Stephanie E. Dreifuss

Spruelike enteropathy associated with olmesartan: an unusual case of severe diarrhea.

A 64-year-old male with a history of hypertension presented with worsening diarrhea and 25-pound weight loss over the preceding three months. Prior screening colonoscopy was unremarkable, and the patient failed conservative management. On presentation, the patient had orthostatic hypotension associated with prerenal azotemia for which olmesartan (40 mg/day) was held. Initial workup for chronic diarrhea was essentially unremarkable. Then, EGD was performed with small bowel biopsy, which showed a moderate villous blunting and an intraepithelial lymphocyte infiltration. Celiac disease was excluded by negative conventional serology tests and the absence of clinical response to a gluten-free diet. In the interim, diarrhea became resolving without any other interventions, and clinical response was achieved even with gluten-containing diet. Two months later, he achieved a complete resolution of diarrhea and regained 20-pound weight. Spruelike enteropathy is a clinical entity manifested by chronic diarrhea and intestinal villous atrophy. Spruelike enteropathy associated with olmesartan as a cause of drug-induced diarrhea is rare, and it has been reported only in a case series to date. This case highlighted the importance for clinicians to maintain a high index of suspicion for olmesartan as a precipitant of spruelike enteropathy.

Prevalence of endogenous CD34+ adipose stem cells predicts human fat graft retention in a xenograft model.

Background: Fat grafting is a promising technique for soft-tissue augmentation, although graft retention is highly unpredictable and factors that affect graft survival have not been well defined. Because of their capacity for differentiation and growth factor release, adipose-derived stem cells may have a key role in graft healing. The authors’ objective was to determine whether biological properties of adipose-derived stem cells present within human fat would correlate with in vivo outcomes of graft volume retention. Methods: Lipoaspirate from eight human subjects was processed using a standardized centrifugation technique and then injected subcutaneously into the flanks of 6-week-old athymic nude mice. Graft masses and volumes were measured, and histologic evaluation, including CD31+ staining for vessels, was performed 8 weeks after transplantation. Stromal vascular fraction isolated at the time of harvest from each subject was analyzed for surface markers by multiparameter flow cytometry, and also assessed for proliferation, differentiation capacity, and normoxic/hypoxic vascular endothelial growth factor secretion. Results: Wide variation in percentage of CD34+ progenitors within the stromal vascular fraction was noted among subjects and averaged 21.3 ± 15 percent (mean ± SD). Proliferation rates and adipogenic potential among stromal vascular fraction cells demonstrated moderate interpatient variability. In mouse xenograft studies, retention volumes ranged from approximately 36 to 68 percent after 8 weeks, with an overall average of 52 ± 11 percent. A strong correlation (r = 0.78, slope = 0.76, p < 0.05) existed between stromal vascular fraction percentage of CD34+ progenitors and high graft retention. Conclusion: Inherent biological differences in adipose tissue exist between patients. In particular, concentration of CD34+ progenitor cells within the stromal vascular fraction may be one of the factors used to predict human fat graft retention.

Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: is it safe?

Background: Brachioplasty continues to be a sought-after procedure among the massive weight loss population. Residual adiposity of the upper arm can make this procedure more difficult. The authors sought to determine the safety of arm liposuction outside the region of excision with concomitant excisional brachioplasty. Methods: Data were analyzed from a prospective registry of massive weight loss patients who underwent brachioplasty alone or with concurrent arm liposuction. Variables examined included age, sex, body mass index, method of weight loss, medical comorbidities, and smoking status. Outcomes included complications such as seroma, wound dehiscence, infection, hematoma, lymphedema, and need for revision. Multivariate analyses were performed to assess outcome measures. Results: One hundred forty-four patients (139 women and five men; mean body mass index, 29.6 ± 4.1 kg/m2; mean age, 46 ± 10.7 years) underwent brachioplasty. Sixty-four patients had concomitant arm liposuction at the time of brachioplasty. The remaining 80 patients underwent excisional brachioplasty alone. Despite significantly higher operative body mass indices among those undergoing concurrent liposuction, no significant differences in complication rates were seen between the liposuction and excision-alone cohorts for seroma (19.1 percent versus 23.1 percent), wound dehiscence (7.9 percent versus 2.6 percent), infection (4.8 percent versus 6.4 percent), hematoma (3.2 percent versus 0 percent), or lymphedema (3.2 percent versus 1.3 percent). Revision rates were similar between the two groups (9.5 percent with liposuction and 8.9 percent without liposuction). Conclusion: Liposuction can be performed safely and effectively outside the region of excision at the time of brachioplasty without the need for prior debulking or staged arm-contouring procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Bilateral congenital amazia: A case report and systematic review of the literature

BACKGROUND Congenital breast anomalies present challenging management decisions to the plastic surgeon. One must consider the optimal age of reconstruction as well as the ideal surgical technique. Amazia, a very rare condition characterised by a complete lack of breast tissue in the presence of a nipple areolar complex (NAC), is one such congenital breast anomaly. METHODS A comprehensive systematic review of the literature was performed to examine the various approaches to reconstruction of congenital breast anomalies. From this review, the data compiled included patient demographics and operative details, including type of reconstruction, treatment of the contralateral breast and treatment of the NAC. A case of bilateral amazia is also reported. RESULTS Of 178 articles, 13 ultimately met the inclusion criteria and 54 individual patient reconstructions were identified from these papers. At the time of reconstruction, the patients were in the range of 13-54 years, with an average age of 27.6 years. Prosthetic and autologous reconstructions were equally represented (19 patients each, 35.2%; Table 2). Autologous reconstruction with prosthesis was slightly less common (15 patients, 27.8%). One patient was reconstructed using autologous lipo-augmentation only. Of the 36 cases in which the approach to the NAC was addressed, most (66.7%) were not reconstructed. CONCLUSIONS Amazia is a very rare congenital anomaly of the breast. This systematic review of the literature highlights the need for better reporting and examination of this type of data to allow for future study and to better advise on decision making regarding the timing of reconstruction, surgical technique and the approach to the NAC.

Characterizing the Saddlebag Deformity After Lower Body Lift

Background One of the commonly cited sequelae of lower body lift is recurrence of the saddlebag deformity. However, there are currently no data that characterize the evolution of the saddlebag following lower body lift, nor is there a classification scheme to objectively quantify the severity of the deformity. Objectives The authors aimed to develop a grading scale to score the severity of the saddlebag deformity and, using this, determine the short- and long-term changes in the saddlebag following lower body lift. Methods Using the Pittsburgh Rating Scale, the Pittsburgh Saddlebag Rating Scale, a 4-point Likert scale, was developed to score the saddlebag deformity. Patients who underwent lower body lifts were parsed from a prospectively maintained database. Two educated observers independently reviewed both preoperative and postoperative photographs and graded the saddlebag deformity according to the Pittsburgh Saddlebag Rating Scale. Results Seventy-nine patients met inclusion criteria, including 5 males and 74 females. The average saddlebag score preoperatively was 1.34, while the average scores at short- and long-term follow up were 1.28 and 1.42, respectively. No significant differences in saddlebag severity scores were noted between preoperative and short- or long-term postoperative time points (P > 0.05). Conclusions This is the first study to objectively demonstrate the postoperative changes in the saddlebag following lower body lift. Results demonstrated that lower body lift does not effectively treat the saddlebag as the deformity only slightly improved in the short-term window but recurred within a year of surgery. Level of Evidence 4

Massive Scrotal Edema: An Unusual Manifestation of Obstructive Sleep Apnea and Obesity-Hypoventilation Syndrome

Obstructive sleep apnea (OSA) may occur in association with obesity-hypoventilation (Pickwickian) syndrome, a disorder of ventilatory control affecting individuals with morbid obesity. Through the pressor effects of chronic hypercapnia and hypoxemia, this syndrome may result in pulmonary hypertension, right heart failure, and massive peripheral edema. We present a case of severe scrotal edema in a 36-year-old male with OSA and obesity-hypoventilation syndrome. A tracheostomy was performed to relieve hypoxemia and led to dramatic improvement of scrotal edema. No scrotal surgery was necessary. Followup at two months showed complete resolution of scrotal edema, improvement in mental status, and normalization of arterial blood gas measurements. This case demonstrates that OSA and obesity-hypoventilation syndrome may present with massive scrotal edema. Furthermore, if OSA is recognized as the cause of right heart failure, and if the apnea is corrected, the resultant improvement in cardiac function may allow reversal of massive peripheral, including scrotal, edema.