Allergic Complications of Hyaluronidase Injection: Risk Factors, Treatment Strategies, and Recommendations for Management.

BACKGROUND: Hyaluronidase is used as a reversal agent for hyaluronic acid fillers and to increase the diffusion of other medications after infiltration. Cases of hyaluronidase allergy have been described in the literature since 1984. However, it is still frequently misdiagnosed. This review aims to summarize the current literature to describe the clinical picture of hyaluronidase allergy and identify any risk factors associated with its development, as well as provide recommendations for management in plastic surgery. METHODS: A digital search of PubMed, Scopus, and Embase databases was performed by two reviewers following the PRISMA guidelines. This search identified 247 articles. RESULTS: Two hundred forty-seven articles were identified, and 37 of them met the eligibility criteria. One hundred six patients with a mean age of 54.2 years were included in these studies. History of allergy to other substances (timothy grass, egg white, horse serum, penicillin, insect bites, wasp venom, thimerosal, potassium, histamine, phenylmercuric acetate, and nickel) and allergic diseases (asthma, dermatitis, atopy, rhinitis) was reported. A large portion of the patients with a history of repeated exposure (2-4) experienced the symptoms with their second injection. Nonetheless, there was no significant association between time to allergy development and the number of exposures (P = 0.3). Treatment with steroids +/- antihistamines resulted in the rapid and predominantly complete reversal of the symptoms. CONCLUSIONS: Prior injections or sensitization by insect/wasp venom might be the primary factor associated with hyaluronidase allergy development. The time between the repeated injections is not a likely contributor to the presentation. 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 .

Digital Imaging in Secondary Rhinoplasty.

BACKGROUND: Rhinoplasty remains one of the most commonly performed operations in plastic surgery. Little is known regarding the use of imaging in secondary rhinoplasty. Secondary rhinoplasty is a far more complex operation than primary rhinoplasty. The objective of this study was to assess the role of software imaging in patients undergoing secondary rhinoplasty. METHODS: A retrospective review was performed to identify patients undergoing secondary rhinoplasty performed by the senior author (R.J.R.) from January of 2000 to August of 2013. Forty consecutive patients met inclusion criteria. The degree of improvement was graded in comparison with both the preoperative photographs and software imaging using a graded scale. RESULTS: A total of 40 patients met inclusion criteria. There were 35 women (87.5 percent) and five men (12.5 percent). The nasal dorsum was found to have an average rating of 2.36 between the two observers, the midvault had an average rating of 2.65, the nasal tip had an average rating of 2.27, the nasal alae had an average rating of 2.63, and the nasal base had an average score of 2.99 CONCLUSIONS:: Based on the results of this study, the authors have determined that preoperative digital imaging can provide a reasonable expectation for patients undergoing secondary rhinoplasty. However, digital imaging must be used with caution, as secondary rhinoplasty patients have heightened expectations and unknown anatomy from their previous operation. The nasal tip and dorsum are especially difficult to adequately predict, and this should be discussed with the patient before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Collagenase Dupuytren Contracture: Achieving Single Treatment Success with a Hand Therapist-Based Protocol.

UNLABELLED: Surgery remains the gold standard in the treatment of Dupuytren contracture but is technically demanding, carries significant risk of complications, and requires prolonged recovery time. Collagenase injection is an efficacious alternative to surgery; however, contracture release often requires multiple treatments spaced a month apart. We report our experience with a new collagenase treatment protocol aimed to minimize the total treatment time per joint contracture. METHODS: We performed a single institution retrospective review of patients with Dupuytren contracture treated with collagenase using our protocol from 2011 to 2013. Patients returned 24 hours after collagenase injection for cord manipulation by a certified hand therapist while under digital block. Treatment success was defined as reduction in contracture to 5 degrees or less. Successfully treated joints were evaluated for recurrence (>10 degrees contracture) at 30-day and 6-month follow-up appointments. Serious adverse events, including skin tears, were recorded. RESULTS: Success was achieved in 36 of 47 treated joints (76.6%) after a single injection. There were 2 recurrences in 32 joints at 30-day follow-up (6.2%) and no recurrences in 17 joints available at 6-month follow-up. Skin tears were the only serious adverse event occurring in 18 of 47 cord ruptures (38.3%). All healed secondarily without complication. CONCLUSIONS: Our protocol preserves treatment efficacy while maximizing efficiency. Achieving successful cord rupture with a single injection allows earlier return of function, reduced cost of treatment, and increased convenience for the patient. Patients, particularly those with greater contractures, should be counseled regarding the risk of skin tear during cord manipulation.

Reconstructive Management of Devastating Electrical Injuries to the Face.

BACKGROUND: Devastating fourth-degree electrical injuries to the face and head pose significant reconstructive challenges. To date, there have been few peer-reviewed articles in the literature that describe those reconstructive challenges. The authors present the largest case series to date that describes the management of these injuries, including the incorporation of face transplantation. METHODS: A retrospective case series was conducted of patients with devastating electrical injuries to the face who were managed at two level-1 trauma centers between 2007 and 2011. Data describing patient injuries, initial management, and reconstructive procedures were collected. RESULTS: Five patients with devastating electrical injuries to the face were reviewed. After initial stabilization and treatment of life-threatening injuries, all five underwent burn excision and microsurgical reconstruction using distant flaps. Two of the patients eventually underwent face transplantation. The authors describe differences in management between the two trauma centers, one of which had the availability for composite tissue allotransplantation; the other did not. Also described is how initial attempts at traditional reconstruction affected the eventual face transplantation. CONCLUSIONS: The care of patients with complex electrical burns must be conducted in a multidisciplinary fashion. As with all other trauma, the initial priority should be management of the airway, breathing, and circulation. Additional considerations include cardiac arrhythmias and renal impairment attributable to myoglobinuria. Before embarking on aggressive reconstruction attempts, it is advisable to determine early whether the patient is a candidate for face transplantation in order to avoid antigen sensitization, loss of a reconstructive "lifeboat," surgical plane disruption, and sacrifice of potential recipient vessels. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Complications related to harvest of the proximal end of the fibula: a systematic review.

BACKGROUND: The fibula is a common source of bone graft used in skeletal reconstruction. Although in most cases only the diaphysis of the fibula is used, there are clinical scenarios in which the proximal end of the fibula and fibular head are harvested for use in articular reconstruction. The purpose of this systematic review is to determine the incidence of knee instability and peroneal nerve motor dysfunction associated with removal of the proximal end of the fibula and fibular head. METHODS: A systematic search was performed using the PubMed, Ovid MEDLINE, and cochrane databases. Studies accepted for review included those that clearly reported donor site morbidity (instability or peroneal nerve motor dysfunction) after proximal fibula resection. All studies in which the proximal fibula was resected for bone graft or for marginal resection of tumor were included. RESULTS: Fifteen studies reporting a total of 337 patients were included. The rate of symptomatic knee instability after proximal fibula resection was 3.9%. The incidence of instability that was detectible on physical examination or stress radiographs was higher. Although transient motor dysfunction was not uncommon, the incidence of persistent peroneal nerve motor dysfunction was 2.6%. CONCLUSION: Although asymptomatic laxity is common, the incidence of symptomatic knee instability after resection of the proximal fibula is relatively low. The incidence of persistent peroneal nerve motor dysfunction is also low when the nerve is intentionally protected during surgery.

Upper eyelid postseptal weight placement for treatment of paralytic lagophthalmos.

BACKGROUND: Left untreated, paralytic lagophthalmos may result in corneal dryness, ulcerations, and subsequent blindness. The most common nondynamic surgical solution is upper eyelid weight placement in a superficial, pretarsal pocket, carrying the risk of visibility, extrusion, and entropion. The authors present a technique useful in patients presenting with either primary symptoms of corneal exposure or complications of previous implants that is equally efficacious, with a potentially decreased risk of complications, in which the weight is inserted into a deeper, postseptal position but requires use of a heavier weight. METHODS: Nineteen patients, 15 primary and four secondary, treated between the years 2008 and 2012 with the postseptal approach, were evaluated for demographics, cause, resolution of primary symptoms, and complications. The average weight difference between that measured in the clinic versus weight used in surgery in the primary group and the average weight difference between that inserted in previous surgery versus weight placed in corrective surgery were calculated. RESULTS: The average weight difference was 0.213 g (range, 0 to 0.4 g) in the primary group and 0.2 g (range, 0 to 0.4 g) in the revision group. Symptoms resolved in all but one patient, neither revisions nor complications were noted, and the longest follow-up was 4 years. CONCLUSIONS: The retroseptal technique has proven to be safe, reproducible, and very useful in both primary and secondary upper eyelid surgery for paralytic lagophthalmos. It successfully addresses several common problems encountered with more superficial weight placement, including visibility, exposure, and entropion, but often necessitates use of a heavier weight. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication rates.

BACKGROUND: The most common form of blepharoptosis is involutional ptosis, commonly caused by the effect of progressive age on the levator aponeurosis. The treatment for this acquired ptosis is strictly surgical. For the plastic surgeon, the ideal lid ptosis repair provides the longest efficacy, the fewest complications and revisions, and, ultimately, the highest functional and cosmetic outcome for the patient. With over 100 different described techniques, there exists a need to make a comparison. A systematic review is considered a higher level of evidence because it is a review designed to be reproducible, with predetermined inclusion and exclusion criteria. To date, there has been no systematic review to study the efficacy and complication rates between different involutional lid ptosis repair techniques. METHODS: A systematic search of the English literature published in the PubMed and Cochrane Central Register of Controlled Trials databases yielded trials on comparison of different adult upper lid involutional ptosis repair techniques regarding their efficacy and complication rates. Predetermined inclusion and exclusion criteria were used. RESULTS: : This systematic review revealed that there are no randomized, prospective, controlled comparison studies on involutional lid ptosis repair techniques. CONCLUSIONS: Although this systematic review revealed a lack of level I data in comparing the different ptosis repair techniques, it is important that the existing studies be reviewed and pooled to improve patient outcomes and to provide direction for future research. In the absence of higher level data studies, the authors propose a treatment algorithm for involutional ptosis repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Adult intimate partner violence perpetrators are significantly more likely to have witnessed intimate partner violence as a child than nonperpetrators.

BACKGROUND: In a previous study, no association was found between intimate partner violence (IPV) victims and being an adult who witnessed IPV as a child (ACW). OBJECTIVE: The objective of the present study was to determine whether perpetrators of IPV (Perps) could be identified in a busy emergency department (ED) and whether Perps were more likely than non-Perps to be ACWs. The hypothesis was that Perps differed significantly from non-Perps in being ACWs, in being victims of IPV, and in demographics. METHODS: The design was a cross-sectional cohort of patients presenting to an academic ED during randomized 4-hour shifts. A choice of computer touch screen data vs paper format was offered. Data collected included demographics as well as scales to determine whether subjects were a Perp, victim, and/or ACW of IPV. Six validated scales were used to screen and confirm victims, Perps, and ACWs. Predictor variables were ACW, ongoing IPV, and demographics. RESULTS: Two hundred thirty-six subjects were entered, 207 had complete data sets. Forty-four (19%) were Perps. By univariate analysis, there was a significant correlation of Perps and ACW (P = .001 by single question) and between Perp and being victims (P = .001). No other univariate variables were significantly correlated. By regression analysis, significant predictors of Perp included ACW and spouse drug abuse. CONCLUSIONS: The Perps were identified in a busy ED setting. Perps were significantly more likely than non-Perps to be ACWs, but not more likely to be victims. Spouse drug abuse and ACW were the 2 significant predictors of Perp.