Marcello Pantaloni

Blindness following cosmetic injections of the face.

Background: Complications following facial cosmetic injections have recently heightened awareness of the possibility of iatrogenic blindness. The authors conducted a systematic review of the available literature to provide the best evidence for the prevention and treatment of this serious eye injury. Methods: The authors included in the study only the cases in which blindness was a direct consequence of a cosmetic injection procedure of the face. Results: Twenty-nine articles describing 32 patients were identified. In 15 patients, blindness occurred after injections of adipose tissue; in the other 17, it followed injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and calcium hydroxyapatite. Conclusions: Some precautions may minimize the risk of embolization of filler into the ophthalmic artery following facial cosmetic injections. Intravascular placement of the needle or cannula should be demonstrated by aspiration before injection and should be further prevented by application of local vasoconstrictor. Needles, syringes, and cannulas of small size should be preferred to larger ones and be replaced with blunt flexible needles and microcannulas when possible. Low-pressure injections with the release of the least amount of substance possible should be considered safer than bolus injections. The total volume of filler injected during the entire treatment session should be limited, and injections into pretraumatized tissues should be avoided. Actually, no safe, feasible, and reliable treatment exists for iatrogenic retinal embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular pressure to dislodge the embolus into more peripheral vessels of the retinal circulation, increasing retinal perfusion and oxygen delivery to hypoxic tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

ALK-1-negative anaplastic large cell lymphoma associated with breast implants: a new clinical entity.

Concerns have been raised recently regarding the increasing number of reports of non-Hodgkin lymphoma (NHL) that developed in close proximity to silicone or saline breast implants. In particular, an increased risk of anaplastic large cell lymphoma (ALCL) in patients with breast prostheses has been proposed. We reviewed clinical and pathologic findings in 40 women who received a diagnosis of breast NHL arising in association with breast implants and of 27 patients who had a diagnosis of ALCL with breast involvement reported in the published literature. Among the 40 reported cases of prosthesis-associated breast lymphomas, 28 were anaplastic lymphoma kinase-1-negative (ALK-1(-)) ALCLs, whereas of 27 ALCLs in patients without implants found in the literature, only 10 were ALK-1(-). The finding of 28 cases of breast ALK-1(-) ALCL occurring in patients with implants compared with 10 cases in women without implants is in favor of an association between silicone breast prostheses and ALK-1(-) ALCL. Although the incidence of this type of lymphoma remains remarkably low given that breast prostheses have been widely used for decades, clinical and pathologic evidence for a causative role is becoming dramatically strong. The histologic, phenomenologic, and clinical similarities of the majority of implant-related ALK-1(-) ALCLs suggest a common mechanism, especially when compared with the counterpart of patients without implants in which very few and highly dishomogeneous cases of the same malignancy were detected. There is convincing evidence that primary implant-related ALK-1(-) ALCL represents a distinct clinicopathologic entity that has been inappropriately fitted into the category of systemic ALK-1(-) ALCL. Thus it should be recognized as a separate category and classified on its own.

Distally based peroneus brevis muscle flap in reconstructive surgery of the lower leg: Postoperative ankle function and stability evaluation

BACKGROUND Defects of the distal third of the lower leg with exposed tendons or bone require either local or free flap coverage. Several flaps have been developed, and the distally pedicled peroneus brevis muscle flap has been proven to be a valid local flap alternative. PATIENTS AND METHODS Peroneus brevis muscle is dissected from the lateral surface of the fibula from proximal to distal, but no further than approximately 3-6 cm proximally to the lateral malleolus, where the most distal vascular pedicle from the peroneal artery enters the muscle consistently. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split-skin graft. Between 2002 and 2008, 10 patients with defects of the lower leg in the distal lower third have been treated using this muscle flap. The defects were located over the Achilles tendon, the medial and lateral malleolar, the anterior region of the ankle and the heel area. Each patient was examined through assigning clinical demerit points according to a modified Weber scale, and through Olerud-Molander ankle score to analyse postoperative ankle stability and functionality after reverse peroneus brevis flap reconstruction of the defect. RESULTS All flaps survived completely, and no secondary local flap was required. In our experience, no complication or patient discomfort was noted. Donor-site morbidity was acceptable and restricted to the scar in the lateral lower leg. As demonstrated by the two score evaluations, the functions of foot eversion and plantar flexion as well as ankle functionality and stability were maintained due to preservation of peroneus longus muscle. CONCLUSION The reverse peroneus muscle flap is ideally suited for small-to-moderate defects of the distal third of the lower leg. This flap offers a convincing alternative for covering defects in the distal leg region. Its arc of rotation allows coverage of more anterior defects of the ankle, of defects of the Achilles tendon and of the heel area as well as of lateral and medial malleolus areas. It is simple to raise and is often transposed easily within the wound without further dissection. As long as the peroneus longus is preserved, ankle instability is not expected.

Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience.

PURPOSE Rhinophyma is characterized by slowly progressive tumour-like enlargement of the nasal skin that will not resolve spontaneously. Though its treatment consists of surgical removal of the hyperplastic alterations, in the literature there is not general agreement about the best method. We presented our experience with two different treatment modalities such as decortication by scalpel and CO2 laser treatment. METHODS The authors reviewed the long-term results of 67 patients affected by rhinophyma treated with two different methods between 1996 and 2011. Outcomes were determined by case notes, clinical review and patient satisfaction questionnaire. RESULTS Forty-five cases were treated with tangential excision and 22 with a CO2 laser. Minor complications, including scarring and hypopigmentation, were seen in 6 patients. All patients were satisfied with their outcomes at the follow-up visit, and no major complications were detected during follow-up. CONCLUSION Both tangential excision and carbon dioxide laser are well-established, reliable procedures for rhinophymaplasty that preserve the underlying sebaceous gland fundi allowing spontaneous re-epithelialization without scarring with similar outcomes and high patient satisfaction. The original nose shape and nearly normal skin surface texture are preserved by quickly removal of the hypertrophic tissue sparing the pilosebaceous tissue. The CO2 laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs.

Skin-reducing mastectomy: New refinements

Abstract Skin-reducing mastectomy is a single-stage technique that helps us to overcome the cosmetic inadequacy of a Type IV Wise pattern skin-sparing mastectomy (final T-inverted scar) in heavy and pendulous breasts by filling the lower-medial quadrant with adequate volume. It also conceals scars as an aesthetic operation and at the same time provides satisfactory and safe coverage of the implant. We report our experience with 22 skin-reducing mastectomies done for 18 women. We modified part of the original description of raising the dermal flap to refine the anatomical results. This flap was mobilised better by detachment of the lateral part of its insertion along the inframammary fold, and this allowed us to close the dermomuscular pouch inferiorly and laterally without raising the serratus anterior or limiting its rise. The total or partial preservation of the serratus muscle together with the creation of a force directed medially, as indicated by the dermal flap, reduced the risks of lateral dislocation of the implant and improved the lateral breast contour to give a more natural shape. Skin-reducing mastectomy is an oncologically safe skin-sparing mastectomy that solves all cosmetic problems and reduces complications of the original Type IV Wise pattern in medium to large breasts. Doing the mastectomy and reconstruction in a single stage aids the favourable psychological approach of the patient. We emphasise the use of our small modification to refine the contour of the breast and improve the aesthetic outcomes by giving a natural curvilinear profile.

A Dermomuscular Pocket Provides Superior Coverage of the Implant in Skin-Reducing Mastectomies

We comment on the paper by Bayram and colleagues entitled Skin-Reducing Subcutaneous Mastectomy Using a Dermal Barrier Flap and Immediate Breast Reconstruction With an Implant: A New Surgical Design for Reconstruction of Early-Stage Breast Cancer [1]. Type 4 skin-sparing mastectomy (SSM) involves heavy and pendulous breasts that require a conspicuous reduction of the skin envelope and a contralateral reduction or mastopexy [2]. Two main limitations have been observed in performing breast reconstruction using this SSM approach. The first limitation is the risk for ischemic necrosis of the two long, thin superior flaps that close down to the inframammary fold, which may lead to healing complications of the inverted T-scar such as superficial epidermolysis, wound dehiscence, and implant exposure. The second limitation is the resulting excessive upper pole fullness due to the presence of a permanent implant in the lower pole of the reconstructed breast that lacks projection. Several personal approaches to overcome these limitations have been proposed. Among these techniques, skinreducing mastectomy (SRM), described by Nava et al. [3], completely releases the pectoralis muscle inferiorly and spares a lower dermal flap sculpted down to the inframammary fold. This procedure allows the creation of a dermomuscular pouch, achieving total implant coverage and overcoming all the inadequacies of type 4 SSM. By augmenting the pocket and providing a new tissue layer at the lower pole of the breast, complications are reduced, and aesthetic outcomes improved compared with those for the traditional inverted T mastectomies [2–7]. We performed 22 SRMs (19 curative and 3 prophilactic) [5] for 18 women following the preoperative assessment according to Nava et al. [3]. For reconstruction of breasts treated with SRMs, style 410 anatomically shaped, highly cohesive silicone gel implants were used. The mediumsized implant was 423 ml. The largest implant was 515 ml and the smallest was 335 ml. We had a minor complication rate of 9% (n = 2), and no severe complication requiring device explantation was observed. One patient (a smoker) experienced superficial epidermolysis of the superior flaps, which was resolved with conservative treatment by regular dressing. In another patient, a 3 9 3-cm area of cutaneous necrosis developed around the T-scar junction and was treated with an autologous split-thickness grafting to respect the timing of chemotherapy. In their paper describing their experience with skinreducing subcutaneous mastectomies (SRSMs), Bayram et al. [1] criticized the submuscular lodging of large prostheses as suboptimal because pressure on the prosthesis may cause low-level breast projection. In addition, they emphasized that preparation of the submuscular area may increase the mean time for the surgical procedure. Notwithstanding, we think that because the implant is well covered, this should help reduce the main sequelae that could affect the final appearance of the new breast, such as capsular contracture after radiotherapy and rimpling due to the thin soft tissue layer coverage, especially in the upper pole and the lateral and medial aspects of the breast. As noted in our experience, SRM prevents complications of type 4 SSM such as a lack of space in the inferior and medial aspects of the submuscular pouch that L. Colizzi D. Gandini M. Pantaloni D. Lazzeri (&) Plastic and Reconstructive Surgery Unit, Hospital of Pisa, Via Paradisa 2, Cisanello, 56100 Pisa, Italy e-mail: davidelazzeri@gmail.com

Plastic surgery and Munchausen's syndrome: ‘surgeon, beware!’

A 24-year-old woman was admitted to our department with a loss of substance of the volar aspect of her right forearm. Surgical debridement and subsequent coverage with skin graft were required. Her symptoms had started 10 months earlier when she had broken her right wrist. Right forearm cellulitis had been diagnosed 2 weeks after the gypsum was removed and treated in several hospitals under different specialties. Because her condition had gradually worsened, she was referred to our unit. The medical history of the patient was considerable despite her young age. She had diagnosis of chronic hyposideremic anaemia, moderate depression, hiatal hernia and haemorrhoids. Moreover, she had already undergone adenoidectomy, appendectomy and reductive mammaplasty. Within the next 5 months four consecutive surgical debridements were performed because of recurrences (painful swelling, skin necrosis, hot and indurated subcutaneous areas and ulcers of different sizes) on her right forearm (Figure 1). Two months later, two abdominal wounds appeared (Figure 2), having the same features of the lesions on the forearm. She was afebrile; all baseline investigations including blood count and serum electrolytes were normal. Necrotic tissue was debrided again thrice in a month. Although further evaluations were carried out, haematologic, rheumatologic, infective, allergic and toxic causes were all excluded. Another area of inflammation developed in much the same way on the patient’s left forearm. Again, histopathological and bacteriological examinations were not helpful, as no organisms had been cultured from any of the wound swabs, blood cultures or tissue specimens. At this stage, suspicion was raised regarding the possible factitious nature of her problem because of an inability to explain the cause of her wounds. Finally, a suspicious amount of toothpaste and after shave cream packaging was found during the inspection of patient’s bathroom while she was out for a consult. Chemical analysis confirmed that subcutaneous toothpaste and cream injections were the organic cause of the multiple inflammatory reactions present in the lesions. We confronted with the patient. She became a little

Ischemic Optic Neuropathy as a Rare but Potentially Devastating Complication of Liposuction

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Lipolysis using a new 1540-nm diode laser: A retrospective analysis of 230 consecutive procedures

Abstract Background: Although traditional liposuction still remains the most required body sculpting procedure, laser lipolysis systems are becoming increasingly popular. The feasibility and efficacy of a new 1540-nm diode laser for suction-assisted laser lipolysis were evaluated. Methods: Two hundred-thirty patients underwent a new 1540-nm diode laser lipolysis. Outcomes were determined by case notes, clinical review of side effects, and a questionnaire through which patient satisfaction was assessed. Macroscopic and histologic effects on subcutaneous fat and collagen deposition were evaluated. Moreover thermal effects were studied through thermography. Results: The treated regions were abdomen in 56 cases, thighs in 54, trochanteric area in 27, flanks in 17, neck in 14, arms in 12, breast in 11, hips in 7, knees in 3; 29 cases were revisions of previous lipoplasties. No adverse effect as scarring, infection, burns, hypopigmentation, bruising, or swelling was observed. The required effects of laser lipolysis such as contour reshaping and skin tightening were achieved in almost all patients with high levels of satisfaction after treatment. Conclusion: Our investigation highlighted the safety and efficacy of the new 1540-nm diode laser assisted liposuction device for removal of small volumes of fat deposits associated with concurrent subdermal tissue contraction, tolerance and quick recovery time.

More on periorbital infections following therapy with biological agents

With great interest, we read the article by Roos and coworkers entitled “Necrotizing group A streptococcal periorbital infection following adalimumab therapy for rheumatoid arthritis (1)” . We congratulate the authors for the management of their case and for the extremely useful review of the literature of cases of eye infections following the administration of biological agents. We would take the opportunity to discuss some more key points on this rare disease and point out the presence in the literature of a case of ocular and adnexal infections occurred after treatment with a further monoclonal antibody, Rituximab. Rituximab has been the first monoclonal antibody to be approved for therapeutic use (2). It is a chimeric monoclonal antibody targeted against the pan-B-cell marker CD20. It is indicated for the treatment of patients with relapsed or refractory CD20-positive follicular non-Hodgkin’s lymphoma and in combination with fludarabine and cyclophosphamide, for the treatment of patients with previously untreated and previously treated CD20-positive chronic lymphocytic leukemia (CLL). Finally, Rituximab in combination with methotrexate is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies. Recently, we have managed a case of periorbital necrotizing fasciitis (NF) caused by Pseudomonas aeruginosa in a 49-year-old patient with a history of CLL that had been treated previously with four complete cycles of chemotherapy (fludarabine, cyclophosphamide, Rituximab) waiting for an autotransplant (3). The patient was immediately started on large dose intravenous (i.v.) broad-spectrum antibiotics, and after the cultural results, the patient was started on high doses of meropenem (2 g every 8 h) and i.v. ciprofloxacin (400 mg every 8 h). In addition, he received daily cycles of oxygen hyperbaric treatments and underwent repeated surgical consecutive debridements. The coverage of the lesion was provided with a microsurgical free flap followed by eyelid reconstruction once the wounds were stable. Although the defect has been almost completely restored and eyelid functionality has been in great measure recovered, residual disfigurement with partial loss of definition of the normal contours of left eyelids still persists. This unusual event (3 ) might be related to deterioration of humoral immunity caused by Rituximab, and to our knowledge, this is the first case of bacterial perior bital NF following this type of monoclonal antibodies use. As already described by Roos and colleagues (1), several further biological agents administration may be followed by bacterial infection of eye and periorbita. Physicians should be aware of these complications in patients receiving biological agents even when no prior history of trauma is reported, thus being early