Reconstruction of large rectangular infraorbital and malar skin defects in elderly patients with a modified "reading man flap" using local tumescent anesthesia.

BACKGROUND: The classical "reading man flap" is a recently described flap named after its appearance and mainly used for reconstruction of circular malar or infraorbital skin defects. It avoids surgical complications such as lower lid retraction and ectropion but is limited to circular skin defects. Local tumescent anesthesia uses a diluted local anesthetic together with diluted epinephrine to anesthetize large skin areas without the need for general anesthesia. OBJECTIVES: To assess the esthetic outcome, pain control, and complications of a modified "reading man flap" under local tumescent anesthesia in elderly patients with rectangular malar or periorbital skin defects. METHODS: Two flaps are used to close the surgical defect, the first rectangular flap is transposed to the defect area, then approximately half to two-thirds of the flap's donor site are closed directly as done with transposition flaps, whereas a second smaller triangular flap is advanced for the closure of the last third of the remaining now triangular donor site, where the greatest tension would occur if closed directly. RESULTS: The median age of patients was 83 years (range 64-92 years) of the total 12 patients, 10 (83%) were women, and two were men. The mean defect size was 9.2 cm(2) (5.5-22.1 cm(2) ). The defect closure was possible in all patients, no lasting postoperative complications occurred, and cosmetic results were satisfactory. Twenty to 70 ml of local tumescent anesthesia were used, and a larger volume (≥ 40 ml) was associated with better pain control (P = 0.03). CONCLUSIONS: The modified "reading man flap" is a good option for the closure of larger rectangular facial skin defects especially in elderly patients, and the use of at least 40 ml of tumescent solution is suggested to achieve optimal pain control.

Treatment of DIHS/DRESS syndrome with combined N-acetylcysteine, prednisone and valganciclovir--a hypothesis.

BACKGROUND: Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is a rare and severe adverse drug reaction with an associated mortality of 10-20%. Clinical worsening despite discontinuation of the culprit drug is considered a characteristic feature of DIHS/DRESS. Besides the early recognition of the syndrome and discontinuation of its causative drug, the mainstay of treatment is systemic corticosteroids. Nevertheless, treatment of severe DIHS/DRESS is not well defined, as corticosteroids may sometimes not be effective, and decreasing the dose may be associated with flaring of the disease. CASE REPORT: A 38-year-old woman with high fever, malaise, abdominal pain, rash, and elevated liver enzymes received immediate high-dose N-acetylcysteine, because acetaminophen hepatotoxicity was suspected. N-acetylcysteine administration was associated with a significant clinical improvement. However, within the next week DIHS/DRESS syndrome was diagnosed, which explained all the symptoms, and which was subsequently treated with prednisone and valganciclovir. CONCLUSIONS: New options necessary to improve treatment of severe DIHD/DRESS have to consider its sequential pathogenetic mechanisms. N-acetylcysteine might neutralize the drug-derived reactive metabolites, which are responsible for protein adduct formation and specific T cell stimulation, and replete the glutathione stores that counterbalance oxidative stress. Prednisone might inhibit lymphoproliferation and valganciclovir might prevent complications related to HHV-6 reactivation. We therefore propose the unprecedented combination of N-acetylcysteine, prednisone and valganciclovir as a treatment option for DIHS/DRESS.