.e., texture, distensibility, color, and hydration). The objective of this prospective study was to examine the effects of treatment with 0.05% tretinoin for one year on the biomechanical behavior and histological changes undergone by facial skin with post-burn scarring. Setting: Tertiary, Institutional. METHOD: Fifteen female patients who had suffered partial thickness burns with more than two years of evolution were selected. Skin biopsies were obtained initially and after one year of treatment. The resistance and elastance of these skin biopsies were measured using a mechanical oscillation analysis system. The density of collagen fibers, elastic fibers, and versican were determined using immunohistochemical analysis. RESULTS: Tretinoin treatment significantly lowered skin resistance and elastance, which is a result that indicates higher distensibility of the skin. However, tretinoin treatment did not significantly affect the density of collagen fibers, elastic fibers, or versican. CONCLUSION: Topical tretinoin treatment alters the mechanical behavior of post-burn scarred skin by improving its distensibility and thus leads to improved quality of life for patients.

Correction of eyelid anomalies in pachydermoperiostosis.

PURPOSE Pachydermoperiostosis, or primary hypertrophic osteoarthropathy, is a rare disease, characterized by pachydermia, acropathy, and periostosis. The authors propose the surgical correction of the eyelid anomalies in one stage. METHODS A 30-year-old patient with moderate blepharoptosis (3 mm) and increased vertical and horizontal dimensions of the upper eyelids underwent fusiform transverse excision of skin, orbicularis muscle, and tarsus; shortening of the levator palpebrae superioris apeoneurosis by 13 mm; and 8-mm-wide wedge excision. RESULTS Histologic findings included hyperplasia of the tarso-conjunctival plate, obstructive cystic dilatation of the sebaceous glands, extensive fibrosis, and granulomatous reaction. Satisfactory functional and aesthetic results were observed after surgery. CONCLUSION Upper eyelid anomalies in pachydermoperiostosis can be corrected in a single stage bilaterally with good results.

Epidemiologic Overview of Synkinesis in 353 Patients with Longstanding Facial Paralysis under Treatment with Botulinum Toxin for 11 Years

Background: Patients with longstanding facial paralysis often exhibit synkinesis. Few reports describe the prevalence and factors related to the development of synkinesis after facial paralysis. Botulinum toxin type A injection is an important adjunct treatment for facial paralysis–induced asymmetry and synkinesis. The authors assessed the clinical and epidemiologic characteristics of patients with sequelae of facial paralysis treated with botulinum toxin type A injections to evaluate the prevalence of synkinesis and related factors. Methods: A total of 353 patients (age, 4 to 84 years; 245 female patients) with longstanding facial paralysis underwent 2312 botulinum toxin type A injections during an 11-year follow-up. Doses used over the years, previous treatments (electrical stimulation, operations), and how they correlated to postparalysis and postreanimation synkinesis were analyzed. Results: There was a significant association between cause and surgery. Most patients with facial paralysis caused by a congenital defect, trauma, or a tumor underwent reanimation. There were no sex- or synkinesis-related differences in the doses used, but the doses were higher in the reanimation group than in the no-surgery group. Synkinesis was found in 196 patients; 148 (41.9 percent) presented with postparalysis synkinesis (oro-ocular, oculo-oral) and 58 (16.4 percent) presented with postreanimation synkinesis. Ten patients presented with both types. Conclusions: This study determined the high prevalence (55.5 percent) of synkinesis in patients with longstanding facial paralysis. Postparalysis synkinesis was positively associated with infectious and idiopathic causes, electrical stimulation, facial nerve decompression, and no requirement for surgery. Postreanimation synkinesis was present in 28.2 percent of reanimated patients and was significantly associated with microsurgical flaps, transfacial nerve grafting, masseteric-facial anastomosis, and temporalis muscle transfers.

Combined Tretinoin and Glycolic Acid Treatment Improves Mouth Opening for Postburn Patients

Postburn tissue repair progresses late, with changes in the skin’s physical properties. Clinically, the skin appears dry, scaly, and dyschromic, with diminished elasticity, particularly in the presence of hypertrophic scars. Improvement of postburn skin can be obtained by using topical agents normally used in pathologies such as acne and photoaging. This study analyzed 77 patients, ages 6 to 46 years, with late perioral burn sequelae. The resulting integument was classified as grafted or restored when it epithelialized spontaneously. Topical treatment consisted of tretinoin (0.01–0.05%) and glycolic acid (5–7%) over a 3-month period. With the mouth opened maximally, the interdental (D) and interlabial (L) distances were measured using a digital caliper. Significant increases in D and L distances were observed after treatment, as compared with controls (p < 0.01). These results were similar in the restored and skin-grafted groups.

Eyelid reconstruction using cartilage grafts from auricular scapha

Abstract The main goal, in eyelid reconstruction, is to promote an adequate protection to the ocular globe, through the reconstitution of all anatomic plans. In order to obtain adequate stability, cartilage grafts are often used in the repair of the internal lamella. Cartilage grafts from auricular scapha in contact with the bulbar conjunctiva were used in this study. Nineteen patients with various pathologies had 20 eyelid reconstructions using this technique (10 cutaneous tumors, 7 post-traumatic, and 3 cases of lower eyelid retraction). Local cutaneous flaps (glabella, Mustardè, etc) were used to reconstruct the external lamella. Epithelialization on the perichondrium (confirmed by the histological examination) occurs between 3 to 4 weeks. The functional and aesthetic result was considered good in 14 cases (70%), acceptable in 5 (25%) and poor in one case (5%). The donor area showed no complications or deformities. The shape of the scapha allows satisfactory conformation of the graft to the curvature of the ocular globe; it is not flat like the nasal septum, and has a smoother curvature than the auricular concha. Furthermore, it is thinner and that is another reason why the aesthetic result was superior to the technique previously used. The functional results were similar.

Successful Treatment of Pyoderma Gangrenosum after Augmentation Mastopexy Using Vacuum Therapy

Background: Pyoderma gangrenosum (PG) is a rare, severe, destructive neutrophilic dermatosis characterized by a progressive, necrotizing process after skin injury. Its cause is still unknown, and diagnosis represents a challenge when ulcers are seen after surgery. Bacterial infection is not found in the wounds. Patients exhibit “pathergy” with the appearance of new lesions after local trauma such as surgical procedures, debridements, and wound care, suggesting altered inflammatory response. The objective of this study was to review the literature and report a case of PG that was satisfactorily treated with vacuum therapy (vacuum-assisted closure [VAC]). Case Report: A 19-year-old healthy patient presented with skin ulceration 4 days after augmentation mastopexy, progressing to extensive necrosis. On the eighth day, she underwent debridement and implant removal. Two days later, the necrotic process was again evident and progressed, resulting in a significant increase in wound size, with each wound reaching 20 × 25 cm. Intense and diffuse neutrophilic exudate and areas of necrosis were present. Systemic corticosteroids and VAC under general anesthesia were initiated 5 days after the second surgery. From the fourth VAC session, some adherence between the mammary gland and pectoral muscles was visible, so deep sutures avoiding the dermis were placed to direct wound closure. Conclusions: PG is a life-threatening complication with devastating outcomes. Early diagnosis is critical. Although some reported cases needed up to 2 years for wound closure, in this case, VAC therapy allowed the patient to be discharged after only 42 days and permitted wound closure without the need for skin grafts.

Pseudoxanthoma Elasticum Treatment with Fractional CO2 Laser

Summary: Pseudoxanthoma elasticum (PE) is a rare genetic disease characterized by calcification and fragmentation of elastic fibers of the skin, retina, and cardiovascular system. We report a case of PE in which fractional carbon dioxide laser treatment was successfully used to achieve improvement of the cervical skin with 2-year follow-up, in a patient with Fitzpatrick skin type IV. After the fifth session, the patient presented with a local herpes infection. The postlaser reaction of the PE skin was similar to that of the normal skin, in terms of the duration of redness, pain, swelling, and duration of crusting. The overall cosmetic result was satisfactory, with improvement in skin texture, irregularity, volume, and distensibility. The herpetic infection reinforces the value of antiviral prophylaxis during laser treatment of extrafacial areas.