Radiation-induced cutaneous vasculopathy of the breast: a rare case report.

BACKGROUND: Radiation therapy is often indicated as part of the treatment for breast cancer and is therefore used frequently worldwide. Vasculopathy is a general term used to describe any condition that affects blood vessels. We present a case report of a patient who presented with vasculopathy as a rare late side effect of radiation therapy to the breast. CASE PRESENTATION: This 66-year-old woman was initially treated with breast-conserving surgery for early-stage receptor-positive left breast carcinoma. She received postoperative radiation therapy and hormonal treatment with tamoxifen. She developed sudden spontaneous painless ecchymosis spread over the whole irradiated area 1.5 years after finishing her radiation therapy. Tumor relapse was excluded. There was no associated vasculitis. The cause was presumed to be multifactorial. She had a history of smoking and was known to have hyperlipidemia. She had undergone several surgical treatments at the left breast one year after her initial breast-conserving treatment and was taking tamoxifen. Anti-inflammatory medicine and treatments increasing local blood flow were prescribed. The ecchymosis resolved completely within one month. CONCLUSIONS: Vasculopathy can occur as a rare late side effect of radiation therapy. It can be reversible. Prevention begins with carefully treating precipitating factors.

Peroperative Cooling in Rhinoplasty: Does it Differ?

The main causes of ecchymosis and edema are osteotomy (bone manipulation), dissection of subcutaneous tissue, and skin manipulation in the rhinoplasty procedure. Eyelid edema following surgery can potentially affect visual acuity, particularly during the initial twenty-four hours after the procedure. These may also delay the patient's return to their normal social life therefore hampering their quality of life. Various surgical and medical methods have been reported to address these issues. This study aimed to compare the effects of using cold saline (0-4 °C) versus room temperature saline (20-25 °C) irrigation throughout the surgery on postoperative edema, ecchymosis, and pain. Fifty patients who underwent open-approach primary rhinoplasty between August 2022 and August 2023 at a tertiary academic center were included. Fifty patients were randomly divided into two groups depending on using cold saline (0-4 °C) (group 1) or room temperature saline (20-25 °C) (group 2) during surgical site irrigation. Patients were assessed for pain, edema, and bruising using a VAS (Visual Analog Scale) on the second and seventh postoperative days. Visual analog score (VAS) was used for subjective outcome analyses. Each patient scored the severity of their periorbital ecchymosis on day two and seven. Periorbital ecchymosis was also evaluated on the second and seventh postoperative days using the SPREE (Surgeon Periorbital Rating of Edema and Ecchymosis) scale. On the second postoperative day, the VAS pain score in group 1, where cold water was used, was found to be statistically and significantly different from the control group (group 2) (p < 0.05). However, there was no statistically significant difference between both groups when comparing the VAS pain scores on the seventh postoperative day. Regarding the VAS ecchymosis score on the seventh postoperative day, there was a statistically significant difference favoring group 1 (p < 0.05). The SPREE scale data also indicated that group 1 had significantly lower scores on the seventh day (p < 0.05). While the SPREE scores on the second day were lower in group 1 than in group 2, this difference did not reach statistical significance (p = 0.061). The findings from our study show that cold saline irrigation may contribute to intraoperative hemostasis by inducing local vasoconstriction. We observed that intraoperative bleeding decreased with the use of cold saline. This approach has the potential to improve patient satisfaction and overall quality of life by reducing postoperative ecchymosis without significantly increasing the cost of the surgical procedure.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 .

Evaluating the Effect of Tranexamic Acid Local Injection on the Intraoperative Bleeding Amount and the Postoperative Edema and Ecchymosis in Primary Rhinoplasty Patients: A Randomized Clinical Trial.

BACKGROUND AND AIMS: The purpose of this study was assessing the effect of local injection of tranexamic acid (TXA) on the amount of bleeding during the primary rhinoplasty and edema and ecchymosis following the surgery. METHODS: In this randomized clinical trial, 50 patients applying for primary rhinoplasty were divided into two groups of intervention and observation. In the intervention group, 10 mg/kg of TXA was injected locally to the operation field. In the observation group, no medicine was injected. The same anesthesia technique was used during the operation for all the patients. Age, sex, blood pressure, bleeding amount during the operation, the amount of edema and ecchymosis on the first and seventh day after the surgery were noted. The data were analyzed by the SPSS software version 24 and using descriptive statistics of frequency and percentage of frequency and Fisher and Mann-Whitney's exact statistical tests. RESULTS: Our results showed that there was a significant difference between the amounts of bleeding during the surgery between two groups (P-value < 0.001). Also, the postoperative edema on the first and seventh day in intervention group was less than the observation group (P-value < 0.001). There were no complications during the surgery and in the follow-up of the patients. CONCLUSION: We revealed that local injection of TXA during the rhinoplasty procedure and decreased the intraoperative bleeding and postoperative ecchymosis and edema without any side effects and complications. 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.

Tranexamic Acid in Patients Undergoing Rhinoplasty: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Rhinoplasty is one of the most popular aesthetic plastic surgeries worldwide. The effects of tranexamic acid (TXA) in patients undergoing rhinoplasty are still being studied to guide a better management. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) analyzing the effects of TXA in patients undergoing rhinoplasty. The outcomes evaluated were blood loss, postoperative edema, postoperative ecchymosis, surgery duration and surgeon satisfaction. RESULTS: Eleven studies comprising 841 patients were included. Overall, TXA reduced total blood loss regardless of dose and administration route (MD = - 39.37 mL; 95% CI = - 62.70 to - 16.05 mL; p = 0.0009; I2 = 92%), using intravenous 10 mg/kg of TXA preoperatively (MD = - 16.30 mL; 95% CI = - 29.49 to - 2.57 mL; p = 0.02; I2 = 61%) and using 1 g of oral TXA preoperatively (MD = - 61.70 mL; 95% CI = - 83.02 to - 40.39 mL; p < 0.00001; I2 = 0%). TXA also decreased edema (MD = - 0.78; 95% CI = - 1.28 to - 0.27 points; p = 0.003; I2 = 80%) and ecchymosis (MD = - 1.13; 95% CI = - 1.99 to -0.28; p = 0.01; I2 = 93%) on postoperative day one (POD 1). Surgeon satisfaction was increased (SMD = 1.55; 95% CI = 0.33 to 2.77; p = 0.01; I2 = 95%). However, there was no difference in surgery duration (SMD = - 0.26; 95% CI = - 0.56 to 0.04; p = 0.09; I2 = 36%). CONCLUSION: This study found a significant reduction in blood loss, periorbital edema and periorbital ecchymosis, along with an improvement in surgeon satisfaction. These results hold the potential to optimize the rhinoplasty management by plastic surgeons. LEVEL OF EVIDENCE I: 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 .

Tranexamic Acid and Rhinoplasty: How Do Different Administration Routes Affect Effectiveness?

BACKGROUND: The aim of this study was to evaluate the effectiveness of the intravenous, oral and local application of tranexamic acid in operation time, intraoperative bleeding, postoperative edema and ecchymosis in rhinoplasty. METHODS: This was a randomized, double-blinded, prospective study. We included 146 patients who underwent rhinoplasty at the Bezmialem Vakif University Medical Faculty Otorhinolaryngology Clinic between April 2021 and April 2022. The patients were divided into four groups: Group 1 (intravenous TXA), Group 2 (oral TXA), Group 3 (topical TXA), and Group 4 (control). Operation time was recorded. Bleeding volume was measured in the suction chamber and nasopharyngeal pack. Postoperative edema and ecchymosis were evaluated using a scale at the end of the operation, on the 1st, 3rd, and 7th days. RESULTS: There was no statistically significant difference between groups in terms of mean operation time (p = 0.894). There was a statistically significant lower mean intraoperative bleeding level in Group 2 from the other groups (p = 0.020). Group 3 had significantly lower scores for postoperative edema than the other groups at the end of the operation, on the 1st, 3rd, and 7th days (p < 0.05), and significantly lower scores for postoperative ecchymosis at the end of the operation (p = 0.013) and on the 3rd day (p = 0.024). Although group 3 had a lower score than the other groups in the ecchymosis measurements on the 1st, and 7th days, no statistically significant results were obtained. CONCLUSIONS: Local application of tranexamic acid is founded more beneficial for reducing postoperative edema and ecchymosis in rhinoplasty than intravenous and/or oral applications in this study. LEVEL OF EVIDENCE I: 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 .

The Effects of Two Different Cold Application Times on Edema, Ecchymosis, and Pain After Rhinoplasty: A Randomized Clinical Trial.

PURPOSE: This study was performed to determine the effects of different cold application times to the periorbital area after rhinoplasty on edema, ecchymosis, and pain. DESIGN: A randomized clinical study. METHODS: Patients were divided into two groups, and cold application was applied to one group for 4 hours and to the other for 48 hours. The cold application was applied with ice packs for 20 minutes every hour to the periorbital region in both groups. Data were collected with the Patient Information Form, Scoring Diagram for Edema, the Scoring Diagram for Ecchymosis, and the Visual Analogue Scale for Pain. FINDINGS: Periorbital edema, eyelid ecchymosis, and pain were not significantly different between the two groups. The mean edema score of the 48-hour group was 0.87 ± 0.93, while the mean edema score of the 4-hour group was 0.70 ± 0.87 (P = .48) on the 2nd day. The mean ecchymosis score was found as 2.03 ± 1.12 in the 48-hour group and 2.10 ± 1.09 in the 4-hour group (P = .817). The mean pain score was 12.50 ± 17.40 in the 48-hour group and 13.00 ± 16.00 in the 4-hour group (P = .98). CONCLUSIONS: The effects of 48-hour and 4-hour cold applications are similar. Cold application for 4 hours may be recommended to patients who undergo rhinoplasty, as it is more practical and easier to apply than the 48-hour practice.

Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial.

BACKGROUND: The use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients. METHODS: In this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction. RESULTS: No statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.). CONCLUSION: TXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.

A Comparison Between Piezosurgery and Conventional Osteotomies in Rhinoplasty on Post-Operative Oedema and Ecchymosis: A Systematic Review.

Piezosurgery use has become increasingly prevalent in osteotomies. Piezoelectric ultrasound waves can cut bone effectively, and some studies have shown reduced post-operative morbidities compared to conventional osteotomies. Oedema and ecchymosis are common complications of rhinoplasty and can impact patient satisfaction, wound healing, and recovery. We aim to provide an up-to-date comparison of post-operative oedema and ecchymosis in piezosurgery and conventional osteotomies. A literature search was conducted using the following online libraries; Pubmed, Cochrane, Science Direct, and ISRCTN (International Standard Randomised Controlled Trial Number). English publications between 2015 and 2020 were included. A systematic review was completed, and a comparison of oedema and ecchymosis in piezosurgery and conventional osteotomies was examined alongside other outcomes such as pain, mucosal injury, and surgery time. Eight randomised controlled trials (RCTs) met our criteria with a combined total of 440 patients: 191 male and 249 female. Piezosurgery had statistically significant (p < 0.05) reduction in short-term oedema compared to conventional osteotomies in 75% of the papers included, and in 50% this persisted across the whole follow-up period. Similarly, ecchymosis scoring was initially statistically lower (p < 0.05) in piezosurgery in 87.5% of the RCTs, and in 75% this persisted across the whole follow-up period. A reduction in pain (p < 0.05) and mucosal injury (p < 0.05) was also seen in piezoelectric osteotomies. The length of surgery time varied. Piezoelectric osteotomies reduce oedema and ecchymosis compared to conventional osteotomies, in addition to improving pain and mucosal injury. However, disadvantages such as length of surgery time and cost have been reported. 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 .

Powered Micro-saw Versus Conventional Osteotome for Septorhinoplasty: A Prospective, Double-Blind, Comparative Study.

BACKGROUND: Various powered instruments are used to perform osteotomy. A consensus on the best method has not been established due to discrepancies in previous studies. This study aimed to compare the conventional osteotome and a powered micro-saw during septorhinoplasty. METHODS: The single-center, prospective cohort study included 60 patients that were grouped into two groups of 30 each. Group 1 underwent open septorhinoplasty using a conventional osteotome, and group 2 underwent open septorhinoplasty using a powered micro-saw. Postoperative edema, ecchymosis, pain, and nasal blockage were compared between groups. Preoperative and postoperative (6 months) functional and aesthetic outcomes were compared based on FACE-Q, SNOT-22, and T-NOSE scores. RESULTS: There were not any differences in age, gender, follow-up duration, the Brinkman index, or level of education between groups. Postoperative pain scores were significantly lower in group 2 on d 1 and d 3 postsurgery. Nasal blockage scores were significantly higher in group 1 on d 3 and d 7 postsurgery. Edema and ecchymosis scores were similar in both groups at all time points. Preoperative and postoperative (6 months) functional and aesthetic outcomes were also similar in both groups. CONCLUSION: Osteotomy using a powered micro-saw is an effective technique that results in less postoperative pain and nasal blockage than when using conventional osteotome. Early postoperative period edema and ecchymosis scores and long-term functional and aesthetic outcomes are similar when using a powered micro-saw and a conventional osteotome. Osteotomy using a powered micro-saw can be considered an alternative to using a conventional osteotome. LEVEL OF EVIDENCE II: 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 .

Role of External Nasal Splinting Following Rhinoplasty: Is It Really Important? A Comprehensive Systematic Review of Literature.

BACKGROUND: Following rhinoplasty, external nasal splints are used to reshape the cartilage and reposition the nasal bone. Despite the popularity of using an external nasal splint in rhinoplasty procedures, there is still a lack of evidence of the effectiveness of using the external nasal splint post-rhinoplasty. This systematic literature review aimed to evaluate the evidence regarding the use of external nasal splints following rhinoplasty. METHODS: A systematic search of Cochrane, Medline, and Embase databases was conducted in September 2022. The literature was screened independently by two reviewers, and the data were extracted. Our search terms included septorhinoplasty, rhinoplasty, osteotomy, splinting, nasal splinting, and external nasal splinting. RESULTS: Initially, 1617 articles were identified, but only four articles were included in the final review. The included studies were all published between 2016 and 2021. The included studies recruited 2425 patients, 20 of whom used external splints and 2415 did not. Out of 2415 patients who did not use an external nasal splint, there were 151 patients with moderate periorbital edema and ecchymosis. There was a decrease in nasal width in 99% of the patients who did not use external nasal splinting postoperatively. CONCLUSION: According to our findings, nasal splinting should not be routinely used following rhinoplasty, but only in certain patients. There is no clear evidence that nasal splints reduce complications, and complications occurred among both patients with and without external nasal splints. Further studies need to be conducted to confirm this conclusion. 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 .

Acute periocular haemorrhage associated with severe proptosis as a presenting sign of orbital tumours.

Periocular haemorrhage without a preceding history of trauma, and in the absence of vascular malformations is rare. While acute proptosis is well described in the setting of orbital pathology, accompanying periocular haemorrhage has been rarely reported. We describe three cases with these concomitant presenting signs in orbital malignancies - metastatic small cell bladder carcinoma, haemangiopericytoma (solitary fibrous tumour) and myeloma. Clinical photographs and radiology are presented with review of the current literature. All cases had an associated rapid onset of severe proptosis and co-existing periocular bruising on the same side. The presence of ecchymosis of the eyelids in addition to proptosis without a history of trauma warrants thorough investigation to rule out underlying potential sight and life threatening illness.

Spontaneous periocular ecchymosis: a major review.

Periocular ecchymosis, or periocular bruising, is a common clinical finding. Periocular skin is thin with an extensive vascular network, making this anatomical region prone to bruising. The most common etiology is trauma, but rarely, patients can present with spontaneous periocular ecchymosis (SPE). The pathophysiology of SPE is complex and varied. In this literature review of 121 articles, we assessed the frequency and variety of causation of this infrequent entity. The main finding was that by far the most common diagnosis causing SPE is amyloidosis and neoplasm, most notably neuroblastoma. Amyloidosis accounted for 23% articles (28/121) and neuroblastoma for 17% articles (21/121). Overall, neoplastic processes accounted for 30% of the articles (36/121), raised intracranial pressure and vascular malformations for 19% of the articles (23/121), migraine and atypical headache for 7% of the articles (8/121), while iatrogenic accounted for 5% of the articles (6/121). Through exploration and appreciation of the pathophysiology, we hope to foster a greater understanding in the clinician to establish underlying etiology, from benign to life-threatening, when presented with SPE.

Drainage tube use for the reduction of postoperative ecchymosis in rhinoplasty.

BACKGROUND: Postoperative healing after rhinoplasty can have a negative impact on patient quality of life. OBJECTIVES: In our study, we aimed to reduce postoperative edema and ecchymosis by applying a minidrain system. We evaluated this intervention's benefit on postoperative morbidity by observing the patient with left and right sides, intervention side and control side respectively. METHODS: All surgeries were performed using a piezo device with an open technique septorhinoplasty. We only used a left-sided minidrain system through the osteotomy lines just in front of the piriform aperture for all patients with no other intervention on the right side of the same patient. RESULTS: Use of a drain on the left side was associated with a statistically significant decrease in ecchymosis at postoperative day 7 (P<0.05). CONCLUSIONS: We found that using a minidrain system through internal osteotomy lines was effective in reducing the amount of ecchymosis by day seven after surgery.

A systematic review on mucocutaneous presentations after COVID-19 vaccination and expert recommendations about vaccination of important immune-mediated dermatologic disorders.

With dermatologic side effects being fairly prevalent following vaccination against COVID-19, and the multitude of studies aiming to report and analyze these adverse events, the need for an extensive investigation on previous studies seemed urgent, in order to provide a thorough body of information about these post-COVID-19 immunization mucocutaneous reactions. To achieve this goal, a comprehensive electronic search was performed through the international databases including Medline (PubMed), Scopus, Cochrane, Web of science, and Google scholar on July 12, 2021, and all articles regarding mucocutaneous manifestations and considerations after COVID-19 vaccine administration were retrieved using the following keywords: COVID-19 vaccine, dermatology considerations and mucocutaneous manifestations. A total of 917 records were retrieved and a final number of 180 articles were included in data extraction. Mild, moderate, severe and potentially life-threatening adverse events have been reported following immunization with COVID vaccines, through case reports, case series, observational studies, randomized clinical trials, and further recommendations and consensus position papers regarding vaccination. In this systematic review, we categorized these results in detail into five elaborate tables, making what we believe to be an extensively informative, unprecedented set of data on this topic. Based on our findings, in the viewpoint of the pros and cons of vaccination, mucocutaneous adverse events were mostly non-significant, self-limiting reactions, and for the more uncommon moderate to severe reactions, guidelines and consensus position papers could be of great importance to provide those at higher risks and those with specific worries of flare-ups or inefficient immunization, with sufficient recommendations to safely schedule their vaccine doses, or avoid vaccination if they have the discussed contra-indications.

Dermatologic Symptoms and Syndromes Associated with Headache.

PURPOSE OF REVIEW: Headache disorders are often accompanied by associated symptoms involving organ systems other than the central and peripheral nervous system, including the integumentary, cardiovascular, and musculoskeletal system. However, skin changes or conditions are not commonly associated with headache disorders. Recognition of possible etiologies of headache in patients with bruising, rash, or neurocutaneous disorders can help guide workup and management. The purpose of this article is to review the various dermatologic presentations associated with headache. RECENT FINDINGS: Multiple review articles and retrospective studies have noted the association between head pain with dermatologic changes including ecchymoses, inflammatory skin conditions, and neurocutaneous disorders. Postulated mechanisms include activation of the trigeminal autonomic system and involvement of similar pro-inflammatory molecules. In this review, we discuss three different classes of rashes including ecchymoses, inflammatory skin conditions, and neurocutaneous disorders, all of which have been associated with migraine and/or headache. We discuss the possible underlying pathophysiology and treatment options.

The effects of 5-degree, 10-degree and 20-degree reverse Trendelenburg positions on intraoperative bleeding and postoperative Edemea and ecchymosis around the eye in open rhinoplasty.

PURPOSE: In this study, we investigated the effect of reverse Trendelenburg position (RTP), with five, ten, and twenty degrees, on intraoperative bleeding and postoperative edema and ecchymosis around the eye in open rhinoplasty operations. MATERIALS AND METHODS: Ninety patients undergoing open rhinoplasty were divided into three groups, 5° angle RTP (Group 5; n = 30), 10° angle RTP (Group 10; n = 30), and 20° angle RTP (Group 20; n = 30). After 3 min of preoxygenation, anesthesia was induced with 3 mg.kg-1 propofol, 1 µg.kg-1 fentanyl, and 0.6 mg/kg rocuronium for muscle relaxation. Maintenance of anesthesia was provided with a minimum alveolar concentration of 1-1.5 with sevoflurane, 1:1 O2/N2O. Hemodynamic variables, intraoperational bleeding, postoperative 1st, 3rd and 7th days ecchymosis and edema around the eyes of the patients were compared between the groups. RESULTS: Edema changes on postoperative 1st, 3rd and 7th days and ecchymosis changes around the eyes on postoperative 1st and 3rd days in Group 20 were found significantly lower than Group 5 (p < 0.017). Besides, the change of ecchymosis on the postoperative 1st day was found significantly lower in Group 20 compared to Group 10 (p < 0.017). The amount of intraoperative bleeding and surgical field evaluation score were found to be significantly lower in Group 10 and Group 20 compared to Group 5 (p < 0.017). CONCLUSION: We concluded that in open rhinoplasty surgeries, 20° degree RTP reduces intraoperative blood loss and provides a more bloodless surgical field, as well as reducing edema and ecchymoses around the eyes in the postoperative period.

Extreme ecchymoses in a migraine patient using concomitant treatment with calcitonin gene-related peptide receptor antibodies and fish oil supplements: a case report.

BACKGROUND: Erenumab, a monoclonal antibody against the calcitonin gene-related peptide (CGRP) receptor, is registered for migraine prevention. Compared to other conventional migraine prevention medicines (i.e. topiramate, betablockers and amitriptyline) erenumab has better tolerability. Impaired hemostasis has not been reported previously. Here, we report the first case of an increased tendency to bruise in a migraine patient treated with erenumab. CASE PRESENTATION: A 41-year old female migraine patient was treated with erenumab for 12 months, which led to a significant reduction of headache and migraine days. Three months after treatment start, she experienced increased tendency to bruise leading to extreme ecchymosis after 4 months treatment. Platelet counts and aggregation, thromboelastography, activated partial thromboplastin time (APTT) and international normalized ratio (INR) were all normal. Thorough interview revealed intake of fish oil supplements for many years prior to treatment. The increased tendency to bruise subsided after discontinuation of fish oil supplements. CONCLUSION: The combination of fish oil supplements and erenumab may cause increased tendency to bruise. Erenumab has no effect on the platelets per se but may cause impaired wound healing by suppression of CGRP. Thus, small and unnoticeable bruises may be aggravated instead in patients with tendency to bruise caused by for instance fish oil supplements.

Ecchymosis in critical coronavirus disease 2019 (COVID-19) patient in Tangerang, Indonesia: a case report.

We have read with great interest the articles regarding cutaneous manifestations in Coronavirus Disease 2019 (COVID-19) infection. Studies showed 20.4% of COVID-19 patients developed cutaneous manifestations. COVID-19 causes vascular endothelial injury, vasculitis and prothrombotic state which might be the underlying cause of hemorrhagic cutaneous manifestations, disseminated intravascular coagulation (DIC), and multiple organ failures. To date, hemorrhagic cutaneous manifestations reported are chilblain-like lesion, purpura to ecchymosis, livedo reticularis, and dry gangrene. We present a case of ecchymosis in COVID-19-positive ICU hospitalized patient.

Intense Pulsed Light as a Treatment for Senile Purpura: A Pilot Study.

BACKGROUND AND OBJECTIVES: Senile purpura is a common condition characterized by recurrent ecchymoses in the elderly on the extensor surfaces of the forearms, hands, and legs. Our objective is to assess the efficacy and safety of a protocol using intense pulsed light (BBL; Sciton Inc., Palo Alto, CA) to improve the appearance of senile purpura on subjects' extensor forearms. STUDY DESIGN/MATERIALS AND METHODS: Five subjects over 65 years of age, with ecchymotic lesions measuring over 1 cm on each forearm and five younger subjects under 35 years of age, without any ecchymotic lesions, were included in the study. The subjects were treated on one randomized forearm with a new intense pulsed light protocol for four weekly sessions. Photographs and subject questionnaires were taken weekly before each treatment as well as 1 month after all treatments. Skin biopsies were taken 1 day after the last of four weekly treatments. Histological analysis, including hematoxylin and eosin, elastic van Gieson, and Masson's Trichrome staining, were carried out to assess both the epidermal thickness and dermal connective tissue structure. The protocol consists of multiple passes using an intense pulsed light (BBL; Sciton Inc.) device in which the wavelength, filter, and fluence are adjusted for each step. Step 1 uses infrared light (800-1,400 nm), high intensity, a smooth adapter, and a constant motion technique. Step 2 employs a 590-nm filter with two different fluences and step 3 utilizes a 560-nm filter. The fluence of steps 2-3 is increased by 1 J each treatment if no side effects are noted. RESULTS: Using a new intense pulsed light protocol in subjects with senile purpura, both the number and square area of ecchymoses on the treated arm were significantly reduced (P = 0.02 and P = 0.04, respectively, paired t test) as compared with the untreated arm at 1 month after four weekly treatments. Despite this pilot study including challenging cases of subjects on both inhaled and injected corticosteroids and blood thinners, all subjects with senile purpura had at least a 50% reduction in the total square area of their ecchymoses on their treated arm. There were no significant or long-lasting side effects, and all subjects reported satisfaction with the treatment with a desire to continue treatments on their control arm. Blinded evaluators were able to select 100% of the time in the subjects with senile purpura, which was the treated arm as compared with the control arm when reviewing photographs from 1 month after the last treatment. In addition, several subjects were noted to have a significant improvement in the appearance of hemosiderin deposition and photodamage. Histologically, intense pulsed light treatments significantly increased epidermal thickness in elderly subjects by 21.14% (P = 0.0153, two-tailed, paired t test), to levels comparable with young subjects. Such restoration is consistent with the other histological observations by blinded evaluators of more abundant and organized collagen fibers in the dermis and reduced aggregates of disorganized elastin fibers. CONCLUSION: This new intense pulsed light protocol is safe and effective in improving the clinical appearance of senile purpura as well as preventing future lesions by improving the structure of the skin by increasing epidermal thickness and improving collagen and elastic fiber morphology. The treatment was well-tolerated, adverse effects were minimal, and there was high patient satisfaction. Lasers Surg. Med. 2020. © 2020 Wiley Periodicals LLC.

Surgical results in penile fracture: Our single center experience.

INTRODUCTION: Penile fracture arises as a result of a unilateral or bilateral rupture of the tunica albuginea of the corpus cavernosum. It is a rare condition that requires urgent surgical intervention. In this study, we aimed to determine the effectiveness of surgical treatment in penile fracture and its effect on complications. METHODS: The data of 21 patients who were admitted to the emergency department of our clinic between 2012 and 2019 and underwent emergency surgical repair with the diagnosis of penile fracture were collected retrospectively. The diagnosis of penile fracture was established by anamnesis and physical examination. Age, etiology, duration from trauma to surgery, physical examination findings,length and localization of the tunica albuginea defect, length of hospital stay, and postoperative first-, third- and sixth-month follow-up results were analyzed. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5). Complications such as penile curvature, penile nodule and painful erection were evaluated. RESULTS: The mean age of the patients was 36.8 ± 8.3 years. The most common reason of penile fracture was manually bending the penis for detumescence. All patients underwent surgery. The mean duration from trauma to surgery was 7.6 ± 3.1 h. The mean length of the tunica albuginea defect was 11 ± 2.5 mm. The mean length of hospital stay was 2.5 ± 0.5 days. The mean IIEF-5 scores in the postoperative first, third and sixth months were 20.5 ± 2.6, 22 ± 2.2, 22.1 ± 1.7, respectively. CONCLUSION: Penile fracture is a urological emergency, and timely surgery is an effective treatment method for preventing postoperative complications.