EBV-Positive Diffuse Large B-Cell Lymphoma in Association with Polyurethane Textured Breast Implants: Case Report and Literature Overview.

OBJECTIVE: Lymphomas associated with breast implants are mostly of the T-cell type which typically present as a late-onset seroma or palpable mass adjacent to the implant. Primary lymphomas of the breast, in the absence of breast implants, are mostly of the B-cell type. However, we present a case of an Epstein-Barr virus-positive diffuse large B-cell lymphoma in a patient with polyurethane textured implants. CASE: A 75-year-old woman presented with a sudden onset of swelling in her right breast. Her medical history revealed a unilateral mastectomy at the age of 48 for an invasive ductal adenocarcinoma in her left breast. Reconstruction was performed using bilateral McGhan style 150 implants. Nine years later, she was diagnosed with Baker IV capsular contracture and bilateral rupture, as seen on magnetic resonance imaging. A complete capsulectomy with implant change (Polytech, Replicon® SL HP) and mastopexy on the right was performed. Given her history and the sudden onset of swelling, the situation was concerning. Ultrasound showed a large mass in contact with the implant and an effusion around it. After mastectomy with explantation and capsulectomy, she was diagnosed with an Epstein-Barr virus-associated diffuse large B-cell lymphoma (DLBCL) of the capsule in association with textured breast implants. CONCLUSION: We report the first case of polyurethane textured implant association with the rare entity of EBV+ DLBCL. Our aim is to renew awareness of the clinical significance of late periprosthetic seroma and highlight the need for documenting all cases to advance our understanding of breast implant-associated lymphoma. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study.

This study measured the number of complications after deep inferior epigastric perforator (DIEP) flap reconstruction performed under opioid-free anesthesia (OFA) combined with goal-directed fluid therapy or opioid anesthesia with liberal fluid therapy (OA). This retrospective cohort study consisted of 204 patients who underwent DIEP flap reconstruction at AZSint Jan Brugge between April 2014 and March 2019. Primary outcomes were complications, according to the Clavien-Dindo classification and the length of hospital stay (LOS). The secondary outcomes were flap failure, postoperative nausea and vomiting (PONV), postoperative pain, postoperative opioid consumption, and postoperative skin flap temperature. OFA included a combination of dexmedetomidine, lidocaine, and ketamine without any opioid administered pre- or intraoperatively. OA included a combination of sufentanil and remifentanil. OFA patients received strict goal-directed fluid therapy, whereas OA patients received liberal fluids to maintain perfusion pressure. All patients except 7 (TIVA with remifentanil) received inhalation anesthesia combined with an infusion of propofol. Of the 204 patients, 55 received OFA and 149 received OA. There were no differences in major complications, but fewer minor complications in the OFA group (17.9% vs. 51.4% and P < 0.001). Flap failure occurred in three patients of the OA group. Six patients developed flap thrombosis (five OA patients and one OFA patient). OFA was associated with fewer postoperative opioids, shorter LOS, less PONV, and less pain. In patients without previous nausea, the PONV incidence was higher in the OA group than in the OFA group (12.7% vs. 43.6% and P < 0.001). Patients with previous nausea more frequently required postoperative opioids and had a nausea rate of 60.87%.

Protein, lipid, and DNA radicals to measure skin UVA damage and modulation by melanin.

Afro-Caribbeans have a lower incidence of skin cancer than Caucasians, but the effectiveness of melanin as a photoprotective pigment is debated. We investigated the UVA and solar irradiation of ex vivo human skin and DMPO using electron spin resonance spectroscopy, to determine whether pigmented skin is protected by melanin against free radical damage. Initial ascorbate radicals in Caucasian skin were superseded by lipid and/or protein radical adducts with isotropic (a(H)=1.8 mT) and anisotropic spectra comparable to spectra in irradiated pig fat (a(H)=1.9 mT) and BSA. DNA carbon-centered radical adducts (a(H)=2.3 mT) and a broad singlet were detected in genomic DNA/melanin but were not distinguishable in irradiated Caucasian skin. Protein and lipid radicals (n=6 in Caucasian skin) were minimal in Afro-Caribbean skin (n=4) and intermediate skin pigmentations were variable (n=3). In irradiated Afro-Caribbean skin a shoulder to the melanin radical (also in UVA-irradiated pigmented melanoma cells and genomic DNA/melanin and intrinsic to pheomelanin) was detected. In this sample group, protein (but not lipid) radical adducts decreased directly with pigmentation. ESR/spin trapping methodology has potential for screening skin susceptibility to aging and cancer-related radical damage and for measuring protection afforded by melanin, sunscreens, and antiaging creams.

Safe and effective treatment of problem scars with the purely thermal non-ablative Er:YAG laser scar mode.

INTRODUCTION: Traumatic events as well as surgery can cause a large variety of scars, which are often a major psychological concern to patients. Moreover, patients often report itching or burning sensations as well as pain. We investigated the efficacy of purely non-ablative laser therapy in order to improve the appearance and quality of these scars. METHODS: A total of 62 patients with problem scars were enrolled in the study. The purely thermal, non-ablative scar mode of an Er:YAG laser (BURANE XL; Wavelight AG, Erlangen, Germany) was used. One to six treatment sessions were performed. The improvement of scar redness, scar flatness, scar quality, itching and burning sensations as well as pain and patient satisfaction were evaluated. RESULTS: The overall scar quality improved in 93% of patients. Similarly, the flatness improved in 89% of scars, itching sensation in 79% and burning sensation in 86% of patients. In 91% of scars a decrease of scar redness was seen and all painful scars showed a pain reduction. Average patient satisfaction was 7.4 on a 10-point scale. Sixty-one patients would recommend the therapy to another person. Side effects were limited to transient erythema and oedema. CONCLUSION: The high success rate combined with the low side-effects resulted in high patient satisfaction. Post-traumatic or post-surgical scars can safely and effectively be treated by the thermal scar mode of the Er:YAG laser used.

Traumatic tattoo: use of the variable pulsed erbium:YAG laser.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of removing traumatic tattoos in the skin by laser. The objective was to achieve selective dermabrasion on the tattoo site without injuries to the surrounding skin, as in the classical mechanical dermabrasion. METHODS: Four patients with traumatic tattoos in the face were treated by a variable pulsed erbium:YAG laser. The fluence of the ablative pulses was 5 J/cm(2). The end-point for the treatment was the macroscopic removal of the foreign bodies. Postoperatively, silver sulphadiazine or polyvinylpyrrolidone was applied daily until wound closure occured. Use of a total sun block was mandatory for a period of 6 months. Pre- and post-operative photographs were taken of all cases. The results were evaluated by a panel of four independent observers, who were asked to judge the percentage of tattoo clearance as well as any evidence of pigmentation problems or scarring. RESULTS: All results were rated from good to excellent. In all patients, a nearly complete clearance of the traumatic tattoo was achieved in one laser session. No scarring, skin atrophy, or hypo- or hyperpigmentation was observed. Furthermore, a high patient satisfaction rate was achieved. CONCLUSION: The selective ablation of scar/foreign body tissue is a safe procedure. Compared to results reported with 1064-nm laser treatments, where several laser procedures are necessary, better clearance and scar quality was observed. Compared to mechanical dermabrasion, the procedure is more reliable and causes fewer side effects.

Treatment of pyoderma gangrenosum with the anti-TNFalpha drug - Etanercept.

Pyoderma gangrenosum (PG) is a rare and painful skin condition of uncertain aetiology characterised by one or more areas of chronic ulceration with well demarcated and undermined borders. The exact pathogenesis of PG is poorly understood but an abnormality in the regulation of the immune system or its effectors is suspected. Pathergy (the development of lesions in areas of trauma) may also play a role in the development of PG. This implies that PG may be the result of an uncontrolled and exaggerated/altered inflammatory response to nonspecific stimuli. Patients of any age may be affected by PG but it occurs predominantly in the fourth or fifth decades of life. Patients with PG present with recurrent and destructive ulcers which may begin as pustules and eventually resolve as crater-like scars. As there are currently no diagnostic tests for PG the diagnosis must be made by exclusion. We now report the successful treatment of a patient with pyoderma gangrenosum, resistant to standard steroid therapy, using the anti-TNFalpha drug Etanercept. We believe that this is the first such report in the plastic surgery literature.